Varicoceles in the pediatric and

adolescent population: threat to

future fertility?
Deborah L. Jacobson, M.D.a,b and Emilie K. Johnson, M.D., M.P.H.a,b
a b
Division of Pediatric Urology, Ann & Robert H. Lurie Children's Hospital of Chicago; and Department of Urology,
Northwestern University Feinberg School of Medicine, Chicago, Illinois

Determining the effect of varicoceles on future fertility is challenging owing to multiple issues in children/adolescents, including: lim-
itations in obtaining and interpreting semen analyses; potential for unequal differential testicular growth during puberty regardless of
varicocele presence; and the potential for a lengthy interval between surgical intervention for varicocele in adolescence and attempts at
paternity. This review presents a summary and evaluation of the available evidence relating to future fertility among children and ad-
olescents with varicoceles. Data relating to proxy fertility measures in children/adolescents, including testicular size asymmetry and
semen analysis abnormalities, demonstrate that these proxy measures are imperfect predictors of future fertility. Two large, recently
published series of adolescents undergoing varicocele treatment showed conflicting paternity outcomes. Pediatric and adolescent vari-
cocele will remain a clinical conundrum, subject to both over- and under-treatment, until more definitive prospective data are available.
(Fertil SterilÒ 2017;108:370–7. Ó2017 by American Society for Reproductive Medicine.)
Key Words: Fertility, pediatrics, varicocele

Discuss: You can discuss this article with its authors and with other ASRM members at https://www.fertstertdialog.com/users/
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selected for final inclusion in this re-

V
aricoceles in the pediatric and evidence relating to the effects of vari-
adolescent population pose a coceles in children and adolescents on view on the basis of relevance to the
clinical challenge because of future fertility. For context, an over- subtopics detailed below.
uncertain effects on future fertility, view of pediatric/adolescent varicocele
and there are currently no guidelines presentation, epidemiology, pathogen-
in place for management of pediatric esis, clinical evaluation, and treatment
PRESENTATION AND
patients with varicoceles. Determining options is also presented. To conduct EPIDEMIOLOGY
the effect of varicoceles on future this review, searches of PubMed, Web The definition and grading system used
fertility is challenging owing to multiple of Science, EMBASE, and Scopus were to characterize varicoceles is identical
issues in children/adolescents, performed. Search terms were entered in children/adolescents and adults. A
including: limitations in obtaining and to identify primary literature related varicocele is defined as an abnormal
interpreting semen analyses (SA); po- to varicoceles, pediatrics, semen anal- dilation of the pampiniform plexus in
tential for unequal differential testicular ysis, testicular hypotrophy, and the scrotum, and children/adolescents
growth during puberty regardless of fertility/infertility. Abstracts were re- with varicocele most often present to
varicocele presence; and the potential viewed by both authors and subcatego- a urologist after an incidental diagnosis
for a lengthy interval between surgical rized. Book chapters and non–English by their pediatrician. Varicoceles in
intervention for varicocele in adoles- language articles were excluded, and children/adolescents are clinically
cence and attempts at paternity. additional articles were selected after graded according to the classification
The purpose of this review is to review of the references from the initial system originally described by Dubin
summarize and evaluate the available articles identified. Articles were and Amelar in 1970 (1), in which grade
1 indicates that the varicocele is
palpable with Valsalva, grade 2 indi-
Received May 8, 2017; revised June 21, 2017; accepted July 13, 2017; published online August 10, 2017.
cates palpability with standing only,
D.L.J. has nothing to disclose. E.K.J. has nothing to disclose. and grade 3 indicates visibility with
Reprint requests: Emilie K. Johnson, M.D., M.P.H., Ann & Robert H. Lurie Children's Hospital, Division standing.
of Urology, 225 E. Chicago Avenue, Box 24, Chicago, Illinois 60611 (E-mail: ekjohnson@
luriechildrens.org). In children/adolescents the preva-
lence and grade distribution of varico-
Fertility and Sterility® Vol. 108, No. 3, September 2017 0015-0282/$36.00
Copyright ©2017 American Society for Reproductive Medicine, Published by Elsevier Inc.
