What are the management options for azoospermia?

Management of Azoospermia

The management of azoospermia requires first differentiating between obstructive azoospermia (OA) and non-obstructive azoospermia (NOA), as these conditions have distinct treatment approaches based on their underlying causes. 1, 2

Diagnostic Approach

Initial Evaluation

• Complete reproductive history and physical examination
• Semen analysis (confirmed azoospermia after centrifugation)
• Hormonal assessment:
  • Testosterone
  • FSH (key differentiator: elevated in NOA, normal in OA)
  • LH
  • Prolactin (if indicated)

Genetic Testing

• Karyotype analysis for men with severe oligospermia or NOA
• Y-chromosome microdeletion testing for men with severe oligospermia or NOA 1
• CFTR mutation analysis for men with congenital bilateral absence of vas deferens (CBAVD) 1

Imaging

• Transrectal ultrasound (TRUS) for suspected ejaculatory duct obstruction 1
• Renal ultrasonography for patients with vasal agenesis 1

Management of Obstructive Azoospermia

Surgical Reconstruction

• Microsurgical reconstruction is the primary approach when feasible:
  • Vasovasostomy for vasectomy reversal (85% patency rate) 3
  • Vasoepididymostomy for epididymal obstruction (42% patency rate) 3
  • Transurethral resection of ejaculatory ducts (TURED) for ejaculatory duct obstruction 1

Sperm Retrieval with ART

• For cases not amenable to reconstruction:
  • Microsurgical epididymal sperm aspiration (MESA)
  • Testicular sperm extraction (TESE)
  • Combined with IVF/ICSI 2, 4

Management of Non-Obstructive Azoospermia

Hypogonadotropic Hypogonadism

• Human chorionic gonadotropin (hCG) injections (500-2500 IU, 2-3 times weekly) 1
• FSH injections after testosterone normalization with hCG
• Response correlates with pre-treatment testicular size 1

Primary Testicular Failure

• Microdissection testicular sperm extraction (micro-TESE) with IVF/ICSI is the mainstay treatment 1
• Sperm retrieval rates of 40-60% reported 1
• Consider pharmacologic optimization before surgical intervention:
  • Selective estrogen receptor modulators (SERMs)
  • Aromatase inhibitors
  • Gonadotropins 1, 5

Post-Gonadotoxic Therapy

• Micro-TESE is recommended for men seeking paternity who remain azoospermic after gonadotoxic therapies 1
• Sperm banking should be encouraged before starting gonadotoxic therapies 1

Important Considerations

Avoid Testosterone Therapy

• Exogenous testosterone therapy must be avoided in men desiring fertility as it suppresses spermatogenesis 1, 6
• Recovery after cessation can take months or even years 1

Genetic Counseling

• Couples with CBAVD should have cystic fibrosis carrier testing for the female partner 7
• Y-chromosome microdeletion and karyotype results provide important prognostic information 7

Assisted Reproductive Technology

• IVF with ICSI typically allows for a 37% live delivery rate per initiated cycle 1
• Success rates are closely related to female age 1

Treatment Algorithm

1. Determine type of azoospermia (OA vs NOA) through hormonal testing and physical examination
2. For OA:
   • If reconstructable: Microsurgical repair
   • If not reconstructable: Sperm retrieval + IVF/ICSI
3. For NOA:
   • If hypogonadotropic hypogonadism: Medical therapy with gonadotropins
   • If primary testicular failure: Consider medical optimization followed by micro-TESE + IVF/ICSI

The prognosis and treatment approach differ significantly between OA and NOA, with OA generally having better outcomes through either reconstruction or sperm retrieval techniques.