Was Van Gogh Azoospermic?
At the beginning of the office visit, I like to ask men with no sperm in the ejaculate who are unable to conceive a simple question: “What crossed your mind when you first heard that you were azoospermic?” The answers varying greatly but are very telling:
- “It must be a mistake.”
- “I shouldn’t have joined that fraternity in college…”
- “It wasn’t the best sample I’ve ever done.”
- “I was simply and utterly devastated.”
- “I was in shock and then got really depressed.”
- “It changed my life…I always thought that I would be a father.”
The Meaning of Azoospermia
Azoospermia is the lack of sperm in the ejaculate. It can be due to a blockage in the system (obstruction) or failure of the testicles to make sperm (nonobstructive). The most common reason for blockage is a vasectomy. Other causes include infections, prior surgery, injury or congenital absence of certain reproductive tract organs. Failure to make sperm can be due to exposures (hot tubs), medications, varicocele, a history of undescended testicles, cancer and cancer treatment. However the largest chunk of men with poor sperm production have none of these issues. Instead, they have a subtle genetic cause: either they are missing genes on the Y chromosome or have other chromosomes harboring subtle alterations that do not otherwise affect their health or lives.
So, like Captain Renault in the movie Casablanca, most men with azoospermia are “shocked, shocked!” because they feel so normal in every other way. And the vast majority are normal (as normal as men can get) in every other way. Most of the things they worry about, like college indiscretions, are exposures that are entirely reversible with time. My response is usually to allay fear and guilt by saying: “This is not something that you have done to yourself; let’s see if we can do something about it at this point.”
Treating Azoospermia
In fact there is a whole lot that we can do with azoospermia. Men with blockages can often be unblocked with microsurgery, one of my favorite things to do. This gives them the chance to conceive naturally again. And most men with poor production as a cause of azoospermia will have pockets of sperm in the testicles that can be identified by techniques like sperm mapping and that can be used for high-technology pregnancies.
What I have learned after caring for hundreds of azoospermic men over two decades is that they really don’t care what their sperm counts are as long as they can be fathers. And once they are fathers, it is clear that that “azoospermic feeling” goes away, as it should.
Related posts:
Karim ZINE
January 26, 2012
Hello Doctor,
I wish you my best wishes for this year.
I do not know if you remember me …?
Karim Paris with azoospermia, varicocele treatment in January 2010, a sperm in April 2010 and nothing since.
I have a repeat semen analysis in January 2012 and we still found a sperm alive but immobile.
We have a biopsy scheduled for February 20 this year.
In your opinion what are my chances?
Really thank you for your answer.
Paul Turek, MD
January 26, 2012
Karim, hard to say. Typically, when even small numbers of sperm are found in the ejaculate, FNA Mapping can find sperm in the testis. However, with a testis biopsy, things are much more variable. Ask your doctor! Good luck.
AA
January 27, 2012
Hi doctor. My husband just found out that he too is azoospermic but not due to a blockage but the doctor thinks its because there is a part of his y chromosome which is reversed.Is this considered a deletion? Is there still a chance that he can produce sperm and if not is there a chance that there could be viable sperm if we do a biopsy.
Paul Turek, MD
January 27, 2012
Marium, although some kinds of y chromosome deletions might suggest that there will be no usable sperm in the testis (AZFa and AZFb deletions in particular), others are associated with substantial chances (AZFc, 60-70% chance of sperm). A simple testis biopsy has the lowest chance of finding sperm compared to FNA mapping (http://www.theturekclinic.com/testicular-mapping.html) or a microdissection. Best of luck!
AA
January 27, 2012
is sperm mapping only available in the states. I live in Alberta, Canada
Paul Turek, MD
January 28, 2012
It was invented in San Francisco and offered by me here and by fellows that I have trained in other countries including Israel, Argentina, Turkey, among others. Honestly, I haven’t trained any fellows who practice in Canada. Maybe consider a long weekend trip to San Francisco!
rabah
January 29, 2012
docteur je vous remercie pour le nobles services offert aux steriles comme moi. jai une azoospermie secretoire depuis 20 ans..biobsie= nombre de spermatozoide mals formes…fsh eleve..ya til un espoir avec vos efforts…je viens en mars a san fransisco pour une consultation..merci docteur de me repondre.
Paul Turek, MD
January 29, 2012
Rabah, I understand French. I am sorry that you have been suffering for 20 yrs. You are good fit for evaluation here. Consider calling 415-392-3200 to continue off line.
