From the Guidelines
Varicocele management options are primarily focused on treating palpable varicoceles, as correction of these can improve semen quality and fertility.
Management Options
- Treatment of a clinically palpable varicocele may be offered to the male partner of an infertile couple when there is evidence of abnormal semen parameters and minimal/no identified female factor, including consideration of age and ovarian reserve 1.
- IVF with or without ICSI may be considered the primary treatment option when such treatment is required to treat a female factor, regardless of the presence of varicocele and abnormal semen parameters 1.
- The treating physician’s experience and expertise, including evaluation of both partners, together with the options available, should determine the approach to varicocele treatment 1.
Diagnostic Evaluation
- Scrotal ultrasound can be used before repair to confirm the presence of varicocele and also following correction to determine procedural success, in the context of shared decision-making with the patient 1.
- Clinicians should not perform transrectal ultrasonography (TRUS) or pelvic MRI as part of the initial evaluation of the infertile male, unless there is suspicion of ejaculatory duct obstruction (EDO) or other specific indications 1.
Key Considerations
- Routine use of ultrasonography to identify non-palpable varicoceles is discouraged, as treatment of these varicoceles is not helpful 1.
- The clinician should be suspicious of distal male genital tract obstruction when the ejaculate volume is low (<1.5mL), with acidic semen (pH <7.0), and consider TRUS evaluation to evaluate for anatomic abnormalities 1.
From the Research
Management Options for Varicocele
The management options for varicocele include:
- Open varicocelectomy performed at various anatomical levels 2
- Laparoscopic varicocelectomy, which has been established as a safe and effective treatment for varicoceles 2
- Robotic surgery, which has been introduced as an alternative surgical option for varicocelectomy 2
- Microsurgical varicocelectomy, which has gained popularity among experts in male reproductive medicine due to its superior surgical outcomes 2
- Percutaneous retrograde and anterograde venous embolization/sclerotherapy, which are minimal invasive varicocele treatment options 2, 3
- Artery-sparing open Palomo surgery 4
- Retrograde percutaneous embolization 4
Treatment Goals
The goal of treating varicocele in adults is to improve current fertility status, while in adolescents, it is to prevent testicular injury and maintain testicular function for future fertility 5
Treatment Outcomes
Varicocele correction has been shown to improve semen parameters in the majority of patients, reducing oxidative stress and improving sperm nuclear DNA integrity, either with surgical or percutaneous approach 3 The overall success rate of varicocele treatment, defined as absence of recurrence or persistence of the varicocele during follow-up, was 87.6% in one study 4
Factors Affecting Treatment Outcomes
Testicular volume differentials and peak retrograde flow on Doppler ultrasonography are important factors in risk stratification of the pediatric varicocele population 6 The length of postoperative surveillance is deemed necessary to assess the risk of varicocele recurrence and hydrocele formation 4