What are the current guidelines for the management of varicocele in patients with infertility?

For men presenting with infertility and a varicocele, the management guidelines vary depending on the varicocele grade and semen parameters, with a nuanced approach to surgery for fertility improvement ¹.

• General Stance on Surgery for Infertility: 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, as it has not been shown to improve pregnancy rates [1, NICE, 2017; RCS, 2016; 2]. Therefore, the male partner of an infertile couple should not be routinely referred for varicocele surgery solely as a form of fertility treatment ¹.
• Differing Guidance and Specialist Advice: More recent guidance from the European Association of Urology (EAU) suggests 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, EAU, 2022a]. Clinical Knowledge Summaries (CKS) suggests that advice from a urologist or fertility specialist should be sought when these criteria are met ¹. This is also supported by patient information from some NHS trusts, which state that varicocele surgery can be carried out to improve fertility [1, Chelsea and Westminster Hospital NHS Foundation Trust, 2023; MKUH, 2023].
• Management Based on Varicocele Grade and Semen Parameters:
  • Sub-clinical or Grade I Varicocele: No treatment is necessary ¹. Semen analysis should be offered if fertility is a concern ¹.
  • 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, BMJ Best Practice, 2021]. However, CKS suggests that further investigations following initial normal semen findings may only be appropriate if fertility issues arise, as most men with varicocele will not experience fertility effects ¹.
  • Grade II or III Symptomatic Varicocele or with Abnormal Semen Parameters: Referral to a urologist for possible surgery is indicated ¹.
• Referral for Unexplained Infertility: Consider seeking specialist advice for men with clinical varicocele, abnormal semen parameters, and otherwise unexplained infertility ¹.
• Patient Information: Reassure the man that nearly two-thirds of men with a varicocele have no difficulty fathering children, despite the association with fertility problems ¹. If surgery is being considered, the urologist will discuss the risks and benefits of available procedures ¹.