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Sperm retrieval for in vitro fertilization/intracytoplasmic sperm injection is the only medical procedure that enables a man with testicular azoospermia to father a child. In obstructive azoospermia after failed refertilization, microsurgical epididymal sperm aspiration is the gold standard, with retrieval rates up to 100%. In nonobstructive azoospermia (NOA), testicular spermatozoa (spermatids) can be recovered by testicular sperm extraction (TESE) in approximately half of the men. No parameters are available to definitively predict a successful recovery individually, but genetic factors, reduced testicular volume, and high serum follicle-stimulating hormone levels are associated with an unfavorable outcome. Retrieval surgery is well standardized, chiefly performed with microsurgical assistance and without severe local complications. Microsurgically assisted TESE (M-TESE) and TESE that is not microscopically supported in low-chance NOA patients may result in hypogonadism in the long term. In patients with Klinefelter syndrome, the outcome is worse with increasing age. For children before chemotherapy, M-TESE for stem cell preservation must be performed with minimal damage to the testicles.

Context Sperm retrieval in combination with IVF/ICSI is the only medical procedure for an azoospermic man to father a child. Different techniques, especially testicular sperm extraction (TESE), have evolved over time and have dramatically improved the outlook for men with testicular azoospermia. However sperm retrieval rates are associated not only with the operation proposed but especially with a distinct pattern of prognostic factors that must be effectively managed for all these infertile patients for their best benefit. Objectives To review the etiology, clinical work-up including operative techniques, and prognostic factors for testicular sperm retrieval in azoospermic men to maximin clinical benefit by these procedures. Evidence Acquisition Data from basic and clinical studies with a defined, standardized approach pre- and postoperatively were analyzed. Evidence Synthesis Different standardized surgical techniques can be offered to extract spermatozoa of azoospermic men from either the epididymis and/or the testis for ICSI. Sperm retrieval offers a treatment for both patients with testicular azoospermia and men with obstructive azoospermia in cases where microsurgical refertilization is not an option or has already failed. Among surgical techniques testicular sperm extraction (TESE) and microsurgical epididymial sperm aspiration (MESA) have become the most popular techniques. However, also percutaneous techniques are employed due their easy feasibility and low costs. By utilizing these techniques together with kryopreservation of extracted spermatozoa a single surgical intervention is able to provide spermatozoa for several ICSI attempts. Extensive surgical interventions in the testis of azoospermic patients have raised concerns about the potential influence on the endocrine compartment of the testis, particularly in patients with small testes and low levels of testosterone. Conclusions Testicular sperm retrieval is a feasible and successful procedure. Testicular spermatozoa can be retrieved from the testis in up to 70% of patients, even in cases with testicular azoospermia and severe disorders of spermatogenesis. However, surgical damage of the testis might also compromise the interstitial compartment of the testis with testosterone deficiency as a consequence. Conclusively, endocrine follow-up can be considered mandatory.