Vasectomy reversal versus IVF with sperm retrieval: which is better?

Anand Shridharani and Jay I. Sandlow

Department of Urology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Correspondence to Jay I. Sandlow, MD, Vice Chair, Department of Urology, Medical College of Wisconsin, 9200 W. Wisconsin Avenue, Milwaukee, WI 53226, USA Tel: +1 414 805 0805; fax: +1 414 805 0771; e-mail: jsandlow@mcw.edu Current Opinion in Urology 2010, 20:503509

Purpose of review This paper will describe why this review is timely and relevant. Over the past two decades, treatment options for couples with reconstructible obstructive azoospermia have improved tremendously. Advances in assisted reproductive technologies (ART), specically sperm retrieval techniques for intracytoplasmic sperm injection coupled with in-vitro fertilization, as well as renements in microsurgical reconstruction have led to improved outcomes and cost-effectiveness. Providing the most up-to-date care based on the most recent data allows for better patient outcomes and satisfaction. Recent ndings Microsurgical reconstruction of the vas has remained a cost-effective, reliable and effective means of restoring fertility in the majority of men who have previously undergone vasectomy when the reconstruction is performed by an experienced microsurgeon. However, there are specic instances in which sperm retrieval/IVF/ICSI may be a more appropriate treatment modality as ART techniques continue to improve. Summary Data comparing surgical reconstruction versus sperm retrieval/ICSI/IVF are neither randomized nor homogenous. Therefore, a comprehensive understanding of the factors that can affect outcomes, overall cost, and the morbidity associated with each treatment modality, respective of the institution providing the treatment, is strongly recommended. Keywords cost-effectiveness, female fecundity, in-vitro fertilization, sperm acquisition, vasectomy reversal
Curr Opin Urol 20:503509 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins 0963-0643

Introduction
Since the inception of intracytoplasmic sperm injection (ICSI) in the early 1990s, the treatment options for couples who have undergone vasectomy and want to resume having children has changed drastically [1,2]. Classically, surgical reconstruction of the vas deferens by vasovasostomy or vasoepididymostomy was the standard of care. However, with the advent of ICSI and improved sperm retrieval techniques used in conjunction with in-vitro fertilization (IVF), couples may achieve comparable live delivery rates to microsurgical reconstruction. This has led to an ongoing debate on which form of therapy, microsurgical reconstruction versus sperm retrieval/ICSI/IVF, is more effective and appropriate for the couple wishing to have a child postvasectomy. When comparing the two forms of therapy, multiple issues need to be addressed prior to selecting a treatment modality. These include the morbidity of the procedure, the likelihood of achieving a live birth, the direct and
0963-0643 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

indirect costs, female fertility issues, future contraception needs, as well as social and cultural concerns that are important in choosing the appropriate treatment. In this review, we will address these concerns, briey review the treatment options, and highlight areas in which one form of treatment may better suit the couple based on the current data and clinical practice. Of paramount importance is the understanding that most of these factors are variable and may change based on surgeon training and preference, reproductive center preference, geographic access to care, and patient needs. To date, no randomized controlled trials exist to guide our decision-making; therefore, treatment must be tailored to each situation differently.

Vasectomy reversal for obstructive azoospermia

Of the patients presenting with azoospermia, approximately 40% have an obstructive etiology, of which vasectomy is the most common cause. With regards to surgical
DOI:10.1097/MOU.0b013e32833f1b35

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504 Andrology, sexual dysfunction and infertility

