Azoospermia: when a semen analysis shows no sperm

For a man, reading the word ‘azoospermia’ on a report is a shock, often experienced in silence. Among the couples I support, it is also a subject on which information is poorly shared. Here are the key points to help you know what questions to ask your urologist or andrologist.

Confirming the diagnosis

A single semen analysis is not enough. It must be repeated at least once, after two to seven days of abstinence, and the laboratory must centrifuge the sample to look for rare spermatozoa in the sediment. Their presence, even in very small numbers (cryptozoospermia), changes everything: ICSI becomes possible without surgery. The basics of the semen analysis are explained here.

Two very different situations

• Obstructive azoospermia: the testicles produce sperm, but they do not get out (congenital absence of the vas deferens, vasectomy, previous infection, obstruction). The chances of finding sperm through surgery are close to 100 per cent.
• Non-obstructive (secretory) azoospermia: sperm production itself is very low or absent in most areas of the testicle. However, pockets of sperm production may still remain.

Diagnostic work-up

• Clinical examination: testicular volume, presence of the vas deferens, varicocele.
• Hormone levels: FSH, LH, testosterone. Elevated FSH suggests a secretory cause.
• Genetics: karyotype (Klinefelter syndrome, 47,XXY), screening for Y chromosome microdeletions (AZF regions), and for the CFTR gene (cystic fibrosis) in cases of absent vas deferens.
• Ultrasound of the testicles and, in some cases, an endorectal scan.

Genetic testing is essential: a complete AZFa or AZFb microdeletion makes it almost impossible to find sperm, thereby avoiding unnecessary surgery. A CFTR mutation requires the partner to be tested.

Treatable causes

Hypogonadotropic hypogonadism (low FSH and LH) is treated with hormones, often leading to the return of sperm within several months. Taking testosterone or anabolic steroids blocks production: stopping often allows for recovery, although this can sometimes take a long time. Following a vasectomy, surgical vasectomy reversal is an alternative to IVF.

TESE and micro-TESE

TESE involves removing small fragments of testicular tissue under anaesthesia, followed by a search for sperm in the laboratory. Micro-TESE is performed under an operating microscope: the surgeon identifies the most dilated seminiferous tubules, which are more likely to contain sperm, and removes less tissue.

In cases of non-obstructive azoospermia, micro-TESE finds sperm in approximately 40 to 60 per cent of men, depending on the study, including some men with Klinefelter syndrome. The sperm are frozen or used on the same day for ICSI.

In cases of obstruction, a simpler aspiration of the epididymis or testis is often sufficient.

Organising the surgery and IVF

Two strategies: performing micro-TESE before stimulation and freezing the sperm; or performing it on the same day as egg retrieval. The first avoids unnecessary stimulation if no sperm is found; the second uses fresh sperm. For a couple travelling, the first is often the safer option. It is important to check in advance that the clinic works with a urologist experienced in micro-TESE.

If no sperm is found

Sperm donation remains an option, and in Greece it is anonymous. This is a decision for the couple to make, and one that takes time. Some couples undergo micro-TESE having prepared a ‘plan B’ with donor sperm set aside on the same day; others prefer to separate the stages. There is no single correct answer, and psychological support is often invaluable.

Frequently asked questions