Varicocele: scrotal veins, male fertility, and when to act

What is a varicocele?

The pampiniform plexus is a network of veins that drains blood from the testis. On the left side, the internal spermatic vein drains into the left renal vein at a right angle — a longer, higher-resistance pathway that makes left-sided venous reflux anatomically much more likely. On the right side, the vein drains directly into the inferior vena cava (IVC) at an acute angle, with lower resistance.

When these veins dilate abnormally and blood pools, the result is a varicocele — essentially varicose veins of the scrotum. The EAU Male Infertility Guidelines (2024) note that varicoceles affect about 15% of adult men in the general population and 35–40% of men presenting with primary infertility. More than 90% are left-sided; bilateral varicoceles occur in about 15% of affected men; an isolated right-sided varicocele (about 2% of cases) warrants urgent investigation to exclude renal pathology.

Varicoceles typically develop during puberty, when testicular growth and venous load increase. They rarely cause dramatic symptoms but represent one of the most common and potentially correctable causes of male factor infertility.

A. Core clinical — the AU general practice framework

Clinical grading

Examination is performed with the patient standing in a warm room, with the cremaster muscle relaxed and the patient performing a Valsalva manoeuvre (bearing down as if straining):

• Grade 0 (subclinical) — not palpable; detected only on ultrasound.
• Grade I — palpable only during Valsalva.
• Grade II — palpable without Valsalva but not visible.
• Grade III — visible through the scrotal skin without palpation.

The decompression test — lying the patient flat — is important: a varicocele should disappear when supine. A varicocele that persists lying flat raises suspicion of mechanical compression from an underlying mass (retroperitoneal or renal tumour) blocking venous drainage.

Testicular volume should be compared bilaterally using an orchidometer or ultrasound measurement. A volume difference of more than 20% is considered significant and may indicate ipsilateral testicular growth impairment.

How varicoceles cause fertility problems

Several mechanisms contribute to impaired spermatogenesis:

1. Scrotal hyperthermia — venous pooling raises scrotal temperature above the optimal 34°C for sperm production.
2. Oxidative stress — venous stasis and hypoxia increase reactive oxygen species, causing sperm DNA fragmentation and reduced motility.
3. Reflux of metabolites — retrograde flow from the renal vein may carry adrenal hormones and metabolites to the testis.
4. Leydig cell dysfunction — severe or long-standing varicoceles can reduce testosterone production.

These mechanisms explain why semen parameters (count, motility, morphology) and testosterone can sometimes improve after varicocelectomy.

Investigations

Scrotal Doppler ultrasound — MBS item 55065. Confirms venous dilatation (vein diameter above 2.5–3 mm), demonstrates reflux on Valsalva, assesses testicular size and volume, and excludes testicular masses. This is the imaging investigation for a suspected varicocele.

Semen analysis × 2 — MBS item 73275. Obtained 2–3 days after sexual abstinence, at least 2–3 weeks apart, at a specialist andrology laboratory. Assesses count, total motility, progressive motility, morphology (strict Kruger criteria), and vitality. Sperm DNA fragmentation index is available at some andrology laboratories and is particularly informative in unexplained infertility.

Hormonal profile — when testicular volume is reduced or hypogonadism is clinically suspected. Total morning testosterone, FSH, LH, SHBG, and prolactin. Elevated FSH suggests primary testicular failure; low testosterone with low or normal LH suggests a secondary (central) cause.

Right-sided or atypical varicocele — CT or MRI abdomen — to exclude a retroperitoneal mass or renal cell carcinoma with IVC thrombus. This is not optional — it is a diagnostic requirement when the right-side red flag is present.

When not to intervene

eTG, EAU 2024, and USANZ agree: do not operate on subclinical varicoceles (Grade 0, detected only by ultrasound). Multiple randomised trials have not demonstrated fertility benefit from treating subclinical varicoceles.

Similarly, do not intervene for an asymptomatic varicocele in a man with a normal semen analysis and no fertility concern. The natural history of asymptomatic varicoceles is benign in most men.

