Mr. Nangong Plant (pseudonym) from Hunan visited our hospital for infertility after 2 years of marriage. His clinical presentation was characterized by normal semen volume but no sperm detected, normal testicular size, normal blood folliculopoietin (FSH) and testosterone levels, bilateral epididymis enlargement, and normal spermatogenic function on testicular biopsy. What is the preliminary diagnosis of obstructive azoospermia and epididymal obstruction? Currently, the internationally accepted treatment for this type of disease is either assisted reproductive technology or surgical treatment (microscopic reconstruction of the vas deferens and epididymis), so how do you choose? What is the basis for the choice? One question that cannot be avoided is whether surgical treatment by male surgeons is becoming less relevant in the field of reproduction in the era of IVF. The answer is clearly no, as many studies have shown that vasectomy epididymal microreconstruction has the following advantages over in vitro fertilization combined with embryo transfer (IVF)/intracytoplasmic sperm injection (ICSI) methods: 1) patients can obtain offspring through natural conception, avoiding possible ethical issues and reducing the risk of multiple births; 2) it is cost-effective, i.e., the cost per offspring is low and the risk of multiple births is low. In China, which is still a developing country and has a large income gap, affordability is a factor that cannot be ignored; 3, IVF/ICSI technology is more disruptive to female physiology. As far as Mr. Nangong’s own condition is concerned, his meager income cannot afford the expensive cost of IVF, and the couple clearly indicated that their only hope of obtaining biological offspring rests on surgical treatment. This is certainly a stressful challenge, but it is gratifying to know that in recent years, our hospital has made a lot of useful explorations and breakthroughs in the surgical treatment of obstructive azoospermia, and we performed microscopic vasovaginal epididymal anastomosis for Mr. Nangong using the international mainstream “double needle overlay technique”, and no sperm was detected in the patient’s semen analysis at the follow-up examination one month after surgery. Six months after the operation, the patient’s spouse had a successful pregnancy and later gave birth to a healthy baby girl in Huangpu Hospital in Guangzhou. Epididymal obstruction can be as high as 3-6% of male infertility patients (epididymal obstruction caused by vasectomy can be treated by relatively simple vasectomy, so it is not included in the statistics), so its treatment has a very important status in male infertility. The vas deferens epididymal duct micro reconstruction technique has undergone continuous improvement through end-to-end vas deferens epididymal duct anastomosis, end-to-side anastomosis, triangular three-needle overlay anastomosis, transverse and longitudinal double-needle overlay vas deferens epididymal anastomosis, etc., and the efficacy has been continuously improved. Longitudinal double-needle stacked vas deferens anastomosis is a major technical breakthrough since the first microsurgical vas deferens anastomosis was started in 1978, and now it has become the preferred technique for vas deferens anastomosis in Europe and America. Unlike the technique of directly suturing the vas deferens to the epididymal section that is still used in many hospitals in China, the double-needle overlapping anastomosis is a 10-0 microscopic nylon thread under 20-25 magnification to perform an overlapping anastomosis of a single epididymal duct (generally only 0.3-0.5mm in diameter) to the vas deferens, and is therefore considered to be one of the most challenging microsurgical techniques. The technical difficulty is far more than microscopic reproductive techniques such as microscopic spermatic vein ligation and vasectomy, which are more commonly performed in China, requiring the operator to have excellent microsurgical skills and rich experience. Using our advanced Zeiss surgical microscope and a gradually modeled workflow, this technique has become a routine procedure in our urology department, with a recanalization rate of 56.3% and a conception rate of 25% among patients who completed the 1-year follow-up. Nevertheless, as with assisted reproductive techniques (e.g. IVF), the method still has a certain failure rate and, not all obstructive azoospermia can be treated with microsurgical techniques. Sometimes, when performing a surgical procedure, one cannot predict whether the seeds of success or failure will be planted, especially when faced with the expectations and full trust of the patient couple, one often feels a sense of pressure and responsibility, and the joy of success and the frustration of failure are often intertwined. In any case, the use of microsurgery provides a practical option for couples who desire to try natural fertility, or who have limited financial means, as well as an important tool for male surgeons to treat this type of disease.