Understanding Your Semen Analysis Results

How Can a Man with No Sperm Have Children?

If your semen analysis showed no sperm, there are still many paths to fatherhood available to you.

With modern reproductive techniques, just one sperm is enough to create a baby. You can potentially find that sperm through:

Diagnostic Re-evaluation

  • A repeat semen analysis may detect sperm that was missed initially
  • Specialized extensive semen analysis using advanced techniques
  • Centrifugation and microscopic examination of semen samples

Addressing Underlying Causes

  • Correcting hormone imbalances (testosterone, FSH, LH)
  • Discontinuing medications that affect sperm production (like finasteride)
  • Treating lifestyle factors (nutrition, stress, sleep, toxin exposure)
  • Resolving physical obstructions in the reproductive tract

Surgical Sperm Retrieval

Men with no sperm in their ejaculate often still produce sperm in their testicles—it simply doesn't reach the ejaculate. Surgical procedures can retrieve this sperm directly from the testicles.

What Happens During a Semen Analysis

During a semen analysis, a trained embryologist examines a tiny drop of your semen under a microscope—less than 1% of your total sample. If no sperm are visible in this initial examination, the sample undergoes centrifugation. This process discards the liquid portion and concentrates any cellular material present. The embryologist then examines a small drop of this concentrated sample before declaring it "azoospermic—no sperm seen."

The Critical Detail You May Not Have Been Told

There's still a possibility that sperm exists in your sample, even after an azoospermic diagnosis. The limited scope of standard semen analysis means sperm can be missed. A typical analysis might report "no sperm seen" even if your sample contained hundreds or thousands of individual sperm cells.

Understanding the Limitations Through an Analogy

During a semen analysis, the embryologist looks through the microscope at a frame (called a "field") of the microscope slide. A normal fertile man may have 100-200 million sperm in a semen sample, and there may be around 1.25 million fields if the embryologist looked through the entire sample.

Instead of microscope fields and sperm, let's use an analogy of basketball courts and people.

Imagine if there were 10 manhattans covered completely in basketball courts, about 1.25 million basketball courts would cover 10 manhattans. In a normal fertile man, every basketball court would have 100 people on it. When the embryologist looks at a random basketball court, they would see 100 people. There are people everywhere!

Now let's take a man with limited fertility. Lets say he had just 100 sperm in his sample, on random basketball courts in NYC. Even if the embryologist looked at 100 basketball courts, they're unlikely to see even one of the 100 sperm.

To help do a slightly better job of finding sperm when there are less sperm, the embryologist will typically centrifuge the semen sample to attempt to concentrate any sperm into a smaller volume. In the above example, they would cut their search area from 1.25 million basketball courts on 10 manhattans to just 125,000 basketball courts on 1 manhattan.

If you had 100 sperm, the embryologist would still have to look at thousands of basketball courts to have a good chance of finding even a single sperm. And in a typical azoospermic semen analysis, the embryologist will only look at up to around 50 or so before declaring the sample azoospermic.

What This Means for You

  • Sperm counts naturally fluctuate over time, which is why your doctor may recommend a repeat semen analysis several weeks after your initial test.
  • An initial azoospermic diagnosis, while serious, doesn't necessarily mean zero sperm exist—it means none were detected in the limited portion examined during standard testing.
  • You may be producing sperm but an obstruction may be preventing that sperm from entering your semen.
  • There's thought to be a minimum level of sperm production in order for sperm to enter the ejaculate. Even in men with severe sperm production issues, there are often small pockets of sperm production that can potentially be found during surgery.

The Reality of Treatment

While there's genuine reason for hope, it's important to understand that natural conception is unlikely. Your path to fatherhood, if possible, will almost certainly involve in vitro fertilization (IVF). This means your wife will undergo a multi-week hormone stimulation process followed by egg retrieval, and any sperm found will be combined with her eggs in a laboratory before transferring the resulting embryo to her uterus.

This journey requires patience, emotional resilience, and often significant financial investment—but many couples successfully have children through these methods.

Obstructive vs Non-Obstructive Azoospermia: Understanding the Critical Difference

There are two distinct types of azoospermia with dramatically different treatment paths and success rates. Understanding which type you have is crucial for setting realistic expectations and planning your treatment approach.