Arnaldo
February 25, 2012
Hello doctor! I am from San Juan, Puerto Rico.48 yr old male with hx of azooespermia diagnosed at age 30 from a mumps orchitis at age 25-26. I had all tests and evaluations done at 30 and the doctor said my only chance was to do a testicular biopsy, but he said that chances were around 50%. Now I am having low T levels. My new wife would love to have children of my own. What are my chances? Do you any good colleague that you may recommend around my area? Thank you so much for your help. You may reply to my email: arnaldo.guzman1@upr.edu
Thank you!
Dr. A Guzman
Paul Turek, MD
February 26, 2012
Arnaldo. Great to hear from you. I have many cases of azoospermia due to mumps orchitis and we have published http://www.ncbi.nlm.nih.gov/pubmed/19400985) that 60-70% of men will have sperm on FNA mapping of the testis. Consider a call to 415-392-3200 to discuss further.
KVR
March 27, 2012
I went for semen analysis last week, here is the report details
PHYSICAL EXAMINATION
———————————–
Volume = 1.0 mL
Liquefaction Time = 30 mins
Viscosity = Reduced
CHEMICAL REACTION
——————————-
Reaction = Alkaline
Fructose = Present
MICROSCOPIC EXAMINATION:
——————————————
Sperm count = No Sperms
OTHER MICROSCOPIC FINDINGS
————————————————
Pus Cells = 8-10/hpf
RBC’s = Nil
Epithelial Cells = Nil
Sperm Aggregation = Nil
Please tell me, how can in interpret this analysis.
Is this obstructive azoospermia or non-abstuctive azoospermia
or anything else.
I am devastated, please kindly help
Paul Turek, MD
March 27, 2012
Dear KVR, a semen analysis, when properly performed, can be very revealing. This one suggests a low volume ejaculate which could indicate a blockage either from ejaculatory duct obstruction or congenital absence of the vas deferens. The presence of fructose (if correct) suggests that at least one duct and seminal vesicle are open. Typically, one must explain the low volume ejaculate to explain the azoospermia. What’s missing is a centrifuged pellet analysis to see if even 1 or 5 or 10 sperm are present in the entire sample, which would make it more likely nonobstructive. Of course most valuable are the history, physical exam, and reproductive hormone levels (T, FSH, LH, prolactin) to complete this.
KVR
May 5, 2012
Dear Sir,
Thank you so much for previous reply, i went for couple more SA to confirm whether its a true azoospermia. All repeated (3 times) shows nil sperm count, so that confirms its azoospermia.
As per my doctor here, i went for physical examination, T, FSH, LH, Prolactin test, all came normal. But when they did FNSA, they could found the following.
Presence of Primary and Secondary spermatocyte and few spermatids, occasionally observed steroli cells.
How can i interpret this? my Doc said, the only option is ART(IVF/TESE) etc.
Is there anything i am missing here?
KVR
May 6, 2012
Hello Dr,
More details below
I took biochemistry tests like TSH, LH, Follicle Stimulating(FS), Prolactin and Testotirone all came back with normal range
and doppler ultrsound of scrotum+Trus came back with normal finding but “Midline simple prostatic cyst measuring 1.3 x 0.8 x 0.8 cms seen, vol-0.5cc. The cyst is seen at the antero superior aspect of the prostate” Dr said, no need to worry on it.
In FNAC – Testis, test found “Primary, Secondary spermatocytes and few spermatid. No sperm could be identified. Occasional Sertoli cells seen in the smears studied. Sertoli Cell index is 2-3/100 cells. and hence confirming MATURATION ARREST – Right and Left Testis.”
Paul Turek, MD
May 6, 2012
Dear KVR, hard to give accurate advise on-line. Sounds like nonobstructive azoospermia and not ejaculatory duct obstruction. Not sure if you had a “mapping” procedure as part of your FNAC as I have described or not, but when “few spermatids” are found on mapping, there is almost always a mature sperm nearby. Consider sending me the glass slides from the “FNAC” procedure and I would be happy to review them again.
KVR
May 8, 2012
Thanks you very much for the response sir.
Please provide me the address, i will send you the slides.
Paul Turek, MD
May 8, 2012
The Turek Clinic
55 Francisco St
Suite 300
San Francsico, CA 94133
Call 415-392-3200 to organize
sekar
April 16, 2012
Dear Sir,
My friend got married 7 months before. They are having good sex life and trying for baby. His wife is not getting pregnant. He did Semen Analysis and got report as follows.
