Varicoceles are present in 15% of the normal male population and in approximately 40% of men presenting with infertility. The preponderance of experimental data from clinical and animal models demonstrates a deleterious effect of varicoceles on spermatogenesis. Testicular temperature elevation and oxidative stress appear to play an important role in varicocele-induced testicular dysfunction, although the exact pathophysiology is not yet completely understood. The American Urological Association and American Society of Reproductive Medicine jointly convened Best Policy Practice Groups for Male Infertility and recently stated, “Varicocele repairs may be considered the primary treatment option when a man with a varicocele has suboptimal semen quality and a normal female partner.” They considered percutaneous embolization and surgery for varicocele treatment and noted that most experts performed inguinal or subinguinal microsurgical repairs to maximize preservation of arterial and lymphatic vessels while reducing the chances of persistence or recurrence. Although these comments represent the considered opinion of 12 experts and 125 consultants in the field of male infertility, anyone familiar with varicoceles knows that discussion of the pathophysiology and management continues to be hotly debated. This review offers recommendations regarding the best infertility treatment for the man with a varicocele: assisted reproduction or varicocelectomy.