celes varies according to whether
http://dx.doi.org/10.1016/j.fertnstert.2017.07.014 epidemiologic or clinical-level studies

370 VOL. 108 NO. 3 / SEPTEMBER 2017


are evaluated. Multiple European studies have reported popu-
lation prevalence estimates of pediatric/adolescent varico-
cele, which are largely derived from school screening
protocols. Overall prevalence estimates range from 4.1% to
35.1%, and prevalence seems to increase with increasing pa-
tient age (2–7). For example, one Turkish study found a 0.8%
varicocele prevalence in boys aged 2–6 years, with an
increase to 11% by age 11–19 years (2). The authors also
noted a sharp rise in prevalence in boys aged 10–14 years
(2). In these population-level studies, grade 1 varicoceles
tended to be most common, followed by grade 2 and then
grade 3. In a cohort of 960 boys from Montenegro, overall
varicocele prevalence was found to be 9.7%. In this study,
51% of 94 boys with a varicocele had grade 1, 33% grade 2,
and 16% grade 3 on screening evaluation (7). Interestingly,
Niedzielski et al. (4) found a stable prevalence of grade 1 vari-
cocele in Polish school boys with increasing age but noted
that grades 2 and 3 became more common as boys began
progress through adolescence. The prevalence of palpable
bilateral varicoceles in adolescents with varicocele ranges
from 10.8% to 59.1%, with subclinical right varicoceles in
an additional 8.7%–17.6% of patients (8–12). Varicoceles
are more common in boys who are taller, have lower body
mass index, and have larger phalluses, although the reasons
for these associations are unclear (3, 13).
Similar to population-level screening studies, clinical
studies of pediatric/adolescent varicocele conducted in urol-
ogy clinics demonstrate that patients with varicoceles tend
to present during mid- to late adolescence. One such study,
spanning a 17-year period, found a mean (
SD) age at pre-
sentation of 15.2
3.5 years (14). In contrast to the larger
epidemiologic studies, children/adolescents evaluated in
urology clinics tend to have a vastly different grade distribu-
tion than boys with varicocele who are identified through
population-based screening. It is rare for boys presenting to
a urology clinic to have a grade 1 varicocele, with rates
ranging from 0 to 15% (15–18). In these studies of patients
evaluated in urology clinics, at least a plurality of patients
tends to present with a grade 3 varicocele. In one study
patients with grade 3 varicocele comprised 68% of the study
sample (18). This difference in grade at presentation in
epidemiologic studies vs. studies of patients presenting to
urology clinics is likely due to referral bias.
PATHOGENESIS
There are multiple proposed pathologic mechanisms for the
relationship between varicoceles and infertility, a full discus-
sion of which is outside the scope of this review. In general it
is not understood why some men with varicocele develop
infertility and some do not. It is postulated that multiple fac-
tors, including poor testicular perfusion, heat stress, oxidative
stress, and endocrine abnormalities, contribute to the devel-
opment of varicocele-associated infertility (19, 20). The
uncertainty about which individuals with a varicocele will
develop infertility is especially vexing for clinicians trying
determine whether treatment for pediatric/adolescent
varicocele is indicated, because any attempts at paternity
will occur many years in the future.
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Fertility and Sterility®
Although not studied as comprehensively as in adults,
several theories about the relationship between varicoceles
and future infertility have been evaluated among adolescents.
For example, one study found elevated levels of nitric oxide
and nitrotyrosine (a marker of nitric oxide damage) in the
spermatic veins of adolescent patients with varicocele (21).
In another study, Bertolla et al. (22) compared SA parameters
and DNA fragmentation in adolescent boys with and without
varicocele. Although no difference was noted between varico-
cele patients and normal controls with respect to SA param-
eters, including concentration, motility, and morphology, a
higher rate of DNA fragmentation was noted in adolescents
with a varicocele. The authors postulate that DNA fragmenta-
tion may be an early marker of apoptosis and/or oxidative
stress, even when SA parameters are normal (22). These find-
ings were corroborated in a 2014 study by Lacerda et al. (23),
in which adolescent patients with significant preoperative
DNA fragmentation demonstrated post-varicocelectomy
improvement in DNA fragmentation rates.
