Male infertility, needle or the knife?
Article kindly provided by Allan Rumney.
This article deals with male infertility issues due to obstruction, whether made intentionally (as in a vasectomy) or due to disease, accident or defect; and how they can be addressed. I am no fertility specialist, let me make that clear from the start. In fact I am an engineer, but I have a wealth of experience from a journey embarked on several years ago together with my wife, our dream to have our own baby. Unfortunately we stumbled out of the starting blocks with a big problem, I had a vasectomy in 1991 in a previous marriage, and to get around this little bump proved to be a very big mountain to circumvent indeed. Without the utterance of an untruth, we tackled this problem relentlessly over a period of several years from every angle, together with other unexpected problems along the way. There were times of big disappointments where we walked away licking our wounds, only to recover our strength and wits and tackle it from a different angle. My article, vetted by good men in the fertility profession, presents up-to-date solutions to obstruction that are proven to work, and should set an incumbent on the correct road to overcoming the obstacles relatively unscathed and hopefully onto fatherhood.
In the last 2 decades there have been huge advances in addressing human infertility and a myriad of assisted reproductive techniques have evolved, for example, AI, GIFT, ZIFT, IVF and ICSI. In South Africa we can be proud that several local clinics exude World-class standards with proven tangible results, the goal of which of course is achieving those otherwise elusive pregnancies and childbirth. And on this point we applaud a handful of fertility specialists here who have strived for and continue to uphold this excellent standard and noble cause. A fuzzy area however is addressing the male infertility factor, largely due to the structure of our medical fraternity: If you are in the game, you are either a gynecologist or a urologist, but strictly speaking you can't be both. This is quite different in some countries, and here I refer specifically to Dr. Silber in the USA who deals directly with both male and female issues. I have no idea of his qualifications and salutations, but the plethora of articles and references to him simply state, 'Dr. Sherman J. Silber, M.D'.
Not so long ago, an infertile couple where the male was azoospermic (no detectable sperm in the ejaculate) had little choice but to fall back on donor sperm in order to conceive. Such men found themselves between a rock and a very hard place, and for some, it is a deeply disturbing prospect and emotionally shattering. Things were turned on their heads for the better however with the advent of ICSI (Intracycloplasmic Sperm Injection), a long sought-after solution to severe male infertility problems. In fact in this technique, per egg aspirated from the female partner, only one single sperm is injected into the egg from a select few to achieve fertilisation. The problem still remained in obtaining the male partner's sperm if he was azoospermic, and needle aspiration techniques were specifically developed to address this issue.
Prior to ICSI however, not much could be done for men with such an affliction, surgical reversals were rarely successful and micro-surgical reconstructive techniques non-existent. But in the 90s, things were changing rapidly, not only did ICSI / sperm aspiration make their debut, but microsurgical techniques entered the fray, addressing a whole host of male and female fertility issues. Dr. Silber mentioned above, is no doubt one of the World's finest fertility experts, specialising in the micro-surgical field. In fact before his very first related human procedure, he reportedly practised and honed his skills performing arterial resections on no fewer than 5 000 rats! Today, Silber and his respective teams, associates and followers, spanning countries and continents, leave a legacy of triumphs and World-firsts. They have been largely instrumental in the creation of many of the artificial reproductive techniques we see today, and continue to expand on their work. I know I am digressing somewhat, but the point is gentlemen, today there are many options available to get around most forms of male, and indeed female infertility.
The alternative to surgical reversals or reconstruction / repair is sperm retrieval by needle aspiration, and the techniques commonly employed, are PESA (Percutaneous Epididymal Sperm Aspiration) and TSE (Testicular Sperm Extraction). Most men are familiar with their soft and squishies, but know little of the epididymis; sausage-like sacs attached behind each testicle that contain meters of tightly coiled miniscule tubes and canals. In essence, they connect the testicles bilaterally to the vas deferens, which constitute the main 'pipeline' of the male's reproductive tract. The epididymis is the subject of controversy, but it can be safely said that they act to accumulate and transport sperm. In the normal male, it takes 6 weeks for sperm to travel their path from genesis in the testicles to ejaculation, and a large part of that time is spent in the epididymis. The controversy though is intriguing. Some specialists believe that the very fine hairs within the epididymis literally stroke the sperm in passing and 'teach' them the fine art of swimming straight. Others believe it all has to do with the epididymal sperm being older or more mature than their testicular compatriots. Nevertheless, normal epididymal sperm generally exhibit this straight-swimming trait, and can fertilise the egg naturally, or by assisted means such as GIFT, IVF and ICSI. Aspirated testicular sperm on the other hand are immature and do little but wriggle a little and go around in circles, they cannot fertilise the egg naturally, and in fact will only effectively work in ICSI. Viable sperm can be obtained with either technique but in TSE, the sperm are immature, that's why a physician's first choice is to try for epididymal sperm, and if he has no luck, go into the testicle. Epididymal sperm freeze and thaw quite well and can be banked for future use, testicular sperm on the other hand do not and are attenuated (weakened) by the process. But above all, fresh ejaculated sperm is tops, and that dear friends sets the gold standard in fertility, naturally.
