What are the next steps for a 26-year-old male patient with abnormal semen analysis (showing low sperm motility and normal sperm count) who was treated with antibiotics, has a left varicocele and probable right varicocele on scrotal ultrasound, and still has abnormal sperm motility on repeat analysis?

Management of Persistent Asthenozoospermia with Bilateral Varicoceles

You should proceed with microsurgical varicocelectomy for the left (and likely right) varicocele, as this represents the most common correctable cause of male infertility and treatment of palpable varicoceles improves both semen parameters and fertility rates. 1

Clinical Context and Diagnosis

Your patient presents with a clear pattern indicating varicocele-induced testicular dysfunction:

• Persistent asthenozoospermia (low sperm motility) despite antibiotic treatment suggests the initial infection hypothesis was incorrect 1
• Normal sperm count with abnormal motility is the classic presentation of varicocele-related infertility 2, 3
• Bilateral varicoceles (confirmed left, probable right) on scrotal ultrasound represent a significant pathophysiologic burden on testicular function 4
• The high pH on initial analysis may have reflected seminal vesicle inflammation, but the persistence of motility problems after antibiotics points to varicocele as the primary etiology 1

Why Varicocelectomy is Indicated

Treatment of clinical (palpable) varicoceles results in improvement in both semen quality and fertility rates, unlike treatment of non-palpable varicoceles which shows no benefit. 1

Key supporting evidence:

• Varicoceles are found in approximately 40% of men with primary infertility and represent the most common correctable cause of male subfertility 2
• Microsurgical varicocelectomy improves sperm motility in 70-80% of men with documented palpable varicoceles and abnormal semen parameters 2, 5
• Treatment of bilateral varicoceles can reverse testicular dysfunction and improve spermatogenesis, with pregnancy rates of 34-36% reported after repair 4, 6
• The pathophysiology involves higher scrotal temperature, testicular hypoxia, and reflux of toxic metabolites—all of which preferentially impair sperm motility 7

Recommended Treatment Algorithm

1. Confirm Physical Examination Findings

• Palpate for varicoceles with patient standing during Valsalva maneuver to confirm clinical (palpable) varicoceles 1
• Use Doppler stethoscope if venous thrill is equivocal to establish diagnosis 3
• Measure testicular volumes with Prader orchidometer to assess for testicular atrophy (volume <12 mL or >2 mL size difference) 7, 8

Critical pitfall to avoid: Do not rely solely on ultrasound findings—only palpable varicoceles benefit from treatment. 1

2. Complete Hormonal Evaluation

Before proceeding to surgery, obtain:

• Serum testosterone and FSH to assess for testicular dysfunction 1
• If FSH >7.6 IU/L with testicular atrophy, consider karyotype and Y-chromosome microdeletion testing (AZFa, AZFb, AZFc) 7, 9

This evaluation helps predict surgical success and identifies genetic causes that would contraindicate repair (complete AZFa or AZFb deletions). 7

3. Proceed with Microsurgical Varicocelectomy

Microsurgical subinguinal or inguinal varicocelectomy is the optimal treatment approach with the highest success rates and lowest complication rates. 2, 5

• Treat the left varicocele definitively and explore the right side if palpable 4
• Bilateral varicocele repair may be necessary given the probable right-sided involvement 4
• Microsurgical technique allows identification of all venous tributaries while preserving the testicular artery and lymphatics 5

4. Post-Operative Monitoring

• Repeat semen analysis at 3-6 months post-operatively, as improvements typically take two spermatogenic cycles 7, 2
• Expected improvements include increased sperm motility (from 8-9% to 29-30% in published series) and potentially improved concentration 4
• If semen parameters remain severely abnormal after 6 months, consider assisted reproductive technology (ART) 2

Alternative Considerations if Surgery Declined

If the patient declines surgery or has contraindications:

• Clomiphene citrate (off-label) has shown benefit in varicocele-associated oligospermia, with 71% achieving low-normal counts and 36% pregnancy rates 6
• However, ART (IVF/ICSI) offers superior pregnancy rates compared to empiric medical therapy and should be discussed early 7, 9
• Avoid exogenous testosterone completely—it will suppress spermatogenesis and cause azoospermia 7, 9

Critical Caveats

• Female partner evaluation is essential—the wife should be thoroughly studied before subjecting the patient to varicocelectomy 3
• Time is a factor: If the female partner has limited ovarian reserve or advanced age (>35 years), consider proceeding directly to ART rather than waiting 6 months post-surgery for improvement 7
• Sperm cryopreservation should be offered before surgery as insurance, particularly if testicular volumes are reduced 9, 8
• Not all varicoceles impair fertility—only 20% of men with varicoceles have fertility problems, but your patient's documented asthenozoospermia confirms pathologic impact 2

Expected Outcomes

Based on published data:

• 82-83% of men show significant improvement in sperm parameters after varicocele repair 4
• Natural pregnancy rates of 20-36% are achievable post-repair 4, 6
• Additional 14-20% achieve pregnancy with ART using improved post-surgical sperm 4
• Treatment may spare >50% of patients the need for testicular sperm extraction if they later require ICSI 4