Many patients assume that an azoospermia diagnosis means that they will never be able to conceive a child. Indeed, if there is no sperm, how can conception take place? However, a semen analysis showing the complete absence of sperm in their ejaculate does not rule out the possibility that they are producing sperm, only that it is not being delivered to the semen, or that interventions may assist the man in producing sperm. Even in cases where following intervention the ejaculate still does not contain any sperm, it is still possible to harvest small amounts of sperm that have been produced in the testes. If the testes are making sperm but none appear in the ejaculate, the sperm will have to be retrieved via another mechanism, either by restoring the sperm’s normal flow, or by circumventing it.
Where possible, treatment of the specific condition that is causing the azoospermia may result in a reversal of the condition, thereby leading to sperm production. This is especially true for azoospermia that occurs as a result of using testosterone supplements or hot tubs or hot baths. In cases of genetic infertility, treatment of azoospermia is not possible and the only way for a couple to conceive would be through the use of assisted reproduction.
Treating Obstructive Azoospermia
Usually, in obstructed men who have no obvious reason for their problem, blockages will be found in the epididymis in 65% of the cases; in the vas deferens in 30% of the cases; and in the ejaculatory duct in 5% of the cases. Microsurgery is able to pinpoint the exact location of the blockage, while microsurgical repair provides a great success rate in enabling the movement of sperm in the ejaculate. This also enables pregnancies in cases of blockages in the epididymis – which is the most challenging area in the system to repair – that are not as a result of a vasectomy. It is important for the female partner in a couple in whom the man suffers from congenital reproductive tract obstruction to undergo a cystic fibrosis (CF) gene mutilation analysis, due to the high risk of the male being a carrier of CF.
With the exception of CAVD, most cases of obstructive azoospermia may be treated with microsurgery or endoscopic reconstruction.Depending on their level of obstruction, patients suffering from acquired obstructive azoospermia may receive treatment through the use of microsurgical reconstruction and transurethral resection of the ejaculatory ducts. If the passage in the reproductive tract or the vas deferens has been blocked, surgical repair may be performed involving a 2-3 hour micro surgery procedure known as vasoepididymal anastomosis (VEA). The aim of this procedure is to bypass the block such that sperm are able to reach the penis.
Should a man change his mind about their completed vasectomy and want to father a child, they may undergo microsurgery to rejoin the cut ends of the reproductive tract, such that the sperm is once again able to pass through into the semen. This reversal surgery is known as a vasovasostomy or a vasovasal anastomosis – VVA. It is also possible to correct the varicocele condition with some minor out-patient surgery.
Antibiotics may be used in the treatment of infections of the reproductive system that may be causing obstructive azoospermia.
Sperm Retrieval & Assisted Reproduction
Spermatogenesis is a complicated process in which sperm is produced by the Sertoli cells within the seminiferous tubules of the testis. Spermatogenesis depends highly on the production of testosterone by the Leydig cells in the testis, as well as many other testicular and pituitary hormone interactions. Following production in the testis, the sperm undergo maturation in the epididymis – a small structure that is attached to the testis. From the epididymis, the sperm will travel through the vas deferens and finally empty into the ejaculatory ducts that are located within the prostate. Once here, the sperm will mix with seminal fluid from the prostate, as well as the seminal vesicles. The development of a single spermatozoon is completed over a 2-3 month period. Therefore, males undergoing medical treatment to improve their spermatogenesis will need to wait 2-3 months before witnessing any therapeutic effects.
One important thing to note about the azoospermia diagnosis is that although no sperm may be found in the ejaculate, usable sperm may often be found in the testis. This is because not all sperm that is made in the testis will actually make it into the ejaculate. Sperm production has a ‘threshold’ effect which means that when production of the sperm in the testis is high enough; the sperm will ‘spill over’ into the ejaculate. However, in the event that this critical level of sperm production is not met, there may still be mature sperm in the testis that will not make it into the semen. This is the concept that underpins the statement “sterility may beget fertility.”
Sperm may be removed from the testicles or the epididymis in the event that there is an obstruction. The sperm that is extracted may be saved or used for purposes of fertilizing the egg of a female. In cases of both obstructive and non-obstructive azoospermia, various methods may be used for sperm extraction from the testis and/or epididymis. These include microsurgery, surgical extraction and needle aspiration. Sperm extraction from the epididymis is often easier in cases of obstructive azoospermia because of the presence of large numbers of sperm, than it is in non-obstructive azoospermia.
A couple may undergo sperm retrieval and use assisted reproduction in order to effect a pregnancy. This procedure has recorded a success rate of 25-65%. Sperm retrieval from the testis in men who undergo treatment for abnormal sperm production and still remain azoospermic is effective in 30-70% of the cases. Once sperm are found, pregnancy rates of 20-50% may be obtained via in vitro fertilization (IVF) and intracytoplasmic sperm insertion (ICSI). Intracytoplasmic sperm insertion is a procedure in which sperm is harvested and then directly injected into the egg.
Treating Non-Obstructive Azoospermia
Medical treatment for non-obstructive azoospermia may assist in the development of ejaculated sperm in men suffering from reversible conditions such as hyperprolactinemia, Kallman’s syndrome and varicocele. However, in most cases, the only hope for men with non-obstructive azoospermia would be to impregnate a female using sperm that is retrieved from the testis with assisted reproduction in the form of IVF or ICSI.
One of the most challenging aspects of non-obstructive azoospermia is that while sperm retrieval in men with obstruction is not difficult, only 50-60% of men suffering from non-obstructive azoospermia possess usable testicular sperm for ICSI. What’s more, the regular clinical features such as the history of ejaculated sperm, biopsy reading, serum FSH level or testicular size do not provide an accurate prediction of whether or not sperm can be recovered from the testis.
Non-obstructive azoospermia is treated by first providing a definition of the causes of low sperm production. These may be obtained through genetic evaluation with Y-chromosome microdeletion analysis, as well as karyotype testing to provide prognostic information on the causes of the disorder.
Hormones may be administered for purposes of treating a hormonal imbalance that may cause non-obstructive azoospermia. Oral medication may also be provided for purposes of treating retrograde ejaculation.
This is a surgical procedure that is used in the treatment of varicocele in azoospermic males. This surgery will involve making a blockage or obstruction in the dilated veins which then stops the blood flow, thereby preventing the pooling of blood in the reproductive tract, which hinders sperm production.
Sperm Retrieval & Assisted Reproduction
For non-obstructive azoospermia cases, obtaining a sufficient number of sperm from the testis will required open surgery, microsurgery and/ or directed multiple needle punctures. In cases of retrograde ejaculation, if the results are negative, the urine may be prepared such that it does not damage the sperm, and the sperm may then be harvested from the post-ejaculatory urine.