Psychological and sexual associations of azoospermia in men: a cross-sectional pre-biopsy study

Azoospermia can lead to significant psychological distress, low self-esteem, and compromised sexual function. However, the impact of these issues before any invasive diagnostic or treatment procedures is not well studied. We conducted a cross-sectional study involving 134 men diagnosed with azoospermia and 164 age-matched fertile controls. All assessments, including anxiety (Beck Anxiety Inventory [BAI]), depression (Beck Depression Inventory-II [BDI-II]), self-esteem (Rosenberg Self-Esteem Scale [RSES]), and erectile function (International Index of Erectile Function-5 [IIEF-5]), were conducted during the diagnosis visit, prior to any testicular biopsy for infertility treatment. Compared with age-matched fertile controls, men with azoospermia exhibited significantly higher anxiety levels (mean ± standard deviation [s.d.]: 17.3 ± 3.9 vs 9.8 ± 2.8), increased depression scores (mean ± s.d.: 24.1 ± 6.3 vs 12.5 ± 5.1), lower self-esteem (mean ± s.d.: 2.8 ± 0.5 vs 1.8 ± 0.3), and poorer erectile function (mean ± s.d.: 17.2 ± 5.1 vs 21.4 ± 5.2), all with P < 0.001. Importantly, decreased self-esteem was strongly correlated with both depression ( r = 0.851) and anxiety ( r = 0.843). Additionally, erectile dysfunction showed an inverse correlation with both depression ( r = -0.867) and anxiety ( r = -0.813), with P < 0.05 for both correlations. The psychological and sexual effects of infertility are often overlooked in the treatment process. Therefore, we advocate that all men with azoospermia receive psychological and sexual support alongside infertility treatment.