Mr. Nangong Plant (pseudonym) from Hunan visited our hospital in May 2007 due to 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. Preliminary diagnosis of obstructive azoospermia: 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 epididymis). So, what is the choice? 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 one of the most challenging microsurgical techniques. The technical difficulty far exceeds that of 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, and our latest follow-up data show a recanalization rate of 67.9% and a conception rate of 40.8% in 139 patients from May 2007 to November 2012. Nevertheless, as with assisted reproductive techniques (e.g. IVF), the method still has a certain failure rate and, not all cases of 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. But in any case, the use of microsurgery offers a practical option for couples who desire to try natural fertility, or who have limited financial means, as well as an important means for male surgeons to treat this type of disease. Frequently Asked Questions: 1. Cost and hospital days: The cost is about $8,000 and the hospital stay is 8-10 days (mainly 7 days of bed rest and minimal exercise is recommended after the procedure). 2.Success rate: Our latest follow-up data shows that among 139 patients from May 2007 to November 2012, the recanalization rate (sperm can be detected in semen after surgery) reached 67,9% and the conception rate reached 40,8%. This actually depends very much on the condition of the patient’s epididymal fluid. Patients with more outflow fluid and more sperm rarely fail; on the contrary, if there is little outflow fluid after the epididymal duct is incised during the operation and sperm are rare or only seen, the success rate of the operation is lower. 3.Whether to check testicular biopsy and vasectomy before surgery: vasectomy is generally not done because it can lead to secondary obstruction; testicular biopsy is analyzed on a case-by-case basis. 4.Is there any anastomosis that cannot be done: Yes, for example, some patients have inoperable vas deferens and unsuccessful guidewire expansion, which is difficult to know in advance before surgery; some patients cannot find epididymal ducts for anastomosis, etc. Overall, a comprehensive assessment will be done before surgery, which is rare. 5.Post-operative sperm vitality is very poor, is natural pregnancy is very low: In fact, due to long-term obstruction, or antibodies and other reasons, most patients show weak and dead sperm in the early post-operative examination, but with the patency of the reproductive tract, most of them will gradually become better, of course, at this time, with some drug-assisted process will generally be faster. Some doctors who do not perform microsurgery are wrong to rush patients to IVF because they do not understand this phenomenon. Of course, the assessment of when to try to conceive naturally and when to receive assisted reproduction is complex, involving the age of the woman, the treatment course, etc. A careful assessment is recommended. 5, risks of the procedure: post-operative scrotal discomfort and pain; testicular atrophy; epididymitis and other reproductive tract infections, etc., are all small probabilities. 6, the value of this anastomosis in the IVF era: first we have to inform the patient couple of the two options available. The purpose of anastomosis is natural pregnancy and lower cost, no physical interference to the woman; the advantage of IVF is that it is less dependent on the own condition of the man and woman and can also be used as a backup plan after anastomosis failure. We have both patients who seek IVF after a failed anastomosis and patients who seek surgery after a failed IVF attempt, which is analyzed in a comprehensive manner.