How it shows up
Most varicoceles cause no symptoms and are found during a routine exam or a fertility workup. When there are symptoms, they are usually a feeling of heaviness or discomfort in the testicle that gets worse at the end of the day or after physical exertion and eases when lying down.
The diagnosis is clinical. It is made on physical examination with the patient standing, and the varicocele is classified by grade. Ultrasound confirms and measures it, but an ultrasound finding on its own, without a matching clinical finding, is not a reason for treatment. Losing sight of this distinction is behind a large share of unnecessary surgeries.
Why it can affect fertility and hormones
The enlarged veins raise the temperature of the testicle and disturb local blood flow. This impairs sperm production and can also affect the cells that produce testosterone.
That is why varicocele shows up on two fronts: infertility, with abnormal semen parameters and increased sperm DNA fragmentation; and hypogonadism, with lower-than-expected testosterone.
When surgery is indicated
Surgery is considered when the varicocele can be felt on physical exam (not just seen on ultrasound) and at least one of the following applies:
- The couple is facing infertility, the semen analysis shows abnormal parameters, and no other apparent cause has been found
- Persistent pain that does not respond to conservative measures
- In adolescents, a persistent reduction in the volume of the affected testicle — a difference of more than 2 mL or 20% compared with the other one — confirmed on two evaluations six months apart
Outside these situations, the approach is monitoring
A subclinical varicocele, seen only on ultrasound, does not need treatment, and neither does a varicocele in an infertile man whose semen analysis is normal. A varicocele that causes no symptoms, in a man who is not planning to have children, does not need surgery. And one important point: varicocele surgery is not indicated as a treatment to raise testosterone.
When infertility is the issue, the decision also takes the female partner's evaluation into account, because surgery only pays off if natural conception is possible and there is time to wait for it. I have this conversation with both partners.
The microsurgical technique
Microsurgical subinguinal varicocelectomy is the technique with the best results. An operating microscope is used to identify and preserve the artery and lymphatic vessels, which reduces the two most significant complications: hydrocele and arterial injury. Recurrence rates are lower than with conventional techniques.
The procedure requires specific training in microsurgery, which is a central part of my own training.
What surgery can fix, and what it cannot guarantee
In well-selected patients, repair improves semen parameters in a good share of cases and reduces sperm DNA fragmentation.
On testosterone, something needs to be said that rarely is. The literature describes a rise in testosterone after repair, but it is a compensatory effect of the procedure. It is modest, on the order of 100 ng/dL, and may not improve symptoms. That is why surgery is not indicated as a way to raise testosterone. This was the conclusion of the review I published on the subject, and its recommendation is explicit: patients should be counseled not to have high expectations.
On pregnancy: surgery improves the chances; it does not guarantee them. The outcome also depends on the female partner's age and evaluation, and on the couple's situation as a whole.
Frequently asked questions
Does a varicocele always need surgery?
No. Surgery is indicated when a palpable varicocele comes with abnormal semen parameters in the context of infertility, persistent pain, or loss of testicular volume. A varicocele that causes no symptoms and has no effects is not a reason for surgery.
Does surgery guarantee that we'll get pregnant?
No. It improves semen parameters in a good share of selected patients and increases the chances, but pregnancy depends on the couple as a whole, including the female partner's evaluation and age.
Does varicocele surgery raise testosterone?
That is not what the surgery is for. The literature describes a rise, but it is a compensatory effect of the procedure, modest, and with no guarantee that symptoms will improve. Having surgery in the hope of treating low testosterone means having it for the wrong reason.
Can a varicocele come back after surgery?
Yes. Recurrence is possible, and it is significantly less common with the microsurgical technique than with conventional ones, precisely because magnification makes it possible to identify veins that would otherwise be missed.
My ultrasound showed a varicocele, but the doctor couldn't feel it on exam. Do I need treatment?
Probably not. A subclinical varicocele, seen on ultrasound but not palpable, does not require treatment in most situations, because there is no consistent evidence of benefit.
