A varicocele is a cluster of enlarged veins inside the scrotum, most often on the left side. The veins that drain the testicle have small one-way valves; when those valves fail, blood pools and flows backward, the veins stretch, and the testicle sits in warmer blood than it should. Varicoceles are common, present in a meaningful share of all men and in a larger share of men being evaluated for infertility. Many cause no trouble. The ones that do cause a dull ache, a shrinking testicle, or a semen analysis that is not what it should be.
Varicocele embolization treats the problem from inside the vein. Dr. Yosef Golowa, our interventional radiologist, enters a vein through a pinhole in the neck or groin, guides a catheter down to the faulty testicular vein under X-ray, and closes it with small coils or a sclerosing agent. Blood from the testicle then reroutes through healthy veins. There is no incision, no general anesthesia, and most men go home within hours and are back at work in a day or two.
At NYMD Center this is the treatment we recommend first for a varicocele that needs treating. Open surgical repair remains a good operation and stays available if it is ever needed, but for most men embolization gets to the same result with less asked of them.
Who it affects and the symptoms that bring people in
Varicoceles usually develop during adolescence and persist. Three groups of men come to us.
The first has pain: a dull, dragging ache in the scrotum that is worse after standing, exercise or a long day, and better lying down. Some men describe a "bag of worms" feeling above the testicle.
The second has noticed that one testicle is smaller than the other or seems to have shrunk. Testicular atrophy is a sign that the varicocele is affecting the tissue, and in younger men it is a reason to treat rather than watch.
The third group is the largest in our practice: men whose semen analysis during a fertility workup showed a low count, poor motility or abnormal shape. A varicocele is the most common correctable finding in male infertility, and correcting it is one of the few interventions that can improve semen parameters rather than work around them. Some men in this group also have a low testosterone level, which a varicocele can contribute to.
How we evaluate it at NYMD Center
The evaluation is done by one of our urologists, Dr. David Shusterman or Dr. Joseph Motta, not by the interventional radiologist. A varicocele is easy to over-treat, and the decision depends on why you came in.
The exam is done standing and lying down, with and without bearing down, which is how a varicocele declares itself. Every man then has a scrotal ultrasound in the office, which we consider part of the standard male workup. It confirms the diagnosis, measures the vein diameter and the reflux with Doppler, measures both testicles precisely, and rules out other causes of pain or swelling.
If fertility is the concern, the workup follows our fertility investigation pathway. That means a semen analysis, and usually two, since results vary from sample to sample; hormone levels including testosterone and FSH through our on-site lab; and genetic testing for any man with a sperm abnormality, because a chromosomal or Y-chromosome cause changes the plan entirely and no procedure will fix it. We also ask about your partner, because her age sets the pace. A couple with time can treat the varicocele and wait the three months it takes to see new sperm; a couple without that time may need to pursue assisted reproduction in parallel rather than in sequence.
Treatment options
Observation
A varicocele that causes no pain, no atrophy and no fertility problem does not need treatment. For adolescents we watch testicular size over time, and for adults with mild ache, supportive underwear and simple pain relief are reasonable. This costs nothing in recovery but changes nothing either, and a man with abnormal semen parameters who wants children should not wait indefinitely.
Varicocele embolization
Closing the refluxing vein from the inside. It is done under sedation through a single pinhole, takes under an hour, and leaves no wound to heal. Most men return to desk work the next day and to full activity within about a week. The trade-offs: the vein is closed rather than tied off, so in a small number of men the body opens collateral veins and the varicocele recurs; X-ray contrast is used, which matters for men with kidney disease or a contrast allergy; and the improvement in semen parameters, when it comes, takes about three months to appear. If embolization does not hold, surgical repair remains fully available.
Surgical varicocelectomy
The traditional operation ties off the veins through a small incision in the groin, usually under general anesthesia and often with an operating microscope. It is effective and durable. The costs are an incision, general anesthesia, more post-operative pain, a recovery of one to two weeks, and small risks of hydrocele or injury to the testicular artery. Our urologists discuss it with men who are not candidates for embolization, whose anatomy makes catheter access difficult, or who have recurred after embolization.
Assisted reproduction
For couples where time is short or where the male factor is severe, intrauterine insemination or IVF with ICSI may be recommended alongside or instead of treating the varicocele. Our urologists coordinate with your partner's reproductive endocrinologist so the two plans fit together.
What to expect at your visit
Your first visit is with a urologist at either office. Bring any prior semen analyses, lab results and imaging. The exam and ultrasound are done the same day, and if fertility is the concern the labs are drawn on site. Once the workup is complete and embolization is the recommendation, you meet Dr. Golowa to review the plan.
The procedure is done in our Manhattan surgery center. You arrive having fasted, an IV is placed, and sedation keeps you comfortable while the vein is closed. You rest for a couple of hours afterward and go home with someone accompanying you. Expect mild soreness at the puncture site and a dull ache in the scrotum for a few days. You can shower the next day and resume light activity right away; we ask you to hold off on heavy lifting and vigorous exercise for about a week.
Follow-up is with your urologist. A repeat ultrasound confirms the vein has closed, and if fertility was the reason for treatment, a repeat semen analysis is done at about three months.
When to seek care urgently
Sudden, severe testicular pain, especially with swelling or nausea, is an emergency and can mean testicular torsion, not a varicocele. Go to the nearest emergency department. After embolization, call us for fever, expanding swelling at the puncture site, or pain that worsens after the first few days rather than easing.
Questions patients ask
Why do you prefer embolization over surgery for varicocele?
Both work, and both are performed widely. Embolization gets there without an incision, without general anesthesia, and with a recovery of a day or two instead of a week or more. It closes the refluxing vein from the inside and can address vessels that are hard to reach surgically. If it ever fails to hold, surgical repair remains fully available. For most men that trade favors embolization, which is why it is our first recommendation.
Will treating the varicocele improve my sperm count?
In many men with an abnormal semen analysis and a clinically significant varicocele, semen parameters improve after the vein is closed, because the testicle is no longer bathed in warm, pooled blood. Improvement takes about three months, the time it takes to make new sperm, and it is not universal. We repeat the semen analysis after that interval and decide the next step together, keeping your partner's age and timeline in mind.
Does the varicocele come back?
Occasionally. The vein that was closed stays closed, but the body can open small collateral veins that reproduce the reflux. This happens in a minority of men after either embolization or surgery. If it does, a repeat embolization or a surgical repair can be done, and the ultrasound at follow-up is how we watch for it.
Will I still need an ultrasound if I can feel the varicocele?
Yes. Scrotal ultrasound is part of our standard male workup because it confirms the varicocele, measures both testicles to detect any size difference, checks for reflux with a Doppler, and rules out other findings that a hand exam can miss. It also gives a baseline that we compare against after treatment.
What does the procedure feel like?
You are sedated through an IV and the puncture site is numbed, so most men remember little of it. Some feel a brief ache in the flank or groin as the vein is closed. Afterward there may be mild soreness at the puncture site and a dull ache in the scrotum for a few days, controlled with over-the-counter medication. There is no wound to care for beyond a small bandage.
Make an appointment
Manhattan (212) 991-9991 · Forest Hills (718) 360-9550 · same-week visits, most major insurance accepted.