Vasectomy Reversal Online Marketing Practices: What Are We Putting Out There?

OBJECTIVE: To determine characteristics of providers marketing vasectomy reversal (VR) online, degree of information available online, the ease with which patients can compare providers, and the differences in VR practice patterns between academic and private practices. MATERIALS AND METHODS: We identified VR practices operating within the top 50 most populous metropolitan areas in the US. Practice websites were reviewed to obtain information such as provider educational background, level of magnification, ability to perform vasoepididymostomy, surgical volume, and cost. Based on information available, providers were assigned a novel REVERSAL score created by the authors. Descriptive statistics were used to compare results. RESULTS: Of the 107 providers identified (29 academic, 78 private), the majority were male urologists with a Doctor of Medicine degree. Academic providers were more likely to have fellowship training than private practice providers, 96.6 vs 43.6%, respectively (P = 0.00001). Compared to non-urologists, urologists were less likely to purchase online ads or disclose cost. Non-urologists charged significantly less than urologists, $3,584 ± 1,554 and $6,591 ± 1,518, respectively (P = 0.00001). Only one provider provided complete information as defined by REVERSAL score of 12, with the majority (61.7%) of providers achieving score ≤6. CONCLUSION: There is significant lack of transparency in publicly available information from VR practices. Practices should implement measures to improve dissemination of information to the public, so that patients can more easily compare providers and make informed decisions regarding VR.

Comparative Cost-Effectiveness Analysis of Modified 1-Layer versus Formal 2-Layer Vasovasostomy Technique.

PURPOSE: Approximately 2% to 6% of men undergoing vasectomy will ultimately have it reversed. Cost is a major consideration for patients and providers with regard to vasovasostomy. Opportunities for cost savings for vasectomy reversal lie in the reduction of variable costs, namely operative time and materials used. In this study we determine the cost benefits of a modified 1-layer vasovasostomy compared to a formal 2-layer vasovasostomy. MATERIALS AND METHODS: A retrospective analysis was performed of a single surgeon experience of vasectomy reversals performed from 2010 to 2015. The cohort consisted of men who underwent bilateral vasovasostomy using a formal 2-layer or modified 1-layer technique. The primary end points of the analysis were total operative time; number, cost and type of suture used; and patency/postoperative semen analysis. Bivariate analysis was performed for these continuous variables using the Wilcoxon rank test and the chi-square test was used for categorical variables. RESULTS: Of the 106 men who underwent bilateral vasovasostomy 81.1% (86) had a formal and 18.9% (20) had a modified 1-layer repair. The modified 1-layer closure resulted in a significantly shorter operative time, lower microsuture cost and lower overall operative cost compared to formal repair (all p <0.05). There were no statistically significant differences in semen parameters between the 2 techniques at the first postoperative visit. CONCLUSIONS: The modified 1-layer vasovasostomy resulted in shorter operative times and lower costs compared to formal repair without compromising postoperative patency. In this era of cost containment the modified repair provides the opportunity to perform vasectomy reversal at a lower cost to patients and providers.

Vasectomy as a reversible form of contraception for select patients.

INTRODUCTION: To provide an effective form of birth control, men may choose a reversible or permanent form of contraception. Vasectomy is presently offered as a permanent option for male contraception. We have had patients who were interested in vasectomy and reversal as a temporary birth control option. The purpose of this paper is to determine if vasectomy should be offered for selected couples as a temporary form of contraception and under which circumstances. MATERIALS AND METHODS: A literature review was conducted to determine the available reversible contraceptive options, risks, failure rates and contraindications to each, and the risks and success rates of vasectomy and vasectomy reversal. RESULTS: Reversible contraceptives include hormonally based methods for women, non-hormonal anatomic barrier devices and spermatocidal agents. Hormone based therapies may be contraindicated in women with cardiovascular disease, hypertension, and some cancers. Non-hormonal contraceptives are generally less effective and may be unacceptable for some couples due to higher failure rates, difficulty of use and lack of acceptance. Both vasectomy and vasectomy reversal are low risk procedures. Reversal may be performed with a high degree of success, particularly with a short obstructive interval (97% patency if performed < 3 years following vasectomy). CONCLUSION: While vasectomy should be considered a permanent form of sterilization for most couples, there are select couples, unable or unwilling to use other forms of birth control, who would benefit from an informed discussion about using a vasectomy as a reversible form of contraception.

