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VARICOCELE

1. What is a varicocele?

A varicocele is a widening and twisting of the veins that drain blood away from the testicle back towards the heart. You can think of it as “varicose veins of the scrotum”.

These veins form a network called the pampiniform plexus. Under normal conditions they:

• Carry “used” blood away from the testicle

• Help to keep the testicle slightly cooler than the rest of the body, which is important for sperm production

In varicocele:

• The veins become overly wide and baggy

• The valves inside the veins do not work properly

• Blood that should travel upwards towards the heart leaks back down towards the testicle (this is called “reflux”)

This reflux creates an environment around the testicle that is:

• Lower in oxygen

• Higher in waste products and oxidants

Over time this may disturb sperm production and in some men can contribute to reduced fertility.

1. How common is varicocele?

Varicocele is quite common:

• It is seen in roughly 10–20% of all men (about 1 in 5 to 1 in 10)

• Among men being investigated for infertility, about one third have a varicocele

• In men who have had a child before but later have difficulty conceiving (so-called “secondary infertility”), varicocele is found even more often

This does not mean every man with a varicocele is infertile. It simply shows that varicocele is the most common treatable cause of male factor infertility.

1. Why does varicocele happen?

We still do not know the exact cause in every case, but several factors are thought to be involved:

• Faulty valves inside the veins
  These valves normally stop blood flowing backwards. If they fail, blood falls back down into the scrotal veins.

• The anatomy of the left testicular vein
  The left vein drains into a larger vein in the abdomen at a less favourable angle, which is thought to be one reason why varicoceles are more common on the left side.

• Increased pressure in the abdominal veins
  Heavy lifting, long periods standing, chronic constipation or straining may increase pressure and contribute to vein dilation in some men.

The end result is pooling of warm blood around the testicle. The testicle is designed to work at a slightly lower temperature than normal body temperature. Even a small long-term increase in temperature, together with the build-up of waste products, can have a negative effect on sperm production and sometimes on testosterone production.

1. What symptoms can varicocele cause?

Many men with varicocele have no symptoms at all. Varicocele is often found by chance during an examination for another reason, such as a fertility assessment or routine urology visit.

When symptoms are present, they may include:

• A feeling of heaviness or dragging in the scrotum

• A dull ache in the testicle or groin, often worse at the end of the day or after standing for a long time

• A visible or palpable “bag of worms” appearance on one side of the scrotum, especially when standing or straining

• A mild sense of swelling or fullness in the scrotum

• In some men, the affected testicle may gradually become smaller over time

Varicoceles are most often on the left side, but they can also be on the right or on both sides.

1. Does varicocele cause infertility?

It can do, but not in every man.

Varicocele is:

• One of the most common correctable causes of male infertility

• A factor that can reduce sperm count, sperm movement (motility) and normal sperm shape (morphology)

However:

• Many men with varicocele have completely normal semen tests and father children naturally

• Having a varicocele does not automatically mean you will be infertile

Treatment is usually considered when:

• There is a clinically palpable varicocele on examination

• The semen analysis shows abnormal sperm parameters

• The couple has unexplained difficulty conceiving and the female partner has no major fertility factor

1. Does varicocele get worse over time?

It can progress in some men.

Even if the visible “degree” of varicocele (how large the veins appear) does not change, there can be:

• Gradual worsening of sperm quality over the years

• Possible reduction in testicular size in some younger men

Because of this, men who are diagnosed with varicocele, especially those who plan to have children in the future, are usually advised to have:

• Regular clinical check-ups

• Periodic semen analyses

• Ultrasound scans if needed

This allows any negative change to be picked up early.

1. How is varicocele diagnosed?

The main method of diagnosis is a physical examination by a doctor, usually a urologist.

During the examination:

• You are examined standing, in a warm room

• You may be asked to take a deep breath and gently strain (Valsalva manoeuvre) to make the veins more obvious

Varicocele is graded roughly as:

• Grade 1: Small, felt only when straining

• Grade 2: Medium, felt when standing, without straining

• Grade 3: Large, easily seen and felt, often described as a “bag of worms”

An ultrasound scan of the scrotum with Doppler may be used to:

• Confirm the diagnosis

• Measure the width of the veins

• Check for backward flow of blood (reflux)

So-called “subclinical” varicocele (only visible on ultrasound, not felt on examination) usually does not need treatment.

1. What tests are needed if I have a varicocele?

For men with varicocele, particularly those concerned about fertility, the typical assessment includes:

1. Physical examination
   To confirm the presence and grade of varicocele and to compare testicular size.

2. Semen analysis (sperm test)
   This looks at:

   • Total sperm count

   • Movement (motility), especially forward progressive movement

   • Percentage of normally shaped sperm

3. Scrotal Doppler ultrasound
   Used when the diagnosis is uncertain, when there is a large difference in testicular size, or to document reflux in the veins.

If you are undergoing a full infertility work-up, additional tests may include:

• Hormone tests (for example FSH, LH, testosterone)

• In selected cases, genetic tests or more detailed assessments

These help to understand whether there are other issues affecting fertility besides varicocele.

1. Does every varicocele need treatment?

No. Many varicoceles do not require active treatment.

Situations where treatment is usually not necessary:

• Small varicocele found by chance

• No discomfort or pain

• Normal semen analysis

• No desire for future children (for example in older men)

In these cases, regular monitoring and repeat semen tests may be enough.

