Limited available evidence suggests that men should not be offered surgery for varicoceles as a form of fertility treatment because it does not improve pregnancy rates.

• A Cochrane review attempted to evaluate the effect of varicocele treatment on pregnancy rates in men from subfertile couples [Evers et al, 2008]:
• The authors searched the Cochrane Menstrual Disorders and Subfertility Group trials register (12 September 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2004), Medline (January 1966 to May 2004), Embase (January 1985 to May 2004), and reference lists of articles. They also hand-searched 22 relevant specialist journals from their first issue until 2004, checked cross-references and references from review articles, and contacted researchers.
• Randomized controlled trials were included if they reported pregnancy rates as an outcome measure and if they reported data in treated (surgical ligation or radiological embolization of the internal spermatic vein) and control groups.
• One of the nine studies that met the inclusion criteria was an extension of a previously published study; this left eight studies for analysis (n = 682). All eight only included men from couples with subfertility problems. One study excluded men with sperm counts less than 5 million/mL, and one excluded men with sperm counts less than 2 million/mL and/or progressive motility less than 10%. Two trials involving clinical varicoceles included some men with normal semen analysis. Three studies specifically addressed only men with subclinical varicoceles.
• The combined Peto odds ratio (OR) of the eight studies was 1.10 (95% CI 0.73 to 1.68), indicating no overall statistical benefit of varicocele treatment over expectant management in subfertile couples in whom varicocele in the man is the only abnormal finding.
• Only three studies in this Cochrane review [Madgar et al, 1995; Nieschlag et al, 1998; Krause et al, 2002] included men with clinical varicoceles and abnormal semen. However, these studies had methodological flaws, including a high drop-out rate, small size, insufficient power, and exclusion of men with low sperm counts.
• The authors concluded that there was no evidence that the treatment of varicocele in men from couples with unexplained fertility improves the couple's chances of conception. They state that it was not appropriate to include the results of the World Health Organization (WHO) multicentre study without full access to its scientific details, but the WHO data will be added to their review if and when they become available.
• The National Institute for Health and Clinical Excellence have based their recommendation on this Cochrane systematic review but acknowledged that the exclusion of the WHO data could have made a difference to the conclusions of the review [National Collaborating Centre for Women's and Children's Health, 2004].
• Not all experts agree that it was acceptable to base guideline recommendations on the Cochrane review and have challenged the decision to combine the studies in a meta-analysis, as they were heterogeneous in terms of inclusion criteria and clinical characteristics of participants [Ficarra et al, 2006]. The Cochrane review also included men with normal semen for whom varicocele repair is not recommended [American Society for Reproductive Medicine, 2006].
• Further primary research to clarify the effect of varicocele treatment on pregnancy rates seems unlikely, as intracytoplasmic sperm injection is now available and no evidence suggests that spermatozoa from men with varicoceles are less likely than those from men without varicocele to achieve fertilization and embryo development in vitro [Templeton, 2003]. Further research is needed comparing the effectiveness of varicocele ligation or embolization with in vitro fertilization, taking into consideration the person's preference and the cost effectiveness of these procedures [National Collaborating Centre for Women's and Children's Health, 2004].