The word itself is a bit of a mouthful and, like many medical terms, one you’re not likely to come across unless it personally affects you.

Characterised by the absence of sperm in the ejaculate, Azoospermia affects approximately 1% of the male population and accounts for between 10% and 15% of infertility cases in men.*

Diagnosing azoospermia involves a comprehensive approach, including semen analysis, physical examination, and hormonal evaluation. Understanding the underlying causes, such as obstructive azoospermia, nonobstructive azoospermia, and pre-testicular azoospermia, is crucial for developing effective treatment plans.

The condition can be a challenging diagnosis for individuals and couples trying to conceive, but advancements in medical science offer various treatment options and hope for parenthood.

Assisted reproductive techniques, including in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI), have revolutionized the treatment of azoospermia, offering hope to individuals and couples struggling with male infertility.

What is Azoospermia, and how does it impact male fertility? 

Azoospermia is diagnosed when no sperm are found in a man’s semen sample. The condition is typically identified through semen analysis, often conducted during fertility evaluations that might take place when couples enlist the help of a fertility specialist and can help determine what the best fertility treatment path is.

Hormonal evaluation, including assessing testosterone levels, can provide insights into the underlying causes of azoospermia.

While Azoospermia can present a serious challenge to fertility, diagnosis doesn’t necessarily preclude the possibility of biological parenthood. Advancements in reproductive technologies have made it possible for many men with azoospermia to father children.

Azoospermia is broadly categorised into three types:

Post-testicular azoospermia

This occurs when sperm production is normal, but there’s a blockage or missing connection along your reproductive tract. Blockages can occur in the ejaculatory duct, preventing sperm from being ejaculated. You’re producing sperm, but it’s getting blocked from exiting. This type is also referred to as obstructive azoospermia. It’s the most common type and affects up to 40% of people with azoospermia.

Testicular azoospermia

This type of azoospermia means you have poor or no sperm production due to a disorder in (or damage to) the structure or function of your testicles. Primary testicular failure is a key condition associated with elevated serum FSH levels and low testosterone, often diagnosed through testicular biopsies. This is sometimes also called non-obstructive azoospermia.

Pretesticular azoospermia

This is when your testicles and reproductive tract appear normal but aren’t stimulated enough by hormones to make sperm. The pituitary gland plays a crucial role in hormonal stimulation necessary for sperm production. This can happen after chemotherapy or due to a hormone imbalance and is also considered a type of non-obstructive azoospermia.

Understanding Sperm Count

Sperm count, also known as sperm concentration, is a critical factor in evaluating male fertility. A low sperm count can indicate underlying issues such as hormonal imbalances, testicular problems, or blockages in the reproductive tract.

Semen analysis is a diagnostic tool used to assess sperm count, motility, and morphology. In cases of azoospermia, sperm retrieval techniques, such as testicular sperm extraction (TESE) or microsurgical epididymal sperm aspiration (MESA), can be employed to retrieve sperm for use in assisted reproductive technologies.

Factors that can affect sperm count include lifestyle choices, such as drinking alcohol, smoking, and exposure to toxins, as well as underlying medical conditions, such as pituitary tumors, erectile dysfunction, and undescended testicles.

What causes Obstructive (Post-testicular) Azoospermia?

  • There are several quite different causes of Obstructive (Post-testicular) Azoospermia. The simplest relates to damage to the vas deferens (the tube that transports sperm from the epididymis, where sperm mature, to the ejaculatory ducts).
  • Blockages in the seminal vesicles can also contribute to obstructive azoospermia.
  • The most common of these is a vasectomy but it can also be caused by infections, such as epididymitis (swelling of the epididymis), trauma or injury, cysts or growths and cystic fibrosis gene mutation, which causes either your vas deferens not to form or a build-up of thick secretions, which then blocks sperm.

What causes Non-Obstructive (Pre-testicular and testicular) Azoospermia?

  • Genetic conditions: Fertility specialists can try and identify these by doing blood tests to check for major chromosome abnormalities. Chromosomal abnormalities, such as Klinefelter syndrome, can lead to non-obstructive azoospermia by impairing sperm production.
  • Hormonal imbalances, such as low testosterone.
  • Exposure to toxins, including radiotherapy and chemotherapy.
  • Use of anabolic steroids and supplements that are taken to enhance performance and muscle bulk.
  • Lifestyle choices like misusing drugs or alcohol.
  • Viral and other illnesses, particularly when associated with fever, may also cause ‘recoverable’ Azoospermia.
Doctor discussing male infertility and azoospermia treatment options

How is Azoospermia diagnosed?

