Azoospermia; Diagnosis and Treatment

Azoospermia, which is one of the reasons for male infertility, is defined as a lack of live sperm in semen. If pregnancy does not occur following one year of regular sexual intercourse without the use of any birth control methods,couples are accepted as infertile.

Azoospermia is one of the reasons for male infertility. Of all men with infertility problems, 10–15% have an azoospermia diagnosis. This health problem generally does not show any symptoms and is identified when couples who want infertility treatments are tested. However, there is a solution to this issue. Today, there are couples who get pregnant with the right azoospermia treatments. Azoospermia can be treated with different methods, such as surgery and medication, and these treatments might eliminate male infertility problems.

What is Azoospermia?

1 ml of healthy male semen contains at least 15 million sperm cells, and this number can go up to 200 million. Azoospermia is a condition that occurs when there are no live sperm cells in semen. Ejaculation after sexual intercourse has approximately 39 million sperm cells.

Men with azoospermia can ejaculate, but the number of live sperm in the semen is zero. Since this lack of sperm cannot be seen with the naked eye, it is not possible to know about this problem unless professional medical treatment is sought. Azoospermia is usually diagnosed when a couple who want to have children start infertility treatments.

Azoospermia is seen in 1 out of every 10 men with male infertility problems, and this problem is due to issues in sperm production, channel structure, or testicles. Men with azoospermia cannot have children in natural ways. However, couples have hope since this disease can be treated in various ways, and a couple can get pregnant as soon as treatment starts.

What are the Reasons for Azoospermia?

Azoospermia accounts for 10% of male infertility, and this problem might be congenital or occur later in life. Insufficient hormone levels for stimulating the testicles, testicle development problems, or blockage in testicle channels might be the reason for azoospermia, and the reasons can be divided into three groups.

1. Pretesticular factors are hormone based and include hypogonadism, thyroid problems, and hormonal medications. This is considered secondary testicular dysfunction.
2. Testicular factors have negative impacts on sperm production. Factors such as chemotherapy and radiotherapy, mumps, testicular inflammation, undescended testis, and chromosomal anomalies might damage sperm production. This is defined as primary testicular dysfunction.
3. Post-testicular factors affect almost 40% of azoospermia patients. These are problems such as anejaculation, retrograde ejaculation, and ejaculatory duct obstruction.

In addition, there are azoospermia cases without any known reasons. Azoospermia patients who cannot be included in any group after hormonal and genetic tests are the most common.

While pretesticular and post-testicular factors can be treated more easily, the success rate of testicular treatments might be lower. Other factors that might cause azoospermia are as follows:

• Old age: Sperm production decreases with decreased testosterone levels.
• Environmental factors: Stress, psychological problems, aggression, and social factors might lead to azoospermia.
• Insufficient nutrition: Unhealthy and low-quality nutritional intake, high calorie intake, and obesity have negative effects on sperm production.

Azoospermia Symptoms

Azoospermia, which is one of the reasons for male infertility, often does not show any symptoms. Rare symptoms might be as follows:

• Decreased sexual desire,
• Male erectile dysfunction,
• Hair and body hair loss,
• Bump or swelling around the testicles,
• Semen color, odor, and texture anomalies.

These symptoms might be due to other health problems, and azoospermia diagnosis is not possible only with these symptoms. The most valid symptom of azoospermia is not having a child, despite regular unprotected sex. But this alone is not enough.

Sperm analysis must be performed to diagnose azoospermia. When there is no sperm in the semen, the patient should consult a urologist/andrologist for various tests and examinations, and treatment plans should cater specifically to that person. Almost 60% of men with azoospermia problems have treatable reasons. Advanced medical treatments for 40% of patients generally give results.

What are the Types of Azoospermia?

Azoospermia types are divided into two groups: obstructive azoospermia and nonobstructive azoospermia.

• Obstructive azoospermia occurs when there is an obstruction preventing semen ejaculation. Although there is live sperm, the sperm cannot be ejaculated with the semen due to channel or testicular obstruction. These obstruction or stricture problems, which are congenital or due to genital infections, can be corrected with operations. Sperm ejaculation is possible after a corrective and dilatation surgery. Treatment efficacy is generally high.
• Non-obstructive azoospermia includes cases without obstruction. This problem is due to genetic or hormonal problems; undescended testicles and radiation mean there is no or a low amount of sperm in the semen. More than half of men with azoospermia problems belong to this group. While there is a chance of success following treatment, there are non-obstructive azoospermia cases in which medication is insufficient. Still, treatment with testicular sperm extraction under microscope (microTESE) procedures can be attempted.

How is Azoospermia Diagnosed?

The most valid diagnosis method for men with a suspicion of infertility is a spermiogram, which is also known as semen analysis. Semen samples must be collected from men at two-week intervals, and the semen must have no sperm cells to yield a diagnosis of azoospermia.

After this stage, a urology examination and chromosome analysis will be applied. These examinations are necessary because 10–12% of azoospermia cases are due to structural or chromosomal problems. The root cause of the problem is identified for azoospermia treatment, and the treatment regimen is planned accordingly.

Men with azoospermia problems caused by varicocele and sperm channel obstruction due to hormonal problems have the highest chance of being successfully treated. It is possible to achieve sperm ejaculation and natural pregnancy with suitable treatments.

Azoospermia Treatment

Treatment methods for azoospermia are determined according to the root cause of the problem. Some of these methods do not treat azoospermia but are sufficient for ensuring pregnancy. Azoospermia treatments are as follows:

• Surgical operations are used in obstructive azoospermia cases to eliminate the obstruction to enable ejaculation.
• Hormone treatments involve medications that are applied to azoospermia patients due to hormonal problems. The treatment will depend on the patient’s age, genetics, spermiogram results, hormone levels, and general body status.
• Testicular sperm extraction under microscope (microTESE) is the preferred method with a high success rate and is about collecting sperm cells through an operation in men without any sperm cells in the semen. A small incision on the testicles enables the collection of tissue samples from the tubule with a fuller view. The collected tissue is then investigated under a microscope to find sperm. This is another version of the TESE that was applied without using a microscope.
• Percutaneous epididymal sperm aspiration (PESA) uses a thin injector to reach the epididymis on the testicles, and the sperm is collected. This method is more suitable for obstructive azoospermia patients.
• In testicular sperm aspiration (TESA),an injector is placed above the testicles that holds the testicles to collect testicular tissue. The sperm is searched for in this tissue.
• Phytotherapy: Phytotherapy, which is commonly preferred by azoospermia patients, is believed to help infertility treatment. However, hearsay treatments without the doctor’s recommendations can cause significant health problems. Therefore, the recommendations of a specialist must be followed. Phytotherapy practices if not applied properly are too time-consuming and might cause toxic effects and sabotage the entire treatment process.
• Vitamin treatments and supplements are recommended to improve general health. However, none of the medications or vitamin supplements must be used to treat male infertility without a doctor’s recommendation. The doctor must plan the treatment based on the test results.