Should Bilateral Varicocele Repair Be Recommended in Cases of a Clinical Varicocele and Contralateral Subclinical Varicocele?

  • Juan D. Cedeno
  • Alan Scott PolackwichJr.


Varicocele is a common clinical entity encountered by many physicians, especially those who see infertile patients regularly. Many times, during an infertility evaluation, a practitioner discovers a subclinical varicocele, that is, a varicocele that appears on imaging, but is not clinically noticeable. Such a varicocele presents a therapeutic dilemma; while the criteria for operating on patients with a clinical varicocele is well established, the role of subclinical varicocele is less well defined. It is not currently recommended to operate on patients with subclinical varicocele in isolation, but many practitioners wonder about surgical repair when patients present with both clinical and subclinical varicoceles, as they are already undergoing an anesthetic and may desire an operation on both varicoceles.

Currently, the evidence is not clear as to the efficacy of bilateral ligation in this situation. This is likely due to variation in definition of a subclinical varicocele in the literature, as well as a variety of ligation techniques being used. As of now, data suggest that subclinical varicocele may have some effect on semen parameters (including motility, morphology, and concentration), but not nearly to the extent that clinical varicocele does. Therefore, the improvements in ligation of subclinical varicocele are less than in clinical varicocele, while the risks of surgery remain the same. In studies directly addressing this question, there are conflicting outcomes; most show improvement in seminal parameters, but overall, bilateral ligation is no better than a unilateral ligation. The few studies that address pregnancy rates only show a modest improvement. When discussing this with patients, the limitations of the data should be discussed and shared decision-making should be used to determine whether this is an appropriate treatment.


Subclinical varicocele Varicocelectomy Male infertility Oligozoospermia Varicocele 


