Should the current guidelines for the treatment of varicoceles in infertile men be re-evaluated?

Male infertility is a major health burden worldwide. In the United Kingdom, the diagnostic and treatment pathway for male factor fertility is fragmented with wide variance in management and funding protocols. There is now a focus on potential overtreatment of couples with IVF and failure to treat male factors before considering assisted reproductive technology (ART). Despite this, contemporary Urological guidelines are not definitive in the indications for varicocele treatment, whilst the current National Institute for Health and Care Excellence (NICE) guidelines do not advocate surgical intervention. While controversy exists concerning the effects of varicocele treatment on natural pregnancy rates, there is growing evidence that varicocele treatment can have additional positive effects on fertility by reducing their impact on sperm DNA fragmentation and improving ART outcomes. Studies have demonstrated that azoospermic men may become oligospermic following varicocele intervention, obviating the need for surgical sperm retrieval. Sperm retrieval rates also increase following varicocele treatment in men with non-obstructive azoospermia. The contemporary literature demonstrates a clear clinical benefit for treating varicoceles in infertile men, which may be more cost-effective than proceeding to immediate ART. This review comprehensively evaluates the current indications for varicocele treatment, and it is proposed that these should be redefined in contemporary guidelines to reflect current advances in male fertility research.