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!