Dear Dr. G

I have a confession, and really hope you can solve the mystery of my missing gem.

I am 32 years old, married for the last three years, and have a two-year-old daughter. Since we are trying for another baby, my wife suggested we go for a medical check up.

In the previous check ups, the doctors tend to just do blood tests. On this occasion, the doctor insisted on examining my manhood.

In truth, I always notice having only one ball in the sac. The only person who knows about my lopsided secret in the pants is my wife, whom I told I lost my testicle during an accident.

The reality is that I didn’t have any accident, and I was just born with a missing gem in the pants.

The doctor did some scans and discovered my lost testicle is stuck in the canal in groin. He told me I should have no subfertility issues with one functioning ball. However, the cancer risk of my poor lost ball is substantial!

I was strongly advised to have the testicle removed to avoid getting cancer.

I would like to put Dr. G on the spot about the causes of undescended testicles.

How common is it? Is the cancer risk really that high?

As I really have no problem in bed and fertility, should I really go under the knife?

The man with missing gem

The absence of one or both testicles from the scrotal sac is termed cryptorchidism. The word cryptorchidism is derived from the Greek word, “Kryptos” meaning hidden; and “orchis” meaning testicles. In the normal development of a foetus, the testicles originate next to the kidneys, at the back of the abdomen. As the gestation progresses, the testicles descend into the scrotal sac via the inguinal canal. Undescended testicles occur when the “missing” testicle deviate or get stuck at any point along the path of descent. About two-thirds of cryptorchidism are one sided, and the rest are both sided. Most missing balls are traceable, as most of the cases are wedged and palpable in the inguinal canal. Though, small numbers of the testicles are stuck in the abdomen and found only by scans. Rarely is the gem truly hidden and nowhere to be found, even with sophisticated imaging.

The medical literature reveals about 3% of full-term and 30% of premature infant boys are born with undescended testis. Despite being born with hidden testicles, 80% of children with cryptorchidism will have the natural descend by the first year of life, without intervention. In reality, this translates to less than 1% of male populations having true incidence of cryptorchidism in adulthood.

Men with one missing gem have a theoretical risk of compromised fertility. In reality, the reduction of sperm quality is only ranging from 6% to 10%, therefore men with unilateral undescended testicle generally do not experience overall subfertility or sexual dysfunction. On the other hand, the reduction of sperm quality can be as high as six-fold in men with bilateral undescended testicles. Early surgical correction is usually encouraged to preserve fertility. The other good news is that boys who had the operation also developed into fairly well adjusted adulthood without gender or sexual problems, despite having one ball smaller than the other.

About one in 500 men born with one or both undescended testicles, is known to be at risk to develop testicular cancer. In addition, the risk is higher when the testicle is stuck in the abdomen.

The New England Journal of Medicine reported in 2017 that surgical rectification for undescended testicle performed before puberty has significant reduction in the risk of cancer. Therefore, men who lived into adulthood with the testicles still stuck in the abdomen or the groin, removal instead of corrected surgery is usually advised.

The balancing act of delivery with both testicles to their rightful place of the scrotal sacs involves intricate processes, influenced by both maternal and fecal factors. It is not uncommon for testicles to be “missing in action” at birth and deviate from their normal path of development. The natural process of maturation or the surgical intervention at infancy can ensure the gems get back in the cooling sacs, ensuring precious purposes of procreation and recreation.

The Roman Stoic philosopher and statesman, Lucius Annaeus Seneca once said: “A gem cannot be polished without friction, nor a man perfected without trials.”

For men who managed to survive into adulthood with one missing ball, but still managed to procreate and recreate, putting Dr. G on the spot on whether to part with his missing gem in the pants. His advice is: “An adult ball missing in the sac is as worthless as the unpolished gem, the friction of getting rid of missing gem is the only treasure to ensure a non-perfected man without the trial of testicular cancer!”

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