Relating economic conditions to vasectomy and vasectomy reversal frequencies: a multi-institutional study.

PURPOSE: It was theorized that the use of permanent contraceptive methods may vary with economic conditions. We evaluated the relationship between vasectomy/vasectomy reversal frequencies at several large referral centers and national economic indicators during 2 recessions spanning 2001 to 2011. MATERIALS AND METHODS: We performed an institutional review board approved, retrospective chart review to identify the number of vasectomies/vasectomy reversals per month at several large referral centers from January 2001 to July 2011. The rates of these procedures were pooled, correlated with national economic data and analyzed in a multivariate linear regression model. RESULTS: A total of 4,599 vasectomies and 1,549 vasectomy reversals were performed at our institutions during the study period. The number of vasectomies per month positively correlated with the unemployment rate (r=0.556, p<0.001) and personal income per capita (r=0.276, p=0.002). The number of reversals per month negatively correlated with the unemployment rate (r=-0.399, p<0.001) and personal income per capita (r=-0.305, p<0.001). Neither vasectomy nor vasectomy reversal frequency significantly correlated with the inflation rate or the S&P 500®. Regression models confirmed that the unemployment rate explained more of the variance in vasectomy/vasectomy reversal frequencies than other indicators. CONCLUSIONS: We noted a correlation between the number of vasectomies/vasectomy reversals performed at our institutions and national economic indicators. The strongest association was with the unemployment rate. This points to the importance of financial pressure on family planning decisions.

Comparison of macroscopic one-layer over number 1 nylon suture vasovasostomy with the standard two-layer microsurgical procedure.

OBJECTIVE: To compare the outcomes of macroscopic one-layer vasovasostomy (MOLVV) with those of two-layer microsurgical vasovasostomy (TLMVV). METHODS: Standard TLMVV was performed in 112 men (Group 1), while MOLVV was performed in 94 patients. All of the MOLVVs were performed with number 1 nylon suture as a temporary stent. The outcome measures were as follows: patency rate, pregnancy rate, operation time, total procedure cost, and complications. RESULTS: The mean operation duration was 114 ± 10 min for the TLMVV technique, and 74 ± 5 min for the MOLVV procedure (P = 0.024). In patients who underwent vasal patency at 6-month postoperative period, the median sperm density (106/mL) was 28.3 and 27.7 in Groups 1 and 2, respectively (P = 0.62). At the same time, the median total motile sperm count (× 106) was 39.4 and 32.6 in two-layer microsurgical and one-layer macroscopic groups, respectively (P = 0.47). Patency rates were 82.1% in Group 1 and 77.7% in Group 2, which were not significantly different (P = 0.21). The pregnancy rate was 28.4% for patients in Group 1 and 26.7% for patients in Group 2 (P = 0.38). CONCLUSIONS: There were no significant differences in terms of patency and pregnancy rates between MOLVV and TLMVV methods, but the MOLVV technique offers a decreased cost and operative time, and a simplified procedure.

Anatomical and histological equivalence of the human, canine, and bull vas deferens.

INTRODUCTION: Several animal models have been utilized for in-vitro experimentation and surgical training exercises of the vas deferens. The canine model is currently the standard for both in-vivo and ex-vivo study. Due to increasing costs associated with experimentation on canines, and in keeping with the principles of refine, reduce, and replace, a novel model that is cost-effective and easily obtained is desired. We compared morphology of the bull vas deferens to that of the human and the canine. MATERIALS AND METHODS: Bilateral vas deferens tissue from the human (n = 6), canine (n = 6), and bull (n = 5) were compared. Outer diameter (OD), inner diameter (ID), and microscopic measurements of the luminal mucosa and muscularis were then determined from each of these tissues. Histological comparisons were performed by a single pathologist. Data was analyzed using Two One-sided Tests (TOST) Analysis of Equivalence. RESULTS: According to the TOST statistical analysis, the vassal ID was equivalent for all three species. Similarly, equivalent microscopic measurements were noted for both vassal mucosal (human-canine and human-bull) and muscularis thicknesses (canine-bull). Lastly, all three species had similar histological characteristics. CONCLUSIONS: The vas deferens' of the human, canine, and bull are equivalent in many ways, including histological similarities. It is reasonable to conclude that the bull vas could be substituted for the human vas for both in-vitro testing and microscopic vasovasostomy simulation exercises. Specimens are cost-effective, provide ample tissue length, and are easy to obtain.

