That Azoospermic Feeling

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.

651 thoughts on “That Azoospermic Feeling

  1. I enjoyed this article – well not “enjoyed” but you know – interesting. And well written. Those guys who can make babies again must feel sheer ‘joy’. You the man PJT.
    xaj

  2. Yes, it happend again today. A successful sperm retrieval procedure at The Turek Clinic for a young man from Cleveland, who had had several procedures there and who was told that “there is really no chance for getting his sperm.” He was teary eyed in the recovery room (sitting there, pain-free) when I told him the news. My Nobel Prize is when patients name their kids “Paul.” PJT

      1. Hello Doctor
        I heard about your interview Regading (one step closer to make sperm from skin) it can be a treatment or solution for Azoosperm while FSH is high

        1. Mohammed, using stem cell based technology along with our artificial testis bioreactor is potentially one great solution for azoospermic men to have biological children, regardless of FSH. We just need some time…

          1. Thanks doctor
            sertoli cells only syndrome is the result of my testis microscope
            this treatment will work for it
            regards

        2. M in the category of azoospermic due to no production and hoping to be a father. How far are you doctor with making sperm from skin

          1. Dear Esau, Researchers around the world, including France, Japan and the US, are actively looking for ways to do this. I am not sure of the time when this will happen, as it depends as much on money and politics as science. Stay tuned though!

      2. My wife and I have been married for 10 years. When we got married many years ago we immediately started trying for a baby. After about 2 years of trying we sought out for help. I underwent testing as well as she… and I was given the terrible news of azoospermia – this was after having a testicular Biopsy. I was devastated. .. we were both crushed. My wife looked me in the eye… and said “we will figure this out. .we will have a family one way or another ” that day in the urologists office is a complete blur. When we walked out we were told ” your only option is adoption ” .. I will never ever forget that feeling..hearing those words.
        After much deliberation, we decided to try IUI using donor sperm..and it worked. We had a beautiful baby girl… we did the same procedure again a couple years later and it worked again..another baby girl.
        As happy as we are with our family…that day is something I’ll never forget. Why do I have this? Is this something hormonal ..can I fix this with some medication..? Is this chromosomal? Am I maybe a carrier of a disease… can it possibly be fixed??
        My wife and I are in no hurry to grow our family.. but the constant on my mind is..why. ( as I said..the day is a blur). If we could have a third child without the heavy cost of iui’s, ivf, donors… we would.
        I am unable to pay thousands of dollars for more testing or surgeries…but we would really appreciate a second opinion if at all possible..we are also in Pennsylvania. I came across your article one night searching ( once again) “azoospermia treatments” . If a simple hormone could help us..why not?
        Thank you for your time

        1. Dear Bobby, You write from the heart about how deeply it affects men to have sterility. Its a pain that always seems to be lurking around. I would be happy to do a Second Opinion and offer information about 1) genetic causes of azoospermia and 2) hormonal issues that can be fixed (however unusual) and 3) whether you may in fact have sperm within your testicles that could be used for high tech (IVF-ICSI) pregnancies. Its amazing how inventive and creative patients can get raising the money needed for IVF-ICSI when they are armed with the fact that they have testicular sperm present to have their own child…

    1. Hi Dr. Turek,
      My husband was diagnosed with azoospermia in April of 2013 and we have been heart broken. Ever since I’ve been trying to do research on the condition and the treatment options and I came across multiple articles by you. His doctor had him take clomid but then took him off in February of 2014 because it didn’t help him. The only types of tests that have been done on him are blood, physical, and 2 semen analysis. I’m wondering if the clomid was the best treatment for the condition and if his doctor really did everything, other than the mapping, to determine if there is anything going on inside, like an ultrasound. And I was also wondering if you have heard of this new drug/vitamin/medicine called Spermhope (www.spermhope.com) suppose to help make more sperm(healthy) for retrieval and ivf. Please help us if you can we are desperate.

    2. My husband was diagnosed with Azoospermia in 2017. What’s unusual it that we had no problem having our first child, a beautiful girl, in 2015. How do you explain a case like this? Can a man suddenly become azoospermic after have no prior infertility issues?

      1. Dear Grace, Yes I have seen this. Its probably true that he had a low count in the past and that you are very fertile, and he has trended downward since then. Something should be able to explain this trend though: genetics, tobacco, pot, hot baths, varicocele, diabetes, medication etc.

  3. I had a right inguinal hernia repair a few years ago and just found out that I have azoospermia as well as low testosterone. I can relate to the feelings of the other men you talked about, but mostly I am angry. I feel that my azoospermia may have been caused by my surgery. Is it possible that this could have resulted in a tube obstruction?

    1. Yes, azoospermia has been reported with inguinal hernia repair. Typically it would occur with: a) mesh hernia repair b) hernia repairs on both sides. If the hernia repair is only on one side, then there needs to be another explanation for why the second side (assuming that you have both testicles!) is not contributing sperm. Maybe you should call me… (415-3092-3200) PJT

  4. oligoasthenoteratospermia, normal testosterone, normal FSH, literally everything else normal. Had child five yrs ago on first try, naturally, giving me dx of secondary male infertility.
    I’ve convinced myself that there must be an obstruction somewhere. Advice???

    1. David, I really doubt that this is an obstruction or blockage. Most men with this have no sperm counts (azoospermic). Sounds more like lifestyle issues or a varicocele correctable). PJT

  5. Had grade 2 varicocele, fixed may 2008. Still, no change. I am the epitome of dietary and lifestyle health. Still think no blockage???

  6. David, I thought that there was a variocele in the picture…I would check hormones (T, LH, FSH, Prolactin) and consider medical therapy to boost production and antoxidants to boost motility. PJT

  7. Hello Dr. Turek.
    I am French from Paris, I have a non-obstructive azoospermia with large varicocele, I wanted to know if having a few sperm cells lines is a good hope. Thank you for your work. I sent you an email. Karime ZINE

    1. Bonjour Karim,
      j’espère que tu vas bien et puis après je sais que je t’écris après des années, j’edpère que tu as trouvé une solution pour ton problème, mon mari a le même problème, son fsh est trop élevée, son inhibine b est trop bas, hypotrophie testiculaire et il y a présence de quelques cellules germinales immatures dans son spermogramme, il a une large varicocèle côté gauche mais le médecin nous a dit que c’est pas à cause de ça, j’aimerais bien entendre de tes nouvelles stp , je te remercie pour tte réponse

      1. Dear Manamissa, I can read French so this is good. Just so you know, despite there being no mature sperm in your ejaculate, there is still a 60% chance or so of having testicular sperm by FNA mapping.

        1. Dear Dr Turek,
          Thank you very much, you reply gave me a lot of hope..in fact in his ejaculte there were some spermatids and some spermocytes, he has not genetic problems, I would to know if we have chances to find spz with fna mapping? if this technic is harmful for the testis because they are very small, here in france we just do practice classic biopsy anddoctors gave us just 10% to fing spz. thank you and good luck for you researchs.
          Imen

  8. I meant to have some cells in the ejaculate sperm lined before varicocele repair.
    thank you very much. Of Paris.

    1. Karim, From our published research, the chance of having sperm is 60-65% with FNA mapping done in the office under local anesthesia in an hour or so. Be glad to help! PJT

  9. Finding out my husband had azoospermia was a very big shock. We’ve been trying forever and like most women I thought the problem was with me. After a while we both got tested and realized that my husband had a zero sperm count. I just can’t seem to get over the ‘why us’s’ because it just seems like our whole lives, things that have been easy for everyone else have been insanely had for us. But we’re trying not to dwell and are just praying that there is hope for us. We were just about to schedule a biopsy when I started reading about the sperm mapping. It gives me some hope that there is a less invasive and more accurate method for finding out if we will ever be able to have a baby.
    I just find myself so scared because I have no idea how we’re gonna pay for any of this. I am a teacher and he works in the office at a school, so we definitely do not make a lot of money. I am almost 36 and I’m just scared that I am running out of time. I’m scared of trying to take out a loan to pay for these procedures. None of us have any children and we have waited our whole lives until we found each other and now we are both worried that our dreams of being parents may never happen. I just applied for a flexible spending medical account at my job, but that is only for about 2,500 dollars. I was wondering if you think it would be wise to do the biopsy (which would be covered under our insurance) and try to use the account, and loans to actually pay for the actual ivf procedures, or is the mapping the best option?

    1. Kerri, great question! Where do you put limited funds? Certainly a biopsy can be helpful. There is about a 30% chance that it will show sperm. FNA Mapping is better with a 60% chance of showing sperm. So, if covered by insurance, it may make sense to do the biopsy first, knowing that it is an OK test but not perfect. If the biopsy shows sperm, then you are on your way and can save for IVF. If it doesn’t, then you either throw in the towel and choose donor sperm and IUI (cheapest alternative), adopt, or consider FNA mapping. Remember this: these decisions are some of THE hardest of your life and that’s why they are difficult to wade through and make. Please think of it as a journey, one of many in life. Setting financial limitations on things is critical to your quality of life and relationship and so must be considered in every decision. If you as a couple can make it through this, you can make it through any challenge to your relationship in the future: death, disease, house burning down, whatever. PJT

  10. Is it possible to produce sperm even if a testicular biopsy revealed no Sertoli or Leydig Cells in somebody with Kallmans Syndrome?

    1. Eric, yes it is. It is complicated though, as the person needs to be on testis stimulating hormones for some time. Remember, a biopsy only looks in a specific region and sperm may be found elswehere, in areas that were not biopsied. Kind of like apples on a tree, not all branches may have apples, so you need to find the ones that do have apples. FNA mapping is perfect for this as it can sample 18 sites in the testis and is far less invasive than a standard biopsy. Read more at: http://www.theturekclinic.com/services/male-fertility-specialist-specialists-infertility-doctor-treatments-issues-zero-sperm-count-male-doctors-male-fertility-clinics/sperm-retrieval-ivf-success-rates/. Doc Paul

  11. My husbands first SA showed only 3 sperm (only 1 moving) and the I don’t know the exact number from second but “there were a few” and “just about the same” is what I was told. The only bw results we have so far are testosterone (442) & prolactin (5.90). Everything felt normal during physical exam. We are going back in one month for transrectal ultrasound.
    The urologist told us that since there were a few sperm there is a good chance that they can find some through TESE or if the numbers go up even slightly he may be able to use a fresh sample for ICSI/IVF. The fresh sample seems risky to me. What if I produce 15 eggs but they only find 1 good sperm? What happens to the rest of the eggs?
    What would you say the chance of finding sperm through TESE would be since there were at least a few? Is it much different than if there weren’t any at all?

    1. Jessica, That is a tougher question…When men have ejaculated sperm of any kind, I tend to use this first. Finding sperm in testicles can be vverrry hard in some cases like this. In fact, its these kinds of cases that led me to invent testis FNA mapping in the first place, as random biopsies to get “backup sperm” failed. So, I would make sure the the sperm lab does a thorough “centrifuged pellet” analysis of the semen for sperm. It’s an extra step that requires skill but could identify 50, 200 or 1000 sperm in each ejaculate that would be worthwhile freezing if motile. The ultrasound is indicated with a low ejaculate volume and normal FSH, but I don’t see the FSH here. Alternatively, I often recommend aggressive medical management of hormones to get men to make 20-30% more sperm than at baseline and to faciliate a reliable, motile ejaculated sperm count. I make more friends by avoiding sperm retrieval procedures…

  12. Thank you for your reply. We just received FSH/LH/Estrodiol. FSH was 6.9, LH 5.43, and estrodial was 24. What type of management of hormones do you normally recommend? I have read about some men given clomid or hcg shots. Do you think something like that would help in our situation?

  13. Jessica, I really must refrain from giving medical care over a blog so advising you and your husband on proper medical treatment is inappropriate here. However, we can continue this conversation off-line. Feel free to call 415-392-3200 (www.TheTurekClinic.com) and have Makenna set something up. PJT

  14. Hello everyone, Hello Dr. TUREK
    I have a question. Thank you in advance for your reply.
    As you know I had a varicocele level 3.
    In my ejaculate there were only a few sperm cells lined.
    Think you a maturation arrest?
    Or a hypospermatogenesis?
    Or Germinal aplasia?
    Thank you for your understanding, I am far from you and it helps morale to have some answers.
    Good luck to all and thank you Dr.

    1. Karime, Really can’t tell the biopsy pattern from the ejaculate or history. Besides, it doesn’ t really matter what that pattern is as there are no real pattern specific treatments available. I would just make sure that the varicocele has not recurred by getting a doppler color ultrasound. A recurrent varicocele could be the reason for poor sperm quality. Doc Paul

  15. my husband haveazospermia then he make atesticular biobsy but we cant find sperms then hetake ahormonal theraby -merional amp-and-purigone-amp-then make abilateral biobsy and we cant find sperm also iwaud ask you about the next step or we stop

    1. Your husband has been through alot. In cases like this, sperm can be hard to find. Although the therapy (injections) may have worked and sperm might have been made, if you don’t sample the testis in enough places, then you may not find what you want. That’s where testis FNA mapping comes in. Samples intensively and finds those pockets of sperm that may be there. A testis biopsy just might not be good enough. Doc Paul

  16. iwould like tosay that allhormones inthe normal form the testecular biobsy says onlylate spermatids seen ,nocrypservation this inthe secondbilateral biobsy but inthe first RTtesticular biobsy sayes(germ cellaplasia-sertoli cell only syndrom) please try to helpme please

  17. Hello Dr. Paul
    I have azoospermia with fsh to 23, inhibin B less than 15
    I wanted to know how long does it take to remake a semen analysis after varicocele operation. ?
    And what vitamins to take to strengthen the production?
    Thank you in advance I’m in Paris so hard to come see you.

    1. Karim, It takes about 2-3 mos to make a sperm, so I generally check the semen for sperm every 3 months after varicocele repair for azoospermia. I expect to see sperm at around 9-12 mos in this situation. If no ejaculated sperm develop, there may still be sperm in the testis that can be detected with FNA mapping. I recommend a good “antoxidant” group of vitamins (see blog post: “Why Blueberries Matter”: http://theturekclinic.wpengine.com/why-blueberries-matter-antioxidants-male-infertility/. In fact, our group is producing an organic, California-made antioxidant herbal based vitamin called “Essential Beginnings-XY” that includes lycoprene, glutathione and Vit D in addition to the usual antioxidants. It should be available at at very reasonable price on line (www.EssentialBeginnings.com) in a few weeks. PJT

  18. Hello Dr.
    Thank you for your encouragement and your support.
    I just did a semen analysis dated April 12.
    They found a single spermmatozoide slower after three months of treatment varicocele.
    I’m happy so I continue my treatment. We’ll see.
    What do you think? And if I come to SA I saltiness with pleasure.
    Sincerely, Karim

  19. Hi Dr.Turek
    7 years gone to my marriage life, after 6 month of my marriage doctor recommend me to test and after results of that test I was shocked because I heard that I am AZOOSPERMIC.
    After that I had tried so many medicines like allopathic, homeopathic and herbal, but there is no change in my test reports in all that period. Dr. every thing is normal in my life but Dr. I would to be a father, please advise me what can I do I am from Karachi, Pakistan
    Cell num is 092-300-9229441 or 092-321-8733953

  20. dr. turek..
    SA = one un-centrifuged was azoospermic. second centrifuged 5 motile 3 immotile. normal volume, + fructose, normal ph . . .
    free testosterone, fsh, lh, prl, all within normal limits. physical exam by urology -unremarkable.
    risk factors: Did sit in a very hot tub perhaps once maybe twice in past 3 months. 5 months ago was rotating in the OR and did not wear lead often and there were many X-ray shots per case.
    should i wait 3 months and repeat analysis or proceed with bx and U/S
    Dr. Turek labs do not point to pituitary dysfunction or end organ dysfunction. but if obstructive azoospermia why is the volume not decreased and normal fructose and pH?
    thx Doc.

    1. Josh, interesting case. Your wet heat exposures are severe enough to cause this; your Xray exposures are a consideration but would have to amount to about 100 Xrays in total to cause temporary sperm count loss. Wonder how “normal” your FSH really is (4 is ok, but 8 is high). Did you have a flu in the last several months? I agree with waiting 3 months to see signs of reversibility. I would then consider proceeding with genetic testing for Y chromosome deletions and a karyotype. Not sure why the ultrasound, as only clinical (exam detected) varicoceles matter. Biopsy can tell you about production but may also be entirely uninformative. FNA mapping is better. Note: obstructive azoospermia implies a blockage in the system. Only one form of blockage causes low volume and low fructose and pH and that is ejaculatory duct obstruction (see: /services/male-fertility-infertility-doctor-treatments-issues-zero-sperm-count/ejaculatory-duct-obstruction-resection/, other types do not show changes in these parameters. Doc Paul

  21. Speaking of wet heat exposures:
    My husband’s SA came back yesterday. Previously we had thought difficulty conceiving was due to my having been on the Mirena IUD for many years and getting back to a regular cycle, but it turns out that my husband has low sperm count (2Million); low motility (5%) and poor morphology (6%). We are crushed. BUT, my husband has been in hot tubs frequently in the past few months (skiing in Feb/March), as well as a prolonged illness at the beginning of January. Would that affect a test done last Friday (May 13th)?
    We might come see you, as we are in San Francisco, depending on insurance, etc.

    1. Tara, in our published work, recovery from hot baths and tubs took 3-6 mos, but most of the recovery occurred after 3 mos. A febrile illness in January is of no concern at this point. Depending on the dose and frequency of tubbing in Feb/March, he could still be recovering from that. However, although these exposures COULD explain the recent abnormal SA, I am not sure that they explain the entire course of infertility. It depends on how long you have been trying. PJT

  22. I was diagnosed with azoospermia 3 months ago. Centrifuged pellet showed no sperm, but normal volume, pH, liquefaction etc.
    All infection tests (both blood and urine based) came back negative.
    Hormone levels showed normal LH, normal estradiol, and normal (but low end of normal) testosterone, but FSH was 22. I was then told that this was non-obstructive azoospermia. Karyotyping and molecular analysis are being done, but not back yet.
    The only risk factors that I can think of are:
    1. The week before I did the sperm test I had been away in the Caribbean, had probably 5-6 alcoholic drinks per day, and would spend up to an hour at a time in the evening in a hottub on several evenings.
    2. I have excema, including on my foreskin sometimes, and so had for several months put 1% hydrocortisone on my foreskin and head of my penis.
    My urologist tells me that he expects that I likely have a sertoli-cell only syndrome, and that there is some chance (but not great) that he will find sperm during a TESA procedure. Should I go this route for sure, or is there any chance (even with that elevated FSH) that this was due to the wet heat exposure and alcohol the week before? I plan to redo the sperm test again sometime in the next month.

    1. Steven, I do not think that the alcohol would cause this severe an effect. Nor would the excema or its treatment. A series of nightly hot tubs might but this effect would “wash out” after 3 mos. So, you should certainly recheck the semen analysis after 3 mos after the exposure. I am not sure that FSH would be that high after hot tubs, although this has never been studied. Your chance of having sperm is 60% with FNA mapping /services/male-fertility-infertility-doctor-treatments-issues-zero-sperm-count/sperm-mapping-testicular/ and 30% with a single biopsy. Its really your decision. Paul

  23. Thanks Dr. Turek. We have been trying since last September (2010), but only using OPKs and timing for 3 months.
    Doctor has me on Clomid right now to “improve the quality” of my ovulation) but so far it has only delayed my ovulation from it’s normal CD21. *sigh*
    This journey is very frustrating.

  24. Hi Dr. Turek, has there been sperm mapping success in azoospermic men with y micro deletions but normal FSH and normal testicular volume? Thanks.

    1. Heather. Yes there has. Sounds like a case of maturation arrest of spermatogenesis. If this is due to AZFa or AZFb deletions, the detection rate is very, very low worldwide by any technique however. AZFc deletions on the Y chromosome have the most potential.

  25. Thank you so much for your prompt response. My husband is still waiting for his test results, but it looks like we would try the sperm mapping route if there is an AZFc deletion. Thanks again for the info.

  26. Hello Doctor,
    I hope you are well.
    Here I have a semen analysis one week ago.
    Result: Zero sperm
    While the last time I had one.
    I am 6 months varicocele treatment
    What you think of this, I still have hope.
    thank you Karim

  27. It may take 9-12 mos to see ejaculated sperm after varicocele repair done for azoospermia. Consider repeating the semen analysis in 3 mos; if still negative, consider FNA mapping /services/male-fertility-infertility-doctor-treatments-issues-zero-sperm-count/sperm-mapping-testicular/ to see if there is mature sperm in the testis. PJT

    1. Hi doctor! Im from the philippines, we would really want to visit the clinic if given the chance. My husband is azospermic. He already had 3x 2weeks interval sperm analysis and hormonal blood test as adviced. All hormones are within normal range. It’s very depressing having to know and experience all of this.

      1. Dear Marz, I agree. Have some hope. If he is azoospermic due to blockage, then he has 100% chance of having sperm. If he is azoospermic due to testis failure, then there is at least a 60% chance of having sperm. That means there’s a pretty good chance that he can be a Dad at this point. Consider a free call to start!

  28. Hi Doctor,
    I am a woman and I write you from France
    We discovered that my husband has an azoospermia without obstruction on july 2010 (one year ago)
    The examinations show:
    -FSH raised 16, normal LH, normal proclatin and normal testosterone, inhibine B low: 29
    – Testicular size is almost normal
    – Normal karyotype and no microdeletion deletion of Y chromosome
    – the echography shows that there is no obstruction just microcysts on the left head of épididymides and both heads of épididymes are upsided down but our Dr says that it’s mild and it doesn’t cause the azoospermia
    -In each of 5 semen analyses there was a leuckospermia but the germs aren’t dangerous and in priori dosn’t cause the azoospermia
    6 months of treatment of vitamins (E, zinc, selenium, B9) whom friends advised us
    4 days before the testicles’ biopsy: 15 sperms are found whom 2 sperms motiles!!!
    The day of the biopsy(15 days ago): the medical team was confident thus request to make 2 semen analysis but result: 0 sperm in the éjaculate and a few hours later my husband had the biopsy on 2 testis but result 0 sperm!! NEGATIVE BIOPSY
    The medical team asks to redo, 3 months later, a semen analysis and to redo a biopsy in 2 years …
    my husband and I are ready to come in the USA to see you, but we would like to know before what do you think about this case? Is there some hope for us or we have to make the mourning to have a child?
    Thanks doctor

    1. Nina, Your story is complicated and full of ups and downs. In my practice, we have reported that ejaculated sperm counts vary widely when they are low to begin with. In men with <10,000 sperm in the ejaculate, about half the there is sufficient sperm found there on the day it is needed for IVF-ICSI and about half the time there is not. And, I actually developed fine needle aspiration mapping /testicular-mapping.html) because I was faced with a case like this in which a routine, random TESE failed to find sperm. Mapping can be done in advance of IVF-ICSI and creates a "template" to look for testicular sperm if the ejaculate fails to produce the necessary sperm the day that you really need it. In essence, it "directs" the testis biopsy for sperm like GPS. And, mapping doesn't really affect the ability to generate ejaculated sperm after it is done, unlike the much more invasive microdissection technique. Banking sperm before IVF-ICSI in such cases is also an excellent solution to the "no sperm that day" problem but needs advanced planning. With a combination of these techniques, we can usually makes sure that the band and food are present on the "wedding day" of IVF egg retrieval.

  29. Hello Doctor,
    Thank you again for your valuable advice indeed!
    I think seriously to come to you.
    I give myself another year, see if after my cure of varicocele I am better.
    I wanted to know if Fna practiced at home in your closet was possible to report the results in France to have the operation here in Paris, because insurance takes care of everything.
    I wanted to know the price of this consultation FNA. As I can save now.
    Thank you in advance for your response, and take care of you, and thank you for helping us.
    Karim

  30. Karim, Would love to help. Why don’t we take this conversation off line. Feel free to call the office to set up a call at 415-392-3200. Doc Paul

  31. Thanks doctor for your answer , we will contcat you when we will decide to come to USA, maybe with Karim! thanks to him I found your web site!
    Nina

  32. hello doctor…
    my husband has done freezing for about 30000 sperms in a IVF centre… can they use it for our next IVF procedure or they will do testicular biopsy for him as now he is azoospermic…
    Best Regards
    Sara

    1. Sara, It depends. Here are some of the factors that determine the usability of sperm: Source? (ejaculate, testis, epididymis); Motility? (yes or no); Viability? (yes or no); Quantity? And even more important: laboratory experience at the IVF center that is planning to thaw the sperm and use it. How many similar cases does the lab see annually? Hopefully more than 15-20 similar cases to give them proficiency.

  33. Thank’s Dr. for reply
    it was from an ejaculate,with occasional motility about 10%,its quantity is about 2-3ml,but i don’t know about its viability….and about the center it has been working in this field for many years but i don’t know actually how many cases they meet like ours.
    i want to add that my husband was having a sperm count about 2 millions from 18 months but unfortunantely his sperm count decreases till zero in a very very rapid way without a known reason..we did last year an ivf but it failed and then he did testicular biopsy but they didn’t find sperms then he took ttt with merional injections and clomid and sperm appear againt but now he become azo…his dr. says that he has chronic epidimitis as sometimes he has high no. of pus cells….sorry for being too long but if u have any advice plz tell me…,thanks..

  34. Dr. Turek,
    I have to say that your website has offered me much more positive information, which is hard to find on the internet. My husband recently went through his first semen analysis. It came back with 4 dead sperm. His second SA showed zero. He did have a swelling of the left testicle last year, which was cured by antibiotics. Given this information, do you suppose he has a blockage?
    With many thanks,
    Karen

    1. Karen, hard to know at this point, but certainly possible. He needs a blood test for reproductive hormones (T, FSH, LH, prolactin) and a good physical exam by a specialist. I’d be happy to help but its best done offline. Consider a call to us at 425-392-3200.

  35. Dear Dr,
    I have been reading and searching all possible article/blogs since the time we found out that my husband has an azoospermia in 2010, two bad news in same year. I lost my mother at the same time.
    We did my husband SA test in may 2010 which showed zero sperm count, after with our doc asked us to do blood test. His blood report showed high FSH level. His FSH level was 23% (as per the Indian style of report). Looking at my husband SA and blood report the doc said that his testis are not functioning and are not producing sperms.
    Also, my husband has only one testical, his left testical is an undescended one. His right testical is normal in size (as per scrotum scan report). He was operated for hernia on his right testical ard 4 years back.
    Doc please advice us what shuld we do next. After looking at our cases do u thinking we have any chances of finding sperms from only one testical and with HIGH FSH level? Do u thinking its possible to find sperms through TESE. My husband is ready to do biopsy, but he is scared as to what wuld be the result. I would love to become a mother….and my hopes r dying :(( pls advice!

    1. ZB, hard to provide care over the internet. However, your husband seems like an excellent candidate for newer technologies such as extended FNA mapping of the testis to find sperm. < 1 hour, local anesethesia, minimally invasive. This is a routine type of case for us. Consider a call at 415-392-3200.

      1. Dr.turky.i m from indian….i was married before five year during dignosis indian dr, told me that u r suffering from azoospermia…..i m very simple person dr, also told me that ur primary testicular is failure….it cannot produce sperm ….it is not possibe to come to ur clinic due to financial problem please any suggestion trhrough my email id……..

        1. Dear Pkm, Although new and fantastic strategies like FNA mapping are not done everywhere, simpler things like testis biopsies are done in India. There might be a 30% chance that you have sperm just based on a simple testis biopsy. You might consider this…

  36. Dear Dr,
    Thank you very much for ur response. I really appreciate you taking time out of ur busy schedule and responding us. I am sure everybody on the site must b greatful to u.
    Just one more question since u said tht FNA mapping wuld be helpful for us I wuld like to knw what are the chance of finding sperm? As we wuld be putting lots of thing on stake before coming (money, his job plus our emotions).
    Also, I wuld like to knw how many similar cases u and ur expert team hve handled before and hve been successful in achiving pregnancy. I jst need a bit of an assurance before taking this big step.
    Thank u once again!

  37. ZB, Best to take these kinds of details offline. Send a e-form to the website (www.TheTurekClinic.com) and we can set up a call to discuss further.

  38. What a great resource! I wish my husband and I found this a ferw years ago when he was diagnosed with non obstructive azoospermia. I agree with your article- we were fortunate enough to receive a sperm donation from my husbands brother and have a beautiful 10 month old girl. The minute she arrived into this world my husband forgot about the challenges we went through. He is so in love with his daughter- its wonderful and he is a fabulous father. I do have a question- can azoospermia ‘go away’? will he ever produce sperm? Can his hormones correct themselves?

    1. Amie, Quite a story! Yes, azoospermia can show some reversibility, but it depends on what causes it. If due to hot baths or tubs, Kallmann syndrome, varicocele, mediations (Propecia) chronic illness, or other fairly well described causes. Most times, sperm counts will not be enough for conception at home though.
      Here is an amazing example: I recently took care of a young man with azoospermia who failed a microdissection TESE in New York and then called me to see what else is possible. I found out he had tuberculosis at that time. Once the TB was treated, instead of trying another sperm retrieval procedure, I told him to just wait and see if things turn around. Sure enough, 9 mos later, he has enough ejaculated sperm for IVF and may develop enough for IUI!!

  39. dear doctor,
    I am an azospermic man. six years ago i performed testicular biopsy it reported that sertoli cell only syndrom (primary maturation arrest) my testosterone level is too little, is there any hope to my case?
    best regards

    1. The ability for you to become a father depends in part on how thoroughly they looked for sperm in the biopsy and how many biopsies were reviewed. Most men get a single testis biopsy in testicle. We published in 2001 that if that same, previously biopsied testicle is sampled in 8 places by fine needle aspiration, 27% of the time we could find sperm in areas away from the biopsy. In addition, 20% of the time the opposite (unbiopsied) testicle would also contain mature sperm. Now, the FNA map consists of 18 sites/testis and so the sperm detection rate has increased from this original study. See: http://theturekclinic.wpengine.com/services/male-fertility-infertility-doctor-treatments-issues-zero-sperm-count-male-doctors/sperm-mapping-testicular/ Happy New Year!

    1. Edina, this situation suggests that there is primary testicular failure. Hormone therapy may be possible but unlikely to boost production to the point of natural conception. However, it may be considered to optimize sperm production for a testis sperm retrieval. Options: Anastrazole, hCG injections.

  40. 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.

    1. 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.

  41. 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.

    1. 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 /services/male-fertility-infertility-doctor-treatments-issues-zero-sperm-count/sperm-mapping-testicular/ or a microdissection. Best of luck!

        1. 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!

  42. 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.

    1. 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.

  43. 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: [email protected]
    Thank you!
    Dr. A Guzman

  44. 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

    1. 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.

      1. 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?

      2. 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.”

        1. 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.

