What is Azoospermia? Causes and Treatments

Azoospermia is a medical term used when there is no sperm in the ejaculate or zero sperm in men. In men, azoospermia can be either obstructive or non-obstructive. If the azoospermia is due to obstruction in the sperm ducts, it is called obstructive azoospermia, and if the sperm count is low due to the reduction of sperm production by the testicles and due to hormonal problems and the effect on sperm production by the testicles, it is called non-obstructive azoospermia.

Is azoospermia a common problem?

About 10% of infertile men and 1% of all men are azoospermic. Imagine a stadium where 50,000 men attend a game; about 5,000 to 7,500 of these men are infertile, and 500 of these men are azoospermic.

Does azoospermia mean that the testes do not produce sperm?

Azoospermia does not mean this; rather, its correct meaning is that the testicle can make sperm, but a significant amount of it may not be released from the semen and zero sperm will be shown in the spermogram.

Causes of azoospermia

Among the causes of azoospermia, or zero sperm, we can point out the lack of sperm production by the testicles due to the presence of various problems or the sperm not being removed from the male body. To better understand the causes of azoospermia, it is best to first know the types of azoospermia. There are three types of azoospermia:

Pre-testicular azoospermia: In this type of azoospermia, the testicles are normal, but they cannot produce sperm. This may happen due to low hormone levels or after chemotherapy. This type of azoospermia is very rare.

Testicular azoospermia: In testicular azoospermia, damage to the testicle disrupts the normal process of sperm production. This issue can be due to:

• The presence of damage in the male reproductive system, such as epididymitis and urethritis (inflammation of the sperm tubes or ductal disease).

• Getting a disease as a child, like viral orchitis (viral inflammation of the testicle), which makes one or both testicles swell.

• impact and damage to the groin area of the thigh.

• Suffering from cancer or its treatment, such as radiotherapy

• or the presence of genetic disorders such as Klinefelter syndrome. As a result, all these factors are the causes of testicular azoospermia.

 

Azoospermia after the testes: In this type of azoospermia, the testes produce normal sperm, but there is an obstacle to their exit in the male reproductive system. Among the factors that prevent sperm from leaving the male body, the following can be mentioned:

Obstruction in the tubes that transport sperm from the testicles to the penis, which is called obstructive azoospermia,

Performing a vasectomy

During an orgasm, sperm can move from the penis to the bladder instead of leaving the penis. This is called retrograde ejaculation.

About 40% of people with zero sperm are of the post-testicular type.

How to diagnose azoospermia?

First, by repeating the sperm test, the doctor is sure that the person has zero sperm. This test can be easily done at home or in the laboratory. Since the duration of sperm's survival and activity outside of body temperature is not long, the collected sperm must be brought to the laboratory within 30 minutes.

In the next step, the type of azoospermia should be determined. In general, the following methods are used to detect the above cases:

• Examining the history of the patient (occupation of the patient, medications, addiction)

• Patients' visits and physical examinations

• Examination of spermogram tests

• Radiological examinations

• A sampling of the testicles (biopsy)

• Measuring the level of hormones such as testosterone and checking secondary traits

• History of chemotherapy

• Getting information about family history, such as birth defects and retardation

• Awareness of testicular inflammation problems

• Impotence and fertility records

• Sexual trauma in the past

• Measuring the testicles and checking whether or not you have varicocele

• Determining the degree of coordination of the testicles

• Infectious disease history, such as epididymal infection or gonorrhea

• History of exposure to extreme heat

• Examining the seminal tubes and finding possible defects

• Scrotal or transrectal ultrasound to examine the testicles with sound waves

• Urine test after ejaculation

 

Treatment options of zero sperm and fertility

There is a type of method to treat zero sperm, which is one of the common causes of male infertility. In the following, we will examine the ways to treat zero sperm:

In the case of obstructive azoospermia, the way to treat zero sperm is surgery. If a sense of progress is created, the probability of success can be increased;

Varicocele is the most common cause of male infertility, and varicocele surgery is important to restore fertility.

By administering these hormones, if zero sperm has occurred due to the causes of LH and FSH and it is of the type of pre-testicular azoospermia, it is possible to help the production of sperm by the testicles. 

But in oval-type azoospermia, the level of LH and FSH hormones is high. The higher the FSH level, the more severe the prognosis of the disease. It is incurable, and affected people must use donated sperm for childbearing.

Sperm extraction is a treatment for people with azoospermia that isn't caused by an obstruction or for people who have an obstruction but can't have surgery for some reason.

In the subcutaneous method, the sperm is removed from the skin of the testicle without creating a wound. For example, during the operation of extracting sperm from the epididymis, or PESA, the surgeon inserts a syringe through the skin into the epididymis (the coiled tubes that remove the sperm from the testicle).

He draws the sperm into the syringe and transports it. If the fluid collected has sperm in it, it will be kept and used later to fertilize an egg and make an embryo.

What is TESA?

Another method called testicular sperm extraction, or TESA, is the process of extracting sperm from the testicles. When there are no sperm in the man's semen during ejaculation, TESA surgery is used to find sperm, which involves inserting a thin needle into the testicles to extract sperm from the nephrotic tubules. 

This method is used if a man has problems in the testicles, defects in sperm production, congenital absence of the vas deferens (in cystic fibrosis patients), or if he has already had a vasectomy but was unsuccessful in returning it to its original state. This surgery is performed under local anesthesia.

What is the TESE method 

In testicular biopsy or TESE, which is performed on an outpatient basis, in addition to shaving unwanted genital hair and fasting on the morning of the sampling day, there is usually a need for a companion, and the person is discharged 2 hours after the operation. This procedure is performed under sterile operating room conditions and with local anesthesia; However, if the patient wishes, due to the high number of procedures and the doctor's discretion, it is also possible to inject intravenous sedatives.

The TESE method involves making small cuts in the testicle and checking for the presence or absence of sperm in the tubes. To anesthetize the person, the appropriate drug should be injected into the scrotum (the part of the scrotum outside the abdomen) and also into the incision site. Lastly, the skin and tissue of the testicle are cut apart so that very small pieces can be taken out and put in a container with the culture medium.

If sperm is observed in the desired tissue under laboratory microscopes, the microinjection method can be used for male fertility. But not seeing sperm or the too small size of the testicles forces the doctor to repeat the sampling to be sure of azoospermia.

In this case, repeating the Micro TESE method or taking a sample of the testicle with a microscope can enlarge the desired tissue, give a better view of the testicular tissue, and make it easier to see if sperm are present or not. If the sperm are normal, it shows that the problem of infertility isn't caused by something else.

What is MESA?

In the mini epididymal surgical sperm extraction, or MESA, the surgeon uses a surgical microscope to magnify the view of the epididymis and makes a small incision in the thin tissue of the epididymis so that the coiled tubes are inserted. A device called a micropipette is then used to puncture one or more tubes and the fluid is removed. After that, the tissue that covers the epididymis is closed with stitches.

Can a man have natural testosterone and be azoospermic?

The answer should be yes. Sperm comes from germ cells in small tubes inside the testes. Testosterone comes from the Leydig or interstitial cells that are between these tubes. 

Because Leydig cells are more flexible than germ cells, they often function partially or completely even in a damaged or weakened testicle. Therefore, a person who has normal testosterone can also be azoospermic.