Many men with infertility have no obvious symptoms, so a diagnosis of azoospermia can be a shock. Here’s what you need to know about having no sperm, the common causes of azoospermia and treatment options.
What is azoospermia?
Azoospermia is the medical term used when there are no sperm in your ejaculate. This might be referred to as having zero sperm count or no sperm count. Usually, sperm produced by your testes travel through your reproductive system and mix with other fluids to form semen. This is what is released during ejaculation. If you have azoospermia you will ejaculate semen, but there’s no sperm in it.
Azoospermia affects 1% of men and accounts for 10–15% of male infertility. You probably won’t realise you have azoospermia until you try to start a family because there are no obvious symptoms.
Obstructive vs non-obstructive
There are two different types of azoospermia — obstructive azoospermia (OA) and non-obstructive azoospermia (NOA).
Obstructive azoospermia (OA) is when obstruction at any site along the male reproductive tract prevents the movement of sperm.
Non-obstructive azoospermia (NOA) is when the testes produce very few or no sperm. Around 60% of men with azoospermia have non-obstructive azoospermia.
Differentiating between obstructive azoospermia (OA) and non-obstructive azoospermia (NOA) is important because it guides how your infertility is investigated and managed.
Healthy Male has created Australia’s first-ever clinical guidelines for the management of male infertility. The 80 expert-backed recommendations provide evidence-based advice to practitioners who manage male patients with infertility in Australia.
You can access the guidelines here.
Common causes of azoospermia
How is azoospermia is diagnosed
If you’ve been trying to conceive for 12 months (or six months if your partner is aged 35+) you should both book an appointment with a doctor to get your fertility investigated. You should both be investigated at the same time to reduce delays in knowing what’s going on and starting treatment if you want it.
Assessment of male fertility involves:
1. Physical examination
Your doctor will have a look at and feel your genitals to detect any physical issues that could be causing infertility. The presence or absence of the vas deferens can confirm a specific type of obstructive azoospermia, a varicocele is often detectable by feel and signs like small testes or reduced body hair can flag an underlying hormonal or genetic condition like Klinefelter syndrome.
2. Medical history
Your doctor will ask about your medical and surgical history, family history, and behaviours that influence your health (like diet and exercise, sleep, smoking and alcohol consumption and your work life).
3. Semen analysis
You’ll then be referred to have a semen analysis. You’ll provide a sample (which can be done at the pathology laboratory or at home and brought in) and it will be examined under a microscope to determine the number of sperm, their size and shape and their movement. If no sperm is detected, you’ll need to have another semen analysis in six weeks’ time.
4. Blood test
If your first semen analysis found no sperm, you’ll probably be referred to have a blood test to measure your hormone levels while you wait for your second test. It will measure testosterone, FSH, LH and prolactin, and can help determine the cause of infertility.
If azoospermia is diagnosed by the second semen analysis, it’s important to determine whether it’s obstructive azoospermia (OA) or non-obstructive azoospermia (NOA).
5. Genetic testing
If non-obstructive azoospermia is suspected, you’ll undergo karyotype testing (to identify Klinefelter syndrome) and Y chromosome microdeletion testing. Men with structural abnormalities of the vas deferens should also be tested for Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) gene mutations.
6. Imaging
Further investigation with MRI or ultrasound can identify varicoceles, obstructions, or abnormalities in the epididymis or ejaculatory ducts.
How is azoospermia treated?
Treatment of azoospermia depends on the cause.
If you have azoospermia that isn’t treatable, you still have options for starting a family.
Surgical sperm retrieval
Surgical sperm retrieval procedures can be used to find sperm in the testes (testicles) of some infertile men. This sperm can then be used to fertilise your partner’s eggs through assisted reproductive technology (ART). There are a few different procedures used to retrieve sperm, including percutaneous epididymal sperm aspiration (PESA), testicular sperm aspiration (TESA), and micro testicular sperm extraction (micro-TESE).
MicroTESE and non-obstructive azoospermia
MicroTESE is the preferred technique for sperm retrieval in men with non-obstructive azoospermia. MicroTESE is an advanced technique performed by specialised microsurgeons. They use a high-powered microscope to find and remove small sections of the testes where sperm are likely to be found. In men with non-obstructive azoospermia, the success rate — defined as finding viable sperm suitable for fertility treatment — ranges from 38% to 60%, depending on patient factors.
Can you still have biological children with azoospermia?
Yes. When a semen analysis shows that you have no sperm in your ejaculate, it doesn’t mean you have no sperm at all.
If you have obstructive azoospermia, your sperm production is normal but it just can’t get out. If you have non-obstructive azoospermia, sperm may still be found in your testes to be used in in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI).
Want to know what it’s like to have azoospermia?
Reece Conca share’s his experience with infertility, microTESE and fatherhood here.
There are also other pathways to parenthood including donor sperm. You can read more about that here.
People also ask
Can a man recover from azoospermia
Yes, depending on the cause. Obstructive azoospermia is more likely to be curable than non-obstructive azoospermia because surgery to overcome obstruction is often successful. Recovery rates for non-obstructive azoospermia depend on the cause. Ejaculation of sperm can be recovered in 20-30% of men with NOA caused by varicocele, with surgery. Most men with NOA caused by taking testosterone recover sperm in their ejaculate eventually.
Can azoospermia be permanent?
Yes it can be, some causes of azoospermia can’t be treated. However, some causes of obstructive azoospermia (such as vasectomy and blockages) and non-obstructive azoospermia (such as hormone imbalances) can be fixed and fertility returned. Even if azoospermia is permanent, there are treatments that can bypass it to start a family, such as surgical sperm retrieval combined with IVF or ICSI.
What does azoospermia look like?
While many men with infertility have no obvious symptoms, a variety of signs and symptoms are associated with OA and NOA. These include groin pain, swelling or a lump in the genitals, small testes and reduced semen volume.
