Aim: This study aimed to evaluate the changes in health-related quality of life (HRQOL) following microsurgical subinguinal varicocelectomy using the WHOQOL-BREF questionnaire, with a specific focus on comparing outcomes across different varicocele grades.

Materials and Methods: This prospective observational study included 50 patients who presented to the tertiary referral center at Istanbul Haseki Training and Research Hospital with complaints of infertility or scrotal pain and swelling and who were considered for microsurgical subinguinal intervention due to varicocele. A careful anamnesis was taken from the patients who participated in the study, and general physical and urogenital system examinations were performed. Afterwards, all patients underwent routine biochemical tests. Color Doppler ultrasonogram and the quality of life scale was applied to these patients, for whom surgery was decided. Quality of life was assessed preoperatively and at postoperative month 3 using the WHOQOL-BREF questionnaire. Patients were stratified according to clinical varicocele grade. Paired statistical analyses were performed to compare pre- and postoperative scores.

Results: The mean age of the patients was 28.5 (18-45). Clinical varicocele was detected in 90% (n=45) of the patients during physical examination. Of the patients with varicocele, 22.2% were graded as Grade I, 33.3% as Grade II, and 44.5% as Grade III. Significant improvement was observed in total WHOQOL-BREF scores following surgery (mean ± SD: 61.4 ± 6.1 vs. 70.1 ± 6.9; p = 0,047). Subgroup analysis demonstrated significant improvement in Grade I (p = 0,020) and Grade II (p = 0,023) varicocele, whereas improvement in Grade III disease did not reach statistical significance at 3 months (p = 0,074).

Conclusion: Microsurgical subinguinal varicocelectomy is associated with significant short-term improvement in quality of life, particularly in patients with low- and intermediate-grade varicocele. These findings suggest that varicocele repair serves as a vital intervention not only for fertility but also for enhancing patient-centered outcomes.

• Microsurgical varicocelectomy; Quality of life; WHOQOL-BREF; Male infertility; Sperm parameters

Ozmez A, Caglar U, Ozgur MO, Ozgör F, Sarilar O (2026) Grade-Dependent Quality-Of-Life Outcomes after Microsurgical Varicocelectomy. JSM Sexual Med 10(3): 1186.

Varicocele is a condition in which the internal spermatic veins in the pampiniform plexus are abnormally dilated and tortuous. Varicocele is the most common correctable cause of male factor infertility [1]. Although the incidence of varicocele is approximately 15% in the general male population, it has been shown to be a factor in approximately one third of infertile men [2]. Current literature emphasizes that varicocele negatively affects not only sperm parameters but also sperm DNA integrity [3].Current studies conducted in 2024 have shown that oxidative stress and temperature increase caused by varicocele may lead to a progressive deterioration in Leydig cell functions responsible for testosterone production [4]. Although the cases are mostly found as left varicocele, 15-20% are found bilaterally. In general, a high degree of varicocele or a 20% reduction in testicular volume is accepted as a surgical indication in order to preserve fertility and preserve testicular functions [5,6].

Microsurgical varicocelectomy remains the preferred treatment method due to its positive outcomes in terms of fertility preservation, pain relief, and low complication rates. While the effects of varicocele repair on sperm quality and pregnancy outcomes have been extensively studied, patient-reported outcomes such as quality of life have received relatively less attention. Quality of life can be significantly affected, particularly by infertility, chronic scrotal pain, or scrotal discomfort.

Etiological hypotheses in adolescent varicocele are not different from the adult age group. The reason why it is more common on the left side is attributed to anatomical differences. The most important factor is the difference in hydrostatic pressure caused by the opening of the right testicular vein to the vena cava and the left testicular vein to the left renal vein [7]. Another view is the compression of the left renal vein between the aorta and the superior mesenteric artery, and an increase in pressure in the left renal vein due to external pressure at this level, and this is called the “nutcracker phenomenon” [8].

