Abstract
Introduction: Non-obstructive azoospermia (NOA) affects 10%–15% of infertile males, posing a significant challenge in fertility management. Microdissection testicular sperm extraction (mTESE) is regarded as the gold standard for sperm retrieval for NOA. However, even when mTESE fails to retrieve sperm, unexpected postoperative findings may still occur. Case: A 31-year-old male with primary infertility and azoospermia underwent two surgical sperm retrieval procedures: percutaneous epididymal sperm aspiration (PESA) and mTESE. Hormonal and genetic evaluations revealed no abnormalities, but no sperm were retrieved during either procedure. Remarkably, six days after surgery, a self-ejaculated sample yielded five motile spermatozoa, which were immediately cryopreserved for intracytoplasmic sperm injection. Histopathology indicated moderate spermatogenesis with Johnsen scores of 6.0 and 7.0 for the right and left testes, respectively, highlighting residual spermatogenic activity. Discussion: The postoperative appearance of spermatozoa may reflect focal or intermittent spermatogenesis that was not detected during surgical sampling. The histopathological findings support the presence of limited residual sperm production despite unsuccessful PESA and mTESE. Conclusion: The detection of motile spermatozoa after failed mTESE highlights the importance of postoperative for follow-up, repeated semen analysis, and timely cryopreservation in the fertility management of patients with NOA.