Varicocele & fertility: when to operate
A varicocele is a dilation of the veins inside the scrotum, something like “varicose veins” around the testis. It is very common: it is found in about 15% of men in the general population and in an even higher proportion of men with fertility problems.
The question that troubles many couples is simple to state but not to answer: should a varicocele be operated on to improve fertility, or not?
How does a varicocele affect fertility?
The dilated veins impair the normal drainage of blood and raise the temperature around the testis. This, together with oxidative stress, can over time affect sperm production and quality.
However, the relationship is not absolute: many men with a varicocele have entirely normal semen and father children without any problem. The mere presence of a varicocele is not, in itself, a reason for treatment.
What is the difference between clinical and subclinical varicocele?
A clinical varicocele is one that is palpable on physical examination — the doctor can “feel” it with the fingers, sometimes only when the man coughs or tenses the abdomen.
A subclinical varicocele is one that cannot be palpated and is detected only incidentally on ultrasound. This distinction is crucial for treatment because, as we shall see, only a clinical, palpable varicocele is operated on.
When is surgery indicated?
According to the guidelines, varicocele repair is considered when all of the following conditions apply: the varicocele is clinical (palpable), the semen analysis is abnormal, the couple has infertility, and there is no other clear cause on the partner’s side (or that is being treated in parallel).
By contrast, surgery is not recommended for a subclinical varicocele nor when the semen analysis is normal: in these situations no benefit has been demonstrated.
What benefit can one expect?
In properly selected men, varicocele repair can improve semen parameters (count, motility) and, according to a Cochrane review, may also increase the couple’s chance of pregnancy. The certainty of this evidence remains, however, moderate.
It is important to have realistic expectations: surgery does not guarantee pregnancy, and the effect on semen takes months to appear, since sperm production takes about three months.
How is the repair performed?
There are several techniques: microsurgical repair (subinguinal, with a surgical microscope), the laparoscopic approach, and embolization of the veins by an interventional radiologist. The microsurgical technique is regarded by many as the most precise, with low rates of recurrence and complications.
It is a minor operation, usually as a day case. The choice of technique is individualized according to the case and the surgeon’s experience.
Are there alternatives to surgery?
Yes. Depending on the severity of the semen problem and the partner’s age, IVF with ICSI may be a faster or more effective route, especially when time is a limiting factor.
The decision between surgery, IVF or a combination is always made jointly, weighing the severity of the male factor, the woman’s age and ovarian reserve, and the couple’s preferences.
Summary
A varicocele is common and can affect semen, but it does not always need treatment. Surgery is indicated only when the varicocele is clinical (palpable), the semen analysis is abnormal and there is infertility; it is not recommended for a subclinical varicocele or normal semen. In properly selected men, repair may improve semen and possibly the chance of pregnancy, with moderate certainty. Alternatively, ICSI is an effective route. The decision is always individualized.
⚕ Medically reviewed by Prof. Stratis Kolibianakis · Thessaloniki Medical Association Reg. No. 16340
ARTICLE 12 · MALE INFERTILITY
