Varicocele and Male Infertility: Causes, Symptoms, Diagnosis and Treatment

What Is a Varicocele?

A varicocele is an enlargement of the veins within the scrotum that drain blood from the testicle.

It is similar in principle to varicose veins that can occur elsewhere in the body.

Varicoceles are relatively common and are frequently found in men undergoing evaluation for infertility. However, having a varicocele does not automatically mean that a man is infertile.

The important question is whether the varicocele is clinically significant and whether it is affecting testicular function or sperm production.

The relationship between varicocele and male infertility has been discussed extensively in reproductive medicine. The ESSM 2014 scientific programme included sessions addressing varicocele, male infertility and surgical approaches to varicocele treatment. ESSM 2014 Scientific Programme

How Does a Varicocele Develop?

The veins surrounding the testicle contain valves that help blood flow in the correct direction.

When these valves do not function properly, blood can accumulate within the veins.

This can cause the veins to become enlarged and more prominent.

Varicoceles occur more frequently on the left side, although they can occur on either side or bilaterally.

Can a Varicocele Cause Male Infertility?

Yes, a clinically significant varicocele can be associated with impaired male fertility.

However, the presence of a varicocele alone does not prove that it is the cause of infertility.

Researchers have proposed several mechanisms through which varicocele may affect testicular function.

These may include:

• Increased testicular temperature

• Oxidative stress

• Impaired blood flow

• Changes in the testicular environment

• Damage affecting sperm production

• Potential effects on sperm DNA integrity

The ESSM programme included scientific discussion of oxidative stress and sperm DNA damage, which are relevant to the mechanisms being investigated in male reproductive health. ESSM 2014 Scientific Programme

How Can Varicocele Affect Sperm?

A varicocele may be associated with abnormalities in several sperm parameters.

Sperm Count

Some men with clinically significant varicoceles have reduced sperm concentration.

Sperm Motility

Sperm movement may also be impaired.

Sperm Morphology

Changes in sperm shape and structure can occur in some men.

Sperm DNA Integrity

Oxidative stress associated with varicocele has also been investigated in relation to sperm DNA damage.

However, not every man with a varicocele will have abnormal semen parameters.

This is why a semen analysis and complete fertility assessment are important before deciding whether treatment is appropriate.

What Are the Symptoms of Varicocele?

Many men with varicocele have no symptoms at all.

The condition may be discovered during a fertility assessment or routine physical examination.

When symptoms are present, they may include:

• A dull ache or heaviness in the scrotum

• Discomfort that becomes worse after prolonged standing

• A feeling of heaviness in the testicle

• Visible enlarged veins

• A difference in testicular size

Some men describe the enlarged veins as feeling like a "bag of worms."

However, symptoms alone do not determine whether treatment is necessary.

Can Varicocele Affect Testicular Size?

A significant varicocele can sometimes be associated with reduced testicular volume or impaired testicular development.

Testicular size is therefore one of the findings that may be assessed during a male fertility examination.

This can be particularly relevant in younger men or in cases where there is concern about impaired testicular function.

How Is Varicocele Diagnosed?

The diagnosis usually begins with a physical examination.

Physical Examination

A specialist may examine the scrotum while the patient is standing and may ask him to perform a Valsalva manoeuvre.

This can make enlarged veins easier to detect.

The specialist may assess:

• Size of the veins

• Location of the varicocele

• Testicular size

• Testicular consistency

• Whether the varicocele is palpable

• Whether the condition appears on one or both sides
  

Scrotal Ultrasound

A scrotal ultrasound with Doppler assessment may be useful when the diagnosis is uncertain or when further evaluation is clinically indicated.

Ultrasound can help assess:

• Vein diameter

• Blood flow

• Reflux

• Testicular structure

• Testicular volume

• Other scrotal abnormalities

However, ultrasound should support the clinical evaluation rather than automatically replace a proper physical examination.

What Is a Clinical Varicocele?

Not all varicoceles have the same clinical significance.

A specialist may distinguish between:

Subclinical Varicocele

A varicocele that cannot be felt during physical examination and is identified only through imaging.

Clinical Varicocele

A varicocele that can be detected during physical examination.

This distinction matters because treatment decisions are generally based on the overall clinical picture rather than an ultrasound finding alone.

Does Every Varicocele Need Treatment?

No.

A varicocele does not automatically require surgery.

Treatment may be considered when there is a clinically significant varicocele together with relevant fertility or testicular problems.

The decision may take into account:

• Fertility status

• Semen analysis

• Testicular size

• Symptoms

• Duration of infertility

• Female partner's fertility

• Other identified causes of infertility

• The couple's reproductive goals

Current EAU guidance recommends considering varicocele treatment in selected infertile men with a clinical varicocele and abnormal semen parameters, particularly when no other clear cause explains the infertility. EAU Male Infertility Guidelines

Can Varicocele Treatment Improve Sperm Quality?

In appropriately selected men, treatment of a clinical varicocele may improve some semen parameters.

Studies have reported improvements in:

• Sperm concentration

• Sperm motility

• Sperm morphology

However, improvement is not guaranteed for every patient.

The purpose of treatment should therefore be based on a realistic assessment of the individual case rather than assuming that surgery will automatically restore fertility.

What Are the Treatment Options for Varicocele?

When treatment is indicated, several approaches may be considered.