Treatment is more often considered if:

• The couple has difficulty conceiving, and the man has a clinical varicocele plus an abnormal semen test

• A young man has a significant varicocele and reduced size of the affected testicle

• There is persistent, bothersome scrotal pain clearly linked to the varicocele and not responding to simpler measures

• There are other specialised indicators of sperm damage in selected cases

1. Can varicocele be treated with medication?

There is currently no medicine that reliably reverses or “shrinks” a varicocele.

Vitamins, herbal remedies or supplements:

• May support general health

• Do not close the enlarged veins or correct the faulty valves

The underlying problem is a mechanical one involving the vein structure. Effective treatment involves:

• Surgically tying off (ligation) the affected veins
  or

• Blocking the vein from the inside using a radiological procedure (embolisation)

1. Treatment options for varicocele

a) Microsurgical varicocelectomy

Microsurgical varicocelectomy is widely regarded as the “gold standard” surgical treatment for clinical varicocele in many specialist centres.

How it is done:

• A small cut (usually 2–3 cm) is made in the groin or just below it (inguinal or subinguinal incision).

• An operating microscope is used to magnify the area 10–40 times.

• The enlarged veins are carefully identified and tied off one by one.

• The testicular artery, lymph vessels and the vas deferens (sperm tube) are carefully preserved.

Advantages of the microsurgical approach:

• Lower risk of recurrence (varicocele coming back) compared with many older techniques

• Lower risk of hydrocele (fluid build-up around the testicle), because lymph vessels are better preserved

• Better protection of the testicular artery, reducing the risk of damage to the testicle

Anaesthesia and hospital stay:

• Usually done under general or spinal anaesthesia

• Most patients go home the same day or the following day

b) Laparoscopic varicocelectomy

In this method:

• Several small keyhole cuts are made in the abdomen

• A camera and instruments are passed in

• The testicular vein is clipped or tied near its origin

Laparoscopy can be useful in some cases, such as:

• Bilateral (both sides) varicoceles

• Certain anatomical situations

However, compared with a well-performed microsurgical operation near the groin, some studies suggest higher rates of recurrence and hydrocele. For this reason, many guidelines favour the microsurgical approach where expertise is available.

c) Radiological embolisation

This is a minimally invasive alternative performed by an interventional radiologist.

• A small tube (catheter) is passed into a vein in the groin or neck

• Under X-ray guidance, the catheter is moved into the testicular vein

• Coils, plugs or special liquids are used to block the vein from the inside

Possible advantages:

• No surgical incision in the groin

• Often quick recovery and return to normal activity

Limitations:

• Not available in all centres

• Slightly higher technical failure or recurrence rates in some series

Embolisation can be particularly helpful:

• In patients who have recurrent varicocele after previous surgery

• In patients who are poor candidates for general anaesthesia, depending on local expertise

1. What are the specific advantages of microsurgical varicocelectomy?

In summary, microsurgical varicocelectomy:

• Allows excellent visualisation of the veins, arteries and lymphatics using magnification

• Targets and ties off only the abnormal enlarged veins

• Preserves the testicular artery and lymphatic vessels more reliably

• Reduces the chances of:

  • Recurrence of varicocele

  • Hydrocele formation

  • Testicular damage

Because of these advantages, many international urological and fertility guidelines recommend the microsurgical technique as the preferred option in experienced hands.

1. What should I expect after surgery?

Recovery varies slightly between individuals and centres, but typically:

• You go home the same day or the next day

• Mild discomfort and swelling in the groin and scrotum are common for a few days

• Light daily activities are usually possible within a few days

• Heavier lifting, strenuous exercise and sexual activity are usually delayed for 2–4 weeks, depending on your surgeon’s advice

Fertility improvement takes time:

• Sperm production takes about 3 months per cycle

• The first follow-up semen analysis is usually done around 3–6 months after surgery

• Further checks may be done up to 9–12 months after surgery

Your doctor will also review your symptoms, check the surgical area and monitor for any recurrence or complications.

1. Will varicocele treatment improve my chances of becoming a father?

This depends on several factors, including:

• Your initial sperm count and quality

• The presence of other male or female fertility factors

• The age of your partner

In suitable men (clinical varicocele, abnormal semen analysis, unexplained infertility), studies have shown:

• Improvement in sperm count, motility and morphology after varicocelectomy in many patients

• Increased chances of natural pregnancy in some couples

• Possible improvement in success rates of assisted reproductive techniques (such as intrauterine insemination or IVF/ICSI) in selected cases

However:

• If the female partner has significant fertility problems, or age is advanced, varicocele surgery alone may not be enough

• Surgery should be considered as part of an overall fertility plan discussed with both a urologist and a fertility specialist

1. Guidelines and reliable sources used

The information in this section is based on clinical practice and on up-to-date guidance from:

• European Association of Urology (EAU) guidelines on male infertility and varicocele

• American Urological Association (AUA) and American Society for Reproductive Medicine (ASRM) recommendations on varicocele and male infertility

• National and international infertility guidelines, including NICE-based advice

• Recent review articles and meta-analyses on varicocele treatment and outcomes

Important note

This page is for general information only. Every patient is different. The best approach for you depends on:

• Your age and plans for having children

• The size and grade of your varicocele

• Your semen analysis results

• Your partner’s age and fertility status

• Any other medical conditions you may have

All decisions about treatment should be made after a detailed discussion with a urologist experienced in managing varicocele and male infertility.