Azoospermia - FAQs
The male reproductive system includes the testicles or testes, prostate, penis, scrotum, vas deferens, epididymis, and seminal ducts. The testicles in the scrotum produce sperms, which then flow through the epididymis, vas deferens, and seminal ducts. Sperms mix with fluid in the seminal ducts to form semen, which leaves the body through the penis. Semen is the thick, white, sperm-containing fluid released during ejaculation (process of ejecting semen from the penis). The male gamete, or sperm, and the female gamete, the egg or ovum, meet in the female's reproductive system to create a new individual. Both the male and female reproductive systems are essential for reproduction. Testes are surrounded by a network of blood vessels. Normally, blood flows to the testicles through an artery, and flows out via a network of tiny veins that drain into a long vein that goes up through the abdomen. The direction of blood flow in this vein should always be up, toward the heart. A series of one-way valves in the vein prevent the reverse flow of blood back to the testicles.
Problems with the production or flow of sperm may affect male fertility. With treatment, such as medicine and sperm extraction, your infertility may be resolved and your partner may conceive.
A. Semen which is discharged at ejaculation in the male consists of secretions of glands and spermatozoa.
Normally the volume is 2 ml or more with sperm concentration more than 20 million spermatozoa per ml and the total sperm number is more than 40 million spermatozoa per ejaculate.
The sperms should have at least -
- Motility - greater than 50% motile (grades a* and b**) or 25% or more with progressive motility (grade a) within 60 minutes of ejaculation
- Vitality - greater than 75% live
- White blood cells: fewer than 1 million per ml
- Morphology: 15% or 30%
A. Azoospermia is a condition where a man has no sperms present in his semen. It is a major cause of male subfertility. Subfertility is a condition where a man has been unable to get a woman pregnant after one year of unprotected (without birth control) regular sex.
A. Azoospermia may be from an Obstructive (where the flow of sperm is blocked and is prevented from leaving the body) or Non-obstructive cause (problem with sperm production).
- Genetic: A man may have been born with genes that may cause infertility by affecting the sperm transport, such as absence of the vas deferens on both sides since birth.
- Infections: Infections of the male reproductive system, such as in the testicles or prostate, may affect male fertility.
- Trauma: Even a mild injury to the testicles can cause severe pain, bruising, or swelling. Most testicular injuries occur when the testicles are struck, hit, kicked, or crushed, usually during sports or due to other trauma. Testicular torsion, when one of the testicles twists around, cutting off its blood supply, is also a problem that some teen males experience, although it's not common. Surgery is needed to untwist the cord and save the testicle.
Previous injury or surgery to the spine, pelvis, lower abdomen, or male sex organs may cause damage to the male reproductive system. Trauma may affect sperm production or cause an obstruction in the flow or transport of sperm.
- Varicocele: Sometimes these one-way valves fail; the reverse flow of blood stretches and enlarges the tiny veins around the testicle to cause a varicocele, a tangled network of enlarged blood vessels, or varicose veins. Varicocele usually develops slowly.
- Vasectomy: A vasectomy is a surgical procedure that is done on males as a method of birth control. The vas deferens (tubes that carry sperms from the testicles to the seminal vesicles) are cut or tied. The semen that is ejaculated no longer contains sperms.
- Drugs: Certain drugs, such as steroids, antibiotics, and drugs to treat inflammation, hypertension or cancer may affect male fertility. Smoking, drinking alcohol, and using illegal drugs may also cause problems with sperm production.
- Genetic: A man may have been born with genes that may affect sperm production or affect the formation of your reproductive (sex) organs.
- Hormones: As production of sperms is dependent on hormones, disorders of the testicles may produce abnormal levels of hormones that may affect the production of sperms.
- Radiation: Radiation, such as that used to treat cancer, may affect sperm production.
- Retrograde ejaculation: Retrograde ejaculation is when semen travels into the bladder instead of outside the body. It is usually caused by a problem with the neck of the bladder and may be due to spinal cord injuries, medicines, or diabetes.
- Testicular cancer: This is one of the most common cancers in men younger than 40. It occurs when cells in the testicle divide abnormally and form a tumor. Testicular cancer can spread to other parts of the body, but if it's detected early, the cure rate is excellent.
