What is the treatment approach for varicocele?

Treatment Approach for Varicocele

Treatment of a clinically palpable varicocele should be offered to the male partner of an infertile couple when there is evidence of abnormal semen parameters and minimal/no identified female factor, including consideration of age and ovarian reserve. 1

Prevalence and Impact on Fertility

• Varicoceles affect approximately 15% of the general male population but are present in 35-40% of men presenting with infertility, indicating a significant association between varicocele and fertility issues 2, 3
• Higher varicocele grade (grade 3) is associated with worse semen parameters and greater testicular dysfunction 2
• The pathophysiology involves multiple mechanisms affecting testicular function, including higher scrotal temperature, testicular hypoxia, reflux of toxic metabolites, and increased DNA damage 2, 3

Treatment Indications

• Treatment is recommended for men with:
  • Clinical (palpable) varicoceles AND abnormal semen parameters 1, 3
  • Persistent small testis (size difference >2 mL or 20%), confirmed on two subsequent visits 6 months apart 2, 4
  • Physical symptoms related to the varicocele 5
• Treatment is NOT recommended for:
  • Subclinical (non-palpable) varicoceles 2, 3
  • Men with normal semen analysis regardless of varicocele severity 3, 4

Treatment Options

1. Surgical Approaches

• Microsurgical varicocelectomy (subinguinal or inguinal approach):
  • Considered the optimal treatment in most cases 6
  • Lowest recurrence and complication rates 5
  • Recommended when microsurgical expertise is available 6

2. Alternative Approaches

• Laparoscopic varicocelectomy: Useful in specific cases 6
• Radiological percutaneous embolization:
  • Minimally invasive option requiring only minimal sedation 7
  • Alternative when surgical approaches are contraindicated 7
• Open varicocelectomy (subinguinal approach):
  • Safe and effective option in settings where microsurgical facilities are unavailable 8

Expected Outcomes and Timeline

• Improvements in semen parameters typically take up to two spermatogenic cycles (3-6 months) 2, 3
• Spontaneous pregnancy typically occurs between 6-12 months after varicocelectomy 3
• Testicular volume improvements typically parallel the timeline for semen parameter improvements 4
• Severe varicoceles show greater improvement in sperm count after surgical repair compared to moderate or mild varicoceles 3

Special Considerations

• In cases of azoospermia:
  • Varicocelectomy may lead to the presence of sperm in the ejaculate, especially for those with hypospermatogenesis 2
  • Treatment of clinical varicoceles improved surgical sperm retrieval rates among patients with non-obstructive azoospermia 2
• IVF with or without ICSI may be considered the primary treatment option when required to treat a female factor, regardless of the presence of varicocele and abnormal semen parameters 1
• Special consideration should be given to couples with a female partner with limited ovarian reserve, as time spent waiting for sperm recovery may impact overall fertility outcomes 2
• Varicocele correction is considered more cost-effective than both intrauterine insemination (IUI) and in vitro fertilization (IVF) for affected couples 9

Common Pitfalls and Caveats

• Routine use of ultrasonography to identify non-palpable varicoceles is discouraged, as treatment of subclinical varicoceles does not improve semen parameters or fertility rates 2, 3
• The quality of evidence regarding varicocele treatment in azoospermia is generally low 2
• If infertility persists beyond 12 months after varicocelectomy, other therapies including assisted reproductive technology should be considered, especially in older couples 6
• The treating physician's experience and expertise, including evaluation of both partners, together with the options available, should determine the specific approach to varicocele treatment 1