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Azoospermia and male infertility – diagnosis and prospects

Birol Aydin, Embryologist
Head of Embryology Lab, Clinical Embryologist, IVMED

Category:
Male Factor

how-is-azoospermia-diagnosed-and-treated
From this video you will find out:
  • What’s azoospermia?
  • How is azoospermia classified?
  • How do you investigate azoospermia?
  • Can azoospermia be genetic?
  • What is a YCMD test?
  • Which is the best sperm retrieval technique for obstructive and non-obstructive azoospermia?
  • How successful is Micro TESE in men with non-obstructive azoospermia?
  • What is Round Spermatid Injection (ROSI), and when is it indicated?

How can I get pregnant with azoospermia?

In this webinar, Birol Aydin, Clinical Embryologist and head of the Embryology Lab at IVMED, explained what azoospermia is, how it is diagnosed, and what treatment options are available for men who suffer from it.

Azoospermia and male infertility

Azoospermia is termed as the condition in which sperm is not detectable in ejaculation. If sperm is still not detectable in a semen sample, it will next be centrifuged at a 3000 g speed for 15 minutes. In the end, if spermatozoids remain undetected, then the diagnosis is azoospermia, which implies a zero sperm count.

Classification of azoospermia

According to the speaker, classification can be understood from the point of view of three different aspects. As regards this classification, normal spermatogenesis is first mentioned, as a large number of concentrations can usually be found on the microscopic checking. In the same way, non-obstructive azoospermia can be classified in terms of 20% of tubes having sperm, since a low production of sperm is still evident. Moreover, it is said that given the fact that 100 hundred tubes have sperm, then it will be classified as obstructive azoospermia. That is to say, sperm is produced by the testing, but motile sperm is not normally found.

  • Obstructive Azoospermia – sperm is produced by the testis, but there is no sperm in the semen
  • Non-obstructive Azoospermia – production of sperm is very low or absent. The defect is found either in the production of sperm by the testis and also at the level of the hypothalamus

Investigation of azoospermia

The basic tests for the investigation of azoospermia are said to include the following:

  • Semen analysis
  • Endocrine evaluation
  • FSH
  • Serum Testosterone
  • LH/Estrogen
  • Prolactin/TSH
  • Genetic testing
  • Karyotyping
  • Y microdeletions

Hormonal profile

Regarding the hormonal profile, a balance in the increment of both FSH and LH triggers the low production of low testosterone. Similarly, if both FSH and LH decreased, similar results of low testosterone will be found. However, normal testosterone levels are usually perceived with an increased FSH and a normal LH with no difficulties.

Azoospermia – Genetic evaluation

When trying to do a genetic evaluation for the non-obstructive azoospermia, karyotype and chromosome microdeletion should be mainly checked due to them being the most known factors of this classification while cystic fibrosis gene mutations must be analyzed in case of obstructive azoospermia.

Karyotype

It is reputed to be a crucial factor in azoospermia for discovering the main causes, including the following. It is mainly explained that Klinefelter syndrome entails two copies of the “X” chromosome and one “Y” chromosome. Other common reasons include chromosomal disease as well as an extra copy of the X chromosome in males among others.

  • Low production of testosterone
  • Small testicles

In these cases, the solution is known as having a micro testicular surgery (microTESE) performed and NGS testing with IVF.

Y Chromosome microdeletion in azoospermia

The basic characteristics of Y chromosome microdeletion are associated with the partial deletion or missing of the Y chromosome in the AZF region. It can be detected through microscope checking, and it is associated with a lack of sperm production. Additionally, when considering undergoing an IVF treatment with chromosome microdeletion, NGS is mentioned to be mandatory for obtaining healthy embryos for the avoidance of genetic transmission risk.

Sperm retrieval techniques

It is reported that three different techniques are performed for obstructive azoospermia.

  • Percutaneous Epididymal Sperm Aspiration
  • Microsurgical Epididymal Sperm Aspiration
  • Testicular Sperm Aspiration

For non-obstructive azoospermia, other sperm retrieval techniques are used:

  • Testicular Sperm Aspiration (It is performed under local anesthesia to extract spermatozoid out of the tubules.)
  • Testicular Sperm Extraction ( It is performed under general anesthesia as part of the testis must be extracted.
  • Microsurgical Testicular Sperm Production (It is stated to be the most successful technique for determining the semen production center in the tubules.)

Which is the best sperm retrieval technique for non-obstructive azoospermia?

  • TESA (Testicular Sperm Aspiration Procedure)
  • PESA (Percutaneous Epididymal Sperm Aspiration)
  • TESE (Testicular sperm extraction)
  • MESA (Microepididymal Sperm Aspiration)

Microsurgical Testicular Sperm Extraction (microTESE)

It is stated in the webinar that microtesticular surgery technology has been developed to detect microscopic testicular tubules. In other words, tubules can be directly found with a microscope, which is said to be a sperm production center, for partial extraction of tubules. Essentially, it is associated with higher chances of finding sperm of good quality and mobility which is aspirated and used for cytoplasmic sperm injection.

