Testicular tissue cryopreservation: 8 years of experience from a coordinated network of academic centers.

STUDY QUESTION: Is it feasible to disseminate testicular tissue cryopreservation with a standardized protocol through a coordinated network of centers and provide centralized processing/freezing for centers that do not have those capabilities? SUMMARY ANSWER: Centralized processing and freezing of testicular tissue from multiple sites is feasible and accelerates recruitment, providing the statistical power to make inferences that may inform fertility preservation practice. WHAT IS KNOWN ALREADY: Several centers in the USA and abroad are preserving testicular biopsies for patients who cannot preserve sperm in anticipation that cell- or tissue-based therapies can be used in the future to generate sperm and offspring. STUDY DESIGN, SIZE, DURATION: Testicular tissue samples from 189 patients were cryopreserved between January 2011 and November 2018. Medical diagnosis, previous chemotherapy exposure, tissue weight, and presence of germ cells were recorded. PARTICIPANTS/MATERIALS, SETTING, METHODS: Human testicular tissue samples were obtained from patients undergoing treatments likely to cause infertility. Twenty five percent of the patient's tissue was donated to research and 75% was stored for patient's future use. The tissue was weighed, and research tissue was fixed for histological analysis with Periodic acid-Schiff hematoxylin staining and/or immunofluorescence staining for DEAD-box helicase 4, and/or undifferentiated embryonic cell transcription factor 1. MAIN RESULTS AND THE ROLE OF CHANCE: The average age of fertility preservation patients was 7.9 (SD = 5) years and ranged from 5 months to 34 years. The average amount of tissue collected was 411.3 (SD = 837.3) mg and ranged from 14.4 mg-6880.2 mg. Malignancies (n = 118) were the most common indication for testicular tissue freezing, followed by blood disorders (n = 45) and other conditions (n = 26). Thirty nine percent (n = 74) of patients had initiated their chemotherapy prior to undergoing testicular biopsy. Of the 189 patients recruited to date, 137 have been analyzed for the presence of germ cells and germ cells were confirmed in 132. LIMITATIONS, REASONS FOR CAUTION: This is a descriptive study of testicular tissues obtained from patients who were at risk of infertility. The function of spermatogonia in those biopsies could not be tested by transplantation due limited sample size. WIDER IMPLICATIONS OF THE FINDINGS: Patients and/or guardians are willing to pursue an experimental fertility preservation procedure when no alternatives are available. Our coordinated network of centers found that many patients request fertility preservation after initiating gonadotoxic therapies. This study demonstrates that undifferentiated stem and progenitor spermatogonia may be recovered from the testicular tissues of patients who are in the early stages of their treatment and have not yet received an ablative dose of therapy. The function of those spermatogonia was not tested. STUDY FUNDING/COMPETING INTEREST(S): Support for the research was from the Eunice Kennedy Shriver National Institute for Child Health and Human Development grants HD061289 and HD092084, the Scaife Foundation, the Richard King Mellon Foundation, the Departments of Ob/Gyn & Reproductive Sciences and Urology of the University of Pittsburgh Medical Center, United States-Israel Binational Science Foundation (BSF), and the Kahn Foundation. The authors declare that they do not have competing financial interests.

Familiarity Trends of Successful Urology Residency Match Applicants.

INTRODUCTION: We sought to determine if training program "familiarity" played a role in the successful match of urological surgery residents. METHODS: We analyzed information from successful urology match participants in the United States between 2015 and 2020. Data were collected from the Association of American Medical Colleges applications, UrologyMatch.com and SurveyMonkey®. Information recorded included each candidate's name, hometown, undergraduate institution, graduate or research program (if applicable), medical school, location of visiting subinternships in urological surgery and urology residency training program. RESULTS: Overall, 1,080 of 1,451 successful urology match candidates (74.4%) met 1 or more "familiarity" criteria. Specifically, 329 (22.7%) and 508 (35.0%) students successfully matched into their home and visiting urology training programs, respectively. Of the remaining applicants 153 (10.5%) and 90 (6.2%) matched into training programs <150 miles from their hometowns and within institutions of previous academic pursuits, respectively. South Central section programs were most likely to match students into their home programs (p=0.010). Visiting students were most and least likely to match at programs from Western (p=0.044) and Northeastern (p=0.001) sections, respectively. The New York section matched more candidates from hometowns within 150 miles compared to other sections of the American Urological Association (p=0.0003). CONCLUSIONS: Student and program "familiarity" may play a role in residency match success. Our study demonstrated nearly 75% of urology applicants matched into either their home institutions, visiting subinternship programs, sites of previous undergraduate/graduate studies or training programs <150 miles from their hometowns.

