Revisiting non-obstructive azoospermia: Is there a best way to retrieve testicular sperm?

Background: Microdissection TESE has been considered the "gold standard" for retrieving testicular sperm in cases of non-obstructive azoospermia (NOA) despite limited scientific support. Here we compare all aspects of microdissection TESE with testis fine needle aspiration mapping (FNA Mapping) and directed TESE procedures for men with NOA. Methods: We examine the history of testicular sperm extraction techniques and the rise of advanced technologies with a focus on microdissection TESE and FNA mapping. We summarize the published literature regarding the success rates, complications, and limitations of these two methods. Main Findings: As there are no randomized controlled trials, the best data come from the Cochrane Reviews, which include meta-analyses concluding that the simplest and safest methods of sperm retrieval should be chosen. Although microdissection TESE is popular, recent reports have questioned its value due to the significant hypogonadal consequences. Among alternative procedures, FNA Mapping is a viable and less invasive alternative to microdissection TESE in finding testicular sperm in NOA patients. Conclusion: Alternatives to microdissection TESE procedures such as FNA Mapping offer several advantages that include similar sperm retrieval success rates, but also less invasiveness and improved understanding of the pathophysiology of NOA.