Invited lecture by Dr Sujoy Dasgupta on "Azoospermia - Evaluation and Management" in a CME on "Standardising Male Factor Evaluation" organised by Indian Fertility Society (IFS) on 20 January 2024.

1. Azoospermia-
Evaluation and Management
Dr Sujoy Dasgupta
MBBS (Gold Medalist, Hons)
MS (OBGY- Gold Medalist)
DNB (New Delhi)
MRCOG (London)
Advanced ART Course for Clinicians (NUHS, Singapore)
M Sc, Sexual and Reproductive Medicine (South Wales, UK)
Clinical Director and Consultant: Reproductive Medicine, Genome Fertility
Centre, Kolkata
Managing Committee Member, BOGS, 2022-23
Executive Committee Member, ISAR Bengal, 2022-24
Clinical Examiner, MRCOG Part 3 Examination
Winner, Prof Geoffrey Chamberlain Award, RCOG World Congress, London,
2019

2. Definition
• Absence of any spermatozoa in semen after the
examination of the centrifuged sample, as per
the WHO recommendation (WHO, 2021).
• Ideally, the semen analysis should be repeated
as soon as possible after maintaining proper
abstinence period (NICE, 2013; Karavolos et al., 2013;
Jungwirth et al., 2018).

3. We cannot treat
We bypass

4. What next?
• Straightaway donor sperm IUI
• Testicular FNAC

5. Problems with indiscriminate FNAC
• Repeat test showed SC 3-4 sperms/ hpf
• Repeat semen analysis- 58 mil/ml, TM 48%

6. Problems with indiscriminate FNAC
• Azoospermia- one occasion
• FNAC- B/L maturation
arrest
• FSH 0.22, LH 0.34, Testo
549
• Pituitary MRI- normal
• Started hMG
• After 6 months- 2 mil/ml

7. Problems with indiscriminate FNAC
• LH 30.10, FSH 43.70, E2 38.48, Testo 432

8. Problems with indiscriminate FNAC
• B/L testes- 6 cc each
• FNAC- B/L
maturation arrest
• FSH 37.2, LH 24.4,
Testo 245.53, E2 37
• Not keen for IVF-ICSI

9. Problems with indiscriminate FNAC
• 37 yr
• Inguinal hernia operated
Rt sided- 2 yr ago and
Lt sided15 yr ago
• B/L testes- 18 cc each
• FSH 5.96. LH 4.74.
Testo 212. Estradiol
14.22.
• FNAC- Sertoli cell
only

10. FNAC- role?
• Isolated foci of
spermatogenesis
ASRM, 2020
• Consider in indeterminate
cases- NOT NECESSARY
FSH (iu/l) >7.6 <7.6
Testicular long axis (cm) <4.6 >4.6
89% chance of NOA 96% chance of OA

11. If previous FNAC was done (Schwarzer, 2013)
Diagnosis Chance of sperm retrieval
(Micro-TESE >> TESE)
Sertoli-cell-only syndrome
(Germ cell hypoplasia)
32%
Maturation arrest 66.7%
Hypospermatogenesis 100%
Tuberous sclerosis 33.3%
Mixed atrophy 95.2%

12. What next?
Investigate in details√
• History
• Physical Examination
• Hormone Assay
• Imaging
• Genetic Tests

13. Severe Male Factor is NOT ONLY a fertility
problem
• Diabetes
• Cardiovascular diseases
• Lymphoma, extragonadal
germ cell tumours, peritoneal
cancers
• Repeated hospitalization
• Increased mortality
• Testicular Cancer
Choy and Eisenberg, 2020; Bungum et
al., 2018; Eisenberg et al., 2013;
Jungwirth et al., 2018; Hotaling and
Walsh, 2009
Self-Testicular
Examination
•Atrophic Testes
•H/O undescended testicles
•Testicular microcalcification
(post-mumps or others)

14. Revisiting History
• Age
• Duration of subfertility
• Previous pregnancy- can have secondary male
subfertility
• Lifestyle
• Occupation- Driving, IT, chemical industry (heavy
metal, pesticides)
• Medical history- Diabetes, Mumps, Cancer
• Surgical history- Hernia, Orchidopexy, Pituitary
Surgery, Bladder neck surgery
• Drug history- Sulphasalazine, Finesteride,
cytotoxic drugs, steroids
• Sexual history- Low libido, ED

15. Darren et al. Male infertility – The other side of the equation . 2017

16. Varicocele- always CLINICAL Diagnosis
(EUA, 2018)
• Subclinical: not palpable or
visible, but can be shown by
special tests (Doppler
ultrasound).
• Grade 1: palpable during
Valsava manoeuvre, but not
otherwise.
• Grade 2: palpable at rest, but
not visible.
• Grade 3: visible at rest

