Definition
No sperm are seen in the ejaculate or in the post-centrifugation pellet.
Male Infertility · No Sperm in the Ejaculate
Azoospermia: Diagnosis and Treatment Options
Azoospermia means that no sperm cells are found in a semen sample, including after centrifugation and pellet examination. Obstructive causes should be distinguished from impaired sperm production.
- Diagnosis is confirmed with at least two appropriately performed semen analyses
- Obstructive and non-obstructive azoospermia are distinguished
- Genetic findings can influence surgical planning and counselling about inherited risks
Understand the topic in one minute
Azoospermia Quick Summary
Two main groups
Azoospermia is classified as obstructive when sperm transport is blocked and non-obstructive when sperm production is severely impaired.
Diagnosis
Repeat semen analysis, clinical examination, hormone tests, genetic assessment and ultrasound when indicated are used in diagnosis.
Treatment
Depending on the cause, reconstruction, epididymal or testicular sperm retrieval and ICSI may be considered.
Key information
What Is Azoospermia?
Azoospermia does not mean absence of semen; it means that no sperm cells are found in the semen sample.
In brief:
Diagnosis is generally confirmed in at least two appropriately collected samples with detailed post-centrifugation examination. The next step is to determine whether the cause is obstruction or impaired sperm production.
In obstructive azoospermia, sperm production may be preserved in the testes, but sperm cannot reach the ejaculate because of causes such as congenital absence of the vas deferens, infection, surgery or vasectomy.
In non-obstructive azoospermia, sperm production is severely impaired. Small focal areas of sperm production may nevertheless remain, and Micro-TESE may be considered to search for sperm in selected patients.
Low semen volume, FSH and testosterone levels, testicular volume, examination of the vas deferens and genetic findings can help with classification.
- Diagnosis is confirmed with post-centrifugation pellet examination
- Obstruction is distinguished from impaired sperm production
- Karyotype and Y-chromosome microdeletion testing are requested when indicated
- Patients with complete AZFa/AZFb deletions should be counselled that surgical sperm retrieval is generally not expected to be successful
Treatment options
The Difference Between Obstructive and Non-Obstructive Azoospermia
In both conditions no sperm are found in the ejaculate, but testicular sperm production and treatment options differ.
Obstructive Azoospermia
Sperm production is often preserved, but sperm transport through the reproductive tract is blocked.
- Testicular volume and hormone levels are often relatively preserved
- MESA, PESA or TESE may be options
- Reconstructive surgery may be considered in selected cases
Non-Obstructive Azoospermia
Sperm production in the testes is markedly reduced and may persist only in focal areas.
- Hormonal and genetic assessment is important
- Micro-TESE is commonly preferred in selected non-obstructive cases
- Sperm retrieval cannot be guaranteed
Why should cryptozoospermia be distinguished from azoospermia?
Finding a very small number of sperm after centrifugation is cryptozoospermia rather than azoospermia and may change treatment planning.
Who should be assessed?
Who Should Have an Azoospermia Assessment?
Any man in whom no sperm are seen on an initial semen analysis should have a structured assessment.
Repeated finding of no sperm
The diagnosis should be confirmed and sample-related error excluded.
Low semen volume
Ejaculatory dysfunction, congenital absence of the vas deferens or ejaculatory-duct obstruction may be investigated.
High FSH or small testes
These findings can increase suspicion of impaired sperm production.
Normal hormones and normal testicular findings
Assessment for possible obstruction may be appropriate.
Chemotherapy or testicular injury
History of gonadotoxic treatment or testicular surgery is relevant.
Genetic or congenital findings
Specific counselling is required for conditions such as Klinefelter syndrome, Y-chromosome microdeletions or congenital absence of the vas deferens.
Does every patient with azoospermia need TESE?
No. Surgery should not be planned before reviewing genetic findings, the likely cause, the female partner’s fertility status and the most appropriate sperm-retrieval method.
Diagnosis and preparation
Which Tests Are Used to Diagnose Azoospermia?
