Varicocele is the most common correctable cause of male factor infertility. The role of varicocele in the etiology of male infertility is still controversial regarding to whom varicocelectomy should be done and the selection should be meticulous. With the recent advances in biomolecular and development of novel sperm functional tests, it has been possible to better understand the mechanism involved in damage provoked by varicocele and therefore, propose ways to reverse them. Clinical studies have shown that varicocele surgery can improve semen quality sufficient to downgrade the type of assisted reproductive technology (ART) procedure required. This reveiw discusses current concepts on the mechanisms for varicocele induced testicular damage and efficacy of varicocelectomy for treatment of infertility. We also review the current guidelines and need for proper case selection before surgery.The authors critically reviewed the cost effectiveness of the surgical treatment of a varicocele compared with assisted reproductive techniques.