Testicular sperm extraction for men with cryptozoospermia - are we jumping the gun?

Cryptozoospermia is a condition where spermatozoa can only be detected with extensive sperm-pellet analysis after routine semen analysis failed to detect any spermatozoa. Intracytoplasmic sperm injection (ICSI) can help these cryptozoospermic patients overcome their infertility issues. ICSI can be done with ejaculated or testicular sperm obtained by surgical sperm retrieval (SSR) techniques, each with its advantages and disadvantages. In managing cryptozoospermic patients, there is a need to first investigate the possibility of improving sperm numbers and quality based on etiologies. SSR is a part of the management, but presents also potential risks. The benefit of SSR is that sperm obtained by SSR in cryptozoospermic patients tend to give better outcomes when used for ICSI. However, besides the physical burden, SSR also has potential drawbacks, such as psychological trauma associated with surgery in some patients, the need for extra funding for the surgery, and immaturity of the sperm. According to recent studies, ICSI using testicular sperm from cryptorchid patients provides better pregnancy and live birth rates, as well as a lower miscarriage rate. Some studies contradict these findings, hindering the possibility of providing a robust answer on this matter. This review aims to present ICSI outcomes with ejaculated or testicular sperm, taken from cryptozoospermic patients, and discuss the results of comparative studies highlighting the possible reasons behind these discrepancies, and eventually offer an expert opinion for clinicians.