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Azoospermia

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Abstract
There are many factors that contribute to the ability to conceive a child. The success depends on internal and external factors. Nutrition, diet and exercise are all key in the overall chance of conception. But there may be factors that may be out of your control. Infertility refers to the inability to conceive a child naturally. About 10% of women (6.1 million) that range in the ages of 15-44 have fertility issues. But infertility isn’t just a woman’s problem. One-third of all infertility issues are due to issues with the man. One of those is called Azoospermia.
In a normal male, the testicles in the scrotum produce sperm that flows through the epididymis, vas deferens, and seminal ducts. Sperm mixes with fluid in the seminal ducts to form semen. Azoospermia is a condition where there are no sperm in the semen. Non-obstructive Azoospermia refers to abnormal sperm production and obstructive Azoospermia refers to normal sperm production with some sort of obstruction. Many years ago there wasn’t much hope for those with non-obstructive Azoospermia as it was thought they would never be able to conceive a child. Luckily with advancements in testing and diagnostic procedures it is now known that there is an equal chance of the capability of both non-obstructive and obstructive Azoospermia men to conceive child through IVF treatments. What is the treatment for Azoospermia? Is there hope for those men with Azoospermia? Does the diagnosis of Azoospermia rule out the chances of ever conceiving a child? Although diagnostic testing, treatment, surgery, and ultimately IVF may be emotionally and financially draining, the outlook for men with infertility problems is increasingly looking better.

There are many factors that can affect the fertility of a man. They can range from environmental factors which you can avoid, to hormonal and genetic disorders where men are predispositioned to fertility issues. Some factors are:
 Blockages, birth defects, or physical damage. Surgery can often fix these types of problems

 Retrograde Ejaculation: semen does not come out of the penis during ejaculation. Instead, it enters the bladder. This can happen as a result of Diabetes, certain medication, or surgery to the bladder, prostate, or urethra.

 Sexually Transmitted Diseases: Chlamydia and Gonorrhea can cause infertility. This type of infertility may be treatable if the STD is treated.

 Genetic diseases: Infertility is rare based on genetics. In men with Cystic Fibrosis, the vas deferens is often missing or is obstructed thus resulting in a very low sperm count. There are also chromosomal abnormalities.

 Autoimmune disorders. The immune system may target sperm cells and treat them as a foreign virus which can cause infertility.

 Hormonal imbalances R/T pituitary and thyroid malfunction.

 Sexual problems including erectile dysfunction and premature ejaculation effect the chance of fertility

 Varicoceles-enlarged varicose veins in the scrotum which prevent the blood from flowing properly. These are found in approximately 40% of men with infertility.

 Drugs: spironolactone, alcohol, ketoconazole, cyclophosphamide, estrogen administration, sulf asalazine

 Viral orchits, granulomatous disease (tuberculosis), sarcoidosis of the testis, neurological diseases i.e. - Myotonic dystrophy.
 Defects associated with forms of liver disease, renal failure, sickle cell disease and celiac disease

 Environmental assaults: over exposure to toxins, chemicals, and infections can cause nil sperm. Chemicals that affect sperm count include: oxygen free-radicals, estrogen emulation pesticidal chemicals(DDT, aldrin, dieldrin, PCP’s, dioxins, and furans) and plastic softening chemicals

 Exposure to certain heavy metals: lead, cadmium, or arsenic

 Radiation treatment will have an effect on sperm production. After radiation it will take two years to recover and some may never recover their ability to produce active sperm

 Misuse of various types of substances including drugs (cocaine and heroin), marijuana, alcohol, and tobacco can all reduce sperm counts. An over usage of steroids can alter motility and health of sperm.

 Excessive exercise-leads to the release of too many steroid hormones

 Stress

 Obesity

 Heat-this is most likely temporary from constrictive clothing, baths, hot tubs or saunas