The aim is not only to look for sperm, but also to identify the cause and relevant associated health risks.
Two semen analyses
The post-centrifugation pellet is examined microscopically.
FSH, LH and testosterone
These provide information about sperm production and the hormonal axis.
Physical examination
Testicular volume, epididymis and vas deferens are assessed.
Karyotype
Chromosomal analysis may be indicated in azoospermia.
Y-Chromosome Microdeletion Testing
Results can inform counselling about the likelihood of sperm retrieval and possible transmission to male offspring.
Ultrasound and CFTR assessment
These may be considered when obstruction, absent vas deferens or another anatomical cause is suspected.
Step-by-step process
How Is Azoospermia Treated?
Treatment is based on the diagnostic category and the couple’s reproductive goals.
Confirm the diagnosis
A repeat semen analysis and pellet examination are performed.
Classify the cause
Medical history, examination, hormone levels and semen volume help with the initial distinction.
Genetic assessment
Relevant tests and genetic counselling are completed when indicated.
Female-partner treatment plan
Age and ovarian reserve influence the timing of surgical sperm retrieval and IVF.
Approach to obstructive azoospermia
Reconstruction or sperm retrieval from the epididymis/testis may be considered.
Approach to non-obstructive azoospermia
In selected patients, Micro-TESE is used to search for focal areas of sperm production.
Laboratory sperm search
Tissue is examined promptly and systematically in the embryology laboratory.
ICSI and cryopreservation
Retrieved sperm may be used fresh or suitable sperm may be cryopreserved.
Timeline
How Long Does Azoospermia Assessment Take?
Diagnostic and genetic testing may take several weeks; the surgical procedure is scheduled separately.
Confirmatory semen analysis
Two separate samples are generally required.
Hormone tests
Results may be available relatively quickly.
Genetic tests
Turnaround time may be longer depending on the laboratory.
Ultrasound
This can often be performed on the same day.
Surgical plan
Timing is coordinated with the female partner’s IVF schedule.
Sperm search
Laboratory assessment is performed on the day of the procedure.
How many days do I need to stay in Cyprus?
The diagnostic consultation itself may be brief. TESE or Micro-TESE often requires the procedure day and short follow-up, although coordinated IVF may change the required stay.
Factors affecting outcomes
What Factors Affect the Chance of Finding Sperm in Azoospermia?
No single hormone level or examination finding can reliably predict sperm retrieval.
Type of azoospermia
Sperm retrieval is generally more likely in obstructive azoospermia.
Underlying testicular sperm production
Whether focal sperm production is present in the testis is important.
Genetic findings
Findings such as complete AZFa/AZFb deletions can determine whether sperm-retrieval surgery is appropriate.
Previous surgery
Previous biopsy or testicular damage can influence surgical planning.
Microsurgical and laboratory expertise
Microsurgical technique and the laboratory’s experience with immediate tissue examination are important.
Female-partner factors
Embryo and pregnancy outcomes after sperm retrieval also depend on oocyte age and quality.
Important distinction:
Finding sperm, achieving fertilisation and achieving a live birth are different outcomes. Even when sperm are retrieved, ICSI, embryo development and pregnancy each have separate uncertainties.
Personalised cost planning
Azoospermia Assessment and Treatment Costs
Costs vary according to diagnostic tests, the surgical method and the IVF laboratory plan.
Repeat semen analysis
Confirmation including post-centrifugation pellet examination.
Hormone tests
FSH, LH, testosterone and selected additional tests.
Genetic tests
Karyotype, Y-chromosome microdeletion testing and CFTR assessment when indicated.
Imaging
Scrotal or transrectal ultrasound.
Surgical sperm retrieval
TESE, Micro-TESE, PESA or MESA.
ICSI and cryopreservation
Use of retrieved sperm, cryopreservation and storage.
Find out what your individual plan may include
Share your semen analyses, hormone and genetic results so the appropriate diagnostic and surgical steps can be reviewed.
