Azoospermia Diagnosis – What Methods Can Be Used?

By BSc, MSc (embryologist) and BA, MA (fertility counselor).
Last Update: 12/12/2018

Azoospermia is defined as the total absence of sperm in the ejaculated semen. Thus, in order to diagnose this sperm disorder, it is necessary to examine the semen sample collected after ejaculation. This study is called semen analysis or seminogram. Other additional tests such as a hormone analysis, physical exploration and testicular biopsy can be performed in order to determine the type of azoospermia.

Semen analysis

A semen analysis (SA) is a test used to examine a semen sample, both macroscopically (color, viscosity, pH...) or microscopically (concentration, motility, morphology...).

In order to render an accurate diagnosis of azoospermia and prevent analytic errors, the World Health Organization (WHO) recommends two semen analysis with a time gap of 2-3 months between each other.

Semen samples are obtained through masturbation after a period of sexual abstinence of between 3 to 5 days approximately. The sample must be collected under the appropriate hygienic conditions in order to avoid interferences with the outcomes and make the analysis easier for specialists.

To examine the sperm count, the sample is assesses under the microscope using a tool called Makler chamber, although there exists another chamber for counting sperm: the Neubauer chamber. The steps followed with both tools is quite similar, so the choice is up to each clinic.

If the sperm count is zero after the microscopic analysis, the diagnosis is azoospermia. If, on the contrary, few sperms are observed, it is not a case of azoospermia, but a case of oligospermia or oligozoospermia.

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If the diagnosis of azoospermia is clear, the patient is asked to wait for 2 to 3 months and then the SA is repeated. Specialists do this to make sure that the absence of sperm is not due to factors like stress, unhealthy diet, medication intake, fever, etc.

Should the result of a second SA be zero sperm count as well, the diagnosis of azoospermia can be considered correct. Afterwards, performing other tests such as a testicular biopsy to determine the cause of azoospermia is strongly recommended.

Hormonal analysis

Spermatogenesis or sperm production is regulated by hormones testosterone and FSH (follicle-stimulating hormone). Endocrine disorders affect the levels of these hormones and subsequently spermatogenesis, resulting in the absence of sperm cells in the semen after ejaculation.

Thus, assessing the levels of FSH and testosterone can help us obtain a more accurate diagnosis of azoospermia:

FSH
It is produced by the pituitary gland and is responsible of regulating sperm production in the testes. Too elevated FSH levels indicate that the amount of stem cells in the testicle (spermatogonia) is too low, causing the sperm count to be low or non-existent. For this reason, it is common for azoospermic males to have too high FSH levels.
Testosterone
This hormone, which is produced by the testis, follows the opposite pattern than FSH. If spermatogenesis doesn't take place, azoospermic males have lower-than-usual testosterone levels.

Simply put, if a hormone analysis shows elevated FSH levels and too low testosterone levels, it is likely that the patient suffers from secretory azoospermia. This means that zero sperm count is due to a lack of sperm production. In other words, it is due to spermatogenesis failure.

If a sperm analysis shows normal hormone levels, the chances are that azoospermia is due to an ejaculatory duct obstruction (EOD), that is, a blockage in the seminal ducts that transport sperm from the testis, where they are produced, to the outside.

Broadly speaking, obstructions typically appear in the epididymis or the vasa deferentia. This type of azoospermia is known as obstructive azoospermia.

Physical exploration

It is recommended that a specialist examines the male reproductive tract while is lying horizontally with the face and torso facing up (supine position) as well as standing up. Moreover, it is important that the room where the exploration is carried out is at an adequate temperature, as cold can cause the layers of the scrotum to contract, making the testicular examination more complicated.

Sometimes, a simple palpation can lead the specialist to think that there may exist some kind of abnormality with spermatogenesis, although rendering a final diagnosis is possible only when the results of the remaining tests are available.

During a physical exploration of male genitalia, your doctor will look for the presence of a varicocele, sexual development, size and testicular position, etc.

Testicular biopsy

Another useful diagnostic test is testicular biopsy. This surgical procedure is simple and involves removing small fragments of the testicle. Then, they are examined in the lab in order to find sperm.

The fragments of testis are examined microscopically. If sperm are found, secretory azoospermia can be dismissed: as long as sperm are found in the testicle, it means that it is capable of producing them.