Different studies are of the opinion that increased testicular arterial flow during adolescence increases venous return and this leads to venous dilatation [9]. Spermatogenesis is the testicular function most affected by the presence of varicocele [10]. Hyperthermia, ischemia, renal venous reflux, increased hydrostatic pressure due to varicocele; It causes free radicals and endocrine imbalance and also causes the release of autoimmunity mediators that can damage normal testicular function. It can increase apoptosis and cause reduction in testicular size (hypotrophy). The above-mentioned reasons lead to a decrease in sperm count, deterioration in morphology, and sperm motility. Despite all these, adolescent varicocele is one of the important causes of infertility that can be treated surgically [11,12].

The routine standard evaluation of an infertile man with varicocele should include a careful medical and reproductive history, physical examination, and at least 2 semen analyzes. The interval between two semen analyzes should be no less than 7 days and no longer than 3 weeks. Further evaluation may be necessary depending on the pathologies detected later. Although methods such as physical examination, Doppler stethoscope, thermography, scrotal ultrasonography, color Doppler ultrasonography, scintigraphy and venography are used in the diagnosis of varicocele, physical examination is the most valuable method [13,14].

Patients with varicocele with sperm count less than 5-10 million/ml should be informed about potential genetic disorders and karyotype and Y chromosome analysis should be performed. Varicocele detected in men with genetic disorders is probably an incidental finding and treatment will not improve fertility in these cases [15].

Varicocele that cannot be detected in physical examination but diagnosed by radiological methods is called “subclinical varicocele”. The effect of treating subclinical varicocele on seminal parameters and pregnancy rates has not been conclusively proven. Current data suggest that subclinical varicocele should not be treated [13].

The purpose of varicocelectomy is to connect all internal spermatic vein branches and external spermatic vein branches; to provide testicular venous drainage by protecting the vas deferens and vessels, and to protect the lymphatic vessels and artery of the spermatic cord.

Radiological occlusion-embolization of the internal spermatic vein (with balloon or coil) or sclerotherapy is another alternative in the treatment of varicocele. Today, it is accepted that the radiological treatment method can be an alternative for recurrences after surgical treatment [14,16].

Previous studies evaluating quality-of-life outcomes after varicocelectomy have reported heterogeneous results, and limited data exist regarding the influence of varicocele severity on postoperative quality-of-life improvement. In particular, whether the magnitude of HRQoL change differs according to clinical varicocele grade remains unclear.

Therefore, the present prospective observational study aimed to evaluate changes in health-related quality of life before and after microsurgical subinguinal varicocelectomy using the WHOQOL-BREF questionnaire, with a specific focus on grade-dependent differences in postoperative outcomes.

This study was carried out on 50 patients who applied to the urology outpatient clinic of Haseki Training and Research Hospital with complaints of infertility or scrotal pain and swelling. A careful anamnesis was taken from the patients who participated in the study, and general physical and urogenital system examinations were performed. Afterwards, all patients underwent routine biochemical tests. Color Doppler ultrasonogram is applied to the patients and World Health Organization Quality of Life Scale (WHOQOL-BREF) was applied to these 50 patients. Five patients were diagnosed with subclinical varicocele and were therefore excluded from surgical intervention and further analyses. Microsurgical subinguinal varicocelectomy was performed in the remaining 45 patients with clinically confirmed varicocele. Patients underwent microscopic subinguinal varicocelectomy.

All procedures were performed using a microsurgical subinguinal approach by experienced surgeons. Internal and external spermatic veins were ligated under optical magnification with preservation of testicular arteries and lymphatic vessels

Quality of life was assessed using the World Health Organization Quality of Life-BREF (WHOQOL-BREF) questionnaire preoperatively and at postoperative month 3. The questionnaire evaluates physical, psychological, social, and environmental domains.

In statistical analyses, appropriate tests (Paired Samples T-Test / Wilcoxon) were used to measure differences in dependent groups, and a p value < 0,05 was considered statistically significant.

Eth?cal approval

The study protocol was approved by the Haseki Training and Research Hospital Ethics Committee (Approval No: 2025/246-2025). All participants provided written informed consent prior to enrollment.

