Azoospermia: Can “nil sperm count” be Cured

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A medical condition affecting about 5% of infertile men, azoospermia, is defined as the absence of sperm in the semen.

The normal diagnosis mode is typical – When a couple has issues with conceiving, they are asked to undergo a detailed study, and the doctor will disgnose the source of the problem. If the problem is with the man, one of the issues the provider could indicate is “azoospermia”.

When a man is diagnosed with having azoospermia, his reproductive healthcare provider will educate him about the condition and recommend the most appropriate course of action. It can either be straightforward, such as abstaining from anabolic steroids, having less hot baths, restoring a person’s natural testosterone balance; or a surgical intervention.

However, in some cases where there is absence of even the precursors of sperm cells (germ cells), termed Sertoli cell only syndrome – unfortunately no medical treatment can help. Such men will have to go for donor sperm to impregnate their partner.

Depending on the type and the severity, azoospermia can be treated surgically (thereby allowing the return of sperm in the ejaculate) or in certain cases ,the condition can be overcome using sperm retrieval technique, which along with assisted reproduction, can help in conceiving a child.

Azoospermia – Types and Causes

Obstructive Azoospermia

Obstructive Azoospermia

It is a condition where the man can produce sperm but it does not reach the ejaculate due to some obstruction. This obstruction can occur in:

  • The epididymis (a duct present behind the testes, through which sperm enters the vas deferens.)
  • The vas deferens ( the duct that transports the sperm into the semen).
  • Ejaculatory ducts (ducts present at the opening of the vas deferens).
  • A genetic abnormality, infection, injury, or prior surgery.

Non-obstructive Azoospermia

In this condition, the man is either not able to produce sperm or produces a small quantity that is unable to turn up in the ejaculate for some reason.

This can happen either due to past infections, hormonal causes, undescended testicles, twisting or injury to the testes, genetic or congenital abnormalities or due to varicocele.

Diagnosis of Azoospermia

When a person is suspected of having azoospermia, he is advised to undergo a detailed examination with his reproductive healthcare provider. During this examination, the doctor will go through medical history – asking about current medications, medical disorders, any surgeries, and family medical history.

Next, a physical examination of the genitalia is performed. This is followed by blood tests to determine the testosterone, estradiol, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) levels.

Finally, the patient undergoes a detailed semen analysis. If the provider is unable to determine the presence of sperm with the first look, a centrifugal test will be ordered, where the sperm sample is spun into a “pellet,” and a microscopic examination of the “pellet” is performed to determine the presence of sperm.

Around 15% of men diagnosed with ‘no sperm’ with the initial look show up with trace quantities of sperm with the pellet examination.

This is important because the presence of sperm in the pellet will mean that obstruction is not the likely cause. In such cases the patient may have to use assisted reproductive treatment for conceiving a child.

Sometimes, these tests are inconclusive. In such cases, the healthcare provider will suggest a detailed examination of the testes to assess the ability to produce sperm. While the traditional method is a testis biopsy, advancements in medicine have helped in the development of a less invasive and more informative procedure known as fine-needle aspiration (FNA) sperm mapping.

Treating Azoospermia

Treatment is dependent on the type as well as the cause.

Microsurgical Reconstruction

If the diagnosis is obstructive azoospermia, then an endoscopic or microsurgical repair is recommended. Skilled microsurgeons perform this complex surgery. A skilled microsurgeon will not only be able to pinpoint the exact location of the obstruction, but also repair it allowing restoration of normal sperm flow into the ejaculate.

Other Medical treatments

If the diagnosis is non-obstructive azoospermia, and the patient produces some semen or atleast has germ cells(the precursors of sperm cells) then the reproductive healthcare provider could recommend necessary treatments that can assist in the development of sperm.

In cases where there is absence of even the precursors of sperm cells (germ cells), termed Sertoli cell only syndrome – no treatment can help.

Couples can also use the sperm that is retrieved from the testes for conceiving. An experienced reproductive healthcare provider can recommend several strategies for finding the sperm as well as minimizing trauma to the testes while procuring sperm. The two most successful approaches are retrieving through microdissection and FNA mapping.

A retired, board-certified Kimberly OB/GYN, Dr Langdon has clinical experience of two decades. She specializes in sexual dyfunction, infertility, STI and contraception among others. For AndrologyForum she writes articles on fertility topics focused on Semen parameters.