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Andrology & Men's Health
Microsurgical varicocelectomy (marmara)
What microsurgical varicocelectomy (Marmara) is, how the subinguinal approach with an operating microscope ties off enlarged testicular veins while sparing the artery and lymphatics, what the evidence says about sperm quality and pain, how it compares with embolization and open surgery, approximate costs in Turkey, recovery and risks.
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Prof. Dr. Zerrin Biçik Bahçebaşı
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Microsurgical varicocelectomy (Marmara): what it is and how it works
Microsurgical varicocelectomy (Marmara), also called the Marmara technique or subinguinal microsurgical varicocelectomy, is an operation that closes the enlarged veins of a varicocele through a small cut in the groin, using an operating microscope. A varicocele is a tangle of dilated veins in the scrotum, similar to varicose veins in the leg. Tying off these veins stops blood pooling around the testicle, which in some men raises testicular temperature, reduces sperm quality and causes a dragging ache. The method is named after Marmara University in Istanbul, where it was developed and described, and it is widely performed by urologists and andrologists in Turkey.
This guide explains how the technique works, what the evidence says about fertility and pain, how it differs from open surgery and embolization, what it costs compared with the UK, US and Germany, and how long recovery takes. See also the main page on urology treatments in Turkey.
What is a varicocele, and when does it need treatment?
A varicocele is found in about 15 percent of men and in a larger share of men who are being investigated for infertility, usually on the left side. Many men have no symptoms and need no treatment. Surgery is considered in four situations: a couple trying to conceive where the man has abnormal semen analysis results and the female partner has normal fertility or a treatable problem, persistent testicular pain, a visible testicle size difference in a teenager, and a large varicocele with symptoms that a doctor judges worth correcting. The European Association of Urology guidelines suggest treating varicocele in infertile men with abnormal semen parameters, and do not recommend it when semen is normal and there is no pain.
Diagnosis combines a physical examination, a scrotal Doppler ultrasound and, for fertility, at least two semen analyses. A urologist should also check hormones and the partner's fertility so that surgery is not offered where it will not help.
How does the Marmara subinguinal technique work, step by step?
The operation is done under general, spinal or sometimes local anaesthesia with sedation, as a day case, and takes about 45 to 90 minutes for one or both sides. The surgeon makes a 2 to 3 cm cut in the groin below the inguinal canal, brings out the spermatic cord, and places it on a support. Under magnification of 6 to 25 times the surgeon identifies and preserves three structures: the testicular artery, which feeds the testicle and is only a millimetre or two wide, the lymphatic vessels, which drain fluid, and the vas deferens with its small vessels. Every enlarged vein is then tied or clipped and divided. A micro-Doppler probe is often used to find the artery. The cord is replaced and the wound closed with stitches under the skin.
The magnification is the reason for the technique. Preserving the artery and lymphatics is intended to lower the chance of two known problems: recurrence of the varicocele and a collection of fluid around the testicle (hydrocele).
Does varicocele surgery improve fertility? What the evidence says
The best evidence supports microsurgical repair in the right men. Meta-analyses of studies in infertile men with abnormal semen report improvements in sperm concentration and motility after varicocele repair, and higher spontaneous pregnancy rates than observation in men with clinical varicocele and abnormal semen. Improvement in semen usually appears after about three to six months, because sperm take around 72 days to form and more time to mature, so a semen analysis is repeated at three months and again at six. For pain, studies show relief in a majority of men, but not all, and results are less predictable if the pain has other causes.
What is not supported is a promise of pregnancy. Surgery improves the chance of conception; it does not guarantee it, and age and fertility of the partner matter greatly. In some men with no sperm in the semen (azoospermia), repair may bring sperm back, but this is uncertain and should be discussed with a fertility specialist.
Microsurgical varicocelectomy (Marmara) cost in Turkey compared with the UK, US and Germany
The approximate ranges below are for one operation including the hospital stay. They are not hospital quotes, and bilateral surgery usually costs more than one side. The hospital confirms its price in a written quote.
| Country | Approximate cost range |
|---|---|
| Turkey | €1,000 – €3,000 |
| United Kingdom | €3,000 – €6,500 |
| United States | €5,000 – €15,000 |
| Germany | €2,500 – €6,000 |
What changes the price: one side or both, the type of anaesthesia, a day-case or overnight stay, the use of a micro-Doppler, the surgeon's microsurgical experience, and whether pre-operative semen analysis and ultrasound are included. A package normally covers tests, the operation, anaesthetist, a night in the hospital if needed, medication and a follow-up check. A first semen analysis at home before travelling and another after three months are usually extra and are arranged with your own doctor.
Marmara technique, open surgery, laparoscopy or embolization?
