Overview
Varicocele is a common condition in males in which the veins within the scrotum become enlarged. While not everyone with a varicocele experiences fertility issues, it may still contribute to infertility as it impacts sperm quality. Varicocele often does not need to be treated if it does not cause discomfort. In some cases, varicocele can cause pain, swelling, discomfort, or difficulty conceiving, which makes it important to seek medical attention. This guide explains how varicocele impacts sperm health, its symptoms, diagnosis, and available treatment options. Understanding the condition early can help you make informed choices and seek the right advice as needed.
What is a Varicocele?
Varicocele is a male medical condition in which the veins in the scrotum become enlarged. The scrotum is the pouch of skin below the penis that holds the testicles.
Varicocele is similar to varicose veins in the legs. However, unlike varicose veins, it’s common in younger men aged 15-25. Normally, these veins have small valves that help blood flow in the right direction.
When normal flow is disrupted, the blood backs up, enlarging the veins. They typically look and feel like spaghetti, a bag of worms, or soft, irregular lumps within the scrotum.
Varicocele is most commonly observed on the left side. Although they are usually painless, they can sometimes cause testicular pain, swelling, increased temperature, and discomfort.
Can a Varicocele Cause Infertility?
A varicocele can contribute to male infertility. However, not everyone with a varicocele experiences fertility issues. Around 15% to 20% of all males have varicoceles.
However, a varicocele may be contributing factor in infertility, as it can reduce sperm quality. About 40% males with infertility issues have varicocele, making it one of the most common causes of male infertility.
How Does a Varicocele Affect Fertility?
Although the exact mechanism by which varicocele affects fertility is not fully understood, it may impair sperm production and quality.
The swollen or enlarged veins cause heat buildup and chemical damage in the scrotum. Men with varicoceles produce 44 million fewer sperm per ml than others, as the enlarged veins disrupt sperm production.
The heat buildup and chemical damage can also affect sperm motility. It harms the sperm tails and reduces their energy. As a result, sperm swim 26-27% less effectively, weakening their ability to fertilise eggs.
How is a Varicocele Diagnosed?
As with many other medical conditions, diagnosing a varicocele involves physical exams and imaging tests.
Physical exam
The health care provider examines a varicocele by visual inspection of the scrotum. This condition is graded on a scale of 1 to 3 based on size and how easily it can be spotted or felt.
- Grade 1 (smallest): When the scrotum has a tiny and hard-to-find varicocele, it is considered grade 1. During the physical exam, the patient is asked to stand and perform a “Valsalva maneuver,” a process in which one takes a deep breath, pinches the nose, closes the mouth, and bears down as if having a bowel movement. In this grade, the varicocele is so small that it can’t be felt unless one performs the Valsalva maneuver.
- Grade 2 (medium): Bigger than grade 1 but still not visible, a grade 2 varicocele can be felt as twisted veins like soft tubes when the patient is standing without performing the Valsalva maneuver.
- Grade 3 (largest): This grade of varicocele is the easiest to spot. The scrotum looks lumpy and swollen on one side, most often the left. The veins feel like a bag full of worms or spaghetti without any additional examination.
Some experts also add grade 0, in which the varicocele is detected by ultrasound, and grade 4, which indicates a very severe varicocele.
Medical tests
- Pelvic ultrasound: This test is recommended to better characterise the varicocele. Veins wider than 3mm and disrupted flow during the Valsalva maneuver are signs of varicocele. Ultrasound uses sound waves to create images of the varicocele and measure the size of the testicles, helping to guide treatment accordingly.
- Semen analysis: This test is optional and suggested only if the patient has a varicocele alongside fertility concerns. Doctors collect a semen sample and test it to assess overall sperm health, including sperm count, motility and morphology.
- Blood test: This test helps assess hormone levels, including FSH and testosterone.
Can a Varicocele Be Treated?
Yes, varicoceles can be treated depending on the severity of the condition. Grade 1 and grade 2 varicoceles are often left untreated if they do not cause discomfort or affect fertility. However, treatment is offered to males in the following situations:
- Infertility: Those with varicocele and infertility concerns are often advised to undergo semen analysis. When the analysis shows low sperm count, weak motility, or DNA damage, treatment may be suggested to improve sperm quality.
