Whatever can we do to improve the outcomes for couples when the men have no sperm at all in the ejaculate? Well, I think the answer – and sometimes the solution – is simply for us, the doctors, to try a bit harder… because it is hard enough already for our patients, so what can we do to try to get the best outcomes for them?
Azoospermia is particularly hard because it has all the ‘features’ which in other medical situations cause the most distress:
- The diagnosis – ‘no sperm at all’ – seems devastating.
- The cause is unknown or ‘idiopathic’.
- The impact (to two people or more) is profound.
- The outcome is both uncertain and unpredictable.
So if we compare this to other serious diagnoses, especially in young people, the doctors – and surgeons – generally do not do very well. It usually goes like this:
‘There is no sperm on the test – none at all.’
What does that mean?
‘Well, we will repeat it to make sure, but it might mean an operation to look for sperm.’
But why has this happened? Is it anything that I have done?
‘Probably not, but we will check your genetic tests.’
Will that help?
‘Well, no, but it might tell us why this has happened.’
So what are the chances?
‘The chances of finding sperm if your genetic tests are okay are anything from 10 to 50%.’ (If you are a gynaecologist watching what generally happens to these men, you get a 10% answer, and if you are a urologist with a special interest you get a 50% answer.)
But surely there is some treatment that might help?
‘Probably not, but we will look at your hormone levels and do a scan.’
So far, this is an unpromising dialogue. There are no real diagnostic opportunities which have been offered and neither have any treatments.
The only solution – finding sperm in the testicle by operation – is at best only 50% likely to succeed, which psychologically is a very unhelpful prediction, but perhaps most importantly what has not been said in this dialogue is that the overall chance of real success, which is having a baby, is probably only 1 in 4 or 1 in 5.
I think that there are two important conclusions from this lamentable dialogue, which is so typical in our practice. The first is that we must redouble our attempts to look after these couples, to manage their expectations and to help them through a real and usually unexpected crisis in their young lives.
The second and equally important issue is how we, the medical profession, can ‘do better’.
To do better we must remember that we cannot, in terms of positive sperm retrieval, do much better than the 50%, but we do have to be honest and not use the ‘best’ as if it were our own data.
So how do you get to a 50% retrieval rate?
Well, first you make absolutely sure of the diagnosis. In my practice I tend to treat everything that just might make even a small difference, and this is the art of marginal gains rather than trying to construct, let alone rely upon, an evidence base. I think:
1. Treating varicoceles is probably worthwhile.
2. Using drugs to modify hormonal responses can be effective, depending upon the starting point of those hormone levels.
3. Looking for predictors of the likelihood of positive sperm retrieval. I believe this to be increasingly important. If, for example, a cell-free DNA test can improve the prediction of positive sperm retrieval from 50/50 to 80/20, this is very helpful both psychologically and practically.
Then we just have to consider the experience, skill and persistence of the surgeon. In my opinion, all three features are important but probably persistence is the most significant.
With surgical sperm retrieval, it is not just the skill of the surgeon but it is also the power and quality of the optics (the operating microscope). It might seem obvious, but when you are operating on tiny structures, the tubules in the testicles, then ×50 magnification is, I think, better than ×20.
And then, when we have managed the expectations, the hormones, the varicocele, the operation and the operating microscope, then comes probably the most important element. In my opinion, this vital element to success is the scientists, technicians and embryologists and their equipment in the laboratory, and their willingness to embrace that technology and use it.
So when it comes to searching for individual sperm in those tiny tubules that the surgeon has excised, there are both human attributes and technological devices which might aid the identification of sperm and therefore the chance of a successful outcome.
The first question, rather like the operation itself, is: how long does, or should, the sperm search take? Well, maybe three or four hours, but in UK clinics such an endeavour is not typical; but if a human operator gets fatigued after even two hours what about some help from AI? AI, in identifying sperm and reducing the time spent identifying that sperm, is I believe an important adjunct to current and future practice.
What ‘views’, ‘opinions’ and practices are best avoided?
- ‘Do not have a sperm retrieval, they never work, just have donor sperm.’
2. ‘There is nothing else we can do, so just have an operation as soon as possible.’
3. ‘We will just stick a needle into the epididymis, and if there are no sperm we will do a biopsy from the testicle.’
It is probably not the best plan to entrust your testicles and a sperm retrieval procedure to a gynaecologist. Just think twice before you allow a potentially life-changing procedure to be done by a practice which really is not the best – I am old enough to say this because I am sure it is true!
So what should you do if you have azoospermia?
You should try to seek out a urologist to help you out. You should not have to rely upon a gynaecologist in a fertility unit to have to manage this.
Azoospermia is a serious condition which deserves and needs to be managed carefully by doctors who understand and who are both sympathetic and skilled in sperm retrieval. For some men, there may be longer-term consequences of azoospermia in terms of male health, and therefore clearly gynaecologists are not best placed to consider men’s testosterone levels, and indeed sexual and urological function.
So, for any of you diagnosed with azoospermia, please do not lose hope. We are working hard to educate healthcare providers, primary care doctors and even politicians about the proper and appropriate way of managing this situation for all of you.
For the men and their partners, try to maintain your role as patients rather than customers. Patients need to be cared for and treated, usually by a doctor, rather than by a ‘source of information’. The Internet can provide excellent information but it usually lacks knowledge and empathy. Some ‘providers’ are very good, but some are well-meaning and inadvertently misleading, and some are just wrong and commercially driven.
So my ‘tribe’ – the doctors, andrologists and scientists – do have to try a bit harder. With a bit of help from past and present patients, the charity Fertility Action is working hard to improve access for couples, to educate more doctors, and to contribute to the vital clinical research which will eventually lead to the Holy Grail in nonobstructive azoospermia – why did it happen in the first place?
