From the Guidelines
Treatment of a clinically palpable varicocele may be offered to the male partner of an infertile couple when there is evidence of abnormal semen parameters and minimal/no identified female factor, including consideration of age and ovarian reserve. This approach is based on the most recent guidelines and expert opinions, as outlined in the 2024 update to male infertility guidelines 1. The correction of palpable varicoceles has been shown to result in improvement in both semen quality and fertility, whereas treatment of non-palpable varicoceles is not associated with such improvements.
When evaluating a varicocele, it is essential to consider the semen parameters, including volume, sperm concentration, vitality, progressive motility, and total motility, as outlined in the World Health Organization reference limits 1. A semen volume of less than 1.4 mL, acidic semen (pH <7.0), and low sperm concentration may indicate distal male genital tract obstruction, and further evaluation with transrectal ultrasonography (TRUS) or pelvic MRI may be necessary.
The use of ultrasonography, including scrotal ultrasound and color Doppler ultrasound, can be helpful in confirming the presence of a varicocele and evaluating the anatomy of the primary organs involved in ejaculation. However, routine use of ultrasonography to identify non-palpable varicoceles is discouraged, as treatment of these varicoceles is not helpful 1.
In terms of treatment, surgical repair (varicocelectomy) is the standard treatment for symptomatic varicoceles, which can be performed microsurgically, laparoscopically, or through embolization. The procedure typically takes 30-60 minutes, with a recovery period of 1-2 weeks, and pain management post-surgery involves over-the-counter medications like ibuprofen or acetaminophen. Scrotal support and ice packs can help reduce swelling, and patients should follow up with their urologist to monitor recovery and fertility outcomes.
Key considerations in the management of varicoceles include:
- Evaluation of semen parameters and identification of abnormal parameters
- Consideration of age and ovarian reserve in the female partner
- Use of ultrasonography to confirm the presence of a varicocele and evaluate anatomy
- Surgical repair (varicocelectomy) as the standard treatment for symptomatic varicoceles
- Pain management and follow-up care post-surgery
Overall, the management of varicoceles requires a comprehensive approach, taking into account the individual patient's symptoms, semen parameters, and overall fertility goals, as well as the most recent guidelines and expert opinions 1.
From the Research
Definition and Causes of Varicocele
- A varicocele is defined as the abnormal dilation of the internal testicular vein and pampiniform venus plexus within the spermatic cord 2
- It is an abnormal dilatation and tortuosity of the veins of the spermatic cord 3
Treatment Options for Varicocele
- Several options for the treatment of varicocele, including surgical repair either by open or microsurgical approach, laparoscopy, or through percutaneous embolization of the internal spermatic vein 4
- Percutaneous embolization offers a rapid recovery and can be successfully accomplished in approximately 90% of attempts 4
- Laparoscopic varicocelectomy is the treatment of choice for bilateral varicoceles 5
- Open surgery still has a role in isolated right-sided varicoceles and in left-sided cases with failed sclerotherapy 5
Comparison of Treatment Outcomes
- Percutaneous coil embolization of the testicular vein offers treatment advantage compared with laparoscopic repair in patients with varicoceles, with lower treatment complication rates 6
- Technical success in interventional and laparoscopic treatment was 95% and 100%, respectively 6
- Embolization treatment resulted in two recurrent varicoceles (4.8%) compared to one patient following laparoscopic repair (2.3%, not significant) 6
Indications and Contraindications for Treatment
- A semen analysis should be obtained for any male patient of reproductive age considering intervention 3
- The main clinical indication used by many urologists to recommend repair is testicular atrophy 2
- Not all varicoceles should be treated equally (or at all), and basic guidelines on the evaluation and indications for treatment of adult varicoceles should be reviewed before counseling and treatment 3