Varicocele embolisation vs surgery

Published 22 October 2026

Most varicoceles never need treating. When one does, usually because of abnormal semen results in a couple trying to conceive, a persistent ache, or a teenager’s testicle that is falling behind in growth, the choice is mainly between radiological embolisation and microsurgical ligation. This page compares them, and the other operations, using European guideline evidence.

What is a varicocele, and why can it matter?

A varicocele is a cluster of enlarged veins above the testicle, much like a varicose vein in the leg. It forms when the one-way valves in the testicular vein fail, so blood flows backwards and pools around the testicle. In adolescents, 78–93% are on the left, which the European Association of Urology (EAU) links to anatomy: on the left, the testicular vein drains into the renal vein.

How a varicocele harms fertility is not fully understood. The main explanations are that pooled blood warms the testicle, reduces its oxygen supply and lets waste products flow back towards it, increasing oxidative stress and sperm DNA damage. Varicoceles are found in almost 15% of men generally and 35–40% of men presenting with infertility, so one does not, on its own, explain a fertility problem.

The EAU grades them as subclinical (seen only on a Doppler ultrasound scan), grade 1 (felt only when you bear down), grade 2 (felt at rest) and grade 3 (visible). Any new scrotal lump should be checked by a doctor rather than self-diagnosed. Sudden, severe testicular pain, or testicle pain with nausea, vomiting or tummy pain, needs A&E immediately or a 999 call, and you should not drive yourself; our testicular pain page explains why.

Do I need varicocele treatment?

Often not, and the EAU guideline is clear in both directions.

When treatment is recommended

• Infertility with a palpable varicocele and abnormal semen results. The EAU strongly recommends treatment where there is otherwise unexplained infertility and the female partner has good ovarian reserve.

When treatment is not recommended

• A subclinical varicocele. In randomised trials, repairing these did not improve the chance of natural pregnancy.
• Normal semen analysis. The EAU strongly recommends against treatment.
• A small varicocele that is not affecting your semen results. As our male fertility treatment page says, this is often best left alone.

The grey areas

The EAU says repair may be considered, a weak recommendation, in men with raised sperm DNA fragmentation, either with otherwise unexplained infertility or after failed IVF or ICSI. Because any improvement takes months, your partner’s age and ovarian reserve matter: if time is short, waiting has to be weighed against moving directly to assisted conception.

A persistent ache is also a grey area. The EAU makes no formal recommendation for pain; it reports that pain resolves in 48–90% of men after surgery, and its paediatric guideline notes that the link between varicocele and pain is unclear and that pain can persist in about 20%.

What are the treatment options for a varicocele?

Every treatment blocks the faulty veins so blood drains through healthy ones; they differ in how and where the veins are reached.

• Radiological embolisation or sclerotherapy: the vein is blocked from the inside, through a fine catheter, with small metal coils or a liquid sclerosant.
• Microsurgical subinguinal or inguinal ligation: the veins are tied or clipped through a small groin incision using an operating microscope.
• Other operations: open inguinal ligation without a microscope, open retroperitoneal (high) ligation above the groin, and laparoscopic (keyhole) ligation inside the abdomen.

Three anatomical details account for many of the differences between techniques. If the lymphatic channels beside the veins are divided, fluid can collect around the testicle as a hydrocele, in up to 40% of cases according to the EAU paediatric guideline; lymphatic-sparing techniques significantly reduce this. The testicular artery is only about 0.5 mm across at the internal inguinal ring, which is why the EAU paediatric guideline recommends magnification for surgical ligation. Recurrence is mostly caused by small branch veins missed at the first repair. Embolisation works inside the vein, so it spares the lymphatics and does not touch the artery.

How is varicocele embolisation done?

Embolisation is a day-case procedure carried out by an interventional radiologist, a doctor who treats conditions through fine tubes guided by imaging. BAUS describes the steps.

• Local anaesthetic is injected into the skin of the lower neck or groin, and the vein is entered through a 3–4 mm nick, normally under ultrasound guidance. Sedation or painkillers can be given if needed.
• A guidewire and catheter are steered into the testicular vein under X-ray, and the vein is blocked with coils or a liquid sclerosant. Contrast dye confirms that all the abnormal veins are closed.
• Most procedures take 45 to 60 minutes, followed by 2 to 3 hours of monitoring.

BAUS lists bruising and pain at the puncture site, and back pain for 48 to 72 hours, as common (between 1 in 2 and 1 in 10). Puncture-site infection and recurrence needing repeat treatment each affect between 1 in 10 and 1 in 50. Rarer risks (between 1 in 50 and 1 in 250) are bleeding from the vein needing repair, a coil moving into the lung, and failure to position the coils so that surgery is needed. Tell the team if you have ever reacted to X-ray contrast.

Because it is X-ray guided, embolisation involves a radiation dose, which the EAU paediatric guideline notes as a drawback; RadiologyInfo describes a slight cancer risk outweighed by the benefit of treatment.

How is microsurgical varicocele ligation done?

Microsurgical ligation is an operation by a urological surgeon, usually under general anaesthetic as a day case; a spinal anaesthetic may be discussed instead. Through a small groin incision, the surgeon uses an operating microscope to tie or clip the swollen veins in the upper scrotum, and Doppler ultrasound can help identify and protect the artery. The stitches dissolve within two to three weeks.

