Azoospermia , as the
name suggests , refers to the condition in which there
are no sperm in the semen. This diagnosis can come as
a rude shock, because most men with a zero sperm count
have normal libido; normal sexual function; and their
semen looks completely normal too. The diagnosis can
only be made by examining the semen under a microscope
in the laboratory.
Azoospermia needs to be differentiated from aspermia,
or the absence of semen. This is a rare condition, in
which the man cannot produce a semen sample, because
he cannot ejaculate. This could be because of a psychologic
problem called anejaculation;
or a medical problem called retrograde ejaculation,
in which the semen is discharged backwards into the
urinary bladder, rather than forwards.
If the lab report shows azoospermia, please ensure
that you have in fact ejaculated properly. It's also
a good idea to repeat the semen analysis it again from
an independent lab. The laboratory should be also
requested to centrifuge the sample and check the pellet
for sperm precursors. Some men will have occasional
sperm in the pellet, which means they are not really azoospermic.
This is called cryptozoospermia.
There are only 2 possible reasons for the sperm count
being zero. One is because of a blockage of the ducts
which carry the sperm from the testes to the penis.
This is called obstructive azoospermia, because it is
a result of a block in the reproductive ducts ( passage).
The other is due to testicular failure, in which the
testes do not produce sperm. This is called non-obstructive
azoospermia ( a mouthful, which simply means that the
problem is not because of a block).
Men with obstructive
azoospermia have normal testes which produce sperm normally,
but whose passageway is blocked. This is usually a
block at the level of the epididymis, and in these
men the semen volume is normal; fructose is present;
the pH is alkaline; and no sperm precursor cells are
seen on semen analysis. On clinical examination, they
typically have normal sized firm testes, but the epididymis
is full and turgid.
Some men have obstructive azoospermia
because of an absent vas deferens. Their semen volume
is low ( 0.5 ml or less); the pH is acidic and the fructose
is negative. The diagnosis can be confirmed by clinical
examination, which shows the vas is absent. If the vas
can be felt in these men, then the diagnosis is a seminal
vesicle obstruction.
Men with non-obstructive azoospermia
have a normal passageway, but abnormal testicular function,
and their testes do not produce sperm normally. Some
of these men may have small testes on clinical examination.
The testicular failure may be partial, which means that
only a few areas of the testes produce sperm, but this
sperm production is not enough for it to be ejaculated.
Other men may have complete testicular failure, which
means there is no sperm production at all in the entire
testes. The only way to differentiate between complete
and partial testicular failure is by doing multiple
testicular micro-biopsies to sample different areas
of the testes and send them for pathological examination.
Sometimes the clinical examination can provide useful
clues as to the reason for the azoospermia. Rarely,
the reason for the testicular failure is because of
inadequate production of the gonadotropin hormones from
the pituitary ( a condition called hypogonadotropic
hypogonadism). Most hypogonadotropic patients are hypogonadal
- that is, they have low levels of the male hormone,
testosterone. This means they have poorly developed
secondary sexual characters; an effeminate appearance,
scanty hair, decreased libido, and small flabby testes.
This can be confirmed by blood tests which show low
levels of FSH and LH.
A clinical examination can also provide useful clues.
Thus, mean with obstructive azoospermia will typically
have normal sized, firm testes, with an epididymis which
is swollen and turgid because it is full of sperm.
Analysing the semen analysis report carefully can often
provide clues as to the reason for the azoospermia.
Thus, if the volume is low ( less than 1 ml; the pH
acidic; and the fructose negative), this means the seminal
vesicles are blocked or absent, a condition often found
in men with congenital absence of the vas deferens.
If the vas can be felt on clinical examination, this
means the man may have a seminal vesicle obstruction.
The presence of sperm precursors in the semen means
that the problem is not because of a block.
It is also a good idea to give a second sample within
1 or 2 hours after the second. This is called a sequential
ejaculate; and in some men who have non-obstructive
azoospermia because of partial testicular failure, there
may be no sperm in the first ejaculate, but there will
be some in the second, because it is "fresher".
For most men with a confirmed diagnosis of azoospermia,
the next test is a testis
biopsy to determine what the reason for the
azoospermia is, so that an appropriate treatment plan
can be formulated.
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