What is the recommendation for varicocoelectomy (varicocele repair) in a patient with infertility?

Varicocelectomy for Male Infertility

Treat infertile men with a palpable clinical varicocele and abnormal semen parameters to improve fertility rates, but do not treat men with normal semen analysis or subclinical (non-palpable) varicoceles regardless of varicocele grade. 1

Who Should Receive Varicocelectomy

Clear Indications (Strong Recommendations)

• Infertile men with clinical (palpable) varicocele AND abnormal semen parameters AND unexplained infertility where the female partner has good ovarian reserve should undergo varicocelectomy 1
• Adolescents with varicocele causing persistent testicular size difference (>2 ml or 20% difference) confirmed on two visits 6 months apart should receive surgery 1

Weak/Conditional Indications

• Men with elevated sperm DNA fragmentation with otherwise unexplained infertility may be considered for varicocelectomy 1
• Men with recurrent pregnancy loss or failure of embryogenesis and implantation during assisted reproductive techniques may be considered for varicocelectomy 1
• Azoospermic men with clinical varicocele, particularly those with hypospermatogenesis on testicular biopsy, may benefit from varicocelectomy as it can lead to sperm appearing in the ejaculate 2

Absolute Contraindications (Strong Recommendations)

• Do not treat men with normal semen analysis, even if they have a clinical varicocele 1
• Do not treat subclinical (non-palpable) varicoceles detected only by ultrasound 1, 3
• Do not routinely use ultrasonography to identify non-palpable varicoceles, as treating these does not improve fertility outcomes 3

Preoperative Evaluation for Severe Oligospermia

For men with sperm concentration <5 million/ml, obtain genetic testing before proceeding with varicocelectomy 2:

• Karyotype analysis - chromosomal abnormalities occur in ~4% of men with severe oligospermia 2
• Y-chromosome microdeletion analysis (AZFa, AZFb, AZFc regions) - complete AZFa or AZFb deletions predict poor surgical outcomes and contraindicate varicocele repair 2

Expected Outcomes and Timeline

Semen Parameter Improvements

• Improvements typically require two spermatogenic cycles (3-6 months) after surgery 2, 3
• Significant improvements occur in sperm concentration, motility, and vitality 4
• Sperm morphology may not improve significantly 5, 4
• Men with preoperative oligospermia (<20 million/ml) show significant improvement, while normospermic men with only asthenospermia or teratospermia may not benefit 5

Pregnancy Outcomes

• Spontaneous pregnancy typically occurs 6-12 months after varicocelectomy 3
• Natural pregnancy rates improve with varicocelectomy in appropriately selected patients 6
• Varicocelectomy before IVF/ICSI improves outcomes in oligospermic and non-obstructed azoospermic men 7

Surgical Technique Considerations

Microsurgical varicocelectomy is the preferred approach based on superior outcomes 8:

• Lowest hydrocele formation rate (0% vs 2.8% open vs 5.4% laparoscopic) 8
• Lowest recurrence rate (2.6% vs 11% open vs 17% laparoscopic) 8
• Better improvement in sperm count and motility compared to open or laparoscopic approaches 8

Critical Pitfalls to Avoid

• Do not delay fertility treatment in couples where the female partner has limited ovarian reserve - the 3-6 month wait for semen improvement may compromise overall fertility outcomes 2, 9
• Do not treat based solely on ultrasound findings of subclinical varicocele - only palpable varicoceles warrant treatment 1, 3
• Do not proceed with varicocelectomy in normospermic men (≥20 million/ml) who have only motility or morphology abnormalities, as they show no significant improvement 5
• For azoospermic men, discuss that varicocelectomy may improve surgical sperm retrieval rates but results are variable, and consider proceeding directly to micro-TESE if the female partner has age-related fertility concerns 2, 9

Special Populations

Non-Obstructive Azoospermia

• Varicocelectomy may lead to sperm appearing in ejaculate, especially with hypospermatogenesis histology 2
• Fully discuss risks and benefits before treatment, as outcomes are less predictable 2, 9
• Consider female partner's ovarian reserve when deciding between varicocelectomy versus proceeding directly to testicular sperm extraction 2, 9

Men with Elevated FSH

• FSH <11.7 mIU/mL predicts favorable surgical outcomes 2
• FSH >7.6 IU/L suggests underlying spermatogenic impairment but does not contraindicate surgery if other criteria are met 2