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Research · Therapies

Varicocele repair

In infertile men with a palpable varicocele, repair raised sperm concentration against no treatment, and pooled trials found more pregnancies at low certainty. Whether more babies are born is uncertain. Testosterone rose after repair, mostly in men with low levels. Hydrocele and recurrence are the main reported harms, both least frequent after microsurgery.

Checked 2026-11-13
Status
A surgical or radiological procedure, performed in the US by licensed physicians, usually urologists or interventional radiologists. The procedures are not approved by the FDA as products, though the instruments, coils and embolic materials used are regulated as medical devices.
Also called
varicocelectomy, varicocele surgery, microsurgical varicocelectomy, microsurgical subinguinal varicocelectomy, inguinal varicocelectomy, Ivanissevich, Palomo, retroperitoneal varicocelectomy, laparoscopic varicocelectomy, varicocele embolization, percutaneous embolization, sclerotherapy, sclero-embolization, varicocele ligation
Used for
male infertility, low sperm count, poor sperm motility, abnormal sperm shape, getting pregnant, IVF and ICSI success, live birth, azoospermia, sperm DNA damage, low testosterone, testicular pain, scrotal pain, testicular growth in teenagers

Strong several reviews agree · Moderate one review or consistent trials · Limited one or a few small studies · Untested no study in people, listed with what it rests on

Shown to help9

Reported risks3

What it is used for, and what was found

Shown to help9

StrongStudied in men

Sperm count and semen quality

Shown to raise sperm concentration against no treatment in infertile men with a palpable varicocele. Reviews disagree on whether motility and sperm shape also improve.

Compared with untreated infertile men with clinical varicocele [1]; observation [2]; before repair, in the same men [3]

The numbers and sources
Effect
Across 16 studies of 2,420 infertile men with clinical varicocele (1,424 repaired, 996 untreated), repaired men had higher sperm concentration (SMD 1.739, 95% CI 1.129 to 2.349), total sperm count (SMD 1.894), progressive motility (SMD 3.301), total motility (SMD 0.887, 95% CI 0.036 to 1.738) and normal morphology (SMD 1.673). Semen volume did not differ (SMD 0.313, 95% CI -0.242 to 0.868) [1]. Across 12 prospective studies (1,357 men), sperm concentration rose 12.34 million/mL more than with observation (95% CI 3.49 to 21.18), while progressive motility and normal morphology did not differ from observation. The benefit was seen in men with an abnormal semen analysis [2]. Across 22 prospective studies measuring the same men before and after repair, concentration rose 12.32 million/mL (95% CI 9.45 to 15.19) [3].
Population
Infertile men with a palpable (clinical) varicocele, in randomized and observational studies [1]; adult infertile men with any-grade varicocele in prospective trials [2]; men with clinical varicocele in prospective studies [3].
Sources
[1], [2], [3]
Caveats
These are semen measures, not pregnancies. Heterogeneity was very high (I² 97% to 98.5%) and publication bias was present for concentration and progressive motility [1]. Most included studies were at intermediate or high risk of bias [2]. Nobody can be blinded to surgery.
Strong

Pregnancy rates

Shown to raise pregnancy rates against no or delayed treatment in two reviews, at low certainty. An older review of four trials found no significant difference.

Compared with no treatment, delayed treatment or non-surgical care [4]; observation [2]; observation, in 4 randomized trials [3]

The numbers and sources
Effect
A Cochrane review found treatment may raise pregnancy rates against delayed or no treatment (RR 1.55, 95% CI 1.06 to 2.26; 13 RCTs, 1,193 couples; I² 65%; low certainty). Pregnancy was 21% without treatment and 22% to 48% after it [4]. A review of 12 prospective studies found more pregnancies than with observation (OR 1.29, 95% CI 1.00 to 1.65, p = 0.048) [2]. An earlier pooled analysis of 4 RCTs in men with low sperm counts found a nonsignificant difference (OR 2.23, 95% CI 0.86 to 5.78) [3].
Population
Couples in which the man had a varicocele and the female partner had no known fertility problem, in 48 RCTs with 5,384 participants overall [4]; adult infertile men [2]; men with low sperm counts [3].
Sources
[4], [2], [3]
Caveats
This block measured pregnancy, not live birth. The Cochrane reviewers rated certainty low because of risk of bias and inconsistency [4]. The lower confidence limit in one review sits at 1.00 [2].
Moderate

Pregnancy and live birth with IVF, ICSI or IUI after repair

One review found higher live birth and pregnancy rates with assisted reproduction when the man's varicocele was repaired first. In men with no sperm, differences were not significant.

