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

Abstract

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.