Does a Varicocele Cause Infertility?

How do varicoceles (varicose veins in the scrotum) affect fertility? How is treatment carried out, and how effective is it? We have the answers.

Why do some men have varicose veins on their testicles? Are these a cause of male infertility?

Many are familiar with varicose veins on the legs. But varicose veins can also appear in the scrotum. The so-called varicocele is not always visible to the naked eye and some people do not even notice that they have varicose veins on their testicles. But if someone begins to experience pain from the condition or are struggling to conceive with their partner, they should contact a urologist for a diagnosis.

What is a varicocele?

The varicocele testis or the varicose vein hernia, as varicoceles are also called, are swollen blood vessels in the testicles. The swelling is due to congestion in the blood vessel, which prevents blood flow. In the case of varicose veins on the testicles, the veins of the spermatic cord (the pampiniform plexus) are congested. Due to the accumulated blood, the vessels sometimes enlarge so much that they can be seen on the testicles with the naked eye.

What is the cause of a varicocele?

The exact cause of a varicocele is not always clear. It has been suggested that it may be due the following causes:

• Anatomical differences in the testicular veins. The left testicular vein (Vena spermatica or Vena testicularis), which carries blood from the left testicle back to the heart, meets the left renal vein at a 90 degree angle. This unfavourable circumstance complicates the outflow of blood. Pressure builds up in the left testicular vein and causes blood to congest. The right testicular vein, which leads from the right testicle to the renal vein, reaches it at a more suitable, acute angle and is therefore often less of a problem. This is also the reason why 90 percent of varicoceles are on the left side of the scrotum.
• Congenital vascular problems. Valves in the veins prevent the blood from flowing backwards due to gravity. This ensures a constant forward flow of blood. The function can be impaired in some people from birth, for example in those who have tissue weakness.
• Tumor. Another cause could be a tumor pressing on the vein, blocking blood flow and causing the congestion.

Varicocele and fertility

It is estimated that around 15 percent of men in the general population are affected by varicose veins in the scrotum. In general, most varicoceles do not impact male fertility. However, it is identified in up to 40 percent of men who have received a diagnosis of male-factor infertility.

The prevalence of a varicocele that impacts fertility has also been found to differ if the male has never been able to father a child (called primary infertility) or if he has previously had children but is struggling to do so again (called secondary infertility).

In one study, 35% of males (352/1,001) with primary infertility had a palpable varicocele while 81% of males (79/98) with secondary infertility had one. This finding is understood by researchers to mean that over time, varicoceles increasingly impact male fertility in a negative way. A man with a varicocele may thus be able to father one child, but later struggle to conceive with his partner again because the condition has worsened.

How does a varicocele impact male fertility?

There are several aspects of varicoceles that have been associated with male infertility:

• Increased testicular temperature. Due to the poor circulation of blood in the enlarged veins, there can be an increase in scrotal temperature. Having a temperature that is outside of the normal range can lead to impaired testicular function, sperm production, semen quality and male fertility.
• Hormonal dysfunction. Varicoceles have also been associated with altered hormone levels, including testosterone. For male reproductive health, testosterone is important for sperm production (spermatogenesis), erectile functioning and libido.
• Decreased blood flow (hypoperfusion). The reduced circulation of blood in varicoceles can mean less oxygen and nutrients are delivered to the testicular tissues. Furthermore, it is suggested that it may contribute to rising testicular temperatures and increased oxidative stress (OS). This is a state in which there are too many cell-damaging free radicals (unstable molecules) in the body, and not enough antioxidants (protective chemicals) available to neutralize them.
• Damage to sperm. The heightened oxidative stress (OS) in the testicular tissue, mentioned above, can result in damage to sperm cells, leading to sperm DNA fragmentation and poorer sperm motility, reducing male fertility.

Keep in mind that, while there is a great deal of research on the topic, there is yet to be a consensus on which of the mechanisms above are responsible. This can be partially difficult to determine due to the fact that it is difficult to rule out additional factors, or examine why some men experience fertility problems and others do not.

How do I know if I have a varicocele?

In some cases, a varicocele is not even noticed because it does not trigger any symptoms in the person affected. If symptoms do occur, they may be:

• Swelling in the testicles
• Changed testicular volume
• Dull or aching pain
• Pain when standing or walking
• Heaviness in the testicles
• Feeling of tension in the scrotum (the thin sac of skin containing the testes)

If you are experiencing these symptoms, it is a good idea to visit your doctor or fertility specialist.

Diagnosing a varicocele

A varicocele may occur in two forms:

• Primary form. The primary form of varicoceles is related to congenital, weakened venous valves or vessel walls.
• Secondary form. The secondary form is also referred to as the symptomatic form. Here, the testicular varicose vein develops due to a disease, for example as a result of a tumor.

