Azoospermia. Now what?

Wondering what next? Here’s an Azoospermia Protocol.

After Mr.E’s diagnosis of azoospermia, I knew my best weapon would be information. I needed to know how to beat it. I found people talking in forums about doing biopsies and sperm retrievals. And then I read about a guy who had to be on testosterone supplements for the rest of his life because of damage done to his testicles during attempted sperm retrieval. There was a whirlwind of information about varicoceles, sperm mapping, genetic tests, TESE (pronounced TES-see) which is Testicular Sperm Extraction, microTESE, pituitary adenomas, ICSI (pronounced ICK-see) which is Intra-Cytoplasmic Sperm Injection, etc. It all had me overwhelmed.

The first thing I decided for sure is that I would be protecting Mr.E’s testicles with my life. Only the best of the best would ever cut into them.

If you have non-obstructive azoospermia (NOA) your options for having children are:
– IVF with ICSI after sperm retrieval
– donor sperm with IUI
– donor egg with donor sperm
– donor embryos
– adoption

If you’re diagnosed with azoospermia and you’re not sure what to do next I recommend the following steps before going straight to donor sperm or adoption. All is not lost!

1. Look at your semen analysis – is it positive for fructose? If it is positive, then you probably have non-obstructive azoospermia. Also, get at least one more semen analysis. Mr.E got one more at the same lab and another one at a different lab, just to be sure. It never hurts to have multiple opinions.

2. Get hormone blood tests. If your hormones are out of whack then you probably have non-obstructive azoospermia. (FSH, testosterone, prolactin, LH, TSH and, for the sake of being complete, you could get estradiol, and inhibin B). Some hormone imbalances can be corrected with medicine and you will start producing sperm again. Yay!
Update 9/5/13: Along with those hormone tests, be sure to get a full thyroid panel including TSH, Free T3, Free T4, total T3, Total T4, Reverse T3, TgAb, and TPOab. Also, be sure to get MTHFR testing done.

3. Get a physical exam by a urologist, preferably a urologist who specializes in male fertility. He’ll check the size of the testicles, for presence of vas deferens, for blockage in epididymis, and for presence of varicocele.

4. If there’s a possibility of a varicocele, then ask for a Doppler scrotal ultrasound. It’s an ultrasound that also checks for adequate blood flow in the testicles. If you do have a varicocele, get a 2nd and 3rd opinion before having repair surgery – it might be a coincidence and not be the cause of the azoospermia! But very large varicoceles can cause azoospermia.

5. If your prolactin is high, get it done again under the following conditions: fasting, no sex the night before, test between 3-5 hours of waking up, and when you’re not stressed out. (So if you wake up at 6 am, get it drawn between 9-11am. And don’t eat breakfast until after the test!)

6. If your prolactin is still high, get an MRI of the pituitary with and without contrast. Some doctors just ask for it without contrast. But that’s a waste of your time and money. If the radiologist sees something suspicious on the MRI he’ll need to see it with contrast to make a determination and you’ll just have to go back and get it again with and without contrast. If you do have a pituitary adenoma, it is most likely treatable with medicine and your sperm count will return to normal. Yay!

7. If it’s just your FSH that is high and/or inhibin B that is low, you’re probably in the same boat we are in: non-obstructive azoospermia. To put it bluntly, your only hope for conceiving a biological child is a successful sperm retrieval. Start researching good urologists nearby who specialize in male fertility.

8. You’ll want to get genetic testing done before doing the sperm retrieval (see 9 and 10 below). Why? Because a simple blood test will tell you and your doctor if having a biological child is even possible and help you avoid unnecessary surgery.

9. Y microdeletion genetic test – results will tell them if it is impossible to find sperm.

10. Karyotype genetic test – results will tell them if genetic counseling is required for IVF.

11. If your genetic tests come back normal you’re cleared for IVF (although your wife may need additional testing). Hopefully by this time you’ve researched IVF clinics and know which doctor you want to work with.

12. Start IVF cycle simultaneous with getting sperm retrieval done. There are several sperm retrieval techniques that you’ll need to evaluate and then decide which one you want. I’ll discuss those in a future post.

13. Supplements/natural remedies: probably the most well-known supplement is FertilAid. There’s no studies that show that it helps or hurts azoospermia patients’ chances at successful sperm retrieval. There’s also no studies showing that it doesn’t hurt your chances. Sorry, I know that’s not very helpful. But that’s where I am right now. Half of me thinks its helping Mr.E and the other half thinks its hurting him.

As I’m writing this I realize how helpful this would have been to find this list 2 months ago to know what to do! I’m glad I’m able to provide it for the next person.

Disclaimer: I am most definitely not a doctor. You should confirm anything and everything you’ve read here with your own research and by talking to your own doctor. YOU are your best advocate. Nobody cares more about you having a baby than you do. It’s your responsibility to do your own research and ask as many experts as many questions as you can. Good luck!

The American Society for Reproductive Medicine has also given their recommendation for the Evaluation of the Azoospermic Male.

UPDATE 12/9/12: consider this #2 above, part B

I recently learned about some therapies for men with low/lower testosterone results, even if they are technically in the normal range. Sometimes doctors will prescribe a regimen of injections including HCG, Arimidex, and/or Clomid. Talk to your doctor about these options if your bio-available testosterone is low (not free testosterone, you want the bio-available test). There are also additional testosterone blood tests that can be done to get more insight into the low T levels, possibly indicating a cause or better treatment options. I don’t know a ton about these because Mr.E’s T is normal, so you’ll have to do your own research, but I wanted to be sure to mention them.

I’ve also heard of women having acupuncture during IVF cycles leading up to egg retrieval and even during the embryo transfer. Some people swear by it. It turns out that some people say it works for men, too, if they have it done regularly for at least 3 months before sperm retrieval.

UPDATE 9/5/13:

I’ve just added some additional blood work to be done with #2. Thyroid blood work and MTHFR genetic testing.

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