Azoospermia is a chromosomal infertility. People have 46 chromosomes in each cell, two of which are sex chromosomes called X and Y. Females have two XX and males have one X and one Y-XY. “Because the males have the Y chromosome, the genes on this chromosome tend to be involved in male sex determination and development. Y chromosome infertility is usually caused by deletions of genetic material in the regions of the Y chromosome called Azoospermia factor (AZF) A, B, or C. Genes in these regions are believed to provide instructions for making proteins involved in sperm cell development, although the specific functions of these proteins are not well understood.” (Genetics Home Reference, 2009) Some of the signs and symptoms of Azoospermia are: increased body fat, hair and breast tissue, clear, watery, or white discharge from the penis, presence of a mass or swelling in the scrotum, testicles that are small, soft, or non-palpable, and veins that are enlarged or twisted. There may be no symptoms present if you have Azoospermia other than not being able to conceive a child after a year of unprotected sex. A physician will recommend testing for both partners to see where the problem lies. There is a possibility that both partners will have some type of fertility issue. The first step in diagnosing Azoospermia is a complete history and physical to identify potentially correctable causes of infertility and to physically examine the male genitalia. The testes may be small in shape or have a form of deformity. Varicoceles are common in infertility and can be confirmed with an ultrasound. Also, during physical examination, the ductal systems can be felt which can detect the absence of the vas deferens or the dilation of the epididymis (Male Fertility Specialists.com). The testing for Azoospermia includes hormonal evaluation, transrectal ultrasounds and possibly other imaging tests, genetic testing, and testicular biopsies. Blood tests will give your physician general information on how your body is functioning. Genetic testing will look for abnormal genes that may cause a problem with sperm production, transport, or the formation of male reproductive organs (www.drugs.com). Hormonal evaluation includes looking at the man’s level of FSH (follicle stimulating hormone). “When the sperm producing capacity of the testes is diminished, the pituitary makes more FSH in an attempt to make the testes do its job. Therefore, if a man's FSH is significantly elevated there is a strong indication that his testicles are not producing sperm optimally (Male Fertility Specialists.com).” The testosterone prolactin, luteinizing hormone (LH), and the thyroid stimulating hormone (TSH) are also measured. Problems with these hormones can alter a man’s ability to produce sperm. A transrectal ultrasound of the ejaculatory ducts and seminal vesicles is used to rule out any type of blockage. During this test an ultrasound probe is place in the rectum as the duct’s lie close to its wall. The ejaculatory duct traverses the prostate which can be felt upon exam of the rectum. If the ultrasounds shows that the seminal vesicles are dilated it means that they are potentially full of semen and cannot empty properly. “Cysts blocking the ejaculatory ducts by exerting pressure on their walls, or calcifications in the ejaculatory ducts themselves, may also be noted(Male Fertility Specialists.com).” Often time’s blockages can be removed with a simple operation. Lastly, if a testicular problem is suspected, a biopsy can be performed to determine the underlying cause. This can be done via needle aspiration or by an incision. In the past, there was no available treatment related to the biopsy results which indicated low or no sperm production. “However, recently that has changed as testicular sperm have been used to achieve pregnancies when coupled with in vitro fertilization (IVF) combined with intracytoplasmic sperm insertion (ICSI). In this procedure the sperm is harvested and then injected directly into the egg (Male Infertility Specialists.com).” These are the different types of ways to extract sperm for examination: Common Methods of Sperm Retrieval Advantages Disadvantages
Microsurgical epididymal sperm aspiration
MESA -Best clinical pregnancy rates
-Large number of sperm retrieved
-Excellent results with cryopreservation
-Reduced risk of hematoma -Requires microsurgical expertise
-Increased cost
-General or local anesthesia
-Incision required
-Postoperative discomfort
Percutaneous epididymal sperm aspiration
PESA -No microsurgical expertise required
-Local anesthesia
-Few instruments
-Fast and repeatable
-Minimal postoperative discomfort -Few sperm retrieved
-Risk of hematoma
-Damage to adjacent tissue
Testicular sperm extraction TESE -No microsurgical expertise required
-Local or general anesthesia
-Few instruments
-Fast and repeatable -Relatively few sperm retrieved
-Limited risk of testicular atrophy(with multiple biopsies)
Percutaneous testicular sperm aspiration
TESA -No microsurgical expertise required
-Local anesthesia
-Few instruments
-Fast and repeatable
-Minimal postoperative discomfort -Few sperm retrieved
-Risk of testicular atrophy
-Risk of Hematoma

