Male factor infertility and azoospermia

Half of the problem, half as often investigated

In roughly half of couples seeking fertility treatment a male factor is present, alone or alongside a female factor. Despite that, investigation and counselling still tend to concentrate on the woman. A single semen analysis is often where the male workup both starts and stops.

What a semen analysis does not tell you

Count, motility and morphology describe the sample but not the DNA inside the sperm. A man with entirely normal parameters can have high DNA fragmentation, which is associated with poorer embryo development, implantation failure and miscarriage — and which ICSI does not automatically overcome, because the sperm is selected on appearance.

• DNA fragmentation index, where there is unexplained failure, poor embryo development or recurrent loss.
• Hormonal evaluation — FSH, LH, testosterone, prolactin — particularly with low counts.
• Clinical examination for varicocele, which is common and sometimes correctable.
• Genetic testing — karyotype and Y-chromosome microdeletion in severe oligospermia or azoospermia.
• Infection, oxidative stress, medication, occupational exposure, smoking, alcohol, weight and sleep.

Azoospermia: no sperm in the sample

Azoospermia is found in a small but significant proportion of men investigated for infertility, and it is not the end of the road. The first question is whether it is obstructive — production is normal but the passage is blocked — or non-obstructive, where production itself is impaired. That distinction determines what is offered.

Surgical sperm retrieval

Where sperm are being produced, they can often be recovered directly. PESA aspirates from the epididymis and is typically used in obstructive azoospermia. TESA retrieves from the testis and is used more widely, including in selected non-obstructive cases. Retrieved sperm are used for ICSI, and surplus material can usually be frozen for later cycles.

Around 1,100 surgical sperm retrievals have been performed at this centre. Dr Gupta holds a Diploma in Male Infertility from MeDEA/ANDROFERT, Brazil, and has published on whether PESA-retrieved sperm changes outcomes in high-risk male factor ICSI.

What this means for the couple

Treating the couple rather than the woman changes the plan more often than people expect. Correcting a varicocele, treating infection, addressing oxidative stress and lifestyle, or simply choosing ICSI with surgically retrieved sperm instead of ejaculated sperm with high fragmentation, can alter the outcome of a cycle that would otherwise be repeated unchanged.