Vasectomy Reversal: Treatment of Choice for Fertility After Vasectomy

Risk, cost, morality impact decision

By: Edmund Sabanegh, MD

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With more than 500,000 vasectomies performed in the United States annually, it comes as no surprise that between 2 and 6 percent of men will change their minds and want to have additional children. While surgical sperm retrieval with intracytoplasmic sperm injection (ICSI) is an option for these couples, vasectomy reversal offers distinct advantages in the areas of success rates for obtaining healthy offspring, cost-effectiveness and safety.

Vasectomy reversal

Vasectomy reversal is a low-risk, outpatient procedure with minor complication rates of well under 1 percent in large series. The choice of reconstruction techniques including vasovasostomy (Fig. 1, A) and vasoepididymostomy (Fig. 1, B) ultimately depends on the level of genital tract obstruction. Longer intervals since the vasectomy raise the chances of secondary epididymal obstructions which necessitate the performance of vasoepididymostomy for restoration of patency.

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Vasovasostomy

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Vasoepididymostomy

Ultimately the success of the procedure depends largely on the time since the vasectomy, as well as the female partner’s age and baseline fertility potential. In the hands of experienced microsurgeons, patency and pregnancy rates range from 82 to 91 percent in patients who are within 15 years of their vasectomy (Fig. 2).

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Figure 2: Obstructive interval and vasectomy reversal. Adapted from Boorjian et al.2

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Female partner age has a marked effect on fertility after vasectomy reversal with pregnancy rates ranging from 54 to 67 percent in women in their 20s through 40, and dropping to 14 percent in women over 40. These rates compare quite favorably to the most recent national data on in vitro fertilization pregnancy rates, with 28 to 46 percent pregnancy rates in women between 20 and 40 years old, and only 9 to 19 percent for women in their 40s.

Assessing costs

In the current cost-conscious environment of healthcare, any comparison of options must also consider cost-effectiveness as an outcome. Most healthcare plans do not consider post-vasectomy fertility to be a covered benefit and, thus, this represents an out-of-pocket expense for couples.

Since 1997, there have been four different cost analyses assessing cost per delivery, all showing large cost advantages to vasectomy reversal over sperm retrieval and ICSI. The most recent analysis confirmed this as it reported cost per successful delivery of around $21,000 for vasectomy reversal vs. between $55,000 and $57,000 for ICSI.

Moral and risk-associated considerations

An even more fundamental question involves the long-term safety and the couple’s attitudes/beliefs toward ICSI. Several studies have suggested small but significant increases in chromosomal anomalies in ICSI offspring. There are also emerging questions regarding potential epigenetic abnormalities in ICSI children which will require large-scale analyses to answer.

In addition, because ICSI cycles often transfer multiple embryos, they are associated with much higher percentages of multiple gestation pregnancies with twins, triplets and higher-order gestations occurring in 20 to 28 percent of pregnancies in mothers younger than age 40. High gestation pregnancies can confer health risks to the offspring and mother.

From a maternal safety perspective, ovarian stimulation protocols required for ICSI have been associated with severe ovarian hyperstimulation syndrome which, while occurring in less than 1 percent of cycles, can potentially be fatal due to associated ascites, liver failure and clotting disorders.

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Finally, natural conception avoids the moral, ethical and religious dilemma that many couples face as they consider the use of assisted reproductive technologies such as ICSI. ICSI involves fertilization of larger numbers of oocytes than are used for the cycle, creating the ethical quandary of the management of unused oocytes and embryos.

A clear choice

As couples search for the most natural, safe and cost-effective technique to have a healthy child after vasectomy, vasectomy reversal clearly emerges as the procedure of choice. It is associated with significantly higher pregnancy rates than are observed with ICSI. It remains the gold standard for the restoration of fertility in the post-vasectomy patient.

Presented at this year’s AUA meeting in New Orleans, Louisiana.

This article originally appeared in AUA News: Volume 20, Issue 9, and is reprinted with permission.

Dr. Sabanegh is Cleveland Clinic’s Associate Chief of Staff, Chairman of the Department of Urology and Professor of Surgery at Cleveland Clinic Lerner College of Medicine at Case Western Reserve University. He also is Vice-Chair of the Glickman Urological & Kidney Institute and Director of the Center for Male Fertility at Cleveland Clinic. For more information contact Dr. Sabanegh at sabanee@ccf.org.