Obstructive Azoospermia (OA): The More Hopeful Diagnosis

What It Means: Your testicles are producing sperm normally, but a physical blockage prevents sperm from reaching your semen. Think of it like a clogged pipe—the factory is working, but the product can't get through the delivery system.

The Good News: If you have obstructive azoospermia, your chances of having biological children are nearly identical to any other couple going through IVF. This condition affects approximately 20-40% of azoospermic men.

Common Causes:

  • Congenital abnormalities (present from birth)
  • Previous infections
  • Prior surgeries (including vasectomy)
  • Physical trauma to the reproductive tract

Treatment Options:

  • Surgical repair of the obstruction
  • Sperm retrieval procedures followed by IVF/ICSI (success rates approach 100% for sperm retrieval)

Of note: IVF outcomes for men with obstructive azoospermia roughly match those of fertile men.

While this may not be the natural conception path you originally planned, and financial considerations remain, the prognosis is excellent.

Non-Obstructive Azoospermia (NOA): The Greater Challenge

What It Means: Your testicles have impaired or absent sperm production. This accounts for 60-80% of azoospermic cases and presents more significant treatment challenges.

Common Causes:

  • Genetic abnormalities (Y-chromosome microdeletions, Klinefelter syndrome, other genes)
  • Hormonal imbalances
  • Testicular dysfunction
  • Exposure to toxins, radiation, or chemotherapy
  • Unknown factors (idiopathic)

Treatment Reality:

  • Approximately 10-20% of NOA men will have sperm found through extensive semen searches
  • An additional 40-50% may have small pockets of sperm production retrievable through a serious and invasive surgery (microTESE).
  • Around 50% of the men who have sperm found will successfully father children.
  • Around 75% of men with NOA will not be able to have biological children, either because no sperm was found or the sperm was unable to create healthy embryos.

How Doctors Determine What Type of Azoospermia You Have

The diagnosis between OA and NOA can usually be made relatively early in your evaluation through several key indicators:

Blood Tests

Your doctor will measure FSH (follicle-stimulating hormone) levels. High FSH (more than 7-9 mIU/mL) typically indicates your body is working overtime trying to stimulate sperm production, suggesting NOA.

Semen Volume

If you have abstained for at least 2 days and your semen volume measures less than approximately 1.4ml, this may indicate obstructive azoospermia, as certain types of obstructions decrease how much fluid enters the ejaculate.

Physical Examination

  • Testicular size: Smaller testicles (typically less than 15ml volume or 4cm length) often indicate NOA
  • Vas deferens assessment: Your doctor will feel for the presence and normalcy of these connecting tubes

Additional Testing (When Necessary)

  • Testicular ultrasound: May provide additional information about testicular structure
  • Transrectal ultrasound: Due to discomfort, this should only be recommended if it will genuinely change your treatment approach

Important Note on Testicular Measurement

Most doctors perform a quick manual assessment of testicular size, which is notoriously inaccurate—three different doctors might give you three wildly different measurements. However, this cursory examination is usually sufficient for the initial OA versus NOA distinction. More precise measurement using an orchidometer (oval beads of known volumes) provides better accuracy when needed.

Finding the Right Specialist Doctor

Your First Major Step

If you haven't already, finding the right doctor is your most important next move. While urologists generally treat male infertility, most have limited experience in this specialized field. Your goal is to find a urologist who specifically focuses on male infertility—sometimes listed under "men's health" or "andrology."

What to Look For

Fellowship Training

Look for urologists who have completed a fellowship in male infertility or andrology. This additional year of specialized training indicates advanced expertise in the field. However, extensive clinical experience can serve as a valuable alternative—if a urologist hasn't completed fellowship training but has substantial experience treating male infertility patients, this hands-on experience may provide comparable expertise.

Fellowship Directors

Consider the small group of doctors (approximately 20 nationwide) who run their own male infertility fellowship programs. These physicians are typically at the forefront of the field and see the most complex cases.

Finding Specialists

These links may help you find a male fertility specialist in the US:

Society for the Study of Male Reproduction Search Male Infertility Guide List of hospitals with fellowship programs

(these hospitals will all have specialists who train other specialists)

Important Perspective

Remember that doctors are knowledgeable professionals, but they're not infallible. They make decisions based on available data and their experience, but they don't have all the answers. While you need medical expertise to guide your treatment, ultimately your health decisions are your own. Don't hesitate to seek second opinions or ask detailed questions about your treatment options.

