Azoospermia is a violation of spermatogenesis characterized by the absence of spermatozoa in the seminal fluid. Depending on the causes, obstructive and non-obstructive azoospermia are distinguished. Disease is accompanied by the inability to conceive naturally, and in some cases – with the help of assisted reproductive technologies. Azoospermia is diagnosed during the examination of a man’s reproductive status (ultrasound, testicular biopsy, determination of hormone levels, spermograms, AST). With obstructive azoospermia, microsurgical restoration of the patency of the vas deferens is required; with the secretory form of pathology, stimulating hormone therapy is required. In case of impossibility of natural conception, resort to the use of IFV.
N46 Male infertility
Azoospermia is a form of male infertility caused by the absence of sperm in the ejaculate. In andrology and urology, there are several variants of spermatogenesis disorders: oligozoospermia, asthenozoospermia, teratozoospermia, azoospermia. In addition, there are combined forms of pathology: oligoastenozoospermia, oligoteratozoospermia, asthenoteratozoospermia, etc. Of all the factors of infertility in men, azoospermia accounts for about 10-20%. Pathology of sperm, including azoospermia is always a reflection of male reproductive health problems, so the main efforts of specialists should be aimed at identifying and eliminating the causes of this condition.
Taking into account the causes of azoospermia, it can be obstructive, non-obstructive (secretory) and temporary. The obstructive form of azoospermia is based on obstruction of the vas deferens, as a result of which spermatozoa cannot get into the ejaculate. At the same time, male germ cells are formed in sufficient quantity, have normal morphology and mobility. The causes leading to obstructive azoospermia may be:
- congenital anomalies (aplasia of the vas deferens);
- inflammatory processes (orchitis, epididymitis, vesiculitis, prostatitis);
- injuries of the scrotum organs;
- inguinal and scrotal hernias;
- urethral stricture;
- operations on the organs of the scrotum (vasoresection, herniation, hydrocele surgery).
With secretory (non-obstructive) azoospermia, the formation of spermatozoa in the testicles is initially disrupted. Factors causing such a condition can serve as:
- bilateral cryptorchidism;
- epidemic mumps complicated by orchoepididymitis;
- testicular tumors;
- radiation exposure;
- toxic effects of heavy metal salts and pesticides.
Violation of spermatogenesis by the type of secretory and obstructive azoospermia can occur in hypogonadism, cystic fibrosis, diabetes mellitus, celiac disease, pituitary tumors, spinal injuries, syphilis and other pathology.
Temporary azoospermia is characterized by transient functional disorders on the part of the genital glands and can develop against the background of acute diseases, stress, taking medications (steroid hormones, antibacterial and antitumor agents), frequent visits to saunas and baths. A temporary decrease in sperm production is observed in sexually active men with frequent sexual intercourse.
Spermatogenesis – the process of formation and maturation of male germ cells begins in puberty and continues until old age. The formation of spermatozoa occurs in the convoluted seminal tubules of the testicles and includes three successive phases: spermatogony proliferation, meiosis and spermiogenesis. This process is most active at a temperature of 34 ° C, which is provided by the anatomical location of the testicles in the scrotum, outside the abdominal cavity. The final maturation of spermatozoa occurs in the appendage of the testicle. The duration of the full cycle of spermatogenesis in a man is approximately 73-75 days.
Various kinds of adverse factors can disrupt the process of sperm formation and maturation, leading to various forms of pathospermia, the most common among which are:
- oligozoospermia – decrease in the number of live sperm (less than 20 million in 1 ml of ejaculate)
- asthenozoospermia is the presence of less than 50% of spermatozoa with type 1 (progressive linear) and type 2 (slow linear or progressive nonlinear) movement or less than 25% of spermatozoa with type 1 movement. The number and shape of spermatozoa are normal at the same time.
- teratozoospermia – more than half of the spermatozoa have abnormalities in the structure of the head and tail. The mobility and number of cells are not changed.
- azoospermia – there are no spermatozoa in the seminal fluid.
The main specific symptom of azoospermia is male infertility. At the same time, a man’s sexual function may remain intact. The remaining clinical symptoms accompanying azoospermia are associated with the underlying disease. Thus, with hypogonadism in a man, the underdevelopment of secondary sexual characteristics is determined: scant hair, female-type physique, gynecomastia. Secretory azoospermia is often accompanied by testicular hypoplasia, micropenis, decreased libido, erectile dysfunction.
With various forms of obstructive azoospermia, a man may be concerned about discomfort, pain, swelling or swelling of the scrotum. During palpation, testicles of normal size and shape are determined, and the appendages of the testicles are enlarged due to the accumulation of spermatozoa in it. Obstructive azoospermia may be accompanied by retrograde ejaculation.
The causes and form of azoospermia can only be established by specialists (andrologists, urologists, endocrinologists) on the basis of a comprehensive examination of the male reproductive system. The following diagnostic techniques are used:
- Collecting anamnesis. The frequency of sexual activity and the duration of the infertility period, past illnesses, occupational hazards, the patient’s lifestyle and other factors are specified.
- Physical examination. The type of physique, the severity of secondary sexual characteristics, the condition of the external genitals are evaluated.
- Ultrasound examinations. To exclude the pathology of the male genital organs, ultrasound of the scrotum, ultrasound of the prostate gland, ultrasound of the scrotum vessels, etc. is performed.
- Spermogram with a MAR test. Important tests that allow us to judge male fertility in general and azoospermia in particular are a spermogram and determination of the level of antisperm antibodies in the blood.
- Hormone tests. The study of the hormonal status in azoospermia (testosterone, prolactin, estradiol) allows us to judge the hypothalamic-pituitary regulation of the activity of the sex glands.
In order to exclude STDs as a factor of azoospermia, the patient is examined for infections by ELISA, PCR methods. To exclude retrograde ejaculation, a post-ejaculatory urine test is performed. Differential diagnosis of forms of azoospermia is facilitated by a diagnostic testicular biopsy.
Conservative and surgical treatment
In all cases of azoospermia, treatment is aimed at eliminating the cause that caused the violation of male fertility. Thus, the main way to solve the problem of obstructive azoospermia is to perform reconstructive surgery to restore the patency of the vas deferens: urethral plasty, vaso-vasoanastomosis or vaso-epididymoanastomosis, surgical elimination of varicocele, etc.
The success rate of fertility restoration after surgical removal of obstruction of the vas deferens is 27-56%. To correct endocrine disorders that led to secretory azoospermia, hormone replacement or stimulating therapy is prescribed. With the help of a course of treatment for male infertility of hormonal genesis, in some cases it is possible to achieve the appearance of sperm in the ejaculate.
Assisted reproductive technologies
If, despite the surgical and conservative treatment of azoospermia, the partner’s pregnancy still occurs, assisted reproductive technologies come to the rescue, the most effective of which is ICSI. For the procedure of in vitro fertilization, spermatozoa are obtained in the process of open or aspiration biopsy from the testicle (TESA / TESE) or biopsy of the epididymis (MESA, PESA).
With irreversible causes of azoospermia, successful treatment of male infertility is not possible. In this case, it is recommended that the couple use donor sperm for fertilization. In general, the chances of conception naturally or using ART methods are higher in men with obstructive form of azoospermia, compared with secretory.