Abstract
Nonobstructive azoospermia (NOA) is a severe form of male factor infertility that typically obligates couples to intracytoplasmic sperm injection (ICSI) with testicular sperm. A significant proportion of these men, however, will also present with a palpable varicocele—a known modifiable risk factor for subfertility. In this review, we will discuss the current evidence that supports the use of varicocele repair in men with nonobstructive azoospermia. Numerous observational noncontrolled studies, substantiated by meta-analyses, now link varicocele repair in return of viable sperm adequate for in vitro fertilization (IVF) with ICSI to the ejaculate, rare unassisted pregnancy, increased testicular sperm retrieval rates, and improved pregnancy outcomes with intracytoplasmic sperm injection. Due to suboptimal study design, these inferred benefits must be met with caution. In this regard, active controversy remains over the efficacy of varicocele repair in men with NOA. Additionally, concerns continue regarding cost-effectiveness, the addition of surgical morbidity, and delays to testicular sperm extraction. We carefully review the data and analysis supporting these counter arguments against varix repair. Finally, alternative indications for varicocelectomy in the NOA population are briefly discussed, representing a set of therapeutic criteria that may settle the decision to treat or to observe.
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