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.

Medicine Without Surgery



A stainless steel scalpel, cold and sharp
Used in Roman medicine…and maybe too much today? (Courtesy: Plamen Petkov)

Blasphemy! A surgeon who chooses not to operate? Precisely. Dr. John Duckett Jr, surgeon extraordinaire and personal role model, once told me: “It tries your patience, and you may go gray faster, but there are times you learn more by not operating.” I have followed his advice many times in my career, and our latest research is a direct result of this advice.

The Heck with That

Many men with azoospermia (the absence of ejaculated sperm) will actually have a few ejaculated sperm (cryptozoospermia) if you look hard enough. However, many clinicians simply don’t look hard enough to find these few good swimmers and others don’t believe that it’s worth looking.  “Heck with that stuff, just go to the testicle for sperm.”

Seems reasonable enough. But, this approach dials up a whole new problem. If so few sperm are in the semen, then sperm production is also way, way down. Fewer apples on the ground mean fewer apples in the tree. So, “just going to the testicle” for sperm could mean a major pruning and usually requires complex and extensive surgical dissection of the testicle, just to find just a few sperm. And often, the surgery fails to find any sperm at all. Ever try to find a needle in a haystack? So, why not use the ejaculated sperm in the first place?

Putting the Knife Down

This week, we are presenting our latest research that says no to surgery at the annual meeting of the American Urological Association—a group of surgeons, no less. For this study, we decided to avoid operating on infertile testicles and simply plan to use as much ejaculated sperm as we could get. We had infertile men freeze consecutive semen samples until sufficient sperm were available for IVF-ICSI. Couples then proceeded to IVF-ICSI using a combination of fresh and frozen-thawed ejaculated sperm. What we learned surprised even us!

Every Sperm is Sacred

Here are the facts of our study to be presented on Tuesday:

  • Men with very few ejaculated sperm have “usable” (motile) sperm in about one of every 2 ejaculates.
  • On average, men with very few ejaculated sperm banked a little over 3 semen specimens before being “cleared” for IVF-ICSI without surgical backup.
  • About 1/3 of men banked from 1-100 motile sperm; 1/3 banked 101-1000 sperm and 1/3 banked >1000 motile sperm per ejaculate.
  • At the time of IVF-ICSI, 85% of men used either fresh ejaculate or banked sperm and required no testicular sperm retrieval. 15% needed surgery to procure enough sperm.
  • At IVF-ICSI, 60% of eggs fertilized normally and 46% of women secured an ongoing pregnancy or live birth.

Bottom line: most men with very low ejaculated sperm counts can bank sperm and avoid surgery to become fathers. And this sperm works about as well as any other sperm you can throw at eggs. Ah, the words of Emily Dickinson ring so true:

Surgeons must be very careful
When they take the knife!
Underneath their fine incisions
Stirs the Culprit—Life!


7 Responses to “Medicine Without Surgery”

  1. ims

    What are the chances of finding an sperm in an azoospermic mail with a good amount of testerone levels?

    Reply
  2. Alan Horsager

    I was curious to get an idea of how many people are thinking about the
    epigenetics of sperm as it relates to male factor infertility? Epigenetics
    refers to modifications “ON” the DNA that lead to changes in function and
    protein expression. Aberrant DNA methylation, one type of epigenetic
    modification, has been linked to disease and disfunction, including cancer.
    Here is a link to some the current research being done on the epigmenetics
    of sperm:
    http://www.plosone.org/article/info:doi/10.1371/journal.pone.0001289.

    I am currently working with a group to develop a diagnostic test that could
    be used in a clinical setting to evaluate male factor infertility. If this
    is something we put together, how many people would be interested in using
    this type of clinical test? What do you think would be an accessible price
    for such a test? If you have 5 minutes, I’ve created a short survey (
    https://www.surveymonkey.com/s/malefactorinfertility001) to get a better
    understanding about how useful such a test might be to the fertility
    community.

    Reply
    • Paul Turek, MD

      Alan, great questions! It was also great to talk to you off-line about this field. I am in as this is a tremendously important and understudied aspect of reproductive health.

      Reply
  3. Jordan

    Would you recommend FNA mapping or sperm extraction to an azoospermic man with Y-Chromosome Microdeletion with complete B deletion and partial C? From all the reading I have done the chances of viable sperm with the complete AZFb is nil.

    Reply
    • Paul Turek, MD

      Great question. If you simply cannot accept the fact that a simple blood test determination of your Y chromosome genetics can end your chances of being a biological father, then you are like many men who want to know more.

      Extended FNA Mapping and microdissection TESE are the two most informative and comprehensive approaches to knowing whether you have testicular sperm. Mapping takes an hour to do under local anesthesia and is far less invasive than microdissection TESE. In addition, it will not, in general, affect testosterone levels as mTESE can. On the other hand, mTESE retrieves sperm at the same time as finding it, unlike FNA mapping which is entirely diagnostic. For most men in your situation, they want to know as much as possible at the smallest risk and choose FNA mapping.

      Reply

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