Blood Tests for Azoospermia: Understanding Your First Doctor Visit

What to Expect at Your First Appointment

The first thing your doctor will do is order a comprehensive set of blood tests. These tests include FSH, testosterone, LH, and estradiol—all hormones that play crucial roles in sperm production.

A minority of men with azoospermia may have one or more of these hormone levels significantly out of range in ways that could potentially cause their condition. While most men won't have an easily treatable hormonal cause of azoospermia, identifying and correcting abnormal levels (especially low testosterone, low FSH, or high estradiol) can sometimes help.

Understanding Treatment Timelines

If your hormone levels are abnormal, your doctor will likely prescribe medications to normalize them. However, patience is essential: it takes approximately three months for a man to produce a single sperm from start to finish. This means you'll need to wait several months to see whether hormonal treatments might restore sperm to your semen.

FSH: The Most Important Value

FSH (follicle-stimulating hormone) is particularly significant for azoospermia patients. In men, FSH has one primary job: it's the hormonal message your brain sends to your testicles commanding them to produce sperm.

How the FSH Feedback Loop Works

  1. Your brain releases FSH to signal your testicles to make sperm
  2. When your testicles successfully produce sperm, they respond by releasing Inhibin B
  3. Inhibin B tells your brain that sperm production is happening
  4. Your brain then reduces FSH production

This inhibin B ↔ FSH cycle provides valuable insight into what's happening in your testicles. While inhibin B would be the more direct measure, FSH is the commonly used metric due to testing practicality.

Interpreting Your FSH Level

FSH above approximately 7.5: This suggests your brain believes your testicles aren't producing much (if any) sperm. Your brain keeps sending the "make sperm" signal because it's not receiving the "mission accomplished" message back.

Important Perspective on High FSH

Don't let a high FSH level discourage you completely. While elevated FSH does indicate impaired sperm production, many men with very high FSH levels still have successful sperm retrievals during surgery.

While data is mixed on whether higher FSH means you have lower chances of sperm found during surgery, all data agrees that many men with even super-high FSH have sperm found during surgical sperm retreival.

Genetic Testing for Azoospermia: What to Expect and When Results Matter

The Reality of Genetic Testing

Your doctor will likely recommend two genetic tests as part of your azoospermia workup. It's important to set realistic expectations: approximately 90% of men will receive these genetic test results that don't provide useful actionable information. However, for the remaining 10%, these tests can be crucial for treatment planning.

Y-Chromosome Microdeletion Testing: The Most Critical Test

Around 5% of men with non-obstructive azoospermia will have a complete deletion in the AZFa or AZFb regions of their Y-chromosome. While this sounds devastating, it's actually valuable information.

Why Complete AZFa or AZFb Deletion is a "Hidden Blessing"

If you have a complete deletion in these regions, sperm retrieval through surgery is virtually impossible. While this news is initially heartbreaking, it prevents you from undergoing:

  • The significant cost of microTESE surgery
  • The physical pain and recovery process
  • Potential lifelong effects of the procedure

Approximately half of all men who undergo microTESE surgery don't find sperm, but they have no way to predict this outcome beforehand. Knowing definitively that surgery won't work, while difficult to accept, allows you to focus your energy and resources on alternative paths to parenthood.

Important Warning

Some less-reputable doctors may still recommend surgery even with complete AZFa or AZFb deletions. If you're in this situation, please seek a second opinion from a reputable specialist.

Klinefelter Syndrome (Karyotype Testing)

Klinefelter syndrome occurs when a man has an extra X chromosome (XXY instead of XY). This condition can affect multiple aspects of health, including causing low testosterone and azoospermia.

What This Means for You

  • Treatment: After your fertility journey, you may need to begin testosterone replacement therapy.
  • Fertility Outlook: Men with Klinefelter syndrome have good success rates with surgical sperm retrieval.
  • Genetic Concerns: Your future children are no more likely to have Klinefelter syndrome than children of men without this condition.

