What is the average increase in sperm count after varicocele (varicose vein in the scrotum) repair in patients with severe varicoceles?

Sperm Count Improvement After Severe Varicocele Repair

Severe varicoceles show greater improvement in sperm count after surgical repair compared to moderate or mild varicoceles, with an average increase of 12.32 million sperm per milliliter following varicocelectomy. 1, 2

Improvement in Semen Parameters

• Varicocele repair leads to significant improvements in multiple semen parameters, including sperm concentration, total sperm count, and sperm motility in men with clinical varicoceles and abnormal semen parameters 3, 4
• The average increase in sperm concentration after varicocele repair is 12.32 million sperm per milliliter (95% CI, 9.45-15.19; p<0.0001) 1
• Total sperm motility improves by approximately 10.86% (95% CI, 7.07-14.65; p<0.0001) following varicocele repair 1
• Progressive motility increases by about 9.69% (95% CI, 4.86-14.52; p=0.003) after varicocelectomy 1

Timeline for Improvement

• After varicocele repair, the average time to improvement in semen parameters is up to two complete spermatogenic cycles, which is approximately 3-6 months 3, 4
• Spontaneous pregnancies typically occur between 6 and 12 months after varicocelectomy 3, 4
• Patients should be counseled that immediate improvements are not expected, and follow-up semen analyses should be scheduled accordingly 5

Factors Affecting Improvement

• The degree of improvement in semen parameters correlates with varicocele grade, with severe varicoceles showing greater improvement after repair 4
• Baseline testicular function and histology are important predictors of improvement - men with severe hypospermatogenesis or maturation arrest at the spermatid stage show better outcomes than those with Sertoli-cell-only pattern 6
• Even in azoospermic men with varicoceles, repair can result in the return of sperm to the ejaculate in approximately 43% of cases, though counts remain low (average 1.2±3.6×10^6/ml) 6

Treatment Considerations

• Varicocele repair should be targeted to men with clinical (palpable) varicoceles and abnormal semen parameters 3, 4
• Treatment of subclinical varicoceles is not effective at increasing chances of spontaneous pregnancy 3, 4
• Microsurgical approaches to varicocele repair result in fewer recurrences and complications than other techniques 1
• In a comparison between surgical varicocelectomy and sclerotherapy, both techniques improved sperm parameters, but sclerotherapy showed better results for motility parameters and had a lower recurrence rate (19.7% vs. 32%) 7

Clinical Implications

• The European Association of Urology strongly recommends treating infertile men with clinical varicoceles and abnormal semen parameters to improve fertility rates 4
• 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) 3
• The most recent and comprehensive meta-analysis (2024) confirms significant improvements in almost all conventional semen parameters following varicocele repair in infertile patients with clinical varicocele 2

Pitfalls and Caveats

• Despite improvements in semen parameters, natural pregnancy rates may still remain low, especially in men with initially very poor parameters 6
• Couples should be counseled that assisted reproductive technologies might still be necessary despite improvements in semen parameters 6
• 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 4