Infertility is a growing global health problem with profound medical, psychological, social, and economic consequences, and male factors contribute either alone or in combination in nearly half of infertile couples. Among the various etiologies of male infertility, varicocele remains one of the most frequently encountered and potentially correctable conditions, yet its exact role in impairing spermatogenesis continues to be debated. A varicocele is defined as abnormal dilatation and tortuosity of the pampiniform venous plexus and internal spermatic veins, leading to impaired venous drainage of the testis and disruption of the testicular microenvironment. Varicocele has been consistently associated with abnormalities in sperm concentration, motility, morphology, and DNA integrity, although not all affected men exhibit infertility, suggesting heterogeneity in disease expression and response to treatment. Proposed mechanisms include scrotal hyperthermia, testicular hypoxia, oxidative stress, reflux of toxic metabolites, hormonal dysregulation, and impaired Sertoli and Leydig cell function. Surgical correction of varicocele has been shown by several investigators to improve semen parameters, testosterone production, and pregnancy rates, whereas others report variable or modest benefits. This ongoing controversy underscores the need for well- designed clinical studies evaluating outcomes of varicocele ligation in defined patient populations. The present study was therefore undertaken to assess the effect of varicocele ligation on semen parameters and spermatogenesis in patients undergoing varicocele surgery at a tertiary care medical teaching hospital.

AIM AND OBJECTIVES

Aim:To study the outcome of varicocele ligation in improving the semen parameters in cases undergoing varicocele surgery.

Objectives:

1. To study the changes in sperm
2. To study the changes in sperm, count and sperm motility
3. To study clinical profile of varicocele
4. To study the effect of varicocele ligation on spermatogenesis

MATERIAL AND METHOD

This prospective observational study included 50 male patients aged 18–42 years with clinically palpable unilateral or bilateral varicocele confirmed by ultrasonography, who were admitted for varicocele ligation and provided informed consent. Patients with recurrent varicocele, azoospermia, total necrospermia, or secondary varicocele were excluded. All patients underwent detailed history taking, physical examination, grading of varicocele using the Dubin and Amelar classification, scrotal ultrasonography, baseline semen analysis after 3–5 days of abstinence according to WHO guidelines, and hormonal evaluation. Varicocele ligation was performed using the inguinal approach under spinal anesthesia. Repeat semen analysis and hormonal evaluation were performed three months postoperatively using identical methodology. Data were analyzed using appropriate statistical tests, and p-values <0.05 were considered statistically significant.

Study Design: Prospective comparative study.

Study Setting: Department of General Surgery, Saraswathi Institute of Medical Sciences, Hapur, Uttar Pradesh.

Study Period: 18 months.

Sample Size: Sample size(n)=Z²PQ/E²

=(1.96)²*0.15*0.85/(0.10)²

=48.96≈50

Inclusion criteria

1. Patients with clinically palpable unilateral or bilateral varicocele (grades 1-3).
2. Age group 18-42
3. Ultrasound proven cases

Exclusion criteria:

1. Patients with recurrent
2. Patients with azoospermia or total
3. Patients with secondary

RESULTS

Table1: Demographic and Clinical Profile of Study Participants(N=50)

Table 2: Baseline Semen Parameters and Hormonal Profile (N=50)

Table 3: Comparison of Semen Parameters Before and After Varicocele Ligation (N=48)

Table 4: Surgical Outcome and Complications (N=50)

Overall, the majority of patients were young adults with primary infertility. Baseline semen analysis showed reduced sperm concentration, motility, and morphology in most patients. Following varicocele ligation, statistically significant improvement was observed in key semen parameters and testosterone levels. More than two-thirds of patients demonstrated marked or moderate improvement. Complications were infrequent and predominantly minor.

DISCUSSION

The present study demonstrates that varicocele ligation leads to significant improvement in semen parameters and hormonal profile in infertile men with clinically palpable varicocele. These findings support the concept that varicocele is an important, potentially reversible cause of impaired spermatogenesis.

Dubin and Amelar were among the earliest investigators to demonstrate a relationship between varicocele size and postoperative improvement in semen quality, reporting better outcomes in men with higher-grade varicoceles. Gorelick and Goldstein highlighted the progressive nature of testicular damage in untreated varicocele and emphasized the association between varicocele and loss of fertility. The baseline abnormalities in sperm concentration, motility, and morphology observed in our study are consistent with these observations.

Several mechanisms have been proposed to explain improvement after varicocele repair. Zorgniotti and Macleod demonstrated that increased scrotal temperature adversely affects spermatogenesis, and reduction of hyperthermia following ligation may restore normal germ cell function. Agarwal and colleagues emphasized the role of oxidative stress in varicocele-associated infertility and showed that surgical correction reduces reactive oxygen species and improves sperm function.

In the present study, sperm concentration and total sperm count improved by approximately 39% and 45%, respectively. Similar magnitudes of improvement have been reported by Al Bakri et al., who observed that semen parameters typically begin to improve within three months following surgery. Cannarella and co-workers, in meta-analyses of before-and-after data, demonstrated significant postoperative increases in sperm concentration, motility, and morphology, supporting the effectiveness of varicocele repair.

Progressive motility showed the most pronounced improvement in our study, increasing by nearly 48%. This finding is clinically relevant, as progressive motility is a key determinant of fertilizing potential. Agarwal et al. reported that improvements in motility after repair are closely linked to reductions in oxidative stress and mitochondrial dysfunction.

Normal morphology also improved significantly in our cohort. Although the absolute increase was modest, even small improvements in morphology may translate into improved fertility potential. Similar findings have been reported by Cannarella et al. and Shah et al., who observed consistent but moderate improvements in morphology after repair.