treatment, microsurgical reconstruction, either by vasovasostomy or vasoepididymostomy, represents the standard of care. Approximately 26% of patients who have undergone vasectomy will seek reversal to restore fertility [36]. Vasovasostomy consists of excising the obstructed length of the vas and a reanastomosis of the cut ends [7,8]. Multiple variations of this technique exist, including a multilayer and modied one-layer anastomosis, the details of which are described elsewhere [9]. Patency and live delivery rates do not seem to be affected by the technique [3]. The overall patency rate and live birth rate of vasectomy reversal, vasovasostomy and vasoepididymostomy together, in the peer-reviewed literature is approximately 86 and 58%, respectively. Specically for vasovasostomy, most series report the patency rate and live birth rates of 8598%, and 3884%, respectively [10]. A vasoepididymostomy is performed when signs of epididymal obstruction exist, and often the nal decision to perform one is made intraoperatively. The likelihood of performing one is proportional to the duration of obstruction [1114]. A vasoepididymostomy consists of anastomosing a patent epididymal tubule directly to the vas deferens, thus bypassing the epididymal obstruction. Multiple techniques have been described; however, we prefer an end-to-side intussuscepted anastomosis due to its facility and comparable patency to other described techniques [1517]. Lower patency rates, 7090%, and live birth rates, 3256%, have been reported when compared with vasovasostomy [1720]. Theories attributed to its lower success include longer duration of deferential obstruction necessitating a vasoepididymostomy and the technical difculty associated with creating the anastomosis, as well as potential epididymal dysfunction. One of the main factors affecting the success of vasectomy reversal is the duration of postvasectomy obstruction [3,1113]. A longer duration of obstruction correlates with the likelihood of performing a vasoepididymostomy, leads to pressure-induced changes and inammation of the epididymis. Other factors inuencing the type of vasectomy reversal include the presence or absence of sperm in the intraoperative vas uid, the gross appearance of the vas uid, the quality of the sperm in the vas uid, the length of the vas segment between the epididymis and the vasectomy site, and the presence or absence of a sperm granuloma at the vasectomy site. The likelihood of pregnancy after vasectomy reversal is also heavily inuenced by the age of the female partner [21].

nancy, compared with IVF using surgically retrieved sperm without ICSI [2224]. Sperm is retrieved either from the testis, epididymis or vas deferens. The goal of sperm retrieval is to obtain the maximum amount of viable sperm for immediate use/cryopreservation with minimal damage to the reproductive tract. Multiple techniques of sperm acquisition have been described, each with their own inherent risks and success rates. For obstructive azoospermia, there is not adequate evidence that the source or method of sperm harvesting affects the outcome of IVF [25,26]. Additionally, there is no conclusive evidence on whether fresh versus cryopreserved sperm achieves better fertilization and/or live pregnancies [27]. The decision to use a specic retrieval modality depends largely upon the surgeon retrieving the specimen and the embryologist who will handle the specimen. It is recommended that a trained surgeon perform the sperm retrieval with management of the possible complications, such as bleeding and infection in mind [21]. Microsurgical epididymal sperm aspiration (MESA), rst described by Silber et al. [28] and Temple-Smith et al. [29] in the 1980s, involves microsurgical puncture or incision or an epididymal tubule and aspiration of its contents. Usually a tubule in the proximal epididymis is chosen after the epididymal tunic is incised. Small amounts of aspirate are sufcient due to the high concentration of sperm (1 million/ml) in the proximal epididymis. Live delivery rates of 2170% have been reported [30,31,32,33]. Although a successful procedure with regards to sperm acquisition, MESA is invasive, requires microsurgical skill and has a higher cost than other sperm retrieval modalities. Nevertheless, it remains an effective method of sperm retrieval when performed by the trained microsurgeon. Percutaneous epididymal sperm aspiration (PESA) is a less invasive, cheaper, and simpler alternative to MESA. The procedure that was rst described by Craft et al. [23] and Shrivastav et al. [34], called for percutaneous aspiration of sperm from the epididymis under local anesthesia by skin inltration and cord block. There has been concern regarding unreliable sperm acquisition/DNA damage compared with testicular aspiration [35]. Nevertheless, if adequate numbers of sperm are not retrieved, a testicular sperm aspiration (TESA), or more invasive MESA or testicular sperm extraction (TESE) may be performed. Like PESA, TESA is a minimally invasive method of sperm retrieval. First described by Belker et al. [36] as a method of diagnosis for azoospermia, it has proven to be a well tolerated and effective means of sperm retrieval and is the rst-line modality at our institution for patients not undergoing microsurgical reconstruction. Pregnancy rates of up to 62% and live delivery rates up to 50% have been

Sperm retrieval with in-vitro fertilization/ intracytoplasmic sperm injection

In patients with obstructive azoospermia, use of ICSI with IVF allows for the most effective means of preg-

