Treatment Recommendations for Varicocele
Treat varicocele surgically only in specific clinical scenarios: infertile men with palpable varicocele and abnormal semen parameters, or adolescents with persistent testicular size difference >2 mL or 20%. 1
When to Treat Varicocele
Infertile Men - Strong Indications for Surgery
Treat infertile men who have all three criteria: clinical (palpable) varicocele, abnormal semen parameters, and otherwise unexplained infertility when the female partner has good ovarian reserve. 1
Do NOT treat men with normal semen analysis, regardless of varicocele presence. 1
Do NOT treat subclinical (non-palpable) varicoceles detected only on ultrasound, as treatment does not improve semen parameters or fertility rates. 1, 2
Adolescents - Strong Indications for Surgery
Offer surgery for varicocele associated with persistent testicular size difference >2 mL or 20%, confirmed on two separate visits 6 months apart. 1
This prevents progressive testicular damage and preserves future fertility potential. 3
Weaker Indications - Consider on Case-by-Case Basis
Varicocelectomy may be considered (weaker recommendation) in men with: 1
- Elevated sperm DNA fragmentation with unexplained infertility
- Recurrent pregnancy loss
- Failure of embryogenesis or implantation during assisted reproduction
For men with non-obstructive azoospermia and clinical varicocele, varicocelectomy may improve surgical sperm retrieval rates, particularly with hypospermatogenesis on testicular biopsy. 3
Diagnostic Approach
Physical Examination is Primary
Diagnosis is made by palpating a prominent pampiniform plexus, which enlarges during Valsalva maneuver. 2
Grade the varicocele clinically (Grade I-III), as higher grades correlate with worse semen parameters. 2
Role of Ultrasound
Use scrotal Doppler ultrasound to confirm varicocele grade when physical examination is difficult (e.g., obese patients). 2, 4
Do NOT routinely use ultrasound to screen for subclinical varicoceles, as treating non-palpable varicoceles is ineffective. 2, 4
Surgical Technique
Microsurgical subinguinal or inguinal varicocelectomy is the optimal approach, offering the best outcomes with lowest complication rates. 5
Laparoscopic varicocelectomy and percutaneous embolization are alternatives for specific cases or recurrent varicoceles. 5
Post-Treatment Expectations
Semen parameter improvements typically require 3-6 months (two spermatogenic cycles) after surgery. 3, 5
Monitor semen analysis at this interval to assess treatment response. 3
If infertility persists after 6 months, consider assisted reproductive technology, especially in older couples. 5
Critical Caveats
Time considerations matter: For couples where the female partner has limited ovarian reserve, prolonged waiting for varicocele repair outcomes may compromise overall fertility. Consider proceeding directly to assisted reproduction. 3
The evidence quality for varicocele treatment in azoospermia is generally low, so fully discuss risks and benefits with these patients. 3
Right-sided or bilateral varicoceles do not routinely require abdominal imaging unless they are new-onset or non-reducible. 4
Varicoceles occur in 15% of normal males but 35-40% of infertile men, yet only 20% of men with varicoceles experience fertility problems—treatment must be selective. 2, 5