PESA and TESA Sperm Aspiration and ICSI vs. Vasectomy Reversal Surgery
Costs and Success Rates of Fertility Options after Vasectomy
Many men have had a vasectomy for contraception and then later have gotten remarried and regretted the decision to become surgically sterilized. There are 3 general options for attempts at further child bearing in such a situation.
- Vasectomy reversal surgery.
- Sperm aspiration from the testicle or vas deferens and then use of the ICSI procedure to fertilize eggs from the female partner and then in vitro fertilization and embryo transfer.
- Donor sperm insemination of the female partner.
Sperm aspiration from the epididymis or testicle - PESA or TESA - and then ICSI and IVF
Sperm can be aspirated with a needle from the testicle or from the vas deferens (a structure right next to the testicle that also contains sperm). The man is given some drugs to sedate him and some local anesthesia is also used to numb the area. Then a small needle is inserted and sperm is aspirated from either the epididymis or the testicle. There should be no severe pain. The procedure generally takes about 30 minutes.
The different sperm aspiration and extraction procedures have long names and also short names (acronyms):
- PESA - Percutaneous Epididymal Sperm Aspiration (can be done in the office)
- TESA - Testicular Sperm Aspiration (can be done in the office)
- TESE - Testicular Sperm Extraction involves a small incision and snipping off some tissue from inside the testicle - often done in a hospital or free-standing surgicenter.
With a PESA or TESA (after vasectomy) there will usually be thousands to millions of sperm retrieved. Unfortunately, there is not enough sperm obtained to get any reasonable success rate from intrauterine insemination IUI of the female partner.
- The sperm should be of sufficient quantity and quality to be able to fertilize the female partner's eggs in the laboratory using a procedure that injects each egg with a single sperm. This process is called intracytoplasmic sperm injection, or ICSI.
- After fertilization has been accomplished, in vitro fertilization - IVF culture techniques are used to culture the resulting fertilized eggs for 3 to 5 days before embryo transfer is performed to the female's uterus.
- Because multiple eggs are needed to have a good chance for success, the woman must go through ovarian stimulation and then an egg retrieval procedure.
Photo of ICSI in progress
ICSI needle inside egg, sperm being injected
Holding pipette at far left holds egg steady
Video demonstrating ICSI
The sperm can be used fresh if it is obtained on the same day that the eggs are obtained from the woman, or it can often be frozen and then thawed and used later. Usually enough sperm is aspirated so that it can be split up into several vials and multiple attempts of IVF can be performed, if that will be necessary.
The sperm aspiration procedure is usually performed by a urologist that specializes in male fertility cases. In some cases it could be done by a reproductive endocrinologist (infertility specialist).
TESA or PESA and ICSI with IVF Costs
The cost for the sperm retrieval procedure depends on several factors including the surgical fees of the physician, charges for sperm freezing, facility fees and anesthesia fees.
If it is performed in a hospital or surgicenter, the costs are generally much higher than if it is done in an office. The total cost of a sperm aspiration including freezing will generally be somewhere between $3000 and $12,000 - depending on the variables mentioned above.
We are currently charging $3300 for sperm aspiration done in our office which includes the urologist's fee, our facility fees, sperm freezing costs and 6 months of frozen sperm storage (paid in advance).
If TESE is required (instead of TESA or PESA) the cost will depend on the setting where it is done and the urologists fees. However, TESE would generally be required only in cases where the testicle has very low sperm production.
TESE should not be needed in a post-vasectomy situation since there should be a good reservoir of sperm "behind the dam" for the urologist to tap with a needle.
ICSI and IVF Costs
Our current cost for ICSI is $1500 and $10,000 for IVF. This includes all monitoring of the ovarian stimulation, all IVF procedures, anesthesia, etc.
Success rates with PESA or TESA and IVF with ICSI
The success rate will depend very much on the IVF live birth success rates of the particular in vitro fertilization laboratory. IVF success rates are also dependent on the age of the female partner - even in these "male factor" cases after vasectomies.
We would generally expect the success rates to be about the same as (or somewhat higher) the rates for other couples with a female partner of the same age going through IVF.
Vasectomy reversal surgery
Vasectomy reversal surgery is more successful if the period of time since the vasectomy has been less than 10 years. At about 10 years out there is a substantial drop in the subsequent pregnancy rates. Therefore, it is generally not recommended that vasectomy reversal be tried when the intervening time has been 10 years or more.
Vasectomy reversal surgery is usually very expensive and is not covered by insurance. This procedure is done by a urologist. The total cost to the couple from what we have heard from patients is approximately $10,000 to $15,000 including the surgeon and the hospital fees.
- The obvious advantage to vasectomy reversal surgery is that if it is successful the couple can conceive further children without medical assistance. Another benefit is that the sex is (hopefully) fun.
- Disadvantages include the high costs and the fact that if surgery is not successful the couple is back at square one - without having improved their fertility at all.
Sometimes couples have a concern regarding future birth control after vasectomy reversal surgery. For example, if they want only 1 more child, and then they are successful, there will be a need for birth control or further surgical sterilization after the pregnancy. This issues applies to both vasectomy reversal and tubal reversal surgery for women.
Donor sperm insemination
This is a fairly simple process in which the couple chooses a donor from a major sperm bank, of which there are several, and the frozen donor sperm is thawed and placed into the uterus at the time of ovulation.
- The process is described on the donor insemination page.
So which option is the best for fertility after a vasectomy?
For many couples with a relatively young female partner and a relatively short time since the vasectomy has been performed, vasectomy reversal surgery may be the best initial option. However, some young couples will choose sperm aspiration and ICSI over reversal surgery as their preferred option.
If the female partner is over 35 years of age, there should always be some evaluation of the fertility status of the female before proceeding with either reversal surgery or sperm aspiration.
- This female evaluation would be best done by a Reproductive Endocrinology and Infertility specialist
- As the female age increases, there is less "fertile time" remaining to work with and at some point the best option will be sperm aspiration and IVF-ICSI
If a vasectomy reversal has been performed and it has not been successful, a second surgery is of low yield and should be avoided.
- Sperm aspiration and IVF is the best option in this scenario, unless the couple prefers donor insemination
Couples should be fully informed of the pros and cons of these approaches prior to making their decision. In many cases it is advisable to consult with both a Reproductive Endocrinologist and an urologist before making the final decision.
General urologists are not well versed in discussing the options of IVF with ICSI since that is not part of their training or professional skills. Likewise, the reproductive endocrinologist does not perform vasectomy reversals and is not the best source for details about that.