Should a varicocele be surgically repaired if sperm count is normal but morphology is borderline and there's a risk of declining fertility parameters?

Should Varicocele Be Repaired with Normal Sperm Count but Borderline Morphology?

Yes, varicocele repair should be strongly considered in this case, as the presence of testicular atrophy indicates progressive testicular damage, and current evidence demonstrates that varicoceles can cause continued deterioration of fertility parameters over time, even when initial sperm counts appear adequate. 1, 2

Risk of Progressive Fertility Decline

• Varicoceles function as progressive lesions that exert ongoing toxic effects on testicular tissue, placing men at risk for subsequent loss of testicular function and infertility even with currently normal semen parameters or documented previous fertility. 2

• The pathophysiology involves multiple damaging mechanisms including elevated scrotal temperature, testicular hypoxia, reflux of toxic metabolites, and increased DNA damage—all of which can worsen over time. 1, 3

• The presence of testicular atrophy is particularly concerning, as the European Association of Urology strongly recommends surgery for varicocele when associated with persistent testicular size difference >2 mL or 20%, confirmed on two visits 6 months apart. 1

Evidence Supporting Intervention

• Men with clinical varicoceles show significant improvements in sperm parameters after repair, with mean increases in sperm concentration of 12.32 million/mL, total motility improvement of 10.86%, and progressive motility improvement of 9.69%. 4

• Varicocelectomy reduces seminal oxidative stress and sperm DNA damage while improving sperm ultramorphology—factors that directly impact fertility potential beyond simple count measurements. 4

• Approximately 35-40% of men presenting with infertility have varicoceles, demonstrating the strong association between untreated varicoceles and fertility problems. 1, 3

Clinical Algorithm for Decision-Making

Proceed with varicocele repair if:

• Clinical (palpable) varicocele is present 1, 3
• Testicular atrophy is documented (>20% size difference) 1
• Any semen parameter is abnormal, including borderline morphology 1, 3
• The patient desires future fertility 3

Do NOT repair if:

• Only subclinical (non-palpable) varicocele detected by ultrasound alone 1, 3
• All semen parameters are completely normal with no testicular atrophy 1, 3

Important Caveats and Timing Considerations

• Improvements in semen parameters typically require 3-6 months (two spermatogenic cycles) after varicocelectomy, with spontaneous pregnancy occurring between 6-12 months post-surgery. 1, 3, 5

• Special consideration must be given if the female partner has limited ovarian reserve, as time spent waiting for sperm recovery may impact overall fertility outcomes. 1, 5

• Microsurgical varicocelectomy is the optimal treatment approach, demonstrating superior outcomes with lower complication and recurrence rates compared to other techniques. 4, 6

• The current borderline morphology combined with documented testicular atrophy suggests early testicular dysfunction that will likely progress without intervention. 1, 2

Prognostic Factors

• Earlier intervention potentially prevents permanent testicular damage, making timing of surgery crucial. 1

• Severe varicoceles (grade 3) show greater improvement in sperm parameters after surgical repair compared to moderate or mild varicoceles. 3

• The presence of testicular atrophy indicates that testicular damage has already begun, making repair more urgent to prevent further deterioration. 1, 2