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Vasectomy reversal versus IVF Shridharani and Sandlow 505

14.5 (12.117.0)

reported in our own series [37]. Adequate amounts of sperm retrieved, a concern associated with percutaneous retrievals, is optimized by having an embryologist in the vicinity for immediate analysis and assessment of the aspirated tissue for immediate use or cryopreservation. TESE or open biopsy of the testicular tissue may be utilized in cases of obstructive azoospermia; however its use is more commonplace for the diagnosis and treatment of nonobstructive azoospermia. It is more invasive and costly than the previously mentioned forms of sperm retrieval.
In-vitro fertilization/intracytoplasmic sperm injection

4142

785 22.7

20.2 20.9 29.3 34.2 24.4 26.6 32.6 14

0.2

3.4

25.6 (24.127.2)

3840

3003 34.8

2.8

Table 1 The Society of Assisted Reproductive Technology data for patients with male factor infertility undergoing assisted reproductive technologies

33.6 (32.235.0)

3537

4278 39.9

3.3

2.4

IVF with ICSI has improved drastically over time and has led to improved live pregnancy rates comparable with vasectomy reversal in certain cohorts. IVF involves the use of exogenous gonadotropins to induce multifollicular growth. Once mature, the follicles are then retrieved by transvaginal ultrasound puncture and aspiration of the follicles. The retrieved embryos are then fertilized by ICSI using surgically retrieved sperm, and transferred into the womans uterus 35 days after fertilization. The number of embryos fertilized and embryos transferred depend upon female age, concern for multiple gestation, quality of sperm, and the preference of the reproductive endocrinologist, embryologist and surgeon. The outcomes may vary based on the previously mentioned factors. The use of ICSI/IVF has some risks associated with its process. The main risks involve ovarian hyperstimulation syndrome induced by exogenous gonadotropins, traumatic injury/infection associated with oocyte retrieval, multiple gestation pregnancy, and a small but not negligible risk of chromosomal anomalies in the offspring [38,39].
Sperm retrieval/in-vitro fertilization/intracytoplasmic sperm injection outcomes

2008

44.4 (43.445.4)

9722 50

<35

4.5

2.2

12.3 (9.914.8)

4142

713 22

3.7

23 (21.424.7)

3840

2490 29.7

0.2

3.2

These numbers must be placed in context because they are not necessarily representative of patients with

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Number of cycles Percentage of cycles resulting in pregnancies Percentage of cycles resulting in live births (Reliability range) Percentage of cycles with elective single embryo transfer Average number of embryos transferred Percentage of pregnancies with twins Percentage of pregnancies with triplets or more

Fresh embryos from nondonor oocytes

The Society of Assisted Reproductive Technology (SART) publishes yearly data on the effectiveness of IVF in different patient populations. A summary of the SART data for patients with male factor infertility undergoing assisted reproductive technology (ART) over a 5-year period, 2003 versus 2008, is provided in Table 1. Approximately 17% of all IVF cycles reported are performed for male factor infertility and this has remained constant since 2000. The live pregnancy rate for ART, with the use of IVF is on the rise, however. In 2003, the live delivery rate for male factor alone across all age groups was 34.5% compared with 37.3% in 2008. The use of ICSI for male factor infertility has also increased from 84 to 87%.

32.8 (31.334.4)

3537

3644 38.7

0.4

2.9

2003

40.3 (39.241.3)

8659 45.7

<35

0.6

2.6

6.4

6.2

5.1

1.9

Number of cycles Percentage of cycles resulting in pregnancies Percentage of cycles resulting in live births (Reliability range) Percentage of cycles with elective single embryo transfer Average number of embryos transferred Percentage of live births with twins Percentage of live births with triplets or more