17. Surgery for Varicocele
(EUA, 2018; AUA/ ASRM, 2020)
• Grade 3 varicocele
• Ipsilateral testicular atrophy
• Pain
• Abnormal semen parameters
• No other fertility factors in the couple

18. Do you recommend varicocelectomy here?
• 35 yr- Azoospermia
• Lt undescended testis
• 19 yr age- Lt orchidopexy
• 21 yr age- left testicular cancer
(mixed germ cell Tx)→
orchidectomy, f/b 3 cycles of
chemotherapy (BPC)
• 33 yr age-Papillary Ca Thyroid→
Total thyroidectomy and neck LN
dissection f/b Radio-iodine. Now
on Eltroxin 150

19. In couples seeking fertility with ART, varicocele repair
• may offer improvement in semen parameters
• may decrease level of ART needed

20. Cryptorchidism in adults (EUA, 2018)
• In adulthood, a palpable undescended
testis should NOT be removed because it
still produces testosterone.
• Correction of B/L cryptorchidism, even in
adulthood, can lead to sperm production in
previously azoospermic men
• Perform testicular biopsy at the time of
orchidopexy in adult- to detect germ cell
neoplasia in situ

21. Cryptorchidism- bilateral in adults?
• 31 yr
• Azoospermia
• USG- Rt testis in lower abdomen, Lt testis in inguinal canal
• FSH 13.40. LH 6.87. Testo 6.89. E2 <10.

22. B/L cryoptorchidism in ADULTS!!!

23. Congenital bilateral absence of vas
deferens (CBAVD)
• Semen- Volume <1.5 ml, pH <7.0, fructose negative
• TRUS
• Renal ultrasound
• Cystic fibrosis mutation (CFTR) testing (EUA, 2018;
ASRM/AUA, 2020)
• Partner testing
• Indian prevalence- 1:10,000- 1:40,000 (Kapoor et al., 2006;
Prasad et al., 2010)

24. CBAVD, TRUS, CFTR mutation
• TRUS-
• B/L agenesis of seminal vesicles
• Male partner- CFTR carrier
• Female partner- CFTR carrier

25. CBAVD is NOT uncommon
• CFTR negative • CFTR carrier
• Wife- normal
• CFTR refused
• CFTR carrier
• Wife- normal
• CFTR negative

26. Hormone Evaluation
FSH, LH, testosterone, HbA1C
FSH, LH low Testosterone low Hypogonadotropic hypodonadism
Pituitary MRI
Testosterone normal/
high
Androgen excess
Exogenous testosterone
Congenital adrenal hyperplasia (CAH)
Testicular adrenal rest tumors (TARTs)
History, Endocrinology referral

27. Hormone Evaluation
FSH, LH, testosterone, HbA1C
FSH, LH low Testosterone low Hypogonadotropic hypodonadism
Pituitary MRI
Testosterone normal/
high
Androgen excess
Exogenous testosterone
Congenital adrenal hyperplasia (CAH)
Testicular adrenal rest tumors (TARTs)
History, Endocrinology referral
FSH high LH high
Testosterone low
Global testicular failure
LH normal
Testosterone normal
Spermatogenesis defect
LH high
Testosterone normal
Sublinical hypogonadism
PRL, TSH If clinically suspected

28. Stories of Hypo/Hypo
• 29 yr, Azoospermia
• Delayed puberty
• Anosmia
• MRI- B/L olfactory bulb absent
• Genetic tests advised, Lost to F/U.
•32 yr, Azoospermia
•sudden loss of body hair, low libido
•Nonfunctioning Pituitary macroadenoma →
Endoscopic surgery H/P Lymphocytic hypophysitis
•Started hCG f/b hMG by endocrinologist
•Sperm conc 1-2/ hpf
• 30 yr, Azoospermia
• 17 yr age, sudden testicular atrophy
• B/L testes 6 cc each

29. Imaging
Scrotal ultrasound
1. Clinically abnormal findings-
mass/ atrophy
2. Tight scrotum (Cremasteric
reflex)
3. Obese patient
• NOT for Varicocele detection
• NOT the replacement for
clinical examination
(EUA, 2018; ASRM/ AUA, 2020)
Transrectal ultrasound (TRUS)
1. Low volume and pH of semen
2. Ejaculatory disorders
(EUA, 2018; ASRM/ AUA, 2020)

30. “Abnormal” scrotal ultrasound
Epididymal cyst Microlithiasis Testicular prosthesis