Compared with couples in assisted reproduction whose male partner's varicocele was not repaired [5]; men with nonobstructive azoospermia and a varicocele who did not have repair [6]

The numbers and sources
Effect
Across 7 studies of 1,241 patients, repair before assisted reproduction was associated with higher live birth rates in men with low sperm counts (OR 1.699) and in men with low or absent sperm combined (OR 1.761), and with higher pregnancy rates in azoospermic men (OR 2.336) and in the combined group (OR 1.760). Live birth after IUI was higher after repair (OR 8.360) [5]. In men with nonobstructive azoospermia using testicular sperm, clinical pregnancy (OR 2.07, 95% CI 0.92 to 4.65) and live birth (OR 2.19, 95% CI 0.99 to 4.83) favored repair without reaching significance [6].
Population
Couples undergoing IUI, IVF or ICSI in which the man had a varicocele and low or absent sperm [5]; 468 men with nonobstructive azoospermia and varicocele in 18 studies [6].
Sources
[5], [6]
Caveats
The review abstract gives no confidence intervals [5]. The studies were observational, and men who chose repair may differ from those who did not. The azoospermia review rated the evidence low to moderate in quality [6].
StrongStudied in menVery common

Sperm in men with no sperm in the ejaculate (azoospermia)

Shown to raise sperm retrieval rates in men with nonobstructive azoospermia and a varicocele. About 44% had sperm in the ejaculate after repair.

Compared with men with nonobstructive azoospermia and varicocele without repair [6][5]; before repair, in the same men [6]

The numbers and sources
How common
Very common: more than 1 in 10 people.
Effect
In 3 controlled studies, surgical sperm retrieval succeeded more often after repair than without it (OR 2.65, 95% CI 1.69 to 4.14). In 15 studies reporting semen after repair, 43.9% of men (range 20.8% to 55.0%) had sperm in the ejaculate [6]. A second review found higher sperm retrieval rates in men still azoospermic after repair (OR 2.509) [5].
Population
468 men with nonobstructive azoospermia and clinical varicocele, treated by surgery or percutaneous embolization [6]; azoospermic men in assisted reproduction [5].
Sources
[6], [5]
Caveats
Only 3 controlled studies informed the retrieval estimate, and the evidence was rated low to moderate in quality [6]. The two reviews share studies, so their agreement is not fully independent.
StrongStudied in men

Sperm DNA damage

Shown to lower sperm DNA fragmentation after repair in infertile men with a palpable varicocele, measured before and after in the same men.

Compared with before repair, in the same men [7][8]

The numbers and sources
Effect
Across 19 studies of 1,070 men, sperm DNA fragmentation was 7.23 percentage points lower after repair (95% CI -8.86 to -5.59; I² 91%), with larger drops in men whose fragmentation was high before surgery [7]. Across 29 studies of 1,491 men, fragmentation fell (SMD -1.125, 95% CI -1.410 to -0.840; I² 91%) and seminal malondialdehyde, a marker of oxidative stress, fell (SMD -2.450, 95% CI -3.903 to -0.997) [8].
Population
Infertile men with clinical varicocele [7][8].
Sources
[7], [8]
Caveats
Neither review compared repaired men with an untreated group, so changes over time without surgery cannot be excluded. Heterogeneity was high [7][8]. A lower fragmentation result is not a pregnancy.
StrongStudied in men

Testosterone

Shown to raise testosterone after repair, by about 100 to 120 ng/dL in men with low testosterone. In men with normal levels, the rise did not differ from untreated men.

