Azoospermia – Diagnosis, Treatment, and the Desire to Have Children When There Are No Sperm

The term infertility refers to a reproductive disorder characterized by the inability to achieve pregnancy. In industrialized nations, the infertility rate is as high as 15 percent.

In Germany today, nearly one in six marriages is involuntarily childless. The causes of involuntary childlessness are varied. In about 30 percent of cases, the cause lies solely with the woman; in another 30 percent, solely with the man; and in the remaining 30 percent, with both partners.

Infertility is clearly a taboo subject: Only 4 to 17 percent of affected couples seek medical advice, even though the emotional distress for those affected is immense.

The World Health Organization (WHO) defines male infertility as the failure to achieve pregnancy despite regular unprotected sexual intercourse over a period of one year with a partner who is apparently healthy.

One possible cause of infertility attributable to the man is azoospermia. This refers to the complete absence of sperm in the semen. This means that, despite ejaculation, no sperm can reach the woman’s egg, and thus pregnancy does not occur.

Generally, there are two main causes of azoospermia:

• disorders in sperm production and
• obstruction of the sperm ducts.

Sperm are produced by the so-called germinal epithelium of the testis. If there is a disorder at this site, no sperm—or an insufficient number—are produced. The seminal fluid, which consists of secretions from the prostate and seminal vesicles, therefore contains no sperm.

After the sperm cells are formed in the germinal epithelium of the testis, they enter the epididymis. The epididymis is a long, coiled tube that transports the sperm cells further into the vas deferens. The vas deferens opens into the urethra near the prostate—this area is also called the seminal hillock.

During orgasm, the seminal fluid and sperm are forced into the urethra and then expelled from the penis.

If there is a blockage along this path, no sperm can reach the urethra. This is also the principle behind male sterilization: by ligating both vas deferens, sperm can no longer reach the urethra.

Treatment for azoospermia depends on the cause. If there is a blockage in the sperm ducts, the doctor will attempt to restore patency. If the blockage is in the epididymis, the doctor can reopen the sperm ducts by making an incision in the epididymis. This procedure is performed using a special instrument through the urethra without making an incision in the skin.

If the blockage is in the area of the vas deferens, the doctor can reconnect the two ends of the vas deferens. In some cases, a vasectomy can therefore be reversed. To do this, the doctor uses a surgical microscope to connect the fine tubes with very fine suture material.

In experienced hands, this can achieve patency rates of 90 percent. Once the sperm ducts have been successfully restored, the couple can try to conceive a child naturally.

Azoospermia cannot be treated in all men. However, if they still wish to have a child of their own, reproductive medicine treatment through artificial insemination is an option.

Using ICSI (intracytoplasmic sperm injection), a single sperm cell is injected directly into a female egg cell. For this, at least one egg and one sperm cell from the couple must be retrieved.

In the woman, egg retrieval can be performed via ovarian puncture following hormonal stimulation. For the man, an attempt can be made to obtain samples directly from the testicular tissue and isolate sperm from them (testicular sperm extraction, TESE). This requires a minor surgical procedure.

In some cases, this is also possible for men who suffer from a disorder affecting sperm production. In approximately 50 to 60 percent of cases, sperm cells suitable for artificial insemination are found in the testicular tissue. If an egg is successfully fertilized, the doctor then implants it into the woman’s uterus.

Azoospermia refers to a severe fertility disorder characterized by the absence of sperm in the ejaculate, meaning that no sperm are present in the ejaculate. A distinction is made between non-obstructive azoospermia and obstructive azoospermia, as well as secretory azoospermia, with each type representing a distinct form of azoospermia.

The causes of azoospermia are varied, as azoospermia can result from various factors, which are often genetic or due to other causes and frequently lead to azoospermia. Medically, the condition is explained as follows: azoospermia occurs when sperm production in the testicles is disrupted, no sperm are produced, or there is a complete absence of sperm. The diagnosis of azoospermia involves several steps; it is typically confirmed through semen analysis until the diagnosis is established and azoospermia is confirmed.Many affected men show few symptoms of azoospermia; however, men with azoospermia are infertile and suffer from the condition, even if it is not always immediately recognized.

In some cases, however, sperm can still be found, for example through a testicular biopsy to retrieve sperm or by extracting sperm from the testicles. Depending on the findings, treatment for azoospermia, surgical procedures, or fertility treatment may be considered, often in combination with assisted reproduction or artificial insemination. Whether azoospermia can be prevented or cured depends on the type of azoospermia, the risk of azoospermia, and whether sperm are detectable in the semen.

The goal of any treatment is to help couples achieve their desire to have children, as men with azoospermia can become fathers, even if azoospermia cannot be completely resolved in every case.