Semen Analysis (azoospermia)
Color : Greyish White
Volume : 10ml
Viscosity : High
Reaction : Alkaline
liqufication : prolonged ( a case of azoospermia)
My question is
1) what is azoospermia?
2) Any natural way to overcome this?
3) Any further testing required for this?
Please revert ASAP
Regards
Sekar K
Paul Turek, MD
April 16, 2012
Dear Sekar. thanks for asking. There is no mention of the sperm count in this report. It could be that the sample contains no sperm (azoospermia: see http://www.theturekclinic.com/azoospermia.html) or that it has a few sperm that were missed. It should be repeated. Then he needs hormone blood tests. If due to blockage then sometimes it can be fixed with microsurgery (see: http://www.theturekclinic.com/azoospermia.html). If not due to blockage it may either be treated medically or one can search for sperm in the testis with FNA mapping (see: http://www.theturekclinic.com/testicular-mapping.html). Your friend should start with a good local urologist. We can help if you want. Set up a time to call at 415-392-3200.
Sam , H
April 29, 2012
Hi doctor ,
I’m really glad to find you on the website ,
I’m having a problem since when I get married ,
I can’t have babies ,because I don’t have any sperms count !
But till now I don’t know the rason why ?
And non of the doctors I went to try to explain to me why ?
I have normal life and my family all have kids , sisters and brothers !
I’m 43 years old , and my wife 31 years old ,
Maybe I have some hope with you Doctor .
And you can help me with something !
At least just to know the reason ?!
I live in Tampa – Florida .
Pleas doctor let me know if we can do something !
I can send you all my papers , if you need it ,
Thank you so much ,
Hope to hear from you soon
Paul Turek, MD
April 29, 2012
Sam, Depending on what going on (blockage or no blockage as cause of no sperm count) the reasons can differ. In about 1/3 to half of cases, we can “explain” the problem. But in rest, they remain unexplained. HOWEVER, because they are unexplained DOES NOT MEAN that you cannot have a kid! Having a kid is simply a matter of looking hard enough for sperm. Consider a call to 415-392-3200 and setting up a call with me.
Brian Choi
May 4, 2012
Dr. Turek,
I have recently been diagnosed with Azoospermia. Its been confirmed on 2 separate SA, one done with strict morphology. I have an FSH level of 41.9 mIU/mL whereas my LH and testosterone levels are normal. I also had a doppler ultrasound it was also normal, with testicles are roughly normal size and no signs of varicoceles. The next step, given by the specialist that I’m seeing, was a biopsy and/or TESE/microTESE. I was wondering what sort of alternatives there were and between a biopsy and TESE/microTESE which one works best? And finally, where does FNA mapping fall w.r.t. to microTESE, as they sound somewhat similar from my novice perspective. Thank you.
Brian
Paul Turek, MD
May 4, 2012
Brian, Great question.
The “best” technique for finding out whether you have usable sperm in the testis when there are no sperm in the ejaculate depends on several factors: cost, convenience, accuracy, risks, complications etc. Here are the most common approaches taken however:
1. Single testis biopsy. Defines whether a blockage is present. There is a 20-30% chance it will identify sperm if there is no blockage. Relatively invasive (requires a cut). Sperm is not saved in general from this approach.
2. FNA Mapping. Defines whether a blockage is present. There is a 60+% chance that it will identify sperm if there is no blockage. Minimally invasive (no cut, mean recovery 1-2 pain pills); Sperm is not saved using this approach. Creates a “map” of testicular sperm production.
3. TESE (multibiopsy). Not great at defining obstruction, but tells you whether there is sperm present. Sperm can be saved. There is a 30-50% chance that sperm will be found if there is no blockage, but this depends on how many different biopsies are taken. Probably one of the most invasive of these techniques(many cuts).
4. Microdissection TESE: Not great at defining obstruction, but tells you whether there is sperm present. Sperm can be saved. There is a 40-60+% chance that sperm will be found if there is no blockage, depending on the expertise of both the surgeon AND the lab that the surgeon uses. The most invasive approach among all approaches (very large cut). Has a measurable chance of damaging the testicle to the point in which temporary or permanent testosterone replacement will be necessary afterwards.
Hope this helps. Feel free to set up a call with me by contacting us at 415-392-3200.
