Treatment of azoospermia

Azoospermia is the absence of spermatozoa in the seminal fluid in the presence of immature spermatogenesis cells, as well as seminal vesicles and products of prostate secretion.

Azoospermia symptoms

The main symptom of azoospermia is the incapacity of conception in the absence of sexual and ejaculatory disorders. During diagnostics, it turns out that the germ cells in the ejaculate are either very few or not at all.

In addition, the following signs may indirectly indicate the presence of azoospermia:

• genetic pathologies that can cause infertility;
• hormonal disorders;
• small amount of semen during ejaculation;
• small size and increased density of the testicles;
• hypoplasia of the prostate;
• sexual and ejaculatory disorders that occurred after an infection.

Treatment methods for azoospermia

How to treat azoospermia? Various treatments for azoospermia can be used to restore sperm fertility.

Treatment for secretory azoospermia depends on the underlying causes and may include conservative and surgical methods, as well as the use of assisted reproductive technologies. So, the treatment of non-obstructive azoospermia caused by genetic pathologies may involve taking medications that helps to adjust the hormonal balance; if an infection is detected, azoospermia is treated by destroying the pathogen and follow-up spermatogenesis stimulating.

Treatment of obstructive azoospermia may involve anastomosis of the ducts and epididymis. However, the percentage of pregnancy after reconstructive surgeries is not great for a variety of reasons due to the imposition of anastomosis of the ducts. In this regard, today preference is given to the extraction of spermatozoa from the testicle or epididymis with further use in the IVF-ICSI program.

Facts about azoospermia

Azoospermia occurs

in 1-2% of men

Average sperm maturation time

90 days

Efficiency of IVF-ICSI in case of man has azoospermia

40-60%

The most common cause of azoospermia

is cryptorchidism

Classification and stages of development of azoospermia

Several types of azoospermia are distinguished: secretory (non-obstructive) and excretory (obstructive) form.

The secretory form of azoospermia (NOA) is characterized by disorder of sperm production in the testicles and can be either primary or acquired.

Obstructive azoospermia (OA) is caused by blockage of the vas deferens while the testicles maintain normal sperm production.

In addition, transient azoospermia should be mentioned separately, it is a condition when germ cells in the seminal fluid are absent only for a certain period of time.

Causes of azoospermia

Mostly, the development of pathology is based on only two reasons:

• the presence of mechanical obstacles on the way from the testicles, where spermatozoa are formed, to the urethra, from where, sperm mixes with the secretion of the prostate gland and seminal vesicles, and then as a result of ejaculation sperm can enter the female genital tract;
• disorder in the process of formation and maturation of spermatozoa.

Obstructive azoospermia (OA) can be caused by:

• fragments of the vas deferens were tied or removed (vasoresection or vasoligation), this surgery is aimed to sterilize a man;
• congenital anomalies, because of which the patient is diagnosed with either agenesis (absence) or hypoplasia (underdevelopment) of the vas deferens;
• acute or chronic epididymitis;
• formation (cyst or tumor), which, as it grows, begins to squeeze the vas deferens, thereby blocking the gap between their walls.

Non-obstructive azoospermia (NOA) can be caused by the following factors:

• changes in hormonal levels due to diseases of the pituitary gland and thyroid gland;
• chromosomal abnormalities (Klinefelter's syndrome, Del Castillo's syndrome, Noonan's syndrome and other congenital pathologies);
• congenital pathologies in which the testes are either completely absent or underdeveloped;
• orchitis;
• dropsy of the testicular membranes. With hydrocele, fluid accumulates in the scrotum, squeezing the testicle and inhibiting normal spermatogenesis;
• inguinal hernia;
• infectious diseases (e.g. mumps);
• STIs;
• chemicals and radiation exposure (caused by working in hazardous industries, or occurred during the treatment of cancer).

There are also factors that can cause both secretory (non-obstructive) and obstructive azoospermia. These include:

• varicocele;
• trauma in the genital area;
• scrotum surgeries.

Transient azoospermia can be triggered by the intake of certain medications (for example, steroids), significant psycho-emotional overstrain, bad habits (alcohol abuse, drug use) and excessively active sex life.

Complications of azoospermia

The absence of sperm in the ejaculate can lead to complications such as:

• significant decrease in reproductive function. In some cases, specialists manage to obtain sex cells by biopsy of the testicle or its epididymis. They are used for fertilization in the IVF-ICSI program. Sometimes there is a need for donor genetic material;
• decrease in sexual activity;
• psychological problems (up to the development of depression).

