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Varicocele represents the most common cause of male infertility, and most reports indicate that varicocelectomy has a beneficial effect on male fertility and pregnancy outcome. Assisted reproductive technologies (ARTs) are an alternative to varicocelec- tomy for the management of couples with a varicocele. The age of the female partner is important in the decision-making process; how- ever, the true influence of female age on pregnancy outcome follow- ing varicocelectomy or ART in these couples is unknown. We eval- uated the outcomes of 2 cohorts of infertile men with a varicocele and a female partner 35 years of age or older; one group selected varicocelectomy and the other a nonsurgical approach. We reviewed a group of consecutive infertile men who underwent microsurgical varicocelectomy and whose partners are 35 years of age or older (n 5 110). We also reviewed a consecutive group of men with vari- coceles who elected not to have surgery and whose partners are 35 years of age or older (n 5 94). The outcome measures included changes in semen parameters, pregnancy rates (assisted and un- assisted), and use of ART. The surgical and nonsurgical groups had comparable semen parameters and female ages. Mean sperm con- centration and motility increased significantly after varicocelectomy (P , .05). At a mean of 30 months follow-up, 35% of couples in the surgical group achieved a spontaneous pregnancy and an additional 6% achieved a pregnancy via ART (20% of this group attempted ART). In the nonsurgical group, 25% achieved a spontaneous preg- nancy and an additional 16% achieved a pregnancy with ART (40% of this group attempted ART). This study on the natural history of infertile men with varicocele and advanced female age suggests that the surgical and nonsurgical approaches offer comparable pregnan- cy outcome (combined assisted and unassisted pregnancy rates are about 40%). Overall, these data suggest that varicocelectomy is an acceptable option for couples with advanced female age, but other female factors must be considered in the decision-making process.