Varicocele Treatment
For men with infertility, abnormal semen parameters, and a palpable varicocele on physical examination, microsurgical varicocelectomy is the treatment of choice, while subclinical varicoceles should never be treated. 1
Initial Assessment and Treatment Candidacy
The diagnosis must be confirmed by physical examination in both supine and standing positions to identify a palpable varicocele, as this is essential for determining treatment candidacy. 1 Obtain semen analysis to assess sperm concentration, motility, and morphology. 1
Treatment is indicated only when ALL of the following criteria are met: 1
- Clinical varicocele confirmed on physical examination
- Abnormal semen parameters documented
- Otherwise unexplained infertility present
- Female partner has good ovarian reserve
Critical Pitfalls to Avoid
Never treat subclinical varicoceles - those not palpable on examination - as this does not improve fertility rates and represents overtreatment. 1 Similarly, do not perform varicocelectomy in men with normal semen analysis, as there is no proven benefit. 1
Treatment Options When Indicated
Microsurgical Varicocelectomy (Preferred Method)
Microsurgical subinguinal or inguinal varicocelectomy is the optimal treatment in most cases, offering superior surgical outcomes with the ability to ligate all spermatic veins while preserving testicular arteries and lymphatic vessels. 2, 3 This approach has gained increasing popularity among experts in male reproductive medicine as the treatment of choice. 3
Alternative Surgical Approaches
- Laparoscopic varicocelectomy: Established as safe and effective, useful in specific cases 3
- High ligation with intraoperative embolization: Can reduce postoperative recurrence rates compared to traditional high ligation alone, particularly useful in primary hospitals without microsurgical capabilities 4
- Radiological percutaneous embolization: An alternative minimally invasive option, though generally reserved for specific cases 2, 3, 5
Expected Outcomes and Follow-Up
After varicocele repair, semen parameters typically take 3 to 6 months to improve. 2 If infertility persists after this interval, consider other therapies including assisted reproductive technology, especially in older couples. 2 Varicocele correction is more cost-effective than both intrauterine insemination (IUI) and in vitro fertilization (IVF) for affected couples. 6
Special Considerations
Varicocele repair may be considered in men with elevated sperm DNA fragmentation, recurrent pregnancy loss, or failure of assisted reproductive techniques despite otherwise unexplained infertility. 1 Varicoceles are found in approximately 40% of men with primary infertility and 80% of men with secondary infertility, though they also occur in 12% of men with normal semen parameters. 2