Treating varicocele in 2018: current knowledge and treatment options.

Varicocele is defined as a state of varicosity and tortuosity of the pampiniform plexus (PP) around the testis caused by retrograde blood flow through the internal spermatic vein. Primary varicocele (unravelled etiology) should be distinguished from secondary forms caused by external compression (tipically abdominal masses). The prevalence of clinically relevant varicocele ranges from 5 to 20% in the male population and is often associated with infertility and reduction of sperm quality. In fact, the presence of varicocele can lead to alterations in seminal parameters (sperm count, motility or morphology) and integrity of sperm DNA, contributing to infertility, reduced pregnancy/live birth rate and possible increased risk of miscarriage during the first trimester. Data from a large number of studies in adolescent and adult males indicate that varicocele correction improves semen parameters in the majority of patients, reducing oxidative stress and improving sperm nuclear DNA integrity either with surgical or percutaneous approach. Thus, varicocele repair seems to represent a cost-effective therapeutic option for all males (both adolescent and adults) with a clinical varicocele in the presence of testicular hypotrophy, worsening sperm alterations or infertility. On the other hand, some investigators questioned the role of varicocelectomy in the era of assisted reproduction. Thus, a better understanding of the pathophysiology of varicocele-associated male subfertility is of paramount importance to elucidating the deleterious effects of varicocele on spermatogenesis and possibly formulating new treatment strategies. In this review the pathophysiology and clinical aspects of varicocele are reviewed along with therapeutic options and treatment effects on sperm parameters and fertility both in adult and in paediatric/adolescent subjects.