Medicine Without Surgery

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 (AUA)—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!

13 thoughts on “Medicine Without Surgery

  1. 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:
    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 (
    to get a better
    understanding about how useful such a test might be to the fertility

    1. 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.

  2. 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.

    1. 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.

  3. Male Infertility Issues ! (no jokes or a-hole answers pasele)?my wife and i have been trying diligently for the past 6 years to conceive a child.I have been told by my parents that I had mumps as a child as well as measles. I have had myself tested and have a low sperm count with 0 mobility. I have changed my diet and excerise more often but there is one problem that i cannot seem to fix, I have tried but to no avail my Scrotum is always hot. Mind you i do wear boxers not boxer briefs or tighty whites, and wear loose non constrictive slacks to wear and shorts at home. yet it seems like my boys are boiling in their case. I have tried ice and that has been nothing but a nuisance. What else can i do to help with the heat down there ( i have been told that i always seem hotter than normal) Plus what type of vitamins or pills or medication could i take to help with the fertility factor?allow me to state that i have no problem with achieving an an erection or ejaculating. 29 year old male with a healthy sex drive (maybe way to healthy) I constantly crave sex from my wife. There are some times when ejaculating it seens to come out hard or slightly painful , but that is not everytime, just every so often

  4. Hello,
    My husband was originally diagnosed with azoospermia. But then his fertility specialist did a SA and found 40,000 sperm(unfortunately they refused to freeze it and told us not to worry we could try banking the next month) well when we came back the next month to freeze he only had 1 single sperm. 🙁 and every banking attempt after that (4) has only had 1 single sperm, and they won’t freeze the 1 sperm. He also had a TESA with nothing found (not sure why the doctor suggested a TESA when my husband is NOA with high FSH LH and low ).
    His doctor is now pushing for a mTESE.
    We are so conflicted on what to do. Should we keep trying to bank (and keep trying to get his diabeties under control, to see of that helps) hopefully his count will go up at some point, or just throw in the towel and do a mTESE?
    We don’t want to end up waiting to long to do the surgery and it end up being to late, but then again we don’t want to risk damageing the testicles and losing that 1 sperm.
    If we do a mTESE will that most definitely shut the sperm production down? Meaning does it remove stuff that is critical to make sperm?
    Thank you!

    1. Dear Conflicted, I see the conflict! It can be very hard to find low numbers of either testicular or ejaculated sperm in cases of nonobstructive cryptoozoospermia. My approach is to spend several months “optimizing” men and trying to freeze ejaculated sperm (tight control of DM, normalization of T levels with clomid or anastrozole, fixing varicoceles etc). If this fails, then testis sperm is an option in cryptozoopermia. TESA has about a 40-45% chance of finding a testis sperm pocket, FNA mapping has about 85-90% as does mTESE. However, mTESE has the highest impact on testosterone levels AND it does definitely remove the stem cells that make the sperm along with the sperm.

  5. Dear Mr Turek
    I have done sperm analysis and first test showed azoospermia where all sperms were dead. While after doing a centrifugal it appear only one sperm but not good quality. So the doctor names it as cryptozospermia. The sperm concentration was 90,000. I had a varicocele grade two which now i just operated. Will varicocele increase the quality and sperm concentration

    1. Dear it-top, Your information is unclear. Sounds like you have a generous degree of cryptozoospermia. Varicocele repair is an excellent way to increase the low sperm counts. If it does not happen within 6-9 most, give us a shout to help out!

  6. I was diagnosed with azoospermia(0 sperm) in july… My hormones level were normal but I had some varicocele. After 3 months of taking some prescribed antibiotic and fertility supplements I went for another checkand then they saw one sperm after centrifuge but not a good one..they called it cryptozoospermia..I had the varicocèle surgery in September and we’re now in december..still praying for some good news. What’re my chances for natural conception?

    1. Dear Fabrizio, In cases of complete azoospermia, the chances for ejaculated sperm are in the 35-40% after varicocele repair. With cryptoozoospermia, it is higher. The natural conception rate is about 5% mainly because female partners don’t always need a “normal” semen analysis to conceive. The record low sperm count with natural conception in my practice is 60 (yes sixty) sperm!

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