What is Azoospermia?
Azoospermia is when a man doesn’t have any sperm in his semen. The average man has 100–300 million sperm in his semen, but if a man has no sperm detected, it can be difficult for couples to get pregnant. Azoospermia can be diagnosed by performing at least two semen analyses. There are two types of Azoospermia:
- Obstructive Azoospermia (OA)
- Non-Obstructive Azoospermia (NOA)
In obstructive azoospermia, a man’s testes produce enough sperm, but there is a plumbing problem that prevents the sperm from traveling out of the testes and entering the ejaculate in the urethra/penis.
Obstructive Azoospermia Causes
- Vasectomy: The most common cause is when a man has a vasectomy, where the vas deferens, which carries sperm from the testicles to the urethra during ejaculation, has been purposefully cut in half. Men choose to get vasectomies as a form of birth control.
- Cystic Fibrosis (CF): Cystic fibrosis is a congenital lung disease that also affects fertility. Nearly all men with CF have a condition called congenital bilateral absence of the vas deferens (CBAVD), which is when both vas deferens do not develop. Although these transportation tubes are missing, the testes produce a normal amount of sperm in 90% of men with CF.
- Ejaculatory Duct Obstruction: Ejaculatory ducts are paired structures formed by the connection between the vas deferens and the seminal vesicle. These ducts allow for sperm from the vas deferens and fluid in semen from the seminal vesicles to enter the urethra. Blockage can be caused by congenital cysts that some men are born with or from inflammation and scarring from sexually transmitted infections.
- Surgical Complications: Men who have had bilateral hernia repairs can have blockage of or injury to the vas deferens, preventing the normal flow of sperm into the ejaculate.
- Phimosis: Narrowing of the foreskin that can block semen from coming out of the penis.
Obstructive Azoospermia Treatment Options
- Vasectomy Reversal: Most men who’ve had a vasectomy in the past can still conceive by having a vasectomy reversal (vasovasostomy or vasoepididymostomy).
- Testicular Sperm Extraction (TESE): TESE is a procedure in which testicular tissue with sperm is extracted either with a small incision or a needle. The sperm that is removed can be used for in vitro fertilization (IVF).
- Transurethral Resection of the Ejaculatory Ducts (TURED): Men who have ejaculatory duct obstruction can have a TURED, a small surgical procedure performed with a camera to remove this blockage and help sperm flow to the natural channels.
- Circumcision: Men who have a narrow foreskin(phimosis) that prevents the ejaculate from coming out of the penis can have a circumcision to remove the foreskin.
Non-obstructive azoospermia(NOA) is a common cause of male infertility in which men do not produce enough sperm to have a detectable amount in their semen.
Non-Obstructive Azoospermia Causes
Non-obstructive azoospermia can be sub-divided into pretesticular and testicular causes.
Pretesticular Non-Obstructive Azoospermia
These are conditions that disrupt the hormones a man needs for normal sperm creation.
- Hypogonadotropic Hypogonadism: This is a problem with the pituitary gland in the brain where it doesn’t make the hormones needed to create sperm or testosterone.
- Kallmann Syndrome: A genetic disorder characterized by hypogonadotropic hypogonadism and lack of sense of smell.
- Certain rare types of pituitary tumors
- Medications, such as testosterone supplementation or anabolic steroids
Testicular Non-Obstructive Azoospermia
These are conditions that prevent the testes from creating normal sperm.
- Varicoceles: Varicose veins in the scrotum, which can cause reduced sperm production in the testicle, but rarely leads to azoospermia.
- Bilateral Undescended Testicles (cryptorchidism)
- Testicular Cancer
- Gonadotoxins: Radiation, chemotherapy, and some industrial chemicals that are toxic to the testes.
- Sertoli-cell Only Syndrome: A condition in which a man has only Sertoli cells in the testes (cells that nurture immature sperm) and completely lacks sperm cells.
- Maturation Arrest: This is a condition in which a man’s sperm can only reach a certain, incomplete stage of development.
- Genetic Syndromes: An example is Klinefelter Syndrome, where a man has an extra X chromosome so they have XXY instead of XY.
Non-Obstructive Azoospermia Treatment
Regardless of the cause of non-obstructive azoospermia, the treatment approach is the same. We start with a semen analysis and a hormone panel (blood work). Treatment may include:
- Varicocelectomy: Surgical procedure to cut varicose veins in the scrotum.
- Drugs/Medications: If a man has a low bioavailable testosterone, *we usually start him on clomiphene citrate (Clomid), which can help raise testosterone levels and increase sperm production. Other hormone medications that can help are anastrazole (Arimidex), HCG, and FSH. One in nine men will have their sperm return to the ejaculate after taking medication to return their testosterone to the normal range. Even in cases where sperm doesn’t return to the semen, taking medication to normalize testosterone doubles the chances of finding sperm during a surgical sperm extraction procedure called microsurgical testicular sperm extraction (microTESE).
- Microsurgical Testicular Sperm Extraction (microTESE): Many men with non-obstructive azoospermia do not have sperm in their ejaculate but may produce small amounts of sperm in the testes. This surgical procedure can be performed to extract the tubules in the testes that may contact sperm.
*Note: bioavailable testosterone is different from the total testosterone that many labs check.