Surgery or Assisted Reproduction? A Decision Analysis of Treatment Costs in Male Infertility

Maxwell V. Meng, Kirsten Greene, and Paul J. Turek
Department of Urology, University of California San Francisco
San Francisco, California

Purpose

Assisted reproductive technology (ART), including in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI), is routinely used to treat male factor infertility. Because of ART’s success, the optimal method to achieve pregnancy with male infertility is controversial. Two examples in which ART competes with traditional male infertility treatments are varicocelectomy and vasectomy reversal. We used formal decision analysis to estimate and compare the cost-effectiveness of surgical therapy and ART in varicocele and vasectomy reversal.

…Vasectomy reversal is more cost-effective across all pregnancy rates provided patency rates are greater than 79%. ”
– Dr. Paul Turek

Material and Methods

Decision analysis models were created for infertile men seeking paternity with varicocele and with post-vasectomy obstruction. Outcome probabilities applied to the model were derived from institutional and published sources. Costs of interventions were calculated from institutional data. Sensitivity analyses determined which elements were most important and were used to calculate threshold values.

Results

Vasectomy reversal is as cost-effective as ART if bilateral vasovasostomy is performed. However, if unilateral or bilateral vasoepididymostomy is required, sperm retrieval/ICSI may be more cost effective due to lower patency rates. Vasectomy reversal is more cost-effective across all pregnancy rates provided patency rates are >79%. Surgical repair of varicocele is more cost effective when the postoperative pregnancy rate is >14% in men with preoperative total motile sperm counts45% in men with >10 million total motile sperm.

Conclusions

A decision analysis-based comparison of ART and classic surgical therapy suggests that varicocelectomy and vasectomy reversal are the most economical treatments in many cases of infertility due to these lesions.

Male Infertility Surgery vs Assisted Reproduction (pdf)