A Guide to Azoospermia ( Zero Sperm Count in the semen)
Azoospermia is the name given to the condition in which there are no sperm in the semen. The semen looks normal, and the diagnosis is made only when is it is examined under a microscope in the lab.
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 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.
You can provide a sequential ejaculate ( a second semen sample 1 hour after the first). This will often contain a few sperm, even when the first does not, because it is "fresher".
Ask them to centrifuge the semen 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 ( hidden sperm) .
There are only 2 possible reasons for the count being zero. One is because of a blockage of the ducts which carry the 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. This is called non-obstructive azoospermia ( a mouthful, which simply means that the problem is not because of a block).
The testicular size ; and a blood test for FSH are useful tools for determining if you have obstructive azoospermia or non-obstructive azoospermia. If your testes are small in size; and if the FSH is high, your chances of having non - obstructive azoospermia are high.
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.
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 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.
There are 2 options for doing a testis biopsy or TESA ( testicular sperm aspiration) - diagnostic; or therapeutic. In a diagnostic TESE, the surgeon performs multiple diagnostic biopsies to determine if sperm are being produced in the testes or not. If no sperm are found , the diagnosis of complete testicular failure is confirmed; and treatment options then include adoption or donor insemination, since there is no treatment at present for this condition. If sperm are found, then these testicular sperm can be cryopreserved; and used for ICSI treatment in the future.
The advantage of doing a diagnostic TESE is that it is less expensive; and there is no need to give the wife expensive injections for superovulation. Unfortunately, the results with testicular sperm cryopreservation are poor in most labs; which means most men will need a repeat TESE if they want to use their sperm for ICSI. This involves a second TESE, after a gap of about 6 months. There is also a 20% risk that no sperm may be found in the second biopsy, since the first biopsy may have removed all the areas of sperm production.
In our clinic, rather than do a diagnostic TESE, we recommend that patients do a therapeutic TESE-ICSI treatment cycle. If we do find sperm, then these can be used for ICSI immediately, maximising the chances of success. If we do not find sperm, and if patients agree, then we can use donor sperm to fertilise the retrieved eggs. The problem arises if we do not find testicular sperm and the patient is not willing to use donor sperm. In this situation, the ICSI treatment cannot proceed any further. However, patients still have peace of mind that they did their best, and did not leave any stone unturned !
Using sperm from the epididymis and testis for ICSI in order to treat patients with obstructive azoospermia is logical, and thus conceptually easy to understand. However, surprisingly, it is possible to find sperm even in patients who have testicular failure ( nonobstructive azoospermia) - even in those men with very small testes. The reason for this is that defects in sperm production are "patchy"- they do not affect the entire testis uniformly
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