Microsurgical vasovasostomy versus microsurgical epididymal sperm aspiration/testicular extraction of sperm combined with intracytoplasmic sperm injection. A cost-benefit analysis.

PURPOSE Vasovasostomy (VVS) represents the standard therapy of choice for the treatment of obstructive azoospermia following vasectomy. However, recently, intracytoplasmic sperm injection (ICSI) has been suggested by some to represent the solution for all cases of malefactor infertility regardless of its etiology based on its success rates. Therefore, we compared VVS to microsurgical epididymal sperm aspiration (MESA)/testicular extraction of sperm (TESE) and ICSI in terms of pregnancy, complications, and costs. PATIENTS AND METHODS Between 1/93 and 6/98, 157 VVS were performed microsurgically using the double-layer technique. Between 9/94 and 9/97, 69 and 42 couples underwent MESA/ICSI and TESE/ICSI, respectively, for epididymal obstruction and azoospermia of testicular origin. RESULTS The mean interval of vasal obstruction was 7.6 (0.5-18) years; patency after VVS was 77%, pregnancy rate was 52%. Local complication rate was 4.7%, no major complications were observed. Costs per life birth after VVS were 5,447 DM or 2,793 Euro. Pregnancy rates after MESA/TESE and ICSI were 22.5 and 19.5%, respectively, with 16 singletons, 3 twins and 3 abortions; local complications occurred in 3.9% of the men. Multiple births were noticed in 15.8% following ICSI, but in only 0.7% following VVS. 5.7 and 1.4% of the female partners experienced serious complications (mild or severe ovarian hyperstimulation syndrome, respectively). Costs per life birth after a MESA/TESE cycle amounted to 28,804 DM or 14,547 Euro. CONCLUSIONS Even in the era of ICSI, microsurgical VVS represents the standard approach for obstructive azoospermia following vasectomy. Based on a cost-benefit analysis, VVS is more successful in terms of pregnancy rates (52 vs. 22.5%). VVS does not expose the female partners to complications following treatment of male infertility. In contrast to ICSI, multiple birth rates do not increase after VVS. We conclude that MESA/ICSI should be reversed for patients who are not amenable for microsurgical reconstruction.