The diagnosis of a varicocele typically unfolds with a doctor through several steps. First, your medical specialist will have a discussion with you about your symptoms and medical history. They then may perform a visual examination, meaning that they check if the varicocele is visible. In a third step, there may be a physical examination where they feel your scrotum for any swelling. Finally, they may perform an ultrasound, particularly if the veins cannot be seen or felt.

Your doctor will assess your varicocele according to four degrees of severity:

• Grade 0. A grade 0 varicocele is when the varicose veins are neither visible from the outside nor palpable. In this case, the varicoceles can only be recognised by an ultrasound. For this reason, this is referred to as a subclinical varicocele.
• Grade 1. The varicocele is detectable with palpation. The doctor may ask you to do the Valsalva maneuver, which involves taking a breath, and holding it while bearing down. This increases the pressure in the head, chest, and groin, creating enough pressure that the varicose veins cannot be felt.
• Grade 2. With this degree of severity, the varicocele can be felt without conscious pressing. However, the enlarged vein is still not visible from the outside.
• Grade 3. With a grade 3 varicocele, you can see the varicose veins with the naked eye, and you can also feel them when palpating.

Treatment Therapies

If there is no tumor or you have no problems with your fertility or any pain, varicoceles do not necessarily have to be treated. If the findings and your situation suggest further measures, the affected veins can be treated by sclerotherapy, embolisation or surgery.

There are many studies that report a positive influence on semen parameters or a higher pregnancy rate after the varicocele has been treated in those affected. Various urology and andrology associations recommend treatment of clinical varicocele if it occurs in combination with the following points:

• OAT syndrome. Oligoasthenoteratozoospermia is characterised by a low sperm count (oligozoospermia), a low number of motile sperm (asthenozoospermia) and malformed sperm (teratozoospermia).
• Abnormal sperm parameters and unexplained male infertility.
• In men without azoospermia (the absence of sperm in ejaculate) but who have abnormal sperm parameters.

Varicocele repair may be done through the following methods:

• Sclerotherapy. In this non-surgical procedure, medication is injected into the vessel wall of the varicose vein. The solution irritates the vein lining and causes it to collapse and stick together. Once the vein is closed, blood will automatically use other vessels to flow back to the heart. Sclerotherapy is a minimally invasive outpatient procedure, which means that the patient can leave the hospital on the same day.
• Varicocele embolisation. During a varicocele embolisation, a radiologist (a medical professional working with radiation) inserts a thin catheter through a small incision into the affected veins. The incision is made through the neck, groin , or knee. Through the catheter, tiny metal coils or a special solution are placed in the varicocele, causing the veins to close off and the blood flow to be redirected. Embolisation is a minimally invasive surgical procedure using local anaesthesia.
• Varicocelectomy. A varicocelectomy (or varicocele surgery) requires general anesthesia and is aimed at closing off the varicose veins around the middle of the ureter. As with the first two techniques, the aim here is that the blood has to flow back to the heart in a roundabout way. For the operation, small incisions are often made in the abdomen and the subsequent steps are carried out using a camera inserted into the abdomen. The procedure is also called keyhole surgery or laparoscopic surgery.

Medical interventions are always associated with risks, however, the above procedures are often performed. The side effects of the procedures include bruising, infections, possible injuries to certain nerves or the vas deferens, and water retention in the testicles.

The most common complication following surgery to treat varicoceles is varicocele recurrence. This means that the varicocele will form again after surgery. The recurrence rates are between 0 and 35 percent.

FAQ

Are varicoceles dangerous?

Varicoceles do not necessarily have to be treated, but it is recommended if you are in pain or have an unfulfilled desire to have children, or if you are bothered by the visual effects on your testicles.

Can I prevent varicoceles?

Varicoceles are due to anatomical causes or diseases. There is therefore little you can do differently to prevent varicoceles.

Should I opt for surgery or a minimally invasive procedure for the treatment of varicocele?

The procedure you choose should be decided together with the doctor treating you. You can also consult your GP for a second opinion.

Conclusion

Treatment of a varicocele is not absolutely necessary if it does not have any negative consequences for the person concerned. If a man still wants treatment because of the external appearance or pain, there are various options available to him. Minimally invasive procedures such as embolisation or sclerotherapy have the advantage that patients can leave the hospital on the same day. Which is the best treatment option is ultimately an individual decision.

Men who have a varicocele and are having trouble conceiving should consider having their varicose veins removed, as studies have shown that sperm concentration and pregnancy rates improve after treatment.