Varicocele Treatment in Infertile Men
Direct Recommendation
Treat infertile men with a clinical (palpable) varicocele and abnormal semen parameters through microsurgical varicocelectomy to improve fertility rates, provided the female partner has good ovarian reserve. 1
Treatment Algorithm
When to Treat Varicocele
Strong indications for varicocelectomy:
- Clinical (palpable) varicocele + abnormal semen parameters + unexplained infertility in couples where the female partner has good ovarian reserve 1
- Adolescents with persistent testicular size discrepancy (>2 ml or >20% difference) confirmed on two visits 6 months apart 1, 2
- Men with elevated sperm DNA fragmentation and otherwise unexplained infertility, or those with recurrent pregnancy loss and failure of embryogenesis/implantation (weaker evidence) 1
Do NOT treat:
- Men with normal semen analysis regardless of varicocele presence 1
- Subclinical (non-palpable) varicoceles detected only on ultrasound, as treatment does not improve semen parameters or fertility rates 1, 2
Optimal Surgical Approach
Microsurgical subinguinal or inguinal varicocelectomy is the preferred technique, offering superior outcomes with the lowest complication rates compared to laparoscopic or radiological embolization approaches 2, 3. The microsurgical approach allows identification of all venous tributaries and minimizes recurrence risk 3.
Special Populations
Men with Azoospermia
Varicocelectomy may restore sperm to the ejaculate in azoospermic men, particularly those with hypospermatogenesis on testicular histology 4. However, the evidence quality is low, and risks/benefits must be thoroughly discussed 4.
Critical preoperative evaluation for severe oligozoospermia (<5 million/ml) or azoospermia:
- Karyotype and Y-chromosome microdeletion testing (AZFa, AZFb, AZFc) is mandatory, as chromosomal abnormalities occur in ~4% of men with severe oligozoospermia 4
- Complete AZFa or AZFb deletions predict poor surgical outcomes and contraindicate varicocele repair 4
- Consider onco-TESE (testicular sperm extraction) at time of orchidectomy for men with testicular cancer and azoospermia 1, 2
Female Partner Considerations
Special consideration must be given to couples where the female partner has limited ovarian reserve, as waiting 3-6 months for semen improvement post-varicocelectomy may compromise overall fertility outcomes 4. In such cases, proceeding directly to assisted reproductive technology may be more appropriate.
Expected Timeline for Improvement
Semen parameter improvements typically require 3-6 months (two spermatogenic cycles) after varicocelectomy 4, 3. If infertility persists beyond this interval, especially in older couples, assisted reproductive technology should be considered 3.
Diagnostic Considerations
Physical Examination
Physical examination is the primary diagnostic tool - a prominent pampiniform plexus with increased spermatic cord diameter during Valsalva maneuver confirms the diagnosis 2.
Role of Ultrasound
Scrotal Doppler ultrasound should be used:
- To confirm varicocele grade when physical examination is difficult (e.g., obese patients) 2
- Pre-operatively to document baseline and post-operatively to confirm procedural success 2
Routine ultrasonography to identify non-palpable varicoceles is discouraged, as treatment of subclinical varicoceles does not improve outcomes 1, 2
Critical Pitfalls to Avoid
Do not treat based on ultrasound findings alone - the presence of venous reflux on ultrasound without clinical palpability does not warrant intervention 2. Varicoceles affect 15% of normal males, and most never require treatment 2.
Acute or right-sided varicocele in men >40 years requires urgent evaluation for retroperitoneal malignancy, especially if the varicocele does not decompress when supine 5.
Always evaluate the female partner thoroughly before proceeding with varicocelectomy, as female factors may be the primary fertility limitation 6.
Hormonal Considerations
Men with **FSH levels <11.7 mIU/mL have favorable prognosis for surgical success**, though levels >7.6 IU/L suggest underlying spermatogenic impairment 4. Elevated FSH in varicocele patients should prompt evaluation for testicular dysfunction beyond the varicocele itself 4.
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