31. Genetic testing
• Karyotyping
• Y chromosome Microdeletion (YCM)
• CFTR testing in CBAVD

32. In presence of genetic defect
• PGT-SR (previously- PGD)
• Prenatal invasive testing (EUA, 2018; ASRM,
2020)

33. Klinefelter’s with “normal” phenotype
• 37 yr
• FSH 35.42, LH 10.13, testo 93, E2 14.45
• Undiagnosed Diabetes
• Prev FNAC- Lt side- Sertoli Only
Syndrome
• TESE – Rt side- No sperms, Lt side-
Motile Sperms

34. Robertsonian Translocation
45, XY rob (14, 21), (q10, q10) Sperm FISH after TESE

35. Alternative- Prenatal testing
46,XY22ps+
• Oligospermia →Azoospermia
• YCM normal
• Spermes obtained by TESA
Amniocentesis
• Normal Karyo & CMA
• Live born by 34/40

36. Other Translocations
46,XY,t(15:17) (q10;q10)
• Azoospermia
• FNAC- B/L SCO
• YCM normal
46,XY;t(2:22)(q37;q11.21)
• Azospermia
• TESE- no sperms available
• YCM normal

37. Other chromosomal aberrations
46,X,del(Y)(q11.23) 46,X,del(Y)(q11.2) 46,X,+mar

38. Genetic abnormality ≠ Advanced interventions
46,XY,15ps+
46,X,Y,q+
46,X,inv(Y)(p11.q11)
46,X,inv(Y)(p11.2q11.2)

39. YCM- look for mutation

40. Y chromosome Microdeletion (AZF)

41. • 39 yr
• FSH 25.4, LH 12.6, Estradiol 14, Testo 61.
46,XX SRY+ sex reversal

42. Surgical Sperm Retrieval (SSR)
f/b ICSI

43. Indication Process Merits Demerits
PESA (percutaneous
epididymal sperm
aspiration)
OA •minimally invasive
•minimum training
•“blind” method
•can cause epididymal
damage/ fibrosis
•sufficient sperms may
not be obtained for
freezing
MESA
(microsurgical
epididymal sperm
aspiration)
OA •higher chance of sperm recovery
•full scrotal exploration
•microsurgical reconstruction can
be attempted
•sufficient sperms obtained for
freezing
•invasive, expensive
•needs expertise
•takes time to recover
TESA (testicular
sperm aspiration)
NOA
OA
•minimally invasive
•minimum training
•“blind” method
•sufficient sperms may
not be obtained for
freezing
TESE (testicular
sperm extraction)
NOA
OA
•higher chance of sperm recovery
•sufficient sperms obtained for
freezing
•invasive, expensive
•can cause testicular
fibrosis/ damage
•needs expertise
•takes time to recover
MicroTESE NOA
OA
•highest chance of sperm
recovery
•sufficient sperms obtained for
freezing
•invasive, expensive
•needs expertise
(Tournaye et al., 2018; Fritz and Speroff, 2011; Coward and Mills, 2017).

44. Differentiation between OA and NOA
OA NOA
Semen Volume low (<1 ml)
pH low (<7)
Volume normal (>1.64ml)
pH normal (>7.4)
Seminal fructose Negative Positive
Testicular size Normal Small
Epididymis Fullness Normal/ small
Vasa May not be palpable Palpable
FSH Normal High
Testosterone Normal May be low
Chance of
sperm
recovery
100% 50-60%

45. Predictors of sperm retrieval?
• FSH
• Testicular Size
• LH, Testosterone
• BMI
• AMH- semen, serum
• Inhibin B- semen, serum
• Age
• Ultrasound parameters
• No reliable positive prognostic factors
guarantee sperm recovery for patients
with NOA
• The ONLY negative prognostic
factor is the presence of AZFa
and AZFb microdeletions.

46. Medical Therapy in
Azoospermia

47. Definitive treatment (Avoids SSR/ ICSI)
Hypo
hypo
•hCG 2000-5000 IU 3 times a week
•If hCG alone cannot restore spermatogenesis, FSH is added 75-150
IU 3 times a week
•Serum testosterone and semen analysis every 1–2 months
•Usual time to recover 6 – 12 months (may take 24 months)
•Initial testicular volume >8 ml, postpubertal onset of HH – responds better
•Often conceive at much lower sperm concentration
(EUA, 2018; ASRM/ AUA, 2020; George and Bantwal, 2013; Anawalt, 2013)
Alternative- Pulsatile GnRH
•Significantly earlier induction of spermatogenesis
•Expensive and cumbersome
•Needs functional pituitary gland
•Only if fails to respond to hCG/ FSH
(Alkandari and Zini, 2021; Kumar, 2013; George and Bantwal, 2013; Zhang et al., 2019; Kumar, 2013; George
and Bantwal, 2013).

