Featuring: Joshua A. Halpern, MD
A 39-year-old man presented to the office with a new diagnosis of neurosarcoidosis causing transverse myelitis. He and his wife were actively trying to conceive their second child, but he was experiencing anejaculation. Perhaps even more challenging, he required urgent medical therapy for treatment of his sarcoidosis, which would involve methotrexate, a gonadotoxic and potentially teratogenic drug. They were seeking consultation for fertility preservation before initiation of methotrexate treatment, and time was of the essence.
Initial laboratory evaluation demonstrated low serum testosterone of 185 ng/dL and elevated follicle stimulating hormone (FSH) of 7.6 mIU/mL, indicating that there was potentially an issue with spermatogenesis, yet another obstacle to overcome. He was started on clomiphene citrate, 25mg daily, and multiple attempts were made at cryopreservation with the assistance of PVS. Unfortunately, he remained unable to ejaculate. Working closely with his neurologist, our team agreed to delay the initiation of methotrexate therapy for one week in preparation for surgical sperm extraction.
The patient had a successful microsurgical TESE, yielding 8 vials of cryopreserved samples. The patient was started on methotrexate therapy for his sarcoidosis, and the couple is planning to begin in vitro fertilization (IVF) in the coming months.
This couple demonstrates the importance of fertility preservation, particularly in the setting of benign disease, wherein many patients and physicians are not aware of the gonadotoxic effects of lifesaving medications. Through multidisciplinary cooperation between the Urology and Neurology teams at Northwestern Medicine, we were able
to help this couple achieve their goal of fertility preservation without compromising treatment for his neurosarcoidosis.
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Joshua A. Halpern, MD Northwestern Medical Group Urology
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