Fun Without Laughing

The case of the month is a patient from The Turek Clinic.
A 37 year-old man presented with his 35-year old wife describing a 2-year history of infertility. After trying for one year, the wife underwent medical evaluation that was normal. The couple then tried four cycles of intrauterine insemination (IUI) at UCSF, my old stomping grounds, but without a pregnancy.

When Low Tech Fails

They were recommended to proceed to in vitro fertilization (IVF) at UCSF. Exhausted, they decided to take several months to regroup. Based on their own research, they sought a male infertility evaluation with me, since his sperm count was low.

Back to Basics

He appeared fit as a fiddle when I met him. He had no significant medical history except for a mesh hernia repair and knee surgery. He had stopped hot tubs 6 months earlier and I commended him for this. On exam, he was thin (body mass index 24) and had an enviably low blood pressure. Both testicles were within the normal range in size, but the left was smaller than the right. Above the testicle, I felt a “ropey” mass of veins–he had a large left varicocele. Reproductive hormones were normal. The semen analysis showed normal volume with a low sperm count (12-14 million sperm/ml) and low sperm motility (20-25%).
My hunch was that this was male factor infertility caused by the varicocele. Happens all the time. These lesions can affect sperm quality and may also impair sperm function. The fact that four IUIs did not work suggested to me that sperm function may be impaired in addition to the abnormal semen analysis.
I suggested the following options to the couple:

  • Consider more sperm testing to define possible functional issues
  • Consider microscopic surgery to eliminate the varicocele
  • Proceed with IVF as planned

Good Care in Action

They were excited that someone had an explanation for their infertility. But they were also concerned about the wife’s age and the prolonged time it might take to conceive after varicocele repair. I explained that the average time to conception after varicocele in my hands is 7 months. IVF might be faster, but it would not fix the cause of infertility. If IVF succeeded, the same issue would rear its ugly head again as their eyes begin to twinkle with thoughts of having more children.
They bit the bullet and chose varicocele repair, but with a caveat: “Just so you know doctor, if we don’t conceive within 5 months, we are headed to IVF.” The hour of microsurgery and three-day recovery went swimmingly.
Just like clockwork, after trying to conceive for 4 more months, they showed up to an IVF planning visit. Talking with the IVF doctor, the wife mentioned that her period was several days late. A pregnancy test that day…was positive. Imagine, four weeks pregnant as she stood at the front door of the IVF center! Their first call was to let me know. A score for infertility care at its finest! Confirms my belief that couples would rather conceive in the bedroom than through office procedures.