Advanced Genetic Testing Options

If your Y-chromosome deletion and karyotype tests are normal, you may consider more comprehensive genetic analysis. While unlikely to change your treatment approach, there's a small chance it could provide useful information.

Commercial Testing Options

These typically cost several hundred dollars and may be covered by insurance when ordered by a physician:

Fulgent Genetics University of Chicago CEGAT Prevention Genetics

Research Studies (Free Alternative)

Research studies examine the same genes as commercial labs while also searching for newly discovered genetic causes. The commercial labs typically know what genes to look for because of these research studies. There's typically no cost to these studies, though results (if any) can take months.

Notable Research Programs:
GEMINI Study
University of Pittsburgh Medical Center

Cystic Fibrosis Gene Testing

If you're suspected of having obstructive azoospermia, your doctor may recommend testing for cystic fibrosis-related genes, particularly CFTR mutations. These genetic variants can cause congenital bilateral absence of the vas deferens (CBAVD), leading to obstructive azoospermia.

Causes of Non-Obstructive Azoospermia: Treatable vs Untreatable

Understanding the cause of your non-obstructive azoospermia can help determine your treatment options and realistic expectations for recovery.

Important Note

While these causes have no cure to restore sperm production, it's still possible (in approximately 50% of cases) that you'll have sperm in your testicles that simply isn't making its way into your semen. This sperm can potentially be found during surgical sperm retrieval.

Untreatable Causes of Non-Obstructive Azoospermia

Common Untreatable Causes

Cancer Treatments
  • Chemotherapy
  • Radiation therapy
Cryptorchidism
  • Undescended testicles (testicles that didn't drop properly during development)
Known Genetic Causes
  • Y-chromosome microdeletions
  • Klinefelter syndrome
  • Other genetic abnormalities affecting sperm production
Testicular Injury
  • Men who experienced trauma to their testicles
Idiopathic (Unknown Causes)
  • Most cases of azoospermia fall into this category
  • Most idiopathic cases are thought to have an underlying genetic basis that hasn't yet been identified

Potentially Treatable/Reversible Causes of Non-Obstructive Azoospermia

Hormonal Imbalances

If your hormone tests show low FSH, low testosterone, or high estradiol, this suggests your testicles may be unable to function properly due to hormonal imbalance. Correcting these levels with medication may restore sperm production.

Obesity

Men with obesity often have high estradiol and low testosterone levels. Achieving a healthy weight may help restore normal hormone levels and potentially improve sperm production.

Testosterone Replacement Therapy

Taking testosterone through any method (supplements, gels, injections) causes testicles to completely shut down, including stopping sperm production. Discontinuing testosterone replacement therapy may allow natural sperm production to resume in several months. In addition to ceasing testosterone replacement therapy, your doctor may recommend additional medications like hCG, which may help jumpstart sperm production.

Heat Exposure

Frequent exposure to high temperatures (hot tubs, saunas, hot work environments) can impair sperm production. While this would generally not cause complete azoospermia, it's theoretically possible. Reducing heat exposure may help restore sperm to the ejaculate.

Finasteride (Hair Loss Medication)

While less well-studied, some reports show that finasteride can lead to male infertility. Stopping this medication may restore sperm production.

Important Timeline for Recovery

Since the sperm production process takes approximately three months from start to finish, most reversible causes will require several months of treatment before you might see any improvement in sperm counts. Patience is essential when addressing potentially treatable causes.

Diagnostic Procedures for Azoospermia: Understanding Your Options

Current Diagnostic Procedures

Needle Biopsy

A needle biopsy involves inserting a needle into the testicle to determine whether you have obstructive or non-obstructive azoospermia. This procedure can be performed in an outpatient setting or immediately before sperm retrieval surgery.

Primary Purpose

To ensure you don't undergo more invasive surgery than necessary. If the needle biopsy confirms obstructive azoospermia, your testicles won't need to be surgically opened as they would for non-obstructive azoospermia treatment.

Testicular Biopsy (Not Recommended)

This procedure involves surgically cutting a portion of the testicle's periphery. These biopsies are generally not recommended and rarely performed because they provide little diagnostic value while causing unnecessary harm to the testicle.

FNA Mapping (Fine Needle Aspiration Mapping)

FNA mapping is an outpatient procedure that systematically samples different areas of the testicle to locate sperm. The process involves multiple needle insertions through the testicle (surprisingly painless and minimally harmful), with each sample analyzed extensively.

