How Patients Teach Doctors a Thing or Two

Ejaculatory Duct Obstruction Diagnosis
New Zealand’s Mt Egmont. For many, climbing this is easier than getting pregnant (Courtesy: Londonfirebird.com)

This Case of the Year is an actual patient of The Turek Clinic
We can learn so much from those we meet. My patients teach me more about life and medicine than any book ever could. I think it was Bill Nye who said: “Everyone that you will ever meet knows something you don’t.”

Up From Down Under

They were in their mid-30s and hailed from Australia. They had been trying to get pregnant for a decade. Early on in their journey, single digit numbers of ejaculated sperm were found. After that, sperm were never seen again. For personal reasons, the couple was not interested in assisted reproduction (IVF) to conceive. It was all-natural or not at all. I respect that.
They had been evaluated by half a dozen of Aussie’s finest urologists with a combined 80 years of experience in the field. He was first deemed to have testicular failure and was given injectable hormonal therapy, but to no avail. Subsequently, having every part of his anatomy imaged by ultrasound, he was diagnosed as being “blocked.” This was confirmed with surgical exploration and the finding of normal sperm production on biopsy.
The next question: where the blockage? His surgeons felt that there might be several blockages, including one near the testicle within the epididymis and another beyond it, in the abdomen. The patient was informed that a blockage in the pelvis is surgically unreachable and therefore unfixable. That was not an acceptable answer for this couple. So, they asked me for my opinion.

Thinking Upside Down

I asked for all of their records and poured over them. My goal was to decipher the “story” of his problem. Every patient has one and each is different. He had seen good doctors. And they had done good work, but an abdominal blockage of the sperm path was incredibly rare. As the old medical saying goes, “when you hear hoofbeats, look for horses not zebras.” I gathered what I believed to be the “truths” of the case:

  • The patient’s history was as clean as a whistle; he had no risk factors for being infertile.
  • His sperm counts had gone from low to zero over time.
  • His semen volume was consistently in the low-normal range.
  • A blockage was present.
  • Since there are 2 testicles, any blockage must affect both sides.

Putting on my Sherlockian hat, it hit me that there was only one diagnosis that fit his story: ejaculatory duct obstruction. Why? With this anatomical issue, the medical history is typically unrevealing. As a condition that can worsen with time, it could cause sperm counts to go from present to absent. Along with this, the semen volume typically trails off to a whisper of its former self. Add to this the fact that it’s an uncommon but not rare form of reproductive tract blockage. And finally, there’s only one place in the system where a single lesion can affect sperm passage from both testicles. A perfect fit.

Come On Up!

On the phone, I told him that it was worth the 8,000-mile journey from Melbourne to the U.S. to re-evaluate things. Sure enough, I repeated the ultrasound and found telltale signs of obstruction. The next day, we proceeded to surgery and within an hour, I confirmed the blockage and removed it. He headed back to Australia a few days later. You can’t imagine how happy I was to see that he had a normal semen analysis four months later. And how absolutely priceless it was to recently hear that his wife is now pregnant, a full 10 years after their journey began.
Patients are amazing. They are resilient, smart and know their bodies best. And because of their drive and persistence, largely driven by hope and optimism, they inspire us to do our best to help. I am honored to help them build their families.

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