From the Guidelines
Varicocele management should prioritize surgical intervention, specifically microsurgical subinguinal or inguinal varicocelectomy, for symptomatic cases or those causing fertility issues, as it has the lowest recurrence and complication rates, as suggested by the Practice Committee of the ASRM; Society for Male Reproduction and Urology 1. When considering varicocele treatment, it's essential to evaluate both partners, taking into account factors such as age, ovarian reserve, and the presence of female factors that may require alternative treatments like IVF with or without ICSI 1. For patients with pain, conservative management should be tried first, including scrotal support, anti-inflammatory medications, and activity modification, with surgical intervention indicated only after conservative measures fail, resulting in approximately 70% of patients experiencing pain relief post-surgery. The treatment approach should be determined by the treating physician's experience and expertise, including evaluation of both partners, together with the options available 1. Embolization by interventional radiology is a non-surgical alternative with similar success rates but higher recurrence rates compared to surgery, and can be effective for relieving orchialgia, with 87% of patients having complete pain relief at 39 months in one review 1. Key considerations in varicocele management include:
- Treatment of a clinically palpable varicocele may be offered to the male partner of an infertile couple when there is evidence of abnormal semen parameters and minimal/no identified female factor 1
- IVF with or without ICSI may be considered the primary treatment option when such treatment is required to treat a female factor, regardless of the presence of varicocele and abnormal semen parameters 1
- Postoperative care includes rest, scrotal support, ice application to reduce swelling, and avoiding heavy lifting for 2-3 weeks, with patients being monitored for complications such as hydrocele formation, testicular atrophy, or recurrence.
From the Research
Varicocele Management Overview
- Varicocele is the most common cause of male infertility and the most common correctable cause of male factor infertility 2
- Varicocele management involves diagnosis, treatment, and prognosis, with physical examination being an essential diagnostic tool 2
Treatment Options
- Various treatment methods exist, including open surgical, laparoscopic, microscopic surgical, and radiologic treatment such as embolization 2, 3
- Microscopic inguinal or subinguinal varicocelectomy has superior outcomes with a low complication rate 2
- Varicocele embolization is a minimally invasive option that offers advantages such as minimal sedation, lower operating time, and faster recovery times 4, 5, 6
Indications for Treatment
- General indications for treatment are limited to patients with proven infertility, clinical palpable varicocele, and abnormal semen characteristics 2
- Other symptoms such as testicular size discrepancy of more than 20% can be an indication for varicocelectomy in adolescents 2
- Varicocele embolization can be considered for patients who experience recurrence after varicocelectomy 6
Outcomes and Prognosis
- Treatment of varicocele can improve semen parameters as a surrogate marker of potential fertility 2
- Varicocele correction is a cost-effective therapeutic modality compared to intrauterine insemination (IUI) and in vitro fertilization (IVF) for affected couples 3
- Technical failure rates for varicocele embolization can be higher than surgical varicocelectomy, especially for bilateral varicoceles 4