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Azoospermia can be caused by the obstruction of the excurrent ductal system of the male reproductive tract or by failure of spermatogenesis in the testes. Various advanced diagnostic tools are available to help clinicians determine the underlying etiologies. These include transrectal ultrasonogram, vasography and antisperm antibody assays. In addition, advanced genetic evaluations, such as karyotype analysis, Y chromosome microdeletion and cystic fibrosis transmembrane conductance regulator mutation screening are used commonly, not only to determine the etiology of azoospermia, but also to provide crucial information for counselling of couples who choose to use assisted reproductive techniques to have children. Recent advances in the management of obstructive azoospermia with microsurgical reconstruction, such as vasovasostomy and vasoepididymostomy, have significantly improved the postoperative outcomes. For patients with spermatogenic failure that requires assisted reproduction, the recent refinements in various surgical sperm retrieval techniques, including microsurgical testicular sperm extraction and epididymal sperm aspiration, have provided more optimal treatment outcomes.