Brian Choi
May 4, 2012
Dr. Turek,
Your answer helps a lot, and is one of the reasons I scheduled a 10 mins consultation call to your office. I do not have a lot of money at my disposal, but I would like to survey all techniques and avenues in terms of sperm recovery (since I have a high FSH even amongst azoospermics from the medical papers I have read). Look forward to speaking with you very soon and discussing some quotes on pricing on FNA mapping as compared to other techniques. Thank you again.
Brian
Brian Choi
May 4, 2012
A follow up question on FNA mapping. Typically for a biopsy there is a 6 month lead time that follows to allow sufficient time for sperm to develop. Is there a similar time frame after an FNA mapping and sperm retrieval for IVF in this case? Thank you again for your time.
Brian
Paul Turek, MD
May 6, 2012
Brian, another good question. After FNA mapping, I suggest that men not do any further sperm retrieval procedures as follows:
When TESA (40% of men) indicated after mapping: proceed immediately
When TESE (40% of men) indicated after mapping: proceed immediately
When mTESE (20% of men) indicated after mapping: wait 3 months before proceeding
Brian Choi
May 6, 2012
That is also very helpful information Dr. Turek, and though my wife and I still have to figure out the finances of all these procedures, it is helpful to note that there is very little downtime between a positive FNA mapping result for finding sperm and a procedure to retrieve sperm for ICSI-IVF. Thanks again for your time and look forward to speaking with you and your staff very soon.
Brian
Brian Choi
May 7, 2012
Dr. Turek,
When you mention “after mapping: proceed immediately,” I just wanted to make sure I understood this correctly. I am assuming you mean that if FNA mapping results in positive results for finding sperm, then proceed immediately to TESA/TESE whereas wait ~3months if moving forward with mTESE? Also, when you say proceed immediately, are you stating that one can literally undergo TESA/TESE a few days (for instance) after FNA mapping? Thank you again for your time.
Brian
Brian
Paul Turek, MD
May 8, 2012
Brian, it takes about 10-14 working days to get the results after FNA mapping. The slides are reviewed by a specially trained team of pathologists, including me at the end. So, the earliest a sperm retrieval can be done after FNA mapping is 2- 3 weeks.
Laura
May 7, 2012
Hi Dr. Turek,
My husbands testicular biopsy showed sertoli cell only. Is there still a chance we could find sperm with a different technique?
Paul Turek, MD
May 7, 2012
Laura, yes there is. In one of our original FNA mapping papers that we published in 2000 (12 years ago!), we found that sperm could be detetected in 27% of testes in which a prior biospy showed no sperm (like Sertoli cell only). In addition, the opposite testis had sperm 20% of the time. This study employed a “maP’ of 8 sites. Now we use 18 sites/testis!
Laura
May 7, 2012
Thank you so much for the response. My husband and I are looking forward to exploring this option. We will be calling to schedule a consultation soon. Thanks for your time.
Brian Choi
May 7, 2012
Dr. Turek,
When you mention “after mapping: proceed immediately,” I just wanted to make sure I understood this correctly. I am assuming you mean that if FNA mapping results in positive results for finding sperm, then proceed immediately to TESA/TESE whereas wait ~3months if moving forward with mTESE? Also, when you say proceed immediately, are you stating that one can literally undergo TESA/TESE a few days (for instance) after FNA mapping? Thank you again for your time.
Brian
Brian Choi
May 9, 2012
Dr. Turek,
I have a general question regarding FSH and testicular volume. I have been reading many medical papers and journals regarding the likelihood of retrieving sperm and FSH, testicular volume, Johnsen’s score, and the presence of spermatids. It seems from these papers, there is almost a consensus that azoospermic men with FSH levels > 25 or so have an extremely slim chance ( < 5%, in many cases 0%) of having any sort of spermatogenesis and, hence, finding any sperm. As I stated before, my FSH level is 41.9 mIU/mL, with testicular volume of approx 6-7mL (for each testis). Though my testicular volume seems fine (from the studies I've read), my FSH level is far higher than ANY patients for which they found sperm (the highest FSH value was 19.4, amongst all the papers I've read). Can you please shed some light and your opinion on this matter? I'm a bit disheartened by these findings which seem, as far as I can tell, to have been performed rather well in a controlled and careful experimental environment. Many thanks again.