          1. Thanks you very much for the response sir.
            Please provide me the address, i will send you the slides.

          2. The Turek Clinic
            55 Francisco St
            Suite 300
            San Francsico, CA 94133
            Call 415-392-3200 to organize

          3. Hello Dr,
            We sent the slides to your address,
            We are in California, please let me know when we can meet you.

          4. KVR, contact the office at 415-392-3200 to set up a call and hear about results if they have been read. The internet is no place to talk about your privates!

  45. 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

    1. 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://theturekclinic.wpengine.com/services/male-fertility-infertility-doctor-treatments-issues-zero-sperm-count-male-doctors/azoospermia-sample-causes-no-sperm-count-success-stories/ 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://theturekclinic.wpengine.com/services/male-fertility-infertility-doctor-treatments-issues-zero-sperm-count-male-doctors/azoospermia-sample-causes-no-sperm-count-success-stories/. 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://theturekclinic.wpengine.com/services/male-fertility-infertility-doctor-treatments-issues-zero-sperm-count-male-doctors/sperm-mapping-testicular/. 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.

  46. 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

    1. 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.

  47. 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

    1. 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.

      1. 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

  48. 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

    1. 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

      1. 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

      2. 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

        1. 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.

  49. Hi Dr. Turek,
    My husbands testicular biopsy showed sertoli cell only. Is there still a chance we could find sperm with a different technique?

    1. 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!

      1. 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.

  50. 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

  51. 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

  52. 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??

    1. 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://theturekclinic.wpengine.com/services/get-a-second-opinion/ by contacting us to see if we can provide information that may help you both.

  53. I was first diagnosed with Azoospermia by a local (Australian) fertility specialist 18 months ago……..or at least I was advised he was a specialist. He informed me that I had a 5% chance at best of providing enough sperm to allow my wife to conceive and this was by undergoing a testicular sperm asiration / biopsy and testicular microscopic exploration. This is virtually like cutting them open wide and hoping for the best…..I imagined this like like driving in the dark with a blindfold on, with no lights on and hoping not to hit anything.
    After taking several months to come to terms with what this meant and the potential lifelong impact this would have re testosterone replacement etc, my wife and I decided not to proceed. We understood that we would be childless.
    A few months later we could not accept this result, there had to be another way. How could it be that this is the only method practiced and accepted here in Australia?
    So we hit the internet, typed in azoospermia and The Turek Clinic came up.
    After reading the information on FNA mapping my wife and I began to smile ……….. we knew straight away that this was a much better, safer and far more accurate way of determining if sperm were able to be retrieved.
    After a few phone calls, a couple of emails later we were booked on the flight over to SF to visit TTC. Who cared that it was 16hrs flight away.
    From driving in the dark with a blindfold on to having a detailed GPS on in the middle of the day on an outback road! This is where we were now.
    From the moment we were greeted by TTC staff, we felt both welcomed and comfortable. TTC does not appear to be a surgery, its more like a cross between a office with unusual furniture and memorabilia hanging from the wall to a friends place whom keeps everything neat and tidy.
    After conducting the FNA procedure we left SF after 3 days and headed back home to Sydney . At no point in time was I ever sore, felt discomfort or was in pain what so ever. The procedure went well without a hitch.
    Almost two weeks later to the day we received the unbelievable news from Dr PJT that enough sperm was located to allow fertilization via IVF. My wife and I cried for about an hour after the news was received. It was honestly the best news we have ever heard.
    Thank-you so much Dr PJT (I now speak of Dr PJT to my wife as Saint Paul) and also Paula Chavez (Paul & Paula…..lol) for your wonderful care, compassion, professional attitude and friendly nature you provided while in your care.
    The news still has me on a high 7 days after the fact.
    Cant wait to see all you guys again soon for the next step in our journey.
    God bless with love from afar
    GKC

  54. Jsut a quick question…what on earth could cause a sample of 19mm 6 months ago, to 9mm but no motility 5 weeks ago, to ‘azoospermia’ diagnosis last week? I have variococele that may have worsened, but honestly, I’ve never read anywhere it can take sperm count to zero, only to low levels. I’m a 42 yo old male, and we have no children. I also have recently been diagnosed with poor urine flow…seems unrelated but maybe not?
    More specifically, would I be a candidate for FMA mapping or does this sound like a hopeless case of testicular failure? Thanks

    1. Mark, It is unusual when sperm counts disappear that quickly. In these situations, one can usually find the reason. Things that are reversible (a flu, hot tubbing, new medication, urinary tract infection etc) are usually present. Occasionally, something irreversible is found (testis cancer, diabetes). Regardless, a hard look at potential causes is a must. Unlikely to be due to a varicocele with such rapid progression. One goal is to try to get the sperm count back by figuring out the reasond and reversing it. So time may be your ally here. FNA mapping could be helpful if there is no recovery of ejaculated sperm with time. This does not sound hopeless at all.

  55. We found out 10 months ago that my husband has NOA. All hormonal, chromosomal tests came back normal. The testis biopsy showed predominantly Sertoli-cell Only with a few tubules exhibiting early maturation arrest. The doctor put him on 25 mg Clomid a day. When he went back for his 6-week blood test his testosterone had jumped from 380 to over 900, which seems considerable to me. Based on these results, is there a chance my husband could begin producing sperm if he continues taking the Clomid? Have any of your patients with Sertoli-Cell Only benefitted from taking Clomid as far as sperm count goes?

    1. Erica, testis biopsy patterns are often “mixed” with two or more patterns present. The use of medical therapy attempts to “push” the most advanced pattern to complete the germ cell sequence anb become sperm. It is not possible to make sperm from a testis full of only Sertoli cells, as you have suggested, as the testis germ line stem cells are absent. So, here the doctor is attempting to push the maturation arrest tubules to make sperm. The likely result is that there will be no sperm in the ejaculate after 6 mos, but there could be slightly more sperm production in the testis that could be detected by testis sperm retrieval or mapping procedures. Frankly, I have not seen sperm develop in any man with an FNA map showing global Sertoli cell only.

  56. dear doctor!
    i m kishwar, 29years, male.
    i have just give testicular biopsy test, where i got jhonsons score “2” .
    now i would like to ask is there any chance for me to b father of a baby?
    will FNA mapping be helpful for me?
    is there any other option?
    please sugest and help.

    1. Dear Kishwar,
      A single testis biopsy showing what sounds like Sertoli cell only syndrome is not great news. However, remember that sperm production in testicles from azoospermic men can occurs in “islands” or “patches.” Looking at a single site like a biopsy does may in fact be insufficient to determine whether testis sperm are present somewhere in the testicle. Using an 8-site map, we published https://en.wikipedia.org/wiki/FNA_Mapping that sperm could be found in 27% of the same testes in this situation (having had a prior biopsy showing no sperm) and in 20% of the testes on the opposite side. That was with 8 sites/testis. Now we do 18 sites with a modern map! So, you should certainly consider FNA mapping before you write off the sperm issue!!

  57. Please refer my above post – Krish
    Recent two months I have seen the sperm like object in my semen under my home seminal analysis microscope after 2 years.
    These videos are taken in 40X microscope zooming.
    Could you please let me know what these are? Even if it is immature sperm or elongated spermatid, I will be happy considering my YCM deletion, abnormal karyotype and Azoospermia.
    The videos are taken with 3 different sperm like objects in semen and hence kindly be patient to look all three videos hence One video can be better than other.
    Video 1 : http://www.youtube.com/watch?v=S9WcNIctV5E&feature=youtu.be
    Video 2 : http://www.youtube.com/watch?v=NxFRRBEk2Nk&feature=youtu.be
    Video 3 : http://www.youtube.com/watch?v=ehRbA8EJLmU&feature=youtu.be
    Thanks very much for your time,patient and kindness.

    1. Krisha, pretty nice videos! Looked at all three. Honestly I do not think that they are sperm as mature sperm heads have a light half (acrosome) and a dark half (nucleus). These do not quite have that look. However, I may be wrong. A differential stain by an andrology could identify them further.

      1. Doctor,
        Agree that these cannot be sperm. May I know what are all these could be? I have never seen such things in my semen in past 1.5 years. Just seeing these for in past two months only.
        Thanks & Regards,
        Krishna.P

  58. Hi Turek,
    Do you have any suggestion to try for my condition? I am from India and did you train any doctor in India or in any other Asia Pacific country for FNA mapping?
    I wonder whether FNA mapping helps me. Considering the fact of my YCM deletion and abnormal karyotype mentioned below.
    ** Married on June 2010
    ** Tried 6 months for child
    ** Semen analysis in November 2010 which shows Zero sperm and Azoospermia
    ** Repetitive Semen analysis in one year period until 2011 shows the same – Zero Sperm and Azoospermia
    ** December 2010 – Tested for Varicocele and found a large Varicocele – Grade III(Severe) bilaterally.
    ** January 2011 – Corrected Bilateral Grade III Varicocele through surgery(varicocelotomy) and tied up 10 big valves.
    ** January 2011 – Testis Biospy done. Revealed maturation arrest at Primary Spermatocyte stage and pre-dominant Setroli cells. No spermatoza is evident.
    ** April 2011 – Done Karyotype and “Y chromosome microdeletion test and found abnormal Karyotype(45,X[33]/46,X,i(Y)(p10).ish
    i(Y)(SRY++)) and YCM deletion in AZFb and partial AZFc deletion(only STS markers sY255, sY269 are found in AZFc). The full AZFa region found without any defect.
    **The very initial Hormone Analysis shown the FSH is slightly above normal level(13 IU/L) and LH is in normal level(5.07 IU/L). The Testostrene is very Low level(5.20 nmol). However I am under Clomid tablet to increase the Testostrene from May 2011 until now(where I have stopped it couple of times in between). The Clomid worked for me and increased the Testostrene to normal levels – 18.5 nmol (side by side the FSH also got elevated 21 IU/L).
    Even though clomid is worked, I am not able to see any sperm in the ejaculation till date. I have imported a home seminal
    analysis microscope from USA and checking the semen every month.
    I were under multi Vitamins, Supplements like Fish Oil, L-Arg, L-car, Flaxseed oil etc. I understand from the research so far these things will
    not helpful for YCM candidates in AZFb+AZFc deletion but want to try this in a little hope.
    **I HAVE DONE THE KARYOTYPE ANALYSIS FOR BOTH MY FATHER AND MY ELDER BROTHER AND BOTH ARE HAVING NO YCM AND BOTH ARE HAVING NORMAL KARYOTYPE.
    Waiting for your kind reply.
    Kindly let me know your mail address if possible to send all my diagnosis copies.
    Regards,
    Krish.

    1. Krish, a complicated story. What matters most to me is this: Men with Y chromosome AZFb deletions, if complete, are very unlikely to have either ejaculated or testis sperm. This is unlike AZFc deletions, of which 60%+ of men have sperm in the ejaculate or testicle.
      However, this statement must be qualified since there are not many men with AZFb deletions that have been investigated thoroughly to date. Probably less than 100-150 men. So the answer to your question is: It is possible, but not very likely, that you have sperm in the testis with an AZFb Y chromosome deletion.
      In this case, some men simply want FNA mapping done to confirm this, for closure in a sense, and to know for sure. Doing a microdissection for the same reason is a much bigger commitment as its side effect profile is much greater (pain, low testosterone) than that observed with mapping.

  59. Dear Turek,
    Once again Krish from India.
    Did you train any doctor in India or in any other Asia Pacific country for FNA mapping? If so, It will be easy for me in both Economic and Travel to do this procedure.
    If no other Asian Pacific country you have trained other than Israel, could you please give me any doctor contact whom you trained in Israel since its nearest to India.
    Thanks & Regards,
    Krish.

  60. Dear Turek,
    Thanks for all your help in the field of male Infertility. Your help is really wonderful.
    1. May I know for those patients who have both YCM and sperm growth arrested at Spermatocyte level, did the Spermatogonia or Spermatocyte will be having the deleted Y chromosome as well?
    I know the Spermatogonia is a stem cell which contains 23 Chromosomes and just wonder whether it contain deleted Y chromosome as well.
    Please note my mosaic pattern for this question : abnormal Karyotype(45,X[33]/46,X,i(Y)(p10).ish i(Y)(SRY++))
    2. In case if scientist are able to grow the sperm outside my body and in case of female embryo grown in test tube, will the female embryo having two cell line of mine? Pls refer my mosaic pattern above. For your kind information, my wife dosen’t have any type of chromomal abnormality.
    3. Referring my above chromosome abnormality, may I know is there any implication invented so far for men of having two SRY genes? I have more sexual desire. Just wonder it’s one among them.
    4. What you think about IVS(In Vitro Spermatogenesis) in my case in case no sperm will get identified in sperm mapping and since I have Spermatogonia and Primary Spermatocyte? I can choose female embryo considering the YCM and chromosome abnormality of mine in case of successful pregnancy. I believe it’s been done on animals successfully. Even in rare labs in world, IVS applied successfully on few humans based on online reports. I even have a contact of Portugal doctor who says she can try that for me. Please let me know if any one in the world whom you know well can do IVS?
    **I believe even though 99 doors are shut, one door still open for me and I am trying to find that ONE.
    Regards,
    Krish.

  61. Doctor I am also a azoospermia patient, my family doctor suggested me to go through testicular biopsy, and result was nil count in testis specimen and result was maturation arrest was there, so please give me what to do, is it this curable or incurable. please please god sake help me… I am waiting for your replay.

    1. Dear Bhimashankar, Read more of these comments as men with maturation arrest patterns on testis biopsy can often a) have pockets of sperm on more extensive analysis (e.g. mapping) or b) be “induced” to make sperm through varicocele repair, removal of toxins, improved health or through injectable medications.

  62. I recently had a basic SA done with revealed low to no sperm
    my info.
    appearance: norm
    liquef. time : 40 mins
    volume: 2.5 ml
    viscosity: normal
    pH: 8.0
    LH: 12
    FSH:11.7
    Test: 118
    Could my sperm count be a hormonal problem with these number and if corrected could my count be restored?

    1. Jay, Hard to know but it appears that both the LH and FSH are high and that both the testosterone and sperm production are down. This implies that testis failure exists both in the sperm and hormone compartments of the testis, whether correctable or not. Medical therapy to correct your testosterone and also keep your fertility can be tried, but I doubt it will normalize your sperm count.

        1. Jay, Research is always chancey. Stem cell research especially. Maybe this is why there are very few true stem cell therapies available some 30 years after they were discovered. Hard work usually pays off though! We are counting on it.

  63. Hello Doctor,
    After my Bilateral Grade III Varicocele surgery, In my groin, Testicle and left, right sides of the spermatic cords, I feel the heat blood flow or kind of heat in every 3 hours. I feel no pain, no redness or any other issues in these areas.
    I only feel the heat and this is fixed if i apply cold water around the areas where the varicocele surgery done and Spermatic cord, Testicle and Groin areas.
    If i don’t apply the water then it become worst. I feel the heat spreads to my chest area, the buttocks and my head, the testicle feels kind of bruising when the heat is intollerable.
    This issue happening after few days of the varicocele surgery
    . I just want to mention two more incidents. Just before a month of surgery, my wife affected with Urinary Tract Infection and she was cured from it. I was not affected that time and was normal. Also I have stopped my 15 years of smoking habit from the day my surgery was done.
    This problem started occurring only after the surgery. Before this surgery, I never felt this issue or apply water like this.
    I feel the heat starts from my abdominal most of the times and spreading down to my testicle, spermatic cord and groin areas. Later spread to chest and head. The condition get fixed when I apply the cool water near my testicle, abdominal, buttocks and groin.
    I feel the heat extremely internal to body and others(including urologists) are not able to feel the heat when they touch the areas outside while checking(other than mild heat).
    I am not sure what is this condition. Whether this is due to my Grade 3 Varicocele surgery where 10 valves are tied up(In usual cases it will be 4 to 7 if I am not wrong) and whether the blood is struggling to flow to the testicle after the surgery due to the reduced valves.
    Or whether it is due to any Infection(I feel no other issues other than the heat)?
    Or its due to my low Testostrene levels? (Because the number of times I apply the water is greatly reduces when I have good Testostrene levels after the surgery. But I had low Testostrene even before the surgery but no issues that time)
    Or is it due to any kidney or liver abnormalities(wonder how that is possible just from the surgery)?
    Or did this is due to any nerve damage during the Varicocele Surgery?
    I need to apply the water every 3 to 5 hours interval(I rush to toilet after I feel the heat starting from abdominal to testis and goes intolerable level). Even In office, I need to apply the water like this, otherwise I am unable to tolerate the heat. Sometimes in nights occasionally I woke up from sleep because of the feeling of the severe heat in these areas.
    I even fear to do long travels due to this condition since I need to apply water frequently.
    Sometimes I feel why did I do this varicocele surgery.
    I have consulted 3 urologist so far and all are done physical analysis of the areas mentioned and saying that nothing abnormal and this is my subjective feeling only. They haven’t taken any particular tests.
    Please , Please , Please don’t say once again its my subjective feeling. Because I was without this issue until my surgery. How come a subjective feeling can affect me this much? I was never do apply water before the surgery like this.
    kindly give me a suggestion what is this condition? what test i need to take? Since the urologists just saying its subjective feeling and stop with just physical checks, I am confused what to do and continuing with this cold water approach for my problem.
    I am 30 years old male with no health issues other than infertility. I am a successful Engineer in Information Technology.
    WAITING FOR YOUR KIND REPLY.
    Thanks and Regards,
    Moorthy

    1. Dear Moorthy, Do not worry. Lots has happened: infertility, wife’s UTI, varicocele surgery, smoking cessation. You are not on fire, and things will not get worse…only better. Have trust!

  64. Hi,
    I have a doubt reg the Y Chromosome Microdeletion. I have AZFb+AZFc deletion along with low hormone and maturation arrest.
    1. Any Azoospermia study you take, where 40-60% of cases have the same clinical condition as I have(Maturation arrest, Low Hormone and Azoospermia) but they are without YCM and normal Karyotype with no other abnormalities. So what is the root cause for them?
    2. Some occasional cases of AZFb+AZFc YCM, the patients have normal sperm production and few cases are Oligospermic . So how could this be possible since AZFb+AZFc deletion means no sperm(not even one) as the medical world believes.
    Thanks.

  65. Hi,
    I have a doubt reg the Y Chromosome Microdeletion. I have AZFb+AZFc deletion along with low hormone and maturation arrest.
    1. Any Azoospermia study you take, where 40-60% of cases have the same clinical condition as I have(Maturation arrest, Low Hormone and Azoospermia) but they are without YCM and normal Karyotype with no other abnormalities. So what is the root cause for them?
    2. Some occasional cases of AZFb+AZFc YCM, the patients have normal sperm production and few cases are Oligospermic . So how could this be possible since AZFb+AZFc deletion means no sperm(not even one) as the medical world believes.
    Thanks.

    1. Steve, Good points.
      1. In the world of fertility genetics, there are probably 1000 genes that control sperm production. We have clear knowledge of maybe 25-20. My view is that many of these currently “unexplained” cases will be genetic.
      2. Good observation. One critically important thing to consider is the quality of the genetic testing. Not all labs are equal; some cut corners to save time and money. With Y chromosome genetics, they may use too few STS markers to adequately call a spade a spade. Many cases of “complete” AZF deletions are actually partial when you look more closely, and men with “partial” deletions may very well have sperm.

  66. What we got for male Infertility? Europe nears first approval for gene therapy
    ———————————————————————————————————
    treatment?
    ——————-
    Dear Turek,
    I have seen the first gene therapy approval soon coming out of Europe for a fat gene treatment and I believe you are aware of it. Links for this news given below:
    http://www.nature.com/news/europe-nears-first-approval-for-gene-therapy-1.11048
    http://www.reuters.com/article/2012/07/20/us-genetherapy-europe-idUSBRE86J0M820120720
    I understand gene therapy is tough and gene therapy is prevented in USA due to a girl death by gene therapy before.
    But the current Europe gene therapy approval proposal giving me some light and I wonder why the same is not even tried in YCM AZF deletions? I am saying it because there are 0 clinical trials in world for YCM patients (proof: USA government clinical trial website : http://clinicaltrials.gov/ ).
    Instead of doing very less promising procedure(mTese , ICSI, FNA mapping etc etc) for these YCM Deletion candidates, why not the medical world concentrating on a high promising technologies like Gene Therapy for these growing number of YCM candidates(atleast for AZF deletions)? If YCM candidates are successful through gene therapy then I believe most tough cases of infertility due to genetic origin in both male and female can all get most benefit.
    I would like to know your thoughts on this since you are one of the major player in field of Infertility.
    Regards,
    Krishna.

    1. Krishna, You raise good points. The US FDA is “gun shy” about gene therapy. It is even more gun shy about “germ line gene therapy” which means altering a subject’s genome not only to cure him but also to cure future generations. This is a highly political situation that may make sense for male fertility (e.g. missing Y chromosome genes) but it is not clear where the line is drawn. For example, do we select for an enhance intelligence, looks, height and sex?
      As we speak, we are working hard trying to create human sperm from embryonic and adult stem cells and testicular stem cells. I think that this is the solution of which you speak. Using adult stem cells, say from a skin biopsy, to make sperm would need to be safe but would not be all that political (no embryos used, no germ line gene therapy). Stay hopeful.

  67. Dear Turek,
    Thank you for all your help.
    May I know what are all the parameters can be identified other than finding sperm in FNA mapping?
    For example :
    1. Early maturation arrest at Primary spermatocyte.
    2. Late maturation arrest at Spermatid level
    3. Pre-dominant Setroli cells with Early maturation arrest at Primary spermatocyte
    4. Basement membrane thickened(which is usually identified through Testicular Biospy)
    Can we identify such findings as above?
    I am planning to do FNA mapping in your clinic by next year February. Just want to widen my knowledge about this procedure.

  68. Dear Turek,
    Thank you for all your help.
    May I know what are all the parameters can be identified other than finding sperm in FNA mapping?
    For example :
    1. Early maturation arrest at Primary spermatocyte.
    2. Late maturation arrest at Spermatid level
    3. Pre-dominant Setroli cells with Early maturation arrest at Primary spermatocyte
    4. Basement membrane thickened(which is usually identified through Testicular Biospy)
    Can we identify such findings as above?
    I am planning to do FNA mapping in your clinic by next year February. Just want to widen my knowledge about this procedure.

    1. Krish, FNA mapping can identify all germ cell stages up to and including sperm. This makes it more precise than either a simple testis biopsy or microdissection TESE and, in fact, gives it alot of its power as a diagnostic tool. To answer your question, it can identify #1-3 above. We have also found cancers with this technique, before they become visible on ultrasound or palpable by hand. It currently does not identify basement membrance thickening.

  69. dear doctor i am from India
    I went for semen analysis last week, here is the report details
    Testorane,LH,TSH,are normal
    PHYSICAL EXAMINATION
    ———————————–
    Volume = 3.0 mL
    Liquefaction Time = 30 mins
    Viscosity = normal
    CHEMICAL REACTION
    ——————————-
    Reaction = Alkaline
    Fructose = Present
    MICROSCOPIC EXAMINATION:
    ——————————————
    Sperm count = No Sperms on first 3time but on last <5millions/ml
    OTHER MICROSCOPIC FINDINGS
    ————————————————
    Pus Cells = 1-3/hpf
    RBC’s = Nil
    Epithelial Cells = Nil
    Sperm Aggregation = Nil
    and i have also done ultrasound of testis no any block seen
    and went FNSA it shows" Occasional sperm seen" .after doctor give me medicine for increase sperm and after 2 months go for IVF ICSI
    now i am totally confused that if i have no blockage and sperm in testis than why they called me for ICSI. please give me right advise what to do and what are the possibility

  70. Thanks very much Turek. It’s great.
    Really proud of seeing your expertise in field of male infertility.
    1. May I know at what stage the artificial testicle project is in?
    2. Do you have any rough timeline until how long it will take to come in clinical practise?
    3. I heard from few countries (one among is Portugal) that the researchers succeed in IVS and successfully produced human child’s through In-Vitro Spermatogenesis using Spermatogonia Stem Cells from human testis. Per your knowledge is that true? If you wish I can provide you the web link for these research papers.
    Thanks & Regards,
    Krishna

    1. Krishna, many groups around the world are trying to make sperm in a dish. As far as I can tell, none have published success at this in reliable, peer-reviewed journals as yet, despite claims to have done so. Not sure when this will happen or when it will be ready for prime time. Stem cell research takes money, patience and time.

  71. I am a 15 year cancer survivor and I have had a semen analysis where volume was 2.0 and sperm count was 0. I have read your article The Quiet After the The Storm of Cancer, http://theturekclinic.wpengine.com/the-quiet-after-the-the-storm-of-cancer/. After reading this article this gives us hope about having a child. I had chemotherapy and not radiation. I was 15 years old while going thur cancer and I am now 31. Do you think this is azoospermia? I plan to get further testing to determine the problem. I have briefly researched the mapping procedure. Do you think it might be a blockage? We would like to come and see you, however, we are across the country in KY. Should I see a urologist or endrocronologist? Any recommendations for specialist in KY? Thinking that I might never be a father biologically is very troubling to us. We want to do all of the right things to know for sure….

    1. Brian, Many questions and hopefully many answers down the line. It appears that you do have azoospermia. THe FSH level will tell us whether it is likely to be obstructive (<8 mIU/mL) vs nonobstructive (>8 mIU/mL). For sure, see a urologist. With FNA mapping, understand that we routinely find sperm in cancer survivors! And, Kentucky is not that far for a 1/2 visit day visit to sunny SF. Spend the weekend seeing the GG bridge, Saucilito and Alcatraz!

  72. Thanks for your comment and much needed information. It does give us hope.
    I was seen today by my primary care physician and had a discussion about this issue. He did not know of any medical centers and physicians that perform the FNA mapping….Still searching for one that would be a little closer home for us….Who know’s we might end up in your office later down the road??? Thanks again.

    1. Krish, this work confirms earlier work that my colleagues at Stanford published in 2010 or so. These new findings come from a good group that is doing good work. However, their findings are similar to what’s been published before: you can take embryonic stem cells and adult stem cells and only push them so far down the germ line sequence of 13 stages in a dish. They go about half way and stop. It appears that a more “natural” environment is needed to go the distance and to make a sperm. We are hoping that our artificial testicle is just that place.

  73. Dr Turek,
    I discovered that I was azoospermia 7 years ago when I performed my own Semen Analysis because I am laboratory technologist. I had low sperm count (<2ml), and no sperm in micriscopic examination. Normal FSH and LH. Normal testiscular biopy with normal sperm production. I knew then, it was brokage, but I didnt know there was a microsurgery surgery to correct the dfficiency. My wife agreed to IVF with my own sperm, where the fertility doctor use a needle to extract sperm from my testicles to fertilized my wife egg. We have two girls now, a 4 yr old and 1.6 yrs from the same frozen embryo. We will prefer to have another child, hopefully a boy, but there is no more embryo, and my wife do not want to go through the medication and injection anymore. Besides, the procedure is expensive. My question is, how much does the micro-surgery cost to remove the brokage which is definately, the solution to my problem. Thank you.

  74. dear dr.Turek
    my husband was diagnosed 3 months ago with azoospermia after doing three semen anaylsis and all came back zero !
    his hormones came back all normal, ultrasound normal. genetic test came back normal as well.
    he recently have done diagnostic single biopsy, and there werent any sperm found,
    my question is where to go next , we are confused and shocked.
    is he diagnosed with maturation arrest and could it be treated.

    1. Dear Hopeful, sounds like he has nonobstructive azoospermia. Yes, despite the 3 semen samples showing no sperm and despite the single biopsy showing no sperm, there is still a chance that he has sperm that can be used for kids. You will need to consider visiting a center that specializes in this. FNA mapping and microdissection TESE are two possible approaches, but very unique and different that can find sperm. I would love to help. Consider setting up a free talk with me about your case: http://theturekclinic.wpengine.com/urologist-beverly-hills-los-angeles-san-francisco-california-contact/

      1. dear Dr,
        thank you for your help:), we are waiting for the result of the diagnostic biopsy. could you refer us to any medical center in europe or middle east region. since going to the usa is a little bit difficulte.
        aslo from your own experience what is the chance for us to find a health sperm considering he have normal horomnes, normal ultra sound, normal karyotype test.
        also in your opinion what is the most cost effective procedure is it micro tese or fna mapping
        looking forward for your reply and thanks alot 🙂

        1. Hopeful, hard to answer the question without knowing the details. FNA mapping is diagnostic and minimally invasive and very informative (60-65% chance of finding sperm). A targeted sperm retrieval is needed with IVF-ICSI afterwards which is usually also a minimally invasive procedure. It is a “know before you go” procedure. mTESE is therapeutic but is also much more invasive, with a similar detection rate.

  75. dear Dr. Turek
    it is hopeful again 🙂
    thank you so much for answering my questions, i was wondering is there any chance to improve maturation arrest by medication or hormones therapy, and in what level.
    thank you so much

  76. Hi Doctor,
    I really appreciate you for educating patients like me suffering from azoospermia.
    My blood test results are as follows:
    a) FSH 3.7 mIU/mL (normal)
    b) LH 1.3 (lower than normal)
    c) Prolactin 2.7 (normal)
    d) Total Testosterone 151 (lower than normal)
    My last few semen analysis results showed azoospermic and normal volume, pH=6.8
    I had biopsy 3 years back in India but the it was not done properly meaning the tissue that was cut was bigger. I had to rest for 2 weeks. Lab technicians were not experts in testicular biopsy. Results showed spermotids (no spermatozoa). Few sertoli cells and leydig cells were also seen.
    Now I am back to US.
    a) Is it obstructive or non-obstructive?
    b) My doctor prescribed tamoxifen for low T. Is there any hope of normal spermtogenesis? What is the probablity that sperms will be seen in the ejaculate?
    Thanks a lot for publishing useful info.
    Regards
    Kris

    1. Kris, no one can tell you exactly what your story is over the internet. However, a professional reading of the biopsy slides would be VERY informative. We do this as part of care here at TTC. My slogan is: Where there are spermatids (your word: spermatoids?) there are usually sperm.” Consider sending the biopsy slides (not the report) to us for review. Assuming sperm were not seen on the biopsy, and the biopsy was done properly (a question here) then by definition you are not obstructed. Whether you have any sperm, enough to have a child, is a different issue that needs more investigation. Be happy to help http://theturekclinic.wpengine.com/urologist-beverly-hills-los-angeles-san-francisco-california-contact/

  77. Dear Dr. Turek:
    My husband was diagnosed to be non-obstructive azospermic in 2009, he completed a TESE procedure which some sperm was found, we also complete ICSI-IVF after successful ferterlization we now have a 2 year old. we recently tried another session of the IVF-ICSI with my husband repeating the TESE again but unfortunately we didn’t have as much luck. no sperm was found. why we ask? his physician could not explain to us. He also used Clomid and Arimidex before undergoing the recent TESE (same as the 1st time). He is now put on HCG injection once a week to help improve the sperm count. is this the right move. recent testesterone level was in the 600 which was higher in April before using clomid and arimidex. is there any hope for us? do you think we should undergo another TESE procedure for the 3rd time?