CLINICAL EVALUATION AND RELIABILITY OF
SIZE ESTIMATION METHODS
Clinical evaluation of the pediatric/adolescent varicocele fo-
cuses on the perceived potential for future infertility, which is
largely based on testicular size estimation and SA (when
feasible). Although large testicular size discrepancies can be de-
tected via physical examination, adjunctive strategies for more
accurate estimation of testicular size are recommended. Multi-
ple different orchidometers have been developed for measuring
testicular size (Table 1) (24, 25), and several formulas for
estimating testicular volume according to ultrasound
measurements have been utilized in relevant publications
(Table 2) (24, 26). The Lambert formula (27) (length  width
 height  0.71) for measurement of testicular volume is the
most commonly used formula in recently published pediatric/
adolescent varicocele literature. A recent survey of pediatric
urologists found that 49% of respondents reported
monitoring testicular size by ultrasound, 38% by
orchidometer, and 11% by physical examination alone (28).
In general, ultrasound measurements are considered
somewhat more accurate for estimating true testicular volume
when compared with orchidometers. This finding is supported
by comparisons made in two recent studies. In the first, or-
chidometer measurements and ultrasonograhic volume cal-
culations were compared with measured testicular volume
among euthanized dogs (24). In the second, orchiectomy
TABLE 1
Orchidometers for testicular volume measurement.
Name of device Shape
Prader Solid ellipse
Rochester Cutout to surround testis
Seager Caliper to measure, then calculate volume
according to a formula
Takihara Cutout to surround testis
Jacobson. Varicoceles in pediatrics. Fertil Steril 2017.
371
VIEWS AND REVIEWS
TABLE 2
Formulas for calculating testicular volume.
Name Formula
Behre (p/6)  L  D2
Ellipsoid L  W  H  0.52
Lambert L  W  H  0.71
Prolate spheroid L  W2  0.52
Note: D ¼ diameter; H ¼ height; L ¼ length; W ¼ width.
Jacobson. Varicoceles in pediatrics. Fertil Steril 2017.
specimens from prostate cancer patients were compared with
several ultrasound-based volume measurements (29). Both
studies concluded that measurements utilizing the Lambert
formula most closely correlated with measured testicular vol-
umes. In a clinical study of men presenting to an infertility
clinic, Prader orchidometer measurements were highly corre-
lated with testicular volumes measured via ultrasound, but
accuracy varied with provider experience. In this study, Behre
et al. (26) found that Prader orchidometer measurements
taken by a more experienced andrologist were more highly
correlated with volumes measured by ultrasound.
For patients who can provide a semen specimen, SA pro-
vides a useful adjunct to history, physical examination, and
testicular size measurements as determined by orchidometer
or ultrasound. However, use of SA is somewhat limited by
multiple factors, including [1] lack of standardized SA values
for adolescent patients, [2] inability to obtain a specimen from
some patients due to physical or emotional maturity con-
straints, and [3] provider reluctance or discomfort with SA.
Fortunately, the concordance between key parameters (total
count, total motile sperm count [TMC]) obtained on consecu-
tive SA seems to be high; thus, even one SA can provide valu-
able information in adolescents (30). Though not validated in
an adolescent population, the World Health Organization
reference values are generally used to interpret SA among ad-
olescents. A recent survey of pediatric urologists indicated
that most (53% of the 168 who responded to the survey) never
ask for an SA in their practice, whereas only 13% routinely do
so (31). In this survey Fine et al. also noted that 25% of pedi-
atric urologists felt uncomfortable discussing SA with adoles-
cents in general, and 22% felt discomfort depending on the
patient/family (31). Even when barriers to SA are overcome
and a SA is obtained, a ‘‘normal’’ SA may not reveal more sub-
tle damage, such as sperm DNA fragmentation, associated
with future fertility challenges (22).
