Azoospermia Treatment: Causes, Types, Micro-TESE & Chances of Becoming a Father

Yes, azoospermia (no sperm in semen) is often treatable. Blockages are surgically correctable, and sperm retrieval (PESA, TESA, TESE) works in about 90% of obstructive cases. In non-obstructive cases, micro-TESE finds sperm in roughly 40-60% of men, depending on the cause. Retrieved sperm is used with ICSI to achieve pregnancy.

Navigating infertility is still one of the toughest challenges for many couples in India. Many think that an azoospermia diagnosis is final. However, it is actually a means to take right steps in being able to achieve their dreams of parenthood.

What is Azoospermia?

Azoospermia is a condition where there is no measurable sperm in a man’s ejaculate (semen). Sometimes, it is referred to as ‘no count sperm.’ It could be the result of genetic disorders, blockages of the reproductive tract, hormonal imbalances, medical treatments, lifestyle issues, and so on.

Azoospermia affects 1 – 3% of all males in the given population. However, depending on the cause, different azoospermia treatments are available to address the underlying cause and help patients with the condition to start a family.

Types of Azoospermia:

Depending on the cause and the treatment required, azoospermia is divided into two types:

1. Obstructive Azoospermia (OA) – The lack of sperm count is due to a blockage in the epididymis (corkscrew-shaped duct where sperm matures), vas deferens and ejaculatory duct (tube that sperm goes through to mix with fluid and form semen). This means that the testes are producing sperm normally, but due to the obstruction, the sperms are unable to leave and mix into the semen and join the partner’s egg to start a pregnancy.

This is seen in roughly 1 in 4 men with azoospermia and is the most common form of the condition. For these causes, azoospermia treatment includes (1) surgical correction and (2) Assisted Reproductive Techniques (ART) like in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). When a couple chooses Assisted Reproductive Techniques, sperm retrieval techniques like Microsurgical Testicular Sperm Extraction (micro – TESE), Testicular Sperm Aspiration (TESA) or Percutaneous Epididymal Sperm Aspiration (PESA) are used.

2. Non – Obstructive Azoospermia (NOA) – The lack of sperm count is not the result of a blockage. Based on the cause, non – obstructive azoospermia is divided into:

• Testicular azoospermia – The testes produce poor or no sperm due to a disorder in (or damage to) the structure or the function of the testicles.
• Pretesticular azoospermia – testicles and reproductive tract appear normal but hormonal or pituitary problems prevent triggers that allow sperm production from occurring.

This occurs in roughly 3 to 4 men. For testicular azoospermia, depending on the cause, the azoospermia treatment includes hormone therapy/stimulation, medication for steroid use, and lifestyle changes. In cases that fall under Pretesticular azoospermia, the azoospermia treatment of micro – TESE with ICSI is used. Another option for both NOAs are alternative family building options like donor sperms or adoption and fostering.

Azoospermia Causes:

For Obstructive Azoospermia, these factors can cause blockages:

• Trauma or injury to the testicles.
• Infections – Common health issues such as epididymitis, common STIs, and reproductive tuberculosis can leave behind scar tissue and create blockage.
• Retrograde ejaculation – for this cause, the sperm flows backwards into the bladder. A simple urine test after ejaculation can show if this is the case, so it can be given the appropriate treatment.
• Cysts or growths in the ejaculatory ducts.
• Past vasectomy.
• Congenital absence of the vas deferens – Some men are born with a condition called CBAVD, where the vas deferens doesn’t develop, often due to a genetic trait.

For Non – Azoospermia, the common causes include:

1. Health/Genetic causes:

• Genetic conditions – Some genetic changes cause the male reproductive organs to develop irregularly. Genetic conditions linked with infertility include: Y chromosome microdeletion, Klinefelter syndrome, Kallmann syndrome and Kartagener’s syndrome.
• Hormonal imbalances – When there are hormonal disruptions like low LH and FSH from the pituitary glands (hypogonadotropic hypogonadism), high prolactin or thyroid problems, it often leads to no sperm production.
• Varicocele – A varicocele is a swelling of the veins that drain the testicle, lowering the sperm count and quality. It is a common of cause of male infertility.
• Undescended testicles – During pregnancy, one or both of an unborn baby’s testicles sometimes don’t drop down into the scrotum.