Compared with before repair, in the same men [9][10][11]; untreated men with varicocele, in 3 studies [10]

The numbers and sources
Effect
Across 9 studies of 814 men, testosterone rose 97.48 ng/dL after surgery (95% CI 43.73 to 151.22) [9]. Across 7 studies of men with varicocele, it rose 34.3 ng/dL overall (95% CI 22.57 to 46.04) and 123 ng/dL in men with low testosterone. Against untreated men in 3 studies, the gain in men with low testosterone was 105.65 ng/dL (95% CI 77.99 to 133.32), and men with normal testosterone showed no significant difference (p = 0.36) [10]. Across 18 studies of 1,225 men with low testosterone, levels rose 113.87 ng/dL (95% CI 103 to 124.75) at both under and over 6 months, erectile function scores rose 3.25 points (95% CI 1.49 to 5.01), LH fell slightly (MD -0.28 mIU/mL) and FSH did not change [11].
Population
Infertile men with varicocele [9][10]; adults with low testosterone, mostly treated by microsurgical subinguinal repair [11].
Sources
[9], [10], [11]
Caveats
Most studies compared the same men before and after, without an untreated group [9][11]. The newest review rated studies with observational quality tools [11].
Strong

Testicular growth and sperm in teenagers

Shown to raise testicular volume and sperm concentration against observation in boys and young men. Effects on later fatherhood are unknown.

Compared with observation [12]; conservative management [13]

The numbers and sources
Effect
Across 98 studies of 16,130 patients aged 7 to 21, treatment raised testicular volume by 1.52 mL (95% CI 0.73 to 2.31) and total sperm concentration by 25.54 million/mL (95% CI 12.84 to 38.25) against observation [12]. Across 9 RCTs, testicular volume rose 3.18 mL (95% CI 1.94 to 4.42) and sperm concentration 25.54 million/mL against conservative management [13].
Population
Children and adolescents aged 7 to 21, in 12 RCTs, 47 nonrandomized studies and 39 case series [12]; patients up to 21 in 9 RCTs [13].
Sources
[12], [13]
Caveats
Neither review found data on paternity or fertility [12][13]. The two reviews report the same sperm estimate, which suggests it rests on the same trials. Evidence was rated low to moderate [13].
Moderate

Microsurgical repair against other surgical methods

Shown to raise pregnancy rates slightly and lower recurrence against other surgical methods, in a Cochrane review rated moderate in certainty.

Compared with other surgical techniques [4]; Palomo, laparoscopic and macroscopic inguinal surgery and radiological embolization, in pooled case series [15]

The numbers and sources
Effect
Microscopic subinguinal repair probably raised pregnancy rates against other surgical repairs (RR 1.18, 95% CI 1.02 to 1.36; 12 RCTs, 1,473 couples; moderate certainty), from 10% to between 10% and 14%. It probably lowered recurrence (RR 0.48, 95% CI 0.29 to 0.79; 14 RCTs, 1,565 men), from 1.4% to between 0.4% and 1.1%. Open inguinal and retroperitoneal repair did not differ in pregnancy, recurrence or adverse events across 9 studies [4]. In pooled series of infertile men, spontaneous pregnancy was 41.97% after microsurgical repair, 37.69% after Palomo, 36% after macroscopic inguinal repair, 33.2% after radiological embolization and 30.07% after laparoscopic repair [15].
Population
Couples in randomized trials comparing surgical techniques [4]; infertile men with palpable varicocele in 36 studies [15].
Sources
[4], [15]
Caveats
The case series were not randomized and were reported by technique, so the men treated differ between series [15]. No trial in this comparison reported live birth [4].
LimitedStudied in men

Testicular pain from a varicocele

Limited evidence: uncontrolled studies report pain improved or resolved in up to 90% of men after repair, more often after subinguinal repair.

Compared with before repair, in the same men [18]; high or inguinal repair [19]

The numbers and sources
Effect
A systematic review of 56 quantitative studies reported that up to 90% of men having repair for pain had improvement or resolution [18]. Across 12 studies, pain resolved more often after subinguinal repair than after high or inguinal repair (RR 0.83, 95% CI 0.76 to 0.90), and dull pain resolved more often than sharp pain (RR 1.11, 95% CI 1.02 to 1.22). Varicocele grade was not linked to resolution [19].
Population
Men with scrotal pain attributed to a varicocele [18][19].
Sources
[18], [19]
Caveats
No study compared repair with no repair or a sham, and pain was self-reported by men who knew they had surgery [18][19].

Mixed results1

Limited

Live birth without assisted reproduction

Limited evidence: two trials pointed in opposite directions, so whether repair raises live births is uncertain.

