Reasons for surgical correction of a diagnosed variocele include relieving significant testicular discomfort or pain not responsive to routine symptomatic treatment, reducing testicular atrophy (volume < 20 mL, length < 4 cm), and addressing the possible contribution to unexplained male infertility. A varicocele may cause progressive damage to the testes, resulting in further atrophy and impairment of seminal parameters.
The Male Infertility Best Practice Policy Committee of the American Urological Society recommends that varicocele treatment should be offered to the male partner of a couple attempting to conceive when all of the following are present:
· A varicocele is palpable.
· 1- The couple has documented infertility.
· 2- The female has normal fertility or potentially correctable infertility.
· 3- The male partner has one or more abnormal semen parameters or sperm function test results.
4- In addition, adult men who have a palpable varicocele and abnormal semen analyses findings but are not currently attempting to conceive should also be offered varicocele repair.
A scrotal varicocele is the most correctable factor in a male with poor semen quality; therefore, varicocele repair should be considered a viable choice for appropriately selected individuals and couples with otherwise unexplained infertility because varicocele repair has been shown to improve semen parameters in most men and possibly improve fertility; in addition, the risks of varicocele repair are small.
The results of treating varicoceles in adolescents are not as clear as the results of treating varicoceles in adults. Although varicoceles first become apparent in adolescence, their natural history and its timeline for the onset of detrimental effects on testicular function remain unclear. Varicoceles occur in approximately 10-15% of the fertile male population, but not all varicoceles impair sperm function, overall semen quality, or fertility.
Important determinations to be made regarding varicoceles in adolescents are whether (1) the varicocele is a progressive lesion and (2) early repair of the varicocele would prevent infertility.
In 1977, Lipshultz and Corriere suggested that varicoceles were associated with testicular atrophy that was progressive with age.They also observed that testicular biopsy specimens taken from prepubertal boys with varicoceles already revealed histologic abnormalities. However, Diamond et al from Harvard have challenged this concept.
In 1987, Kass and Belman were the first to demonstrate a significant increase in testicular volume after varicocele repair in adolescents.Although Kass and Belman noted catch-up growth, they did not study semen parameters. Collecting a semen sample from an adolescent is not always easy; consequently, studying the effects of a varicocele and the benefits of treatment is difficult.
The indications for repairing varicoceles in adolescents include the presence of significant testicular asymmetry (>20%) demonstrated on serial examinations, testicular pain, and abnormal semen analysis results. Very large varicoceles may also be repaired; however, in the absence of atrophy, this indication is relative and controversial. Young men with varicoceles but normal ipsilateral testicular volume should be offered follow-up monitoring with annual objective measurements of testicular volume, semen analyses, or both.