What is the evidence on the management of varicocele in subfertility?

Management of Varicocele in Subfertility

Varicocele repair should be offered to infertile men with clinical (palpable) varicoceles and abnormal semen parameters, as this improves fertility outcomes and semen quality. 1, 2

Prevalence and Association with Infertility

• Varicoceles are present in approximately 15% of the general male population but occur in 35-40% of men presenting with infertility, demonstrating a significant association between varicocele and fertility issues 1, 2
• The pathophysiology involves multiple mechanisms affecting testicular function, including higher scrotal temperature, testicular hypoxia, reflux of toxic metabolites, and increased DNA damage 1
• Higher varicocele grade (grade 3) is associated with worse semen parameters and greater testicular dysfunction 1

Evidence-Based Treatment Recommendations

• Treatment should be targeted specifically to men with clinical varicoceles and abnormal semen parameters 1, 2
• Treatment of subclinical (non-palpable) varicoceles is not effective at increasing chances of spontaneous pregnancy and is therefore not recommended 1, 2
• The European Association of Urology strongly recommends surgery for varicocele when associated with a persistent small testis (size difference >2 mL or 20%), confirmed on two subsequent visits 6 months apart 1
• Severe varicoceles show greater improvement in sperm count after surgical repair compared to moderate or mild varicoceles 2

Treatment Outcomes

• After varicocele repair, improvements in semen parameters typically take up to two spermatogenic cycles (approximately 3-6 months) to show enhancement 1, 2
• Spontaneous pregnancy typically occurs between 6 and 12 months after varicocelectomy 2
• Varicocelectomy may lead to the presence of sperm in the ejaculate for men with azoospermia, especially for those with a histological diagnosis of hypospermatogenesis 1
• Treatment of clinical varicoceles improved surgical sperm retrieval rates among patients with non-obstructive azoospermia (NOA) 1
• Varicocelectomy may also improve outcomes in men undergoing assisted reproductive technologies 2

Special Considerations

• The quality of evidence regarding varicocele treatment in azoospermia is generally low 1
• The risks and benefits of varicocele repair must be discussed fully with patients with non-obstructive azoospermia and a clinically significant varicocele before treatment 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 1
• 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, 2

Hormonal Changes After Varicocele Repair

• After varicocelectomy, there is a significant decrease in sex hormone binding globulin (SHBG) levels 1
• Hormonal improvements typically parallel the timeline for semen parameter improvements, taking approximately 3-6 months to show enhancement 1, 3

Common Pitfalls in Varicocele Management

• Treating subclinical varicoceles detected only by ultrasound - this does not improve fertility outcomes 1, 2
• Treating men with normal semen parameters - not recommended regardless of varicocele presence 1, 2
• Failing to monitor semen parameters after repair - improvements typically take 3-6 months to manifest 1, 2
• Not considering the female partner's fertility status and ovarian reserve when deciding on treatment approach 1