Less Can Mean More

Posted on by Paul Turek, MD

The Case of the Month is an actual patient from The Turek Clinic.
The couple stared at me excitedly. “We’re here because we want to have FNA mapping done. We heard that you invented it and that you can find sperm from a rock and I was told that I am shooting blanks.”
It’s true that he was azoospermic. Absolutely no sperm whatsoever in any of his many semen samples he had provided over two years. But there was something else striking about his story. It was gleaned only after peeling through the stack of medical records that he brought with him. The volume or amount of semen he produced was low. Very low. Too low.

Causes of Low Ejaculate Volume

“Do you have pain with ejaculation? Any blood?” I asked him. Nope.
“Have you noticed any change in the amount of semen you make?” Nope.
“Any trouble collecting the semen specimens that you have given?” Nope.
Now things were getting interesting. Why? Because low ejaculate volume is typically explainable and the infertility associated with it usually treatable. And by treatable, I mean forgetting about using assisted reproduction.
The following list of causes of low ejaculate volume was in my mind as he spoke:

Ejaculatory Duct Obstruction

First described in 1973, ejaculatory duct obstruction causes 1% to 5% of male infertility. It is a blockage to sperm flow within the small ducts as they pass through the prostate, well beyond the testicle. Basically it’s a flow problem. Sperm are made normally, but have trouble getting out. One can be born with this problem, or develop it as an adult. A subtle diagnosis, it is often missed.
I’ve published a lot on this subject, so it is a top-of-mind diagnosis for me. Some of the things that I have learned about ejaculatory duct obstruction over the last 15 years:

  • It is probably more common than we think.
  • Both “functional” and “physical” blockages exist and must be distinguished.
  • Surgical treatment works great for “physical” blockage but fails for “functional” blockages.
  • I have developed a neat way to confirm the diagnosis of “physical” blockage that improves treatment success enormously.

After listening to his story and incorporating this information, I told the couple: “You don’t need an FNA map. You need an ultrasound instead. I think that you’re engine’s running fine, but your exhaust is blocked. And this is a good thing because I am a Midas guy.”  Can’t wait to get this Holiday card!