Varicocele and Infertility

Varicocele Signs and Symptoms, How They Cause Infertility, and Treatment Options

Man holds overweight belly, while standing on scale
Being overweight may increase your risk of developing a varicocele.. Photo: Dimitri Otis / Digital Vision / Getty Images

A varicocele (pronounced VAR-a-co-cell) is an enlarged vein in the scrotum and testicle, usually found on the left side, but also possibly found on both sides of the scrotum, and very rarely only on the right side. You're likely familiar with varicose veins, which occur in the legs. As with varicose veins, when a varicocele is present, the vein's valve that helps blood flow upward to the heart becomes dysfunctional.

This causes blood to pool in the area. This may lead to swelling, testicular shrinking, infertility, and sometimes pain.

Varicocele's are relatively common, occurring in up to 15% of men. They are, in fact, the leading cause of male infertility, found in 40% of men with low sperm counts. Varicoceles are treatable, and as long as other fertility problems aren't present for the male or female partner, pregnancy without additional fertility treatment may be possible.

However, whether varicocele treatment improves pregnancy success rates in all cases is a matter of debate, with some studies showing improved conception rates and others not. You should speak to both a urologist and a reproductive endocrinologist on whether the surgery makes sense for your particular situation.

Varicocele Symptoms and Diagnosis

Most men aren't aware of a varicocele until they experience fertility problems. An abnormal semen analysis result will be followed up by a doctor's physical exam, and this is when the varicocele may be discovered.

However, some men do experience signs or symptoms beside infertility. They may include the following:

  • A dull ache or feeling of heaviness in the testicle, especially after exercise
  • A swelling or mass in the scrotum, sometimes described as feeling like a bag of noodles
  • One testicle noticeably smaller than the other

    A varicocele can be diagnosed during a physical exam. The urologist may ask you to stand up and bare down. He will then physically exam your scrotum. If a varicocele is present, your bearing down will usually cause the varicocele to enlarge and become apparent. It may also be visible without needing to bare down. Your doctor may also exam you while lying down. A varicocele should disappear when you're in a horizontal position.

    It's possible to have a varicocele that isn't noticeable during a physical exam, and only discovered with the use of ultrasound. However, a varicocele of this size is usually left untreated, as research has not found an association to infertility in these cases.

    Your doctor may order an ultrasound of the scrotum if the physical exam is inclusive, or if there is testicular mass that doesn't seem to be a varicocele. While a varicocele is typically considered harmless if pain and fertility aren't an issue, do not assume that a mass you find on your scrotum is a varicocele.

    The mass may be something more serious that does requires immediate treatment.

    How a Varicocele May Cause Infertility

    The presence of a varicocele has been associated with lowered sperm count, an increase in DNA damaged sperm, poor sperm morphology (or shape), and poor sperm movement. It's not exactly clear why varicoceles cause infertility, but there are theories.

    The most popular theory is that the pooled blood raises the overall temperature in the scrotum and testicles. Increased scrotal heat can be damaging to sperm.

    Another theory is that poor circulation leads to increased levels of toxins, which in turn leads to poor semen health. Another theory suggests the increased scrotal pressure harms semen health. Poor oxygenation of the testicles is yet another theory.

    Varicocele Causes and Risk Factors

    No one is sure what causes varicoceles to form. They may first appear in puberty and are most common in men ages 15 to 25. Being overweight may possibly increase your risk of developing a varicocele.

    Varicocele Treatment

    Whether or not to treat a varicocele will depend on the size of the varicocele, whether it causes you pain, whether there are additional fertility factors at play, and what you and your partner's recommended fertility treatment plan looks like. The age of the female partner will also be taken into account, since treatment doesn't yield results quickly. (More on this below.)

    If, for example, IVF treatment is needed due to female factor infertility, treatment to repair the varicocele will likely not be recommended. Another reason treatment may not be recommended is if your semen analysis found no sperm, also known as azoospermia, and the azoospermia is not caused by an obstruction within the male reproductive organs. Some research has not found the varicocele treatment worthwhile in this case, and men who have had the surgery may still need TESE (or testicular sperm extraction) to retrieve sperm for IVF.

    On the other hand, if there are no additional fertility factors at play, and your sperm counts are only abnormally low (as opposed to being completely absent), treatment may be a good option for you.

    Varicocele treatment options include:

    • Microsurgical varicocelectomy: This highly skilled surgery is performed inguinal, meaning via the groin, or subinguinal, meaning via a single incision that is about one inch above and to the side of the penis, and uses a microscope to aid in the repair. This surgical technique has the fewest risks and a shortest recovery time, making it the surgical treatment of choice.
    • Laparoscopic varicocelectomy: In this case, the repair is done via the abdomen. Because of the increased risk and longer recovery time, this is rarely chosen.
    • Percutaneous embolization treatment (also known as radiologic ablation): This is a nonsurgical technique with fewer risks and pain than either of the above surgical treatments. This treatment involves a radiologist injecting into the problem vein small coils or alcohol to block the vein causing the trouble. This treatment requires a radiologist knowledgeable in this technique, which may not be available in all areas. There's some controversy over the long term success rates of this treatment.

    All of these treatments carry some degree of risk, with percutaneous embolization carrying the least risk and laparoscopic surgical repair carrying the greatest amount of risk. Be sure to discuss with your doctor all your treatment possibilities, including complete information on risks, success rates, and recovery times.

    Success rates will vary from person to person, but some research has found improvement in semen health in more than two-third of patients. Also, 30 to 50% of couples will be able to achieve pregnancy naturally after surgery.

    Note, however, that due to the life cycle of semen, it will take three to four months after the repair before semen health will show improvement. Your doctor may suggest follow-up semen analysis every three to four months post repair, to see if the treatment was indeed successful. It may take six to twelve months before pregnancy will occur post treatment.

    More on the male side of infertility:

    Sources:

    Ficarra V, Crestani A, Novara G, Mirone V. "Varicocele repair for infertility: what is the evidence?" Curr Opin Urol. 2012 Nov;22(6):489-94. doi: 10.1097/MOU.0b013e328358e115.

    Varicocele: Patient Fact Sheet. American Society for Reproductive Medicine. Accessed June 20, 2013. http://www.asrm.org/uploadedFiles/ASRM_Content/Resources/Patient_Resources/Fact_Sheets_and_Info_Booklets/Varicocele.pdf

    Varicocele. Weill Cornell Medical College, James Buchanan Brady Foundation, Department of Urology. Accessed June 20, 2013. https://www.cornellurology.com/clinical-conditions/male-infertility/general-information/varicocele/

    Report on varicocele and infertility. The Practice Committee of the American Society for Reproductive Medicine. Accessed June 20, 2013. http://www.asrm.org/uploadedFiles/ASRM_Content/News_and_Publications/Practice_Guidelines/Joint_Reports/Report_on_varicocele%281%29.pdf

    Schlegel PN, Kaufmann J. Fertil Steril. 2004 Jun;81(6):1585-8. "Role of varicocelectomy in men with nonobstructive azoospermia."

    Schlesinger MH, Wilets IF, Nagler HM. "Treatment outcome after varicocelectomy. A critical analysis." Urol Clin North Am. 1994 Aug;21(3):517-29.

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