Varicocelectomy in adolescents – Does it safeguard future fertility? A single centre experience

Published:December 04, 2021DOI:



      There is paucity of literature comparing varicocelectomy to observant management amongst adolescent boys with hormonal and semen abnormalities resulting from high grade unilateral varicoceles and consequent testicular volume loss. Furthermore, it is not known whether surgical correction in such adolescents improves paternity rates in future compared to their non-operated cohort.


      The primary objective was to compare adolescent boys with unilateral high grade varicocele with associated ipsilateral testicular volume loss who were operated versus those who were not, in relation to their fertility markers (hormonal, semen parameters, and testicular volume) over a 5 year follow up period. The secondary objective was to compare the paternity rates in the respective groups over long term.

      Study design

      This was a single center, retrospective study of a prospectively maintained database conducted from 2010 to 2020, based on a standardized protocol. All adolescent boys >15 years of age (middle and late adolescence), with grade II or III unilateral varicoceles with abnormal fertility markers, who were operated (Group A) and not operated (Group B) were included. The changes in hormonal assay, sonographic assessment, semen analysis at presentation, 1st year and the 5th year follow up amongst both the groups were collated and analysed. Primary paternity rates amongst both the groups was documented by telephonic or email conversations.


      Of the 182 boys referred for varicocele management, 110 boys (Group A −70 boys and Group B - 40 boys) satisfied our inclusion criteria and were analysed. Mean age at presentation amongst Group A boys was 16.5 years (15–18 years) and Group B boys was 16 years (15–18 years). Grade III varicoceles were more predominant amongst both the groups. There was a significant improvement in all Group A boys (operated) in the fertility markers from the time at presentation to the 5th year follow up (p < 0.001). In Group B, (boys not operated) there was no significant improvement in the above parameters. The testicular catch up growth was 92% at the 5th year follow-up in Group A and 42% in Group B. At long term follow-up, the paternity rate was 80% and 36% in Group A and B respectively.