    1. Karrisa, All good questions! Generally when a TESE sperm retrieval works once, it works again. But this depends on lots of issues. As one of my goals with such procedures is to get enough sperm for several IVF-ICSI cycles with a single sperm retrieval, I assume that this is not the case here.
      If the first TESE was actually a “microdissection TESE” then there may not be any more sperm left in the testicle, as this is a pretty invasive and excavating procedure. If it was a simple testis biopsy TESE, then it may be because sperm production within the testis is occurring in “pockets” and they are hard to find with randomly taken biopsies typical of TESE procedures.
      I find FNA mapping particularly useful here. Through this relatively simple and non-invasive procedure, I can learn whether and where there might be pockets of testis sperm available for another TESE. Overall, we have over a 95% chance of finding sperm by TESA/TESE after FNA Mapping shows where it is in the testicle. That makes couples more comfortable proceeding with IVF-ICSI and fresh sperm retrieval, knowing that there is an excellent chance that sperm will be found.

  78. Dear Dr. Turek
    I was diagnosed with azoospermia after semen analyses and blood test. Fsh was 13.8 and lh was normal. Physical exam was normal. Testosterone was low. The doctor put me in clomid and vitamins aafter one year of treatment on clomid
    got blood test done and seman analysis still no sperm. But t/e ratio was low. He put me on arimidex. All genetic testing was normal. In your experience with patients. What do you think my chances are with the new medication. I take both clomid and arimidex, thank you

    1. Dear Azoo, I am not sure waiting another year on two medications will help you develop an ejaculate sperm count. You might consider trying to figure out whether there is testicular sperm available at this point. I would recommended FNA mapping for this /services/male-fertility-infertility-doctor-treatments-issues-zero-sperm-count-male-doctors/sperm-mapping-testicular/).

      1. Thank you for your response Dr. Turek. I will definitely consider this. Is this available in NY? Also what are my chances with FNA mapping considering my situation. And according to your research, is low t:e ratio curable? Have you treated patients with this situation and what were the outcomes? I would appreciate your help. Thank you

  79. Dr. Turek,
    My husband was diagnosed with NOA a year and a half ago and was told he had a predominant Sertoli cell only pattern when they did a testis biopsy. The doctor put him on Clomid but said he didn’t really expect to see any improvement. However, after taking it for 4-5 months our SA showed sperm! We were thrilled, but the numbers are very, very low. One SA showed 52 sperm (half of them motile) and a second SA showed 20 sperm (13 motile, 7 not). My question for you is, is it possible to do IVF/ICSI with such a low number of sperm in the ejaculate? Or would we need to do some kind of sperm retrieval technique (PESA, MESA, TESE) for better success? The fact that he has any sperm at all making it into his ejaculate would mean that he is producing quite a few sperm, correct? I am hoping we would be able to retrieve sperm from the vas deferens or the epididymis rather than directly from the testis, as these would be less invasive.

    1. Dear EA, Congratulations! This is called cryptozoospermia, where small numbers of usable (motile) ejaculated sperm are found in the semen that is otherwise devoid of them. Goes to show you that a single testis biopsy, showing any pattern whatsoever, does not represent what is happening elsewhere in that same testicle or the other one.
      We recently presented our findings from 40 such men over the last 2 years in our practice at the national fertility meetings (ASRM) in San Diego in October. Basically, we found that 85% of men were able to move forward with IVF-ICSI using only ejaculated sperm (fresh or banked) and 15% needed “backup” procedures to get enough sperm. Normal fertilization rates were easily 60% and ongoing clinical pregnancy rates were 46% with female partners averaging over 35 years of age. THIS SPERM WORKS! So, I would: 1) bank samples until the IVF lab has enough to go forward without a sperm retrieval procedure (this might be hard as many labs don’t handle such low numbers of sperm), 2) realize that sperm retrieval procedures with this condition can be VERY difficult (easily involving the heavily invasive microdissection technique) and have a high chance of failing as that tiny island producing small numbers of sperm may be hard to find.

      1. Thank you for taking the time to respond to my question! Your reply has given my husband and I some hope regarding our chances of having our own biological child. We are very excited that he has any sperm at all, but recently got discouraged when we visited an IVF clinic where the doctor told us he didn’t feel confident using such low numbers of sperm to do IVF/ICSI. He said we needed to get our numbers up to somewhere in the hundreds before he would consider helping us. We left the clinic feeling like we were back at square one. Based on what you have told me, it sounds like we need to find a clinic willing to work with our extreme situation and help us bank what little sperm we have. We are in the East Tennessee area.

  80. Dr. Tureck,
    My husband & I have been TTC for over a year. He had surgery for a hernia repair & left testical removal (due to deformity) when he was 2 years old. After being unsuccessful in conceiving, we went for 2 seperate semen analysises. First SA was 1.0 mL with 0 sperm. Second SA was 0.8mL and 0 sperm. Further testing revealed Prolactin 10.3 ng/ml, LH 5.2 miu/ml, FSH 7.6 miu/ml, testosterone 397.40 ng/slow. His seminal fructose was positive. We had a prostate ultrasound, and his urologist said everything was normal. He said from bloodwork to ultrasound it was all normal, just low volume and no sperm. He stated we would need some sort of IVF or insemination to become pregnant but offered no explaination as to why azoospermia. It seems to me that he just wanted to wash his hands of us. We have an appointment with a Floridia fertility clinic, but I am terrified they will say he has no sperm to use, or use up all of our money doing more random testing. We have limited funds and no health insurance, so we don’t want to waste time and money for further heartbreak, but are completely lost.
    Could his condition be a result of his hernia? Testical removal? Blockage? Is it even possible for him to father a child naturally or through IVF?
    Please help point us in right direction.
    Thank you so much.

    1. Kristy, the facts of the case are that he has one testicle (small or normal size?), relatively normal reproductive hormones (although that FSH is slightly at the high end of normal, which is 8) and low ejaculate volume. Here are some other facts:
      1. Men with one testicle are generally as fertile as men with two.
      2. Having a hernia repair or a testicle removed does not cause a low ejaculate volume
      So, it is not clear whether he is blocked or not at this point. By having fructose in the ejaculate and a normal prostate ultrasound (if well performed) then ejaculatory duct obstruction is unlikely.
      Best bet is to determine whether sperm production is normal or not. My choice for this (least invasive and damaging, most informative) is FNA mapping /services/male-fertility-infertility-doctor-treatments-issues-zero-sperm-count-male-doctors/sperm-mapping-testicular/). Hope this helps.

  81. My husband and I have visited your clinic in San Francisco almost 2yrs ago. You explained to us that my husband has azoospermia and that sperm mapping was the way to go. Also that my husband was suffering from malnourishment. We have recently discovered that he has an intolerance to gluten. He is feeling better and vitamin levels are rising. Do you think that Gluten can be the cause of his azoospermia??? Fingers crossed!!!

    1. La Shawn, Interesting! I would say that any disease that “starves” the body will sacrifice infertility…it’s one of the first things to go in a stressed body. Whether this stress is severe enough to cause the sperm count to go to zero is another matter. Less likely but possible. He should check his sperm count again.

  82. Hi Doctor Turek,
    My husband is azoospermic with a y-chromosome microdeletion (AZF B+C). His hormonal test results are normal & he’s fit & healthy. As expected, no sperm were found during a biopsy (the surgeon said he “had a good look around” in both testicles, but it was a standard biopsy, not micro) … the lab analysis was SCO.
    My question is, has sperm *ever* been found in men with AZF B+C deletions via FNA mapping (& if so was it then able to be retrieved, & suitable for IVF/ICSI)? We are trying to decide whether it’s worth making the (international) journey to your clinic or if we’d just be wasting our time/money/emotional energy! All the research points to the latter, but as you’ve mentioned, so (relatively) few cases have been closely examined.
    Unfortunately for us (I’m in my mid-late 30s) any success from your wonderful work with the artificial testicle will probably be a few years too late 🙁
    Kind regards,
    TTC.

    1. TTC, I have found sperm on mapping in men with complete AZFc deletions (as have many others) and in men with partial AZFb-c deletions. The “partial” really applies to the AZFb deletion part of this as finding sperm in a man with a complete AZFb deletion is highly unusual. Regarding the artificial testicle and its time to clinical use, you could consider freezing your eggs (not embryos) now for use later….

  83. Dear Dr Turek,
    I’m 38 years old. I’m azospermic and live in Poland. FSH 30 mlU/ml, LH 12 mlU/ml, Testosteron 3 ng/ml. Genetic ok. I am preparing for microTESE in Poland. In this reason I have a question. Will microTESE damage my testis and I will have to take testosteron to the end of my life?
    Kind regards
    JO

    1. JO, You certainly need to talk to your doctor about the chances that your planned procedure will affect your testosterone balance, either temporarily or permanently.

  84. Hi dr. Turek,
    I’m Sandra, from Indonesia. My husband had an Obstructive Azoospermia. All the hormones are in a normal range. Testiscular USG done, and the result were Varicocele grade-III at the left testicle, and grade-I at the right testicle. Also had a Spermatocele on the left testicle. The Urologyst examine my husband, and my husband revealed to have a gonorrhea in 10 years ago (according to my DH, said that it’s been cured). In Jan2012 my husband got varicocele operation along with tese biopsy. The result were 3 straws of sperms (don’t know the exact numbers of sperm), it were all immotile before washed, but then it were motile. It were all frozen till September2012. We had IVF with ICSI methods. I got 12 follicle, 12 are mature (all are contained with oocyte), after ICSI, only 3 embryos come as the result. 1 is poor grade, 1 is moderate, and one is good. The poor and good are 6 cells, and the Good are in 8 cells.
    So, dr Turek. i would like to ask your opinion. What would be the case of our failure IVF Program? How to increase my husband sperm?
    Thanks for your time 🙂
    Last September 2012 we got IVF with ICSI method.

    1. Sandra, this is certainly a complex case. If your husband is truly “obstructed” then the sperm should really be fine for IVF-ICSI and they should not be the cause of either poor fertilization or poor development of embryos. I would suggest that female factors or laboratory issues be examined for risk of poor quality embryos. Regarding ways to improve his sperm counts, that gets complicated…no simple answers. But, consider a Second Opinion if you want (http://theturekclinic.wpengine.com/services/get-a-second-opinion/).

    1. Sandra. They use the same tool (fine needles to aspirate) but FNA mapping is done on the testicle and PESA is done on the epididymis. Testis FNA will not block the system upon healing but PESA can block the subsequent flow of sperm out of the epididymis, and possibly in an irreversible way. In other words, sticking needles in the epididymis can lead to a irreversible blockage in the reproductive tract that may not be reconstructable with microsurgery. Consider having such procedures done only on one side…

  85. Dear DR Turek,
    Thank you so much for replying. But taking into consideration your experience can microTESE lower the testoseron level since it is invasive procedure as you mentioned in your blog?

  86. Dr. Turek, I am a 28 year old male diagnosed with azoospermia. After doing a testcular biopsy (microTESE) no sperm were found, and I was diagnosed with sertoli-cell only syndrome. The doctor gave me a 0% chance of becoming a biological father. He said I was born without sperm and won’t ever have sperm. What’s your take on this? Do I have a chance at all with sertoli cell only syndrome?

  87. Dear Dr Turek,
    I have one more question. I decided to take microTESE in Poland. My urologist suggested put off the surgery and presrcribed Tamoxifen and Undestor Testocaps to lower my high FSH 30 ng/ml and rise Testosteron 2,6 ng/ml. What do you think about this procedure? Regards
    Jacek Olszewski

    1. Jacek, I get the idea of giving tamoxifen to improve testosterone balance before looking for sperm in the testis, but am totally unclear about the rationale for “undestor testocaps” for same. Lowering FSH has not been shown to improve sperm production in men with high FSH. Get a good explanation and maybe some literature on this approach!

      1. Dear Dr. Turek,
        Thank you so much for your help. I got back to my urologist with your feedback and he maintains that combination of Tamoxifen and Undestor may improve quality and number of sperm. I don’t know what to do now. I wish to make mTESE or mapping in your clinic but its far i.e. 20 hours by plane from Poland… Distance is only one obstacle.
        Kind regards
        Jacek

  88. Dear Dr Turek, Harmone Test was done this month
    FSH = 6.56miu/ml
    testosterone = 2.3ng/ml
    estradiol = 53.05pg/ml
    I am non obstructive azoospermic since last year and half. Doc has prescribed tamoxifen citrate 10 mg daily . Is it possible to find sperm in my testis during ICSI after 2 months of treatment.

    1. James, Tamoxifen will raise your testosterone level which could help optimize sperm production. However, it can also raise your estradiol level which might impair sperm production. The way to know is to check the T/E ratio 4 weeks after starting the pill. Generally, it is advised to give medical therapy for at least a full cycle of sperm production, which is 3 months.

  89. Dear Dr. Turek
    I have non obstructive azoospermia for 3 years. My doctor said microdissection TESE is a proper surgery in my case. Taking into consideration my hormone resuults: FSH 31 mlU/ml, LH 12 mlU/ml, Testosterone 3 ng/ml he decided to implement medical treatment: Tamoxiffen 40 mg per day for 6 weeks. After 6 months my results are: FSH 46 mlU/ml, LH 19 mlU/ml, Testosterone 574 ng/dl. He said I had to stop medication now and wait maybe 4-6 weeks for surgery. Is it normal that all my hormones grew up significantly after medication therapy? Could it worse my situation?

    1. Damien, On a very significant dose of tamoxifen, you have increased pituitary drive to the testicle and increased native testosterone production. Although commonly used to increase testosterone levels to “normal” prior to “looking” for sperm in the testicle, medical treatments like this are believed to “optimize” sperm production. However, good data to suggest that this actually happens is not available (i.e. no randomized trials). So, in fact, it is not clear whether it might worsen the situation.
      Generally, I maintain the treatment while “looking” for sperm with mTESE or FNA mapping and do not stop it before looking. Given that your baseline testosterone level is low to begin with and that you are not likely to be taking tamoxifen for the rest of your life, mTESE has a measurable risk of resulting in temporary or permanent hypogonadism, possibly leading to chronic testosterone replacement therapy. For this reason, you may want to consider a far less invasive, but also highly informative approach to finding pockets of testicular sperm: FNA mapping. Contact us it you want to talk further,

  90. Dear Dr Turek,
    Thank you for reply! Sorry I made the mistake in my post. I meant not 6 months but 6 weeks after medical treatment my hormons evaluated. Last Friday I stopped with medication. Should I wait now for FNA mapping or mTESE couple of weeks to normalize my hormones FSH, LH, Testosterone, since my FSH is very high right now 46 mlU/ml?

  91. Dear Dr.
    Im a 35 years old woman married to a 34 man with NOA since he was 26. He went through 2 FNA, one of them revealed 2 round spermatids that where used to fertilize 2 eggs of his ex wife but no pregnancy was achieved. They performed another 2 biposies with zero sperm or spermatids. All this in an arabic country.
    2 years later we got married and we have just perfome and icsi procedure with ROSI. His hormone levels has always been normal, no cromosome Y delation. They made a biopsy and they found that right testicul has no spermatids but round spermatids where found on the left one. They found 8 and used in Icsi with the result of 4 fertilized. 1 embrio was 8 cells, 1 6 cells, another of 5 cells, and a late fertilized one of 2 cells. all with fragmatation and where describe in the report as 2:3 quality. all this was done in Europe. They transfared the 3 better ones but today we got our negative beta result.
    my question is…is there any thing we can do? hormone therapy? mapping? I dont want my husbend to go under other procedure that can harm his hormone levels for life or make damage in his testis but our relgion dosent admit donation options. we have 12 oocytes frozen to be used if we find any solusion as my stimuation results on 20 mature oocytes.

  92. Dear Dr. Sorry to write again, just want to add that my husbend never took hormonal therapy, only vitamins and that the urologist of the last biopsy in europe sayed the testis are still ok and can support a new biopsy but i dont want a new procedure if the case is imposible.

    1. Dear Malak, Wow, what a story! I see several facts here:
      1. ROSNI/ROSI are technologies that are not routinely performed in the U.S. as they are considered entirely experimental.
      2. If it is true that your husband has round spermatids on testis biopsy, then we have learned from FNA Mapping that in most of these cases where there are spermatids, there is also sperm.
      3. Many cases of late maturation arrest can be “pushed” to make mature sperm with aggressive management of overall health, fixing varicoceles and potentially giving medications. Might be worth a call to us.

      1. Dear dr, than u for your asnswer, we wil contact u soon to discuss the possible trearments. just a questin, if there is no variciceles is it still posible that hormonal therapy makes a diffrerence? What % of patients with maturation arrest have succeed with this “pushing” treatment? Thank u so much.

  93. i’m at the stage were I’ve just been told and ever since I haven’t been myself. my partner has had her checks and is fine thankfully….but I cant seem to get over this feeling, Ive no idea whats going to happen, Ive only had one sperm count of zip (0) and a examination by a ‘expert’ at a hospital and he said it was congenital as my testis’s are smallish… i hadn’t noticed, but never went round comparing.
    all I know is that I’m extremely down at the mo, family have tried to comfort me but…Im just not feeling it. there’s not many people to talk to it seems and writing on this site is hard, but i think I really do need some help and advice, but I’d really like some factual answers.

  94. Dear doctor Turek,
    I have azospermia…I was at biopsy before three weeks and now i wait final report.
    After biopsy doctor which performing biopsy in Slovenia told me that 3 biology seen multicells mooving parasite in my testicule tissue and after few days he told me that parasitologist didnt sucess to izolate parasite…
    Can parasite damage my spermatogenesis, what do you think?
    He told me that they didnt find sperm only imature cells but i will wait final report…
    about my hormons FSH is high =20, Lh= 8, testosteron= 9 and i have varicocele ( grade III) on my left testise…
    can tou wtire me your opinion please?

    1. Nemanja, I have seen Trichomonas in sperm but have never seen a “parasite” in the testicle (just TB). Not sure about this. Regarding whether or not you have mature sperm, it really depends on how hard they looked. Be happy to give you a detailed Second Opinion if you so desire.

  95. Thank you very much for you answer,
    they telll me that day when i have biopsy that they suspect on parazite called shistozoma something like that. Can I send you my report when he comes on some e mail because i an planing to come to you to do FNA mappin very soon

  96. Dear Dr Turek
    My husband’s first semen analysis came back as zero/azoospermic. He was sent for blood tests LH and Prog normal and FSH 12.1 which I understand is just within the normal range? Is this correct? Hvaing read some of the comments on your website I wanted to ask you if you thought his habit of having at least two hot baths a week for the last 3 years could be the cause of the zero sperm? Can it also contribute to the raised FSH? Thank you so much for your advice.

    1. I should add that I took the temperature from our hot water tap recently ( as when he bathes it is almost entirely from the hote water tap) and this showed a temp of 40 degrees

      1. Remember, any temp above 35 degrees C would be too high for sperm production. Good investigative work! Let’s see what happens when he stops the baths! Keep me informed.

    2. CP, YES, the baths could be the thing. In my published study of men in tubs, the dose, duration and frequency of baths that your husband has been taking would be considered “high.” We saw azoospermia in men with this dose of tubs. The elevated FSH is also possible. The answer will lie in stopping the baths (use showers instead) for 3-6 months and seeing what happens. After 6 mos, I would attribute the azoospermia to other causes.

      1. Dear Dr Turek
        Thank you for taking the time to respond to my post. I will certainly let you know the outcome in the next 3 -6 months. Fingers crossed….!

      2. Dear Dr Turek
        I wanted to update you. My husband has stopped the hot baths – this has been for almost 3 months now since he last took a hot bath. He had his blood test done again and the FSH was still ‘slightly elevated’ at 12.1 in your opinion is this hopelessly high – or would it indicate we still have a chance of finding sperm. He has yet to repeat his second sperm sample – he will do this in early October. We are hoping that with the fertility supplements and cool showers we will not have another zero result. I would be itnersted on your thoguhts regarding this second FSH result though… thank you so much as always

        1. Dear Dr Turek
          Further to my prvious post his FSH actually came back as 14.8 on the second blood test ( 12.1 The first time) The doctor said this was high and it coudl mean bad news for us. But I have read online that normal range is between 5-15? Which would mean he was still in a normal range. However I suppose given that his first semen sample was ZERO this is why the doctor has reacted this way. However we are still waiting for the second sperm test follownig 3 months of no hot baths. As his other hormone levels were normal – do you think he needs to be tested for normal chromoomes? Or would some of the other hormnes been out of kilter is this was a genetic reason why he does not produce sperm? Thank you for you thoughts… it is another month before we can see a sepcialist and it feel like a long time trying to know answers.

          1. Dear Dr Turek
            What do you think to the above? Could it still be hot baths and 3 months just wasn’t long enough for him to start producing sperm again? What are our chances?
            Please reply if you can – thank you so much

          2. Hi CP,
            I was wondering — did stopping hot baths help at all? I’ve wondered the same for my husband, who sounds similar to yours.

  97. Dr. Im a azfc delections, i made two biopsis they found esperamtics. The dr. toldo me to go to IAD what is your opinion?

    1. Rubens, 60-70% of azoospermic men with AZFc deletions will have sperm, but it depends on how hard you look. FNA mapping is better than two simple biopsies in this regard. Consider it before going to IAD (donor sperm insemination).

    1. Rubens, I trained a fellow named Dr. Marcelo Cohen in Buenos Aires. Look him up and say hi to him for me!

  98. Hi Dr. Turek,
    My husband had a sperm analysis and unfortunately resulted in azoospermia. He had blood work done & the results came back as follows: FSH=8.6, Testosterone=286, & all other hormone levels normal. In the same blood they ran the Y chromosome microdeletion and results came back positive for a deletion of AZFb, AZFc, and AZFd. We saw a urologist last week specializing in infertility and he said that my husband has Grade 2 & 3 varicoceles on each scrotum. He sent us to re-do the blood work. This made us hopeful since he said that his hormone levels didn’t show signs of infertility however, he said that the lab agency should have not reported the AZFd. Since I work in the medical field & have researched this if he has a microdeletion of the Y chromosome there will be no point in doing additional test or a micro Tese right? We would only have the varicocele repair for his comfort I am assuming. Please advise

    1. Just to add we are awaiting the blood work he sent us to re-do. We had it done on Friday. The information I supplied is based on the first blood work we had done.

    2. Wow, that’s pretty complicated. Regarding AZFd, many of us don’t believe it exists as a separate entity. What is absolutely KEY here is whether the AZFb-c deletion is complete and contiguous. If not, the chances of sperm are much higher than if it is. The FSH does not predict much of anything; it should definitely be below 8.0 to be called normal. To me, this FSH is elevated. The role of varicoceles here is much more complicated. We have published that it is not worth fixing them to IMPROVE NATURAL FERTILITY in the setting of genetically define infertility, but the data in men who are just interested in improving sperm production in the testis is much weaker.
      Despite a potentially bad prognosis with certain Y deletions, some couples want to pursue things further but not as invasively as a microTESE (with a baseline borderline T). In such cases, FNA mapping can be very informative and is much less invasive.

  99. Hello, my husband got his results back and the chromosome was 46 which is normal and there were two other tests that were ok, one of which showed no microdeletion. All the tests were normal. Does he have non-obstructive azoospermia or obstructive? His semen sample was zero. He is also HIV positive, does this affect his fertility, in terms of the medication? He drinks alot and smokes too.
    His testicles are very small.
    I am trying to figure out what this all could mean? How could his hormones and chromosomes all be normal but there is no sperm? is it non obstructive or obstructive?

    1. Being HIV anything should not affect sperm production unless he is physically ill from it (or taking testosterone replacement to prevent muscle wasting). Nonobstructive azoospermia can exist in men with normal hormonal profiles as the hormones don’t accurately reflect what is going on in the testicle.

  100. …. pardon me again doctor, we live in the UK and the doctor told us that they would do surgery to see if there is sperm in the tubes and if not they would proceed further to see if there is any being produced at all. With the results of the tests being normal as mentioned above, what are they likely to find? Can you be in the normal range and be non obstructive? Does non obstructive mean you are just not producing? If so, how can your hormones and chromosomes be normal but one is not producing?

    1. Sara, these are great questions for your doctor. Yes, you can have nonobstructive azoospermia with genetic tests that are negative, since we do not know the entire genetic universe of male fertility yet. It could be “genetically undefined” male infertility. Yes, you can have normal hormones and not be blocked due to a form of nonobstructive azoospermia termed “maturation arrest” or “meiotic arrest.” Microdissection TESE in such cases is quite difficult as all seminiferous tubules look the same to the operating surgeon and distinguishing those containing sperm vs no sperm is complex.

  101. Hi doctor,i was wondering what are your statistics in sperm retrival in man with non obstructive azoospermia after chemo ?wath are the chances to find sperm with micro tese if all tests are normal including hormones?do you think that bilateral varicocele in these man must operate for better results?what are the chances to find sperm?thank you

    1. Ivana, Many men with post-chemotherapy and azoospermia will have sperm. We have published that about 65% of men in general in this situation will have sperm. I have even found sperm in men after many, many cycles of chemotherapy and then bone marrow transplantation! I am not sure that fixing varicoceles after chemotherapy makes sense if there are no germ cells in the testicle to respond in the first place.

      1. Doctor,do you suggest to do diagnostic biopsy first to see if there are germ cells present and than to fix varicocele or to go direct for micro tese?is there any theraphy like clomid to take for better results?please advice us what to do next

  102. i am 43 years old and before one year my semen count was 210 million per ml and after one year it became 2 million is this will happen , why or test will be credible, other two time it was 210,230 millionper mi

    1. Abraham, sperm counts can vary widely, even among normal individuals. If this difference in sperm counts persists over time, I would highly recommend a thorough evaluation with a history, physical exam, medication and medical history and look closely for some explanation, some change in health.

  103. Hi Dr aturek,
    Its Nas, you may remember i had a fna mapping a year or so ago. I am looking to do another micro tese and wanted to ask, the fna mapping how much of a percentage is the testis explored for sperm. Are all the sites covered all only a selection?
    I have been on clomid and preg injections. I have noticed a change in my testes size.
    I will keep you updated on my development.

    1. Nas, good to hear from you. Great question! The total area of testicle that is sampled after FNA mapping is unclear. But, since the sample size is high, my gut after over 1200 cases is that it fairly accurately represents what is going on in the testicle. You can ask the same question of microdissection as typically 100% of the testis is not sampled through this technique either.

  104. Dear Dr. Turek,
    I suffer from azoospermia (FSH 33 mlU/ml, LH 10 mlU/ml, testostreone 3,5 ng/ml). I had the phone consultation with you as well as wrote hier in April. I got microTESE in Poland three months ago.
    Result – 90% of tubules are SCO, the rest that keeping spermatogenesis consist of just few round and elongated spermatids. No mature sperm were found.
    I have a question. Does it make any sense to proceed with one more microTESE? Do I still have chances or they are rather low? I would like to add that prior to microTESE I had taken 6 weeks medication Tamoxifen + Undestor Testocaps + Agapurin which rised my Testosterone, FSH and LH, than I stopped with taking medication for 2 months to normalize my hormones.

    1. Damian, that is unfortunate. However, with FNA mapping, I have found that where there are spermatids, there are usually sperm nearby. The problem with mTESE is two fold: 1) testis tubules with late maturation arrest (spermatids present but no sperm) look the same as normal tubules so the surgeon cannot distinguish the two during the mTESE procedure, and 2) the lab that gets the tissue can really only tell you if there is mature sperm or not, as finding earlier germ cells is quite unreliable.
      If these are really your findings, you might consider 1) waiting 6 mos before another procedure 2) stop the testosterone and other supplements 3) consider FNA mapping instead of another mTESE as the latter, if repeated enough, poses serious risk to your testosterone levels for life.

      1. Dear Dr. Turek
        Many thanks for your detailed explanation. During microTESE I had 3 cuts per testicle (top, middle, bottom). From each cut the doctor collected two the best looking samples. So I understand it is also a type of mapping and the number of samples should be representative?? All the samples were very precisely searched and no mature sperm were found!
        What do you suggest in my case. Where can I take the new procedure and how to link it with ICSI since I live in Europe? Do you also use Tamoxifen prior to sprem extraction as I had recently?

    1. Raj, begin to read and get educated about what is possible. Although you may not be able to have ejaculated sperm in your life, you may still be able to have kids. Read more about azoospermia.

    1. Raj, since many cases of azoospermia are genetic in nature, there is often not much to do “naturally” to fix it. However, there are “correctable” causes of azoospermia (blockage, ejaculatory duct obstruction, Kallman syndrome) and these can certainly be pursued. A visit with a male reproductive specialist should be able to identify the correctable causes of azoospermia.

  105. Hi Doctor,
    I think my previous post was on a wrong thread and hence it was removed. Hoping to get some response here.
    My husband got his semen analysis done earlier this month and the result was Azoospermic.
    His FSH is high at 24 and Inhibin is very low around 8.
    Our Andriologist suggested a Micro TESE done. No sperms were retrieved even after centrifuge method was performed. The final TESE reports are sent for the lab and we are waiting for them.
    My husband has had a testicular surgery done at the age of 14 for an undescended testicle. We assume that right now, only one testis is functioning as expected.
    At this junction, doc do you think we still stand a chance? Could a FNA mapping help?
    Please help! Totally clueless and waiting to hear from you.
    Regards,
    Shilpa

  106. Dear dr. Turek,
    I have already made 2x tese op. With the diagnosis Sertoli-cell only Syndrome. Now we still try to stimulate, with Brevactid 1500iE 2x a week. Do you have any experiences with the therapy? Or do you know a better therapy for this Diagnose?
    I Look forward to your response.
    Sincerely A.Ali

    1. Dear A.ali, Brevactid is the same as human chorionic gonadotropin (hCG). It is the molecule LH that stimulates the testicle to make testosterone. It can be used for medical treatment of male infertility but works best in hypogonadotrophic hypogonadism to help men with this condition make ejaculated sperm. In the case of biopsy proven (is your case biopsy proven?) Sertoli cell only syndrome, in which testicular stem cells are not present to stimulate in the first place, this therapy might boost your testosterone levels but is unlikely to help you generate sperm. It is considered “empirical” therapy for your condition. There may be no better therapy than looker harder with FNA Mapping or waiting for stem cell technologies to improve (=years).

  107. My husband had mtese done in New York with Dr Schelgel. Unfortunately no sperm was found and we were told my husband does not have the cells at all that produce sperm. We were told this was just down to genetics and there is no hope for us ever having our own child. Is there any point trying the mapping with that diagnosis??

    1. Mrs C. I have done FNA Mapping on several of Dr. Schlegel’s failed mTESE procedures and have not found sperm. The number is low. With maturation arrest pathology, the chances are higher as mTESE does not offer much benefit over simple TESE.