Needle aspiration is normally quite quick and convenient, with only mild resultant pain or discomfort, and can be performed under a local aneasthetic, but I personally would prefer not thank you. And be warned, if you choose this option, make sure the performing physician is skilled, this technique in hapless hands has the propensity for mass destruction to the the very fine epididymis and injury to the testicle/s. Please be absolutely sure that the physician knows his oats, and understands the importance of steering clear of the head of the epididymis where damage to the delta of minuscule canals would be very difficult to bypass or repair, if you one day decide for a reversal. Also, ask your physician to only work on the one side, and resort to the other only if things are not going to plan. Finally on this point, remember the number one doctrine of any doctor or surgeon is to first do no harm, and although this technique leaves little leeway for such an idyllic notion, damage control is important. Understandably you don't want to end up in the hands of a butcher, and I use this word with no apology, and for lack of a better one.
Today, men (and of course their respective fertility specialists and consultants), do have choices when standing at the crossroads: Indeed, needle or the knife? In an ideal World, conception should happen naturally, thankfully for many a very private affair, enjoyed intimately behind closed doors. For the unlucky afflicted with the curse of infertility however, clinical programs are the only way forward and not for the faint-hearted, weighing heavily on finances but above all, our emotions. With this in mind, the knife is most tantalising, all can be fixed or reversed and 'wham-bam, thank-you mam', all done and dusted! Unfortunately in many cases, it's not that simple.
The cost of a reversal by the most gifted surgeon today will set you back as much as R150 000, depending on what needs to be sorted out, and the waiting list is long. And if you opt for the best surgeon, you need to get to him and the logistical implications are daunting. And then of course, depending on the complexity of the surgery, there is always the risk of only partial success or even failure, and in the case of very difficult reconstruction, it may take as long as 18 months for sperm to return. But in the right hands, you have more than a 90% chance of at least partial recovery, regardless of the complexity, and this is re-assuring indeed.
I went to Silber in May 2006 for my reversal, after 2 failed attempts in South Africa and needle aspiration back in 2004. Post-surgery, Silber explained that my 4-hour op was one of the most difficult he had undertaken in over 6000 such operations. Of my left testicle, he could do zip, such was the destruction to the head of the epididymis from needle aspiration. The right side was also almost totally destroyed but barely repairable, and using a much more difficult type of procedure known as a vasoepididymostomy, the repair was made. My vas were also way too short and he had to cut deep and high up into my groin to free up and pull down vas. So, the odds of success were seemingly stacked heavily against me and only time would tell, yet this man's prognosis was excellent , a 93% chance of success. I questioned his cockiness, until the day I got my first positive sperm count of 10 million / ml! It had taken a mere 8 months to recover.
So to summarise, what are the pros, cons, and pitfalls to the needle and the knife?
1) Needle aspiration:
- Quick with only moderate post-discomfort, lasting no more than 2 or 3 days.
- Can be performed at short short notice conveniently, and can be timed into a fertility cycle with the female partner.
- Can be done with only a local anaesthetic, (but I would rather pay a bit extra for a general, I for one don't want to be awake while someone sticks needles in my testicles, thank you!)
- Adequately addresses situations where entering a fertility program is a matter of urgency, such as the 'window of opportunity' is fast running out.
- Low cost, low-tech approach, that can be done in a doctor's rooms.