      Discussion and conclusion

      In adolescent boys in whom hormonal assay, testicular volumes and semen characteristics are negatively affected by high grade unilateral varicoceles, surgical correction could normalize these values, thereby safeguarding their fertility in the long term.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic and Personal
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Pediatric Urology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Akbay E.
        • Cayan S.
        • Doruk E.
        • Duce M.N.
        • Bozlu M.
        The prevalence of varicocele and varicocele-related testicular atrophy in Turkish children and adolescents.
        BJU Int. 2000; 86: 490-493
        • Kolon T.F.
        Evaluation and management of the adolescent varicocele.
        J Urol. 2015; 194: 1194-1201
        • Gordetsky J.
        • van Wijngaarden E.
        • O'Brien J.
        Redefining abnormal follicle-stimulating hormone in the male infertility population.
        BJU Int. 2012; 110: 568-572
        • Çayan S.
        • Akbay E.
        • Bozlu M.
        • Doruk E.
        • Erdem E.
        • Acar D.
        • et al.
        The effect of varicocele repair on testicular volume in children and adolescents with varicocele.
        J Urol. 2002; 168: 731-734
        • Fiogbe M.A.
        • Alao M.J.
        • Biaou O.
        • Gbenou S.A.
        • Yekpe P.
        • Sossou R.
        • et al.
        Ultrasound diagnosis of varicocele in the adolescent: our experience from Benin.
        Afr J Paediatr Surg. 2013; 10: 295
        • Bertolla R.P.
        • Cedenho A.P.
        • Hassun Filho P.A.
        • Lima S.B.
        • Ortiz V.
        • Srougi M.
        Sperm nuclear DNA fragmentation in adolescents with varicocele.
        Fertil Steril. 2006; 85: 625-628
        • Locke J.A.
        • Noparast M.
        • Afshar K.
        Treatment of varicocele in children and adolescents: a systematic review and meta-analysis of randomized controlled trials.
        J Pediatr Urol. 2017; 13: 437-445
        • Lenzi A.
        • Gandini L.
        • Bagolan P.
        • Nahum A.
        • Dondero F.
        Sperm parameters after early left varicocele treatment.
        Fertil Steril. 1998; 69: 347-349
        • Preston M.A.
        • Carnat T.
        • Flood T.
        • Gaboury I.
        • Leonard M.P.
        Conservative management of adolescent varicoceles: a retrospective review.
        Urology. 2008; 72: 77-80
        • Salzhauer E.W.
        • Sokol A.
        • Glassberg K.I.
        Paternity after adolescent varicocele repair.
        Pediatrics. 2004; 114: 1631-1633
        • Dubin L.
        • Amelar R.D.
        Varicocele size and results of varicocelectomy in selected subfertile men with varicocele.
        Fertil Steril. 1970; 21: 606-609
        • Cayan S.
        • Kadioglu A.
        • Orhan I.
        • Kandirali E.
        • Tefekli A.
        • Tellaloglu S.
        The effect of microsurgical varicocelectomy on serum follicle stimulating hormone, testosterone and free testosterone levels in infertile men with varicocele.
        BJU Int. 1999; 84: 1046-1049
        • Kanakis G.A.
        • Tsametis C.P.
        • Goulis D.G.
        Measuring testosterone in women and men.
        Maturitas. 2019; 125: 41-44
        • Oehme N.H.B.
        • Roelants M.
        • Særvold Bruserud I.
        • Madsen A.
        • Eide G.E.
        • Bjerknes R.
        • et al.
        Reference data for testicular volume measured with ultrasound and pubic hair in Norwegian boys are comparable with Northern European populations.
        Acta Paediatr. 2020; 109: 1612-1619
        • Vaganée D.
        • Daems F.
        • Aerts W.
        • Dewaide R.
        • van den Keybus T.
        • De Baets K.
        • et al.
        Testicular asymmetry in healthy adolescent boys.
        BJU Int. 2018; 122: 654-666
        • Cooper T.G.
        • Noonan E.
        • Von Eckardstein S.
        • Auger J.
        • Baker H.W.
        • Behre H.M.
        • et al.
        World Health Organization reference values for human semen characteristics.
        Hum Reprod Update. 2010; 16: 231-245
        • Birowo P.
        • Wijaya J.R.
        • Atmoko W.
        • Rasyid N.
        The effects of varicocelectomy on the DNA fragmentation index and other sperm parameters: a meta-analysis.
        Basic Clin Androl. 2020; 30: 1-9
        • De Iuliis G.N.
        • Thomson L.K.
        • Mitchell L.A.
        • Finnie J.M.
        • Koppers A.J.
        • Hedges A.
        • et al.
        DNA damage in human spermatozoa is highly correlated with the efficiency of chromatin remodeling and the formation of 8-hydroxy-2′-deoxyguanosine, a marker of oxidative stress.
        Biol Reprod. 2009; 81: 517-524
        • Dindo D.
        • Demartines N.
        • Clavien P.-A.
        Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.
        Ann Surg. 2004; 240: 205
        • Clavien P.A.
        • Barkun J.
        • De Oliveira M.L.
        • Vauthey J.N.
        • Dindo D.
        • Schulick R.D.
        • et al.
        The Clavien-Dindo classification of surgical complications: five-year experience.
        Ann Surg. 2009; 250: 187-196
        • Kolon T.F.
        • Clement M.R.
        • Cartwright L.
        • Bellah R.
