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Testicular Abnormalities
Case: 42 year old male with a history of unproven fertility, an unremarkable medical history, a semen analysis revealing oligoasthenospermia (a reduction in the concentration and the motility of the sperm), and a left sided large varicocele on Urologic (physical) examination, and a normal hormone evaluation.
Question: What should be considered given this information?
Answer:
The cause of oligoasthenospermia often remains unclear. If a varicocele is identified during the basic male factor evaluation, then one should consider either treating the varicocele (surgically) or performing intrauterine inseminations with the available sperm.
The degree of damage that occurs in sperm production and quality due to a varicocele varies enormously. Some men with large varicoceles have a normal semen analysis and proven fertility while other men may be azoospermic.
There is considerable controversy over when to suggest surgery (or repair) of an asymptomatic varicocele. Some Urologists believe that varicoceles are the most common treatable cause of male factor infertility and therefore suggest treatment of all varicoceles (even very small ones). Other Urologists do not find the available literature (reports on studies associating an improvement in fertility with treatment of a varicocele) consistent enough to recommend surgical repair of any asympotomatic varicocele. In the middle ground, most Urologists and infertility specialists believe that the repair of moderate to larger sized varicoceles has a reasonable chance of improving reproductive potential if the FSH concentration is not markedly elevated (suggesting testicular failure) and the sperm concentration is greater than 3-5 million per mL.
Case: 25 year old male with a history of unproven fertility, an unremarkable medical history, status post bilateral orchiopexy (surgical repair that brings the testes into the scrotal sac) at 5 years of age, a semen analysis revealing marked oligospermia (a severe reduction in the concentration of sperm), a physical exam revealing moderate decrease in size of both testes, and a hormone evaluation revealing an elevated concentration of both LH and FSH (with a low testosterone concentration).
Question:
What should be considered given this information?
Answer:
Undescended testes can result in a compromised blood and nerve supply to the testes, which can then result in long term damage (in terms of sperm production). If the damage to the testes is extensive, the actual size of the testes may be reduced and the circulating concentrations of FSH and LH may be elevated. In situations involving undescended testes the damage that occurs is usually irreparable.
The usual current rule of thumb when identifying undescended testes at birth is to wait for about one year for spontaneous descent (most testes that will descend do so within a year). If the testes remain undescended at 1 year of age, then orchiopexy should be considered by about 2 years of age. If the orchiopexy is delayed the risk of damage to the testes is increased.
If the testes are producing sperm but the concentration or quality of the sperm does not seem to be adequate for a reasonable success with intrauterine inseminations, then one can consider assisted fertilization (such as ICSI). With assisted fertilization using ICSI, you basically place one living sperm into an egg’s cytoplasm so that you only need as many living sperm as you have mature eggs at the time of In Vitro Fertilization (usually up to 20-30).
Case: 9 year old male with a history of the sudden onset of severe (incapacitating) testicular pain, an unremarkable medical history, and no history of trauma to the scrotum.
Question:
What should be considered given this information?
Answer:
Immediate medical attention is suggested to assess the possibility of a testicular torsion. Diagnostic testing and treatment alternatives are best coordinated with an Urologist when available.v
If a testicular torsion is identified, surgical repair is normally performed immediately. If the twisted testis can be salvaged, then it may be “tacked” (anchored) to the side or base of the scrotal sac to minimize the chances for further torsion. The contralateral (other) testis should also be assessed and this other testis is also often sutured in place to restrict it from twisting in the future (since the congenital abnormality that predisposes to testicular torsion generally affects both testes).
A torsion of the testis generally results in an insult to the vascular supply to that testis (the vessels are twisted along with the testis and are often occluded) and if the blood supply to the testis is not re-established within a certain time frame, then permanent damage may occur.
Case: 42 year old male with a history of unproven fertility, an unremarkable medical history, normal semen analyses, and a sperm cervical mucus interaction abnormality (abnormal postcoital test) is found to have a surprisingly low sperm concentration and sperm motility at the time of a planned intrauterine insemination. This gentleman had a bad cold (viral syndrome with 102-103 oF fever) about 2 months prior to the abnormal sperm collection.
Question:
What should be considered given this information?
Answer:
There is a normal variability in sperm concentration in fertile men. Occasionally, the sperm counts of a man with proven fertility and generally normal semen analyses will be less than normal.
A systemic and febrile (relating to fever) illness in a man can reduce the motility of the sperm that is stored in the epididymis and also reduce sperm production in the testes. This results in oligoasthenospermia (low concentration and decreased motility of the sperm).
Spermatogenesis and storage in the epididymis are lengthy events, such that it takes roughly 3 months to make and release a mature sperm cell. Therefore, if an illness may be associated with abnormal sperm then the sperm may remain abnormal for about 3-4 months following complete resolution of the illness.
In this situation, the sperm count and its motility were found to be abnormal. Given this information, I would suggest reassessing the semen quality about 3-4 months after the illness resolved and if “back to normal” for this man then I would continue with intrauterine inseminations at that time.
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