Sperm retrieval is most commonly performed for azoospermic men. Azoospermia may be the result of severely impaired sperm production (azoospermia due to spermatogenic dysfunction) or normal sperm production in the setting of physical blockage of sperm transport (obstructive azoospermia). Although microsurgical reconstruction is possible for many men with obstructive azoospermia, some couples will still elect sperm retrieval with use of assisted reproductive technology (ART), including in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). ART allows men who have surgically retrieved sperm to contribute to pregnancies, even when limited numbers of viable sperm are available and even if sperm have not matured by proceeding through the entire male reproductive system. The management of men with obstructive azoospermia and of those with azoospermia due to spermatogenic dysfunction is markedly different. Not only does the genetic/diagnostic testing vary for these two conditions, but also the management and outcomes take different directions.

The male’s contribution to early embryo development remains an underappreciated aspect of reproductive physiology that may become of increasing importance in the application of advanced reproductive technology (ART) in the coming years. Evidence is emerging regarding the importance of sperm chromatin organization, DNA integrity, and sperm-based epigenetic signals that are delivered to the oocyte. In this review we will discuss the current understanding of how the sperm influences early embryogenesis. The existing data connecting sperm factors to poor ART outcomes is critically presented. Finally, practical laboratory methods currently available to the clinical embryologist for sperm optimization will be outlined.

Recent advances in the treatment of cancer have led to greater longevity among men in reproductive ages with a 75% five-year cancer survival rate in boys aged 15 years or younger [1] and 66% among men aged 15–44 [2]. There is increased recognition that quality of life including paternity is significant issues for cancer survivors. We will focus primarily on patients with testicular cancer and lymphoma that generally affects younger patients in the reproductive window with an excellent overall survival. However, one must realize in our modern society the age of desiring paternity has increased due to postponement of marriage as well as for other social reasons. Therefore, this chapter will focus not only on those who completed chemotherapy as children but adult cancer patients as well.

All sperm accrue varying amounts of DNA damage during maturation and storage, a process that appears to be mediated through oxidative stress. The clinical significance of genetic damage in the male germ line depends upon severity and how that damage is distributed among the sperm population. In human reproduction, the embryo is capable of significant DNA repair, which occurs prior to the first cleavage event. However, when the magnitude of genomic damage reaches pathologic levels, reproductive outcomes begin to be affected. Evidence now exists linking excessive sperm DNA fragmentation with time to pregnancy for natural conception, pregnancy outcomes of intrauterine insemination and in vitro fertilization, and miscarriage rates when intracytoplasmic sperm injection is employed. This review will discuss the pathophysiology of sperm DNA damage, the studies linking it to impaired reproductive outcomes, and how clinicians may render treatment to optimize the chance of paternity for their patients.

Obstructive azoospermia (OA) is a common presenting condition of male infertility, resulting from either congenital or acquired blockage of the reproductive tract. Men facing a diagnosis of OA now have an array of treatment options, including definitive reconstruction and various forms of sperm retrieval. The optimum treatment decision for OA will depend on the goals, values, and expectations of the patient and his partner. In this review we will discuss the therapeutic approach to OA, stressing the requirement of a clear and thoughtful plan for staged intervention. Any proposed treatment strategy should optimize the chances of paternity while minimizing damage to the male genitourinary system. Special attention will be paid to the role of microdissection testicular sperm extraction (microTESE), as it is a useful and often underutilized rescue procedure for OA. Specifically, the advantages and disadvantages of microTESE will be evaluated, with particular focus on success rates and safety.