Turek on men's health
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Award-winning urologist - and pioneer in Men's Health - Dr. Paul Turek blogs weekly about issues such as infertility, vasectomy and vasectomy reversal, sexual and hormonal dysfunction and more. Keep up with the latest on this fascinating field of medicine.

Biology Always Wins



Humble men such as William Penn are good for this world
William Penn. Humble Quaker, thought leader and founder of Pennsylvania (Courtesy: Atwater-Kent Museum)

The case of the month is an actual patient of The Turek Clinic.

“I thought for sure that I never wanted kids. They broke the mold when they made me,” he told me. But then, he met the woman he never thought he would meet. “She changed everything. Nothing was the same after her,” he said with a wide, intoxicating smile.

A Perfect Record

He came in to talk about a vasectomy reversal. He had the vasectomy 11 years prior. No unexpected loads, no muddied waters, no Craignancies in his past. A perfect record capped off with a vasectomy.

As is my habit, I took a good long history and performed a physical exam on him. As a guy who crosses his t’s and dots his i’s, I also checked his reproductive hormones, since he had not conceived in the past. Just making sure that things are a “go” for a new launch. Vasectomy reversal microsurgery is certainly a pleasure for me to perform, but it’s more important that it’s the right choice for the patient.

A Man’s Intuition

A week after his visit, we talked on the phone. Something didn’t sit right with me. His testicular volume, a great measure of sperm output, was a little low. And, although his testosterone level was normal, his follicle stimulating hormone (FSH) was on the high side. Maybe sperm production wasn’t completely normal. Maybe it was non-existent. In either case, a vasectomy reversal might NOT be the way to go, as I couldn’t reassure him of a robust sperm count after the procedure. Best to be sure the engines are ready for the launch.

The Biological Truth

“What are you saying Doc?”
“Well, you might not be fertile after a vasectomy reversal. Your engine’s not running well.”
“How do you know for sure?”
“Right now it’s a strong hunch, but instead of investing time and money in a reversal, I’d suggest looking closer at the engine to see how well it’s running.”
“How do we do that?”
“Lets ‘map’ the puppies and see what’s going on.”

I am a firm believer in following instincts. And although surgeons can be good, maybe even great, they are always, and I mean always, trumped in the end by biology.

Sure enough, testicular mapping showed that sperm production was present but in only very low amounts. So low that there was no way he would have had sperm in the ejaculate after a reversal. Fast-forward 3 months: we performed a testicular sperm retrieval instead of a vasectomy reversal and his wife went through in vitro fertilization and ICSI and they conceived first shot. Point is that even if you have a big hammer, not everything is a nail. In the words of William Penn: “Sense shines with a double luster when it is set in humility.”


3 Responses to “Biology Always Wins”

  1. Al

    Hi Dr Turek,
    I am a regular follower of your blog and comment regularly in my search for answers. My husband was diagnosed with NOA six months ago after a unsuccessful TESA. However, that is where our fertility specialist told us that donor or adoption was our only hope. Devasted!
    Over the last couple of months I have been questioning a few things that I was hoping you might clear up.
    Firstly, all my husbands blood work and genetic testing came back normal apart from his ACTH was high (this was later tested further and was told it was normal) and his free testosterone was low but testosterone normal. This was dismissed as “nothing” by our specialist. could this mean something?
    And secondly, our specialist never once examined my husband physically even though I questioned him about a varicocele that the urologist who did his ACTH tests had mentioned. Again he dismissed this.
    Am I just clutching at straws here or should we seek another opinion?
    **We are from Australia but have been keeping an eye on the development of your MRI scan for sperm and plan to come to your clinic as soon as it is available.

    Sorry about the long comment but just need some answers. Thank you for your time and work that you do everyday. It is appreciated by many.

    Al.

    Reply
    • Paul Turek, MD

      AI, couple of issues.
      1. A TESA involves a simple needle aspiration. If only a few sites were taken, then pockets of sperm might still be present that were missed by this approach. There may be other more comprehensive techniques currently available (e.g. FNA mapping) that might find these pockets. Microdissection TESE is a more invasive approach, but could also further lower testosterone levels.
      2. If testosterone levels are very low, then sperm production could be impaired. In many cases, clomiphene citrate or anastrazole can help raise testosterone levels and optimize sperm production, although this preparation can take 3-6 months.
      3. Varicoceles are classic causes of low semen quality, and also (but more rarely), NOA. Whether repairing this lesion will help or not depends in part on what biopsy pattern (Sertoli only, maturation arrest) is present in the testis. This may or may not have been information obtained at the time of the TESA procedure.
      4. NOt sure about the ACTH issue. Should be easy enough to clear with an endocrinologist and is very unlikely to be related to his fertility.

      Reply
      • Al

        Thanks for your reply Dr Turek,
        We have discussed FNA Mapping, but are a little reluctant on proceeding with another operation which is why we are interested in the MRI.
        With the testosterone. We were told that only the “free” testosterone was low. can this affect sperm production. Could the clomiphene citrate/anastrazole help.
        Thanks again for your help. You have given me lots to think about.

        Reply

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