Turek on men's health
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Award-winning urologist - and pioneer in Men's Health - Dr. Paul Turek blogs weekly about issues such as infertility, vasectomy and vasectomy reversal, sexual and hormonal dysfunction and more. Keep up with the latest on this fascinating field of medicine.

Meet Mr. Varicocele



This is no unicorn
Varicocele: Unicorn or workhorse?

How can something so soft and warm and blue, and no wider than a pencil, have such a devastating effect on your ability father children? Meet the varicocele (veri-ko-seal), the unicorn of male fertility.

The Inimitable Varicocele

As posted previously, the varicocele is unique to humans and is a consequence of our upright posture. It is a bag of veins in the scrotum that, except if it caused low-grade discomfort, you probably would never know you have.

Varicocele as Unicorn

Yet, as I live and breathe the nuances of this field daily, the varicocele never ceases to amaze me.  Although first recognized in the first century AD, it gained modern notoriety when a Dr. Tulloch surgically repaired one in the 1950s in a man who had no sperm in his ejaculate. Lo and behold, sperm returned to the ejaculate and the patient’s wife conceived naturally. Is this the story of a unicorn?

Not really. Unlike the ephemeral unicorn, the varicocele exists and is, in fact, quite common. Look hard and you will find them in 15% of healthy men and in 40% of men having trouble conceiving their first child. It is even more common in men having trouble having a second child. Having said this, it is also true that most men with varicoceles are normally fertile. So how does this work?

A Susceptibility Thing

No one really knows why varicoceles affect the fertility of some men but not others. Maybe it’s the size of the lesion or maybe it’s the exposure time (time from their onset at puberty to the age at which men try to conceive) that matters. As a consequence, some clinicians don’t believe in them and others, like me, do. In fact, I have spent a great deal of time pondering them in infertile men. Because of this, I feel I know their personality quite well.

The Varicocele Personality

Having read, studied and published on the varicocele over the last 2 decades, here is my letter of recommendation about varicoceles:

Dear Parent to Be:

I am delighted to write this letter of support about Mr. Varicocele, someone whom I have known well for the last 20 years and feel comfortable commenting on his personality and future potential.

      1. In most men, he coexists peacefully and never bothers anybody.
      2. In some men, he disturbs sperm production and can wreak havoc on fertility.
      3. Fixing him can help couples conceive naturally
      4. Fixing him can help eliminate scrotal pain
      5. Fixing him fixes a problem and can help couples build entire families (i.e. have several children)
      6. Fixing him can help couples considering IVF for family building to avoid IVF and conceive naturally
      7. Fixing him can help couples considering IVF to have children to use less invasive technology (i.e. IUI) instead of IVF to conceive
      8. Fixing him in men who fail to conceive with IVF can help with IVF conceptions
      9. Fixing him in men with genetic causes of infertility will not help them conceive naturally
      10. Fixing him in men with no ejaculated sperm counts will generally not help them conceive naturally but can help them conceive with IVF

In summary, I believe in Mr. Varicocele has the potential to have a great impact on the world of human fertility. Please consider him seriously whether you are simply contemplating, or actually building, your family as he can be invaluable in these situations. Personally, I recommend him highly to as one of the most common correctable conditions associated with infertility. Please call me if you have any questions about this rather strong recommendation.

Sincerely yours,

Paul Turek MD

Director, The Turek Clinic


49 Responses to “Meet Mr. Varicocele”

  1. Al

    Hi Dr Turek,
    I find this blog very interesting. My husband had a uncessessful TESA about six months ago and we were told that the found no sperm cells or cells that can become sperm and therefore he will never father his own child. At the time I asked our doctor about a varicocele that another specialist had pointed out in a recent visit and was told that this had would have nothing to do with his azoospermia. Just wondering your thoughts on this or should we get a second opinion?

    Reply
  2. Al

    I guess what I’m asking is can a varicocele cause total NOA? I know it can decrease sperm count but can it stop production entirely?

