What are the diagnosis and treatment options for a varicocele in a male of reproductive age?

Varicocele: Diagnosis and Treatment in Males of Reproductive Age

Diagnosis

Varicocele diagnosis is primarily clinical through physical examination, with imaging reserved only for equivocal cases—routine ultrasonography to identify subclinical varicoceles should be avoided as their treatment does not improve fertility outcomes. 1, 2, 3

Physical Examination

• Palpate the scrotum with the patient standing and performing Valsalva maneuver to detect dilated, tortuous veins of the pampiniform plexus 4
• Grade the varicocele clinically: Grade 1 (palpable only with Valsalva), Grade 2 (palpable without Valsalva), Grade 3 (visible through scrotal skin) 1
• Assess testicular volume bilaterally—a size difference >2 mL or 20% is clinically significant 1

Laboratory Evaluation

• Obtain two semen analyses at least one month apart with 2-3 days of abstinence before collection 1
• Perform endocrine evaluation including serum testosterone and FSH if sperm concentration is <10 million/mL 1
• For sperm concentration <5 million/mL, obtain karyotype testing and Y-chromosome microdeletion analysis (AZFa, AZFb, AZFc regions), as chromosomal abnormalities occur in approximately 4% of these men—tenfold higher than the general population 1

Imaging Considerations

• Do not routinely use ultrasonography to identify non-palpable varicoceles, as treatment of subclinical varicoceles does not improve semen parameters or fertility rates 1, 2, 3
• Reserve imaging for cases where physical examination is inconclusive or when objective documentation is necessary 5

Treatment Indications

Treat only infertile men with palpable (clinical) varicoceles AND abnormal semen parameters when the female partner has good ovarian reserve—do not treat subclinical varicoceles or men with normal semen analysis. 1, 3

Clear Indications for Surgery

• Infertile men with clinical varicocele + abnormal semen parameters + otherwise unexplained infertility when female partner has good ovarian reserve 1, 3
• Adolescents with persistent testicular size difference >2 mL or 20% confirmed on two visits 6 months apart 1
• Men with elevated sperm DNA fragmentation and otherwise unexplained infertility 1

Contraindications to Treatment

• Subclinical (non-palpable) varicoceles—treatment is not effective regardless of semen parameters 1, 2, 3
• Men with normal semen analysis—no benefit from treatment 1, 3
• When IVF/ICSI is required primarily for female factor infertility 1
• Men with complete AZFa or AZFb deletions—these predict poor surgical outcomes and contraindicate repair 1

Special Population: Non-Obstructive Azoospermia (NOA)

• Varicocelectomy may lead to sperm return in ejaculate, especially in men with hypospermatogenesis on histology 1, 2
• Fully discuss risks and benefits before proceeding, as evidence quality is low 1, 2
• Critical caveat: Consider female partner's ovarian reserve—time spent waiting for sperm recovery (3-6 months) may impact overall fertility outcomes 1, 2
• Men with **FSH <11.7 mIU/mL** have favorable prognosis for surgical success, though levels >7.6 IU/L suggest underlying spermatogenic impairment 1

Surgical Approach

Microsurgical subinguinal or inguinal varicocelectomy is the optimal treatment in most cases, offering the best balance of efficacy and lowest complication rates. 6, 4

Preferred Technique

• Microsurgical varicocelectomy (subinguinal or inguinal approach) with operating microscope and micro-Doppler probe for easier identification of vessels and lymphatics 7, 4
• Use inguinal approach as primary technique; reserve subinguinal approach for patients with previous inguinal surgery 7

Alternative Techniques

• Laparoscopic varicocelectomy and radiological percutaneous embolization are useful only in specific cases 6

Expected Outcomes and Timeline

Improvements in semen parameters typically require 3-6 months (two spermatogenic cycles), with spontaneous pregnancy occurring between 6-12 months after surgery. 1, 2, 3, 6

Semen Parameter Improvements

• Monitor semen parameters starting at 3 months post-operatively 1, 6
• Higher grade varicoceles (Grade 3) show greater improvement after repair compared to lower grades 3
• Varicocele repair improves semen parameters and may improve outcomes in men undergoing assisted reproductive technologies 3

Hormonal Changes

• SHBG levels decrease significantly post-surgery (mean decrease 32.72 nmol/L) 1
• Hormonal improvements parallel semen parameter timeline (3-6 months) 1

Critical Pitfalls to Avoid

• Do not treat based on ultrasound findings alone—subclinical varicoceles identified only by imaging should not be treated 1, 2, 3
• Do not delay alternative therapies indefinitely—if infertility persists after 6 months post-repair, consider assisted reproductive technology, especially in older couples 6
• Do not attribute elevated FSH solely to varicocele—FSH >7.6 IU/L suggests spermatogenic failure or testicular dysfunction requiring further evaluation 1
• Do not proceed with surgery without genetic testing in men with sperm concentration <5 million/mL, as complete AZFa/AZFb deletions contraindicate repair 1