Appendix
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Urology

Azoospermia

Male infertility contributes to approximately 50% of infertility cases, making comprehensive evaluation of male factors essential when assessing couples experiencing difficulty conceiving. This course reviews azoospermia, defined as complete absence of spermatozoa in 2 separate centrifuged semen specimens, which represents the most severe form of male infertility and affects approximately 1% of men and 10% to 15% of infertile males. This activity examines the evaluation and management of obstruc

v1 · Reviewed Nov 7, 2026 by Automated Clinical Reviewer (Strict Verbatim v1)
  • Testicular torsion occurs in approximately 1 in 4,000 males before age 25.
  • The condition requires prompt surgical exploration, corrective detorsion, and bilateral orchidopexy because the risks associated with nonoperative management remain well documented.
  • Azoospermic men are also at lifelong increased risk of developing cancer compared to the general population, as between 5% and 8% of men with testicular cancer will be azoospermic.
  • Diagnostic evaluation may include hormonal assessment, semen biomarkers, genetic testing, ultrasonography, testicular biopsy, and vasography.
  • Transrectal ultrasound represents the best diagnostic tool for identifying distal obstruction of the male reproductive system.
  • At least two separate semen analyses should be performed with three days of sexual abstinence preceding each examination.
  • The absence of fructose in the semen suggests ejaculatory duct obstruction or congenital absence of the vas deferens, while low seminal levels of neutral α-glucosidase are associated with sperm blockage within the epididymis.
  • Hormonal profiles, including total testosterone (free testosterone is not required), FSH, luteinizing hormone (LH), prolactin, and estradiol, should be obtained in addition to a thyroid profile.
  • In nonobstructive azoospermia, genetic causes that demonstrate chromosomal defects account for up to 20% of cases.
  • All men with primary testicular failure (confirmed azoospermia on 2 separate semen samples, elevated FSH with normal or low testosterone, and typically with small (<10 mL) testes) should be given karyotype and Y-chromosome microdeletion testing.
  • Scrotal and transrectal ultrasound helps differentiate obstructive from nonobstructive azoospermia and identify ejaculatory duct cysts as well as epididymal abnormalities.
  • If the diagnosis remains uncertain between obstructive and nonobstructive azoospermia (for example, when normal-sized testes are found with normal serum FSH levels), a testis biopsy can be used to establish the correct diagnosis.
  • The main aim of managing obstructive azoospermia is to correct the site of obstruction by using reconstructive surgical techniques, such as vasoepididymostomy and vasovasostomy.
  • In cases of ejaculatory ductal obstruction, surgical correction with transurethral resection is performed to achieve patency of the ejaculatory ducts.
  • Advanced assisted reproductive techniques are required for most patients with nonobstructive azoospermia.
  • Micro-TESE together with ICSI is potentially extremely beneficial to these patients.
  • Men who become azoospermic as a result of testosterone supplementation therapy have an excellent chance of recovery of spermatogenesis just by stopping the hormonal treatment and waiting.
  • To stimulate spermatogenesis in cases of hypogonadotropic hypogonadism or pretesticular azoospermia (secondary hypogonadism, testosterone therapy), gonadotropin analogs or FSH and HCG are used.
hCG
Not specified in source
Adult
1,000 to 3,000 IU, 2 to 3 times weekly
Renal
Not specified in source
Duration
Not specified in source
FSH
Not specified in source
Adult
150 IU daily or 200 to 300 IU every other day
Renal
Not specified in source
Duration
for 3 months
  • Assisted reproductive techniques are useful in patients suffering from congenital absence of vas deferens, as surgical reconstruction in these patients is not feasible.
  • In obstructive azoospermia not amenable to surgical reconstruction, microsurgical epididymal sperm aspiration (MESA) is optimally used for sperm retrieval when possible.
  • If medical treatment is unsuccessful, assisted reproductive techniques are recommended.
  • Given the associated costs and potential genetic consequences, couples should seriously consider artificial insemination, ICSI using donor sperm, or adoption before starting expensive advanced reproduction treatments.
  • The only absolute contraindications for an attempt at sperm retrieval in male nonobstructive azoospermic patients are Y-chromosomal microdeletions of the AZFa or AZFb subregions and postbilateral orchiectomy, as the sperm retrieval rates will be zero.
  • Testosterone supplementation is specifically not recommended.
  • Complications of azoospermia or associated surgical treatment include the following: Failure to produce a pregnancy; prolonged or continuing infertility Hematoma formation due to surgery Infection Parenchymal fibrosis of the testis Testicular atrophy
  • Additionally, azoospermia can lead to significant emotional distress, impacting the mental health of affected individuals and straining relationships.
  • The pursuit of fertility treatments, while offering hope for conception, may also entail financial burdens and emotional stress.
  • Male infertility increases the overall risk of early mortality by 26%, and this is even higher in azoospermic men.
  • Therefore, conducting complete and comprehensive health screenings periodically for men diagnosed with azoospermia is crucial.
  • review
    Azoospermia. StatPearls [Internet] — Stephen W. Leslie, Elsa S. Vadakekut — StatPearls Publishing, 2026

Decision support only. Verify against local protocols and current labeling. Source: www.ncbi.nlm.nih.gov