Varicocele surgery vs embolisation: which is right for you?
Both are legitimate ways to treat a varicocele. They differ in who performs them, how you recover and which risks you accept — and neither should be done unless the varicocele genuinely needs treating.
When a varicocele needs treating, there are two well-established routes. Microsurgical ligation is an operation: a urological surgeon ties off the abnormal veins through a small groin incision under an operating microscope. Embolisation is a radiological procedure: an interventional radiologist blocks the vein from the inside, guided by X-ray, under local anaesthetic. I perform the first, but I regard both as legitimate, and some men are better suited to embolisation. The table summarises the trade-offs; the sections below explain them.
| Aspect | Microsurgical ligation | Embolisation |
|---|---|---|
| Who performs it | A urological surgeon (andrologist) | An interventional radiologist |
| Anaesthetic | General or regional; day case | Local anaesthetic, with sedation if needed; day case |
| Access | 2–3cm incision low in the groin | 3–4mm puncture in the neck or groin |
| Back to normal | Desk work within a few days; sport and heavy lifting at 3–4 weeks | Normal activities after 24 hours |
| Not cured, or comes back (BAUS risk band) | Between 1 in 10 and 1 in 50 | Between 1 in 10 and 1 in 50 |
| Risks specific to the method | Haematoma; hydrocele; testicular damage; anaesthetic risks | Back pain for a few days; coil moving to the lung (uncommon); X-ray exposure |
Should my varicocele be treated at all?
Only if it is causing a problem: a fertility issue backed by abnormal semen results, pain that has not settled, or in selected cases low testosterone or a shrinking testicle.
Around 15% of all men have a varicocele, and it is more common in men with fertility problems, but most men with one are fertile. If yours causes no pain and does not affect your fertility, your testosterone or the size of your testicle, no treatment is needed. When fertility is the reason, I recommend repair only when all of the following apply:
- The varicocele can be felt on examination, not merely seen on a scan
- There is a documented abnormality of the semen, or raised sperm DNA fragmentation
- The couple has documented infertility
- The female partner has normal fertility, or a treatable and identified cause
“Documented” matters. One semen sample is not enough to judge, because results vary considerably between samples; I want to see two analyses performed properly, and the semen analysis guide explains what the numbers mean. When these criteria are met, the evidence is supportive: BAUS notes that treating clinically significant varicoceles is associated with better sperm number and quality and higher rates of natural and assisted conception, and that both the European and American urological associations advocate treatment in their male infertility guidelines. Varicocele is one of several causes I look for when assessing male infertility, and it is the most frequently identified correctable one.
Decide whether before deciding how
Selection is what matters. A varicocele that can only be seen on an ultrasound scan, or one in a man with normal semen and no pain, should not usually be treated by either method. Treating it exposes you to the risks below without an expected benefit.
What happens in microsurgical varicocele repair?
A urological surgeon ties off the abnormal veins through a 2–3cm incision low in the groin, using an operating microscope, under general or regional anaesthetic as a day case.
The magnification is the point of the technique. It lets me identify and protect the testicular artery, whose injury risks shrinkage of the testicle; preserve the lymphatic vessels, which is what prevents a hydrocele (a fluid collection around the testicle); and tie every draining vein, including the small ones that are invisible to the naked eye. The incision is closed with dissolving stitches. BAUS describes the microscope as improving the success rate and reducing the risk of complications. This is the approach I use; the varicocele microsurgery page covers the operation in more detail.
What about laparoscopic or open surgery?
Laparoscopic (keyhole) ligation and open ligation without a microscope are also used. Microsurgical subinguinal ligation is widely regarded as the reference standard, because without magnification the lymphatics are harder to see and preserve, and hydrocele is a common complication of non-microsurgical techniques.
What happens in varicocele embolisation?
An interventional radiologist threads a fine tube into the testicular vein through a 3–4mm puncture in the neck or groin, then blocks it with metal coils or a sclerosant liquid.
Interventional radiologists are consultants with particular expertise in using imaging to guide wires and catheters around the body. The procedure takes place in the radiology department under X-ray guidance. The skin is numbed with local anaesthetic, and a sedative or painkillers can be given if required; after that first injection it is usually not painful, although you may feel a brief warm sensation when the contrast dye is injected. The arteries to the testicle are not affected. It typically takes 45 to 60 minutes, you are monitored for two to three hours afterwards, and you normally go home the same day.
Who is embolisation a good choice for?
Men who want to avoid an incision and a general anaesthetic, whose varicocele has returned after surgery, or who need to be back to normal within a day.
There are real advantages. According to BAUS, embolisation is less invasive than surgery, eight out of ten patients (80%) have a successful outcome, and there is no significant risk of testicular shrinkage or hydrocele compared with surgical approaches. It is a particularly reasonable option when a varicocele recurs after an operation.
My own view is that microsurgical ligation generally has the lower recurrence rate and is the more established approach when the reason for treatment is fertility, and it involves no X-ray exposure. To be fair to embolisation, though, the BAUS patient leaflets — which give risks in bands rather than exact figures — place the chance of the varicocele not being cured, or coming back, in the same band for both: between 1 in 10 and 1 in 50. BAUS advises asking about the technique that will be used and about the operator’s own results, so whichever route you choose, ask that person about theirs.
Embolisation is not for everyone. If you have ever reacted to X-ray dye (contrast), the radiology team must know beforehand, and occasionally the coils cannot be positioned satisfactorily and surgery is needed instead.
How long is recovery after varicocele surgery or embolisation?