- Chronic pain or discomfort: Varicocele can cause ongoing dull ache, scrotal heaviness, or swelling. Moreover, it worsens when standing, exercising, or in the heat. However, if it does not improve with rest or ice, doctors may suggest treatment.
- Teen with testicular issues: During puberty (ages 15-19), if one testicle is shrinking, growing more slowly, or much smaller than the other, it may be a sign of concern. Doctors suggest early treatment to prevent permanent damage.
How is a Varicocele Treated?
Varicocele treatment varies depending on its severity. Doctors recommend both at-home and surgical treatments after evaluating the condition.
At-home treatment
- Changes to routine: Doctors may suggest basic changes to your daily routine to help manage discomfort from varicocele. These include avoiding tight-fitting underwear, such as spandex or jockstraps, particularly while exercising or standing for long periods.
- Application of ice: When a varicocele causes a dull ache or discomfort, applying ice or a cold pack to the area can relieve pain.
- Over-the-counter medications: Although there are no drugs that can treat or prevent varicoceles, you can take over-the-counter medications such as acetaminophen or ibuprofen to relieve pain.
Surgery
The main goal of varicocele surgery is to seal off the enlarged veins and redirect blood flow through healthier veins. These surgeries are usually performed under anesthesia. In most cases, patients can return home the same day.
There are two surgical options:
- Microsurgical Varicocelectomy: This is a 2-3-hour procedure in which a surgeon makes a small incision about 1 cm above the scrotum. Using a high-powered microscope, the surgeon ties off the enlarged veins while preserving important structures, such as arteries, lymphatic vessels, and the spermatic ducts.
- Laparoscopic varicocelectomy: In this procedure, the surgeon inserts thin tubes into the abdomen to seal the enlarged veins without making a cut near the groin. This process is generally quicker and can be completed within 30-40 minutes.
Risks of surgery
Recovery time and post-operative are generally similar for both procedures. In most cases, patients return to their normal routine within one or two weeks, with mild pain.
Although varicocele treatment is generally safe, like any other medical procedure, it may carry some risks, such as:
- Varicocele remaining or coming back.
- Fluid forming around the testicle
- Injury to the testicular artery
Most of these risks are manageable; experts recommend the most suitable option based on the patient’s condition.
Alternative to surgery: Percutaneous Embolisation
Embolisation is a non-surgical treatment for varicocele. In this process, a radiologist inserts a small catheter into a vein and blocks the affected veins using coils or a special solution, restoring normal blood flow without the need for an incision.
Can You Conceive Naturally After Varicocele Surgery?
Yes, many patients conceive naturally within a year of varicocele surgery, as the treatment may improve sperm health. The main goal of varicocele repair is to restore normal blood flow in the scrotum, which may help improve sperm count, motility and overall quality over time.
However, results can vary from person to person, and many factors influence the outcome. The key factors include:
- The severity of varicocele
- Duration of the condition
- Baseline sperm quality before treatment
- Age and reproductive health of both partners
Improvements in sperm parameters may take time, as a sperm production cycle typically lasts 2 to 3 months. Changes may become obvious gradually over a few months after surgery.
It is essential to remember that varicocele surgery may improve the chances of natural conception, but it does not guarantee pregnancy, as many factors influence fertility in both partners.
Conclusion
Varicocele is a common and often manageable condition that can affect male fertility, but does not always lead to infertility.
Since a significant number of men facing infertility are found to have varicocele, the condition should not be ignored, especially when symptoms such as pain, swelling, or difficulty conceiving are present. Early evaluation and proper diagnosis can make a meaningful difference in managing the condition and improving reproductive outcomes.
Both surgical and non-surgical treatments are available for varicocele, and doctors recommend the most suitable option based on overall severity and individual circumstances. If you notice persistent discomfort in the scrotum or experience any other symptoms, it is advisable to consult a healthcare professional. Taking timely action can help prevent permanent damage and better address the condition.