# Azoospermia



## Jayne (Jan 26, 2003)

What is azoospermia and can a person with azoospermia have biological children?

Azoospermia is the term used when there is a complete absence of sperm in the ejaculate. Most males diagnosed with azoospermia would assume that this diagnosis means they would never be able to conceive a child; if there are no sperm how can there be conception? In reality however, a semen analysis which shows the absence of sperm in the ejaculate does not remove the chance that sperm is being produced and not delivered to the semen, or that interventions may help the man produce sperm. Even in cases where after intervention there is still no sperm in the ejaculate, there may be a possibility of harvesting small amounts of sperm, which have been produced in the testes as a result of the interventions.

A Production Problem or a Delivery Problem? 

Investigations need to be carried out to disocer whether the testes are simply not producing sperm, or are producing sperm but unable to deliver it in the ejaculate. If the testes are making sperm but none are in the ejaculate, the sperm must be retrieved by some other mechanism, either by restoring the normal flow of sperm or by circumventing it. If the testes are not producing sperm then exploration of whether the problem can be reversed can be undertaken. Even if the problem cannot be reversed, it is possible that the level of spermatogenesis is advanced enough to allow sperm "harvesting" in conjunction with advanced reproductive techniques (ART) and micromanipulation.

The three major causes for lack of sperm production are hormonal problems, "testicular failure," and varicocele.

*Hormonal Problems*: 
The testicles need pituitary hormones to be stimulated to make sperm. If these are absent or severely decreased, the testes will not produce maximum sperm. If a male uses androgens (steroids) for body building purposes, this can shut down the hormones needed to make sperm.

*Testicular Failure*:
This refers to the inability of the sperm producing part of the testicle (the seminiferous epithelium) to make adequate numbers of mature sperm. This failure may occur at any stage in sperm production for a number of reasons. Either the testicle may completely lack the cells that divide to become sperm (this is called "Sertoli cell-only syndrome") or there may be an inability of the sperm to complete their development (this is called a "maturation arrest"). This situation may be caused by genetic abnormalities, which must be screened for.

*Varicocele*:
A varicocele is dilated veins in the scrotum, (just as an individual may have varicose veins in their legs.) This condition may be corrected by minor out-patient surgery.

Sperm Delivery Problems: Ductal Absence or Blockage?

Sperm delivery complications are generally caused either by a problem with the ductal system that carries the sperm, or problems with ejaculation. The sperm carrying ducts may be missing or blocked. Thus the patient may have been born with an absence of the vas deferens in both sides. Alternatively, there may be obstructions either at the level of the epididymis (the delicate tubular structure draining the testes) or higher up in the more muscular vas deferens.

Sperm are stored in sacs called the seminal vesicles, and then are deposited in the urethra, which is the tube through which men urinate and ejaculate. The sperm must pass through the ejaculatory ducts to get from the seminal vesicles to the urethra. If these are blocked on both sides this will prevent sperm from getting through.

Finally, there may be problems with ejaculation. Before a man ejaculates, the sperm must first be deposited in the urethra (emission). There may be neurological damage from surgery, diabetes, or spinal cord injury, which prevents this from happening. Also, for the sperm to be pushed out the tip of the penis, the entry to the bladder must be closed down. If it does not close down the sperm will be pushed into the bladder, and later washed out when the patient urinates.

Evaluation of Azoospermia

Determining which of the above causes, or a combination of them, is the reason for the patient's azoospermia is often complex. Some of the available tests are listed below.

*Physical Examination:*
This is the simplest test. If the size of the testicles is severely diminished, this is an indication that the seminiferous epithelium is affected. Follow up hormonal profiles can determine whether this is a primary problem or caused by less than adequate hormonal stimulation.

The scrotum is examined for the presence of varicocele. Their presence can be confirmed by an ultrasound probe placed on the skin at the scrotum.

During a physical exam, the ductal systems can be felt. If they are absent, the patient has what is called congenital bilateral absence of the vas deferens, (CBAVD). In most cases this is considered to be due to the patient's genetic make-up and requires chromosomal analysis as part of the evaluation and treatment.

Finally, during examination of the ductal structures, the epididymis may feel as though it is dilated. Generally, it is flat and the middle cannot be felt. Thus, a dilated epididymis may be indicative of a blockage.

*Hormonal Evaluation: * 
Follicle stimulating hormone (FSH) is the hormone made by the pituitary, which is responsible for stimulating the testes to make sperm. When the sperm producing capacity of the testes is diminished, the pituitary makes more FSH in an attempt to make the testes do its job. Therefore, if a man's FSH is significantly elevated there is a strong indication that his testicles are not producing sperm optimally. (Testosterone polactin, leutenizing hormone (LH) and thyroid stimulating hormone (TSH) are also measured to assess a man's hormonal status. These may reveal problems that can have a significant impact on sperm production).

*Genetic Testing: * 
Screening for the genes that can cause cystic fibrosis is sometimes suggested. There are tests for specific genetic abnormalities on the male chromosomes that can cause azoospermia. If a son were to inherit this, he may have the same problem.

*Transrectal Ultrasound:*
In order to rule out a blockage of the ejaculatory duct, an ultrasound of the ejaculatory duct and seminal vesicles is often performed. If the seminal vesicles are dilated, this indicates that they may be full of semen because they cannot empty properly. Cysts blocking the ejaculatory ducts by exerting pressure on their walls, or calcifications in the ejaculatory ducts themselves, may also be noted. A cyst may in some cases may be unroofed by operating through the urethra to open it thus decompressing the ejaculatory duct. If the blockage occurs within the ejaculatory duct, the blocked part may be removed in a similar operation.

*Urinalysis:*
It is possible that ejaculation is occurring backwards, ie. the sperm is being pushed into the bladder, and then washed out when the man urinates after ejaculation. Sometimes this can be corrected by oral medication. If not, the urine can be prepared so that it does not damage the sperm as much, and the sperm is then harvested from the post-ejaculatory urine.

*Testicular Biopsy:*
Finally, if a primary testicular problem is suspected then a testicular biopsy can be undertaken.


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