Varicocele is one of the most common findings in men being evaluated for infertility. Roughly 15 percent of all men have one, and the number climbs to about 40 percent among men with fertility problems. Yet despite how common it is, a varicocele remains a confusing diagnosis. Some men are told they need surgery right away, while others are advised to do nothing at all.

The truth is somewhere in between. Not every varicocele affects fertility, but in the right context, repairing one can make a meaningful difference, sometimes restoring a couple’s ability to conceive naturally. The challenge is knowing when a varicocele matters and when it can be safely left alone.

In this article, I will explain what a varicocele is, how it affects male fertility, when it should raise concern, and when treatment is most likely to help.

What is a varicocele?

A varicocele is essentially a tangle of enlarged veins in the scrotum, often compared to “varicose veins of the leg.” These veins drain blood from the testicle, and when their valves fail, blood pools and the scrotal temperature rises. Over time, this can affect how well the testicle functions.

For many men, a varicocele causes no symptoms at all and is only discovered during an infertility work-up or a routine exam. Others may notice a heavy feeling in the scrotum, visible veins, or, in adolescents, one testicle appearing smaller than the other.

Varicoceles are much more common on the left side, because of the way the left testicular vein drains into the left renal vein at a right angle, which creates higher venous pressure compared with the right side.

What makes varicocele important in male fertility is its impact on the environment where sperm develop. Increased scrotal temperature, reduced oxygen delivery, and oxidative stress can disrupt normal sperm production. The result may be lower sperm counts, reduced motility, abnormal shapes, or even DNA damage in sperm.

Varicocele is common, affecting about 15 percent of all men and up to 40 percent of men with primary infertility. This makes it the most common correctable cause of male infertility. Still, not every varicocele leads to trouble, which is why deciding who should be treated requires careful evaluation.

When to worry

Not every varicocele is a cause for concern. Many men live with one for years without it ever affecting their health or fertility. But there are situations where a varicocele deserves attention and possibly treatment.

The clearest red flag is when a man is part of an infertile couple and has both a palpable varicocele (detectable on physical exam) and abnormal semen parameters. Multiple guidelines, including the American Urological Association (AUA) and American Society for Reproductive Medicine (ASRM), highlight this as the strongest indication for repair.

In adolescents, a varicocele should raise concern if the affected testicle is smaller or growing more slowly compared to the other side. Early treatment can prevent permanent testicular damage and preserve fertility potential later in life.

Another important signal is chronic scrotal pain. While pain alone is not always a reason for surgery, persistent discomfort that interferes with daily life and does not improve with conservative measures can justify intervention.

In short, you should worry about a varicocele if:

• Fertility is impaired and semen tests are abnormal
• The condition affects testicular growth in adolescents
• Scrotal pain persists and reduces quality of life

Outside of these situations, most varicoceles can safely be observed.

When not to treat

Just as important as knowing when a varicocele requires attention is recognizing when it does not. Many men with a varicocele never experience fertility problems, and in those cases, intervention is unnecessary.

Asymptomatic fertile men with normal semen parameters and hormone levels generally do not benefit from surgery. Guidelines caution against operating simply because a varicocele is present if fertility and testicular function are intact.

Another situation where treatment is usually avoided is the so-called subclinical varicocele, one that can only be detected by ultrasound but is not visible or palpable on physical exam. Most studies show that repairing these varicoceles does not meaningfully improve semen quality or fertility outcomes.

In practice, this means that if a man has no symptoms, no fertility issues, and normal semen and hormonal testing, the varicocele is best left alone. Observation, reassurance, and regular monitoring are all that is needed.

Treatment options and what to expect

When a varicocele does need treatment, there are a few different approaches. The most common is a microsurgical varicocelectomy, usually done through a small incision in the groin. Using an operating microscope, the surgeon ties off the enlarged veins while sparing the arteries and lymphatic channels. This technique has the best success rates and the lowest risk of complications.

Other options include a laparoscopic approach or a radiologic procedure called embolization, where a catheter is used to block the abnormal veins from the inside. These methods can be good choices in certain cases, though recurrence rates may be a bit higher than with microsurgery.

What can men expect after repair?

In most cases, sperm counts and motility start to improve within three to six months, but improvements can continue for up to a year. Some couples are able to conceive naturally after repair, while others may still need assisted reproduction. The key is that surgery can shift the odds in favor of pregnancy, even if it does not guarantee it.

For men with pain, about two-thirds will experience relief after surgery. Complications are uncommon but include fluid build-up around the testicle (hydrocele), recurrence of the varicocele, or, very rarely, testicular atrophy.

Conclusion

Varicocele is common, and hearing that diagnosis can leave men wondering whether their fertility is at risk. The reassuring news is that most varicoceles are harmless and do not require surgery. But for couples struggling with infertility, or for men with abnormal semen results or ongoing scrotal pain, repair can make a real difference.

Guidelines from leading societies are clear: Treat when fertility is impaired and a palpable varicocele is present, observe when fertility and testicular function are normal. That balance helps men avoid unnecessary procedures while making sure those who can benefit are not left untreated.

For patients, the takeaway is straightforward: Not every varicoicocele needs to be “fixed.” But if fertility is a concern, or symptoms are interfering with quality of life, it is worth a conversation with a urologist. Varicocele remains one of the most treatable causes of male infertility, and with the right evaluation, men can know whether action or simple reassurance is the best path forward.

Martina Ambardjieva is a dedicated urologist and medical educator with extensive experience in both clinical practice and academic instruction. She earned her MD from the University “Sv. Kiril i Metódij” in Skopje and is a PhD candidate in urological oncology, with a focus on bladder carcinoma. Her scholarly work includes numerous publications in oncologic urology, urinary calculosis, and men’s health.

Dr. Ambardjieva currently serves as a urologist at the PHI University Surgical Clinic “Naum Ohridski” and completed her residency training at the University Urology Clinic in Skopje. Earlier in her career, she practiced as a general medical doctor at Sante Plus General Hospital and completed a medical internship at the University of Ljubljana.

In addition to her clinical responsibilities, Dr. Ambardjieva is a teaching assistant at the Medical Faculty in Skopje. She works additionally as a collaborator for Dr. Telx. She has held leadership positions in the European Medical Students’ Association and actively participates in international medical education and policy. She has attended numerous congresses and workshops in France, Italy, Canada, and Turkey, and serves as a delegate for the European Association of Urology (EAU), contributing to cross-border initiatives in urology. Certified in laparoscopic surgery, she continues to integrate patient care, research, and education in her professional work.