Modern medical science has developed several methods to help couples who have difficulty conceiving after a year or more of trying. Assisted reproduction techniques (ARTs) are advanced treatments for infertility; couples most commonly use ART when their infertility is due to causes other than the vasectomy.
In some family situations where the couple wants to conceive another child (but the man has had a vasectomy), ART may be considered an option. Initially, couples typically go through an infertility evaluation before being considered for the assisted reproductive techniques.
Assisted reproduction techniques are generally more complicated and more expensive than a vasectomy reversal. If the female partner is otherwise healthy and fertile, a vasectomy reversal may be a more suitable initial course of action to consider before attempting ART.
Sperm Plus Egg
Quite simply, assisted reproduction techniques are procedures that utilize high technology to combine sperm and eggs to treat infertility and achieve pregnancy. While there are a number of methods and variations, the most common ones are similar to, or variations of, in vitro fertilization (IVF). These include gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), and intracytoplasmic sperm injection (ICSI).
First, the Sperm
Various techniques for extracting sperm from a man's reproductive organs have been perfected. Experience and research has led to the understanding that the fluids in the ejaculate from the prostate and seminal vesicles are essential for fertilization to occur inside the woman. Therefore, only ejaculated sperm can be used for artificial insemination. Sperm that is retrieved can only be used with IVF and intra-cytoplasmic sperm injection.
Sperm may be retrieved from the male reproductive organs through a surgical incision or a needle (percutaneously). All techniques will likely and reliably extract sperm.
Techniques of Sperm Retrieval
The various sperm retrieval techniques are termed 1) Microsurgical Epdidymal Sperm Aspiration or MESA, 2) Percutaneous Epdidymal Sperm Aspiration or PESA, 3) Testicular Sperm Extraction or TeSE, 4) Testicular Sperm Aspiration or TeSA, and 5) Testicular Perc-Biopsy.
Microsurgical Epididymal Sperm Aspiration (MESA): An incision is made through the scrotal skin. Using optical magnification, the tiny epididymal tubules can be incised and sperm rich fluid aspirated. A large number of motile sperm is typically retrieved and it can be used immediately for intracytoplasmic injection into an egg, or can be frozen in several batches for delayed or subsequent cycles of IVF-ICSI should they be necessary.
Percutaneous Epididymal Sperm Aspiration (PESA): A needle is passed through the scrotal skin and into the epididymis in order to aspirate sperm. Because the epididymal tubule is very delicate and convoluted, the yield with a needle is typically small and usually only sufficient for a single cycle of IVF-ICSI performed on the same day as the PESA. Occasionally sperm may not be reliable retrieved at all.
Testicular Sperm Extraction (TeSE): Through a small scrotal skin incision, the testicle is explored. Small pieces of tissue are cut directly out of the testicle and sperm is extracted from this tissue by the embryologist. The sperm are plentiful enough to survive freezing of the tissue for later use.
Testicular Sperm Aspiration (TeSA): A needle is passed through the scrotal skin into the testicle. With syringe suction and numerous excursions of the needle through the testicle tissue, a very small amount of testicular tissue can be retrieved. It will usually be adequate for a cycle of IVF-ICSI that day, but typically not for freezing and subsequent use.
Testis Perc-Biopsy: Similar to TeSA, this technique uses a larger gauge biopsy needle and the yield is larger. Although sperm aspiration may avoid having a vasectomy reversal, it is only the first step in attempting assisted reproductive techniques.
Second, the Egg
Most assisted reproduction techniques also involve the stimulation of the ovaries to produce multiple eggs. Some of these ARTs include:
IVF / In Vitro Fertilization. In this process, a woman's eggs are retrieved from the ovary through a laparoscope to mix with sperm in a lab dish for return to the uterus after external fertilization.
GIFT / Gamete Intrafallopian Transfer. A woman's eggs are retrieved with a laparoscope, mixed with sperm and returned as a mixture to the fallopian tube for fertilization there.
ZIFT / Zygote Intrafallopian Transfer. A woman's eggs are retrieved with a laparoscope, mixed with sperm and the externally fertilized egg is returned to the fallopian tube. (Both GIFT and ZIFT require that the fallopian tubes be intact.)
ICSI / Intracytoplasmic Sperm Injection. A woman's eggs are retrieved with a laparoscope. To cause fertilization, a sperm's genetic component is microscopically injected into an egg. Any resulting embryo is returned to the uterus or the fallopian tube.
The various procedures are performed on an outpatient basis. Because of the large yield, MESA may be reliably performed on the husband ahead of time allowing him to recuperate and subsequently assist his wife at the time of her egg retrieval. The procedures may be performed with various degrees of anesthesia ranging from local to general. The recovery from the incisional procedures is similar to that of a vasectomy-48 hours of very limited activity and about one week of no sex or exercise. The recovery from a percutaneous procedure is less.
The risks of the various retrieval procedures are similar, mainly bleeding, infection, and permanent damage to the testicle resulting in shrinkage and possibly the need for lifelong testosterone supplementation. Fortunately these complications are uncommon. Procedures such as MESA and PESA potentially scar the epididymis in such a way as to make a subsequent vasectomy reversal unable to be performed on that side.
The Cost of ART
Sperm retrieval procedures coupled with IVF-ICSI has enabled men with surgically unreconstructable obstruction and men who have severely low sperm production with no sperm in their ejaculate to father children. Assisted reproduction techniques cost from $10,000 to $15,000 per attempt, not including costs associated with sperm aspiration. This is significantly greater than a vasectomy reversal.
Due to the costs and risks involved to both partners, the consensus statement of the American Society for Reproductive Medicine recommends vasectomy reversal over sperm retrieval with IVF-ICSI for a man who has had a vasectomy and whose partner has no known infertility risk factors.
In Summary:
- Assisted reproduction techniques (ART) exist mainly for couples experiencing infertility problems.
- ART requires combining sperm with eggs in the hope of fertilization and pregnancy. ART methods are significantly more expensive than vasectomy reversal.
