What is the treatment for varicocele?

Treatment of Varicocele

Surgical treatment is strongly recommended for infertile men with clinical varicocele, abnormal semen parameters, and otherwise unexplained infertility in couples where the female partner has good ovarian reserve to improve fertility rates. 1

Indications for Treatment

Treatment decisions for varicocele should be based on specific clinical scenarios:

Strong Indications for Surgical Treatment:

• Adolescents: Surgery is strongly indicated for varicocele associated with a persistent small testis (size difference >2 ml or 20%), confirmed on two subsequent visits 6 months apart 1
• Infertile men: Treatment is strongly recommended for those with:
  • Clinical (palpable) varicocele
  • Abnormal semen parameters
  • Otherwise unexplained infertility
  • Female partner with good ovarian reserve 1

Conditions Where Treatment Should Be Avoided:

• Infertile men with normal semen analysis 1
• Men with subclinical varicocele (non-palpable, only detected by ultrasound) 1

Conditions Where Treatment May Be Considered (Weaker Evidence):

• Men with elevated sperm DNA fragmentation with otherwise unexplained infertility 1
• Men with failure of assisted reproductive techniques, including recurrent pregnancy loss and failure of embryogenesis and implantation 1
• Men with non-obstructive azoospermia (NOA) and clinical varicocele, particularly those with hypospermatogenesis on testicular biopsy 1

Treatment Options

Surgical Approaches:

1. Microsurgical varicocelectomy: Shows the best results with lowest recurrence rates (1-3%) 2

   • Considered the gold standard approach
   • Improves semen parameters in 60-70% of cases 3

2. Endovascular therapy (embolization):

   • Highly effective for pain relief (87% complete pain relief at 39 months) 3
   • Good alternative for recurrence after surgery

3. Laparoscopic varicocelectomy:

   • More commonly used in adolescents than adults 4

Expected Outcomes After Treatment

1. Semen Parameters:

   • Improvements usually observed after surgical correction in men with preoperative abnormal sperm quality 1
   • Average time to improvement: up to two spermatogenic cycles (approximately 3-6 months) 1

2. Pregnancy Rates:

   • Spontaneous pregnancy typically occurs between 6-12 months after varicocelectomy 1
   • Recent meta-analyses show treatment of clinical varicocele is associated with improvements in pregnancy and live birth rates 1

3. Special Cases:

   • In azoospermia: Varicocelectomy may lead to the presence of sperm in the ejaculate 1
   • In oligozoospermia: Varicocelectomy may improve outcomes following assisted reproductive techniques (OR 1.69,95% CI 0.95-3.02) 1

Post-Treatment Evaluation

• Ultrasound evaluation and repeat semen analysis 3-6 months after treatment 3
• Assess for potential complications:
  • Recurrence (more common after non-microsurgical approaches)
  • Hydrocele formation
  • Testicular atrophy (rare with modern techniques)

Common Pitfalls and Considerations

1. Recurrence risk:

   • Missing collaterals from the gonadal vein are the key factor in varicocele recurrence 2
   • Microsurgical techniques with thorough revision of spermatic cord components during primary operation minimize recurrence 2

2. Treatment selection:

   • For recurrent varicocele, consider the method of primary treatment when selecting the approach 2
   • For primary cases, microsurgical approach offers lowest recurrence rates

3. Alternative options:

   • In cases of severe oligospermia, IVF with ICSI may be considered alongside or instead of varicocele repair 3
   • Consider sperm banking before intervention, especially with significant testicular volume loss 3

4. Secondary varicoceles:

   • Consider underlying causes such as Nutcracker Syndrome, especially when hematuria is present 5
   • Additional imaging may be warranted in atypical presentations

By following these evidence-based guidelines, clinicians can optimize outcomes for patients with varicocele while minimizing unnecessary interventions.