Azoospermia is a condition that occurs when your semen contains no sperm. This can happen for many reasons, and it affects about 1% of all men and 15% of infertile men. If you and your partner have tried to get pregnant without success, azoospermia could be the cause.
What Causes Azoospermia?
Azoospermia can be caused by conditions that prevent your testicles from making sperm. It may also be due to problems that prevent your sperm from mixing with semen, so it doesn’t leave the body when you ejaculate.
Experts often refer to these broad categories as obstructive and nonobstructive azoospermia.
Nonobstructive azoospermia
When your testicles don’t make sperm or make too little of it to get into your semen, you have nonobstructive azoospermia. It accounts for about 60% of those diagnosed with azoospermia.
Many things, such as medical conditions, medications, alcohol, and illicit drugs, can interfere with sperm production. Depending on where the problem starts, your doctor may refer to your azoospermia as pretesticular or testicular; however, most experts today favor the broader term nonobstructive azoospermia, no matter the cause.
Pretesticular azoospermia. With pretesticular azoospermia, problems with your hypothalamus gland and your pituitary gland, both located in your brain, can cause a hormonal imbalance that keeps your testicles from producing sperm.
Possible causes of pretesticular azoospermia include:
- Testosterone replacement therapy (TRT)
- Chemotherapy
- Taking illicit drugs
- Poor nutrition
- Low testosterone
- Pituitary tumors
- Hypopituitarism, in which the pituitary gland can’t produce enough (or any) of certain hormones
- Anabolic steroid abuse
Testicular azoospermia. This is when zero sperm count can be traced to the testicles themselves.
“All the tubes are open, but the testicle itself just isn't making the sperm,” says urologist Boback Berookhim, MD, director of the male fertility and microsurgery program at Northwell Lenox Hill Hospital in New York City.
There are several possible causes, including:
- Undescended testicles
- Klinefelter’s syndrome, in which males are born with an extra X chromosome
- Sertoli cell-only syndrome, in which you don’t have sperm-producing cells in your testicles
- Y chromosome deletions, in which certain genes in the Y chromosome are missing, affecting sperm production
- Exposure to certain chemicals and pesticides
- Varicoceles, enlarged veins in the scrotum that can lead to overheating of the testicles, affecting sperm production
- An infection in your reproductive tract, such as epididymitis and urethritis
- A childhood illness, such as viral orchitis, which causes swelling of one or both testicles
- A groin injury that damages your testicles
- Cancer or certain treatments, such as chemotherapy and radiation
Obstructive azoospermia (post-testicular azoospermia)
“Post-testicular means that the testicles are doing their job, but the sperm is not making its way out,” Berookhim says.
These obstructions can occur in three main areas:
- Epididymis, which stores sperm after it has been produced by your testicles
- Vas deferens, the tubes that carry sperm from your epididymis to your ejaculatory duct (or sperm duct)
- Ejaculatory duct, the tube that connects to your urethra, where sperm mix with your semen
“The most common cause of azoospermia from a blockage is a previous vasectomy,” says Jesse Mills, MD, a urologist and director of the Men’s Clinic at UCLA in Los Angeles.
A vasectomy is a male birth control procedure in which a surgeon closes off the vas deferens so that your sperm can’t mix with your semen.
However, there are other reasons obstructions can occur. These include:
- Trauma and injury, such as to the epididymis or testicles
- Infections like epididymitis
- Inflammation
- Genetic conditions such as cystic fibrosis
- Surgeries around your pelvis, such as a hernia repair
- Growths or cysts
About 40% of men with azoospermia have the obstructive, or post-testicular, type.
How Do You Know if You Have Azoospermia?
If you’ve been trying without luck to get your partner pregnant, your doctor might check you for this condition.
First, you’ll give samples of your semen, and a lab will examine them with a high-powered microscope. If the results show no sperm in your semen on two separate occasions, then you’ll be diagnosed with azoospermia.
Your doctor will then try to figure out what’s causing the problem. They’ll give you a complete physical exam, ask you about your medical history, and test your blood to measure your hormone levels.
If your hormone levels are normal, your doctor may order a scrotal or transrectal ultrasound to look for an obstruction. An MRI may confirm the diagnosis. Sometimes, surgery is the only way to find the obstruction.
If you don’t have a blockage, genetic tests can find out if you have a problem in your genes.
Does azoospermia have any symptoms?
Azoospermia itself has no symptoms other than an inability to get your partner pregnant. You won’t know for sure that you have it without undergoing diagnostic tests, such as examining semen samples under a microscope.
Keep in mind that azoospermia can be caused by conditions that have other symptoms. For example, if you have low testosterone, you may notice a drop in your sex drive (libido). Infections leading to azoospermia may cause lumps on your testicles.
How Is Azoospermia Treated?
There are a few types of treatment that can help people with azoospermia.
The right treatment for you will depend on the cause. Options are available for nonobstructive and obstructive forms of azoospermia.