When to intervene

The four clinical indications for referral and discussion of repair are:

1. Infertility with abnormal semen + clinical (palpable) varicocele + no major female-partner factor — the best-evidence indication, supported by the Cochrane review (Persad et al., 2019).
2. Chronic scrotal pain that has persisted for 3 months or more despite scrotal support, analgesics, and lifestyle adjustments.
3. Testicular volume asymmetry in an adolescent — more than 20% volume difference on orchidometry — suggesting ipsilateral growth impairment. Most asymptomatic adolescent varicoceles should be observed annually; only growth arrest warrants surgery.
4. Hypogonadism (confirmed low testosterone) in a man with a clinical varicocele — varicocelectomy improves testosterone in approximately 70% of such cases.

Surgical and procedural options

The EAU 2024 guidelines and Healthy Male recognise several approaches:

Microsurgical sub-inguinal varicocelectomy — the gold standard. A small sub-inguinal incision is made and an operating microscope used to identify and ligate all abnormal veins while preserving the testicular artery, lymphatics, and vas deferens. Recurrence rate approximately 1%; hydrocele rate approximately 1%. Semen parameter improvement occurs in 60–70% of operated men. MBS items 37623–37626 cover varicocelectomy procedures.

Laparoscopic varicocelectomy — useful for bilateral varicoceles. Requires general anaesthesia. Higher recurrence rate (5–15%) and greater risk of testicular artery injury than microsurgical approach.

Radiological embolisation — percutaneous coil or sclerosant occlusion of the spermatic vein via a femoral catheter, performed under local anaesthesia and sedation. Day procedure with rapid recovery. Particularly useful for recurrence after open repair. Recurrence rate approximately 5–10%.

Repeat semen analysis at 3 and 6 months post-procedure measures response.

B. Evidence appraisal

Does varicocelectomy actually improve fertility?

The Cochrane systematic review (Persad et al., 2019) pooled data from randomised trials and meta-analyses examining clinical varicocele plus abnormal semen in subfertile couples. The analysis found a statistically significant improvement in pregnancy rates in the treatment group, with a number needed to treat of approximately 7–9 for clinical pregnancy. The evidence quality is rated moderate — not perfect — because older trials had methodological limitations. The key qualifier: benefit was demonstrated only for clinical (palpable or visible) varicoceles with abnormal semen, not for subclinical varicoceles or normal semen analysis.

A meta-analysis by Esteves et al. (Fertil Steril 2017) showed sperm parameter improvement in approximately 60–70% of operated men, including improvements in count, total motility, progressive motility, and morphology. Sperm DNA fragmentation improved in 60–80% of treated men.

Microsurgical vs other approaches

Comparative data consistently show microsurgical sub-inguinal varicocelectomy produces the lowest recurrence rate (approximately 1%), the lowest hydrocele rate (approximately 1%), and the best fertility outcomes compared with open inguinal, retroperitoneal, laparoscopic, and embolisation approaches. The main limiting factor is access to a urologist with microsurgical training — not all urologists offer this technique.

C. Australian operations

MBS items

• Standard GP consult: items 23 / 36 / 44.
• Scrotal Doppler ultrasound: item 55065; specific testicular items in the 55833 range.
• Semen analysis: item 73275 — Medicare-rebatable.
• Hormonal testing (testosterone, FSH, LH, prolactin): item 73529 range.
• Varicocelectomy surgical items: items 37623–37626 for open and laparoscopic approaches; embolisation under interventional radiology items.
• GPCCMP: items 965 and 967 — for infertility management and chronic pain as chronic conditions.
• MHCP: items 2715 and 2717 — infertility-related anxiety and relationship distress are very common and warrant psychology referral under Better Access.

PBS medicines

• NSAIDs for scrotal pain — general schedule; consider gastroprotection with long-term use.
• Testosterone replacement if confirmed hypogonadism — requires specialist initiation with documented low testosterone plus elevated or low-normal LH/FSH, per Healthy Male. Note: testosterone replacement is contraindicated in men trying to conceive — it suppresses endogenous testosterone production and markedly reduces spermatogenesis.