      1. Could any medication be used to help my huband and then try FNA mapping or repeat mtese? I dont want to give up on the hope of us having children.

  108. Hello Dr Turek,
    My husband has a child from a previous relationship. However when we went for fertility tests (i have pocs and endometriosis) he was diagnosed with azoospermia?? Is this possible and what could have caused this?? If you can please provide any information I would greatly appreciate your help. We have been struggling to find answers.
    Many thanks

    1. Sarah, I am sorry about your struggle. The fact that your husband has children in the past just means that he had sperm in the ejaculate; it does not necessarily mean that his sperm count was normal. Conception can occur with low sperm counts as well. Alternatively, he may have incurred a blockage of some sort. Be happy to help. Contact us!

      1. Many thanks for your response. I am convinced that my husband does have a blockage. He does get a swelling come up and pain in his testicle he had ultrasound scan and Dr’s confirmed small blockages but we’re unhelpful as to removing them. Can you recommend anyone in the UK that could help? We are also considering going to Poland for TESE and IVF as the costs in the UK are too high! Many thanks

  109. Hi Dr Turek,
    My husband was recently diagnosed with Sertoli Cell Only Syndrome. His fsh was slightly elevated (around 17-18), genetic testing all normal and no deletions on the Y chromosome. He also has a varicocele on both sides. What are the chances of finding sperm through FNA mapping?
    Thanks

    1. Dear TD, it’s hard to say. It depends alot on how many biopsies were examined to make the diagnosis of Sertoli cell Only Syndrome. The more you sample the more you find. The question is doing it safely. With a single testis biopsy, I would suggest that there is a 30-40% chance (conservatively) of finding sperm with an extended FNA mapping procedure with 18 sites/testis.

  110. Hi Doctor Turek
    I was dianosed with Azoospermia 2 years ago and needed your expert advise on my present condition
    Did my first SA in Jan 2012. Semen Volume was 1 ml with normal PH. Zero Sperm Count. Second SA a week later also showed same result. Testosterone Total was very low. Inhibin-B was also way low. My Free Test and Bio Avail Test was in range though and SHBG was less than normal. FSH -> 8.86, LH -> 7.45, Testosterone (T) -> 1.83ng/ml, Free T -> 0.181 ng/ml, SHBG -> 13.88, Free Test Index -> 45.75%, Bio-Avail Test -> 4.24, prolactin -> 8.62, Estradiol -> 24, inhibin-b was 6.8 ml and L-> 5.9 ml
    Underwent trial FNAC on right testes. Testis Biopsy was done, and confirmed Sertolli Cell Only Syndrome
    Tested for y chromosome microdeletion and Karyotyping. Both were normal
    Underwent HCG Injections for ~4 months. Testosterone climbed upto 7. Did SA again. Still no count. Doc here advised me to take injections for 2 more months and do microTESE. Knowing this was pretty invasive, I didnt want to go through this unless i had exhausted all options to increase sperm count otherwise and also needed to know some acceptable % of finding sperm when microTESE was done. My wife and myself dont want to go through a emotional rollercoaster trying to do so .
    Since Injections eventually did not help in increasing my Sperm Count though Testosterone increased, i Had stopped injections for past 7 months. i also read somewhere that too much of HCG can cause other illness and cause Prostate issues. Did latest hormone readings and SA 2 days back. Testosterone went down again to 2.18 probably because i stopped taking injections. FSH -> 7.74 and LH -> 7.73. SA showed 1 ml volume with Psu Cells (1-2/hpf) and Fructose Test was negative. I assume this means Fructose was absent and had confirmed with pathologist. Is this Primary or Secondary Hypogonadism. ?. I am trying to figure out what kind of azoospermia i have and my doctor was unable to tell me my exact condition which is pretty frustrating to hear
    I needed your advice on what to do next regarding medications and treatment. Is there any treatment to increase sperm count in my current state. ? I live in india and would have come directly to you if my financial situation had allowed me to do so. So please help. Is there hope ?

    1. Dear Nabi, You have detailed your case greatly here. Although the specifics of your care should not be discussed in public, a few of your details are generalizable. They are: 1) you have nonobstructive azoospermia if Sertoli cell only cytology/histology was found and sperm were not seen on testicular tissue sampling, 2) Your FSH is slightly high (<8 is normal for FERTILE men) which would support this diagnosis, and 3) the assessment of whether or not you may have sperm in the testicles is not as comprehensive and complete as is possible. It sounds like you had a single FNAC and a ?single biopsy. If true, with more intensive sampling with FNA mapping or mTESE, sperm may be present. Correction of testosterone to normal levels for 3-4 mos prior to sampling and sampling the testis at least 6 mos after a prior testis biopsy is recommended to get the best results.

      1. thanks for the reply dr turek,
        i had few more questions based on your reply. hoping you will reply to this also
        1) its been 7months since i stopped hcginjections to which i had responedand now testosterone levels are at 2.18. i have done only a single fnac and biopsy till date. is it advisable to go for another fnac now or should i get my testosterone levels back to normal again?. i believe there is no option for sperm mapping here in india.
        2) are there any side effects to hcg injections after long use ?
        3) are there any other medications available to icrease testosteroene levels apart from hcg injections.
        4) do i need to make my fsh levels normal. is it even possible ?
        5) are there any long term side effects that can be caused due to mtese.
        6) assuming that there is a 50% success with mtese the first time, how would the success % vary for the second mtese in the event the first one fails and how long we need to wait to try mtese again after the first time.
        7) wanted to know what % of success would you have seen from patients with my clinical history with my current levels of fsh,lh, testosterone and sertoli cell only syndrome.
        eagerly looking forward for your reply
        thanks

  111. Dear Doctor,
    I have nonobstructive azoospermia.I had done semen analysis twice and no sperms were found.Later I went to a fertility centre.They had performed TESE and no sperms were found.The biopsy report mentioned ” early stage of spermatogenesis with early maturation arrest and absence of spermatids.No granulonma or malignancy identified”. My blood report were as mentioned below.
    DHEA-S : 170.2
    Progesterone – 17 OH : 1.15
    FSH :14.62
    Testosterone : 3.94
    Do you think the condition is curable.Really hoping a reply from you.
    Aju

    1. Aju, You have nonobstructive azoospermia. Although most forms of this condition are not “curable” (meaning reversible with restoration of natural fertility), they may in fact be associated with sperm that could be used with assisted reproduction (IVF-ICSI). Our research has shown that a proportion of men with maturation arrest pathology on biopsy can be “induced” to make more mature germ cell forms, including sperm. Alternatively, “pockets” of sperm may often be found in men with this biopsy pattern, depending on how thoroughly the TESE was done.

  112. Husband had no sperm in two samples: blood work results were: FSH 12.1 IU/l
    LH 6.5 IU/l
    Testosterone 22.2 nmol/l
    Bloods repeated due to elevated FSH
    This time results were
    FSH 14.8
    LH 8.2
    we are based in London – so far none of the doctors have suggested TESE. he is 31 years old and otherwise seems healthy. What % chance would you suggest we have in finding any sperm? Many thanks for your advice

    1. MrsP
      Your husband’s evaluation is almost complete. Be nice to know if his physical examination reveals a varicocele. Also do you know if he has a Y chromosome deletion or a karyotype abnormality (30% chance). If these are negative, then FNA Mapping can find sperm in about 60% of men like your husband.

      1. Dear Dr Turek
        I wanted to up date you, if I may. We have since learned ( from getting a record of historical medical notes) that my husband had a ‘primary repair to inguinal hernia’ at the age of two. He didn’t remember this so we didn’t have the information until now. How possible is it that this is the course of the azoospermia and can anything be done to help him? Regarding his SA – I noticed the ph level was 8.1 which is just outside of normal range. What would this mean? thank you

        1. Dear Mrs P: generally an inguinal hernia repair is not a risk factor for azoospermia. If it is performed along with an orchidopexy, then it may be a risk factor, and a favorable one at that. The pH of 8.1 probably does not relate significantly to azoospermia. A hard look at the testicle, with techniques such as FNA mapping, might be your best chance at finding sperm for pregnancy.

          1. Thank you. We have the Chromosome and Karotyping tests booked shortly and following that we will have to investigate options for Micro TEse. I cannot find anyone in the UK that offers the FNA mapping – though if there is someone you would recommend please do let me know. We won’t give up hope or faith that sperm will be found. x

  113. Hi Doctor, 29 yrs Trying to concieve 1 year , twice semen analysis detected azospermia both times but positve fructose (may be no blockage) and ph 7-8. Normal FSH (3.5) , LH (6) testostreone(500) and prolactin (13) levels. Undergone operation at 8 years of age for left undescended testicle.Ultrasound of scrotum showed left testicle slightly small but right is ok.No veriocele.What can be cause of azospermia..Since FSH is normal that means we can retrieve germ cells from testes or cant be said.Since right testicle is ok then why did we got azospermia ? Please suggest i am very worried.

  114. Hi Doctor Please help!
    Husband and me 29 yrs age.TTC 1 yr 3 months.Went for SA twice- azospermia , positive fructose,PH – 7-8.volume was less 1.5 ml.
    Husband had surgery at 8 yrs for unilateral undescended testicle( only left).Hormones – fsh -3.3 testosterone – 507 , LH (6) , prolactin (12) (all normal).
    Ultrasound of testes – no variocele, hydrocele, right testes normal size and left is slightly small (though insignificant).
    Is it indicative of non obstructive azoospermia? If left testes has problem due to surgery then right should be ok and able to generate sperms , then why azoospermia was detected? Will we able to get sperms with biopsy? Please suggest if unilateral undescended testicles surgery has any side effects on fertility and testes impairment? If yes , then why we got FSH , Testo hormones normal? we are very worried .Please give your kind advice.
    Thank you so much in advance

    1. Dear Varuna, this is a relatively complicated case. It is not clear whether there is blockage or testis failure as a cause of azoospermia. The normal hormones and normal testis size suggest the possibility of blockage. The low ejaculate volume suggests that it could be ejaculatory duct obstruction. The history of a unilateral undescended testicle goes along with a sperm production problem, as a problem on one side can affect the other with many testicular conditions. Consider a transrectal ultrasound to rule out blockage or missing seminal vesicles (CAVD). A testis biopsy can define a blockage but may not fully inform you of whether there are sperm present for assisted reproduction if there is testis failure. FNA mapping is much better a procedure for this purpose.

      1. Thanks doctor for your advice.We had scrotum ultrasound done twice. 1st time size of RT = 3.88X1.92X2.59 = 19.29cc and LT (orchipexy done at 8 yrs) = 2.36X1.55X1.87 = 6.85 cc)
        2nd ultrasound showed RT 3.62X1.74X2.40 = 15.12cc) LT = 3.58X1.78X2.55 = 16.25cc)
        Epididymis size Right = 3.34X1.03 Left = 2.99 X 0.81
        Fructose was positve in semen test.
        Please suggest if left testicle is smalle but right is normal size , we can find hope in testicular biopsy or go with FNA mapping.
        Thanks for help doctor

    1. Stefan, Wow! I looked at these sites. As a physician with a track record of publishing in stem cell journals and having coffee with some of the best stem cell scientists in the field, I am simply appalled by what these sites claim to do. The Chinese site does not include male infertility among the 40 or so other diseases it cure with stem cells. Where are the stem cells coming from? The German site is inexplicable! The FDA in the US would NEVER allow a clinic to inject the cells from sheep into a human without years of clinical trials showing safety and benefit. If it were only this easy, there would be several Nobel prizes awarded already to these institutions. The words that come to mind when I see what they claim to do: SNAKE OIL.

  115. Dear Dr. Turek,
    We used to talk and correspond here as well. I suffer from non obstructive azoospermia. According to your new post, would it be possible to come to San Francisco and chceck my situation using radiation-free, MRI scanner istead of FNA or microTESE and than proceed with artificial testicle if the result is positive?

  116. Hi Dr. Turek we have spoken several times over the phone and reading your latest success story revitalizes my own hopes to become a biological father. Several years ago I was diagnosed with non-obstuctive azospermia. After months of hormone therapy and FNA mapping I learned to find I had absolutely nothing. In the back of mind I always wondered if my physician was the best at what he did. Im on the east coast CT/NY and found your website only days after my results. But what if I went to you, a master and pioneer at what you do, what if. My wife and I were running out of money to pay for all the procedures and decided to just move on. Im on trt now for a couple of years but always wondered should I take a flight out to see you. thx Dr.t

  117. Dr Turek,
    I had low sperm counts (15 million/ml) and 2% rapid sperm about 5 months ago. Now it has gone down to almost no sperm except rare non-motile sperm. I have not changed my life style. Any reason?

    1. Dear Priyantha, In case of dissolving sperm counts, I generally can find a reason. It is VERY uncommon to just have one’s sperm count “tank” for no reason. Evaluation should include a history, physical and reproductive hormones for sure by a qualified specialist.

  118. Hello Dr. Turek.
    My husband have non-obstructive azoospermia (maturation arrest) normal testis,normal hormones.. A year ago he had a biopsy, Results: sertoli cells,spermatogonia & primary spermatocytes… What are the chances of finding sperm through FNA mapping?
    Thank you.

    1. Dear Denis, Finding sperm in men with early maturation arrest really depends on 1) if the cause (genetics, environmental, varicoceles) can be defined and 2) how hard (i.e. how many biopsies) they looked. Some of these cases are “inducible” and can be converted into making sperm by lifestyle changes or varicocele repair. Others are global and these cases are more likely genetic. Assuming that none of these issues exist and that a single biopsy was taken, I would estimate that the chance of finding sperm on extended FNA mapping to be 25-35%.

  119. I am Azoospermia patient. Please find the details
    Noticed Grade 2 Varicocele in left side(2.8mm) and Grade 1 on right side (Bilateral Varicocele).
    Please suggest me best way to overcome this problem.
    Whether I should go for varicocele repair ? What is the reason to get azoospermia in my case.
    History Details : –
    Fructose is positive in semen analysis report
    Chicken Pox : at age 2
    Testis Increased in size at the age of 7 for 4 days.(May be orchitis not sure it went off after 4 days)
    3 to 4 times small injuries (Cricket Ball hitting testis and someone hitting testis)
    Hormone levels :
    First time checked before 8AM without breakfast :
    FSH : 2.16 mIU/ml
    LH : 1.91 mIU/ml
    Testosterone : 2.63 ng/mL
    Prolactin : 12.69 ng/ml
    Second time checked at 9 AM morning without breakfast :
    FSH : 5.40 mIU/ml
    LH : 3.92 mIU/ml
    Testosterone : 4.61 ng/mL
    Prolactin : 3.54 ng/ml
    Karyotyping : Normal
    Y chromosome micro deletions : Normal

    1. I have not done Biopsy still I have doubt whether it is obstructive or non obstrutive ?
      Please tell me how to proceed from here .
      whether varicocele(Bilateral Grade 2 on left and Grade 1 on right) surgery required ?
      I had mild increased in my chest that even my father had and other male factors are fine

    2. Dear Venky, If we assume that your semen volume is normal and that your testicular volume is normal, then this could represent either an obstruction or not. The classic approach is to do a simple testis biopsy as it can define obstruction. However, if it is not obstructed there is only a 30% chance that sperm will be found. FNA mapping provides far more information either way (defines obstruction, 60% chance of finding sperm without obstruction) and is far less invasive. To me, the varicoceles are a secondary issue and repair of them should only be considered once sperm production is better defined, as it may be needless surgery.

      1. What caused azoospermia in my case ?
        Semen Volume (2 ml) normal , Testicular volume also normal , Testis and epididymis are normal in size and shape except Varicocele (Bilateral grade 2 on left and Grade 1 on right ) as per doppler study and Genetic test normal
        Do you think my hormone levels are normal ?
        Testostrene is 2.63 when I checked early morning 8AM and it is 4.61ng/mL at 10AM . Do you think testosterene is in normal range ?
        What I can expect in my biopsy report can u please guess it
        Also fructose is positive and FSH and LH normal .
        irst time checked before 8AM without breakfast :
        FSH : 2.16 mIU/ml
        LH : 1.91 mIU/ml
        Testosterone : 2.63 ng/mL
        Prolactin : 12.69 ng/ml
        Second time checked at 9 AM morning without breakfast :
        FSH : 5.40 mIU/ml
        LH : 3.92 mIU/ml
        Testosterone : 4.61 ng/mL
        Prolactin : 3.54 ng/ml
        Karyotyping : Normal
        Y chromosome micro deletions : Normal
        If the biopsy report says maturation arrest can I do varicocele surgery ?
        Please suggest me

        1. Dear Venky, hard to predict a biopsy result before you have it done. I suspect this is early maturation arrest (nonobstructive azoospermia) or normal (obstructive azoospermia). FNA Mapping might offer you much more information than a simple biopsy (and is much less invasive) of the problem is the first of these two.

          1. Thanks Turek
            Okay I will go for Biopsy
            .
            Please guide me below questions
            1. Tell me whether my Testosterne level is normal or not
            2. If it is maturation arrest shall i go for varicocele repair or not

  120. Hello Dr. Turek. My husband has the sertoli cell only syndrome. A TESE was negative (no sperm, no germ cells) we still have a chance to have a baby? maybe in a few years?

    1. Dear Christina, There is always hope! Maybe worth a talk, as finding sperm with Sertoli cell only syndrome depends alot on HARD HOW YOU LOOK. For example a simple TESE (biopsy) will not show sperm as often as FNA Mapping or a micro-TESE. There may still be CURRENT opportunities. I see such patients every day in my practice.

  121. Dear Doctor
    My husband 30 yrs diagnosed with azoospermia.Underwent orchiopexy for unilateral crypto at 8 yrs of age of right testes.
    We performed ultrasound and they say right testes size is smaller than left testes.But left testes is normal size.all hormones are also normal and no elevated fsh.semen volume was 1ml and 1.5 ml only and postive fructose was seen.
    I was reading his article http://humrep.oxfordjournals.org/content/18/12/2534 which says
    ” Our data suggest the existence of congenital or acquired obstructive anomalies of the seminal ducts in azoospermic orchidopexed men”
    Does this mean unilateral crypto can result in obstruction of seminal tubules and have more chances of sperm retrieval as compared to unknow NOA?
    I was bit hopeful after reading this.
    Please suggest what procedure should we go forward with – TESA,PESA.MESA,TESE or micro TESE?
    Thanks so much

    1. Dear Ria, In men with a history of undescended testes (or cryptorchidism) and nonobstructive azoospermia, our rate of finding testicular sperm is 65-69% by FNA mapping. Once found on mapping, a later sperm retrieval is usually at least 95% effective getting sufficient sperm for IVF-ICSI. This rate (65-69%) is slightly higher than men with unexplained or genetic nonobstructive azoospermia without undescended testis (Ref: Shefi, Kaplan, Turek

      1. Thanks doctor
        If we come for sperm retrieval from you , where can we go for ivf procedure.Will you also take care of ivf process for female? Please advise how will the whole process work? Thanks

        1. Dear Ria, I work with several/many IVF programs in California and around the world. If an FNA mapping procedure is done and finds sperm, then a subsequent sperm retrieval can be done locally where you live, or done with me in association with neighboring IVF programs in Los Angeles or San Francisco. Whether you can stay locally or need to come hither for sperm retrieval depends mainly on the FNA map findings and the projected complexity of the sperm retrieval procedure. Easy retrievals (TESA) can easily done locally with high success, but more complex sperm retrieval procedures (mTESE) are advised to be done with me.

          1. Thanks Doctor.We stay in Santa Clara so we SFO is local for us.Can you send us list of IVF centers you have collaborated with or please suggest us where can we go for consultation of IVF-ICSI for this procedure.
            Regards
            Ria

  122. Dear Sir,
    I am azoospermia patient. i have done testicular biopsy which signifies:- “Mainly hyalanized seminiferous turbules with ocassionally seen sertoli cells and leydig cell hyperplasia” Result-no sperm
    please tell me what does that mean
    and i got my fsh and lh checked – FSH- 38 & LH- 24. But i am getting treatment locally my fsh came to- 29 and lh- 17. does that mean my testes start functioning and what are the chances of getting normal sperm ?

    1. Dear Akash, A testis biopsy showing Sertoli cells and Leydig cells and hyalinized tubules is simply a variation of what is called “Germ cell aplasia” or “Sertoli cell-only” patterns. In essence, the biopsy showed no germ cells, which means neither the seeds (spermatogonial stem cells) nor flowering plants that those seeds make (mature sperm) are present. So that’s not good news.
      HOWEVER, depending on how many biopsy pieces were taken and from how many places, there is still a good possibility that mature sperm could be found in locations other than where the biopsy was taken. In essence, the harder you look, the more you will find sperm in the testicle, regardless of FSH levels. FNA mapping is one of the most comprehensive yet noninvasive ways to “look harder” for sperm. As to whether the sperm is “normal” or not is not really knowable, but we assume that mature sperm with tails are acceptable for use with IVF-ICSI in general.

  123. Thank you doctor for your service to all patients
    I am azoopsermia patient . One doctor said it is Non obstructive azoopspermia.
    My testis size
    LT = 3.5*1.8*1.7 cms
    RT = 3.7*2.7*2.2 cms
    Hormone levels
    FSH : 2.20 mIU/ml
    LH : 1.91 mIU/ml
    Testosterone : 2.64 ng/mL
    Prolactin : 12.54 ng/ml
    Genetical test is normal
    Please answer me below questions
    1. Do you think my testicular size and Hormone level are normal ?
    2. If u say everything normal then What should I do to improve my sperm count . Any chances to get sperm in ejaculation ?

    1. Dear Veeru, Your hormone levels are fairly normal. Your testicular size may or may not be normal, depending on your ethnicity. Generally azoospermia is more complicated than simply taking a pill to get a sperm count. For example, if it is due to Y chromosome microdeletions or a chromosomal issue (karyotype) than it not likely fixable but you may still have usable sperm in the testicle. On the contrary, if you are blocked, then it may in fact be fixable. A testis biopsy or FNA mapping procedure can tell which which one of these that you are and is generally considered to be you next step.

      1. Thank you sir
        Karytoping and Y chromosome is normal
        I had bilateral varicocele(Left>right) and if biopsy report says maturation arrest. Shall I undergo Varicocele repair ?
        or
        Let me know how to get sperm in ejaculation before proceeding with FNA mapping
        Please guide me

        1. Veeru, About 39% of men with varicoceles and azoospermia will developed ejaculated sperm after varicocele repair. An EARLY maturation arrest biopsy pattern is less likely to respond to surgery and result in sperm compared to a LATE maturation arrest biopsy pattern.

  124. Dear Dr. Turek
    My husband has been diagnosed with non- obstructive Azoospermia Sertoli Cell only. In 2010 he had a Micro- TESE biopsy and we were able to find little sperm to be able to have a beautiful girl. Ever since then we have tried three Micro – TESE biopsies to show no sperm found. We have now been advised that it’s very difficult to find anymore sperm. My husband has testosterone levels of ( 12.1 nmol/L) LH levels at (27.0 IU/L) and very high FSH (53.8 IU/L).
    The histology of the testicular biopsies showed prominent Sertolic cell only components but some tubules with residual spermatogenesis were also obtained through micro-dissection. However, these tubules were affected by maturation arrest with most advancement to primary spermatocyte and rarely round spermatid stage .
    D o you think we still have a chance in finding sperm?
    We would like to do one more micro- TESE biopsy but before that we want to try and increase our chances of finding sperm. Do we try to increase his testosterone levels before we do it by taking natural herbs or by using a testosterone gel? Should we give the spermhope supplement for six months a try or should we consider sperm mapping as an alternative to micro- TESE? If we don’t find any sperm again do you recommend we stop our hope or continue again every year jeopardising my husband’s health in the reduction of testosterone levels.
    Your response would be so much appreciated. Thank you so so much in advance

  125. I’m writing to you from Sydney Australia. My husband has been diagnosed with non- obstructive Azoospermia Sertoli Cell only. In 2010 he had a Micro- TESE biopsy and we were able to find a little sperm to be able to have a beautiful girl. Ever since then we have tried three Micro – TESE biopsies to show no sperm found. We have now been advised that it’s very difficult to find anymore sperm. My husband has testosterone levels of ( 12.1 nmol/L) LH levels at (27.0 IU/L) and very high FSH (53.8 IU/L).
    The histology of the testicular biopsies showed prominent Sertolic cell only components but some tubules with residual spermatogenesis were also obtained through micro-dissection. However, these tubules were affected by maturation arrest with most advancement to primary spermatocyte and rarely round spermatid stage (Stages too early in DNA maturation to be used for fertility treatment).
    D o you think we still have a chance in finding sperm?
    We would like to do one more micro- TESE biopsy but before that we want to try and increase our chances of finding sperm. Do we try to increase his testosterone levels before we do it by taking natural herbs or by using a testosterone gel? Should we give the spermhope supplement for six months a try or should we consider sperm mapping as an alternative to micro- TESE? If we don’t find any sperm again do you recommend we stop our hope or continue again every year jeopardising my husband’s health in the reduction of testosterone levels.
    Your response would be so much appreciated. Thank you so much in advance

    1. Dear Micheline, this is a VERY complicated case. When microdissection fails, it probably will fail again. Its a technique quite limited by the need to find visually “normal” looking tubules, as such tubules might contain sperm or not. Maturation arrest tubules are the classic confounder for the microdissectionist: these tubules appear “normal” to even the most experienced eye, but may not contain sperm if biopsied. This represents the limit of the technique. FNA mapping, however, evaluates tubules differently and is far less invasive and may in fact show sperm. After that, a microdissection can be “targetted” to a certain testis and even regions within the testis, to make sperm retrieval more focused and successful. Consider this option going forward.

      1. Dear Dr. Turek
        Thank you very much for your response. We look forward to contacting your clinic and having the pleasure of speaking to you.

  126. Hello Doc,
    My husband did semen analysis 2 days back and doctor is saying i can not see any sperm.We are in shock.how is it possible since my husband is very healthy and we have no problem in intercourse.
    He is a very very good person but after hearing this news he broke down and not talking much .
    1. Is it possible like suppose I check today sperm count and find no sperm count and some other day test again find some sperm count?
    2. Is there any way to produce sperm by my own (like some food,tablets).
    3. Can semen analysis test give wrong result.

    1. Dear Param, I am sorry about that news that you received! Certainly having no sperm can be temporary and due to, for example, illness, fevers, chemotherapy, wet heat exposures and hormonal issues. Repeating the semen analysis after a month or two is important for this reason. Sure semen analyses can vary in quality, some centers finding sperm when others do not. In some men, hormonal treatments can be used to stimulate treatment and in others a blockage can be repaired microsurgically. However, in most men it is unexplained and the best you can do is find sperm and use it with IVF-ICSI.

  127. Dear Sir,
    This is param from india but my husabd working in USA. My husband went for the semen analysis , and no sperm found. and my primary doc suggest for urologist, I went there and he did not check anything and only said you have only thing to do i.e IVF. I asked him is there any blockage? he said no blockage i am 100% sure.
    My question is , Is there any test to find out blockage ? he did not test any blockage . I am very much worried about it. What should i do now?
    I am in charlotte,Nc , Could you suggest please suggest me good specialist for this here who is your under guidance since i can not come to CA . Please sir help me out …(my English is not good so please consider it)

    1. Dear Param, Having azoospermia just means that there is no ejaculated sperm. If serum hormones show elevated FSH (<8 mIU/mL), then it is likely due to nonobstructive azoospermia and not a blockage (obstructive azoospermia). With reasonable certainly, this tells you that a blockage is not present, but having a high FSH does not accurately tell you that you do or do not have sperm. A testis biopsy or FNA mapping can confirm whether sperm production is normal and therefore truly defines a blockage, but does not tell you where that blockage might be located.

  128. Dear Dr. Turek,
    I am Payam wrote on your nice blog few times. This time I would like to know if you know well trained doctors in doing FNA in Iran or Turkey. I live in Iraq and I can’t afford travelling and getting treatment in US.
    Many thanks to you Doctor

    1. Payam, thanks for circling back. I have a fellow that I trained named Dr. Sela Cayan, who practices in the university in Mercin, Turkey. He may be doing sperm FNA mapping.

    1. Dear Param, Consider searching the national IVF registry (SART.org) to find programs in your area. Be sure to talk with them regarding their experience with cases like yours.

  129. Sir,
    According to you what is the normal range of FSH , LH and Testosterone in men ?
    When FSH is considered low and when it is considered as High ?
    What is the best time to check hormone level ? whether this should be with empty stomach ?
    Thanks

    1. Dear Meera,
      The normal ranges of reproductive hormones vary by the laboratory that does them. In general, testosterone should be between 300-800 ng/dL; FSH 2-8 mIU/mL, and LH 2-12 mIU/mL. The lower the FSH the better (think of it as gas being sent to the engine to help it run; well tuned engines need less gas to run than ill-tuned engines). Best time to check FSH and LH is whenever, but the best time to check testosterone is in the morning before 10am as T levels are highest in the morning and lowest in the late afternoon. In fact there can be a 30% difference in T levels in an individual over the course of a single day.

      1. Thanks paul,
        Why FSH is normal in some NOA patients ? considering other Parameters hormone level ,y chromosome , Karyotyping are normal , Why these patients still suffer with ZERO count

  130. Hello sir,
    As I told you my husband did semen analysis second time and doc was saying no sperm found …i asked him for the hard copy of the report and he gave us but we did not see in report no sperm found.
    Here below are the report …please help me out sir i am in need….
    Abstinence 4.0
    Phsemen L
    Appearance semen normal
    liquefaction at 20 mins normal
    viscosity semen normal
    htf addition no
    gel particles normal
    round cells <6
    cellular debris normal
    mucus normal
    rbc none
    other cellular components none
    sample volume 2.0
    motile count see comments
    wbc per 100 sperm 0.0

  131. Hello sir,
    As I told you my husband did semen analysis second time and doc was saying no sperm found …i asked him for the hard copy of the report and he gave us but we did not see in report no sperm found.
    Here below are the report …please help me out sir i am in need….
    Abstinence 4.0
    Ph semen L 6.4
    Appearance semen normal
    liquefaction at 20 mins normal
    viscosity semen normal
    htf addition no
    gel particles normal
    round cells <6
    cellular debris normal
    mucus normal
    rbc none
    other cellular components none
    sample volume 2.0
    motile count see comments
    wbc per 100 sperm 0.0

    1. Param, you are correct. Neither the sperm count nor the sperm motility is given in the report that you post.

  132. Doctor Turek,
    can you please tell me manes of doctors that you train for FNA mapping in Europe?
    We are very fahr from you, Who would you recommend to us?

  133. Thanks paul,
    Why FSH is normal in some NOA patients ?
    considering other Parameters hormone level ,y chromosome , varicocele , Karyotyping are normal ,
    Why these patients still suffer with ZERO count

    1. Meera, Great questions! We are not sure why the FSH is normal is nonobstructive azoospermic men with early maturation arrest histology or in 10% of men with Sertoli cell-only histology. Regarding why men with genetic-negative azoospermia are azoospermic, its because we do not yet understand the entire universe of genetic infertility. See the blog post “Fitting into Your Genes” for a better explanation.

