Can grade 2 and grade 3 varicoceles (varicose veins in the scrotum) affect fertility?

Impact of Grade 2 and Grade 3 Varicoceles on Fertility

Grade 2 and grade 3 varicoceles significantly affect fertility and are strongly associated with impaired semen parameters, with grade 3 varicoceles causing more severe fertility impairment than grade 2. 1, 2

Prevalence and Association with Infertility

• Varicoceles are present in approximately 15% of the general male population but are found in 35-40% of men presenting with infertility, demonstrating a clear correlation between varicocele and fertility problems 1, 2
• Higher varicocele grades (grade 3) are associated with worse semen parameters and greater testicular dysfunction compared to lower grades 1, 3

Mechanism of Fertility Impairment

• Varicoceles impair fertility through multiple mechanisms affecting testicular function:
  • Increased scrotal temperature
  • Testicular hypoxia
  • Reflux of toxic metabolites
  • Increased DNA damage 1, 2
• Grade 3 varicoceles may also affect epididymal function in addition to testicular effects, further compromising sperm quality 4

Impact Based on Varicocele Grade

• Grade 3 varicoceles:
  • Associated with lower preoperative sperm counts compared to grade 1 and 2 varicoceles 3
  • Linked to higher levels of seminal reactive oxygen species, which damage sperm 5
  • Show more significant improvement after repair compared to lower grades 3
• Grade 2 varicoceles:
  • Still associated with abnormal semen parameters but typically less severe than grade 3 3
  • Show significant improvement in sperm concentration after repair (33 ± 5 million/cc to 41 ± 6 million/cc) 3

Treatment Outcomes

• Varicocele repair improves semen parameters in men with clinical varicoceles and abnormal semen analysis 2
• After varicocelectomy, improvements typically take 3-6 months (two spermatogenic cycles) to manifest 1, 2, 6
• Men with grade 3 varicoceles show greater improvement in fertility index (128%) after repair compared to men with grade 2 (21%) or grade 1 (27%) varicoceles 3
• Pregnancy rates after varicocele repair are approximately 40-46% across all grades 3

Clinical Implications and Recommendations

• The European Association of Urology strongly recommends surgery for varicocele when associated with a persistent small testis (size difference >2 mL or 20%) 1
• Treatment should be targeted to men with clinical varicoceles and abnormal semen parameters 2, 7
• Treatment of subclinical (non-palpable) varicoceles is not effective at increasing chances of spontaneous pregnancy 1, 2
• Earlier intervention may prevent permanent testicular damage, particularly in higher grade varicoceles 1

Pitfalls and Caveats

• Not all men with varicoceles experience fertility problems—only about 20% of men with documented varicoceles suffer fertility issues 6
• Fertile men with grade 3 varicoceles may have higher seminal reactive oxygen species than those with lower grade varicoceles, potentially putting them at risk for future fertility problems 5
• After varicocele repair, if infertility persists beyond 6 months, other therapies including assisted reproductive technology should be considered, especially in older couples 6
• Routine use of ultrasonography to identify non-palpable varicoceles is discouraged as treatment of these subclinical varicoceles does not improve fertility outcomes 2