A recent sperm count showed not even one sperm. My doctor said that I was sterile for life. He said that treatment could help if I had shown a low count, but with none at all, there was nothing he could do. Is there any chance that this might be treatable? Should get a second opinion or search for treatment options, or would that be a waste of time?

-- Rob

A complete absence in sperm in the ejaculate, called azoospermia, can be due to a number of factors. Before diagnosing your condition, suggesting treatment and giving you a prognosis, your doctor must gather more information. The first step is a complete history and physical examination. You may be asked the following questions:

-- Have you noticed difficulty in maintaining an erection or ejaculation?
-- Has the volume of ejaculation changed?
-- Have you been exposed to cancer chemotherapy agents or radiation?
-- Does your beard grow slower?
-- Do you note headaches or loss of taste or smell?
-- Did you go through puberty at the normal time?
-- Have you or your partners had any sexually transmitted diseases, such as chlamydia or gonorrhea?

During the physical examination, your doctor will check the size and consistency of the testicles. If the testicles are small and softer than normal, the problem may be due to low levels of the hormones required for sperm production. If the testicle is small and hard, testicular failure may be the cause. Your doctor should measure levels of FSH and testosterone hormones to help differentiate between these two conditions.

Chromosomal evaluations and testing for Y-chromosome abnormalities with a "microdeletion test" can reveal a genetic basis for the absence of sperm. This is the case in up to 10 percent of men with azoospermia.

An examination of the scrotum and epididymis can reveal signs of scarring from an old infection or congenital absence of the vas deferens (CAVD), the tube that connects the testicle to the ejaculatory ducts. CAVD is not all that rare; it is frequently seen in men who carry the cystic fibrosis (CF) genetic abnormality but do not have the disease. If the wife also carries one abnormal CF gene, offspring may have cystic fibrosis. Therefore, if CAVD is found, you should also be screened for CF as part of the evaluation.

A rectal examination allows your physician to determine whether there is prostate tenderness, which may imply scarring and blockage of the ejaculatory stream. If the ejaculate volume is low, your physician will want to perform an ultrasound exam to look for a complete obstruction of the ejaculatory ducts. Finally, a biopsy of the testicle may indicate normal sperm production and confirm the diagnosis of blockage in the epididymis, vas deferens or ejaculatory ducts.

After a thorough evaluation is made, your physician can determine whether hormone treatment (rarely beneficial), microsurgical correction of a blockage, or retrieval of sperm for in vitro fertilization and sperm injection (IVF-ICSI) might offer the possibility of success.