What to Do if the Sperm Sample is Negative
Hi everyone, today I thought we could run through Azoospermia, which means no sperm in the sperm sample. So, what might have happened is you brought in a sample for analysis, the lab has run their checks on it, and we’ve generated a report that says no visible sperm in the sample. Well, the first step is always going to be to repeat that test. We always want to have two samples telling us that there’s no sperm in the sample.
I just want to start the section of by covering a few things. Firstly, this is a devastating diagnosis to give any couple of there’s no sperm in the sperm sample. It’s really important to check in with your man and make sure that he is coping with this diagnosis. Men don’t have the same sort of social support network; they don’t reach out the same way that women do. They don’t join the groups and the blogs and follow different people and Instagram to try and get an idea of what other people have gone through. So, make sure that your man is coping with this diagnosis, that you are available to speak to him nonjudgmentally about it. And if he is taking strain, bring it up to your healthcare provider so that we can put you in contact with the right people to help and support him through this.
So, what can you expect when we’ve done two sperm tests and we’ve seen there’s no sperm in the sample? We’re going to start with a physical examination, will examine the testicles, make sure that they’re the right size, that they’re not tender at the little part that runs from the testicle to the base of the penis is actually there and make sure that there are no other abnormalities that we might’ve missed that would send us in a specific direction.
We will then also ask for some blood tests which check hormone levels. Some of those hormones are made by little glands in the brain and they tell the testicle to make sperm and to make testosterone. Remember the testosterone is important for supporting the sperm function. Some other hormone tests that we will check, not only your testosterone levels, but quite often we will check your estrogen levels as well. Every man needs to have a certain amount of estrogen, just like every woman needs to have a certain amount of testosterone. We might check your thyroid, which is a little gland that sits here, and we might check your prolactin levels, which is a little gland in the middle of the brain. And sometimes when those levels are very high, it might interfere with the other hormones coming from the brain.
As a next step what we might decide to do is check a few genetic things. So, the first thing we would consider is a karyotype; now what a karyotype is, is the basics to your genetics. So, 46 X Y would be a normal carrier type for a man, we always want to double check that we’re not sitting with 47 chromosomes or an extra X chromosome. Always wants to check a little area called the SRY region of your genes and we look for a little deletion of a gene there that can result in problems with sperm. We might also check for cystic fibrosis in certain men, you might be a carrier of cystic fibrosis as this might be associated with absence of that little pipe that runs between the testicle and the base of the penis. If we find that situation, we want to know if you are a carrier simply so that we can actually test your partner and make sure we reduce the risk of you having a child with cystic fibrosis.
So, once we have all of these tests results, we can usually then classify the problem into one of two things, either an obstruction problem. So, there’s a blockage, even though there’s normal sperm functions and the hormones coming from the brain or, or find that sperm actually is getting obstructed from coming out at some point from the testes to the end of the penis. The other option is a non-obstructive cause, which is usually coming from either problem in the hormones being made in the brain, acting on the testicle or the testicle itself, which might not be functioning.
So, let’s start with the top level of the brain. If those hormone levels have come back very low, then we would be concerned that you’re not making these hormones to actually act on the testicle. Quite often then all we need to do is actually replace those hormones and the testicle should eventually then come back to normal functioning. There are a variety of reasons for this to happen, sometimes it’s something you’re born with a situation called Coleman syndrome. Sometimes you might have had brain surgery or radiation or something like that that can actually affect the function of the brain.
So, let’s say this is the case and there isn’t enough of this LH and FSH hormone to actually tell the testicle what to do. What do we do then? We’ll replace them with injections. This is a course of treatment. It’s unfortunately not an instant fixer sperm does usually take around about 80 days to be produced. So, we usually see that it takes between about six, about three and six months to be able to get good sperm samples. If we get a normal sperm sample, you can then try to conceive naturally at home. While on these injections, we can always freeze some samples for future use or if we are concerned about other factors or was taking too long, we might consider inseminations or even IVF. But the option is there to try and produce the sperm.
