Jamie* and Alex* are a young couple starting out their married life. They came to see me shortly after Jamie completed his treatment for testicular cancer about 2 years ago. He had banked sperm at the local fertility clinic before starting treatment and asked to see me to learn more about what they would need to do to start a family. He described his experience at the fertility clinic as one of the most embarrassing of his life but now, 2 years later, his treatment a success, he could laugh about it. He recounted that Alex wanted to come with him to “help” the process along but the receptionist at the clinic was not at all pleased with the idea and relegated Alex to the waiting room with a no-nonsense stare. He could not recall the information that he had been given at the initial consultation with the fertility specialist. It was all a blur—he had just been diagnosed with cancer and he had to hurry to make the “donations” before treatment started. And there was the embarrassment issue that effectively made hearing and understanding impossible. And they couldn’t find the printed material they have been given at the clinic because they had moved three times since then and some of their possessions got lost in the process.

I went through the options with the couple. The protocol at this clinic was to always do intra-cytoplasmic sperm injection (ICSI) to maximize the potential for conception when there is a limited supply of sperm. This is expensive and I am upfront and honest with patients about the costs of fertility preservation and even more so about the costs of using the banked tissues. At the time, Jamie and Alex decided that they would try to do things naturally. Alex had accepted a position as a teacher in a small rural community about 3 hours north of the city and Jamie was finishing up a contract with an IT start up, so they would be living separately for a while and then looking for a job for him closer to where Alex was teaching.

I didn’t hear anything from Jamie for about another year. This time when he came to see me, he was feeling less confident in their ability to conceive. A whole year had gone by and nothing had happened. They only saw each other at weekends; Jamie had not been able to find work in the town where Alex was teaching so he had taken a job in the city, and they were living separately for now during the week so they could both work and catch up financially. Jamie did not relish the idea of having to shell out thousands of dollars to pay for ICSI but what could he do? We decided that the next step should be a semen analysis; this was the most logical strategy given that they had been trying for over a year to conceive. If his sperm count was low, at least they would know what they were dealing with. If his sperm count and other parameters were normal, then perhaps their failure to conceive was due to their living arrangements and poor timing.

Two days later I received the results of the semen analysis. They could not find a single sperm in the sample.

I have had to break bad news to many people over the years of my career. I have told young men that they are HIV-positive and witnessed their world fall apart with the few words that I uttered. I have told women in the throes of labor that their baby had inexplicably died some time between yesterday when they felt fetal movement and today when we could not find a heartbeat. The tears in my eyes reflected the wails that came out of their mouths. Bad news is something that we in health care are practised in telling, but I for one have never gotten used to the telling.

I called Jamie as soon as I read the report.

“I’m so sorry to tell you this, Jamie, but they could not find any sperm in your sample…”

And in the silence that followed as he heard the words, I could hear their world shatter. That’s why we call it “breaking” bad news.

*Names and identifying details changed for privacy.