Vasectomy reversal versus IVF with sperm retrieval: which is better?

PURPOSE OF REVIEW: This paper will describe why this review is timely and relevant. Over the past two decades, treatment options for couples with reconstructible obstructive azoospermia have improved tremendously. Advances in assisted reproductive technologies (ART), specifically sperm retrieval techniques for intracytoplasmic sperm injection coupled with in-vitro fertilization, as well as refinements in microsurgical reconstruction have led to improved outcomes and cost-effectiveness. Providing the most up-to-date care based on the most recent data allows for better patient outcomes and satisfaction. RECENT FINDINGS: Microsurgical reconstruction of the vas has remained a cost-effective, reliable and effective means of restoring fertility in the majority of men who have previously undergone vasectomy when the reconstruction is performed by an experienced microsurgeon. However, there are specific instances in which sperm retrieval/IVF/ICSI may be a more appropriate treatment modality as ART techniques continue to improve. SUMMARY: Data comparing surgical reconstruction versus sperm retrieval/ICSI/IVF are neither randomized nor homogenous. Therefore, a comprehensive understanding of the factors that can affect outcomes, overall cost, and the morbidity associated with each treatment modality, respective of the institution providing the treatment, is strongly recommended.

Cost-effectiveness of vasectomy reversal.

In this era of cost-consciousness and containment, it is imperative to examine not only treatment outcomes but also cost of these treatments. With improvements of in vitro fertilization outcome and continued development of less-invasive sperm retrieval methods, physicians and couples must examine all options available after surgical sterilization. Vasectomy reversal remains the gold standard of treatment; however, certain situations may be present in which sperm acquisition/in vitro fertilization may be a better option. A physician's responsibility is to present all options with the pros and cons of each, including cost, to help arrive at an informed decision.

A decision analysis of treatments for obstructive azoospermia.

BACKGROUND: Treatments for post-vasectomy obstructive azoospermia include vasectomy reversal, microsurgical epididymal sperm aspiration (MESA) or percutaneous testicular sperm extraction (TESE) with IVF/ICSI. We examined the cost-effectiveness of these treatments. METHODS: A decision analytic model was created to simulate treatment. Outcome probabilities were derived from peer-reviewed literature and the Society for Assisted Reproductive Technologies database. Procedural costs were derived from a sampling of high-volume IVF centers and the Medicare Resource Based Relative Value Scale. Indirect costs of complications, lost productivity and multiple gestation pregnancies were considered. Sensitivity analyses were performed. RESULTS: Vasectomy reversal was more cost-effective than either MESA or TESE under all probability conditions. In 1999, vasectomy reversal demonstrated superior cost-effectiveness to TESE and MESA ($19,633 versus $45,637 and $48,055, respectively, equivalent to $25,321 versus $58,858 and $61,977 in 2005 dollars). In 2005, vasectomy reversal ($20,903) remained the most cost-effective treatment over TESE ($54,797) and MESA ($56,861). The cost-effectiveness of all treatments improved over projections by inflation. The relative cost-effectiveness of the therapies was unchanged over time. CONCLUSIONS: Vasectomy reversal appears more cost-effective than percutaneous TESE and MESA for treatment of obstructive azoospermia when the impact of indirect costs is considered. The absolute cost-effectiveness of all therapies improved over time. These results may be tailored with institution-specific data to allow more individualized results.

