Varicocele is accepted as a common cause of male subfertility, even though many men with varicocele appear to have normal fertility. The pathophysiology of the varicocele effect on fertility remains unclear, but the association of varicocele with decreased testicular size, abnormal testicular histology, and abnormal semen parameters is clearly established. Because a small varicocele may impair fertility, it must be diligently sought, and the Doppler stethoscope may be helpful in establishing the diagnosis when a venous thrill is equivocal during the Valsalva maneuver in a standing patient. Abnormal semen parameters should be demonstrated in subfertile males with varicocele prior to advising varicocelectomy. Decreased sperm motility or a "stress pattern" in the semen should be documented; however a decreased sperm count may or may not be present. Various surgical approaches are available. When suprainguinal approaches have been used, failures have been shown to be attributable to secondarily incompetent cremasteric system veins. When high inguinal approaches are used, unsuccessful operations are probably secondary to a failure to identify one of the several venous tributaries that may be present at this level. The surgeon's approach should be based on available data, and his patients should be informed that failures are possible with any method of varicocelectomy until experience indicates otherwise. In most series, improvement in semen quality and pregnancy rates have been reported in a significant percentage of patients undergoing varicocelectomy for infertility. However, prior to subjection of the patient to varicocelectomy, the wife of the varicocele patient should be thoroughly studied (and treated when indicated).
PIP: Varicocele, found in 8-22% of the general population but in 21-39% of men attending infertility clinics, is now accepted as an important cause of male infertiltiy. The mechanisms by which varicocele affects fertility remain undetermined; however, decreased testicular size, abnormal testicular histology, and abnormal semen parameters have been noted in patients with varicocele. Sinc the size of the varicocele is not related to the degree of fertility impairment, care must be taken to detect subclinical varicocele. The presence of a small varicocele is suggested by an equivocal venous thrill during the Valsalva maneuver. This can be confirmed by noninvasive diagnostic tests in which the Doppler stethoscope is utilized. Before surgical intervention, other possible causes of subfertility (including factors in the female partner) should be excluded. If no other abnormality is found, and if both decreased sperm motility and increased numbers of tapered sperm and immature germinal cells in the semen are noted, varicocelectomy is indicated. The suprainguinal and high inguinal approaches are currently used for ligation and division of the internal spermatic vein. The safety of the suprainguinal division of the internal spermatic artery in the absence of prior dissection of the spermatic cord at a lower level has been demonstrated by experimental and clinical data. Reviews of the results of varicocele ligation in subfertile men have noted improved semen quality in 55-85% and pregnancy in 25-55% of wives.