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

A varicocele is the widening and dilation of the veins around the spermatic cord inside the scrotum, most often on the left side. It is a common condition that can sometimes play a role in male fertility concerns, though many men with a varicocele have completely normal fertility.

It affects around 15–20% of the general male population, most of whom are fertile with a normal semen analysis. However, it is found in 20–40% of men experiencing infertility.

Symptoms of varicocele

•       Often no symptoms at all.

•       Dull discomfort.

•       Heaviness in the scrotum that increases with sitting or standing, tends to worsen over the day, and is relieved by lying on the back.

•       Feeling a lump or swelling in the scrotum.

How varicocele may affect fertility

•       The dilation of the veins draining blood from the testicles happens due to abnormal venous valves, most commonly on the left side. The blood in these dilated vessels can raise the temperature around the testicles, which may affect sperm production and quality.

•       Increased pressure inside the testicle can reduce blood flow, potentially leading to low oxygen levels (hypoxia) and reflux of toxic substances from the adrenal gland.

•       These changes may contribute to DNA damage in the sperm head through oxidative stress.

•       Repairing a varicocele that can be felt on examination, in a man whose semen analysis is abnormal, can improve sperm count and motility and appears to increase the chance of natural pregnancy, although more high-quality studies are still needed.

Many fertile men also have a varicocele with normal sperm, so finding one does not, on its own, prove that it is the cause of a delay in pregnancy.

When improvement in semen parameters occurs after surgery, it is usually noticeable within the first 3–6 months.

When is treatment advised?

The decision to treat a varicocele is based on specific criteria. Your doctor will look for one of the following:

1.     Pain and discomfort, or

2.     Infertility (usually after one year of trying, or after six months if the wife is 35 or older), together with all of the following: the wife’s tests are normal; the semen analysis is abnormal; and the varicocele can be felt on clinical examination (grade 1, 2 or 3), or

3.     Adolescents showing progressive failure of testicular development.

Treatment may also be considered in men with a varicocele that can be felt and high sperm DNA fragmentation, repeated failed IVF/ICSI, or, in selected cases, no sperm in the semen (azoospermia).

How is a varicocele diagnosed?

A varicocele is diagnosed through a physical examination, standing up, by a specialist experienced in male infertility, such as an obstetrics and gynaecology specialist or a urologist. On examination it is often described as feeling like a “bag of worms.”

Scrotal ultrasound is used to confirm the diagnosis when the examination is uncertain and to look for other causes of pain or swelling. A varicocele found only on ultrasound is not, by itself, a reason for surgery (see below).

Grades of varicocele

•       Subclinical: cannot be felt by the doctor, even when the man bears down; seen only on Doppler ultrasound.

•       Grade 1: felt by the doctor only when the man bears down (the Valsalva manoeuvre).

•       Grade 2: felt by the doctor while the man is standing, without bearing down, but not visible.

•       Grade 3: large enough to be seen through the skin of the scrotum.

Subclinical varicocele: an ultrasound finding, not a reason for surgery

Many men come to my clinic after a scrotal ultrasound that reported a “subclinical varicocele” with veins of 2–3 mm, and they have already been told they need an operation. This deserves a closer look.

•       2–3 mm is at the border of normal. The European Society of Urogenital Radiology uses a vein of 3 mm or more — measured standing and while bearing down — as the point at which a varicocele can be diagnosed on ultrasound. Veins under 3 mm do not reach that threshold.

•       Surgery has not been shown to increase pregnancies. When the randomised trials of surgery for subclinical varicocele were pooled (seven trials, 548 men), there was no statistically significant rise in the pregnancy rate, and the authors judged the quality of the studies to be very low. Surgery slightly improved sperm motility — but a better number on a semen report is not the same as a baby.

•       The guidelines say no. The American Urological Association with the American Society for Reproductive Medicine, and the European Association of Urology, recommend against repairing a subclinical varicocele.

•       Surgery is not free of cost. It carries its own risks — hydrocele, recurrence, and rarely injury to the testicular artery — and months of waiting while the wife’s age keeps moving.

