C

Vasectomy reversal versus IVF w

ith 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,USATel: +1 414 805 0805; fax: +1 414 805 0771;e-mail: jsandlow@mcw.edu

Current Opinion in Urology 2010, 20:503–509

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),

specifically sperm retrieval techniques for intracytoplasmic sperm injection coupled with

in-vitro fertilization, as well as refinements 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 findings

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 specific 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 20:503–509� 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins0963-0643

IntroductionSince the inception of intracytoplasmic sperm injection

(ICSI) in the early 1990s, the treatment options for couples

who have undergone vasectomy and want to resume hav-

ing children has changed drastically [1,2]. Classically,

surgical reconstruction of the vas deferens by vasovasos-

tomy 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, micro-

surgical 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

opyright © Lippincott Williams & Wilkins. Unauth

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, briefly 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 import-

ance 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 obstructiveazoospermiaOf the patients presenting with azoospermia, approxi-

mately 40% have an obstructive etiology, of which vasec-

tomy is the most common cause. With regards to surgical

orized reproduction of this article is prohibited.

DOI:10.1097/MOU.0b013e32833f1b35

C

504 Andrology, sexual dysfunction and infertility

treatment, microsurgical reconstruction, either by vasova-

sostomy or vasoepididymostomy, represents the standard

of care. Approximately 2–6% of patients who have under-

gone vasectomy will seek reversal to restore fertility [3–6].

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 modified 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 vasect-

omy reversal, vasovasostomy and vasoepididymostomy

together, in the peer-reviewed literature is approximately

86 and 58%, respectively. Specifically for vasovasostomy,

most series report the patency rate and live birth rates of

85–98%, and 38–84%, respectively [10�].

A vasoepididymostomy is performed when signs of epi-

didymal obstruction exist, and often the final decision to

perform one is made intraoperatively. The likelihood of

performing one is proportional to the duration of obstruc-

tion [11–14]. A vasoepididymostomy consists of anasto-

mosing 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 [15–17]. Lower patency rates, 70–90%, and

live birth rates, 32–56%, have been reported when com-

pared with vasovasostomy [17–20]. Theories attributed

to its lower success include longer duration of deferential

obstruction necessitating a vasoepididymostomy and the

technical difficulty associated with creating the anasto-

mosis, as well as potential epididymal dysfunction.

One of the main factors affecting the success of vasectomy

reversal is the duration of postvasectomy obstruction

[3,11–13]. A longer duration of obstruction correlates with

the likelihood of performing a vasoepididymostomy, leads

to pressure-induced changes and inflammation of the

epididymis. Other factors influencing the type of vasect-

omy reversal include the presence or absence of sperm in

the intraoperative vas fluid, the gross appearance of the vas

fluid, the quality of the sperm in the vas fluid, the length of

the vas segment between the epididymis and the vasect-

omy site, and the presence or absence of a sperm granu-

loma at the vasectomy site. The likelihood of pregnancy

after vasectomy reversal is also heavily influenced by the

age of the female partner [21�].

Sperm retrieval with in-vitro fertilization/intracytoplasmic sperm injectionIn patients with obstructive azoospermia, use of ICSI

with IVF allows for the most effective means of preg-

opyright © Lippincott Williams & Wilkins. Unautho

nancy, compared with IVF using surgically retrieved

sperm without ICSI [22–24]. 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 tech-

niques 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 con-

clusive evidence on whether fresh versus cryopreserved

sperm achieves better fertilization and/or live pregnan-

cies [27]. The decision to use a specific retrieval modality

depends largely upon the surgeon retrieving the speci-

men and the embryologist who will handle the specimen.

It is recommended that a trained surgeon perform the

sperm retrieval with management of the possible com-

plications, such as bleeding and infection in mind [21�].

Microsurgical epididymal sperm aspiration (MESA), first

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 sufficient due to the high con-

centration of sperm (1 million/ml) in the proximal epidi-

dymis. Live delivery rates of 21–70% 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 first described by Craft et al. [23]

and Shrivastav et al. [34], called for percutaneous aspira-

tion of sperm from the epididymis under local anesthesia

by skin infiltration and cord block. There has been

concern regarding unreliable sperm acquisition/DNA

damage compared with testicular aspiration [35]. Never-

theless, 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 first-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

rized reproduction of this article is prohibited.

