JBRA Assisted Reproduction 2025;29(Suppl.2 SBRA 2025):254
Poster Presentation
29th Annual Congress of the SBRA. São Paulo/SP - Brazil, 2025
doi: 10.5935/1518-0557.20263827
P-242. Vasectomy Reversal versus Assisted Reproductive Tech niques: A Contemporaneous Cost-Effectiveness and Outcome-Based Analysis for Post-Vasectomy Fertility Restoration
Isabela Ferreira Torres1, Maiara Peixoto Paiva2, Clara Murta Nassif3, Melynne Maira dos Reis Henriques3, Marcelo Horta Furtado4
1 Faculdade Ciências Médicas de Minas Gerais - Minas Gerais – Brasil
2 Hospital Mater Dei, Belo Horizonte – MG – Brasil
3 Faculdade Ciências Médicas de Minas Gerais - Belo Horizonte – MG -Brasil
4 Departamento de Reprodução da Rede Mater Dei de Saude - Belo Horizonte – MG - Brasil
Objective: To compare vasectomy reversal (VR) and intracytoplasmic sperm injection (ICSI) with surgical sperm retrieval (SR) in terms of reproductive outcomes and cost-effectiveness for fertility restoration in men with prior vasectomy, particularly considering cases with prolonged obstruction intervals and/or advanced maternal age.
Methods: A comprehensive literature review and decision-analytic modeling were conducted to evaluate reproductive outcomes, costs, and clinical variables influencing the success of VR versus ICSI with SR. The analysis included data on surgical success rates, pregnancy and live birth rates, complications, and direct and indirect treatment costs. Specific attention was given to key prognostic factors such as female partner age and vasectomy-obstruction interval. Cost-per-live birth and cost-per-quality-adjusted life year (QALY) were used to assess cost-effectiveness across various clinical scenarios.
Results: VR yields high patency rates (80–95%) and pregnancy rates ranging from 44–60% following vasovasostomy and approximately 41% after vasoepididymostomy. Live birth rates following VR range from 36% to 47%. ICSI with SR achieves comparable live birth outcomes (18–54% per attempt), but with greater procedural burden and cost. Notably, the average time to pregnancy is significantly shorter with ICSI and SR (~8.2 months) compared to VR (~16 months), due to the natural conception process following surgical recovery in the latter. Despite this faster timeline, VR remains consistently more cost-effective. Cost per live birth ranges from $14,892 to $31,099 for VR, compared to $51,024 to $103,940 for ICSI with SR. Moreover, decision models incorporating combined strategies—such as "backup VR" with cryopreserved sperm—further improved outcomes and cost-efficiency. VR remained the most cost-effective approach across all age groups, with cost-per-QALY values below $7,500, outperforming all other strategies, including ICSI-only treatments. Even in women over 37 years old, where urgency is often greater, live birth rates were similar between strategies (17% for VR vs. 19.7% for ART), but with markedly lower costs for reversal. Additionally, VR allows for natural conception of multiple pregnancies without repeated intervention. In men with prolonged obstruction intervals (>15 years), VR still achieved high success rates when performed by experienced microsurgeons, with one cohort showing 85% patency, 43% pregnancy, and 36% live birth rates. ART in this setting also experiences diminished outcomes due to the negative effects of long obstruction on sperm quality. Finally, ART shifts the majority of procedural risks to the female partner, including hormonal stimulation, oocyte retrieval, and higher rates of multiple gestation and associated complications. VR, in contrast, avoids these burdens and offers long-term reproductive autonomy for couples.
Conclusion: Although ICSI with SR achieves pregnancy more quickly, microsurgical VR remains the most cost-effective and clinically comparable fertility restoration strategy for men after vasectomy, even in cases of advanced maternal age and long obstruction intervals. When performed by experienced surgeons, VR provides natural conception opportunities, lower female partner burden, and the possibility of multiple pregnancies without additional interventions. Although ICSI with SR is a viable alternative, particularly in cases of female infertility, it should not be the default choice based solely on maternal age or obstruction duration. Treatment planning should be individualized, prioritizing shared decision-making based on reproductive goals, clinical conditions, timing expectations, and financial resources. VR should be presented as a first-line treatment, and combined strategies with SR and cryopreservation may offer optimal flexibility and efficiency for selected couples.