What are the evaluation and treatment options for a patient presenting with a varicocele, particularly in relation to fertility and testicular function?

Varicocele: Evaluation and Treatment

Direct Recommendation

Treat infertile men with palpable (clinical) varicoceles and abnormal semen parameters with microsurgical varicocelectomy to improve fertility outcomes, while avoiding treatment of subclinical varicoceles or men with normal semen analysis. 1, 2, 3

---

Clinical Evaluation Algorithm

Physical Examination Requirements

• Examine the patient in both supine and standing positions to assess for palpable varicocele, as clinical (palpable) varicoceles are the only ones that warrant treatment 2, 3
• Grade the varicocele severity (Grade 1-3), as higher grades are associated with worse semen parameters and greater testicular dysfunction 1
• Measure testicular volumes bilaterally to identify size discrepancies >2 mL or 20%, which strongly indicates need for surgery when confirmed on two visits 6 months apart 1
• Be alert for right-sided or acute-onset varicoceles in men over 40, as these may indicate retroperitoneal malignancy 4

Laboratory Evaluation

• Obtain semen analysis evaluating volume, concentration, motility, and morphology to identify abnormal parameters that justify treatment 2, 3
• Measure FSH, LH, and testosterone levels to assess testicular function and predict surgical outcomes 1, 2
• Perform karyotype and Y-chromosome microdeletion analysis (AZFa, AZFb, AZFc) for all men with sperm concentration <5 million/mL, as chromosomal abnormalities occur in 4% of these patients (tenfold higher than general population) 1

Critical Diagnostic Pitfall

• Do NOT routinely use ultrasonography to identify non-palpable varicoceles, as treatment of subclinical varicoceles does not improve semen parameters or fertility rates 1, 2, 3

---

Treatment Indications

Clear Indications for Varicocelectomy

• Palpable varicocele + abnormal semen parameters + infertility 1, 2, 3
• Testicular size discrepancy >2 mL or 20% confirmed on two visits 6 months apart 1
• Azoospermia with palpable varicocele, especially with hypospermatogenesis on histology, as varicocelectomy may restore sperm to ejaculate 1

Contraindications to Treatment

• Normal semen analysis regardless of varicocele grade 1, 3
• Subclinical (non-palpable) varicoceles detected only by ultrasound 1, 2, 3
• Complete AZFa or AZFb deletions predict poor surgical outcomes and contraindicate repair 1

Prognostic Factors

• **FSH <11.7 mIU/mL predicts favorable surgical outcomes**, though levels >7.6 IU/L suggest underlying spermatogenic impairment 1
• Grade 3 varicoceles show greater improvement in sperm count after repair compared to lower grades 3

---

Surgical Approach

Preferred Technique

• Microsurgical subinguinal or inguinal varicocelectomy is the optimal treatment in most cases, with other procedures useful only in specific situations 5, 6
• Use operating microscope and micro-Doppler probe to identify vessels and lymphatics, minimizing complications 6
• Perform high ligation of internal spermatic vein and all collaterals 7

---

Post-Treatment Expectations

Timeline for Improvement

• Semen parameter improvements require 3-6 months (two spermatogenic cycles) after varicocelectomy 1, 2, 3, 5
• Spontaneous pregnancy typically occurs 6-12 months after surgery 3
• Hormonal improvements parallel semen parameter timeline, taking approximately 3-6 months 1

Expected Outcomes

• Significant improvements in sperm motility, morphology, and count 7
• Reversal of testicular hypotrophy 7
• Pregnancy rates of 58% in treated patients with grade I varicocele 7
• Improved surgical sperm retrieval rates in non-obstructive azoospermia, particularly with hypospermatogenesis 1

---

Special Populations

Non-Obstructive Azoospermia

• Discuss risks and benefits fully before treatment, as evidence quality is low 1
• Consider female partner's ovarian reserve, as time waiting for sperm recovery may impact overall fertility 1
• Histological diagnosis of hypospermatogenesis predicts better outcomes 1

Adolescents

• Treat if pain or testicular growth retardation is present 6
• Monitor testicular volumes on serial examinations 1

---

Key Clinical Caveats

• Approximately 35-40% of infertile men have varicoceles, but only 20% of men with varicoceles experience fertility problems 3, 5
• Varicocele can coexist with other causes of infertility, requiring comprehensive evaluation 5
• If infertility persists 6 months post-surgery, consider assisted reproductive technology, especially in older couples 5
• Varicocelectomy may improve ART outcomes in oligozoospermic men (OR 1.69,95% CI 0.95-3.02) 3