Diagnosis of azoospermia

Usually, azoospermia is detected in patients who consult with a specialist about infertility.

In order to identify the causes of decreased fertility and develop the most effective treatment regimen, a complete examination is required.

Anamnesis collection and examination

The doctor needs to find out whether infertility is primary or secondary, that is why he asks questions about whether the patient has biological children, whether a pregnancy has ever occurred with the use his sperm. Also, the specialist will be interested in hereditary and chronic diseases, injuries and operations in the testicular area, infections that occurred in the past.

External exam makes it possible to assess the patient's sexual development, identify problems with excess weight, gynecomastia and other signs that may indicate the likely causes of azoospermia.

By palpating the testicles, the doctor determines their size, shape, consistency.

Also, when viewed using functional tests, varicocele, which is varicose veins of the spermatic cord, can be detected.

Semen analysis

Azoospermia cannot be diagnosed basing on the results of a single semen analysis. If there are no germ cells in the ejaculate, the doctor will recommend to redo the analysis, but only in 10-14 days.

With transient azoospermia, after a while, mature motile spermatozoa can be found in the ejaculate.

Hormonal balance

It is necessary to determine the level of follicle-stimulating (FSH) and luteinizing (LH) hormones, testosterone, estradiol, prolactin. A significant indicator is the concentration of inhibin B, the level of which reflects the quality of reproductive function.

Ultrasound and transrectal ultrasound

Through ultrasound scan the doctor can assess the condition of organs such as the testes and epididymus. During transrectal ultrasound, the condition of the prostate and seminal vesicles is examined. For example, specialist can detect echo signs of blockage of the vas deferens or abnormalities in testicular tissue.

Genetic examination

Since azoospermia is often caused by genetic pathologies, the patient will need to do the following tests:

1. Karyotyping, according to the results of which it is possible to ascertain what is the complete set of the patient's chromosomes. The normal male karyotype is 46XY. For example, in Klinefelter's syndrome, 47XXY (the most common), 48XXYY, 49XXXXY, etc. karyotypes can be detected.
2. Identification of CFTR gene mutations, which are a marker of obstructive azoospermia. Various mutations associated with a disease such as cystic fibrosis (a hereditary pathology characterized by damage of the exocrine glands).
3. AZF factor, which is a marker of secretory azoospermia. Testicular dysfunction occurs with the deletion (disappearance) of some of the fragment of this part of the male chromosome: AZFa, AZFb or AZFc. The possibility of obtaining germ cells with a biopsy depends on which fragment is lost, as well as on whether it is completely or partially lost. While the chances of success are minimal with an AZFa deletion, the loss of the AZFc fragment suggests a possibility of successful outcome.

Diagnostic biopsy of the testicle

If the exact cause of the absence of germ cells in the ejaculate is not determined, the doctor may recommend a diagnostic biopsy of the testicular. During this manipulation, spermatozoa can be detected, in this case spermatozoa are vitrified for further use in the IVF-ICSI cycle. If secretory azoospermia is suspected, biopsy can be performed on different parts of the testicle.

Treatment methods for azoospermia

Treatment of obstructive azoospermia

In some cases, surgery can be performed with the imposition of anastomoses on the vas deferens and epididymus, but the chances of restoring natural fertility after reconstructive surgery are rather small. As a result, specialists prefer assisted reproduction methods. Sex gametes for use in the ART program (IVF-ICSI) are obtained by biopsy from the testicle or its epididymis.

Treatment of secretory azoospermia

In case of not obstructive azoospermia, several methods of surgical sperm extraction are used: PESA, MESA, TESA, TESE, and microTESE. Extracted spermatozoa can be immediately used for fertilization in the IVF-ICSI program or cryopreserved for a certain period of time.

Treatment of transient azoospermia

In this case, it is important to eliminate the negative factor. Depending on whether azoospermia is obstructive or secretory, the doctor develops the optimal treatment regimen, which may involve conservative therapy or surgical intervention. In the absence of a positive effect, the use of ART methods is recommended.

Prognosis and prevention of the disease

The prognosis depends on what causes azoospermia. The chances of restoring natural fertility and success of the ART program are higher in case of OA (obstructive azoospermia).

To reduce the risk of developing azoospermia, it is recommended:

• regularly (once a year in the absence of complaints) undergo a routine examination by a urologist-andrologist;
• timely treat infectious diseases, including STIs;
• if you suspect hereditary pathologies that can provoke reproductive dysfunction, undergo a genetic examination;
• avoid testicles injures;
• keep to be active, give up bad habits and eat healthy.

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