The mean age of the patients in our study was 28.5 (18- 45 years). It was found that of 50 patients, 12 (24%) applied to the outpatient clinic with complaints of infertility, 21 (42%) left inguinal pain, 17 (34%) complaints of palpable swelling in the left scrotum and visual difference compared to the contralateral scrotum. Clinical varicocele was detected in 45 (90%) of the 50 patients on physical examination, while 5 patients (10%) were diagnosed with subclinical varicocele. Of 45 patients with varicocele, 10 (22,2%) had grade I, 15 (33,3%) grade II, 20 (44,5%) grade III varicocele. Bilateral varicocele and right varicocele were not detected in any of the patients by physical examination. In the physical examinations, testicular dimensions of all patients were found to be normal (Table 1).

Table 1: Demographic and varicocele ?nformation about patients

When patients were stratified according to surgical indication, both the infertility group and the pain/ swelling group demonstrated significant postoperative improvement in WHOQOL-BREF scores. However, the magnitude of improvement did not differ significantly between the two groups (p > 0.05) (Table 3).

There was statistically significant improvement (p ?0,05) between the quality of life score and the patient’s condition after varicocele surgery. Subgroup analysis showed statistically significant improvement in Grade I and II patients, while Grade III patients demonstrated numerical improvement without statistical significance at the 3-month follow-up.It was observed that the quality of life improved after surgery (Table 2).

Table 2: Relationship between varicocele types of cases and Quality of Life Scale

* Statistically significant at the p < 0,05

Table 3: Quality of life outcomes according to surgical indication

According to the results of the patients examined, varicocele causing infertility was determined as a factor that negatively affects the quality of life. Individuals who think that they cannot fulfill their social roles such as not being able to fulfill their reproductive function and not being a parent are exposed to social isolation, feelings of guilt and anger, deterioration of the relationship between spouses, and sexual dysfunction. It has been determined that there is a decrease in the quality of life due to all these reasons and the factors experienced during the treatment (intensive drug use, exposure to invasive procedures such as oocyte collection, semen delivery, increased expectations and concerns caused by the pregnancy outcome, etc.). Individuals with low quality of life generally have problems such as unhappiness, dissatisfaction with life, loss of life expectations and goals, and depression, which negatively affect the general health level. The decrease in the quality of life due to infertility may increase the stress level in individuals and cause the treatment process to be adversely affected.

The effect of varicocele on quality of life was investigated. In all previous studies on this subject, varicocele or infertility caused by it was determined as a factor that negatively affects the quality of life. Individuals suffering from varicocele feel inadequate because they cannot fulfill the role of being a parent [17,18]. Men perceive varicocele, which will cause infertility, as the loss of their strength and masculinity, and women feel guilty because they cannot fulfill their duty of reproduction and continuation of the lineage [19].

In a comprehensive meta-analysis published in 2023, it was reported that microsurgical varicocelectomy not only eliminated infertility but also chronic scrotal pain caused by varicocele by over 80%, improving the daily activity performance of patients [20].

One of the basic instincts of man is the desire to reproduce and continue his lineage. Failure to realize this instinct results in serious stress in individuals. The cause of stress is not only the inability to have children, but also the placing of the reproductive function in the center of body image. Men who have not taken on the role of parents feel deficient in terms of body image [21]. Men perceive infertility and all the diseases that may cause it as a loss of masculinity due to the inability to fulfill the expectation of the society to continue the lineage [22].

The belief that infertility is synonymous with impotence is common in some societies. These beliefs and attitudes towards male sexuality cause social isolation, feelings of anger and guilt, increased stress, and sexual dysfunction in infertile men, negatively affecting their quality of life.

In our study, the fact that the p-value remained at the statistically significant limit (p=0,074) in the Grade III group may be related to the more severe disease in this group. However, clinical evaluations for 2025 predict that hormonal and physical improvements achieved after surgery in patients with advanced varicocele will lead to more significant increases in quality of life scores in the long term (after 12 months) [23,24]. Therefore, the quality of life of infertile men is lower than that of fertile men. For this reason, in our study, it was observed that the quality of life of patients increased after varicocele surgery.

The limitations of this study include the relatively small sample size, short follow-up period, and limited number of patients with grade III varicocele; this may have reduced the statistical power to detect grade-dependent differences. However, the prospective design and the use of a validated quality of life measurement tool strengthen the clinical significance of the findings. The individual nature of treatment response underscores the need for personalized patient counseling. Longer follow-up studies with a larger number of patients are considered necessary to fully determine the improvement in quality of life in advanced (grade 3) disease.

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