Con: Should Varicocele Be Repaired Before ART?

  • Samuel J. Ohlander
  • Rodrigo L. Pagani
  • Craig S. Niederberger


Varicoceles are present in 15–20% of post-pubertal men with a 2–3 times increased likelihood of diagnosis in those presenting for infertility evaluation. However, not all men with varicoceles suffer from subfertility. There is no diagnostic measure in current clinical practice that may predict which individuals will have a negative sequela or which will see improved fertility potential following repair. Despite decades of published literature, the heterogeneous study populations and methodological parameters, as well as a broad range of outcome measures, there continues to be a lack of consensus on the management of varicoceles in the infertile couple. The clinical debate that surrounds the repair of a clinically palpable varicocele prior to assisted reproduction focuses on two patient cohorts: the non-azoospermic male and the azoospermic male.

In reproductive care, management is unique in that it relies upon management of the couple and a very specific outcome: delivery of a healthy child. Interpretation of the published literature must focus not only on the findings but also on the methods, assessing the applicability of a given study to broad clinical practice. For better or worse, age, female factors, and clinical timeline often play an integral part in the reproductive management of a couple, and, therefore, broad application of management studies ought to be applied with such considerations in mind.


Varicocele Varicocelectomy Intrauterine insemination IUI In vitro fertilization IVF Intracytoplasmic sperm injection ICSI Outcomes 


