Azoospermia: Shooting Blanks

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.

Shooting Blanks

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.

Shooting Blanks?

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.

Common Causes

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.

Hormonal Imbalances

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.

Steroid Use

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.


Topic: Hypogonadism

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

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

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.

Klinefelter syndrome

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

Topic: Cryptorchidism

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

Topic: Infection

“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.

Plumbing Problems

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.

Retrograde Ejaculation

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.

Diagnostic Tests

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.

Hormone Analysis

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.

Genetic Testing

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.


Topic: Treatments

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.

Sara SDx

Sara SDx

Editor of Don't Cook your Balls, Co-Founder of, Health Coach and Men's Health Advocate. Passionate about sperm, men's health and helping people build their families.
Sara SDx

Author: Sara SDx

Editor of Don't Cook your Balls, Co-Founder of, Health Coach and Men's Health Advocate. Passionate about sperm, men's health and helping people build their families.

32 thoughts on “Azoospermia: Shooting Blanks”

  1. Hello Sara, how r u hope u r fine i am facing problem after my marriage. My first semen test there no sperm seen and indicated azoospermia then doctor suggest me to do scrotum ultrasound to check the blockage but the reports were 100% perfect. them doctor suggest me to do Harmones Test for FSH, LH, Prolactine and Testosterone. This harmones test also came perfect i dont know what going on bus again i checked semen test still the same zero sperm

    1. hm.. mystery.

      How’s your health?

      What does the doctor think? What did the doctor say to do next?

  2. Dear Sara, I and my husband has been trying for conception for 2 years+. Had an ultrasound last august with multiple fibroid though was told that the location shouldn’t stop conception. Went for hsg last month and was certified ok. My husband went for seen analysis with the following result:
    Vol 2.89ml, Viscosity -non viscous, Morphology -normal cells 40% abnormal 60%, Mobile cells 40%, slugishly motile 40%, non motile 20%, Viable cells 40%, Non Viable 60%.
    What are our chances and the next step medically?

  3. Hi – I went for my first test and I had azoospermia. One week later I had 19m m/l total 76m 96% movement. Couple months later 4m /ml total 12m only 36% movement. Then a month later 10m /ml all dead. 3 tests since have resulted in azoospermia. My FSH level on my second azoospermia result was 27 and lh 12.9. I have been on a crash diet as I’m overweight. I am also tee total for the last few months. My result today of fsh was 19 and my LH was 4 which is normal levels of LH. Doctor says is primary testical failure however how can my LH go from elevated to normal and my FSH is decreasing? I have tested for all genetic issues and am fine. Ultrasound also didn’t spot anything.

    1. This is kind of a strange case. I don’t think I’ve ever seen anything like this. Do you have a urologist in your area that specializes in reproduction? I would recommend getting a second opinion, because you have sperm production and you are seeing fluctuations in your hormone numbers.

      You may also consider seeing an endocrinologist to discuss the hormone issues. I don’t know how reproductive hormones respond to weight loss. That may do something. Most of what I’ve seen in research discusses fluctuations and cortisol, testosterone, and estrogen among others as weight fluctuates. Hope, among others. Lh & FSH are up stream of these, and only respond to issues in the testicle or with the pituitary gland. An endocrinologist would have a better beat on the hormone pathways and could give you some good insights I’m thinking.

      As a side note, being overweight can dramatically reduce sperm count, so I would recommend poking things a little further.

      Good luck, buddy. I’ll have my fingers crossed. And would love to hear follow up.

      1. Hi Sara , thanks for the reply. I have seen multiple doctors in multiple countries. In china it is just a case of “give up nothing u can do” and recommend a testical biopsy as the usual next step. No where are they really interested in finding whats causing it – its just pushed to next department. So i have taken it uppn myself to find the cause/treatment.

        After talking to the fertility doctor in the UK he said because of the high FSH i would stand less than 10% chance of SSR. When i went to the regular NHS doctor he said its premature andropause which the fertility doctor disagreed on.

        My diet has changed dramitically and ive lost 10kg which is over 5kg a month. And im exercising daily . I had weighed 120kg ,6ft. So i will reduce to 80kg. I am 35 years old and previously got a girl pregnant.

