What is azoospermia? How should azoospermia be diagnosed and treated? In my usual work, I often meet patients who panic when they get the report card and rush to ask me. In fact, there are several kinds of azoospermia. Nowadays, medical technology has advanced to the point that as long as you have a normal sperm, you have a chance to have a child. Once the azoospermia is determined, there are further tests to be done, not that you have lost your fertility from now on, so there is really no need to worry too much. The following is my introduction to the azoospermia diagnosis and treatment process.
1. What is azoospermia?
Azoospermia refers to the absence of sperm in the patient’s semen. The WHO Manual of Standardized Examination and Treatment of Male Infertility clearly states that azoospermia is defined as sperm density equal to 0 and no sperm can be found after semen centrifugation. If no spermatozoa are found in the routine semen analysis, but a small amount of spermatozoa can be found in the semen specimen after centrifugation, it is called cryptospermia. The diagnosis of azoospermia can be confirmed only after 3 times of centrifugal sediment microscopic examination of semen and exclusion of non-ejaculation and retrograde ejaculation.
2.What are the causes of azoospermia?
The common causes of azoospermia are: lifestyle habits (smoking, alcohol consumption, hot water baths, sauna, etc.), diet (consumption of cottonseed oil containing cotton phenol, etc.), abnormal working environment (high temperature, radiation, etc.), congenital abnormalities, acquired diseases, and various other factors, which are divided into the following three cases.
(1) Pre-testicularity
This refers to azoospermia secondary to hypothalamic and/or pituitary endocrine dysfunction when the testes themselves are functioning normally. There is a hypothalamic-pituitary-testicular axis in the human body, and once the hypothalamus or pituitary gland malfunctions, it will inevitably affect the following links. Typically, the hypothalamus in patients with idiopathic hypogonadotropic hypogonadism, which is a congenital disorder, completely or partially lacks the function of releasing gonadotropin-releasing hormone and cannot stimulate the pituitary gland to release gonadotropin, so the testes often stop developing before puberty and thus cannot produce sperm. There are also endocrine diseases such as pituitary gland and thyroid gland lesions that may also present azoospermia. This is similar to a river that is stopped from its upper reaches, and without the irrigation of the river all the plants and animals downstream, such as fish and shrimp, die. This type of azoospermia caused by lesions of the endocrine axis can be uniformly classified as pre-testicular, and the patient’s sex hormone levels often show low levels during sex hormone testing.
(2) Testicular sex
The hypothalamic-pituitary-testicular endocrine axis functions normally, and the testes themselves lose their ability to produce sperm for various reasons. The most common ones are Crohn’s syndrome, bilateral cryptorchidism, azoospermia, supportive cell syndrome, testicular trauma, torsion, testicular vasculopathy, etc. In such patients, there are no spermatogenic cells in the testes or only a few scattered spermatogenic cells; severe and long-term testicular atrophy and softening caused by varicocele can also cause spermatogenic disorders. In addition, severe orchitis secondary to mumps should also be treated aggressively, which may also lead to azoospermia. This is when the testicles are like an abandoned processing plant, which looks normal on the outside but in fact does not produce any product on the inside. This type of azoospermia due to lesions of the testes themselves is classified as testicular sex, and the patient’s sex hormone levels often show high levels during sex hormone testing.
(3) Post-testicular sex
Post-testicularity, as the name implies, refers to obstruction or congenital absence of sperm transport ducts, such as epididymal tuberculosis, bilateral epididymitis, bilateral vas deferens combined with seminal vesicle absence, ejaculatory duct obstruction, and gonorrhea. In this way, although the testicles produce a large amount of sperm, they cannot be discharged to the body, so there is no sperm in the semen. This is like a processing plant that can produce a qualified product, but cannot transport it out. This type of azoospermia caused by lesions in the sperm transport pipeline is classified as post-testicular, and the patient’s sex hormone levels tend to show normal levels during sex hormone tests.
3. What tests should be done in azoospermia patients?
In the outpatient clinic, when semen examination reveals the absence of sperm, the semen routine analysis + seminal plasma biochemistry should be repeated again to determine if there is an error in the examination or an error in the patient’s sperm extraction. I have encountered many patients who had their first test: azoospermia, let them rest well, and after 5 days of abstinence, the semen analysis results of the second test were more or less normal, and only after questioning did they realize that there was leakage of semen during the first semen retrieval, or they were not used to the environment of the retrieval room, or they had never masturbated to retrieve semen, etc. This shows the importance of the second semen test, and if necessary, they even need to do three semen analyses all for azoospermia before they can If necessary, even three semen analyses are needed to confirm the diagnosis. And there are many patients who do not understand the difference between azoospermia and azoospermia. It should be noted that the semen of azoospermia patients is no different from that of normal people, and there is nothing abnormal about their sexual process, sexual pleasure and ejaculation process, except that there is no any sperm in the semen.
