The obstructive side is a little bit more plumbing now, which is truly what most of us do as urologists is unblocked pipes. And in the reproductive tract, there are multiple sources of obstruction and it’s important for me to determine where the obstruction is. Now obviously or maybe not so obviously, the most common point of obstruction is a vasectomy. So that’s exactly what we’re doing, essentially don’t change anything else in the reproductive tract when a man decides that he wants to have a vasectomy for birth control. All we’re doing is basically blocking the highway.
So a big part of my practice is to put those back together when a man or a couple change their mind. Knowing exactly where the vasectomy was done, I can go in using a microscope and put those two channels back together, so that he can have continuity and we relieve the obstruction and sperm come back. It’s not always that straightforward. There are things that men can be born with either genetic defects or even blockages from cysts, stones, all kinds of things that can cause obstruction elsewhere in the reproductive tract.
One of the most common genetic abnormalities in at least a European population is cystic fibrosis gene. Up to 1 in 25 men are people who carriers cystic fibrosis gene and so the incidence of the disease is a lot less than that. But if a man has at least one copy of that gene, usually takes two, he may have an absence of the vas deferens, where basically again the sperm production is there, but he’s not actually able to get sperm into the ejaculate.
I’ve also seen obstruction from inguinal hernia repairs, so again, if you’re a male thinking about fertility and you have a hernia, talk to your surgeon about either if he’s going to use mesh take extra caution around the vas deferens, so that area isn’t blocked.
And then lastly infections can also cause a problem with fertility. Epididymitis which is that little tube. It can get so gummed up with infection inflammatory tissue that all the sperm are blocked at that level as well. Most of the time we are able to catch epididymitis and treat it with antibiotics, we don’t see that, but this is certainly something I’ve seen in my career.
So how do I make the diagnosis of obstructive subfertility? With the non-obstructive again we go back to blood work, and we go back to obviously looking at the semen analysis and a physical exam. So on obstructive subfertility, a man’s physical exam should essentially be normal. Now occasionally a man will have some obstruction higher up in the reproductive tract near the prostate, or near the seminal vesicles, where the semen is made. And I may be able to feel that on a rectal exam. But for the most part, you should have normal testicles, maybe I won’t be able to feel that vas deferens and that will lead me down the pathway of thinking about that cystic fibrosis gene we talked about. Maybe I won’t be able to tell anything is wrong at all and we’ll have to use some other diagnostic modalities. I use a lot of ultrasound in my practice to look for those sent areas of obstruction for example.