Secretory azoospermia may be primary or secondary, and the absence of sperm in semen is caused by inefficient, deficient, or absent germ cell proliferation, meiosis, and differentiation. Based on the diagnostic testicular biopsy, three major histopathological syndromes are recognized in secretory azoospermia, sertoli cell-only syndrome, maturation arrest, and hypospermatogenesis. Elongating spermatid microinjection is rarely applied as most cases also have elongated spermatids; elongated spermatid microinjection showed to be a very successful approach; and round spermatid microinjection, unfortunately, was proved to be seldom useful. Analysis of world clinical series using elongating and elongated spermatids retrieved by testicular sperm extraction (TESE) shows 28 percent of mean term pregnancy rate. On the contrary, only 3 percent of term pregnancy rate is achieved with round spermatids. In order to avoid any fetal abnormalities, strict criteria should be used to select morphologically normal spermatids for microinjection.