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INFERTILITY and VARICOCELE

1. What are the causes of infertility?

Infertility means not achieving a pregnancy after 12 months of regular, unprotected intercourse. In around 50% of couples with infertility there is a male factor. Male causes include:

• No sperm production (azoospermia)

• Reduced sperm number or quality

• Failure of sperm to reach the ejaculate due to blockage (obstructive azoospermia)

These may arise from conditions that reduce sperm quality (such as varicocele), genetic problems (inherited or acquired), hormonal disorders involving FSH, LH or testosterone, and blockages in the sperm ducts (obstructive azoospermia). Before treatment, these areas should be assessed to make an accurate diagnosis. Many hormonal causes can be managed with medication; varicocele can be treated either radiologically or surgically; and some men with genetic problems may still achieve fatherhood using assisted reproductive techniques. (Uroweb)

1. Is surgery the only treatment for varicocele?

No. Varicocele is a common cause of impaired sperm quality, but not everyone with a varicocele needs treatment. When treatment is indicated (for example, infertility with abnormal semen parameters and a palpable varicocele, or persistent pain), options include:

• Percutaneous embolisation performed by an interventional radiologist

• Microsurgical varicocelectomy performed by a surgeon

In UK practice, many centres offer embolisation as a minimally invasive first-line option under local anaesthetic, particularly where interventional radiology expertise is readily available. Surgery remains a standard option and is preferred in some settings. (baus.org.uk)

1. What are the advantages of microsurgical varicocele repair?

Microsurgical varicocelectomy is the established operation performed using an operating microscope that magnifies the field up to around 40 times. This allows precise identification and preservation of arteries and lymphatics while ligating veins. Compared with non-microsurgical techniques, it is associated with lower recurrence and fewer complications, and is recommended as the preferred surgical approach in major guidelines. (AUA Network)

1. What are the advantages of percutaneous embolisation?

Varicocele embolisation is a non-surgical day-case procedure under local anaesthetic. Through a small vein puncture, coils or sclerosant are used to block the abnormal veins while preserving arterial flow. Benefits include no groin incision, rapid recovery, and low risks of hydrocoele or testicular atrophy. Technical success depends on vein anatomy, and a small proportion of cases may need a second attempt or surgical treatment if access is difficult or the varicocele recurs. Many UK centres consider embolisation a suitable initial treatment where available. (baus.org.uk)

1. Which treatment is better for fertility?

High-quality evidence shows both surgery and embolisation can improve semen parameters. Data on live birth are mixed, though more recent analyses suggest treatment can improve pregnancy outcomes in selected men with abnormal semen tests. When a decision is needed for fertility, guidelines recommend offering repair to men with infertility, a palpable varicocele and abnormal semen parameters, with microsurgical subinguinal repair the preferred surgical method. Choice between embolisation and microsurgery should consider local expertise, anatomy, recovery time, prior treatment and patient preference. (cochranelibrary.com)

1. Who should have a TESE procedure? What is the advantage of the microscopic technique?

TESE (testicular sperm extraction) involves a small incision in the testis to retrieve sperm for assisted reproduction when no sperm are seen in the ejaculate. It is considered when there is an ejaculatory blockage or in some men with non-obstructive azoospermia after counselling about chances of finding sperm and alternatives. Using an operating microscope (micro-TESE) helps target dilated seminiferous tubules, potentially increases sperm retrieval and aims to minimise testicular tissue loss. (Uroweb)

Key points to discuss with your clinician

• Whether treatment is needed at all based on symptoms, fertility goals and semen results

• Local availability and experience with embolisation and microsurgery

• Recovery time, complication and recurrence risks for each option

• Plans for semen analysis follow-up and, if relevant, assisted reproduction pathways (AUA Network)

References for current guidance and patient information

• EAU Guidelines on Sexual and Reproductive Health: Male Infertility. (Uroweb)

• AUA/ASRM Guideline: Diagnosis and Treatment of Infertility in Men (2024). (AUA Network)

• BAUS patient leaflet: Varicocele embolisation (2024). (baus.org.uk)

• NICE CKS: Varicocele management overview. (CKS)

• Cochrane Review: Surgery or radiological treatment for varicoceles in subfertile men (2021). (cochranelibrary.com)

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