What are the management options for testicular varicocele?

Management of Testicular Varicocele

Treatment should be targeted exclusively to men with clinical (palpable) varicoceles and abnormal semen parameters in the context of infertility, while conservative management with observation is appropriate for symptomatic varicoceles causing pain. 1, 2

Diagnostic Approach

Clinical Examination

• Diagnosis is clinical, performed in both supine and standing positions with Valsalva maneuver to detect palpable varicoceles 3
• Only clinical (palpable) varicoceles warrant treatment consideration—subclinical varicoceles detected solely by ultrasound should not be treated 1, 2
• Routine ultrasonography to identify non-palpable varicoceles is discouraged, as treating these does not improve semen parameters or fertility rates 1, 2

Preoperative Evaluation for Infertility Cases

• Obtain semen analysis to document abnormal parameters before proceeding with treatment 1, 2
• For men with sperm concentration <5 million/ml, perform karyotype testing and Y-chromosome microdeletion analysis (AZFa, AZFb, AZFc regions) immediately before varicocelectomy, as chromosomal abnormalities occur in approximately 4% of these men 1
• Complete AZFa or AZFb deletions predict poor surgical outcomes and contraindicate varicocele repair, while AZFc deletions still allow for potential benefit 1
• Evaluate the female partner's ovarian reserve and fertility status, as the decision to treat must consider both partners—limited ovarian reserve may make waiting for sperm recovery counterproductive 1, 3

Treatment Indications

Primary Indication: Infertility

• Treat adult men with clinical varicoceles AND abnormal semen parameters in couples attempting conception, provided the female partner has satisfactory ovarian reserve and no uncorrectable infertility cause 1, 2, 3
• Men with FSH levels below 11.7 mIU/mL have favorable prognosis for surgical success, though levels above 7.6 IU/L suggest underlying spermatogenic impairment 1
• Treatment improves semen parameters and fertility outcomes, with spontaneous pregnancy typically occurring 6-12 months after varicocelectomy 2, 3

Secondary Indications

• Symptomatic varicoceles causing testicular pain: Start with conservative, non-surgical management and observation; varicocelectomy resolves pain in approximately 80% of carefully selected candidates with clinically palpable varicoceles 4
• Adolescents with: reduced testicular growth, ipsilateral decreased testicular volume, or size difference >2 mL or 20% between testes confirmed on two visits 6 months apart 1, 5
• Adults with spermogram abnormalities may be offered treatment even without immediate paternity plans 3

Contraindications to Treatment

• Normal semen analysis regardless of varicocele grade 1, 2, 6
• Subclinical (non-palpable) varicoceles 1, 2
• Complete AZFa or AZFb deletions on genetic testing 1

Surgical Techniques

Preferred Approach

• Microsurgical subinguinal or inguinal varicocelectomy is the reference surgical technique, offering lower recurrence rates and complication rates compared to high surgical approaches (laparoscopic or non-laparoscopic) and surgeries without magnification 3, 7
• Microsurgical techniques have gained popularity with minimal complication rates and favorable outcomes 4

Alternative Approach

• Percutaneous retrograde embolization is a minimally invasive alternative to microsurgery, offering satisfactory outcomes with rare and often benign complications 3
• This approach may be useful in specific cases where microsurgery is not feasible 7

Adolescent-Specific Considerations

• Laparoscopic varicocelectomy is more commonly used in adolescents, though microsurgical approach remains the gold standard 8, 5

Expected Outcomes and Timeline

Semen Parameter Improvements

• Improvements typically take 3-6 months (two spermatogenic cycles) to manifest 1, 2, 6, 3, 7
• Hormonal improvements parallel semen parameter improvements over the same timeframe 1, 6
• Higher grade varicoceles (grade 3) show greater improvement in sperm count after surgical repair compared to moderate or mild varicoceles 2

Fertility Outcomes

• Spontaneous pregnancy typically occurs 6-12 months after varicocelectomy 2, 3
• Varicocelectomy may improve outcomes in men undergoing assisted reproductive technologies, with improved ART outcomes in oligozoospermic men (OR 1.69,95% CI 0.95-3.02) 2
• In severe cases (azoospermia, severe oligospermia), improvement may allow avoidance of testicular sperm extraction or enable intrauterine insemination rather than ICSI 3

Azoospermia-Specific Outcomes

• Varicocelectomy may lead to presence of sperm in ejaculate for men with azoospermia, especially those with histological diagnosis of hypospermatogenesis 1
• Treatment improves surgical sperm retrieval rates among patients with non-obstructive azoospermia, particularly with hypospermatogenesis 1
• The quality of evidence regarding varicocele treatment in azoospermia is generally low, requiring full discussion of risks and benefits 1

Critical Pitfalls to Avoid

• Do not treat subclinical varicoceles—they do not improve fertility or semen parameters regardless of ultrasound findings 1, 2
• Do not treat men with normal semen analysis—no benefit regardless of varicocele grade or hormonal status 1, 2, 6
• Do not delay evaluation of female partner—treatment decisions require assessment of both partners 1, 3
• Do not proceed without genetic testing in men with sperm concentration <5 million/ml, as complete AZFa or AZFb deletions contraindicate repair 1
• Do not expect immediate results—counsel patients that improvements require 3-6 months minimum, and if infertility persists after this interval, consider assisted reproductive technology, especially in older couples 7