        1. Dear Meera, Yes we do. Pretty regularly. I would estimate that between 10-20% of men with maturation arrest patterns on testis biopsy or microdissection TESE can be found to have sperm after aggressive medical and lifestyle treatments after 6-9 mos as evaluated by FNA mapping.

  134. Doctor Turek,
    can you please give me name of doctors that you are train for FNA mapping in Europe?
    We wont do mapping but we are vwey fahr from you

  135. Hi Doctor
    We have appointment with you on 16th June.We just went for SA test at Kaiser and it came Azoo with positive Fructose.
    We had previous SA 4 months back also with same outcome. However volume is always less 1ml or max 1.5ml Also FSH = 3.3.
    Does this mean Obstructive or NOA?My husband had rectractile testes Left only which doctors corrected at age of 8 yrs.
    Do you suspect NOA? We are seeing you on coming Monday, desparately waiting for appointment to clarify so many questions.Can physical examination by you rule out obstruction!
    Thanks

    1. Ria, so looking forward to meeting you on June 16th. Not a great way to give care over the blog. But, yes the history and physical can get us a long way to deciding whether there is a blockage or not. The low volume and positive fructose suggests that blockage of the ejaculatory duct is unlikely. The FSH is consistent with either blockage or nonobstructive azoospermia due to maturation arrest histology pattern. I will do my best to help you figure this out.

      1. Hi Doctor
        It was so nice to see you today..I just loved the way I am feeling relieved after consulation with you.I feel hopeful.
        Thank you
        Ria (Ruchi)

        1. Hi Doctor We were planning to order Pre natal for him and myself from essential beginings.Wanted to confirm the dosage from you.On the website it says 6 tablets per day.Can you please guide us if we actually need 6 or lesser tablets per day.
          Thanks so much
          Ria

          1. Ria, Essential Beginnings XY is a prenatal, preconception pill for men. It was designed by several doctors, including myself, and a cancer nutritionist. What I really like about it is that the “binders” that we melded with the vitamins, herbs and minerals in it lead to good absorption, and are the best in the business. This means higher levels of absorption and higher chances for improvement. The twice daily dosing (3 pills 2x daily) is based on the fact that water soluble vitamins have a short half life and need replenishing.

          2. Hi Dr.We saw you last year and you diagnosed obsrtuctive azoo.We went to our hometown and got ivf /icsi done with PESA and now we are pregnant with twins 6 months.We are so happy and want to thank you with all our heart,mind and soul.You are doing a very noble work on this earth.Kudos to you!!
            Thanks for helping us point the root cause.
            Ria

  136. Hi Doc,
    i gave my semen test and no sperm found .here is my test result…….Please suggest what to do?
    WBC [3.6-10.4 K/uL] 6.4 K/uL
    RBC [4.16-5.83 M/uL] 5.64 M/uL
    HGB [13.0-17.4 gm/dL] 15.9 gm/dL
    HCT [39-52 %] 48 % 4
    MCV [82-99 fL] 85 fL 5
    MCH [27-34 pg] 28 pg
    MCHC [32-35 gm/dL] 33 gm/dL
    RDW [12.2-16.3 %] 12.0 %
    *LOW*
    Platelet [142-328 K/uL] 185 K/uL
    MPV [6.0-9.5 fL] 8.7 fL
    Diff Type AUTOMATED
    Absolute Neut [1.60-7.71 K/uL] 2.92 K/uL
    Absolute Lymph [1.05-3.20 K/uL] 2.70 K/uL
    Absolute Mono [0.20-0.90 K/uL] 0.48 K/uL
    absolute EOS [0.00-0.50 K/uL] 0.27 K/uL
    Absolute Basos [0.00-0.11 K/uL] 0.05 K/uL
    Neutrophils [41-74 %] 45 %
    Lymph [15-48 %] 42 %
    Monocytes [5-13 %] 8 %
    Eosinophils [0.0-7.0 %] 4 %
    Basophils [0.0-2.0 %] 1 %
    Sodium Level [136.0-145.0 mmol/L] 139 mmol/L
    Potassium Level [3.5-5.5 mmol/L] 4.0 mmol/L
    Chloride Level [98.0-107.0 mmol/L] 100 mmol/L
    CO2 [22.0-29.0 mmol/L] 27 mmol/L
    Glucose Level [70-100 mg/dL] 87 mg/dL
    BUN [6.0-20.0 mg/dL] 8 mg/dL
    Creatinine [0.70-1.20 mg/dL] 0.70 mg/dL
    Estimated GFR Non-African American [>59 mL/min/1.73 m2] >59 mL/min/1.73 m2
    Estimated GFR African American [>59 mL/min/1.73 m2] >59 mL/min/1.73 m2
    Calcium Level [8.4-10.4 mg/dL] 9.5 mg/dL
    Albumin Level [3.50-5.20 gm/dL] 4.7 gm/dL
    Total Protein [6.6-8.7 gm/dL] 7.9 gm/dL
    Total Bilirubin [0.0-1.2 mg/dL] 0.8 mg/dL
    Alkaline Phosphatase [40.0-129.0 IU/L] 77 IU/L
    ALT [0.0-41.0 IU/L] 80 IU/L
    *HI*
    AST [0.0-40.0 IU/L] 46 IU/L
    *HI*
    Cholesterol [<200 mg/dL] 155 mg/dL
    Triglycerides [<150 mg/dL] 148 mg/dL
    HDL-Cholesterol [40-60 mg/dL] 43 mg/dL
    LDL-Cholesterol [<100 mg/dL] 82 mg/dL
    Non HDL Chol (LDL+VLDL) 112 mg/dL
    TSH [0.270-4.200 uIU/mL] 1.100 uIU/mL
    Urine Color YELLOW
    Urine Clarity CLEAR
    Urine Glucose [NEG] NEGATIVE
    BILE [NEG] NEGATIVE
    Urine Ketones [NEG] NEGATIVE
    Urine Specific Gravity [1.001-1.030] <1.005
    Hemoglobin-Urine [NEG] NEGATIVE
    Urine pH [4.6-8.0] 7.0
    Urine Albumin [NEG] NEGATIVE
    Urobilinogen [0.2-1.0 mg/dL] 0.2 mg/dL
    Urine Nitrite [NEG] NEGATIVE
    Urine Leuko. Esterase [NEG] NEGATIVE
    Reducing Substance [NAP] NOT APPLICABLE

    1. Dear OM, From the looks of it, your bone marrow is fine, urine is fine, cholesterol balance is good, electrolytes are good, thyroid is good, pancreas is good but your liver is a bit out of whack. None of these tests explain the 0 sperm count. An evaluation with a male reproductive health specialist is needed for a good history, physical exam and blood tests for reproductive hormones, along with a good semen analysis with extended search for low sperm numbers.

  137. Dr. Turek, Daniel and I spoke with you on the phone today. We read your blogs and absolutely love them. You give us hope and we feel extremely confident to be on this journey with you. Thanks again.

  138. Dear Doctor,
    I’ve been going through your blog and I am impressed and happy by all that I have read so far.
    My brother in-law was diagnosed of Azoospermia and he was told that there is no hope. Since then himself and his wife (my sister) have been so devastated but now my hopes are high for them. My challenge is that we live in Nigeria my Country. Considering the distaance please is there any way he can contact you?

    1. Sure Vivian, By contacting the office, we can arrange either a 1) Free 10-min call to discuss his case or 2) 2nd Opinion to really evaluate the details (costs money). Try us from a distance. We have dozens of Nigerian patients in the practice!

  139. Hi doctor, I have PCOD Problem and my husband has no sperm count (Azoospermia with puscell 6-8). I’m really scared. Do we have any option?

    1. Dear Irish, Of course you have options! Some you may like and others you may not. Your husband’s chance of having sperm in the testis ranges from 60% (nonobstructive azoospermia) to 100% (obstructive azoospermia). Just let me at him!

  140. Hello Dr. Turek, I´m writing from South America, have been reeding a lot of your articles and interviews. Our case si that we are azoospermic, he is 42 and had a biopsy 8 years ago finding 90% with spermatids and 5% of tubules with spermatozoa, diagnosed NOA with maturation arrest. There is a varicocele on the left side(found in a physical examination), left testicle smaller in size than the right. Doctors here do not considerate this relevant for the azoospermia and even say there are cases where the surgery just make it worse, but we´ve read that in many cases there were improvements and even natural pregnancy (rare). Do you recomend surgery for the varicocele in this case? Are there any risks?

    1. Dear Nat, I understand that you have nonobstructive azoospermia. However, you said that the biopsy showed “5% of tubules with spermatozoa.” This means that sperm are already present. If you goal is to only try naturally, then the varicocele repair has a 40% chance of resulting in ejaculated sperm and this is associated with a 5% natural pregnancy rate. You must decide if that is worth it. The side effects the subinguinal varicocelectomy are minimal. I require only a 1 day stay in town for this procedure and a return to full activity in 5 days.

      1. Dear Dr. Turek, thank you very much for your response. This is great news for us, as we feel natural that removing this problem would have at least some benefit. We will evaluate the possibility of going to L.A. and contact your clinic for further information.

  141. Hi Turek,
    I have azoospermia with FSH=2.41 miu/ml, LH between 3.5 to 7 miu/ml, Testosterone between 230 to 300, prolactin was 24 but now 16, TSH was 41 but now between 1-2
    with thyronorm.
    Normal testis size and volume.
    Not sure what to do next and what is the diagnosis. should i do karyotyping or go for FNA? Please advice.

    1. Dear Abhis, You could do either, meaning either pursue the cause of the azoospermia with genetic testing (chromosome or karyotype testing along with Y chromosome microdeletion testing) or pursue whether you have sperm or not with mapping. It is only rarely that the genetic tests will actually tell you definitively whether or not you have sperm. And, if your azoospermia is due to a blockage outside the testicle (as suggested by the normal FSH and testis volume) then these genetic tests will be negative for sure. In this last case, another genetic test might be more appropriate: Cystic fibrosis gene mutation (CFTR) tests. So, in general, I suggest that if it is not entirely clear whether the azoospermia is due to blockage or not, figure that issue out first (with, say FNA Mapping) before you enter the relatively complex world of genetic testing.

  142. Sir, is there any chances of fertility of azoospermia because of undescended testis…. Please please help

  143. Hi Sir… Is there any hope for a person with azoospermia because of undecended testis. The sperm count is zero. One testical has been descended to colder part but not fully descended. Please sir reply I m so disopinted. Please reply . Regards Ahmad from canada

    1. Dear Ahmad, MOST men with a single undescended testicle in the setting of azoospermia will have sperm. In fact, using FNA sperm mapping, our published data suggest that 69% of men in this situation will have testicular sperm present in one or the other testicle. It does help alot if at least one testicle is actually within the scrotum.

      1. Hi Sir,
        Thanks for the reply. Both testis were undescended but one was moved to to colder spot ( as per to the doctor’s advice) at the age of 30. Reaction and testosterone is normal. If you think there is any chance for us, kindly give me time to visit you. Once again thanks for kind reply, I really really appreciate that you took time for me to reply.

  144. My name is Camille bruno Valdez my partner and I have been trying for a baby for over two years now, We were going to a fertility clinic for about 5 months before somebody told us to contact this spell caster who is so powerful, We contacted him at this email; [email protected], for him to help us, then we told him our problem, he told us that we will either conceive in February 2014 or March 2014,but after two years of trying we were at a point where we were willing to try anything. And I’m glad we came to Dr Dahiru, Because his pregnancy spell cast put us at ease, and I honestly believe him, and his gods really helped us as well, I am thankful for all he has done. contact him via email: [email protected] if you are trying to get a baby or want your lover back. he has powers to do it, he has done mine you can as well add him on facebook (Arewa Dahiru) To enable you have a taste of his nice work too.

  145. Dear Doctor,
    My brother in – law was diagnosed of Azoospermia and this is the result of his test:
    Scrotal scan report:
    Scrotum- Normal scrotal fluid noted. No obvious sign of varicocele or hydrocele noted.
    Testicles – Rt testicle measures 20mm X 10mm while Lt testicle measures 22mmX12mm with mild compromised parenchymal echopattern. Both epididymis are small in sizes but other vessels are intact.
    Impression: Features noted are suggestive of testicular pathiology.
    Microscopy: Pus cells- numerous.
    Culture: Yielded moderate growth of stephococus.
    Semen Analysis:
    Colour- Grey white.
    Consistency- Watery
    Volume- 0.8mls
    Non motile cells- 0%
    Sluggish cells- 0%
    Motile cells- 0%
    Actively motile cells -0%
    Morphology:
    Normal cells – 0
    Abnormal cells- 0
    Count- 0
    Comment – Azoospermia.
    The doctor gave him and his wife treatment for the stephococus but he told them their is no hope for the Azoospermia.
    Pls doctor what type of Azoospermia is this and can he be treated?

    1. Dear Vivian,
      It is not possible to tell what kind of azoospermia exists here. Hormones such as FSH, LH and Testosterone would help. Low ejaculate volume suggests either low testosterone or ejaculatory duct obstruction. The scrotal ultrasound assessment of testicular volumes suggest that the testes are small, indicating nonobstructive azoospermia. Sperm mapping likely has a 60% (nonobstructive) to 100% (obstructive) chance of finding sperm.

  146. My husband’s two semen analysis shows he is azoospermic. Semen Fructose gives 280mg/dl. He is of 32 years old and FSH is 5.3 and LH is 4.70. After these tests urologist suggested us to do a TURS ultrasound and based on that result he suggested us to do a semen biopsy. We are from India. His both testes are smaller than usual. Doctor, can there any chance to get our own baby in any way please.

    1. Dear Estello, Azoospermia in the setting of normal reproductive hormones is either a blockage (normal production) or testis failure (low or no sperm production). If FNA Mapping is used instead of a testis biopsy, you have a 60% (testis failure) to 100% (blockage with normal production) chance of having testicular sperm. So, YES, there is a very good chance that you can have your own baby.

  147. Dear Dr. Turek,
    I am 55 years old man residing in Saudi Arabia for last six years. I had children from prior marriage with last born child born in 1994. I am now remarried for past 10 years.
    For the last two years repeated sperm analysis show zero sperm count.
    I also had Varicocele operation two years ago and seven IVF with my wife resulting in having two miscarriages.
    My last FSH is 12 and testosterone is 3.5.
    Any hope. Please share with me any advise as FNA mapping is not available here in SA.
    Thank you.
    Please help what to do to
    I had
    I married

    1. Dear Ismail, Most men who are CURRENTLY azoospermic but have a past history of fertility, had low sperm counts to begin with and these counts fell with time and age. The high FSH (>8) suggests that no blockage is present and that this is a sperm production problem. Not sure where the sperm came from for these IVF cycles but the more sperm retrievals you do, the lower the testosterone level will become. Eventually, it may so low that you need T replacement. FNA Mapping could help you avoid this by “knowing before you go.”

  148. Dear Doc,
    I just had my TESA and not a single sperm was seen unfortunately. My doctor took semen from both of my normal and athropic testis. I had orchitis when I was 27 y/o, now I am 33. I have learned that severe orchitis can disable sperm production totally. Is there any chance or treatment that can restore production of even tens of sperms?

    1. Dear Rommel, TESA involves needle aspiration and its ability to find sperm for you depends on sample size and number. I love using it AFTER FNA mapping when I know where the sperm are but as a tool to find sperm, not so good. In our published series of men in which we looked at sperm detection rates using mNA mapping based on diagnosis, men with a history of epididymoorchitis or mumps orchitis had sperm 60-100% of the time. So, yes the potential is high that you have usable testicular sperm there.

  149. Sir
    I’m dr Mohit from delhi India. Working as senior dentist 33 yrs old. Sir last year I done my semen analysis. Came to 16 million with 60 motility then taken few multivitamin after that my wife got pregnant but after 6 week dr told she got miscarriage then now we again done semen analysis came to 4 million with 35 motility then again after 10 days smen analysis done came to 1 million I’m moving towards azospermia then I went for scotal Doppler for varicocele but no varicocele urologist diagnose inguinal hernia on left side. My question how to improve sperm count and motility and should I operate hernia now

    1. Dr Mohit, I must say that is unusual to go from normal, verifiable pregnancy-inducing semen quality to very low over what appears to be months of time. When evaluating this, I would expect to find SOMETHING to explain the trend in semen quality. I agree with a testicular ultrasound to look for new onset testis cancer, but varicoceles alone would not act this fast. A recent illness, significant weight gain, fevers or even natural variation in semen quality could be present. Certainly, this deserves a hormonal evaluation for hypogonadism and prolactinema. Forget the hernia for now.

      1. sir i checked my TESTOSTERONE FSH AND LH they all are normal .gyanae and urologist advise for Multivitamin lycozyme ferture M ETC FOR ONE MONTH. NO PAST ANY ILLNESS NOTHING UNNORMAL FINDING .I WANT TO IMPROVE MY SPERM QUALITY AND MOTILITY WITH VOLUME ANY ADVICE YOU WANT TO GIVE ME SIR.THANKS
        REGARDS
        DR.MOHIT

  150. Hi Dr. Turek,
    thank you for this informative post and dialogue.
    I had a question. I notice with normal FSH you say it could be maturation arrest. But how can one tell, with normal FSH, that it is not hypospermatogenesis? Could it be either?

  151. hello Dr, Turek My name is Imad & I am from Islamabad, Pakistan. I also have Azoospermia. Had a semen Analysis & had no sperm in it so the doctor advised me to have a TRANSRECTAL ULTRASOUND OF BILATERAL VESICLES Conclusions were no evidence of abnormal dilatation of ejaculatory ducts is seen also complimentary ultrasound of scrotum was also performed which revealed; Bilateral small size testis. the parencymal texture is homogenous and normal. no focal lesion in either testis is noted. The right testis measures 23 x 20 x 12 mm the left testis measures 23 x 18 x 11 mm. & both epididymus are unremarkable. No hydrocele seen. Right seminal vesicles measures 35 x 10 mm & left seminal vesicles measures 35 x 08 mm. Prostate measures 40 x 22 x 37 mm which corresponds to 17 grams. Inner & peripheral zone of prostrate are identified. Both are isoechoic to each other & shows homogenous parenchymal texture. No evidence of diffuse inflammation or abscess is seen. Prostatic capsule appears well preserved with intact peri-prostatic venous plexus. LH is 21.55mIU/mL FSH is 28.74mIU/mL Prolactin is 18.92ng/mL & Testosterone is 1.54 ng/mL. i can also fax these results to you regards Imad

  152. Hi doctor,
    This is param.My husband semen analysis found out no sperm. So I am switching to do IVF. But i have concern , my doc says you need to take birth control pill about 6 days . If suppose my IVF did not work and later i will start IUI so because of birth control pill there will be any problem to occur pregnancy??I am so scared.My first IUI cycle did not work.
    Please doc I am in very much need.
    Thank you.

  153. Hi doctor,
    This is param.My husband semen analysis found out no sperm. So I am switching to do IVF. But i have concern , my doc says you need to take birth control pill about 6 days . If suppose my IVF did not work and later i will start IUI so because of birth control pill there will be any problem to occur pregnancy??I am so scared.My first IUI cycle did not work.
    Please doc I am in very much need.
    Thank you.

    1. Param, I would love to help but I strictly deal with male infertility. Your IVF doctor should be able to answer all of your questions. I was just wondering how they were going to approach your husband’s azoospermia problem. Feel free to set up a free call with us.

  154. Dear Dr Turek
    Husband has been diagnosed with Azoo. Blood test show FSH 12.1 IU/l
    LH 6.5 IU/l
    Testosterone 22.2 nmol/l
    and second test fsh 9.6 and Test 17
    Testis size we are told is normal for his build and ethnicity etc. Our consultant believes he can feel the Vas present.
    We are due to have the micro TESE surgery. Based on the above what would you rate as our chance of finding sperm? My husband is 32 non smoker, does not drink etc – no history of any medical problems. Did have surgery for primary inguinal hernia’ at the age of two. I am not sure if this has any bearing on why he seems to be infertile. thank you for your thoughts.

    1. Worried, hard to know the chance of finding sperm from just the numbers. I would estimate 60-65% by FNA Mapping and probably a similar chance by mTESE. Be sure to ask what the chance of lowering his testosterone level temporarily or permanently in the hands of the surgeon doing it.

      1. Dear Paul
        Thank you for the reply – I am sorry I don’t completely understand the last sentence about the testosterone… please could you give a little more insight? Do you mean that the surgery could damage his testosterone levels?? or are they too high already and lowering them might help? So far he was prescribed tamoxifen for 3 months to see if it would stimulate production but there sample still came back zero. nothing was mentioned about testosterone. thank you for clarifying!

        1. Worried, Yes, procedures performed on testicles to retrieve sperm also have the potential to lower testosterone levels. The impact varies with the extent of the procedure, starting T levels, and number of sperm retrieval procedures.

  155. I have been diagnosed with azoospermia. I am 30 years old and married for 5 years. I have undergone frequent semen analysis, all shows nil sperms. I have undergone testis biopsy the findings of which says ” extensive maturation arrest, marked peritubal fibrosis and marked leydig cell hyperplasia – there is only a very rare focus of even partial spermatogenesis without evidence of complete development in any area of the biopsies. “. My hormone levels are FSH 25.9, LH 14.90 testosterone 191. the ultrasound scan of testes shows right testes measures 2.23*1.52*0.92 cm, left testes measures 2.21*1.59*0.84 cm with left grade 1 varicocele, epidydimis normal in both testes. I am on clomid from the past four months. Kindly suggest if FNA mapping would be helpful in my case since I am considering visiting you if its worthwhile. It would also be very helpful if you could guide me on further course of action. I am non alcoholic and non smoker.

    1. Dear Yogesh, Having had a simple biopsy showing maturation arrest with any focus of “partial spermatogenesis” may be significant. FNA mapping or mTESE could help find potential pockets of sperm. Even in cases of 100% early maturation arrest on biopsy, 30% of men may have mature sperm on Mapping. These numbers only rise if pockets of other patterns are present, such as late maturation arrest. I also noticed that your testosterone appears low and your LH appears high, so mTESE would likely lower things further (unlike mapping, which is far less invasive). Consider a Second Opinion in which you send the histology slides from your biopsy for review to get a better idea of the chance of finding sperm before you commit to going anywhere.

  156. Hi Dr.Turek! Have heard great things about you and it is wonderful work you are doing.
    My husband was also diagnosed with azoospermia this past Spring. His hormone levels are good, and all of the genetic tests came back normal. How likely is it that there is a blockage? Is it possible that there still won’t be any sperm found in the biopsy? We are encouraged by the normal lab results, but don’t want to get our hopes up too high. Thanks!

    1. Dear Erin, Normal hormones, normal testis volume, normal genetics. It’s either a blockage or non obstructive azoospermia due to maturation arrest pattern testis tubules. Hard to guess the percentage of each. A good physical exam is key here as in the maturation arrest pattern, the epididymides are not dilated to palpation.

  157. Dr. Turek,
    My husband was diagnosed with azoospermia. He just turned 27 last month. We have eliminated any issues with me and have been trying for over a year to get pregnant. After his semen analysis he went to a urologist and his bloodwork found his FSH to be 16. We have an appt set up to see a urologist and a fertility clinic in December. I have started him on CoQ10 and maca root. My question is have you ever found these meds to help with sperm production? How much should he take? Also, any bit of hope you can shine on our situation as far as sperm retrieval? We will do whatever we need to to have children but I just don’t want anyone cutting into him. Would you suggest a biopsy or just TESE procedure? Thanks in advance!

    1. Dear Beth, I am a big fan of herbals and minerals to improve sperm health and motility (Check our supplement, XY from Essential Beginnings [Essbeg.com] which has exactly what you’re giving him) but have not seen miracles with it producing sperm in men with azooospermia. Regarding sperm retrieval in cases of non obstructive azoospermia, we find at least 60% of men will have sperm on FNA mapping.

      1. Thank you so much for your quick response. I will check out XY! Also, does the level of FSH correlate with chances of sperm retrieval or the fact that it is elevated just indicate NOA? Also, is FNA mapping a procedure most urologists who specialize in male infertility do? Thanks again Dr. Turek!

        1. Beth, your welcome. FSH does not correlate well with the chance of finding sperm. FNA mapping is performed by only a few formally trained people in the world. I will be offering a much more formal, certified training program for all interested urologists starting next year.

  158. Dear Doctor
    My semen analysis report is as follows.
    Volume: 2ml
    Viscosity:Normal
    Appearance:Opaque white
    Consistency:Normal
    Liquifaction: More than 1hours
    pH: 8.0
    Sperm concentration:0million/ml
    Pus cells : 4-5/hpf
    Epithelial cells:2-3/hpf
    Serum test:
    LH:4.5mIu/ml
    FSH:6.93mIu/ml
    Prolactin:14.29ng/ml
    Kindly advice me the way ahead. I have consulted an Urologist. He suggested for testicular biopsy. With the above serum results, is it possible to guess the availability of sperm in my testicles.
    I have left side hydrocele (found through ultrasound scanning).

    1. Ibrahim, This is consistent with either a blockage (obstruction) or non obstructive (no blockage) azoospermia. A biopsy can help determine which of these it is. Remember that either a biopsy or FNA Mapping can tell you whether you are blocked or not (which can possibly be fixed later on with microsurgery), but if you are not blockage a simple biopsy has a 30% chance of showing sperm but a map doubles that (60%).

  159. Hello Dr. Turek,
    My husband diagnosed with azoospermia after 3 semen analyses within 2 months. All his SA shows normal semen volume ( 3.0, 2.5, 3.5 ml), normal pH (all 8.0), normal liquefaction (<30 mins), normal appearance.
    His physical test also turn out normal; normal size, no sign of varicocele, CABVD, etc.
    My husband had mumps at around 5 years old.
    His blood test shows FSH within normal range (3.9 mIU/ml).
    All men in his family have biological children.
    Do you think it is necessary for us to do the TRUS, or testicular ultrasound? Or maybe other test like urine, testosterone, fructose, inhibin B, LH, etc? Or is it way better if we just proceed with biopsy. FYI, we do not practise FNA Mapping here in Malaysia.
    From all the information, do you think my husband do produce sperm? is it likely that he has blockage somewhere?

  160. Hello Dr. Turek
    Recently my husband was diagnosed with Azoospermia He is 32 year old ,there was 0 sperm found in his SA , all the tests are normal(no blockage ,Genetic tests) , his testosterone level is normal, but he has very Low FSH and LH levels ?my Question is , what should be our next step? Dr suggested us for testicular biopsy. is it possible to guess the availability of sperm?

  161. Testicular biopsy done , found no usable sperm. 2 occasional sperms were found in earlier tests with 10% motility , then I don’t understand why they couldn’t find sperm on the day of my wife’s ivf . We had to abandon the ivf with icsi process , all our time and money were wasted, they told me only donor sperm was possible .

    1. Dear Khan, I am sorry about what happened. Please keep your spirits up. Sperm retrievals can be complex and difficult because small numbers of ejaculated sperm can come from islands or pockets in the testicle, and these pockets can be very difficult to find. That’s one reason that I like FNA mapping, as it is very good at detecting sperm pockets in such situations and can guide sperm retrieval.

  162. Hello doctor,
    I underwent testicular biopsy for azoospermia. My biopsy report shows active spermatogenesis with sloughing in the lumen but microscopic study of the biopsy tissues shows very rare twitching sperm. How does this correlate. Will this very rare twitching sperm enough to fertilize eggs by IVF-ICSI. Please reply.

    1. Dear Senthil, Your biopsy sounds like you might have NORMAL sperm production, which means that you may have a blockage and not a sperm production problem. If your ejaculate volume is low, this may be due to ejaculatory duct obstructive (reconstructable) or an absent vas deferens (CAVD). If it is normal, you may also have CAVD, but epididymal obstruction (reconstructable). Rare, twitching sperm is NORMAL for a testis biopsy that is examined fresh.

    1. Dear Davy, 40% motility in fresh TESE (testicular) sperm is EXCELLENT! Means that it will likely freeze and thaw well too. Since sperm really develop the ability to move as they pass out of the testicle into the epididymis, MOST testicular sperm motility is twitching only. But remember that twitching=moving=alive and so twitching is good enough!

  163. Dr. Turek,
    Hello, I am new to this thread. My husband suffers from NOA. He has an elevated FSH level at 27. All genetic testing has came back normal and all his other infertility lab work is normal. His testosterone is normal but on the lower normal. We are talking with the urologist about an aspiration/biopsy. What is the likely hood of finding sperm with a FSH level at 27? My husband has no other help problems and has never had children before. He also denies any trauma to his genital area. He is currently on some vitamins but no other medications. He is 32 and I am 26. Thank you and I look forward to hearing back from you.

    1. Dear Emily, Honestly the FSH level is not really used to decide on whether sperm may be present or not in cases of NOA. It simply does not predict the presence or absence of sperm very well. I would estimate that there is at least a 60% chance of finding sperm by FNA mapping and 30% by a single testis biopsy.

  164. Hello Dr. Turek,
    My husband diagnosed with azoospermia after 3 semen analyses within 2 months. All his SA shows normal semen volume ( 3.0, 2.5, 3.5 ml), normal pH (all 8.0), normal liquefaction (<30 mins), normal appearance.
    His physical test also turn out normal; normal size, no sign of varicocele, CABVD, etc.
    My husband had mumps at around 5 years old.
    His blood test shows FSH within normal range (3.9 mIU/ml).
    All men in his family have biological children.
    Do you think it is necessary for us to do the TRUS, or testicular ultrasound? Or maybe other test like urine, testosterone, fructose, inhibin B, LH, etc? Or is it way better if we just proceed with biopsy. FYI, we do not practise FNA Mapping here in Malaysia.
    From all the information, do you think my husband do produce sperm? is it likely that he has blockage somewhere?

  165. Hi Dr. Turek, i am 24 year old male, I was diagnosed with non obstructive azoospermia recently, married since 7 months but no pregnancy, i have a history of high dose chemotherapy for bone marrow transplantation at age of 10 because i had a genetic aplastic anemia ( fanconi anemia) , i have normal hormone test except of having slight decrease of total testosterone
    I underwent mtesa , 20 biopsies for each testis but showed no sperms at all, waiting for pathology report, please doctor advise me what is next step, if i can do testicular mapping ? and if any hormonal injections can help ? Do u advise to do another mtesa ?

    1. Dear Yousif, I’m sorry that your mTESE procedure did not show sperm. I have published the ability of Mapping to find sperm in bone marrow transplant survivors but the actual rate of finding sperm in a population of men such as yourself has not yet been reported. Given this, there might be a chance that FNA mapping would find sperm, but first I would recommend that you check your testosterone level to see where it sits AFTER the mTESE procedure…

      1. Thank you Dr for your reply, i will check my testesterone soon, do you advise having HCG OR FSH injections before doing testicular mapping ?

