Vasoepididymostomy‐First Versus Primary ICSI for Epididymal Obstructive Azoospermia: Real‐World Reproductive Outcomes for Treatment Selection

ABSTRACT Background In couples with epididymal obstructive azoospermia (EOA), choosing between microsurgical vasoepididymostomy (MVE)‐first and primary intracytoplasmic sperm injection (ICSI) remains a practical treatment‐selection challenge. Conventional endpoints such as patency and pregnancy rates provide an incomplete assessment of the real‐world consequences of an MVE‐first strategy, including transition to assisted reproduction, subsequent ICSI outcomes, and time to live birth. It remains uncertain whether MVE‐first preserves natural‐conception potential without compromising subsequent ICSI live‐birth outcomes. How this time trade‐off should inform couple‐level treatment selection is also unclear. Methods This retrospective cohort study included 397 couples (270 MVE‑first, 127 primary ICSI). Treatment trajectories after MVE, including postoperative patency, natural conception, transition to assisted reproductive technology, and subsequent ICSI, were evaluated. The primary comparative outcome among ICSI‐treated couples was cumulative live birth rate (CLBR) after all embryo‐transfer cycles derived from the first oocyte retrieval. Post‐MVE ICSI included ICSI using ejaculated sperm after MVE patency and ICSI using surgically retrieved sperm after persistent azoospermia. Results Among the 241 men who remained evaluable after MVE, postoperative patency was achieved in 177 (73.4%). After additional follow‐up losses, 236 couples comprised the final post‐MVE follow‐up cohort; 84 couples achieved natural conception (35.6%), resulting in 80 live births. A female age ≤ 28 years and an AMH concentration >2.91 ng/mL were associated with a higher probability of natural conception. Among couples who subsequently underwent ICSI, CLBR was 45.9% after MVE versus 43.8% after primary ICSI (difference, +2.1 percentage points; one‐sided 95% CI lower bound, −8.3%), which met the non‐inferiority criterion. Major pregnancy, birth, and neonatal safety outcomes were comparable among the ICSI groups. Among ICSI‐treated couples, post‐MVE ICSI was associated with a lower live‐birth hazard than primary ICSI (adjusted hazard ratio [aHR] 0.22, 95% CI 0.15–0.35; p < 0.001), whereas higher baseline AMH was associated with a higher live‐birth hazard (aHR 1.13, 95% CI 1.03–1.25; p = 0.010). Conclusion An MVE‐first strategy enabled natural conception in over one‐third of the post‐MVE follow‐up cohort. Among couples who ultimately required ICSI, cumulative live‐birth outcomes were not compromised by the MVE‐first pathway, although time to live birth was longer than with primary ICSI. In this cohort, MVE‐first may be favored for couples with a female partner aged ≤ 28 years and an AMH level > 2.91 ng/mL. Primary ICSI may be more appropriate when minimizing time to live birth is the main priority.