Getting the phone call that you have flunked (even worse, scored a “zero”) yours or your guy’s semen analysis can be pretty devastating. The rush of emotions that runs through your head is more extreme than the waves seen in the famous Eddie Aikau surf competition. And when you realize what it could mean for your fertility, it’s like wiping out and then getting worked by the wave all in one go.
The first thing you should do is take a deep breath. One semen analysis doesn’t mean it’s the end of the road. However, if the repeat test confirms that there is nothing there, further investigative work needs to be done.
The medical term for no sperm is azoospermia (this is different than aspermia, which is the absence of sperm and seminal fluid at the time of ejaculation). Because men with azoospermia frequently have normal ejaculates, they can go undiagnosed for years—sperm is microscopic, so unless someone is looking really close at it with a high-powered lens, you can’t see those swimmers.
While azoospermia is every guy’s fear, it is actually pretty rare, phew! Only about 1% of all men have azoospermia (it is higher in couples that suffer from male factor infertility, and in these patients can be as high as 15%).
If your guy is one of the unlucky 1% and are searching for answers and information, we recommend thinking about it in the following way: Imagine you have three connecting flights coming into the airport at the same time. One is from New York City, one is from Boston, and one is from Atlanta. They are all connecting through Chicago to LA—all the passengers will be on the same second flight although they originated in different places. Azoospermia is the end point for post-testicular, testicular, and pre-testicular conditions; they all arise from different diseases (or departing cities) but ultimately land in the same place.
From City A, we have post-testicular azoospermia. (The testicles are making sperm, but there is a blockage preventing it from exiting and getting in the ejaculate). From City B, you have testicular azoospermia. In these cases, the exit pathway is clear, but the testicles are not producing sperm. The latter or “B” cases are generally much more difficult and often require donor sperm. From City C, we have pre-testicular azoospermia. Here, the testes are ready and waiting, but the signal is either not coming down correctly from the brain OR, due to underlying endocrine (hormonal) problems, the testes have failed to produce sperm.
After the initial diagnosis of azoospermia has been confirmed (two azoospermic samples where the seminal fluid is centrifuged for 15 minutes at super-high speed), your guy is usually sent to a urologist (specifically, one that specializes in male factor infertility) to see which “city” you have departed from. Through a full review of the medical history, a physical exam, an ultrasound, and lots of blood work, the urologist can usually get to the bottom of why there does not appear to be any sperm in the ejaculate. The tests that your partner will go through in many ways will mimic what you have been asked to do—we will check his FSH , LH , testosterone, thyroid hormone , and prolactin. We will also do extensive genetic testing to see if we can identify the problem.
It’s very important to do the full genetic work-up because there are often abnormalities which, if identified, can be passed on to future generations. Not good. While you may not know exactly what or why we are testing your plus one for, you should make sure that a full testing panel is performed. You should also make sure that you sit with both yours and your partner’s doctor so that, together, you come up with the best plan for you as a couple.
We don’t expect to make you urologists or even sperm connoisseurs, but we do want to help you better understand the potential answers to the azoospermia conundrum. We are going to give you a very basic review (and no quiz!) to help you better answer the questions that are likely racing through your head the minute you get the news.
Flight A = Post-testicular Azoospermia: Here the problem happens not in the testes but after the testes. Going back to basic bio, the problems happen in the ducts that connect the testes to the urethra (think vas deferens). It can also occur from ejaculatory dysfunction. We don’t want you to cringe or try and picture it in your head, but the visual that you should have is that, in most cases, the testes are making lots of good-quality sperm. The sperm has just been stranded on an island waiting for a rescue boat (or connecting flight!). The rescue boat is either a surgical procedure to unblock the blockage (basically re-open the road), or if the road is totally beyond repair (think most major cities highways), then we go above the blockage (a.k.a. the testes). The latter is called a testicular extraction of sperm (nickname TESE or TESA). Surgically, a urologist will enter the testes and extract sperm (ouch, that doesn’t sound fun—don’t worry, you will get anesthesia!). This sperm can be used to fertilize eggs in an IVF cycle. The rescue mission is usually successful, and the resultant pregnancy rates are often quite good. Bonus is that we can often freeze sperm for use in the future (like years later) IVF cycles. Obstructive azo (as we fertility doctors call it) occurs in about 40% of men with azoospermia.
Flight B = Testicular Azoospermia: When the testes themselves are the cause of no sperm, it can be a bad situation. Like planes in a blizzard, nothing is taking off for a long time. Despite our advancements and flashy technology, much like ovarian failure, we cannot overcome testicular failure. Think of testicular failure like premature menopause; for some reason, the testes stopped making sperm long before their time. We usually know that we are dealing with option B (as opposed to A) because the FSH is elevated and the testosterone is low. Much like ovaries that are sort of done, when the testes stop working, testosterone (which is made in the testes) stops being produced. Last, in a physical exam, the testes are small (medically termed atrophic), and we have a pretty good idea we won’t find sperm. However, with this being said, barring a serious genetic condition, many urologists and fertility doctors will still go for the testicular sperm extraction surgery to confirm that we are truly running on empty. However, it is important to note that many testicular cases of azoospermia are a result of genetic abnormalities. Unfortunately, we don’t really know many of the genes causing the significant decline in sperm production. Therefore, if the sperm is successfully extracted and used to fertilize eggs, you could be passing some “bad fertility/sperm genes” on without even knowing what they are. While we are not saying you should not use the sperm, we are recommending that you chat with your doctors and a genetics counselor first.
Flight C: Pre-testicular azoospermia causes of azoospermia are the rarest. They are most frequently due to hormonal abnormalities that result in testicular failure or mixed signals coming down from the brain. If the brain is on a break and does not appear to be doing its job (or something is impinging on its ability to do its job), we can usually fix that. With the help of medications, we can get things back on track. It may take several months to get the engines going again, but it will get there. In fact, if sperm production can be restored, your guy may not need any surgical interventions, and while you still may need our help to get pregnant, you may not need IVF.
There is almost nothing more devastating than hearing that you or your plus one has run out of eggs or sperm before your time was supposed to be up. It’s unfair, it’s frustrating, and it can be downright infuriating. While using our services or donor sperm (if it comes to that) is likely not how you envisioned making a family, our goal is to make you a father. We can most certainly do that; even when the waves seem big and you can’t imagine riding another one, we promise you can. Just hang ten, and let us guide you to calmer waters.