Step One: Analyze a Semen Sample
An evaluation for suspected male infertility or Azoospermia will always begin with evaluation of a semen sample. When a semen sample has no sperm in it, the first thing the lab should do is place the semen sample in a centrifuge to look for small numbers of sperm that otherwise would not be detected.
The semen sample should be repeated several weeks to a month later, since sperm counts can fluctuate significantly over the course of the year. Typically, we will see patients for a consultation after they have had two abnormal semen samples.
Step Two: Consultation with Dr. Werthman
At your first consultation with Dr. Werthman, he will take a thorough history, paying special attention to all the factors that can cause azoospermia, including: developmental, medical, sexual, family, environmental and occupational histories.
Dr. Werthman will then perform a full physical examination and assess your overall health and physical characteristics. Careful examination of the scrotum and its contents is important to assess testicular size, any masses, the presence or absence of the vas deferens sperm duct, the epididymis and the presence of a varicocele.
Based on the results of the semen analysis, medical history and physical exam, the type of Azoospermia can usually be determined.
Step 3: Hormone Level Testing
In all cases of Azoospermia, Dr. Werthman will next perform hormone testing to check reproductive hormone levels, including Follicle Stimulating Hormone (FSH), Luteinizing Hormone (LH), Testosterone, Estradiol, and Free Testosterone (Free T).
It is common for men with non-obstructive Azoospermia to have an elevated FSH level (above 9.0) and sometimes a low testosterone level. These levels indicate testicular dysfunction. However, a normal FSH level and testosterone level does not necessarily mean that you have normal sperm production and an obstruction, although patients are sometimes told this. In reality, there are a number of scenarios where the hormones and physical exam are normal and the patient is still not producing sperm. Conversely, a high FSH level does not mean that a patient is not producing sperm within the testicle. Men have been found to have some sperm production within the testicle even when FSH levels are over 60.
Step 4: Genetic Testing
Depending on the hormone test findings on and physical examination, Dr. Werthman may recommend genetic testing. Men who have an absence of the vas or a suspected blockage without an apparent cause should be tested to make sure they are not carriers of a mutation of the cystic fibrosis (CF) genes. Congenital absence of the vas deferens (CAVD) is more common in men who are carriers for CF. Men with suspected non-obstructive Azoospermia should have blood drawn to analyze their chromosomes (Karyotype) and specifically the genes on the Y-chromosome, looking for translocations and deletions.
The results of these genetic screening blood tests can give insight into the cause of the Azoospermia, the chances that the patient is producing sperm, and allow physicians to make sure to screen the embryos created from IVF to ensure a child born from the patient’s sperm is healthy.
Step 5: Ultrasound of the Prostate
Men with low volume on the semen analysis, normal size testicles and normal hormones might have a blockage of the ejaculatory ducts in the prostate and might consider having an ultrasound of the prostate to confirm this.
Step 6: Diagnosis
With all of this information, Dr. Werthman will be able to tell in many cases with reasonable accuracy, whether or not you have obstructive Azoospermia. However,, the only way to be 100% certain that a patient is making sperm is to actually see the sperm either in the fluid or in a specimen taken from the testicle. At this point, Dr. Werthman will want to outline for you your treatment options, and help you decide on the best way for you and your partner to proceed.
Remember, with modern micro-surgical techniques, most men can still become fathers, even those with profound Azoospermia.
Treatment for Azoospermia
Exciting new micro-surgical techniques have enabled Dr. Werthman to help most men become fathers.