There are some less invasive newer methods to determine the cause of infertility. In Vasography, contrast dye is injected into the vas deferens to check for blockage. MR Spectroscopy is a metabolic scan which combines the use of H Spectroscopy with Magnetic Resonance Imaging. This scan can be used to find sperm in men with non-obstructive Azoospermia. It also measures the metabolic activity in the testis. Studies have shown that it is more accurate than the more invasive biopsies in reading abnormal patterns of sperm in men with Azoospermia. Lastly, the MR Spectroscopy can evaluate testis metabolism in one-hundred different areas which increases the possibility to retrieve a sperm sample (News, Medical-Non-Invasive MR Spectroscopy to determine ability to be fathers, 2/5/10). The treatment of Azoospermia depends upon the type that you have. Non-obstructive Azoospermia was once thought to be untreatable. These men were said to be sterile and their only option to have a child was through donor spermatozoa or to adopt. For men with hormone deficiencies, hormone replacement therapy can improve sperm concentration and motility. For those men with Varicoceles, a varicocelectomy can help reduce the swollen veins. In a vericocelectomy the affected veins are tied off and the blood flow is directed through healthy veins. Although men with non-obstructive Azoospermia have lower motility, they can still be used for Intracytoplasmic sperm injection (ICSI) during IVF. The TESE sperm extraction is used to obtain the sperm. During ICSI a single sperm is injected into the egg. Pregnancy rates are about 20% for each attempt (www.fertilityauthority.com). Obstructive Azoospermia treatment depends on if the cause of the obstruction is fixable. Men who have obstructive Azoospermia may need surgery to correct the obstruction. This surgery may make pregnancy possible without the need for IUI, IVF, and ICSI. A vasoepididymostomy is performed in men with an epididymal obstruction. This will allow for sperm to enter the ejaculate. 20-40% of men that have this procedure are able to conceive a child naturally (www.fertilityauthority.com). A TURED (transurethral resection of the ejaculatory duct) is recommended for men who have an obstruction in the ejaculatory duct. 50-75% of patients that have this procedure have sperm in the ejaculate. The success rate for pregnancy following this is 25%. If surgery is able to correct the obstruction causing the fertility issues, it is possible for men to once again conceive children without the need for fertility treatments. Retrieval of sperm directly through the testis or epididymis along with IVF or ICSI can increase the chance of success (www.fertilityauthority.com). There are some recent studies being done involving vitamins and their correlation to infertility issues. Some doctors say that taking 5 mg of Folic Acid along with 66 mg of Zinc Sulphate can help with spermatogenesis which helps infertile men conceive children. Sperm tests will be needed to measure the effectiveness and improvement of sperm production. In Pakistan, a vitamin regiment of 1000 mg Vitamin C daily for at least one month along with Zinc Met 3x,or 6x or Selenium 30 x twice a day for an unspecified amount of time is said to cure 7/10 infertility patients(Natural Fertility, 2011). When it comes to Azoospermia, there is no correlation to the specific ethnicity of the man affected. The prevalence of Azoospermia is less than 1% among all men and approximately 10-15 % among infertile men. “Because Y chromosome infertility impedes the ability to father children, this condition is usually caused by new deletions on the Y chromosome and occurs in men with no history of the disorder in their family. When men with Y chromosome infertility do father children, either naturally or with the aid of assisted reproductive technologies, they pass on the genetic changes on the Y chromosome to all their sons. As a result, the sons will also have Y chromosome infertility. This form of inheritance is called Y-linked. Daughters, who do not inherit the Y chromosome, are not affected (www.asrm.org).” There are many factors for the nurse to consider from the time of diagnosis to the time of treatment for a man and his significant other affected by Azoospermia. This is a couple that has been most likely already trying to conceive a child for at least a year. To receive a diagnosis related to infertility would be devastating. Not only will this decrease their chances of conceiving a child naturally but the whole process will now be prolonged. Depending on the type of treatment and need for IUI or IVF it may take years to conceive. This is an exhausting process mentally and financially. As a nurse, you need to be open and honest with your patient. You need to facilitate a relationship with the patient where he/she feels comfortable to ask questions and express concerns. Patient education is key for any new diagnosis. For Azoospermia, I as a nurse would inform the patient of the possible procedures that will help in diagnosing his type of infertility. The patient has a right to know of the ups and downs related to different procedures and what their success rates are. Informational pamphlets can be given or websites where the patient can go home and do some research on his own. The patient may be experiencing anxiety, depression, or a feeling of inadequacy when he receives his diagnosis. As a nurse, I need to offer reassurance. I would direct him to support groups and offer other resources and referrals to help him cope with his feelings. Along with supporting the male with Azoospermia, I would also support his significant other. Nurses should inform the patient that a diagnosis of Azoospermia doesn’t mean there is no chance of conception.
Care Plan for a patient with Azoospermia:
Nursing Diagnosis Goal/Expected Outcome Nursing Interventions Evaluation
Altered Sexuality Patterns R/T fear of rejection by partner -Pt. will express verbalization of a perception of self as sexually acceptable and adequate within 3 months of diagnosis -Facilitate communication between pt. and partner; focus on feelings the couple shares and assist them to identify changes which may affect their sexual relationship
-Perform actions to promote a positive self-concept
-Assist the patient and significant other in identifying possible options to overcome situational, temporary, or long-term influences on sexual functioning
-Offer information on resources, referrals, and support groups RN communicated with pt. and significant other and assisted them to identify the changes that are affecting their relationship. Pt. expresses satisfaction with his capability of sexual functioning. He has no fear of rejection from his partner.
Anxiety R/T threat or perceived threat to physical and emotional integrity -Pt. identifies positive coping mechanisms within 1-3 months of diagnosis -Assess pt.’s level of anxiety
-Determine how the pt. copes with anxiety
-Maintain a calm manner while interacting with the pt.
-Assist the pt. in recognizing symptoms of increasing anxiety; exploring alternatives to use to prevent the anxiety from immobilizing him. RN assessed pt.’s level of anxiety and current coping mechanisms. Alternatives to prevent and eliminate anxiety were recognized. Pt. has identified some non-pharmacological methods to reduce anxiety including relaxation and guide imagery.
Fear R/T treatment and invasive procedures -Patient manifests coping behaviors and verbalizes a reduction or absence of fear within 1-3 hrs. of explanation of procedure to be performed -Determine what the pt. is fearful of by careful and thoughtful questioning
-Create an atmosphere that facilitates trust through active listening
-Document behavioral and verbal expression of fear
-Assist the pt. in identifying strategies use in the past to deal with fearful situations
-Instruct the pt. in the performance of the following self-calming measures that may reduce fear or make it more manageable: breathing modifications, exercises in relaxation, meditation, or guided imagery RN assesses pt.’s current level of fear related to impending diagnostic procedures. RN ensured that patient felt he was in a comfortable atmosphere where he could ask questions and receive answers to any and all questions he had. Pt. expressed knowledge of self-calming measures to reduce his fear including breathing techniques and meditation. Pt. had a reduction in his fear prior to his procedure.