The Theory: If sperm is found, doctors know which testicle and specific location contains sperm, potentially guiding future surgical retrieval.

Important Limitations of FNA Mapping
Success Rate Comparison:
  • FNA mapping finds sperm in approximately 25% of men
  • MicroTESE surgery finds sperm in approximately 50% of men

The Math: If FNA mapping is negative, you still have a 1 in 3 chance of finding sperm during microTESE.

Decision Points:
  • FNA mapping can be considered an extra, unnecessary step before microTESE
  • FNA mapping likely only makes sense if you're comfortable with lower accuracy and would choose not to proceed to surgery if results are negative.
  • FNA mapping is easily recoverable and doesn't cause the long-term damage that microTESE can.

Doctors Performing FNA Mapping

Ultrasound

Some doctors perform testicular or transrectal ultrasounds for several purposes:

Testicular Ultrasound:

  • Measure testicle size accurately
  • Check for varicoceles (enlarged veins)
  • Identify obstructions, tumors, or other testicular issues

Transrectal Ultrasound:

  • Examine internal reproductive structures
  • Should only be recommended if results will genuinely change treatment approach

Research-Based Diagnostics (Experimental)

Hormone Prediction Models

Extensive research has attempted to predict sperm retrieval success based on hormone levels. Unfortunately, no hormone markers reliably predict successful sperm retrieval surgeries.

cfDNA and RNA Testing

Researchers are developing tests that analyze cell-free DNA and RNA in azoospermic semen samples, hoping to determine the likelihood of finding sperm in the testicles. This research at UCSD and Inherent Biosciences is ongoing.

High-Frequency Ultrasound

Advanced ultrasound technology can measure tubule sizes within testicles. Some studies have tried to predict microTESE success using these detailed measurements, though this remains experimental.

Extended Sperm Searches: Finding Rare Sperm Before Surgery

Why Standard Semen Analysis Misses Sperm

As mentioned earlier, a standard semen analysis reporting "0 sperm" doesn't actually examine your entire sample—searching the complete sample would take several hours. Some men literally have just a single sperm in their ejaculate, which, if found, can enable them to have biological children.

The Problem with Current Practice

Extended sperm searches are unfortunately not commonly performed on azoospermic patients, despite their potential value. This gap exists due to various factors including financial incentives, technical difficulty, insurance reimbursement issues, and misunderstanding of the procedure's benefits.

Urologists are surgeons by training, so they naturally default to considering surgery as the primary solution to fertility problems, even when a non-surgical option exists for some men.

Why You Should Get an Extended Search

If you were diagnosed with non-obstructive azoospermia and have the financial means, you should absolutely get an extended sperm search before considering surgery.

These specialized tests can find rare sperm in 10-40% of men who were initially diagnosed with azoospermia. The procedure should be considered a requirement for all azoospermic men prior to considering surgery, but should be considered especially essential if you have an FSH under 8 mIU/mL or have ever had even a single non-motile sperm seen on any previous semen analysis.

As only one individual sperm is needed to have a child, a successful extended sperm search can mean completely removing any need for surgery.

Available Extended Search Options

Most Promising Technology

STAR Test - Columbia University, New York City

This test uses advanced microfluidic and AI technology to find and isolate rare sperm. Their testing has successfully identified sperm that human technicians missed, which makes sense—finding sperm is difficult and time-consuming work that is likely better suited for computers than humans.

  • Diagnostic only: $500
  • With sperm freezing capability: $3,000
  • No insurance coverage

Other Specialized Labs

Maze Labs - New York City
  • Cost: ~$2,000
  • No insurance coverage
  • Additional fees for cryopreservation
Weill-Cornell Andrology Lab - New York City
  • Cost: $570 (may be covered by insurance)
  • Requirement: Must be a patient of a Cornell IVF doctor
  • Freezing: ~$300 additional (refunded if no sperm found)
Bruce Gilbert, MD (Men's Reproductive Health) - New York City
  • Cost: ~$700
  • No insurance coverage
  • Some people report this clinic has stopped offering extended sperm searches.
Jumeirah American Clinic - Dubai
  • Director: Dr. Ramasamy (fertility expert)
  • Uses AI technology from Neogenix Biosciences.

