Microsurgical Vasovasostomy(Micro VVA) and newer techniques of Microsurgical Vaso Epididymal Anastomosis(Micro VEA) have very good success rates. In cases of obstructive azoospermia, these procedures are preferred instead of Assisted Production with ICSI. If VEA is successful, the couple could expect to achieve pregnancy with natural cycles.

During Surgery small quantity of sperms Cryopreserved. If the surgery fails ICSI can be done using these sperms or by espiretion of fresh sperms.

Many clinics consider Intrauterine Insemination (IUI) routinely as the treatment for male factor infertility. In severe forms of Oligo Astheno Teratospermia (IUI) will not be beneficial, and repeated attempts at IUI may produce scarring of uterine cavity and infections resulting in tubal blockage. IUI could be considered only in cases of men with normal or near normal semen parameters or idiopathic infertility, cervical hostility or failure of deposition of sperms due to erectile or ejaculatory dysfunction.

IVF has changed the prospects in the female. IVF involves retrieving eggs from the ovaries by Trans Vaginal aspiration and incubating the sperms in a dish resulting in formation of embryos which are then transferred into the Uterine Cavity. IVF has proven to be effective for Tubal factors(PID) and for conditions like polycystic ovarian disease(PCOD), endometriosis etc. For IVF to be successful we require more than 100,000 actively motile sperms per egg, but infertile male do not fulfill this criteria. IVF cannot be used for severe male factor infertility and for the sperms retrieved from the testis or epididymis.

With ICSI procedure, men with severe oligo asthenospermia and azoospermia have an opportunity to produce their own biological child, without resorting to Donor Insemination or Adoption. In cases of Congenital Bilateral Vasal Agenesis (absence of VAS), failed vasoepididymal anastomosis(VEA) and non obstructive azoospermia, ICSI has proved to be successful. In cases of repeated failure with conventional In Vitro fertilization, ICSI could be considered to maximize the chances.

ICSI (Intracytoplasmic Sperm Injection), is a procedure where a single sperm is injected into the egg. To achieve fertilization the sperm is withdrawn into a tiny pipette, the egg fixed with a holding pipette and the sperm injected into the cytoplasm of the metaphase II (mature Oocyte). After the ICSI procedure the Oocytes are incubated and the resultant embryos are transferred into Uterine cavity by using a specially designed embryo transfer catheter. After the embryo transfer, Progesterone supplementation is given. The confirmation of Pregnancy done with estimation of HCG and after 6 weeks for the foetal heart on ultrasound.

The sperms for ICSI are obtained from the ejaculate. The sperms obtained during VVA and VEA are cryopreserved.

In cases of obstructive azoospermia sperms were retrieved by,

a)	Percutaneous Epididymal Sperm Aspiration(PESA)
b)	Micro Epididymal Sperm Aspiration (MESA)
c)	Modified Testicular Sperm Extraction(TESE)

In case of blocks to sperm pathways epididymis or VAS, the epididymal ducts are dilated which contain plenty of motile sperms. Using a 21 guage butterfly needle attached to a 20ml syringe, fluid is drawn and examined under microscope. This is a simple procedure which does not involve operative surgical expertise.

This is a good procedure for retrieving sperms from dilated epididymal tubules using magnification. The individual tubule is entered and fluid aspirated and examined for the presence of sperms. The sperms obtained could be cryopreserved (Freezing) for subsequent use.

In case of Non Obstructive Azoospermia, most of the tubules show atrophic changes. Still there could be some tubules which may contain sperms adequate for purpose of ICSI. A few seminiferous tubules are thus excised and they are teased out for presence of sperms. These cases of Non Obstructive Azoospermia are not suitable for any form of medical or surgical treatment and ICSI with the sperms recovered from the testis is the only option for them to get biologically their own child.