Couples experiencing fertility difficulties who consult their GP and are referred to a fertility specialist will usually undergo a variety of tests and assessments to identify the cause.

For a male party, this will involve a semen analysis. If on two separate occasions, the analysis results show no sperm, the healthcare providers usually diagnose azoospermia.

What other tests diagnose azoospermia?

To determine the cause of azoospermia, your healthcare provider will usually start by asking you about your medical history to establish factors such as:

  • Previous injuries or surgeries to your pelvic area.
  • Infections like urinary tract or sexually transmitted infections.
  • Use of alcohol, marijuana or drugs.
  • What other medications you might take or have taken in the past.
  • Frequency of exposure to extreme heat, such as saunas.
  • Family history of birth disorders, cystic fibrosis or infertility.

They will also conduct a thorough physical examination of your scrotum and may include a rectal exam.

Other tests might include:

  • Hormonal blood tests to assess levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), and testosterone to evaluate testicular function
  • Genetic testing to identify potential genetic causes, such as Klinefelter syndrome or Y-chromosome microdeletions
  • Ultrasound examinations of the scrotum to detect blockages or structural abnormalities
  • Transrectal ultrasound to evaluate potential obstructions in the reproductive system, such as in the seminal vesicles.

How is Azoospermia treated?

Getting pregnant naturally can be challenging for couples affected by azoospermia. However, with the help of assisted reproductive technologies, such as IVF and ICSI, many individuals and couples can overcome male infertility and achieve pregnancy

The treatment options for azoospermia depend on what type of azoospermia you might have and the underlying cause:

Testosterone replacement therapy can negatively impact male fertility by suppressing natural testosterone synthesis and decreasing sperm production.

Obstructive Azoospermia

Surgical Correction:

Procedures like vasovasostomy or epididymovasostomy can restore the flow of sperm by correcting blockages.

Sperm Retrieval Techniques:

Methods such as percutaneous epididymal sperm aspiration (PESA) or testicular sperm extraction (TESE) allow for the collection of sperm directly from the reproductive tract, which can then be used in assisted reproductive technologies like intracytoplasmic sperm injection (ICSI).

Non-Obstructive Azoospermia

Hormonal Therapy:

In cases where hormonal imbalances are identified, hormone treatments may be prescribed to readdress the balance.

Microdissection TESE:

This surgical technique involves extracting small samples of testicular tissue to locate viable sperm, which can then be used for ICSI. This method has enabled many men with Non-Obstructive Azoospermia to achieve biological parenthood.

Experimental Therapies:

Research is ongoing into innovative treatments, such as stem cell therapy, to stimulate or regenerate testicular tissue to restore sperm production. Sertoli cell only syndrome is a condition characterised by the absence of germ cells and impaired sperm production, which experimental therapies aim to address.

Man receiving emotional support after azoospermia diagnosis

How can you prevent azoospermia?

If your azoospermia isn’t a genetic problem, doing the following can help lessen the chance of azoospermia:

  • Avoid activities that could injure your reproductive organs, or wear protection (like a cup when playing sports).
  • Avoid exposure to radiation.
  • Understand the risks of medications that could harm sperm production.
  • Avoid lengthy exposure of your testes to hot temperatures, for example, in saunas and hot tubs.
  • Prevent mumps orchitis through vaccination to reduce the risk of acquired testicular azoospermia.

Emotional and psychological considerations

While azoospermia is a significant cause of male infertility, numerous treatment options offer hope for affected individuals. Advancements in medical and reproductive technologies continue to improve outcomes, making biological parenthood a possibility for many men diagnosed with this condition.

Even so, a diagnosis of azoospermia can have a profound emotional impact on a man and his partner, including feelings of grief, inadequacy and anxiety around the stigma of not being able to conceive naturally. Conditions causing male infertility can potentially be transmitted to male offspring, and couples should be counselled on the genetic implications of assisted reproductive technologies.

It’s crucial for individuals and couples to seek psychological support and counselling to navigate these challenges and to make sure they keep the line of communication open with one another and talk through the challenges.

Fertility groups and communities like the IVFN can also provide valuable support and reassurance both from leading fertility experts, like urologist and male fertility specialist Jonathan Ramsay, and people who are going, or have been through, similar experiences.