Outside US Options

MFC Lab - Israel
  • Microfreeze technology (same technology used by Maze Labs)
  • Contact for details

Unconfirmed but Possible Options

Note: These require verification but may offer extended searches:

  • Pacific Fertility Center - San Francisco and Los Angeles (possibly when referred by Dr. Turek)
  • Dr. Larry Lipschultz - Baylor, Houston, TX
  • CCRM Colorado
Australia - Neogenix Biosciences

The company providing AI sperm search technology to Jumeirah American Clinic also works with several Australian clinics which may (unconfirmed) offer ai-enhanced extended searches:

  • IVF Australia
  • MelbourneIVF
  • Virtus Health

Surgical Sperm Retrieval: A Comprehensive Guide to Your Options

Critical Prerequisites Before Considering Surgery

Surgery is a serious decision with potential lifelong negative impacts. Before considering any surgical sperm retrieval, ensure you have completed ALL of the following:

Essential Testing and Waiting Periods

  • Multiple semen analyses: At least two analyses separated by several months
  • Extended sperm search: At least one comprehensive search of your entire semen sample
  • Hormone optimization: Blood tests confirming normal hormone levels, with several months of treatment and waiting if levels were abnormal
  • Testosterone history: Never taken testosterone replacement therapy, or if you have, you've stopped for an extended period (many months or years), and potentially used hCG.
  • Finasteride consideration: If you were taking finasteride, stopped for an extended period before repeating semen analyses
  • Genetic testing: Confirmed you do not have a complete Y-chromosome AZFa or AZFb deletion
  • Obstruction verification: If FSH isn't extremely elevated, confirmed you don't have obstructive azoospermia (or ensure your doctor will perform needle biopsy before starting the more invasive surgery)

You should only consider surgery after completing this entire checklist. The decision for surgery is extremely serious and irreversible.

Surgical Options

TESA/PESA (Least Invasive)

Procedure: Inserting a fine needle into the testicle (TESA) or epididymis (PESA) to aspirate tissue and fluid.

Anesthesia: Usually local anesthesia or light sedation

Best For: Obstructive azoospermia (lower success rates for non-obstructive cases)

Recovery: Less invasive surgery means limited recovery time.

Chances for success: For men with obstructive azoospermia, TESA/PESA has near a 100% success rate at collecting sperm. For men with non-obstructive azoospermia, TESA finds sperm in around 20% of cases.

MicroTESE

Most urologists in 2025 typically recommend microTESE for men with non-obstructive azoospermia. The full name of the procedure is sometimes referred to as microsurgical, microscopic, or microdissection testicular sperm extraction.

  • The Consensus: For non-obstructive azoospermia, no surgical technique finds sperm more often than microTESE. This is almost universally agreed on.
  • The Controversy: Significant debate exists regarding specific techniques and lifelong side effects, leading some doctors to recommend alternative approaches.
  • The Reality: MicroTESE is hard on the testicles. This is a major decision requiring careful consideration of pros, cons, and your surgeon's specific techniques.

Potential complications from microTESE

MicroTESE surgery carries significant risks that may affect you for life. Potential complications include permanent testicular damage, chronic pain, testicular shrinkage (atrophy), decreased testosterone production requiring lifelong hormone replacement therapy, and impact on remaining natural fertility. Some men experience long-term discomfort, changes in testicular sensation, or psychological effects from the physical changes. The deeper the surgical dissection into testicular tissue, the higher the risk of these complications. While success rates for finding sperm are important, these potential lifelong consequences must be carefully weighed against the possibility of surgical failure. Recovery can take weeks to months, and some effects may not become apparent until years later. Understanding these risks is crucial for making an informed decision about whether to proceed with surgery.

Critical Question for Your Surgeon

Is an Embryologist Present During Surgery?

The Wrong Approach: Some surgeons perform complete surgeries on both testicles before sending samples to a lab for sperm examination. This is absolutely not recommended as it doesn't minimize patient harm.

The Right Approach: An embryologist should examine tissue during surgery so that if sperm is found, the procedure can be stopped immediately, preventing unnecessary additional damage.

Ask your surgeon: "Will an embryologist be present during surgery to enable you to stop if sperm is found?"

