The total absence of sperm from the semen needs to be confirmed in repeated tests with vigorous centrifugation of the semen and careful examination of the pellet. Sperm maybe found in apparently azoospermic samples using more sensitive sperm-counting methods by examining larger volumes with fluorescence microscopy. Rarely, an illness or difficulty with collection will cause transient azoospermia; however, this can also occur for unexplained reasons. With severe spermatogenic disorders and some obstructions, sperm may be present in the semen intermittently. If any live sperm can be found, these can be cryopreserved for intracytoplasmic sperm injection (IVF ICSI). Dr Barak will investigate the nature of the azoospermia and if sperm will be retrieved , ICSI will be performed.
Approximately 6% of infertile men have blockages in the genital tract that prevent the passage of sperm between the testes to the penis and result in absence of sperm in the semen.
There are three major groups of causes of male genital tract blockages:
(1) Disorders of development of the epididymis, vas and seminal vesicles,
(2) Scarring from inflammation (especially gonorrhoea)
Rarely other blockages may occur in the vas and ejaculatory ducts.
Some patients can be treated with bypass surgery, joining the tube in the epididymis above the blockage to the vas deferens. The results depend on the level of the blockage, being poor with blockages close to the testis. This is partly because the sperm are immature, having not passed through parts of the epididymis in which maturation usually occurs. With blocks in the tail of the epididymis or vas, sperm appear in the semen of up to 80% of men after surgery, although only about half of these produce pregnancies within one year.
It is possible to obtain sperm by a surgical operation from the tubes above the obstruction, by sucking liquid out of the epididymis or epididymal cysts through a needle or from a testicular biopsy. These sperm can be used for intracytoplasmic sperm injection (ICSI) with in vitro fertilisation (IVF) by Dr Barak . This approach is particularly useful for: absence of the vasa deferentia, high epididymal obstructions for which the results of surgery are predicted to be poor, and failures of vasectomy reversal or other operations.
About 15% of infertile men have no sperm in their semen (azoospermia), because the sperm producing cells in the testes either did not develop or have been irreversibly destroyed (Primary Seminiferous Tubal Failure). This may be caused by chromosomal or genetic disorders, inflammation of the testes or treatment with certain drugs. It may also be associated with failure of the testes to descend into the scrotum during childhood. For couples in this category who wish to have a family, Dr Barak will perform a testicular biopsy. testicular biopsy is a reasonable primary approach. If sperm can be retrieved, it can be used for intracytoplasmic sperm injection (ICSI) with in vitro fertilisation (IVF) also performed by Dr Barak.
Failing that, the use of donor insemination or adoption are probably the only options of couples in this category to achieve their own family.
Testicular biopsies are necessary to assess spermatogenesis in men with presumed genital tract obstruction. A significant proportion of men with azoospermia, normal testicular size, and normal FSH are found to have severe spermatogenic disorders. Some severe spermatogenic defects may be incomplete, and because ICSI can be performed if sperm can be obtained from the testes, diagnostic testicular biopsies should be offered to men with severe primary spermatogenic tubule disorders with persistent azoospermia. If any elongated spermatids can be found, it should be possible to perform ICSI. However, if no elongated spermatids are seen in the diagnostic biopsies it still may be possible to find spermatids by more extensive sampling of testicular tissue with open biopsies (see later).
It is most important that tissue for histology is removed from the testes with minimal damage and placed in a suitable fixative, such as Bouin’s or Steive’s solution. Standard formalin fixatives destroy the cytoarchitecture.
Dr Barak performs Testis biopsies under local or general anesthesia. Needle biopsy may obtain only isolated cells but these may be sufficient for diagnosis based on cytology or for flow cytometry. Complications are rare and include minor bleeding in the skin and testis, and rarely hematoma or reactions to the local anesthetic. Failure to obtain tissue occurs particularly with fibrosed or small (<5mL) testes
In the presence of azoospermia, Dr Barak will perform an open testicular biopsy. This might not just be a therapeutic approach in the way of sperm retrieval, but also the only way of excluding early testicular germ cell neoplasia or even an overt testicular cancer.
Infertile men are more likely to develop testicular cancer compared to men with normal fertility. Testicular intra-tubular germ cell neoplasia of the unclassified type (ITGCNU) also called carcinoma in situ (see below) is the precursor of testicular germ cell tumors in which the neoplastic cells are confined within the seminiferous tubules. This makes it a non-invasive stage of the disease. It can be found in testicular tissue adjacent to germ cell tumours in more than 90 percent of adult cases.
The incidence of ITGCNU in men undergoing fertility evaluation ranges between 0.4 – 1.1 percent. As ITGCNU is asymptomatic, patients remain undiagnosed until an overt tumour can be identified usually by palpation. A sample from a sperm retrieval open biopsy is sent by Dr Barak to histopathology routinely.