C

Vasectomy reversal versus IVF Shridharani and Sandlow 505

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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

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 woman’s uterus 3–5 days after fertilization. The num-

ber of embryos fertilized and embryos transferred depend

upon female age, concern for multiple gestation, quality of

sperm, and the preference of the reproductive endocrinol-

ogist, 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, trau-

matic injury/infection associated with oocyte retrieval,

multiple gestation pregnancy, and a small but not neg-

ligible risk of chromosomal anomalies in the offspring

[38,39].

Sperm retrieval/in-vitro fertilization/intracytoplasmic

sperm injection outcomes

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 per-

formed 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%.

These numbers must be placed in context because

they are not necessarily representative of patients with

opyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

C

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 preg-

nancy rate in the obstructive azoospermia population.

Female factor infertility and age

The female partner should always be considered prior to

undertaking any microsurgical reconstruction. The pre-

sence of significant female factor may significantly

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 dis-

ease/obstruction is evident on evaluation, sperm retrie-

val/ICSI/IVF would be more appropriate than vasectomy

reversal considering the morbidity and cost of microsur-

gery 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 suc-

cess was significantly 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 54–67%, 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

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

uthor (year) Study designMore cost-effective VRversus SR/IVF Comments

avlovich and Schlegel (1997) [43] Model VR VR pregnancy rates based on six fellowship-trainedurologists, IVF pregnancy rates based on averageof four different IVF centers.

olettis and Thomas (1997) [18] Retrospective case review VR All VR were VE. IVF live delivery rate 29%.onovan et al. (1998) [44] Retrospective case review VR All VR were redo procedures; SR cost the same as VR.eck and Berger (2000) [45] Retrospective case review VR IVF pregnancy rates extremely low (8%) for women

>36 year of age.eidenreich et al. (2000) [31�] Retrospective case review VR Based on IVF pregnancy rates from 1998.arceau et al. (2002) [46] Review VR Based on four studies, all retrospective.asqualotto et al. (2004) [47] Review VR if <15 year, SR/IVF if

>15 year or female factor—

eng et al. (2005) [48] Decision modeling VR if patency >80%, SR/IVFif patency <80%

Used computer-generated model and algorithm.

sieh et al. (2007) [49�] Markov modeling VR if WTP <$65 000, SR/IVFif WTP >$65 000

Based on WTP. At higher rates of WTP, female agehas less impact, favors IVF. Obstructed intervalno effect

ee et al. (2008) [50] Decision analysis model VR VR success rates based on six high-volumecenters, IVF success rates based on fivehigh-volume centers, indirect costs alsofactored into analysis.

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

T

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opyright © Lippincott Williams & Wilkins. Unautho

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 postva-

sectomy 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 define 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 35–40 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 dimin-

ished [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 retrie-

val/IVF; however, each couple is unique and must be

counseled on an individual basis.

Cost-effectiveness

When counseling patients on which modality to choose,

many factors must be incorporated into the decision as

mentioned previously. Of utmost importance is finding

the treatment that will achieve the highest success.

Unfortunately, a simple comparison of the live birth rates

of each will not suffice, 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).

rized reproduction of this article is prohibited.

C

Vasectomy reversal versus IVF Shridharani and Sandlow 507

Pavlovich and Schlegel [43] performed one of the first

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 final 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 incorpor-

ating indirect costs into the analysis. Additionally, sperm

retrieval/IVF/ICSI was suggested in the setting where

a unilateral or bilateral vasoepididymostomy was anti-

cipated 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 couple’s health state changes. It was deter-

mined 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, vasect-

omy 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 retrie-

val/ICSI/IVF over a greater female age group than vasec-

tomy reversal.

