Objective: This study aims to evaluate spermatogenic failure in azoospermic men by characterizing patterns in Modified Johnsen Scores from testicular biopsies, examining their correlation with clinical and hormonal parameters, and determining the probability of live sperm retrieval. Novelty: As one of the largest datasets on azoospermia in Indonesia, this study provides a comprehensive histopathological and hormonal profile of azoospermic patients, while also emphasizing the diagnostic value of bilateral testicular biopsies—an area often underexplored in Southeast Asian populations. Methods: A retrospective analysis was conducted on azoospermic patients who underwent bilateral testicular biopsies between April 2011 and July 2024. Testicular tissue samples were assessed using the Modified Johnsen scoring system (range: 1 to 10), and classified histopathologically from tubular fibrosis to complete spermatogenesis. Clinical parameters, including age, body mass index, sperm retrieval outcomes, and serum levels of follicle-stimulating hormone, luteinizing hormone, and testosterone, were collected and analyzed. Statistical associations between these parameters and histopathological subtypes were determined using significance testing. Results: A total of 409 testicular biopsies were evaluated. The most frequent Modified Johnsen Scores were 7 (20%) and 5 (16.6%). Histopathological analysis showed that 40.3% of cases exhibited spermatogenic arrest, while only 7% demonstrated normal spermatogenesis. Discordant histopathological patterns between the two testes were observed in 18.5% of patients. Follicle-stimulating hormone and luteinizing hormone levels showed statistically significant associations with histopathological subtypes (p < 0.001). Age, body mass index, and testosterone levels did not correlate significantly. Conclusion: Spermatogenic arrest is the predominant abnormality in azoospermic men, with hormonal variations—particularly in follicle-stimulating hormone and luteinizing hormone—strongly associated with testicular pathology. The discordant histology between the testes underscores the importance of bilateral biopsies. Higher Modified Johnsen Scores were positively correlated with the likelihood of successful sperm retrieval. Copyright: © 2026 Parikesit D et al.