Brian
shahid
May 13, 2012
Dear Doctor,
I live in Pakistan. I am 32 and my husband is of 33 years old. We got married in October 2010. In Feb 2011 I got to gynecologist to get my check up for why I could not get pregnant. She got ultrasound report and my menstruation cycle all was normal. On her advice we got to get sementic analysis. And it was figured out that my husband has no semens to be tested. I took to consult gynecologist and urologist in my first attempt. They took a blood sample and FSH(found to be 8.7) and Testosteron(found to be 2.9) hormone was tested and urine test showed an infrction causing blood drops from 2-3 in urine. Report datwd: 28 May 2011 was as under:
Physical Examination:
Color: yellow
Sp.Gravity: 1018
Turbidity: Nil
Deposit: Nil
Chemical Examination:
PH: 5.0
Sugar: NIL
Protein: Nil
Ketone : Nil
Urobilinogen: Normal
Bilirubin: Nil
Blood: Nil
Bile salts: Nil
Nitrite: Nil
Microscopic Examination / H.P.F :
Pus cells: 1-2
Epithelal cells: 2-3
Red Blood Cells: Nil
Crystals: Nil
Crystals: Nil
Casts: Nil
Casts: Nil
Amorphous: Nil
Organisms: Nil
Others: Nil
Renal Funtion Tests Dated: 15 May2011 are as under:
Serum Creatinine 1.3
Blood Haematology Dated: 14 May 2011 as under:
Haemoglobin: 13.4
T.L.C: 6800
E.S.R: 55mm/1st hour
D.L.C:
Neutrophils: 60%
Lymphocytes: 35%
Monocytes: 03%
Esinophils: 02%
The Urologist had examined him and said that he needs to take an X-ray of testes and a tissue of testis will be taken to examin whether sperms are produced or not. After hearing this my husband never turned up to medical treatment he simply refused. He is inclined more to take herbal / homeopathic medicine to increase the fluid at ejaculation. We have taken herbal medicin which took him to svere cough and its impact was such that he found difficulty in erection or lost of erection. Homeopathic treatment effected in this regard that his erection is controlled now. But to get a pregnancy is still a dream. He psychologically is disturbed as he wants to get a baby if I want but have no interest in sincere medication and its me who want to get information atleast from internet to find the word azoospermia for his problem. In Feb 2011,after marriage, he revealed that before 7 years he got worried of no semens and tells that he has not experienced more than a drop in his early adulthood. Now I again asked him not to waste his and my time to these herbal or homeopathic medication and go to the same urologist for that treatment he is not agreeing for that even.
What he has done is got a shipment from USA for a medicine named Volume Plus Semen Booster manufactured in USA for Moving Ahead Inc. containing : Zinc as Zinc oxide: 50 mg,L Arginine as L-Arginine Hydrochloride, L-Lysine as L-Lysine Hydrochloride, Homy Goat Weed (Epimediumsagittatum), Muria Puama(Ptychopetalum olacoides); Hawthorn Berry (Crataeguspinnatifida), Cranberry juice(Vacciniium oxycoccos), L-Camitine(as L-Camitine Fumarate), Catuaba Bark (Erythroxylum catuaba), Pumpkin seed (curcubitamaxima), Tribulus fruit(tribulus terrestris), oat straw10:1 PE (Avena sativa), maca root (lypedium meyenii), longjack root (eurycomalongifolia), sarsaparilla root (smilax species),Licorice root (glycyrrhiza glabra).
I have not let him use this volume plus for semen boosting. I do not want to harm any of his health side to intake unadvised medicine. I beg you to kindly help me in this regard I have been reading all the day and night on internet how to get pregnant and reached your webpage. I look forward to read from you soon as I have kept all the incidents before you from A-Z. I want you to hear me and advise us and tell us what is the right way to adopt and what is less hazardous. And whether I can have a baby or I will die without anything in my lap………Please advise me can I get this mapping if it suits my husband in Pakistan???? What should I do doctor??
Paul Turek, MD
May 13, 2012
Dear Shahid, That is quite a story! I must admit, the reaction that your husband is having to hearing the news of having no sperm count is common. It is tough to take. I will also say that you may need some time for him to “come around” as most men want what their partner’s want in the long run. Keep the faith. Keep the hope.
Regarding the homeopathic approach, it is very popular in some countries. I believe it has a role but what you can ask from it might be more limited than, say FNA mapping or assisted reproduction. Consider a Second Opinion http://www.theturekclinic.com/urologist-san-francisco.html) by contacting us to see if we can provide information that may help you both.