- Other factors: Pesticides, heavy metals, heat, and undescended testes (testicles that did not move from the abdomen into the scrotum) may affect sperm production.
A. One may have any of the following:
- Inability to get the female partner pregnant.
- Increased body fat, body hair, and breast tissue.
- Clear, watery, or whitish discharge from the penis.
- Presence of a mass or swelling on the scrotum that feels like a bag of worms (varicocele).
- Stress or emotional pressure from not being able to conceive a child.
- Testicles that are small, soft, or non-palpable (cannot be felt).
- Veins that are enlarged, twisted, and may be seen in the scrotum (varicocele).
A. Determining which of the above causes, or a combination of them, is the reason for the patient's azoospermia is often complex. Following are some of the available ways and tests that could help in determining the cause.
- History: A complete medical, reproductive, and sexual health history and for how long the couple have been trying to have a baby would be taken by the doctor. The timing and frequency of the couple's sexual activities, and problems with sexual urges and functions are also important. The couple's lifestyle, including alcohol intake and smoking, medications taken, and past diseases is also important.
- Physical examination: The doctor will look for signs of any imbalance in the male partner's hormones, such as increased body fat, body hair, and breast tissue. The size and shape of the testicles will also be examined. Digital rectal exam (DRE) is done to check the prostate and other parts of male reproductive system.
- Biopsy: A sample of the testicle is taken by a needle or through a small incision (cut) in the scrotum. The sample is sent to a lab for tests. This will help determine the ability of the testicles to produce normal sperms.
- Blood tests: Blood is tested to rule out any other diseases like diabetes, abnormal lipids and also levels of hormones which may have effect on sperm production.
- Genetic screening: Genetic testing may be done to look for abnormal genes. Abnormal genes may cause problems with sperm production, sperm transport, or formation of the male reproductive organs.
- Magnetic resonance imaging scan (MRI): An MRI uses magnetic waves to take pictures of the pituitary gland to check for other causes of male infertility.
- Spermatic venography: This test will examine and show the position of the veins in the scrotum. It may be used to check for a varicocele.
- Ultrasonography: A scrotal or transrectal ultrasound uses sound waves to find lumps and other changes in the testicles and scrotum. These tests may be used to check for a varicocele or any missing parts of the reproductive system.
- Semen analysis: A semen analysis is a test to check a man's fertility. It is done by taking a semen sample which is analyzed for the number, motility and structure of sperms.
- Post-ejaculatory urinalysis: Urine after ejaculation is tested for the presence of sperm in the urine, which may suggest an obstruction or problems with ejaculation.
A. The treatment will depend on the cause of azoospermia. Different options are:
- Medicines: Antibiotics may be given to treat an infection of the reproductive system. Hormones may be used to treat a hormonal imbalance.
- Surgery: Surgery may need to be done, such as removing a varicocele or repairing a blocked vas deferens. Surgery to correct a varicocele is usually done on an outpatient basis. After a cut is made, usually in the lower abdomen, the doctor disconnects the network of tangled blood vessels by tying off the abnormal veins so that the blood will now flow around the area into normal veins. Ice pack is kept on the area for the first 24 hours after surgery to reduce swelling.
After the surgery it is important not to have sexual intercourse for one week. It takes about 72 days for sperms to generate, so there would be a waiting period of three or four months after surgery to get a semen analysis to determine whether the varicocele repair was successful in restoring fertility.
- Sperm extraction: Sperms may be removed from the testicles or epididymis if there is an obstruction. The sperms that are taken out may be saved or used to fertilize a woman's egg.
- Testicular biopsy: Finally, if a primary testicular problem is suspected, a testicular biopsy is performed. A biopsy simply means obtaining actual tissue for laboratory/microscopic examination. This may be done using a needle through the skin, or by an incision.
Most men facing a semen analysis dread the diagnosis of azoospermia. However, it does not necessarily mean that the man, who produces no sperms, can never be made to produce any sperms or will never have a biological child. Accurate diagnosis of the cause of azoospermia is important. Correctible causes must be found and treated. Even then if there are no sperms in the ejaculate, sperms can often be collected from the testes and used to achieve fertilization.
For more information, consult your doctor.