Surgery or assisted reproduction? A decision analysis of treatment costs in male infertility

Purpose: Assisted reproductive technology (ART), including in vitro fertilization and intracytoplasmic sperm injection, is routinely used to treat male factor infertility. Because of the success of ART, 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 for varicocele and vasectomy reversal. Materials 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, thus, were used to calculate threshold values. Results: Vasectomy reversal is as cost-effective as ART if bilateral vasovasostomy can be performed. However, if unilateral or bilateral vasoepididymostomy is required, sperm retrieval/ intracytoplasmic sperm injection may be more cost-effective due to lower patency rates. Vasectomy reversal is more cost-effective across all pregnancy rates provided that patency rates are greater than 79%. Surgical repair of varicocele is more cost-effective when the postoperative pregnancy rate is greater than 14% in men with a preoperative total motile sperm count of less than 10 million sperm and greater than 45% in men with greater than 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. Tailoring the decision models to individual centers permits more accurate comparisons using specific costs as well as the surgical outcomes and results of ART.