Varicocelectomy in men with varicocele-associated infertility: a narrative review of semen quality and reproductive outcomes

Background and Objective: Varicoceles, defined as an abnormal dilation of the pampiniform venous plexus within the scrotum, are considered the most common surgically correctable cause of male infertility. Yet, it remains unclear exactly how to best select patients for the procedure and how the different surgical methods compare in practice. While prior reviews have established the general benefits of varicocelectomy, there is a clinical need to synthesize recent data on emerging molecular markers like sperm DNA fragmentation, alongside conventional parameters and final reproductive outcomes. The objective of this review is to evaluate the effects of varicocele repair on overall semen quality and male fertility outcomes, while comparing the safety and efficacy of different surgical approaches.

Methods: A literature search was conducted across the PubMed and Embase databases for English-language clinical trials published between January 2010 and April 2026. Studies were eligible if they evaluated adult men undergoing varicocelectomy and reported quantitative postoperative data on semen parameters, pregnancy rates, or surgical complications. The extracted data were qualitatively synthesized to provide a broad clinical overview of treatment efficacy.

Key Content and Findings: A total of 24 core clinical trials were included in the primary analysis. The synthesized evidence demonstrates that varicocelectomy significantly improves conventional semen parameters and reduces molecular damage. Microsurgical techniques consistently outperformed laparoscopic and open methods, offering the highest spontaneous pregnancy rates and the lowest incidence of complications. The literature reveals ongoing inconsistencies regarding the optimal management of subclinical contralateral varicoceles, with varying reproductive outcomes reported across different cohorts.

Conclusions: Varicocelectomy is an effective method for treating male infertility, leading to improved semen quality and increased chances of natural conception. Microsurgical varicocelectomy remains the method of choice due to its highest efficacy and lowest complication rate. Current literature is still limited by varied methodologies and inconsistent reporting of long-term reproductive outcomes. Debate also continues regarding the exact extent of surgery needed in bilateral or subclinical cases. Future trials should use standard outcome measures and group patients by specific baseline characteristics to help tailor treatments to individual patients.