48. Definitive treatment (Avoids SSR/ ICSI)
Hypo
hypo
•hCG 2000-5000 IU 3 times a week
•If hCG alone cannot restore spermatogenesis, FSH is added 75-150
IU 3 times a week
•Serum testosterone and semen analysis every 1–2 months
•Usual time to recover 6 – 12 months (may take 24 months)
•Initial testicular volume >8 ml, postpubertal onset of HH – responds better
•Often conceive at much lower sperm concentration
(EUA, 2018; ASRM/ AUA, 2020; George and Bantwal, 2013; Anawalt, 2013)
Alternative- Pulsatile GnRH
•Significantly earlier induction of spermatogenesis
•Expensive and cumbersome
•Needs functional pituitary gland
•Only if fails to respond to hCG/ FSH
(Alkandari and Zini, 2021; Kumar, 2013; George and Bantwal, 2013; Zhang et al., 2019; Kumar, 2013; George
and Bantwal, 2013).
Androgen
excess
•Stopping the exogenous testosterone- may take 2 years
•Addition of gonadotrophins to accelerate recovery
•Glucocorticoid CAH, TARTs (Alkandari and Zini, 2021, Kumar, 2013; Engels et al., 2019;
Ring et al., 2016.

49. Medical Therapy in Idiopathic Azoospermia
(mostly hypergonadotrophic hypogonadism)
• To improve the chance of sperm retrieval
• Sometimes, can lead to appearance of sperms in the ejaculate
Testosterone
supplementation
Strongly CONTRAINDICATED
Feedback inhibition on FSH, LH→ secondary hypogonadism
Aromatase inhibitors
(Letrozole, Anastrozole)
If T:E2 ratio <10 (T- ng/dl, E2- pg/ml)
Anti-estrogens (CC,
Tamoxifen)
•Block pituitary E2 receptors→ stimulate secretion of FSH, LH
•Men with normal FSH, low testosterone but normal T:E ratio
Gonadotrophins •“resetting” of the Gn receptors in testicles → improve the sensitivity
of testicles to gonadotrophins
•may be increase intratesticular testosterone
•work better in case of eugonadism rather than high FSH
•If successful in raising FSH level 1.5 times baseline and
testosterone 600-800 ng/dl, high success rate of microTESA
(Alkandari and Zini, 2021; Kumar, 2021; Holtermann et al., 2022; Dabaja and Schlegel, 2014; Holtermann et al., 2022; Anawalt, 2013;
Flannigan and Schlegel, 2019; Ring et al., 2016; Chehab et al, 2015; Foran et al, 2023). Shiraishi et al., 2012)

50. Hormone treatment vs ART
• Priority for natural conception
• Other indications of ART- female partners
• Time to pregnancy
• Age of female partners
• Cost

51. Surgical Management in OA
• Vasovasostomy
• Vasoepididymostomy
• Transurethral resection of ejaculatory ducts in
EDO
• Patent tract ≠ Conception
Baker and Sabanegh, 2013

52. Azoospermia
Repeat test (centrifugation)
1. History
2. Physical Exam
3. Repeat semen ASAP
4. Hormonal evaluation
Low FSH, LH
Pituitary imaging
hCG/ FSH
supplementation
High FSH
Karyotype
YCM
SSR+ ICSI
Donor sperms as alternative
Normal hormones
S/O obstruction
Idiopathic
TRUS
CFTR test for CBAVD
Pituitary failure
Testicular failure
Surgical reconstruction
possible?
Surgery
Not possible

53. Non-targeted investigations ?
• Delayed puberty
• Testo 100.86. FSH 28.33. LH 13.65. E2 27.83
• Testosterone injection started at puberty - sec sex charac, voice, genital size
improved
• MRI pitutary microadenoma
• GH, TSH, Cortisol, PRL, - all normal

54. Disclaimer
• Written consent from all the patients

55. Donor sperms
• AID
• IVF using donor sperms
• Financial reason
• No sperms obtained by
SSR
• Poor prognosis- AZFa/
AZFb deletion
• Repeated failure with
self sperms

56. Future aspects
• Spermatogonial stem cell (SSC) transplantation
(Roshandel et al., 2023; Vij et al., 2017; Abdelaal et al., 2021)
• Other stem cells- ESC, iPSC, MSC (Roshandel et al.,
2023; Zhankina et al., 2021)
• “Artificial gametes” (AG) (Hendriks et al., 2016)
• Gene therapy- for genetic defects (like YCM) (Vij et
al., 2017; Alkandari and Zini, 2021)
• Newer molecules- nerve growth factors, oxytocin,
selective androgen receptor modulators (SARMs)
(Krzastek and Smith, 2019)

57. Treatment burden for MALE
infertility falls on FEMALE