https://orcid.org/0009-0001-8954-7824
Figures
Abstract
Objectives
Although sterilization is intended to be permanent, some individuals later seek fertility. In such cases, options can be limited and financially burdensome. This review evaluated the cost-effectiveness of sterilization reversal surgery in previously sterilized individuals.
Methods
We searched MEDLINE, Embase, and Scopus from inception in 1946 through December 2025, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance. We included studies that analyzed cost-effectiveness or reported the costs of sterilization reversal in males (vasectomy reversal) or females (tubal anastomosis), with assisted reproductive technologies as comparators. Study quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards 2022 checklist. Two authors independently screened each study to reduce bias. All costs per outcome were converted to 2024 United States dollars for analysis and comparisons.
Results
Of 1628 identified articles, 24 studies met the eligibility criteria. Almost all examined populations in high-income countries, such as the United States, the Netherlands, and Singapore. Thirteen studies evaluated tubal anastomosis, and eleven evaluated vasectomy reversal. Most studies reported lower total costs for sterilization reversal than for assisted reproductive technologies, with comparable outcomes. Vasectomy reversal was preferred for male patients irrespective of the female partner’s age, whereas tubal anastomosis was preferred for female patients aged 40 years or younger. For older patients, assisted reproductive technologies were more cost-effective.
Citation: Chongthanadon B, Untaaveesup S, Kositamongkol C, Phisalprapa P, Panyakhamlerd K, Titapant V (2026) Economic evaluation of sterilization reversal in infertility treatment: A systematic review. PLoS One 21(6): e0350275. https://doi.org/10.1371/journal.pone.0350275
Editor: Iwaho Kikuchi, Medical Park Minatomirai, JAPAN
Received: December 22, 2025; Accepted: May 12, 2026; Published: June 1, 2026
Copyright: © 2026 Chongthanadon et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its Supporting Information files.
Funding: This research was funded by the Royal Thai College of Obstetricians and Gynaecologists (grant number 011 RTCOG2309). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Surgical sterilization is a highly effective permanent contraceptive option, particularly attractive to individuals with a well-defined family plan. With no observed pregnancies within 6 months after vasectomy and a 2.9% pregnancy rate within 12 months after tubal sterilization, these sterilization techniques offer a reliable, long-term solution that often surpasses other methods in effectiveness and convenience [1,2].
Sterilization is classified into 2 categories: vasectomy in males and tubal sterilization in females. Vasectomy disrupts sperm transport from the proximal to the distal vas deferens, whereas tubal sterilization occludes the fallopian tube to prevent fertilization [3,4]. However, following the 2026 ESGO consensus statement, opportunistic salpingectomy has increasingly become the standard of care to significantly reduce the risk of tubo-ovarian carcinoma [5]. For individuals who initially opted for vasectomy or tubal sterilization, they may choose surgery or assisted reproductive technologies (ARTs) to regain fertility. On the other hand, if female individuals underwent salpingectomy, ARTs are the only options, as the procedure is anatomically impossible to be reversed. Surgical procedures to regain fertility include vasectomy reversal (VR) for males or tubal anastomosis (TA) for females. ARTs involve manipulation of oocytes or embryos and include in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), and related procedures such as cryopreservation and donation of oocytes and embryos [6].
VR, introduced more than a century ago to restore fertility, is performed using 2 techniques [7]. Vasovasostomy anastomoses the severed ends of the vas deferens, whereas vasoepididymostomy (epididymovasostomy) joins the vas deferens to the epididymis. These procedures achieve pregnancy rates of 22%–68% (mean 49%) [8]. TA—also called tubal ligation reversal or tubal re-anastomosis—reconnects the ligated fallopian tube and has a pregnancy rate of 42%–69% [9]. In comparison, ART such as IVF has a pregnancy rate of approximately 46% [10]. However, TA is associated with a higher risk of ectopic pregnancy (6.7%) compared with both IVF (5.6%) and the general population (2%) [11].
Sterilization can lead to regret when life circumstances change and the desire to conceive returns. A retrospective analysis of National Survey of Family Growth data reported that approximately 10% of females regretted sterilization [12]. Without appropriate management, secondary infertility can impose a burden; therefore, addressing infertility in this population is important.
