Sperm can also be obtained surgically for azoospermia patients, either directly through IVF or by freezing the sperm before IVF to achieve fertility. The methods we often use are sperm retrieval by puncture and open surgical sperm retrieval, which can be used for diagnosis and second-generation IVF assisted conception technique (ICSI). I. Indications for surgical sperm extraction 1. Obstructive azoospermia (OA): inability to surgically recanalize, such as congenital malformations of the vas deferens and irreversible injuries due to acquired causes; Obstructive azoospermia: failure of surgical recanalization; 2. Non-obstructive azoospermia (NOA): a certain degree of spermatogenesis is still remaining in the testicular tissue. Second, the common causes of obstruction of the spermatic duct 1, congenital malformation: such as epididymis head, body, caudal segment is missing, a section of the vas deferens or completely missing, the absence of the seminal vesicles, epididymis, vas deferens or seminal vesicle underdevelopment, etc. 2, genitourinary infections: such as epididymitis, prostatitis, seminal vesicle, epididymal vas deferens tuberculosis and so on. 3, injuries: such as hernia repair, varicocele surgery, etc. can be injured to the vas deferens; prostate surgery can cause Prostate surgery can cause occlusion of the ejaculatory duct; or although there is no direct damage, but the postoperative infection adhesion scar formation, resulting in ejaculatory duct pressure, obstruction. 4, tumor: such as epididymal tumors, seminal vesicle tumors, prostate tumors, ejaculatory duct cysts, etc., can cause obstruction of the vas deferens. Third, the indications of surgical sperm extraction 1, vas deferens sperm extraction: indications: distal vas deferens obstruction and can not be lifted OA patients Surgical method: scrotal incision, with the help of a surgical microscope with a fine needle into the vas deferens, suction out a sufficient amount of sperms (usually more than 10 × 106) placed in a culture fluid for assisted reproduction technology. Characteristics: Since the sperms in the vas deferens have already completed the maturation process in the epididymis, the sperms obtained are more mature than those obtained by other surgical methods. 2.Epididymal sperm retrieval: Indications: absence or scarring of vas deferens and epididymis tail Characteristics: (1) Since the sperm in the head of epididymis has better vitality and morphology, sperm is usually retrieved from the head of epididymis; (2) Sperm in the head of epididymis has not completed the whole maturation process, so it can only be used in ICSI; (3) Only active sperm can be used in ICSI when retrieving sperm from epididymis. 3.Testis sperm retrieval: Indications: obstructive azoospermia that is unable to get sperm in epididymis, and the sperm is not able to get to the testis. Obstructive azoospermia, non-obstructive azoospermia (NOA) Characteristics: (1) spermatozoa in the testis do not go through the maturation process in the epididymis and usually do not have the ability to be active, but they can still be used for ICSI; (2) spermatogenesis is not balanced in the testis in NOA, or even focal spermatogenesis, which often requires multi-point puncture or micro sperm extraction. Fourth, the way of surgical sperm extraction: 1, percutaneous epididymal sperm aspiration (PESA): using a 5ml syringe or connecting a butterfly needle, aspirate about 0.5ml of sperm culture, percutaneous puncture along the longitudinal axis of the head of the epididymis into the head of the epididymis, apply negative pressure until there is a milky white liquid suction, and immediately microscopic examination. Sperm with spermatozoa were given for cryopreservation. 2.Micro epididymal tube sperm aspiration (MESA): incise the epididymal peritoneum under 20 times magnification, separate and incise a single epididymal tube, insert a fine needle, apply a slight negative pressure to aspirate the fluid in the epididymal tube, prolong the time of suction to get more, and close the epididymal tube by microscopic suture. 3.Comparison of different epididymal sperm retrieval procedures Percutaneous epididymal sperm aspiration (PESA) Advantages: easy and economical Disadvantages: blind penetration, great damage to the epididymal ducts, many complications, low sperm retrieval rate in the second operation Micro epididymal sperm aspiration (MESA) Advantages: little damage to the epididymal ducts, fewer postoperative complications, high sperm retrieval rate in the second operation Disadvantages: complicated operation, requires microsurgical equipment 4. Testicular excision to obtain sperm (TESE): Spermatic cord block anesthesia, make an incision in the middle of the epididymal opposite edge of the testis, incise the leucorrhoea, gently squeeze the testis and then use scissors to cut off a small amount of testicular tissue, part of the tissue is put into a sterile culture fluid for microscopic examination, and sperm are frozen. Part of the tissue was placed in Bouin’s solution for fixation and sent for pathological examination. Testicular aspiration to obtain spermatozoa (TESA) A testicular puncture gun or a simple puncture needle is used to insert the needle in the middle of the opposite edge of the epididymis of the testis, and then puncture into the testis, pump the needle to apply negative pressure, and then pull out the puncture needle quickly, so as to obtain one or more varicose spermatic tubes. The same method is used for microscopic and pathologic examination. 6.Comparison of different testicular sperm retrieval procedures Open retrieval (TESE) Advantages: large volume of sperm retrieval, easy to obtain more sperm Disadvantages: greater damage, more postoperative complications Percutaneous aspiration by puncture (TESA) Advantages: simple operation, less damage, fewer postoperative complications Disadvantages: small volume of sperm retrieval, low retrieval success rate 7.Testis focal spermatogenesis and multipoint sperm retrieval by puncture: used for spermatogenesis unevenly in the testis. 8, testicular microscopic sperm extraction (MESE) Indications: testicular spermatogenesis is extremely low, focal spermatogenesis of patients Surgical method: general anesthesia or epidural block, in the equatorial surface of the testis to open the leucorrhoea in the 25 times microscope to find the color of the white, opaque, thick and full of varicose spermatic ducts, after obtaining the chopped and placed in an inverted microscope to look for spermatozoa. Characteristics: (1) High sperm acquisition rate. (2) Less trauma to testicular tissue. (9) MESE has a higher rate of sperm acquisition. v. Sperm cell injection Problems: Technique for accurate identification of round sperm cells Lack of activation of oocytes Potential adverse effects on the centrosomes of the embryo Health, fertility, and genetic defects of the offspring Currently limited to clinical trials Indications: azoospermia in which there are no mature spermatozoa in the testes but elongated or rounded spermatids can be seen.