Fresh embryos from non-donor oocytes

1.9

1.9

1.6

0.9

506 Andrology, sexual dysfunction and infertility

postvasectomy obstructive azoospermia. These patients carry the diagnosis of male factor infertility that includes the nonobstructive azoospermia population. Given the majority of patients who have undergone vasectomy had documented fertility at one time, the SART data may actually underestimate the live delivery rate and pregnancy rate in the obstructive azoospermia population.
Female factor infertility and age

delivery rate for ages 40 and under was 35.5% compared with 12.3% for 41 and older. A similar drop is noted in 2008, from 38.3 to 14.5%. Although these numbers may still continue to be an underestimation for the postvasectomy obstructive azoospermia population, the trend is evident. A possible measure of female fecundity, ovarian reserve testing, can be useful in determining which treatment option to choose. Although ovarian reserve by itself cannot dene the complete fertility potential of the partner, it may offer information to prognosticate on treatment viability and success. Its utilization would be most applicable in the partner age range of 3540 years old when ART may shorten the time to pregnancy compared with vasectomy reversal, or in the 40 years old and above population when ART success is diminished [42]. In summary, female factor is an important element in the decision for postvasectomy fertility. In the majority of couples, vasectomy reversal is more cost-effective and may even have higher pregnancy rates than sperm retrieval/IVF; however, each couple is unique and must be counseled on an individual basis.
Cost-effectiveness

The female partner should always be considered prior to undertaking any microsurgical reconstruction. The presence of signicant female factor may signicantly decrease the success of achieving live delivery even after a successful reconstruction. The fertility status of the female is related to age and other risk factors, such as ovulatory dysfunction and endometriosis. If tubal disease/obstruction is evident on evaluation, sperm retrieval/ICSI/IVF would be more appropriate than vasectomy reversal considering the morbidity and cost of microsurgery on both partners. Female age has been an independent predictor of success for both vasectomy reversal, and IVF, with a younger age associated with better outcomes. Hinz et al. [40] in a retrospective analysis found that vasectomy reversal success was signicantly worse when performed in men whose partners were 40 years or older compared with 39 years or younger. Likewise, Gerrard et al. [41] found that a female partner age greater than 40 was associated with a precipitous drop in pregnancy rate compared with younger age groups, 14 versus 5467%, respectively . The effectiveness of ICSI/IVF is also dependent on maternal fecundity. An analysis of the SART data over time shows on a yearly basis that when comparing women undergoing ICSI/IVF, that ages 40 and under have higher live birth rates than 41 years or older. In 2003, the live

When counseling patients on which modality to choose, many factors must be incorporated into the decision as mentioned previously. Of utmost importance is nding the treatment that will achieve the highest success. Unfortunately, a simple comparison of the live birth rates of each will not sufce, and no randomized controlled trials placing the two modalities head-to-head to guide our decision-making. However, efforts to compare the cost-effectiveness of each modality have been made and may offer direction in our guidance to patients (Table 2).

Table 2 Studies comparing cost-effectiveness of vasectomy reversal versus in-vitro fertilization

Author (year) Pavlovich and Schlegel (1997) [43] Kolettis and Thomas (1997) [18] Donovan et al. (1998) [44] Deck and Berger (2000) [45] Heidenreich et al. (2000) [31] Garceau et al. (2002) [46] Pasqualotto et al. (2004) [47] Meng et al. (2005) [48] Hsieh et al. (2007) [49 ] Lee et al. (2008) [50]


Study design Model Retrospective case review Retrospective case review Retrospective case review Retrospective case review Review Review Decision modeling Markov modeling Decision analysis model

More cost-effective VR versus SR/IVF VR VR VR VR VR VR VR if <15 year, SR/IVF if >15 year or female factor VR if patency >80%, SR/IVF if patency <80% VR if WTP <$65 000, SR/IVF if WTP >$65 000 VR

Comments VR pregnancy rates based on six fellowship-trained urologists, IVF pregnancy rates based on average of four different IVF centers. All VR were VE. IVF live delivery rate 29%. All VR were redo procedures; SR cost the same as VR. IVF pregnancy rates extremely low (8%) for women >36 year of age. Based on IVF pregnancy rates from 1998. Based on four studies, all retrospective. Used computer-generated model and algorithm. Based on WTP. At higher rates of WTP, female age has less impact, favors IVF. Obstructed interval no effect VR success rates based on six high-volume centers, IVF success rates based on ve high-volume centers, indirect costs also factored into analysis.