BAUS lists scrotal swelling for several days, and clear fluid seeping from the wound, as common (between 1 in 2 and 1 in 10). About 1 in 10 men have pain for a few weeks as the blocked veins become inflamed. Between 1 in 10 and 1 in 50 have a haematoma needing drainage, and the same range is given for failure to cure the varicocele; BAUS advises asking your surgeon for their own results. Rare risks (between 1 in 50 and 1 in 250) are damage to or shrinkage of the testicle, a later hydrocele, and anaesthetic or cardiovascular complications.

The EAU concludes that microsurgery has fewer complications and lower recurrence than other surgical techniques, but requires microsurgical training.

Embolisation vs surgery: how do they compare?

Embolisation is done under local anaesthetic and you are back to normal activities sooner; microsurgery usually needs a general anaesthetic and a longer recovery, and has the lowest recurrence in published series, although trials comparing the two directly have not shown a clear difference. Neither has been shown to give clearly higher pregnancy rates than the other.

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Recurrence and hydrocele by technique

The EAU pools published series for each technique. The ranges come from different studies, not head-to-head trials, so treat them as a guide.

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The EAU table lists hydrocele in 10% after retrograde embolisation, yet a meta-analysis in the same guideline (738 surgical ligations, 647 sclero-embolisations) found hydrocele significantly more common after surgery, with similar recurrence and overall complications but more inflammation of the testicle and epididymis after radiological treatment.

Does varicocele repair improve fertility, and does the method matter?

Treatment may help the right couples, but the evidence is less certain than often suggested. The 2021 Cochrane review, covering 48 randomised trials and 5,384 men, found that treatment may improve pregnancy rates: where untreated couples had a 21% chance of pregnancy, the rate after treatment was between 22% and 48%. That is low-certainty evidence, and any effect on live births remains uncertain.

Meta-analyses cited by the EAU show improved sperm concentration and total count after repair in men with abnormal results, with less consistent effects on motility and shape, and reduced sperm DNA fragmentation. Our guide to semen analysis results explains these measures.

Whether the method matters is unsettled. The Cochrane review could not show a difference between surgery and radiological treatment in pregnancy rate (risk ratio 1.13, confidence interval 0.75 to 1.70) or recurrence. A systematic review cited by the EAU found that surgery improved pregnancy rates compared with untreated controls, while the same was not demonstrated for radiological treatment. A small, non-randomised French study of 49 microsurgical and 27 embolisation patients found no significant difference in semen improvement or pregnancy rate (36.7% and 33.3%), with faster recovery and less pain after embolisation.

What is recovery like after each procedure?

After embolisation, BAUS advises resting for the rest of the day, simple painkillers, and normal activities after 24 hours.

After microsurgery, expect swelling and bruising of the groin and scrotum for a few days. A scrotal support, simple painkillers and wrapped ice packs help. Avoid heavy lifting and strenuous exercise for two to three weeks, and return to work when you are comfortable.

If treatment was for fertility, semen analysis is repeated about three months later, as BAUS notes it takes at least that long to see improvement. After either procedure, contact your treating team if you develop a fever, spreading redness or pus at the wound or puncture site, or pain and swelling that worsen day by day; if you cannot reach them, call NHS 111. If a puncture site keeps bleeding after 10 to 20 minutes of firm pressure, go to A&E. For chest pain, breathlessness or coughing up blood, call 999.

Should a varicocele be treated in a teenager?

Treatment is advised mainly for a testicle that stays small. Varicoceles are found in 14–20% of adolescents, but most have no difficulty fathering children later, so the EAU warns of a significant risk of over-treatment. Its paediatric guideline states there is no evidence that treating in childhood gives a better result than treating later.

The firm indication is a testicle that stays smaller than the other by more than 2 mL or 20%, confirmed at two visits six months apart, because growth can be temporarily uneven in healthy adolescents. Treatment can be considered case by case for pain (which can persist after surgery), varicoceles on both sides, a problem with the other testicle, abnormal semen results in an older adolescent, or cosmetic concerns about scrotal swelling. If you are asking on behalf of a teenager, call us before booking to check whether we can see them.

What happens if a varicocele comes back?

A recurrence is confirmed with a Doppler ultrasound scan and treated again only if it is still causing problems, usually by a different technique so the second procedure works through untouched tissue. The EAU recommends the scan if semen results stay disappointing after repair, and its paediatric guideline reserves retreatment for a recurrence that remains symptomatic or shows no improvement in testicular size. Retreatment can be surgical or by embolisation.

How do we help you choose between them?

The first question is whether treatment is worthwhile at all, based on examination, semen analysis, a scan where it helps and your partner’s fertility picture, as described on our male fertility treatment page. If treatment is advised, we explain the trade-off between embolisation’s quicker recovery and the lower recurrence reported in microsurgical series, which head-to-head trials have not confirmed, and your consultant can advise which route suits you.

Our consultant urological surgeons, Mr Maj Shabbir and Ms Raveen Kaur Sandher, both include male infertility and microsurgery in their practice and practise at Guy’s & St Thomas’, named by Newsweek in 2025 as the number one urology service in Europe. We see patients at HCA at The Shard (SE1 9BS), HCA at Canary Wharf (E14 5NR) and HCA at Guy’s Hospital (SE1 9RT). Consultation fees are on our fees and insurance page; procedures are quoted separately. Call +44 7889 318584 (lines open Monday to Friday, 8am to 4pm) or email contact@theandrologycentre.co.uk.

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References and further reading