Case of the Year: Reversible Azoospermia & the Power of Observation
The Case of the Year is an actual patient of The Turek Clinic
A couple that had recently emigrated from Myanmar (Burma) was desperate to have a child. However, they had just received terrible news. He was diagnosed with testicular masses on both sides, and it was recommended that he have both testicles removed for fear of cancer. Surgery was planned in 2 days, and a semen sample done in an attempt to bank sperm before surgery showed no sperm. Frantic and confused, the couple huddled in front of me wondering how we could preserve the man’s fertility in the face of this life-altering diagnosis.
Listen and Observe
The solution that immediately crossed my mind was to freeze sperm-containing tissue from around the testicular tumor at the time of testis removal. But as I listened to his story, I realized that it was not typical for cancer. The tumors appeared suddenly several months ago, along with fevers, swelling and redness. “That sounds more like an infection,” I thought. Indeed, so did others, who treated him with antibiotics, but to no avail. What was also odd was that the tumors did not appear (on an ultrasound) to have grown over the past several months. “Testicular cancer is notoriously fast growing. Maybe this isn’t cancer,” I thought.
Next I examined him. Sure enough, there were masses on both sides. But on closer examination, they were in the epididymis and not in the testicle. “That’s odd too!” Cancers of the epididymis are extremely rare, to the point that I had only read about them and had never seen one. But what I saw next sealed the deal for me: there was a scarred but healed “tract” leading from the testicle to the scrotal skin. Typical for a healed abscess. Tuberculosis!
The Great Imitator
Tuberculosis (TB) is rampant in developing countries like Myanmar. Roughly 7,000,000 new cases are diagnosed annually around the world and roughly 2.5 million people die of the disease. And it’s a sneaky one, as up to 20% of TB is found only in the reproductive-urinary tract and never shows up in the lungs. So, screening chest X-rays used by immigration agencies miss this all the time.
Within 2 hours, an ultrasound confirmed that the masses were not testicular. I then cancelled the man’s surgery and called the Health Department to report a case of TB. I also ordered the definitive test for genitourinary TB: first morning urine samples that grew out the bacteria, clinching the diagnosis.
Instead of having both of his testicles removed, the man had 6 months of triple antibiotic therapy and the masses disappeared. A month or so later, they were back in my office, not frantic, but ecstatic and giddy. His sperm count was now normal, and she was pregnant! An education from simple observation.
