Introduction：Many friends are diagnosed by the doctor as “azoospermia” is very frustrated, especially when the doctor told him that he can only through adoption or “sperm supply” to obtain offspring, will carry a heavy mental burden. In fact, the real absolute spermless people are after all a minority. Due to the late start of male medicine in China, the regional development is not balanced, some regional hospitals male diagnosis and treatment is not standardized, which may bring some misguidance to our patients. Strict diagnostic standards and individualized treatment plans in the field of assisted reproduction is crucial, here we come together to understand how to achieve sperm “from nothing”. The World Health Organization (WHO) defines azoospermia as a condition in which no spermatozoa are detected by microscopic examination of semen after centrifugation on three or more occasions, and retrograde ejaculation is excluded. Therefore, an occasional semen examination without sperm or semen specimens without centrifugal examination cannot be arbitrarily regarded as azoospermia. What is retrograde ejaculation then? Retrograde ejaculation is a condition in which a man has an orgasmic sensation of ejaculation, but no semen is ejected from the urethra, so where does the semen go? That is due to the bladder neck can not be closed or membrane urethra resistance is too large, so that the semen shot into the bladder, so that may be a little abstract, look at the following picture, it is clear at a glance: “from nothing” the first move: retrograde ejaculation of sperm into the bladder can be discharged through the urine, the collection of urine centrifugation to obtain sperm, IVF fertilization, can get their own children, can get their own children, can get their own children. You can get your own child. So how to treat azoospermia that excludes retrograde ejaculation? First of all, we have to find out whether it is “non-obstructive” azoospermia due to testicular spermatogenesis failure or “obstructive” azoospermia due to testicular spermatogenesis, but the vas deferens is impassable because the treatment options are completely different for the two types of azoospermia. The treatment options for these two causes of azoospermia are completely different. The common causes of obstructive azoospermia include intratesticular obstruction, obstruction caused by inflammation of the epididymis, obstruction of the ejaculatory ducts, and congenital bilateral absence of the vas deferens. The testicular volume and blood hormone level of these patients are often normal, and we can further clarify the diagnosis through physical examination and ultrasound. The second trick of “creating something out of nothing”: this kind of patients can take out sperm through testicular or epididymal puncture, and get a real child of their own through “in vitro fertilization” technology; or realize the reconnection of the vas deferens through surgery, so that the sperm can be discharged from the body normally, thus obtaining an offspring, thus realizing the goal of “creating something out of nothing”. In this way, the offspring can be obtained, thus realizing “creating something out of nothing”. Compared to non-obstructive azoospermia, the treatment of non-obstructive azoospermia is much less difficult and less successful. Common clinical causes of non-obstructive azoospermia include genetic abnormalities (Y chromosome microdeletion, Kirschner’s Syndrome), endocrine abnormalities (Kalman’s Syndrome, HH Syndrome), orchitis, varicocele, cryptorchidism, and so on. Such patients tend to have smaller testicular volume, abnormal blood hormone levels, and cannot produce or can only produce a very small amount of sperm in the testes, resulting in sperm not being found in the semen. So how do you treat non-obstructive azoospermia? The third trick of “creating something from nothing” (medication): some patients with low hormone levels (FSH/LH/androgen) can be treated with HCG/HMG injections or hormone pump injections that mimic the pulsatile hormone release of the pituitary gland; some patients with a low androgen to estrogen ratio can be treated with letrozole to inhibit the conversion of androgen to estrogen, thus increasing the androgen to estrogen conversion, and thus increasing the androgen to estrogen conversion. estrogen, thus increasing androgen levels and favoring spermatogenesis. Recently, growth hormone has also been used in the treatment of azoospermia. “The fourth trick (surgical treatment): “three-step sperm retrieval” method, the first step: sperm retrieval by testicular puncture, the second part: sperm retrieval by testicular biopsy; the third part: sperm retrieval by testicular microscopy. The success rate of sperm retrieval by puncture is the lowest, about 15%; the success rate of sperm retrieval by microscopy is the highest, about 50%. Only after all the failed attempts do we consider adoption or “donor” IVF! Never give up until the end!