Compared with no treatment [4]

The numbers and sources
Effect
Two RCTs comparing surgical or radiological treatment with no treatment reported live birth with differing directions of effect (RR 2.27, 95% CI 0.19 to 26.93; 204 couples; I² 74%; very low certainty) [4].
Population
204 couples in 2 randomized trials in which the man had a varicocele [4].
Sources
[4]
Caveats
Two trials, very low certainty and a confidence interval running from a large harm to a large benefit. The Cochrane review found no trial data on adverse events or quality of life for this comparison [4].

Not shown to help2

ModerateStudied in men

Varicocele seen only on imaging (subclinical)

Not shown to raise pregnancy rates when a varicocele found only on imaging was repaired. Sperm counts rose slightly in men whose counts were already normal on average.

Compared with men with an unrepaired subclinical varicocele [14]; men with a repaired clinical varicocele [14]

The numbers and sources
Effect
Across 13 studies of 1,357 men, repair of a subclinical varicocele was associated with a small rise in sperm density and total motile sperm count against no repair, in men who were on average normospermic beforehand. Pregnancy rates did not rise. Against repair of a clinical varicocele, the gain in total motile sperm count was smaller and the yearly pregnancy rate did not differ [14].
Population
Men with subclinical varicocele, detected by imaging and not by examination [14].
Sources
[14]
Caveats
Risk of bias was high, heterogeneity was high, and studies defined a subclinical varicocele in different ways [14].
Moderate

Surgery against embolization

Not shown to differ in pregnancy rates between surgery and embolization. Embolization had fewer hydroceles, and reviews disagree on whether it recurs more often.

Compared with radiological treatment [4]; sclero-embolization [16][17]

The numbers and sources
Effect
Pregnancy rates were uncertain between surgical and radiological treatment (RR 1.13, 95% CI 0.75 to 1.70; 5 RCTs, 456 couples; low certainty), as was recurrence (RR 1.31, 95% CI 0.82 to 2.08; 3 RCTs) [4]. Across 30 studies, sclero-embolization had more recurrence than high ligation (OR 1.37, 95% CI 1.03 to 1.82), fewer complications overall (OR 0.65, 95% CI 0.47 to 0.91) and fewer hydroceles (OR 0.19, 95% CI 0.10 to 0.35). Sperm concentration did not differ significantly (MD 7.09, 95% CI -0.14 to 14.31) [16]. Across 20 studies, pregnancy, recurrence, overall complications, sperm count and motility did not differ, while normal sperm forms were 2.54 percentage points higher after sclero-embolization [17].
Population
Couples in randomized trials [4]; patients in 30 cohort and randomized studies [16]; children, adolescents and adults in 20 studies [17].
Sources
[4], [16], [17]
Caveats
Most comparisons rest on nonrandomized studies. The two newer reviews disagree on recurrence [16][17].

Protocols studied

The trials and series used several methods. Surgical repair tied off the veins through the groin (inguinal, or Ivanissevich), below the groin (subinguinal), above it (retroperitoneal, or Palomo) or by laparoscopy, with or without an operating microscope [4][15]. Radiological repair blocked the vein from inside with coils, glue or a sclerosing agent through a catheter (percutaneous embolization or sclerotherapy), which succeeded in about 90% of attempts in reported series [20][16]. Comparison groups were no treatment, delayed treatment or observation [4][2]. Testosterone was measured from under 6 months to over 6 months after repair [11], and semen at follow-ups of months [1][2].

Risks

Reported risks3

ModerateCommon

Hydrocele (fluid around the testicle)

Reported in about 0.4% to 8% of men after surgery, depending on the method, in pooled series. Embolization and lymphatic-sparing surgery had fewer hydroceles.

