What is the initial approach to managing a left varicocele?

Initial Management of Left Varicocele

Begin with physical examination to confirm a palpable (clinical) varicocele, then obtain semen analysis to determine if treatment is indicated—treatment is only recommended for men with both a clinical varicocele AND abnormal semen parameters. 1, 2

Diagnostic Approach

Physical Examination

• Examine the patient in a standing position during Valsalva maneuver to detect enlargement of the pampiniform plexus 2, 3
• Grade the varicocele clinically: Grade 1 (small), Grade 2 (moderate), or Grade 3 (large) based on palpation findings 2
• An increase in spermatic cord diameter during Valsalva is diagnostic of varicocele 3
• Assess testicular volume bilaterally—a size difference >2 mL or 20% is clinically significant 1, 3

When to Use Ultrasound

• Do NOT routinely order scrotal ultrasound to screen for subclinical (non-palpable) varicoceles, as treating these does not improve fertility outcomes 1, 2, 3
• Reserve Doppler ultrasound for specific situations: obese patients where physical exam is difficult, or when dartos muscle contraction prevents adequate examination 2, 3
• Ultrasound can confirm varicocele grade and evaluate blood flow patterns when clinically indicated 3

Laboratory Evaluation

• Obtain semen analysis to document abnormal parameters before considering treatment 1, 4, 5
• Look for decreased sperm motility, abnormal morphology, or decreased count—these "stress patterns" indicate treatment candidacy 5
• Consider measuring FSH if concerned about testicular dysfunction, though FSH is typically normal (<7.6 IU/L) in varicocele alone 6

Treatment Decision Algorithm

DO NOT TREAT if:

• Semen analysis is normal, regardless of varicocele size 1, 2
• Varicocele is subclinical (non-palpable on exam) 1, 2, 3
• Patient has no fertility concerns and no testicular size discrepancy 1

TREAT if patient meets ALL criteria:

• Clinical (palpable) varicocele on examination 1, 2, 3
• Abnormal semen parameters documented 1, 2, 4
• Otherwise unexplained infertility 1, 3
• Female partner has good ovarian reserve 1, 3

Special Populations Requiring Treatment:

• Adolescents: Offer surgery if persistent testicular size difference >2 mL or 20%, confirmed on two visits 6 months apart 1, 3
• Azoospermia: Varicocelectomy may restore sperm to ejaculate, particularly in men with hypospermatogenesis on testicular biopsy 6
• Recurrent ART failure: Consider treatment in men with elevated sperm DNA fragmentation, recurrent pregnancy loss, or failed embryogenesis 1, 3

Treatment Options

Microsurgical subinguinal or inguinal varicocelectomy is the optimal approach in most cases, offering the best balance of efficacy and low complication rates 3, 4

Alternative approaches include:

• Laparoscopic varicocelectomy for specific cases 4
• Percutaneous embolization as a minimally invasive option requiring only minimal sedation 7

Post-Treatment Expectations

• Semen parameter improvements require 3-6 months (two spermatogenic cycles) to manifest 6, 2, 4
• Monitor semen analysis at this interval before considering additional interventions 6, 4
• Pregnancy rates improve in approximately 70% of treated men with infertility 4, 8

Critical Pitfalls to Avoid

• Do not treat based on ultrasound findings alone—physical examination demonstrating a palpable varicocele is required 2, 3
• Do not proceed with surgery without documenting abnormal semen parameters first (except in adolescents with testicular size discrepancy) 1, 5
• Evaluate the female partner thoroughly before subjecting the male to varicocelectomy, as female factors may be the primary issue 5
• Consider female partner's age and ovarian reserve—if limited, time spent waiting for post-surgical sperm recovery may negatively impact overall fertility outcomes 6
• For bilateral varicoceles, treating the left side alone is sufficient—bilateral ligation offers no additional benefit 9