Lee et al. [50] compared the cost-effectiveness of vasect-

omy reversal with that of sperm retrieval/IVF/ICSI using

TESE and MESA. In 1999, vasectomy reversal demon-

strated superior cost-effectiveness to TESE and MESA

($19 633 versus $45 637 and $48 055, respectively, equiv-

alent to $25 321 versus $58 858 and $61 977 in 2005

dollars). In 2005, vasectomy reversal ($20 903) remained

opyright © Lippincott Williams & Wilkins. Unauth

the most cost-effective treatment over TESE ($54 797)

and MESA ($56 861). Vasectomy reversal remained cost-

effective over time, incorporating inflation, 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

surgeon’s and IVF group’s 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.

ConclusionMany factors play a role in the decision to perform vasect-

omy 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 post-

vasectomy reversal contraception should be strongly con-

sidered when counseling couples. Nevertheless, vasect-

omy reversal remains the gold standard for treatment

of postvasectomy obstructive azoospermia. Ultimately,

it is recommended that the physician understands the

orized reproduction of this article is prohibited.

C

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.

References and recommended readingPapers of particular interest, published within the annual period of review, havebeen highlighted as:� of special interest�� of outstanding interest

Additional references related to this topic can also be found in the CurrentWorld Literature section in this issue (p. 537).

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3 Belker AM, Thomas AJ Jr, Fuchs EF, et al. Results of 1,469 microsurgicalvasectomy reversals by the vasovasostomy group. J Urol 1991; 145:505–511.

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�Lee R, Li PS, Schlegel PN, Goldstein M. Reassessing reconstruction in themanagement of obstructive azoospermia: reconstruction or sperm acquisi-tion? Urol Clin North Am 2008; 35:289–301.

This review analyzed the success rates, as well as the costs (both direct andindirect) of surgical reconstruction and sperm acquisition/IVF for obstructiveazoospermia. The authors concluded that surgical reconstruction was favoredin most situations.

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�AUA 2010 Education and Research Inc. The management of obstructiveazoospermia: AUA best practice statement (revised).

These guidelines were put together by a panel of male infertility experts. Thestatement outlines the various treatment options available.

22 Results in the United States with microaspiration retrieval techniques andassisted reproductive technologies. The Sperm Microaspiration RetrievalTechniques Study Group. J Urol 1994; 151:1255–1259.

23 Craft IL, Khalifa Y, Boulos A, et al. Factors influencing the outcome of in vitrofertilization with percutaneous aspirated epididymal spermatozoa and intra-cytoplasmic sperm injection in azoospermic men. Hum Reprod 1995;10:1791–1794.

24 Palermo GD, Schlegel PN, Hariprashad J, et al. Fertilization and pregnancyoutcome with intracytoplasmic sperm injection for azoospermic men. HumReprod 1999; 14:741–748.

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�Nicopoullos JD, Gilling-Smith C, Almeida PA, et al. Use of surgical spermretrieval in azoospermic men: a meta-analysis. Fertil Steril 2004; 82:691–701.

This meta-analysis determined that the sperm source (epididymal versus testicu-lar), etiology (obstructive versus nonobstructive), and fresh versus frozen did notimpact fertilization or pregnancy rates in this group of patients.

26 Schwartzer JU, Fiedler K, v Hertwi I, et al. Sperm retrieval procedures andintracytoplasmatic spermatozoa injection with epididymal and testicularsperms. Urol Int 2003; 70:119–123.

27 Janzen N, Goldstein M, Schlegel PN, et al. Use of electively cryopreservedmicrosurgically aspirated epididymal sperm with IVF and intracytoplasmicsperm injection for obstructive azoospermia. Fertil Steril 2000; 74:696–701.

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30 Anger JT, Wang GJ, Boorjian SA, et al. Sperm cryopreservation and in vitrofertilization/intracytoplasmic sperm injection in men with congenital bilateralabsence of the vas deferens: a success story. Fertil Steril 2004; 82:1452–1454.

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�Heidenreich A, Altmann P, Engelmann UH. Microsurgical vasovasostomyversus microsurgical epididymal sperm aspiration/testicular extraction ofsperm combined with intracytoplasmic sperm injection. A cost-benefit ana-lysis. Eur Urol 2000; 37:609–614.

This paper describes a single institutional experience with surgical reconstructionand sperm acquisition/IVF. The authors conclude that surgical reconstruction hasa higher success rate and is more cost-effective, although there are some flaws inthe methodology.