2. Environmental causes

Exposure to toxic environments for long periods of time can lead to a decrease in sperm count and function. These include:

• Industrial chemicals (e.g. insecticides, pesticides, organic solvents, etc.)
• Heavy metals.
• Radiation or X-rays.
• chemotherapy
• High – temperature environments (bakeries, saunas, hot tubs, etc.).

3. Medications and previous surgeries:

Low sperm production can be a side – effect for patients who are on medications or treatments for other conditions. These include:

• arthritis
• depression
• anxiety
• low testosterone levels
• digestive trouble
• high blood pressure

Previous surgeries can lead to a blockage, which may prevent the sperm from entering and exiting in your semen. Often, for these cases, surgery can be used to correct these blockages. These include:

• inguinal hernia repairs
• surgeries to treat the scrotum/testicles
• prostate surgeries
• large abdominal surgeries for testicular and rectal cancers

4. Lifestyle choices:

When it comes to lifestyle, there are periods of time, and the consumption of certain substances that can negatively affect sperm quality, count and function. These include:

• Anabolic steroids
• testosterone injections or gels (very common in gym users)
• emotional stress
• obesity
• heavy alcohol
• smoking
• recreational drugs (e.g. cocaine and marijuana)

Azoospermia symptoms:

Usually, azoospermia goes undetected until a couple is unable to become pregnant after 12 months of regular, unprotected sex. Depending on the cause, some men may also notice:

• Low semen volume
• Small, soft or painful testicles
• A lump or swelling in the scrotum (possible varicocele)
• A history of undescended testes, mumps, genital infection, surgery or cancer treatment
• Low sex drive
• Fatigue
• Reduced facial or body hair.

Azoospermia diagnosis:

An Azoospermia diagnosis follows a stepwise process. Once the cause for the zero sperm count is found, the azoospermia treatment plan which suits the patients’ needs is determined:

1. Detailed history and examination: At this stage, the doctor will examine your childhood & family history, past surgeries, medications and steroid use, and any cancer treatments. They will then conduct an examination of the testes, vas deferens and epididymis.
2. Repeat semen analysis: at least two samples on separate days, with the sample centrifuged and examined for any sperm. Semen volume and pH are noted. Very low volume and acidic semen can point to a blockage near the ejaculatory ducts or absent vas deferens.
3. Post-ejaculation urine test: to rule out retrograde ejaculation.
4. Hormone blood tests: FSH, LH, testosterone and prolactin. A high FSH with small testes suggests the testicles are not producing sperm well. Low FSH and LH point to a pituitary problem that may be treatable.
5. Scrotal and transrectal ultrasound: looks for varicocele, testis size, epididymal changes and blocked ejaculatory ducts.
6. Genetic tests: karyotype (for Klinefelter syndrome), Y-chromosome microdeletion testing, and CFTR testing if the vas deferens is absent.
7. Testicular biopsy or sperm mapping: used selectively, often at the time of sperm retrieval.

Azoospermia Treatment:

Depending on the cause found during the azoospermia diagnosis, there are different azoospermia treatment plans.

Obstructive Azoospermia (OA):

When sperm production is normal and there is a blockage, doctors can either remove the blockage or go around it.

