When it comes to planning a family, you might take the sperm end of the equation for granted. This makes good sense, of course, because the majority of men have enough strong swimmers to fertilize female eggs. But for some couples, azoospermia, or a lack of sperm in the ejaculate, may stand in the way of conception. It is often an overlooked problem because most men with azoospermia have normal semen volumes but may not realize that there’s no sperm in their fluid.
Azoospermia means there’s no sperm or measurable sperm in a man’s ejaculate. Its causes include a blockage along the reproductive tract, hormonal problems, ejaculation problems or issues with testicular structure or function.
Many causes are treatable and fertility can be restored. For other causes it may be possible to retrieve live sperm to be used in assisted reproduction through specialised surgical procedures. For some couples, azoospermia, or a lack of sperm in the ejaculate, may stand in the way of conception.
According to the World Health Organization, a normal sperm count is considered to be 15 million/mL or more. Men with low sperm counts (oligozoospermia or oligospermia) have a sperm concentration of less than 15 million/mL. So if you have azoospermia, you have no measurable sperm in your ejaculate. Infertility affects about 1 in 4 couples and of this group, a significant proportion suffer from azoospermia. The rest of this group have either oligospermia (low sperm count or concentration), asthenospermia (slow swimmers) or both conditions together.
ortunately, if you’re trying to conceive, and you have azoospermia, it isn’t the end of the world. There are many treatment options available for men with this condition to become biologic fathers, so it certainly doesn’t mean there’s no hope.
There are two main types of azoospermia and they are defined as obstructive and nonobstructive. If you have the obstructive variety, it means that sperm is being produced inside the testicles but it’s somehow blocked and can’t get out.
The problem with the non-obstructive type of azoospermia lies in the non- production of sperm. Most cases are idiopathic or have unknown causes. For both kinds of azoospermia, there may be rare genetic causes that impair sperm production or transit.
The most common type of obstructive azoospermia is caused by a congenital absence of the vas deferens (or CAVD), which is the duct leading from the testis to the penis. Without this channel, sperm can not travel out the end of the penis and most men with it also carry the gene for cystic fibrosis.
Nonobstructive causes of azoospermia include a chromosomal abnormality such as Klinefelter syndrome, pituitary dysfunction resulting in low hormone production, and certain operations like prostate removal or a bilateral hernia repair.
Medical conditions like diabetes can cause reversal of the flow of semen or retrograde ejaculation. Cancer patients who need to undergo radiation and chemotherapy may develop azoospermia as these two treatments destroy the sperm-producing cells and are therefore advised to see an Onco-fertility specialist before commencing these treatments.
Also, any type of scrotal injury sustained in sports can harm the testes or epididymis, where sperm matures, leading to production or transport issues.
Be aware that excessive use of testosterone can result in a temporary, or even permanent, case of azoospermia. For diagnosis there aren’t any obvious symptoms, such as pain, that might indicate that you have azoospermia. The exception to this are those men who have low hormone levels. Males with Klinefelter syndrome will have other physical features typical of the syndrome that may include enlarged breast tissue, low energy levels, small genitals and above average height.
Azoospermia is most commonly diagnosed when a couple discovers they are unable to conceive. An analysis of the semen is the only way to determine whether this condition is present.
If there’s zero sperm, you may then be referred to a urologist who will further establish whether it is obstructive or nonobstructive. A blood test for follicle stimulating hormone (FSH) and testosterone and genetic tests will confirm the diagnosis. If FSH is elevated and the testis is small and soft, then this is typically a case of nonobstructive azoospermia.
If the FSH, testosterone, and testis are all normal and the ducts are missing or swollen with sperm that can’t get out, obstructive azoospermia may be the diagnosis.
Azoospermia is diagnosed when, on two separate occasions, your sperm sample reveals no sperm when examined under a high-powered microscope following a spin in a centrifuge. As part of the diagnosis, your healthcare provider will take your medical history, including fertility success or failure in the past (your ability to have children) and family history of birth defects, mental retardation, reproductive failure or cystic fibrosis.
The care for azoospermia depends on the cause. For the obstructive variety that is caused by complications due to sexually transmitted infections, or a hernia repair that injured the vas deferens. Surgery may be attempted in such cases (though success rate may not be particularly encouraging).
Obstructive azoospermia due to congenital missing ducts is treated by sucking out sperm microsurgically (sperm aspiration) and using it to fertilize your partner’s eggs retrieved by in vitro fertilization (IVF).
Avoiding sexually transmitted diseases, or at the very least getting early treatment of genital infections, may lower the risk of azoospermia. For men receiving cancer treatments, freezing sperm prior to treatment can preserve fertility even if future sperm production is compromised.
There are also prophylactic measures that can be taken to lessen testicular exposures in certain cases of radiation treatments for cancer. As stated, treatment of azoospermia depends on the cause. Genetic testing and counseling are often an important part of understanding and treating azoospermia.
Treatment approaches include:
If a blockage is the cause of your azoospermia, surgery can unblock tubes or reconstruct and connect abnormal or never developed tubes.
If low hormone production is the main cause, you may be given hormone treatments. Hormones include follicle-stimulating hormone (FSH), human chorionic gonadotropin (HCG), clomiphene, anastrozole and letrozole.
If living sperm are present, they can be retrieved from the testes, epididymis or vas deferens for assisted pregnancy procedures such as IVF with intracytoplasmic sperm injection (ICSI).
If the cause of azoospermia is thought to be something that could be passed on to children, your healthcare provider may recommend genetic analysis of your sperm before assisted fertilization procedures are considered.
There is no known way to prevent the genetic problems that cause azoospermia. If your azoospermia is not a genetic problem, lifestyle changes can help lessen the chance of azoospermia.
Every cause of azoospermia has a different prognosis. You and your healthcare team will work together to determine the cause of your azoospermia and treatment options. Hormonal problems and obstructive causes of azoospermia are usually treatable and fertility can potentially be restored. If testicular disorders are the cause, it’s still possible to retrieve live sperm to be used in assisted reproductive techniques.