From the Guidelines
Management of azoospermia should prioritize identifying the underlying cause and may involve surgical interventions, hormone replacement therapy, or assisted reproductive technologies, with the goal of optimizing outcomes and minimizing morbidity, mortality, and impact on quality of life. The approach to managing azoospermia depends on whether the condition is obstructive or non-obstructive. For obstructive azoospermia, surgical interventions like vasal reconstruction or transurethral resection of ejaculatory ducts may restore sperm to the ejaculate 1. In cases of non-obstructive azoospermia, treatment depends on the specific etiology, such as hypogonadotropic hypogonadism, which can be addressed with hormone replacement therapy using gonadotropins (hCG and FSH) for at least 6-12 months to stimulate spermatogenesis 1.
Some key considerations in managing azoospermia include:
- Avoiding exogenous testosterone therapy in males pursuing or planning to pursue family building, as it can inhibit spermatogenesis 1
- Using aromatase inhibitors, human chorionic gonadotropin (hCG), selective estrogen receptor modulators (SERMs), or a combination thereof for infertile men with low serum testosterone 1
- Considering treatment using a Follicle-Stimulating Hormone (FSH) analogue to improve sperm concentration, pregnancy rate, and live birth rate in men with idiopathic infertility 1
- Informing patients with non-obstructive azoospermia about the limited data supporting pharmacologic manipulation with SERMs, AIs, and gonadotropins prior to surgical intervention 1
The most effective management strategy for azoospermia is often a combination of medical and surgical approaches, with a focus on optimizing spermatogenesis and minimizing the risk of complications, as supported by the most recent guidelines and evidence 1. When medical or surgical approaches fail, sperm retrieval techniques such as testicular sperm extraction (TESE) or microdissection TESE (microTESE) combined with intracytoplasmic sperm injection (ICSI) offer reproductive options 1. Patients with genetic causes like Y-chromosome microdeletions or Klinefelter syndrome should receive genetic counseling before pursuing assisted reproductive technologies. Throughout treatment, lifestyle modifications including smoking cessation, reduced alcohol consumption, weight management, and avoiding excessive heat exposure to the testes are recommended to optimize outcomes.
From the Research
Management Options for Azoospermia
The management options for azoospermia can be categorized into two main types: obstructive azoospermia and non-obstructive azoospermia.
- Obstructive azoospermia may be treated using microsurgical reconstruction or transurethral resection of the ejaculatory ducts, depending on the level of obstruction 2, 3.
- Alternatively, sperm retrieval with assisted reproduction may be used to effect pregnancies, with success rates of 25-65% reported by different centers 2.
- Non-obstructive azoospermia may be treated by defining the cause of low sperm production and initiating treatment, which may include hormonal therapy 4, 5, 6.
- Genetic evaluation with Y-chromosome microdeletion analysis and karyotype testing provides prognostic information in these men 2, 3.
- For men who have had any factors potentially affecting sperm production treated and remain azoospermic, sperm retrieval from the testis may be effective in 30-70% of cases 2.
- Once sperm are found, pregnancy rates of 20-50% may be obtained at different centers with in vitro fertilization and intracytoplasmic sperm injection 2.
Medical Management of Non-Obstructive Azoospermia
Medical management of non-obstructive azoospermia may include the use of hormonal therapies such as clomiphene citrate, human chorionic gonadotropin (hCG), and human menopausal gonadotropin (hMG) to increase follicle-stimulating hormone (FSH) and testosterone levels, which are essential for spermatogenesis 4, 5, 6.
- Clomiphene citrate administration may result in sperm in the ejaculate of patients with non-obstructive azoospermia or simplify testis sperm retrieval 5.
- A new protocol of clomiphene citrate, hCG, and hMG in the treatment of non-obstructive azoospermia achieves an increase in the levels of FSH, luteinizing hormone (LH), and total testosterone to target levels, resulting in an increased rate of sperm in the ejaculate and increased likelihood of successful micro-testicular sperm extraction 6.
Surgical Management of Azoospermia
Surgical management of azoospermia may include microsurgical epididymal sperm aspiration with in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) for obstructive azoospermia 3.