Markov modeling of vasectomy reversal and ART for infertility: how do obstructive interval and female partner age influence cost effectiveness?

OBJECTIVE: To apply Markov models to assess the cost effectiveness of the relative impact of obstructive interval and female partner age on fertility using either assisted reproductive technology (ART) or vasectomy reversal, and elucidate the impact of these variables on fertility. DESIGN: Markov models based on review of published literature and available ART outcome data. SETTING: University-based clinical practice. PATIENT(S): Simulation runs of 50,000 patients for each analysis. INTERVENTION(S): Varying vasectomy obstructive interval and maternal age. MAIN OUTCOME MEASURE(S): Cost effectiveness, willingness to pay (WTP), and net health benefit. RESULT(S): Base case analysis showed ART yields a higher pregnancy rate and higher cost than vasectomy reversal. Sensitivity analysis showed female age has a greater effect on cost effectiveness than obstructive interval. At a WTP < $65,000, vasectomy reversal is more cost effective than ART. With increasing WTP, ART is more cost effective over wider windows of female age. CONCLUSION(S): Markov modeling of fertility after vasectomy suggests female age has more impact than vasectomy obstructive interval on cost effectiveness.

Sperm harvesting and cryopreservation during vasectomy reversal is not cost effective.

OBJECTIVE: To determine whether sperm harvesting and cryopreservation at the time of vasectomy reversal is cost-effective. DESIGN: Model of actual costs and results at five institutions. SETTING: Multicenter study comprising five centers, including university hospitals and private practices. PATIENT(S): Men undergoing vasectomy reversal. INTERVENTION(S): We established two models for vasectomy reversal. The first model was sperm harvesting and cryopreservation at the time of vasectomy reversal. The second model was sperm harvesting at the time of IVF only if the patient remained azoospermic after vasectomy reversal. Vasectomy reversal procedures modeled included bilateral vasovasostomy and bilateral epididymovasostomy. The costs for each procedure at the five institutions were collated and median costs determined. MAIN OUTCOME MEASURE(S): Median cost of procedure and calculated financial comparisons. RESULT(S): The median cost of testicular sperm extraction/cryopreservation performed at the time of bilateral vasovasostomy was $1,765 (range, $1,025-$2,800). The median cost of microsurgical epididymal sperm aspiration or testicular sperm extraction with cryopreservation performed at the time of epididymovasostomy was $1,209 (range, $905-$2,488). The average of the median costs for percutaneous sperm aspiration or testicular sperm aspiration for those patients with a failed vasectomy reversal was $725 (range, $400-$1,455). CONCLUSION(S): Sperm retrieval with cryopreservation at the time of vasectomy reversal is not a cost-effective management strategy.

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.

Current practice in the management of vasectomy reversal and unobstructive azoospermia in Merseyside & North Wales: a questionnaire-based survey.

OBJECTIVE: To investigate the current incidence of vasectomy reversal procedures, the techniques used and which practitioners use them. PATIENTS AND METHODS: Using a questionnaire, 130 general surgeons and urologists practising in Merseyside and North Wales were surveyed. RESULTS: The response rate was 74%, with 24 urological surgeons and 14 general surgeons undertaking vasectomy reversal. Annually, urological surgeons carried out significantly more procedures than did general surgeons, at 8.5 and 5.3 (P = 0.029), respectively. They were also more likely to use double-layer closure and microsurgical techniques, whilst significantly less likely to use stents. Urologists reported significantly greater patency rates, at 76% and 52% (P = 0.017), respectively, with no significant differences in subsequent pregnancy rates (30% vs 25%). Only one practitioner checked tubal patency in the female partner before vasectomy reversal. CONCLUSIONS: The use of vasectomy reversal is a cost-effective treatment for men wanting paternity after vasectomy. The technique used by the clinician and proper audit of the results require close attention; it would also appear to be obvious that all the partners of men seeking a vasectomy reversal should have their fertility status established before reversal, something that is clearly not done at present.

Economic implications of assisted reproductive techniques: a systematic review.