    Reply
  3. Samson

    I recently had a left side varicocele repaired by Interventional Radiology hoping that it would boost my testosterone levels. I didnt have any problems with fertility, but lowT and scrotal pain. Unfortunatly after 3 months my T levels did not increase, but what did occur was remarkable. Within 1 week of the surgery I went from being practically an insomniac to sleep soundly through the night. I havent seen this published anywhere, but I have a hunch many men with unidentified sleep problems may be related to undiagnosed varicoceles.

    Reply
    • Paul Turek, MD Paul Turek, MD

      Samson, interesting. Maybe the scrotal pain was preventing you from getting good sleep and now that is gone. Either way, better sleep may also increase your testosterone levels.

      Reply
    • Paul Turek, MD Paul Turek, MD

      Dear Al, Anything that reduces the pain/discomfort of a varicocele is good. The real question is whether the varicocele is potentially affecting your future fertility (if that is an issue at all!). A semen analysis may be of help here. As long as the discomfort is under control and the semen analysis remains normal, you should be good to go.

      Reply
  4. rahul

    Sir,I suffering from grade-1 left sided varicocele,Sir I consult the andrlogist,he suggested me to operation,is neccesary operation for grade1 varicocele,if operation is necessary which operation method is best with low complications,and reaccurence and formation of hydrocele.please suggest me sir.my sperm count is 52 millions/no,progressive motility is65 and non progressive motility is 20.what I do.my left sided scrotum is swelled.is swelling can decrease after surgery.and I have also back pain.Please suggest me sir.is embolization good,or micro surgery .please suggest me sir.iam praying you sir please suggest me.iam in dialama

    Reply
    • Paul Turek, MD Paul Turek, MD

      Dear Rahul, there are two and maybe 3 reasons to fix varicoceles: 1) infertility with an ABNORMAL semen analysis (sounds like yours is fine) b) scrotal pain that goes away when lying down (sounds like you have back pain which is not typical) and 3) maybe low testosterone. Not looking good that a varicocele repair will help you… I prefer the microsurgical subinguinal repair because of very high reliability and low recurrence.

      Reply
  5. ALEX

    I m married fro 3 yra now but have no children yet. \my sperm analysis is low and Doctor said I had varicocele. He is suggesting surgery which I don’t want. Pls is there any other remedy?. What do I do?. Thank you sir.

    Reply
    • Paul Turek, MD Paul Turek, MD

      Dear Alex, often, fixing the problem (ie. varicocele) is the best way to solve the fertility issue. Much cheaper than alternative (IVF, IVF-ICSI) and allow you to have a lot more fun trying to have a baby at home and not in the laboratory. The average time to conceive in our practice after repairing a varicocele is 6-7 months.

      Reply
  6. Joe

    Dr. Turek,

    I had a microsurgical varicocele repair on both testicles two years ago, and I am a little self conscious and embarrassed about the scars. I was wondering if you had any recommendations as to how to improve or diminish the appearance of these. Is is safe to try a silicone gel? I just want to make sure that this wouldn’t negatively impact my sperm or testosterone levels. Any advice you could provide would be greatly appreciated. Thanks so much.

    Joe

    Reply
    • Paul Turek, MD Paul Turek, MD

      Joe, at this point, 2 years after surgery, silicone gel is not likely to help for keloids. Surgical scar revision is relatively simple and then using silicone gels immediately afterwards for several weeks would probably be best way to improve things. There are no concerns about sperm or testosterone levels with simple scar revisions.

      Reply
  7. shilparoy

    Good post!! My uncle suffered from varicocele with heavy pain in testicles. Last month after a great research we came to know about non surgical varicocele embolisation treatment by Dr. Abhilash at http://www.interventionsinradiology.com/. It was a good treatment with in a month he was completely cured.

