Many of our friends are very frustrated when they are diagnosed with “azoospermia”, especially when they are told 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 really 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 one occasional semen examination or the absence of centrifugation of semen specimens cannot be arbitrarily considered as azoospermia. What is retrograde ejaculation then? 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 ejaculated 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. What is the treatment for azoospermia that excludes retrograde ejaculation? First of all, we need to clarify whether the azoospermia is “non-obstructive” due to testicular spermatogenesis failure or “obstructive” due to intact testicular spermatogenesis but inaccessible vas deferens, because the treatment options for azoospermia due to these two causes 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 caused by inflammation of the epididymis, obstruction of the ejaculatory duct, 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 sperm removed through testicular or epididymal puncture to obtain a real child of their own through “IVF” technology; or they can have their vas deferens reopened through surgery, so that the sperm can be discharged normally. In addition, we can also obtain sperm from the vas deferens to allow the sperm to exit the body normally, thus creating 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 are: genetic abnormalities (Y chromosome microdeletion, Creutzfeldt-Jakob syndrome), endocrine abnormalities (Kalman syndrome, HH), orchitis, varicocele, cryptorchidism and so on. Such patients often 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 the inability to find sperm in the semen. So, how to treat non-obstructive azoospermia? The third trick of “making something out of nothing” (medication) is that some patients with low hormone levels (FSH/LH/androgen) can be treated by HCG/HMG injection or hormone pump injection that simulates pituitary pulsatile hormone release; some patients with 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): “three-step sperm retrieval” method, the first step: testicular puncture to retrieve sperm, the second part: testicular biopsy to retrieve sperm, and the third part: testicular microscopic sperm retrieval. 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%.