Editing CUA: Azoospermia (2015) (section)

== Diagnosis and Evaluation ==

* '''After at least 2 semen analyses have confirmed azoospermia, men should be investigated with a thorough history and physical examination.''' '''Most men will also require laboratory and imaging studies.'''
* '''History'''
** '''Infertility history'''
*** Duration of infertility
*** Whether the infertility is primary or secondary
*** Any treatments to date
*** Libido, sexual function, sexual activity
** '''General health of the man''' (diabetes, respiratory issues, recent illnesses)
*** '''If there has been a recent serious medical illness or injury or evidence of a recent reproductive tract infection, semen testing should be repeated at least 3 months following recovery from the illness'''
** '''Surgery of the reproductive tract''': testis cancer, undescended testis, hydrocelectomies, spermatocelectomies, varicocelectomies, vasectomies
** '''Proven or suspected GU infections/inflammation:''' sexually transmitted infections, epididymo-orchitis, mumps orchitis
** '''Medications and therapies which might have an adverse impact on spermatogenesis'''
**# '''Hormone/steroid therapy'''
**# '''Antibiotics (sulphasalazine)'''
**# '''Alpha-blockers'''
**# '''5-alpha-reductase inhibitors'''
**# '''Chemotherapy'''
**# '''Radiation'''
**# '''Narcotics'''
*** '''If there has been exposure to any gonadotoxic agents, these medications should be stopped and semen should be retested in 3 to 6 months'''
** '''Environmental exposures''' (pesticides, excessive heat on the testicles)
** '''Recreational drugs''' (marijuana, excessive alcohol)
** '''History of any genetic abnormalities in the patient or the family'''
* '''Physical exam'''
** '''Body habitus'''
*** '''Obese men have'''
**** '''Elevated estradiol;''' mechanism: adipose cells have aromatase which metabolizes testosterone to estradiol
**** '''Reduced serum testosterone and reduced SHBG''' (therefore, more bioavailable testosterone component of total testosterone)
** '''State of virilisation'''
** '''Abdominal examination'''
*** Scars indicative of previous inguinal surgery or treatment of undescended testis.
** '''Scrotal examination'''
*** '''Size and consistency of the testis (long axis length <4.6cm associated with impaired spermatogenesis, volume <20mL considered low'''); size correlates well with sperm production
*** Epididymis (engorgement may suggest obstruction)
** '''Phallus''' (meatal displacement)
** '''Prostate and seminal vesicles'''
** '''Vas deferens'''
*** '''Absence of the vas deferens is usually associated with absence of the seminal vesicles'''
*** '''Unilateral absence suggests complete lack of Wolffian duct development on that side, including renal agenesis.'''
*** '''Bilateral absence: consider investigation for CF gene mutation'''
*** '''Abdominal US to assess for renal agenesis is indicated in men with congenital bilateral or unilateral absence of the vas deferens who are not carriers of cystic fibrosis mutations since these men have a higher chance of having absence of one of their kidneys'''
**** '''26% of men with unilateral congenital absence of the vas deferens (CAVD) and 11% of men with bilateral CAVD had an absent ipsilateral kidney'''; most of the bilateral CAVD patients with an absent ipsilateral kidney are in patients with no identifiable CF gene mutation. '''Semen is almost always of low volume and acidic in patients with bilateral CAVD due to hypoplasia or absence of the seminal vesicles, which provide alkalinity.'''
** '''Varicoceles'''
*** '''See Varicocelectomy Chapter Notes'''

'''Subsequent investigations are based on reduced volume (<1.5 mL) vs. normal volume azoospermia'''