From the Guidelines
Azoospermia, or the absence of sperm in a man's ejaculate, should be diagnosed through semen analysis and treated based on the underlying cause, with options including surgical correction, sperm retrieval techniques, hormone therapy, and lifestyle modifications, as recommended by the most recent guidelines 1. The diagnosis of azoospermia is crucial in determining the appropriate treatment approach. According to the 2024 AUA/ASRM guideline 1, azoospermia is defined as the absence of spermatozoa in the semen, and it can be classified into two main types: obstructive azoospermia and non-obstructive azoospermia.
Key Considerations
- Obstructive azoospermia is suspected when the physical examination reveals testes of normal size, fully descended into the scrotum, and bilaterally dilated and/or indurated epididymides with or without absence of the vas deferens, and FSH levels are usually less than approximately 7.6 IU/L 1.
- Non-obstructive azoospermia is more likely when the testes are atrophic, especially in the presence of FSH greater than 7.6 IU/L 1.
- A low volume, acidic pH, azoospermic ejaculate is typically indicative of distal obstruction in the genital tract, commonly seen in patients with congenital bilateral absence of the vas deferens (CBAVD) or ejaculatory duct obstruction (EDO) 1.
Treatment Options
- For obstructive cases, surgical correction of the blockage or sperm retrieval techniques like TESE (testicular sperm extraction) combined with IVF/ICSI may be effective 1.
- For non-obstructive cases, hormone therapy with medications like clomiphene citrate, anastrozole, or hCG might stimulate sperm production in some cases 1.
- Lifestyle modifications, including weight loss, avoiding hot baths, quitting smoking, and reducing alcohol consumption, can also help 1.
Additional Recommendations
- Men diagnosed with azoospermia should be evaluated by a urologist specializing in male fertility, as the condition can sometimes indicate other health issues like genetic abnormalities or hormonal imbalances that require treatment beyond fertility concerns 1.
- Clinicians should recommend karyotype testing for males with primary infertility and azoospermia or sperm concentration <5 million sperm/mL when accompanied by elevated FSH, testicular atrophy, or a diagnosis of impaired sperm production 1.
From the Research
Diagnosis of Azoospermia
- Azoospermia is diagnosed based on the absence of spermatozoa after centrifugation of complete semen specimens using microscopic analysis 2.
- History and physical examination, hormonal analysis (FSH, testosterone), and diagnostic testicular biopsy are undertaken to define the cause of azoospermia 2, 3, 4.
- Azoospermia can be classified into two types: obstructive azoospermia (OA) and non-obstructive azoospermia (NOA) 2, 5, 3, 4.
Treatment of Obstructive Azoospermia
- Obstructive azoospermia may be treated using microsurgical reconstruction or transurethral resection of the ejaculatory ducts, depending on the level of obstruction 2, 5.
- Sperm retrieval with assisted reproduction may be used to effect pregnancies, with success rates of 25-65% reported by different centers 2.
- Microsurgical epididymal sperm aspiration with in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) is utilized for those cases not amenable to reconstruction 5.
Treatment of Non-Obstructive Azoospermia
- Non-obstructive azoospermia may be treated by defining the cause of low sperm production and initiating treatment 2.
- Genetic evaluation with Y-chromosome microdeletion analysis and karyotype testing provides prognostic information in these men 2, 5.
- Sperm retrieval from the testis may be effective in 30-70% of cases, and once sperm are found, pregnancy rates of 20-50% may be obtained at different centers with in vitro fertilization and intracytoplasmic sperm injection 2.
- Microdissection testicular sperm extraction with IVF/ICSI may be used for appropriate candidates based on laboratory/genetic testing 5.
Diagnostic Parameters
- Serum hormonal levels, such as FSH and testosterone, can be used to distinguish between OA and NOA 4.
- Testicular long axis, as measured by ultrasound, can also be used to distinguish between OA and NOA 4.
- A combination of serum FSH and testicular long axis can be used to predict the type of azoospermia, with a positive predictive value of 97.02% for NOA and 78.8% for OA 4.
Histological Evaluation
- Histological examination of testicular biopsy samples can provide additional diagnostic information on infertility 6.
- Histological alterations in the testicular tissues are frequently observed in azoospermic men, including hypospermatogenesis, Sertoli-cell-only syndrome, and germ cell arrest 6.
- The prevalence of Sertoli-cell-only syndrome varies from 27 to 68%, and the mean spermatozoid recovery rate is between 16 and 33% 6.