Cost-effectiveness is a key consideration when choosing between reversal surgery and ARTs. Multiple studies have compared sterilization reversal with ARTs; several reported favorable economic outcomes for reversal, whereas others favored ARTs. Reviews commonly concluded that VR was more cost-effective than ARTs [13,14], but findings for TA were variable [9]. However, comprehensive syntheses remain scarce, and many are narrative reviews without formal search methods, which can yield biased or misleading conclusions. The most recent systematic review reporting the cost-effectiveness of VR, conducted in 2002, emphasized ARTs rather than surgical reversal procedures [15].
To address this gap, this systematic review aimed to evaluate the cost-effectiveness of VR and TA compared with ARTs. Furthermore, by assessing studies without publication date restrictions, this review aims to evaluate the longitudinal shifts in cost-effectiveness driven by technological advancements in both surgeries and ARTs. We anticipate that the findings will inform evidence-based policy planning in infertility care.
Materials and methods
Literature search
We conducted a systematic literature search from inception date of each database through December 2025 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol [16] (S1 Table). We searched MEDLINE (via PubMed, 1946–2025), Embase (1947–2025), and Scopus (1960–2025) following a protocol registered on PROSPERO (CRD420250588564) [17]. We also performed manual searches of reference lists of included studies and of relevant systematic reviews, narrative reviews, and meta-analyses. The detailed search strategy is provided in S2 Table.
Inclusion criteria
We included economic evaluations (e.g., cost-effectiveness analyses, cost-utility analyses) of VR in males and TA in females, irrespective of language. The screening of non-English records was facilitated by a digital translation tool (i.e., Google Translate, Google LLC). We also considered clinical studies that reported economic outcomes as a prespecified outcome or secondary endpoint.
Eligible populations comprised individuals seeking to restore fertility after prior sterilization, regardless of sex or demographic characteristics. Populations could include patient cohorts from medical records or simulated cohorts in model-based analyses.
Interventions of interest were VR in males and TA in females, including vasovasostomy and vasoepididymostomy (epididymovasostomy) for VR and tubal ligation reversal or tubal re-anastomosis for TA. Comparators were ARTs, namely IVF, ICSI, and related procedures. We included studies comparing sterilization reversal with ARTs, regardless of terminology used.
Exclusion criteria
We excluded studies of nonhuman subjects, as well as studies comparing variations of the intervention itself (e.g., 1-layer versus 2-layer VR or manual versus robotic TA). Additionally, studies focusing on same-sex couples were excluded. The primary objective of sterilization reversal is to restore fertility for unassisted reproduction. However, reproduction in same‑sex couples inherently requires ARTs or third-party gametes; therefore, evaluating sterilization reversal against ARTs is not clinically applicable in this cohort. We also excluded studies without full text or abstract, systematic or umbrella reviews, and studies using comparators that do not involve manipulation of oocytes or embryos, such as intrauterine insemination.
Screening process
Two authors (B.C. and S.U.) independently screened titles and abstracts in Covidence, a web-based screening platform. Eligibility questions were addressed during screening; unresolved disagreements prompted full-text review and adjudication by a third author (C.K.). Only studies meeting all inclusion criteria proceeded to data extraction.
Data extraction
One author (B.C.) extracted data, which a second author (S.U.) then cross-checked. Clinical variables included population demographics (country, sex, age); specified interventions; time horizon; and outcomes, including pregnancy, delivery, or live birth rates. Economic variables included intervention costs, discount rate, analytic perspective, cost per outcome, and the incremental cost-effectiveness ratio. When data were not specified, we recorded “not reported” in the extraction form. We recorded “not applicable” for fields that did not apply to a specific study design (e.g., time horizons in model analyses). We extracted each study’s conclusion on whether the intervention was more cost-effective than the comparator and categorized it as “yes,” “no,” or “inconclusive.”
Data analysis
We categorized included studies into 2 groups based on biological sex: male and female. To compare costs across years, we adjusted each cost per outcome for inflation using the country’s healthcare consumer price index (CPI), standardizing to 2024 prices in the local currency. If a study did not report the reference year for currency conversion, we assumed the publication year. We then converted costs to 2024 United States dollars (US dollars, $) using the annual foreign exchange rate [18]. We reported results in a comparison table, categorized by participant sex and sorted by study year. We also stratified data by maternal age because this factor influences infertility [19]. For studies that did not report cost per outcome, i.e., those reporting only incremental costs, or only costs and outcomes separately, we included them in the analysis table as “not reported.” For studies reporting multiple interventional pathways, calculation was limited to isolated sterilization reversal arms and isolated ART arms to prevent confounding. Within each intervention category (VR or TA), the option with the lower inflation-adjusted cost per outcome was deemed more cost-effective.
