The treatment of male infertility has advanced greatly in medicine, and many infertile couples can have children through microsurgery or assisted reproduction techniques. The treatment of obstructive azoospermia has the greatest chance of successful fertility, but its treatment methods are varied, which requires the treating physician to have a full understanding of the various treatment methods and to know the various treatments to choose for different patients, only then can the patient get the best treatment and get the best results. A male infertility patient is often found to have significant abnormalities during semen quality examination. When semen examination reveals no sperm does it mean that he must be infertile? No! Some of these patients have a good chance of having a baby through the “right treatment”. For patients with azoospermia found in clinical semen examination, some of them still have “sperm to be found”, but these patients have poor testicular function and produce very little sperm, so that sperm cannot be detected during semen examination; while others have an obstruction in a part of the reproductive tract, which is the obstructive azoospermia discussed in this article. In the case of a male infertility patient, under what circumstances would obstructive azoospermia be suspected? Generally speaking, obstructive azoospermia can be initially suspected if the patient has normal testicular volume, normal follicle stimulating hormone (FSH), swelling of the epididymis, and no sperm on semen examination. Of course, the final diagnosis depends on testicular biopsy and other special tests. If the specific site of obstruction is to be determined, the presence or absence of spermatozoa in the vas deferens will be examined by meticulous physical examination, transrectal ultrasonography or microscopic examination during surgery. Vasectomy is generally not recommended for routine use because the contrast agent is harmful to sperm and because the contrast test can damage the vas deferens and risk causing medically induced obstruction. What are the treatment options for obstructive azoospermia? These include microsurgery (vas deferens-vas deferens anastomosis, vas deferens-epidididymal anastomosis), transurethral ejaculation ductotomy, and assisted reproductive technologies. Intracytoplasmic single sperm injection (ICSI, in which a single morphologically and motile sperm is injected by microinjection into the plasma of a mature oocyte) is indicated for patients with obstructive azoospermia that cannot be resolved by microsurgery, or when the patient has a combination of other abnormalities (e.g., congenital anomalies of the vas deferens, long vas deferens, or reproductive problems in the female partner). Although ICSI can be used for all infertility due to obstructive factors and is no more dangerous than IUI, the basic principle of fertility still prevails to allow the patient to conceive as naturally as possible. Therefore, microsurgery plays an extremely important role for infertile couples who wish to conceive naturally and should be considered as the first line of treatment. The point is that not every male urologist is trained in microsurgery, and the surgeon must be highly trained and regularly perform such procedures to achieve satisfactory results. The basic principle of microsurgery is the reanastomosis of healthy tissue, and the key to its success includes the maintenance of good blood flow in the tissue after surgery, the absence of any tension in the anastomosis, and the precise anastomosis of the mucosal tissue. Because the lumen of the vas deferens has a very small inner diameter of approximately 0.5 to 0.8mm, the difficulty and precision of the procedure can be imagined with six stitches and three layers of sutures for such a microscopic diameter, making it difficult for untrained surgeons to perform this procedure. Cornell Medical Center in New York, USA is the world leader in microsurgery for infertility. The recanalization rates of their vas deferens anastomosis and vas deferens epididymal anastomosis are 99% and 70%, respectively, and the post-operative conception rates are 70% and 45%, respectively. Why is there such a discrepancy between the recanalization rate and the conception rate? It is related to the duration of the genital tract obstruction and the presence or absence of anti-sperm antibodies in the body. Nevertheless, microsurgery has a much higher success rate than the various forms of assisted reproduction techniques and is far less expensive. When the obstruction is located in the ejaculatory duct, we can use transrectal ultrasound, vasectomy, MRI or cystoscopy to find out the exact location and extent of the obstruction. If the testicular biopsy confirms normal spermatogenesis, and if the combination of epididymal obstruction or vas deferens obstruction is excluded, transurethral ejaculatory ductotomy can be used for treatment, with a success rate of 50%. Of course, some patients may have postoperative reflux of urine into the ejaculatory duct, seminal vesicles or vas deferens, which may lead to epididymitis, in addition to retrograde ejaculation. For patients with severe obstructive azoospermia that cannot be resolved by microsurgery, medical advances will still give them hope for fertility, but of course this depends on close cooperation and collaboration between urogynecologists and obstetricians and gynecologists to jointly improve the success rate of assisted reproduction. In general, male urologists first obtain sperm from the testes or epididymis. There are many methods of sperm retrieval, such as percutaneous epididymal aspiration (PESA), microsurgical epididymal sperm retrieval (MESA), percutaneous testicular aspiration (TFNA), percutaneous testicular puncture biopsy (TNB) and open testicular biopsy sperm retrieval (TESE), among others. The choice of sperm extraction method depends on the experience of each doctor. Cornell Medical Center currently uses microsurgical epididymal sperm retrieval because it allows for as much sperm to be obtained as possible, has a high success rate (99%), and allows for excess sperm to be frozen and stored for future use. In conclusion, when a patient is diagnosed with obstructive azoospermia, every male physician is faced with many treatment options, and as a treating physician, one must have enough experience to choose the most appropriate treatment for the patient. When simple and less expensive microsurgery can solve the problem, the patient should not be advised to choose assisted reproduction, which is, after all, the last line of defense in solving infertility. And there are still some reproductive and ethical medical issues that need to be further clarified, so patients should not be advised to use assisted reproduction lightly. After all, natural conception and reproduction are in accordance with the natural laws of human reproduction.