What are the treatment options for a male patient of reproductive age with obstructive azoospermia?

Managing Obstructive Azoospermia

For men with obstructive azoospermia and a female partner with normal fertility, microsurgical reconstruction of the reproductive tract is the preferred treatment to restore natural fertility, while sperm retrieval with assisted reproductive technology remains an effective alternative when reconstruction is not feasible or has failed. 1, 2

Confirming the Diagnosis

Before initiating treatment, confirm that the azoospermia is truly obstructive rather than non-obstructive:

• Physical examination findings suggesting obstruction include normal-sized, fully descended testes, bilaterally dilated and/or indurated epididymides, palpable vas deferens, and low ejaculate volume (<1.5 mL) with acidic pH 2, 1

• Hormonal profile in obstructive azoospermia shows normal FSH (<7.6 IU/L), normal testicular volume, and normal testosterone levels, distinguishing it from non-obstructive azoospermia which presents with testicular atrophy and elevated FSH 1

• Transrectal ultrasound (TRUS) is indicated when ejaculate volume is low with acidic semen and palpable vas deferens to evaluate for ejaculatory duct obstruction, looking for seminal vesicle diameter >15 mm, ejaculatory duct caliber >2.3 mm, dilated vasal ampulla >6 mm, or prostatic cysts 1, 2

Mandatory Genetic Testing

All azoospermic men must undergo karyotype analysis and Y-chromosome microdeletion testing before any sperm retrieval procedure or ICSI, regardless of whether obstruction is suspected, as this identifies genetic abnormalities that affect prognosis and have implications for offspring 2, 1

Treatment Algorithm by Type of Obstruction

Post-Vasectomy or Acquired Obstruction

Microsurgical reconstruction (vasovasostomy or vasoepididymostomy) is preferable to sperm retrieval when the female partner has normal fertility potential, as it can restore natural fertility without requiring assisted reproductive technology 1, 2

• Vasovasostomy achieves 81% patency rates and 37.5% fertility rates 3
• Epididymovasostomy shows 71% patency rates and 29% fertility rates 3
• Both procedures offer the advantage of enabling multiple pregnancies without repeated interventions 1

Sperm retrieval with ICSI is an alternative option for couples who prefer assisted reproduction or when reconstruction has failed, with clinical pregnancy rates of 35.7% per cycle 3, 4

Ejaculatory Duct Obstruction

Transurethral resection of ejaculatory ducts (TURED) may be offered when obstruction is confirmed by TRUS findings or when seminal vesicle aspiration reveals sperm presence in an azoospermic male 1, 2

• The goal is to resolve obstruction and allow sperm to enter the ejaculate for unassisted conception, IUI, or ART 1
• Surgical sperm extraction (TESE, TESA, or PESA) remains an alternative for men with ejaculatory duct obstruction seeking fertility treatment 1

Congenital Bilateral Absence of Vas Deferens (CBAVD)

For CBAVD, sperm retrieval with assisted reproduction is the only option, as reconstruction is not possible 5, 3

• Critical pitfall: The female partner must undergo cystic fibrosis gene mutation analysis due to the high risk of the male being a CF carrier 5
• TRUS does not contribute to diagnosis or treatment in CBAVD and should not be performed 1

Sperm Retrieval Techniques for Obstructive Azoospermia

For men with obstructive azoospermia undergoing surgical sperm retrieval, sperm may be extracted from either the testis or epididymis with no substantial differences in ICSI success rates 1

• Percutaneous epididymal sperm aspiration (PESA) is less invasive and successful in most obstructive cases 4, 3
• Microsurgical epididymal sperm aspiration (MESA) provides higher sperm yields when PESA fails 4, 3
• Testicular sperm extraction (TESE) is reserved for when epididymal retrieval fails to produce adequate spermatozoa 4

Cryopreserved or fresh sperm yield equivalent ICSI outcomes in obstructive azoospermia, allowing sperm retrieval and cryopreservation prior to ART rather than requiring simultaneous procedures 1

• Fertilization rates of 47% and clinical pregnancy rates of 25.6% per treatment cycle are achievable 4
• Success rates of 25-65% are reported across different centers 5

Assisted Reproductive Technology Outcomes

IVF/ICSI treatment typically allows for a 37% live delivery rate per initiated cycle, with outcomes closely related to female age—progressively lower success occurs with female age over 35 years 1

• Approximately 12.5% of deliveries involve twins 1
• Additional pregnancies may result from one IVF cycle if embryos are available for cryopreservation 1

Critical Pitfall to Avoid

Never prescribe exogenous testosterone therapy to men interested in current or future fertility, as it provides negative feedback to the hypothalamus and pituitary, resulting in inhibition of intratesticular testosterone production and suppression of spermatogenesis, potentially causing azoospermia that can take months to years to recover 1, 6

Special Considerations

For men with aspermia (complete absence of ejaculate), surgical sperm extraction or induced ejaculation including sympathomimetic agents, vibratory stimulation, and electroejaculation may be performed depending on the patient's condition and clinician's experience 1

Infertility associated with retrograde ejaculation may be treated with sympathomimetics and alkalinization of urine with or without urethral catheterization, induced ejaculation, or surgical sperm retrieval 1