  1. 1.
    Kohn TP, Ohlander SJ, Jacob JS, Griffin TM, Lipshultz LI, Pastuszak AW. The Effect of subclinical varicocele on pregnancy rates and semen parameters: a systematic review and meta-analysis. Curr Urol Rep [Internet]. 2018. [cited 2018 Jul 15];19(7). Available from:
  2. 2.
    Chen SS-S. Significant predictive factors for subfertility in patients with subclinical varicocele. Andrologia. 2017;49(10):e12781.CrossRefGoogle Scholar
  3. 3.
    Cantoro U, Polito M, Muzzonigro G. Reassessing the role of subclinical varicocele in infertile men with impaired semen quality: a prospective study. Urology. 2015;85(4):826–30.CrossRefGoogle Scholar
  4. 4.
    Dubin L, Amelar RD. Varicocele size and results of varicocelectomy in selected subfertile men with varicocele. Fertil Steril. 1970;21(8):606–9.CrossRefGoogle Scholar
  5. 5.
    Seo JT, Kim KT, Moon MH, Kim WT. The significance of microsurgical varicocelectomy in the treatment of subclinical varicocele. Fertil Steril. 2010;93(6):1907–10.CrossRefGoogle Scholar
  6. 6.
    Pilatz A, Altinkilic B, Köhler E, Marconi M, Weidner W. Color Doppler ultrasound imaging in varicoceles: is the venous diameter sufficient for predicting clinical and subclinical varicocele? World J Urol. 2011;29(5):645–50.CrossRefGoogle Scholar
  7. 7.
    Belay R, Huang G, Shen J-C, Ko EK. Diagnosis of clinical and subclinical varicocele: how has it evolved? Asian J Androl. 2016;18(2):182.CrossRefGoogle Scholar
  8. 8.
    Patil V, Shetty SMC, Das SK. Redefining the criteria for grading varicoceles based on reflux times: a clinicoradiological correlation. Ultrasound Q. 2016;32(1):82–5.CrossRefGoogle Scholar
  9. 9.
    Marsman JW. Clinical versus subclinical varicocele: venographic findings and improvement of fertility after embolization. Radiology. 1985;155(3):635–8.CrossRefGoogle Scholar
  10. 10.
    Gonda R, Karo J, Forte R, O’Donnell K. Diagnosis of subclinical varicocele in infertility. Am J Roentgenol. 1987;148(1):71–5.CrossRefGoogle Scholar
  11. 11.
    Majzoub A, Sabanegh E. Symptomatic male with subclinical varicocele found on ultrasound evaluation. Asian J Androl. 2016;18(2):313–4.CrossRefGoogle Scholar
  12. 12.
    Eskew LA, Watson NE, Wolfman N, Bechtold R, Scharling E, Jarow JP. Ultrasonographic diagnosis of varicoceles. Fertil Steril. 1993;60(4):693–7.CrossRefGoogle Scholar
  13. 13.
    Sofikitis N, Miyagawa I. Effects of surgical repair of experimental left varicocele on testicular temperature, spermatogenesis, sperm maturation, endocrine function, and fertility in rabbits. Arch Androl. 1992;29(2):163–75.CrossRefGoogle Scholar
  14. 14.
    Zheng YQ, Gao X, Li ZJ, Yu YL, Zhang ZG, Li W. Efficacy of bilateral and left varicocelectomy in infertile men with left clinical and right subclinical varicoceles: a comparative study. Urology. 2009;73(6):1236–40.CrossRefGoogle Scholar
  15. 15.
    Pasqualotto FF, Lucon AM, de Góes PM, Sobreiro BP, Hallak J, Pasqualotto EB, et al. Is it worthwhile to operate on subclinical right varicocele in patients with grade II–III varicocele in the left testicle? J Assist Reprod Genet. 2005;22(5):227–31.CrossRefGoogle Scholar
  16. 16.
    Hallak J. Asymptomatic male currently not desiring fertility with bilateral subclinical varicocele found on ultrasound evaluation and borderline semen analysis results. Asian J Androl. 2016;18(2):315.CrossRefGoogle Scholar
  17. 17.
    Cervellione RM, Corroppolo M, Bianchi A. Subclinical varicocele in the pediatric age group. J Urol. 2008;179(2):717–9.CrossRefGoogle Scholar
  18. 18.
    Zhang Y. Asymptomatic postpubertal male with palpable left varicocele and subclinical right varicocele. Asian J Androl. 2016;18(2):311.CrossRefGoogle Scholar
  19. 19.
    Witt MA, Lipshultz LI. Varicocele: a progressive or static lesion? Urology. 1993;42(5):541–3.CrossRefGoogle Scholar
  20. 20.
    Shiraishi K, Takihara H, Matsuyama H. Elevated scrotal temperature, but not varicocele grade, reflects testicular oxidative stress-mediated apoptosis. World J Urol. 2010;28(3):359–64.CrossRefGoogle Scholar
  21. 21.
    García-Peiró A, Ribas-Maynou J, Oliver-Bonet M, Navarro J, Checa MA, Nikolaou A, et al. Multiple determinations of sperm DNA fragmentation show that varicocelectomy is not indicated for infertile patients with subclinical varicocele. Biomed Res Int. 2014;2014:1–6.CrossRefGoogle Scholar
  22. 22.
    Wan X, Wang H, Ji Z. Microsurgical varicocelectomy for clinical varicocele: a review for potential new indications. Andrologia. 2017;49(10):e12827.CrossRefGoogle Scholar
  23. 23.
    Jarow JP, Ogle SR, Eskew LA. Seminal improvement following repair of ultrasound detected subclinical varicoceles. J Urol. 1996;155(4):1287–90.CrossRefGoogle Scholar
  24. 24.
    Kim HJ, Seo JT, Kim KJ, Ahn H, Jeong JY, Kim JH, et al. Clinical significance of subclinical varicocelectomy in male infertility: systematic review and meta-analysis. Andrologia. 2016;48(6):654–61.CrossRefGoogle Scholar
  25. 25.
    Sun X, Wang J, Peng Y, Gao Q, Song T, Yu W, et al. Bilateral is superior to unilateral varicocelectomy in infertile males with left clinical and right subclinical varicocele: a prospective randomized controlled study. Int Urol Nephrol. 2018;50(2):205–10.CrossRefGoogle Scholar
  26. 26.
    Ketabchi AA, Ahmadinejad M, Ehsan M. Comparison of the effects of varicocelectomy on the spermiogram of patients with subclinical versus clinical varicocele. 2005;4.Google Scholar
  27. 27.
    Elbendary MA, Elbadry AM. Right subclinical varicocele: how to manage in infertile patients with clinical left varicocele? Fertil Steril. 2009;92(6):2050–3.CrossRefGoogle Scholar
  28. 28.
    Report on varicocele and infertility: a committee opinion. Fertil Steril. 2014;102(6):1556–60.Google Scholar
  29. 29.
    Yamamoto M, Hibi H, Hirata Y, Miyake K, Ishigaki T. Effect of varicocelectomy on sperm parameters and pregnancy rate in patients with subclinical varicocele: a randomized prospective controlled study. J Urol. 1996;155(5):1636–8.CrossRefGoogle Scholar
  30. 30.
    Unal D, Yeni E, Verit A, Karatas OF. Clomiphene citrate versus varicocelectomy in treatment of subclinical varicocele: a prospective randomized study. Int J Urol Off J Jpn Urol Assoc. 2001;8(5):227–30.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Juan D. Cedeno
    • 1
  • Alan Scott PolackwichJr.
    • 2
  1. 1.Department of UrologyMount Sinai Medical CenterMiami BeachUSA
  2. 2.Columbia Department of Urology at Mount Sinai Medical Center in Miami BeachMount Sinai Medical CenterMiami BeachUSA

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