    Reply
  8. Kareem

    Dr., i have a left side grade 3 varicocele, no pain (just slight discomfort after a long day of standing), no testicular atrophy and I’m doing semen analysis this week as determined by my andrologist, can you please tell me about my chances that it would come out to be normal, I’m much curious about this please give me your opponion

    Reply
    • Kareem

      Oh, I’m 21 and unmarried, if it was recommended for me to undrego varicocelectomy, would you advise me to have it now or after marriage (around 5-6 years from now)

      Reply
      • Paul Turek, MD Paul Turek, MD

        Dear Kareem, Great Question and hard to answer! Most men with varicoceles will never have a problem with pain and infertility, and some will. Problem is there is no way to predict but in general large varicoceles associated with smaller testicles are more worrisome.

        Reply
    • Paul Turek, MD Paul Turek, MD

      Dear Kareem, hard to say the chances of it being normal. I would say that with a smaller testis on the side of the varicocele and a large varicocele that the chances of having a low sperm count are higher.

      Reply
  9. Jack

    Doc, It’s been recommended to me to get a varicocelectomy as I have a grade 3 varicocele and my wife and I are having trouble conceiving. However, I do menial labor for a living and I was just wondering if after this repair I might be at an increased risk for a hernia? Is there any truth to that? Thank you

    Reply
    • Paul Turek, MD Paul Turek, MD

      Jack, I love the microscopic, subinguinal approach which does not lead to any increased risk of hernia afterwards. Never seen it. You must ask your surgeon what kind of repair he/she does (inguinal, retroperitoneal) and what the chance of hernia is.

      Reply
  10. Ahli

    Dr. I had a sperm analysis and found no sperm count.
    Blood tests FSH 24
    No microdeletions found on chromosome Y
    And I have a varicocele on the left of 2.3mm diameter
    Can you tell me the chances of conceiving a child? Is there hope to find sperm through microTESE?

    Reply
    • Paul Turek, MD Paul Turek, MD

      Dear Ahli, This picture is typical of non obstructive azoospermia with a small (possibly inconsequential) varicocele. In our publication of results using FNA mapping, 63% of men had pockets of sperm in the testis. Once sperm are found, the chances of conceiving a child depend almost entirely on your partner’s fertility potential.

      Reply
  11. mwang

    Dr, i have been married for 6 months now without conceiving, i did semen analysis twice and both had no sperm found and i was told its azoospermiam i did some tests, my hormone and testosterone is normal but i was told i have a mild left varicocele. i went to the ulologist and he told me to have surgery in mid august. he suggested that it could the reason i have azoospermia but he assured me that he is not 100% if thats the cause. advise please

    Reply
    • Paul Turek, MD Paul Turek, MD

      Dear MWang, In the setting of azoospermia that is not caused by obstruction, there is a 30-40% chance that a varicocele repair will lead to ejaculated sperm. This might take 6-8 mos to occur. Generally, the ejaculated sperm counts achieved will not be sufficient for at-home conception, but will generally need IVF to work. If obstruction is present, then varicocele repair will not result in ejaculated sperm. So, in general, azoospermia is NOT due to the varicocele. Genetic causes (Y deletion and karyotype) should be looked into first as we have published that fixing varicoceles in the setting of genetic infertility does not improve semen quality or lead to natural pregnancies. Genetics generally drives things.

      Reply
  12. Khair

    Hi Doctor,

    I am 24 years old. Recently I have met an injury at the very delicate place, done ultrasound scrotum, it says bilateral varicocele I have no pain at all and report also said both the testis appear normal in size, shape and contours. Urologist said I do not require any treatment. My questions are
    1. It is due to injury?
    2. If it is due to injury, will it be healed itself, after a few months?
    3. I have no pain at all, will it develop later?
    4. Will I be able to father a child?
    5. Any good medicine (ayurvedic, unani, homeopathy) to eliminate it, or at least stop it from developing?

    Thanks a ton in advance.

    Reply
    • Paul Turek, MD Paul Turek, MD

      Dear Khair, the details of your “injury” are not clear. However, you have had it checked out by a urologist, and even had an ultrasound. Varicoceles are incidental and unlikely to be a problem in the future. If you are still worried about them, consider getting a semen analysis to know some more about you fertility.

