Non-obstructive azoospermia (NOA) is a severe form of male infertility. The only option to help men with NOA to become biological fathers is to surgically extract spermatozoa from the testicles, and in this review different modalities are discussed. Microdissection testicular sperm extraction seems to achieve better sperm retrieval rates compared with both testicular sperm aspiration and testicular sperm extraction. However, there are significant limitations in the current literature, and without prospective randomised trials it is not possible to define the optimal sperm retrieval technique for the management of NOA.