  166. Hey doctor
    I m still have doubts with all rhiq and i would like your oppinion on the matter
    I m azospermic
    T value 7.7
    Fsh 9.9
    No chromosal defects
    Had a tese done
    Results
    Count 0.1 x 10^6 /ml
    Motily 40% immotile 60%
    Non progressiv 39%
    Sluggish 1%
    urologist that did the tese says obstruction
    Andrologist says non obstructive
    Who am i to believe or can it be both
    Plz give me your oppinion
    Thnx

      1. Yes it is. But it is also possible that a blockage exists. The exact relationship between testis sperm numbers that characterize blockage vs no blockage is relatively understudied. We published that finding 5 sperm/hpf on a testis tissue specimen is basically normal and finding sperm in the epididymis in the 100K to 1 million range is also likely normal.

          1. Dear Davy, in cases of obstruction, looking for sperm BEYOND the testicle where they are made can make sense. In these cases, PESA or MESA procedures can be helpful. However, if there is no blockage and there is a sperm production problem, sperm may found in the testicle but are not being made at high enough levels to reach the epididymis. Therefore, MESA and PESA procedures are quite uninformative in this instance. Really need FNA mapping or something to find out what’s happening there.

  167. Hello Doctor,
    My DH was diagnosed with Azoospermia in 2009 he did a testicular biopsy that shows spermatids maturation arrest, we had 4 IVF cycles with round and elongated spermatids with no pregnancy, in the last IVF cycle he did a testicular microdissection and came out with two elongated spermatids only and the ivf didn’t work also. do you think is there any chance to find any sperm that can be used for IVF? Please note that he has high FSH level & was treated with GONAL F injections for 3 months before each cycle.

    1. Dear Daisy, thats quite a go at things!! Interestingly, using round or elongating spermatids is considered experimental therapy and not common clinical practice in the U.S. My first concern is your husband’s testosterone levels after several (?) sperm retrieval procedures. Second, FNA mapping may provide unique information here, as micro dissection is relatively uninformative with this biopsy pattern (as late maturation patterns and normal testis tubules look identical on mTESE procedures). One common statement with FNA Mapping is “where there are spermatids, there are usually sperm.” This might then direct a sperm retrieval to ONLY those locations in the testis where the mature sperm with tails are found. Give us a holler!

  168. My wife and I havexpect being trying to have a child for the past one year but no result. My sperm analysis show azoospermia and scan show varicocele on the right testis which was operated upon 3 days ago but my doctor said varicocele can not cause azoospermia and went ahead to take some tissue from my testis he called it biopisy. Please what is my chances of becoming a father am 34 years of age.
    Thank you

    1. Dear Yunusa, a right sided varicocele is very rare. There is no real data on the chance of finding testicular sperm with right varicoceles. With a left varicocele and non obstructive azoospermia, the chance of finding ejaculated sperm after varicocele repair is 39% in a recent metaanalysis. I believe that varicoceles only rarely cause azoospermia. Men in whom this is true would be expected to have a normal right testis (no varicocele) and a smaller left testis, but not by much (16 ml). If both testes are smaller than this, then something else is likely going on, like a concurrent underlying genetic issue with sperm production.

      1. Thank you so much. The biopsy result is out and it shows gam cell aplasia however the sample collected was kept in a refrigerator and it takes more than 18 before taken to the lab and 5 days after before getting this result. What do you think of this? Should I do biopsy of the left testicle? What is my chance of finding a sperm. Thank you.

  169. My husband was diagnosed with non obstructive azoospermia recently. Physically he is the picture of health. Anatomically he has everything and it is where it all should be. Testicles are the correct size. No varicoseles. Genetic testing showed he was fine. Hormone testing shows he is fine. We just do not understand what could be causing the azoospermia if everything is coming back fine but the semen analysis. He even has good semen production just no sperm. Any ideas or further testing to suggest?

    1. Dear Naomi, Your partner may in fact be…obstructed. Sure sounds like it. If he has had a biopsy and it shows no sperm, then the pattern on biopsy is probably maturation arrest. Our research has shown that in about half of these cases, the pattern has genetic underpinnings and in the other half it doesn’t. This could be an issue with meiotic failure in the testis due to faulty recombination. That is about as genetic as one can get!

  170. Dear dr. Turek,
    I was diagnosed with NO azoospermia a while ago. My fsh level was 18 theb decreased to 15, i only took vitamins and herbal supplements. After my TESE , they told me they found few sperms and spermatides. My question is, is it possible to find sperm again through tese or fna? And do i have to take any hormonal meds before attempting another surgical sperm retreival to maximise my chances. I mean is it possible yo boost these spermatides into sperms ??
    Thank you

    1. Dear MK, Yes, depending on the expertise of the surgeon and sperm retrieval team, sperm can be found on repeat sperm retrieval procedures if they are repeated. I usually see patients who have had many sperm retrievals to the point that no one can find sperm anymore. I have had luck with FNA mapping finding hard to detect pockets of sperm in these men and then targeting sperm retrieval. It may be helpful to “optimize” you medically before going forward as well. The most important point here is not to repeat a sperm retrieval within 6 months of the last one to allow the testicles to recover from the “shock” of the procedure.

  171. Dear Dr. Turek,
    I’m a 32yr old that have been diagnosed with non-obstructive azoospermia. I have done series of tests- two semen analysis and several hormone analyses. The two things that stood out from my tests and physical examination (in the opinion of the Urologist I saw) were high FSH and small testes. I have tested the FSH over a year now; it typically ranged from 16.9mIU/mL to 20.9. There was an outlier of 1.3mIU/mL this past December 2014- I thought it might be a positive, as I abstained from sexual activities for more than two weeks before the test. I have been taking fertilaid and count boost vitamins. I also started exercising- my testosterone has moved from 592ng/dL to 728 with LH higher than normal in two tests but normal in one (8.3 to 10). I have tried doing genetic testing but for financial constraint I could not.
    I will like to seek your opinion on surgical sperm retrieval but my greatest fear is if anything will be found. My wife has also been diagnosed with PCOS- it’s hard. I will appreciate your opinion on the following:
    1.What is the prospect of finding healthy sperm from a man with small testes and high fsh; I’ll appreciate any data from your outstanding works on this.
    2.What is the success rate of men in your practice with similar conditions that succeeded with having biological child/children- we are looking at FNA/TESE/IVF. Any success story would help.
    I look forward to your kind response.
    Thank you.

    1. Dear Mike, The FSH and small testes really don’t matter that much when we think about sperm in NOA. Very small testes (75) might make me pause a bit, but other than that it doesn’t. I would estimate that there is a 60% chance of sperm on FNA Mapping. Once mature sperm are found the pregnancy rate depends almost entirely on FEMALE issues (her age, egg quality etc). We have routine success in this scenario. Check on FB for baby pics!

  172. Dear Dr. Turek,
    I am Shirley from China. My husband were diagnosed with Non Obstructive Azoospermia (High FSH :25, Small Testis :5ml, Bilateral varicocele, Both Y chromosome microdeletions & Karyotype are Normal)on October 2014. The doctor did not suggest TESE. He had been taking the medical treatment(Tamoxifen Citrate Tablets/ Diosmin Tablets / Levocarnitine Oral Solution / Vitamins and herbal supplements for everyday, Plus intramuscular HCG 2000iu + HMG75iu for every three days) for nearly three month. The doctor had told us that the treatment is useless for NOA, but we don’t really want to give up.
    My question is:
    1. Is there any problem with his above medical treatment?
    2. After the medical treatment for 3-6 month, if there is still no any improvement, Should we try the FNA Mapping ?
    3. I saw your former reply to other one : FNA mapping is performed by only a few formally trained people in the world. I will be offering a much more formal, certified training program for all interested urologists starting next year . Would you like to tell me is there any hospital or urologists in China that will offer the FNA mapping? We live in Guangzhou, the south city of China.
    Thanks in advance !
    Greeting
    Shirley

    1. Dear Shirley,
      Your hubby has genetic-negative NOA. It is not clear whether his testosterone balance is normal but he is taking medications (tamoxifen and hCG) to boost pituitary drive to the testis to make even more FSH and to (I assume) normalize testosterone balance. This might help “optimize” him if T is out of balance, but will probably not help if baseline T is in normal range. Multivitamins in this situation cannot hurt but may not help. After 3-6 mos of such therapy is it very reasonable to do FNA mapping and see what’s there. Unfortunately, there is no one in China trained in FNA Mapping at this time and the proposed training program that I will offer will take 1-2 years to fully train them to the highest quality.

      1. Dear Dr. Turek,
        Thank you very much for your precious reply. My husband’s testosterone balance is normal . I have saw our local doctor yesterday, he asked my husband to check the Sperm analysis , serum inhibin B (Former :12.6 pg/ml) and FSH (Former: 25 mIU/ml) after these 3 month’s medical treatment in next week, the doctor said he will prescribe medicine for my hubby’s next 3 month’s treatment after he get the result.
        I have asked our doctor about the FNA MAPPING, he did not suggest my hubby to try it because he said my hubby’s testis is too small (5ml) to do the FNA MAPPING, he assumed that it may lead to the small testis testicular atrophy if take 11-18 FNA samples through the scrotal skin. We feel rather confused now.
        Greeting
        Shirley

        1. Shirley, I live both the dream and the potential nightmare of testis FNA Mapping. Our sperm retrieval rates approach the mid-90s% with a single sperm found at a single site in a single testis on FNA mapping. How could this be possible if we are doing a pile of damage to the testicle? Just not what we are seeing..

          1. Dear Dr. Turek,
            Thank you for your kind reply. I am sorry to bother you many times
            I got my hubby’s result two days ago. Our Dr.Lee said it is a very complicated situation.
            He said it is not only Non Obstructive Azoospermia, but also exists Obstructive Azoospermia possibility. There are big change in my hubby’s blood test after 3 month medical treatment (Tamoxifen Citrate Tablets/ Diosmin Tablets / Levocarnitine Oral Solution / Vitamins and herbal supplements for everyday, Plus intramuscular HCG 2000iu + HMG75iu for every three days) . Here is the result on as following:
            FSH ( Before: 24.73 mIU/mL After: 3.08 mIU/mL )
            LH (Before: 5.79 mIU/mL After: 0.18 mIU/mL )
            T (Before: 5.78 nmol/L After: 32.71 nmol/L )
            E2 (Before: 69 pg/mL After: 140.45 pg/mL)
            PRL (Before: 9.6 ng/mL After: 8.76 ng/mL)
            INHB (Before: 12.6 pg/mL After: 5.28 pg/mL)
            AMH (Before: 22.1 ng/mL After: 0 ng/mL)
            Seminal Plasma elastase ( 1475.49 ng/ml )
            Seminal Plasma fructose (Before: 50.37 umol After: 2.5 umol)
            Seminal Plasma Neutral Alpha-Glucosidase (Before: 39.13 mU After: 83.24 mU)
            Semen Analysis still showed no sperm
            Then we went to another hospital to recheck the sexual hormone again for twice (2015-2-13 FSH 1.99 IU/L, 2015-2-14 FSH 4.17 IU/L, my hubby took the intramuscular HCG 2000iu + HMG75iu at night on 2015-2-13) . Our new Dr. Zhang did not think my hubby exists Obstructive Azoospermia possibility, he thought my hubby is Non Obstructive Azoospermia.
            Now our new medical treatment is (Diosmin Tablets / Levocarnitine Oral Solution for everyday, Plus intramuscular HCG 2000iu + HMG150iu for every three days), the dosage of HMG is increased from 75iu to 150iu.
            My question is :
            1. Why did our local two doctors take different opinion of my hubby’s diagnose?
            2. The former Dr. Lee stopped my hubby’s intramuscular HCG +HMG, but the latter Dr. Zhang suggested that we should continue the treatment of intramuscular HCG +HMG for more 2 months, after then , if there is still no change, we should try the microsurgical testicular sperm extraction. What do Dr. Turek you think about it ?
            Thanks in advance !
            Greeting
            Shirley

  173. Dear Dr. Turek,
    I was diagnosed with azoospermic on first semen analysis.
    then I consulted with another expert they told me for some tests Color dopler of scrotom Report was :
    IMPRESSION: : BILATERAL RELATIVELY SMALL SIZED TESTIS WITH HETEROGENOUS
    ECHOTEXTURE OF LEFT TESTIS ? SIGNIFICANCE.
    Report :: : Both Testis are normally positioned in the scrotum and are of normal size. Right testis
    measures 2.01 x 1.20 x 2.59 cm (3.31 cc) Left testis measures 1.52 x 2.31 x 3.25 cm (5.25 cc) Right
    testis show a uniform parenchymal echogenicity, smooth outlines and absence of any focal or diffuse
    lesion however mild heterogenous echotexture is noted of left testis. Both Epididymis are of normal
    size and echogenicity. The pampiniform plexus was examined using colour doppler before and after
    valsalva’s maneuver. There is no evidence of Varicocele, Hydrocele or Hernia in both Scrotal Sacs.
    Right pampiniform plexus measures 3 mm while left pampiniform plexus measures 1.9 mm with no
    positive response with valsalva’s maneuver. The Inguinal Regions are normal with no evidence of
    lymphadenopathy.
    (above reports of US of scroum)
    Prolactin and Testestorone is normal .
    LH :17.3
    FSH : 15.8
    Gone thru FNAC of Testis Also:
    Conclusion was : less Sertoli Cell and Leydig Cells , Sperms are being produced occasionally in all the different stages ,
    Conclusion was normal Spermatogenesis process (May be the case of Severe Oligospermia)
    Now Doctors are suggesting to go to IVF With TESA.
    Please Suggest me if This may be treated naturally as I am Obess (BMI 36). Once I have gone thru Mumps in age of 26 , I had habit of smoking Light , and Tobacco in past before 0.5 Years.
    please suggest if I change my life style it may be cured . My second Semen sample within 10 days are AZOOSPERMIC In nature. Is ART is the only solution ???
    Please please please help!!!!

    1. Dear Bhupendra, The fact that the testicles are smaller in size than normal and that the LH (hormone that drives testosterone production) and FSH (hormone that drives sperm production) levels are high suggests bicompartmental (hormones and sperm) testis failure. In the absence of varicocele (not present by ultrasound) or other treatable condition, ART is the best and maybe only solution to have biological children. Sure, you should stop smoking and lose weight (to reach a BMI <25) too, but this would probably only help sperm production by 10-20% and may not result in sufficient numbers of ejaculated sperm to avoid IVF. But do both anyway, so that you live a longer life with your kids!!

      1. Thanks Dr. For your kind reply. If i try to change my lifestyle and lose my weight , to see the change it will take time..of 3 to 6 Months. Kindly advise if i retain for this condition will not deteriote, because i want to take some time i.e. Approx 6 Month to prepare me economically and physically…is it advisable..? Thanks in advance.

  174. Hello doctor, any progress about metabolic mapping for testis ” Spectroscopy” as i have sertoli cell only syndrome and failed Mtese to find sperm. When could this imaging be used in real life ?

    1. Dear Ramez, It is precisely patients like yourself who might benefit from metabolic mapping. Research and development has slowed recently but is still ongoing at The Turek Clinic. Expect to hear more possibly as soon as 2016.

  175. Dear Dr. Turek, my husband has sertoli cell only syndrome, we pray to god every day to have some solutions to this problem as so far we tried everything but nothing helped really, we are looking for stem cell therapy that could help us being parents but I am afraid by the time It is used in practice i would be old to have children, I am 25 years old, could you dr give me an estimate when could it be available in your clinic ?? Thank you so much.

    1. Dear Sana, we have published some exciting work this past year and I will have a dramatic announcment concerning funding for our artificial, stem cell-based research on man made sperm soon. However, it will take time, at least 5 years to develop this technology. Consider freezing your eggs and calling me for a the second child…

  176. My biopsy result is out and it shows gam cell aplasia however the sample collected was kept in a refrigerator and it takes more than 18 before taken to the lab and 5 days after before getting this result. What do you think of this? Should I do biopsy of the left testicle? What is my chance of finding a sperm. Thank you.

    1. Dear Yunusa, a single biopsy showed Sertoli cell only. Really doesn’t matter where it was kept or stored. What matters more is whether, on further sampling of the testis, there might be pockets of sperm that could be used with IVF-ICSI. I would definitely consider looking at both testes! Chance of finding sperm by FNA mapping is 30-40%.

  177. Dear Dr.Turek,
    I am from Sydney-Australia. Twice I got my semen analysis done and both showed as zero sperm (with centrifuged pellet analysis). I got my blood test done with results as FSH – 8, LH – 3.65, Testostrone – 10.9 nmol/l. Karyotype, cystic fibrosis, y chromosome microdeletion all were normal. Got my Scrotal Ultrasound done, no problems were found. Testicular Volume showed as, right testis – 10ml and left testis – 9ml. No testicular biopsy has been done so far. Dr.Turek, with your experience, what would the probability of finding sperm(s) in my testis with these readings. With Thanks, Vincent

    1. Dear Vincent, You have non obstructive azoospermia which is not classically genetic in origin. It may still be caused by a genetic problem, it’s just that we do not have the genetic knowledge to know what it might be at this time. I would estimate that the chance of finding sperm by FNA mapping would be 50-60%.

  178. Hi Dr. Turek
    I was recently diagnosed with maturation arrest azoospermia. After a testi biopsy the outcome was incomplete maturation arrest with a Johnsen score of 9, 4 straws where frozen for icsi. My understanding of all this is that I am producing sperm but not very well, in fact so bad that I am azoospermic. What I dont understand is what is incomplete maturation arrest and if it’s possible to correct it through a intensive lifestyle change (stop smoking, lose weight, increase activity etc…) Also whether my might have obstruction as both SA was also indicative of this.
    Thanks an Regards Dr. T

    1. Dear Adriaan, Normal spermatogenesis and late maturation arrest can be easily confused. If you have sperm, then you have late incomplete maturation arrest…or you’re normal. The only way to tell the difference is to look at the relative numbers of spermatids and mature sperm in the testis. And, since testis biopsies are not good at showing mature sperm with tails, the only real way to do this is testis cytology, such as is done with FNA mapping. True late maturation arrest is a rare cause of azoospermia and is likely due to faulty spermiogenesis genes (not spermatogenesis but its latter half in which mature sperm are formed from round cells called spermatids). As far as I know, no testable human spermiogenesis genes are known that could examine this issue.

      1. Hi Dr. Turek.
        I appreciate the reply, it has me unfortunately asking more questions now. The Fertility Clinic that I had the biopsy done at do provide FNA and its seems FNAC provides a more concise cause of azoospermia in men. So I need to do some digging. Could you please advise if you have trained any Doctors from South Africa who can do FNA Mapping. I am still unsure of what the real cause is of my azoospermia and would like a second opinion.
        Again many thanks Dr. T

  179. Dr. Turek, my husband has been seeing a Male Infertility Urologist at a reproductive center here in Atlanta because of zero sperm. His first blood tests showed his testosterone level in the very low 100’s, was put on Pregnyl HCG injections (it has now been 8 or 9 months), had a testicular ultrasound which they said showed nothing wrong and for the last two months has been taking Follistim injections and are about to start month 3. Last two SA showed 500,000 and 800,000 premature sperm or round cells and testosterone in the high 200’s. No one can seem to give us any kind of answer on what this really means. Will these turn into mature sperm? How long does it take? Is a biopsy a bad idea? I should also mention he is almost 55 and I am almost 35. We don’t have any idea what is causing this – age? steroids? low testosterone? genetics? Time is of the essence and we desperately want a baby. Would a phone consultation help at all? Is there a doctor in Atlanta that does your sperm mapping? I don’t know that coming to California is a viable option for us but I sure could use some help! Thank you, Allyson

    1. Dear Allyson, the Atlanta group is excellent and these are great questions to ask your doctors, not me. In general, they are trying to optimize hormone balance before looking for sperm. I do not know the significance of seeing round cells in the semen; not sure that sperm will follow…Be happy to talk further by phone.

      1. Thanks for reply. Is the Atlanta group a Urology office? We are currently at RBA…I think we need to speak. We have asked questions and are still so unsure of anything. I just feel like you are more knowledgeable and can give us a better understanding of where we are. Thanks, Allyson

  180. Hi Dr. Turek,
    My husband has y chromosome micro-deletion AZFc. Quick history on our journey:
    We were trying to conceive over a year (2013-2014) after that, my doctor urged me to do infertility testing, where I checked out okay & everything is normal, then – we had my husband do a semen analysis, the results came back as abnormally low sperm count in early October 2014 (~500 sperm), he did his 2nd analysis in late October 2014 and the results improved a bit (around 2400 motile sperm) -and also at this time he did the genetic testing where the results came back positive for the ychromosome microdeletion. Since sperm was present, the doctor informed \we could do ICSI-IVF. My health insurance changed the beginning of the new year so we transferred to a new clinic, all our records got transferred & we were picking off where we left off to start the IVF cycle after a few preliminary tests in January of this year. Since then, everything went downhill. He went in for his 3rd semen analysis (his first at this new clinic) & they were going to freeze this sample for a backup to our IVF procedure – and the results came back as ZERO sperm found. This was daunting to us, as his two previous analyses had sperm! And only 2 months ago! We did another analysis in Feb, same result – azoospermic & then again in March, azoospermic again. He went to see a urologist and with the results at hand, he recommended he do the microTese procedure. Since there was sperm found before and that he was AZFc, he felt there was a chance in finding sperm in the testes. We rushed this and did the procedure 3 weeks ago. The results were no sperm were found. We are still reeling from this news – My husband is feeling like we rushed into this procedure and now I am also regretful we made this decision – but it was at the recommendation of experts, and felt they had our best interest at heart – now, after the fact, I hear about sperm mapping. Why was this not suggested prior to this invasive procedure? Now, I’m concerned of damage to his testes after doing MicroTese- he’s still healing and we are not wanting to give up hope. We have a consult for a 2nd opinion with another urologist in a month – whom I have heard does sperm mapping. I just wish we need about this first…
    There are so many unanswered questions which our doctors haven’t given us a definitive answer or logical explanation…
    we went from having sperm to no sperm in less than 2 months time…why? nobody can answer this.
    also, I cant help but feel this all happened after we moved to the new clinic, now, this clinic is very well known – with top doctors, (we are in Seattle) it could all be coincidence but it makes me question their lab, did they not look hard enough? – and/or I am questioning the first clinic we went to, and if their analyses was wrong.
    Please let me know if you have insight into our situation – we want to believe we can have a biological child of our own, but I don’t want to keep having to put my husband through the ringer.
    Thank you in advance. PS- this site is wonderful and a wealth of knowledge for those that are going through this. Many of us feel lost and don’t have the right information – sometimes, I feel the doctors just go through a protocol, and not really looking deeper at each individual situation..this may just be my personal experience right now. Thank you again.

    1. Dear Stella. That is quite a story. You are living the nightmare of variable biology and variable expertise with IVF. Now you are experienced and shopping smart, which is good. First, men with ejaculated sperm clearly have a pocket of testicular sperm SOMEWHERE in the testicle, but these surgical searches can be demanding and can fail. Second, men with low sperm counts can vary between 0 and <1000 sperm and it is normal to vary. Read my blog entitled “Sperm from Thin Air” and realize that even low numbers of sperm can be excellent for IVF-ICSI in our experience. Third, after mTESE, a return of ejaculated sperm may not happen. You may start checking again in 4-6 mos. Certainly, no procedures should be done within 6 mos of an mTESE procedure. After that I would check the ejaculate all over again and then consider FNA mapping to see if a small pocket of sperm can be found that would justify another sperm retrieval. I am now certifying providers in FNA mapping, but no one in Washington is certified at this time.

  181. Hello Dr.Turek
    we are from canada , My husband was diagnosed with azoospermia about 6 months ago, he got Two semen Analysis done(Centrifuged Pellet Analysis)- results with zero sperm count,Ph 8 ,volume -2.
    he also got blood test done with Testosterone level -257, FSH 0.100, LH- 0.100 (Doctor said that this is unusual result ) all his other tests are normal(Karyotype ,Chromosome Y deletion,Cystic fibrosis ) , testicular size is also normal .No Problems found in scrotal ultrasound
    No biopsy has been done so far
    Doctor has straight away suggested for TESE
    According to these results what are the chances of finding sperm , is it obstructive or Non Obstructive Azoospermia ?
    He is 32 year old , non -smoker ,No alcohal
    Thanks

    1. Dear Ajay, This is an unusual set of blood tests! They need repeating, especially the LH and FSH. I am assuming that you are not on anabolic steroids….That said, if LH and FSH are truly low, then you have non obstructive azoospermia that is medically TREATABLE (Kallmann variant) and natural fertility is possible. If the FSH is >8 and LH normal then you have non obstructive azoospermia that may or may not be definable but there still may be a 60% chance of having sperm by FNA mapping or mTESE. If your LH and FSH are both normal (<10) then you may in fact be obstructed and there may be procedures to unblock you that lend themselves to natural fertility. Lets talk! http://theturekclinic.wpengine.com/male-fertility-consultation/

      1. Thank you Dr.Turek for your reply ,it means a lot . He took blood test all over again , results are not out yet
        He has no history of any drugs , took steroids about 7 years ago
        otherwise he is quite Healthy , normal muscular guy
        Thank you soo much

      2. Hi Turek ,
        You have mentioned in the above comment if FSH and LH are Low it is medically treatable and natural fertility possible . Can you tell me how it is treatable so we will plan. My Husband hormone levels are below tested at different times
        1.
        FSH : 2.16 mIU/ml
        LH : 1.91 mIU/ml
        Testosterone : 2.63 ng/mL
        Prolactin : 12.69 ng/ml
        2.
        FSH : 5.40 mIU/ml
        LH : 3.92 mIU/ml
        Testosterone : 4.61 ng/mL
        Prolactin : 3.54 ng/ml

  182. Dr Turek. I’m wondering if you can help us. We are based in the UK. My husband has been diagnosed with non-obstructive Azoospermia. His testicles are normal in size and appearance, he has one very small variocelle . All his genetic tests have come back clear (no deletions), no cystic fibrosis, no retrograde ejaculation. His FSH, LH and prolactin levels are raised, (FSH 21.9, LH 10.1 and Prolactin 449). Do you have any recommendations for doctors in the UK (ex. Ramsay) or should we travel to the US (Turek or Schlegel at Cornell). What are the chances, given his hormone levels, that mTESE will be successful?

    1. I should add that the doctors doing the MRI and ultrasound said that the very small variocelle was so small, it wasn’t worth repairing. I know Schlegel tends to operate on even the smallest of these. I would be interested in your opinion and also wondering, given the raised LH, FSH and prolactin levels, if any hormonal or supplement treatments are available to him?

      1. Dear EP1984, I read both of your posts. I believe that real, live clinical varicoceles can be considered for treatment but small, scan-detected ones tend to produce little or no effect. If you are considering a “blind” procedure like micro dissection TESE, then practitioners of the art will want you to be “”optimized” as much as possible and suggest that a small left varicocele be repaired ahead of time. However, if you consider FNA mapping instead of microdissection TESE, the results from this much less invasive and simple procedure will inform your decision about whether or not to bother fixing the small varicocele before a sperm retrieval. Think about it, as it’s a “know before you go” approach. Given the elevated hormones, the prolactin should be repeated to ensure that a prolactinoma is not present. Usually elevated prolactin is due to a stressful blood draw. With a clinical varicocele, FNA mapping has a 65% chance of finding testicular sperm. Talk to Dr Ramasy in UK about your case~!

  183. Hi Turek ,
    You have mentioned in the above comment if FSH and LH are Low it is medically treatable and natural fertility possible . Can you tell me how it is treatable so we will plan. My Husband had Non obstructive azoospermia and hormone levels are below tested at different times
    1.
    FSH : 2.16 mIU/ml
    LH : 1.91 mIU/ml
    Testosterone : 2.63 ng/mL
    Prolactin : 12.69 ng/ml
    2.
    FSH : 5.40 mIU/ml
    LH : 3.92 mIU/ml
    Testosterone : 4.61 ng/mL
    Prolactin : 3.54 ng/ml
    whether this is naturally treatable ?

  184. Dear doctor turek.
    My semen analysis sample report is as follows.
    i hav done 2 sample . one sample.on 29/9/2014 and second sample in dhaka.volume – 02 mlliquefaction-  completely liquefied ( after incubation at 37 c for 30 min)ph – alkalinesperm count -nilsperm motility- not applicablesperm morphology – not applicablepus cell – 1-2/hpfepithelial cells 1-2/hpfgerm cell – absentrbc- Nilsperm clumping – not applicablecomment – Azoospermia
    Scrotal scan –  Normal Scan
    FSH – 8.17miu/mlTestosterone – 516 ng/dl
    Now the gynae doctor advised me to do FNA of th Testis. on 21st april 2015 i have tried to do ICSI in dhaka. there the urologist did aspiration from testis under local anaesthesia. they said from 2 samples of my testis no sperm found. so we couldnt do sperm transfer to my wife. My wife is perfectly healthy. 
    is there ny new hope or new technology tat can help me.wat shall i do?Pls i hav asked a lot of questions from u. pls dnt mind. i am really devastated. Help me as much as u can with ur honest advice.
    thanx.

  185. Hi Dr. Turek,
    I’ve scheduled a full consult visit with you in June, but I had a quick question about my condition. 30 years ago I was diagnosed with childhood leukemia and now I’m married and we are talking about children. Does the fact that I had chemo treatments so young have an effect on the chances of finding sperm? I’ve had a biopsy recently that discovered Sertoli Cell Only Syndrome and past semen analysis have confirmed azoospermia. Thanks, and i look forward to meeting you soon!

    1. Dear bMAc, good to hear that we will meet soon. We don’t really know whether it is better in the long run to get chemo as a prepubertal child vs post pubertal teen/adult regarding eventual fertility potential as an adult. There are fewer stem cells in the testicle as a child (not good) but they are not dividing as rapidly as in the adult (good). Jury is still out on this one.

  186. HI, I am 31 year old male from Canada.I have diagnosed with Azoospermia.My blood test is showing below result
    Testosterone – 13.1
    Testosterone Free -215
    FSH : 26,
    LH-12
    and prolactin-21
    Cytogenetics report is showing normal male karyotype,No clonal chromosomal aberration.Molecular genetics report show no microdeletions of the three AZG regions on the Y chromosome were detected.We have schedule appointment with urologist on 18th July.So can you please help to understand what is type of Azoospemia and what are chances to get treated.

    1. Dear Ajit, This sounds like non obstructive azoospermia. You will be offered a testis biopsy, micro dissection TESE or possibly FNA mapping to learn whether there are pockets of sperm in the testicle. A simple biopsy is about half as good as FNA Mapping or mTESE in finding sperm. However, be aware that the testosterone levels are being maintained with a higher than normal LH so that there is some hormonal “testis failure” present. This means that the least invasive procedure the better to preserve testosterone balance in the future.