It’s been also noted that spermatozoa cannot be obtained by microdissection test operation. It is known that spermatozoa might not be obtained by microdissection test operation in 60 % of cases.

Alternative routes

ROSI (Round Spermatid Injection)

This technique is said to be a relatively new one. It is stated that spermatids can be found if the patient has active tubules. Spermatid is described as the first version of sperm, and it can be used for fertilization and

According to a study on evaluation of the outcome of conventional TESE in patients with nonobstructive Azoospermia in cases when FSH and LH are detected to be high, testicular surgery negative results are expected to be found as spermatozoid cannot be found as well as if low testosterone levels are prevalent due to FSH and LH working opposite to it.

The graph presented shows testicular positive and negative cases by the FSH level. When the FSH level increases, testicular surgery negative results equally increase.

Another study on male and female factors that influence ICSI outcome in azoospermia or aspermia shows that fertilization and pregnancy rates are stated to be much higher because of numerous possibilities for the female factor to improve the number of oocytes whereas the male factor is limited due to the necessity of advanced technology to increase the activity.

On the other hand, Spermatid is mainly used for fertilization and the samples with the best potential to create a spermatozid are usually selected.

Sperm banking and sperm donation

If neither option is working, sperm donation can be considered. Sperm donation is the process of a man donating his sperm to someone who wants to have a baby. Donated sperm can be used for these treatments:

  • IUI (Intra Uterine Imsamination)
  • ICSI (Intra Cytoplasmatic Sperm Injection)

There is the possibility of having a baby through donor sperm for heterosexual couples who have male factor issues, lesbian couples, and single women.

It is fundamental that after obtaining sperm from a testicular surgery, the samples obtained be kept frozen.

There are several methods for cryopreservation:

  • Direct Freezing
  • Freezing After Dissection as Tubules
  • Freezing After Dissection and Centrifugation as Sperm

As mentioned in a study on cryopreservation of testicular and epididymal sperm that compares the technical and clinical outcomes. Taking into consideration the fertilization and implantation rate between fresh and frozen sperm, there is no significant difference in testicular sperm extraction. Therefore, cryopreservation of sperm has no risk.

In the case of the single sperm cryopreservation (SSF) technique, when there is a very low concentration of sperm count after Micro TESE or low count spermiogram this special technique gives a chance to freeze single sperm or individually selected sperm.

Conclusions

  • MicroTESE is more effective than all other surgical techniques for obtaining spermatozooid.
  • MicroTESE gives the possibility to get a small size of testicular tissue and direct tubules receiving the increasing chance of sperm finding.
  • After receiving sperm through microsurgical techniques, advanced laboratory technologies may increase embryo quality and the chance of pregnancy.
  • There is no significant difference in fertilization rate, blastocyst rate, and pregnancy rate between fresh and frozen testicular sperm.
  • The single sperm freezing method is promising for testicular sperm, severe oligozoospermia, and teratozoospermia.
  • Round Spermatid Injection technique is very promising in case of no sperm retrieval after testicular surgery and who is not considering sperm donation.
  • Sperm donation is very effective as the last option to have a child through IVF. The genetic potential of sperm donors needs to be analyzed well to avoid possible genetic problems in the future.
- Questions and Answers

Can azoospermia be prevented in any way?

Sometimes there is a way, especially when there is azoospermia because of channel blockage. I had many patients who didn’t have any spermatozoid after semen collection however, after hormonal treatment or some small surgical operation, they started to produce sperm. As we couldn’t find any spermatozoid, we did the testicular surgery, and after several times, the patient tried to give a fresh sperm sample and finally, he started to produce sperm, but it’s not so easy. Such treatment takes a long time, and of course, there is this surgical part involved. 

Do you have adult photos of the sperm donors or only baby photos?

It depends on country and regulation, so there are two kinds of donors anonymous and open donors. Some sperm banks are giving a possibility to see adult photos. In our sperm bank, we prefer to provide mostly child photos because there is limited regulation in our country. There are sperm banks that can also provide adult photos, the same as egg donor photos. 

In which cases do you use activation medium (piezoelectric stimulation)?

Firstly, if there is an implantation failure or if there is a fertilization failure before, the patient can try several attempts, but again, there is no fertilization, or there is a very low blastocyst rate, cleavage arrest. When we see that sperm quality is very low, and in teratozoospermia cases or a very high sperm DNA fragmentation, we are using this activation. We use it in cases where we need to do testicular surgery, we obtain sperm, we are using activation. According to our statistic and results, when we can’t get any blastocysts or fertilization and use the activation, we get many blastocysts and very high fertilization rates.

With sufficient antibodies in sperm, is ICSI able to wash the sperm well and increase the chance of getting pregnant? Are there any other options to reduce the antibodies?