Hopelessness R/T prolonged treatments or diagnostic studies with no positive results -Pt. begins to recognize choices and alternatives within 3 months of diagnosis. -Evaluate the pt.’s ability to set goals or make decisions and plans
-Assess for feelings of hopelessness, lack of self-worth, or giving up
-Assess for potential sources of hope( significant other, religion)
-Assess the pt.’s social support system
-Express hope for the pt. who feels hopeless RN evaluated pt.’s feelings of hopelessness and lack of self-worth. Sources of hope were identified which included family, friends and his faith. Pt. has begun to express hope in his ability to conceive a child.

Many years ago a diagnosis of Azoospermia was thought to be the end to a couple’s hopes and dreams of having children on their own. Thankfully, this is no longer the case. Depending on the type of Azoospermia there are simple procedures and some more invasive procedures that improve the chances of conception. These along with the advancements in IUI and IVF treatments now make it more realistic for those with Azoospermia to father a child of his own.
References
Azoospermia - Care Guide. (n.d.). Drugs.com | Prescription Drug Information, Interactions & Side Effects. Retrieved February 5, 2012, from http://www.drugs.com/cg/azoospermia.html
BioMed Central. (2009, December 2). Hope for men with nonobstructive infertility. Retrieved February 5, 2012, from www.sciencedaily.com¬ /releases/2009/12/091202205623.htm
Can Supplements Help Male Fertility? | Natural Fertility. (n.d.). Natural Fertility. Retrieved February 9, 2012, from http://fertility.amuchbetterway.com/can-supplements-help-male-fertility/
Disteche, C. (2007, March 19). Y Chromosome Infertility - GeneReviews - NCBI Bookshelf. National Center for Biotechnology Information. Retrieved January 18, 2012, from http://www.ncbi.nlm.nih.gov/books/NBK1339/
Gulanick, M., & Myers, J. L. (2007). Nursing care plans: nursing diagnosis and intervention (6th ed.). St. Louis, MO: Mosby.
Male Infertility Specialists.com - What is azoospermia and can a person with azoospermia have biological children? . (n.d.). Male Infertility Specialists.com - Home - Find a male infertility specialist near you. Retrieved January 18, 2012, from http://maleinfertilitymds.com/faq5.htm
Nirhira, M. (2010, February 25). Fertility Tests for Men: How to Check Fertility in Men. WebMD - Better information. Better health.. Retrieved January 25, 2012, from http://www.webmd.com/infertility-and-reproduction/guide/male-fertility-test
Non-Invasive MR Spectroscopy to determine ability to be fathers. (n.d.). News Medical. Retrieved January 25, 2012, from www.news-medical.net/news/20100205/Non-invasive-MR-Spectroscopy-to-determine-ability-to-be-fathers.aspx
Non-Obstructive Azoospermia. (n.d.). Fertility & Infertility Information. Retrieved February 6, 2012, from http://www.fertilityauthority.com/men-only/medical-causes-male-infertility/non-obstructive-azoospermia
The Management of Infertility due to obstructive azoospermia. (n.d.). American Society for Reproductive Medicine. Retrieved January 18, 2012, from www.asrm.org/uploadedFiles/ASRM_Content/News_and_Publications/Practice_Guidelines/Educational_Bulletins/The_management_of_infertility(1).pdf
Y chromosome Infertility. (n.d.). Genetics Home Reference. Retrieved January 18, 2012, from ghr.nlm.nih.gov/condition/y-chromosome-infertility

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