Dr. S.K. Jain Burlington Clinic Pvt. Ltd.
Azoospermia: When Your Sperm Count Is Zero
Azoospermiais a condition where there are no sperm found in the ejaculate (or semen) after orgasm. Affecting about 1 in 100 of the general population—but up to 1 in 10 of men with fertility problems—azoospermia is an uncommon but severe form of male infertility. The best course of treatment depends on the specific cause of the azoospermia, along with the fertility potential of the female partner.
You might assume that men with azoospermia can’t have genetic children, but this isn’t necessarily so. With the help of assisted reproductive technology, and sometimes with the help of surgery, some men with azoospermia can have genetic offspring.
This is not, however, always possible. In these situations, using a sperm donor, embryo donor, or pursuing adoption or a childfree life are alternatives.
Sperm production to ejaculation
Illustration by JR Bee, Verywell
Sperm Production
To understand azoospermia, having at least a basic understanding of how sperm are produced and get into the ejaculate can help.
Sperm cells begin their journey in the testicles, which are held slightly outside of the body in the scrotum. The testicles are slightly outside of the body because sperm are sensitive to heat. A man’s body temperature is too high for sperm cells to survive.
The sperm cells don’t just float around in a pool of fluids in the testicles, but instead, they develop inside a system of tiny tubes known as the seminiferous tubules
Sperm cells also don’t just start in their tadpole-like form, with a head and a tail. They begin as tiny round cells. Only when exposed to reproductive hormones like testosterone, FSH (follicle stimulating hormone), and LH (luteinizing hormone) do they mature and develop into the sperm cells you're more familiar with. These hormones are controlled and produced by the pituitary gland and the testicles.
After the sperm cells get to a certain level of maturity in the seminiferous tubules, they move into the epididymis, a long, coiled tubal area. They continue to develop further here for several weeks.
After the epididymis, the sperm cells move into the vas deferens. (The vas deferens is what’s cut during a vasectomy.)
After the vas deferens, the sperm travel in the seminal vesicle, also known as the seminal gland. Here, the majority of the fluid that makes up semen is produced. This fluid nourishes the sperm cells. The next stop is the prostate gland, where prostate fluids are added to the overall semen mix.
The prostate gland is the last stop 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.
Just below the prostate gland sit two pea-sized glands known as the bulbourethral glandor Cowper's Gland. While sperm don’t directly travel through these glands, before ejaculation, the glands release a fluid that neutralizes any acidity in the urethra left from previous 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 from leaving the bladder during male arousal.
Types
There are two ways to talk about azoospermia: in terms of at what point in the reproductive cycle things go wrong, or regarding whether it’s caused by a blockage or not. There’s a debate over which classification system is better.
If talking about where in the reproductive cycle things go wrong, azoospermia can be broken down into three categories: pre-testicular, testicular, and post-testicular.
Pre-testicular azoospermia is when the issue is primarily hormonal problems related to the pituitary gland or hypothalamus. This is sometimes called secondary testicular failure. The endocrine glands in the brain are not producing the right cocktail of chemicals to trigger healthy sperm development.
Testicular azoospermia is when the problem is primarily within the testes themselves. In this case, the testes may not be producing testosterone, or the testes may not be responding to hormones being released by other endocrine glands. Another possibility is that something may be wrong with the cellular development of sperm. An example of testicular azoospermia would be in a case of primary testicular failure.
Post-testicular azoospermia is when the problem is primarily a blockage or ejaculation dysfunction—for example, retrograde ejaculation (when semen and sperm fall back into the bladder instead of going out the urethra during ejaculation) or a blockage (or absence) of the vas deferens or epididymis.
The most common way to talk about azoospermia is in reference to whether it’s caused by blockage or not. Your doctor may tell you that you have obstructive azoospermia or nonobstructive azoospermia.
Obstructive azoospermia is when the sperm can’t get into the semen or ejaculate due to a blockage or issue with ejaculation. Nonobstructive azoospermia is when the cause is primarily hormonal or an issue with the sperm development.
