Androlog Mail
On 3/29 Dr. Yalcin inquired about intermittent azoospermia. The
patient's count, on three separate Semen Analyses, went from 25 million
per ml. to 5 million per ml. to Zero in a 10 month period of time.
However, the S.A. results were obtained from different laboratories.
The fact that the tests were performed at different labs makes it
impossible to make a completely valid comparison of results over that
period time. But, the point is: There were sperm, and now there are
none. What hapened?
My first question would be...Are you sure there were NO sperm? Whenever
we are presented with a specimen that appears to be azoospermic, we
automatically centrifuge the entire ejaculate in a conical centrifuge
tube at 400 or 500 x g for 10 or 12 minutes. A small portion of the
resulting pellet is then observed on the microscope for the presence of
sperm cells. Many times, when the ejaculate initially appears to be
azoospermic, after centrifugation a few sperm cells can be found in the
pellet which can be used for ICSI. This saves the patient from having to
undergo Epididymal Aspiration and/or Testicular Biopsy (ouch). If no
sperm are present in the concentrated pellet, your suspicion of
azoospermia can be confirmed.
Without knowing anything more about the patient, my first suspicion
would be that the vas deferens may have become constricted due to scar
tissue forming around the vas as a result of a vasectomy reversal. I
have seen this happen on several occasions. A case in point: Patient had
a successful vas reversal but delayed infertility treatment for 2 years
assuming everything was ok. Scar tissue slowly closed off the vas again,
and hubby had to repeat the vas reversal (double ouch). This was before
ICSI and Epididymal and Testicular Aspirations. But it drives home the
point that, any patient that has a successful vas reversal should begin
freezing sperm cells ASAP, because you never know if or how quickly
scarring and closure of the vas may occur.
If no vas reversal was performed, the next thing I would want to check
for is possible retrograde ejaculate. Even if the patient produces an
ejaculate, the majority of the sperm cells may still be entering the
bladder. It's quite easy and quick to centrifuge the post-ejaculatory
urine to rule out the unexpected onset of ejaculatory dysfunction.
If retrograde ejaculate is not the problem, the next thing I would check
for is the use of medications (prescription OR over-the-counter), herbal
or dietary supplements, or recreational drug use. Don't forget to rule
occupational or home exposure to potentially toxic substances.
If that is negative, then draw a tube of blood and run an endocrine
profile.
If that is ok, next thing might be a testicular biopsy (ouch again) to
rule out Maturational Arrest.
We, very recently, had a patient present on initial semen analysis with
300,000 sperm per ml, with 10% motility. We recommended freezing a
couple of specimens as back-up for their upcoming ART cycle. Four days
later, he presented with a handful of immotile sperm. Three additional
collections yielded the same. Edididymal and testicular apiration
revealed an occasional twitching sperm cell which were severely
amorphous. His sperm failed to fertilize with ICSI. We have no
explanation for his sudden drop in count or the near absence of sperm in
the epididymis and testicle. It is quite frustrating, but reiterates
that we still have alot to learn about male infertilty.
To end on a positive note, we used frozen donor sperm on the other half
of this patient's eggs, and she is carrying twins. We always present
frozen donor sperm as a potential option to our patients when doing ICSI
with testicular sperm, due to poor fertilization rates with these sperm
cells. Even though we all love to sell the possibilities that ICSI gives
to couples, we should always remember to let the patient know that
frozen donor sperm is still a very cost effective alternative to the
expensive and invasive ART procedures for the treatment of male factor
infertility.
Hope this is helpful!
Bob Heit
mailto:pbfclab@gate.net
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