Micro-TESE in men with non-obstructive azoospermia: a narrative review of sperm retrieval benefit, testicular injury, and endocrine risk

Abstract Background Microdissection testicular sperm extraction (micro-TESE) is an important treatment option for men with non-obstructive azoospermia (NOA) because it can provide sperm for intracytoplasmic sperm injection when other routes to biological fatherhood are unavailable. Counseling, however, should include not only the probability of sperm retrieval but also postoperative structural, endocrine, symptomatic, and repeat-procedure outcomes. Main body This narrative review used structured searches of PubMed/MEDLINE, Scopus, and Web of Science from database inception to May 2026, supplemented by Google Scholar and reference-list screening. Human micro-TESE studies were prioritized; mixed surgical retrieval studies, mechanistic studies, and guidelines were used when direct evidence was limited. Micro-TESE appears less damaging than conventional testicular sperm extraction, but focal ultrasonographic abnormalities, testicular volume change, testosterone decline, gonadotropin change, and occasional clinically relevant atrophy have been reported. Most changes appear transient or asymptomatic, whereas men with small testes, borderline testosterone, elevated luteinizing hormone, Klinefelter syndrome, previous cryptorchidism or orchidopexy, adverse histology, relevant comorbidities, or failed previous retrieval may require closer counseling and follow-up. Proposed mechanisms, including inflammation, blood–testis barrier disturbance, oxidative stress, and local microcirculatory stress, should be distinguished from direct post-micro-TESE evidence. Repeat surgery should be counseled differently after prior successful retrieval and after initial failed retrieval. Conclusions Micro-TESE should not be discouraged when clinically indicated. A practical counseling approach should balance the chance of sperm retrieval and cryopreservation against testicular reserve, possible structural injury, endocrine risk, symptoms, genetics, comorbidities, and patient preferences. Men with small testes or persistent symptomatic hypogonadism require endocrine-andrology reassessment. Testosterone therapy should be reserved for confirmed symptomatic testosterone deficiency after fertility goals and any further sperm-retrieval plans have been addressed.