Symptoms
Azoospermia itself—a lack of sperm in the semen—doesn’t have any specific symptoms.
Couples trying to conceive will experience infertility if the male partner has a zero sperm count. A couple is said to be dealing with infertility if they don't get pregnant after one year of unprotected intercourse. Infertility is frequently the only sign that something is wrong.
With that said, some causes of azoospermia can lead to noticeable signs and symptoms.
Signs or symptoms that may indicate you’re at risk for azoospermia include:
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
It is possible to have none of these symptoms, however, and still have azoospermia.
Obstructive Azoospermia Causes
Obstructive azoospermia may be caused by:
a congenital anomaly.
infection or inflammation of the reproductive tract.
previous trauma or injury (including surgical).
retrograde ejaculation (even though technically there is no blockage involved in this situation).
Congenital Source
There are some genetic causes or congenital anomalies that can lead to obstructive azoospermia. Some men are born with a blockage in the epididymis or ejaculatory duct, while others may be missing the vas deferens on one or both sides of the reproductive tract. The causes of these anomalies are not always known.
Men without a vas deferens on both sides are said to have a congenital bilateral absence of the vas deferens, or CBAVD. Bilateral absence of the vas deferens is associated with the cystic fibrosis gene (CFTR).
Three out of four men with bilateral absence of the vas deferens have genetic mutations in CFTR gene.
While almost all men with cystic fibrosis will be missing the vas deferens, not all men who are missing the vas deferens have cystic fibrosis. For those with mutations on the cystic fibrosis gene, but not the full disease, they may have mild breathing or digestive problems. Others will be carriers of the CFTR gene, meaning they are at risk for passing on full cystic fibrosis to a child if their female partner also carries the gene.
For men who are missing the vas deferens on both sides, have mutations on the CFTR gene, but don’t have full-blown cystic fibrosis, they are said to have atypical cystic fibrosis.
Because of the risk of passing on this potentially life-threatening genetic disorder, genetic testing in both the male and female partner is recommended if azoospermia is caused by the absence of the vas deferens. Cystic fibrosis is a recessive disorder, meaning that for a child to inherit the disease, both parents need to be carriers.
(More about what happens if both the male and female partner are carriers in the treatment section of this article below.)
Infection or Inflammation of the Male Reproductive Tract
Blockage of the epididymis or ejaculatory duct can be caused by infection or inflammation. Infection of the epididymis is known as epididymitis
A possible cause of these infections is an untreated sexually transmitted infection. Note that the blockage can still be present even after an infection has been treated. This is because scar tissue may be formed during the active inflammation stage of infection. The antibiotics will get rid of the infection but won't fix the scar.
If you have a history of sexually transmitted disease, tell your doctor, even if you think that was “in the past.”
Non-sexually transmitted infections can also lead to inflammation, scar tissue, and blockage. For example, childhood mumps can cause viral orchitis, which is inflammation of one or both testicles. This infection in childhood can lead to permanent scarring, which later in life may mean infertility due to azoospermia.
Previous Trauma and/or Surgical Causes
Previous trauma to the male reproductive tract can cause damage, scar tissue, and blockage to the vas deferens, epididymis, or ejaculatory duct.
Sometimes, surgery in the general area—but not specifically on—the male reproductive tract can lead to unintentional scaring or injury. For example, surgery to treat an inguinal herniacan lead (in rare cases) to injury to the testes or vas deferens.
A previous vasectomy—a form of permanent birth control where the vas deferens are cut or blocked intentionally—is a possible cause of azoospermia. While this is the goal of vasectomy surgery, some men decide in the future to have the vasectomy reversed.
Retrograde Ejaculation
Retrograde ejaculation is when semen (and sperm) move backward into the bladder during ejaculation, instead of moving forward out the urethra. This can lead to both low semen volume (the amount of ejaculate) and low to zero sperm count, depending on the severity.
