What percentage of men with varicocele experience infertility issues?

Percentage of Varicocele Patients with Infertility Issues

Approximately 35-40% of men presenting with infertility have varicoceles, indicating a significant association between varicocele and fertility problems. 1

Prevalence and Association with Infertility

• Varicocele is present in approximately 15% of the normal male population, but this percentage increases to 25% in men with abnormal semen analysis and 35-40% in men presenting with infertility, demonstrating a clear correlation between varicocele and fertility issues 1
• Studies from the 1990s reported similar findings, with varicoceles found in 10-20% of all males but in 30-40% of men presenting to infertility clinics 2
• More recent research confirms that varicoceles affect up to 20% of healthy men but approximately 40% of men with primary infertility 3, 4

Mechanism of Fertility Impairment

• The exact association between varicocele and reduced fertility remains incompletely understood, but several mechanisms have been proposed 1
• Higher scrotal temperature, testicular hypoxia, and reflux of toxic metabolites can cause testicular dysfunction and infertility through increased DNA damage 1
• Varicoceles can impair semen parameters and sperm DNA integrity, which are linked with lower pregnancy and live birth rates 4

Treatment Outcomes and Considerations

• Varicocele repair has been shown to improve semen parameters and fertility outcomes in men with clinical varicoceles and abnormal semen analysis 1
• Of men who undergo treatment for varicoceles, 50-75% show some improvement in semen quality, and 30-40% achieve pregnancy 2
• Treatment of subclinical (non-palpable) varicoceles is not effective at increasing chances of spontaneous pregnancy 1
• After varicocele repair, improvements in semen parameters typically take up to two spermatogenic cycles (approximately 3-6 months), with spontaneous pregnancy occurring between 6 and 12 months after varicocelectomy 1, 5

Clinical Implications

• Despite the high prevalence of varicoceles among infertile men, recent electronic health record data suggests varicoceles are underdiagnosed, with only 9.6% of men with male infertility receiving a varicocele diagnosis 3
• Not all men with varicoceles experience fertility problems; only about 20% of men with documented varicoceles suffer fertility issues 5
• Treatment should be targeted to men with clinical varicoceles and abnormal semen parameters, as treatment of men with normal semen analysis or subclinical varicoceles is not recommended 6, 1
• Varicocelectomy may also improve outcomes in men undergoing assisted reproductive technologies, with a meta-analysis showing improved outcomes following ART in oligozoospermic men (OR 1.69,95% CI 0.95-3.02) 1

Pitfalls and Caveats

• Routine use of ultrasonography to identify non-palpable varicoceles is discouraged, as treatment of these subclinical varicoceles is not associated with improvement in either semen parameters or fertility rates 1
• The presence of a varicocele does not always affect spermatogenesis, highlighting the importance of proper patient selection for treatment 5
• Varicoceles can occur concomitantly with other conditions causing impaired spermatogenesis, which may complicate treatment decisions 5
• If infertility persists beyond 6 months after varicocele repair, other therapies including assisted reproductive technology should be considered, especially in older couples 5