Isolated abnormal strict morphology is not a contraindication for intrauterine insemination.

This study sought to investigate whether isolated abnormal strict morphology (<5% normal forms) and very low strict morphology (0-1% normal forms) affects pregnancy rates in intrauterine insemination (IUI). This was a retrospective study performed at an Academic Medical Center/Reproductive Medicine Center. Four hundred and eight couples were included for 856 IUI cycles. 70 IUI cycles were performed in couples with abnormal strict morphology and otherwise normal semen parameters. Outcomes were measured as clinical pregnancy rate per IUI cycle as documented by fetal heart activity on maternal ultrasound. Clinical pregnancy rate did not significantly differ between the group with abnormal strict morphology [11/70 (15.7%)] and the normal morphology group [39/281 (13.9%)]. Additionally, there was no significant difference between the pregnancy rate in the abnormal morphology group compared to that of our overall institutional IUI pregnancy rate [145/856 (16.9%)]. Furthermore, there was no significant difference between pregnancy rate in the very low morphology group [3/14 (21.4%)] compared to those with normal morphology or the overall IUI pregnancy rate. Patients with isolated abnormal strict morphology have clinical pregnancy rates similar to those with normal morphology for IUI. Even in those with very low normal forms, consideration of IUI for assisted reproduction should not be excluded.

Azoospermia in a 46,XX/47,XXX phenotypic male.

We report the unique case of a 34-year-old 46,XX/47, XXX man with complete masculinization and azoospermia. Analysis of the patient's deoxyribonucleic acid failed to detect the azoospermia factor (AZF) region. Lack of germ cell elements on subsequent testicular biopsy illustrates the importance of the AZF region for spermatogenesis. Discussion concerning the genetics of testicular and germ cell formation is undertaken in the context of the patient presented.

Localization and expression of the c-kit receptor protein in human and rodent testis and sperm.

OBJECTIVES: To examine the localization and expression of the c-kit receptor protein in the testes of the mouse, rat, and human, and then compare these among the three species. METHODS: Testis tissue from all three species was obtained through biopsy or orchiectomy. Immunohistochemistry was used for the localization, using a monoclonal antibody to the c-kit receptor. The expression of the c-kit receptor protein was examined in the testes and sperm with Western blot analysis. RESULTS: Localization was noted in the early spermatogenic cells, most likely type A spermatogonia, as well as in the acrosomal region of more mature germ cells, such as the round spermatids. The c-kit receptor was localized in analogous sites in all three species. The Western blot data revealed testicular expression of the c-kit receptor protein in all three species as well. Similar bands were recognized on the Western blots of all three species in testes at approximately 75 kDa and approximately 90 kDa, and sperm at approximately 90 kDa only. CONCLUSIONS: The c-kit receptor protein is expressed in the early spermatogenic cells, as well as the later stages of spermatogenesis, specifically, the acrosomal granules of the round spermatids, and the acrosomal region of testicular spermatozoa, in the mouse, rat, and human. All three species exhibit similar expression of the c-kit receptor protein in both testis and sperm, although to a varying degree. We believe that these observations allow direct valid comparisons concerning the expression of the c-kit receptor to be made cautiously to the human condition from experimental data obtained from rodents.

A change in practice: current urologic practice in response to reports concerning vasectomy and prostate cancer.