Study assessment
We assessed study quality using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 checklist, a structured framework for reporting economic evaluations [20]. Although developed as a reporting guideline, CHEERS is widely used to appraise health economic evaluations and was suitable for this review [21]. The checklist comprises 28 items spanning clinical and economic dimensions. We rated each item as fulfilled, not fulfilled, or not applicable. Studies meeting more CHEERS criteria were deemed to be of higher quality.
Results
Study selection
From the 3 databases, 1615 articles were identified. An additional 13 articles were found through citation searches, yielding 1628 in total. After removing 204 duplicates, 1424 titles and abstracts were screened. During screening, 1080 articles were excluded, leaving 344 articles for full-text retrieval. Of these, 24 were not retrieved due to lack of both full text and abstract, and 296 articles were excluded for the following reasons: 190 were excluded due to irrelevant outcomes; these were studies that did not report pregnancy, delivery, or live birth rates or any economic outcome; 17 were excluded due to ineligible comparators (i.e., studies that did not include ART as the comparator); 16 were excluded due to ineligible interventions; and 73 were excluded due to ineligible study designs, including non‑economic studies and those with ineligible populations. After full evaluation, 24 articles were included for data extraction and outcome interpretation (Fig 1).
Study characteristics
Most studies (23 of 24) were conducted in high-income countries, with 16 from the United States. Two each were from the Netherlands [22,23] and Singapore [24,25], and 1 each from Australia [26], Belgium [27], Germany [28]. The remaining study [29] was conducted in China, the sole upper-middle-income country represented. Seven studies [22,23,30–34] were published between 1990–1999, two studies [28,35] were published between 2000–2002. Of these, only five studies [30,32–35] were included in the previous systematic review [15]; the remaining 15 studies were conducted after 2002.
Study designs and evaluation types
Cost-effectiveness analyses predominated (n = 21), with 2 cost-utility analyses [36,37] and 1 cost-minimization analysis [29]. Model-based analyses were most common, accounting for 11 studies, followed by retrospective (n = 10) and prospective cohort (n = 3), respectively. Thirteen studies evaluated TA in females, and 11 evaluated VR in males. Most were 2-arm studies (n = 17), with fewer 3-arm (n = 4) and 4-arm (n = 3) designs (Fig 2).
Time horizons and perspectives
Time horizons were reported primarily for cohort-based cost-effectiveness and cost-utility analyses. Nearly all cost-effectiveness analyses [22,24–28,30–33,35] and 1 cost-minimization analysis cohort study [29] reported time horizons of 2–11 years; 1 study did not report a horizon [23]. However, time horizons were marked as “not applicable” for static model-based analyses, as these specific studies evaluate costs and outcomes at a single point in time rather than tracking a cohort longitudinally. For studies’ perspective, only 6 of the 23 studies reported the analytic perspective [24,32,37–40]. Four used the patient perspective [24,32,37,38], 1 used the healthcare provider perspective [39], and 1 used the societal perspective [40]. Detailed characteristics are presented in Table 1.
Study populations
TA studies (female sterilization reversal).
Eight studies used patient records, with or without age restrictions [22–27,30,31]. Three reported results for females younger than 40 years [24,25,30]. Only 1 study reported results for females aged 40 years or older [26]. Three additional TA studies used hypothetical patients without age restrictions; all were model-based analyses [39–41]. Two other model-based analyses in the TA group did not specify population details [38,42].
VR studies (male sterilization reversal).
Almost half of the VR studies (n = 5) included real patients [28,29,32,33,35]. Among these, 1 study specified female partners older than 37 years [35], and 1 specified female partners younger than 40 years [29]. The remaining 6 studies modeled hypothetical male patients [34,36,37,43–45]. None reported male partner age; however, 1 specified female partners aged 35 years or older [37], 1 specified female partners aged 39 years or younger [34], and one stratified female partners aged from 25 to 45 years. Three studies specified the surgical technique: vasoepididymostomy [29,33] or vasovasostomy [28].
Clinical and economic outcomes
TA outcomes.
