Gonadotropin therapy is highly effective at inducing spermatogenesis and fertility in gonadotropin-deficient men. The introduction of IVF and ICSI has transformed the treatment of male infertility by requiring a minimal number of sperm to achieve pregnancy. Various techniques for testicular sperm retrieval are available including testicular sperm extraction or microdissection, as well as percutaneous and microsurgical epididymal sperm aspiration. This case highlights the complexities of induction of spermatogenesis, sperm extraction techniques, and methods of inducing antegrade ejaculation after local surgery.

A 36-year old man was diagnosed with a testicular germ cell tumour in 2003. He underwent a left orchidectomy, para-aortic lymph node resection, and chemotherapy. In 2006 he represented with a history of headaches and double vision. A diagnosis of macroprolactinoma was confirmed on biochemistry (prolactin: 46,000 mIU/L) and MRI pituitary (2.5 x 1.5 x 1.5 cm tumour).  The remainder of his pituitary profile showed evidence of testosterone, cortisol and thyroxine deficiency. He was managed with Cabergoline 750mcg weekly, Thyroxine 100mcg daily, and Testosterone undecanoate 1000mg every 12 weeks. He had good biochemical response (prolactin: 596 mU/L), and pituitary MRI in March 2010 showed no residual tumour.

In March 2011 he presented desiring fertility. His 33-year old nulliparous wife described regular menstrual cycles. He described retrograde ejaculation since his surgery. His Testosterone therapy was ceased. Baseline bloods showed a testosterone of 6.8 mmol/L, LH of 2.6 IU/L, FSH of 4.0 IU/L, prolactin of 333 mIU/L, TSH of 1.8 mIU/L, and free T4 of 16pmol/L. Analysis of a post-ejaculatory urinary study showed no sperm. The patient was commenced on recombinant HCG 125 mcg twice weekly, and FSH 150 units three times weekly with urinary alkalinisation. Subsequent analyses of post-ejaculatory urine samples revealed occasional non-motile sperm. Treatment with pseudoephedrine did not induce antegrade ejaculation. He was referred for epididymal biopsy.