Azoospermia: When Your Sperm Count is Zero

Azoospermia is a condition in which there are no sperm in the ejaculate (also called “semen“) after a sexual act. Azoospermia is a rare but severe form of male infertility. It affects about 1 in 100 people in the general population and up to 1 in 10 men with fertility problems. The best way to treat azoospermia depends on what caused it and the ability of the female partner to have children.

Overview

You might think that men with azoospermia can’t have genetic children, but this isn’t always the case. Some men with azoospermia can have genetic children with the help of assisted reproductive technology and sometimes surgery.

This is not, however, always possible. In these cases, you could use a sperm donor or an embryo donor, or look into adoption or living without children.

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Sperm Production

To understand azoospermia, it can be helpful to know how sperm are made and how they get into the ejaculate.

Sperm cells start their journey in the testicles, which are held in the scrotum just outside of the body. Sperm can’t handle heat, so the testicles are a little bit outside of the body. Sperm cells can’t live in a man’s body because it’s too hot.

In the testicles, the sperm cells don’t just float around in a pool of fluid. Instead, they develop inside a system of tiny tubes known as the seminiferous tubules.

Sperm cells also don’t start in their tadpole-like form, with a head and a tail, either. They start out as small, round cells. Only when they’re exposed to hormones like testosterone, FSH (follicle-stimulating hormone), and LH (luteinizing hormone), do they grow up and turn into sperm cells. The pituitary gland and the testicles are in charge of and make these hormones.

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Sperm Maturation

When the sperm cells in the seminiferous tubules reach a certain level of maturity, they move to the epididymis, which is a long, coiled tubal area. They’ll keep getting better here for a few more weeks.

The sperm cells move from the epididymis to the vas deferens. During a vasectomy, the vas deferens is cut.

After traveling through the vas deferens, sperm move through the seminal vesicle, which is also called the seminal gland. Most of the fluid that makes up semen is made in this area. The sperm cells are fed by this fluid. The next stop is the prostate gland, where fluids from the prostate are added to the mix.

The prostate gland is the last stop the sperm make on their journey before they move into the urethra during ejaculation. The urethra travels from the bladder, through the prostate gland, and eventually through the penis.

The bulbourethral gland, or Cowper’s gland, is made up of two pea-sized glands that are right below the prostate gland. Even though sperm don’t travel directly through these glands, they do release a fluid before ejaculation that neutralizes an acid left in the urethra from urination.

What keeps urine from ejecting through the urethra during ejaculation? The muscles around the “neck” of the bladder tighten when a man has an erection. This keeps the urine in the bladder when a man gets excited.

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Types

There are two ways to talk about azoospermia: in terms of when things go wrong in the reproductive cycle or in terms of whether or not it is caused by a blockage. People disagree about which way to organise things is best.

If you want to talk about where in the reproductive cycle things go wrong, azoospermia can be put into three groups: before the testes, during the testes, and after the testes.

Pre-testicular azoospermia happens when the pituitary gland or hypothalamus are the main sources of the problem. This is sometimes called secondary testicular failure. The brain’s endocrine glands aren’t making the right mix of chemicals to help sperm grow in a healthy way.

When the problem is mostly in the testes, this is called testicular azoospermia.

In this case, the testes may not be making testosterone or may not be responding to hormones released by other endocrine glands. Another possibility is that something may be wrong with the cellular development of sperm. A case of testicular azoospermia would be when the testes don’t work at all.

Post-testicular azoospermia is when the main problem is a blockage or a problem with ejaculation, like when semen and sperm fall back into the bladder instead of going out the urethra during ejaculation or when the vas deferens or epididymis are blocked or don’t exist.

Most of the time, people talk about azoospermia in terms of whether or not it is caused by a blockage. Your doctor might say that you have either obstructive or nonobstructive azoospermia.

When sperm can’t get into the sperm or ejaculate because of a blockage or a problem with ejaculation, this is called obstructive azoospermia. Nonobstructive azoospermia is when the main cause is a hormonal problem or a problem with how sperm grows.

