Varicocele Repair Should Be Performed First, Not Sperm Banking
Given your clinical varicocele with testicular atrophy and abnormal morphology, varicocele repair should be prioritized first, as surgical correction can improve semen parameters and prevent progressive testicular damage, with sperm banking reserved only if post-operative parameters fail to improve after 3-6 months. 1, 2
Rationale for Prioritizing Varicocele Repair
Evidence Supporting Immediate Surgical Intervention
Your testicular atrophy is a strong indication for surgery. The European Association of Urology strongly recommends surgery when there is persistent testicular size difference >2 ml or 20%, which you have with your atrophied left testicle. 1
Clinical varicocele with abnormal semen parameters (your low morphology) is a clear indication for treatment. Guidelines strongly recommend treating infertile men with clinical varicoceles and abnormal semen parameters to improve fertility rates. 3, 1, 2
Your FSH of 9.9 IU/L is favorable for surgical success. Men with FSH levels below 11.7 mIU/mL have a favorable prognosis for varicocele repair outcomes, though levels above 7.6 IU/L suggest underlying spermatogenic impairment that makes intervention more urgent. 4
Why Not Bank First
Varicocele causes progressive testicular damage. The pathophysiology involves elevated scrotal temperature, testicular hypoxia, reflux of toxic metabolites, and increased DNA damage to sperm—all of which worsen over time. 1, 2
Banking now captures damaged sperm. Your current sperm, while adequate in count and motility, has poor morphology reflecting ongoing testicular dysfunction. Banking these suboptimal sperm when you could potentially improve them surgically is counterproductive. 5
Testicular atrophy indicates existing dysfunction that will worsen. When testicular hypotrophy is present, testicular dysfunction is very likely, and 100% of patients with asymmetrical testis failed WHO criteria for normal spermiograms in one study. 5
Expected Timeline and Outcomes
Post-Surgical Improvements
Semen parameter improvements take 3-6 months (two spermatogenic cycles) after varicocelectomy. 4, 2
Spontaneous pregnancy typically occurs between 6-12 months after surgery. 2
Varicocelectomy improves semen parameters, pregnancy rates, and live birth rates in men with clinical varicoceles and abnormal semen parameters. 1
Risk Considerations
10.9% of men experience clinical "downgrading" after varicocelectomy, but this risk is outweighed by the 65-90% who improve or stabilize. 6
Larger left testis size was associated with clinical downgrading, but your atrophied left testicle suggests you're not in this higher-risk category. 6
Recommended Clinical Algorithm
Immediate Actions (Now)
Proceed with varicocelectomy given your clinical varicocele, testicular atrophy, and abnormal morphology. 1, 2
Obtain genetic testing before surgery: karyotype and Y-chromosome microdeletion analysis (AZFa, AZFb, AZFc regions) are recommended for all men with potential fertility issues, as chromosomal abnormalities occur in approximately 4% of men with fertility concerns. 4
Verify hormonal assessment is complete: testosterone and FSH levels (which you have) to evaluate for hypogonadism and spermatogenic failure. 1
Post-Operative Follow-Up (3-6 Months)
Repeat semen analysis at 3 months and 6 months post-operatively to assess improvement. 4, 2
If parameters improve or stabilize: proceed with natural conception attempts or assisted reproductive technology as needed. 3
If parameters worsen or fail to improve: consider sperm banking at that point before further decline. 6
Critical Caveats
When Banking Would Be Appropriate First
If your female partner has limited ovarian reserve, time spent waiting for sperm recovery may impact overall fertility outcomes, and banking followed by immediate ART might be preferable. 4
If you had complete AZFa or AZFb deletions on genetic testing, these predict poor surgical outcomes and would contraindicate varicocele repair, making banking the only option. 4
Monitoring for Complications
Testicular atrophy increases risk for testicular germ cell tumors. If ultrasound shows testicular microcalcification along with your atrophic testis, discussion of testicular biopsy is recommended. 1
Your LH of 7.0 is elevated, warranting continued monitoring for Leydig cell dysfunction and potential testosterone deficiency. 1
What Not to Do
Do not delay surgery waiting for "natural improvement"—varicocele-induced damage is progressive. 1, 2
Do not bank now and delay surgery—you would be preserving damaged sperm while allowing further testicular deterioration. 5
Do not consider treatment if ultrasound shows only subclinical varicocele—but your 4mm varicocele with atrophy indicates clinical significance. 1, 2