Varicocele: SA’s Most Missed Male Fertility Problem

A swollen vein in the scrotum sounds minor. But varicocele — the medical name for this condition — is quietly behind a significant share of infertility cases investigated in South Africa every year. It is correctable with surgery, yet many men spend years cycling through fertility clinics without anyone examining them for it first. That gap costs time, money, and, for some couples, a realistic chance of conception.

What exactly is a varicocele?

Think of a varicocele as a varicose vein, but inside the scrotum rather than on the back of your leg. The testicular veins normally carry blood away from the testes toward the heart. When the valves in those veins weaken or fail, blood pools and the veins dilate. The result is a collection of enlarged, twisted vessels — most often on the left side, because of the angle at which the left testicular vein drains.

The pooled blood raises the temperature inside the scrotum. Sperm production is exquisitely sensitive to heat — healthy spermatogenesis requires a temperature roughly 2–4 °C below core body temperature. Sustained heat stress disrupts sperm development, damages DNA in sperm cells, and over time reduces both sperm count and motility. A 2019 meta-analysis in Human Reproduction Update found that men with varicocele had, on average, 35–39% lower sperm concentration and 10–12 percentage-point lower progressive motility compared with unaffected men.

How common is it in South Africa?

Globally, varicocele affects roughly 15% of all adult men. Among men investigated for infertility, that figure rises to between 35% and 40%. No large-scale South African prevalence study has been published to date — this is a recognised gap in local reproductive medicine data. However, the South African Male Fertility Study (a multi-centre audit published in the South African Medical Journal in 2020) confirmed that varicocele was the single most frequently identified anatomical finding in men referred to urology for infertility workup, consistent with international figures.

South Africa’s broader reproductive health burden matters here too. Conditions such as HIV, which affects approximately 7.8 million South Africans according to UNAIDS 2023 estimates, and poorly controlled type 2 diabetes — both of which independently reduce sperm quality — mean that some men carry multiple simultaneous risks. A varicocele on top of an existing sperm-quality problem compounds the damage.

Why it gets missed in public primary care

The physical examination for varicocele takes roughly two minutes: a doctor asks the patient to stand, sometimes to perform a Valsalva manoeuvre (bearing down as if straining), and palpates the scrotum for the characteristic “bag of worms” texture of dilated veins. Grade I varicoceles are small and felt only during Valsalva. Grade II are palpable without straining. Grade III are visible to the naked eye.

The problem in South Africa’s public sector is not ignorance of the technique — it is consultation structure. A community health centre (CHC) doctor managing 40–60 patients per session, dealing with TB, hypertension, and HIV, is unlikely to conduct a genital examination on a man presenting with vague concerns about fertility unless someone specifically flags it. Male infertility is also underdiscussed culturally; many men present late or via their partner’s gynaecologist rather than seeking care directly.

Scrotal ultrasound with Doppler — the standard confirmatory test — is available at district and regional hospitals but waiting times at public facilities can stretch to several months.

Symptoms: what to look out for

Many men with varicocele have no symptoms at all, which is part of why it goes undetected. When symptoms are present, they typically include:

• A dull ache or feeling of heaviness in one or both testicles, usually worse after standing for long periods or physical exertion
• A visible or palpable lump above the testicle (almost always on the left)
• Mild scrotal discomfort that eases when lying down

Varicocele does not typically cause acute pain. If you experience sudden, severe testicular pain, seek emergency care — that presentation points to testicular torsion, a surgical emergency.

Crucially, the absence of symptoms does not mean the condition is absent. Most men discover a varicocele only when investigating why conception is not happening.

Diagnosis: the pathway from GP to urologist

If you suspect varicocele — or if you and your partner have been trying to conceive for 12 months without success (six months if your partner is over 35) — the starting point is a GP or clinic doctor who can perform or refer for a physical examination.

A Doppler scrotal ultrasound confirms the diagnosis and grades the varicocele. It measures vein diameter (a diameter above 3 mm is generally considered diagnostic) and detects retrograde blood flow, which is the hallmark of valve failure.

Alongside the ultrasound, a standard semen analysis — checking count, motility, morphology, and volume — gives a baseline picture of sperm quality. Repeat it twice, at least two weeks apart, because semen parameters fluctuate significantly day to day.

Treatment options and what outcomes look like

Not every varicocele needs treatment. Guidelines from the European Association of Urology (EAU), which South African urologists use in the absence of a local equivalent, recommend intervention when all three conditions are met: the varicocele is palpable (Grade II or III), the semen analysis is abnormal, and the couple has either documented infertility or sub-fertility.