Microsurgical Varicocelectomy

Microsurgical varicocelectomy is a specialised surgical approach used to ligate the abnormal veins while attempting to preserve important structures such as the testicular artery and lymphatic vessels.

Microsurgical techniques can allow precise identification of the relevant veins.

This approach is commonly considered when surgical treatment is appropriate.

Laparoscopic Varicocelectomy

Laparoscopic surgery can also be used to treat varicocele.

Small incisions are used to access and ligate the affected veins.

The appropriate surgical technique depends on the patient's anatomy, clinical findings and the surgeon's expertise.

Embolisation

Another option is percutaneous embolisation.

Instead of open surgery, an interventional radiologist accesses the venous system through a catheter and blocks the abnormal veins.

The choice between surgery and embolisation should be individualised.

What Is Microsurgical Varicocelectomy?

Microsurgical varicocelectomy uses magnification to help the surgeon identify and preserve important structures while treating the abnormal veins.

Potential advantages include:

• Precise identification of veins

• Preservation of the testicular artery

• Reduced risk of lymphatic injury

• Treatment of smaller veins that may otherwise be difficult to identify

The exact approach depends on the patient's anatomy and the surgeon's experience.

The ESSM scientific programme included discussion of microsurgical varicocelectomy and male infertility, reflecting the role of surgical treatment within the broader management of varicocele-associated fertility problems. ESSM 2014 Scientific Programme

How Long Does It Take for Sperm to Improve After Varicocele Treatment?

Sperm production takes time.

For this reason, changes in semen parameters are generally not expected immediately after treatment.

A specialist may recommend follow-up semen analyses after an appropriate interval to assess whether sperm concentration, motility or other parameters have changed.

The exact timing depends on the individual case and treatment approach.

It is also important to remember that the ultimate goal is not simply to improve a laboratory number but to improve the couple's reproductive prospects.

Can Varicocele Come Back After Treatment?

Varicocele can recur after treatment, although the likelihood depends on the technique used and individual factors.

Recurrence may occur if some abnormal veins remain open or new collateral veins develop.

If fertility parameters do not improve as expected, the specialist may reassess the patient and determine whether a persistent or recurrent varicocele is present.

What Are the Risks of Varicocele Surgery?

As with any surgical procedure, varicocele surgery carries potential risks.

These can include:

• Infection

• Bleeding

• Recurrence

• Hydrocele

• Injury to the testicular artery

• Persistent discomfort

• Failure to improve fertility parameters

The risk profile varies according to the surgical technique and individual circumstances.

A detailed consultation should therefore include a discussion of the potential benefits and risks before treatment.

Does Treating a Varicocele Guarantee Pregnancy?

No.

Treating a varicocele may improve semen parameters in appropriately selected men, but pregnancy depends on many factors.

These include:

• Male reproductive health

• Female fertility

• Age of both partners

• Duration of infertility

• Severity of sperm abnormalities

• Other medical conditions

• Whether assisted reproductive treatment is required

Varicocele treatment should therefore be considered as one part of a comprehensive fertility strategy.

Varicocele and Sperm DNA Fragmentation

One area of interest in male reproductive medicine is the relationship between varicocele and sperm DNA fragmentation.

Oxidative stress may affect sperm DNA integrity, and varicocele has been investigated as one possible contributor to increased oxidative stress.

The ESSM 2014 programme included presentations discussing oxidative stress and sperm DNA damage, providing relevant background to this area of male fertility research. ESSM 2014 Scientific Programme

However, sperm DNA fragmentation testing is not automatically required for every man with varicocele.

It should be considered based on the individual clinical situation.

When Should You See a Specialist About a Varicocele?

A specialist fertility assessment may be appropriate if you have:

• A diagnosed varicocele

• An abnormal semen analysis

• Low sperm count

• Reduced sperm motility

• Difficulty conceiving

• Testicular discomfort

• A difference in testicular size

• A history of infertility

• A previous unsuccessful fertility treatment

The goal is to determine whether the varicocele is clinically significant and whether it may be contributing to the fertility problem.

Varicocele and Male Infertility: The Key Takeaway

A varicocele is not automatically a cause of infertility, and not every man with a varicocele needs treatment.

However, a clinically significant varicocele can be associated with impaired sperm production and may contribute to reduced fertility in some men.

A proper assessment usually combines:

Physical examination↓Semen analysis↓Assessment of testicular function↓Ultrasound when clinically indicated↓Evaluation of other fertility factors↓Individualised treatment decision

When treatment is appropriate, options may include microsurgical varicocelectomy, other surgical techniques or embolisation.

The most important step is identifying whether the varicocele is actually relevant to the man's fertility before deciding on treatment.

Book a Male Fertility Consultation

If you have a varicocele and are concerned about your fertility, a specialist assessment can determine whether it may be affecting sperm production and whether treatment could be appropriate.

Book a consultation with Professor Amr Raheem to discuss varicocele, abnormal semen analysis and male fertility treatment.

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References

1. European Society for Sexual Medicine (ESSM). 16th ESSM Congress Joint with the 12th EFS Congress – Final Programme, Istanbul, 2014. The programme includes scientific sessions addressing varicocele, male infertility, microsurgical varicocelectomy, oxidative stress and sperm DNA damage. ESSM 2014 Congress Programme

2. European Association of Urology (EAU). EAU Guidelines on Sexual and Reproductive Health – Male Infertility. Current recommendations concerning evaluation and treatment of varicocele in infertile men. EAU Male Infertility Guidelines