(1) History taking and physical examination: detailed questioning to understand any medical history that may cause azoospermia; comprehensive and detailed physical examination is the most basic and important examination for azoospermia, according to which the cause of azoospermia can be initially determined.
(2) Combination of routine semen analysis + seminal plasma biochemistry. The results of semen examination are the basis of azoospermia diagnosis. Semen specimens are usually collected after 3-7 d of abstinence. The amount of semen volume also has an important significance (normal ≥1.5mL), and the etiology of azoospermia can be initially determined based on the results of seminal plasma biochemical examination.
(3) Chromosome examination: chromosome examination should be routinely performed in patients with azoospermia to determine the presence of chromosomal abnormalities.
(4) Serum sex hormone examination: This examination also helps to determine the cause of azoospermia initially.
(5) Testicular biopsy: Based on the results of the above tests, a comprehensive judgment should be made as to whether further testicular biopsy is needed.
4.How should azoospermia be treated?
Azoospermia is not an incurable disease, and there is hope for treatment if it is detected in time or if the condition is not very serious: viral orchitis, which occurs after mumps, is an acquired damage to the testicles and impairs the spermatogenic function, and azoospermia may also occur. The key to this disease is prevention, once the infection factor is found, it should be treated in time to prevent the disease from aggravating; genital injury, external injury leading to testicular damage or torsion, spermatic cord torsion, etc., or trauma due to hernia repair surgery, prostate surgery, etc., can also affect testicular function and lead to sperm production disorder, this situation is mainly prevention and timely and effective measures; sperm is very fragile, if in Powerful electromagnetic waves, radiation, will be exterminated, the cause of this disease is only good prevention; testicular local high temperature, frequent, long time scalding bath, sauna, or other factors caused by the testicular temperature rise, will affect sperm production, but most of such cases are less sperm, too much sperm death, etc.
(1) Idiopathic hypogonadotropic hypogonadism, which can be treated with hCG or hMG, takes six months to a year to be effective, and the later such patients are seen, the worse the treatment will be. Some adult patients are seen with testicles as if they were children, which makes the treatment ineffective. This treatment plan is like a dried up river being refilled with water so that the fish and shrimp in the river can grow again.
(2) Treatment of cryptorchidism, surgery for cryptorchidism is advocated before the age of 2. The later the time, the greater the impact on fertility. If surgery is performed when azoospermia occurs in adulthood, there will be no improvement on the spermatogenic function of the testes.
(3) For patients who have bilateral vasectomy, it is very clear that it is a case of vas deferens obstruction, vasectomy can be performed directly, and the rate of recanalization is higher with microscopic anastomosis technique.
(4) For some patients with distal obstruction of the vas deferens, vasectomy can be done by interventional methods or surgical recanalization according to the specific situation.
(5) For most patients with azoospermia, the best choice is to choose assisted reproductive technology for fertility. ICSI allows patients with severe oligospermia, weak and malformed spermatozoa, congenital bilateral vas deficiency, obstructive azoospermia that cannot be treated surgically, and patients with failed vasectomy to have the possibility of having children.
5. Some advice for all patients.
(1) Azoospermia is not an incurable disease, you do not have to panic after getting the test report, but to go to the male department of the regular hospital reproductive center to further improve the examination.
(2) Men should avoid long periods of time in a high-temperature environment, kitchen, sauna, steam room, bathtub, high-temperature outdoor and other places to go less, sperm are most afraid of heat, long-term high-temperature environment is a great harm to sperm.
(3) Avoid infection with gonorrhea, syphilis, epididymitis and other diseases, because infection with these diseases may also appear azoospermia.
(4) Azoospermia that can be cured by drugs is after all a minority, and most azoospermia patients should choose a regular hospital to perform “IVF” as soon as possible after confirming that there is sperm in the testicles. In clinical practice, we often encounter many patients who had sperm in their testicles half a year ago, and thought they were fine, but ended up coming to me with no sperm, and no sperm could be found by puncture, which means they didn’t hurry up. Therefore, timing is very important, seize the time is the right way.
(5) Try to choose a regular hospital, many patients travel around the country to spend a lot of money, eat a lot of drugs, waste a lot of time, in fact, it is not necessary, you just need to choose a regular large public hospital reproductive center from beginning to end, listen carefully to the doctor’s advice, follow the doctor’s advice step by step treatment, you can.