Across TA studies [22–27,30,31,38–42], outcomes were reported as pregnancy, delivery, cumulative delivery, or live birth rates. As expected, pregnancy rates exceeded delivery and live birth rates, but values varied widely. Pregnancy rates for TA ranged from 5.0% [40] to 77.8% [24], compared with 10% [23,40] to 46.8% [24] for ARTs. Delivery rates in 1 study ranged from 36.6% to 72.2% for TA and from 51.4% to 52.4% for ARTs [27]. Live birth rates ranged from 23.7% [31] to 97.7% [39] for TA and from 12% [38] to 75.6% [39] for ARTs.
Almost all TA studies reported costs; however, 2 did not specify cost details [41,42]. Only 5 studies adjusted costs over time within their study periods [26,38–41].
VR outcomes.
VR studies reported pregnancy, delivery, and live birth rates; additionally, 2 reported quality-adjusted life years [36,37]. Eight VR studies reported total costs, either with a cost breakdown [28,32–34] or without detailed cost information [29,35,37,43]. Two model-based studies reported procedural costs only [44,45], and 1 did not specify cost details [36]. Only 1 study adjusted costs over time using a medical care CPI [44].
Details are summarized in Table 2.
Cost-effectiveness findings
Cost per outcome reporting.
In TA studies, cost-effectiveness was reported by clinical outcome; 2 studies reported incremental cost per live birth rather than cost per live birth [39,41]. In the VR group [28,29,32–37,43–45], nearly all studies reported cost per outcome; however, 1 cost-minimization analysis reported only intervention costs [29], and 1 cost-effective analysis reported only total costs [43].
TA findings.
In total, 9 of 13 studies concluded that TA was more cost-effective than ART. One study favored TA regardless of patient age or other characteristics [38]. However, 7 studies favored TA over ARTs for females below specific ages: below 37 years in 1 study [27], below 40 years in 3 studies [24,25,42], and below 41 years in 3 studies [39–41]. One study favored TA for females older than 40 years [26]. Two studies found ART to be as cost-effective as TA [22,23], and 2 favored ART over TA [30,31].
VR findings.
All VR studies concluded that VR was more cost-effective than ARTs for males seeking to restore fertility after prior vasectomy. Detailed cost-effectiveness data are presented in Table 3.
Inflation-adjusted analyses
Adjustment methods.
Using the reported cost per outcome, we inflation-adjusted the costs from 17 studies to 2024 local currency values. We applied the Australian healthcare CPI [46], Belgian healthcare expenditure CPI [47], German healthcare CPI [48], Singaporean healthcare CPI [49], and United States medical care CPI [50]. We then converted values to 2024 US dollars using annual foreign exchange rates [18]. Calculation details, categorized by cost per outcome for comparison and stratified by maternal age, appear in S3 Table. Owing to substantial heterogeneity, we summarized findings in a table, as shown in Table 4, and performed no meta-analyses or sensitivity analyses.
TA findings.
Studies conducted before 2000 favored ARTs over TA [30,31] or concluded that ARTs were as cost-effective as TA [22,23]. However, all studies conducted after 2000 concluded that TA was more cost-effective than ARTs for females younger than 40 or 41 years, with thresholds varying by study. One study reported higher cost per pregnancy for TA than for ARTs among females older than 40 years ($283 332 versus $144 352) [40].
VR findings.
VR was more cost-effective than ARTs in all studies, regardless of female partner age. Although two studies included multiple arms evaluating a combination of VR and ARTs [36,37], only isolated VR and ART arms were used for calculation. Cost estimates varied widely; however, 1 longitudinal analysis reported a lower cost per live birth for VR in 2005 than in 1999 [44].
Assessment of study quality
Fig 3 summarizes CHEERS 2022 compliance by evaluation category. Almost all studies met more than 20 of 28 items; however, only 8 studies met at least 23 of 28 items (> 80%) [23,27,32,34,37,39,40,44]. One study met fewer than 10 items [42]. Six studies reported the year of currency conversion [26,38–41,44], and only 3 specified a discount rate [39,40,44]. Detailed study-level assessments appear in S4 Table.
Discussion
Cost-effectiveness patterns differed by sex. In the TA group, studies conducted before 2000 reported ARTs to be either more cost-effective or as cost-effective as TA for achieving pregnancy. These findings align with the results of the previous systematic review published in 2002 [15]. In 1 study, the total cost of ART exceeded that of TA ($22 288.04 versus $20 039.74) [30]. However, the cost per pregnancy was slightly lower with ART ($23 718.80 versus $24 333.89) owing to a higher incidence of multiple gestations in the ART group. Despite higher total costs, multiple gestations reduced the cost per pregnancy. These findings aligned with the rapid expansion of ART availability after the first birth from IVF in 1978 [51].
