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NIL sperms (Azoospermia)
What is Nil Sperms
Causes of Nil Sperms
Investigations & Diagnosis of Nil Sperms
Treatment of Nil Sperms
Response of Treatment
What is Azoospermia (Nil Sperm):
Azoospermia is called when there is no sperm in semen. This type of
semen disorder is found in approximately 3% of infertile men i.e.
absent sperm. You should know that testis has two separate functions
Production of normal sperms in semen which needed for pregnancy
& normal fertility.
The other function of testis is production of male hormones
i.e. testosterone & others. So in most patients with nil sperms though
semen has absent sperms still production of male hormones remains
How sperms develop:
When boy becomes of 14 years of age then L.H. & F.S.H. hormone
secretion from pituitary increases. The rise in these hormones leads
to proliferation of sperm forming cells (Germ Cells) in the testis.
These germ cells start multiplying under the effect of above-mentioned
pituitary hormones along with assistance of other hormones as
testosterones, Growth hormones, Androstenidione, insulin like growth
factor-I, Thyroids hormone, paracrine hormone & growth factors. Under
the control of above-mentioned hormones germs cells divide &
transformed into primary spermatocytes. Then further maturation of
primary spermatocytes to spermatids & then finally into mature
spermatozoa (i.e. normal sperms) occurs under the control of
above-mentioned hormones. After few weeks of progressive maturation
inside the testis these sperms become normally motile & develop the
capacity to fertilize the ovum. This total sperm cycle, from first
stage to final stage of normal mature sperms is of three months. Thus
to produce normal sperms testis should have normal sperm producing
germ cells & normal regulating hormones. Any major hindrance in the
development of these spermatozoa will lead to absent sperm production
resulting into nil sperm..
Causes of Nil Sperms: The
various causes of nil sperm are as follows :
Hormone disorder : The various endocrine (Hormone) disorder
leading to azoospermia are as follows
(i) Hormone deficiency of pituitary gland as L.H., F.S.H.,
Prolactin, thyroids hormone, hypothalmic deficiency of GnRH, Pituitary
gland failure, Hypopituitarism, Idiopathic hypopituitarism, Kallman
syndrome, Isolated hypogonadotropic hypogonadism, Drugs, toxins,
Idiopathic hypogonadotropic hypogonadism & due to many more causes.
(ii) Obstruction in the outflow of semen (Sperms) from testis
to outside through urethral opening. Many times the production of
sperms in testis is absolutely normal but these sperm are unable to
come out due to obstruction in the out flow tract leading to absent
sperms in the semen. The various causes of obstruction are absent vas
deferens, absent seminal vesicle, posttraumatic, post surgical
ligation of vas deferens. After some infections, as chlamydial,
gonococcal urethritis. It may also be due to post tubercular
epididimo-orchitis. The sperm may also not come out of testis if the
are imotile due to any of the following causes as imotile cilia
syndrome, kartagener syndrome cystic fibrosis & many other rare
(iii) Absence of germ cells in testis also called sertoli cell
only syndrome. In this there are no germs cells i.e. sperm forming
cells in the testis. For you knowledge, I wish to inform you that in
testis germ cell come to testis from neural cord area of the body
during neural cord area of the body during development of fetus. So in
some fetuses this migration of sperm cells do not occurs leading to
testis only having testosterone forming & sertoli cells. Thus this
condition is called sertoli sell only syndrome it is a developmental
(iv) Maturation Arrest (. Spermatid arrest): of primary
spermatocytes to secondary spermatocyte, spermatids or to mature
spermatozoa. Due to may local, systemic, hormonal growth factor
deficiency or due to idiopathic factor. The various paracrine hormones
and growth factors are essential for normal development i.e.
maturation of one germ cells to multiplication of ultimately
production of multiple mature, normal & motile sperms. Many other
factor as infection, varicocele, drugs, chemotherapy may also lead to
maturation arrest. The other causes may by developmentally defective
germs cells & spermatocyte. So that they did not have inherent
capacity of developing into a mature & motile sperms.
4) Testicular disorders (primary leydig cell dysfunction),
Chromosomal (Klinefelter syndrome and variants, XX male gonadal
dysgenesis), Defects in androgen biosynthesis, Orchitis (mumps, HIV,
other viral, ),Myotonia dystrophica, Toxins (alcohol, opiates,
fungicides, insecticides, heavy metals, cotton seed oil), Drugs (cytotoxic
drugs, ketoconazole, cimetidine, spironolactone)
5) Varicocele (Grade 3 or more severe): A varicocele is a
varicose vein in the cord that connects to the testicle. (A varicose
vein is one that is abnormally enlarged and twisted.)
Varicocele decreases sperm productions by elevating temperature of the
testis, may produce higher levels of nitric oxide chemical in the
testis which blocks sperm production, varicocele damages sperms
directly & lastly varicocele decrease the oxygen supply to testis.
