How should I assess the severity of a varicocele and its potential impact on fertility?

Assessing the severity of a varicocele and its potential impact on fertility involves clinical grading and, for fertility concerns, semen analysis ¹.

• Severity Assessment: Varicoceles are typically graded based on palpability and visibility ¹. While the provided context does not explicitly define each grade, clinical practice often uses:
  • Subclinical or Grade I: Not palpable, or palpable only with a Valsalva manoeuvre ¹.
  • Grade II: Palpable without a Valsalva manoeuvre ¹.
  • Grade III: Visible on inspection ¹.
  Standardization and documentation of varicocele evaluation are important for consistent assessment (Stahl and Schlegel, 2011).
• Potential Impact on Fertility: Although varicoceles can be associated with fertility problems, nearly two-thirds of men with a varicocele have no difficulty fathering children ¹. The assessment of fertility impact primarily relies on semen analysis ¹,⁴.
  • Semen Analysis: If fertility is a concern, semen analysis should be offered ¹. Normal World Health Organization reference values for semen analysis include a semen volume of 1.5 ml or more, sperm concentration of 15 million spermatozoa per ml or more, total sperm number of 39 million spermatozoa per ejaculate or more, total motility (progressive and non-progressive) of 40% or more (or 32% or more with progressive motility), vitality of 58% or more live spermatozoa, and sperm morphology of 4% or more normal forms ⁴. If the first semen analysis result is abnormal, a repeat confirmatory test should be offered, ideally three months later to allow for the spermatozoa formation cycle to complete, but sooner if a gross deficiency is detected ⁴.
  • Management Based on Severity and Fertility Concern:
    • For adult men:
      • For sub-clinical or Grade I varicocele, no treatment is necessary ¹.
      • For Grade II or III asymptomatic varicocele with normal semen parameters, observation with semen analysis every 1–2 years may be considered if clinically appropriate ¹. However, CKS suggests that further investigations following initial normal semen findings may only be appropriate if fertility issues subsequently arise ¹.
      • For Grade II or III symptomatic varicocele, or with abnormal semen parameters, referral to a urologist for possible surgery should be considered ¹.
    • For adolescents (from age 10 years onwards):
      • For subclinical or Grade I varicocele, no treatment is necessary, and advice and reassurance should be provided ¹.
      • For Grade II or III varicocele with symmetrical testes, observe with annual examinations; the primary indication for surgery is testicular growth arrest ¹. Approximately 25% of boys with Grade II or III varicocele and symmetrical testes will ultimately develop testicular growth arrest ¹.
      • For Grade II or III varicocele with asymmetrical testes, refer to a urologist for possible surgery ¹. Referral to a urologist is also indicated if there are concerns about reduced ipsilateral testicular volume ¹. Following surgery, patients can expect a 50–80% chance of ipsilateral catch-up growth of the affected testis, which may take up to six months ¹.
  • Varicocele Surgery and Fertility: The National Institute for Health and Care Excellence (NICE) and the Royal College of Surgeons (RCS) do not recommend surgery for varicocele solely to improve fertility ¹,⁴. However, more recent guidance from the European Association of Urology (EAU) states there is strong evidence to treat infertile men with a clinical varicocele, abnormal semen parameters, and otherwise unexplained infertility in a couple where the female partner has good ovarian reserve, to improve fertility rates ¹. CKS suggests seeking advice from a urologist or fertility specialist where these criteria are met ¹.