OBJECTIVE: To examine the practice patterns of urologists performing vasectomy in response to studies reporting an increased risk of prostate cancer in vasectomized men. DESIGN: A mailed survey. SETTING: A university medical institution. PARTICIPANTS: One thousand five hundred randomly selected United States urologists under the age of 65 years. MAIN OUTCOME MEASURE: Urologists reported practice patterns of vasectomy in response to studies showing possible link between vasectomy and prostate cancer. RESULTS: A response rate of 51% (759/1,500) was obtained. Although > 90% state that these studies have had little or no effect upon their practice of vasectomy, 27% screen vasectomized men earlier for prostate cancer, and 20% would be reluctant to recommend a vasectomy to a man with a strong family history of prostate cancer. CONCLUSIONS: Over one fourth of urologists who screen for prostate cancer have altered their screening patterns even though they responded that the studies have not affected their practice patterns.

Decreased expression of the heat shock protein hsp70-2 is associated with the pathogenesis of male infertility.

OBJECTIVE: To examine the expression of the heat shock protein hsp70-2, and the possible relationship with the pathogenesis of male infertility. DESIGN: Prospective study. SETTING: Reproductive testing laboratory in a university hospital. PATIENT(S): Men undergoing testicular biopsy during an investigation of subfertility. INTERVENTION(S): Testicular tissues were obtained from biopsies of men undergoing infertility evaluation and subdivided into three groups: normal testes, maturational arrest and Sertoli cell-only syndrome. Immunostaining and Western blotting techniques determined expression of the heat shock protein hsp70-2 MAIN OUTCOME MEASURE(S): Expression of the heat shock protein hsp70-2 in the testes. RESULT(S): The experimental data demonstrated that the heat shock protein hsp70-2 was expressed in the normal and maturation arrest testicular specimens. The heat shock protein hsp70-2 was strongly present in the cytoplasm of spermatocytes and spermatides in the adluminal compartment of the seminiferous epithelium in normal testis. However, maturation arrest testis tissue demonstrated light staining in spermatocytes and spermatides, and Sertoli-only specimens demonstrated no staining for the heat shock protein hsp70-2. The Western blotting data showed a 70-kDa heat shock protein in the normal and maturation arrest testicular tissues, but not in the Sertoli-only tissues. CONCLUSIONS: These results suggest that the heat shock protein hsp70-2 is expressed in spermatocytes and spermatides in normal and maturation arrest tissues. However, the expression of the heat shock protein hsp70-2 was low in maturation arrest, and no heat shock protein hsp70-2 was demonstrated in Sertoli-only specimens. Therefore the decreased expression of the heat shock protein hsp70-2 is associated with the pathogenesis of male infertility.

Psychological correlates of vasectomy.

OBJECTIVE: To examine the thoughts and concerns of men contemplating vasectomy before speaking to a physician as well as their partner's role in reaching this decision. DESIGN: A questionnaire analysis using response rates, ANOVA, and regression analyses. SETTING: A large Midwestern teaching hospital. PATIENT(S): Visitors to the urology clinic of the hospital. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): [1] Questionnaire designed by authors. [2] Measures of self-concept, relationship satisfaction, and problem-solving abilities. RESULT(S): [1] Subjects had been considering vasectomy for an average of 1 year and were fairly certain of their decision. [2] Anxiety about vasectomy surgery was mostly driven by fear about pain and fear of the unknown. [3] Concerns about the finality of the procedure did not emerge as a big concern. [4] There is confusion about the reversibility of the procedure. [5] Subjects are better problem solvers and have a higher self-concept than people in general. CONCLUSION(S): Our findings demonstrate the need for adequate prevasectomy counseling, particularly in the area of postoperative expectations, as well as reversibility of the procedure.

Decreased expression of the c-kit receptor is associated with increased apoptosis in subfertile human testes.

