Azoospermia and its Treatment in India at IVF-ICSI CENTER Delhi

Azoospermia is the medical condition of a male not having any measurable level of sperm in his semen. It is associated with very low levels of fertility or even sterility, but many forms are amenable to medical treatment. In humans, azoospermia affects about 1% of the male population and may be seen in up to 20% of male infertility situations.IMG-20140827-WA0005

Azoospermia can be classified into three major types as listed. Many conditions listed may also cause various degrees of oligospermia rather than azoospermia.

Pretesticular azoospermia

Pretesticular azospermia is characterized by inadequate stimulation of otherwise normal testicles and genital tract. Typically, follicle-stimulating hormone (FSH) levels are low (hypogonadotropic) commensurate with inadequate stimulation of the testes to produce sperm. Examples include hypopituitarism (for various causes), hyperprolactinemia, and exogenous FSH suppression by testosterone. Chemotherapy may suppress spermatogenesis. Pretesticular azoospermia is seen in about 2% of azoospermia.

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Testicular Azoospermia
In this situation the testes are abnormal, atrophic, or absent, and sperm production severely disturbed to absent. FSH levels tend to be elevated (hypergonadotropic) as the feedback loop is interrupted. The condition is seen in 49-93% of men with azoospermia. Testicular failure includes absence of failure production as well as low production and maturation arrest during the process of spermatogenesis.

Causes for testicular failure include congenital issues such as in certain genetic conditions (e.g. Klinefelter syndrome), some cases of cryptorchidism or Sertoli cell-only syndrome as well as acquired conditions by infection (orchitis), surgery (trauma, cancer), radiation,[3] or other causes. Mast cells releasing inflammatory mediators appear to directly suppress sperm motility in a potentially reversible manner, and may be a common pathophysiological mechanism for many causes leading to inflammation.

Generally, men with unexplained hypergonadotropic azoospermia need to undergo a chromosomal evaluation.

Posttesticular azoospermia
In posttesticular azoospermia sperm are produced but not ejaculated, a condition that affects 7-51% of azoospermic men. The main cause is a physical obstruction (obstructive azoospermia) of the posttesticular genital tracts. The most common reason is a vasectomy done to induce contraceptive sterility. Other obstructions can be congenital (example agenesis of the vas deferens as seen in certain cases of cystic fibrosis) or acquired, such as ejaculatory duct obstruction for instance by infection.

Ejaculatory disorders include retrograde ejaculation and anejaculation; in these conditions sperm are produced but not expelled.

Diagnosis and Evaluation

Azoospermia is usually detected in the course of an infertility investigation. It is established on the basis of two semen analysis evaluations done at separate occasions (when the seminal specimen after centrifugation shows no sperm under the microscope) and requires a further work-up.

The investigation includes a history, a physical examination including a thorough evaluation of the scrotum and testes, laboratory tests, and possibly imaging. History includes the general health, sexual health, past fertility, libido, and sexual activity. Past exposure to a number of agents needs to be queried including medical agents like hormone/steroid therapy, antibiotics (sulphasalazine), alpha-blockers, 5 alpha-reductase inhibitors, chemotherapeutic agents, pesticides, recreational drugs (marijuana, excessive alcohol), and heat exposure of the testes. A history of surgical procedures of the genital system needs to be elicited. The family history needs to assessed to look for genetic abnormalities.

Absence of the vas deferens may be detectable on physical examination and can be confirmed by a transrectal ultrasound (TRUS). If confirmed genetic testing for cystic fibrosis is in order. Retrograde ejaculation is diagnosed by examining a postejaculatory void for presence of sperm.

Low levels of LH and FSH with low or normal testosterone levels are indicative of pretesticular problems, while high levels of gonadotropins indicate testicular problems. However, often this distinction is not clear and the differentiation between obstructive versus non-obstructive azoospermia may require a testicular biopsy.

Serum inhibin-B weakly indicates presence of sperm cells in the testes, raising chances for successfully achieving pregnancy through testicular sperm extraction (TESE), although the association is not very substantial, having a sensitivity of 0.65 (95% confidence interval [CI]: 0.56–0.74) and a specificity of 0.83 (CI: 0.64–0.93) for prediction the presence of sperm in the testes in non-obstructive azoospermia.

It is recommended that men primary hypopituitarism may be linked to a genetic cause, a genetic evaluation is indicated in men with azoospermia due to primary hypopituitarism.Azoospermic men with testicular failure are advised to undergo karyotype and Y-micro-deletion testing.

Genetic causes of Azoospermia

Genetic factors can cause pretesticular, testicular, and posttesticular azoospermia (or oligospermia) and include the following situations:The frequency of chromosomal abnormalities is inverse proportional to the semen count, thus males with azoospermia are at risk to have a 10-15% abnormalities on karyotyping versus about < 1 % in the fertile male population.azoos2

Pretesticular azoospermia may be caused by congential hypopituitarism, Kallmann syndrome, Prader-Willi syndrome and other genetic conditions that lead to Gnrh or gonadotropin deficiency. Testicular azoospermia is seen in Klinefelter syndrome(XXY) and the XX male syndrome. In addition, 13 % of men with azoospermia have a defective spermatogenesis that is linked to defects of the Y chromosome. Such defects tend to be de novo micro-deletions and affect usually the long arm of the chromosome. A section of the long arm of the Y chromosome has been termed Azoospermia Factor (AZF) at Yq11 and subdivided into AZFa, AZFb, AZFc and possibly more subsections. Defects in this area can lead to oligospermia or azoospermia, however, a tight genotype-phenotype correlation has not been achieved. Spermatogenesis is defective with gene defects for the androgen receptor.

Posttesticular azoospermia can be seen with certain point mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene commonly associated with congenital vas deferens abnormalities.

Genetic counselling is indicated for men with genetic causes of azoospermia. In terms of reproduction, it needs to be considered if the genetic defect could be transmitted to the offspring.

Azoospermia is the term used when there is a complete absence of sperm in the ejaculate. Most patients assume that this diagnosis would rule out the possibility of his ever conceiving a child.

Azoospermia is called when there is no sperm in semen. This type of semen disorder is found in approximately 3% of infertile men i.e. absent sperm.

Azoospermia is the term used when there is a complete absence of sperm in the ejaculate. Most patients assume that this diagnosis would rule out the possibility of his ever conceiving a child; if there are no sperm how can there be conception? However the reality is that a semen analysis which shows the absence of sperm in the ejaculate does not rule out either the possibility that sperm is being produced and not delivered to the semen, or that interventions may help the man produce sperm. Even in those 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.

FAQ’s about Azoospermia : –
Q. What is azoospermia and can a person with azoospermia have biological children ?

A. 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?…

Q. A Production Problem or a Delivery Problem ?

A. Investigations need to be carried out to discover 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…

Treatment of Azoospermia I India with IVF-ICSI CENTER, Delhi
Azoospermaia can be treated successfully. Pregnancy may be achieved by treating azoospermia or by assisted fertility treatment like IVF. To find out more, send your details at, or fill out a form.