What is the management approach for a male patient of reproductive age with varicocele?

Management of Varicocele in Males of Reproductive Age

Treat varicocele surgically only in infertile men with clinical (palpable) varicocele AND abnormal semen parameters when the female partner has good ovarian reserve; do not treat subclinical varicoceles or men with normal semen analysis. 1

Diagnostic Approach

Clinical Examination

• Diagnose varicocele by physical examination in both supine and standing positions with Valsalva maneuver 2
• A prominent pampiniform plexus with increased spermatic cord diameter during Valsalva is diagnostic 3
• Approximately 90% of varicoceles are left-sided due to anatomical differences in venous drainage 4
• Critical pitfall: An acute right-sided varicocele or one that doesn't disappear when lying down in men over 40 may indicate retroperitoneal malignancy and requires urgent imaging 4

Role of Ultrasound

• Scrotal Doppler ultrasound should be reserved for cases where physical examination is difficult (e.g., obese patients) or to confirm grade 3
• Do not routinely use ultrasound to identify non-palpable varicoceles, as treatment of subclinical varicoceles does not improve semen parameters or fertility rates 1, 3, 5
• The presence of reflux on ultrasound alone does not determine clinical significance 3

Initial Workup for Infertile Men

• Obtain two semen analyses at least one month apart, with 2-3 days of abstinence before collection 1
• Perform endocrine evaluation (serum testosterone and FSH) if sperm concentration is <10 million/mL 1
• Obtain 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 men 6
• Complete AZFa or AZFb deletions predict poor surgical outcomes and contraindicate varicocele repair 6

Treatment Indications

Strong Indications for Surgical Treatment

• Infertile men with clinical varicocele + abnormal semen parameters + otherwise unexplained infertility when female partner has good ovarian reserve 1
• Adolescents with varicocele associated with persistent testicular size difference >2 mL or 20%, confirmed on two visits 6 months apart 1
• Men with symptomatic (painful) varicocele 2

Weak/Conditional Indications

• Men with elevated sperm DNA fragmentation and otherwise unexplained infertility 1
• Men with recurrent pregnancy loss or failure of embryogenesis/implantation after assisted reproductive techniques 1
• Azoospermic men with clinical varicocele, particularly those with hypospermatogenesis on testicular biopsy 6

Contraindications to Treatment

• Do not treat men with normal semen analysis 1
• Do not treat subclinical (non-palpable) varicoceles 1, 5
• Men with complete AZFa or AZFb deletions 6

Surgical Technique

Preferred Approach

• Microsurgical subinguinal or inguinal varicocelectomy is the reference standard, offering lower recurrence and complication rates compared to high approaches 2, 7
• Use operating microscope and micro-Doppler probe for easier identification of vessels and lymphatics 8
• Laparoscopic varicocelectomy is useful only in specific cases 9
• Percutaneous retrograde embolization is a minimally invasive alternative with satisfactory outcomes 2

Expected Outcomes and Timeline

Semen Parameter Improvement

• Improvements typically occur after 3-6 months (1-2 spermatogenic cycles) 9, 2
• Most studies report improved semen parameters, increased serum testosterone, and improvement in functional sperm defects 8
• In severe cases (azoospermia, severe oligospermia), improvement may allow avoidance of testicular sperm extraction or enable intrauterine insemination rather than ICSI 2

Fertility Outcomes

• Recent data suggest varicocelectomy increases natural pregnancy rates, though some conflicting data exists 9, 2
• If infertility persists after 6-9 months post-surgery, consider assisted reproductive technology, especially in older couples 9

Hormonal Changes

• SHBG levels decrease significantly post-varicocelectomy (mean decrease 32.72 nmol/L) 6
• Hormonal improvements parallel semen parameter improvements at 3-6 months 6

Special Populations

Azoospermic Men

• Varicocelectomy may lead to presence of sperm in ejaculate, especially with hypospermatogenesis 6
• Treatment improves surgical sperm retrieval rates in non-obstructive azoospermia 6
• Discuss risks and benefits fully, particularly with couples where female partner has limited ovarian reserve, as time spent waiting for sperm recovery may impact overall fertility 6

Men with Testicular Cancer

• Perform sperm cryopreservation before planned orchidectomy or oncological therapies 1
• Offer onco-TESE at time of radical orchidectomy in men with azoospermia or severe semen abnormalities 1, 3