Is azoospermia (absence of sperm) caused by a varicocele reversible?

Reversibility of Varicocele-Induced Azoospermia

Varicocele-induced azoospermia can be reversible in some cases, with approximately 20% of men showing return of sperm to the ejaculate after varicocelectomy, though only about 10% achieve adequate motile sperm counts for natural conception or ICSI without requiring testicular sperm extraction. 1

Varicocele and Its Impact on Fertility

• Varicoceles are present in approximately 15% of the general male population but are found in 35-40% of men presenting with infertility, demonstrating a significant association between varicocele and fertility issues 2, 3
• Higher varicocele grades (grade 3) are 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

Treatment Outcomes for Azoospermia in Varicocele

• Varicocelectomy may lead to the presence of sperm in the ejaculate for men with azoospermia, especially for those with a histological diagnosis of hypospermatogenesis 2
• Studies show varying success rates:
  • 12-20% of men with non-obstructive azoospermia (NOA) recover sperm production within one year after bilateral varicocelectomy 4
  • Only 9.6% of men achieve adequate motile sperm in the ejaculate for ICSI without requiring testicular sperm extraction (TESE) 1
• Treatment of clinical varicoceles improves surgical sperm retrieval rates among patients with NOA 2

Factors Affecting Reversibility

• The likelihood of recovery depends on:
  • Duration of azoospermia (shorter duration has better outcomes) 5
  • Testicular histology (hypospermatogenesis has better prognosis than Sertoli-cell-only syndrome) 6
  • Absence of genetic abnormalities 4
  • Absence of obstruction in the spermatic tract 4
• Improvement in semen parameters typically takes 3-6 months (two spermatogenic cycles) after varicocele repair 3, 7

Treatment Recommendations

• The American Urological Association recommends treatment for men with clinical (palpable) varicoceles and abnormal semen parameters 8, 3
• Treatment of subclinical (non-palpable) varicoceles is not effective at increasing chances of spontaneous pregnancy 2, 3
• Routine use of ultrasonography to identify non-palpable varicoceles is discouraged 8, 3

Important Considerations and Caveats

• The quality of evidence regarding varicocele treatment in azoospermia is generally low 2
• Risks and benefits of varicocele repair must be discussed fully with patients with NOA and a clinically significant varicocele before treatment 2
• Consider sperm cryopreservation before surgery in men with severe oligozoospermia, as there are rare cases of post-operative deterioration to azoospermia 9
• 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
• In some cases, assisted reproductive technologies may still be required even after successful varicocelectomy 5

Monitoring After Treatment

• Monitor semen parameters after varicocelectomy, as improvements typically take up to two spermatogenic cycles (3-6 months) 2, 3
• If sperm does not return to the ejaculate after varicocelectomy, TESE may still be required for sperm retrieval 1
• A history of prior varicocele repair does not appear to negatively affect the chance of sperm retrieval by TESE for men with clinical varicoceles and NOA 1