What are the management and treatment options for a patient with a varicocele, considering its potential impact on fertility and testicular health?

Management of Varicocele

Treat this varicocele with microsurgical varicocelectomy if the patient has abnormal semen parameters and is experiencing infertility, or if there is testicular size asymmetry >2 ml (or 20%) confirmed on repeat examination 6 months later. 1

Clinical Significance Assessment

The presence of a varicocele alone does not mandate treatment. The decision depends on specific clinical criteria:

• Do NOT treat if semen analysis is normal or if this is a subclinical (non-palpable) varicocele, as treatment provides no benefit in these scenarios 1
• Do NOT treat based solely on ultrasound findings of reflux without clinical palpability, as subclinical varicoceles do not improve fertility outcomes with intervention 1, 2

Indications for Treatment

Primary Indication: Infertility with Abnormal Semen Parameters

Strongly recommend varicocelectomy for infertile men with:

• Clinical (palpable) varicocele 1
• Abnormal semen parameters 1
• Otherwise unexplained infertility 1
• Female partner with good ovarian reserve 1

This represents the strongest evidence-based indication, as varicocele repair improves both semen quality and fertility rates in this population 1, 2.

Secondary Indications

Testicular size asymmetry in adolescents:

• Treat if testicular volume difference is >2 ml or 20% 1
• Must be confirmed on two separate visits 6 months apart 1, 3
• This prevents progressive testicular damage 3

Additional considerations for treatment:

• Men with elevated sperm DNA fragmentation and unexplained infertility (weak recommendation) 1
• Recurrent pregnancy loss or failure of embryogenesis/implantation in assisted reproduction (weak recommendation) 1
• Chronic testicular pain, which responds well to treatment with 87% achieving complete pain relief 3

Red Flags Requiring Imaging Before Treatment

Obtain abdominal/pelvic imaging if:

• New-onset, large, or non-reducible varicocele 3
• Right-sided or bilateral varicoceles (especially if right side is large) 3
• These features suggest possible retroperitoneal pathology or venous obstruction requiring exclusion before proceeding 3

Preoperative Evaluation for Severe Oligozoospermia

If sperm concentration is <5 million/ml:

• Obtain karyotype testing and Y-chromosome microdeletion analysis (AZFa, AZFb, AZFc regions) 4
• Complete AZFa or AZFb deletions predict poor surgical outcomes and contraindicate varicocele repair 4
• This testing occurs in approximately 4% of men with severe oligozoospermia, tenfold higher than the general population 4

Treatment Modality

Microsurgical varicocelectomy is the optimal approach for most cases, offering the best outcomes for semen parameter improvement and fertility 2, 5. Alternative approaches (laparoscopic varicocelectomy or percutaneous embolization) are reserved for specific clinical scenarios 5.

Expected Timeline for Improvement

• Semen parameter improvements require 3-6 months (two complete spermatogenic cycles) after varicocelectomy 4, 5
• Hormonal improvements follow a similar timeline 4
• If infertility persists beyond 6 months post-repair, consider assisted reproductive technology, particularly in older couples 5

Special Population: Azoospermia

For men with non-obstructive azoospermia and clinical varicocele:

• Varicocelectomy may restore sperm presence in ejaculate, particularly in those with hypospermatogenesis on testicular biopsy 4, 3
• Discuss risks and benefits thoroughly, especially if female partner has limited ovarian reserve, as time spent waiting for sperm recovery may impact overall fertility outcomes 4
• Consider offering testicular sperm extraction (TESE) at time of varicocele repair in select cases 1

Common Pitfalls to Avoid

• Do not pursue ultrasound-detected subclinical varicoceles for treatment, as this does not improve outcomes 1, 2
• Do not treat men with normal semen analysis regardless of varicocele grade, as there is no fertility benefit 1
• Do not delay imaging for atypical presentations (right-sided, bilateral, new-onset, or non-reducible), as these may indicate secondary causes requiring different management 3
• Do not attribute all fertility issues to varicocele without excluding other causes, particularly in men with elevated FSH suggesting primary spermatogenic failure 4