Varicocele Embolization: The Non-Surgical Alternative to Surgery

A dull, dragging ache in the testicle. A heavy feeling in the scrotum that builds after a day on your feet, a workout or a long drive. Sometimes a soft “bag of worms” you can feel above the testicle. Many young men live with this for years, feel awkward asking about it, or only find out when a semen test comes back abnormal. A varicocele is common and benign, and today it can be treated without surgery, without an incision and without general anesthesia: by closing the faulty vein from the inside (varicocele embolization).

A varicocele is an enlargement of the network of veins that drains blood from the testicle. Normally, valves in the testicular vein stop blood from flowing backwards. When they fail, blood pools around the testicle, the veins widen and the local temperature rises. Sperm production is sensitive to heat, so in some men a varicocele is linked to lower sperm quality. Most varicoceles are on the left side, because of the way the left testicular vein drains into the kidney vein.

A 2022 review in Seminars in Interventional Radiology reports that varicoceles are found in about 10 to 15 percent of men of reproductive age and in up to about 35 percent of men with primary infertility. A 2025 study in CVIR Endovascular notes that pain occurs in about 2 to 10 percent of men with a varicocele. In other words, most men with a varicocele have no symptoms, and not every varicocele needs treatment.

• A dull ache or heaviness in the testicle, usually on the left, that builds with standing, effort and heat and eases when lying down.
• A soft, twisting structure above the testicle that is easier to feel when standing.
• A difference in size between the two testicles, especially in adolescents.
• Difficulty conceiving with an abnormal semen analysis.

Sudden severe testicular pain, rapid swelling, fever, redness or a hard lump are not typical of a varicocele. Get checked the same day to rule out urgent conditions such as testicular torsion or infection.

On physical examination, varicoceles are usually graded with the Dubin and Amelar system, as described in a 2022 study in the Journal of Reproduction and Infertility:

• Subclinical (grade 0): not palpable, seen only on ultrasound.
• Grade 1: palpable only while bearing down (Valsalva maneuver).
• Grade 2: palpable at rest, but not visible.
• Grade 3: visible through the scrotal skin.

The grade matters for the decision. The joint guideline of the American Urological Association and the American Society for Reproductive Medicine (AUA/ASRM, 2021) advises against treating a non-palpable varicocele found only on imaging when the goal is fertility.

Diagnosis starts with a physical exam standing and lying down, at rest and while bearing down. A Doppler ultrasound of the scrotum confirms the diagnosis, shows the enlarged veins and the backward flow, and compares the volume of the two testicles. When fertility is the question, a semen analysis is added, and sometimes hormone blood tests at the urologist’s discretion. Before the procedure I review the tests with you and explain whether embolization is the right option for you.

The AUA/ASRM guideline recommends considering varicocele repair in men trying to conceive who have a palpable varicocele, infertility and abnormal semen parameters (a moderate-strength recommendation). The guideline cites a meta-analysis in which the pregnancy rate without treatment was estimated at 17 percent, and after different surgical techniques at 35 to 42 percent, and stresses that these figures should be read with caution because most studies were not randomized. In men with no sperm at all (non-obstructive azoospermia), there is no definitive evidence that repair helps.

In the Irish study of 225 men treated with embolization, 19 of the 37 men treated for infertility reported a pregnancy. This is a small group and self-reported data. A varicocele is only one possible factor, so the decision is made with a urologist or fertility specialist, after the female partner has also been evaluated.

Young men ask this a lot. A meta-analysis in the American Journal of Men’s Health (2023) found an average rise of about 35 ng/dL in testosterone after surgical varicocele repair. The authors themselves note that the studies were small, that most compared patients with themselves before and after, and that a large randomized trial is needed. So there is a signal of improvement on average, but a change in any one man cannot be promised, and low testosterone alone is not a reason for treatment without a full work-up.

• Pain or heaviness that affects daily life, after other causes have been ruled out.
• A palpable varicocele with difficulty conceiving and an abnormal semen analysis.
• Adolescents and young men with a significant difference in testicular size, on a urologist’s recommendation.
• A varicocele that returned after surgery. Here embolization has a clear advantage, because the vein is reached from the inside rather than through the operated area.

• A small varicocele without pain and without a fertility problem: follow-up is usually enough.
• A varicocele seen only on ultrasound, when the goal is fertility.
• Severe contrast allergy or significant kidney failure, which require special preparation or a different approach.
• Unusual vein anatomy that a catheter cannot navigate. In that case surgery is the better option.

Both approaches close the faulty vein and are considered effective. Surgery ties off the vein through an incision, usually microsurgically in the groin. Embolization closes it from the inside. According to a meta-analysis by Liu et al. (Journal of Vascular and Interventional Radiology, 2022), as cited in the Seminars in Interventional Radiology review:

• Complications were lower with embolization (relative risk 0.63).
• There was no significant difference in recurrence.
• There was no significant difference in pregnancy rates.

