What are the European Association of Urology (EAU) guidelines for managing varicocele in infertility?

European Association of Urology Guidelines for Management of Varicocele in Infertility

The European Association of Urology (EAU) strongly recommends treating infertile men with clinical varicoceles and abnormal semen parameters to improve fertility rates. 1, 2

Prevalence and Association with Infertility

• 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 1, 2
• Higher varicocele grade (grade 3) is associated with worse semen parameters and greater testicular dysfunction 1
• The pathophysiology involves multiple mechanisms affecting testicular function, including higher scrotal temperature, testicular hypoxia, reflux of toxic metabolites, and increased DNA damage 1, 2

Diagnostic Approach

• Diagnosis of varicocele should be clinical, performed in both supine and standing positions with Valsalva maneuver 3
• The EAU 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
• Routine use of ultrasonography to identify non-palpable (subclinical) varicoceles is discouraged, as treatment of these is not associated with improvement in either semen parameters or fertility rates 1, 2

Treatment Recommendations

• Treatment should be targeted specifically to men with:
  • Clinical (palpable) varicoceles 1, 2
  • Abnormal semen parameters 1, 2
  • In the context of couple infertility 3
• Treatment should NOT be offered for:
  • Subclinical varicoceles (regardless of semen parameters) 1, 2
  • Men with normal semen analysis (regardless of varicocele severity) 1, 2

Treatment Options and Outcomes

• Microsurgical varicocelectomy (inguinal or subinguinal) is considered the reference surgical technique due to lower rates of recurrence and complications compared to other approaches 3, 4
• Percutaneous embolization is a minimally invasive alternative to surgery with satisfactory outcomes 3
• After varicocele repair:
  • Improvements in semen parameters typically take 3-6 months (two spermatogenic cycles) 1, 2
  • Spontaneous pregnancy typically occurs between 6-12 months after treatment 2, 3
  • Hormonal improvements generally parallel the timeline for semen parameter improvements 1

Special Considerations

• For men with non-obstructive azoospermia (NOA) and varicocele:
  • Varicocelectomy may lead to the presence of sperm in the ejaculate, especially for those with hypospermatogenesis 1, 5
  • Treatment of clinical varicoceles improved surgical sperm retrieval rates among patients with NOA 1
  • The risks and benefits must be discussed fully with patients before treatment 5
  • 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, 5

Common Pitfalls and Caveats

• The quality of evidence regarding varicocele treatment in azoospermia is generally low 1
• Despite clear guidelines, there remains significant global practice variation in varicocele management 6
• The decision to treat varicocele must be taken after evaluation of both partners of the couple 3
• Severe varicoceles show greater improvement in sperm count after surgical repair compared to moderate or mild varicoceles 2