The decision to pursue varicocele repair in adolescents remains controversial. The prevalence of varicoceles in adolescent boys reaches about 15% by the age of 15, similar to that of adults, making it a common diagnosis.¹ Varicoceles in adults are frequently discovered and subsequently treated during an infertility workup. However, when a varicocele is diagnosed in adolescence, it is unclear which individual will go on to experience infertility and thus require treatment.

As adolescent varicoceles became increasingly recognized, initially, the recommendations for treatment were based on testicular hypotrophy or varicocele grade, with a higher grade warranting repair.² However, it was eventually determined that there is no correlation between grade of varicocele and degree of testicular disproportion, thus deemphasizing grade as an indication for repair.³ Over time, some groups discovered that Tanner stage V adolescents with varicoceles and large testicular volume differentials were also found to have significantly decreased sperm concentration and total motile sperm count (TMSC). As a result, our current indications for adolescent varicocele correction in prepubertal males are testicular volume differential >20% or clearly associated discomfort, or abnormal semen parameters.^4,5

To date, though, it has been generally presumed that a varicocele repair improves TMSC in adolescents, there are minimal data available to verify this, as preoperative and postoperative semen analyses are rare. Our goal was to provide these data and to investigate the optimization of semen parameters in adolescents post-varicocelectomy.

We retrospectively examined over 1,600 patients ≤20 years of age from the Boston Children’s Hospital adolescent varicocele database for patients who underwent a varicocelectomy and also had both pre- and postoperative semen analyses. From this, 15 Tanner stage V adolescents were identified. Of our 15 patients, 12 had complete resolution of their varicocele, with all but 1 of them experiencing an improvement of their TMSC postoperatively (see Figure). Nine patients had an abnormal preoperative TMSC as defined by <20 million,⁶ and 5/9 (55.6%) of them improved to within a normal range of $20 million following successful varicocele repair.

Figure. Increase in TMSC after surgical cure of varicocele.

Our rate of improvement of TMSC was 91.7%, similar to that of Chu et al’s series, which had a rate of improvement of 82%. Additionally, our 55.6% rate of normalization was similar to Chu et al’s rate of 55%. Together, our results demonstrate that in the majority of adolescents undergoing varicocelectomy TMSC will improve as with adults, and in over half of cases an abnormal preoperative TMSC will increase to within normal parameters postoperatively.

Even amongst adult men undergoing varicocele repair for infertility, the pregnancy rate following varicocelectomy alone is documented at ˜38%.⁷ It is reasonable to question if the fertility of the remaining 62% could have been salvaged through treatment at a younger age, which may highlight the importance of identifying a more objective measure to predict which adolescent may experience infertility in adulthood. Therefore, a semen analysis should be obtained when considering varicocele repair in adolescents and counseling patients on management options.