Azoospermia

Azoospermia means no sperm at all in the ejaculate. It is found on a semen analysis, confirmed on a second sample, and it splits immediately into two very different situations depending on whether the testicles are producing sperm that cannot get out, or barely producing any.

Where you'll meet it

It arrives in a semen analysis report, often as a single word with nothing else on the page. It can be a real shock, partly because most men have had no reason to think about their fertility before.

The first thing to know is that it is far from the end of the conversation. A good proportion of men with azoospermia still have sperm somewhere, and surgical retrieval with ICSI exists precisely for this.

Confirming it before anything else happens

One sample is never enough. A result of no sperm is repeated, usually after a few weeks, and the laboratory spins the sample down and examines the pellet under the microscope, because the occasional sperm can hide there. If a few are found, the label changes to cryptozoospermia and the plan changes with it.

Nothing else should be decided until two samples agree, especially a decision as big as using donor sperm.

Obstructive and non-obstructive

This is the distinction the whole plan hangs on.

Obstructive azoospermia means production is fine and the plumbing is blocked. A previous vasectomy, an absent vas deferens, scarring from infection or earlier surgery. Testicular size and hormone levels are usually normal. Retrieving sperm from behind the blockage is generally successful, which is why this is the straightforward group.

Non-obstructive azoospermia means the testicle is making little or nothing. Hormones often tell the story, with a raised FSH suggesting the testicle is not responding fully to the body's signal. Here retrieval is a search rather than a collection, and micro-TESE, where a surgeon works through the tissue under high magnification looking for the small pockets that are still producing, is the technique that belongs to this group. Sperm are found in around half of men, and the odds vary with the underlying cause.

The workup that follows

Expect hormone tests, a physical examination, a scrotal ultrasound and genetic testing, typically a karyotype and a check for Y chromosome microdeletions. Some findings are treatable, and the genetic results also matter for any child conceived, which is the part that deserves a proper counselling appointment rather than a line in a letter.

Some causes are reversible. A hormone problem higher up can respond to treatment. A blockage from a vasectomy can sometimes be reversed surgically instead, and whether that beats retrieval with ICSI depends on time, cost and the female partner's age as much as on the man.

Questions to ask

Ask whether the diagnosis has been confirmed on a second sample with the pellet examined. Ask which type it is and what the hormone and genetic results suggest. If retrieval is proposed, ask how many the surgeon does a year and what proportion find sperm in men with non-obstructive azoospermia, because that number varies between operators more than almost anything else on the male side. Ask what the plan is if nothing is found on the day, since that conversation is much easier to have in advance.

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