What Is Azoospermia?
About 1% of males in the general population suffer from azoospermia or lack of sperms in semen. Azoospermia can be due to either,
-
Post testicular azoospermia - A block in the reproductive tract (obstructive azoospermia).
-
Pre testicular and testicular azoospermia - Lack of production in the testis (non-obstructive azoospermia).
Usually, it is diagnosed when a couple presents to an andrologist for evaluation of infertility, generally after one year of marriage. When there is no sperm seen in microscopic examination of semen on at least two occasions, azoospermia is diagnosed.
A properly focused history, physical examination, and hormonal analysis are undertaken by the andrologist to find out the cause for azoospermia. Transrectal ultrasonography is sometimes required to diagnose obstructive azoospermia. Obstructive azoospermia may be congenital (from birth) or acquired from infections, vasectomy, etc
What Are the Causes of Azoospermia?
Each type of azoospermia has specific causes and associated conditions. The overall genetic conditions affect the Y chromosome in about 10 to 15 percent of no or low sperm count cases.
1. Pre-Testicular Azoospermia:
Certain genetic disorders may bring about this non-obstructive type. For example, Kallmann syndrome is a genetic disorder that affects the body to produce gonadotropin-releasing hormone (GnRH) and, in turn, impacts sperm production. In addition, problems with the brain, especially damage to the pituitary gland or hypothalamus, may cause this type of azoospermia. Certain medications or undergoing radiation treatments for cancer can also cause this condition.
2. Testicular Azoospermia:
It is also called as non-obstructive type, and it may happen due to:
-
Testicles that are still not dropped (cryptorchidism).
-
Absence of testicles (anorchia).
-
Testicles that do not have mature sperm (spermatogenic arrest).
-
Testicles that do not produce sperms (Sertoli cell-only syndrome).
-
Klinefelter syndrome in which a person is born with XXY chromosome instead of XY.
-
Mumps in late puberty.
-
Radiation.
-
Tumors.
-
Reactions to certain medications.
-
Prior surgery.
-
Varicocele (dilatation or widening of the veins coming from testicles).
3. Post-Testicular Azoospermia:
It is an obstructive type that is present in 40 percent of azoospermia cases. Obstruction occurs due to a missing connection in the vas deferens tubes or epididymis that move and store sperm. In some cases, congenital conditions also cause obstruction. For example, a bilateral congenital absence of the vas deferens is a hereditary condition where the vas deferens tubes that carry sperm from the testes may be absent. It is also associated with having or carrying genes for cystic fibrosis. Other obstructive azoospermia causes include cysts, injury, previous or current infection, or vasectomy.
What Are the Symptoms of Azoospermia?
There will not be any symptoms, or the person will not even know they have azoospermia until the efforts to conceive are unsuccessful. The signs and symptoms encountered may be in relation to the underlying causes, like hormonal imbalances or chromosomal genetic conditions. The other possible symptoms are:
-
Erectile dysfunction.
-
Low sex drive.
-
Swelling around the testicles.
-
Lump on the testicles.
-
The decreased growth of hair on the face or body.
How Is Azoospermia Diagnosed?
Medical History:
A complete evaluation is done with a complete medical and surgical history, along with history of childhood illnesses, genital trauma, medications, allergies, and an inspection of past infections, such as sexually transmitted diseases. It is important to assess gonadotropin exposures and prior radiation therapy or chemotherapy. In addition, male infertility cases may be a consequence of a serious or potentially fatal disorder. Thus, it is always important to recognize because infertility may be the initial manifestation of a severe medical condition.
Physical Examination:
A general physical examination is an essential part of the evaluation of an individual with azoospermia, and the patient should be examined in the supine and standing position in a warm room.
Endocrine Evaluation:
An endocrinologic evaluation of patients who have severe male factor infertility leads to specific diagnosis and treatment strategies in a large population of infertile men. Routine screening of the male hypothalamic-pituitary-gonadal axis, endocrine screening of men with sperm counts of less than 10 million/mL based on serum testosterone and FSH levels alone will detect the vast majority of clinically significant endocrinopathies. If the testosterone level is low, a complete evaluation will be necessary to analyze total and free testosterone, luteinizing hormone (LH), prolactin and estradiol levels.
Semen Analysis:
Azoospermic patients with an average ejaculate volume may have obstruction of the reproductive system or abnormalities in spermatogenesis. Azoospermic men with a low semen volume and normal-sized testes may have ejaculatory dysfunction or ejaculatory duct obstruction. All patients presenting with absent ejaculation or low-volume ejaculation (<1.5 ml) should be asked to repeat the semen analysis and provide a post-ejaculation urine specimen.
Diagnostic Testis Biopsy:
Testicular histology is the only definitive way to diagnose azoospermia. However, the pattern of the testis tissue is heterogeneous, and spermatogenesis most often occurs only in focal areas; therefore, a biopsy is rarely used as a diagnostic tool. Usually, testicular characteristics and laboratory findings are suggestive of nonobstructive azoospermia. A normal testicular biopsy is pathognomonic for obstruction, and a vasography should be indicated to identify the site of the obstruction.
How Is Azoospermia Treated?
Obstructive azoospermia is treated with microsurgery or endoscopic surgery based on the level of the block. Alternatively, sperm retrieval with assistive reproductive technology can be used based on the couple's wish or when an andrologist who can perform microsurgeries is not available. Obstructive azoospermia has a better prognosis than non-obstructive azoospermia. Sperm retrieval is possible in nearly 100% of these men. The cause and prognosis of non-obstructive azoospermia are delineated by genetic evaluation with Y-chromosome microdeletion analysis and karyotype testing.
Even when there are no sperms in ejaculated semen, sperms can be found in up to 50-60% of these men. These are obtained by a microsurgical procedure called Micro-TESE (Testicular Sperm Extraction). In this procedure, the andrologist opens the testis under a surgical microscope and searches for the tubules which potentially contain sperms. Once sperms are found, these can be injected into eggs retrieved from the wife through ICSI (Intracytoplasmic Sperm Injection). Thus, even men without sperm in semen can father their child with the help of recent technologies and expertise.
Conclusion:
When you have been diagnosed with azoospermia or a low or no sperm count, it may be scary. This condition does not mean that you cannot have biological children. Firstly, it is important to consult with a doctor and know the underlying cause, which will help in identifying the different treatment options available to correct the blockage. If these treatment modalities fail, then procedures like in vitro fertilization can help you in achieving pregnancy with your partner.
