Surgical repair of varicocele in men with clinical varicocele and impaired spermatogenesis improves semen parameters and increases likelihood of natural pregnancy, with microsurgical subinguinal varicocelectomy demonstrating the most favorable profile in terms of efficacy, safety, and recurrence rates.
Key Findings
Results
Surgical repair of clinical varicocele improves semen parameters, including the number of progressively motile spermatozoa, and increases the likelihood of natural pregnancy in men with impaired spermatogenesis.
The review synthesized data from clinical guidelines, systematic reviews, meta-analyses, and original studies.
Improvements were observed specifically in men with clinical varicocele combined with impaired spermatogenesis.
Key semen parameter improved was the number of progressively motile spermatozoa.
Results
Varicocelectomy performed before assisted reproductive technologies (ART) is associated with higher clinical pregnancy and live birth rates and may be economically beneficial by improving ART efficacy.
Surgery prior to ART was associated with higher clinical pregnancy rates compared to proceeding directly to ART.
Surgery prior to ART was associated with higher live birth rates.
The economic benefit was attributed to improved ART efficacy following surgical correction.
Results
In men with severe oligozoospermia, microsurgical varicocelectomy may allow some patients to proceed to intrauterine insemination or postpone IVF/ICSI.
This finding applies specifically to the subgroup with severe oligozoospermia.
The benefit described is the potential to use less invasive or less costly reproductive interventions after surgery.
Not all patients with severe oligozoospermia achieve this outcome; the paper notes 'some patients' may benefit.
Results
In non-obstructive azoospermia (NOA), varicocelectomy may result in the appearance of spermatozoa in the ejaculate and increase the likelihood of successful sperm retrieval by micro-TESE.
No consistent economic advantage of a 'surgery-first' strategy over immediate micro-TESE+ICSI has been demonstrated in NOA patients.
The appearance of spermatozoa in the ejaculate following surgery represents a potential benefit for this otherwise severely affected group.
The evidence for NOA management strategy remains inconclusive regarding cost-effectiveness.
Results
Antioxidant therapy moderately improves semen parameters and reduces sperm DNA fragmentation, but its effect on clinical pregnancy and live birth rates remains insufficiently established.
The effect of antioxidant therapy on semen parameters was characterized as 'moderate.'
Sperm DNA fragmentation was also reduced with antioxidant therapy.
Clinical pregnancy and live birth rate effects were described as 'insufficiently established,' indicating a gap in the evidence base.
Results
Microsurgical subinguinal varicocelectomy demonstrates the most favorable profile among available techniques in terms of efficacy, safety, and recurrence rates.
The comparison included laparoscopic, endovascular, robot-assisted, and exoscopic techniques.
Laparoscopic and endovascular techniques were identified as 'valid alternatives.'
Robot-assisted and exoscopic technologies were noted to require further evidence regarding their clinical and economic efficiency.
Microsurgical subinguinal varicocelectomy was superior across all three evaluated dimensions: efficacy, safety, and recurrence.
Conclusions
The overall evidence base for varicocele treatment remains heterogeneous, and large prospective studies with clinical pregnancy and live birth as endpoints are needed.
The review identified a need for large prospective studies to clarify effectiveness and cost-effectiveness of different approaches.
Current heterogeneity in the evidence limits definitive conclusions.
Clinical pregnancy and live birth were specified as the required primary endpoints for future research, rather than semen parameters alone.
What This Means
This research summarizes what is currently known about treating varicocele—enlarged veins in the scrotum—as a cause of male infertility, focusing on both how well treatments work and whether they are cost-effective. The review found that for men who have a clinically detectable varicocele along with poor sperm quality, surgical repair improves sperm movement and increases the chances of achieving a natural pregnancy. When surgery is done before fertility treatments like IVF, it appears to improve success rates and may save money overall by reducing the number of costly fertility procedures needed.
The review also found that the specific surgical technique matters: microsurgical subinguinal varicocelectomy (a precise, minimally invasive operation performed under a microscope through a small incision near the groin) had the best combination of effectiveness, safety, and low recurrence rates compared to other approaches such as laparoscopic or robotic surgery. For men with the most severe cases—either very low sperm counts or no sperm at all in the ejaculate (azoospermia)—surgery can sometimes help enough that less intensive fertility treatments become possible, though the economic advantage over going straight to advanced fertility procedures is not yet clearly proven.
This research suggests that antioxidant supplements may modestly improve sperm quality and reduce DNA damage in sperm, but it is not yet clear whether they actually help men father children. Overall, the authors note that the existing research is inconsistent and that larger, well-designed studies are still needed—particularly ones that track actual pregnancies and live births rather than just laboratory measures of sperm quality—to give patients and doctors clearer guidance on which treatments are most worthwhile.
Shomarufov A B, Bozhedomov V A, Giyasov Sh I. (2026). [Clinical and economic efficiency of varicocelectomy in the treatment of male infertility].. Urologiia (Moscow, Russia : 1999). https://pubmed.ncbi.nlm.nih.gov/42742560/