What is Azoospemia or Zero sperm count evaluation?

Azoospermia is when a male semen sample has zero sperm or no sperm count, also known as zero sperm count evaluation (semen without sperm). A male suffering from azoospermia cannot become father naturally.

Male infertility constitutes 40% of the infertility causes of which Male suffering from Azoospermia (Zero sperm count) is found in 15% of cases. This number is higher in Indian male population, upto 40% of men with infertility, due to undiagnosed filariasis (roundworms or parasites_ and genital tuberculosis at a young age. Due to the undiagnosed nature and only symptom being unable to conceive in a relationship patients are unaware of the factor leading to azoospermia.

In a normal male, testicles produce sperms and are stored in a thin tube called epididymis. Sperms then travel & get mixed with semen produced from the prostate gland. Finally, semen with sperm moves out through the urethra and penis.

But in Indian men with azoospermia , due to severe damage to vas deferens or epididymis (the transport anatomy for sperm ejaculation) the Surgical approach of Sperm retrieval is more successful.

There are 2 types of azoospermia

Obstructive Azoospermia (post testicular) – In Obstructive Azoospermia the Male testicles produces sperm but the sperm is not ejaculated (flown out) due to the block or obstruction in the Tube (genital tract).
Non-Obstructive Azoospermia (pre-testicular & testicular) – In Non- Obstructive Azoospermia the Male testicles are unable to produce any sperm, this can be a congenital disorder (present from birth). There can also be a case where the sperm growth is stopped during the early stage of sperm maturation.
- Children or young males presenting with Orchitis (bacterial or viral infection) or cryptorchidism( non-descent of testis to scrotal sac) can also present with non-obstructive azoospermia in adulthood.
- Unfortunately in many countries including India, young adults are not appropriately identified or diagnosed at the right time to avoid azoospermia and by the time they visit an IVF Specialist, azoospermia many times is irreversible.
- Akruti IVF with support of a Senior Uro-Andrology team, we are able to identify and treat non-obstructive azoospermia with physical or infective reasons with appropriate Surgical and medical options.

Causes of Obstructive Azoospermia (post testicular) –

Injury or a trauma to the male testicles.
Inflammation or Infections of epididymitis (tube block that carry sperm) or prostate.
Retrograde ejaculation (dry orgasm, sperm travels to urine bladder instead of penis)
Males born with prostate cysts or missing portions of their vas deferens.
Surgical procedures executed to correct conditions such as a hernia produce scar tissue that obstructs the reproductive tract.
A vasectomy blocks sperm ducts intentionally to stop semen from flowing.

Causes of Non-Obstructive Azoospermia (pre-testicular & testicular) –

Abnormal function of the testicles or reproductive hormones (low testosterone, hyperprolactinemia & androgen)
Genetic conditions like kallman syndrome (lack of sex hormone), Klinefelter syndrome (extra X chromosome), or Y-chromosome micro-deletion.
Varicose veins forming around testicles (varicocele) that affect the count and quality of sperms
Lowered sperm production in the testicles (hypospermatogenesis) resulting in zero sperm or Azoospermia.
Inadequate development or maturation of the sperm
Reaction to certain medication which harms sperm production
Not having testicles or having undescended testicles (testicles not dropping to scrotum before birth, requires surgery)
Orchitis (swelling in testicles)
Other factors including chemotherapy, diabetes, sickle-cell anemia, steroid intake, and exposure to heavy metals or toxins.

How is Azoospermia (zero sperm evaluation) Diagnosed?

AT Akruti IVF the full diagnosis of azoospermia is done by a Uro-Andrologist (Dcotor for male infertility & reproductive issues) who counsels, helps & explains the issue to the husband (male). He is supported by a Senior Andrology laboratory team certified in World Health Organization mandated Semen Analysis and evaluation of azoospermia The evaluation is done in 3 steps:

