A common yet treatable condition in men often goes unnoticed for years, quietly undermining the chances of pregnancy. Known as varicocele, it is one of the leading correctable causes of male infertility, according to Dr Naushad Karim, a consultant interventional radiologist at Aga Khan University Hospital.
What is varicocele?
To understand varicocele, Dr Karim explains that the testicles are positioned outside the body because sperm production requires a temperature slightly lower than normal body heat. Like any other organ, the testes receive blood through arteries and drain it through veins.
In varicocele, the valves within the veins malfunction. Instead of flowing back towards the heart, blood pools in the scrotum, causing the surrounding veins to enlarge.
The result, in more advanced cases, is a swelling that Dr Karim describes as resembling ‘a bag of worms’.
The pooling of blood raises the local temperature of the testicle. Even a modest increase can impair sperm quality.
‘Even when the count is normal,’ explains Dr Karim, ‘The quality of the sperm, particularly motility and the ability to achieve conception, may be significantly reduced.’
The condition can also suppress testosterone levels, leaving some men with unexplained fatigue, low energy and a gradual decline in sexual health. These symptoms are often misattributed to stress, work pressure or ageing.
Varicocele most commonly affects the left side due to anatomical differences. The left testicular vein drains into the renal vein at a near-right angle, creating greater resistance, while the right drains more directly into a larger vessel.
Silent burden
Varicocele does not announce itself dramatically. It exists on a spectrum, and in its milder stages, symptoms are easily dismissed.
There may be a dull ache deep in the scrotum that worsens after standing for long periods, lifting heavy objects or exercising. A man may notice a visible or palpable swelling in the shower but not mention it for months or even years. In some cases, there are no symptoms until a couple seeks help for infertility.
Dr Karim identifies three reasons the condition often goes undetected.
‘The symptoms are tolerable enough to be ignored. Men are less likely than women to seek medical attention, and there is a stigma, particularly when the subject touches on fertility. This makes men reluctant to discuss it even with a trusted doctor.’
This stigma, he says, is significant. In the emotionally charged context of infertility, men may feel isolated if they perceive themselves as the source of the problem, a burden rarely discussed openly.
While varicocele can occur at any age, it commonly develops in adolescence and is often identified in men in their 20s and 30s.
The condition also forces men to confront a deeply private aspect of their health, which can be difficult in a social context where masculinity and male identity remain sensitive subjects.
It is found in roughly 35 to 40 percent of men with primary infertility and up to 70 to 80 percent of those with secondary infertility, making it one of the most common and treatable causes of male infertility.
Varicocele does not resolve without treatment. There is no supplement, lifestyle change or watchful waiting that can reverse damage to the venous valves once they have failed.
However, the decision to treat is not always straightforward. Dr Karim says it depends on the individual case. Pain may justify intervention, as does a desire to improve fertility outcomes. Where neither applies, monitoring is a reasonable option.
‘Early detection and an open conversation with a doctor remain the most effective tools available,’ says Dr Karim.
Treatment options
Dr Karim says diagnosis is straightforward. A scrotal ultrasound, the same imaging used to rule out infections and other causes of discomfort, can confirm varicocele and determine its severity.
He recommends the test for any man with persistent scrotal discomfort, whether or not fertility is a concern.
Once confirmed, there are two treatment options. The traditional approach is surgery, which involves tying off the affected vein under general anaesthesia.
Varicocele embolisation, a newer approach, has become the preferred standard in Western Europe, North America and Australia, and is now available at Aga Khan University Hospital.
Embolisation is a non-surgical, permanent procedure performed on an outpatient basis while the patient is awake. A catheter is guided through a vein in the neck to the affected testicular vein, where tiny metal coils and a sealing agent permanently close it. There are no incisions, and patients can go home the same day.
The outcomes of both approaches are consistent. ‘Almost all patients report an improvement in their symptoms and in the quality of their sperm,’ says Dr Karim.
Whether this results in pregnancy depends on several factors, including the health of the female partner, timing and the nature of the couple’s infertility.
Cost barrier
What stands between many men and treatment is cost. Because the coils used are imported, embolisation costs between Sh800,000 and Sh1,000,000, beyond the reach of most families dealing with infertility. The procedure is not covered by the Social Health Authority (SHA).
Dr Karim receives two to three enquiries a week, but many do not progress beyond the initial consultation.
According to the World Health Organisation (WHO), varicocele affects about 10 to 15 percent of men worldwide but is significantly more common among those with infertility.
It is found in roughly 35 to 40 percent of men with primary infertility and up to 70 to 80 percent of those with secondary infertility, making it one of the most common and treatable causes of male infertility.
Varicocele does not resolve without treatment. There is no supplement, lifestyle change or watchful waiting that can reverse damage to the venous valves once they have failed.
However, the decision to treat is not always straightforward. Dr Karim says it depends on the individual case. Pain may justify intervention, as does a desire to improve fertility outcomes. Where neither applies, monitoring is a reasonable option.
‘Early detection and an open conversation with a doctor remain the most effective tools available,’ says Dr Karim.