NONOBSTRUCTIVE AZOOSPERMIA

 

Less than a decade ago, patients with nonobstructive azoospermia were often unable to be successfully treated. Since the introduction of intracytoplasmic sperm injection (ICSI), treatment of most men with azoospermia can now be considered. Intracytoplasmic sperm injection (ICSI) is a technique performed as part of an IVF cycle that has revolutionized the treatment of severe male factor infertility. ICSI involves the injection of a single sperm into each oocyte, in vitro, during an in vitro fertilization (IVF) cycle. ICSI essentially bypasses all natural barriers to fertilization, such as sperm interaction with the zona pellucida and sperm-egg fusion. Subsequent pregnancy rates are then primarily dependent on female factors, emphasizing the tremendous value of ICSI in overriding specific sperm defects that heretofore may have limited treatment of severe male factor infertility.

If possible, specific treatment of identified factors that may affect fertility should be addressed first. Patients with severe male factor infertility require IVF with gamete micromanipulation in the form of intracytoplasmic sperm injection (ICSI). Poor sperm parameters as an indication for ICSI have not been universally defined. Most centers consider ICSI when sperm concentration is less than 1 x106, sperm motility less than 5% and normal morphology by strict criteria is less than 4%. Patients with nonobstructive or obstructive azoospermia due to congenital and acquired unreconstructable reproductive tract obstruction (e.g. CBAVD, failed multiple reconstructive procedure, untreatable ejaculatory dysfunction) are good candidates for ICSI with microsurgically retrieved sperm from vas deferens, epididymis or testis. In certain cases, the patient may decide to proceed with sperm retrieval and assisted reproduction instead of specific surgical reconstruction.

Men with obstructive azoospermia have a higher success rate for sperm retrieval and are at risk of different genetic defects than men with NOA. Since the success rate and genetic risks to offspring may determine whether a couple will proceed with sperm retrieval and ICSI, it is worthwhile to make this determination before treatment.

 

 Retrograde Ejaculation

Retrograde Ejaculation is observed in about 0.3-0.4% of infertile men and 10-15% of patients with azoospermia. It involves semen emission into the bladder via incompetent bladder neck during ejaculation. In classic from patient complains of azoospermia while orgasmic sensation is preserved. 

Diagnosis is usually confirmed by postejaculatory urine analysis (PEU) for spermatozoa and fructose. Medical treatment of RE is based on increasing tone at the bladder neck, or on decreasing the parasympathetic activity. The most commonly used medications are alpha-adrenergic agents.

 

Drug

 

Dose

Pseudoephedrine hydrochloride

60mg QID

Ephedrine

25-50mg QID

Phenylpropanolamine

75mg BID

Imipramine hydrochloride

25mgBID/50mg BID

If antegrade ejaculation cannot be achieved, urine may be alkalinized and sperm retrieved from postejaculate urine processed and used for IVF or IUI

 

Selected Bibliography

  1. Yavetz H., Yogev L., Hauser R., Lessing JB., Paz G., Hommonai ZT. Retrograde ejaculation. Hum Reprod 1994;9:381-386
  2. Tournaye H., Camus M., Goossens A., Liu J., Nagy P, Silber S., Van Steirteghem AS, Devroey P. Recent concept in the management of infertility because of non-obstructive azoospermia. Hum Reprod 1995; 10, suppl 1:115-119

 

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