• Credits
  • Section Writer: Dr. Om J Lakhani
  • Section Editor: Dr. Om J Lakhani

Q. Give a broad outline for a patient with male infertility

Q. What is Azoospermia?

• Azoospermia is defined as a complete absence of sperms in the ejaculate

Q. How is Azoospermia confirmed?

• Must be confirmed on two separate occasion
• Using Centrifugation of the semen for 15 min at 3000 pm

Q. Which are three broad categories of azoospermia?

• Pretesticular- hormonal causes- secondary testicular failure
• Testicular- Primary testicular failure
• Post testicular – obstructive azoospermia

Q. Give a broad outline of how you will differentiate between these three types of azoospermia?

Q. Give an approach to azoospermia with normal FSH, LH, and testosterone?

Q.  Why is the volume of ejaculate essential while dealing with azoospermia?

• Ask if the volume of ejaculate is one teaspoon or few drops (1-6 ml)
• if the volume is low- it suggests
• Seminal vesicle absent
• Seminal vesicle non-functioning
• Obstruction post-ejaculatory duct

Q. What is the best way to look for absent vas deferns?

• Clinical examination is often enough!
• But TRUS may confirm

Q. What is done if vas deferens is absent?

• PESA followed by ICSI

Q. What is the problem with fructose in the semen test?

• Fructose comes from the seminal vesicle
• However, at least 1 ml of ejaculate required to do the test

Q. How are anti-sperm antibodies detected?

• They are detected using MAR test and immunobead test

Q. What is the role of empirical medical therapy in patients with Non-obstructive azoospermia (NOA) ?

• It helps in increasing the sperm yield in the various sperm extraction methods

Q. Which are the drugs used for the above purpose?

• Clomiphene citrate
• Aromatase inhibitor – anastazole
• Gonadotropins- HCG

Q. Does clomiphene improve sperm count in patients with OAT syndrome?

• Improvement in sperm count with clomiphene in males has been debated
• There is some role in the improvement of testosterone

Q. Why would HCG be helpful if the LH/FSH is high?

• It would help to rest the endogenous gonadotropins
• So there is some help even if LH and FSH are high

Q. Enlist the causes of obstructive azoospermia?

• congenital bilateral absence of vas deferens (CBAVD)
• Congenital absence of epididymis
• epididymal cyst- due to prenatal diehtyestilbesterol exposure
• Vasectomy
• Post-infectious fibrosis of genital tract
  • Chlamydia
  • Gonorrhea
  • Leprosy
  • Tuberculosis
• Young syndrome

Q. Name the key genetic causes of male infertility that can lead to azoospermia

• CFTR mutation
  • This produces a congenital absence of vas deferens
• Klienfelter syndrome - The most common cause
• Y chromosome microdeletions producing Y Chromosome infertility
• Genetic causes attribute to 15-30% of male infertility
• Chromosomal abnormalities produce more severe disorders like azoospermia or severe oligospermia

**Sperm retrieval techniques **

Q. What are the various techniques for Sperm retrieval?

• PESA - Percutenous epididymal sperm aspiration
• MESA- Microsurgical epididymal sperm aspiration
• TESA - Transcutenous epididymal sperm apsiration
• TESE- Transcutenous epididymal sperm extraction
• MicroTESE
• Vasal Aspirate

Q. Which of these techniques is suitable for obstructive azoospermia?

• Any of the above may be used for obstructive azoospermia

Q. Which is better for Non-obstructive azoospermia (NOA) ?

• MicroTESE

Q. What is MicroTESE?

• Here, the entire seminiferous tubule is extracted using microsurgical techniques

Q. What is PESA?

• Percutenous epididymal sperm aspiration
• This is the simplest method of sperm extraction

Q. What is the most standard method for sperm aspiration?

• TESA
• Also called needle aspiration biopsy – NAB

Q. What is MESA?

• Microepididymal sperm aspiration
• A more complicated procedure
• Yet it gives less yield