A testicular varicocele is an enlargement of the veins within the scrotum. In most cases, it appears unilaterally, that is, in one of the testicles, but there are cases of bilateral varicocele in which both the right and left testis are affected.
In general, the symptoms of varicocele are not severe, although it can cause pain or become a cause of male infertility. For this reason, when the patient wishes to have children, it must be treated with the most adequate treatment option for each patient. In the most severe cases, surgery may be required in order to recover fertility.
The different sections of this article have been assembled into the following table of contents.
Causes & symptoms
About 15 percent of men with a varicocele do not have infertility issues, whilst 35 percent have primary infertility, and the remaining 81 percent have secondary infertility.
In the vast majority of the cases (about 87%), it affects the left testis. In 7% of the cases, it is bilateral, and only 3% of the patients have a varicocele in the right testis.
The main cause why the veins within the scrotum become enlarged is an alteration in the blood flow of testicular veins. The veins are filled with blood due to the backflow of blood (i.e. regurgitation) from the renal vein to the testis, causing an enlargement and affecting the testicular function.
As explained above, the only noticeable symptom of a varicocele is pain, and it does not appear in all cases. A number of patients have an asymptomatic varicocele.
A varicocele can cause testicular atrophy, which is to say, a decrease in testicular size.
To render a correct diagnosis of varicocele, your doctor will carry out a rigorous physical exploration of the scrotal and inguinal content, preferably while you are lying flat. Afterwards, you will be asked to get up and increase pressure in the abdomen. This allows the urologist to examine blood flow from upwards and see how it fills the inguinal canal and the testicular vein.
Based on how challenging the diagnosis process becomes, the urologist classify it into one of the following grades of severity
- Grade 1
- Diagnosis is complicated. It requires extra pressure on the abdomen. Your doctor might ask you to cough or forcibly blow out.
- Grade 2
- By touching the testicle, an urologist can confirm whether the volume of the veins is greater than normal.
- Grade 3
- The enlarged veins are visible to the naked eye.
When varicocele cannot be diagnosed with a physical exploration, performing an ultrasound scan to detect the presence of enlarged veins is advisable. To check the speed of blood flow, a Doppler ultrasound is used.
The blood vessels that nurture the testis start in the abdomen. When they descend, they become part of the spermatic cord. The flow of blood vessels is controlled by a set of valves that prevent the backflow of blood. Alterations of these blood vessels are the physiopathological basis of varicocele.
In the case of varicocele, regurgitation increases intratesticular temperature, affecting spermatogenesis (sperm production and maturation process). This is the reason why the testes are outside the rest of the body, since spermatogenesis must occur at a temperature that is 2 °C lower.
Due to all these consequences, between 50 and 70% of the patients are diagnosed with one of the following sperm disorders after a semen analysis:
- Low sperm concentration.
- Sperm motility issues.
- Abnormal sperm morphology.
In the most severe cases, it can even lead to azoospermia, that is, the total absence of sperm in the semen ejaculated.
On the other hand, a varicocele can cause alterations in the hormone system that regulates spermatogenesis, with the subsequent decrease of testosterone levels.
Finally, another effect derived from varicocele is oxidative stress, which can have a highly severe effect on male fertility and can lead to sperm DNA fragmentation.
Alterations in the testicular function can affect both testes, irrespective of whether the varicocele is unilateral or bilateral, since an increase in temperature affects both sides.
Varicocele requires treatment when the pain it causes is unbearable for the patient, and it cannot be relieved with medication. Also, when the patient wishes to have a baby and the varicocele is causing trouble.
According to experts, men who do not wish to conceive, are diagnosed with a varicocele, and have a normal semen analysis (normozoospermia), should be offered treatment as well. In the case of young males with varicocele and a normal semen analysis, their progress will be tracked with a semen analysis every two years.
Surgery is the most effective treatment option for varicocele. The procedure is called varicocelectomy.
Different surgical procedures can be used to treat a varicocele. Today, the technique of choice is microsurgery. Based on the size of the varicocele, inguinal or subinguinal microsurgery can be used. The risks associated with this procedure are minimal.
The technique of choice depends on the grade of severity, as well as on the expertise and skills of the surgeon. It can be performed with laparoscopic surgery as well. In any case, it does not take longer than 15-30 minutes, and it is carried out using epidural anesthesia, although sometimes general anesthesia is used.
