What is Azoospermia
Most if not all male infertility cases can be traced to their sperms.
Azoospermia which is one of the sperm conditions that causes male infertility can be defined as a medical condition in which there is absence of sperm in the semen. It is associated with very low levels of fertility or even sterility, affects about 1% of the male population and may be seen in up to 20% of male infertility situations. Studies in Nigeria recognized that azoospermia is a common finding among infertile males. The condition was found to be present in 6.5% of males attending a general infertility clinic and 35% in those attending male infertility clinics.
Obstructive vs Non Obstructive Azoospermia
Azoospermia may be classified as Obstructive and Non-Obstructive Azoospermia.
This refers to no sperm in the semen due to ductal obstruction which can occur anywhere along the male reproductive tract disrupting sperm delivery. It is classically characterized by normal or near normal sperm production and accounts for around 40% of azoospermia cases.
Obstructions occur most commonly in the following:
- Epididymis: The coiled tube on the back of each testicle.
- Vas deferens: The tube that transports sperm from the epididymis
- Ejaculatory duct:
The tube from which the sperm exit into the urethra and mix with fluid to form semen.
This refers to no sperm in the semen due to abnormal sperm production.
Causes of Azoospermia
Normally, the hormones of the brain stimulate the testis, the testis produces spermatozoa which travel to the exterior through patent and properly functioning seminal ducts. A disruption of this process can cause Azoospermia.
Cause of obstructive Azoospermia
- Blockage In The epididymis
Infections causes epididymitis with inflammation and scarring of the epididymis which can lead to blockage. Gonorrhea and chlamydia are the most common sexually transmitted infections (STIs) that cause of epididymitis in young, sexually active men. For boys and men who aren’t sexually active, epididymitis can be caused by non-sexually transmitted bacterial infections. In boys and men with urinary tract or prostate infections, bacteria might spread from the infected site to the epididymis.
- Scrotal trauma/injury
- Genetic conditions:
They can be caused either a blockage or abnormal development. Cystic fibrosis for example, can cause thickened secretions which could buildup and trap the semen This is sometimes even a problem for men with a cystic fibrosis gene mutation but no other disease symptoms.
- Obstruction involving the vas deference:
Hernia repair, vasectomy (the surgeon cuts or clamps each vas deferens, stopping the flow of sperm), Prostate surgery.
- Genetic Conditions:
Congenital absence of the vas difference (CAVD),Cystic fibrosis gene mutations (can cause the normal connection to the urethra not to form)
- Ejaculatory duct Obstruction:
Some ejaculatory duct blockages are present at birth (congenital). Others develop later on (acquired).
Cause of Ejaculatory Duct Obstruction Include:
- Prior surgery
- Endoscopic surgery can relieve the blockage and often restore sperm to the semen.
Causes of Non-obstructive Azoospermia
- Genetic Causes:
Klinefelter syndrome (characterized by poor testicular function as well as low sperm counts and testosterone levels), Kallmans syndrome. there’s a risk of passing genetic abnormalities to offspring.
- Radiation and toxic chemicals:
Certain exposures can impair sperm production. These include Heavy metals, Pesticides, Chemotherapy, Radiotherapy. Prior to chemotherapy or radiotherapy treatment there is the option of freezing (cryopreserve) sperm ahead of time. However, It’s still possible to find sperm after such cancer treatment.
Several medications can harm sperm production. Testosterone is one example: While this hormone is necessary for normal reproductive function, taking it in supplemental form(Testosterone Supplements) can often cause azoospermia
- Hormone imbalance.
A varicocele is the swelling of the veins inside the scrotum. These veins are found along the cord that holds up the testicles (spermatic cord). A varicocele can impair normal sperm production and quality.
- Medical conditions like diabetes, Spinal cord injuries.
- Illegal drug use
- Excessive alcohol consumption.
- Exposure to heat.
- Infections: e.g mumps which can cause inflammation of the testis (orchitis)
Azoospermia Treatment Process
First thing first, Azoospermia is normally detected through Seminal fluid analysis (SFA) screening . After which further evaluation is required to arrive at a diagnosis and determine the cause. This evaluation includes Obtaining a medical history of the male patient, examination of the testis and scrotum,Hormone profile (FSH, LH, Testosterone, Prolactin) Transrectal Ultrasound scan, Testicular biopsy (if required).
Treatment of Obstructive Azoospermia
Men with obstructive azoospermia may need microsurgery to correct the obstruction. This surgery may make natural pregnancy possible without assisted reproductive technology, such as IUI (artificial insemination), IVF(Invitro fertilization) and ICSI (Intracytoplasmic sperm Injection).
To treat obstruction due to infection of the reproductive system.
A surgical procedure called vasoepididymostomy can be performed in men with an epididymal obstruction, which can prevent the sperm from entering into the ejaculate. The American Society for Reproductive Medicine estimates that 20-40 % of couples in which the male receives this procedure can achieve a pregnancy without assisted reproductive techniques.
For men with an ejaculatory duct obstruction, a technique called the transurethral resection of the ejaculatory duct (TURED) may be recommended.
Following this procedure, sperm appears in the ejaculate of around 50 -75% of patients. These patients have a pregnancy rate of about 25%
If surgery is able to correct the obstruction causing azoospermia, couples may be able to conceive naturally without the help of fertility treatments.
However, there are sperm retrieval techniques that can also allow for conception. Men with obstructive azoospermia may be able to father a child through retrieval of sperm directly through the testis or epididymis, followed by IVF or ICSI.
Common methods of sperm retrieval include: Testicular sperm aspiration (TESA), testicular sperm extraction (TESE) microsurgical epididymal sperm aspiration (MESA) and percutaneous epididymal sperm aspiration (PESA).
Treatment of Non-Obstructive Azoospermia
Treatment of reversible causes of non–obstructive azoospermia such as elevated prolactin levels (hyperprolactinemia) varicocoele and Kallmans syndrome may assist in leading to sperm in the ejaculate. Below are some treatment options available for Non-Obstructive Azoospermia
If the cause of the non-obstructive azoospermia is due to hormonal imbalance hormones may be administered for treatment.
To correct varicocele for example.
Assisted Reproductive Technology
The challenging aspect of non-obstructive azoospermia is that only 50-60% of men with this condition possess usable sperm for ICSI.
Furthermore, the regular clinical features seen in the medical history, testicular biopsy results, serum FSH levels or testicular size, do not provide accurate prediction of whether or not sperm can be retrieved from the testis. The option of the use of donor sperm may be advised.