Should I undergo surgical repair of a left varicocele measuring 3.6 mm with reflux and a reduced left testicular volume of 10 mL despite normal semen analysis?

Surgical Repair is Strongly Recommended for Your Left Varicocele

You should undergo surgical repair of your left varicocele because you have testicular atrophy (10 mL volume represents significant size reduction) with documented reflux, which meets the strongest indication for varicocelectomy regardless of your normal sperm count. 1, 2

Why Surgery is Indicated Despite Normal Semen Analysis

Testicular Atrophy is an Absolute Indication

• Your left testicular volume of 10 mL represents significant atrophy, as normal adult testicular volume ranges from 15-25 mL, and the European Association of Urology strongly recommends surgery when there is a persistent size difference >2 mL or 20% between testicles. 2

• Testicular atrophy indicates progressive testicular damage that will likely worsen over time if left untreated, even when current semen parameters appear normal. 3

• The presence of reflux with reduced testicular volume suggests ongoing testicular dysfunction through mechanisms including elevated scrotal temperature, testicular hypoxia, and reflux of toxic metabolites. 1, 4

Normal Sperm Count Does Not Preclude Surgery in Your Case

• While the European Association of Urology typically recommends against treating varicoceles in men with normal semen analysis, this guideline specifically excludes patients with documented testicular atrophy, which is considered a separate and independent indication for surgery. 1, 2

• Varicoceles represent a progressive lesion - men with currently normal semen parameters remain at risk for subsequent loss of testicular function and fertility if left untreated. 3

• Approximately 15% of normal men have varicoceles, but your combination of reflux plus atrophy places you in a high-risk category for future fertility decline. 1, 4

Expected Outcomes After Repair

Testicular Volume Recovery

• In adults with clinical varicocele and testicular atrophy, varicocele repair increases left testicular volume by an average of 1.5 mL, with improvements in both testicular size and semen profiles. 5

• In adolescents (which provides the best evidence for catch-up growth), varicocele repair reversed testicular growth arrest, with the atrophy index improving from 12.7% preoperatively to 3% at 12 months post-surgery. 6

• The earlier you intervene, the better the potential for testicular recovery, as prolonged varicocele exposure may cause irreversible damage. 1

Timeline for Improvement

• Testicular volume improvements become apparent within 3-6 months after surgery (two spermatogenic cycles). 1, 5

• Even though your current sperm count is normal, you may see further improvements in semen parameters within this timeframe. 1, 7

Critical Surgical Considerations

Ensure Clinical (Palpable) Varicocele

• Your varicocele must be palpable on physical examination to qualify for surgery - the 3.6 mm measurement with reflux suggests this is likely a clinical varicocele, but confirm it is palpable. 1

• Do not proceed with surgery if the varicocele is only detectable by ultrasound (subclinical), as treatment of subclinical varicoceles does not improve outcomes. 1, 4

Check for Bilateral Disease

• Have your surgeon carefully examine for a right-sided varicocele, as bilateral palpable varicoceles require bilateral repair for optimal outcomes. 8

• Even small palpable right varicoceles (grade I) continue to have detrimental effects on bilateral testicular function if left unrepaired. 8

• Bilateral repair results in significantly greater improvement in seminal parameters (95.8% increase in motile sperm concentration) compared to unilateral repair (42.6% increase) when bilateral disease is present. 8

Common Pitfalls to Avoid

• Do not delay surgery waiting for semen parameters to worsen - testicular atrophy itself is the indication, and waiting may result in irreversible damage. 2, 3

• Avoid relying solely on ultrasound findings - the varicocele must be clinically palpable to meet treatment criteria. 1

• Do not assume normal sperm count means no treatment needed - this only applies to men without testicular atrophy or other concerning features. 1, 2

• Consider your partner's fertility status and age, as this influences the urgency of intervention, though testicular atrophy remains an indication regardless. 1