History of infection—whether urinary tract infection, prostatitis, epididymitis, or sexually transmitted diseases—may evoke the possibility of OA whether on epididymal or ejaculatory duct level. Tuberculosis can cause seminal tract obstruction at different levels. Therefore, a history of tuberculosis, especially genitourinary, may be a major clue toward diagnosis of OA. In filarial endemic areas, history of filariasis could be the cause of obstruction. Similarly, history of schistosomiasis should be asked, especially in endemic areas.

Trauma to inguinal or scrotal areas may lead to OA, especially, if penetrating and is complicated by infection. Surgical history must include history of vasectomy, as well as other inguinal or scrotal surgeries, such as hernia repair or hydrocelectomy, which may raise the possibility of iatrogenic obstruction especially if performed bilaterally.

Presence of other manifestations of cystic fibrosis, such as recurrent respiratory tract infections or family history of similar condition will aid the diagnosis of congenital OA [2, 11, 84].

Low ejaculate volume is often seen in patients with ejaculatory duct obstruction and may be the main presenting symptom together with painful ejaculation or hematospermia [84].

Clinical examination plays a very important role in diagnosis of OA. These patients will have normal virilization with well-developed secondary sexual characteristics. Abdominal examination may show an inguinal scar of prior surgery. Usually a well-trained urologist will be able to diagnose OA on local genital examination. The presence of normal size testis together with fully engorged epididymis will confirm the diagnosis. Epididymal nodule can be palpated on the tail of the epididymis in cases with previous history of STD. Usually, the vas deferens can be easily palpated during examination as a unique cordlike tubular structure. Unilateral or bilateral absence of vas, which may be associated with partial absence of the epididymis, will confirm the diagnosis of congenital vassal aplasia. Other abnormalities on vassal examination may include: beaded vas in case of tuberculosis, thickened vas in case of schistosomiasis, and a vassal defect with or without granuloma in post vasectomy cases [84–87].

The patients should be properly counseled about both options of treatment. The decision is multifactorial and includes whether the couple has primary or secondary infertility, desired number of children, and history of previous surgery that can affect the success rate of microsurgical reconstruction; e.g., redo-surgery and inguinal obstruction of the vas during hernia repair or vassal or epididymal injury during hydrocelectomy. Proper evaluation of the female partner is also very important in decision-making, especially if her age is above 35 and her chances of achieving normal pregnancy is low, as well as the time needed for surgical reconstruction to function can extend up to 1 year [96]. The financial background of the couple is one of the detrimental factors, as cost-effective analysis has proved reconstruction to be the most effective for a patient with epididymal or post vasectomy obstruction [97]. Risk associated with ICSI such as ovarian hyperstimulation, multiple gestations, and congenital anomalies must be discussed with the couple [98–100].

Sperm retrieval for OA is done either during surgical correction for possible future use or primarily if the patient opted to go for ICSI. Methods used for sperm retrieval are listed in Table 8.2.

The choice of method depends on the surgical and embryologist preference with no impact on the ICSI outcome [102]. Similarly, using fresh sperms or freezing the sperms for future use has no impact on ICSI outcomes with clinical pregnancy rates of 30–40% and delivery rate of 30% [103–106].