The numbers and sources
How common
Common: between 1 in 100 and 1 in 10 people.
Effect
In pooled series of infertile men, hydrocele formed after 8.24% of Palomo repairs, 7.3% of macroscopic inguinal or subinguinal repairs, 2.84% of laparoscopic repairs and 0.44% of microsurgical repairs [15]. Hydrocele was less frequent after sclero-embolization than after surgical ligation (OR 0.19, 95% CI 0.10 to 0.35) [16], and more frequent after surgical ligation than embolization in a second review (OR 3.06, 95% CI 1.06 to 8.88) [17]. In children and adolescents, lymphatic-sparing surgery had fewer hydroceles than non-sparing surgery (p = 0.02) [12]. In randomized trials of microsurgery against other surgery, results for hydrocele, hematoma, testicular atrophy, wound infection, scrotal pain and swelling were inconclusive [4].
Population
Infertile men in 36 studies [15]; patients in 30 studies [16] and 20 studies [17]; patients aged 7 to 21 [12].
Sources
[15], [16], [17], [12], [4]
Caveats
Rates come mostly from case series, not head-to-head trials [15].
ModerateCommon

Varicocele coming back (recurrence or persistence)

Reported in about 1% to 15% of men depending on the method, least often after microsurgical repair and most often after Palomo repair and embolization in pooled series.

The numbers and sources
How common
Common: between 1 in 100 and 1 in 10 people.
Effect
In pooled series, recurrence was 14.97% after Palomo repair, 12.7% after radiological embolization, 4.3% after laparoscopic repair, 2.63% after macroscopic inguinal or subinguinal repair and 1.05% after microsurgical repair [15]. In randomized trials, recurrence was 0.4% to 1.1% after microsurgical subinguinal repair and 1.4% after other surgery (RR 0.48, 95% CI 0.29 to 0.79) [4]. One trial of 30 men found 13% recurrence after both sclerotherapy and embolization [4]. Sclero-embolization recurred more often than high ligation (OR 1.37, 95% CI 1.03 to 1.82) [16].
Population
Infertile men in 36 studies [15]; couples in randomized trials [4]; patients in 30 studies [16].
Sources
[15], [4], [16]
Caveats
Recurrence was defined and checked differently across studies.
LimitedHow often is not known

Complications of embolization

Case series describe vein perforation, coil migration and clotting in the testicular veins after embolization, with no rate given. Testicular inflammation was more frequent than after surgery in one review.

The numbers and sources
How common
How often is not known: the sources give no rate.
Effect
A review of percutaneous embolization lists vascular perforation, coil migration and thrombosis of the pampiniform plexus as potential serious complications, and reports technical success in about 90% of attempts [20]. Orchiepididymitis, inflammation of the testicle and epididymis, was more frequent after sclero-embolization than after surgical ligation (OR 0.26 for surgery against embolization, 95% CI 0.08 to 0.85) [17].
Population
Published embolization series [20]; patients in 20 comparative studies [17].
Sources
[20], [17]
Caveats
The review gives no frequency for the serious complications [20].

Claims tested and not found

  1. That repairing a varicocele seen only on imaging raises pregnancy rates. Across 13 studies of 1,357 men, pregnancy rates did not rise after repair of a subclinical varicocele [14].
  2. That repair raises testosterone in men whose levels are normal. Against untreated men, the change in men with normal testosterone did not differ significantly (p = 0.36) [10].
  3. That repair has been shown to raise live births without assisted reproduction. Two randomized trials pointed in opposite directions (RR 2.27, 95% CI 0.19 to 26.93, very low certainty) [4].