Surgery: Surgical correction can be done to unblock the tubes and ducts or connect and reconstruct the ones that are preventing the sperm from entering the semen. The blockage may occur at various points in the reproductive system, including the epididymis, vas deferens and ejaculatory ducts. Some surgeries include:

• Vasovasostomy – This surgery reconnects the vas deferens and is the standard way to reverse a vasectomy.
• Vasoepididymostomy – If a block is found between the vas deferens and the epididymis, this surgery builds a new connection. It is a complex but effective way to restore transport.
• Transurethral Resection of Ejaculatory Ducts – For ductal blocks, an endoscopic procedure can clear the way. Success depends on the block’s location

Risks and complications:

When taking the route of surgery, these are the potential risks and complications:

• Infection – An infection may develop at the site of the surgery, but these are usually easy to treat with antibiotics and medical care.
• Bleeding – It is common to have a little bleeding or some bruising after your operation or sperm retrieval procedure.
• Scarring – Scar tissue can sometimes form after surgery.
• Failure to restore sperm flow – In some cases, the surgery might not be successful in restoring natural sperm flow.

Sperm Retrieval Techniques: When surgical reconstruction fails or the patient is unable to proceed with surgery, sperm retrieval techniques like standard TESE, TESA or PESA are used. Once the sperm is collected, the patients can move forward with IVF or ICSI treatment.

1. PESA (Percutaneous Epididymal Sperm Aspiration

PESA uses a needle to collect sperm from the epididymis immediately. It is a minimal procedure and is done under 10 – 30 minutes, and local anaesthesia often enough. The sperm is then used with ICSI. The sperm retrieval success rate is 90 – 95% for Obstructive Azoospermia (OA).

1. TESA (Testicular Sperm Aspiration)

In this procedure, a needle collects sperm from the testis, it is usually used when PESA fails and is also done under 10 – 30 minutes. The sperm retrieval success rate is 90% for OA but 20 – 30% in NOA.

 

• TESE (Testicular Sperm Extraction)

Small incision into testis; tissue sample taken and processed in the lab. It is less precise than micro-TESE but more sampling than TESA. The sperm retrieval success in 90% in OA but 30 – 50% in NOA.

If sperm retrieval and IVF-ICSI are chosen, the success of the outcome depends on other factors, including:

• Age of the female partner
• Quality of retrieved sperm
• Overall reproductive health

Non – Obstructive Azoospermia (NOA):

As non – obstructive azoospermia is caused by other factors like hormonal imbalances, health problems, etc., the azoospermia treatments that medical professionals use are:

Hormone treatment – If disruptions in hormone production are the cause, hormone treatments that use drugs like Follicle – Stimulating Hormone (FSH), Human chorionic gonadotropin (HCG), clomiphene and anastrazole are used to improve hormone regulation.

Varicocelectomy – Some men may have a varicocele, or enlarged and widened veins on the scrotum that can impede sperm production. During the surgery, an operating microscope is used to identify and tie off the offending veins while preserving the arteries, vas deferens and lymphatic channels.

Micro – TESE technique – The sperm retrieval technique micro – TESE is usually employed for treating azoospermia.

What is Micro – TESE?

For Non – Obstructive Azoospermia, micro – TESE is the recommended retrieval technique. This is because it identifies the small areas of active sperm production under an operating microscope. Surgeons performing micro – TESE use highly advanced microscopes to detect and identify specific areas, called seminiferous tubules, that are more likely to contain sperm. Only those areas are carefully removed, rather than larger sections of tissue.

How is Mico – TESE done?

• Under general or regional anaesthesia, the urologist makes a small incision in the scrotum, opens the testis and examines the tubules under high magnification.
• The tubules that look healthier and more swollen are collected, and an embryologist checks the tissue in the laboratory right away.
• Sperm may be used fresh (often timed with the partner’s egg collection) or frozen for later ICSI.

It is usually a day-care procedure, and most men resume light activity within a few days. Your surgeon will give specific advice on rest and exercise.

