Course / Azoospermia
Azoospermia refers to the complete absence of sperm in the ejaculate and affects approximately 1% of all men and 10–15% of men with infertility. It can result from problems at different stages of sperm production or transport, and identifying the type is critical for treatment planning.
There are three primary categories:
Pre-testicular (non-testicular) azoospermia – due to hormonal or signaling dysfunction.
Testicular (non-obstructive) azoospermia – due to intrinsic testicular failure.
Post-testicular (obstructive) azoospermia – due to blockage in sperm transport.
A clear diagnostic pathway, combining hormonal tests, genetic screening, and testicular biopsy, helps define the cause and determine the most effective management or retrieval approach.
In this form, the testes are structurally normal but do not receive the necessary hormonal signals from the brain (pituitary or hypothalamus) to stimulate sperm production.
Common Causes:
Hypogonadotropic hypogonadism (e.g., Kallmann syndrome)
Pituitary disorders or tumors
Prior anabolic steroid use
Excessive stress, illness, or rapid weight changes
Diagnostic Clues:
Low FSH and LH levels
Low testosterone
Normal testicular size on ultrasound
Treatment Options:
Hormonal therapy (with hCG and FSH or GnRH analogs) can restore sperm production in many cases.
Some men may even achieve natural conception after hormone correction.
If sperm appear in the semen, it can be frozen for future use in IVF/ICSI.
This type occurs when the testes themselves are unable to produce sperm, even though hormonal signals are adequate.
Common Causes:
Genetic abnormalities (Klinefelter’s syndrome, Y-chromosome microdeletions)
Previous chemotherapy or radiation
Testicular trauma or infection (mumps orchitis)
Idiopathic testicular failure (unknown cause)
Diagnostic Findings:
Elevated FSH levels (reflecting testicular damage)
Small testicular volume
Absent sperm in the ejaculate despite normal ductal anatomy
Clinical Approach:
Even in severe testicular failure, small foci of active sperm production may still exist. For these cases, microsurgical retrieval techniques like microTESE can help recover viable sperm directly from the testicular tissue.
Testicular Sperm Extraction (TESE) and Microsurgical Testicular Sperm Extraction (MicroTESE) are procedures designed to retrieve sperm directly from testicular tissue in men with azoospermia.
TESE (Conventional):
Small tissue samples are taken randomly from the testes.
Simpler and quicker, but may miss areas where sperm production is occurring.
MicroTESE (Microsurgical):
Performed under an operating microscope (×20–25 magnification).
The surgeon visually identifies enlarged, active seminiferous tubules — increasing the likelihood of finding sperm.
Minimizes tissue damage and preserves testosterone-producing areas.
Success Rates:
TESE: Sperm retrieval success ~30–40%
MicroTESE: Success rates up to 50–60%, depending on the underlying cause
These retrieved sperm are used for ICSI (Intracytoplasmic Sperm Injection) during IVF treatment.
Once sperm are obtained via TESE or MicroTESE, they can be used fresh on the day of egg retrieval or frozen for future use.
Fresh Sperm Use:
Ideal if coordinated with a female partner’s egg retrieval.
Ensures immediate fertilization but requires tight scheduling between surgical and IVF teams.
Frozen (Cryopreserved) Sperm:
Allows sperm banking for future IVF cycles.
Offers flexibility, avoids repeated surgery.
Studies show comparable fertilization and pregnancy rates between fresh and frozen surgically retrieved sperm when handled properly.
At Surrogacy4All’s partner clinics, state-of-the-art cryopreservation protocols maintain optimal sperm viability for future assisted reproduction.
If no sperm are found during the first TESE or MicroTESE, it’s essential to avoid unnecessary repeat surgeries unless new evidence suggests improved sperm production.
Avoid Repeat Surgery If:
The first MicroTESE was comprehensive and performed by an experienced surgeon.
No hormonal or medical changes have occurred since the first attempt.
Consider a Repeat Retrieval If:
The initial surgery was a simple TESE and not a MicroTESE.
Hormonal therapy or medical optimization has occurred since.
Genetic testing reveals a potentially reversible cause.
Expert Advice:
At Surrogacy4All, a detailed review of prior surgical records and hormonal results helps determine whether another retrieval is worthwhile. The goal is always to balance maximizing success with minimizing surgical risk and patient stress.
| Parameter | TESE | MicroTESE |
|---|---|---|
| Surgical Technique | Blind tissue sampling | Microscope-guided targeted retrieval |
| Sperm Retrieval Rate | 30–40% | 50–60% (up to 70% in select cases) |
| Tissue Damage | Moderate | Minimal |
| Recovery Time | Short | Slightly longer but with better outcomes |
| Best For | Obstructive cases or mild testicular failure | Non-obstructive azoospermia with patchy sperm production |
Conclusion:
MicroTESE is the gold standard for men with non-obstructive azoospermia. It maximizes sperm recovery and minimizes damage, offering the best possible chance of biological paternity.
In this form, sperm are produced normally, but a blockage prevents them from reaching the ejaculate.
Common Causes:
Prior vasectomy or failed reversal
Congenital absence of the vas deferens (linked to CFTR gene mutations)
Infection or inflammation (epididymitis)
Scar tissue from previous surgery
Diagnostic Findings:
Normal testicular size
Normal FSH and LH levels
Low semen volume and pH
Absence of sperm in semen but presence on testicular aspiration
Treatment Options:
Microsurgical reconstruction (vasovasostomy or vasoepididymostomy) in select cases.
Sperm retrieval + ICSI, which bypasses the obstruction and allows conception without complex surgery.
Both percutaneous epididymal sperm aspiration (PESA) and microsurgical epididymal sperm aspiration (MESA) can yield excellent results when combined with IVF/ICSI.
Accurate Diagnosis is Key: Distinguishing between obstructive and non-obstructive azoospermia determines whether medical, surgical, or assisted reproductive treatments are appropriate.
MicroTESE Over TESE: For non-obstructive azoospermia, MicroTESE offers the best sperm retrieval success and minimal testicular damage.
Freeze When You Can: Always cryopreserve any retrieved sperm to avoid repeat surgeries.
Pre-Surgical Hormone Optimization: Address low testosterone or FSH imbalances before retrieval to improve outcomes.
Genetic Counseling: Y-chromosome microdeletion or CFTR testing should be standard before surgical sperm retrieval.
Collaborative Care: A urologist and reproductive endocrinologist working together ensures comprehensive diagnosis, optimal retrieval, and effective use of sperm in IVF/ICSI.
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