There are several ways to close a varicocele, and the recurrence and complication rates differ between them. The table summarises the main methods as they are usually described in the urological literature.
| Method | Best suited to | Typical limits |
|---|---|---|
| Microsurgical subinguinal (Marmara) | Men with fertility concerns or pain who want the lowest recurrence and hydrocele risk | Needs a microsurgeon and a longer operation |
| Open high ligation (Palomo) or inguinal without microscope | Simpler cases; older technique | Higher risk of recurrence and hydrocele |
| Laparoscopic ligation | Some bilateral or adolescent cases | Needs general anaesthesia; hydrocele risk |
| Embolization by radiology | Men who want to avoid a cut, or recurrence after surgery | Radiation exposure; vein not always reachable |
Our pages on varicocelectomy and on microsurgical intervention for varicocele describe the related methods in more detail. Because the Marmara technique uses the subinguinal route, the cut is below the groin canal, which tends to hurt less than a cut higher in the abdomen.
Who is a good candidate, and who is not?
A good candidate is an adult or adolescent with a confirmed clinical varicocele and either abnormal semen with a couple who have not conceived, persistent testicular pain, or testicular shrinkage. You are less suited if your semen is normal and you have no symptoms, if the female partner has a major fertility problem that makes conception unlikely whatever the semen quality, or if you have a general condition that makes anaesthesia unsafe. In these cases other fertility treatments, such as assisted reproduction, may be discussed first. Tell the doctor about previous groin or scrotal surgery, because scarring changes the plan.
Recovery after varicocele surgery and your trip to Turkey
You normally go home the same day or after one night. Expect groin and scrotal bruising, swelling and a dull ache for one to two weeks, which simple painkillers and a supportive underwear usually control. Walking is encouraged from the first day. Many men go back to desk work within three to five days, avoid heavy lifting, sport and sex for about two weeks, and return to full activity at three to four weeks if the surgeon agrees. The skin stitches are usually dissolving.
Most patients stay two to four nights in Turkey, long enough for a wound check and for the surgeon to clear you to fly. The sperm result is judged only after three to six months, so plan the follow-up semen analysis with your doctor at home and ask the clinic to share the operation report with them.
What are the risks of microsurgical varicocelectomy?
Every operation carries risk. Common effects are bruising, swelling, soreness and mild numbness near the cut. Less common problems include a hydrocele (fluid around the testicle), infection, bleeding into the scrotum, recurrence of the varicocele and, rarely, damage to the testicular artery that can reduce the size of the testicle. The microscope lowers the chance of recurrence and hydrocele compared with older methods, but does not remove it. The NHS and the European Association of Urology describe these risks, and the surgeon should explain how often they have seen them in their own practice.
How to choose a urology team, and what to ask
Look for a urologist or andrologist who performs microsurgical varicocelectomy regularly, a hospital with microscope facilities and an anaesthetist, and a written plan that explains the expected semen follow-up. Red flags include a promise of pregnancy, surgery offered without a semen analysis or ultrasound, no mention of the testicular artery, and no information about recurrence. Read how our process works and send your reports through the free quote page.
- Is surgery really indicated by my semen results, pain or ultrasound?
- Will the operation be done under a microscope, and from which side?
- How do you protect the testicular artery and lymphatics?
- When and where should I repeat the semen analysis?
- What are your recurrence and hydrocele rates?
- What does the price include, and what happens if I need a revisit?
Conditions treated with Microsurgical Varicocelectomy (Marmara)
Hospitals with Urology in Turkey
Frequently asked questions
It is an operation that ties off the enlarged veins of a varicocele through a small groin cut, using an operating microscope. The surgeon spares the testicular artery and lymph vessels, and the technique is named after Marmara University in Istanbul.
In men with abnormal semen and a clinical varicocele, studies report better sperm concentration and motility and higher natural pregnancy rates than observation. It improves the chance of conception but does not guarantee it.
Approximate ranges are €1,000 to €3,000 in Turkey, against about €3,000 to €6,500 in the UK. The price depends on one or both sides, anaesthesia and the hospital stay. A written quote confirms the exact cost.
Microscopic surgery generally gives lower rates of recurrence and hydrocele than older open methods, because the artery and lymphatics can be seen and spared. It needs a surgeon with microsurgical training.
Many men return to desk work after three to five days and avoid sport, heavy lifting and sex for about two weeks. Bruising and a dull ache usually fade within one to two weeks.
Sperm take about three months to form and mature, so improvement usually appears at three to six months. Doctors repeat the semen analysis at those times instead of judging the result early.
You are asleep or numbed during the operation. Afterwards most men have soreness and swelling in the groin and scrotum for a few days, usually controlled with simple painkillers and supportive underwear.
Possible problems include bruising, infection, hydrocele, recurrence and rarely damage to the testicular artery. The microscope lowers the chance of recurrence and hydrocele compared with older methods, but does not remove it.
Usually not. Guidelines do not recommend repair for men with a varicocele, normal semen and no pain. A urologist may suggest surgery for pain, testicular shrinkage in a teenager or other specific reasons.
Usually two to four nights, so the surgeon can check the wound and clear you to fly. The sperm result is judged at three to six months, so arrange the follow-up semen analysis at home.
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