Gym Goer Whose Semen Analysis Shows No Sperm — Free SCA Practice Case

Character Overview: You are Rohan Pillai, a 31 year old mortgage adviser for an independent broker. You have been married to Divya, a 29 year old optometrist, for four years. You have been trying for a baby for about 18 months and you badly want to be a dad. You are talkative and upbeat, quick with a joke, and proud of how you look. You train at the gym five days a week. Three years ago a lad at your gym put you onto testosterone injections to get past a plateau, and you have never told Divya or your family. She once called men who take "that stuff" idiots, so you kept it hidden. You are on a video call from the second bedroom while she is at work. You expect the result to be fine, or at worst a bit low. If told there were no sperm at all, your voice slows and flattens and you go quiet before the jokes stop. You do not connect the injections with the result and never suggest they might be the cause. You mention them only when asked directly about steroids, testosterone, performance enhancing drugs or injections for the gym. Then your voice drops and you ask the doctor not to tell Divya.

Opening Sentence: "Hi doctor, thanks for fitting me in. I was told to book a call about the sample I dropped off. I'm sure it's all fine, but I'd rather hear it from you."

History if Asked (Data Gathering Phase)

• ●Trying for a baby: "About eighteen months. We stopped using anything not long after our anniversary and it just hasn't happened." Intercourse two or three times a week, more around ovulation. Neither of you has ever been pregnant or got anyone pregnant. Divya's bloods and scan at her surgery were normal, "so they said it was my turn".
• ●The sample: "I did it at the lab. Four days since the last time, and nothing spilled. The nurse said it all went in the pot."
• ●Medicines and supplements (if asked in general terms): "Nothing from the doctor. I don't take any tablets." Supplements: whey protein, creatine, a pre workout drink and a vitamin D tablet.
• ●Alcohol, smoking and other drugs: "A few pints at the weekend, maybe ten units a week. I've never smoked or vaped. I don't do drugs, never have."
• ●Testosterone and steroids (only if asked directly about steroids, testosterone, hormones, performance enhancing drugs or injections for the gym): A pause, then quietly: "Yeah. I do take testosterone. Please don't tell Divya. She doesn't know and she'd go mad."
• ●What, how much and how long (only after you have admitted it): "Just testosterone, the mixed kind in little ampoules, a mil in each. Five hundred milligrams a week, so two mils, two jabs a few days apart, into my backside. My last one was two days ago. Three years now, near enough. I've never properly come off it."
• ●Source and equipment (if asked): "A lad at my gym sells it online. I don't know what's really in it. New needle every time from the needle exchange. I've never shared anything."
• ●Other products (if asked about hCG, clomifene, tamoxifen, growth hormone or tablets): "No, just the testosterone."
• ●The time you stopped (if asked whether you have ever come off it): "Once, when I ran out for about two weeks. I felt flat and tired, I was snappy with everyone and I couldn't be bothered to train. As soon as I started again I was fine."
• ●Effects you have noticed (if asked): "My testicles are a bit smaller than they used to be, but everyone at the gym says that's normal on it."
• ●Who knows: "Only the lad who sells it and a couple of blokes at the gym who do the same. Not Divya, not my family, not work."

Ideas, Concerns, Expectations

Gating note: Rohan raises none of this himself. Each part comes out only when the doctor asks what he makes of the result, what is worrying him, or what he was hoping for.

• ●Ideas: He assumed any problem would be Divya's, because he is the fittest he has ever been, eats clean and does not smoke. When told the result he wonders if the lab got it wrong. "Are you sure they haven't mixed it up with someone else's?"
• ●Concerns: His first worry is Divya, who has been through every test and cried in the car after her last period. If the doctor asks more, he admits he is afraid she will think he has lied for three years and leave. "If she finds out I've been jabbing myself behind her back, I don't know what she'll do." He does not want it written down or passed on. "Will this be on my record? I don't want anyone finding out."
• ●Expectations: He hoped it was a one off and the doctor would just repeat the test. He would take a tablet or injection if it put things right quickly.