After the procedure, the patient is recommended to rest for 1 or 2 days, apply ice on the genitalia and, in particular cases, use a scrotal support. Normal daily routines can be resumed within a week or 10 days, which means that the recovery process is rather fast.
Assisted procreation, as any other medical treatment, requires that you rely on the professionalism of the doctors and staff of the clinic you choose. Obviously, each clinic is different. Get now your Fertility Report, which will select several clinics for you out of the pool of clinics that meet our strict quality criteria. Moreover, it will offer you a comparison between the fees and conditions each clinic offers in order for you to make a well informed choice.
Percutaneous varicocele embolization is another treatment option that can be used to fix a varicocele in those cases where there is backflow of blood in the blood vessels.
Percutaneous embolization involves inserting a small catheter in a large vein located in the inguinal area. The catheter is approached to the varicocele, which is then blocked using tangible means. This procedure is effective in patients who already had a varicocele in the past. In these cases, percutaneous embolization can turn out to be the definitive solution for varicocele.
Results & risks
Thanks to these treatments, the normal temperature of the testicle is recovered, thereby recovering normal testicular function. By reestablishing it, spermatogenesis will occur with normality.
In 90% of the cases, the treatment of varicocele is successful. In fact, most studies show an improvement of sperm quality of between 40 to 60%. Also, pregnancy rates experience an increase of 20-60%. So, as one shall see, treating a varicocele with surgery improves fertility.
The most common complications of microsurgery are hydrocele and discomfort in the epididymis.
Several tests should be run after surgery to treat varicocele in order to make sure the results have been optimal.
A spermatic venography is typically the method used to identify potential areas where backflow of blood persists. If it were identified, treating it again would be required. Post-op semen analysis should be performed every three months during a year or until pregnancy is achieved.
For some experts, surgery is ineffective to eliminate infertility caused by varicocele. If pregnancy is not achieved naturally after surgery for varicocele, Assisted Reproductive Technology (ART) offers a wide range of options to achieve so, including sperm donation.
Pregnancy with varicocele
According to Antonio Alcaide Raya, PhD a varicocele can diminish the chances for a couple to achieve a pregnancy, since it affects sperm production. The fact that the sperm count is reduced and their viability compromised does not mean that, once pregnancy is achieved, the varicocele affects the pregnancy in any way.
When a patient visits a fertility clinic with a varicocele, the first thing the staff should do is to examine the semen sample. If quality is sufficient—and by "sufficient" we mean a quality level that allows us to use a fertility treatment with a minimum guarantee of success—we can proceed with the treatment. If the quality is too poor, or the varicocele is very painful, then previous surgery might be required.
In the worst-case scenario, that is, grade 3 varicocele, it is necessary to analyze the sample firstly as well. That is the only way we can determine whether surgery is required prior to starting with a fertility treatment or not.
FAQs from users
Can a varicocele be cured without surgery?
It depends on the grade of severity. Males with a mild-to-moderate varicocele are more likely to being able to conceive naturally. On the other hand, severe cases of varicocele affect male fertility significantly and surgery may be the only solution.
Is a varicocele the same as having varicose veins in the testis?
Yes, a varicocele is defined as having varicose veins or enlarged veins in the testis.
Can a varicocele have a negative impact on libido?
Yes, there exist cases of varicocele where the man has experienced a decrease of libido, probably due to abnormal testosterone levels. Nonetheless, although it is possible, it is uncommon.
Also, this diminished libido as a result of varicocele can lead to sexual impotence, but only in very severe or extreme cases.
Can a varicocele cause cancer?
No, a varicocele is unlikely to turn into a cancerous tumor.
Can a varicocele be prevented?
Unfortunately, contrary to what happens to varicose veins in the legs, there is no possible way for a varicocele to be prevented.
What is the difference between a varicocele and a hydrocele?
A varicocele is an enlargement of the veins in the testicles due to an abnormal blood flow. Conversely, a hydrocele is the presence of fluid in the scrotum, which function is to allow testicular mobility and to absorb the shocks. A hydrocele is commonly caused by inflammation of the testes.
Can I have sex relations if I have a varicocele?
Yes, as long as it is not painful for you.
Can a varicocele cause erectile dysfunction?
