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 Too Hot To Handle

Some years ago, a milled-aged  couple came to see me.  The husband and wife must have both been  in their  mid-thirties.  Both looked  apathetic and listless.  I couldn’t  understand why anyone looking like that would voluntarily seek  andrological  consultation.  You on the fast guys and  other seminal matters , andrology is a quality of life (QOL) specialty are in medicine.  Those who don’t have any  interest in life and living  in the first place are hardly likely  to care much about its quality.  Hence, andrology didn’t  seem at all to fit in with this couple’s demeanour.

I thought that these people had made a mistake somewhere.  They looked more   like lambs being led to a slaughterhouse than like my usual patients.  I was almost  tempted to tell them that  mine is not  an intensive care unit  or a mortuary, so  that they  would realize their blunder and go away.  To add to my bewilderment, the man was carrying an enormous suitcase.  I suspected that he might have even paid excess baggage for it,  that’s how awesome  it looked.  I was dying to know what it contained.  He probably thought that I was a cardio-thoracic surgeon and had brought  along my fees for a coronary bypass operation or  something,  I figured,  using deductive logic.

The mystery  was getting deeper and deeper.
Sure, hospitals  and clinics  are admittedly depressing places and nobody goes  there unless it is inevitable.  But  even at hospitals, such sad looking  guys  are not an everyday sight.  Something was seriously wrong here, I told  my self help is the best help .  I was keen to find out what the matter was.

Even though I asked them several times to sit down, the Despondent chose to remain standing.  Again, I got the distinct impression that they had regretted  coming  here.  It appeared that a part of them was contemplating turning around and  bolting  through the door.

Eventually, after what seemed  like an eternity, they made up their minds to stay and sat down abruptly.  I started at the ceiling,  and waited, anything  happens in this world, I told   myself.  Only, here it was happening to me.

‘We have given up hope, doctor,’ the husband finally uttered.
What a way to start!  It was certainly not  very flattering to me.  I wanted to ask them what the point in seeing me was if they had already lost all hope, but I desisted, not wanting to further beleaguer them.

‘Can we at least discuss the problem before jumping to hasty conclusions?’   I recommended.

I expected him to tell me about the heart attack he had suffered  and about the coronary passage to manhood operation he wanted me  to perform. 

‘Well, doctor, let me summaries it for you,’ the wife butted in.  ‘We’ve been trying to have  a baby for six years now, right from the time we got married.  For  the first four years, we tried diligently, but to no avail.  Then we started seeing doctors.  Over the past two years. We’ve visited several and have had eight attempts at IUI (intra-uterine  insemination) and  three attempts  at IVF (in vitro fertilization- test tube baby).  As you can see,  they have all been failures.  We’re tired of scans,  semen analyses,  injections and medicines. We’ve spent lots of money, and both of us, being  working people, have gain one organ, lose another a lot of leave and pay too.   We just want to know whether to give   up  hope altogether or whether it makes sense for us to continue to try .  just  tell us  bluntly, doctor.   My husband has reached a stage where he now  can’t even have sex or collect a sample of semen on the desired  date any more.  How much  semen they’ve  taken out of my poor baby!’

‘At least he’s not going to get a heart attack in my office and die right here and now,’ I thought to myself, with a sigh of relief.  Semen loss and infertility are easy.

‘I see what you mean,’ I said, understandingly.
Mr Despondent then  opened his  enormous suitcase and pulled out several massive files and place them on the desk.  I went through   the pile  one by one.  The poor  man must have undergone nearly two hundred semen  analysis.  I couldn’t help thinking that he might  have probably had a better chance of fathering a child if he had inseminated all that semen  into his wife rather than surrender it meekly to the lab technician. When I finished studying the files’ voluminous contents, I noticed  to my horror that the man hadn’t been physically examined by a doctor even once in all these years!   It was the  wife on whom all

examinations and tests had been done.  The man was  simply handing over semen samples  to the fertility  center whenever required.  To me, all this seemed less like human husbanding and more like animals husbandry.  I couldn’t believe it!  This was supposed to be the best center  in their  town.  But  I didn’t say anything.  No point  rubbing it in, I thought.  They were feeling lousy enough already.