IVF, in-vitro fertilization; SR, sperm retrieval; VE; vasoepididymostomy; VR, vasectomy reversal; WTP, willingness to pay. Reproduced with permission from [42].

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Vasectomy reversal versus IVF Shridharani and Sandlow 507

Pavlovich and Schlegel [43] performed one of the rst cost-effectiveness analyses using a model based on expected costs and results of microsurgical reconstruction versus ICSI/IVF in men with postvasectomy infertility and a female partner of age less than 39. Using an estimated live birth rate for vasectomy reversal of 47% and mean weighted delivery of 33% per cycle of ICSI/IVF, the estimated cost per delivery was $25 475 and $71 896, respectively. The price range is remarkable due to the incorporation of indirect costs, that is, costs associated with lost productivity and multiple gestation pregnancies. When epididymal obstruction is present, microsurgical vasoepididymostomy can still be more cost-effective than ICSI/IVF. Kolettis and Thomas [18] demonstrated that the cost per delivery for vasoepididymostomy was $31 099 compared with $51 024 for ICSI, assuming 36 and 29% delivery rates, respectively. Indirect and direct costs were incorporated into the nal cost, and vasectomy reversal was more cost-effective than IVF/ICSI over all obstructed intervals. Meng et al. [48] performed a different type of analysis using a computer-generated decision analysis model. Vasectomy reversal was favored over ICSI/IVF in the analysis only when postreconstruction patency rates were greater than 79%. Differing from other studies, the base costs were relatively similar, with vasectomy reversal costing $38 983 and sperm retrieval/IVF/ICSI costing $39 506. This may be attributed to the lack of incorporating indirect costs into the analysis. Additionally, sperm retrieval/IVF/ICSI was suggested in the setting where a unilateral or bilateral vasoepididymostomy was anticipated because of lower associated patency rates. Hsieh et al. [49] used a Markov decision analysis model to determine the cost-effectiveness between vasectomy reversal and IVF. The Markov model allows analysis over time as the couples health state changes. It was determined through sensitivity analysis that female partner age had more of an effect on cost-effectiveness than the obstructed interval had. Additionally, for couples willing to pay up to $65 000 for their fertility treatment, vasectomy reversal was more cost-effective over the entire age group. A willingness to pay more than $65 000 was associated with more cost-effectiveness for sperm retrieval/ICSI/IVF over a greater female age group than vasectomy reversal. Lee et al. [50] compared the cost-effectiveness of vasectomy reversal with that of sperm retrieval/IVF/ICSI using TESE and MESA. In 1999, vasectomy reversal demonstrated superior cost-effectiveness to TESE and MESA ($19 633 versus $45 637 and $48 055, respectively, equivalent to $25 321 versus $58 858 and $61 977 in 2005 dollars). In 2005, vasectomy reversal ($20 903) remained

the most cost-effective treatment over TESE ($54 797) and MESA ($56 861). Vasectomy reversal remained costeffective over time, incorporating ination, direct and indirect costs into total cost. In summary, on the basis of the previous data, vasectomy reversal seems to be more cost-effective than sperm retrieval/IVF/ICSI over a broader range of female age. However, cost-effective analysis has its own limitations, and assumptions cannot be made in regard to individual couples. The average follow-up for vasectomy reversal is 1 year, whereas IVF success is measured per cycle; this may skew the data in favor of vasectomy reversal success but not necessarily alter the cost-effectiveness of each modality. Loco-regional costs and outcomes may vary greatly between institutions; therefore, reanalysis of a surgeons and IVF groups own data may serve the couple more appropriately when making a decision. Although cost containment is indoctrinated in our clinical practice, couples with the means to pay or those who have full coverage of fertility treatment by their insurance carrier may have other concerns that may lead to their decision-making. A preference of natural versus assisted conception may drive a decision to vasectomy reversal in the absence of female factor. Sperm retrieval/ICSI/IVF may be warranted if time to conception is a concern, especially in the context of advanced maternal age. On the contrary, if issues with maternal fecundity exist, based on age, vasectomy reversal may be more effective over a longer period of time given the low success rate with IVF in women with advanced maternal age and diminished ovarian reserve. The issues of maternal fecundity, multiple gestations, care of ART children downstream, and the need for future contraception after vasectomy reversal have not been considered in most cost-effective studies at large [10,42]. Unfortunately, these may not be addressed in the future due to the complexity and cost of such analyses; however, these concerns must be addressed by the practitioner to best serve their patients.