OBJECTIVE: To examine the expression of the c-kit receptor and its ligand, stem cell factor, and their possible relation with apoptosis in infertile men. DESIGN: Prospective laboratory study. SETTING: Urology laboratory in a university hospital. PATIENT(S): Men undergoing testicular biopsy during an investigation of subfertility. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Expression of the c-kit receptor protein, stem cell factor, and apoptosis in the testes. RESULT(S): The c-kit receptor was strongly present in Leydig cells and type A spermatogonia of normal testes, with decreased staining in Leydig cells and type A spermatogonia of testes with maturational arrest, and staining in only Leydig cells of Sertoli cell-only specimens. Stem cell factor was demonstrated in Leydig cells and Sertoli cells in all specimens. Western blotting demonstrated the 150-kd c-kit protein in the normal testes and the testes with maturational arrest, but not in the testes with the Sertoli cell-only pattern. Stem cell factor was expressed in all specimens, with a protein size of 45 kd. Increased apoptosis was demonstrated in type A spermatogonia and spermatocytes of tissue with maturational arrest compared with normal testicular tissue. CONCLUSION(S): C-kit receptor expression is decreased in subfertile testicular tissue compared with normal testicular tissue. Stem cell factor expression is present in Leydig cells and Sertoli cells. Increased apoptosis is seen in tissue with maturational arrest compared with normal tissue.

Expression of c-KIT and its ligand, stem cell factor, in normal and subfertile human testicular tissue.

The c-KIT proto-oncogene encodes for a transmembrane receptor and is associated with maturation of several cell types, including germ cells. The ligand of the receptor has been identified as stem cell factor (SCF). Loss or alteration of the expression of either of these factors leads to anemia, albinism, and/or sterility in mice. We examined the expression of c-KIT and SCF by immunohistochemistry in specimens from normal and infertile human testis. All specimens were obtained in the evaluation of male subfertility. We were able to demonstrate staining for c-KIT in Leydig cells in all specimens. Normal testis stained for c-KIT in the cytoplasm of early spermatogenic cells, as well as the acrosomal granules of the round spermatids and the acrosome of testicular spermatozoa. However, staining in testis demonstrating maturation arrest failed to demonstrate acrosomal staining, and Sertoli-only specimens demonstrated staining for c-KIT in Leydig cells only. The results for SCF demonstrated an overall uniform staining of Leydig cells in all specimens. The intensity of staining of Sertoli cells increased from normal to maturation arrest to Sertoli-only specimens. Germ cell staining was consistently negative. We hypothesize that these staining patterns for SCF are due to either lack of staining of the receptor-ligand complex or overexpression of the kit ligand in tissue that does not express the kit receptor. It appears that the c-kit receptor is expressed in the acrosome of developing germ cells, as well as in Leydig cells and early spermatogenic cells, suggesting a role in the acrosome reaction, as well as germ cell maturation and differentiation.

Development of an immunocontraceptive vaccine. Current status.

Development of an effective and modern contraceptive vaccine is a key factor in the global issue of regional population growth as well as agricultural, medical, economic and social development. A review was done of the current medical literature concerning development of an immunocontraceptive vaccine and relative molecular biology technology. Various approaches have been taken to identify candidate-specific antigens for immunocontraceptive development, such as sperm, zona pellucida and hormonal antigens. Suppressed fertility and the reversibility of these effects on mammalian species, including humans, have been demonstrated. The successful results obtained so far support the continued investigation for an effective immunocontraceptive vaccine.

Shattering the myths about male infertility. Treatment of male factors may be more successful and cost-effective than you think.

Male factors play a role in up to half of subfertile couples, contrary to the myth that male factors rarely play a role. In this article, Dr Sandlow counters this and other myths about male infertility and suggests that primary care physicians can increase a couple's chance of conceiving by evaluating for male as well as female factors. This article will also help primary care physicians provide appropriate education and treatment, as well as determine when to make a referral to a male-infertility specialist.

Characterization of human sperm antigens reacting with anti-sperm antibodies from an infertile female patient's serum.