My advice: if your varicocele was seen only on ultrasound and cannot be felt on examination, do not have surgery for it. Ask for a careful examination by a specialist and a repeat semen analysis instead.

Smoking and varicocele: the factor that is often overlooked

When a man is told he has a varicocele, he is often not asked whether he smokes. He should be, because the two together do more harm than either one alone. This applies to argileh (shisha) as well as cigarettes.

What the research shows

•       Together they are worse. In a study of 715 men, those with a varicocele who smoked more than 10 cigarettes a day had clearly poorer sperm motility and shape than non-smokers with a varicocele. Other studies found more sperm DNA damage and oxidative stress in smokers with a varicocele, and a study from Saudi Arabia found that regular argileh smoking in men with a varicocele lowered testosterone and sperm motility.

•       Smokers gain less from surgery. Among 378 men who had varicocele surgery, those smoking 10 or more cigarettes a day showed a smaller improvement in sperm count and motility three months later. In a second study of 63 men, non-smokers had better motility 3 and 6 months after surgery and became pregnant sooner; the pregnancy rate was also higher in non-smokers (53%), although in such a small group that difference did not reach statistical significance.

•       The husband’s smoking raises the risk of miscarriage. A review of eight studies found that when the man smokes 11–19 cigarettes a day before conception, the risk of miscarriage is about 12% higher, and about 23% higher at 20 or more a day — even after allowing for the wife’s own smoking. In a large study of nearly 159,000 pregnancies, men who stopped smoking before the pregnancy had a lower miscarriage risk than men who carried on.

•       Stopping works, and fairly quickly. Heavy smokers who stopped showed a significant rise in sperm concentration, total sperm count and semen volume three months later, and another study found continuing improvement up to six months.

An honest note on the evidence

No study has yet followed men with a subclinical varicocele specifically, comparing smokers with non-smokers after surgery, for pregnancy, miscarriage and live birth. Nor has any trial compared surgery directly with stopping smoking. But the picture is clear enough to act on: surgery for a subclinical varicocele has not been shown to increase pregnancies, while stopping smoking improves sperm, lowers the risk of miscarriage, costs nothing and carries no surgical risk.

What I advise my patients

1.     Subclinical varicocele (seen only on ultrasound, veins about 2–3 mm): no surgery.

2.     Stop smoking completely — cigarettes, argileh and e-cigarettes — ideally both husband and wife together.

3.     Repeat the semen analysis about three months after stopping, because sperm take around 72 days to form.

4.     Do not let the man’s treatment delay the wife’s assessment, especially if she is 35 or older.

5.     If the varicocele can be felt on examination and the semen analysis is abnormal, surgery can help — and stopping smoking before the operation gives it the best chance.

Treatment of varicocele

Mild discomfort can often be managed with pain relievers such as anti-inflammatory tablets and supportive, well-fitted underwear.

As described above, in certain situations a varicocele may need surgical treatment. The aim is to stop blood from pooling in the swollen veins, which reduces the excess heat around the testicles.

Types of surgical intervention

•       Open surgery: usually a day-case procedure under general or local anaesthesia, through a small incision in the groin.

•       Microsurgery: a microscope helps protect the testicular artery and lymphatic vessels; this technique has the lowest rates of recurrence and hydrocele and is generally considered the preferred method.

•       Laparoscopic surgery: requires general anaesthesia.

•       Percutaneous embolisation: can be performed under local anaesthesia.

Possible complications

•       Infection

•       Bleeding

•       Blood clots

•       Hydrocele (fluid collection in the scrotum)

•       Recurrence of the varicocele

•       Testicular atrophy (shrinkage)

(The scrotum is the sac that holds the testicles.)

If you have been told you need varicocele surgery on the basis of an ultrasound alone, or if you have questions about varicocele, smoking and your chances of pregnancy, the team at Dr. Najeeb Layyous’s clinic is here to help you and your wife decide on the right next step.

Dr Najeeb Layyous F.R.C.O.G

Consultant Obstetrician, Gynaecologist and Infertility Specialist