Taking History
Doing Physical examination
Conducting Investigations

HISTORY- Husband (Male partner) and his family’s detail history is taken to directly or indirectly correlate causes of his infertility, which may include Information such as :
- About childhood or any medical illness/ abnormalities and treatment performed.
- Hormonal imbalance (Diabetes, hypogonadotropic hypogonadism, CAH, etc.).
- Occupational hazards –
  - Exposure to Environmental toxins such as pesticides,
  - Patient working in working in industries like chemical or radiation exposure
  - Patient exposure to excessive heat like furnace, boiler, heavy engine etc
- Lifestyle factors:
  - Professional mental stress
  - Very tight undergarments
  - excessive Sauna baths,
  - Keeping laptop on lap & working long may cause sperm abnormalities.
- Addictions:
  - Heavy or Chain Smokers,
  - Intake of marijuana, opiates, Hookah, cocaine, causes oxidative DNA damage of sperms.
- Impact of steroids: Anabolic steroids used by Body builders (gym) and Use of testosterone supplementation causes toxic effects.
- Chemotherapeutic agents: Due toxicity of the chemo agents it is advisable to do fertility preservation by cryopreserving the testicular tissue.
- Drugs:
  - Antidepressant drugs
  - Antipsychotic drugs or antihypertensive drugs,
  - High antibiotics may cause Hyperprolactinaemia causing impair sexual activity.
HYSICAL EXAMINATION – At Akruti IVF the physical Andrological examination is done by a specialist uro-andrologist (Dcotor for male infertility & reproductive issues) when the semen analysis report shows abnormalities. Physical inspection is always indicated in
- Azoospermic individuals (undescended testes),
- Patient with history of failure to deposit semen in vagina
- Absence of beard, moustache
- Curvature of penis
- Palpation of testes
- Examination of scrotal sac,
- varicocele, rectal examination, etc.
INVESTIGATIONS:
- Semen analysis – A Semen Analysis is a IVF laboratory test done to identify azoospermia in Male. At Akruti IVF the test is done according to the WHO (world health Organisation) laboratory manual for evaluating human semen.
- Fructose test – A fructose test is done for patients suffering from azoospermia.
- Sperm DNA fragmentation Index Test: A male fertility test that identifies the amount of DNA damage to sperm.
- Azoospermia Confirmatory Test : A WHO mandated test to confirm Azoospermia and confirmation if azoospermic patient is wrongly identified. About 15% of patients have cryptozoospermia ( few spermatozoa in entire sample) and can conceive without Surgical approach and Intra-cytoplasmic Sperm Injection(ICSI) with sperm motility inducer
- Other investigations: are done as per the patient medical condition e.g. Hormonal assessments, Genetic testing, Radiology, Diagnostic Testicular Biopsy.

How is azoopsermia treated?

Treatment of Azoospermia is based on the cause, appropriate genetic testing & Genetic counseling are the important aspects of azoospermia treatment, The treatment methods include;

Performing surgery to unblock tubes or retrieve sperms via Microsurgery or Endoscopy (AKRUTI IVF has combined Microsurgery and Endoscopy 3D Unit : A Rare Scenario in India).
In case of damaged tubes where reconstruction has low chance or success for the male patient or non-obstructive azoospermia where testis produces very few spermatozoa, we directly access the testicular tissue and retrieve sperms via Microsurgery (microTESE)
In case of Hormonal imbalance, administering Hormones to stimulate sperm production.
Retrieving sperm directly from testes & performing ICSI procedure to fertilize eggs.
Genetic counseling in cases where the azoospermia can be passed on to future baby.

Sperm retrieval procedures

TESA (Testicular sperm aspiration) – TESA is done with a help of a simple needle the sperms are aspirated from the testis & processed.
PESA (Percutaneous Epididymal Sperm Aspiration) – PESA involves aspiration of epididymal fluid via a needle.
TESE (Testicular sperm extraction) – A small incision is made on the testis & presence of sperm is examined in the tubules.
MESA (Microepididymal Sperm Aspiration) – MESA is done for vasal or epididymal obstruction (congenital bilateral absence of the vas deferens)
MicroTESE (Microdissection Testicular Sperm Extraction) – Preferred procedure for Azoospermic patients performed by Urologist-Andrologist.

AKRUTI IVF CENTRE DOMBIVLI is one of the only handful clinics in India which are equipped with the advanced microscope required to conduct this procedure. Single most important advantage of this procedure compared to conventional TESE procedure is amount of testicular tissue retrieved is very less so patient doesn’t have the risk of long term side effects after this procedure. In conventional TESE approximately 50-70 mg tissue is retrieved while Micro TESE required only 10-15 mg of tissue.
Patient can go home same day as this procedure is completely painless.

Akruti IVF Centre has been performing MicroTESE for many years; a male Sr. Urologist-Andrologist who is specialist in male infertility performs this micro surgery with the help of Advanced Microscope dedicated for performing MicroTESE.

AKRUTI IVF CENTRE DOMBIVLI, We have successfully treated many couples with this procedure and helped them get pregnant with their own sperms even if their semen sample doesn’t show any sperms (Azospermia).