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To a couple undergoing interventions for infertility, being told that the husband’s semen is devoid of sperm is incredibly devastating. All hopes of starting a family completely crumble and the feeling of hopelessness is quite overwhelming.
Normally, sperm is produced in the testicles, then passed along tubes within the scrotal sac (containing the testicles) and is finally emitted from the penis at orgasm. The absence of sperm in the ejaculate, or semen, is known as azoospermia. Azoospermia is a dreaded diagnosis that occurs in 10% of men with infertility. The semen analysis will have to be repeated with a fresh sample and if the second analysis yields the same findings, this unfortunately confirms the diagnosis of azoospermia.
ALL HOPES OF FATHERHOOD DASHED?
Fortunately in this day and age, with the advent of in-vitro fertilisation (IVF) and intra-cytoplasmic sperm injection (ICSI), a large number of azoopsermic men can still hope to attain parenthood as long as some sperm, however scarce, can be found via a small surgery on the testicles. Each sperm is then injected directly into a female egg (oocyte) to aid fertilisation, a process called ICSI.
This journey that began with a simple semen analysis will now require more extensive assessment of the male partner. It starts with a thorough medical history and physical examination, inclusive of evaluation of the male genitals. Blood is also drawn and sent off to test for the hormones that regulate sexual development and formation of sperm (spermatogenesis). Genetic and chromosomal testing is carried out in some cases. Some men might have an ultrasound scan evaluation of their scrotal sac and its contents if the physical examination suggests an abnormality.
These test results are invaluable to the fertility specialist who is trying to narrow down possible causes of the azoospermia and plan the most appropriate approach for the couple. In most cases, a surgery to retrieve sperm directly from the collecting tubes (epididymis) within the scrotum, or from the testicles themselves, would need to be done. The surgery is a minor procedure and usually takes less than an hour to complete. The surgically retrieved sperm can then be used for ICSI.
A pre-requisite to ICSI is that the woman will need to go through a cycle of IVF where her ovaries are stimulated with hormone injections and eggs are collected by the fertility specialist through a minor procedure.
WHAT CAN BE DONE?
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Here’s a brief description of treatment strategies for some of the more common conditions associated with azoospermia.
A man who is suspected of having a blockage anywhere along his ejaculatory tract has the highest likelihood of having sperm successfully retrieved during surgery, as the cause of azoospermia is obstruction and not failure of sperm production. These sperm can be used to fertilise his partner’s eggs via ICSI, resulting in pregnancies in a high proportion of couples.
Men who have undergone a previous sterilisation procedure (vasectomy) for contraceptive purposes has the option of reversing the procedure and trying to conceive naturally. Alternatively, sperm can be obtained with the aforementioned surgical procedures and used for ICSI.
Men with extensively enlarged veins (called varicocele) in the scrotal sac may benefit from surgery to correct these abnormalities first. This can improve sperm quality and enhance the probability of achieving natural conception, thus avoiding IVF/ICSI.
Retrograde ejaculation is a condition that occurs when the semen enters the bladder instead of being ejaculated through the penis during orgasm. It is easily diagnosed by examining a urine sample after ejaculation. Sperm collected from the urine can also be used to fertilise eggs during ICSI.
In some cases, when the fertility specialist suspects that the cause of the azoospermia stems from failure of the testicles to produce sperm, specific genetic tests are done to look for abnormalities in the man’s Y-chromosome. Certain types of abnormalities on the Y-chromosome preclude the possibility of finding sperm. Therefore for this small number of men, it will be impossible for the fertility specialist to offer any further means of obtaining the man’s own sperm for fertility treatment.
On the other hand, in other variations of sperm production failure, the fertility specialist may consider prescribing hormonal treatment to induce production of sperm. This usually involves several months of treatment with regular monitoring for response. Eventually, the above-mentioned surgeries will still need to be carried out to look for sperm that will then be used for ICSI.
In some men, blood tests may reveal a profound lack of regulatory hormones that control sperm production from the testicles. This condition is easily treatable with hormone injections which will replace the deficiency and spur sperm growth in the testicles. This also involves prolonged periods of treatment. The good news is that this treatment modality usually leads to the couple achieving natural conception, since there will be sufficient sperm produced during ejaculation. However, if natural conception does not occur, ejaculated sperm can be used for ICSI, thereby avoiding testicular surgery.
Azoospermia can also occur after cancer treatment, specifically chemotherapy or radiotherapy. There have been reports of successful retrieval of sperm with surgery on the testicles, with or without prior hormonal treatment to enhance sperm production.
As has been described above, all hope is not lost when the initial bad news is broken. Further tests and examinations will go a long way in determining the next course of action in the journey to parenthood for the azoospermic man. However, if all attempts fail, the couple might want to consider going down the noble path of adoption. For some couples, when using donor sperm is feasible, it is an alternative to consider.
No doubt the path is laden with uncertainties, but patience and grit are necessary at every step of the way for the azoospermic man and his other half undergoing fertility treatment; whereby a relatively large number of couples may eventually conceive a pregnancy through Assisted Reproductive Technology as described above.
Dr Sumithra Devi Valiapan is an obstetrician, gynaecologist and fertility specialist.
[This article belongs to The Malaysian Medical Gazette. Any republication (online or offline) without written permission from The Malaysian Medical Gazette is prohibited.]