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Subclinical and Adolescent Varicocele

Sub-clinical varicocele (SCV) is characterized by normal clinical examination and diagnosed mainly by Doppler Ultrasound imaging. About 10 – 15% of infertility cases were found to be SCV. SCV is one of the common causes of primary infertility and major cause in males with secondary infertility. Presence of sub-clinical varicocele in case of pediatric patients is considered a risk factor as it progresses to palpable clinical varicocele. 
Despite various imaging modalities being tried to diagnose SCV, Colour Doppler Ultrasound is considered the gold standard imaging for diagnosis of SCV, having a sensitivity and specificity of nearly 100%. Diagnostic criteria parameters of SCV includes measurement of diameter of scrotal veins in supine, upright & after valsalva maneuver along with sum of venous diameter, venous blood flow volume and retrograde flow direction during valsalva. 
SCV exerts a significant impact on spermatogenesis. Of all the theories proposed, the most accepted one is the oxidative stress theory. In many instances, SCV is the only abnormality associated with oligospermia. 
Various meta-analyses have shown a significant improvement in seminal parameters following surgical intervention but pregnancy rate did not improve much when compared to the non-intervened group. Controversies in surgical management are all centered on the pregnancy rate. This leaves the treating andrologists and urologists even more confused on how to go about managing these patients with SCV. The American society of Reproductive Medicine and American Urological Association do not recommend surgical repair for SCV, if the indication for varicocelectomy is to improve the pregnancy rate. 
The management of adolescent varicocele carries even more challenges, in view of the ethical issues involved in treating a boy who is young and immature. Guidelines have been framed to summarize the indications for surgical intervention in such patients. Both laparoscopic and open techniques have yielded equally good results.