Success rate of Micro – TESE in India:

For micro – TESE, the sperm retrieval success rates of 40% to 60% in men with NOA. However, the success rate also depends on other factors like:

• Age of Male Partner: Older age can correlate with lower sperm retrieval rates.
• Hormonal Levels: Lower Follicle-Stimulating Hormone (FSH) levels correlate with higher success rates.
• Testicular Volume: Increased testicular volume, particularly 20 ml or higher, enhances the success of sperm retrieval.
• Surgeon experience: Experienced surgeons have superior sperm retrieval rates due to technical skill and anatomical knowledge.
• Histopathology: Favourable biopsy results correlate highly with successful sperm retrieval in Micro – TESE.
• Surgery Timing: Micro – TESE surgery timing after orchidopexy or other surgery should be noted to improve outcomes, while delaying may harm spermatogenesis.

Success rate for genetic conditions:

Klinefelter syndrome (47, XXY) – Sperm can be found in a significant share of men, commonly reported at around 40 to 50 percent with micro-TESE. Earlier age and good hormone levels are discussed as helpful, but evidence varies.

Y-chromosome microdeletion, AZFc – Sperm can often be found, in about half of men in many reports. A son will inherit the deletion.

Y-chromosome microdeletion, complete AZFa or AZFb – Sperm can often be found, in about half of men in many reports. A son will inherit the deletion.

Azoospermia treatment cost in India

The cost depends on the city and hospital, the type of azoospermia, the procedure chosen and how many ICSI cycles are needed. It is more helpful to look at what makes up the total than at a single figure:

• Consultation, semen analysis, hormone tests, scans and genetic tests
• Hormone medicines, which can run for several months
• Surgery fees: varicocele repair, vasectomy reversal or reconstruction, or sperm retrieval (PESA, TESA, TESE or micro-TESE), plus anaesthesia and hospital charges
• Laboratory fees: sperm search, processing and freezing, and storage
• The IVF-ICSI cycle for the couple, including stimulation medicines, egg collection, embryo culture and transfer, and any frozen transfers
• Optional extras such as genetic testing of embryos

Always ask for a written estimate that states exactly what is and is not included, and what happens to the cost if sperm are not found or if a second cycle is needed. Check whether payment options are available.

 

Frequently Asked Questions:

Can azoospermia be cured?

It depends on the cause. A blockage can sometimes be corrected by surgery, and some hormonal causes respond to treatment. In many men a “cure” in the sense of sperm in the ejaculate is not possible, but sperm retrieval with ICSI can still make fatherhood possible.

Can a man with azoospermia have his own biological child?

Often yes. If sperm can be found in the testis or epididymis, they can be used for ICSI. The chance depends on the type and cause of azoospermia.

Is azoospermia permanent?

Not always. Causes such as steroid use, some hormonal problems, infections and certain blockages can be treated, and sperm may return. In other cases, such as some genetic conditions, it is permanent.

What is the difference between azoospermia and oligospermia?

In azoospermia there are no sperm in the ejaculate. In oligospermia the sperm count is low, but sperm are present.

What is the success rate of micro-TESE?

In non-obstructive azoospermia, sperm are found in roughly 40 to 60 percent of men in many reports, but the figure varies with the cause, hormone levels and surgeon experience. Finding sperm does not guarantee a pregnancy.

Can azoospermia be treated naturally with diet or herbs?

There is no proven natural cure. A healthy lifestyle supports sperm health, but true azoospermia needs medical evaluation and treatment.

Does azoospermia affect sexual performance?

Usually not. Erections, desire and ejaculation are generally normal. If testosterone is low, sex drive may be reduced, and this can be treated.

Is azoospermia hereditary?

Some causes are genetic, for example Y-chromosome microdeletions (passed to sons) and CFTR changes. Others, such as infection or injury, are not. Genetic counselling is advised.

Does varicocele cause azoospermia?

Varicocele can reduce sperm production and is seen in some men with azoospermia. Surgery helps some men, but not all.

Is sperm retrieval painful?

PESA and TESA are usually done with local or short anaesthesia and cause mild discomfort. Micro-TESE is done under anaesthesia, with soreness and swelling for a few days that can be managed with medicines.