A varicocele is an enlargement of the veins within the scrotum, caused by valves that no longer prevent blood from pooling. The mechanism is comparable to varicose veins in the leg.
It is present in approximately 15 percent of men generally and in a considerably higher proportion of those evaluated for infertility. It is also one of the more treatable contributors to impaired sperm production, which is why it is looked for during a male fertility assessment.
Varicocele Symptoms in Males
Varicocele symptoms in males are often absent, and many are diagnosed only when a semen analysis returns an abnormal result. Where symptoms occur, they typically include:
- A dull ache or heaviness in the scrotum: Worse after prolonged standing or exertion, and relieved by lying down.
- A visible or palpable mass: Often described as resembling a bag of worms, and more apparent when standing.
- Asymmetry between the testes: The affected testis may appear smaller, reflecting impaired growth over time.
Most varicoceles occur on the left side, a consequence of the anatomy of the left testicular vein. One appearing on the right side alone warrants further evaluation to exclude another underlying cause.
Can Varicocele Cause Infertility
Yes, although not in every case. Many men with a varicocele father children without difficulty, so the presence of the condition alone does not establish it as the cause of a couple’s infertility.
What the evidence supports is an association. Varicoceles are identified in a higher proportion of men with abnormal semen parameters than in the general population, and they are the most common correctable finding in male infertility. The clinical question is therefore not whether a varicocele is present, but whether it is affecting sperm production in that patient.
How Varicocele Affects Sperm Production
The question of how varicocele affects sperm production has several answers operating together.
- Raised scrotal temperature: Sperm production requires a temperature below core body temperature, and pooled blood raises the local temperature.
- Oxidative stress: Varicoceles are associated with elevated reactive oxygen species, which damage the sperm membrane and the DNA within the sperm head.
- Reduced oxygen supply: Impaired venous drainage lowers oxygen delivery to testicular tissue.
- Reflux of metabolites: Backflow from the adrenal and renal veins may expose the testis to substances that interfere with sperm development.
- Hormonal disturbance: Testosterone production within the testis may be reduced, affecting sperm maturation.
These effects are progressive in a proportion of men, which is one reason treatment is considered earlier in younger patients with abnormal parameters.
Low Sperm Count Due to Varicocele
Low sperm count due to varicocele is the most commonly recognized effect, but rarely the only one. The typical pattern involves reduced concentration alongside impaired progressive motility and a lower proportion of normally formed sperm.
Sperm DNA fragmentation is also frequently elevated, and may persist even where standard parameters appear acceptable. Where a varicocele is present, and a couple has unexplained infertility or recurrent pregnancy loss, DNA fragmentation testing may be recommended.
Assessing Varicocele and Infertility
Diagnosis begins with a physical examination performed with the patient standing, since a varicocele is more readily detected in that position, followed by scrotal ultrasound with Doppler to confirm the finding and assess testicular volume. Assessment of varicocele and infertility also requires at least two semen analyses several weeks apart and a full assessment of the female partner, since a varicocele identified in isolation does not complete the clinical picture.
Varicocele Treatment for Infertility
Treatment is not recommended for every man with the condition. Intervention is generally considered where the varicocele is clinically palpable, semen parameters are abnormal, the couple has documented infertility, and the female partner has normal or correctable fertility.
The available approaches include:
- Microsurgical subinguinal varicocelectomy: Generally the preferred technique, with lower recurrence and complication rates than alternative surgical methods.
- Laparoscopic varicocelectomy: Used in selected cases, particularly where both sides are affected.
- Percutaneous embolization: A radiological procedure that blocks the affected vein without an incision.
Improvement in semen parameters, where it occurs, becomes apparent over three to six months, since sperm production follows a cycle of approximately three months. Treatment does not guarantee conception, and where the female partner’s age is a limiting factor, proceeding directly to assisted reproduction may be more appropriate.
Conclusion
A varicocele is common, frequently asymptomatic, and does not invariably cause infertility. Where it coincides with abnormal semen parameters in a couple struggling to conceive, it becomes clinically relevant, and it is one of the situations in which treatment can improve the underlying problem rather than work around it.
The decision to intervene depends on factors such as the size of the varicocele, the semen analysis findings, the duration of infertility, and the age of the female partner.
FAQs
No. Semen parameters improve in a proportion of appropriately selected patients, and improvement takes three to six months to become apparent. Conception depends on additional factors, including the female partner’s age and fertility, so the decision to operate should be weighed against the couple’s overall timeline.
Generally not. A varicocele detected only on imaging and not palpable on examination, in a man with normal semen parameters, is usually managed with observation. Periodic semen analysis may be recommended to confirm the parameters remain stable.
Consult a Fertility Specialist at 9M Fertility
Where a varicocele has been identified, or a semen analysis has returned abnormal results, the next step is an assessment that considers both partners together. The specialists at 9M Fertility evaluate semen parameters alongside clinical examination and imaging, and advise whether treatment is likely to be of benefit in a given case.
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