      Reply
      • Khair

        Glad to see your reply so early.. Thanks a ton…

        I was riding a bike and suddenly a vehicle came and hit it hardly and my penis was erect when it happened and it was like I don’t know what happened but tears came out of my eyes. And after 5 minutes everything was normal.. After four days when I masrurbation u saw semen color as violet and shocked and went to urologist he suggested the ultrascan scrotum. And gave me some medicines and in only two days color of my semen was normal I was very happy. But after seeing reports(varicocele) doctor said it is common and should be left untreated and I asked why was my semen violet he said due to injury, which is again very common he said. And asked me to take the same medicines for 10 days, that should be more than enough he said.

        Details of the report.

        Both testis appear normal in size, shape and contours.
        Echotexture appears normal and homogenous.
        Right testis measures 40×27×22mm.
        Left testis measures 38×27×21mm
        Both epididymi appear normal in size and echotexture.
        *Mild dilatation of pampinoform plexus seen, more on left side.
        * Bilateral spermatic cords are mildly thickened and hyperechoic.
        No evidence of hydrocele is seen on either side.
        Scrotal wall thickness normal.

        IMPRESSIONS:
        BILATERAL FUNICULITIES.
        BILATERAL VARICOCELE.

        Request you to give me details and please help me get my peace of mind back.

        Reply
  13. Johnny

    Hi Turek.. I’m 32 & married for a year… I was diagnosed with vericocele very long time ago..my doctor said there’s no need for operation as it doesn’t not pain at all… I have a desk job which requires long hours for me to work.. Both me & my wife are trying to conceive but so far nothing.. It’s becoming frustrating now.. I’m very healthy.. What do u advise?

    Reply
    • Paul Turek, MD Paul Turek, MD

      Johnny, Varicocele are very common and usually do not cause fertility problems. 15% of high school students have them. 30% of primarily infertile men and up to 80% of men trying and unable to have a second child. I would suggest a good initial fertility evaluation by a urologist to include a history, physical exam and two semen analyses. IF the sperm counts are low, then hormone studies such as testosterone, LH, FSH and prolactin are indicated.

      Reply
  14. Khair

    I was riding a bike and suddenly a vehicle came and hit it hardly and my penis was erect when it happened and it was like I don’t know what happened but tears came out of my eyes. And after 5 minutes everything was normal.. After four days when I masrurbation u saw semen color as violet and shocked and went to urologist he suggested the ultrascan scrotum. And gave me some medicines and in only two days color of my semen was normal I was very happy. But after seeing reports(varicocele) doctor said it is common and should be left untreated and I asked why was my semen violet he said due to injury, which is again very common he said. And asked me to take the same medicines for 10 days, that should be more than enough he said.

    Details of the report.

    Both testis appear normal in size, shape and contours.
    Echotexture appears normal and homogenous.
    Right testis measures 40×27×22mm.
    Left testis measures 38×27×21mm
    Both epididymi appear normal in size and echotexture.
    *Mild dilatation of pampinoform plexus seen, more on left side.
    * Bilateral spermatic cords are mildly thickened and hyperechoic.
    No evidence of hydrocele is seen on either side.
    Scrotal wall thickness normal.

    IMPRESSIONS:
    BILATERAL FUNICULITIES.
    BILATERAL VARICOCELE.

    Request you to give me details 

    Reply
  15. TOM

    I born with bilateral varicocele is it possible for me to become a father now I am 38 years old I am married have normal sex but no kids any help please

    Reply
    • Paul Turek, MD Paul Turek, MD

      Dear Tom, ABSOLUTELY it’s possible to have normal fertility with bilateral varicoceles! In fact, I would assume something else is causing the problem first. Consider a formal urological evaluation with a male fertility specialist to identify other potential causes. Varicoceles are generally innocent bystanders…

      Reply
  16. Kristine

    Dr. Turek,

    This information is very helpful. My husband has a single variocele with a slightly smaller testicle. We started TTC about 6 months ago. We have had 3 chemical pregnancies in that time. My question, if we are able to get pregnant (just not able to keep the pregnancy), should we be concerned that the variocele may be contributing to these early losses, or is it more likley some other issue? In other words, when seen with infertility, do varioceles typically prevent pregnancy all together, or do they also cause low quality sperm that may make a pregnancy non-viable? I will see a specialist, but need to decide whether my husband should as well.