        The positive thing about being in china is its quick and u can get things done cheap. Around 15usd for a SA so im doing weekly tests. So i am having blood tests weekly. I done all sex checks and genetics are all fine. There was bacteria in urine but not many so i had a urine and semen culture however not enough bacteria to evaluate so ill do another one in the next few days.

        But like u say u have never heard of a case where u go 0 to normal. And i have not found one case similar to mine. It seem to happen so quickly also. My testes are completely normal size and had ultrasound and checked by doc to confirm this however my semen is more watery. My libido is low. I have started acupuncture and multi vitimins and eating alot of garlic and spinach as well as freezing my balls every day.

        So i question if i have a infection due to a parasite or other reason as i travel alot of places and in the months before the decline i had been in malaysia , philippines, australia which are all hot beds for mosquitos or parasites. I am yet to have a rectal exam for prostate.

        All the causes listed apart from overweight doesnt apply to me. Wear loose underwear, dont cycle.

        So my lh is now normal , fsh decreasing it seems, testosterone rising, i know fsh is just the indicator but if my fsh level lowered to normal levels would that mean they would be working again?

        I am hesitant to have the SSR until i have tried everything and exhausted every avenue however the uk fertility doc does say the longer u leave it the less chance as im worried in time my testicals will shrink. He also says all testical failure is irreversible however there is a exception in all cases to impossible and im seeking that possibility. Do u think it is worth having a MRI scan for the pitutary gland as far as i know high fsh means its working?

        This site has the most info i have found on the net and helps so many people. So full respect to you.

        1. This is an interesting case. I can’t give you much opinion as I’m not a doctor. I do feel it warrants a true second opinion. I think I can set you up for a telehealth consult with a leading urologist here (In the states) if you are interested. (Ill have to check rates but should be reasonable cost)

          Overall, i think the weightloss is good and as someone who has been through it, i know it can mess with hormones.

          I have read a fair bit on tropical diseases and male fertility. There are a few that can cause problems. I don’t hear any symptoms that raise a red flag from what I know, but again I’m not a doctor so there may be some I don’t know about.

          Let me know if you’d like a consult. I can try to set something up. You can email me at snaab AT sandstonedx DOT com

          Happy to chat in more detail over email or here, whatever works…

          1. Hi Sara – I did send you a email. But not heard back so I’m not sure you have received,

            Just thought I would update you here also. I have had a sperm test done a fortnight ago that now shows sperm. Total was 20million from 5ml. Although low its quite a few as the previous 4 tests that were all 0. Unfortunately all sperm were dead. I had another test yesterday and showed a total 6m from 3ml. Again all were dead.

            But I see some kind of hope here being that production seems to have restarted and I’m hoping that as I continue with the exercise and weight loss I may see some moving sperms in the next tests.

  4. If you had mumps as a child can you have no sperm! his blood work shows he has hormone imbalnace as well

    1. yes. unfortunately mumps can cause damage to the testicle and cause problems with sperm production and hormone imbalances. I would recommend talking to a urologist about this.

  5. Hi my partner was taking steroids on and off then he done six/seven months using anabolic steroids no pct no break.. taking a mixture of steroids.
    We now found out he has non obstructive azoospermia high fsh of 38 and testosterone 12.5 and lh 12 Could this be from the steroids? He is now taking tamoxifen As from what I read steroids usually cause low fsh but could it cause high fsh because he took them for such a long time with no break and no pct. we have been given the awful news it’s non obstructive I’m just hoping it is the steroids rather than Sertoli cell only. Any advice would be appreciated. We are under a urologist but we have just been given medication and hoping for a improvement.

    1. Sorry to hear about this. Steroids can do a lot of damage.

      If there is an ability to improve, the urologist should be able to help. There are a number of medications that you can try to get sperm production started.

      The steroids can cause damage to tissues in the testicle. While you are on them, your testosterone is high (because of them) and your FSH and LH are low. When you come off, the FSH and LH go on overdrive trying to force the testicle to start working again. Testosterone levels are usually really low (which can cause a lot of symptoms). This crash is why a lot of guys stay on — it is also why many men use PCT. PCT drugs are used to help the body recover natural function between cycles. If the damage is not permanent, eventually, the hormones cause the testicle to start working and testosterone levels go up and sperm production begins. In some cases, the damage is too extensive and unable to recover.