  187. Hi Turek,
    Yesterday I had semen analysis and found 4 to 5 Normal(Proper head , Neck , Tail ) Dead sperms ….. What is ur opinion …. Is it possible to improve sperm production naturally ? your suggestion please

  188. Hi Turek,
    In the last semen analysis I got 4 to 5 Normal dead sperms , My Hormone levels and Karyotyping Normal . Whether I should go for TRUS test ? Can you share your opinion on this …. Is it possible to improve the sperm count naturally with some medicines

    1. Dear Gi, you have cryptozoospermia. I would try to bank several/many samples of sperm (if motile only) and use them for IVF-ICSI. A TRUS will help diagnosis ejaculatory duct obstruction which can do this, but the EJACULATE VOLUME should be low (<1.5mL) for it to be of any value.

      1. Thanks Paul,
        All are dead sperms so I want to improve it with some medicines . Is it possible to increase the count at this stage i mean from just 4 dead normal sperms to some millions ?

  189. I have come across your website whilst searching online from the UK.
    I am a 29 year old male, married for 2 years. My wife and i have been trying to conceive for over 2 years now with no success.
    A year ago I was diagnosed with Azoospermia due to unknown causes from several sperm samples.
    I had all “reasonable” tests carried out by my urologist and all came back normal.
    FSH Levels – Normal
    Genetic Tests – Normal
    Testosterone – Normal
    Testes Size – Normal
    Semen Production – Normal
    Rectal Ultrasound – Normal
    Testicle Ultrasound – Normal
    I then went onto undergo a testicular biopsy to see if any sperms could be extracted. None present.
    He was not able to give me a reason for the Azoospermia.
    All of this happened a year ago and my wife and I have not been back to him since.
    I also had a rectal ultrasound and they took some fluid from prostate for culture and all was normal.
    I did contract Chlamydia when I was 21 which was treated with a 7 day course of antibiotics.
    The main symptoms did go away post treatment however i really do not feel the same ever since that period of treatment ended. Even now 8 years on i still have a burning sensation when i urinate and ejaculate. Also ejaculation feels different and less intense if that makes sense..
    I have been back since to my local GUM clinic to do urine tests and the said i do not have Chlamydia anymore.
    I cant help but think that i wasnt treated properly in the first instance back when i was 21 and now i am paying the price.
    I am going back this week to test for Trichamoniasis, could this potentially be the cause of my infertility if it is detected?
    I have also have been noticing bad smelling urine and it is sometimes cloudy.
    My wife in the last 2 months has started to get creamy white discharge which is unusual for her. She has recently had a smear and her GP said that she has a strawberry cervix. Could this be all related?
    Sorry if this message is long winded
    Your advice is much appreciated
    Kind regards

    1. Dear PD, this sounds a lot like non obstructive azoospermia due to maturation arrest pathology. In this case, everything looks great, testicles, hormones etc, but in fact sperm production is stopping at the primary spermatocyte stage (i.e. about half way through the sequence to mature sperm). This tends to be more genetic than infectious, as infections tend to cause blockages and not maturation arrest of spermatogenesis. Since we know to test for only a fraction of the entire genetic universe, it could still be genetic despite the routine genetic tests not showing any positive results. Thing is, if you look hard enough, there may be areas in the testis in which mature sperm are being made. Hence, the value of FNA mapping. Microdissection TESE in cases of maturation arrest is hard because it is largely a visual technique and all the tubules in the testis look the same. This makes finding that specific tubules (among 700 feet of tubules) with sperm that much harder.

  190. Doc,
    My husband, 27 y.o. was diagnosed with azoospermia. He did 3 physical tests with 3 doctors and all seem fine. His testis size is okay, with distended epididymis, no sign of varicocele or CABVD. He had childhood mumps at around 4-5 y.o.
    Below is his hormonal study:
    Blood test done on 23.9.2014 :
    FSH 3.7 iu/L
    Blood test as on 31.1.2015 :
    FSH 5.2 iu/L
    LH 3.3 iu/L
    Testosterone 12.4 nmol/L
    Prolactin 9.6 ug/L
    He did PESA at both testes in March 2015, which failed to retrieve any sperm.
    In April 2015, he did PESA and followed by TESE at both testes, also no sign of sperm.
    Our doctor sent a sample of testicular tissue to Pathology Lab. Result as below:
    MACROSCOPY:
    A: Multiple fragments of tan tissue measuring 15mm in aggregate diameter. Entirely submitted in 1 block.
    B: Multiple fragments of tan tissue measuring 10mm in aggregate diameter.
    MICROSCOPY:
    Section of testicular biopsy shows seminiferous tubules with thickening of basement membrane and spermatocytic maturation arrest at secondary spermatocyte. No spermatids or mature spermatozoa are seen within the tubules. Leydig cells are seen in the intestitium. There is mild intestitial fibrosis. No inflammation, granuloma or malignancy noted. No tubular hyalinization seen.
    Interpretation:
    Right & Left testes: Spermatocytic arrest.
    Blood test 1 month after TESE:
    FSH: 13.2 iu/L
    T: 13.4 nmol/L
    Doc, from the report, is there any chance that we can find sperm if we repeat TESE? What cause the FSH to increase after TESE?

    1. Dear Ima, This is most likely early maturation arrest at the primary spermatocycte stage (not secondary stage as stated as secondary spermatocytes only exist briefly in the system and quickly progress to the next cell type). Yes, there is a chance that if the testicles are sampled more intensively, say with FNA Mapping or mTESE, then sperm might be found. Unfortunately, mTESE relies on visual cues (sperm tubule size) to find sperm which can be VERY Difficult in this case as all tubules appear normal looking. FNA mapping does not rely on visual cues (it uses cytology) and may be of help here. Your FSH is likely higher in response to the “insult” of the procedure and will likely fall back down as the system recovers.

  191. Dear Dr. Turek,
    I am 39 years old.
    i have been operated for unilater crypsorchy at 6 years old. Also been operated for hypospadias. At 21 years old, i had a tumor in my cryptorchic testicle. Biopsy showed that it was nothing bad. My testicles are very small (i dont know the exact size, maybe 4-5 ml the bigger one.). My penis is also small. My spermodiagram shown azoospermia (zero sperm, but 8*10^5/ml germ cells). Sperm volume 4ml.
    testosterone is 4.54 ng/ml. FSH is 31.51 mlU/ml and LH is 17.47 mlU/ml.
    I went with my wife to 2 fertility clinics in Greece. One of them suggest me doing open biopsy, and the other do micro tese. Each of them says that any other method is useless and dangerous. They give me very little chance of having spermatozoa (<10 spermatozoa).
    What do you think doctor? Is there any serious possibility? Will microTese destroy my testicles? Can my testosterone level afford doing microTese? Will it drop dramatically? What about the other method, open biopsy? Is it safer?
    I have also read that "Kallistem, which develops innovative cell culture technologies in reproductive biology, today announces a world first: human spermatogenesis in vitro". How far are we from this?
    Thanks for your time doctor, and awaiting your reply!

    1. Dear George, Both mTESE and simple biopsy TESE are invasive, no doubt. Opening up a previously repaired testicle either way is a significant undertaking. In addition, although your testosterone level is normal, there is not much room to spare as the LH is high. Too many (or too much of) invasive procedures could certainly put you at risk of hypogonadism requiring T replacement. You are an excellent candidate for extended FNA mapping, a much less invasive way to determine whether sperm are present in the testicle before incisions are made. In our published series of men with undescended testes, we obtained a 60-69% rate of finding sperm.

      1. Dear Doc,
        thank you for your reply! Can you help me approximatelly with the cost of an FNA mapping and mTese afterwards? I am from Greece. How long do i need to stay in the hospital?
        Thank you once again

        1. Dear George, Contact us on line for price and scheduling details. FNA Mapping is a 1-2 hour outpatient procedure…but it takes 3-4 weeks to get results, so typically patients fly back home and we talk about the results by phone. Sperm retrieval is planned for 1-3 months after the mapping.

  192. I performed semen test. Analysis shows Sperm Count – 62.6m/ml,
    Alkaline, Total Motility is 70%. Excellent forward progressive IV is 40%. Fructose test shows NEGATIVE. Viscosity shows “Slightly Increased”. Can fructose test negative is problem considering all above results. Also, I have type 2 diabetes for last 4 years or so, just for your information. Sample tested was 1ml.

  193. I performed semen test. Analysis shows Sperm Count – 62.6m/ml,
    Alkaline, Total Motility is 70%. Excellent forward progressive IV is 40%. Fructose test shows NEGATIVE. Viscosity shows “Slightly Increased”. Can fructose test negative is problem considering all above results. Also, I have type 2 diabetes for last 4 years or so, just for your information. Sample tested was 1ml. All blogs talks about sperm count zero and fructose negative. Nobody explains what if sperm count is normal and fructose is negative.

    1. Dear Ajay, the fructose cannot be negative in the presence of sperm. It could be low however, maybe too low for the limit of assay detection. Diabetics get low ejaculate volumes not from blockages (which fructose absence suggests) but from retrograde ejaculation due to improper closure of the bladder neck during ejaculation. Have them check your urine after ejaculation to see it this is happening.

      1. Dear Ajay, the fructose cannot be negative in the presence of sperm. It could be low however, maybe too low for the limit of assay detection. Diabetics get low ejaculate volumes not from blockages (which fructose absence suggests) but from retrograde ejaculation due to improper closure of the bladder neck during ejaculation. Have them check your urine after ejaculation to see it this is happening. My Gall bladder was removed at age of 25 as there were stones in it, almost 12 years ago. If fructose is very very low and sperm count is 62m/ml, will they be able to fertilize my wife’s egg and help me become father. Id fructose is blocked, does that mean even sperms are blocked. or they use different path during ejaculation.

      2. Dear Ajay, the fructose cannot be negative in the presence of sperm. It could be low however, maybe too low for the limit of assay detection. Diabetics get low ejaculate volumes not from blockages (which fructose absence suggests) but from retrograde ejaculation due to improper closure of the bladder neck during ejaculation. Have them check your urine after ejaculation to see it this is happening.
        To above reply
        My Gall bladder was removed at age of 25 as there were stones in it, almost 12 years ago. If fructose is very very low and sperm count is 62m/ml, will they be able to fertilize my wife’s egg and help me become father. Id fructose is blocked, does that mean even sperms are blocked. or they use different path during ejaculation.

  194. Dr. Turek:
    I am 30 years old and healthy, with no bad habits. I went with four doctors already and did several semen tests and an FNA biopsy and the doctors said I was azoospermic. They couldn’t relate it to anything in my medical history and some told me that it was common to be infertile if your mother got pregnant with you right after giving birth to a sibling (not spacing the pregnancies enough). Is this true?
    Thank you

    1. Dear Alfredo. Huh? Never heard of this “fact” before. Can’t imagine that its true!! Regarding your evaluation, an FNA map has about a 40-50% chance of finding sperm.

  195. Thank you so much for your patience in replying to all of the questions, your blog is incredible resource for any one struggling with infertility problems.
    I will try to be short. My husband has 0 sperm count, and recent Genetic test showed he has AZFb and AZFc deletions. I understand that with AZFb chances are 0 %, but we don’t have full info if deletions are partial or not. With our salaries probably we can cross atlantic and get to SF to do the FNA mapping only in couple of years, which we would still want to try if you think that is worth. So would you recommend to do FNA mapping in this situation?
    Also you have mentioned in some of your comments that you have trained some doctors in Israel, is there a specific clinic that you would recommend? Getting to Israel would be more likely.
    Thank you so much for reading our comments and replying to them !!!
    Anna

    1. Dear Anna, the likelihood that there would be sperm found on FNA mapping or mTESE with a complete AZFb-c deletion is very, very remote. There are no formally trained and certified FNA mapping physicians in Israel. Dr. Shai Shefi (Tel Aviv) is a fellow of mine but prefers mTESE to FNA Mapping.

      1. Thanks a lot for your reply Dr. Turek. We will get more detailed Genetic tests and see where we should go from there.

  196. Dear Dr. Turek,
    Please help me.
    When I was 21 I was diagnosed with Germ Cell cancer in the mediastinal. This is a type of testicular cancer that usually occur in the testes. I am now 28 years old.
    I was treated with three chemo rounds of bleomycin, etoposide, and cisplatin. Then another two rounds but with ifosfamide instead of bleomycin. I believe the cisplatin is biggest contributor to infertility.
    The tumor was then removed from my chest after chemo.
    We tried to freeze sperm one day before chemo but were unsuccessful. I wish I knew the importance of this before chemo…
    I did a sperm analysis last week with a zero count. I believe my next step is getting a second test (with requesting a centrifuge) and also a blood test to check my hormones. I’ve read that sperm production could return years after chemo but I would think seven years would be enough.
    Is a biopsy worth it or is there no hope after chemo?

    1. Dear Daniel, mediastinal germinomas are treated similar to testis cancer and testis cancer treatments are generally less toxic to sperm production than chemotherapies used for other cancers. The other good thing here is that you probably have both of your testicles as men with testis cancer have the affected testicle removed and are only running on one. Seven years is plenty of time to wait after chemotherapy. I would estimate that the chance of finding sperm on FNA mapping would be 55-65%.

      1. Thank you for the response.
        Correct, I do have both of my testicles as they were not affected by the cancer.
        Is it common to have a zero sperm count after a seven year period from six rounds of chemo?
        Is there a chance of it coming back for a natural pregnancy or would FNA mapping be an only hope?
        Any recommendations for doctors for advice/FNA mapping in Florida?
        My next step is get another SA (with centrifuge), blood tests, and start to discuss FNA mapping while doing a SA every 3-6 months.
        I know I have a few questions but any feedback would be greatly appreciated.

        1. Daniel, Yes it is common to have 0 sperm count after 6 rounds of chemo at any time. Unlikely that after 7 years after chemotherapy that sperm will return to the ejaculate. There are no doctors certified in FNA mapping in Florida.

          1. Thank you.
            I am considering making an appointment at your office. Which would be a very expensive trip for me…
            It makes since to me to do FNA mapping before a biopsy. Are you the only doctor that does it? I am just wondering where else I could have this done since going to CA would cost me so much.
            I was not able to find you on UnitedHealth Care’s website, do you accept health insurance (if it is covered)?
            For azoospermia, a person would strictly see a urologist and not a fertility doctor or endocrinology, correct?
            I am currently looking for the best local urologist for my situation but having difficulty.
            What kind of questions should I ask the office before making appointments?
            Should I also find a fertility doctor just to have SA’s performed?

  197. Dear Dr. Turek,
    you can probably tell from my email address who I am. I got my FNA mapping done by you in June this year and was diagnosed with 100% early maturation arrest with idiopathic non obstructive azoospermia.
    I’m now on Tamoxifin w Dr. Ramsay and waiting to see if it works. In the meantime, I came across this very recent research report on NEJM:
    http://www.nejm.org/doi/full/10.1056/NEJMoa1406192
    To my knowledge, the genetic profile I got done did not test for mutations of the TEX11 gene. Do you know if testing for this mutation is commercially available? if so should I get it done?
    Best,
    Faisal

    1. Faisal, great question. Dr Alex who wrote the NEJM article is a good friend. Testing for male infertility genes on the X chromosome is not routinely offered at this point, but I am sure will be offered in the future.

  198. oops – could you please delete my name from the comment i just submitted? or just delete that comment altogether and reply straight to my email? thank you.

  199. Dear Dr. Turek
    My husband was diagnosed with Azoospermia 3 months ago. His urologist found a cyst on his prostate that was causing the blockage. The cyst was removed a moth and a half ago. We just did the semen analysis again and the test show no sperm again. Do you think it was done too early ( 5 weeks after the surgery)? Also, before the surgery his semen looked normal, but now is watery, almost see through, slightly sticky. How long after the surgery we can realistically expect to see improvements? What would be the next steps in our case? After initial evaluation his doctor said he “feels” the sperm is being produced therefore he ordered more test and discovered the cyst however no test was done to confirm the sperm production. Do you think that should be done now, without waiting another couple months to see if the sperm is there and can be ejaculated?
    I feel like my husband’s doctor in not being proactive. I am 38 years old and fell the time pressure so maybe I am being not fair with my judgment. Please advise.
    Thank you very much!

    1. Dear Iwona, Great questions! Ejaculatory duct obstruction is one of my favorite things to think about with azoospermia. Responses to TURED surgery are usually immediate. Several results can occur: Increased semen volume with persistent lack of sperm; increased semen volume with sperm; persistent low volume without sperm. Your hubby is one of these. If he is the first, then he may be obstructed elsewhere. If he is the third, then yes, its time to investigate the possibility of a sperm production problem with biopsy or FNA mapping.

      1. Thank you so much for getting back to me Dr Turek.
        My husband’s semen was actually pretty normal ( volume wise and consistency) before the surgery but then changed after to become “watery” and less. Do you think something might have been damaged during the cyst removal surgery?
        I forgot to mention before that my husband has also low testosterone- 150 with all the other hormones/ tests being normal. Would you suggest any testosterone therapy to increase sperm production?
        I read differences between your mapping and biopsy and would rather do FNA mapping. We live in New York. Have you trained anybody here so we don’t have to travel to LA? Any recommendations? How much does it cost at your clinic?
        I definitely consider second opinion with you but feel we need to do more tests to have better picture before I reach out to you.
        Thank you
        Iwona

  200. Dear Dr. Paul Turek,
    We have a very difficult situation. My husband (30 years old) has a variant of Klinefelter’s syndrome – Y chromosome microdeletion, also deletions in the AZFa and AZFb regions.
    Testosterone level is normal at 410,
    but high FSH – 34.7,
    and high LH – 18.
    Also He did undergo varicocele surgery at the age of 16.
    The only types of tests that have been done on him are blood (for genetic abnormalities), physical, and semen analysis.
    Now we are considering all possibilities even thought know there is a very little chance for success. I found your article about FNA mapping. Do you recommend us to try this procedure? Or this is not going to be helpful for us.
    Thank you!
    Best Regards

    1. Dear Victoria. Great questions. Complete AZFa-b deletions are not known to have sperm by any method used to look. However, PARTIAL or INCOMPLETE AZFa-b deletions could have sperm. Consider a Second Opinion to see which one of these genetic conditions exists.

  201. Dear Dr. Turek,
    With all hopes to find peace to my mind, am sharing to you my test results and diagnosis so far.
    Please let me know what could this possibly be and what is the next step.
    I got married last year, couple of months back me an my wife started thinking about fertility issues. We got all the tests done. HSG and follicular study of my wife came back as normal. But, my semen analysis showed nil spermatozoa. Second test as well came back as ‘Azoospermia’.As advised by doctors here, i did the scans and blood tests which showed normal organ developments and high FSH (23). LH, Prolactin and testerostone levels seem normal.
    Results of the two tests are as below. Please share your understandings from these and guide us.
    From various sites, we could find a relation with infection to genital track. Liquefaction time > 1 hour, PH = 9, Pus cells = 8-10HPF, small epididymis cyst (1 * 2mm), can these observations be linked to infection?
    Also, i see a genetic connection to Coeliac disease as my aunts suffer from the same. If this can be a reason, how can we confirm it.
    Right Testis – 4.0 * 2.2 * 2.4cm
    Left testis – 3.8 * 2.4 * 2.6 cm
    Semen Analysis 1
    Color, Liquefaction, Viscosity – Normal
    Volume – 4 ml
    PH – 9
    Agglutination – Nil
    Round cells 1hr
    Reaction – Alkaline
    Pus Cells – 8 to 10 HPF
    RBC – 0 to 1 HPF
    Epithelial cells – 0 to 1 HPF
    Fructose – Positive
    Volume – 1.2 ml

    1. Dear Vyas, this sounds like garden variety non-obstructive azoospermia due to genetic (definable or not) causes. Y chromosome micro deletion testing and a chromosomal (karyotype) analysis should be considered. I highly doubt that it is related to occult infection, familial celiac disease or other issue. Although the low ejaculate volume might suggest a blockage, the high FSH takes the cake. There is still an excellent chance of finding sperm in the testicles.

      1. Thanks for your advise doctor. I am considering genetic tests asap.
        But for my sake I am still in the want of some answers. Based on my extensive enquiry, this is a first time occurrence in my family. Also i presume the sizes of my genital organs fall within the normal range and all my ultrasound reports conclude “normal study”
        I was also afflicted with malaria 4 times in a span of 3 years during my teens(if this information is of any help!)
        Hypothetically, doctor if the genetic causes are ruled out what can possibly be my diagnosis with all these available data?
        Also if sperm mapping is my only saviour
        (1)does “buying time”(by taking antioxidants for months together etc) have any adverse effects on the possibility of finding sperms during mapping?
        (2)is there any lifestyle change,specific diet I should follow before the procedure for a certain period in time??
        Pardon me for flooding ur time with my queries! Along with my current state, I also now lament the fact that I am geographically inconvenienced to have a consultation with you doctor.
        Eagerly awaiting your reassuring replies(I hope),
        Vyas

      2. Dear Doctor Turek:
        I am an MD in family medicine practicing in Pakistan.
        My recent bloodwork and semen test, revealed Azoospermia. I am 40 years old with no known health issues except this new revelation of Azoospermia. My wife is very healthy and younger than me.
        Serum FSH
        23.10 ml
        Testosteron
        2.44ng/ml
        Prolactin
        25.13ng/ml
        Monomeric Prolectin
        8.18 ng/ml
        L.H
        11.97 mlU/ml
        Me & my wife desire to have a successful conception.
        I request you to please advise me some regimen to achieve a successful conception.
        Sincerely
        Dr Zad

        1. Dear Dr. Zad, You have non obstructive azoospermia with high FSH and borderline T and compensated (high) LH. I would suggest getting checked for genetic infertility (Y chromosome deletions, karyotype) and consider a highly expert semen analysis and pellet assessment for sperm (10% chance). After that, you have the choice of testis biopsy, FNA Mapping or microTESE to see if you have testicular sperm that could be used for IVF-ICSI. Be careful making this decision, however, as microTESE has the highest chance of lowering your natural testosterone levels to the point of needing testosterone replacement for life.

    2. Thanks for your advise doctor. I am considering genetic tests asap.
      But for my sake I am still in the want of some answers. Based on my extensive enquiry, this is a first time occurrence in my family. Also i presume the sizes of my genital organs fall within the normal range and all my ultrasound reports conclude “normal study”
      I was also afflicted with malaria 4 times in a span of 3 years during my teens(if this information is of any help!)
      Hypothetically, doctor if the genetic causes are ruled out what can possibly be my diagnosis with all these available data?
      Also if sperm mapping is my only saviour
      (1)does “buying time”(by taking antioxidants for months together etc) have any adverse effects on the possibility of finding sperms during mapping?
      (2)is there any lifestyle change,specific diet I should follow before the procedure for a certain period in time??
      Pardon me for flooding ur time with my queries! Along with my current state, I also now lament the fact that I am geographically inconvenienced to have a consultation with you doctor.
      Eagerly awaiting your reassuring replies(I hope),
      Vyas

  202. Hello,
    I am a 29 year old male in the UK and I was diagnosed with Azoospermia at the start of this year. There was zero sperm in my ejaculate.
    I had various blood tests for hormones, cystic fibrosis, ultrasound on testicals and the Dr informed me that everything was at the normal levels, except my prolactin levels were high. They re-tested my prolactin levels and they were lower than the first test but still higher than normal for a male. I was advised that Surgical Sperm Retrieval would have a 60-70% chance of finding sperm that could be used in IVF/ICSI.
    I had SSR last week (I think it was TESE) under general anesthetic. They took a biopsy from each testicle, the right one showed no sperm. The left one had no mature sperm. The DR advised he was confident they would find sperm and checked himself but confirmed they would be no use for ICSI / IVF. They also said the tissue was fibrous which isn’t normal?
    They couldn’t give me an explanation why I don’t produce sperm.
    I would be interested to hear your thoughts on the above? Sorry I don’t have the exact results like other people but I was told everything was normal except the high prolactin levels.
    What are your thoughts on this?

    1. Dear C, you must certainly have that azoospermic feeling at this point. About 1/3 of NOA cases have an identifiable genetic cause (Y chromosome deletion or other chromosome issue). Much of the rest is also likely genetic but we just don’t know enough about the genetics to say exactly what is causing it. Depending on how extensive your TESE procedure was, there could be a 15-40% chance of sperm on more extensive sampling, either by FNA mapping or mTESE.

  203. My husband (age 35) was recently tested after long suspecting he was infertile, and had a zero sperm count. Considering his blood test numbers below, I think it is likely more genetic than blockage?
    FSH value <0.7 std rng 1.6-8.0
    LH value <0.2 std rng 1.5-9.3
    SHBG value 8 std rng 10-50
    He tested very low for testosterone (free and total), but I don't have the exact numbers. He was also late to start puberty (16-17yo), though otherwise appears developed normally.
    We are just beginning to try and figure this out, but if it is genetic with these numbers, is there any reasonable likelihood that sperm could be found or treatment had to boost production?

    1. Dear SM, most cases of non obstructive azoospermia are genetic in cause but are characterized by normal T and high FSH and high or normal LH. Rarely, it can be characterized by having low T, low LH and low FSH and this is termed Kallman syndrome. The good news is that by treating with LH (hCG) and FSH over a 9-12 mos period, sperm counts can be generated in excess of 90% of men and natural pregnancies are not uncommon. Be happy to help manage this. Contact us if you like.

  204. Hello Dr. Turek,
    How are you? I hope are you doing great!
    I don’t know if you remember me or not but I wrote to you on another of your blogs a few weeks ago. But here are the results:
    Me:
    31 years old
    Healthy male
    NOA- Azoospermia
    Y chromosome Deletion AZFb complete (Done in NYC)
    My brother
    33 years old
    Healthy male
    NOA Azoospermia Y Chromosome Deletion AZFb complete (Done in NYC)
    He had his first Y chromosome analysis before and that one came out as a non continues partial deletion AZFb (done at lab corp)
    Dr. Turek we are definitely feeling that “Azoospermic feeling” and and we wonder how can the exact problem (Y chromosome deletion AZF b complete) happen to both of us? Since this was suppose to be “de novo.” Our dad had a total of 6 children, my brother and i with my mother, and then the other four with a different woman. Two of my half brothers are already fathers.
    My brother and I are wondering if there’s any hope for us? Perhaps a second opinion at your clinic? So many things going around our heads right now that we would be willing to make any effort even it means that it would only serve as research purposes because this “Azoospermic feeling” is not a pleasant feeling. Thanks hope to hear from you.

  205. Hi Turek,
    I am NOA patient , whenever I do semen analysis I get one or two dead sperms …. This Time I got one dead abnormal sperm with clear head ….. surrounded by many round shaped …. Is it spermtids ? …. If this is spermtids what next for me …. Is it possible to convert to getting some sperms in semen with lifestyle changes and treatment ? Everything normal except I had orchitis in childhood.

    1. Dear Gow, Cryptozoospermia is the find of small numbers of moving or nonmoving sperm in the ejaculate. It is bad news in that natural fertility is much harder than if normal sperm numbers were present but it is good news because this means that there must be a pocket of sperm production somewhere in the testicles. We have published on the use of fresh and frozen cryptozoospermic semen samples for IVF-ICSI and, because of this, I believe in this sperm…if you can get motile ones and enough of them. One can also consider improving sperm production by improving lifestyle issues (eat well, lose weight, stop smoking and hot baths etc) and medically ‘optimizing’ the patient with varicocele repair and possible hormonal treatments. If all else fails, FNA Mapping is an excellent way to locate the sperm pocket in the testicle for use with IVF-ICSI.

  206. Hi
    I’m from Africa,my husband is 35 years old and 5 years ago was diagnosed with non obstructive azoospermia after undergoing testes biopsy. He has had a history of Hodgkins hypsertension between the ages of 7 – 8 years old.
    Would FNA mapping be an option in finding sperm?
    What are the chances of success?
    Would it be possible if I could send you a copy of the biopsy results as well as blood results for a second opinion?
    Thank you for your valuable time.

    1. Mrs A, Great question. Yes, FNA mapping has a chance of finding sperm in the setting of Hodgkins disease and treatment even with testis biopsies not showing sperm. Hard to estimate chances but it might range from 20-30%. Be happy to review records using the Second Opinion format. Can include actual biopsy slides as well.

  207. Hi Turek,
    I have great question for you ….. Everything Normal in my case but I am NOA patient …… I noticed I have gynecomastia , Lack of Muscle mass but sex libido is good …. Is this sign of Primary testicular failure ? … I had childhood Orchitis ….. Once I got 3 to 4 Dead sperms six months ago ….. Have u faced this scenario ? Have you got sperms with cases like me ? …. Is it possible to improve sperm production with this type of cases or Is it possible to find sperm in FNA mapping

    1. Dear Vi, Gynecomastia can indicate very low T which is a sign of testis failure, or very high estrogens which can be from various other causes. Having childhood orchitis is a classic cause of testis failure. With this history, we can find sperm in up to 70% of men with azoospermia. Bust since you have had sperm in the ejaculate (cryptozoospermia) that rate is even higher!

  208. Hi Dr,
    I wrote before about my husband but wanted to follow up. He’s been diagnosed with azoospermia. All testes aside from fsh are normal. Fsh is 12, then jumped to 22 testosterone is normal but on the lower side within the range (12). All samples aside from 1 showed 0 count. Sample in December 2015 showed 10,000 dead sperm. He had tesa done in January 2016, no sperm were found. He then had mTESE in June 2016 and no sperm were found. Samples from mtese were sent to the lab and they didn’t find anything but gave diagnosis of sertoli cell only. Doctor said he took a sample from each quadrant of both testes.
    Not sure what else we can do to find sperm? Where did the 10,000 come from that he had in previous sample? What are the options and chances for fna mapping finding sperm?

    1. Dear KJ, Wow what a story. And what’s up with that teaser semen analysis? Clearly, having had ejaculated sperm at some point means that there must be a site of sperm production in the testis. And that can present a real challenge to find, using any technique. Yes, FNA mapping is an alternative for you at this point, and in our latest published work, we found mature sperm in the testis on FNA mapping in 78% of men with cryptozoospermia of which about 50% had TESE/mTESE procedures between the finding of ejaculated sperm and the FNA map. A 6 mos wait is mandatory, though, to allow full recover after the mTESE procedure.

