[Male fertility after varicocelectomy: possible management algorithms, prediction, and a multidisciplinary approach]

Varicocelectomy remains one of the most effective surgical options for the treatment of male infertility associated with varicocele. However, the likelihood of spontaneous pregnancy after surgical intervention varies considerably even when semen parameters improve objectively. Current evidence highlights the importance of a personalized approach to postoperative management based on changes in the total number of progressively motile spermatozoa in the ejaculate. Clinical algorithms have been proposed to stratify patients into management groups, including active surveillance, intrauterine insemination (IUI), and in vitro fertilization (IVF/ICSI), depending on the total motility count. Predictive tools, such as nomograms and criteria for "clinically meaningful improvement", have also been developed to optimize clinical decision-making. In addition, antioxidant therapy may be considered in selected cases to improve semen quality in patients with moderate improvement in semen parameters. A multidisciplinary approach involving specialists in reproductive medicine, dietitians/nutritionists, and physicians of other specialties is also extremely important for achieving the best reproductive outcomes in couples after varicocelectomy.