Can men with severe varicoceles (enlarged veins in the scrotum) have normal fertility if left untreated?

Varicoceles and Fertility: Can Men with Severe Varicoceles Have Normal Fertility?

Yes, men with severe varicoceles can have normal fertility even if left untreated, as only about 20% of men with documented varicoceles experience fertility problems. 1

Relationship Between Varicoceles and Fertility

• Varicoceles are present in approximately 15% of the normal male population, but this percentage increases to 25% in men with abnormal semen analysis and 35-40% in men presenting with infertility, demonstrating a correlation between varicocele and fertility issues 2
• Despite the association with infertility, the presence of a varicocele does not always affect spermatogenesis, as approximately 80% of men with documented varicoceles maintain normal fertility 1
• The exact mechanism linking varicocele to reduced fertility remains incompletely understood, but proposed mechanisms include higher scrotal temperature, testicular hypoxia, and reflux of toxic metabolites that can cause testicular dysfunction through increased DNA damage 2

Varicocele Severity and Fertility Impact

• Severe varicoceles typically show greater improvement in sperm count after surgical repair compared to moderate or mild varicoceles, suggesting they may have a more significant impact on fertility 2
• However, the presence of a varicocele, regardless of severity, does not guarantee fertility problems will occur 1
• Routine use of ultrasonography to identify non-palpable (subclinical) varicoceles is discouraged, as treatment of these varicoceles is not associated with improvement in either semen parameters or fertility rates 2, 3

Treatment Considerations

• Treatment should be targeted to men with clinical varicoceles and abnormal semen parameters, as treatment of men with normal semen analysis is not recommended 2
• After varicocele repair, improvements in semen parameters typically take up to two spermatogenic cycles (approximately 3-6 months), with spontaneous pregnancy occurring between 6 and 12 months after varicocelectomy 2
• The European Association of Urology strongly recommends surgery for varicocele when associated with a persistent small testis (size difference >2 mL or 20%), confirmed on two subsequent visits 6 months apart 4

Monitoring and Evaluation

• Specialized sperm function tests, particularly analysis of sperm DNA fragmentation and measurements of oxidative stress markers, provide independent measures of fertility in men with varicocele that may be normal even when conventional semen parameters are affected 5
• These diagnostic modalities offer both diagnostic and prognostic information complementary to, but distinct from conventional sperm parameters 5
• Hormonal alterations may occur in some men with varicoceles, including decreased testosterone levels and higher FSH and LH levels, which may normalize after varicocelectomy 6

Clinical Implications

• For men with varicoceles who have normal semen parameters and are not experiencing fertility issues, watchful waiting is appropriate 2
• In men with varicoceles and abnormal semen parameters who are trying to conceive, varicocele repair should be considered as it may improve fertility outcomes 2
• If fertility issues persist after varicocele repair and the typical 3-6 month recovery period, other therapies including assisted reproductive technology should be considered 1