A varicocele is when there is an enlargement of the blood vessels in the scrotum, which is the sac that holds the testicles. It is similar to a varicose vein that occurs in the legs.

Around 15% of American men have a varicocele that usually becomes evident during puberty. Because of the anatomical structure of men, they occur most frequently on the left side but can occur in either, or both sides of the scrotum.

What are symptoms of varicocele?

Most males with a varicocele have no symptoms at all, but some of the common signs are a lump, swelling, visible or twisted veins in the scrotum and/or dull pain. Pain may become more noticeable after long periods of standing or exercising.

What causes varicocele?

Varicoceles are caused when the blood vessels prevent the blood from flowing properly through the scrotum and testicles, this causes blood to become pooled and then the vein becomes dilated and swollen.

It is not known why this happens in some men and not others. Varicoceles are not caused because of poor health choices, injury, or playing sports, they are caused because of the anatomy of the scrotal region and the way the blood flows.

How are varicocele diagnosed?

Varicoceles are usually found through self-examination and then confirmed by a doctor. The appearance of a varicocele is sometimes described as looking like a "bag of worms" because of how they look and feel.

A doctor will do a manual examination and may order an ultrasound to get a better understanding of the blood flow. Varicoceles are graded from 1 to 3 with grade 1 being the smallest and grade 3 being the largest.

How do varicocele impact fertility?

Approximately 40% of men with varicocele also have issues with infertility, although it is possible that a low sperm count is a coexisting condition that is coincidental. Varicoceles cause changes in sperm production, mostly by increasing the temperature of the testes. There may also be increased pressure in the testicles, known as hypoxia, that is caused by altered blood flow and other hormonal and metabolite imbalances

It is suspected that varicocele may have a progressive impact on sperm production as the condition has been associated with secondary infertility.

Varicocele Treatment

If the varicocele is not causing any pain or discomfort, the doctor may decide to do nothing at all. However, there are situations when the doctor will recommend surgery to repair the blood flow to the scrotum. Usually, this is for men who have been found to have a low sperm count, chronic pain, or if the left testicle is much smaller than the right one.

  • Varicocelectomy is a surgical treatment that is done in the hospital by a urologist. During this procedure, the doctor will clamp the abnormal veins and divert the blood around the varicocele and reduce the pain and swelling.
  • Varicocele embolization also called percutaneous embolization, is another treatment option and is less invasive (although less commonly used). A small coil is inserted through a major leg or neck vein and is left in place in the groin. This stops the blood from flowing to the varicocele and will reduce the symptoms.

Fertility Prognosis After Varicocele Treatment

Infertility is a common complication of a varicocele. A semen analysis should be done 3-6 months after surgery or repair to see if the sperm count has improved. Some studies show fertility improves after varicocele repair, while other studies don’t. In general, semen quality improves in about 6 out of 10 infertile men after varicocele repair, especially those who had a grade 3 varicocele, which is a large varicocele that is noticeable.

There is a good chance of being able to conceive after varicocele repair, but it may be necessary to do in vitro fertilization (IVF) with Intracytoplasmic sperm injection (ICSI) - especially if the sperm count is very low. The benefit of ICSI is that you only need the ratio of one sperm per egg, meaning that even with a small number sperm being produced, the chances of successful fertilization are good. Of course, age and diagnosis of the female partner are also relevant considerations.

If the sperm count is within the low-normal range your doctor may recommend Intrauterine Insemination (IUI) where the sperm is concentrated into a small volume and placed directly in the uterus.

Keep in mind that it's always worth trying to conceive through intercourse at home while waiting to see your post-surgery results or waiting for fertility treatments to start.

Fertility Prognosis Without Varicocele Treatment

IVF pregnancy rates with and without surgery for a varicocele appear to be similar and so if you do not have any symptoms you may choose to undergo fertility treatments or continue to try and conceive naturally without having a varicocelectomy.

A doctor will be able to advise you of your chances of conceiving based on your semen analysis. Most doctors recommend having varicocele surgery if you have been trying to get pregnant for more than a year and do not wish to consider other fertility treatments such as IVF with ICSI.