The couple sat in front of me, cleared their throats, looked into my eyes and said, “You are our last hope.” Always game for a breeding challenge, I leaned in and calmly said, “How can I help?” Trying to conceive now for 4 years, they had tried timed intercourse, intrauterine insemination and several cycles of IVF, all of which failed miserably. Not even a positive pregnancy test. And, almost in tears, she said: “We’re in our late 20s, very healthy and you can set a clock to my cycles they’re so regular.” I had to agree that the female factor is unlikely here.
Well, I turned to it, and it did appear as billed: it fits like a fiddle. “I’m a physical therapist who tries to be an example of good health for my patients,” he explained. “And I know good health is important for good fertility, but I can’t for the life of me understand why my sperm analysis is so bad!” Looking over his reports over the past few years, I nodded. One of the sperm analysis numbers, sperm motility, was low, and I mean very low, even almost zero at times. This was true of every sample he produced. Upon further review of his semen analyses, ejaculate volumes were steadily decreasing over time, which should not normally be the case. Registering this, I looked up and asked him a question, “Any pain with sex or ejaculation?” He angrily replied, “Well, yeah, kind of… in the ballpark lately.” I looked up at both of them and said, “I think I can help.”
Simple Truths
I’m a big fan of Occam’s razor, also known as the ‘law of parsimony’. It is a well-known philosophical truth-seeking tool that “shaves” improbable or complex explanations in favor of simpler ones. In fact, the simplest explanation is probably the correct one.
I applied this principle to this case and here’s how it went. There are numerous causes of low sperm motility ranging from exposure to medications, drugs and hot baths, to collection error, abstinence from ejaculation and varicocele. But there are only a few reasons for really low motility, such as genetic defects in the tail of the sperm, the use of toxic lubricants or physical obstacles to the flow of sperm. Similarly, there are several reasons for low ejaculate volume, however only a few causes of decreased ejaculate volume include low testosterone, advanced age, and obstruction of sperm flow. Finally, there are many causes of scrotal pain, but only a few caused by ejaculation, such as prostatitis, pelvic floor dysfunction, and obstruction of the flow of sperm into the prostate. Looking at these three lists of possible diagnoses, only one of them is common to all of them and explains its symptoms and findings: obstruction of the ejaculatory duct.
Clogged pipes
All this theory is fine, but we needed more evidence to solidify the diagnosis. Fortunately an ultrasound can do just that. Like a dam that causes low flow forward and too much backup behind it, with blockages in the ejaculatory duct, there is less forward flow of sperm and a backup fluid inside the seminal vesicles, making them larger. The combination of large seminal vesicles and a cyst, calcification or stone right where the ducts empty into the urethra is quite specific findings for obstruction.
In this case, we found a small but critically positioned Mullerian cyst within the prostate that interrupts the flow of ejaculate. Interestingly, this cyst is the male remnant of the female uterus that had not completely subsided during fetal development. Sitting in the path of sperm flow, it can cause traffic congestion and result in sperm being held back until they run out of gas and enter ejaculation old and dead. It can also cause back pressure in the system and send that sensation back to the testicles, causing pain.
I suggested removing the cyst in surgery endoscopically (without incisions) in a relatively short procedure called transurethral resection of ejaculates (TURED). He went swimming and within several days, his ejaculate volume went up and sperm motility increased dramatically. More importantly, they seized the first chance they got next. There couldn’t have been a better outcome. Three cheers for analyzing the root cause and treating male infertility! In the words of the learned Thomas Fuller, “A known disease is half cured.”