I studied his papers for the next  several minutes and then  did what  I usually do when  the facts are  overwhelming.  I start  from the very beginning.   I requested  the wife  to step out for a few minutes saying that I wanted to examine the gentleman.  I have never understood  the absurd logic behind this  strangely  Indian medical  customs.   This couple has been trying to make a baby for six  years now, yet I’m asking  the lady  to leave  the room now in the interest of modesty!  Corny,  but that’s how it is usually  done in this part of the world.  The wife left the room hastily too, with  head  bowed down in a classical display of Indian  feminine hypocrisy. It was almost  like  she was  saying, ‘if the lights are   on, I’m out; if the lights are out,  I’m on’.

The Indian  woman, it appears, is  a creature of the night, like Laura Brannigan.
A simple physical  examination  of the man revealed what a second  year medical  student would  have picked up in two minutes flat- a very large left varicocele!  The varicocele is the commonest cause of male infertility and yet, two years and hundreds of tests later, it had been completely missed  and remained undiagnosed in Mr Despondent’s case!  What could I say!?
‘What’s the matter, doc?’  Mr Despondent asked , starting  down possessively at his unmentionables as I was examining  them.  Not too many  had handled these parts of his body earlier , I guessed.   When I finally pronounced that he  has a varicocele,  he wanted  to know  everything  about it.  I asked him to get dressed and call the wife in.  no point in having to repeat   myself.

I told Despondent that nature  has intentionally  placed the testes  (testicles )  outside  the body.  This is because  the core  of the human body is hot  and, if  the tests remain inside  there, hey cannot produce sperms.   The tests need a lower (cooler) temperature in order to produce sperms.   By placing the testes  outside  the body, it is possible to reduce the temperature  by three to five degrees Celsius.  This is why humans and some mammals have their  testes  outside their bodies, I explained, and told them how the testes travel all the way  from near  the kidneys to their  final destination in the scrotum, just  for his purpose.

‘Yes, yes, doctor, now I have understood everything.  I have  seen  testicles  hanging out and bouncing  up and down  in dogs  and horses also.  Am I right?’

‘Absolutely,’ I said, thinking him to be  rather astutely observant.  I continued.
‘However, sometimes  the veins which  carry blood away from  the tests back to the  heart become  long and large.  This is known  as a varicocele, a condition quite analogous  to varicose veins in the leg.  When this happens, the blood cannot flow up against  gravity efficiently  and, in fact, hot blood  from inside the body begins to flow backwards  into the testes instead.’

‘Oh, I see,’   said Mr Despondent.  ‘This means that the testes becomes  very hot and cannot produce  sperms properly, just like  how we  cannot  work properly in the office without air conditioning .  am I right, doctor?’

I nodded and continued.  This man was a lot of  more brilliant than I had  imagined.
‘Varicoceles occur  in as thirty-five  percent of men with primary  infertility (inability to father first child) and in as many as seventy to eighty percent  of those   with secondary infertility (inability to father subsequent children). Male  infertility accounts for nearly fifty percent of all infertility.  While it is  true that not all varicoceles cause infertility, many studies including those by the World health Organizations) have  shown that in infertile men with this condition, there is  impairment in sperm counts  and  motility, reduction  in testis size  and function, and  abnormalities in sex hormone levels in the blood.  Diagnosis is by clinical examination and scrotal Doppler studies.  The best treatment  method is microsurgery.   Conventional surgery, optical loupe surgery, and laparoscopy to not offer the same success rates.  Microsurgery can produce successes in eighty percent  of cases and can result in sex during  pregnancy in up to sixty percent.’

Since Mr Despondent had tried every conceivable medicine  for conceiving, I unhesitatingly  advised   him to undergo a microsurgical varicocelectomy operation after conducting  a few perfunctory tests.  I was the pioneer of this kind of surgery in India  and had a large experience, I told them,  by way  of sales pitch.

‘We know doc,’ they chorused.  I didn’t want to embarrass myself by asking them why they hadn’t come to me much earlier  in the first place then.

The operation was performed under spinal anaesthesia one  fine  morning, and Mr Despondent  left the hospital  the same evening .
Eighteen months after microsurgical operation, the Despondent became  the proud  parents of a beautiful  baby girl.   It was time to change their name  now.  Taking  a cure from  my  lawyer friends, I renamed them ‘The Respondents.’

I always feel on top of the world when babies are conceived in the bedrooms rather than in the laboratory.

Take Home Message:

It is lamenstable and unfortunate fact that, since the advent of assisted reproductive  technologies (ART) and IVF –ICSI, male factor evaluation often gets  left  out at many infertility centers.  It is only the semen sample  that gets examined, not the man.  Since the male factor  omission, as many causes of male infertility are  treatment  must insist on an andrological   evaluation of the male partner.