Azoospermia is a condition in which a man’s ejaculate contains no sperm. It can be caused by a blockage in the reproductive tract, hormonal issues, ejaculation issues, or structural or functional issues with the testicles. Many causes of infertility can be treated, and fertility can be restored. It may be possible to retrieve live sperm for use in assisted reproductive techniques for other reasons.
Azoospermia is a condition in which a man’s ejaculate contains no detectable sperm (semen). Male infertility is caused by azoospermia.
Male infertility can be caused by this condition. To achieve pregnancy, assisted reproductive technology may be used. For artificial insemination, sperm can be surgically extracted or provided by a donor.
What is “azoospermia”?
Azoospermia – When there are no sperm in the ejaculate, the medical term is azoospermia. It can be “obstructive,” meaning there is a blockage preventing sperm from entering the ejaculate, or “nonobstructive,” meaning the testis is producing less sperm.
Is azoospermia common?
Yes. Around 10 percent of infertile men and 1 percent of all men have azoospermia. Imagine a stadium with 50,000 men attending a game — around 5,000 to 7,500 of those men will have infertility, and 500 of those men will be azoospermic!
What causes azoospermia? What is the most common cause of azoospermia?
We know of many potential causes, including some genetic conditions such as Klinefelter’s syndrome, medical treatments such as chemotherapy or radiation, recreational drugs such as some narcotics, and anatomical abnormalities such as varicoceles or absence of the vas deferens on each side. Perhaps the most obvious cause would be a vasectomy, which prevents sperm from joining other fluids in the ejaculate. In most cases, though, azoospermia is likely due to factors we don’t fully understand, such as genetic conditions, poor testicular development as a fetus/child or environmental toxins.
Vasectomy: The most common cause of obstructive azoospermia is from a vasectomy. The vas deferens, which carries sperm from the testicles to the urethra during ejaculation, has been purposefully cut in half during a vasectomy.
I had a semen analysis showing azoospermia — what should I do?
Aside from seeing a specialist in male infertility, the first step would be to get a repeat semen analysis at a lab that has a lot of experience doing semen and sperm tests, because results can vary a lot from test to test and lab to lab. Also, having small numbers of sperm can change the management/treatment options drastically, so the first step should be getting proper confirmation of the finding.
Can we tell whether it is due to a blockage problem versus a “factory” problem?
Not with 100 percent accuracy, but we have some good indicators. First, a very careful physical exam is crucial to assess the reproductive structures. In addition, lab tests such as FSH and inhibin B can give an indication of testicular function.
Does having azoospermia mean that the testis makes no sperm?
Not necessarily. The testis can be making sperm, but it might not be enough to have any noticeable amount come out in the ejaculate.
Should azoospermic men undergo a diagnostic testis biopsy?
Previously, almost all men with azoospermia had a biopsy to differentiate between obstructive and nonobstructive causes and to get a more specific diagnosis. In today’s world, however, biopsy is rarely used alone. We can usually tell whether a man has an obstructive cause of azoospermia with a high degree of accuracy.
We’ve learned that different areas of the testis may show different patterns of nonobstructive azoospermia since we started performing testicular dissections to look for sperm. For example, one area may have decreased mature sperm production (hypo spermatogenesis or maturation arrest), while another may have no sperm precursor cells at all (Sertoli-cell-only syndrome). As a result, in the modern era, performing a diagnostic biopsy for men with nonobstructive azoospermia does not always result in a different treatment plan.
We offer microdissection testicular sperm extraction (microTESE) for those men, which gives them the best chance of finding sperm that can be used in assisted reproductive technologies (ART). We may send a small sample for pathological evaluation at the time of the microTESE to rule out a precursor to malignancy called intratubular germ cell neoplasia (ITGCN).
What treatments are available? What is the best treatment? How do I get rid of azoospermia?