So next, let’s chat about a problem at the level of the testicle. So sometimes you might have had chemotherapy, radiation, testicular surgery, injury to the testicle. There might also be one of those genetic problems that I discussed earlier. So, you might have an abnormal karyotype, so the baseline genetics might not be quite what they should be. Sometimes the testicle then might fail, by fail we mean almost like a male menopause where the testicle will stop making the sperm and all the hormones that it needs to make. If that is the case and we can’t actually get the testicle to respond normally then what we usually find is very high levels of these hormones coming from the brain.
If you think about it in terms of, if you’re trying to push a couch and the couch doesn’t move what do you do? You push harder? That’s what your brain is doing, your brain is making that FSH and LH hormone to tell the testicle to respond. The testicles is not responding by making testosterone, so the brain is pushing harder with higher levels of hormones. So, when we see these very high levels of hormones, often, slightly smaller, or firm testicle we get very concerned, there’s nothing we can really provide medically to try and make that testicle respond.
So, in the situation, obviously everything needs to be individualized. Some men might still be offered the chance of a surgical retrieval. So, I’m going to cover this in a bit more detail under the obstructive Azoospermia section, but this would then be when we actually take a little sample of the testicle and try to find sperm. We can always give you an idea of what we think the success rate will be with this, because sometimes when the hormone levels aren’t too high and when the testicles themselves are not feeling too small or too firm. We might think there’s a chance of actually retrieving sperm this way and that might be an option and alternative to the spot will always be sperm donation. We do have sperm banks, your partner, and you can choose a sperm donor and we can then do treatment using the sperm donor.
So, when we talk about obstructive Azoospermia, what we mean is that the hormone is coming from the brain are normal. The testicle is functioning normally and making sperm it’s just, there’s some kind of obstruction to how the sperm is getting from the testicle, obviously out through the ejaculate into the vagina. Now this obstruction can be at a variety of levels, it can be in the epididymis, that little area that stores the sperm. It can be within the part that connects the epididymis and the testicle to the base of the penis, and eventually out through the end of the penis. And they can be a variety of different courses for these obstructions.
The most obvious cause is an intentional obstruction, a vasectomy which is a male sterilization. And sometimes even when this has been reversed, if it hasn’t worked and there’s an obstruction, you might still find that you can’t get the sperm all the way out and you might still have Azoospermia. Other causes might be infections such as STDs, surgery that’s been done in the area for example, to the prostate or hernias in the groin area. And also, very importantly, absence of that duct from the testicle that connects it all the way to the end of the penis. So, this is something that you’re born with and that’s why we examine to make sure that it is there. And that specifically, when we’re going to be doing cystic fibrosis testing to make sure that you are not a carrier for cystic fibrosis when you are lacking that special pipe.
So, when it comes to obstructive Azoospermia, we do have a couple of treatment options. If you’ve had a vasectomy and you would like this reversed, we don’t actually offer vasectomy reversals, you, we need to see a urologist who is trained in this specifically. So, vasectomy reversal is an option. As an alternate option, we can always offer a surgical retrieval of sperm. The important thing to notice when we do surgically retrieve sperm, this is not a way that you can then conceive naturally, and we can’t do inseminations. For an insemination, we will need a couple of million sperm at least and when we do this procedure, we are usually retrieving sperm in a very small quantity, which will be enough for us to do what we call ICSI. So intracytoplasmic sperm injection, when we take the little sperm and actually inject it into the egg directly. So, the moment we do a surgical retrieval, we’re talking IVF as a treatment option to fall pregnant.
So, how does this work? Most men are very uncomfortable discussing the idea of a surgical retrieval. Not to worry, it’s not so bad: what will happen is you’ll come into our clinic, you’ll see the anesthetist. The anesthetist will obviously knock you out so you’re not feeling anything. It’s not a full anesthetic in terms of major surgery, where you’re actually paralyzed, and we breathe for you. Throughout this procedure, you will breathe for yourself, but you will be completely unaware of what is happening. We will numb the area where we want to do the retrieval, we will make a very small incision, it’s usually about a centimeter in size. We will then open up the different layers of the testicle to get to the tissue. We will then take a sample of this tissue, which is passed directly to our lab, the lab will then prepare the sample and have a look for sperm.
