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?

Since 1986, we have performed microscopic reconstruction in 18 menfollowing failed microscopic vasectomy reversal. Between 1994 and 1996,nine couples have undergone microscopic epididymal sperm aspiration (MESA)/intracytoplasmic sperm injection (ICSI) treatment for male infertility dueeither to congenital absence of the vas deferens (CAVD) or inoperableexcurrent duct obstruction. We compared the cost efficiency of repeatvasectomy reversal to that for MESA combined with ICSI/in-vitrofertilization (ICSI/IVF). The cost of male partner procedures (vasectomyreversal, MESA) was based on physician and hospital charges, while the costof ICSI/IVF included preparation of the female partner (medications andphysician charges) and procedures (physician and hospital charges includingoocyte retrieval, micromanipulation, and embryo transfer). Our costexamination does not include charges related to follow-up visits, prenatalmonitoring, complications of pregnancy (i.e. miscarriage) or delivery ineither group. Overall patency and pregnancy rates in the repeat vasectomyreversal group were 78 and 44% respectively. The cost per delivered baby(including multiple metachronos deliveries per couple) was $14892.Fertilization of oocytes has been achieved in 37/72 (51%) and pregnancieshave occurred in 6/9 (67%) attempts and 5/9 (56%) report delivery. Theaverage cost per pregnancy was $25637 and the average cost per deliveredbaby (or ongoing pregnancy) was $35570. The cost per delivery by MESA/ICSI/IVF is 2.4 times the charges per delivery obtained through repeatvasectomy repair. Couples attempting to overcome infertility caused byvasal obstruction should be informed that vas reconstruction remains a costeffective means of re- establishing fertility even in men who havepreviously failed vasectomy reversal.