The Periphery-Only vs Full Dissection Debate

Understanding Standard MicroTESE Evolution

TESE (Repeated biopsies)

This was the technique used for the first ~10 years after advanced IVF capabilities called ICSI was developed, allowing embryos to be formed with just a single sperm. This technique involved making multiple random slices from the outside of both testicles, then examining the slices for sperm.

MicroTESE, first performed in 1999, made two key changes from previous TESE methods:

  1. Used a microscope to identify enlarged tubules and take much smaller cuts
  2. Cut deep inside the testicle instead of staying only on the periphery

It's well established that microTESE made significant improvements to the rate of men who had sperm found (roughly from 25% with TESE to 50% with microTESE).

While microTESE showed higher sperm retrieval rates than traditional TESE, it's unknown how much (if any) benefit comes from cutting deep into the testicle vs taking a more exhaustive sampling of healthy looking seminiferous tubules.

The Case for Periphery-Only MicroTESE

The Biological Logic:
  1. Testicles contain approximately 300 tubules, each tightly coiled
  2. When sperm exists somewhere in a tubule, it likely exists throughout that entire tubule
  3. Sperm production is self-replicating—if sperm is made, additional sperm stem cells must be produced. If sperm exists in the tubule it would naturally spread within that tubule.
  4. Evidence shows all (or nearly all) tubules radiate outward from the testicle center and touch the periphery before returning to center

The Conclusion: If sperm exists throughout tubules AND all tubules touch the periphery, then periphery-only microTESE (pomTESE) should achieve equivalent success rates with far less risk of lifelong, irreversible testicular damage.

Doctors Offering Periphery-Only Techniques

Dr. Silber - St. Louis
  • Only offers surgery combined with full IVF cycle
  • Dr. Silber is in his 80s, so has a lot of experience but likely won't be doing surgeries in 10 more years.
Dr. Werthman - Los Angeles
  • Technique likely doesn't sample all tubules, potentially less effective than Dr. Silber's approach

Research Need: Due to microTESE's development history, periphery-only microTESE has never been directly compared to standard microTESE. More doctors and research are needed in this area.

Additional Considerations

Salvage MicroTESE

If your first microTESE failed to find sperm, you may consider a second procedure. This decision is extremely difficult to evaluate. Some studies show success after previous failed microTESE, but results are somewhat questionable.

Cost Considerations

Cheapest Option: Salt Lake City offers the most affordable surgical sperm retrieval in the country at $2,750 for microTESE. If insurance doesn't cover costs and finances are a concern, consider: https://malefertilityandpeyroniesclinic.com/microtese-home/

Successful births with surgically retrieved sperm

Even if sperm is found, the battle is only half over. There are a lot of problems using surgically retrieved sperm. On average, only about half the couples who successfully have surgically retrieved sperm will have a successful full-term pregnancy with a live birth. One of the most sobering statistics: Of 100 men going in for microTESE surgery, 50 will find sperm, and out of those 50, only about 25 will end up with a baby. The low chance of ultimate success should be a consideration with your journey.

IVF

If you are moving forward with any type of sperm retrieval option, this means you'll attempt to get pregnant through lab assistance using a process called IVF (likely IVF/ICSI). This process involves harvesting eggs from your wife, injecting each egg with one sperm to form an embryo, and then implanting those embryos into your wife. It's a daunting process but millions of couples go through each year.

There are some special considerations for IVF combined with azoospermia, and some general things about IVF to understand.

Fresh vs. Frozen Sperm After microTESE

Fresh sperm

Fresh sperm can be used immediately if the female partner undergoes egg retrieval on the same day as microTESE. This approach may offer slightly better fertilization rates since it avoids freeze-thaw damage, but requires precise coordination of both partners' cycles and creates significant logistical challenges.

Frozen sperm

Frozen sperm is the preferred approach at most centers. Sperm retrieved during microTESE are cryopreserved and used later when the female partner is ready for her IVF cycle. While there may be minimal loss of quality from freezing, the practical advantages are substantial: flexible timing, backup samples for multiple cycles, and elimination of coordination stress. Fertilization rates with frozen testicular sperm remain excellent with ICSI, making this the standard approach despite the theoretical advantage of fresh sperm. Some number of men may have so few sperm that not enough sperm survive the thaw.

