There are a lot of reasons why sperm goes awol. Sometimes its an issue of mis-firing the gun and others because there aren’t any bullets to load. The first step is to figure out the underlying issue, then to put together a plan for how to fix it. Thanks to incredibly skilled surgeons and advances in modern medicine many men with azoospermia are able to father children. This article details some of the underlying causes, how they are diagnosed and what treatment options are available.
10-20% of infertile men and about 1% of all men suffer from azoospermia. The very first step to figuring out what’s going on is to try to answer the question is zero really zero. Often the doctor will request a second semen analysis to make sure it wasn’t a fluke. If the result still shows zero, lab technicians will centrifuge the semen. If any sperm cells are present they will pellet to the bottom of the tube. If they discover sperm then the technical diagnosis changes to cryptozoospermia, which means hidden sperm. Once azoospermia has been confirmed the next step is to figure out if there is a blockage somewhere along the line that leaves sperm stranded in the testicle (obstructive azoospermia) or if there is an issue that prevents sperm production (nonobstructive azoospermia). Doctors will order a variety of tests to uncover and treat the root cause of the problem. Luckily, in most cases, there is a lot that can be done.
Causes of azoospermia can be broken into 3 categories: Hormonal Imbalance (Pre-testicular): problems with hormones the enable testicles to produce and mature sperm.Testicular Failure: the inability of the testicle to produce sperm due to congenital defect, disease or injury and Plumbing Problems (Post-testicular), issues with plumbing or ejaculation. Pre and post testicular causes are generally treatable and have seen incredible rebounds in sperm production. Testicular failure is more complicated and sometimes unable to be treated. In cases of testicular failure, it is possible to try sperm aspiration techniques to see if there are any sperm anywhere in the testicle that can be extracted and used for IVF with ICSI.
Topic: Hormonal Imbalances
Pre-testicular causes of azoospermia typically have to do with hormonal imbalances. For one reason or another the body isn’t producing enough of the right kinds of hormones or too many of the wrong ones to support the creation of sperm (learn more about how hormones impact sperm production). These tend to be treated with medications that stimulate missing hormones and in some cases can help the body recover natural hormone levels.
Topic: Steroid Use
Use of anabolic steroids may be the leading cause of azoospermia. By artificially raising blood testosterone levels, men send a signal to the brain that says the body is producing too much testosterone and shuts down testosterone production in the testicle. Unfortunately, testosterone is a key ingredient for sperm production.
A natural imbalance of sex hormones including Luteinizing hormone (LH), Follicle Stimulating Hormone (FSH) and Testosterone (T) is called hypogonadism and is a fairly common cause of male infertility. Hypogonadism can be caused by congenital defects or injuries of the testicle or by problems with the pituitary gland. A blood hormone profile can help diagnose the cause of imbalances and determine whether there are medications available to help improve sperm production.
Kallman syndrome is a genetic condition where abnormalities in several genes cause an individual to not complete puberty and strangely have no sense of smell. Men (though women can have it too) with Kallman Syndrome are often diagnosed during their teenage years and have very low LH and FSH levels.
Testicular failure is the one cause of infertility that medicine can’t do a whole lot about. It occurs when the cells of the testicle are unable to produce or nourish sperm to maturation. There are several reasons this can happen. Injury can cause tissue within the testicle to die. Various genetic disorders can cause prevent the development of key cell types or prevent cells from expressing proteins needed for the creation of sperm.
Men generally have a “XY” chromosomal makeup (women are “XX”). However, occasionally boys are born with an extra X chromosome in their genetic makeup – “XXY”, or “47,XXY”. This condition is known as Klinefelter Syndrome, and it has been shown to drastically reduce the man’s fertility.
Cryptorchidism: Missing balls
Poor descent of the testicle is one of the most common birth defects in baby boys affecting 3% of full-term babies and up to 30% of premies. Often the testicle will descend on its own during the first year of life (usually during the 1st 3 months), however sometimes surgery is required. In these cases, fertility is at risk as keeping the testicle in the body longer overheats the cells responsible for producing sperm and permanently cooking the ball. Boys with crytorchidism are also more likely to have other structural issues which can cause blockages leading to azoospermia.
Cancer is incredibly hard on the body. Treatment of cancer, radiation and chemotherapy is equally hard. Because cancer is a rapidly dividing cell, cancer therapies target cells that rapidly divide. This is why patients undergoing chemo loss hair and experience nausea. Unfortunately, sperm cells and the cells in the testicle that create sperm cells fall in the category of rapidly dividing cell and therefore can be wiped out during cancer treatment. If you have cancer, it is possible to donate a semen sample before undergoing treatment to freeze and preserve your fertility.
