In the case of infertility, it is not always the woman that is unable to produce the necessary products for conceiving; men can have infertility issues as well that cause problems with the couple becoming pregnant.
It is suggested that in approximately 30% of cases, the cause of infertility is associated with a male related factor. Another 30% of infertility cases are associated with a female related factor. Thirty percent are a combination of both male and female and the remaining 10% is unexplained.
Therefore, during a routine infertility work-up, we will talk with and perform tests on both the man and the woman to determine and identify what issue(s) are contributing to your reduced chance of conceiving.
Unfortunately, it is important to realise that despite the technologies available, sometimes the cause of infertility can not be identified and as such, this is referred to as idiopathic or unexplained fertility. In the case of the man, there are a number of problems that he may face, one of which is a complete lack of sperm, which is otherwise known as Azoospermia.
What is Azoospermia?
Azoospermia is the medical term for a man that does not have any sperm in his semen. Semen is the cloudy white fluid that is secreted during ejaculation. Most of the fluid in semen is made up of secretions from the male reproductive organs. This fluid carries sperm, fructose and other enzymes that assist the sperm to reach their destination for fertilising the egg.
In fact, only about 2% of an ejaculate is made up of sperm. So, although a man may produce semen, it does not necessarily mean that there will always be sperm in the ejaculate. This does not mean that he does not produce sperm at all; it just means that they are not present in his ejaculate.
Given that the process of ejaculation, for a man, is not one which requires invasive methods of investigation, it is one of the first investigations that should occur during the work-up for male infertility. A man will be asked to ejaculate into a sterile specimen container (which can be purchased from a chemist or collected from the clinic), which is evaluated within an hour of production to determine the sperm count (i.e. how many sperm are present in the sample) and motility (i.e. how well they are moving). If there is no sperm found in the sample after centrifugation, azoospermia is assumed.
The good news is that azoospermia is not often found, and further tests may reveal that you are still able to produce sperm and subsequently conceive. Sometimes sperm are present in the testes, but are just not making their way out into the ejaculate, in the traditional way perhaps due to a blockage.
There are many ways to determine if this is the case, and if so, sperm may be able to be retrieved directly from the testes, and used for assisted reproductive treatments (i.e. in-vitro fertilisation).
Determining The Reasons
During the work-up for male infertility, many aspects of a man’s life will be evaluated. It will start with a review of his medical, family and physical history. Any past illnesses, including STD’s will be discussed; previous surgeries; injuries; and any family history of infertility.
Once the patient’s history is thoroughly discussed, a physical exam is typically done to ensure that everything is intact and that there are no obvious reasons for the lack of sperm production, such as enlarged prostate or an alteration to the normal size and appearance of the testes.
Along with the physical exam, we will request a blood sample to be collected to test your hormonal profile (specifically testosterone and FSH levels). Typically, if the hormonal profile comes back normal, it suggests that there may be a blockage in the testes which is reducing the number of sperm produced or not allowing them to be delivered in the traditional way.
If the levels come back abnormal, it may mean there is something wrong in producing the sperm rather than a blockage, which would require further medical investigation.
Azoospermia with abnormal hormone levels typically indicates that there are issues with the signals that are sent between the brain and the testes that normally result in sperm production. This generally means that sperm will not be able to be retrieved surgically, and other options may have to be explored by the Fertility Specialist to determine the cause of azoospermia, and treatment options.
How Follicle Stimulating Hormone (FSH) Levels Play a Role
FSH is a hormone that is excreted from the pituitary gland located in the brain that stimulates the testes to produce sperm.
FSH levels in the blood tell a lot about a man’s ability to produce sperm. If the levels are normal, typically that means that he is producing sperm; however, if there are no sperm in the ejaculate, it could suggest a blockage preventing sperm from being delivered into the ejaculate.
If there is no sperm production, the pituitary gland works harder, and releases more FSH to try and stimulate sperm production in the testes. This results in high FSH levels in azoospermic men, and typically points to the possibility that no sperm or very little sperm is being produced in the testes.
If the hormonal profile is normal, an ultrasound of the area or a biopsy of the testicle can be taken and assessed to determine if there is a blockage.
In the case of an ultrasound, the ejaculatory duct and testes are evaluated to see if there is a blockage and what the cause is. If there is a blockage, the ultrasound will often show the vesicles in the testes where the semen is created are full, which means that there is a backup of semen that is unable to be delivered.
This could be due to cysts, calcifications, vasectomy, or a deformity in the way the testis were formed when the male was born. If there is an obvious cyst or blockage, surgery can be performed and a biopsy is not needed. Surgery oftentimes resolves the issue and the sperm can then be ejaculated as it normally would or it can be captured and used for in-vitro fertilisation (IVF) procedures.
Sperm Aspiration and Testicular Biopsy
With adequate sperm, there are ways for the Fertility Specialists to get it out; sometimes requiring surgical procedures including TESA, PESA or testicular biopsy (TESE). These are useful for men with obstructive or ejaculatory disorders that cannot be overcome using other treatment methods.
Testicular Sperm Aspiration (TESA) is a method used to retrieve sperm using a fine needle inserted into the testicle under a general or local anesthetic.
A small amount of material is aspirated from the seminiferous tubules (network of tiny tubules where sperm are found) and assessed by an IVF scientist to determine the presence of sperm.
If sperm is found, this can then be used for attempting to fertilise an egg or it can be frozen and stored for later use. The sperm retrieved from the testicles are less mature and motile than sperm found in ejaculated samples and therefore, sperm obtained using this method are best suited to Intracytoplasmic Sperm Injection (ICSI) to achieve fertilisation.
ICSI involves individually selecting sperm to be injected into an egg. PESA is similar to TESA, however the needle is inserted to, and material aspirated from, the epididymis. The epididymis is a set of tiny collecting tubules next to the testicle.
Testicular Biopsy (TESE)
In some cases, such as a failed TESA, a testicular biopsy may be necessary to retrieve the sperm. This is a surgical procedure performed under general anaesthetic, where the scrotum is opened, and a small biopsy of testicular tissue is removed. Your IVF scientist will then search through the tissue for the presence of sperm. The results of the biopsy will determine if there are sperm in the testes that can later be used for ICSI or if there are no sperm being produced by the testes.
Each of these tests sound invasive, but they are not as bad as they sound. Even as mentioned earlier, the biopsy is simply taking a sample of the tissue from the testicle. There is generally very little recovery time for the TESA or PESA, unless the procedure has been performed under a general anaesthetic; the hardest part for the patient is typically waiting for the results.
For more information on male infertility, please call 1300 FERTILITY (1300 337 845). We offer a complimentary 1-on-1 consultation if you would like to discuss your fertility questions in more detail.