TREATMENT
Common indications for surgical treatment of pediatric/
adolescent varicocele include testicular size discrepancy, SA
abnormality, and patient discomfort. Variability in urologists'
interpretation of these indications exists, and not all urolo-
gists recommend varicocelectomy for every indication. In
one recent survey of pediatric urologists, 96% reported rec-
ommending varicocelectomy for decreased ipsilateral testic-
ular size, 79% recommended varicocelectomy for testicular
pain, and only 39% recommended the procedure for altered
372
SA parameters (32). In another contemporary survey of pedi-
atric urologists, 59% reported following adolescents for
persistent size discrepancy over time, whereas 32% reported
intervening after a size discrepancy has been documented
once (28). Recently it has been suggested that an abnormally
low total testicular volume may be a more accurate reflection
of the negative effects of a varicocele on testicular function
(14, 33), thus this parameter may replace size differential as
an indication for pediatric/adolescent varicocelectomy in
the future.
When treatment is recommended on the basis of the indica-
tions discussed above, options for repair of pediatric/adolescent
varicocele are similar to adult treatment options. These include
embolization/sclerotherapy, laparoscopic varicocelectomy
(with or without artery sparing), Palomo retroperitoneal varico-
celectomy, inguinal varicocelectomy, and subinguinal micro-
surgical repair. Recent reports have indicated increasing
utilization of laparoscopic repairs and decreased utilization of
retroperitoneal repairs when compared with surgical ap-
proaches reported more than a decade ago (31, 32, 34).
Presently laparoscopic varicocelectomy is the most common
approach in the pediatric/adolescent population, with 38%–
44% of pediatric urologists selecting this approach (31, 32).
Subinguinal microsurgical varicocelectomy rates have
remained relatively stable over time, with approximately 25%
of urologists reporting this as their preferred approach in both
older and more contemporary reports (31, 32, 34). In a recent
review of 15 adolescent series a bilateral procedure was
performed 0%–85.7% of the time (median 5%) among boys
undergoing varicocelectomy (8). Reported recurrence rates for
adolescent varicocele treatment modalities include 13% for
percutaneous embolization (35), 3% for sclerotherapy (36),
3%–5% for laparoscopic varicocelectomy (37, 38), and 6%–
7% for inguinal and subinguinal approaches (37, 39, 40).
RELATIONSHIP BETWEEN ADOLESCENT
VARICOCELE AND ENFERTILITY
Traditional indications for treatment of pediatric/adolescent
varicocele, including asymmetric growth and SA abnormal-
ities, assume that these indications serve as a reliable proxy
for future fertility potential. There is an inherent assumption
that varicocelectomy will result in improvement of such pa-
rameters, and ultimately future fertility, whereas observation
will result in deterioration of fertility potential over time.
Many investigators have sought to clarify the relationship be-
tween proxy measures of future testicular function (testicular
volume, SA abnormalities, hormonal abnormalities) and
fertility, as detailed below. Emerging data have also begun
to examine the relationship between treatment of varicocele
during childhood/adolescence and paternity outcomes.
Testicular Consistency, Asymmetry, and Total
Testis Volume
Historically, testicular consistency was considered a reliable
indicator of the quality of spermatogenesis (41), and changes
in testicular consistency were considered an indication for
surgical intervention in adolescents with varicocele (42).
VOL. 108 NO. 3 / SEPTEMBER 2017

Although testicular consistency is occasionally reported in
more contemporary literature, it is not generally the outcome
of interest. A 2013 cross-sectional cohort of more than 4,000
Turkish schoolboys used testicular consistency as an indicator
of testicular atrophy, but consistency-specific outcomes were
not reported (2). Studies by Gershbein et al. (43) and Ku et al.
(44) considered palpably soft testes an indication for surgical
intervention, but postoperative testicular consistency was not
discussed. A 2002 study by Cayan et al. (45) reported on 15
boys with a clinically palpable varicocele and associated
soft testicle, all of whom normalized postoperatively.