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Symptoms

Azoospermia itself a lack of sperm in the semen doesn’t have any specific symptoms.

If the man in the couple doesn’t have any sperm, the couple won’t be able to get pregnant. A couple is said to be dealing with infertility if they don’t get pregnant after one year of unprotected intercourse. Often, not being able to have children is the only sign that something is wrong.

Still, some things that cause azoospermia can show up as signs and symptoms.

If you have any of the following signs or symptoms, you may be at risk for azoospermia:

• Low ejaculate volume or “dry” orgasm (no or little semen)
• Cloudy urine after sex
• Painful urination
• Pelvic pain
• Swollen testicles
• Small or undescended testicles
• smaller than normal penis
• Delayed or abnormal puberty
• Difficulty with erections or ejaculation
• Low sex drive
• Reduced male hair growth
• Enlarged breasts
• Muscle loss

But you can still have azoospermia even if you don’t have any of these signs.

Obstructive azoospermia causes

These factors can contribute to this type of infertility:

• a congenital anomaly.
• The reproductive system has an infection or inflammation.
• previous trauma or injury (including surgical)
• retrograde ejaculation (even though, technically, there is no blockage involved in this situation).

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Retrograde Ejaculation

Retrograde ejaculation is when the semen and sperm move back into the bladder instead of out the urethra when a man urinates. Depending on how bad it is, this can cause both low semen volume (the amount of ejaculate) and a low or no sperm count.

Technically speaking, there is no blockage when a man ejaculates backwards. Still, it is often put in the “obstructive” group of azoospermia. Instead, the process of ejaculating itself isn’t working right. The good news is that this type of obstructive azoospermia is usually easier to treat than other types.

Nonobstructive azoospermia causes

These factors can contribute to this type of infertility:

• a mistake in the genes or chromosomes.
• Radiation, chemotherapy, or other toxins can cause damage to the testes.
• hormonal imbalances.
• side effects of hormone supplements or medicines.
• a varicocele.

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Genetic and chromosomal anomalies

Up to a quarter of the time, nonobstructive azoospermia can be traced back to a genetic or chromosomal cause. It’s not always possible to find the specific gene at fault, and there’s still a lot we don’t understand or know about how genes cause infertility.

Nonobstructive azoospermia has at least three known genetic or chromosomal causes. These are Y-chromosomal microdeletions, Klinefelter syndrome, and Kallmann syndrome.

You may know that having two X chromosomes means you are female, and having two Y chromosomes means you are male.

With Y-chromosomal microdeletions, some genes are taken out of the Y chromosome. This can make men unable to have children and cause their sperm counts to be low or nonexistent. Some men have small or undescended testes, while others have no other symptoms.

When a person has XXY sex chromosomes instead of XY, they have Klinefelter syndrome. Some men with Klinefelter syndrome have physical and mental symptoms that lead to a diagnosis during puberty or early adulthood. Other men, on the other hand, have mild or almost no symptoms and don’t get a diagnosis until they have problems getting pregnant.

The ANOS1 gene on the X-chromosome is linked to a genetic condition called Kallmann syndrome. Men with Kallmann’s syndrome may not go through puberty normally, have a weaker sense of smell (or none at all), and are often unable to have children. Hypogonadotropic hypogonadism, which is talked about more below, could be caused by Kallmann’s syndrome.

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Radiation, chemotherapy, or toxin exposure

Toxic substances can cause azoospermia for an extended period of time or permanently. Azoospermia can happen if radiation therapy is used directly on the male reproductive organs to treat cancer.

During treatment, azoospermia is a common side effect of chemotherapy, but it is hard to tell if it will last after the treatment is over. Some people may be able to get pregnant again quickly after treatment for cancer. In other cases, the body will start making sperm again after a few years. In other places, it could take up to 10 years. Less often, the ability to make sperm may never come back.

If you can, before you start treatment for cancer, talk to your doctor about freezing your sperm.
Toxic chemicals at work can also cause male infertility and nonobstructive azoospermia, which means that the sperm doesn’t work. Some pesticides and heavy metals can stop men from having children.