IVF Clinic Ranking

All IVF clinics in the US report their success data publicly. However, this can be hard to compare, as different clinics have different groups of patients (primarily age related). Someone put together a ranking of the IVF clinics with the best success data in the US here:

Best IVF Clinics in the USA

But really, for azoospermia, it's important to go to an IVF center that commonly deals with azoospermic patients. Looking for rare sperm in ejaculate and surgical samples is something that requires a lot of experience.

Mini-IVF vs. Conventional IVF

Mini-IVF uses low-dose or oral fertility medications to produce 2-5 eggs per cycle, while conventional IVF uses high-dose injectable hormones to retrieve 10-15+ eggs.

Mini-IVF Benefits:

  • Lower cost and fewer injections
  • Reduced side effects and OHSS risk
  • More natural approach
  • Some evidence that the eggs are better quality

Conventional IVF Benefits:

  • Higher success rates per cycle
  • More embryos for transfer and freezing
  • Better cost-effectiveness per pregnancy

Best Candidates for Mini-IVF:

Poor responders to high-dose stimulation, patients at high OHSS risk, or those preferring less intensive treatment.

Trade-off:

Mini-IVF is gentler but typically requires more cycles to achieve pregnancy compared to conventional IVF's higher per-cycle success rates.

Experimental Treatments for Azoospermia

Varicocele Repair

Varicocele repair involves surgically removing enlarged blood vessels (varicoceles) in the testicle. Some theorize this procedure may help azoospermic patients either regain sperm in their ejaculate or achieve better surgical outcomes during sperm retrieval.

The Problem with This Theory: It's very difficult to understand how varicoceles—which are extremely common in fertile men—would actually cause azoospermia. The available data is not conclusive, making varicocele repair an experimental treatment for azoospermia at best.

Realistic Expectations: Varicocele repair likely doesn't work for azoospermia, and if it does have any effect, it's probably very minor.

PRP, Stem Cell, and Exosome Injections

These treatments are extremely theoretical, with potentially some (though highly debatable) scientific basis. These approaches are essentially experimental ideas and should not be generally considered viable treatment options.

For the Desperate: If you're someone willing to try anything and potentially invest in unproven treatments, you could consider one of these options—but understand you may be purchasing ineffective therapy.

Isotretinoin

Retinoic Acid Pathway and Spermatogenesis

Isotretinoin is a synthetic retinoid that affects retinoic acid signaling, which plays a crucial role in spermatogenesis. Retinoic acid is essential for the initiation of meiosis in spermatogonia and the proper differentiation of germ cells. In NOA, there's often disrupted spermatogenesis, and isotretinoin may help restore normal retinoic acid signaling pathways that support sperm production.

There is evidence suggesting retinoic acid may be produced during spermatogenesis rather than being strictly necessary for its initiation. Some research indicates that retinoic acid production may be a consequence of normal spermatogenic activity and the spermatognesis+retinoic acid relationship may be more of a feedback loop rather than a simple requirement.

Why All Experimental Treatments Likely Don't Work

Understanding the biology of non-obstructive azoospermia explains why these experimental approaches are problematic:

Two Main Categories of NOA

Rare Cases: Men who have no sperm stem cells whatsoever (which would normally develop into sperm)

Most Cases: Men who have stem cells that stop progressing during the sperm development process. This arrest is typically genetic—specific genes cause the sperm production process to halt partway through. In some less common instances, supporting environment issues within the testicle, specifically Sertoli cell dysfunction, can interfere with sperm development.

The Logic Problem

Given that most non-obstructive azoospermia cases are fundamentally genetic, it's difficult to reason how PRP, stem cell injections, or exosome treatments would address the underlying genetic causes preventing sperm development. These treatments don't correct genetic defects or restore missing cellular machinery needed for sperm production.

Making Informed Decisions

While the desire to try any possible treatment is understandable, it's important to recognize that these experimental approaches:

  • Lack strong scientific evidence for effectiveness
  • May be expensive with no insurance coverage
  • Could delay more established treatment options
  • May not address the root genetic causes of azoospermia

Before considering experimental treatments, ensure you've fully explored proven diagnostic and treatment options, including extended sperm searches and consultation with experienced fertility specialists.