If you have a condition that prevents you from ejaculating normally, such as retrograde ejaculation, your doctor may suggest a nonsurgical procedure to induce ejaculation using vibration or electrical energy.
If you have the obstructive type, surgery can often remove the blockage. It can also be done to connect or reconnect sperm-carrying tubes. For example, if you have had a vasectomy and later wish to have a child, surgery can reverse the procedure. This involves reattaching your vas deferens, allowing sperm to travel and mix with your semen. The more recent your blockage, the more likely it is that the surgery will be successful.
Sperm retrieval
When you don’t have sperm in your semen, your doctor may be able to collect sperm from inside your reproductive system. This is called sperm retrieval. “In about 60% of men, even those with a zero sperm count in the ejaculate, you can find sperm within the testicle that can be used," Berookhim says.
There are several ways to approach sperm retrieval. It can be done for both obstructive and nonobstructive azoospermia.
“If it’s obstructive azoospermia, such as after a vasectomy or in a man with cystic fibrosis, it’s pretty straightforward to extract sperm from the testicle or the epididymis and use it for IVF,” Mills says.
If you have nonobstructive azoospermia, you will need a more complex procedure called a microdissection testicular sperm extraction (microTESE). “This is a technically difficult surgery and needs to be done by a trained male reproductive urologist working with an embryologist who can look at the extracted tissue and isolate sperm for IVF," Mills says.
Other procedures include:
Testicular sperm aspiration (TESA). For this procedure, your doctor uses a very fine needle to extract sperm from a testicle. It’s done for obstructive azoospermia.
Percutaneous epididymal sperm aspiration (PESA). For a PESA, your doctor uses a fine needle to collect sperm from your epididymis. It’s done for obstructive azoospermia.
Testicular sperm extraction (TESE). For this procedure your doctor makes small incisions in a testicle to look for sperm. It’s done for nonobstructive azoospermia.
Microepididymal Sperm Aspiration (MESA). For MESA, your doctor makes an incision in your epididymis to extract sperm. It’s done for obstructive azoospermia.
Microdissection TESE (microTESE). With a microdissection TESE, your doctor removes tissue from your testicles to find sperm samples. It’s done for nonobstructive azoospermia.
Once sperm is collected, it can be used for a type of in vitro fertilization (IVF) called intracytoplasmic sperm injection (ICSI). In this, your sperm is injected directly into an egg in a lab. The retrieved sperm can also be frozen for later use. Some people opt to freeze their sperm and have it stored in a sperm bank before undergoing medical treatments that can cause azoospermia, such as certain treatments for prostate cancer, bladder cancer, and testicular cancer.
Can a person with azoospermia impregnate a woman?
If you have azoospermia that your doctor can’t treat, you won’t be able to get a woman pregnant via intercourse. That’s because your semen contains no sperm, making it impossible to fertilize an egg. However, a successful sperm retrieval can offer enough sperm to start a pregnancy with in vitro fertilization.
Unless the azoospermia is cured, “a man with azoospermia will always need IVF,” Mills says.
Takeaways
Azoospermia means you have no sperm in your semen. That results in an inability to get a woman pregnant via intercourse. Depending on the cause, your azoospermia may be treatable. Even if it can’t be cured, it’s often possible to extract sperm from your reproductive system to be used in in vitro fertilization.
Azoospermia FAQs
Can a man with azoospermia impregnate a woman naturally?
A man with untreated azoospermia can’t get a woman pregnant via sexual intercourse. But depending on the cause of the azoospermia, surgery to correct a blockage or hormonal therapy may make this possible. In other cases, sperm may be extracted and used to fertilize an egg by in vitro fertilization or intracytoplasmic sperm injection.
How is azoospermia diagnosed?
If you have been trying to impregnate your partner for six months or more, you may have azoospermia. Your doctor will examine two semen samples under a microscope to check if any sperm are present. If not, you have azoospermia. Your doctor will then need to figure out the cause.
Can azoospermia cure itself?
Rarely. It may resolve on its own within 6-12 months if it’s due to a systemic illness caused by an infection, such as the flu or COVID. But you should still see your doctor for a full checkup, as your azoospermia could be the result of a more serious illness, such as testicular cancer, says Berookhim.
Can smoking cause azoospermia?
Smoking harms sperm quality, but it’s not known to cause azoospermia, according to Mills, who says that heavy marijuana use causes greater damage to sperm quality and, possibly, azoospermia.
How can you increase sperm count in azoospermia?
If your sperm count is any number above zero, you don’t have azoospermia. If you do have a zero sperm count, your doctor can identify the cause and recommend treatment, which may restore sperm to your semen. Even if treatment is not possible, you may have sperm in your reproductive tract that can be extracted for use in IVF.
Can azoospermia be reversed?
In some cases, yes. For example, if your azoospermia results from a vasectomy, a vasectomy reversal may be able to restore your sperm’s ability to enter your semen.
