The incidence of infertility in China is about 10-15%. The male factor accounts for about 40%, the female factor accounts for about 40%, both factors account for about 10% to 20%, and 10% to 15% have unknown causes (i.e., idiopathic infertility). Male infertility is the result of multiple diseases and/or factors and is usually classified as pre-testicular, testicular and post-testicular depending on the disease and the interfering or affecting reproductive link, but there are still a significant number of patients for whom no clear cause can be found. When it comes to the treatment of male infertility, the first thing that comes to many people’s mind is taking medication, not only western medicine, but there are few who consider receiving herbal treatment. But some of the diseases that lead to infertility are not effective, at this time, perhaps more people will immediately think of resorting to assisted reproductive technology, commonly known as “in vitro fertilization”, despite the rapid development of assisted reproductive technology, but taking into account economic factors, reproductive risks, cost-benefit comparison study results, possible ethical and moral issues, multiple births Despite the rapid development of assisted reproductive technology, it should not be the first choice due to economic factors, reproductive risks, comparative cost-benefit studies, possible ethical and moral issues, risks of multiple births, and disturbance to the female physiology. What to do? Many people may shake their heads if we say that male infertility can still be treated surgically… What is the situation? Over 70% of male infertility can be treated with microsurgery or combined assisted reproductive techniques (MIM/ IVF/ ICSI). The main types of surgical treatment options available for male infertility are as follows: 1. Varicocele surgery: Varicocele is a common cause of male infertility. Surgery is the main means of treating varicocele. Studies have shown that one year after surgery can have about 40% natural pregnancy rate of the spouses while two years pregnancy rate can be up to 70%. Interventions for varicocele repair include interventional techniques (cis or retrograde) and surgical treatment. Surgical interventions include traditional transinguinal route, retroperitoneal route, transinguinal subserosal route spermatic vein ligation, microtechnical inguinal route or subserosal route spermatic vein ligation, and laparoscopic spermatic vein ligation. According to some information, microscopic spermatic vein ligation is the most ideal treatment at present and is called the “gold standard”. 2.Vasectomy anastomosis: microsurgical vasectomy is feasible for proximal obstruction after vasectomy, i.e. vas deferens-vasectomy. In case of limited obstruction of the scrotal segment of the vas deferens caused by inflammation, anastomosis with excision of the obstructed segment can also be done. In cases of bilateral absence of vas deferens due to injury from hernia or testicular descending fixation surgery performed in childhood, optional assisted reproductive technology can be used, and vas deferens anastomosis can also be used for treatment, and we were the first in China to introduce microscopic vas deferens anastomosis assisted by laparoscopic technology. There are several methods of vasectomy to choose from, the simplest being the single-layer anastomosis technique or the modified single-layer anastomosis technique, which has the advantage of being simple to operate, requiring low microscopic skills and easy to promote, but with a lower success rate than the more advanced multi-layer anastomosis technique, of which the success rate of the Cornell Institute for Reproductive Research’s fine microdot multi-layer anastomosis technique can reach 99.5%. We are currently using the multilayer technique. 3.Vasectomy epididymal anastomosis: About 10-15% of male infertility patients are caused by obstructive azoospermia, and its treatment has a very important status in male infertility. As the most effective treatment for epididymal obstruction, vasovaginal epididymal anastomosis is of great value in the treatment of obstructive azoospermia. In another case, if no spermatozoa are found in the vas deferens fluid near the epididymis when a vasectomy is performed, but a toothpaste-like mucus is found, it means that the long-term ligation has led to secondary epididymal obstruction, and then an epididymal vas deferens anastomosis is also needed instead of the traditional vas deferens anastomosis. In 1978, Silber in the United States pioneered the use of microsurgical techniques to perform end-to-end vasovasovaginal anastomosis, and in 2000, Marmar invented the transverse double-needle overlay technique, based on many previous improvements. The new anastomosis technique for the overlapping vas deferens is similar to the traditional method in terms of semen quality and pregnancy rates, with lower restenosis rates, making this extremely challenging anastomosis simple to perform. PT Chan of the Cornell team has modified the transverse double stitch technique to a longitudinal double stitch technique, which is now considered one of the preferred methods for vasoductal epididymal anastomosis. We have performed this technique in over 200 cases since 2007, and the current follow-up results of our center show a 67.9% success rate of anastomosis and a 40.8% natural pregnancy rate in the female partner. 4.Ejaculatory duct obstruction: for azoospermia or severe oligospermia caused by ejaculatory duct orifice obstruction, natural pregnancy can be achieved in some patients’ spouses through spermoscopic exploration or transurethral ejaculatory ductotomy/ejaculatory duct cystectomy, etc. 5.Microscopic sperm retrieval for non-obstructive azoospermia: For azoospermia not caused by obstructive factors such as hypospermia, due to the possibility of “focal spermatogenesis” in the testis, the small testis can be cut open under the assistance of microscope to search for sperm, which can not only protect the testicular tissue to the maximum extent, but also find the scattered sperm more accurately. The spermatozoa can be found in a scattered manner with maximum protection of the testicular tissue. In technically mature centers, the sperm discovery rate of this exploratory procedure can reach 60-70%, and then combined with assisted reproduction techniques, it eventually enables more people to obtain biological offspring. 6.Erectile dysfunction: For infertility secondary to failure of intercourse due to erectile dysfunction, the first choice is first-line drug therapy, or second-line negative pressure suction, penile cavernous body drug injection, etc. For patients with poor results or who cannot tolerate it and are not willing to directly use assisted reproductive technology, vascular surgery of the penis or penile support implantation can be used according to the etiology. For sexual intercourse disorders due to penile curvature deformity, the 16-point technique can be used to correct penile curvature. As far as the current treatment for male infertility is concerned, medication, surgery and assisted reproductive technology each have their own most appropriate applications, but sometimes the choice varies depending on the physician’s expertise and preference. For example, for the same patient with varicocele, some physicians may recommend surgery, others may recommend medication, and the fertility center physician may directly recommend assisted reproduction. Who is right? Who is right? It may be a matter of analysis rather than generalization. We should not expand the indications for surgery because we are good at it, nor should we give patients medication because we don’t do surgery, nor should we expand the application of assisted reproduction technology indiscriminately. Of course, these techniques can sometimes be applied in combination. For example, a patient with non-obstructive azoospermia who is treated with medication to improve the chances of obtaining sperm by microscopic techniques and then through assisted reproduction techniques to finally allow the patient to obtain offspring is the most perfect combination of the three.