OBJECTIVE To evaluate treatment of couples who are infertile due to unreconstructable obstructive azoospermia with microsurgical epididymal sperm aspiration or testicular sperm and intracytoplasmic sperm injection (ICSI). METHODS Prospective. METHODS The Egyptian IVF-ET Center in association with Cairo University. METHODS Twenty-three couples who are infertile due to obstructive azoospermia in which reconstructive microsurgery failed or was not possible. METHODS Microsurgical epididymal or testicular sperm retrieval and ICSI in 24 cycles. METHODS Fertilization and pregnancies. RESULTS All 24 cycles had successful fertilization and reached the ET stage. In microsurgical epididymal sperm aspiration cases, fertilization rate per metaphase II oocyte was 63% (109/ 172). Six patients became pregnant, including one set of twins and one set of triplets. One pregnancy resulted from the use of cryothawed epididymal sperm. In testicular sperm aspiration cases, the fertilization rate was 59% (32/54) and four clinical pregnancies resulted. CONCLUSIONS The use of microepididymal sperm aspiration or testicular sperm aspiration in conjunction with ICSI provide a highly precise and efficient procedure for achieving pregnancy in cases of unreconstuctable obstructive azoospermia.