  209. Dear Dr. Turek,
    my husband (34) and me were trying to conceive a few months. About 14 days ago he was diagnosed with azoospermia. The test was repeated twice with the same result.
    His Hormones (T, LH,FSH,Prolaktin) were all normal. FSH was about 4.
    Since his brother has the Klinefelder Syndrome he already did a semen analysis back in 2009. That time everything was ok. Total sperm count was about 80 million. Therefore the doctor said that he doesn’t have the same.
    Now we got married and tried to conceive and are so shocked that he has ZERO sperm. Ultrasound was normal too, as well as normal sized testicle.
    What can this be? Could it be a genetic cause? It is hard to believe that because why would he have a normal sperm count 7 years ago if it’s genetic?
    No infections, chemotherapy or injuries have occured to think of an obstruction.
    Only thing he had a cold or flu 2 months ago. Can that cause a temporary azoospermia?
    We are really shocked and can’t thing of any reasons.
    Your advice is much appreciated in this hard time of ours.
    Best
    P.A.

    1. Dear P.A. Agree! This is strange and definitely needs an explanation. Acquired causes of azoospermia are possible and are most commonly due to infections or trauma. However a bad flu can also cause temporary azoospermia, as can hot baths and other high-level acute metabolic insults. Definitely repeat the semen analysis after 6-8 weeks and see whats up. I have a feeling that he is headed back to normal…Call me if he doesn’t.

      1. Dear Dr. Turek,
        thank you so much for your reply. We hope it will be normal in a few weeks and we try not to loose hope. In this blog i read about maturation arrest. That was something where the Hormone Levels were normal. I really hope it isnt the case but do you think maturation Arrest could occure to someone who had normal sperm account years ago?
        Regrettably my husband didnt check his temperature when he was ill. But he says it started with a Cold, then a bronchitis and coughing strong for 2-3 weeks. He felt feverish too. If it is due to that only i will be the happiest person. But to be honest i cant really understand why not even one dead sperm comes out then.
        If in 6 weeks its zero again we will definately call you.
        Best
        P.A.

  210. Hi Dr. Turek! I’m hoping you can give us a word of advice or something! About 5 years ago, my husband had woken up with extreme pain in his testicles. He went to a urologist, who sent him home with pain pills and basically said he couldn’t find anything. Husband never went back as the pain had went away.
    Just before that, we were trying for our 3rd baby, and after trying for 4.5 years, we decided to finally try for some answers. I had an hsg done, and was all clear. He had a SA done at the same time, and it came back zero. So he got a new urologist and started seeing him. They did a pellet test there, and it was also zero. He then had blood work (all of which was aways just above normal), and an ultrasound, which revealed one slightly swollen testicle, and one smaller, misshapen one. I can’t remember which sides were which. He then had a biopsy, in which they took 2 samples from each. Results came back with only Sertoli and leydig cells. He had pre cursor cells but no spermatids. I think that’s correct wordage lol. They told him that basically he had to have some sort of trauma and his body shut down sperm production. And that the smaller side wasn’t doing anything and would probably need extracted in time.
    I can’t imagine that both testicles are still there, one is working away at producing testosterone and everything else, yet it cannot begin making sperm again? Please give us some sort of hope! We have started loading him up on all the necessary vitamins and he started fertil aid capsules, and we plan to try some herbs in the meantime. And lots of praying. Any advice for us would be SUPER appreciated. We are devastated.

    1. Dear Melissa, Wow, You have two kids, no problem and were trying 4.5 yrs for a third and hubby is azoospermic? Clearly SOMETHING happened in between. Either he had normal semen quality before and now developed a blockage (maybe related to the pain), or he was always teetering around a low sperm count and it went to zero recently. This is quite typical for a varicocele. The biopsy results would suggest the latter, which is quite common with genetic infertility. I like the approach you are taking which is to make sure that he is eating healthy but I would think that genetic testing and an FNA Mapping procedure would help figure out whether he has any testicular sperm for another child (with IVF-ICSI…)

  211. Hi dr paul …. iam really exhausted and confused I wrote you my condition that involved undescended testicles that I had done at age 20 therefore zero sperm in the semen but found in the semen rare spermatids and spermatocytes …. had an mtese but it came out with sertoli only…. and I only have one testicle that I could operate on and the doctor told me that I only have one other chance for mtese due to the small size of my testicle … then I read about the kallistem sperm. … I dont know whats the next step for me

    1. Dear MM, You have been through a lot, but the bottom line is that there was no sperm on the mTESE, regardless of what cells were thought to be in the semen. Agree also with the issue that repeating an mTESE operation might be risky to the solitary testicle’s ability to make normal amounts of testosterone in the future. Although you could consider FNA Mapping, which is far less risky to testis health, to see if it could find sperm, that likelihood is <10% (Mapping works better in mTESE failures with maturation arrest biopsy pattern). You should call Kallistem and talk with them directly regarding where they are with things. My take is that to make sperm for men in the future, they will require spermatogonial stem cells from the testicles to start and it doesn't appear that you have them.

      1. Thank you Dr Paul, so you’re opinion is that I should consider having FNA mapping which holds a 10 % success rate for me … I mean I thought that there maybe pockets of sperm elsewhere in the testicle

  212. Hello Dr Turek,
    J.S here. I was at your office July 11, 2016. Hope all is well, I wanted to share this article with you. I’m pretty sure you read this already but I wanted to know/ask you if you know if this is a real article or not? Thanks.
    http://www.urotoday.com/recent-abstracts/men-s-health/male-infertility/90417-complete-azfb-deletion-of-y-chromosome-in-an-infertile-male-with-severe-oligoasthenozoospermia-case-report-and-literature-review.html

    1. Dera Mr JS, well there you go! I knew about a case of complete AZFb Y micro deletion from Brazil who has sperm too. This makes sense as drawing conclusions from small case numbers in the field of genetics to backfire at some point. So this means that there is some hope for sperm in men with AZFb deletions. The question is whom?

      1. Yes, as I mention to you when we spoke, my full blooded older brother has the same exact deletion as me, he hasn’t done Mapping yet to see what he has but from what he says is that he will reach out to your office in the very near future. I’m sure he would want some type of closure (if no sperm is found)while we wait for technology in the very near future. Do you see maturation arrest having a cure in the very near future, 2-5 years maybe?

  213. Hi Dr. Turek,
    we have spoken on the phone a few weeks ago and i wanted to update you to some more information.
    My husbands genetic results came back. Klinefelter is negative as you predicted. Also no AZF Deletions. So genetically everything is ok.
    He did another sperm test. Zero again.
    This time Inhibin B was tested too (175 ng/l)
    FSH 3,4 IU/l
    LH 3,4 IU/l
    Testosteron 3,97 ng/ml
    The doctor assumes an obstruction since his hormones are normal and he had normal sperm count 7 years ago.
    Therefore the Alpha Glucosidase was tested which is 15,61 mlU/ml.
    He said this is normal so the obstruction is not epididymal. He assumed an obstruction in the vas deferens.
    My question now is is it likely to be an obstructive azoospermia? Because I read if its obstructive then Alpha Glucosidase is low. It is also low in men with vasectomy. But his result is normal. Wouldn’t this mean NOA?
    Also 2 doctors said if it’s not known where the obstruction is it is not possible to do surgery. Other 2 doctors say it is possible. We don’t know what to believe and hope for your opinion.
    And why doesn’t sperm come out if obstruction is one sided. If its obstructive then it must accured naturally for no reasons. Why should it be both sided? I don’t understand this.
    Sperm volume is 4,4 ml. So I assume no obstruction in the ejaculatory duct.
    Thank you in advance Dr. Turek
    Best regards
    P.A.

    1. Dear PA, please realize that online public forums like this are no place for care! Normal volume azoospermia is either a blockage (has to be bilateral, I agree) or no blockage with testis failure due to maturation arrest. A testis biopsy or FNA mapping are two of the best ways to tell the difference.

  214. Hello doctor, we would be grateful if you could help us. My husband (33 y/o) and I (26 y/o) are trying to conceive for one year now with no luck. Therefore, my husband did a SA test on 3rd of August and the results came back with no sperms!! He did another two SA and all came back with the same results! He did then hormones test and all came back normal except FSH was high. He olso did ultrasound. Here are his Blood test results:
    FSH: 22.33 mIU/mL
    LH: 7.1 U/L
    Prolactin: 14.9 ng/mL
    Testosterone: 356 ng/dL
    I’ve also attached his SA results. Our Urologist did not help us and all what he said is that we need to look for a fertility specialist! We are really lost and we don’t know what to do next! What could be the reasons behind high FSH and normal hormones level! Could proxeed plus help him ? And is T level normal or low for his age?

    1. Dear Nora, So sorry about the news. Good to see you reaching out and educating yourselves about non obstructive azoospermia. This field has gone well beyond what most general urologists feel comfortable doing. I would recommend seeing a reproductive urologist who can have the answers to all of your questions. Contact us if you want us to take care of you!

  215. Hello Dr. Turek,
    I had conversation with you about my husband’s case in this blog previously. My husband had done three SA and all of them returned zero sperm and he did FNA mapping in Seattle where they put 12 needles in each testicles but sadly they couldn’t find any sperm or sign of sperm production. The Dr. said my husband could be born with out sperms. He said the reason couldn’t be known. I want to check if you have different perspectives about what could be the reason and if there is any hope at this stage.
    Thank you for your help.

  216. Hello Dr. Turek,
    I had conversations with you about my husband case. He is 41 and did three SA and all of them return with zero sperm. The result of all the hormone and blood tests was normal. He did FNA mapping in Seattle where they put 12 needles in his each testis but sadly the result doesn’t show any sperm or indication of sperm production. The Dr. couldn’t tell the reason. he said this could be natural meaning my husband could be born with this problem. I want to check with you if there could be any hope for having biological child at this stage.

    1. Dear Dafas, that is not great news. FNA mapping in Seattle is done by a fellow whom I have trained and who is very good. You should consider alternatives at this point, sad to say.

  217. Hello Dr. Turek,
    Mr J.S here. How are you? I hope all is well. I was reading about Kallistem and it seems like they are making some process with their technologies which eventually will help patients like me with maturation arrest. How realistic do you think their technologies would come into a reality and what time frame do you give it, in your opinion? I’m guessing if this does ever come a reality, it would help so many men like me and others.

    1. Dear JS, Maybe they can help and maybe they cannot. Kallistem will require a normal spermatogonial stem cell to make sperm in the future (You need to ask them when that might be). However, if there is a genetic cause of the maturation arrest, then simply doing it somewhere else outside the body may not help. Germ line protein therapy, such as we have described, may also be necessary.

  218. Dr Turek,
    Hello from Canada. Thank you so much for all of the information you’ve shared on your website and on youtube!
    My husband has been confirmed azoospermic after 2 semen analysis. Blood work shows FSH, testosterone, and LH all within normal range. Our family doctor did a physical exam of his testicles and according to her everything feels and looks normal. We have our first appointment with the urologist in one month.
    I am hoping it’s an obstructive case since this would be the best case scenario from what I’ve read. He had 2 surgeries as a child for inguinal hernia. First time was on one side, and second time was on both sides. What do you think the chances are that they could have done damage that is causing an obstruction as an adult??
    Would love your opinion based on experience. Thank you so much!!
    H.J.

    1. Dear HJ, generally the higher the FSH, the more likely that an obstruction is not present. Typically the acceptable FSH range for “healthy” men is 1-18, but the acceptable range for “healthy fertile” men is 1-8. There is still a great chance for sperm though, as FNA Mapping can find it in about 60% of cases.

  219. Hi Dr Turek,
    I just wrote you about an hour or so ago. I stated in my comment that my husband’s hormone levels were within normal range. Well this is what we were told by our family doctor based on the normal ranged as defined by the lab. Now reading through all of your replies it looks like they are not normal after all ! 🙁 I am now in panic mode, here are his numbers:
    LH is 2.6 (lab says range should be 0.6 – 12.0)
    FSH, 11.8 (lab says range should be 1.0 – 12.0)
    testosterone 10.21 (lab says range should be 8-32)
    Does this mean we are definitely dealing with non-obstructive?

  220. Dear Dr. Turek,
    I am a 30 year old male who has been recently diagnosed with Azoospermia. So far, I had physical examination, two semen analysis and two blood tests completed as part of my testing. In my physical examination, my family physician has informed me that everything looks and feels good. The only thing she said she found was some varicocele on my left side. (I am also slightly bigger on my right side). Below are my blood test results:
    Blood Test #1 (collected at 3pm)
    LH 2.6
    FSH 12.0
    Testesterone 10.21 nmol/L (~294 ng/dl)
    Blood Test #2 (collected at 8am after a long night with little sleep)
    LH 2.7
    FSH 11.8
    Testesterone 9.62 nmol/L (~277 ng/dl)
    In terms of my patient history, when I was 7 I was diagnosed with hydrocele on left side and had a surgery through my scrotum. At the age 10, I was told that the first surgery wasn’t successful by another physician, and I was suggested to have surgery on my both sides this time. My surgeon’s logic was “typically if you have it on one side, you may end up getting it on the other side. We may as well do both sides while you are under anesthesia”. The 2nd surgery was completed through incisions that are about 2-3 inches on both sides of my lower abdomen (not through scrotum). I am not sure if mesh was used or not. Also a number of years ago, my girlfriend at the time was diagnosed with chlamydia and her and I received antibiotics (one dose, two or four pills, I can’t remember the exact amount). Lastly, I have hashimoto thyroiditis. There was a small period of time when I had a nodule on my thyroid that I had to use some pills for (when I was 15-16). The nodule was gone with the treatment and since then, I do regular blood checks and ultrasounds however I am told I don’t require to use any medication for it.
    To your experience,
    1. does my medical history play a role in my elevated FSH? (hyrocele, varicocele on one side, hernia repairs, hashimoto thyroiditis)
    2. in your experience, what are the chances of my condition being obstructive vs. non-obstructive?
    3. what should be approach in further testing and treating my condition given the history I have provided?
    Thank you,
    B.G.

    1. Dear BG, this is complicated. However, hydroceles or their repair typically do not lead to testis failure (it is likely to be non obstructive with an FSH above 8). If the hydroceles were actually repairs of undescended testicles, then this could be the cause of azoospermia. Genetic causes must be considered (Y chromosome and karyotype) as STDs and thyroid issues are very unlikely as well.

  221. Dear Dr. Turek,
    I write you because my wife and I are devastated after the result of my biopsy in June 2016, and the journey is getting pretty hard. I still have some faith, as this is the last thing a person should lose…
    I have NOA, in particular Sertoli Cell Only Syndrome. My wife and I started our journey in Jan 2016 and after different semen analyses they conduct a TESE back in June 2016. Unfortunately the doctor did not find any sperm.
    However in the first sperm analysis, and after pellet analysis they found 6 non-motile sperms! This give me some hope (my wife is completely devastated and thinking to move forward in terms of adoption, etc). Is it a sign that some kind of spermatogenesis is taken place?? Kindly please please advice.
    My wife had mumps six years ago, but I was isolated and with no apparent signs of getting infected?? Apart from that I suffer when I was a kid and until I was a teenager from problems of high fever due to flu, bronchitis, asthma, etc. Could be this a reason for the SCOS? I read something about Young syndrome or Kartagener syndrome?? But this should have come up in the genetic test that was all OK, correct?
    Here are my medical results:
    -First spermiogram (March 2016) counted zero sperm. However after pellet analysis (sample centrifuged) there were 6 non-motile sperm in it. Unfortunately they were not frozen!…Second spermiogram (May 2016) counted zero too but there were no non-motile sperm in it.
    -First hormone analysis: FSH value was higher than normal (19,1). Second FSH analysis was also high (18,5). All other hormones like TSH, T4, etc were tested. TSH were higher (5,98) and I started taking Eutirox in June 2016. Now is back to normal (even lower than normal values – 0,02). I do not know if TSH could have some influence on FSH, etc?
    -Microdelection cromosome Y was all negative. Genetics no problem at all.
    -Ecography on testis was all OK. Therefore no varicocele problems etc.
    -TESE clinical report result: SCOS. We went to another doctor here in Spain who conducts mTESE, and he informed us that the probabilities with SCOS to find sperm are very low (around 10-15%), and that I should wait at least 6 months (better 1 year) that all the testis are back to normal (no internal bruises). He advised to do some additional sperm analysis, first now in December 2016, as he found few cases where some sperm pockets were active. Also he adviced that the non-motile 6 sperm found in March could possibly give us some little hope??
    -After the final clinical result (SCOS) and our visit to the doctor specialized in mTESE, I started taking supplements of vitamin (Vitamin A, B, C, selenium, Q10, Androferti, etc) and homeopathic medicines to give it a chance before the mTESE.
    Due to the anxiety, and my constart research on internet, I did another hormones test (November 2016), where tested also Inhibin B and AMH. The results are as follows:
    FSH: 18,7 (max: 12,5). Other test I did in October (because of the thyroids) showed 18,5 with max value: 18,1??
    LH: 11,53 (max: 8,6)
    Prolactine: 13,48 (max: 15,2) – OK
    TSH: 0,02 (min: 0,27)
    T4 free: 2,34 (max: 1,7)
    Testosterone: 4,32 (max: 8,36)
    Inhibin B: 15 pg/ml (min: 25; max: 325)
    AMH: 7,81 ng/ml (1,4-11,6)
    Do you think that we really have a little chance to find some sperm with mTESE, and any hope by taking the supplements (taking into account that this is a NOA)?
    FSH has been only been reduced one point, from 19 to 18 (in less than 6 months). AMH is ok within the range, but Inhibin B is prettly low. I have read that inhibin B could be more important than FSH in patients with NOA. Still it is said that FSH needs to be tested. The fact that inhibin B is not zero could give us some hope that some little spermatogenesis takes place, and therefore a chance to find sperm by carrying out mTESE?
    Should we wait 1 year or by contrary should be conducted the mTESE beggining of next year?
    Kindly please advice what to do, as we are depressed and very anxious due to the waiting period and the little hope because of the non-motile sperm found.
    Many thanks indeed for your time and valuable experience! Looking forward to hearing from you.
    Have a nice weekend.
    Kindest regards.

    1. Dear Carlos, you have many good questions. The single most encouraging news in all of this was the finding of nonmotile sperm in the pelleted semen sample. That means that there must be a focus of sperm production in the testis. The problem is finding it. In our experience, FNA mapping finds pockets of sperm in 78% of men with cryptozoospermia. However, in that group of men, almost HALF had prior TESE procedures between finding the sperm and seeing me. This sounds genetic to me, and entirely unrelated to past health issues (thyroid, fevers).

      1. Dear Dr. Turek,
        Many thanks really for your prompt and encouraging reply. I hope it still exists some hope for my wife and I…
        Let me ask you some questions as I am not fully clear on that:
        1. Does it mean that having nonmotile sperm in my first spermiogram I suffer from cryptozoospermia and not NOA (SCOS) as the doctor told me?
        2. The fact that a TESE was already carried out on my testis, means that the chance now to find sperm by doing FNA mapping could be lower (material on my testis has been reduced)?
        3. Is 78% the real probability altough I suffer from Sertoli Cell Only Syndrome (SCOS)?
        3. If FNA is conducted by you in USA and therefore testis map is obtained, could the sperm retrieval (TESA, TESE or mTESE) & IVF-ICSI be carried out later on when my wife and I are back in Spain? I asume we do not need to stay in USA to carry out the whole process? I saw your video and I understood that the waiting time is 1-3 months, correct?
        4. Is nonmotile sperm viable to carry out an IVF-ICSI and achieve pregnancy? I learnt from your video that the motility is increased in 5-10% (NOA) after 24 and 48 hours respectively..
        5. Any comments about the fact that my inhibin B is low (but out of range) and AMH is in the range?
        Many thanks once again and looking forward for your reply! Let me wish a nice week.
        Kindest regards.
        Carlos.

  222. Dear Dr. Turek,
    I have azoospermia. The specialist wants to do a testicular biopsy, rather than taking it from the epididymis. I have normal testicle size, FSH 5.8, LH 4.1, testosterone 16.5, normal facial hair etc. Swollen epididymis around 1cm in diameter, which has mild burning often. Would it not be better to try PESA first?
    Thanks,
    Craig

    1. Dear Craig, It might be better to look for PESA sperm. However, if obstruction is suspect, why not consider a biopsy to show that its true and then consider a reconstruction procedure to reconnect the blockages and try to have kids at home. I am not a big fan of PESA procedures as they tend to scar the caput epididymis and make microsurgical reconstruction much more difficult.

  223. Husband and I conceived naturally three different times in 2012-2013. First two pregnancies resulted in miscarriage and third produced a beautiful, healthy, brilliant, now 2 1/2 year old son.
    After trying unsuccessfully for baby #2 for an extended period of time, we moved on a fertility clinic. As I was about to start IVF medications next week, husband’s semen sample results came back azoospermic. We suspect blockage due to repeated episodes of epididymitis since childhood as well as a bout of chlamydia since conception of baby #1 (we share healthy, committed, non-monogamous marriage).
    Husband’s immediate reaction is to just be grateful for our one child and stop trying due to his fear of surgery, general anesthesia, biopsy or anything going “in” to him.
    Can an ultrasound or some imaging be done to confirm healthy sperm in the testes? Can you point me to more information about microsurgery and how painless and easy it can be? Or testicular sperm collection for IVF? Or anything else to assuage husband’s physical fears?
    We’re located relatively near your Beverly Hills clinic the San Gabriel Valley and, after a second semen analysis and appointment with my fertility doctor in Pasadena, it looks likely that we’ll be consulting personally with you! As our son–and we!–are getting older every day, I’m anxious to make a plan to solve this problem and move on with baby #2 as soon as possible.
    Thank you for any advice or links to more information.

    1. Dear Jenny, typically when a man has a sperm count (as clearly your husband did as evidenced by paternity) and then is diagnosed with sterility (!), there really must be an explanation and often a cure. You are very unlikely to get your husband to move forward with procedures to figure out what’s happened, but I am pretty good at that and do not like to hurt men (I make more friends that way). A visit with me would be great.

    1. Dear Jass, set up a call to talk about the details and read, read, read! A high FSH does not mean that you and your partner can’t have a baby!

  224. Hello Dr Turek,
    Approx how long do you think it would be until we have a solution for male infertilty? Such as the artificial testicle you were working on and others? The demand for this cure is in high numbers. I know Kallistem is working on it and others but why not more institutions in the USA doing the same? Like they say, the more the better.

  225. Hi Dr. Turek
    I did a SA after TTC for 2 years and it came back zero. I also did a blood work testing for FSH/LH (7.4/4.2), Y-microdeletion (neg), E2(12.1), T/f-T (514/11.6), semen volume (5.5). The specialist wants to do a testicular biopsy to check for sperm.
    Can you give me your opinion as to whats the best way to approach this problem at this time? (FNA mapping, another SA, etc)
    Based on the information given can you tell if its obstructive or non-obstructive?
    Thanks a lot in advance.

    1. Dear Mario, It is very difficult to tell whether this is a blockage or testis failure, so some form of procedure is needed to know for sure. A biopsy is OK with a 30% chance of finding sperm if no blockage is present and 100% if it is. FNA Mapping is 60-100% without the need for an incision.

  226. Dear Dr. Turek,
    I have been diagnosed with azoospermia and my tests results as per below:
    FSH = 11.8 IU/L
    LH = 2.6 IU/L
    T = 10.2 nmol/L (~295 ng/dl)
    No genetic abnormalities including karyotype & y deletions (Aza, AZb, AZc)
    Biopsy = SCO
    Given above I would like to ask you:
    1. Is my T, and LH within normal limits? Do I need medication to improve my chances of producing sperm?
    2. Is there any correlation between biopsy and FNA mapping results? What are the chances (%) of finding sperm with FNA mapping given SCO and no genetic abnormalities?
    3. What are the risks, and potential damages associated with FNA mapping? And also what are the chances (%)?
    4. Is there an error rate associated with FNA mapping? In other words what are the chances of finding sperm post positive FNA mapping results? what are the chances of finding sperm post negative FNA mapping results?
    5. Is there a duration post biopsy (completed in Jan ’17) I am required to wait before mapping?
    6. How long of a trip do I (and my wife) need to plan in LA to complete the mapping in terms of days? We will be flying in from outside USA.
    We are very eager to make a decision on my care plan very quickly. Thanks in advance for helping us out…

    1. Dear Bob, Your hormones are fine for finding sperm. Improving T balance may or may not help make sperm in the setting of Sertoli cell only. If you had a maturation arrest phenotype, then, yes, I would aggressively push the hormones. The chance of finding sperm with FNA Mapping depends more on how many biopsies you had than what was found on them. I would estimate that the chance of finding sperm with single bilateral biopsies showing no sperm to be 30-35%. I do not have a complication “rate” with mapping. In 2000+ cases, no infections, no bleeds, 2 small cord hematomas, no chronic pain, no lowering of testosterone levels, 4 cases of hematospermia (single events). Quite quiet in this regard. So far out of 66 known cases in which negative FNA maps underwent subsequent mTESE procedures, no one that I know of has found sperm around the world. That would mean that FNA Mapping is associated with a 1-2% false negative rate. I would wait 6 mos after a biopsy to consider FNA Mapping. Let things cool off down there. You will need a two to three day trip. You can leave the day after mapping if needed, but tour the California coast before going home! Great questions!

      1. Hi Dr. Turek,
        Thank you for your quick and informative reply. To clarify, my biopsy was from right side (not bilateral) so maybe that will increase my overall chances for positive results via FNA mapping by another 5% (?).
        Re: the wait times, what is the wait required in between FNA mapping and mTESE (assuming FNA mapping provided positive results)? Is it another 6mos?

        1. Dear Bob Sure, increase it by 5-10%. The wait between FNA Mapping and TESA/TESE/mTESE ranges from 1-3 months, depending on the findings.

  227. Hi Turek,
    What are the risks, and potential damages associated with mtese after FNA mapping , please explain as per your wonderful experience

    1. Dear Murthy, I have few complications doing mTESE after FNA mapping, generally because 50% of men DO NOT NEED mTESE (just something simpler like TESA or TESE procedures) after FNA Mapping and when mTESE procedures are needed, 1/4 involve bilateral (both sides) procedures. So, after FNA mapping fewer men need mTESE and even fewer need it on both sides. My complication rate is very, very low: <1% hematoma; no chronic pain, no infections after n=400 cases. There is a chance of low testosterone levels but this is <5% as most men only get one side done to get enough sperm for multiple IVF-ICSI cycles.

  228. Dear Dr Turek,
    I have azoospermia. I had bilateral orchidopexy and inguinal hernia repair as a child. My blood test results in December 2016 were FSH 5.6, LH 2.6, Testosterone 16, SHBG 60, Oestradiol 102, Prolactin 229, Karyotype 46XY and Cystic Fibrosis mutation negative. I had a testicular ultrasound in Dec 2016, which showed normal size testicles, but chronic orchitis on the right side and normal appearance of the right epididymis. Normal appearance of the left testis. Ductal ectasia noted in the rete testis. The left epididymis is thickened and mildly hyperaemic in keeping with epididymitis. I completed a course of antibiotics and I have had antibiotics 3 times in my life prior to this for epididymitis. Recently I had a PESA retrieval on both sides, which did not find any sperm. The doctor wants to perform a multifocal TESE.
    What is the success rate based on my hormone levels? Are my hormone levels normal? Is there any way of reversing the damage done by the epididymitis? I am worried that if I have TESE, it will damage my testicles and lower my testosterone. Also, is there any way of halting or reversing the damage caused by chronic epididymitis? I don’t want my testicles to be destroyed by the epididymitis/orchitis.
    Many thanks,
    Craig

    1. Dear Craig, this is a complicated and rare case, so advice over the internet may not have real value. Epididymitis is quite common in young men but orchitis is very rare. I have never seen the diagnosis of orchitis made on ultrasound alone. If you are worried about testicular destruction by inflammation, then a sperm retrieval is a reasonable thing to do.

  229. Good afternoon Dr. Turek,
    My husband was recently diagnosed with non-obstructive azoospermia. He has one testicle due to testicular torsion during labor. One testicle was removed and the other was tacked down to prevent future torsion.
    We had the following hormone profile after 2 zero count semen analysis (zero count after pellet analysis)
    FSH = 2.9 IU/L
    LH = 1.7 IU/L
    T = 164 ng/dl
    Estradiol = 40 pg/ml
    No genetic abnormalities including karyotype & y deletions (Aza, AZb, AZc)
    Fructose positive semen analysis
    He was prescribed Clomid and Arimidex to increase FSH and Testosterone, as well as decrease Estradiol. After a month of these medications, FSH= 11.0, T=631, Estradiol = 37.7. He will continue on these medications for another 2 months then do another semen analysis. If the semen analysis is still zero, a biopsy will be performed.
    My question: Is this the right course of action? Is 3 months on these medications sufficient time before performing a biopsy? Will performing a biopsy decrease the effectiveness of a future FNA mapping? What would the success rate be for finding sperm under these conditions?

    1. Dear Michelle, Nice work. Normalizing hormones is a great way to “optimize” men for sperm production. The timeline seems just right. Having a simple testis biopsy has a 30% (nonobstructed) to 100% (obstructed) chance of finding sperm here. If none is found, then you should wait at least 6 mos after the biopsy to perform any other procedures, such as FNA Mapping or mTESE, to let things heal up first.

  230. Hi Turek,
    I have great question to ask you.
    I am NOA patient (everything normal and still no sperms) with my knowledge it is acquired because of Orchitis in childhood and I can make out NOA symptoms on my body as well.
    But question is my cousin brother also found azoospermia and we dint have any detail study to him and with my observation he dont have azoospermia symptoms on body like gynocomestia , lack of muscle mass.
    Is this because of genes as my father and his father are brothers . Also my own brother and his brother have kids they are fine.
    Another important note is my cousin brother is alcoholic .
    Whether you come such situation where family members have azoospermia…. Is this hereditary ?

    1. Dear Murth, I am having some difficulty understanding the relationship between you and your cousin-brother. You have different fathers (who are brothers) but I am assuming the same mother? Certainly chromosomal issues can run in families and this could account for azoospermia. Also, men can carry Y chromosome deletions, so your father and uncle may in fact have passed down this issue as well. Lastly, among the 2500 genes thought to be associated with male infertility, we only know of <100 of them, so undefined genetic infertility is certainly possible.

      1. No Doctor it is not same mother it is different mother.
        I had orchitis so i am suffering from azoospermia but recently my cousin brother also diagnosed with azoospermia so i got this question.
        My own brother and my cousin brother’s own brother both have kids
        Hope you understood the problem now

  231. dr.. my DH is azoospermic .. he made TRUS it shows normal inside .. normal testis size .. all hormones in normal levels …in semen analysis there is 10000 spermatogenic cells only
    and he has third degree varicocele in left TS..
    He went to a doctor and put him on tamoxifen 20 once daliy ..and pentoxifylline 400 three times daily .. for 3 months
    he did not make any biopsy yet
    ..
    what may the cause of azoospermia ??… if treatment will make a diffrance ? thanks doc..

    1. Dear RAN, Keep reading as azoospermia can be due to blockage or testis failure. So far, sounds like it is not clear which version he has. Genetics, varicocele and exposures can cause testis failure. Blockage is usually due to inherited causes (CAVD) or past infections. A testis biopsy is a great way to figure out which o