Identification of sperm antigens that elicit immunoglobulin (Ig) production and knowledge of their roles in sperm transport and fertilization may enhance diagnosis and treatment of immunologic infertility. Sperm antigens recognized by a female patient's serum anti-sperm antibodies were characterized using an indirect immunobead-binding test, immunoblot analysis, and immunochemical labeling. The anti-sperm antibodies' effect on sperm function was evaluated by acrosome induction by calcium ionophore. Immunobeads specific for IgG were bound to the head of 79% of motile donor sperm. Immunochemical labeling of antibody-binding sites was restricted to the plasma membrane over the acrosomal crescent. No labeling was observed on the inner acrosomal membrane of acrosome-reacted sperm. The antibodies reacted with 35-, 40-, 47-, and 65-kd proteins extracted from acrosome-intact donor sperm. Sperm incubated in 1:4, 1:8, 1:16, and 1:32 dilutions of anti-sperm antibody-positive serum had similar rates of spontaneous acrosome reaction and significantly lower rates of ionophore-induced acrosome reaction compared with sperm incubated in control serum. These results suggest that sperm antigens recognized by the patient's serum anti-sperm antibodies are restricted to the acrosomal region of the plasma membrane. The antibodies may impair fertility by compromising the sperm's ability to undergo capacitation and/or acrosome reaction.

C-kit receptor and its possible function in human spermatozoa.

The presence and role of the c-kit proto-oncogene protein was investigated in the mature sperm of the human. A polyclonal antibody against the c-kit peptide was used to perform immunohistochemical (IHC) staining, electron microscopy (EM) studies, and Western blot analysis. The acrosomal region of fresh sperm specifically stained with the antibody. No acrosomal staining or staining limited to the equatorial region was noted in the acrosome-reacted (AR) sperm. EM studies demonstrated immunogold label on the plasma membrane (PM) of the acrosome, and confirmed the lack of binding following the acrosome reaction. A 150 kDa band was detected by Western blot analysis. This protein was released from the sperm surface during sperm capacitation and the acrosome reaction. Antibody against the c-kit receptor significantly inhibited the acrosome reaction and increased sperm agglutination, but did not significantly inhibit sperm motility. These results suggest that the c-kit receptor protein is present in mature human sperm and is released during capacitation and/or the acrosome reaction. The assessment of the c-kit receptor may also be a useful assay for sperm function in male infertility.

Expression and function of the c-kit proto-oncogene protein in mouse sperm.

The presence and role of the c-kit protein were examined in mature sperm of the mouse. Monoclonal antibodies (mAbs) against the c-kit protein were used to perform immunohistochemical staining, electron microscopy studies, and Western blot analysis. The acrosomal region of both fixed and unfixed noncapacitated sperm stained with the antibodies. No acrosomal staining was noted in acrosome-reacted (AR) sperm. Electron microscopy studies demonstrated immunogold label on the plasma membrane of the acrosome and confirmed the lack of binding following the acrosome reaction. Proteins corresponding to 33 kDa, 48 kDa, and 150 kDa were detected by the antibodies utilizing Western blot analysis. The 48-kDa and 150-kDa proteins were released into the media during sperm capacitation, and release from the acrosome was dependent upon the acrosome reaction. The mAbs significantly inhibited the acrosome reaction and increased sperm agglutination. Monoclonal antibody ACK1 significantly inhibited the motility of the sperm, whereas mAbs ACK2 and NCL-ckit did not. These results suggest that c-kit-related proteins are present in mature sperm and may play a role in capacitation and/or the acrosome reaction.

Testicular amyloid deposition as a cause of secondary azoospermia.

We present a case of secondary infertility due to familial amyloidosis. The patient presented with azoospermia, and no other sequela of the disease. A testis biopsy revealed tubules demonstrating full spermatogenesis interspersed with hyalinized tubules containing amyloid, confirmed with Congo red stain. A discussion regarding testicular amyloidosis is presented as well.

The c-kit receptor and its possible signaling transduction pathway in mouse spermatozoa.

