Dilemma of postvasectomy procreative management with older female partners: is in？vitro fertilization really better? - Fertility and Sterility

The determination of how to manage a couple who present for fertility postvasectomy should involve a complete, informed, honest, unbiased discussion of all the options tailored to the couple without conflicts of specialty (gynecology vs. urology) and financial interests. Therefore, this should be based on the complete understanding of the literature for vasectomy reversal, assisted reproduction technology (ART) options, and outcomes as well as alternative options, for example, donor sperm with IUI versus adoption or maintaining the status quo. For vasectomy reversal, patency and pregnancy outcomes are affected by length of time from vasectomy, vasectomy factors (e.g., location of vasectomy site from testicle and presence of sperm granuloma), complexity of vasectomy reversal (vasovasostomy vs. vasoepididymostomy), skill/training of the surgeon, and female age and reproductive potential including the subsequent nadir semen parameters. It is incumbent on both reproductive gynecologists and urologists to ensure both partners, as best as possible, are maximized for their fertility potential before proceeding with sperm retrieval and intracytoplasmic sperm injection (ICSI) or vasectomy reversal. One of the increasing dilemmas is managing couples who present relatively later in their lives especially with advanced female age being the only female factor. The main question is ovulatory reserve and whether this is the “rate-limiting step,” and therefore trying to shorten the time to pregnancy becomes very important. The perceived sense and bias by many clinicians is that vasectomy reversal in such situations is not an option based on the longer time to pregnancy and potentially worse pregnancy rates and shorter time to allow for ART if vasectomy reversal fails. This is understandable and may be true by consensus, but the literature shows weak support for this, especially the time taken to achieve pregnancy with each method used, for example, if more than one (nondonor egg) ICSI cycle is needed versus just vasectomy reversal alone versus vasectomy reversal plus ART. There is no actuarial table or large study for vasectomy reversals to predict outcomes based on both time from vasectomy and female age. The closest has been a predictor model (1x1Parekattil, S.J., Kuang, W., Kolettis, P.N., Pasqualotto, F.F., Teloken, P., Teloken, C. et al. Multi-institutional validation of vasectomy reversal predictor. J Urol. 2006; 175: 247–249 Abstract | Full Text | Full Text PDF | PubMed | Scopus (16) | Google ScholarSee all References)(1). In the largest series of vasectomy