Let’s talk about balls.
More specifically, let's talk about varicocele - little varicosities that can occur within the balls. In my experience, if a couple are struggling with long term infertility and a varicocele is found, it is usually significant and it's worth considering treating it to rule it out as a causative or contributing factor.
Varicocele are thought to be present in around 15% of all men, but in 35% of men with primary infertility and around 70% of men with secondary infertility (even though it was not an issue for them for the previous conception). So if you are struggling with infertility and a varicocele is present, it maybe significant. Even if a varicocele has been there for many years, and you have previously been told it's not going to impact your fertility. It is worth having that conversation again with a urologist who specialises in treating male infertility.
Varicocele are associated with poor sperm morphology, and higher sperm DNA fragmentation. which means:
- an increased risk of long term infertility
- an increased risk of implantation failure
- an increased risk of early losses
- an increased risk of losing embryos between day 3-5
What is a varicocele?
It is thought that varicocele occurs when the little valves in the blood vessels no longer function properly - valves are structures that are found inside of veins, they prevent the blood from flowing backwards and keep the flow moving in the right direction. The presence of a varicocele means that the valves are not working properly so blood pools in the balls more than it should and passes through that area more slowly than it should. This can cause the balls to feel a bit heavy and ache a bit at the end of the day, it can also cause the balls to feel noticeably warm. And both of those things indicate that the varicocele is causing an issue. The warmth and poor blood flow have an impact on sperm development and on the integrity of the sperm DNA. If blood passes through the balls more slowly, the blood and fluids will be less fresh and the level of toxins higher than ideal for very small, very delicate sperm which can cause damage to the sperm; if the balls feel warm, the temperature in there may be too high for very delicate, very small sperm cells which can in turn stress the structure of the sperm DNA.
A varicocele is more likely to form on the left, but it is possible to have a varicocele on the right or on both sides. Some men with varicocele have perfectly good semen analysis results, but other men with varicocele may find their semen analysis results are poor - we most often see varicocele associated with low sperm count and low sperm morphology (low % of normal forms).
How do you know if a varicocele is there?
If there is a varicocele present, you may be able to feel it – it may feel like a little cluster of worms in the scrotum (usually only detectable when the man is standing up, and will often disappear when he is lying down).
You may notice some of the following symptoms:
Pain in the testicles (can be a sharp pain or a dull ache)
Pain that worsens if you spend a long time on your feet, or do vigorous exercise such as running.
Pain is often worse at the end of the day
Lying down will usually ease the pain
Some varicocele are only detected with an ultrasound.
A varicocele maybe too tucked away to be felt by an inexperienced hand – a urologist is a much better judge of the presence of a varicocele. So if you notice the balls feel heavy or achey, or they feel unusually warm your GP should refer you for an ultrasound or to a urologist for further assessment. A GP is unlikely to refer you for a check on your varicocele from a fertility perspective - but they should refer you if you are bothered by aching, heavy testicles. Insist on it.
How are varicocele fixed?
The procedure to fix a varicocele is quick and simple and the impact on sperm health can be really significant. The usual treatment is called an embolism, it is a fairly painless procedure that can be done in a very short time. If previous tests showed issues with poor sperm morphology or high sperm DNA fragmentation, test results usually improve over the 3-6 months following the embolism - though we often find pregnancy happens before a retest if that was the only limiting factor (though long-term infertility can be more complex than that!). Many men also report that their balls feel great afterwards – no longer aching or feeling heavy or hot.
Not all varicocele need to be treated, and some men are able to father children without having to repair their varicocele. A semen analysis, and sometimes a sperm DNA fragmentation test will be used by a urologist to determine whether a varicocele should be treated or not. If you have been through a previously unsuccessful IVF cycle, there may be more weight in the argument to treat rather than leave a varicocele untreated.
If you are struggling with long term unexplained infertility, implantation failure or recurrent early losses, get this one ticked off.
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Sylvia Yan, Maj Shabbir, Tet Yap, Sheryl Homa, Jonathan Ramsay, Kevin McEleny & Suks Minhas (2021) Should the current guidelines for the treatment of varicoceles in infertile men be re-evaluated?, Human Fertility, 24:2, 78-92, DOI: 10.1080/14647273.2019.1582807
Does Varicocele Repair Improve Male Infertility? An Evidence-Based Perspective From a Randomized, Controlled Trial, European Urology, Volume 59, Issue 3, 2011, Pages 455-461,
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