Research examines vasectomy reversal
As a family planning provider, you stress in your contraceptive counseling that vasectomy is a permanent form of birth control. However, even with careful counseling, some men will seek reversal following a divorce or remarriage, a child’s death, or when they desire more children.1
About 45 million couples throughout the world are using vasectomy as a method of birth control, compared with about 150 million for female sterilization.2 In the United States, approximately half a million vasectomies are performed each year.3 It is estimated about one out of six men older than age 35 in the United States have received vasectomies, with the prevalence increasing along with education and income. Among married couples in the United States, only female sterilization and oral contraception are relied upon more often for birth control.3 The probability of pregnancy after vasectomy is about 0.1% in the first year.1
It is estimated that up to 6% of men who undergo voluntary sterilization eventually will request reversal.4 For those who do seek reversal, recently published research indicates that vasectomy reversal is effective and compares favorably with intracytoplasmic sperm injection (ICSI), an assisted reproductive technology procedure, for achieving pregnancy.5
"The general belief that vasectomy reversal is less effective than assisted reproductive technology for these patients is not always correct," states Lawrence Ross, MD, president of the Society for Male Reproduction and Urology, an affiliate of the Birmingham, AL-based American Society for Reproductive Medicine. "This study, considered with other studies showing that the per-delivery cost-effectiveness of vasectomy reversal compares favorably with that of assisted reproductive technologies, will strengthen the interest in vasectomy reversal as a treatment option."
A vasectomy reversal involves a surgical procedure that restores the flow of sperm through the vasa deferens, the tubular structures that allow sperm to travel from the testicles. It usually is performed by an experienced microsurgeon using specialized instruments, including an operating microscope.6
Vasectomy reversal costs, including the surgeon’s fee, the hospital’s charge for use of the operating room and ambulatory care facility, and the anesthesia fee, can range from approximately $5,000 to $15,000.6 In comparison, ICSI adds about $2,500 to the cost of in vitro fertilization, which can range from $8,000 to $10,000.7
A vasovasostomy, which entails stitching the cut ends of the vas deferens together, is the operation most frequently performed for vasectomy reversal.6 However, if excessive inflammation or scarring has occurred in the epididymis, a vasoepididymostomy must be performed to bypass the blockage. This procedure entails stitching one end of the vas deferens directly to the epididymis.
Look at the research
In the just-published research, physicians at the Oregon Health and Science University in Portland found that men electing reversal 15 or more years after their initial vasectomy procedure had slightly better chances of achieving pregnancy with their partners than men undergoing a sperm extraction procedure combined with in vitro fertilization and ICSI.5
The study group included 116 men who waited at least 15 years from the time of vasectomy to the time of reversal. The investigators compared pregnancy rates for this group with published results for a patient group that had utilized ICSI for obstructive azoospermia (absence of sperm in the ejaculate due to an obstruction), since vasectomy results in a comparable, though intentionally-created, condition. They found an overall pregnancy rate of 43% for vasectomy reversal patients, compared to a pregnancy rate of 40% for ICSI patients.
According to the research findings, the most important influence on pregnancy rates for post-reversal patients is the age of the female partner. Researchers found that when the female partner was younger than age 30, couples had a 64% chance of conceiving; when the female partner’s age was older than 40, the pregnancy rate dropped to 28%. The obstructive interval also had an impact on pregnancy rates; men who had an interval of 15-19 years between vasectomy and reversal had a pregnancy rate of 49% vs. a rate of 33% for men with an interval of 20-25 years.
"The success of reversal is dependent on several things, including the length of time since the vasectomy," says Eugene Fuchs, MD, professor of surgery/urology at Oregon Health Sciences University and lead author of the research. "If you have your vasectomy reversed before seven years or so, the results are around 75%-80%; if you wait until 15 years, then it is around 40%-45%."
It’s still permanent
Better microsurgical techniques, use of vasoepididymostomies, and awareness of the influences of partner age and interval time have led to increased success rates for vasectomy reversals, observes Fuchs, who estimates he has performed more than 2,200 such procedures in the past 20 years.
However, Fuchs says he has not changed his counseling prior to performing vasectomies. He continues to tell patients that they should not have a vasectomy if they are seriously considering having it undone in a few years.
"It isn’t a temporary form of birth control; it is a permanent form of birth control," states Fuchs. "Because even under the very best of circumstances, reversal is not 100%."
References
1. Hatcher RA, Trussell J, Stewart F, et al. Contraceptive Technology. 17th revised ed. New York City: Ardent Media; 1998.
2. Finger WR. Attracting men to vasectomy. Network 1998; 18(3):27.
3. National Institute of Child Health and Human Development. Facts about Vasectomy Safety. Bethesda, MD; 1996.
4. Potts JM, Pasqualotto FF, Nelson D, et al. Patient characteristics associated with vasectomy reversal. J Urol 1999; 161:1,835-1,839.
5. 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; 77:516-519.
6. Fisch H. The Patient’s Guide to Vasectomy Reversal. New York City: Center for Biomedical Communications Columbia Presbyterian Medical Center; 1995.
7. Paying the Price for Infertility. Accessed at www.drkoop.com/hcr/insurance/library/health/basics/infertility3.asp.
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