The American guideline is written around surgery, because most fertility studies were done with surgery. In the direct comparisons above, embolization was not worse for pregnancy rates. The decision is made together, based on your tests, your anatomy and your preference.

• At the consultation we review your tests, your medications and any allergies, especially to contrast.
• A kidney function blood test is sometimes requested.
• You are usually asked to fast for a few hours. Exact instructions are given in advance.
• Plan for someone to take you home, and bring supportive underwear.

1. Admission: the procedure is done in the interventional radiology unit at Shaare Zedek as a day procedure.
2. Local anesthesia: you stay awake. A small spot of skin, usually in the groin or neck, is numbed, and mild sedation is given if needed.
3. Catheter: through an opening of a few millimeters, a thin catheter is guided under X-ray to the testicular vein. Contrast shows the backward flow and all the branches.
4. Closing the vein: the faulty vein is closed with tiny coils, sometimes with a sclerosing agent, so blood is rerouted through healthy veins. The testicle’s blood supply is preserved, because it comes through an artery.
5. Finish: the catheter is removed and pressure is applied. No stitches. After a short rest you go home the same day.

The procedure itself usually takes less than an hour.

Most patients return to normal daily activity the next day. The Seminars in Interventional Radiology review describes returning to daily activities after 24 hours and avoiding heavy lifting for two weeks. In practice: office work the next day, walking straight away, running and strength training after about two weeks. Mild discomfort in the lower back or groin may occur in the first days and usually settles with simple pain relief. If the goal is fertility, a repeat semen test is usually done about three months after treatment or later, because sperm production takes time.

• Technical success: in an Irish study of 225 men treated over 15 years, the procedure was technically successful in 96 percent, and in 96.9 percent after repeat procedures.
• Clinical success: improvement in the complaint was reported in 93.75 percent of technically successful cases.
• Recurrence after surgery: in the same study, all 7 men whose earlier surgery had failed were treated successfully with embolization.

Embolization is considered safe. In the Irish study, the complication rate was 1.78 percent (4 of 225), with no major complications. Possible, uncommon complications include bruising or tenderness at the entry point, temporary pain, a reaction to contrast and, very rarely, coil migration. The procedure involves X-ray exposure, which we keep as low as possible.

A varicocele can come back after any treatment, including surgery. In the Irish study, ultrasound-confirmed recurrence was found in 6.25 percent of those who responded to follow-up (6 of 96) over a mean of about 8 years, and a quarter of responders reported that symptoms had returned. In the Seminars in Interventional Radiology review, technical failure was much higher on the right side than on the left (19.3 vs. 2.3 percent). If a varicocele returns, it can usually be treated again, by embolization or surgery.

Dr. Adam Farkas: “Varicocele embolization at Shaare Zedek is covered by all the supplementary insurance plans (Shaban) of the Israeli health funds.”

Consultations take place at Elite Medical in Modiin. When you book, we explain what to arrange with your health fund before the procedure.

Dr. Adam Farkas is Director of the Vascular Interventional Radiology Unit and Vascular Anomalies Clinic at Shaare Zedek Medical Center, Jerusalem, and Chair of the Israel Society of Interventional Radiology. Consultations take place at Elite Medical in Modiin, and the procedure itself is performed in the unit at Shaare Zedek.

1. Torkian P, Rosenberg M, Talaie R, Golzarian J. Varicocele Embolization: Interventional Radiologist’s Perspective. Semin Intervent Radiol. 2022;39(6):581-586. https://pmc.ncbi.nlm.nih.gov/articles/PMC9767774/
2. Ni Mhiochain de Grae M, et al. A fifteen-year retrospective analysis of varicocele embolization. CVIR Endovascular. 2025;8:59. https://pmc.ncbi.nlm.nih.gov/articles/PMC12283497/
3. Schlegel PN, et al. Diagnosis and treatment of infertility in men: AUA/ASRM guideline part II. Fertil Steril. 2021;115(1):62-69. https://doi.org/10.1016/j.fertnstert.2020.11.016
4. Abolhasani Foroughi A, et al. Relationship of Clinical and Ultrasonographic Grading of Varicocele with Semen Analysis Profile and Testicular Volume. J Reprod Infertil. 2022;23(2):84-92. https://pmc.ncbi.nlm.nih.gov/articles/PMC9363911/
5. Tian D, et al. Effects of Varicocele Surgical Repair on Serum Hormone and Inhibin B Levels: A Systematic Review and Meta-Analysis. Am J Mens Health. 2023. https://pmc.ncbi.nlm.nih.gov/articles/PMC10496478/