Varicocele and Male Fertility: What You Need to Know

A varicocele is an enlargement of the veins within the scrotum, the loose bag of skin that holds the testicles. These veins, called the pampiniform plexus, normally drain blood from the testicles. When the valves in these veins don't work properly, blood pools and the veins become swollen, similar to varicose veins in the legs.

Varicoceles most commonly occur on the left side (around 85% of cases), though they can occur on both sides. They typically develop during puberty and may grow larger over time. Many men have varicoceles without any symptoms or fertility problems.

The connection between varicoceles and male fertility is well established, though not all men with varicoceles experience fertility problems. The main ways varicoceles can affect sperm include:

• Increased testicular temperature, the pooled blood raises scrotal temperature, which can impair sperm production. Optimal sperm production requires the testicles to be slightly cooler than body temperature.
• Reduced oxygen supply, poor blood flow may decrease oxygen delivery to the testicles
• Toxin accumulation, metabolic waste products may not be cleared efficiently
• Hormonal effects, varicoceles may affect testosterone production in some men
• Oxidative stress, can lead to increased sperm DNA fragmentation

Semen analysis in men with varicoceles often shows reduced sperm count, decreased motility (movement), and abnormal sperm morphology (shape).

Varicoceles are usually diagnosed through:

• Physical examination, a doctor can often feel larger varicoceles during an examination. You may be asked to stand and perform a Valsalva manoeuvre (bearing down as if having a bowel movement) to make the varicocele more prominent.
• Scrotal ultrasound, used to confirm the diagnosis and measure the size of the veins. Ultrasound can detect smaller varicoceles that aren't palpable on examination.

Varicoceles are graded by size:

• Grade 1 (small), only detectable when bearing down
• Grade 2 (medium), palpable without bearing down
• Grade 3 (large), visible through the scrotal skin

Not all varicoceles require treatment. Treatment is generally considered when:

• The couple is experiencing infertility and the man has abnormal semen parameters
• There is documented decline in testicular size or function
• The varicocele causes significant pain or discomfort
• Adolescents show testicular growth delay on the affected side

For couples pursuing assisted reproduction, treatment decisions depend on individual circumstances. Some couples may proceed directly to ICSI if there are other factors involved, while others may choose varicocele repair first.

Varicocele treatment aims to block the abnormal veins while preserving healthy blood flow. Options include:

• Microsurgical varicocelectomy, the most common surgical approach. Through a small incision near the groin, a surgeon uses a microscope to identify and tie off the affected veins. This technique has the lowest recurrence rate and complication risk.
• Laparoscopic surgery, performed through small incisions using a camera and instruments. Less commonly used today.
• Percutaneous embolisation, a non-surgical option where a radiologist threads a catheter through a vein and blocks the varicocele using coils or a sclerosing agent. No incision is required, and recovery is quicker, but recurrence rates may be slightly higher.

Improvements in semen parameters are typically seen 3 to 6 months after treatment, as sperm production takes approximately 74 days. Studies show:

• 60 to 80% of men show improvement in semen quality
• Natural pregnancy rates of 30 to 50% within one to two years
• Potential improvement in sperm DNA integrity

Results vary depending on factors such as the grade of varicocele, duration of infertility, partner's age and fertility status, and whether other male or female factors are present.