Azoospermia is the complete absence of sperm in the semen and as such means that a man will be completely infertile. The diagnosis of azoospermia is sometimes still made even though as many as 500,000 sperm per ml of semen may have been seen because it is extremely unlikely that the man will be able to father a child naturally with this number of sperm. It's incredible to realise that millions are needed for any chance of natural conception!
However, modern techniques such as ICSI (intra cytoplasmic sperm injection) mean that a man can still father his own biological child with expert medical help - This means that you must ask your doctor whether you have either (i) a very low sperm count so that you know you do at least make some sperm or (ii) absolutely no sperm at all which is the worst case scenario for any man to face.
In fact it is rare that a man has absolutely no sperm at all and as long as some sperm are produced it is possible nowadays to help couples have children via the ICSI procedure. So, if the doctor says you have azoospermia make sure you ask for a copy of the semen analysis results so that you can understand the situation.
Azoospermia occurs in about 2% of men in the general population. So whilst not common there are plenty of infertile men around - in the UK alone we would expect to find at least 300,000 men with azoospermia and many of these would appear extremely healthy and have no indication that any problem might exist !
Around 10-20% of men attending infertility centers will probably have azoospermia as well. This means that if you and your partner have been trying for a year or more to have a baby there is an increased risk that you may have a problem. Aspermia is an absence of any ejaculate (semen) and is much rarer.
Frequently Asked Questions about Azoospermia
What is azoospermia and can a person with azoospermia have biological children?
Azoospermia is the term used when there is a complete absence of sperm in the ejaculate. Most males diagnosed with azoospermia would assume that this diagnosis means they would never be able to conceive a child; if there are no sperm how can there be conception? In reality however, a semen analysis which shows the absence of sperm in the ejaculate does not remove the chance that sperm is being produced and not delivered to the semen, or that interventions may help the man produce sperm. Even in cases where after intervention there is still no sperm in the ejaculate, there may be a possibility of harvesting small amounts of sperm, which have been produced in the testes as a result of the interventions.
A Production Problem or a Delivery Problem?
Investigations need to be carried out to discover whether the testes are simply not producing sperm, or are producing sperm but unable to deliver it in the ejaculate. If the testes are making sperm but none are in the ejaculate, the sperm must be retrieved by some other mechanism, either by restoring the normal flow of sperm or by circumventing it. If the testes are not producing sperm then exploration of whether the problem can be reversed can be undertaken. Even if the problem cannot be reversed, it is possible that the level of spermatogenesis is advanced enough to allow sperm "harvesting" in conjunction with advanced reproductive techniques (ART) and micromanipulation.
The three major causes for lack of sperm production are hormonal problems, "testicular failure," and varicocele.
Hormonal Problems: The testicles need pituitary hormones to be stimulated to make sperm. If these are absent or severely decreased, the testes will not produce maximum sperm. If a male uses androgens (steroids) for body building purposes, this can shut down the hormones needed to make sperm.
This refers to the inability of the sperm producing part of the testicle (the seminiferous epithelium) to make adequate numbers of mature sperm. This failure may occur at any stage in sperm production for a number of reasons. Either the testicle may completely lack the cells that divide to become sperm (this is called "Sertoli cell-only syndrome") or there may be an inability of the sperm to complete their development (this is called a "maturation arrest"). This situation may be caused by genetic abnormalities, which must be screened for.
A varicocele is dilated veins in the scrotum, (just as an individual may have varicose veins in their legs.) This condition may be corrected by minor out-patient surgery.
Evaluation of Azoospermia
Determining which of the above causes, or a combination of them, is the reason for the patient's azoospermia is often complex. Some of the available tests are listed below.
This is the simplest test. If the size of the testicles is severely diminished, this is an indication that the seminiferous epithelium is affected. Follow up hormonal profiles can determine whether this is a primary problem or caused by less than adequate hormonal stimulation.
The scrotum is examined for the presence of varicocele. Their presence can be confirmed by an ultrasound probe placed on the skin at the scrotum.
During a physical exam, the ductal systems can be felt. If they are absent, the patient has what is called congenital bilateral absence of the vas deferens, (CBAVD). In most cases this is considered to be due to the patient's genetic make-up and requires chromosomal analysis as part of the evaluation and treatment.
Finally, during examination of the ductal structures, the epididymis may feel as though it is dilated. Generally, it is flat and the middle cannot be felt. Thus, a dilated epididymis may be indicative of a blockage.
Follicle stimulating hormone (FSH) is the hormone made by the pituitary, which is responsible for stimulating the testes to make sperm. When the sperm producing capacity of the testes is diminished, the pituitary makes more FSH in an attempt to make the testes do its job. Therefore, if a man's FSH is significantly elevated there is a strong indication that his testicles are not producing sperm optimally. (Testosterone polactin, leutenizing hormone (LH) and thyroid stimulating hormone (TSH) are also measured to assess a man's hormonal status. These may reveal problems that can have a significant impact on sperm production).
Screening for the genes that can cause cystic fibrosis is sometimes suggested. There are tests for specific genetic abnormalities on the male chromosomes that can cause azoospermia. If a son were to inherit this, he may have the same problem.
In order to rule out a blockage of the ejaculatory duct, an ultrasound of the ejaculatory duct and seminal vesicles is often performed. If the seminal vesicles are dilated, this indicates that they may be full of semen because they cannot empty properly. Cysts blocking the ejaculatory ducts by exerting pressure on their walls, or calcifications in the ejaculatory ducts themselves, may also be noted. A cyst may in some cases may be unroofed by operating through the urethra to open it thus decompressing the ejaculatory duct. If the blockage occurs within the ejaculatory duct, the blocked part may be removed in a similar operation.
It is possible that ejaculation is occurring backwards, ie. the sperm is being pushed into the bladder, and then washed out when the man urinates after ejaculation. Sometimes this can be corrected by oral medication. If not, the urine can be prepared so that it does not damage the sperm as much, and the sperm is then harvested from the post-ejaculatory urine.
Finally, if a primary testicular problem is suspected then a testicular biopsy can be undertaken.
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