No, in principle a varicocele does not affect erection. Only if testosterone levels drop dramatically, the man may experience erectile dysfunction, but it is uncommon.
Can a varicocele cause premature ejaculation?
No, a varicocele cannot cause premature ejaculation.
Suggested for you
As one shall see, a varicocele can affect male fertility to a large extent. To learn more about how to become a father in spite of having a varicocele, continue reading here: Achieving Pregnancy with a Varicocele.
Also, if you wish to get more info on the whole set of causes that can lead to male infertility, read: What Causes Male Infertility? – Symptoms & Treatment.
Our editors have made great efforts to create this content for you. By sharing this post, you are helping us to keep ourselves motivated to work even harder.
Coolsaet BL: The varicocele syndrome: venography determining the optimal level for surgical management. J Urol 1980;124:833– 839.
Delaney DP, Carr MC, Kolon TF, Snyder HM 3rd, Zderic SA: The physical characteristics of young males with varicocele. BJU Int 2004;94:624–626.
Dubin L, Amelar RD: Varicocele size and results of varicocelectomy in selected subfertile men with varicocele. Fertil Steril 1970; 21:606–609.
Gat Y, Bachar GN, Zukerman Z, Belenky A, Gornish M: Varicocele: a bilateral disease. Fertil Steril 2004;81:424–429.
Gorelick JI, Goldstein M: Loss of fertility in men with varicocele. Fertil Steril 1993;59: 613–616.
Handel LN, Shetty R, Sigman M: The relationship between varicoceles and obesity. J Urol 2006;176:2138–2140.
Hirsh AV, Cameron KM, Tyler JP, Simpson J, Pryor JP: The Doppler assessment of varicoceles and internal spermatic vein reflux in infertile men. Br J Urol 1980;52:50–56.
Jarow JP: Effects of varicocele on male fertility. Hum Reprod Update 2001;7:59–64.
Lyon RP, Marshall S, Scott MP: Varicocele in childhood and adolescence: implication in adulthood infertility? Urology 1982;19:641– 644.
May M, Taymoorian K, Beutner S, Helke C, Braun KP, Lein M, Roigas J, Hoschke B: Body size and weight as predisposing factors in varicocele. Scand J Urol Nephrol 2006;40: 45–48.
Meacham RB, Townsend RR, Rademacher D, Drose JA: The incidence of varicoceles in the general population when evaluated by physical examination, gray scale sonography and color Doppler sonography. J Urol 1994; 151:1535–1538.
Pasqualotto FF, Sundaram A, Sharma RK, Borges E Jr, Pasqualotto EB, Agarwal A: Semen quality and oxidative stress scores in fertile and infertile patients with varicocele.
Reproducción Asistida ORG. Video: Embarazo con varicocele (Pregnancy with a varicocele), by Antonio Alcaide Raya, BSc, MSc, PhD, Dec 12, 2017. [See original video in Spanish].
Sakamoto H, Ogawa Y, Yoshida H: Relationship between testicular volume and varicocele in patients with infertility. Urology 2008;71:104–109.
Skoog SJ, Roberts KP, Goldstein M, Pryor JL: The adolescent varicocele: what’s new with an old problem in young patients? Pediatrics 1997;100:112–121.
Wishahi MM: Anatomy of the spermatic venous plexus (pampiniform plexus) in men with and without varicocele: intraoperative venographic study. J Urol 1992;147:1285– 1289.
World Health Organization: The influence of varicocele on parameters of fertility in a large group of men presenting to infertility clinics. Fertil Steril 1992;57:1289–1293.
World Health Organization: WHO Manual for the Standardized Investigation, Diagnosis and Management of the Infertile Male. Cambridge, Cambridge University Press, 2000.
Zini A, Buckspan M, Berardinucci D, Jarvi K: The influence of clinical and subclinical varicocele on testicular volume. Fertil Steril 1997;68:671–674.
FAQs from users: 'Can a varicocele be cured without surgery?', 'Is a varicocele the same as having varicose veins in the testis?', 'Can a varicocele have a negative impact on libido?', 'Can a varicocele cause cancer?', 'Can a varicocele be prevented?', 'What is the difference between a varicocele and a hydrocele?', 'Can I have sex relations if I have a varicocele?', 'Can a varicocele cause erectile dysfunction?' and 'Can a varicocele cause premature ejaculation?'.