This chapter deals with the management of azoospermia. It is imperative to pursue in every azoospermic patient a proper diagnostic process, during which one should classify the patients according to the etiology of their azoospermia due to pretesticular, testicular, or post-testicular causes. Methods of surgical sperm retrieval (SSR) include epididymal and testicular sperm retrieval, which can be open, close, or with microdissection. Microepididymal sperm aspiration (MESA), percutaneous epididymal sperm aspiration (PESA), testicular fine-needle aspiration (TEFNA), testicular sperm extraction (TESE) are various sperm retrieval techniques. The underlying etiology of azoospermia could influence the viability of the retrieved sperm cells as well as determine their maturational status being from epididymal or testicular source, in obstructive azoospermia (OA) or nonobstructive azoospermia (NOA), respectively. Cryopreservation of the remaining testicular tissue after sperm extraction or of individual sperm cells isolated after TESE represents a technical challenge.

Secretory azoospermia may be primary or secondary, and the absence of sperm in semen is caused by inefficient, deficient, or absent germ cell proliferation, meiosis, and differentiation. Based on the diagnostic testicular biopsy, three major histopathological syndromes are recognized in secretory azoospermia, sertoli cell-only syndrome, maturation arrest, and hypospermatogenesis. Elongating spermatid microinjection is rarely applied as most cases also have elongated spermatids; elongated spermatid microinjection showed to be a very successful approach; and round spermatid microinjection, unfortunately, was proved to be seldom useful. Analysis of world clinical series using elongating and elongated spermatids retrieved by testicular sperm extraction (TESE) shows 28 percent of mean term pregnancy rate. On the contrary, only 3 percent of term pregnancy rate is achieved with round spermatids. In order to avoid any fetal abnormalities, strict criteria should be used to select morphologically normal spermatids for microinjection.