Conclusion
Many factors play a role in the decision to perform vasectomy reversal versus IVF/ICSI to treat postvasectomy obstructive azoospermia. Cost-effectiveness, obstructive interval, and female partner age are among the most studied. However, maternal fecundity, ovarian reserve, potential increased cost of obstetric care for multiple gestations associated with ART, and the need for postvasectomy reversal contraception should be strongly considered when counseling couples. Nevertheless, vasectomy reversal remains the gold standard for treatment of postvasectomy obstructive azoospermia. Ultimately, it is recommended that the physician understands the

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508 Andrology, sexual dysfunction and infertility

limitations of the current data and offer all of the options, along with the pros and cons of each, including outcomes and cost based on the providing institution, in order to help the couple arrive at an informed decision.

21 AUA 2010 Education and Research Inc. The management of obstructive  azoospermia: AUA best practice statement (revised). These guidelines were put together by a panel of male infertility experts. The statement outlines the various treatment options available. 22 Results in the United States with microaspiration retrieval techniques and assisted reproductive technologies. The Sperm Microaspiration Retrieval Techniques Study Group. J Urol 1994; 151:12551259. 23 Craft IL, Khalifa Y, Boulos A, et al. Factors inuencing the outcome of in vitro fertilization with percutaneous aspirated epididymal spermatozoa and intracytoplasmic sperm injection in azoospermic men. Hum Reprod 1995; 10:17911794. 24 Palermo GD, Schlegel PN, Hariprashad J, et al. Fertilization and pregnancy outcome with intracytoplasmic sperm injection for azoospermic men. Hum Reprod 1999; 14:741748. 25 Nicopoullos JD, Gilling-Smith C, Almeida PA, et al. Use of surgical sperm  retrieval in azoospermic men: a meta-analysis. Fertil Steril 2004; 82:691 701. This meta-analysis determined that the sperm source (epididymal versus testicular), etiology (obstructive versus nonobstructive), and fresh versus frozen did not impact fertilization or pregnancy rates in this group of patients. 26 Schwartzer JU, Fiedler K, v Hertwi I, et al. Sperm retrieval procedures and intracytoplasmatic spermatozoa injection with epididymal and testicular sperms. Urol Int 2003; 70:119123. 27 Janzen N, Goldstein M, Schlegel PN, et al. Use of electively cryopreserved microsurgically aspirated epididymal sperm with IVF and intracytoplasmic sperm injection for obstructive azoospermia. Fertil Steril 2000; 74:696701. 28 Silber S, Balmaceda J, Borrero C, et al. Pregnancy with sperm aspiration from the proximal head of the epididymis: a new treatment for congenital absence of the vas deferens. Fertil Steril 1988; 50:525528. 29 Temple-Smith P, Southwick G, Yates C. Human pregnancy by in vitro fertilization (IVF) using sperm aspirated from the epididymis. J In Vitro Fert Embryo Transf 1985; 4:298303. 30 Anger JT, Wang GJ, Boorjian SA, et al. Sperm cryopreservation and in vitro fertilization/intracytoplasmic sperm injection in men with congenital bilateral absence of the vas deferens: a success story. Fertil Steril 2004; 82:1452 1454. 31 Heidenreich A, Altmann P, Engelmann UH. Microsurgical vasovasostomy  versus microsurgical epididymal sperm aspiration/testicular extraction of sperm combined with intracytoplasmic sperm injection. A cost-benet analysis. Eur Urol 2000; 37:609614. This paper describes a single institutional experience with surgical reconstruction and sperm acquisition/IVF. The authors conclude that surgical reconstruction has a higher success rate and is more cost-effective, although there are some aws in the methodology. 32 Sharma RK, Padron OF, Thomas AJ Jr, et al. Factors associated with the quality before freezing and after thawing of sperm obtained by microsurgical epididymal aspiration. Fertil Steril 1997; 68:626631. 33 Tournaye H, Merdad T, Silber S, et al. No differences in outcome after intracytoplasmic sperm injection with fresh or with frozen-thawed epididymal spermatozoa. Hum Reprod 1999; 14:9095. 34 Shrivastav P, Nadkarni P, Wensvoort S, et al. Percutaneous epididymal sperm aspiration for obstructive azoospermia. Hum Reprod 1994; 9:20582061. 35 OConnell M, McClure N, Lewis SE. Mitochondrial DNA deletions and nuclear DNA fragmentation in testicular and epididymal human sperm. Hum Reprod 2002; 17:15651570. 36 Belker A, Sherins R, Dennison-Lagos L, et al. Percutaneous testicular sperm aspiration: a convenient and effective ofce procedure to retrieve sperm for in vitro fertilization with intracytoplasmic sperm injection. J Urol 1998; 160:20582062. 37 Garg T, LaRosa C, Strawn E, et al. Outcomes after testicular aspiration and testicular tissue cryopreservation for obstructive azoospermia and ejaculatory dysfunction. J Urol 2008; 180:25772580. 38 Schlegel PN, Girardi SK. Clinical review 87: in vitro fertilization for male factor infertility. J Clin Endocrinol Metab 1997; 82:709716. 39 Hansen M, Bowen C, Milner E, et al. Assisted reproductive technologies and the risk of birth defects: a systematic review. Hum Reprod 2005; 20:328 338. 40 Hinz S, Rais-Bahrami S, Kempkensteffen C, et al. Fertility rates affecting vasectomy reversal: importance of age of the female partner. Urol Int 2008; 81:416420. 41 Gerrard ER Jr, Sandlow JI, Oster RA, et al. Effect of female partner age on  pregnancy rates after vasectomy reversal. Fertil Steril 2007; 87:13401344. This paper demonstrates that women over 40 have a signicantly lower natural conception rate than women under 40; however, this rate is still comparable to what is reported for IVF pregnancy rates in the over 40 age group.

