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

Patient Selection for Treatment

Indications for Treatment:

• Adolescents:

  • Surgery is strongly indicated for adolescents with varicocele associated with a persistent small testis (size difference >2 ml or 20%), confirmed on two subsequent visits 6 months apart 1

• Adults:

  • Infertile men with clinical varicocele and abnormal semen parameters 1
  • 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 scrotal pain syndrome associated with varicocele 2

Contraindications for Treatment:

• Infertile men with normal semen analysis 1
• Men with subclinical varicocele 1

Treatment Options

1. Surgical Approaches:

• Microsurgical varicocelectomy:
  • Considered the gold standard with best results and lowest recurrence rate (1-3%) 2
  • Subinguinal approach is commonly used for primary varicocele 2
  • Most effective for improving semen parameters (60-70% of cases) 3

2. Non-surgical Approaches:

• Endovascular therapy (embolization):

  • Highly effective for pain relief (87% complete pain relief at 39 months) 3
  • Particularly useful for recurrent varicocele after surgical ligation 4
  • Has higher recurrence rate (38.5%) compared to microsurgery when used for recurrent varicocele 2

• Sclerotherapy:

  • Used for small to medium veins or recurrent varicocele 3
  • Involves ultrasound-guided injection of sclerosing agents

Treatment Algorithm

1. For adolescents:

   • If testicular size difference >2 ml or 20% confirmed on two visits 6 months apart → Surgical correction (strong recommendation) 1

2. For adults with infertility concerns:

   • If clinical varicocele + abnormal semen parameters + unexplained infertility → Surgical correction (strong recommendation) 1
   • If clinical varicocele + normal semen parameters → No treatment (strong recommendation) 1
   • If subclinical varicocele → No treatment (strong recommendation) 1
   • If elevated sperm DNA fragmentation or failure of assisted reproductive techniques → Consider varicocelectomy (weak recommendation) 1

3. For men with pain:

   • If pain is associated with varicocele → Surgical correction or embolization (90-95% pain relief) 2

Expected Outcomes

• Improvement in semen parameters occurs within two spermatogenic cycles (approximately 3 months) after varicocelectomy 1
• Spontaneous pregnancy typically occurs between 6-12 months after varicocelectomy 1
• Pain relief occurs in 90-95% of cases after surgical treatment 2
• Improvement in sperm parameters occurs in 73-75% of patients with pathospermia 2

Post-Treatment Evaluation

• Repeat semen analysis 3-6 months after varicocele repair 3
• Ultrasound evaluation 3-6 months after treatment to assess testicular size and confirm procedure success 3

Potential Complications and Pitfalls

• Recurrence rates: 1-3% after microsurgical varicocelectomy, higher with other techniques 2
• Missing collaterals from the gonadal vein are the key factor in varicocele recurrence 2
• Preserved branches of the gonadal vein near the testicular artery are commonly found during reoperation for recurrent varicocele 2

Special Considerations

• For recurrent varicocele after non-microsurgical varicocelectomy, microsurgical subinguinal varicocelectomy is recommended 2
• For recurrent varicocele after microsurgical varicocelectomy, endovascular surgery or redo microsurgical varicocelectomy may be considered 2
• Varicocelectomy may lead to the presence of sperm in the ejaculate for men with azoospermia, especially those with hypospermatogenesis 1