What are the treatment options for varicocele?

Treatment Options for Varicocele

The primary treatment options for varicocele include surgical repair (microsurgical varicocelectomy) and percutaneous embolization, with microsurgical approaches offering the lowest rates of recurrence and complications for patients with symptomatic varicoceles or those with infertility. 1, 2

Indications for Treatment

Treatment is indicated in the following scenarios:

• Adult men with clinical varicocele and abnormal sperm parameters in the context of couple infertility 2
• Men with symptomatic varicocele (typically scrotal pain or discomfort) 2
• Adolescents with:
  • Reduced testicular growth
  • Ipsilateral decrease in testicular volume
  • Size gradient between the two testes 2

Diagnostic Approach

1. Clinical examination - performed in both supine and standing positions with Valsalva maneuver 2
2. Scrotal ultrasound with Doppler - typically performed as part of infertility evaluation or when physical examination is difficult 2

Important: Only clinically palpable varicoceles should be treated. Routine use of ultrasonography to identify non-palpable varicoceles is discouraged, as treatment of these varicoceles has not been shown to improve fertility outcomes. 1

Treatment Options

1. Surgical Approaches

• Microsurgical varicocelectomy (inguinal or subinguinal) - considered the gold standard surgical approach 2

  • Lowest recurrence rates (1-3%) 3
  • Lowest complication rates 2
  • Better outcomes than high surgical approaches or surgeries without magnification

• Other surgical approaches:

  • Laparoscopic varicocelectomy (more common in adolescents) 4
  • High ligation (non-microsurgical)

2. Percutaneous Embolization

• Endovascular therapy using coils or sclerosants 1
• Advantages:
  • Minimally invasive alternative to surgery
  • Requires only minimal sedation
  • Effective for relieving orchialgia (87% of patients experience complete pain relief at 39 months) 1
  • Satisfactory outcomes with rare and typically benign complications 2

Expected Outcomes

1. Improvement in sperm parameters - typically seen 3-9 months after treatment (after 1-2 cycles of spermatogenesis) 2
2. Increased natural pregnancy rates 2
3. Pain relief - in 90-95% of symptomatic cases 3
4. Potential to avoid more invasive fertility treatments:
   • May avoid testicular sperm extraction in severe cases
   • May allow for intrauterine insemination rather than ICSI 2

Recurrence Management

If varicocele recurs after treatment:

• After non-microsurgical varicocelectomy: Microsurgical subinguinal varicocelectomy is recommended 3
• After microsurgical varicocelectomy: Either endovascular embolization or redo microsurgical varicocelectomy 3

Note: The main cause of recurrence is typically preserved branches of the gonadal vein that were missed during the initial procedure. 3

Cost-Effectiveness

Varicocele correction is more cost-effective than both intrauterine insemination (IUI) and in vitro fertilization (IVF) for affected couples with infertility. 5

Potential Complications

• Recurrence (1-3% with microsurgical approach, higher with other techniques) 3
• Hydrocele formation
• Testicular atrophy (rare)
• Infection

Key Considerations

1. The decision to treat varicocele in the context of infertility should be made after evaluation of both partners 2
2. Microsurgical techniques offer superior outcomes and should be preferred when surgical correction is indicated 2, 3
3. Treatment results typically require 3-9 months to manifest 2

Caution: Routine imaging based solely on the presence of a right varicocele is unnecessary unless there are concerning features such as new onset or non-reducible varicocele. 1