Case Challenges

Can a man with one testicle have children?

An infertility work-up does not need to be complicated.

Ronald Tamler

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.

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.

What is the next best step in the management of this patient?

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.

Ronald Tamler

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.

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.

What is the next best step in the management of this patient?

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.