The use of testicular asymmetry (also referred to as hypo-
trophy, or testicular volume differential) as a surrogate for
testicular dysfunction among adolescents with varicocele is
controversial. Part of the debate stems from lack of consensus
on what constitutes asymmetry, with authors reporting on ab-
solute size differentials of 2–3 mL (46), relative size differentials
ranging from 10% to 25% (47), or some combination of these
values. A 2016 survey of 168 Society for Pediatric Urology
members (53% response rate) found that 58.7% of respondents
defined asymmetry as a >20% size differential, whereas 6.6%
used a >10% criterion, and 31% of respondents considered
longitudinal changes only (31). In large population-based co-
horts, the estimated prevalence of adolescent testicular asym-
metry in the setting of varicocele is between 6.5% and 9.3%,
depending on the use of a 10% vs. 20% threshold, whereas there
is no evidence of asymmetry among pre pubertal patients (6,
10). In adolescent cohorts referred for clinical follow-up, prev-
alence estimates range from 33% to 70% for >10% asymmetry
(18, 45, 48, 49), 17% to 55% for >15% asymmetry (43, 49, 50),
and 7% to 48% for >20% asymmetry (14, 17, 23, 48, 49, 51–53)
In addition to varying definitions of asymmetry, measurements
may be obtained via various orchidometers (Table 1) or via
ultrasound measurements using one of several volume
formulas (Table 2). These discrepancies make it difficult to
compare values between studies.
Even if one assumes that consistent methods for deter-
mining testis volume and standard definitions of asymmetry
exist, the natural history of testicular asymmetry remains un-
clear. A 2009 study by Kozakowski et al. (18) found that 71%
of 24 patients with >20% asymmetry had persistent or wors-
ened asymmetry at a mean 13.2 months' follow-up. An addi-
tional 36% of the 53 patients without initial asymmetry
developed >20% asymmetry during that same period. How-
ever, Kolon et al. (54) followed 133 adolescents for a mean
3.5 years and noted resolution of size asymmetry among
71% of conservatively managed patients. The group deter-
mined that asynchronous growth often normalizes over
time and recommended extended follow-up before interven-
tion. A retrospective review by Van Batavia et al. (50) shows
more mixed results, with 33% resolution vs. 24% stability vs.
43% progression at a mean 11.7 months of observation. These
variable reports of changes in testicular asymmetry make
studies of testicular growth after varicocelectomy somewhat
difficult to interpret, because it is unknown exactly how
many boys would have experienced a resolution in size asym-
metry without intervention.
The concept of postoperative testicular catch-up growth
was first introduced in 1987, when Kass et al. (55) noted
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Fertility and Sterility®
postoperative volume gain among 16 of 20 adolescents under-
going microsurgical varicocelectomy for grade 2–3 varicocele
who were followed for a mean of 3.3 years. Since that time,
randomized controlled trials have demonstrated significant ab-
solute increases in bilateral testis volumes (56, 57) and
improved differential volumes (58) among adolescents
treated for varicocele without concomitant improvements
among control patients. A recent meta-analysis of 14 studies
involving 1,475 patients also demonstrated significant postop-
erative reductions in testicular asymmetry, with an overall
average testicular catch-up growth rate of 76.4% (59). Rates
of catch-up growth in retrospective series range from 69% to
86% (11, 17, 43, 54, 60). Catch-up growth begins as early as
9 months after surgical repair, with the most significant in-
creases noted at 12 to 24 months (61). Factors including vari-
cocele grade, duration of follow-up, and presence of unilateral
vs. bilateral varicocele have not been associated with catch-up
growth (11, 17, 45, 62). Ipsilateral testicular hypertrophy after
surgical intervention has also been reported in some series,
with up to 38% of patients affected (43, 45, 60).
Similar to the clinical interpretation of catch-up growth,
the implications of testicular asymmetry itself are also un-
clear. A study by Diamond et al. (63) demonstrated signifi-
cantly lower sperm concentration and TMC in patients with
testicular asymmetry >10%, with increasingly dramatic dif-
ferences for larger volume differentials. Among patients
with 10% vs. 15% vs. 20% asymmetry, median sperm concen-
trations were 70 106/mL vs. 35 106/mL vs. 15 106/mL,
respectively, and TMC were 64 106 vs. 32 106 vs. 10
106 (63). Similarly, Keene et al. (64) found that sperm con-
centration and quality were lower in adolescent patients with
>20% asymmetrical testes. However, Christman et al. (49)
demonstrated that the presence of >20% testicular asymme-
try was not predictive of abnormal semen analysis; instead,
the total testicular volume at the time of final ultrasound
was associated with low TMC (<20 106/mL). In a recent
report, Kurtz et al. (14) found an association between testic-
ular volume differentials >20% and low TMC (odds ratio
[OR] 2.1, 95% confidence interval [CI] 1.0–4.1), with a signif-
icantly stronger association between total testis volume
<30 mL and low motile sperm counts (OR 4.2, 95% CI 1.8–
9.7) (14). The studies by Christman and Kurtz suggest that to-
tal testis volume may be more important than testicular
asymmetry for predicting of future fertility.