BACKGROUND: Approximately one in six couples experiences problems with their fertility at some point in their reproductive lives. The economic implications of the use of assisted reproductive techniques require consideration. Herein, the health economics research in this area are critically appraised. METHODS: Multiple strategies were used to identify relevant studies. Each title and abstract was independently reviewed by two members of the study team and categorized according to perceived relevance. The selected papers were then assessed for quality and data were extracted, converted to UK pounds sterling at 1999/2000 prices, tabulated and critically appraised. RESULTS: A total of 2547 papers was identified through the searches; this resulted in 30 economic evaluations, 22 cost studies and five economic benefit studies that met the selection criteria. The quality of these studies was mixed; many failed to disaggregate costs, discount future costs or conduct sensitivity analyses. Consistent findings included the following: initiating treatment with intrauterine insemination appeared to be more cost-effective than IVF; vasectomy reversal appeared to be more cost-effective than ICSI; factors associated with poor prognosis decreased the cost-effectiveness of interventions. CONCLUSIONS: The cost-effectiveness of different interventions should be considered when making decisions about treatment. Future economic appraisals of assisted reproductive techniques would benefit from more robust methodology than is evident in much of the published literature to date.

[Microsurgical vasovasostomy in the age of modern reproduction medicine. A cost-benefit analysis]. / Die mikrochirurgische Vasovasostomie im Zeitalter der modernen Reproduktionsmedizin. Eine Kosten-Nutzen-Analyse.

WS represents the standard procedure of choice for the treatment of obstructive azoospermia following vasectomy. However, recently, ICSI has been suggested by some to represent the solution for all cases of male factor infertility regardless of its etiology based on its success rates. Therefore, we compared VVS to MESA/TESE and ICSI in terms of pregnancy, complications, and costs. Between 1/93 and 6/98 157 VVS was performed microsurgically using the 2-layer technique in 157 patients following prior vasectomy. Between 9/94 and 9/97 69 couples underwent MESA/ICSI for epididymal obstruction not amenable to micro-surgical reconstruction such as post-inflammatory obstruction and congenital absence of the vas deferens; in the same time period 42 couples underwent TESE/ICSI for azoospermia of testicular origin due to cryptorchidism, testicular atrophy, obstruction of the rete testis. In most cases MESA or TESE and ICSI were performed metachronously. Mean intervall of vasal obstruction was 7.6 (0.5-18) years; patency after VVS was 77%, pregnancy rate was 52%. Local complication rate was 4.7%, no major complications were observed. Costs per life birth after VVS were as high as 5,447,-DM or 2,800 Euro. Pregnancy rates after MESA/TESE and ICSI were 22.5% and 19.5%, respectively with 16 singletons, 3 twins and 3 abortions; local complications occurred in 3.9% of the men. Multiple birth were noticed in 15.8% following ICSI, but only in 0.7% following VVS. 5.7% and 1.4% of the female partners experienced serious complications as a mild or severe ovarian hyperstimulation-syndrome, respectively. Costs per life birth after MESA/TESE cycle were as high as 28,804,-DM or 14,100 Euro. Even in the era of ICSI microsurgical vasovasostomy represents the standard approach for obstructive azoospermia following vasectomy. Based on a cost-benefit analysis VVS is more successful in terms of pregnancy rates (52% vs. 22.5%). We conclude that MESA/ICSI should be reserved for patients not amenable for microsurgical reconstruction.

Microsurgical vasovasostomy versus microsurgical epididymal sperm aspiration/testicular extraction of sperm combined with intracytoplasmic sperm injection. A cost-benefit analysis.