There is a publication about this. For such cases, we are trying to use it differently. There are two kinds of ways to wash sperm. The first is a swim-up, and the second is a sperm gradient technique. When we get sperm from a patient with azoospermia, and after the testicular surgery, the only one that is possible is a gradient technique because, with the swim-up technique, it will be impossible to reduce antibodies and the second when we make a high density of gradient, of course, there is a chance of reduction, and of course, ICSI technique is the only way to increase the chance of pregnancy. 

How quickly can sperm donor samples be shipped to another country if one can’t make it to Ukraine?

We transport such samples quite often from Ukraine to other countries, and mostly we have a ready database where the patient can choose online from the database which sperm donor they like. There are two kinds of shipment. The first is a hand-carry shipment, of course, because of COVID-19 restrictions, sometimes it’s difficult, but still, a cargo shipment is also available. We are trying to do what a patient prefers, but it depends on patient treatment and the country. When patients choose the donor, our carrier companies try to prepare documentation quickly, and we are shipping quickly, so there is no waiting list or long waiting time.

What can you say about long-term health for the babies in which piezoelectric activation was used?

Piezoelectric activation is a new technology, it’s a very low length wave of the electric. No article or publication is suggesting there is any side effect because we are doing it in a very early stage, a fertilization stage. If there were some mechanical side effects, we should see them during embryo development, but none are found. We already have babies born where this technique was used, and we didn’t see any anomalies on the ultrasound during pregnancy. Also, babies don’t have any abnormalities or health problems.

This is a technique that is used for 1 or 2 years, so we still need time to analyse it. Finally, there can be two sides. The first is the mechanical side, we can see some physiological effect, but there is none. From the genetic side, the embryo is already tested, and we are using piezoelectric activation, we are trying to do NGS sequencing in almost 90% of our cases before the transfer, and we didn’t see any anomaly or health problem till now.

Do you have a guarantee program with the donor sperm if the eggs are also good?

This is a difficult question. We don’t have such a program, I don’t think anyone has, but because it’s a difficult issue. In our clinic, we can consider much more, but when we are shipping sperm somewhere, there are many issues such as quality of the lab, their techniques, kinds of treatment they have, but also, the egg quality is questionable. There are different views for everyone, that’s why for egg donation, we have a guarantee program, but for sperm donation, we don’t have such a program because even if you have donor sperm, you cannot avoid the chance of sperm DNA fragmentation for 100% because you cannot be sure which sperm you select for fertilization will have a 0% of DNA fragmentation, so that’s why it is difficult to guarantee such program.

What genetic screening would you suggest for a patient with non-obstructive azoospermia?

For non-obstructive azoospermia, I would suggest performing a karyotype for sure. Karyotype should be performed in every patient considering IVF. Especially for non-obstructive azoospermia, the karyotype is mandatory. Second is Y chromosome micro dilation (YCM) because this is one of the main reason for obstructive azoospermia, and if you find out Y chromosome micro dilation, then the next step after the fertilization and creation of the embryo will be NGS, so we should check embryo with NGS to transfer healthy embryos because it can pass from generation to generation.

Do you use piezoelectric activation in all men with teratozoospermia, for the first IVF cycle, or after a failed cycle?

We don’t use it for all men, we need to see at least one failed cycle with fertilization failure, or let’s say blastocyst failure. If you have 100 million spermatozoids, and if you have teratozoospermia, that means only 1% of sperm are normal. There’s still much sperm, so still, a hundred thousand sperm are normal, so I have a chance to select high spermatozoid quality. However, when we have azoospermia, and after a testicular surgery, we find several spermatozoids, we are using piezoelectric activation, even in the first cycle. When it’s a regular teratozoospermia, normal semen condition, and of course, if we receive requests from patients, we are considering it, but we are not using it as a common technique. 

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Authors
Birol Aydin, Embryologist

Birol Aydin, Embryologist

Birol Aydin is a biologist, leading clinical embryologist and head of the embryology laboratory at IVMED. Certified member of ESHRE Birol graduated from Mustafa Kemal University of Science from the Biology department. He has 12 years of working experience in embryology and andrology, practising in 12 different countries in the embryology field: Australia, Sweden, Finland, Turkey, Serbia, Macedonia, Estonia, Georgia, Cyprus, Albania and others. His everyday work results in numbers of IVF cycles: Practice in IVF centre by fresh and frozen ICSI/ET more than 30,000 cycles | Practice in IVF centre by PGS&PGD more than 5,000 cycles | Practice in IVF centre by egg donation: more than 3,000 cycles.
Event Moderator
Caroline Kulczycka

Caroline Kulczycka

Caroline Kulczycka is managing MyIVFAnswers.com and has been hosting IVFWEBINARS dedicated to patients struggling with infertility since 2020. She's highly motivated and believes that educating patients so that they can make informed decisions is essential in their IVF journey. In the past, she has been working as an International Patient Coordinator, where she was helping and directing patients on their right path. She also worked in the tourism industry, and dealt with international customers on a daily basis, including working abroad. In her free time, you’ll find her travelling, biking, learning new things, or spending time outdoors.