Many of our friends are very frustrated when they are diagnosed with “azoospermia”, especially when the doctor tells them that they can only obtain offspring through adoption or “donor sperm”, they will carry a heavy mental burden. In fact, the number of people who are truly absolutely spermless is after all a minority. As a result of the late start of male medicine in China and the uneven regional development, some regional hospitals male medicine treatment is not standardized, which may bring some misguidance to our patients. Strict diagnostic criteria and individualized treatment plans are essential in the field of assisted reproduction, so let’s learn how to achieve “sperm from nothing”. The WHO (World Health Organization) definition of azoospermia is the absence of sperm on microscopic examination after 3 or more semen centrifuges, and the exclusion of retrograde ejaculation. Therefore, the absence of sperm in an occasional semen examination or the absence of centrifugal examination of semen specimens cannot be arbitrarily considered as azoospermia. So what is retrograde ejaculation? Retrograde ejaculation is when a man has the orgasmic sensation of ejaculation but no semen is ejected from the urethra, so where does the semen go? That is because the bladder neck can not close or the membrane urethra resistance is too large, so that the semen is ejected into the bladder, this may be a bit abstract, look at the following picture, it is clear: “nothing from nothing” the first trick: retrograde ejaculation of sperm into the bladder can be discharged through the urine, collect urine centrifugation to obtain sperm, IVF fertility assistance, can be obtained. It is possible to obtain a child of your own. How can azoospermia be treated when retrograde ejaculation is excluded? First of all, we have to clarify whether it is “non-obstructive” azoospermia due to testicular sperm failure or “obstructive” azoospermia due to intact testicular sperm production but inaccessible vas deferens, because the treatment options for these two causes of azoospermia are completely different. The treatment options for these two causes of azoospermia are completely different. The common causes of obstructive azoospermia are: intra-testicular obstruction, obstruction due to inflammation of the epididymis, obstruction of the ejaculatory ducts, congenital bilateral vas deferens, etc. 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 method of “making something out of nothing”: these patients can have their sperm removed through testicular or epididymal puncture to obtain a real child through “IVF” technology; or they can have their vas deferens reopened through surgery, so that the sperm can be discharged normally. This can lead to the creation of a child from nothing. Treatment of non-obstructive azoospermia is much more difficult and less successful than obstructive azoospermia. The common clinical causes of non-obstructive azoospermia include genetic abnormalities (Y chromosome microdeletion, Crohn’s syndrome), endocrine abnormalities (Kalman syndrome, HH syndrome), orchitis, varicocele and cryptorchidism. In such patients, the testes are often smaller in size, the blood hormone levels are abnormal, and no or very small amounts of sperm can be produced in the testes, resulting in no sperm being found in the semen. So, what should be done to treat non-obstructive azoospermia? ”Some patients with low hormone levels (FSH/LH/androgen) can be treated with HCG/HMG injections or hormone pump injections that mimic pituitary pulsatile hormone release; some patients with a low androgen to estrogen ratio can use letrozole to inhibit the conversion of androgens to estrogen conversion, thus increasing androgen levels and favoring spermatogenesis. Recently, growth hormone has also been used in the treatment of azoospermia. The fourth method of “creating sperm from nothing” (surgical treatment): the “three-step sperm extraction” method, the first step: testicular puncture for sperm extraction, the second part: testicular biopsy for sperm extraction, and the third part: testicular microscopic sperm extraction. The success rate of sperm extraction by puncture is the lowest, about 15%; the success rate of sperm extraction by microscopy is the highest, about 50%. Only after all attempts have failed do we consider adoption or “donor” IVF for pregnancy! Never give up until the end!