After 2000, all studies favored TA over ARTs, particularly for females younger than 40 or 41 years, reflecting the sharp fertility decline after age 40. This growing favor toward TA in this younger cohort demonstrates a longitudinal shift in economic viability, likely driven by modern advancements in microsurgical techniques. Although ART success is substantially lower in this age group than in younger cohorts [52], 1 model-based analysis concluded that ART was more cost-effective than TA ($111 445 versus $218 742 per ongoing pregnancy) [40]. These findings suggest that ARTs are more economically viable for females of advanced maternal age; therefore, females in this age group should proceed directly to ARTs. Nevertheless, due to an increasing trend of opportunistic salpingectomy for the prophylaxis of tubo-ovarian carcinoma [5], a growing cohort of female patients lacks fallopian tubes required for re-anastomosis. For these individuals, ARTs are the only options to regain fertility, regardless of age.
VR studies demonstrated consensus despite differences in reported outcomes. Consistent with TA findings, 2 studies reported lower cost per outcome in male patients with younger female partners [36,37]. Nonetheless, costs varied widely by country, setting, and study year. After converting costs per outcome to 2024 US dollars (Table 3 and S3 Table), VR generally demonstrated lower costs per outcome. One longitudinal study comparing VR and ART in 1999 and 2005 found improved cost-effectiveness over time, with VR remaining more cost-effective [44].
Therefore, rather than dictating clinical practice, the economic thresholds identified in this study provide an evidence base for shared decision-making. If anatomical reversal is possible, the data support counseling females over 40 years old to proceed directly with ARTs to prevent delay in care. Conversely, for the younger female cohorts, tubal anastomosis yields a superior economic return by allowing multiple unassisted reproduction attempts. Vasectomy reversal is preferred over ARTs regardless of age in male patients, as a single successful surgery provides a more cost-effective reproduction than a recurrent financial burden in ART cycles.
Despite the limited number of studies, substantial heterogeneity existed in reported results. Metrics varied, including cost per pregnancy, cost per delivery, and cost per live birth, with inconsistent application across studies. Even within the same intervention, there was no consensus on which outcome should serve as the denominator. Outcome selection may have favored measures that made the evaluated intervention appear cost-effective [53]. Consequently, an intervention with higher total cost might appear more cost-effective when evaluated using a different clinical outcome. Although cost per live birth is the definitive metric for clinical success, many studies reported only intermediate outcomes, such as cost per pregnancy. This likely reflects the logistical constraints of surgical cohort studies, where tracking initial postoperative conception is more feasible than maintaining the long-term follow-up required to confirm a live birth. In addition, several studies failed to report key components of economic evaluation, such as the analytic perspective, time horizon, and discount rates. Therefore, thorough evaluation should consider total costs, the chosen outcome measure, and other reported metrics.
Moreover, none of the included studies reported a stratification of male partners’ age. For studies evaluating tubal anastomosis, it was clinically sensible to factor in maternal age, as ovarian reserve predictably declines with advanced maternal age [54,55]. In contrast, although paternal age has been shown to negatively affect semen volume, motility, and morphology [56], a multivariate analysis revealed no significant difference in pregnancy rates after vasectomy reversal between males over and under 50 years old [57]. Therefore, while clinical pregnancy rates remain stable, future economic evaluations incorporating paternal age for vasectomy reversal could further address this gap.
Regarding cost adjustment, only 6 studies adjusted costs for inflation [26,38–41,44]. Of these, only 3 reported a discount rate [39,40,44]. Absent proper discounting, estimates drawn from different time periods may misstate the interventions’ economic value. Our systematic review addressed this limitation by standardizing all costs to 2024 US dollars, enabling direct comparisons and revealing trends across 4 decades.
Another limitation observed among primary economic evaluations is the geographic concentration of evidence. Nearly all studies were conducted in high-income countries, except for 1 study from China [29], which is the sole representative of upper-middle–income countries [58]. This distribution likely reflects disparities in access to reproductive technologies across socioeconomic settings, limiting generalizability to lower-income settings. Therefore, direct extrapolation of these findings to low- and middle-income countries should be done with considerable caution, as procedures may be structured differently. For instance, the relative costs of specialized surgical labor versus laboratory-intensive ART cycles are likely to follow different economic paradigms in resource-constraint settings. Additionally, an individuals’ true health financial burden is heavily influenced by income, local health policies, and insurance coverage. These are variables that cannot be retrospectively adjusted for in this analysis.
