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

Treatment of Varicocele in Males of Reproductive Age

Treat varicocele surgically with microsurgical varicocelectomy in infertile men who have a clinically palpable varicocele, abnormal semen parameters, and otherwise unexplained infertility when the female partner has good ovarian reserve. 1, 2

Diagnostic Confirmation

Before proceeding with treatment, confirm the diagnosis and establish treatment candidacy:

• Physical examination is essential - a prominent pampiniform plexus with increase in spermatic cord diameter during Valsalva maneuver confirms the diagnosis 2
• Obtain two semen analyses at least one month apart with 2-3 days of abstinence to document abnormal parameters 1
• Scrotal Doppler ultrasound should be performed to confirm varicocele grade and evaluate blood flow patterns, particularly useful in obese patients where examination is difficult 2
• Do NOT routinely use ultrasound to identify non-palpable varicoceles - treatment of subclinical varicoceles does not improve semen parameters or fertility rates 1, 2

Treatment Indications - When to Operate

Strong indications for surgical treatment include: 1, 2

• Infertile men with clinical (palpable) varicocele AND abnormal semen parameters AND otherwise unexplained infertility when female partner has good ovarian reserve
• Adolescents with varicocele associated with persistent testicular size difference >2 mL or 20%, confirmed on two visits 6 months apart
• Men with elevated sperm DNA fragmentation and otherwise unexplained infertility

Special considerations: 1

• Varicocelectomy may be considered in men with recurrent pregnancy loss or failure of embryogenesis/implantation
• For men with non-obstructive azoospermia, varicocelectomy may improve surgical sperm retrieval rates, especially with histological diagnosis of hypospermatogenesis

Surgical Approach

Microsurgical inguinal or subinguinal varicocelectomy is the optimal technique with superior outcomes and low complication rates 3, 4, 5

• Use of operating microscope and micro-Doppler probe allows easier identification of vessels and lymphatics 4
• Alternative approaches (laparoscopic varicocelectomy, radiological embolization) are useful only in specific cases 3
• The subinguinal approach is preferred when there is history of previous inguinal surgery 4

Expected Outcomes and Timeline

Improvements in semen parameters typically require 3-6 months (two spermatogenic cycles) after varicocelectomy 1, 3

• Most studies report improved semen parameters, increased serum testosterone, and improvement in functional sperm defects 4
• Return of motile sperm may occur in selected azoospermic men 4
• Monitor semen parameters after surgery to assess response 1

When NOT to Treat

Do not offer varicocelectomy in these scenarios: 1, 2

• Subclinical (non-palpable) varicoceles detected only on ultrasound
• Men with normal semen parameters regardless of varicocele grade
• When IVF/ICSI is required primarily for female factor infertility - proceed directly to assisted reproduction rather than delaying for varicocele repair 6

Critical Caveats

Female partner evaluation is essential - consider her age and ovarian reserve, as time spent waiting for sperm recovery after varicocelectomy may negatively impact overall fertility outcomes in couples with limited ovarian reserve 1

Genetic testing before surgery: For men with sperm concentration <5 million/mL, obtain karyotype and Y-chromosome microdeletion analysis, as complete AZFa or AZFb deletions predict poor surgical outcomes and would contraindicate varicocele repair 1

Risks and benefits must be fully discussed with patients with non-obstructive azoospermia and clinically significant varicocele before treatment, as the quality of evidence in this population is generally low 1