Sources

  1. Agarwal A, Cannarella R, Saleh R, et al. Impact of Varicocele Repair on Semen Parameters in Infertile Men: A Systematic Review and Meta-Analysis. The World Journal of Men's Health. 2023. https://doi.org/10.5534/wjmh.220142
  2. Fallara G, Capogrosso P, Pozzi E, et al. The Effect of Varicocele Treatment on Fertility in Adults: A Systematic Review and Meta-analysis of Published Prospective Trials. European Urology Focus. 2023. https://doi.org/10.1016/j.euf.2022.08.014
  3. Baazeem A, Belzile E, Ciampi A, et al. Varicocele and Male Factor Infertility Treatment: A New Meta-analysis and Review of the Role of Varicocele Repair. European Urology. 2011. https://doi.org/10.1016/j.eururo.2011.06.018
  4. Persad E, O'Loughlin CA, Kaur S, et al. Surgical or radiological treatment for varicoceles in subfertile men. Cochrane Database of Systematic Reviews. 2021. https://doi.org/10.1002/14651858.cd000479.pub6
  5. Kirby EW, Wiener LE, Rajanahally S, et al. Undergoing varicocele repair before assisted reproduction improves pregnancy rate and live birth rate in azoospermic and oligospermic men with a varicocele: a systematic review and meta-analysis. Fertility and Sterility. 2016. https://doi.org/10.1016/j.fertnstert.2016.07.1093
  6. Esteves SC, Miyaoka R, Roque M, Agarwal A. Outcome of varicocele repair in men with nonobstructive azoospermia: systematic review and meta-analysis. Asian Journal of Andrology. 2016. https://doi.org/10.4103/1008-682x.169562
  7. Lira Neto FT, Roque M, Esteves SC. Effect of varicocelectomy on sperm deoxyribonucleic acid fragmentation rates in infertile men with clinical varicocele: a systematic review and meta-analysis. Fertility and Sterility. 2021. https://doi.org/10.1016/j.fertnstert.2021.04.003
  8. Cannarella R, Shah R, Saleh R, et al. Effects of Varicocele Repair on Sperm DNA Fragmentation and Seminal Malondialdehyde Levels in Infertile Men with Clinical Varicocele: A Systematic Review and Meta-Analysis. The World Journal of Men's Health. 2024. https://doi.org/10.5534/wjmh.230235
  9. Li F, Yue H, Yamaguchi K, et al. Effect of surgical repair on testosterone production in infertile men with varicocele: A meta-analysis. International Journal of Urology. 2012. https://doi.org/10.1111/j.1442-2042.2011.02890.x
  10. Chen X, Yang D, Lin G, et al. Efficacy of varicocelectomy in the treatment of hypogonadism in subfertile males with clinical varicocele: A meta-analysis. Andrologia. 2017. https://doi.org/10.1111/and.12778
  11. Aboukhshaba A, Almajed E, Bin Shunayf M, et al. Effect of Varicocelectomy on Testosterone Parameters in Hypogonadism: A Systematic Review and Meta-Analysis. The World Journal of Men's Health. 2026. https://doi.org/10.5534/wjmh.250255
  12. Silay MS, Hoen L, Quadackaers J, et al. Treatment of Varicocele in Children and Adolescents: A Systematic Review and Meta-analysis from the European Association of Urology/European Society for Paediatric Urology Guidelines Panel. European Urology. 2019. https://doi.org/10.1016/j.eururo.2018.09.042
  13. Locke JA, Noparast M, Afshar K. Treatment of varicocele in children and adolescents: A systematic review and meta-analysis of randomized controlled trials. Journal of Pediatric Urology. 2017. https://doi.org/10.1016/j.jpurol.2017.07.008
  14. Kohn TP, Ohlander SJ, Jacob JS, et al. The Effect of Subclinical Varicocele on Pregnancy Rates and Semen Parameters: a Systematic Review and Meta-Analysis. Current Urology Reports. 2018. https://doi.org/10.1007/s11934-018-0798-8
  15. Cayan S, Shavakhabov S, Kadioğlu A. Treatment of Palpable Varicocele in Infertile Men: A Meta-analysis to Define the Best Technique. Journal of Andrology. 2009. https://doi.org/10.2164/jandrol.108.005967
  16. Chen H, Liu K, Liu M, et al. Comparison of sclero-embolization and surgical ligation for varicocele treatment: a systematic review and meta-analysis. World Journal of Urology. 2025. https://doi.org/10.1007/s00345-025-06014-4
  17. Fabiani A, Pavia MP, Stramucci S, et al. Do sclero-embolization procedures have advantages over surgical ligature in treating varicocele in children, adolescents and adults? Results from a systematic review and meta-analysis. Andrologia. 2022. https://doi.org/10.1111/and.14510
  18. Lundy SD, Sabanegh ES. Varicocele management for infertility and pain: A systematic review. Arab Journal of Urology. 2018. https://doi.org/10.1016/j.aju.2017.11.003
  19. Han DY, Yang QY, Chen X, et al. Who will benefit from surgical repair for painful varicocele: a meta-analysis. International Urology and Nephrology. 2016. https://doi.org/10.1007/s11255-016-1246-7
  20. Halpern J, Mittal S, Pereira K, Bhatia S, Ramasamy R. Percutaneous embolization of varicocele: technique, indications, relative contraindications, and complications. Asian Journal of Andrology. 2016. https://doi.org/10.4103/1008-682x.169985

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