Furthermore, most included studies did not incorporate quality-adjusted life years into their analyses. Authors may have chosen outcome-specific metrics to allow readers to assess different dimensions of effectiveness without utility weighting [53]. However, the absence of quality-adjusted life years hindered aggregation of parental, fetal, and neonatal outcomes into a single metric and shifted focus to intermediate fetal outcomes rather than final neonatal health outcomes.
Limitations
This systematic review focused exclusively on studies directly comparing sterilization reversal with ARTs, potentially excluding relevant cost data from other clinical or surgical contexts that could inform health economic decisions. Furthermore, given the scarcity of cost adjustments and the absence of paternal age stratification of included studies, future primary economic evaluations addressing these specific variables would provide a more comprehensive understanding of sterilization reversal costs. Moreover, although we performed an extensive citation search without language restrictions, some studies, especially those published in local languages, may have been overlooked because only English search terms were used.
Nevertheless, this review represents the most current and comprehensive synthesis of evidence on sterilization reversal; the last systematic review on this topic was published in 2002 [15]. All costs were standardized to 2024 US dollars, ensuring consistency and comparability across studies. The review also encompasses both male (VR) and female (TA) sterilization reversal. These strengths position this review as the most thorough and up-to-date resource available.
Conclusions
Assuming anatomical feasibility, TA is cost-effective for restoring fertility, particularly for females younger than 40 years. For older females, ARTs are more cost-effective. Furthermore, for patients lacking fallopian tubes due to prior salpingectomy, ARTs remain the sole viable option, regardless of age. For males with prior vasectomy, VR is more cost-effective regardless of the female partner’s age. Therefore, sterilization reversal may confer an economic advantage over ARTs. However, owing to substantial methodological heterogeneity and the large proportion of evidence from high‑income countries, application of these findings requires careful consideration of local infrastructure, funding mechanisms, and health policy.
Supporting information
S3 Table. Cost per outcome of sterilization reversal in 2024 US dollars.
* Health CPI of base year only. Only studies that reported costs per outcome were calculated. Abbreviations: ART, assisted reproductive technology; AUD, Australian dollar; CPI, consumer price index; EUR, Euro; LCU, local currency unit; NA, not applicable; QALY, quality-adjusted life-year; SGD, Singapore dollar; SR, sterilization reversal; USD, US dollar.
https://doi.org/10.1371/journal.pone.0350275.s003
(PDF)
S4 Table. Consolidated health economic evaluation reporting standards 2022 checklist.
Abbreviations: N, “not fulfilled”; NA, “not applicable”; Y, “fulfilled.”.
https://doi.org/10.1371/journal.pone.0350275.s004
(PDF)
Acknowledgments
We thank Euarat Mepramoon for project coordination. We also thank David Park for English-language editing. Artificial intelligence was not utilized for literature searching and screening, data collection, analysis, or critical appraisal of the included literature. During the manuscript preparation, the authors used Gemini (Google) to improve language readability and consolidate structural ideas. After using this tool, the authors and a native‑English‑speaking medical‑manuscript editor reviewed and edited the manuscript as needed. The authors take full responsibility for the final content of the publication.
References
- 1. Barone MA, Irsula B, Chen-Mok M, Sokal DC, Investigator study group. Effectiveness of vasectomy using cautery. BMC Urol. 2004;4:10. pmid:15260885
- 2. Schwarz EB, Chiang AY, Lewis CA, Gariepy AM, Reeves MF. Pregnancy after tubal sterilization in the United States, 2002 to 2015. NEJM Evid. 2024;3(9):EVIDoa2400023. pmid:39189861
- 3.
Marino S, Canela CD, Jenkins SM, Nama N. Tubal sterilization. Treasure Island (FL): StatPearls Publishing; 2025.
- 4.
Stormont G, Deibert CM. Vasectomy. Treasure Island (FL): StatPearls Publishing; 2025.
- 5. Piek JM, Schauwaert J, Ellis LB, Zapardiel I, Planchamp F, Koblos K, et al. Opportunistic salpingectomy for prevention of tubo-ovarian carcinoma: the european society of gynaecological oncology consensus statements. JAMA. 2026;335(10):894–902. pmid:41627806
- 6.
