Azospermia means absence of sperms in the ejaculate. Its prevalence is 1% among all men and 10-15% among infertile men. It is important to differentiate severe oligospermia and azospermia. Because it is possible to obtain sperm for microinjection in the ejaculate of men with severe oligospermia. Fort his reason, WHO recommends two separate semen analysis for the diagnosis of azospermia.
Most common form of azospermia is defective production in the testicles with open ejaculatory ducts (nonobstructive azospermia). This condition may be either due to defective production in the testes or due to defects in the pituitary gland. In 40% of cases, testicular production is adequate but the ejaculatory ducts are blocked (obstructive azospermia).
In case of azospermia, a proper history and a complete physical examinations are mandatory. Serum FSH and testesterone level determinations are important for azospermic patients.
Vas deferens is an important part of physical examination. Urinary tract abnormalities may accompany bilateral absence of vas deferens. Bilateral absence is also common among patients with cystic fibrosis. If the mother is also a carier of the mutation, the child may be born with cystic fibrosis. In these cases, testicular sperm production is normal and surgery yields sperms in most of cases.
Testicular size is also important during physical examination. If the testicles are atrophic, hormonal tests may reveal the etiology. If testicles are atrophic, FSH is elevated and testesterone is decreased, the problem is the testicular tissue itself. This condition is called testicular failure and a peripheric karyotype is required in these patients.
If along with atrophic testes, FSH and testesterone levels are decreased, hipogonadotrophic hipogonadism is the diagnosis. In this case, the pathology is in either hypothalamus or in the pituitary gland. These conditions are either congenital (Kallmann syndrome) or acquired and for the latter a cranial MRI is required.
With normal vas deferens and testicular volume, ejaculate volume and FSH levels are diagnostic. With normal ejaculate volume, azospermia may be either obstructive or nonobstructive. If FSH level is doubled, azospermia is nonobstructive. Value of testicular biopsy for the diagnosis is controversial. Failure in sperm retrieval during biopsy does not necessarily mean TESE will not reveal any sperm. Furthermore, if biopsy reveals sperm, freezing of sperm in nonobstructive azospermia does not yield good pregnancy rates. Thus, we recommend microinjection with fresh sperm.
In patients with normal testicular size, normal ejaculate volume and FSH levels, azospermia is obstructive and aspiaration yields sperms in almost all of cases. In this case, microinjection with fresh sperm is recommended, similarly. In brief, in both cases, testicular biopsy is not recommended.
In patients with normal hormon levels, testicular size and decreased ejaculate volume, the problem is usually obstruction of ejaculatory ducts. Ejaculatory duct obstruction can be diagnosed by rectal ultrasonography and sperm aspiration yields sperms in almost all of cases.
Getting back to genetical testing in azospermic patients, microdeletions in Y chromosome should be searched in nonobstructive azospermia. 2/3 of chromosomal abnormalities belong to the chromosome Y in infertile men and the most common is Klinefelter syndrome. In case of any chromosomal aberration in the male partner, the couple should be informed about the increased abortion rate and about the increased chromosomal abnormality in the off-spring. In such cases, PGD may prove useful. Microdeletions in the chromosome Y can be detected in 15% of azospermic men. These defects can be diagnosed only via polymerase chain reaction (PCR). If PCR reveals that there is a microdeletion, chance of getting sperm on TESE decreases. Microdeletions involving AZFa and AZFb regions show especially bad prognosis.
Sperm aspiration or extraction in azospermic patients do not solve the problem but help them get a pregnancy. Replacement of hormons in hipogonadotrophic hipogonadism may restore sperm production. In cases of testicular failure, the problem is either congenital or secondary to viral infections, radiation, chemotherapy or trauma. Tuberculosis, sertoli cell only syndrome and maturation arrest can also be the reason. Actually, there is no treatment for any of these and the only way to achieve a pregnancy is microinjection if TESE reveals any sperm.
Can microsurgery relieve the problem in obstructive azospermia? Microsurgery is a difficult procedure requiring excessive skills. Success rates are around 25 to 40%.
All surgical sperm retrieval procedures can be performed either under local or general anesthesia. General anesthesia is usually preferred for patient comfort. They are all daily outpatient surgical procedures. The procedure lasts around 10 minutes to half an hour. . The patient can get back to daily activities after the procedure. The procedure is performed at the IVF center and sperms are searched simultaneously under microscope. Once sperm is obtained, the procedure is ceased.
Surgical sperm retrieval procedures are explained below;
PESA: Percutaneous Epidydimal Sperm Aspiration. A fine needle is inserted to the epididyms and sperms are aspirated. Testes is not opened surgically.
PTSA: Percutaneous Testicular Sperm AspirationA fine needle is inserted to the testicles to aspirate sperms.
TESE: Testicular sperm extraction. Testicles and tunica albuginea are opened surgically via a small incision. Small biopsies are obtained from the testicles.
Micro TESE: Microscopic Testicular sperm extraction. Testicles and tunica albuginea are opened surgically via a small incision. Testicles are examined under microscope and biopsies are obtained accordingly. This procedure is thought to be less harmful to the testicles.
In almost all of obstructive azospermia and half of nonobstructive azospermia cases, sperm can be obtained.
Once sperm is obtained, can they be freezed for future use?
This can work for obstructive azospermia cases. But, the success rates are significantly lower for nonobstructive azospermia cases.
How many times a man can undergo these procedures?
For obstructive azospermia cases, up to 7 successful procedures have been reported. For nonobstructive azospermia cases, if the first TESE revealed sperms, up to 6 other successful TESE have been reported. Pregnancy rates are similar with recurrent TESE applications.
What should be done for nonobstructive azospermia patients whose first TESE did not reveal sperms?
Chance of getting sperms in a patient with a first negative TESE is around 25%. Among our patients, this rate has been found around 5%. This dereased rate is probably due to a more extensive first TESE.
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