  1. 1.
    Irvine DS. Epidemiology and aetiology of male infertility. Hum Reprod. 1998;13(Suppl 1):33–44.CrossRefGoogle Scholar
  2. 2.
    Sharlip ID, Jarow JP, Belker AM, Lipshultz LI, Sigman M, Thomas AJ, et al. Best practice policies for male infertility. Fertil Steril. 2002;77(5):873–82.CrossRefGoogle Scholar
  3. 3.
    Pryor JL, Howards SS. Varicocele. Urol Clin North Am. 1987;14(3):499–513.PubMedGoogle Scholar
  4. 4.
    Redmon JB, Carey P, Pryor JL. Varicocele–the most common cause of male factor infertility? Hum Reprod Update. 2002;8(1):53–8.CrossRefGoogle Scholar
  5. 5.
    Gorelick JI, Goldstein M. Loss of fertility in men with varicocele. Fertil Steril. 1993;59(3):613–6.CrossRefGoogle Scholar
  6. 6.
    Tulloch WS. Varicocele in subfertility; results of treatment. Br Med J. 1955;2(4935):356–8.CrossRefGoogle Scholar
  7. 7.
    Daitch JA, Bedaiwy MA, Pasqualotto EB, Hendin BN, Hallak J, Falcone T, et al. Varicocelectomy improves intrauterine insemination success rates in men with varicocele. J Urol. 2001;165(5):1510–3.CrossRefGoogle Scholar
  8. 8.
    Marmar JL, Agarwal A, Prabakaran S, Agarwal R, Short RA, Benoff S, et al. Reassessing the value of varicocelectomy as a treatment for male subfertility with a new meta-analysis. Fertil Steril. 2007;88(3):639–48.CrossRefGoogle Scholar
  9. 9.
    Schlesinger MH, Wilets IF, Nagler HM. Treatment outcome after varicocelectomy. A critical analysis. Urol Clin North Am. 1994;21(3):517–29.PubMedGoogle Scholar
  10. 10.
    Yamamoto M, Hibi H, Tsuji Y, Miyake K. The effect of varicocele ligation on oocyte fertilization and pregnancy after failure of fertilization in in vitro fertilization-embryo transfer. Hinyokika Kiyo. 1994;40(8):683–7.PubMedGoogle Scholar
  11. 11.
    Boman JM, Libman J, Zini A. Microsurgical varicocelectomy for isolated asthenospermia. J Urol. 2008;180(5):2129–32.CrossRefGoogle Scholar
  12. 12.
    Esteves SC, Oliveira FV, Bertolla RP. Clinical outcome of intracytoplasmic sperm injection in infertile men with treated and untreated clinical varicocele. J Urol. 2010;184(4):1442–6.CrossRefGoogle Scholar
  13. 13.
    Haydardedeoglu B, Turunc T, Kilicdag EB, Gul U, Bagis T. The effect of prior varicocelectomy in patients with nonobstructive azoospermia on intracytoplasmic sperm injection outcomes: a retrospective pilot study. Urology. 2010;75(1):83–6.CrossRefGoogle Scholar
  14. 14.
    Inci K, Hascicek M, Kara O, Dikmen AV, Gurgan T, Ergen A. Sperm retrieval and intracytoplasmic sperm injection in men with nonobstructive azoospermia, and treated and untreated varicocele. J Urol. 2009;182(4):1500–5.CrossRefGoogle Scholar
  15. 15.
    Pasqualotto FF, Braga DP, Figueira RC, Setti AS, Iaconelli A Jr, Borges E Jr. Varicocelectomy does not impact pregnancy outcomes following intracytoplasmic sperm injection procedures. J Androl. 2012;33(2):239–43.CrossRefGoogle Scholar
  16. 16.
    Gokce MI, Gulpinar O, Suer E, Mermerkaya M, Aydos K, Yaman O. Effect of performing varicocelectomy before intracytoplasmic sperm injection on clinical outcomes in non-azoospermic males. Int Urol Nephrol. 2013;45(2):367–72.CrossRefGoogle Scholar
  17. 17.
    Practice Committee of the American Society for Reproductive Medicine, Society for Male Reproduction and Urology. Report on varicocele and infertility: a committee opinion. Fertil Steril. 2014;102(6):1556–60.CrossRefGoogle Scholar
  18. 18.
    Goldstein M, Eid JF. Elevation of intratesticular and scrotal skin surface temperature in men with varicocele. J Urol. 1989;142(3):743–5.CrossRefGoogle Scholar
  19. 19.
    Richardson I, Grotas AB, Nagler HM. Outcomes of varicocelectomy treatment: an updated critical analysis. Urol Clin North Am. 2008;35(2):191–209, viii.CrossRefGoogle Scholar
  20. 20.
    Hajder M, Hajder E, Husic A. The effects of Total motile sperm count on spontaneous pregnancy rate and pregnancy after IUI treatment in couples with male factor and unexplained infertility. Med Arch. 2016;70(1):39–43.CrossRefGoogle Scholar
  21. 21.
    Hamilton JA, Cissen M, Brandes M, Smeenk JM, de Bruin JP, Kremer JA, et al. Total motile sperm count: a better indicator for the severity of male factor infertility than the WHO sperm classification system. Hum Reprod. 2015;30(5):1110–21.CrossRefGoogle Scholar
  22. 22.
    Samplaski MK, Lo KC, Grober ED, Zini A, Jarvi KA. Varicocelectomy to “upgrade” semen quality to allow couples to use less invasive forms of assisted reproductive technology. Fertil Steril. 2017;108(4):609–12.CrossRefGoogle Scholar
  23. 23.
    Kohn TP, Kohn JR, Pastuszak AW. Varicocelectomy before assisted reproductive technology: are outcomes improved? Fertil Steril. 2017;108(3):385–91.CrossRefGoogle Scholar
  24. 24.
    Marmar JL, Corson SL, Batzer FR, Gocial B. Insemination data on men with varicoceles. Fertil Steril. 1992;57(5):1084–90.CrossRefGoogle Scholar
  25. 25.
    Ashkenazi J, Dicker D, Feldberg D, Shelef M, Goldman GA, Goldman J. The impact of spermatic vein ligation on the male factor in in vitro fertilization-embryo transfer and its relation to testosterone levels before and after operation. Fertil Steril. 1989;51(3):471–4.CrossRefGoogle Scholar
  26. 26.
    Esteves SC, Roque M, Agarwal A. Outcome of assisted reproductive technology in men with treated and untreated varicocele: systematic review and meta-analysis. Asian J Androl. 2016;18(2):254–8.CrossRefGoogle Scholar
  27. 27.
    Kirby EW, Wiener LE, Rajanahally S, Crowell K, Coward RM. Undergoing varicocele repair before assisted reproduction improves pregnancy rate and live birth rate in azoospermic and oligospermic men with a varicocele: a systematic review and meta-analysis. Fertil Steril. 2016;106(6):1338–43.CrossRefGoogle Scholar
  28. 28.
    Kim ED, Leibman BB, Grinblat DM, Lipshultz LI. Varicocele repair improves semen parameters in azoospermic men with spermatogenic failure. J Urol. 1999;162(3 Pt 1):737–40.CrossRefGoogle Scholar
  29. 29.
    Matthews GJ, Matthews ED, Goldstein M. Induction of spermatogenesis and achievement of pregnancy after microsurgical varicocelectomy in men with azoospermia and severe oligoasthenospermia. Fertil Steril. 1998;70(1):71–5.CrossRefGoogle Scholar
  30. 30.
    Lee R, Li PS, Goldstein M, Schattman G, Schlegel PN. A decision analysis of treatments for nonobstructive azoospermia associated with varicocele. Fertil Steril. 2009;92(1):188–96.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Samuel J. Ohlander
    • 1
  • Rodrigo L. Pagani
    • 1
  • Craig S. Niederberger
    • 1
  1. 1.Department of UrologyUniversity of Illinois at Chicago Hospital and Health Sciences SystemChicagoUSA

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