References and recommended reading

Papers of particular interest, published within the annual period of review, have been highlighted as:  of special interest  of outstanding interest Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 537). 1 Palermo G, Joris H, Devroey P, Van Steirteghem AC. Pregnancies after intracytoplasmic injection of single spermatozoon into an oocyte. Lancet 1992; 340:1718. Van Steirteghem AC, Nagy Z, Joris H, Devroey P, et al. High fertilization and implantation rates after intracytoplasmic sperm injection. Hum Reprod 1993; 8:10611066. Belker AM, Thomas AJ Jr, Fuchs EF, et al. Results of 1,469 microsurgical vasectomy reversals by the vasovasostomy group. J Urol 1991; 145:505 511. Fenster H, McLoughlin MG. Vasovasostomy: microscopic versus macroscopic techniques. Arch Androl 1981; 7:201204. Potts JA, Pasqualotto FF, Nelson D, et al. Patient characteristics associated with vasectomy reversal. J Urol 1999; 161:18351839. Sandlow JI, Westefeld JS, Maples MR, Scheel KR. Psychological correlates of vasectomy. Fertil Steril 2001; 75:544548. Owen E. Microsurgical vasovasostomy: a reliable vasectomy reversal. Aust N Z J Surg 1977; 47:305309. Silber S. Microscopic vasectomy reversal. Fertil Steril 1977; 28:1191 1202. Lipshultz LI, Thomas AJ Jr, Khera M. Procedures to improve sperm delivery: vasectomy reversal and vasoepididymostomy. In: Wein AJ, editor. CampbellWalsh Urology. 9th ed. vol 1. Philadelphia: WB Saunders; 2007.