Hormonal Imbalance

The hypothalamus, pituitary gland, and testes all work together to make the hormone signals and chemicals that are needed to make sperm. Problems with the production of hormones, their quantity, or their interactions with one another can result in infertility, including non obstructive azoospermia.

Numerous factors, such as genetic or inherited conditions, hormonal issues you’ve developed over time, or even your lifestyle, can contribute to hormone imbalance.There are times when the exact cause cannot be found.

Hypogonadotropic hypogonadism happens when the pituitary gland or hypothalamus in the brain aren’t working right. This can be present at birth or develop over time. Possible causes include genetic conditions, exposure to radiation, side effects or abuse of medications or drugs, too much exercise, or unknown causes.

Primary testicular failure happens when a hormone imbalance is linked to problems with the testes. This can cause the testes to not make enough testosterone and sperm to not form or form poorly, even though the pituitary and hypothalamus also make hormones.

When hormones break down in the pituitary gland or hypothalamus, even though the testicles may be working fine, this is called secondary testicular failure.

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Medication Side Effects

Some medications can cause azoospermia.

Taking extra testosterone is frequently the cause of side effects of medications like azoospermia. As with chemotherapy drugs, athletes who use anabolic steroids can also end up with no sperm.

Some drugs that cause azoospermia only have this effect for a short time. In other cases, azoospermia can last for a long time.

Other drugs that could cause non-obstructive azoospermia are:

• Colchicine (used to treat gout)
• Chlorambucil (a cancer medication)
• Cyclophosphamide (a cancer medication)
• Procarbazine hydrochloride (treatment for Hodgkin’s disease)
• Vinblastine sulphate (cancer medication)
• Everolimus is a cancer drug that is also used to prevent organ rejection after transplants.
• Sirolimus (used to prevent organ rejection after transplant)

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Varicocele

A varicocele is a scrotum or testicle vein that is bigger than it should be. Because this vein is bigger, blood pools in the area. This makes the testicles hotter and can also cause swelling, testicle shrinkage, and pain. Varicocele is a common reason why men can’t have children.

Most of the time, having varicoceles means having less sperm. But between 4 and 13% of men with a varicocele will have a very low number of sperm or none at all.

Diagnosis and Testing

Only a test of your sperm can tell you if your sperm count is normal or if it is zero. If your first test for sperm shows that you have no sperm, your doctor will have you take the test again in a few months.

Azoospermia is found when two separate analyses of sperm show that there are no sperm in the samples.

After azoospermia is found, the next step is to try to find out why it is happening. Your treatment plan will be based on what is thought to be the reason why you have no sperm.

Possible next steps for testing:

• Taking a detailed medical history (that includes reporting any serious childhood illness (like the mumps) or previous sexually transmitted infections)
• Physical exam of the testicles
• Blood work is specifically needed to measure FSH and testosterone levels, with the possibility of also measuring prolactin or oestrogen levels.
• Karyotype testing and (maybe) genetic testing for specific inheritable diseases
• Transrectal ultrasound (TRUS) to look for blockages or abnormalities of the male reproductive tract
  Testicular biopsy (in some cases)

A proper evaluation won’t necessarily include all of the above tests. If other tests have already found the likely cause, invasive tests like a testicular biopsy shouldn’t be done.

A full evaluation of the female partner’s fertility is also needed, because that will affect which treatment path is best for the couple. Both partners may also be told to get genetic testing and counseling.

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Treatment

Treatment for infertility will depend on the type of azoospermia and what caused it. Also, the female partner’s fertility situation will also determine treatment choices.

Treatment of any lingering infections

If there is an active infection, it should be treated before any other treatments are thought about.

Some men will have signs of an infection, like pain when they urinate, but up to one in four men won’t have any signs of an infection. Still, the infection can hurt their fertility and cause permanent damage to the reproductive tract, even if they don’t notice any symptoms.

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Originally posted 2023-04-12 06:46:04.