Azoospermia means there are no sperm in the ejaculate. It affects about 1% of all men and 10–15% of infertile men. There are two main groups: obstructive, where the testes produce sperm but a blockage prevents them from reaching the semen, and non-obstructive, where the testes produce few or no sperm.
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Obstructive azoospermia (normal testes)
Blocked vas deferens or epididymis
The vas deferens carries sperm from the testis to mix with fluid from the seminal vesicles and prostate. A blockage traps the sperm, so they are absent or very few in the semen. The volume of semen may be normal, because most of the fluid comes from the seminal vesicles and prostate, not the testes. Blockages usually result from infection of the ducts (sexually transmitted, urinary or general), which causes scarring, or from injury during groin surgery such as hernia or varicocele repair. A vasectomy deliberately cuts the vas for contraception.
Congenital absence of the vas deferens
Some men are born without one or both vasa deferentia, sometimes with absent seminal vesicles. Congenital bilateral absence of the vas is strongly linked to cystic fibrosis gene mutations, so both partners should be tested before treatment.
Retrograde ejaculation
If the muscle at the bladder neck does not close during orgasm, semen flows back into the bladder instead of out of the penis. Causes include congenital problems, nerve or spinal cord injury, pelvic fractures, prostate or bladder neck surgery, diabetes and certain medications. The ejaculate then contains few or no sperm.
Non-obstructive azoospermia (testicular failure)
- Genetic causes: Klinefelter syndrome (47,XXY) is the most common; Y-chromosome microdeletions (AZF regions) are another; very rarely the testes are absent from birth.
- Infections: mumps orchitis after puberty, sexually transmitted infections and other genital infections can damage the testes.
- Radiation, accidental or therapeutic, depending on dose and duration.
- Chemicals and drugs, including chemotherapy, petroleum products, toxic fumes and lead, and anabolic steroids or testosterone.
- Undescended testes: the testis normally descends from the abdomen into the scrotum before birth. If it stays in the abdomen or groin, the higher temperature damages it and increases the risk of cancer. It should be brought down surgically in early childhood (ideally by 12–18 months); if this is not possible, it may need removal. A “retractile” testis that moves up and down in young boys is a normal variant.
- Hormonal causes: low FSH and LH from the pituitary (hypogonadotropic hypogonadism), which is very treatable.
Diagnosing the cause
The aim is to distinguish a problem with sperm production from a problem with sperm transport. Semen analysis should be repeated, and the sample centrifuged to look for even a few sperm.
Checking for ejaculation problems
A low semen volume suggests retrograde ejaculation or a duct obstruction. Examining a urine sample taken right after orgasm for sperm confirms retrograde ejaculation.
Hormone tests
Testosterone, LH, FSH and prolactin are measured. Low testosterone with high FSH and LH indicates testicular failure. Low testosterone, FSH and LH together suggest a pituitary or hypothalamic problem. Normal hormones with normal-sized testes suggest an obstruction or retrograde ejaculation. High prolactin can cause erectile problems and suppress sperm production.
Imaging
Scrotal ultrasound assesses the testes and epididymis, and transrectal ultrasound can show blockage of the ejaculatory ducts or absent seminal vesicles. Vasography (X-ray with dye injected into the vas) is now rarely used on its own, and is usually performed only during reconstructive surgery.
Genetic tests
Karyotype and Y-chromosome microdeletion testing are recommended for men with non-obstructive azoospermia or very low counts, and cystic fibrosis testing for men with absent vasa.
Testicular sperm retrieval
Testicular biopsy is now combined with sperm retrieval, so that any sperm found can be used for ICSI at the same time or frozen for later. Under local or general anaesthesia, small samples are taken from the testis and examined by the embryologist. Because sperm production can be patchy, microdissection TESE (micro-TESE), using an operating microscope to find the areas most likely to contain sperm, gives the best results in non-obstructive azoospermia.
Treatment
- Obstruction after vasectomy or injury: microsurgical vasectomy reversal (vasovasostomy) or bypass of an epididymal blockage (vasoepididymostomy) can restore sperm in the semen and allow natural conception, with good results in experienced hands. Alternatively, sperm can be retrieved surgically for ICSI.
- Ejaculatory duct obstruction: can be opened by a transurethral procedure.
- Retrograde ejaculation: medication to tighten the bladder neck, or sperm recovered from urine for IUI or ICSI.
- Hormonal causes: hCG and FSH injections restore sperm production in most men.
- Testicular failure: micro-TESE with ICSI. Sperm are found in about half of men, including many with Klinefelter syndrome. Sperm can be frozen at the time of retrieval so that the procedure does not need repeating.
International Guidelines
In line with global standards, Dr. Sabry follows the latest recommendations from the American Society for Reproductive Medicine (ASRM), European Society of Human Reproduction and Embryology (ESHRE), and Royal College of Obstetricians and Gynaecologists (RCOG). Thus, patients receive care that is safe, ethical, and evidence-based.
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Why Choose Dr. Ashraf Sabry?
Dr. Ashraf Sabry, consultant in obstetrics, gynecology, fertility, and aesthetic gynecology, is recognized among the best OBGYN and fertility specialists in Cairo. With over 20 years of experience, he combines science and compassion to provide world-class care. Book your appointment through the contact page, WhatsApp, or call +201022224442.