The presence and role of the c-kit protein was investigated in the mature sperm of the mouse. The c-kit monoclonal antibody (mAb) ACK2 reacted specifically with the acrosomal region and the principal piece of fixed noncapacitated sperm but did not react with the acrosome region in acrosome-reacted sperm. ACK2 significantly inhibited the acrosome reaction; this inhibition was relieved by the calcium ionophore A23187. The kit ligand stem cell factor (SCF) significantly increased the percentage of sperm undergoing acrosome reaction. This increase was partially inhibited by the calcium channel inhibitor (verapamil), the PI3k inhibitor (wortmannin), and the PLC inhibitor (U-73122). ACK2 predominantly recognized c-kit proteins of 33, 48, and 150 kDa by Western blotting of mouse sperm extracts. The 48- and 150-kDa protein bands were released into the media and tyrosine autophosphorylated at low basal levels during acrosome reaction. On stimulation with SCF, the level of c-kit phosphorylation increased significantly. These findings suggest that c-kit is present in mature sperm, and its binding to SCF may result in the activation of PLC gamma 1 and PI3K, leading to receptor autophosphorylation, and ultimately may play a role in capacitation and/or the acrosome reaction.

Need for sperm retrieval and cryopreservation at vasectomy reversal.

PURPOSE: Controversy exists on whether to obtain sperm for cryopreservation routinely at vasectomy reversal. With recent improvements in in vitro fertilization with intracytoplasmic sperm injection, it is now possible to obtain a small amount of testicular tissue for cryopreservation in the event of reversal failure. However, to our knowledge no studies exist of who is most likely to benefit from this procedure. MATERIALS AND METHODS: We reviewed 84 consecutive vasectomy reversals performed by 1 surgeon (J. I. S.) between July 1996 and March 2000 with followup available for 77. We grouped cases by procedure as vasovasostomy, vasoepididymostomy and vasovasostomy with vasoepididymostomy as well as bilateral or unilateral. Sperm was retrieved at reversal in 15 of 46 vasovasostomy (none used), 11 of 18 vasoepididymostomy (3 used) and 13 of 20 vasovasostomy with vasoepididymostomy (none used) cases. RESULTS: The overall anastomotic patency rate after unilateral or bilateral vasovasostomy, unilateral vasovasostomy with contralateral vasoepididymostomy and unilateral or bilateral vasoepididymostomy was 96%, 83% and 57%, respectively. The natural pregnancy rate without in vitro fertilization was 57%, 50% and 14%, respectively. The most recent vasoepididymal anastomoses were performed by the Berger triangulation technique with a 78% patency and 25% pregnancy rate. Only 8% of men with banked sperm eventually used it for assisted reproductive techniques, in whom unilateral or bilateral vasoepididymostomy failed in all. CONCLUSIONS: We currently do not recommend routine sperm retrieval for cryopreservation in men who undergoing vasovasostomy. We encourage men who require bilateral vasoepididymostomy to bank sperm at reversal. In men who undergo vasovasostomy with vasoepididymostomy we base the decision on preoperative counseling and intraoperative findings.

Migration and ultrastructural localization of the c-kit receptor protein in spermatogenic cells and spermatozoa of the mouse.

PURPOSE: The c-kit receptor is a proto-oncogene important in germ cell migration and maturation and has also been demonstrated on the acrosomal region of mature sperm. The purpose of the present study was to examine the ultrastructural location of the c-kit receptor in mouse testis and sperm. MATERIALS AND METHODS: Testis and sperm from mature male mice were examined for the c-kit receptor utilizing electron microscopy and Western blot analysis techniques. Thin sections of mouse testis and sperm were stained with immunogold-labeled anti-c-kit antibodies. The protein from these testes and sperm was also utilized for Western blot analysis. RESULTS: The c-kit protein was localized within the mouse testes to the type A spermatogonia, the round spermatids, and the mature testicular spermatozoa. The c-kit receptor was noted to migrate from the lumen of the acrosomal vesicles in the early spermatids to the plasma membrane of the late spermatids. It was also noted in the acrosomal region of the testicular spermatozoa, as well as the sperm from the epididymis. Sperm undergoing the acrosome reaction demonstrated association of the c-kit receptor with the plasma membrane of the acrosome, but not on the acrosomal membrane itself. Western blot analysis demonstrated protein bands of 150 kDa in testis and intact sperm. CONCLUSIONS: The present study confirms the presence of the c-kit receptor in mouse testis and sperm. It also demonstrates that this receptor is localized to the region of the developing acrosome.

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.