The simplicity of the surgical procedure, as well as the high rate of success and low rate of complications, is of particular importance for varicocelectomies. We compared operative parameters, complication rates, and sperm parameters after retroperitoneal, microsurgical subinguinal and high inguinal varicocelectomy approaches in infertile men with varicoceles. This study included 307 infertile men with left varicoceles who underwent varicocelectomy by the retroperitoneal (n = 43), microsurgical subinguinal (n = 107), or high inguinal (n = 157) approach. The operative time was shorter for the retroperitoneal approach (29 minutes) compared with the microsurgical approaches and was significantly shorter for the high inguinal approach (52 minutes) compared with the subinguinal approach (66 minutes). Pain, as assessed by a visual analogue scale, and the use of nonsteroidal anti-inflammatory drugs were greatest following the retroperitoneal approach and significantly preferable following the high inguinal compared with the subinguinal approach. Recurrence/hydrocele was observed in 9.3%/9.3%, 0.9%/0.9%, and 1.3%/0.6% of patients after use of the retroperitoneal, subinguinal, and high inguinal approaches, respectively. Significant postoperative improvements in sperm concentration and motility were observed after all approaches, but such improvements were observed sooner and showed higher sperm concentration and motility after the use of the microsurgical approaches. Both microsurgical subinguinal and high inguinal approaches yielded comparable success rates, but the operative time and pain control were superior with the high inguinal approach. Because of its favorable safety profile, the microsurgical high inguinal approach should be of value to both experienced microsurgeons and trainees.