Medico-legal documentation

Australian medicolegal standards require documentation of bilateral testicular examination with volume comparison and clinical grading at every initial varicocele assessment. For the right-sided red flag (isolated right varicocele in an adult), the record must document whether imaging was arranged and the result.

D. Special populations

Men using testosterone or anabolic steroids

Exogenous testosterone and anabolic-androgenic steroids suppress the hypothalamic-pituitary-gonadal axis and dramatically reduce spermatogenesis — causing acquired azoospermia in many users. This is a clinically important and under-recognised cause of male infertility. The history must always ask specifically about testosterone supplements, anabolic steroids, and “performance-enhancing” agents, including non-prescription products. Stopping exogenous testosterone is the first step; recovery of spermatogenesis can take 6–18 months and is not guaranteed.

Adolescents

The management of adolescent varicocele is deliberately conservative. Most asymptomatic adolescent varicoceles do not progress and resolve spontaneously or cause no lasting harm. Annual examination and testicular volume measurement are appropriate for asymptomatic cases. Intervention (microsurgical varicocelectomy) is offered when testicular volume difference exceeds 20% (growth arrest) or when symptoms significantly affect quality of life. Informed consent involving both the adolescent and family is essential and must be documented.

Men with severe oligospermia or azoospermia

In men with very low sperm counts (fewer than 5 million/mL) or absent sperm (azoospermia) plus a clinical varicocele, specialist andrology review is needed before deciding on varicocelectomy. In some cases of secondary non-obstructive azoospermia, varicocelectomy can recover sperm in the ejaculate — avoiding the need for surgical sperm retrieval (testicular sperm extraction, TESE). In primary non-obstructive azoospermia with no varicocele effect, TESE with IVF/ICSI may be the primary path. Karyotype (to exclude Klinefelter syndrome, 47 XXY) and Y-chromosome microdeletion testing should be performed before any intervention for severe oligospermia or azoospermia.

Female partner — concurrent workup is non-negotiable

Male and female fertility evaluations must happen in parallel, not sequentially. Waiting for varicocele repair before assessing the female partner delays the couple’s overall fertility journey unnecessarily. Female age is a critical fertility determinant — every month matters when the female partner is over 35. Refer both partners simultaneously when infertility is the presenting concern.

When to escalate

Urgent (same week) imaging referral:

• New or isolated right-sided varicocele in an adult man — CT or MRI abdomen to exclude renal cell carcinoma with IVC thrombus.
• Varicocele that does not decompress lying flat — exclude retroperitoneal mass.

Urgent specialist (within 1 week):

• Acute testicular pain with varicocele — exclude testicular torsion (ED referral if severe acute pain).
• Rapidly enlarging varicocele at any age.

Routine urology referral (2–4 weeks):

• Clinical varicocele with abnormal semen analysis in an infertile couple.
• Chronic pain refractory to 3 months of conservative management.
• Testicular volume asymmetry over 20% in an adolescent.
• Clinical varicocele with low testosterone.

What this article is and is not

This article provides general patient education about varicocele for people in Australia. It is not a substitute for individualised assessment by a GP, urologist, or reproductive endocrinologist. Fertility assessment is complex and depends on factors specific to each couple. If you are concerned about fertility, seek a consultation rather than relying on this article alone. If you notice a new right-sided scrotal lump or one that does not resolve lying flat, see your GP promptly for urgent imaging.

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Sources cited

• EAU 2024 — Male Infertility Guidelines
• Persad E et al. — Cochrane Review 2019: surgical or radiological treatment for varicocoeles
• Esteves SC et al. — varicocele repair outcomes meta-analysis. Fertil Steril 2017
• Therapeutic Guidelines (eTG) — Urology
• Australian Medicines Handbook
• Healthy Male (Andrology Australia) — Varicocele
• USANZ
• HealthDirect — Varicocele