In the past five years, very few fields in modern medicine have changed as dramatically as reproductive medicine, especially for the new treatment of male infertility by use of (1) intracytoplasmic sperm injection (ICSI) techniques1 (Figure 1) and; (2) advanced surgical epididymal and testicular sperm retrieval techniques.2,3,4,5,6 Those two major technical advances have completely changed the treatment for previously untreatable testicular failure or unreconstructable obstructive azoospermia.ICSI is highly efficient at producing fertilization as long as the spermatozoa are conceivable and can be retrieved from male reproductive tract.
Evaluation of azoospermic men
Prior to sperm retrieval, initial evaluation of female partner should be carried out to confirm that she has adequate ovarian reserve to undergo assisted reproduction for IVF-ISCI procedure.
For men with low semen volume (< 1ml), a postejaculate urinalysis should be performed to rule out retrograde ejaculation. A complete history is needed to assess for risk factors that may have led to azoospermia, such as cryptorchidism bilateral inguinal hernia procedures, or family history of cystic fibrosis. A man with a history of cryptorchidism and testicular capacity of 8 ml most likely has non-obstructive azoospermia (NOA), whereas the patient with bilaterally absent vasa, testicular volume of 16 ml or greater, and an enlarged caput epididymis almost certainly has obstructive azoospermia. The physical examination should also be thorough, with special attention to the volume of the testes (normal finding is greater than 15 ml), presence of epididymal dilation of fullness that suggestive of obstruction, and the existence of the vasa deferens. The testis should be carefully examined for tumors, a not uncommon cause of azoospermia and the most common cancer in men 15-45 years old. Ancillary evaluation, such as transrectal ultrasound, may examination help to determine if ejaculatory duct obstruction is presented. Scrotal ultrasound can be helpful for men with scrotal masses or a history of cryptorchidism to detect small testis tumor.
Evaluation for non-obstructive azoospermia (testicular failure)
Non-obstructive azoospermia is a condition in which no sperm are present in the ejaculate because of severely abnormal sperm production. Most of these men have small-volume testes, elevated follicle-stimulating hormone, and empty epididymides. In this condition, a diagnostic therapeutic testis biopsy will reveal abnormal sperm production.
The general histologic patterns are found in men with non-obstructive azoospermia (NOA) are Sertoli cell-only, maturation arrest and hypospermatogenesis.
(1): Sertoli cell-only syndrome: In this condition, only the supporting cells (Sertoli cell) are present, with no germ cells in the seminiferous tubules.
(2). Maturation arrest. Maturation arrest is a condition in which Sertoli cells and immature germ cells are present in seminiferous tubules
(3). Hypospermatogenesis. hypospermatogenesis signifies a defect in sperm production in which decreased numbers of germ cells are present in seminiferous tubules but rare or no mature spermatids are present within the testis.