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. 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”. 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 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. The same group of patients was followed up until October 2012 with a success rate close to 70%. Nevertheless, as with assisted reproductive techniques (e.g. IVF), there is still a certain failure rate with this method 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. 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. What are the costs and the number of days of hospitalization? Now that the bed adjustment is underway, hospitalization in the special care ward is required. The cost may now be around 1,5-1,60,000 RMB, which will fluctuate from patient to patient. The hospital stay is 8-10 days (mainly post-operative bed rest is recommended for 7 days with minimal exercise), and the details can be obtained by consulting Dr. Xiaojian Yang. 2.Overall success rate? My assistant, Dr. Yang Xiaojian, has been following up with my patients for 5 years as of November 2012 and shows that my overall success rate (i.e. sperm found in semen) is over 67.9% and the spousal conception rate is 40.8%. And this actually depends very much on the condition of the patient’s epididymal fluid, if there is more outflow and more sperm, it rarely fails, on the contrary, if there is very little outflow after the epididymal duct is incised during the operation, and sperm are rare or only seen, the success rate of the operation will be lower. (Last year, Dr. Yang Xiaojian’s follow-up process was very difficult because some patients changed their contact information and some patients refused to accept the follow-up because they were afraid of being cheated, which was a big project; the follow-up was not done until 2014 because the success rate and conception rate needed to be observed one year after the operation) 3. Some eager patients have found sperm in 20 days or so, but of course I am against such early examination, because we recommend to start sexual life only after one month, and some patients may take one and a half months to return to sexual life. Some patients may take a month and a half to return to sexual intercourse. There are also cases where sperm are found only a year after surgery. Go to check 1, 3, 6 after and inform me the result for further treatment to improve the sperm function. 4. Is testicular biopsy and vasectomy checked before surgery? Vasectomy is generally not done because it can lead to secondary obstruction; testicular biopsy is analyzed on a case-by-case basis. 5.Is there any anastomosis that cannot be done? For example, in some patients, the vas deferens is incompetent and the guide wire dilation is unsuccessful, but it is difficult to know in advance before surgery; in some patients, no epididymal duct can be found for anastomosis, etc. In general, a comprehensive evaluation will be done before surgery, and this is rare. But in any case, there are cases that cannot be done or are done very reluctantly, as in one case of consultation surgery, I operated on the stage for 5 hours, and both sides of the epididymis were explored in 6 places in the tail, body and head, and fortunately, a suitable anastomotic epididymal tube was found in the head of the left epididymis, otherwise, I really felt the pressure and expectation of my own sense of regret, the expectation of the patient and the family, and the pressure and expectation of the colleagues of the sister units invited to the consultation intertwined together heavy pressure. Prof. Li Shihua from Cornell, USA said that the vas deferens epididymal duct anastomosis is not known after the completion of the surgery, and I further added that in China, since the obstruction is mostly caused by infection, it is not known whether the anastomosis can be done before the surgery. 6. Is natural pregnancy very low because of poor sperm motility after surgery? In fact, due to long-term obstruction or antibodies, most patients show weak or dead sperm in the early post-operative examination, but most of them will gradually get better as the reproductive tract is open, of course, the process is usually faster at this time with some medication to assist. 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. 7. Surgical risks? Post-operative scrotal discomfort and pain; testicular atrophy; epididymitis and other reproductive tract infections are all small probabilities. 8, the value of this anastomosis in the IVF era? First of all, we have to inform the patient couple of these two options. The purpose of anastomosis is natural pregnancy and lower cost with no physical disturbance to the woman; the advantage of IVF is that it is less dependent on the man and woman’s own condition and can also be used as a backup option 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.