PURPOSE: Vasovasostomy (VVS) represents the standard therapy of choice for the treatment of obstructive azoospermia following vasectomy. However, recently, intracytoplasmic sperm injection (ICSI) has been suggested by some to represent the solution for all cases of malefactor infertility regardless of its etiology based on its success rates. Therefore, we compared VVS to microsurgical epididymal sperm aspiration (MESA)/testicular extraction of sperm (TESE) and ICSI in terms of pregnancy, complications, and costs. PATIENTS AND METHODS: Between 1/93 and 6/98, 157 VVS were performed microsurgically using the double-layer technique. Between 9/94 and 9/97, 69 and 42 couples underwent MESA/ICSI and TESE/ICSI, respectively, for epididymal obstruction and azoospermia of testicular origin. RESULTS: The mean interval of vasal obstruction was 7.6 (0.5-18) years; patency after VVS was 77%, pregnancy rate was 52%. Local complication rate was 4.7%, no major complications were observed. Costs per life birth after VVS were 5,447 DM or 2,793 Euro. Pregnancy rates after MESA/TESE and ICSI were 22.5 and 19.5%, respectively, with 16 singletons, 3 twins and 3 abortions; local complications occurred in 3.9% of the men. Multiple births were noticed in 15.8% following ICSI, but in only 0.7% following VVS. 5.7 and 1.4% of the female partners experienced serious complications (mild or severe ovarian hyperstimulation syndrome, respectively). Costs per life birth after a MESA/TESE cycle amounted to 28,804 DM or 14,547 Euro. CONCLUSIONS: Even in the era of ICSI, microsurgical VVS represents the standard approach for obstructive azoospermia following vasectomy. Based on a cost-benefit analysis, VVS is more successful in terms of pregnancy rates (52 vs. 22.5%). VVS does not expose the female partners to complications following treatment of male infertility. In contrast to ICSI, multiple birth rates do not increase after VVS. We conclude that MESA/ICSI should be reversed for patients who are not amenable for microsurgical reconstruction.

Comparison of microscopic epididymal sperm aspiration and intracytoplasmic sperm injection/in-vitro fertilization with repeat microscopic reconstruction following vasectomy: is second attempt vas reversal worth the effort?

Since 1986, we have performed microscopic reconstruction in 18 men following failed microscopic vasectomy reversal. Between 1994 and 1996, nine couples have undergone microscopic epididymal sperm aspiration (MESA)/ intracytoplasmic sperm injection (ICSI) treatment for male infertility due either to congenital absence of the vas deferens (CAVD) or inoperable excurrent duct obstruction. We compared the cost efficiency of repeat vasectomy reversal to that for MESA combined with ICSI/in-vitro fertilization (ICSI/IVF). The cost of male partner procedures (vasectomy reversal, MESA) was based on physician and hospital charges, while the cost of ICSI/IVF included preparation of the female partner (medications and physician charges) and procedures (physician and hospital charges including oocyte retrieval, micromanipulation, and embryo transfer). Our cost examination does not include charges related to follow-up visits, prenatal monitoring, complications of pregnancy (i.e. miscarriage) or delivery in either group. Overall patency and pregnancy rates in the repeat vasectomy reversal group were 78 and 44% respectively. The cost per delivered baby (including multiple metachronos deliveries per couple) was $14892. Fertilization of oocytes has been achieved in 37/72 (51%) and pregnancies have occurred in 6/9 (67%) attempts and 5/9 (56%) report delivery. The average cost per pregnancy was $25637 and the average cost per delivered baby (or ongoing pregnancy) was $35570. The cost per delivery by MESA/ ICSI/IVF is 2.4 times the charges per delivery obtained through repeat vasectomy repair. Couples attempting to overcome infertility caused by vasal obstruction should be informed that vas reconstruction remains a cost effective means of re-establishing fertility even in men who have previously failed vasectomy reversal.

Sterilization: Canadian choices.

Significant differences in cost and safety between vasectomy and tubal ligation have been reported. For this reason the incidence of these two procedures between 1976 and 1986 was studied to obtain information upon which future policy decisions might be based. Although tubal ligation predominated in almost every province and year its rate declined by 27.6% over the study period, whereas the rate of vasectomy increased by 39.1%. When projected to 1988 the national rates for the two procedures became nearly equal; those for Quebec had become equal by 1986. Provincial differences were most marked in eastern Canada, where neighbouring provinces had the highest and the lowest rates of sterilization in the country. Given the relative economic and surgical disadvantages of tubal ligation, policymakers may wish to consider fostering an increased acceptance of vasectomy, particularly in areas where such acceptance continues to be slow.