Beginning or the end?


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I would like to start the first article of 2016 by quoting my hero, Winston Churchill.

Arguably the most celebrated wartime leader of the 20th century, Churchill once said: “Now is not the end. It is not even the beginning of the end. But it is, perhaps the end of the beginning!”

I often have to pause and ponder for a while when reading about this quote. Is the start of the New Year the “beginning of the end” of 2015? Or is the start of the New Year perhaps is “the end of the beginning” of 2016?

With that confusing thought, lets venture into the New Year addressing Adam’s “end of troubles of infertility” and “the beginning of the journey of parenthood” and “the end of the beginning for the quest for answers”.

Dear Dr. G,

It has been a delight reading your articles on Sunday mornings on The Star Online. (Well, most of the time in the morning, anyway)

I think you have done a good job in making a taboo subject humorous and simple enough for most men to digest.

Since it is the New Year, I have great news to share with all. My wife and I previously had been having trouble conceiving after 10 years of trying.

The fertility doctors eventually discovered the problems I had was due to blocked sperm ducts, and managed to get good quality sperms for IVF, after a small operation.

My wife is now four months pregnant and we are expecting twins in 2016.

Although we are incredibly excited about the end of our infertility nightmare and look forward to the beginning of parenthood, we are also very worried about the genetic basis of my male infertility.

I understand this is a condition called congenital bilateral aplasia of vas deferens. The doctors also said the condition can be passed on to the children and is also associated with other medical conditions.

Is there a need to worry about the kids? Is this the end of the beginning?

Please help.

Adam

The vas deferens is the tube that links the testicles to the prostate. Spermatogenesis and maturations of the sperms occur in the testicles and epididymis, and sperm is subsequently delivered to the prostate prior to ejaculation. Congenital bilateral absence of the vas deferens (CBAVD) occurs when the tubes fail to develop properly resulting in infertility.

The men who suffer from CBAVD have no symptoms and will have normal sexual functions and ejaculatory ability. The testicles continue to produce sperms normally but the drainage is occluded due to failed vas development. Effectively, this is like nature performing vasectomy on the affected men. The condition is only apparent due to failure of couples to conceive and analysis shows the semen to be azoopermic (firing blanks!).

Although CBAVD is not very common, statistics reveal it affects 1 to 2% of all men presented with infertility problems. Interestingly, the prevalence of the condition has increased over the years. The reasons behind the increase, though, is largely unknown.

However, despite the fact that condition may come as a shock to the affected men, it carries a very good prognosis for successful pregnancy, with assisted reproductive technology.

Many men are grateful when viable sperms can be retrieved, and their ability to father a child through in-vitro fertilisation (IVF) ends the infertility nightmare. When men are considering the beginning of the journey of parenthood, many will begin to question the genetic basis, fearing how this can affect the next generations.

CBAVD may occur independently, it is also associated with a mutation in the CFTR gene. This gene is responsible for the production of free flowing mucus that protects and facilitates drainage of airways, digestive systems and reproductive organs. Hence more than half of all men with CBAVD have a mutation of the CFTR gene that can result in cystic fibrosis. Of course, there are also sporadic cases of CBAVD that are not related to genetic defects. The etiology of such hereditary basis is unknown. 

When CBAVD is the result of a mutation of the CFTR gene, it is inherited through an autosomal recessive pattern. Men with this condition who choose to father a child through IVF have an increased chance of having a child with cystic fibrosis. Of course, modern day genetic testing can determine the genes and can also be done on the unborn child through amniocentesis.

In reality, the research of the etiology of male infertility begun in the last two decades and largely remains unknown. Why has the prevalence increased and how it may impact on future generations is uncertain.

For many couples, the quest for fertility may bring joy of future parenthood. However, it is also important to have genetic counselling prior to any analysis as this may open up a Pandora’s box of more unknowns.

My other war hero, who is the youngest person to have served as Secretary of Defence in the USA, Donald Rumsfeld once said: “There are known knowns. These are things we know that we know. There are known unknowns. That is to say, there are things that we know we don’t know. But there are also unknown unknown. These are things we don't know we don't know.”

With such deep and confusing thoughts from these wartime heroes, I know we all can venture into the beginning of the unknown journey of happiness in 2016.

> The views expressed are entirely the writer’s own.

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Dr George Lee

Dr George Lee

Dr George Lee is a consultant Urologist and Clinical Associate Professor whose professional interest is in men’s health. The column “Ask Dr G” is a forum to help men debunk the myths and taboos on men’s issues that may be too “hard” to mention. You can send him questions at askdrg@thestar.com.my

   

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