6) Drugs (e.g. spironolactone, alcohol,
ketoconazole, cyclophosphamide, estrogen administration, sulfasalazine)
7) Presence of Antisperm antibody. These
Antisperm antibodies bind with sperms & either make them less motile,
totally immotile or even dead which is called necrospermia
9) Environmental toxins
10) Viral orchits
11) Granulomatous disease as tuberculosis,
sarcoidosis of the testis
12) Defects associated with systemic diseases,
Liver diseases, Renal failure, Sickle cell disease, Celiac disease
13) Neurological disease as myotonic dystrophy
14) Development and structural defects, Germinal
cell aplasia, sertoli cell only syndrome, Cypt-orchidism
15) Androgen resistance
16) Mycoplasma infection
17) Cystic fibrosis patients often have missing or obstructed
vas deferens (the tubes that carry sperm) and hence a low sperm count.
18) Klinefelter syndrome patients carry two X and one Y
chromosomes (the norm is one X and one Y), which leads to the
destruction of the lining of the sperm forming germ cell in the
19) Environmental Assaults: Over exposure to environmental
assaults (toxins, chemicals, infections) can cause nil sperm either by
direct suppression of sperm production or on the hormone. Some
chemicals that affect sperm production men are: Oxygen-Free Radicals,
Estrogen emulation pesticidal chemicals (DDT, aldrin, dieldrin, PCPs,
dioxins, and furans), plastic softening chemicals like Phthalates,
hydrocarbons (ethylbenzene, benzene, toluene, and xylene)
20) Exposure to Heavy Metals: Chronic exposure to heavy metals
such as lead, cadmium, or arsenic may affect sperm production and may
cause nil sperms in otherwise healthy men. Trace amounts of these
metals in semen seem to inhibit the function of enzymes contained in
the sperms, the membrane that covers the head of the sperm.
20) Radiation Treatment: Over-exposure to radiation & xrays
affect any rapidly dividing cell, so cells that produce sperm are
quite sensitive to radiation damage. Cells exposed to significant
levels of radiation may take up to two years to resume normal sperm
production, and, in severe circumstances, may never recover.
21) Misuse of substances: There are a
number of banned substances that can have potentially lethal effects
on sperm production. Taking anabolic steroids, for example, to
increase performance in sports such as weight lifting, can
dramatically alter both the motility and the health of the
spermatozoa. Other banned substances, such as cocaine, marijuana and
heroin can reduce sperm production & may make a man infertile.
22) HGH Deficiency
Diagnosis of Cause of Nil Sperm Count
For correct diagnosis of
cause of nil sperm count, we need detail history & physical
examinations then certain relevant investigations are required.
History & Physical Examinations: First
step in proper treatment is accurate diagnosis of cause of nil sperm
count. So we first try to find out cause. We take detailed history,
thorough drug history, and general physical examination, examination
of testis, epididymis & testicular veins & sperm carrying duct
examinations. These examinations give idea about whether testis is
normally developed or not & how is its function. After that depending
on likelihood of particular, cause
relevant tests are done. All testing
facilities are available at our centre. Thus you may consult us at our
centre & at same time you may get all tests done. The time taken in
getting all the reports ready is 36 hours. So if you are from out of
Delhi, you may come here for two days.
Investigation & Diagnosis: For
completes diagnosis of causes of azoospermia (nil sperms) one or more
of the following tests may be required as:
1) Complete male
: This profile includes all the male hormone tests
which affect testicular development, growth & other genital organ
development as well as genital functions. L.H., F.S.H., Testosterone,
prolactins, thyroids test,
3) USG or Doppler study
of scrotum & testis
4) Semen culture
5) Semen fructose
6) Fine Needle
Testicular Biopsy of the testis to look for evidence of
spermatogenesis & testicular structure.
8) Human Sperm-Zona
Pellucida Binding Ratio
9) Human Sperm-Zona
Pellucida Pentration test
10) Genetic Studies
11) FNAC Testis
12) Egg penetration
13) Molecular genetic
studies done in some special cases
14) Chromosome analysis
i.e. Karyotype (chromosome analysis)
15) Assessment of
16) Combined Pituitary
hormone tests is performed when needed
17) Immunobead test
18) MRI head, Hemogram,
test for systemic diseases.
19) Olfactory test is
done to find out kallman's syndrome
At our center
facility for all the above tests are available.
Treatment of Nil
finding out cause of azoospermia treatment is started depending on the
The various treatments are as follows:
First of all we try to find out the primary
cause of nil sperms by above mentioned investigations. Then we correct
the basic defect i.e. correction of hormone disorder & other defects.
We also give following treatment for permanent cure of low sperm count
& motility disorder.
Correction of Hormone
Once the hormone
is found then it is
corrected by any of the below medicines. Usually sperm count
normalizes in three month time with proper hormone treatment.
