Vasectomy reversal is the most common microsurgical intervention for the treatment of male infertility. Originally introduced in 1977, microsurgical vasectomy reversal has become highly sophisticated and is a minimally invasive, highly efficient and cost-effective treatment option for men with a desire to have children after vasectomy. It can be an effective physiological method of restoring fertility in more than 90% of vasectomized men. Although assisted reproductive technology (ART) is an alternative to vasectomy reversal, it is normally associated with higher costs without offering higher cumulative chances of a pregnancy. Recovery of physiological male fertility can take up to 2 years after vasectomy reversal, especially if reversal is performed >10 years after vasectomy, owing to impaired epididymal function. Under these circumstances, ART can be used to bridge the time until recovery of natural fertility. Although the basic principles of microsurgical vasovasostomy have been established since the late 1970s, there have since been numerous technical innovations to improve the delicate operation and promising new technical modifications, particularly for vasoepididymostomy, have been described. Robotic vasectomy reversal is an emerging field in specialized urologic centers, but whether the high quality of conventional microsurgical vasectomy reversal can be matched by robotic platforms is yet to be seen.