Steady improvements in the long term outlook for adolescents and young adults with cancer require a shift in focus towards ensuring quality of life after cancer treatment as well as quantity. An important component of quality of life for many men is the ability to father a biological child. However, direct effects of malignancy, as well as potentially gonadotoxic cancer treatments, render many men azoospermic. Where cryopreservation of a good quality semen sample is not possible or was not offered prior to initiation of treatment, microdissection testicular sperm extraction (mTESE) offers a potential route to biological fatherhood. This review explores current evidence supporting the use of mTESE in patients treated for cancer, as well as some of the barriers and questions that still remain before this technique can form part of routine practice.