Objective: To evaluate the paternity rate in a large cohort of asymptomatic adult varicocele patients undergoing nonsurgical management and surgery. Methods: The study population included 1845 men with varicocele and 9286 healthy controls. All data were retrospectively obtained from the Israeli Defense Forces medical database. Patients were divided according to the management strategy: 1758 (95.2%) were followed up nonsurgically, 63 (3.4%) had preventive surgery (patients without known infertility), and 24 (1.4%) had secondary surgery (patients with varicocele and primary infertility) as young adults. The primary outcome was the live birth rate. Results: The live birth rate was similar in the preventive surgery and control groups. Both preventive surgery and control groups had higher live birth rate than the nonsurgical group. Finally, the secondary surgery group had the lowest live birth rate of all groups. Conclusion: Preventive surgery for asymptomatic varicocele provides similar fertility outcomes to control groups, whereas nonsurgical strategy provides inferior outcomes and may be overutilized.