Should I have percutaneous embolisation of my left‑sided varicocele given left testicular atrophy (3.4 mm) and abnormal sperm morphology despite a normal total sperm count?

Should You Undergo Embolization for Your Left Varicocele?

No, you should not undergo embolization for your 3.4mm left-sided varicocele, as this represents a non-palpable (subclinical) varicocele that does not meet treatment criteria, and the testicular atrophy is likely unrelated to this small varicocele. 1, 2, 3

Why Treatment Is Not Indicated

Your Varicocele Does Not Meet Clinical Criteria

• A 3.4mm varicocele is subclinical (non-palpable) and falls well below the threshold for clinical significance—grade I varicoceles average 5.0mm, grade II average 5.8mm, and grade III average 6.6mm or greater. 2
• Guidelines explicitly recommend against treating subclinical varicoceles, as they do not improve semen parameters, fertility rates, or pregnancy outcomes regardless of whether reflux is present on ultrasound. 4, 1, 2
• The presence of reflux on ultrasound alone does not determine clinical significance—varicoceles affect 15% of normal males, and most never require treatment. 2
• Routine ultrasonography to identify non-palpable varicoceles is actively discouraged because it leads to overtreatment without proven benefit. 1, 2, 3

The Testicular Atrophy Is Not Caused by This Small Varicocele

• Non-palpable varicoceles do not cause clinically significant testicular damage, and you should not attribute testicular atrophy to a 3.4mm varicocele—this is a common clinical error that leads to unnecessary surgery. 3
• Your testicular atrophy requires alternative investigation, including hormonal evaluation (FSH, LH, testosterone, SHBG) to assess for primary testicular dysfunction, and consideration of other causes such as prior trauma, infection, genetic abnormalities, or systemic conditions. 3
• If your sperm concentration is below 5 million/mL, genetic testing including karyotype and Y-chromosome microdeletion analysis should be performed, as chromosomal abnormalities occur in approximately 4% of men with very low sperm counts. 3

When Varicocele Treatment IS Indicated

Absolute Requirements for Surgery or Embolization

• You must have a palpable (clinical) varicocele on physical examination—typically grade II or III, meaning the varicocele can be felt without imaging. 1, 2
• You must have abnormal semen parameters on at least two separate analyses performed at least one month apart with 2-3 days of abstinence. 1
• Your female partner must have adequate ovarian reserve, as time spent pursuing varicocele repair may compromise overall fertility outcomes if she has diminished reserve. 1, 2
• The infertility must be otherwise unexplained, meaning no significant female factor requiring IVF/ICSI primarily for her issues. 1

Special Consideration for Testicular Size Discrepancy

• In adolescents and young men, a persistent testicular size difference exceeding 20% or 2mL absolute volume difference, confirmed on two examinations six months apart, is a strong indication for varicocele repair even with normal semen parameters. 1, 2
• However, this applies to clinical (palpable) varicoceles causing progressive atrophy, not to pre-existing atrophy with a small subclinical varicocele. 3

What You Should Do Instead

Immediate Diagnostic Workup

• Obtain comprehensive scrotal duplex Doppler ultrasound to measure both testicular volumes precisely, assess testicular texture and homogeneity, and evaluate for alternative pathology such as masses, prior infarcts, or inflammatory changes. 3
• Perform hormonal evaluation including FSH, LH, total testosterone, and SHBG to investigate whether you have primary testicular dysfunction causing the atrophy. 3
• Repeat semen analysis at least once more (minimum two analyses total, one month apart) to confirm your morphology abnormality and document total sperm count, concentration, and motility. 1

Address the Morphology Issue

• Low morphology with normal count may reflect epididymal dysfunction, oxidative stress, or DNA fragmentation rather than varicocele-related pathology. 4
• Consider sperm DNA fragmentation testing if you have otherwise unexplained infertility or recurrent pregnancy loss, as some causes (antidepressant use, genitourinary infection) are easily reversible. 4
• Evaluate for reversible factors including medications, heat exposure, smoking, and infections that may impair sperm morphology. 4

Critical Pitfalls to Avoid

• Do not pursue embolization based solely on ultrasound findings of a small varicocele with reflux—this will not reverse your testicular atrophy and does not meet evidence-based treatment criteria. 1, 2, 3
• Do not delay evaluation of your female partner's fertility status, as her ovarian reserve critically influences all treatment decisions. 1
• Do not assume the varicocele caused your testicular atrophy—investigate alternative etiologies through hormonal and genetic testing before attributing causation. 3
• Recognize that even if you had a clinical varicocele, persistent testicular atrophy after adolescence suggests irreversible damage, and some patients benefit suboptimally from surgical correction. 5