Getting it Just Right with Patients

Rubik cube
Every patient is a puzzle waiting to be solved.

There are many ways to solve problems. But there is beauty and clarity in finding the best solution, and I believe it’s worth spending the the extra mental energy to achieve this. Can’t tell you how, when or why I think this way, but Steve Jobs captured this concept when he said:

“When you first start off trying to solve a problem, the first solutions you come up with are very complex, and most people stop there. But if you keep going, and live with the problem and peel more layers of the onion off, you can often times arrive at very elegant and simple solutions.”

The Sweet Spot

I love to apply this philosophy when helping patients build families. It starts with a concrete problem, say azoospermia (no sperm). The goal is children, preferably their own. The problem is how to get there. The solution must consider many variables including timelines, economics, belief systems, and medical treatments and their attendant risks. The solution is individually tailored to the couple, of which no two are exactly alike. And their must be complete goal-alignment, yours with theirs. This, my friends, is the art of medicine made manifest.

The Combo Platter

The couple I’m reminded of was young, childless and had limited resources. She was extremely healthy but he had azoospermia, a clinical left varicocele and low-normal testosterone levels. Their wish was to have children as naturally as possible.

I discussed several options with them, honestly not favoring any approach over another. This is all about ”walking the walk” with patients to help them come to the best decision for themselves. Here’s a list of options for them to have biological children:

  • Proceed straight to a surgical procedure called microdissection testis sperm extraction and IVF-ICSI. The biggest hammer. The most invasive, expensive and technologically demanding option.
  • Perform a testis biopsy. The classic, somewhat antiquated and relatively invasive technique that offers limited information about sperm production.
  • Surgically repair the clinical varicocele with the hope of generating sperm in the ejaculate and also boosting native testosterone levels. This is the only “treatment” than has any real chance of conceiving naturally, but that chance is low.
  • Perform Sperm FNA Mapping to determine the location and density of any sperm present in the testicles despite the absence of ejaculated sperm. This offers the best chance of knowing that a sperm extraction procedure will find sperm.
  • A combination of the above.

Here’s where the discussion went pretty deep. Their desire was to fix anything that might result in ejaculated sperm, but they also wanted to know whether there was any sperm at all. So, they chose a combo platter of Sperm Mapping with a surgical fix of the varicocele under a single anesthetic. They chose “knowing before you go” and “fixing things that are broken.” Several weeks later the Sperm Mapping came back and showed that he had mature sperm in both testicles. Great, sperm extraction and IVF-ICSI was now an option, albeit a costly one.

And the Answer Is….

“I’d wait.” I told them. “Given the Map findings, there’s a good chance that you’ll develop ejaculated sperm over the next 6 months after fixing the varicocele.” So they waited.

Six months later, lo and behold, he developed ejaculated sperm. Actually, hundreds of thousands of them. And, his testosterone level climbed 40% higher than before to now rest smack in the middle of the normal range. Check. No more surgical sperm retrieval procedures needed. Check. No more testosterone issues.

Two months later, he was due for another semen analysis, as I expected more improvement in semen quality. He showed up to collect his sample with big wide smile on his face and spilled the beans…his partner was pregnant! At home. No muss. No fuss. Check, no more infertility issue. In the words of Dr. Suess, “Sometimes the questions are complicated and the answers are simple.”

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