Severe Male Factor Infertility - Azoospermia - NYCIVF

Dr. Amr Azim of New York City IVF explains Severe Male Factor Infertility, Azoospermia. http://nycivf.org

My name is Amr Azim, I am a reproductive endocrinologist at New York City IVF and I want to talk to you today about a severe form of male factor infertility called Azoospermia. Azoospermia means the absence of detectable sperms in the ejaculate. In other words when
a couple comes in for a fertility consultation one of the initial lab tests is a sperm analysis and
the sperm analysis shows no sperm. This diagnosis and treatment requires multiple expertise
to produce a successful outcome at the end. When a man is diagnosed with no sperm in the
ejaculate four things need to happen.
The first thing is, is it truly Azoospermia? A repeat sperm analysis should be performed, with
spinning of the sperm sample multiple times incase a few sperm were missed in the initial
sperm analysis. This should be done in a lab that has the capability of doing sperm freezing
immediately, because this is valuable biological material and it cannot be used to waste, and
this cannot be done in a regular lab that does not have sperm freezing capabilities. Once the diagnosis of Azoospermia is ascertained, the next three things have to happen, number two is a genetic evaluation of the male partner. In a subset of men with Azoospermia about 10%, there is a genetic underlying reason. The genetic underlying reason could be because he has abnormalities in the sex chromosomes, an example of that could be Klinefelter's syndrome, which has an extra X chromosome or a defect or a piece of the genes
that direct the testes to make sperm on the Y chromosome is absent, and the third genetic or inherited well known
reason for the absence of sperm would be the congenital bilateral
absence of the vas deferens, which is a variant of cystic fibrosis and can lead to sperm
production but the sperm cannot egress or come out of the testes to the outside because the
duct or the vas deferens that conducts the sperm from the testes to the outside is genetically
not existent. It is very important that genetic factors are investigated because they can be
potentially passed to offspring, for example a defect in the Y chromosome in a father can be
transferred to his male offspring.
The third thing that has to happen is an evaluation of the female partner, especially ovarian
reserve, which is defined as the number and the quality of eggs remaining in the ovary at a
given age. This is usually done by performing a vaginal ultrasound for antral follicle count,
getting a blood sample for day three FSH, or anti mullerian hormone to get a very good idea about the number of eggs in the ovary. This is extremely important because men with no sperm in the ejaculate, men with Azoospermia require IVF with intracytoplasmic sperm injection because even with successful sperm retrieval the number of sperm retrieved is not
going to be enough for intercourse or insemination. So the few sperm that will be retrieved need to be injected directly into the egg and the success of IVF is very much dependent on ovarian reserve and age of the female partner. So a thorough evaluation of the female partner is a priority. The fourth thing is a urological evaluation of the male. Meeting with a urologist well versed in male reproductive medicine and surgery is a must. The urologist will do an examination, an ultrasound, and some other lab tests, and the aim is to A, differentiate between Azoospermia because of no production of sperm in the testes, or because of obstruction, meaning the sperm is being produced but it cannot come out because of a block. When Azoospermia is due to a blockage it is much easier to harvest sperm from the testes, and the success of harvesting sperm from the testes is much higher than in cases where there is no production in addition to other factors. After this evaluation is completed, if no sperm was found in the ejaculate, then the next step is to try to harvest sperm directly from the testes. In obstructed cases the sperm could be harvested from the testes or from the ducts of the vas. And in cases with no sperm production, sperm has to be harvested directly from the testes. The procedure is called TESE. Testicular sperm extraction.

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