Should You Have Varicocele Surgery?

Before considering surgery, you need to know the NNT, and the complete list of benefits vs risks.

In order to repair a varicocele the following criteria should be fulfilled 1:

1. Involuntary infertility of at least one year.
2. Presence of a palpable varicocele at the upright position and during a Valsalva manoeuver.
3. No detectable or at least no irreversible cause of female infertility.
4. Normal testicular size (> 15 cm3) or small reduction of the ipsilateral testis 2.
5. Evaluation of at least two semen analyses at three months interval. The presence of normal semen analyses excludes varicocele as the cause of infertility. The usual effects of varicocele on sperm parameters include mild and moderate asthenospermia, teratospermia or astheno- teratospermia. Initially, sperm concentration is not seriously affected, though later all three semen parameters can gradually deteriorate, resulting in azoospermia in very few cases 3.
6. Normal values or slight increase (less than the double of the upper normal range) f serum FSH levels, as very high levels of serum FSH denote primary testicular failure.

Additional factors that must be considered before deciding the therapeutic approach of varicocele in an infertile couple include 4:

1. The advanced age of the wife (older than 35 years) and high serum FSH levels should drive the decision towards the ICSI solution rather than repair of varicocele 5.
2. In case of chronic presence of varicocele and advanced male age, surgery should be avoided.
3. Surgical repair of varicocele is recommended in case of secondary male infertility 6, 7. On the other hand, if the patient has primary infertility, azoospermia, small testicular size and high serum FSH levels, the presence of varicocele should be ignored and surgery should be avoided, as the diagnosis in this case pleads towards primary testicular failure.
4. The diagnosis of SCOS or maturation arrest in FNA or open testicular biopsy denotes primary testicular failure. Thus, the presence of varicocele should be ignored. On the contrary, the presence of mild or moderate hypospermatogenesis can be attributed to varicocele in which case surgery can be a reasonable therapeutic approach.