2) Gonadotropin Therapy: Gonadotropins are
most potent natural stimulators of sperm production in the testis.
Once we start gonadotropin therapy, these gonadotropins stimulates the
sperm producing cells in testis. Under the stimulating influence of
gonadotropins dormant sperm forming cells which were not producing any
sperms, they start dividing & produce multiple immature sperm cells
with in three to four weeks. These are further matured in next two to
three month into mature sperms under the influence of gonadotropin
treatment. Thus in more than 90% cases sperm production can be
normalized in three to four months time if it is started in properly
selected cases of nil sperms. Gonadotropin therapy is most successful
of all the available treatment for nil sperms till now. In many cases
of nil sperm count, when all other treatment has failed even in those
cases gonadotropin therapy is effective. Thus treatment of nil sperms
with gonadotropin results in pregnancy soon.
Gonadotropin-releasing hormone (Gn-RH)
7) Growth hormone therapy in many cases
where somatropin deficiency is found
8) In cases of Antisperm antibody induced
cases treatment is sperm washing followed by intrauterine
insemination, steroid use or intra-cytoplasmic injection of sperms (ICSI).
Growth Factor, Mineral & Micronutrient
9) Free Radial Scavengers: These are drug
to reduce the free damaging oxidative radical in the testis. For your
information every minute lot of oxidant radicals are generated inside
the testis which damages sperm forming cells. These special
antioxidant drugs scavenge these damaging oxidative free radicals thus
leading to production of normal sperms by the testis. In many study
these free radical scavengers have been found to be very-very
effective in normalizing sperm count.
10) Coenzyme ubique: These drugs improve
the nutritional status of the testis. Thus sperm forming cells get
enough nutrient which helps in fast generation of sperms in good
number with good motility & fertilizing capacity.
11) carnititine supplimentation increases
the production of sperm, with normalization of sperm count in three
13) Bromocriptine. This medication is for
men who has elevated levels of prolactin, then this hormone rise
decreases the sperm production
14) Correction of thyroid hormone
15) Correction of congenital adrenal hyperplasia
27) Certain Newer Drugs has been found very
28) Surgery: Depending on the surgery may
be a treatment option for nil sperm count due to blockade of the tract
from testis to the tip of penis (i.e. obstructive azoospermia).
Surgery is also the treatment of choice for significant varicocele.
Similarly surgery may be one of the treatment options for many
Surgical reconstruction When obstruction in transport of sperm
from testis to outside is diagnosed, it is treated by surgical
reconstruction. All this surgical treatment facility is provided by
our expert micro surgeon. In this obstruction segment is bypassed by
29) But there are many cases of azoospermia in
which inspite of best treatment sperm production either does not
improves or is impossible. In these cases we do fine needle testicular
biopsy in which sometimes we may get some normal sperms or even
spermatids. These spermatocytes or sperms are then injected in ovum
leading to formation embryo. These embryos are ten transferred into
uterus leading to achievement of pregnancy.
30) But in some cases inspite of all efforts no sperm can not be
produced. In such cases we advise
artificial insemination by semen
r. In this normal semen is taken from sperm i.e. semen
bank. This is one of the very successful method of treatment with
minimal cost involvement.
31) Test tube baby is also delivered
with our efforts by use of intra-cytoplasmic sperm injection (ICSI),
then transfer of embryo to uterus of mother.
32) Semen Bank: Facility for good quality
sperm is semen bank in also available. At our center we have facility
for all the testing & treatment facility required for low sperm count
to achieve pregnancy.
33) Assisted reproductive technology (ART)
ART has revolutionized the treatment of infertility. Each year
thousands of babies are born in India as a result of ART. Medical
advances have enabled many couples to have their own biological child.
The most common forms of ART include:
In vitro fertilization (IVF).
This is the very effective ART
technique. IVF involves retrieving mature eggs from a woman,
fertilizing them with a sperm from sperm bank in a dish in a
laboratory and implanting the embryos in the uterus three to five days
Surgical sperm aspiration.
This technique involves removing sperm
from part of the male reproductive tract such as the epididymis, vas
deferens or testicle. This allows retrieval of sperm if blockage is
Intracytoplasmic sperm injection (ICSI).
This technique consists
of a microscopic technique (micromanipulation) in which a single sperm
is injected directly into an egg to achieve fertilization in
conjunction with the standard IVF procedure.
A varicocele is an
abnormal tortuosity and dilation of veins of within the scrotum. It
can be surgically treated - which might help fertility in some cases.
At our center we have facility for all the
testing & treatment facility required for nil sperm count to achieve
Response of Treatment: By above
treatment many patients are cured in three to four months times. But
if we diagnose that this problem is not curable in such cases we tell
the patient that your problem is incurable & suggest them other
available options as test tube baby, ICSI, AIH etc..
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appointment / or online) click
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