Of course, the best treatment for any given patient is a customized approach based on many factors, including the age and reproductive function of the partner, physical exam findings, blood test results, long- and short-term family goals, and even finances. Many treatments may be available depending on the suspected causes. For some men, reconstruction may be the best option if there is a blockage (or a history of vasectomy).
In some cases, the first step may be to eliminate offending agents such as medications or recreational drugs. There may be hormonal issues that need to be addressed, and treatment may increase sperm production in a small percentage of men.
In some men, surgery to correct anatomical abnormalities or varicoceles is an option, while in others, going directly into the testicle to retrieve sperm for ART is the best option.
It’s critical that these procedures are carried out by a select group of doctors who have the necessary training, expertise, and experience to ensure the best possible results and chances of sperm retrieval. Finally, men with azoospermia should remember that by using donor sperm or adopting an infant or child, countless couples around the world have created families filled with unsurpassed happiness and love. After being evaluated (see below why it is so important to be evaluated), these are completely acceptable paths for couples to choose.
Isn’t testosterone made by the testis? Can a man have normal testosterone and be azoospermic?
Yes and yes. Sperm come from “germ cells” in small tubules within the testis. Testosterone comes from “Leydig” or “interstitial” cells in between the tubules. Since Leydig cells are more resilient than germ cells, they will often function partially or fully, even in a damaged or poorly formed testicle.
Why should men with azoospermia be evaluated and counseled by a specialist?
After getting a diagnosis of azoospermia, men are undoubtedly concerned about their chances of starting a family, but often they do not think about the potential relationship of infertility to their general health. However, studies have found significant medical conditions (including cancer) in up to 6 percent of infertile men who were thought to be healthy, and the risk seems to correlate with semen and hormonal abnormalities. More importantly, evaluation by a specialist is imperative to rule out any dangerous underlying medical conditions, to help couples optimize their chances of building the family they desire and to give guidance regarding risk and screening for medical conditions later in life.
What procedures are used to retrieve sperm?
For men with obstructive azoospermia, there is often an abundance of sperm within the reproductive structures, and various procedures can be used to obtain sperm. These include testicular sperm extraction, testicular sperm aspiration, microsurgical epididymal sperm aspiration, and others. The choice is based on both patient factors, patient priorities, and the preferences of the reproductive endocrinologists. For men with nonobstructive azoospermia, various approaches are available, but the procedure most likely to find usable sperm for use with in vitro fertilization and intracytoplasmic sperm injection is micro test. When performed by an experienced expert in the field, this procedure involves careful dissection through the tubules of the testis to search for the tissue most likely to be actively making sperm. This allows for maximum yield of sperm with maximum preservation of other tissues in the testis, including the Leydig cells that produce testosterone.
Success story of Azoospermia And Severe OAT (Male Infertility) conceived through IVF- ICSI
Successfully helping a couple with Azoospermia and Severe OAT conceive their own biological child
A couple visited Nova IVF Fertility, Chennai to consult about their fertility issue with Dr. Madhupriya. Both husband and wife were initially advised to undergo routine fertility tests. The wife’s cycle and hormonal analysis were normal, but the husband’s semen analysis revealed a case of Azoospermia and severe OAT. The male had very few motile sperms.
Understanding Azoospermia and Severe Oligoasthenoteratozoospermia (OAT)
Men who don’t have any sperm in their semen suffers from a condition called Azoospermia. It impacts about 1% of men and it can be the reason for infertility for about 15% of infertile men.
Such men will not be able to use their own semen to make their partner pregnant unless they are treated for the specific cause and get it rectified. If nothing works out, another potential treatment choice is to use a sperm donor.
One of the possible reasons for Azoospermia is the testicles being unable to make sperm or a condition that prevents sperm from getting out of the body.
There are three main types of Azoospermia:
- Pretesticular Azoospermia: Testicles are normal, but not producing any sperm. It is a very rare condition that might happen because of low hormone levels or after chemotherapy.