Semen Analysis Abnormalities
Semen analysis has the potential to serve as a useful adjunct
to testicular size estimation in determining who may benefit
from treatment of pediatric/adolescent varicocele. However,
as mentioned earlier, there are multiple barriers to obtaining
SA in the pediatric/adolescent population. In patients for
whom an SA is obtained, this measurement can provide
potentially valuable insight into fertility potential and can
be used to assess the success of varicocelectomy (similar to
adults). However, controversy exists about the utility of SA
as a proxy measure of future fertility, and it is not completely
clear that improvements in SA parameters will translate into
improved fertility outcomes for adolescents with varicocele.
373
VIEWS AND REVIEWS
Among infertile adults with a varicocele, SA parameters (in
addition to paternity rates) are an important component of the
patient assessment and one of the key outcome measures as-
sessed after varicocelectomy. Adults with varicocele frequently
have abnormal SA findings (46, 65), with a large cross-
sectional study demonstrating a negative association between
sperm concentration and increasing varicocele grade. Sub-
group analysis of patients with bilateral varicoceles demon-
strated sperm concentrations in between those of men with
grade 2 and grade 3 varicoceles (65). Multiple studies have
demonstrated improvement in TMC and other SA parameters
after varicocelectomy (66, 67). In one retrospective study,
Zorba et al. (67) reported a mean TMC increase from 10.7 
106/mL to 30.2  106/mL among adult men undergoing
varicocelectomy. Steckel et al. (68) examined the relationship
between varicocele size and response to varicocelectomy in
86 men, finding that SA among men with a grade 3
varicocele improved more than in those with lower-grade var-
icoceles. A 1996 study by Takahara et al. (69) corroborated
these findings, though there were no grade-associated differ-
ences noted in a subsequent study by Ishikawa et al. (70).
As seen in adults, varicoceles also seem to negatively affect
SA parameters in adolescents. As previously mentioned, Dia-
mond et al. (63) demonstrated a dramatic decrease in TMC with
increasing degrees of testicular asymmetry. In another prospec-
tive study by Mori et al. (71), sperm concentration and progres-
sive motility were lower in boys with varicocele vs. those without.
However, both SA parameters were within normal limits accord-
ing to 1999 World Health Organization reference values.
The natural history of SA parameters among adolescents
with varicocele is still being elucidated. A recent study by Chu
et al. (16) indicates that abnormal SA findings among many
adolescents with varicocele will normalize without interven-
tion. In this retrospective review, 47% of adolescent boys with
an abnormal initial TMC (<20  106/mL) normalized without
surgical correction of the varicocele.
As in adults, varicocelectomy in adolescents seems to
improve SA parameters, including sperm concentration and
motility (44, 72). Yamamoto et al. (57) conducted a randomized
trial of Palomo varicocelectomy vs. observation in adolescents
and found that sperm concentration increased significantly in
patients undergoing varicocelectomy vs. observation. Sperm
concentrations were also higher in the varicocelectomy group
compared with normal controls (57). However, all values (even
preoperative) were within normal limits, indicating uncertainty
as to whether the observed increase after varicocelectomy
would be clinically significant in terms of future paternity. In a
retrospective review of adolescents and adults undergoing
varicocelectomy, Ku et al. (44) reported a significant
improvement in both sperm concentration (31.7  106/mL to
40.7  106/mL) and motility (41.8% to 52.1%) after
varicocelectomy. In this study, the increase in motility was not
significant among adults, and the authors suggest that this
provides an argument in favor of prophylactic varicocelectomy
for adolescents. A recent retrospective analysis of adolescents
undergoing varicocelectomy demonstrated improvement in
TMC in 82% and normalization of TMC in 55% of patients
whose only indication for surgery was abnormal findings on
SA (73).
