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In its 1993 report the Canadian Royal Commission on New Reproductive Technologies challenged the effectiveness of in vitro fertilization for severe male infertility. To address the Commission's concern, the authors compared the relative effectiveness of in vitro fertilization combined with intracytoplasmic sperm injection for severe male infertility and conventional in vitro fertilization for complete tubal occlusion in women.This historical cohort study was done at the PROCREA Fertility Centre, a private tertiary human reproduction centre in Montreal. Three groups of infertile couples were compared: 122 couples with severe male infertility treated by in vitro fertilization with intracytoplasmic injection of fresh sperm from ejaculate (group 1); 27 couples with obstructive azoospermia treated by in vitro fertilization with intracytoplasmic injection of epididymal sperm (collected by microepididymal or percutaneous epididymal sperm aspiration) (group 2); and 98 couples with tubal factor infertility (bilateral tubal occlusion) treated with conventional in vitro fertilization (with sperm from ejaculate) (group 3). The main outcomes measured were rates of fertilization, pregnancy, clinical pregnancy and implantation.Pregnancy rates per started cycle were 35%, 40% and 34% for groups 1, 2 and 3 respectively. When prognostic factors were controlled for, none of the outcome measures differed significantly between the 3 groups.In vitro fertilization with intracytoplasmic injection of sperm from the ejaculate or the epididymis is as effective for treating severe male infertility as conventional in vitro fertilization is for treating complete occlusion of the fallopian tubes in women.