If we find sperm excellent, we are very happy with this. If not, we might opt to then move to the other testicle and make a second incision there. Once we’ve done that, we will close it up with a little stitches usually under the skin. We’ll make sure that it’s nice and numb. We provide very supportive dressings and we always recommend that you then were very supportive underwear. We’ll make sure that there’s no swelling, there’s no major issues and we’ll be able to send you home with some painkillers. It usually takes a couple of days for you to go back to normal. It will feel like you’ve been kicked between the legs unfortunately, but every day should be better than the day before. The testicle will swell up a little bit, we do advise that you refrain from intercourse and that you refrain from any sporting activities or exercise until completely healed.
So, once we’ve got that sperm sample, we can either freeze it or use it in the future. Or what we can also do is if it’s done part of an IVF cycle, we would prepare that sperm and then use it in that cycle to inject the eggs for your partner. So, some of the options that we might consider, if this doesn’t work might be trying to supplement with some of those injections that we previously would have used. The FSH injections and those LH injections to try and make sure that we can try and boost the brain activity. They’re very specific patients we would consider the same and we might recommend seeing one of a specialized urologist for what we call a micro teaser.
Now that’s a testicular biopsy that it’s called micro, but it’s a bit of a bigger operation. What they will actually do is open the entire testicle and search through all the little pipes where sperm is produced one by one to try and find little areas where this still sperm production. This is basically working on the idea that where we are biopsied, maybe it wasn’t sperm, but in another area, there might be some sperm production. This is something that a specialized urologists will do, and we don’t do it simply because it is a lot more invasive and there’s always that chance that it might cause some decrease in the testicular function afterwards. But this is an option we can consider.
We do always have to mention the other option, which would be using sperm donation. So, we do have a sperm bank and while it’s always a very difficult decision to get to that point to say, we’d stopped in trying to retrieve sperm on you specifically. There’s something to consider when we ran out of options so that your partner can conceive. That would obviously be a little less invasive simply because we would be doing inseminations and not necessarily IVF, unless she requires IVF for another reason. If we are doing a surgical retrieval, one of the things we like to often do is actually take a little bit of that sample and send it off to the normal laboratory. There they will have a very close look at that sample and try and understand what the underlying problem is. We try and see where the problem with sperm development is? Does it start early in the sperm production cycle? Does it start late, is it all over the sample? Is it only in specific areas? That also gives us a very good understanding whether we think you would benefit from some of these injections and a more invasive kind of testicular biopsy.
So, the important take home messages about finding no sperm in the sperm sample is that we do need to go through the whole investigation process. We need to do the blood tests, the examination, sometimes the genetic testing, and then we can decide what we think the best treatment options might be. While it’s not a one size fits all solution, where we now find experiment the sample. Once we’ve individualized, the underlying causes, we can usually find the most appropriate treatment. And when we reach the end of the line and we haven’t unfortunately gotten any sperm, there is always the option of sperm donation to consider.
So what I encourage every male patient who’s been told there’s no sperm in the sample to do is to ask your doctor for a clear explanation as to what tests are going to be done and why, what those test findings mean so that you understand where the issue is, is it coming from the glands in the brain? Is it coming from the testicle itself or is there an obstruction? That way you can better understand why the treatment that has been recommended for you has been recommended and you can understand all of your treatment options. Remember that knowledge is power and not having sperm in the sample is no reflection on your masculinity. It’s simply telling us that there is some kind of a physiological issue underneath, and we need to try and get around this.
So, thanks for joining me today for our chat about Azoospermia. If you have any questions, please feel free to message us. You can get ahold of us on our Instagram page, our Facebook page, you can send us messages via our YouTube channel. With this video will be posted there and you can always email us at firstname.lastname@example.org.
We’re always happy to answer your questions and to try and help you as best as we can until next time stay safe.