    Thank you!

    Reply
    • Paul Turek, MD Paul Turek, MD

      Kristine, GREAT QUESTION!! We know that varicoceles can cause infertility and have known this for years. Recently, it has become more clear that varicoceles can affect the quality of DNA packaging (DNA fragmentation) and DNA fragmentation may also lead to miscarriages. So the answer is YES, varicocele are thought to affect miscarriage rates as well. Sperm DNA fragmentation is now a routine test on the semen, so you can check this. A specialist is a great idea P.S. I also think that varicoceles can cause epigenetic changes to sperm DNA and this can also affect a women’s pregnancy. A test for this is not currently available but will be quite soon (Episona.com).

      Reply
  17. Uri

    I don’t know if you’re still replying here but I have some questions. I had microvaricocele repair of a medium-large varicocele causing infertility in 2007. Fertility returned and I have 2 kids. I’ve had recurrence since, big enough that it’s visible without palpaltation, and it’s causing some pain so I’d like to try again. My Urologist says it can be revised as many times as necessary without additional risk, that other veins pick up the load or new veins grow. Is that the case? Since then I’ve learned I have severe obstructive sleep apnea, obstructed nasal breathing, and CPPS from tight pelvic musces, all which I think contribute and which I have surgeries/therapy planned to address. I know there’s no published link but what’s your opinion on the potential relationship? Should I consider traveling for a revision varicocele repair and if so, who should I look for to do it (I’m in Austin if it helps)? I also have low-normal T (310-350ng/mol) but large testicles. Any evidence that my T may look more normal afterwards? I’m also starting to have ED issues, which could be other factors so I’m hoping this may help. Is a cat scan needed for revision surgery? My Urologist ordered one for me recently and afterwards I noticed how massive a dose of radiation I received (10-20mSv). If it’s necessary, then I’d opt to address it sooner than later to reuse the existing imaging. My brother is a Radiologist and I had him review it, he noted “mild pelvic venous congestion”. Is that related to the varicocele or having any impact on treatment otherwise? Sorry for the flood of questions, appreciate any help you can provide!

    Reply
    • Paul Turek, MD Paul Turek, MD

      Dear Uri, I am not a proponent of repeated varicocele repair with surgery, as the spermatic cord is filled with delicate things and scar tissue makes them hard to discern. Risk to testis health and viability goes up with repeated procedures. I recommend radiological embolization in the event of subinguinal varicocelectomy failure. A recurrent varicocele is most conveniently diagnosed with a doppler scrotal ultrasound showing sustained, reversal of flow. CT does not ad value in routine cases.

      Reply
  18. mwang

    Hi doc,
    i had vericocele surgery and did a biopsy. the results came out with traces of sperms and my ulorogy doc prescribed me with carnisure 500 and protec. he said the results are not bad.
    what are the chances of having sperms and conceiving naturally and how long.

    Reply
  19. Ali

    Dear Dr Paul,
    I had a SA 2 and 1/2 years ago and told that everything is perfet except a littlie bit abormal motility. I had a SA last year in Marh and told that I have poor everything! my last SA was on last Oct 2015 and things become even worse (count went down from 7.5 mil/ml to 3 mil). At that time I was diagnosed with varicocele. I finally did the surgery two days ago. Mu questions are:
    1. What are my chances to be fertile and achieve natural pregnancy after surgery?
    2. For how long should I wait to see results in my SA?

    Btw, we have been TTC for 42 months with no luck.

    Reply
    • Paul Turek, MD Paul Turek, MD

      Dear Ali, You should asking your treating urologist these questions, based on his experience treating varicoceles. My results are published. 1. 35-50% (depending on starting semen analysis, hormones, size of treated lesion) natural pregnancy rates following repair, and 2. Average time to conception is 7 mos after repair.