32 Sharma RK, Padron OF, Thomas AJ Jr, et al. Factors associated with thequality before freezing and after thawing of sperm obtained by microsurgicalepididymal aspiration. Fertil Steril 1997; 68:626–631.

33 Tournaye H, Merdad T, Silber S, et al. No differences in outcome afterintracytoplasmic sperm injection with fresh or with frozen-thawed epididymalspermatozoa. Hum Reprod 1999; 14:90–95.

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36 Belker A, Sherins R, Dennison-Lagos L, et al. Percutaneous testicular spermaspiration: a convenient and effective office procedure to retrieve sperm forin vitro fertilization with intracytoplasmic sperm injection. J Urol 1998;160:2058–2062.

37 Garg T, LaRosa C, Strawn E, et al. Outcomes after testicular aspiration andtesticular tissue cryopreservation for obstructive azoospermia and ejaculatorydysfunction. J Urol 2008; 180:2577–2580.

38 Schlegel PN, Girardi SK. Clinical review 87: in vitro fertilization for male factorinfertility. J Clin Endocrinol Metab 1997; 82:709–716.

39 Hansen M, Bowen C, Milner E, et al. Assisted reproductive technologies andthe 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 affectingvasectomy reversal: importance of age of the female partner. Urol Int 2008;81:416–420.

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�Gerrard ER Jr, Sandlow JI, Oster RA, et al. Effect of female partner age onpregnancy rates after vasectomy reversal. Fertil Steril 2007; 87:1340–1344.

This paper demonstrates that women over 40 have a significantly lower naturalconception rate than women under 40; however, this rate is still comparable towhat is reported for IVF pregnancy rates in the over 40 age group.

rized reproduction of this article is prohibited.

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Vasectomy reversal versus IVF Shridharani and Sandlow 509

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�Robb P, Sandlow JI. Cost-effectiveness of vasectomy reversal. Urol Clin NorhAm 2009; 36:391–396.

This is an excellent review of the factors that affect cost-effectiveness ofvasectomy reversal, as well as factors to be considered when decidingbetween vasectomy reversal and IVF. This paper reviews the factors that areimportant in determining the cost-effectiveness for treatment of postvasectomyazoospermia, as well as outlining specific scenarios wherein one treatment may besuperior.

43 Pavlovich C, Schlegel P. Fertility options after vasectomy: a cost-effectivenessanalysis. Fertil Steril 1997; 67:133–141.

44 Donovan JF Jr, DiBaise M, Sparks AE, et al. Comparison of microscopicepididymal sperm aspiration and intracytoplasmic sperm injection/in-vitrofertilization with repeat microscopic reconstruction following vasectomy: issecond attempt vas reversal worth the effort? Hum Reprod 1998; 13:387–393.

45 Deck AJ, Berger RE. Should vasectomy reversal be performed in men witholder female partners? J Urol 2000; 163:105–106.

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46 Garceau L, Henderson J, Davis LJ, et al. Economic implications of assistedreproductive techniques: a systematic review. Hum Reprod 2002; 17:3090–3109.

47 Pasqualotto FF, Lucon AM, Sobreiro BP, et al. The best infertility treatment forvasectomized men: assisted reproduction or vasectomy reversal? Rev HospClin Fac Med Sao Paulo 2004; 59:312–315.

48 Meng MV, Greene KL, Turek PJ. Surgery or assisted reproduction? A decisionanalysis of treatment costs in male infertility. J Urol 2005; 174:1926–1931.

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�Hsieh MH, Meng MV, Turek PJ. Markov modeling of vasectomy reversal andART for infertility: how do obstructive interval and female partner age influencecost effectiveness? Fertil Steril 2007; 88:840–846.

The authors utilize a model to determine factors that impact cost and success inobstructive azoospermia. Although IVF provides greater success over a widerrange of female age, willingness to pay influences the outcome, with $65 000being the cut point.

50 Lee R, Li PS, Goldstein M, et al. A decision analysis of treatments forobstructive azoospermia. Human Reprod 2008; 23:2043–2049.

orized reproduction of this article is prohibited.