Serum testosterone increased significantly after surgery in our study. Tanrikut et al. demonstrated that varicocele is a risk factor for androgen deficiency and that repair can improve testosterone levels, particularly in men with low baseline values. Improvement in testosterone may further enhance spermatogenesis and overall testicular function.

Regarding safety, the overall complication rate in our study was 36%, with most complications being minor and self-limiting. Scrotal edema was the most common complication, while serious complications such as testicular atrophy or spermatic artery injury were not observed. These findings are comparable to those reported by Goldstein et al., who emphasized that meticulous surgical technique minimizes complications.

The main strengths of the present study include its prospective design, standardized evaluation, and paired comparison of preoperative and postoperative parameters. Limitations include relatively small sample size and short follow-up duration, which may not capture long-term fertility outcomes such as spontaneous pregnancy rates.

CONCLUSION

Varicocele ligation results in significant improvement in semen parameters and testosterone levels in a majority of patients with clinically palpable varicocele. Surgical correction is a safe and effective treatment option for selected infertile men and can contribute to restoration of spermatogenesis.

REFERENCES

1. Dubin L, Amelar Varicocele size and results of varicocelectomy in selected subfertile men with varicocele. Fertility and Sterility. 1970;21(8):606–609.
2. World Health Organization. The influence of varicocele on parameters of fertility in a large group of men presenting to infertility clinics. Fertility and Sterility. 1992;57(6):1289–1293.
3. Gorelick JI, Goldstein M. Loss of fertility in men with varicocele. Fertility and Sterility. 1993;59(3):613–616.
4. Goldstein M, Gilbert BR, Dicker AP, Dwosh J, Gnecco C. Microsurgical inguinal varicocelectomy with delivery of the testis: an artery and lymphatic sparing Journal of Urology. 1992;148(6):1808–1811.
5. Al Bakri A, Lo K, Grober E, Cassidy D, Cardoso JP, Jarvi K. Time for improvement in semen parameters after varicocelectomy. Journal of Urology. 2012;187(1):227–231.
6. Zorgniotti AW, Macleod Studies in temperature, human semen quality, and varicocele. Fertility and Sterility. 1973;24(11):854–863.
7. C K, N P, Rk L, Ps L, M Effect of varicoceles on spermatogenesis. Seminars in Cell and Developmental Biology. 2022;121:1–10.
8. Agarwal A, Sharma RK, Desai NR, Prabakaran S, Tavares A, Sabanegh E. Role of oxidative stress in pathogenesis of varicocele and infertility. Urology. 2009;73(3):461–
9. Comhaire F, Vermeulen A. Varicocele sterility: cortisol and catecholamines. Fertility and Sterility. 1974;25(1):88–95.
10. Tanrikut C, Goldstein M, Rosoff JS, Lee RK, Nelson CJ, Mulhall JP. Varicocele as a risk factor for androgen deficiency and effect of repair. BJU International. 2011;108(9):1480–1484.
11. Cannarella R, Shah R, Ko E, Kavoussi P, Rambhatla A, Hamoda TAAAM, et al. Effects of varicocele repair on testicular endocrine function: a systematic review and meta-analysis. World Journal of Men’s Health. 2025;43(4):818–843.
12. Cannarella R, Shah R, Hamoda TAAAM, Boitrelle F, Saleh R, Gul M, et al. Does varicocele repair improve conventional semen parameters? A meta-analytic study of before-after data. World Journal of Men’s Health. 2024;42(1):92–132.
13. Ramon R, Warli SM, Siregar GP, Prapiska FF, Kadar DD, Tala MRZ. Varicocele repair in improving spermatozoa, follicle-stimulating hormone, and luteinizing hormone parameters in infertile males with azoospermia: a systematic review and meta-analysis. Asian Journal of Andrology. 2024;26(6):628–634.
14. Shah R, Agarwal A, Kavoussi P, Rambhatla A, Saleh R, Cannarella R, et al. Consensus and diversity in the management of varicocele for male infertility: results of a global practice survey and comparison with guidelines and recommendations. World Journal of Men’s Health. 2023;41(1):164–197.
15. Agarwal A, Cannarella R, Saleh R, Boitrelle F, Gül M, Toprak T, et al. Impact of varicocele repair on semen parameters in infertile men: a systematic review and meta-analysis. World Journal of Men’s Health. 2023;41(2):289–310.
16. Vu Tan L, Phuc Cam Hoang N, Ba Tien Dung M, Vinh Phu P, Martinez M, Minh Duc N. Spontaneous pregnancies post-microsurgical varicocelectomy in infertile men with severe oligozoospermia: a preliminary report. Clinical Therapeutics. 2023;174(2):126–131.
17. Wang Q, Yu Y, Liu Y, Wang L. Outcome of varicocelectomy on different degrees of total motile sperm count: a systematic review and meta-analysis. Systematic Biology in Reproductive Medicine. 2019;65(6):430–436.
18. Ou N, Zhu J, Zhang W, Liang Z, Hu R, Song Y, et al. Bilateral is superior to unilateral varicocelectomy in infertile men with bilateral varicocele: systematic review and meta-analysis. Andrologia. 2019;51(11):e13462.
19. Niu Y, Wang D, Chen Y, Pokhrel G, Xu H, Wang T, et al. Comparison of clinical outcome of bilateral and unilateral varicocelectomy in infertile males with left clinical and right subclinical varicocele: a meta- analysis of randomized controlled Andrologia. 2018;50(9):e13078.
20. Dubin JM, Greer AB, Kohn TP, Masterson TA, Ji L, Ramasamy R. Men with severe oligospermia appear to benefit from varicocele repair: a cost-effective analysis. Journal of Urology. 2018;199(1):128–134.