Is bilateral surgery always required for varicocele (varicocoele)-related infertility?

Bilateral Varicocele Surgery for Infertility

No, bilateral surgery is NOT always required for varicocele-related infertility—only clinically palpable varicoceles with documented abnormal semen parameters should be treated, and the decision to operate on bilateral varicoceles depends on whether both sides are clinically palpable and meet treatment criteria. 1

Treatment Indications: The Core Algorithm

Treat only when ALL of the following are present:

• Clinical (palpable) varicocele on physical examination in standing position with Valsalva maneuver 1, 2
• Documented infertility in the couple 2, 3
• Abnormal semen parameters confirmed on at least two separate analyses 3
• No uncorrectable female infertility factor or female partner has satisfactory ovarian reserve 2, 3

The Bilateral Question: A Practical Approach

For bilateral varicoceles, surgery should address only the clinically palpable side(s). The evidence is clear that:

• Only clinical (palpable) varicoceles should be treated—subclinical or ultrasound-only detected varicoceles should NOT be operated on 1, 2
• Routine ultrasonography to identify non-palpable varicoceles is discouraged, as treatment of subclinical varicoceles does not improve semen parameters or fertility rates 1, 4
• In the 51 left-sided and 13 bilateral cases analyzed, treatment decisions were based on clinical palpability, not imaging findings 5

Laterality Considerations

• Left-sided varicoceles are most common (approximately 80% of cases), but bilateral varicoceles occur in a significant minority 5
• When bilateral varicoceles are both clinically palpable and the patient meets treatment criteria, both sides should be addressed during the same surgical procedure 2
• Do not operate on a non-palpable contralateral varicocele even if detected on ultrasound—this does not improve outcomes 1

Surgical Approach: The Gold Standard

Microsurgical inguinal or subinguinal varicocelectomy is the reference technique, offering:

• Lower recurrence rates compared to high surgical approaches 2
• Lower complication rates than non-magnified techniques 6, 2
• Superior outcomes when performed by experienced surgeons 6

Percutaneous retrograde embolization is an acceptable minimally invasive alternative with satisfactory outcomes and rare complications 2

Expected Outcomes and Timeline

Improvements follow a predictable pattern:

• Semen parameter improvements require 3-6 months (two spermatogenic cycles) 1, 4, 2
• Spontaneous pregnancy typically occurs 6-12 months after varicocelectomy 1
• The pregnancy rate after varicocelectomy (60%) significantly exceeds conservative treatment (28%) in properly selected patients 5
• Higher-grade varicoceles show greater improvement in sperm count after surgical repair 1, 5

Critical Pitfalls to Avoid

Do NOT treat:

• Subclinical (non-palpable) varicoceles detected only on ultrasound 1, 2
• Men with normal semen analysis, regardless of varicocele grade 1
• Patients without documented infertility 3

Special consideration for azoospermia:

• Varicocelectomy may restore sperm to ejaculate in non-obstructive azoospermia, especially with hypospermatogenesis histology 7
• However, discuss risks/benefits thoroughly and consider female partner's ovarian reserve, as waiting 3-6 months for potential sperm recovery may impact overall fertility outcomes 7, 4

Preoperative Evaluation

Before proceeding with surgery:

• Confirm clinical palpability on physical examination (standing, Valsalva) 2, 3
• Document abnormal semen parameters on at least two separate analyses 3
• Evaluate female partner for correctable infertility factors 2, 3
• Consider genetic testing (karyotype and Y-chromosome microdeletion) for severe oligospermia (<5 million/mL), as complete AZFa or AZFb deletions predict poor surgical outcomes 7