When treatment is indicated, two main options exist:

Surgical ligation (varicocelectomy): A urologist ties off the dilated veins, rerouting blood through healthy vessels. Microsurgical subinguinal varicocelectomy — performed under magnification — has the lowest recurrence and complication rates. It is a day procedure under general or spinal anaesthesia, typically 60–90 minutes.

Percutaneous embolisation: A radiologist threads a catheter through a groin or neck vein and blocks the affected vessel with coils or foam. Equally effective in experienced hands, but availability in SA public hospitals is limited.

What can men expect? A 2021 Cochrane review — the most rigorous synthesis of the evidence — found that surgical varicocele repair increased pregnancy rates compared with no treatment or observation, with an odds ratio of approximately 2.4 (meaning roughly twice the likelihood of conception over the follow-up period). In absolute terms, studies show roughly 30–40 additional pregnancies per 100 treated couples compared with observation alone over two years, though results vary by baseline sperm quality. Sperm parameters typically begin improving three months post-surgery and peak at nine to 12 months — one full sperm production cycle.

Varicocelectomy does not guarantee conception, and couples with severe male factor infertility or female-factor issues may still need assisted reproduction. But for many couples, it is the right first step before spending R40,000–R120,000 on IVF.

Getting treatment in South Africa: public vs private

Healthcare access

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Public sector pathway: Start at your nearest CHC or district clinic. Request a referral to a urologist at the district or regional hospital — in most provinces, this is the gateway to both specialist consultation and Doppler ultrasound. Waiting times for a first urology appointment at public facilities commonly run four to eight months in major centres (Groote Schuur, Chris Hani Baragwanath, Tygerberg, Steve Biko Academic Hospital). Once seen, surgical treatment is available at no out-of-pocket cost for state patients. Bring your semen analysis results if you have had them done, as this speeds up the referral process.

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Private sector costs: A private urologist consultation typically costs R900–R1,800 depending on the practice. Scrotal Doppler ultrasound at a private radiology practice runs R1,500–R2,500. Microsurgical varicocelectomy in a private hospital, including anaesthetist and facility fees, generally costs R25,000–R50,000 all-in. These figures vary significantly by province and surgeon.

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Medical aid: Varicocele with infertility falls under Prescribed Minimum Benefits (PMBs) when it meets the diagnostic criteria for male infertility. This means your medical aid must fund diagnosis and surgically indicated treatment, regardless of plan option, at cost — though pre-authorisation is required and the definition of PMB coverage for “male infertility” can be contested. Check your scheme rules and appeal in writing if a claim is declined, citing the PMB regulation.

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Practical barriers: Load-shedding affects radiology equipment and hospital theatre schedules at some public facilities. If your appointment falls during a disruption, confirm 48 hours in advance. For men in rural areas, provincial health departments operate periodic specialist outreach clinics — ask your clinic sister about the nearest urology outreach date.

When to see a doctor

See a GP or clinic doctor if:

– You and your partner have been trying to conceive for 12 months without success (6 months if she is over 35)

– You notice scrotal heaviness, ache, or a palpable lump

– You have had a previous semen analysis showing poor results and no structural cause has been investigated

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Seek emergency care immediately for sudden, severe testicular pain.

The scare around the evidence — and what the data actually shows

After the 2012 Cochrane review questioned whether varicocele repair meaningfully improved pregnancy rates, media coverage in several countries discouraged men from pursuing treatment. That review was later updated (most recently in 2021) with better-quality trials included, and the conclusion reversed: treatment does improve pregnancy rates in appropriately selected men. The key word is selected — treatment is unlikely to help if the varicocele is subclinical (found only on ultrasound, not palpable) or if semen parameters are normal. The EAU guidelines reflect this nuance. Do not let the old headlines stop you from getting a proper assessment.

Bottom line

• Get examined: A two-minute physical examination can identify a condition that surgical treatment can correct — ask your GP explicitly to check.
• Do not skip the semen analysis: Grade the varicocele and check sperm quality before deciding on treatment.
• Use the public pathway: A CHC referral to a district hospital urologist costs nothing and leads to free surgery if you qualify.
• Check your PMB rights: Medical aid schemes must cover varicocele treatment when infertility criteria are met — push back if coverage is denied.
• Allow time post-surgery: Sperm parameters take up to 12 months to peak after varicocelectomy; do not assess outcome too early.