If Asked: Medical History and Medications

Gating note: Rohan answers each of these plainly when asked.

• ●Past health and testicles: "Nothing. I had my tonsils out at eight." Testicles came down normally, no mumps, no injury, operation or hernia in the groin. No chest, sinus or bowel problems.
• ●Infections and treatment: No STIs, both checked before the wedding, no discharge or burning. No chemotherapy or radiotherapy.
• ●Family history: "Mum and Dad are fine. My brother's got two kids. Nobody has had trouble having children, and nobody has cystic fibrosis."
• ●Checks and tests: "My blood pressure was fine when I registered. I haven't had it checked since and I've never had any blood tests. I've never been tested for HIV or hepatitis." No chest pain, breathlessness or swollen legs.
• ●Mood: "I'm not depressed. I'm stressed about the baby thing and short tempered now and then. I've never thought about hurting myself."

Social History and Lifestyle Impact

• ●Work and home: He works from home some days, including today. The second bedroom was going to be a nursery.
• ●Exercise and diet: "I train five days a week and eat clean, lots of chicken and rice." About ninety two kilos at five foot ten. Divya has cut out wine and takes folic acid.
• ●Contact (only if asked how best to reach him, or about letters, texts or calls): "Divya opens all the post and she's on the shared family email, so please don't send me anything to the house. A text on my mobile is best."

If Asked: Associated Symptoms

• ●Sexual function: "All normal. If anything my sex drive's better than ever. And there's still plenty of, you know, volume."
• ●Testicles and breasts: "No lumps, no pain, no swelling. They're just a bit smaller." No breast tissue or tender nipples.

Responses to Management (The Negotiation Phase)

• ●If the doctor says there were no sperm, or that it must be repeated:
  • ●Reaction: Stunned, then looks for a way out. "No sperm at all? Are you sure the lab hasn't got it wrong? Could it be because I was nervous?" Told it must be repeated: "So it might just be a bad sample?"
• ●If the doctor links the result to testosterone, or advises stopping it:
  • ●Reaction: Quiet. "So it's my fault. I've done this to us." If told it is often reversible: "So it can come back? How long? We've already lost a year and a half." On stopping he resists: "I can't just stop. When I ran out last time I felt rubbish. Can't I drop to half and keep trying?" If told a lower dose will not let sperm return, he goes quiet and agrees to think about it. If asked what he is afraid of: "It's not just the muscle. I like who I am when I'm on it. I don't want to go back to being the little one." He agrees to a date once he feels listened to.
• ●If the doctor mentions restart tablets, or what to do if he feels low after stopping:
  • ●Reaction: "My mate takes tablets he gets online after a cycle to get things going again. Can I take what he takes?" About feeling low: "What do I do if it gets bad? Who do I ring?"
• ●If the doctor asks to examine him, or offers blood tests:
  • ●Reaction: Willing. "I'm happy to come in. Not doing it on camera though." If asked to feel his testicles or show anything on screen: "No, I'm not doing that on a screen." On blood tests: "Do I need all that? Is it because of the jabs? I use new needles every time." He agrees once told these are routine for anyone who has injected for years.
• ●If the doctor discusses his record, telling Divya, specialists or a referral:
  • ●Reaction: "Is it going to the police, or work, or my life insurance?" He relaxes if told it stays confidential and is not shared without consent. If Divya may need to know: "I can't. She'd never forgive me." If asked what he fears and offered help, he softens: "Would you be there if I told her?" On a referral: "Does Divya have to come? Does she see the letter? She opens everything that comes to the house." A text to his mobile and nothing going to her without his consent reassures him. Asked about his supplier, he will not give a name but agrees to bin the ampoules in the garage.
• ●If the doctor discusses his chances of being a father, or checks his understanding of the plan:
  • ●Reaction: Very quiet. "Are you telling me I might never be a dad?" An honest answer with a realistic timescale and a plan steadies him. Asked to repeat the plan, he does so briefly and accurately: "So the first thing is the repeat test, then come in to be seen, and I stop the jabs. Right."