Laboratory and traceability01 02 03 04 05 06
Tissue Examination and Sperm Traceability in Azoospermia
Surgical tissue should be handled through an uninterrupted identity and documentation chain between the operating theatre and embryology laboratory.
Pellet confirmation
A detailed post-centrifugation search is performed when confirming azoospermia.
Tissue transfer to the laboratory
Tissue from each sampled testicular area is labelled separately and transferred to the laboratory.
Mechanical tissue processing
Seminiferous tubules are processed carefully and examined microscopically for sperm.
Viability assessment
Viability of immotile sperm may be assessed using appropriate laboratory methods when needed.
Cryopreservation
Suitable retrieved sperm may be stored in small, traceable aliquots.
ICSI identity matching
The sperm and oocyte sources are verified through the laboratory identity system.
Multidisciplinary approach
Azoospermia Clinical and Laboratory Team
Urology/andrology, the IVF physician and embryology laboratory coordinate timing.
Obstetrics, Gynaecology and IVF Specialist
Op. Dr. Beril Yüksel
Coordinates the female partner’s IVF and oocyte-retrieval timing with surgical sperm retrieval.
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Scientific Director
Prof. Dr. Münevver Serdaroğulları
Coordinates diagnosis, genetic counselling and multidisciplinary treatment decisions.
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Embryology Laboratory Director
Zafer Atayurt
Manages laboratory sperm search in surgical tissue, viability assessment, ICSI and cryopreservation.
View profile →Urology and andrology assessment
Classification of azoospermia and surgical sperm retrieval should be planned by an appropriate urology/andrology specialist.
Balanced information
Risks and Limitations of Azoospermia Treatment
Realistic expectations and genetic counselling are important parts of treatment.
No sperm retrieved
No sperm may be found during TESE or Micro-TESE.
Surgical risks
Pain, bleeding, infection, haematoma and temporary changes in hormone levels can occur.
Genetic risk
Some genetic causes may be transmitted to male offspring.
Surgery unlikely to be beneficial
Surgical sperm retrieval is generally not recommended with complete AZFa/AZFb deletions.
Limited number of sperm
The number of retrieved sperm may be insufficient for freezing or repeated future use.
No guarantee of pregnancy
Finding sperm does not guarantee embryo development, pregnancy or live birth.
Common questions
Frequently Asked Questions About Azoospermia
Key information about diagnosis, genetic assessment and sperm-retrieval options.
What is azoospermia?
It means that no sperm cells are found in the semen sample, including after centrifugation and pellet examination.
Can azoospermia be diagnosed with one test?
It is generally confirmed with at least two appropriately performed semen analyses.
Is azoospermia the same as absence of semen?
No. In azoospermia, semen may be ejaculated but no sperm are present in it.
Is biological parenthood possible with azoospermia?
Depending on the cause, surgical sperm retrieval followed by ICSI may make treatment possible, but success cannot be guaranteed.
What is obstructive azoospermia?
Sperm are produced but cannot reach the ejaculate because of obstruction or absence of part of the reproductive tract.
What is non-obstructive azoospermia?
It is a condition in which sperm production within the testes is severely impaired.
Which genetic tests may be used in azoospermia?
Karyotype and Y-chromosome microdeletion testing are commonly considered; CFTR testing may be appropriate when congenital absence of the vas deferens is suspected.
Is TESE or Micro-TESE used in azoospermia?
The method depends on whether obstruction or impaired production is present; Micro-TESE is commonly preferred in selected cases of non-obstructive azoospermia.
Does high FSH mean sperm cannot be found?
High FSH may be associated with a lower retrieval probability but cannot predict the result with certainty on its own.
Can Micro-TESE be repeated if no sperm are found?
It may be discussed in selected cases after reviewing previous surgical findings and genetic results.
Is donor sperm the only option in azoospermia?
No. The cause and possible surgical sperm-retrieval options should be assessed first; donor sperm is a separate treatment option.
How long does azoospermia treatment take in Cyprus?
Diagnostic tests may be completed in advance; the surgical procedure and short follow-up can often be planned within a brief stay.