Assisted reproduction for the treatment of azoospermia

Assisted reproduction for the treatment of azoospermia

Types, causes, treatments and all you have to know about azoospermia.

Azoospermia is the medical condition of a man whose semen contains no sperm. It is associated with infertility and affects about 1% of the male population. Azoospermia does not cause specific symptoms but is diagnosed when a man undergoes a semen analysis to evaluate the number and quality of his sperm.

Types of azoospermia

Obstructive azoospermia:

This type of azoospermia means that there is a blockage or missing connection in the epididymis, vas deferens, or elsewhere along your reproductive tract. You are producing sperm but it’s getting blocked from the exit so there’s no measurable amount of sperm in your semen.

Nonobstructive azoospermia:

This type of azoospermia means you have poor or no sperm production due to defects in the structure or function of the testicles or other causes.

What are the causes of azoospermia?

The causes of azoospermia relate directly to the types of azoospermia. In other words, causes can be due to obstruction or nonobstructive sources.

Obstructions that result in azoospermia most commonly occur in the vas deferens, the epididymis, or ejaculatory ducts. Problems that can cause blockages in these areas to include:

1. Trauma or injury to these areas.

2. Infections.

3. Inflammation.

4. Previous surgeries in the pelvic area.

5. Development of a cyst.

6. Vasectomy (planned permanent contraceptive procedure in which the vas deferens are cut or clamped to prevent the flow of sperm).

7. Cystic fibrosis gene mutation, which causes either the vas deferens not to form or causes abnormal development such that semen gets blocked by a buildup of thick secretions in the vas deferens.

Nonobstructive causes of azoospermia include:

Genetic causes. Certain genetic mutations can result in infertility, including:

  • Kallmann syndrome: A genetic (inherited) disorder carried on the X chromosome and that if left untreated can result in infertility.
  • Klinefelter’s syndrome: A male carries an extra X chromosome (making his chromosomal makeup XXY instead of XY). The result is often infertility, along with a lack of sexual or physical maturity, and learning difficulties.
  • Y chromosome deletion: Critical sections of genes on the Y chromosome (the male chromosome) that are responsible for sperm production are missing, resulting in infertility.
  • Hormone imbalances/endocrine disorders, including hypogonadotropic hypogonadism. hyperprolactinemia and androgen resistance.
  • Ejaculation problems such as retrograde ejaculation where the semen goes into the bladder.

Testicular causes include:

1. Anorchia (absence of the testicles).

2. Cryptorchidism (testicles have not dropped into the scrotum).

3. Sertoli cell-only syndrome (testicles fail to produce living sperm cells).

4. Spermatogenic arrest (testicles fail to produce fully mature sperm cells). Mumps orchitis (inflamed testicles caused by mumps in late puberty).

5. Testicular torsion.

6. Tumors.

7. Reactions to certain medications that harm sperm production.

8. Radiation treatments.

9. Varicocele (veins coming from the testicle are dilated or widened impeding sperm production).

The diagnosis

To diagnose azoospermia, a semen analysis is performed first. This is the most important step that requires, in addition to careful examination, centrifugation, since in several samples, which are initially negative for the presence of sperm, sperm are finally detected after centrifugation of the sample. If no sperm are found after the test then the sample can be classified as azoospermic. In these cases a repeat sperm schedule is recommended to confirm the first observation.

In general, if there are no sperm in 2-3 sperm counts (with a time interval between them), the patient should discuss with his doctor the possibility of treatment or testicular biopsy. In most cases of azoospermia, a testicular biopsy remains the only test that will show whether or not there are sperm in the testicles.

The treatments

Testicular biopsy (TESE method)

Once azoospermia is detected and confirmed, a careful investigation follows to determine its possible causes. In most cases, a testicular biopsy is recommended.

For all cases of azoospermia (except in cases of hypogonadotropic hypogonadism) testicular biopsy remains the oldest and most appropriate method to determine whether or not there are sperm in the testicles.

If the testicular sample to be obtained contains even immature forms of sperm, they can in many cases be isolated, cultured with special techniques to mature and then used for in vitro fertilization.

ICSI microfertilization

ICSI (Intra-Cytoplasmic Sperm Injection) is a method of in vitro fertilization in which a single sperm is inserted directly into the egg in order to be fertilized. ICSI micro fertilization or intracellular sperm injection has been used successfully around the world since the early 1990s and is a truly effective treatment for achieving pregnancy.

How the ICSI technique is performed

After sperm collection, depending on the number and motility of the sperm, the treatment is applied to activate them, with small modifications. If the sperm sample is not enough, the partner is asked to give a second, additional sample a few days later. If the sperm contains even a few dozen motile sperm, micro fertilization can be performed normally.

Similar to conventional in vitro fertilization, the ICSI micro fertilization process presupposes that ovaries have been stimulated with fertility drugs to produce many mature eggs. The eggs, after being aspirated, are then subjected to a special “treatment” with an enzyme (hyaluronidase), in order to remove the granulocytes that surround them. This is necessary, otherwise, they will not be able to penetrate the sperm, as in ICSI the sperm is injected and not by themselves as is the case with conventional IVF. This “treatment” takes 1-2 minutes and once the eggs are free of the granulocytes, it is possible to assess which ones are mature and suitable for ICSI and which ones are not.

The final step in the ICSI procedure is to immobilize one egg at a time using a thin glass pipette and another thinner glass pipette (resembling an injection needle) to isolate each sperm and then insert it into the cytoplasm of each egg. Each “introduction” takes a few seconds, but the whole process can take many hours, especially if the sperm are scarce and difficult to find.

After the process of “introduction” is completed, the eggs are placed again in special culture materials until their fertilization is completed and embryos are produced.

The method is completed, following the well-known process of in vitro fertilization: after the formation of blastocysts, the embryos are selected and finally the embryo transfer.

Success rates

The success of the ICSI technique depends on several factors such as:

  • sperm viability
  • the quality of the eggs
  • the effective activation of eggs
  • the ability of the egg to withstand the endo cytoplasmic process.

The success rate of pregnancy per attempt with the ICSI technique is 65-75%. The potential factors that may influence success rates during pregnancy and consequently completion of the birth with ICSI micro-fertilization are similar to those of conventional in vitro fertilization.



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