Diagnosis and Treatment of Azoospermia

Azoospermia is the term used to denote the male medical condition when there is no sperm content in the semen. However, apparently, the semen looks absolutely normal and it ejaculates in the way it is meant to. As the male experiences orgasm in sexual intercourses or on other situations of sexual excitements, the semen gets released in a normal manner. The abnormality can only be analysed and examined under a microscope in the laboratory. The diagnosis of Azoospermia can come as a rude shock to most men who have a normal libido and sexual function, yet a zero count of sperm. Yes, men with usual sexual appetite and standard semen release can also suffer from the syndrome of Azoospermia.

We have to understand that there is a difference between Azoospermia and Aspermia. Aspermia is the condition where the man cannot produce samples of semen at all. To be more specific, the person is not able to ejaculate. Such person might have a normal sexual urge and interaction, but do not release semen on orgasm. The reason behind such abnormality is a psychological problem called anejaculation. This is a medical problem known as the retrograde ejaculation, where the semen is discharged backward towards the urinary bladder instead of flowing forward.

If your laboratory test report discloses azoospermia to you, it is advised to take a second opinion. One thing that is ensured by this test result is that that you ejaculate properly. This is a good sign. It is wise to repeat the semen analysis from another independent laboratory. Request the laboratory to centrifuge the semen sample and check the pellet to find out the traces of sperm precursors. On rare occasions, the sperm is located in the pellet. This confirms that you are not azoospermic but suffering from a syndrome called cryptozoospermia.

There could be two reasons for zero sperm count in a semen sample. It can happen due to the blockage of the ducts connecting the testes to the penis. This syndrome is known as obstructive azoospermia since it occurs due to the blockage of the reproductive ducts. The other reason for azoospermia is testicular failure. This is known as non-obstructive azoospermia since there is no problem of any sort of blockage.

The testicular size along with the blood test report for FSH determines the occurrence of obstructive azoospermia or non-obstructive azoospermia. In case the testes are small in size and FSH is high, the chances of non – obstructive azoospermia are higher.

In case of obstructive azoospermia, testes produce sperm normally but it cannot come out due to the blockages in the passageway. The block is usually at the level of the epididymis. The volume and fructose content of semen in these men are normal. There are no sperm precursors cells present in the semen.

Men suffering from obstructive azoospermia do not have vas deferens. The volume of semen volume is also low. It is calculated to a level of 0.5 ml or even less. The pH level of the semen is acidic with negative fructose content. Clinical examinations confirm the presence of vas is absent. In case the vas is present, the diagnosis is a seminal vesicle obstruction.

Men suffering from non-obstructive azoospermia have a normal passageway. Their testicular function is however abnormal and their tests fail to produce sperm normally. These men mostly have small testes on clinical examination. The partial testicular failure can be a reason for such abnormality. Few areas of the testes might still be able to produce sperm. However, the sperm production is very low and not at all enough for ejaculation. Some men suffer from complete testicular failure. There is zero sperm production in the entire tests. Doctors differentiate between complete and partial testicular failure by executing series of testicular micro-biopsies of samples of various areas of the testes. The samples are sent to the pathological laboratory for proper examination.

Clinical examinations provide useful information regarding the cause of azoospermia in a person. The causes of testicular failure are rarely due to the inadequate secretion of the gonadotropin hormones by the pituitary. This rare condition is known as hypogonadotropic hypogonadism. Almost every male suffering from hypogonadotropic patients are hypogonadal. This means the level of the male hormone, testosterone is low in them. These men usually have poorly developed sexual characters, scanty hair, effeminate appearance, reduced libido, and small testes. The levels of FSH and LH can be confirmed by blood tests.

A clinical examination also brings forward useful information. Men with obstructive azoospermia have normal sized, firm testes, and a swollen and turgid epididymis.

The semen analysis report discloses the reason for the azoospermia. If the volume of semen is below 1 ml, acidic and contains zero fructose, the seminal vesicles are either blocked or absent. This condition is commonly noticed in men with congenital absence of the vas deferens. In case the vas is found to be present in the clinical examination, the man may be suffering from a seminal vesicle obstruction. If the sperm precursors are present in the semen, the problem is not caused due to any blockage.

It is better to give a second sample to the laboratory after a couple of hours of the first sample. This is known as sequential ejaculation. Men having non-obstructive azoospermia due to partial testicular failure may not have sperms in the first session of ejaculation but might have in the second attempt.

The next test for men with a confirmed diagnosis of azoospermia is a testis biopsy. This test determines the actual cause of azoospermia and help in formulating an appropriate treatment plan.

There are 2 ways of testis biopsy or testicular sperm aspiration, commonly known as TESE. These are:

1. Diagnostic; or

2. Therapeutic

The diagnostic TESE includes multiple diagnostic biopsies that ascertain the production of sperm in the testes. In case of zero sperm content, the diagnosis of complete testicular failure is confirmed. The remedy for such abnormality includes either adoption or donor insemination as there is no treatment till date for this condition. In case sperm is found, the testicular sperm is cryopreserved (frozen and stored) and used in future for ICSI treatment.

There are monetary benefits related to going for a diagnostic TESE. In this procedure, the wife is not given expensive injections to enhance her ovulation. Unfortunately, the results of testicular sperm cryopreservation are not accurate in most laboratories and require to be done again after a gap of about 6 months.

In most reputed IVF clinics, consultants go for a diagnostic TESE. A therapeutic TESE-ICSI treatment cycle is recommended for the patients after the diagnosis. If sperm is found, those are immediately used for ICSI to achieve maximised chances of success. In case there is no sperm content in the semen, patients are recommended to use donor sperm in order to fertilise the retrieved eggs in the IVF cycle. There are a number of quality sperm donors who can be used for such purpose. In case there is neither any testicular sperm present in the semen nor the patient is not willing to use donor sperm, the doctors cannot proceed with the ICSI treatment any further. We usually counsel the patients under such circumstances to help them decide wisely.