      In general, it can take about a year to recover sperm … you might see some improvement in 3-6 months but it could take longer to get things going in the right direction. It takes about 3 months to develop a sperm – so if there are 0 sperm. The earliest you would see one is in 3 months (if the medication started working on day 1.)

      My thoughts and best wishes are with you. I’m happy to be a sounding board as you figure out next steps.

  6. Great info: Super-informative. My blood test came back with extreme high fsh:31.8. Obviously, 2 semen analysis with no results (azoo). From what I gather, this would be due to hormonal issues? Are you aware of any meds to lower fsh or otherwise balance out the hormones?

  7. My husband has had two tests which have come back at zero. He did a course of anabolic steroids for 11 weeks but just imidiately stopped them without a pct. I am desperate for a family and have had fertility issues myself. My periods have now returned after 10 months and I’m not sure what to do. What are the chances of his sperm returning to normal? And what sort of time frame? We are having all the tests mentioned above so heading in the right direction.

    1. Big number to look for is FSH and T. If FSH is high and T is low that isn’t the best news. If fsh is normal then much better chances.

      How long ago did he stop steriods? Typical recovery is 6 – 12 mo depending on damage.

      Docs can help kickstart things. Bloodwork is first place to start.

      Does that help?

    2. Hi Becky we are experiencing something similar.. what was his fsh level.? . my boyfriend took anabolic steroids on and off for afew years never used a pct and then stupidly done a 6/7month cycle on them no break (from what I read it’s extremely stupid) we now have a fsh of 38 testoreone is on the lower side of 12.5 and we are seeing a uroligist to see if we can get some sperm for micro tess

  8. My case is similar to Kevin, both SA came out the same, azoo, blood test for FSH came out normal as well.

    Doctor recommend to go for testicular biopsy.

    Im just wondering how can we check for obstructive or non-obstructive azoo, my doctor told me that since mysemen is about 6ml for both, the likelihood of having obstructive azoo is higher.

    I thought the seminal gland and sperm came up from different part of the whole set up.

    Can anyone dumb in down for me please.

    1. They are definitely different setups. I’m not a doctor so I don’t have as much insight as he would but here’s my guess.

      In obstructive Azoo — the testicle is functioning normally. This means that hormones will come back in the normal range.
      Semen volume is somewhat controlled by testosterone. If a guy has lower T, sometimes his semen volume will drop.
      Your labs and semen seem to indicate that reproductive system is functioning well.

      Therefore, the urologist has a hunch that there is some sort of blockage. .. Tubes down there are tiny. Smaller than a human hair. It can be very difficult to find blockages through ultrasound or whatnot. Have you had any ultrasounds to look for blockages?

      I’m not sure I fully agree with biopsy. A lot of the docs that I’ve talked to might suggest an epididymal sperm retrieval if they were pretty certain that it was obstructive. But again, I’m not a doctor.

      Do you have any risk factors for obstructive? have you had any surgeries, infections, mumps, or anything else affecting the region?

  9. I have done 2 semen analysis, retrograde ejaculation, and blood work. All three analysis came back zero sperm, and my blood work came back good. I have an appointment with a fertility specialist what’s are the chances it’s a blockage. I have have symptoms of Varicocele but have never been diagnosed with yet. I’m just really nervous I won’t be able to become a father. Please any answers will help.

    1. Did you check genetics or just hormones? Have you had any infections, bad sicknesses or surgeries in the area? Have you taken our risk assessment?

  10. i have done 2 test of semen..both shows azoospermia..i contact to docter. he did not tell me more about this..i want to become father and want treatment..tell me any good instituation

  11. I have done one test for semen analysis and it says that you have no living or dead spermatozoa in your semen in 0.8ml so can you please tell me that what should I do.thanks.

    1. You need to schedule an appointment with a urologist who specializes in male fertility to get a complete work up. This should include another semen analysis, a physical exam, a full medical history and a couple of blood tests to understand what could be going on. Have you had any of these things done?

  12. a very good thank you to all the Doctors in the world who are trying by all means to help patients suffering from Azoospermia and other diseases affecting them in all angles. we all want to be Fathers and family men.

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