In a reproductive‑age male with bilateral varicocele presenting with scrotal discomfort, testicular atrophy, or infertility, when is surgical intervention indicated and what is the preferred management?

Management of Bilateral Varicocele

In reproductive-age males with bilateral varicocele, surgical intervention (preferably microsurgical varicocelectomy) is indicated when there is: (1) clinical (palpable) varicocele with abnormal semen parameters and unexplained infertility (when female partner has good ovarian reserve), (2) persistent testicular atrophy (>2 mL or >20% size difference confirmed on two visits 6 months apart), or (3) significant scrotal pain impacting quality of life. 1, 2

Diagnostic Evaluation

Physical Examination and Confirmation

• Diagnosis is primarily clinical—a prominent pampiniform plexus on physical examination is diagnostic of varicocele 2
• An increase in spermatic cord diameter during Valsalva maneuver confirms the diagnosis 2
• Scrotal Doppler ultrasound should be used to confirm varicocele grade, evaluate blood flow patterns, and assess testicular size/texture, particularly when physical examination is difficult (e.g., obese patients) 2
• Ultrasound confirms varicocele when dilated veins measure >2 mm (clinical) or 1.5-2 mm (subclinical) with increased diameter during Valsalva 3

Critical Caveat on Subclinical Varicoceles

• Routine ultrasonography to identify non-palpable (subclinical) varicoceles is discouraged, as treatment of subclinical varicoceles does not improve semen parameters or fertility rates 1, 2
• The presence of reflux on ultrasound alone does not determine clinical significance—varicoceles affect 15% of normal males, with most never requiring treatment 2

Laboratory Workup for Infertility Concerns

• 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
• For sperm concentration <5 million/mL, obtain karyotype testing and Y-chromosome microdeletion analysis (AZFa, AZFb, AZFc regions) before proceeding with surgery, as chromosomal abnormalities occur in ~4% of these men (tenfold higher than general population) 1
• Complete AZFa or AZFb deletions predict poor surgical outcomes and contraindicate varicocele repair 1

Surgical Indications

Strong Indications for Surgery

Infertility-Related:

• Infertile men with clinical (palpable) bilateral varicocele AND abnormal semen parameters AND otherwise unexplained infertility, when female partner has good ovarian reserve 1, 2
• Men with elevated sperm DNA fragmentation and otherwise unexplained infertility 1
• Men with FSH levels below 11.7 mIU/mL have favorable prognosis for surgical success 1

Testicular Atrophy:

• Adolescents or adults with persistent testicular size difference >2 mL or >20%, confirmed on two subsequent visits 6 months apart 1, 2

Symptomatic Pain:

• Scrotal pain significantly impacting quality of life that has failed conservative management 3, 4

When Surgery is NOT Indicated

• Men with normal semen parameters regardless of varicocele grade 1
• Subclinical (non-palpable) varicoceles detected only on ultrasound 1, 2
• When IVF/ICSI is required primarily for female factor infertility 1
• Intermittent mild pain alone without impact on quality of life 3

Preferred Surgical Approach

Microsurgical subinguinal or inguinal varicocelectomy is the current surgical standard 5

• Inguinal approach is preferred in most cases 4
• Subinguinal technique is employed when there is history of previous inguinal surgery 4
• Routine use of operating microscope and micro-Doppler probe affords easier identification of vessels and lymphatics, reducing complications 4
• For bilateral varicoceles with other scrotal comorbidities (hydrocele, epididymal cyst), a single scrotal access approach under local anesthesia is safe and effective 6

Expected Outcomes and Timeline

Semen Parameter Improvements

• Improvements in semen parameters typically take 3-6 months (two spermatogenic cycles) to manifest 1
• Monitor semen parameters after varicocelectomy at this interval 1
• Most studies report improved semen parameters, increased serum testosterone, and improvement in functional sperm defects 4

Fertility Outcomes

• Varicocelectomy improves both semen quality and fertility rates in appropriately selected patients 2
• For men with non-obstructive azoospermia (NOA), treatment of clinical varicoceles improved surgical sperm retrieval rates, especially for those with hypospermatogenesis 1
• Varicocelectomy may lead to presence of sperm in ejaculate for men with azoospermia 1

Hormonal Changes

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

Important Clinical Caveats

Special Considerations

• For couples with female partner having limited ovarian reserve, time spent waiting for sperm recovery after varicocelectomy may negatively impact overall fertility outcomes—consider proceeding directly to assisted reproduction 1
• The quality of evidence regarding varicocele treatment in azoospermia is generally low—fully discuss risks and benefits with patients 1
• Higher varicocele grades (Grade III, >6mm) are associated with worse semen parameters and greater testicular dysfunction 1, 2

Post-Operative Follow-Up

• Follow-up scrotal ultrasound is indicated post-varicocelectomy to confirm procedural success and resolution of venous reflux 3
• Repeat imaging is warranted for change in clinical presentation (new acute severe pain, palpable mass, testicular enlargement) 3
• Routine surveillance imaging for stable bilateral varicoceles is NOT recommended—physical examination is sufficient for monitoring 3

Bilateral Considerations

• Bilateral varicoceles are common—ultrasound studies show up to 70% of men with clinically evident left varicocele have bilateral disease on imaging 7
• This high percentage of bilateral involvement may explain the pathophysiological mechanism by which varicoceles produce bilateral testicular dysfunction 7, 8
• Both sides should be addressed surgically when bilateral clinical varicoceles are present with the above indications 6