Technically, there’s no blockage in retrograde ejaculation. Still, it’s frequently placed in the category of “obstructive” azoospermia. Instead, the ejaculation process itself isn’t functioning properly. The good news is that this is an easier problem to treat (usually) than other causes of obstructive azoospermia.
Nonobstructive Azoospermia Causes
Nonobstructive azoospermia may be caused by:
a genetic or chromosomal anomaly.
damage to the testes from radiation, chemotherapy, or other toxin exposure.
hormonal imbalances.
side effects of medications or hormonal supplements.
a varicocele.
Genetic and Chromosomal Anomalies
Nonobstructive azoospermia can be traced to a genetic or chromosomal cause up to a quarter of the time. The specific gene involved cannot always be traced, and there is still a lot we don’t understand and know about genetic causes of infertility.
Three known genetic or chromosomal causes of nonobstructive azoospermia include Y-chromosomal microdeletions, Klinefelter syndrome, and Kallmann syndrome.
You may be familiar with the idea that two X chromosomes indicate a female genotype, while XY indicates a male genotype.
With Y-chromosomal microdeletions, the Y chromosome is missing some genes. This can cause male infertility and lead to low (or absent) sperm counts. Many men have no other signs or symptoms, while others might have small or undescended testes.
Klinefelter syndrome is when instead of presenting with XY sex chromosomes, a person presents with XXY. While some men with Klinefelter syndrome will have physical and cognitive symptoms that lead to diagnosis during puberty or in young adulthood, other men have mild or almost no symptoms and go undiagnosed until they have fertility problems.
Kallmann syndrome is a genetic condition associated with ANOS1 gene, located on the X-chromosome. Men with Kallmann’s syndrome may not go through normal puberty, have a reduced sense of smell (or no sense of smell), and often are infertile. Kallmann’s syndrome is a possible cause hypogonadotropic hypogonadism, which is discussed further below.
Radiation, Chemotherapy, or Toxin Exposure
Exposure to toxic elements can lead to temporary or even permanent azoospermia. If radiation therapy has been used directly on the male reproductive organs during cancer treatment, azoospermia may result.
Chemotherapy often leads to azoospermia during treatment, but whether azoospermia will continue after treatment is unpredictable. Fertility may return quickly after cancer treatment in some. In other cases, sperm production will return after a few years. In others, it may take up to 10 years to return. Less commonly, sperm production may never return.
Whenever possible, before you start cancer treatment, talk to your doctor about cryopreservation of sperm.
Toxic chemical exposure at work can also lead to male infertility and nonobstructive azoospermia. Exposure to certain pesticides or heavy metals can lead to male infertility.
Hormonal Imbalance
The pituitary gland, hypothalamus, and testes work together in creating the hormone signals and chemicals required for sperm production. Abnormalities in hormone production, levels, or interactions can lead to infertility, including nonobstructive azoospermia.
There are many possible causes of hormone imbalance, anything from inheritable or genetic conditions, to acquired hormonal problems, to lifestyle-based triggers. Sometimes, the exact cause is not identified.
Hypogonadotropic hypogonadism is when there is a problem with the pituitary gland or hypothalamus in the brain. This may be present from birth or may arise later in life. Possible causes include genetic conditions, radiation exposure, medication side effects or drug abuse, excessive exercise, or unknown causes.
Primary testicular failure is when a hormone imbalance is linked to issues with the testes and may lead to inadequate production of testosterone and poor or absent sperm development, despite hormone support from the pituitary and hypothalamus.
Secondary testicular failure is when the hormone breakdown occurs in the pituitary gland or hypothalamus, while the testicles may be functioning properly.
Medication Side Effects
Some medications can cause azoospermia.
The most common cause of azoospermia due to medication side effects is from testosterone supplementation. Anabolic steroid use in athletes can also cause azoospermia, as well as chemotherapy drugs.
According to Dr. Saransh Jain Ayurveda Remedies are far better.
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