374
Hormonal Abnormalities
Along with evaluations for testicular asymmetry and SA ab-
normalities, a hormonal evaluation may help to determine
whether a varicocele is affecting testicular function. Multiple
hormonal abnormalities have been noted among adult men
with varicocele. A large cross-sectional study of European
men undergoing compulsory evaluation before military ser-
vice demonstrated that varicoceles are associated with signif-
icant elevations in FSH and inhibin B; there was no
association between serum T and varicocele status (65). A pro-
spective, nonrandomized, comparison study of men with a
history of infertility, clinical varicocele, and hypogonadism
who underwent either microscopic varicocelectomy or assis-
ted reproduction demonstrated that the mean total T rose
from 1.77 ng/mL to 3.01 ng/mL in the varicocelectomy
cohort, whereas it declined from 1.85 ng/mL to 1.77 ng/mL
in the assisted reproduction cohort. The authors conclude
that varicocelectomy significantly improves serum T among
infertile, hypogonadal men with varicocele (74). These find-
ings were corroborated by Hsiao et al. (75), who found
increased serum T values in 65 of 78 men with treated varico-
celes, with a mean 109.1-ng/mL elevation. Zalata et al. (76)
found that androgen receptor expression was significantly
diminished in 125 infertile men with varicocele when
compared with 107 infertile men without varicocele and 67
fertile controls.
Studies of hormonal abnormalities among adolescents
with varicocele have shown mixed results. Abnormalities
in GnRH stimulation (77), LH response (78), FSH levels
(62), inhibin B levels (79), and T (12) have been reported
in small retrospective series. Fideleff et al. (80) performed
a larger, prospective study of 93 adolescents aged
8–16 years (mean 12.8 years) with left varicoceles who un-
derwent baseline and stimulated hormonal testing
including GnRH, LH, FSH, and T. Laboratory results were
compared with those from 29 normal controls, and the au-
thors found no correlation between presence of a varicocele
and hormonal findings when controlling for Tanner stage.
Twenty-eight adolescents ultimately underwent varicoce-
lectomy, and postoperative laboratory testing was
completed in 14 patients. There were no statistically signif-
icant differences in pre- vs. postoperative hormonal pa-
rameters, leading the authors to conclude that there is
not a reliable biomarker for predicting testicular function
in adolescents (80). To date, hormonal abnormalities have
not been frequently utilized in the evaluation and follow-
up of children/adolescents with varicocele.
Effect of Varicocele Treatment in Childhood/
Adolescence on Paternity
Although proxy measures of future fertility are used by ne-
cessity to determine which children/adolescents with vari-
cocele may benefit from treatment, the ultimate outcome
measure is paternity. Varicoceles are present in approxi-
mately 31% of men evaluated for infertility (81), and re-
sults from studies of infertile adults with varicocele are
used, in part, to justify treatment of varicocele in child-
hood/adolescence. Spontaneous paternity rates among
VOL. 108 NO. 3 / SEPTEMBER 2017

men with a history of infertility and subsequent varicoce-
lectomy range from 33% to 48% (66, 82, 83). Abdel-
Meguid et al. (83) reported on a prospective, nonmasked,
randomized controlled trial of 145 men aged 20–39 years
with a history of infertility, varicocele, and at least one
impaired semen parameter who underwent microscopic
varicocelectomy vs. observation. Spontaneous pregnancy
was achieved in 33% of treated patients vs. 14% of controls
over 1 year of follow-up (OR 3.04, 95% CI 1.3–7.0). The
authors posited that varicocelectomy was superior to
observation in this population and calculated that the
number needed to treat to allow one extra pregnancy was
5.27 men (83).