      Reply
  20. shomade Adeyinka

    dear doctor,my wife and I have been trying for babes but to no avail .the doctor said I have varicocele on both tescle left is grade two while the right is grade three .pls sir,is there any chance for me to father a child after the surgery and where can I get a good doctor in Nigeria since I am not financially buoyant to seek international medical attention.thank God bless your good job

    Reply
    • Paul Turek, MD Paul Turek, MD

      Dear Shomade, bilateral varicoceles could certainly be a culprit in male infertility, causing impaired semen quality as well as impaired sperm function in the setting of relatively normal semen quality. I agree that you should shop for a good urologist in Nigeria, preferably one who does at least 25 such cases annually.

      Reply
  21. Rajesh Gupta

    Dear Dr Turek
    Your information is very helpful. I have been diagnosed with grade 1 varicocele. While lifting heavy weight, it has started causing pain. I am 29 years old. The ultrasound for prostate and scrotum give everything as normal except for grade 1 varicocele. Now the pain has almost gone once i have started wearing supportive underwear. My urologist has prescribed me prostaquil and flotral 10 mg apart from a vitamin b tablet. However these tablets sem to have reduced the libido and erections. I am unmarried at the moment. Request you to help me understand if these medications can cause these side effects and if these medications are even required or not. Would be really grateful for your kind reply.

    Reply
    • Paul Turek, MD Paul Turek, MD

      Dear Rajesh, Sounds like the only anatomical diagnosis here is a varicocele. The pain it causes is typically only in the scrotum and only on the side of the scrotum with the varicocele. The pain is mild but can be bothersome and typically GETS BETTER after lying down for some time. You should never have varicocele pain in the morning as you awake from sleep, as it depends a lot on gravity and standing. Not sure why your prostate is being treated for varicocele pain. Varicoceles are treated by nonsurgical embolization or surgical procedures like microsurgical varicocelectomy.

      Reply
  22. David

    Dear Dr. Turek, do you think prepubertal (presented at 9 years old) grade III varicoceles can interfere with pubertal development by lowering testosterone?

    Reply
    • Paul Turek, MD Paul Turek, MD

      Dear David, What a great question! The answer is clear: I have no idea. It has never been studied. What has been studied is the ability of varicocele repair to increase testosterone levels in adults (with baseline normal testosterone levels but having sexual symptoms). Given that the effect of most clinical varicoceles are progressive over time, my gut is that it would generally not be the case that puberty would be affected by a large varicocele.

      Reply
  23. Amr

    Dear Dr. Turek,

    I’ve been diagnosed with Azoospermia, have done the semen analysis test twice and both gave back 0 sperm count as a result.

    Tests for testosterone, LH, PRL, FSH, TSH, Estrogen are all normal. Semen volume is 2.5ml and pH level is above 7.2. Semen analysis is generally good except that the sperm count is 0.

    The Dr. Has done a physical test and says I have strong varicoceles, however they are definitely not grade III and I hardly have pain.

    Based on my readings azoospermia in this case could be due to 1. Varicoceles 2. Epidyemi obstruction 3. Vas deferens obstruction.

    Your analysis would be highly appreciated and pls let me know if these cases are reversible and if natural conception is possible.

    Thank you very much,
    Amr

    Reply
    • Paul Turek, MD Paul Turek, MD

      Dear Amr, please see my other response to this query. Agree that there are other causes of azoospermia to consider before blaming it on small varicoceles.

      Reply
  24. Kunal Verma

    Hi Sir, last month I have done sperm analysis and the report shows Azoospermia. Then doctor asked me to go for doppler scan and the report came out with Bilateral varicocele on both side. I am recently married and looking for the best treatment to repair my varicocele and to cure azoospermia. please suggest me if it can be curable after varicocele treatment.

    Reply
    • Paul Turek, MD Paul Turek, MD

      Dear Kunal, Many men have varicoceles, even bilateral ones, but far fewer have azoospermia. You should look for other causes rather blame these usually innocent lesions (i.e. think blockage, hormones, lifestyle, genetics). Varicocele repair will not cure azoospermia due to blockage and will results in some low level of ejaculated sperm about 30% of the time if due to non obstructive azoospermia.

      Reply

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