After embolisation, normal activities can usually resume after 24 hours; after microsurgery, most men return to desk work within days and to sport at three to four weeks.
After microsurgery, discomfort and bruising last around one to two weeks, supportive underwear helps in the first fortnight, and cycling and heavy lifting are best left until three to four weeks. After embolisation you rest for the remainder of the day; the veins above the testicle often become more prominent and tender for the first few days, and back pain for 48 to 72 hours is common.
Physical recovery is not the same as fertility recovery. Sperm production runs on roughly a three-month cycle, and it takes at least three months to see an improvement in the sperm count after varicocele treatment. I repeat the semen analysis at three months and again at six, and where improvement occurs it typically continues over the first six to nine months.
How risky is varicocele surgery?
Complications are uncommon with microsurgical technique, and the commonest side effects of either method are short-lived; the main difference is which risks you are exposed to.
The BAUS leaflets list these among the after-effects of each procedure:
- Microsurgery: scrotal swelling lasting several days (between 1 in 2 and 1 in 10 men); pain from inflamed, clotted veins lasting a few weeks (about 1 in 10); a blood collection needing drainage (between 1 in 10 and 1 in 50); and, each between 1 in 50 and 1 in 250, a hydrocele developing months later or damage to the testicle if its blood supply is affected. A general anaesthetic carries its own small risks.
- Embolisation: bruising, pain at the puncture site and back pain are each common (between 1 in 2 and 1 in 10) but settle; infection at the puncture site occurs in between 1 in 10 and 1 in 50. Rarer events, each between 1 in 50 and 1 in 250, include damage to the punctured vein needing repair and a coil moving into the lung, which can often be retrieved and if not is unlikely to cause long-term problems.
Embolisation is guided by X-ray, so it involves some radiation exposure; microsurgery involves none. If radiation matters to you, ask the radiologist what dose to expect. With either method, there is also the possibility that your semen does not improve.
Is varicocele 100% curable?
No. Either treatment can fail to cure the varicocele or be followed by recurrence, and even a successful repair does not guarantee better sperm or a pregnancy.
Recurrence is possible with any technique, and a recurrence can itself be treated, often by embolisation. Bear in mind too that the visible veins rarely disappear completely after treatment, even when it has worked; the measure of success for fertility is the semen analysis, not the appearance of the scrotum. In appropriately selected men, improvement in semen quality is seen in a substantial proportion, along with improved pregnancy rates, but no treatment is guaranteed.
Is varicocele treated by the NHS?
Availability varies between NHS areas, so I cannot give a single answer; your GP is the right person to advise on the local funding policy and referral route.
I work as an NHS consultant at Guy’s Hospital as well as in private practice, but NHS eligibility rules and waiting times change and differ by area, and I would rather not quote figures that may not apply to you.
How much does varicocele surgery cost in the UK?
There is no single price: the total depends on the hospital, anaesthetic, length of stay and insurance, and you receive a written quotation once a plan is agreed.
A surgical quotation sets out three separate fees: the surgeon’s fee, the anaesthetist’s fee and the hospital fee. Semen analyses and scans are charged separately by the hospital, and you are told the cost before anything is arranged. Embolisation is carried out by an interventional radiologist in the X-ray department, so its cost is made up differently; ask the radiology team for their own quotation. A consultation with me is £350 in person, £300 by video or telephone, and £250 for a follow-up. If you are insured, check your policy specifically, because some policies limit cover for fertility investigation and treatment. The fees and insurance page has the details, and if you would like to talk through which option suits you, you can book a consultation.
Sources and further reading
Frequently asked
Do I need an ultrasound scan before deciding on treatment?
Examination matters more than the scan. The key question is whether the varicocele can be felt; one that is visible only on ultrasound should not usually be treated, because the evidence does not support benefit. A scrotal ultrasound is still useful as part of a full fertility assessment, but a scan-only finding on its own is not a reason for surgery or embolisation.
Is it worth treating a varicocele if we are already planning IVF?
It can be. BAUS notes that treating a clinically significant varicocele is associated with higher rates of assisted as well as natural conception, and I aim to optimise sperm quality before IVF where possible. Whether waiting at least three months for an improvement is sensible depends on your partner’s fertility, which is why I prefer to plan this jointly with the fertility team.
Can raised sperm DNA fragmentation alone be a reason to treat?
It can count as the semen abnormality, but not on its own. I recommend repair for fertility when the varicocele can be felt, there is abnormal semen or raised DNA fragmentation, the couple has documented infertility, and the female partner’s fertility is normal or has a treatable cause. DNA fragmentation testing is used in selected cases rather than routinely.
Does the size of my varicocele matter?
Less than whether it can be felt and whether it is causing a problem. Varicoceles are graded from subclinical, visible only on ultrasound, to large and easily visible. A larger one is not automatically a reason to operate, although in selected men low testosterone associated with a large varicocele is an accepted reason to consider repair.
Will I be awake during embolisation?
Usually, yes. Embolisation is done under local anaesthetic, injected into the skin of the neck or groin, and a sedative or painkillers can be given if you need them. After that first injection the procedure is usually not painful, because the veins do not feel the wires moving inside them. You may feel a brief warm sensation when the dye is injected.
Can I choose embolisation even if surgery is recommended?
Yes. Both are legitimate treatments, and the decision is yours once you understand the trade-offs. I will tell you which I think suits your situation and why. If you choose embolisation, it is carried out by an interventional radiologist in the hospital X-ray department.
Speak to my team
Appointments at The Shard and Canary Wharf are arranged by my PA, Jeanette Bush. Tell us briefly what the problem is and we will find the right clinic slot for you.