Infection & Injury
“Protect the family jewels” has an element of truth to it. Injury to the testicle can destroy tissue needed for sperm production. A cheap shot below the belt isn’t likely to do it but if you somehow injure yourself and the pain doesn’t subside it is a good idea to go to the ER. Sometimes blood flow to the testicle can get cut off and cause irreversible damage. Infections can also cause severe damage. Often these can be treated with medication. Take home point: if it hurts or it’s weird and it doesn’t go away. Good idea to see a doctor, even if its embarrassing. Your balls will thank you.
Sertoli cell-only syndrome
There are two main types of cells involved with the maturation of sperm. Sertoli cells act as mothers to the baby sperm. They feed and take care of them. Leydig cells act more like fathers and provide things that baby sperm need including testosterone. In sertoli cell-only syndrome, there either aren’t enough leydig cells or there is something wrong with them.
The male reproductive tract is a marvel of fluidic engineering. There over 20f feet of tiny tubes inside the testicle alone. A kink in any one of these tubes can keep sperm from getting to their intended destination. Here are some of the more common things that can happen.
Topic: Retrograde Ejaculation
You’ve heard of “shooting blanks” – this is where your semen contains little or no sperm. Retrograde ejaculation takes it a step further – this is a condition where a man “shoots nothing at all”. This is also referred to as a “dry orgasm”. In other words, even though you’ve reached orgasm, you’re not ejaculating any semen (and therefore not likely to be able to impregnate your lady). What’s happening?!?
Ejaculatory duct obstruction
There are several causes for an obstruction that would lead to azoospermia. Infections can cause inflammation or the development of cysts both of which can cause blockages. Men can also develop calculi, or stone similar to a kidney stone, which can create a blockage by putting a kink in the hose. Cystic Fibrosis often prevents the formation of the vas deferens.
Might be a bit obvious, but getting snipped is a cause of azoospermia. It is becoming increasingly common for men to reverse their vasectomy. While the procedure is a little more involved than a vasectomy, it is still relatively painless and is performed as an outpatient procedure. Following the procedure, it takes time to build production back up but most men are successfully able to conceive within a year.
The first step to treating azoospermia is to figure out what’s causing it. Doctors rely on a number of key diagnostic tests to strengthen findings from the semen analysis, physical examination and medical history. Here are some of the most common follow-on tests that male fertility experts rely on to diagnose and treat underlying causes of azoospermia.
A blood test to determine hormone levels is critical to determining the underlying cause of azoospermia. The key hormones that doctors look are are: Testosterone (T), Follicle Stimulating Hormone (FSH) and Lutinizeing Hormone (LH) which are critical to sperm production. They may also want to look at Prolacin (PRL), Thyroid Stimulating Hormone (TSH) and Sex Hormone Binding Globulin (SHBG) to better understand underlying causes of hormonal imbalances.
Scrotal Doppler Ultrasound
Topic: Scrotal Doppler Ultrasound
Scrotal ultrasounds are almost always done on patients that have azoospermia. They are a very accurate way to measure how big the testicle is and look for blockages in the pipes that transport sperm out of the testicle. Ultrasounds are painless windows into the inner workings of the testicle that do not present any risk to the patient.
Transrectal Ultrasound (TRUS)
Topic: Transrectal Ultrasound
Like the scrotal ultrasound, TRUS employs ultrasound technology to image the the plumbing of the male reproductive tract. Similar to submarine SONARs, ultrasounds use high frequency sound waves to build an image of internal tissue structures. In the case of the transrectal ultrasound, the doctor is looking to see the structure of the various tubes that transport sperm and the prostate gland. For azoospermic patients, a TRUS is commonly performed when semen volume is lower than average or when the scrotal ultrasound shows potential blockages and is for diagnosing obstructions in tubes that are deeper in the body and not visible on scrotal ultrasound.
Karotyping: is a genetic test that examines the chromosomal pairs for abnormalities. It is most commonly used to diagnose genetic disorders such as Down’s syndrome and Turner’s syndrome. In male fertility patients, it is used most commonly to screen for Klinefelter’s.
Y Microdeletion analysis: is a genetic test that screens for missing genes on the Y chromosome which are known to affect sperm production.
Cystic Fibrosis Test: many people have CF without showing any symptoms.
The battle plan for attacking azoospermia depends largely on getting a good diagnosis for the underlying cause. If there are hormonal issues at play, there are a number of medications that have been shown to increase production. If there is a problem with the plumbing, surgery might be required. In cases of testicular failure or bad genes, there may be hope to pull a few sperm directly from the testicle to be used with artificial reproduction techniques.