4 5 6 7 8 9

10 Lee R, Li PS, Schlegel PN, Goldstein M. Reassessing reconstruction in the  management of obstructive azoospermia: reconstruction or sperm acquisition? Urol Clin North Am 2008; 35:289301. This review analyzed the success rates, as well as the costs (both direct and indirect) of surgical reconstruction and sperm acquisition/IVF for obstructive azoospermia. The authors concluded that surgical reconstruction was favored in most situations. 11 Silber SJ. Reversal of vasectomy and the treatment of male infertility. Role of microsurgery, vasoepididymostomy, and pressure-induced changes of vasectomy. Urol Clin North Am 1981; 8:5362. 12 Silber SJ. Microsurgery for vasectomy reversal and vasoepididymostomy. Urology 1984; 23:505524. 13 Fuchs EF, Burt RA. Vasectomy reversal performed 15 years or more after vasectomy: correlation of pregnancy outcome with partner age and with pregnancy results of in vitro fertilization with intracytoplasmic sperm injection. Fertil Steril 2002; 77:516519. 14 Chawla A, OBrien J, Lisi M, et al. Should all urologists performing vasectomy reversals be able to perform vasoepididymostomies if required? J Urol 2004; 172:10481050. 15 Berger RE. Triangulation end to side vasoepididymostomy. J Urol 1998; 159:19511953. 16 Marmar JL. Modied vasoepididymostomy with simultaneous double needle placement, tubulotomy, and tubular invagination. J Urol 2000; 163:483 486. 17 Chan PTK, Brandell RA, Goldstein M. Prospective analysis of outcomes after microsurgical intussusception vasoepididymostomy. BJU Int 2005; 96:598 601. 18 Kolettis PN, Thomas AJ Jr. Vasoepididymostomy for vasectomy reversal: a critical assessment in the era of intracytoplasmic sperm injection. J Urol 1997; 158:467470. 19 Matthews GJ, Schlegel PN, Goldstein M. Patency following microsurgical vasoepididymostomy and vasovasostomy: temporal considerations. J Urol 1995; 154:20702073. 20 Silber SJ, Grotjan HE. Microscopic vasectomy reversal 30 years later: a summary of 4010 cases by the same surgeon. J Androl 2004; 25:845 849.

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Vasectomy reversal versus IVF Shridharani and Sandlow 509

42 Robb P, Sandlow JI. Cost-effectiveness of vasectomy reversal. Urol Clin Norh  Am 2009; 36:391396. This is an excellent review of the factors that affect cost-effectiveness of vasectomy reversal, as well as factors to be considered when deciding between vasectomy reversal and IVF. This paper reviews the factors that are important in determining the cost-effectiveness for treatment of postvasectomy azoospermia, as well as outlining specic scenarios wherein one treatment may be superior. 43 Pavlovich C, Schlegel P. Fertility options after vasectomy: a cost-effectiveness analysis. Fertil Steril 1997; 67:133141. 44 Donovan JF Jr, DiBaise M, Sparks AE, et al. Comparison of microscopic epididymal sperm aspiration and intracytoplasmic sperm injection/in-vitro fertilization with repeat microscopic reconstruction following vasectomy: is second attempt vas reversal worth the effort? Hum Reprod 1998; 13:387 393. 45 Deck AJ, Berger RE. Should vasectomy reversal be performed in men with older female partners? J Urol 2000; 163:105106. 46 Garceau L, Henderson J, Davis LJ, et al. Economic implications of assisted reproductive techniques: a systematic review. Hum Reprod 2002; 17:3090 3109. 47 Pasqualotto FF, Lucon AM, Sobreiro BP, et al. The best infertility treatment for vasectomized men: assisted reproduction or vasectomy reversal? Rev Hosp Clin Fac Med Sao Paulo 2004; 59:312315. 48 Meng MV, Greene KL, Turek PJ. Surgery or assisted reproduction? A decision analysis of treatment costs in male infertility. J Urol 2005; 174:19261931. 49 Hsieh MH, Meng MV, Turek PJ. Markov modeling of vasectomy reversal and  ART for infertility: how do obstructive interval and female partner age inuence cost effectiveness? Fertil Steril 2007; 88:840846. The authors utilize a model to determine factors that impact cost and success in obstructive azoospermia. Although IVF provides greater success over a wider range of female age, willingness to pay inuences the outcome, with $65 000 being the cut point. 50 Lee R, Li PS, Goldstein M, et al. A decision analysis of treatments for obstructive azoospermia. Human Reprod 2008; 23:20432049.

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