Vasectomy IVF/ICSI

In vitro fertilization with intracytoplasmic sperm injection (IVF/ICSI) is now the treatment of choice for severe male factor infertility and obstructive male infertility not amenable to reconstructive surgery.

IVF/ICSI involves ovarian hyperstimulation to produce a large number of eggs simultaneously. These eggs are then retrieved usually via ultrasound guided transvaginal approach. Sperm, whether ejaculated,aspirated or extracted, is then injected one per egg with special micromanipulation instruments. The injected eggs are incubated and examined for fertilization and embryo development. The embryos are then transferred to the uterus to achieve pregnancy. ICSI represents an extension of the conventional IVF. Conventional IVF involves mixing sperm and eggs in the test tubes; sperm attach and penetrate on their own. This approach works well with high quality eggs and sperm such as in females with blocked fallopian tubes. 50,000 motile sperm per egg is required. In men with severe male infertility obtaining 50,000 morphologically normal and motile sperm per egg is not possible, not to mention the minimal 1 to 3 millions motile sperm post wash needed for inseminations.

Several groups of men may require IVF/ICSI:

1. Severe male factor infertility: Severe oligospermia/asthenospermia and NOA. See Sperm Extraction &Testis Biopsy. In men with NOA, consideration should be given for donor sperm backup at the time of TESE and egg retrieval since 30% to 60% of all TESE may fail to yield sperm despite the diagnostic biopsy report and previous TESE results.

2. Obstructive azoospermia: Men with CBAVD or failed vasectomy reversals do very well with ICSI. PR is the highest in this group.

3. Immuno-infertility: The presence of anti sperm antibodies, which have failed sperm washing/IUI and medical therapy.

4. Intrinsic sperm defects: Sperm without the acrosomal cap (round-headed sperm) or with defective tail ultrastructure (Kartagener's) will require ICSI.

5. Necrospermia: An unusual phenomenon, which leads to dead sperm in the ejaculates, TESE may be, needed to obtain live sperm.

6. Preimplantation genetic diagnosis, PGD: IVF provides us the opportunity to remove one or 2 cells from the developing embryo for genetic testing prior to transfer and only the non affected embryos are transferred. PGD has been applied in a number of conditions such as hemophilia, Tay-Sachs disease, CF, Kleinfelter's and others. PGD's only indication is for the detection and identification of embryos with inherited genetic diseases in order to selectively transfer the healthy embryos. Sex selection for the sole purpose of parental preferences does not constitute as a medical indication and will not be considered.

The major determining factor in terms of pregnancy rate (PR) following ICSI is the female age. Source of the sperm may also impacts on the PR although to a lesser degree. In general, all sperm do fairly well provided they are carefully selected to ensure viability. In men with NOA requiring TESE, the overall PR is less (20-30% vs.30- 40% or more for obstructive azoospermia). PR following ICSI using incompletely developed round spermatid (ROSNI) is less than 10%. We do not recommend the ROSNI procedure at this time.

Vasectomy Reversals or Sperm Aspiration/ICSI?
IVF/ICSI provides another reproductive option for men who had previous vasectomies. The decision to pursue either approach must be individualized. In the presence of any significant female factor(s) for which IVF may be needed, it makes little sense to reverse vasectomies. In men with long standing vasectomies (15 years or more) and spouses approaching 40 years of age, IVF/ICSI is reasonable since female reproductive potential is not further lost while waiting for the sperm to return following EV which may take up to one year or more.For most men,assuming that significant female factors do not exist, vasectomy reversal is preferred for the following reasons:

1. Direct cost: Routine reversal (VV) is between $6,000 to $8,000 and EV is between $8.000 to $10,000. VVs and EVs are safe procedures with PR of 30% to 70% for VVs (average 50%) and 30% for EVs. IVF/ICSI costs between $12,000 to $15,000 per attempt with a PR of 30% to 40%. For men with obstructive intervals less than 10 years, reversals will be twice as likely to result in pregnancy than IVF/ICSI and at a lower cost.

2. Indirect cost: One third of all IVF attempts fail to reach the egg retrieval stage due to various reasons including complications from ovarian hyperstimulation. These prematurely terminated attempts represent unrecoverable cost. Reversals are safe and require one week of time loss from work.

3. Multiple gestations: Pregnancies following reversals are conceived through natural means with 1% chance of being multiple births. 30% of all IVF pregnancies result in multigestational births. Modern obstetrical care have enabled us to obtain excellent
pregnancy outcomes but at a significant pre and postnatal cost. One should also consider the long-term financial implications following such births.

I would like to remind you that adoptions and donor sperm are two just as viable options and I encourage you to become familiar with all of them and only by being well informed can you arrive at a decision that is right for you.