Retrospective cohort studies demonstrate comparable
outcomes. A 1994 review of 13 infertile patients with a his-
tory of varicocele and prior unsuccessful IVF cycle demon-
strated improvements in oocyte fertilization rates after
Palomo varicocelectomy and subsequent IVF. Whereas
only 8 of 82 oocytes (10%) were successfully fertilized pre-
operatively, 31 of 76 (41%) were fertilized postoperatively,
for a 31% overall pregnancy rate (84). Similarly, Kamal
et al. (66) reviewed pregnancy outcomes among 159 infer-
tile couples at a mean 30 months after microsurgical vari-
cocelectomy. The authors found an association between
preoperative sperm concentration and spontaneous preg-
nancy rates, with an 8% pregnancy rate for men with con-
centrations <5  106/mL, a 42% rate for men with
concentrations 5–10  106/mL, and a 74% rate for
men with concentrations >20  106/mL (66). A recent
meta-analysis by Kirby et al. (85) also demonstrated
improvement in live birth rates among oligospermic and
azoospermic men with undergoing varicocele repair (OR
1.76, 95% CI 1.2–2.5). Although these cohorts were limited
to infertile adults, improvements in postoperative paternity
rates are often used to justify adolescent procedures.
Several studies of paternity among men who under-
went adolescent varicocele repair have recently been pub-
lished. The largest of these compared paternity rates and
time to conception among 286 men who underwent micro-
scopic varicocelectomy at age 12–19 years with paternity
among 122 men who were managed conservatively in
that same time period. Overall paternity rates were 221 of
286 (77%) in the treatment group vs. 59 of 122 (48%) in
TABLE 3
Pediatric/adolescent varicocele: summary recommendations and targets for future research.
Topic Summary recommendations
Size estimation Testicular size should be followed with serial
measurements via either orchidometer or testicular
ultrasound. Physical examination alone is not
recommended.
Semen analysis A single SA should be offered to all peri- or postpubertal
boys.
Future paternity
Jacobson. Varicoceles in pediatrics. Fertil Steril 2017.
VOL. 108 NO. 3 / SEPTEMBER 2017
Fertility and Sterility®
the control group (OR 3.6, 95% CI 2.3–5.7), leading the au-
thors to conclude that adolescent varicocele repair is bene-
ficial for paternity (12). However, Bogaert et al. (86)
reported contradictory results among patients participating
in a Belgian adolescent screening program. The authors
surveyed 361 men diagnosed with varicocele following
adolescent screening, 58% of whom underwent sclerother-
apy at age 11–18 years and 42% of whom were conserva-
tively followed. The two groups had similar age at
diagnosis, prevalence of testicular asymmetry, varicocele
grade, and desire for paternity. Overall, 158 men desired
paternity. At a median follow-up of 14 years, paternity
was documented in 67 of 86 (78%) of the active treatment
group and 61 of 72 (85%) of the conservative managed
group. Between-group outcomes were not significantly
different, leading the authors to conclude that there is no
benefit to treatment for adolescent varicocele (86). Other
small surveys report paternity rates of 75%–100% but are
limited by small sample sizes (12–18 patients) and rela-
tively youthful cohorts (87, 88).
RECOMMENDATIONS FOR PEDIATRIC/
ADOLESCENT VARICOCELE
On the basis of the data presented in the previous sections,
summary recommendations for evaluation based on size esti-
mation and SA were developed and are displayed in Table 3.
Also included are key targets for future research related to pe-
diatric and adolescent varicocele.
To conclude, varicoceles are a common entity in adoles-
cents, and concern exists that they may negatively affect
future fertility potential. Testicular asymmetry and SA abnor-
malitity are the traditional proxy measures of future fertility
that have been used as indications for varicocelectomy in
children/adolescents. Although multiple series have shown
improvement in these proxy parameters after varicocelec-
tomy, these measures are limited by uncertain natural history
and lack of a direct relationship between improvement in
these parameters and future paternity. Two large, recently
published series of adolescents undergoing varicocele treat-
ment showed conflicting paternity outcomes. Pediatric/
adolescent varicocele will remain a clinical conundrum,
Targets for future research
Determining whether testicular size discrepancy or total
testicular volume is a better proxy for future fertility
Creating SA parameters to account for adolescent semen
analyses and expanding parameters outside the
traditional SA (i.e., DNA fragmentation) to determine
the efficacy of varicocelectomy
Increase the number of longitudinal studies of paternity
among adolescents with a history of varicocele
375
VIEWS AND REVIEWS
subject to both over- and under-treatment, until more defin-
itive prospective data are available.
Acknowledgments: The authors thank Peggy Murphy,
M.I.L.S., for her assistance with the literature review for this
article; and Ilina Rosoklija, M.P.H., for her critical review
and feedback on the manuscript.
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