A 35-year-old male patient visited the clinic after abnormalities were detected during a semen analysis performed at an infertility center. The test showed problems with sperm motility and sperm count. The patient also reported that he had previously felt a lumpy structure around his testicle, and the infertility specialist recommended a urology consultation. After visiting our clinic, we first conducted a detailed medical history review and physical examination. To obtain a more precise diagnosis, we also performed a color Doppler ultrasound examination.
The results confirmed a grade II varicocele, meaning that dilated veins could be detected within the scrotum even without increased abdominal pressure. Because the patient wished to conceive and the condition was affecting sperm quality, surgical treatment was recommended. The procedure involved ligating the affected veins to prevent abnormal venous reflux. Three months after surgery, follow-up semen analysis showed that sperm parameters had returned to normal levels. A few months later, the patient shared the good news that natural pregnancy had been achieved.
Varicocele can be understood more easily when compared with varicose veins in the legs. The term “spermatic cord” refers to the network of veins that carry blood from the testicles toward the heart. In varicocele, these veins become enlarged and dilated, similar to varicose veins. The veins above the testicle form a network resembling a mesh, and when these veins expand abnormally, blood can flow backward due to increased pressure caused by gravity. As a result, the veins become enlarged and tortuous.
More than 85% of varicocele cases occur in the left testicle. This happens because the left testicular vein is longer than the right one. In addition, the right testicular vein drains diagonally into the inferior vena cava, which allows relatively smooth blood flow. In contrast, the left testicular vein drains almost at a right angle into the left renal vein, which increases the likelihood of venous reflux and pressure buildup.
At our clinic, the diagnosis of varicocele is not based on a single test. Instead, several diagnostic methods are combined to achieve greater accuracy. The evaluation begins with visual inspection and physical examination. Because advanced varicocele can sometimes cause testicular shrinkage, we also measure testicular size using a testicular volumeter. In addition, color Doppler ultrasound is performed, which is considered one of the most accurate diagnostic methods because it allows detailed visualization of the dilated veins and blood flow.
Environmental conditions can also affect the accuracy of the examination. For example, during colder weather, patients are typically asked to remain indoors for about ten minutes before the examination to allow the scrotal muscles to relax. Furthermore, examinations are more accurate when performed in a standing position rather than lying down, because varicocele symptoms can temporarily disappear in the supine position.
As demonstrated in the earlier case, varicocele is one of the most common causes of male infertility. Studies show that approximately 35% of men with primary infertility—those who have never conceived a child—have varicocele. Among men experiencing secondary infertility, meaning difficulty achieving a second or third pregnancy, the prevalence can be as high as 85%.
Varicocele can impair fertility through several mechanisms. Toxic metabolic substances from the adrenal gland and kidney may reflux into the testicular veins, and pooled venous blood can raise the temperature within the scrotum while reducing oxygen supply. As a result, testosterone production in the testicles decreases, and both sperm count and sperm motility decline. Abnormal sperm forms, including immature or irregularly shaped sperm, also increase, reducing the proportion of healthy sperm. For these reasons, treating varicocele is often essential when addressing male infertility.
One of the most common questions patients ask after being diagnosed with varicocele is whether the condition can resolve naturally. Unfortunately, once varicocele is clearly diagnosed, spontaneous recovery is extremely unlikely. In most cases, the condition gradually worsens over time. Medication generally has little effect, so surgery is recommended when the patient meets the appropriate clinical criteria.
Surgery is typically recommended when semen analysis results are abnormal, because varicocele is closely associated with male infertility. Surgical treatment is also indicated when the affected testicle has shrunk by more than 20% compared with the healthy testicle on the opposite side. Testicular size is directly related to reproductive capacity, so a reduction of more than 20% suggests decreased fertility potential. Finally, surgery may also be recommended when varicocele causes significant testicular pain.
According to data from the Health Insurance Review and Assessment Service (HIRA) in Korea, the number of patients diagnosed with varicocele increased from 12,664 in 2018 to 15,270 in 2022, representing a 20.6% increase. Because varicocele is strongly associated with male infertility, surgical treatment is often recommended once the diagnosis is confirmed.
Clinical studies have shown that after varicocele surgery, approximately 50% to 80% of patients experience normalization of semen parameters, and about 30% to 40% of couples are able to achieve natural pregnancy. In many university hospitals, varicocele surgery requires general anesthesia and hospitalization. However, at our clinic, accumulated clinical experience allows the procedure to be performed under local or spinal anesthesia, typically lasting about 30 minutes to one hour.
If a patient meets the clinical criteria for treatment, consulting a urology specialist to discuss surgical options is strongly recommended.
As men age, various urologic conditions may begin to interfere with daily life. By providing objective and practical information about urologic health, the goal is to help individuals maintain a healthier and more comfortable life during middle age and beyond.