Would you perform varicocelectomy in a non-obstructive azoospermic patient with grade 3 varicocele or proceed straight to sperm retrieval?

Assuming no Y chromosomal microdeletions, no karyotypic anomalies, and no testosterone use, yes, I would. About 25% or so will achieve some level of spermatogenesis 4 months later for use with ICSI, and that would obviate the need for a TESE. If no sperm have returned to the ejaculate, at least you have maximized as best possible the chances for TESE success - if no sperm are found on mTESE, terrible news for the couple, but at least all know that as much was done as possible to optimize the cha...

It depends on the initial diagnosis. If it is secondary infertility, I will perform the varicocelectomy and then reassess with a semen analysis after 3 months. I will be hesitant to go ahead with the varicocelectomy if it is primary infertility. This is all after the chromosomal analysis, and the Y-microdeletion tests are normal.

Addressing this varicocele is a very reasonable pathway, given that data show that ~10% (some studies higher) will have spontaneous return of sperm to the ejaculate after varicocele ligation in the setting of nonobstructive azoospermia (NOA). This is a very meaningful outcome, as it spares microdissection testicular sperm extraction (mTESE) (and the cost) and allows them to proceed to assisted reproductive technology (ART). There is also some mediocre evidence that it may improve sperm retrieval...