The confused infertile man with a low sperm count

I received this email today.

I have a low sperm count ( severe oligoasthenospermia). We have seen 3 urologists so far and each giving us different opinions. The first was found a cyst in the prostate and a grade 1 varicocele on right testes and a grade 2 varicocele on left testis. This doctor asked us to proceed with TURP. When we visited the 2nd urologist and mentioned this to him, he said that TURP is completely out of the question and he suggested that we do a varicocele surgery instead. Last month, we underwent an IVF ICSI procedure and that was unfortunately negative. Yesterday we met with the 3rd urologist who checked the reports and he said that the varicoceles are not very significant so there is no need of the varicocele surgery at the moment. However, he feels that there is a blockage in the tubes leading to the prostate and the cyst in the prostate is causing this. He recommended repeating an ultrasound to confirm the diagnosis and if this is the case then to proceed with surgery to remove the blockage. If not, as an alternate, he suggested repeating the IVF ICSI cycle but collected sperm through the TESA procedure. What would you suggest? That we undergo surgery to remove the blockage or repeat an IVF ICSI cycle with TESA?

It's extremely common to see infertile men who are completely  confused as to what they should be doing. They complain when they receive such conflicting advise and don't know who to believe or trust.

Sadly, most IVF/ICSI specialists are typically gynecologists, who have no idea how to deal with male infertility. Most of them don't even know how to examine an infertile man, and their standard knee-jerk reflex when they see a man with a low sperm count is to refer him to a urologist or andrologist.

Now while a urologist is supposed to be a specialist in the treatment of genito-urinary problems in the man, most are specialists in dealing with the urinary system, and know surprisingly little about male infertility.

Andrologists are specialists in dealing with male infertility, but it's only the ones who work in an IVF clinic who can call themselves true male infertility specialists, because the treatment for most male infertility problems requires ICSI, which can only be done in an IVF lab.

Because of their lack of exposure to the newest advanced reproductive techniques, most urologists are clueless about treating the infertile man, as documented by the above real-life example.

For a man with a low sperm count ( oligospermia) , there's really no point in testing for a varicocele. Even if he has  a varicocele , surgically treating it will not help to improve the sperm count, which means doing the test is completely pointless, and will just mislead him.

Similarly, testing for a block in the male reproductive system by asking for a TRUS ( transrectal ultrasound) in a man with a low sperm count is completely useless. The fact that there are sperm in the semen proves that there is no block ! If there was a block in the male reproductive system ducts, the sperm count would have been zero . In  fact, a TRUS should only be done in azoospermic men with low semen volume , an acidic pH and a negative fructose, to look for an ejaculatrory duct obstruction. It should never be done otherwise.

This is why it's so important that tests for the infertile man be done selectively, after looking at his semen analysis report. However, most urologists are not well-trained enough to understand the value of proper testing. Like most specialists, they tend to over-test and order lots of pointless tests. Now these tests may throw up some abnormalities, but these are of no clinical important and should not be "treated" ! In fact, treating them will just make the problem worse ! Doing the TURP ( transurethral resection of the prostate) can actually cause retrograde ejaculation.

Similarly, if there are sperm in the semen, there's absolutely no need to do a TESA ( testicular sperm extraction). We can use the ejaculated sperm , and there's no need to subject the man to the unnecessary expense and pain which a TESA entails.

Do you have a sperm problem and are confused as to what you should be doing ? Please send me your medical details by filling in the form at www.drmalpani.com/free-second-opinion so that I can guide you better !