If the sperm found are live, in spite of having low motility, they can be used for Intracytoplasmic Sperm Injection (ICSI), Thus, a testicular biopsy is both a diagnostic test (it helps to confirm a diagnosis of secretory azoospermia) and a treatment (sperm collection for ICSI).

FAQs from users

Are both types of azoospermia diagnosed using the same methods?

By Andrea Rodrigo BSc, MSc (embryologist).

Yes, the tests used are the same. In addition to a semen analysis, which indicates the absence of sperm, your doctor may carry out an exploration of your genitalia to verify if there's activity in the testicles.

Also, a hormone check is use to check if it is a case of secretory or obstructive azoospermia.

Another test that can be helpful is a testicular biopsy, which can tell us whether there's sperm production or not.

Is a testicular biopsy painful?

By Andrea Rodrigo BSc, MSc (embryologist).

No, it is a surgical procedure that is performed using anesthesia, which prevents pain for the patient. However, it is likely that you feel mild discomfort in the testicular area.

How long does it take for an azoospermia diagnosis to be rendered?

By Andrea Rodrigo BSc, MSc (embryologist).

As explained earlier, to get a correct diagnosis of azoospermia, doing at least two semen analysis at different time periods is different. The results of a semen analysis are available within two weeks on average, although it depends on the clinic or center where it is done.

If you undergo other tests such as a testicular biopsy, it make take longer.

My first semen analysis says azoospermia and the second says oligospermia, is it normal?

By Andrea Rodrigo BSc, MSc (embryologist).

Yes, it is. For example, it can happen that a particular circumstance in your life (like too high stress levels) caused azoospermia in the first analysis due to changes in hormone levels. However, after another semen analysis (done 4 months after), if the special circumstance has disappeared, it is likely that your hormones have returned to normal levels, and subsequently sperm production is normal again.

Suggested for you

To sum up, throughout this article we have seen the different diagnostic methods used to check if a male has obstructive or non-obstructive azoospermia. To learn the differences between them, click here:

Also, once a patient has obtained a conclusive diagnosis, the best treatment option will be recommended. Learn about the different options available here: Treatment of Azoospermia.

Our editors have made great efforts to create this content for you. By sharing this post, you are helping us to keep ourselves motivated to work even harder.

References

Cerilli LA, Kuang W, Rogers D. A practical approach to testicular biopsy interpretation for male infertility. Arch Pathol Lab Med. 2010 Aug;134(8):1197-204.

Dohle GR, Elzanaty S, van Casteren NJ. Testicular biopsy: clinical practice and interpretation. Asian J Androl. 2012 Jan;14(1):88-93.

Esteves SC. Clinical management of infertile men with nonobstructive azoospermia. Asian J Androl. 2015 May-Jun;17(3):459-70.

Hessel ML, Ramos L, D'Hauwers KW, Braat DD, Hulsbergen-van de Kaa CA. Beneficial value of testicular sperm extraction-AgarCyto in addition to the standard testicular biopsy for diagnosis of testicular germ cell tumors in nonobstructive azoospermia. Fertil Steril. 2016 Feb;105(2):308-14.e1.

Sigman M, Zini A. (2009). Semen analysis and sperm function assays: what do they mean? Semin Reprod Med; 27: 115-123

World Health Organization (WHO) (2010). WHO laboratory Manual for the examination of human semen and sperm-cervical mucus interaction. Cambridge Academic Press.

FAQs from users: 'Are both types of azoospermia diagnosed using the same methods?', 'Is a testicular biopsy painful?', 'How long does it take for an azoospermia diagnosis to be rendered?' and 'My first semen analysis says azoospermia and the second says oligospermia, is it normal?'.

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Authors and contributors

 Andrea Rodrigo
Andrea Rodrigo
BSc, MSc
Embryologist
Bachelor's Degree in Biotechnology from the Polytechnic University of Valencia. Master's Degree in Biotechnology of Human Assisted Reproduction from the University of Valencia along with the Valencian Infertility Institute (IVI). Postgraduate course in Medical Genetics. More information about Andrea Rodrigo
Adapted into english by:
 Sandra Fernández
Sandra Fernández
BA, MA
Fertility Counselor
Bachelor of Arts in Translation and Interpreting (English, Spanish, Catalan, German) from the University of Valencia (UV) and Heriot-Watt University, Riccarton Campus (Edinburgh, UK). Postgraduate Course in Legal Translation from the University of Valencia. Specialist in Medical Translation, with several years of experience in the field of Assisted Reproduction. More information about Sandra Fernández

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