Does Treating Varicoceles Improve Fertility? Know Its Stages

The scrotum is the loose pouch of skin behind the penis that hangs behind your penis and holds your testicles. The testicles receive oxygen-rich blood through two testicular arteries, with one artery supplying each side of the scrotum. Two veins in the testicles carry blood low in oxygen back to the heart. On each side of the scrotum, a network of small veins called the pampiniform plexus helps transport this oxygen-depleted blood from the testicle to the main testicular vein. A varicocele occurs when the pampiniform plexus becomes enlarged. Varicoceles are like varicose veins of the legs.

Varicoceles usually develop during puberty and may worsen as time goes on. While they can cause discomfort or pain sometimes, many people experience no symptoms or issues at all. In some cases, a varicocele can affect the growth of a testicle, reduce sperm production or lead to other fertility concerns.

Symptoms

Varicoceles usually do not cause noticeable symptoms, but you may experience:

• A dull ache or discomfort in your testicles or scrotum, which tends to improve when you lie down
• Testicles or scrotum swelling
• Testicular atrophy (shrinking of testicles)
• Infertility
• A tiny lump above the affected testicles

Causes

The exact cause of the varicoceles is not known, but one possibility is a problem with one of the valves in the veins of the spermatic cord. The spermatic cord is a bundle of tissues that keeps your testicles in place, and it has veins that carry blood away from your testicles. These veins have valves that work like switches with two flap-like parts that help your blood flow toward your heart. If the valve does not work properly, blood may pool in the veins of your testicles, which causes them to swell over time.

Complications

Having a varicocele can interfere with the body’s ability to regulate testicular temperature. This can lead to oxidative stress and the accumulation of toxins, which may contribute to various complications.

• Poor testicular health: In adolescent boys, a varicocele can interfere with testicle growth, hormone production and other aspects of testicular health and function. In adult men, it may lead to gradual shrinkage of the testicles due to tissue damage.
• Infertility: While a varicocele does not always lead to infertility, around 10% to 20% of men with a varicocele may struggle with conception. Among men facing fertility issues, approximately 40% have a varicocele.

Diagnosis

To diagnose a varicocele, a healthcare provider will begin by reviewing your medical history and discussing your symptoms. They will also conduct a physical examination. During this exam, you might be asked to stand, take a deep breath, close your mouth and nose and bear down as if you are trying to push air out. This procedure is called the Valsalva manoeuvre. While you perform this manoeuvre, your provider will gently palpate your scrotum to check for any enlarged veins.

They might also request additional tests to verify their diagnosis:

• A pelvic ultrasound: It is a straightforward, non-invasive imaging test that gives your healthcare provider a clear view of the veins in your testicles. It is the most frequently used test for diagnosing varicoceles.
• Semen analysis: Here, a sample of semen is sent to a laboratory, where technicians will analyse it to evaluate the quantity and quality of the sperm. Your healthcare provider might suggest this test if they think a varicocele could be impacting your fertility.
• Blood test: Here, your blood sample is sent to a laboratory, where technicians will analyse your hormone levels, including follicle-stimulating hormone (FSH) and testosterone.
• Once a varicocele is confirmed, your healthcare provider will determine its severity or grade. The grades of varicocele are as follows:

Physical exam grading of varicoceles:

• Varicocele grade 0: This is the insignificant form of varicocele. Your healthcare provider cannot detect it during a physical exam, but it can be seen on an ultrasound.
• Varicocele grade 1: In this stage, the varicocele is not visible to your provider, but they can feel it when you perform the Valsalva manoeuvre.
• Varicocele grade 2: At this stage, your provider can feel the varicocele even without the Valsalva manoeuvre, though it is still not visible.
• Varicocele grade 3: This is the most severe form of varicocele, and it is large enough that your healthcare provider can both see and feel it easily.

Ultrasound grading of varicoceles:

• Varicocele grade 1: Reflux in the spermatic cord veins in the inguinal area during a Valsalva manoeuvre without a noticeable scrotal varicocele.
• Varicocele grade 2: Veins remain nondilated while lying down. Upon standing, dilated veins extend to the upper pole of the testicle. Reflux occurs only in the upper pole veins during a Valsalva manoeuvre.
• Varicocele grade 3: Veins are nondilated when lying down. Upon standing, dilated veins extend to the lower pole of the testicle. Reflux occurs only in the lower pole veins during a Valsalva manoeuvre.
• Varicocele grade 4: Dilated veins are present while lying down, with reflux occurring during a Valsalva manoeuvre.
• Varicocele grade 5: Dilated veins exhibit reflux even without performing a Valsalva manoeuvre.

Treatment

The approach to curing varicocele varies based on its grade. In mild cases, your healthcare provider may recommend managing it with home remedies, such as:

• No treatment: If your varicocele is not causing any pain or affecting your fertility, you might not need any varicocele treatment.
• Changes in the daily routine: You might need to make some adjustments to your daily routine if certain activities cause discomfort. Wearing tighter-fitting underwear, such as spandex or a jockstrap, while exercising or standing for long periods can help relieve symptoms.
• Ice: Using ice or cold packs on your scrotum can provide relief from pain and discomfort. Make sure to wrap the ice in a towel before applying it to your skin to avoid direct contact. Limit the application to no more than 15 minutes at a time.
• Pain killers: Your healthcare provider may prescribe nonsteroidal anti-inflammatory drugs (NSAIDs) to relieve pain or discomfort in the scrotum or testicles.

Surgery: Surgery may be recommended in the following cases:

• A testicle that is showing delayed development
• Low sperm count or other sperm issues (typically tested in adults)
• Ongoing chronic pain that is not relieved by pain medication
• A varicocelectomy is a surgical procedure designed to address significant varicoceles that lead to discomfort or affect fertility. In this operation, a healthcare provider will either remove or close off the problematic veins.  
• The goal of surgery is to close off the affected vein and redirect blood flow to healthy veins. This is possible because two other artery and vein systems provide circulation to and from the scrotum.

Possible varicocele treatment outcomes include:

• The affected testicle may gradually return to its normal size, and in teenagers, it may ‘catch up’ in development.
• Sperm count may improve, and sperm irregularities may be corrected.
• Surgery could enhance fertility or improve semen quality for in vitro fertilization.

Prevention

Medical experts are not completely sure about the exact causes of varicoceles. Consequently, they also lack definitive guidance on how to prevent varicocele.

Conclusion

A varicocele is a common condition that can affect males at birth at various ages and life stages. Most people experience few or no symptoms. Whether to treat a varicocele is a personal decision. For mild symptoms, wearing supportive underwear or a jockstrap or taking pain relievers may be sufficient. However, varicoceles can lead to infertility. A varicocelectomy can correct a varicocele and, in some cases, improve fertility. It is important to discuss varicocele treatment options with a healthcare provider, including how surgery might impact your fertility.