Varicocele and Male Infertility: When Does Surgery Actually Help?

A varicocele is a widening of the veins that drain blood from the testicle — the same process as varicose veins in the legs. It is found in a substantial proportion of men, and most of the time it causes no symptoms at all.

Sperm production is sensitive to heat, which is why the testicles sit outside the body. In a varicocele, blood flow slows and the temperature of the area rises, which can impair sperm production.

The critical point, though, is that a varicocele on its own is not a reason for surgery. A man with no symptoms, a normal semen analysis and no difficulty conceiving does not need any intervention.

Surgery is considered when three things come together: a varicocele that can be felt on examination, abnormal semen parameters, and a couple who have not been able to conceive.

A varicocele that is visible only on ultrasound and cannot be felt on examination is generally not recommended for surgery. Knowing this distinction protects you from an operation you do not need.

Pain can also be a reason: testicular pain that affects daily life, gets worse with standing, and has no other explanation.

In adolescents, a testicle on the side of the varicocele that is clearly smaller than the other is a separate reason for assessment.

In many countries the investigation starts with the woman alone, and years of her treatment can pass before anyone asks for the man's semen analysis. That delay is hard to justify. Assessing the man — a semen analysis and a clinical examination — is simple, and it should happen early, alongside the woman's assessment rather than after it.

The reverse applies too. Finding a varicocele should not be where the investigation stops. The regularity of the woman's ovulation, the state of her fallopian tubes and her age all directly affect the outcome, and the likely benefit of varicocele surgery cannot be judged without them.

If the woman's age is advanced, for example, time becomes an important factor, and moving straight to assisted reproduction may be wiser than waiting for the result of varicocele surgery. That decision is made together with a gynaecologist.

The aim of varicocele surgery is to tie off the dilated veins while preserving the artery and the lymphatic vessels.

In the microsurgical approach, a microscope is used to magnify the vessels and tell them apart. It is widely preferred because lower rates of recurrence and of fluid collection around the testicle (hydrocele) are reported with it.

Laparoscopic and conventional open techniques are also used. Which one is chosen depends on the varicocele and on the surgeon's experience.

Sperm production runs in a cycle, and new sperm take about three months to form. A semen analysis done immediately after surgery is therefore meaningless.

Change is usually followed with repeat semen analyses from the third month onwards. The wait is hard on couples, but it cannot be avoided.

An improvement in the numbers is not the same as a pregnancy. Sperm count or motility can rise without a pregnancy following, and the reverse is also possible.

Varicocele surgery can improve semen parameters in carefully selected men. Not every man improves, and not every couple whose numbers improve goes on to conceive.

Be cautious of anyone who promises you a definite outcome. Before surgery, it is worth agreeing on the answer to a simple question: what will we count as success?

Varicocele surgery and assisted reproduction are not necessarily alternatives. For some couples, surgery is planned to improve the chances of fertility treatment that follows.

Swelling and discomfort in the area can last a few days, and heavy lifting and strenuous activity should be avoided for a period.

Recognised risks include fluid collection around the testicle, recurrence of the varicocele and, rarely, injury to the testicular artery. These should be discussed before surgery, not after it.

If you are travelling for the operation, send a recent semen analysis and your partner's fertility assessment before you book, so that whether surgery is worthwhile is decided first. And because the result is judged at three months, agree before you leave who will review your follow-up semen analyses at home, and how you will send them.

This article is general information and does not replace medical advice.