Jain M, Singh M. Assisted Reproductive Technology (ART) techniques. Treasure Island (FL): StatPearls Publishing; 2025.
- 7. Fantus RJ, Halpern JA. Vasovasostomy and vasoepididymostomy: indications, operative technique, and outcomes. Fertil Steril. 2021;115(6):1384–92. pmid:33926720
- 8. Namekawa T, Imamoto T, Kato M, Komiya A, Ichikawa T. Vasovasostomy and vasoepididymostomy: review of the procedures, outcomes, and predictors of patency and pregnancy over the last decade. Reprod Med Biol. 2018;17(4):343–55. pmid:30377390
- 9. van Seeters JAH, Chua SJ, Mol BWJ, Koks CAM. Tubal anastomosis after previous sterilization: a systematic review. Hum Reprod Update. 2017;23(3):358–70. pmid:28333337
- 10. Wang J, Yang Z, Chen Y, Gao F, Zhao W, Cao S, et al. Analysis of factors influencing clinical pregnancy rates in frozen-thawed embryo transfer cycles. Front Endocrinol (Lausanne). 2025;16:1551530. pmid:40636712
- 11. Schippert C, Soergel P, Staboulidou I, Bassler C, Gagalick S, Hillemanns P, et al. The risk of ectopic pregnancy following tubal reconstructive microsurgery and assisted reproductive technology procedures. Arch Gynecol Obstet. 2012;285(3):863–71. pmid:21947340
- 12. Danvers AA, Evans TA. Risk of sterilization regret and age: an analysis of the national survey of family growth, 2015–2019. Obstetrics Gynecol. 2022;139(3):433–9.
- 13. Robb P, Sandlow JI. Cost-effectiveness of vasectomy reversal. Urol Clin North Am. 2009;36(3):391–6. pmid:19643241
- 14. Shridharani A, Sandlow JI. Vasectomy reversal versus IVF with sperm retrieval: which is better?. Curr Opin Urol. 2010;20(6):503–9. pmid:20852426
- 15. Garceau L, Henderson J, Davis LJ, Petrou S, Henderson LR, McVeigh E, et al. Economic implications of assisted reproductive techniques: a systematic review. Hum Reprod. 2002;17(12):3090–109. pmid:12456608
- 16. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. pmid:33782057
- 17.
Chongthanadon B, Kositamongkol C, Phisalprapa P. Economic evaluation of sterilization reversal in infertility treatment: a systematic review. 2025. https://www.crd.york.ac.uk/PROSPERO/view/CRD420250588564
- 18.
Governors TFRB o. Foreign exchange rates - G.5A. 2025. Accessed 2025 January 6. https://www.federalreserve.gov/releases/g5a/current/default.htm
- 19.
Carlson K, Sparzak PB. Age-related fertility decline. StatPearls. Treasure Island (FL): StatPearls Publishing; 2026.
- 20. Husereau D, Drummond M, Augustovski F, de Bekker-Grob E, Briggs AH, Carswell C, et al. Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS 2022) statement: updated reporting guidance for health economic evaluations. BMC Medicine. 2022;20(1):23.
- 21. Watts RD, Li IW. Use of checklists in reviews of health economic evaluations, 2010 to 2018. Value Health. 2019;22(3):377–82.
