Medically reviewed by Dr. Shweta Agarwal, MBBS, DGO. Last updated: June 2026.
Information on this page is educational and does not replace a medical consultation. Outcomes depend on individual clinical factors.
In Marathi, this condition is referred to as शिरावैरिकोसील — abnormal dilation of the testicular veins that, when clinically significant, can affect sperm quality. This page covers the varicocele condition specifically. For a broader overview of male fertility causes, see male infertility.
What exactly is a varicocele, and why does it affect sperm?
A varicocele forms when the valves within the testicular (pampiniform) veins fail to work properly, causing blood to pool instead of draining efficiently. The testes require a temperature approximately 2–3 °C below core body temperature for normal sperm production. The pampiniform plexus normally functions as a countercurrent heat exchanger, cooling arterial blood before it reaches the testis. When veins dilate and blood pools, this cooling mechanism is disrupted — scrotal temperature rises, and the resulting heat and oxidative stress from pooled blood can impair spermatogenesis.
The effects on sperm can include:
- Reduced sperm count (oligospermia) — fewer sperm produced.
- Impaired sperm motility (asthenozoospermia) — sperm move less effectively.
- Increased morphological abnormalities (teratozoospermia) — higher proportion of abnormally shaped sperm.
- Elevated sperm DNA fragmentation (DFI) — oxidative stress raises reactive oxygen species, damaging sperm DNA integrity. If you have a raised DFI result, a sperm DNA fragmentation test provides a more precise picture.
These combined abnormalities are sometimes grouped under the term OAT (oligoasthenoteratozoospermia) — see abnormal sperm / OAT. The broader male-factor context — how these parameters are interpreted together — is covered at male infertility.
Does a varicocele always cause symptoms, or can it be silent?
Most varicoceles produce no symptoms at all and are discovered only during a fertility investigation or a routine physical examination. When symptoms do occur, they are typically:
- Dull aching or dragging discomfort in the left testicle or scrotum — tends to worsen after prolonged standing, physical exertion, or by the end of the day, and eases when lying down.
- A "bag of worms" sensation on gentle palpation of the scrotum — the feel of soft, irregular, cord-like structures above the testicle.
- Visible scrotal fullness in higher-grade varicoceles, apparent through the scrotal skin.
- Testicular asymmetry — in longstanding or severe varicocele, the affected side may feel smaller due to progressive testicular atrophy.
Varicocele is predominantly left-sided because the left testicular vein drains at a right angle into the left renal vein, creating greater back-pressure. Bilateral varicocele occurs in a minority of cases. An isolated right-sided varicocele is uncommon and warrants further investigation to rule out a mass compressing the right testicular vein — this is an important clinical point.
The absence of symptoms does not mean the varicocele is not affecting sperm. A semen analysis is the essential next step to assess impact.
How are varicoceles graded?
Varicoceles are graded on clinical examination, typically using the Dubin-Amelar classification, with the patient standing and performing a Valsalva manoeuvre (bearing down):
| Grade | What it means |
|---|---|
| Subclinical | Not palpable or visible on examination; detected only on scrotal Doppler ultrasound during Valsalva |
| Grade I | Palpable only during Valsalva manoeuvre; not visible |
| Grade II | Palpable without Valsalva; not visible |
| Grade III | Visible through the scrotal skin; palpable without Valsalva |
For fertility decisions, clinical palpability matters: subclinical varicocele (detectable only on ultrasound, not by examination) is generally not treated in the current evidence framework for infertility. Clinically palpable Grade I–III varicocele associated with abnormal sperm parameters is the relevant finding for treatment consideration.
How is a varicocele diagnosed?
Diagnosis combines physical examination and imaging, and is completed alongside a semen analysis to understand the functional impact.
Physical examination
The doctor examines the scrotum with the patient standing and asks the patient to perform a Valsalva manoeuvre to reveal venous distension. This clinical examination is the foundation for treatment decision-making.
Scrotal Doppler ultrasound
Scrotal Doppler ultrasound confirms the clinical finding, measures pampiniform vein diameter (a diameter above 3 mm during Valsalva is the accepted threshold), and detects venous reflux (reverse blood flow during Valsalva). It also assesses testicular volume on both sides — useful for monitoring over time.
Semen analysis
A semen analysis is essential to establish whether the varicocele is affecting sperm count, motility, and morphology. Without this, a treatment decision cannot be made. In selected cases, a sperm DNA fragmentation test adds further information about DNA integrity.
Does every varicocele need to be treated?
No — and this is one of the most important things to understand about this condition. Many men with varicocele have completely normal sperm parameters and father children naturally. A varicocele is not an automatic indication for surgery or embolisation.
Treatment in a fertility context is generally considered when all three of the following apply:
- The varicocele is clinically palpable (Grade I or higher on examination — not subclinical alone).
- There is documented impairment of semen parameters — a low sperm count, reduced motility, poor morphology, or elevated DNA fragmentation on semen analysis.
- The couple is actively trying to conceive, and female fertility is either normal or has correctable factors.
If sperm parameters are normal, repair for fertility purposes is not routinely indicated. Repair may also be considered for significant symptomatic pain regardless of fertility status.
What are the treatment options if repair is recommended?
When varicocele repair is clinically indicated, the aim is to block or ligate the dilated veins so that blood is redirected through normal drainage pathways, relieving the heat and oxidative stress on the testis.
Microsurgical varicocelectomy
The current preferred surgical approach in most centres. Under surgical microscopy, the dilated veins are ligated through a small subinguinal incision while preserving the testicular artery and lymphatics. Microscopic magnification reduces the rates of recurrence and complications compared to conventional open surgery.
Laparoscopic varicocelectomy
Performed under general anaesthesia through small abdominal ports. Outcomes are comparable to microsurgical repair; may suit certain clinical situations.
Percutaneous embolisation
A radiological (non-surgical) procedure in which the testicular vein is blocked with coils or sclerosant material, delivered through a catheter introduced via the groin or neck, typically under local anaesthesia. Outcomes are broadly comparable to surgery.
What to expect after repair
Any improvement in sperm parameters takes time. Sperm production (spermatogenesis) runs on a cycle of approximately 72–90 days, so improvement — if it occurs — typically begins to show after 3 months or more. A follow-up semen analysis is usually scheduled at 3–6 months post-procedure. It is important to understand that improvement is not guaranteed — not every man sees a meaningful change in sperm parameters after repair, and the degree of improvement varies between individuals.
When is IVF or ICSI considered instead of, or alongside, repair?
For couples where sperm parameters are severely impaired or where time is a factor — for example, if the female partner is older or has her own fertility concerns — ICSI (intracytoplasmic sperm injection) or IVF may be the recommended path rather than waiting 3–6 months to see whether repair improves sperm. Even a very small number of viable sperm is often sufficient for ICSI, which bypasses the barriers that impaired sperm cannot overcome on their own.
ICSI and varicocele repair are not mutually exclusive — in some situations, repair may be performed with the intention of improving sperm quality before a planned IVF/ICSI cycle. The right path depends on the couple's individual clinical picture, and is decided together with Dr. Shweta Agarwal after a full assessment.
When should a man seek an evaluation for varicocele?
Consider a consultation if:
- A semen analysis has returned abnormal results and a varicocele has been identified or is suspected.
- You have a dull, persistent scrotal ache that worsens during the day or after physical activity.
- You and your partner have been trying to conceive for 12 months without success (or 6 months if the female partner is 35 or older) and no female cause has been identified.
- You are a younger man with a known varicocele who wishes to understand whether it may affect future fertility.
A fertility assessment is the right starting point — it will include the relevant history, physical examination, and baseline semen analysis.