In some individuals, sperm may not be present in the ejaculate. This condition is called Azoospermia. This can be either due to problems in sperm production itself (non obstructive azoospermia) or due to obstruction to the out flow of semen, during ejaculation. (obstructive azoospermia). Reproductive tract obstruction can be acquired (as a result of infection, trauma, iatrogenic injury which can occur during bladder neck, pelvic, abdominal or inguinal-scrotal surgery) or can be inherited congenital condition such as congenital bilateral absence of the vas deferens (CBAVD). This condition of CBAVD is many times associated with an autosomal recessive geneticdisorder of cystic fibrosis. In azoospermia’s one should do geneticstest of Karyotyping (to rule out Klinefelter’s syndrome), Hy deletion to rule out inheritable deletion conditions, as well as to predict sperm recovery) and carrier testing for Cystic fibrosis. Normally obstructive azoospermia due to infection or surgical block can be overcome by, surgically bypassing the block by doing microsurgical vasovasostomy (VVA) or vasoepididymostomy (VEA). After successful VEA, in which sperms will be present in the ejaculated semen, some people conceive naturally or through IUI or ICSI. If the VEA fails to achieve sperms in the ejaculated semen sample, one can do PESA or TESA to retrieve the sperms directly from testis, followed by ICSI. Very rarely you may need to do TESE in these patients. If the patients are suffering from non-obstructive azoospermia one can do the following three procedures, all of which are done in our labs:
- One can do TESE. If that fails to obtain sperms, one can do micro TESE at the same sitting. If that fails to obtain sperms, & if the couple is against using donor sperm, one can freeze the eggs and try at a later date with ejaculated sample or one can discard the eggs. If the couple is ok for using donor sperm, if there is failure to obtain sperm on TESE., consent for emergency donor insemination should be taken many days in advance and appropriate frozen donor sample should be received from the sperm bank & kept in the lab as a back up.
- In patients of Non obstructive azoospermia, where oocytes are frozen, but one has not found sperms on TESE, one can call the husband for repeated sperms ejaculation and examination of the centrifuged sample under high power inverted microscope. Normally the husband is asked to not have any abstinence and is asked to produce two semen samples at 2-4 hours interval. Sometimes, one may get very few sperms in an occasional ejaculate. These very few sperms can be frozen in a special NEW sperm Freezing device called Sperm VD. After freezing enough number of sperms with sperm VD, the oocytes & sperms can be thawed and ICSI carried out. Our first pregnancy following sperm VD freezing is ongoing in our centre .We are the first to use sperm VD in India.
- Nowadays, whenever a patient of non-obstructive azoospermia comes to us, we give the husband empirical treatment with oral clomiphene and ask them to produce multiple semen samples without abstinence. If we get sperms in any of the samples on extended screening and search of the centrifuged specimen , we freeze them with sperm VD .Taking this a little further , one can also do TESE or Micro TESE & search for sperms if we find them we freeze them with Sperm VD .When 2 to 8 sperms are frozen, we do egg pick up , thaw the sperms , do ICSI and obtain embryos for transfer and pregnancy . In this way we can avoid unnecessary egg retreivals and TESE or micro TESE procedures.
In azoospermia patients if everything else fails, one can go for donor sperm insemination by obtaining HIV quarantined samples from the semen bank.