        • Carr M.C.
        • Canning D.A.
        • et al.
        Transient asynchronous testicular growth in adolescent males with a varicocele.
        J Urol. 2008; 180: 1111-1115
        • Minevich E.
        • Wacksman J.
        • Lewis A.G.
        • Sheldon C.A.
        Inguinal microsurgical varicocelectomy in the adolescent: technique and preliminary results.
        J Urol. 1998; 159: 1022-1024
        • Paduch D.A.
        • Skoog S.J.
        Current management of adolescent varicocele.
        Rev Urol. 2001; 3: 120
        • Çayan S.
        • Shavakhabov S.
        • Kadioğlu A.
        Treatment of palpable varicocele in infertile men: a meta-analysis to define the best technique.
        J Androl. 2009; 30: 33-40
        • Walker W.H.
        • Cheng J.
        FSH and testosterone signaling in Sertoli cells.
        Reproduction. 2005; 130: 15-28
        • Kass E.J.
        • Freitas J.E.
        • Salisz J.A.
        • Steinert B.W.
        Pituitary gonadal dysfunction in adolescents with varicocele.
        Urology. 1993; 42: 179-181
        • Guarino N.
        • Tadini B.
        • Bianchi M.
        The adolescent varicocele: the crucial role of hormonal tests in selecting patients with testicular dysfunction.
        J Pediatr Surg. 2003; 38: 120-123
        • Zampieri N.
        Hormonal evaluation in adolescents with varicocele.
        J Pediatr Urol. 2021; 17 (49–e1)
        • Takeyama M.
        • Honjoh M.
        • Kodama M.
        • Sakaguchi H.
        • Koh E.
        • Kondoh N.
        • et al.
        Testicular steroids in spermatic and peripheral veins after single injection of hCG in patients with varicocele.
        Arch Androl. 1990; 24: 207-213
        • Takihara H.
        • Cosentino M.J.
        • Sakatoku J.
        • Cockett A.T.
        Significance of testicular size measurement in andrology: II. Correlation of testicular size with testicular function.
        J Urol. 1987; 137: 416-419
        • Riebel T.
        • Herrmann C.
        • Wit J.
        • Sellin S.
        Ultrasonographic late results after surgically treated cryptorchidism.
        Pediatr Radiol. 2000; 30: 151-155
        • Lemack G.E.
        • Uzzo R.G.
        • Schlegel P.N.
        • Goldstein M.
        Microsurgical repair of the adolescent varicocele.
        J Urol. 1998; 160: 179-181
        • Paduch D.A.
        • Niedzielski J.
        Repair versus observation in adolescent varicocele: a prospective study.
        J Urol. 1997; 158: 1128-1132
        • Seo J.W.
        • Cho K.S.
        • Han S.W.
        Ipsilateral testicular catch-up growth after varicocelectomy in adolescents.
        Korean J Urol. 2007; 48: 731-734
        • Zampieri N.
        • Mantovani A.
        • Ottolenghi A.
        • Camoglio F.S.
        Testicular catch-up growth after varicocelectomy: does surgical technique make a difference?.
        Urology. 2009; 73: 289-292
        • Moursy E.E.S.
        • ElDahshoury M.Z.
        • Hussein M.M.
        • Mourad M.Z.
        • Badawy A.A.
        Dilemma of adolescent varicocele: long-term outcome in patients managed surgically and in patients managed expectantly.
        J Pediatr Urol. 2013; 9: 1018-1022
        • Guzick D.S.
        • Overstreet J.W.
        • Factor-Litvak P.
        • Brazil C.K.
        • Nakajima S.T.
        • Coutifaris C.
        • et al.
        Sperm morphology, motility, and concentration in fertile and infertile men.
        N Engl J Med. 2001; 345: 1388-1393
        • Ku J.H.
        • Kim S.W.
        • Park K.
        • Paick J.-S.
        Benefits of microsurgical repair of adolescent varicocele: comparison of semen parameters in fertile and infertile adults with varicocele.
        Urology. 2005; 65: 554-558
        • Cayan S.
        • Acar D.
        • ÜLger Sül
        • Akbay E.
        Adolescent varicocele repair: long-term results and comparison of surgical techniques according to optical magnification use in 100 cases at a single university hospital.
        J Urol. 2005; 174: 2003-2007
        • Kadioglu T.C.
        • Aliyev E.
        • Celtik M.
        Microscopic varicocelectomy significantly decreases the sperm DNA fragmentation index in patients with infertility.
        BioMed Res Int. 2014; 2014
        • Telli O.
        • Sarici H.
        • Kabar M.
        • Ozgur B.C.
        • Resorlu B.
        • Bozkurt S.
        Does varicocelectomy affect DNA fragmentation in infertile patients?.
        Indian J Urol IJU J Urol Soc India. 2015; 31: 116
        • De Win G.
        • De Neubourg D.
        • De Wachter S.
        • Vaganée D.
        • Punjabi U.
        Peak retrograde flow a potential objective management tool to identify young adults with varicocele ‘at risk’for a high sperm DNA fragmentation.
        J Pediatr Urol. December 2021; 17: 760.e1-760.e9
        • Çayan S.
        • Şahin S.
        • Akbay E.
        Paternity rates and time to conception in adolescents with varicocele undergoing microsurgical varicocele repair vs observation only: a single institution experience with 408 patients.
        J Urol. 2017; 198: 195-201
        • Bogaert G.
        • Orye C.
        • De Win G.
        Pubertal screening and treatment for varicocele do not improve chance of paternity as adult.
        J Urol. 2013; 189: 2298-2304