- Can address specific fertility problems that that cannot be surgically corrected, for example, the complete bilateral absence of the vas deferens
- Post-procedural abstinence is not an issue
- The propensity of permanent damage to the epididymis and / or testicles looms large in the hands of the careless. In serious cases, this damage may render further aspiration attempts, usually months later, disappointing or even useless, and may have sealed the fate of the incumbent should he then decide to try a vasectomy reversal. If you are considering a reversal, don't do needle aspiration and then expect to breeze through a simple reversal, at least some damage will most probably occur and this sets the stage where the only recourse will be a bilateral vasoepididymostomy, where the damaged epididymis need to be bypassed.
- Aspirated sperm is generally genetically inferior to ejaculated sperm, simply because it is not fresh, and in some cases, so badly attenuated and old that it consists literally of dead cells.
- Every time sperm is required (unless banked frozen viable sperm is available), the procedure must be performed again, and the risk of failure to aspirate suitable or even no sperm on the day is always a factor to consider.
- If only testicular sperm is aspirated, they make poor candidates for cryogenic freezing and banking for future use.
- If you undergo the knife and it proves to be successful, it is the ultimate solution, and regardless of the level of fertility returned, at least you have a chance to conceive naturally, and if it does not happen, your options are normally not as restrictive. And fail as you might every month to conceive, provided your wife's fertility is reasonable, at least it can happen every month, which is better than no chance at all.
- Having your fertility returned for the right reasons is emotionally a big boost to a man's moral, and even an ego-trip for some. For me, it was the best thing, after a doctor had told me only a few months before that I had reached the end of my road and I would never conceive a child with my wife, it would have to be donor sperm. I have yet to prove him wrong, but at least I now do have a chance, even naturally, which is better than no chance at all.
- Should it be necessary to return to the Fertility specialist, at least you have fresh ejaculated sperm available, which is generally the best possible option.
- At the time of reversal, in many cases, sperm can be recovered from the re-sectioned ducts before suturing, frozen and banked, in case the procedure ultimately fails.
- Even the most complicated cases, performed by the best surgeon, almost guarantees a positive outcome, and this includes most forms of obstruction to the vas or epididymis.
- The old adage that the chances of recovering fertility diminishes with time since the date of vasectomy is generally no longer valid. What it should in fact imply is that the required corrective surgery tends to get more complex, undertaken by only the best surgeon available.
Even after 1 or 2 attempts at a simple reversal fail, there is still a good chance of success in the right hands. In many cases, by the time a man gets to a third attempt however, the vas are by now very short, but vas embedded in the groin can be freed up and stretched down.Cons:
- You have to resort to the best surgeon money can buy, to maximise your chances of success, especially if previous attempts have failed, and 3 failures basically is the end of this road.
- The recovery can be long and frustrating, depending on the extent of the necessary surgery.
- High-tech micro-surgery is the only effective approach, and capable theatres and surgeons are very expensive and in the case of the latter, literally a single individual. The fact is you basically have no choice if you want to be assured of a good outcome, in case complex surgery is the only answer, and this will only become truly evident during the surgery, and determines whether a vasoepididymostomy and / or freeing up of vas will be necessary. Granted the surgeon can thumb-suck a bit out of your history, what to reasonably expect, but who knows what surprises may be in stall on the day.
- A reversal in the wrong hands can spell not only failure, but resultant chronic discomfort, especially if the vas are too short. This was the case for me after my second attempted reversal. Thankfully, after Silber, rarely now do I experience pain or discomfort..
- Abstinence for 3 week post-surgery is mandatory, and this can make you quite mad, believe me!
- It can take as long as 18 months for sperm to return to the ejaculate, and of course, in a small percentage of cases, this may not happen at all. There is a low percentage (less than 2%) of males who will naturally scar down, regardless of the quality of workmanship performed by the surgeon, resulting in only partial success or even failure
- The quality of the sperm is not guaranteed when it does eventually return, and normally for the first few weeks, its poor quality. It takes time for the debris and 'geriatrics in their wheelchairs and on walkers' to vacate and the reproductive tract to settle down to normal.
- The controversy of the existence of sperm antibodies rages, but is nevertheless a valid argument, which can effect the chances of natural conception anyway, and the trip to the fertility specialist may still be necessary. (Silber specifically tackles this issue head-on, and in his opinion, sperm antibodies are more related to poor repairs where sperm permanently leak into the surrounding tissue, to which the body's defence mechanism reacts. In the case of a good repair, this should not occur).