- Testicular Azoospermia: Damage to testicles stops them from making sperm normally. It can happen because of an infection in the reproductive tract, such as epididymitis and urethritis or a childhood illness such as viral orchitis, causing swelling of one or both testicles. Additional causes include a groin injury, Cancer or its treatments, like radiation and genetic conditions, such as Klinefelter’s syndrome.
- Post-testicular Azoospermia: Testicles make normal sperm, but something prevents from getting out, e.g. vasectomy, a blockage, (called obstructive Azoospermia) impacting the tubes that carry sperm from testicles to penis or retrograde ejaculation, in which the semen goes back into the bladder instead of out of the penis. About 40% of men with Azoospermia have the post-testicular type.
Diagnosis involves testing of sperms, and if there is a complete absence of sperms, the medical history is checked, and physical, and blood tests are conducted to check the hormone levels. If hormone levels are normal, a scrotal or transrectal ultrasound is performed to look for obstruction(s) in the vas deference. An MRI may confirm the diagnosis. Sometimes, surgery is the only way to locate the obstruction. If there is no blockage, genetic tests are required to identify genetic conditions.
Treatment options for Azoospermia include treatment with certain hormones, coaxing sperm back to semen or increasing the likelihood of finding sperm during extraction. These hormones include Follicle-stimulating hormone (FSH) and Human chorionic gonadotropin (HCG).
Sperm retrieval is performed for men with non-obstructive Azoospermia or those who have a blockage but don’t want surgery. A tiny needle is used to draw sperms directly from the testicle and the sample subsequently frozen for use later for IVF treatment.
Oligoasthenoteratozoospermia (OAT) is a condition that includes oligozoospermia (low number of sperm), asthenozoospermia (poor sperm movement), and teratozoospermia (abnormal sperm shape). OAT is the commonest cause of male subfertility.
Treatment Suggested by Dr. Madhupriya, Fertility Specialist
The patient was advised an option of pulling motile sperm from the ejaculate or a testicular aspiration if needed. They were counselled to go ahead with ICSI after subjecting the sperm to HOS and selecting the motile sperm.
Hypo Osmotic Swelling (HOS) Test
The hypo osmotic swelling (HOS) test is a relatively new assay used to evaluate the functional integrity of the sperm’s plasma membrane and useful addition to routine semen analysis. This is a good sperm indicator that can help manage fertility outcomes better.
Factors monitored in the HOS test include progressive motility, morphologically normal spermatozoa, percentage of swelling with the hypo‐osmotic test. The hypo‐osmotic test provides a simple evaluation of membrane function and the results obtained show that those with low swelling scores (<40%) to be of doubtful fertility.
Intracytoplasmic Sperm Injection (ICSI)
Intracytoplasmic sperm injection is an IVF procedure in which a single sperm cell is directly injected into the cytoplasm of an egg. This technique is used for preparing the gametes to obtain embryos which can be transplanted into the maternal uterus. The most important indicator of ICSI success is the fertilisation rate achieved. Typical fertilisation rates are exceptional and in the ranges of 80 to 85 per cent. In this process, one selected sperm is injected into the cytoplasm of an individual oocyte (egg).
Apart from an exceptionally high fertilisation rate, an added advantage of this procedure is that a clean and washed sperm sample can be prepared using multiple techniques in order to eliminate poor quality sperm, thereby using a very high-quality sperm for IVF.
Successful Treatment Outcome
IVF cycle was initiated for the lady. Sperm sample was retrieved through the aspiration technique and was subjected to the washing procedure. The HOS positive sperms were used for carrying out the ICSI procedure and injected into the cytoplasm of the twenty eggs that were retrieved from the female partner.
9 of these eggs were fertilised, and 2 blastocysts were formed. Both the blastocysts were transplanted into the uterus of the lady.
The couple sub sequentially conceived with twins. Everything went well, as expected, during the pregnancy period, and the couple was blessed with their own biological twins.
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Reference: Cleveland Clinic
