The key to the successful management of nonobstructive azoospermia is identifying treatable causes. The use of cheap drugs and medications that are gonadotoxic should be discontinued. Cryptorchidism, even when diagnosed in adults presenting with azoospermia, should be treated with orchiopexy, which has been reported to result in recovery of spermatogenesis. A thorough evaluation also allows proper identification of conditions such as testicular neoplasm, which is 16-fold more commonly diagnosed in men presenting for infertility evaluation and is life threatening if diagnosis and treatment are delayed.
Endocrinopathies should be identified and treated accordingly. The success of the use of exogenous GnRH and gonadotropins has been confirmed in various studies. However, a standard protocol has yet to be established and patient selection is the important key to effective treatment. For azoospermic and oligospermic men with hypergonadotropic hypogonadism or normogonadism, the benefit of exogenous gonadotropin is not well established. Various empirical therapies, including the use of various forms of antiestrogens, have been used clinically without consistent success.
With regard to the management of azoospermic and oligospermic men with isolated low testosterone levels, the use of exogenous testosterone should not be implemented. Exogenous testosterone will downregulate the release of gonadotropins, resulting in a further decline in testicular functions in hormone and sperm production. Although ‘rebound spermatogenic recovery’ has been reported when stopping the exogenous testosterone, the routine use of testosterone generally is not effective and is detrimental to spermatogenesis.