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The most severe expression of male factor infertility is azoospermia, where no sperm are present in the ejaculate. Azoospermia is found in 15-20% of men evaluated for infertility. Causes of azoospermia include congenital and acquired reproductive tract obstruction as well as spermatogenic failure.

Azoospermia may have different etiologies previously described as pretesticular (i.e. abnormal Hypothalamo-Pituitary-Gonadal hormonal axis), testicular (i.e. secondary to abnormal testicular function) and posttesticular (i.e. obstruction or ejaculatory dysfunction). This classification, although physiologically correct, is not always practical for treatment decision making. The division of azoospermia into OBSTRUCTIVE and NON-OBSTRUCTIVE categories allows better determination of specific treatment options available to a particular patient. It is also critically important since patients with nonobstructive azoospermia have different genetic problems.

The approach to azoospermic patient has changed significantly with the introduction of sperm retrieval techniques and assisted reproduction , especially IFV/ ICSI. Nevertheless, specific treatment of azoospermia remains not only successful but also a cost-effective option.

Testicular biopsy remains the oldest and most informative diagnostic modality to differentiate between obstructive and nonobstructive azoospermia. Previous recommendations of not performing biopsy in patients with 2-3 times elevated serum FSH level are outdated. It was shown consistently that gonadotropins as a markers of spermatogenesis are imperfect. Normal FSH level may be observed in patients with testicular dysfunction while significantly elevated FSH does not indicate complete absence of the spermatogenesis. Presently, testicular biopsy may not only discriminate between the types of azoospermia, but have a predictive value for sperm presence in the testis in cases of nonobstructive azoospermia. As soon as the cryopreservation of the testicular tissue with subsequent use in the assisted reproduction becomes widely available, testicular biopsy will also be a valuable treatment procedure.