So, what will it be? Lets start with the most sound advice of all. The most important factor gentlemen is to first find yourself a good, straight-shooting fertility specialist who knows the game and will put you on the right road from the start, and help you make the right and best decision. If you already have one that you feel comfortable with and has a string of successes, that's great.
But if you are currently in the thick of years of fruitless fertility treatment and feeling battered, bruised and frustrated, you should consider a second opinion, trust me, it was the best thing my wife and I ever did. Sometimes a second specialist will pick up something the other did not, and it can mean the difference between continued failure or success at last! Fertility treatment is financially expensive, but most taxing of all are the emotional aspects, especially when repeatedly, no progress is made . So, in saying that, it's entirely your choice, but you owe it to your partner and yourself, and you make damm sure you are on the right road with the right fertility specialist from day one. We did everything wrong from the start, and for years we literally plodded back for more of the same pulverizing in the ring. Every time the same dismal negative outcome, and that feeling of abject hoplessness my friends eventually gets to you.
However, out of the quagmire we did crawl, found the error in our ways, did our homework and located the right specialists for us. We started a fresh chapter in our quest with our new specialist with whom we have a personal relationship, and whose integrity and compassion is beyond reproach. For ethical reasons, I cannot name or recommend him, but I can tell you his approach to our problem has been meticulous and methodical, from the foundations. First thing was an HSG on my wife, revealing many issues that were thankfully resolvable and surgically eliminated. My sperm were next in line which revealed a low count but normal quality, thankfully. We think the World of this man, not only has he taken a personal interest in our case, but we have made unprecedented progress, and there are no words to express our gratitude. After years of relentlessly tackling an inpenetratable barrier, at last we have made a breach, for the first time I am proud to say my wife is pregnant. We are not out of the woods yet but pray, as do our friends in the forum and our specialist and team, that all will bode well over the next few crucial weeks. Nevertheless, it's a massive victory for us to get this far. If I could press the rewind button back to 2003, we would no doubt have gone straight to this man, where I know a reversal would have been one of the options mentioned up front.
I am also quite sure that the name Silber would have cropped up. In fact, I initially tested our new specialist and his general knowledge on fertility: I sent him an email to the effect of, 'We dont know each other and please forgive me for my strange demeanour, but who would you consider to be the World's top fertility expert?". Within 10 minutes, I had the reply "Sherman J Silber! Please contact me on 08**********" . Like I said, had the name Silber come up, it would have been a more simple and successful reversal back then, and this is a deeply unsettled issue for me. Again for ethical reasons I cannot divulge the exact details, but like I said, needle aspiration in the wrong hands is disasterous and cost me my chances of full a recovery, and for those responsible they are unforgivable, doing what they did, so badly, without my informed consent. And in the desperate end I presented myself in an appalling state on Sherman Silber's doorstep, with my hat in my hand, and I am being dead-serious, I begged this man to consider my case: Thankfully he did.
I tell you this not to attract sympathy, but illustrate just how crucial it is to be well informed and make those correct decisions. It also speaks volumes of the miraculous transformation possible due to modern science and technology, microsurgical techniques and the skill of a master surgeon, regardless of just how bad things may seem, and in this light, there is always hope, if you know where to look. Take heed of what is said here, it could save lots of tears and pain, and make sure if you do either needle aspiration or the surgical reversal route, enter into it with factual and well-informed consent and the knowledge that the attending physician is really up to it. Above all, don't jump into things on the whim of inflated and empty promises, enter into it when you are ready, well informed, and that may require a bit of time and research, and even a second opinion. My personal journey has been long, educational like no other and at times it tested me beyond my limits. With what I know today, I would have gone straight for the reversal option, had I known of Silber up front and his incredible string of successes. And as for the cost, how do you quantify something that is priceless?
But in retrospect, had we chosen needle aspiration in the right hands, my view of the landscape today could have been totally different. And that is the pivotal issue chaps, do things right in a factually informed manner from the start, and don't just let anybody have a go at your family jewels or your wife's plumbing.
To conclude, visit the site of Silber at www.infertile.com for concrete facts. For fertility support we have an excellent local site, www.fertilicare.org, in case you found this article elsewhere. It's your duty to educate yourselves, and good luck!
Article kindly provided by Allan Rumney.