Objective: Varicocele is the most common correctable cause of male infertility, and microsurgical varicocelectomy (MSV) is the gold standard treatment. This study aims to compare the inguinal and subinguinal approaches in microsurgery and to evaluate the effect of external spermatic vein (ESV) ligation on semen parameters. Materials and Methods: A total of 464 patients who underwent MSV between January 2017 and December 2023 were retrospectively reviewed. Patients were divided into two groups based on the surgical approach: subinguinal ( n = 133) and inguinal ( n = 331). Semen analysis was performed preoperatively and at the postoperative sixth month. Demographic data, intraoperative findings, and complications were recorded. Results: Both surgical techniques provided significant improvement in sperm concentration, total motile sperm count (TMSC), progressive motility, and morphology ( p < 0.001). The improvement in morphology was significantly higher in the subinguinal group compared to the inguinal group (0.82 ± 1.56 vs. 0.46 ± 1.45, p = 0.017). In the group where ESV ligation was performed, the increase in progressive motility (5.26 ± 11.92 vs. 2.74 ± 9.00, p = 0.019) and the decrease in immotility (−5.48 ± 12.22 vs. −2.83 ± 14.13, p = 0.035) were more pronounced. Furthermore, an increase in the number of ESVs showed a significant correlation with an increase in progressive motility ( r = 0.144, p = 0.002) and a decrease in immotility ( r = −0.124, p = 0.007). The subinguinal approach significantly increased the probability of accessing the ESV (82.7% vs. 57.7%, p < 0.001). Conclusion: MSV provides effective improvement in semen parameters. The subinguinal approach is more advantageous for morphological improvement and accessing ESVs. Ligation of the ESVs has a positive effect, particularly on sperm motility, and should be considered a critical step for surgical success.

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