A 37-year-old man was referred to me by his primary care physician for
an infertility workup. The patient came to see me alone and stated that his
wife had a full workup by a gynecologist and no abnormalities were found. The
couple had been trying for children for one year. The man reported good libido,
was shaving daily, had no erectile dysfunction and no gynecomastia. He had a
history of left-sided cryptorchidism with orchiopexy and subsequent removal of
the left testicle. He entered puberty around the age of 13.
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Ronald Tamler
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Other medical history consisted of rosacea, alopecia areata (in
remission) and a motor vehicle accident. The patient had never smoked, rarely
consumed alcohol and was not using recreational drugs. He was working as an
engineer at a museum. There was no history of exposure to radiation or
chemotherapeutic agents.
On physical exam, this was a normal-weight man in no acute distress,
5’8”, 156 lb, heart rate of 76, BP of 118/70 mm Hg. Normal phallus
size and male-pattern pubic hair distribution. Left testicle absent, right
testicle with normal consistency and around 18 mL in volume. Exam otherwise
unremarkable.
Morning testosterone, luteinizing hormone, follicle-stimulating hormone
and semen analysis had been ordered by the primary care physician, but tests
had only been partially completed and no results were available.
A. Tell him that one testicle does not produce sufficient semen to
father a child and that his efforts are futile.
B. Ask more questions about his relationship with his wife.
C. Testicular biopsy.
D. Tell the patient that he is fine and that infertility is almost
always the responsibility of the female partner.
E. Start testosterone supplementation.
CASE DISCUSSION:
The answer is B.
Expensive lab tests often do not provide the answers to the medical
challenges that confront us. In this case, the patient was working the evening
shift from 4 p.m. to midnight. His wife, a nurse, was working the morning shift
at a hospital and had to leave the house around 4:30 a.m. The couple had
relations once every other week on average and, when pressed, the patient had
trouble remembering the last time he had intercourse with his wife — the
two were simply too exhausted and were not spending enough quality time
together.
While cryptorchidism is associated with hypogonadism and testicular
cancer, this man has undergone a normal development and demonstrated no
clinical signs of low testosterone. One testicle is usually sufficient to
produce semen and testosterone (A), although decreased semen production and
quality are often seen with this condition. A testicular biopsy is not
necessary as long as the semen analysis demonstrates viable sperm (C), which
could be used in an in vitro fertilization procedure. Testosterone
supplementation would only suppress semen production and would be
counterproductive in this case (E). Finally, it is a profoundly unfair and
false statement to declare fertility (or the lack thereof) solely the
responsibility of the female partner. The cause of infertility is a female
factor in approximately one-third of the cases, male factor in roughly another
one-third and attributable to both partners in the remaining one-third of
couples seeking treatment for fertility.
In this particular case, pending final lab results, I recommended a
vacation and dedicated romantic time to the patient. I also recommended
focusing energy on the time of the cycle that is most likely going to “pay
off.”
Ronald Tamler, MD, PhD, MBA, is Assistant Professor in the Division
of Endocrinology at Mount Sinai School of Medicine, N.Y.