- 22. Haan G. Effects and costs of in-vitro fertilization. Again, let’s be honest. Int J Technol Assess Health Care. 1991;7(4):585–93. pmid:1778703
- 23. Haan G, van Steen R. Costs in relation to effects of in-vitro fertilization. Hum Reprod. 1992;7(7):982–6. pmid:1430141
- 24. Tan HH, Loh SF. Microsurgical reversal of sterilisation - is this still clinically relevant today?. Ann Acad Med Singap. 2010;39(1):22–6. pmid:20126810
- 25. Chua KH, Chan JKY, Liu S, Tan TY, Phoon JWL, Viardot-Foucault VC, et al. Laparoscopic tubal re-anastomosis or in vitro fertilisation in previously ligated patients: a comparison of fertility outcomes and survey of patient attitudes. Ann Acad Med Singap. 2020;49(4):180–5. pmid:32296806
- 26. Petrucco OM, Silber SJ, Chamberlain SL, Warnes GM, Davies M. Live birth following day surgery reversal of female sterilisation in women older than 40 years: a realistic option in Australia?. Med J Aust. 2007;187(5):271–3. pmid:17767430
- 27. Boeckxstaens A, Devroey P, Collins J, Tournaye H. Getting pregnant after tubal sterilization: surgical reversal or IVF?. Hum Reprod. 2007;22(10):2660–4. pmid:17670765
- 28. Heidenreich A, Altmann P, Engelmann UH. Microsurgical vasovasostomy versus microsurgical epididymal sperm aspiration/testicular extraction of sperm combined with intracytoplasmic sperm injection. A cost-benefit analysis. Eur Urol. 2000;37(5):609–14. pmid:10765102
- 29. Zhang Z, Zhang Y, Zhang N. Clinical outcome of microsurgical vasoepididymostomy versus epididymal or testicular sperm retrieval combined with intracytoplasmic sperm injection in obstructive azoospermia males. Andrologia. 2022;54(8):e14458. pmid:35688176
- 30. Copperman AB, Mukherjee T, Shaer J, Patel D, Sandler B, Grunfeld L, et al. A cost analysis of in vitro fertilization versus tubal surgery within an institution under two payment systems. Journal of Women’s Health. 1996;5(4):335–41.
- 31. Holst N, Maltau JM, Forsdahl F, Hansen LJ. Handling of tubal infertility after introduction of in vitro fertilization: changes and consequences. Fertil Steril. 1991;55(1):140–3. pmid:1986954
- 32. Donovan JF, DiBaise M, Sparks AE, Kessler J, Sandlow JI. 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?. Hum Reprod. 1998;13(2):387–93.
- 33. Kolettis PN, Thomas AJ Jr. Vasoepididymostomy for vasectomy reversal: a critical assessment in the era of intracytoplasmic sperm injection. J Urol. 1997;158(2):467–70. pmid:9224325
- 34. Pavlovich CP, Schlegel PN. Fertility options after vasectomy: a cost-effectiveness analysis. Fertil Steril. 1997;67(1):133–41. pmid:8986698
- 35. Deck AJ, Berger RE. Should vasectomy reversal be performed in men with older female partners?. J Urol. 2000;163(1):105–6. pmid:10604325
- 36. Cheng PJ, Kim J, Craig JR, Alukal J, Pastuszak AW, Walsh TJ, et al. “The Back-up Vasectomy Reversal.” Simultaneous sperm retrieval and vasectomy reversal in the couple with advanced maternal age: a cost-effectiveness analysis. Urology. 2021;153:175–80. pmid:33812879
- 37. Cheng PJ, Kim J, Craig JR, Alukal J, Pastuszak AW, Walsh TJ, et al. “The Back-up Vasectomy Reversal.” Simultaneous sperm retrieval and vasectomy reversal in the couple with advanced maternal age: a cost-effectiveness analysis. Urology. 2021;153:175–80. pmid:33812879
- 38. Alford CE, Csokmay JM, Segars JH, Armstrong AY. Cost analysis of in vitro fertilization (IVF) versus bilateral tubal reanastomosis (BTA) to achieve a live birth. Fertility and Sterility. 2010;94(4):S34.
- 39. Hirshfeld-Cytron J, Winter J. Laparoscopic tubal reanastomosis versus in vitro fertilization: cost-based decision analysis. Am J Obstet Gynecol. 2013;209(1):56.
- 40. Messinger LB, Alford CE, Csokmay JM, Henne MB, Mumford SL, Segars JH, et al. Cost and efficacy comparison of in vitro fertilization and tubal anastomosis for women after tubal ligation. Fertil Steril. 2015;104(1):32-8.e4. pmid:26006734
- 41. Winter JA, Hirshfeld-Cytron JE. Laparoscopic tubal reanastomosis versus in vitro fertilization: cost- based decision analysis incorporating multiple patient ages, ligation technique and impact of multiple gestation. Fertil Sterility. 2012;98(3):S36.
- 42. Womack AS, Tsang A, Buskmiller C, Mahnert ND, Keenan J, Avritscher E. Cost-effectiveness analysis of tubal surgery versus in vitro fertilization as treatment for tubal infertility. J Minimally Invasive Gynecol. 2020;27(7):S143–4.
- 43. Kassab J, Mutascio C, Lipshultz L. (077) Economic analysis of post-vasectomy fertility restoration options. J Sex Med. 2024;21(Supplement_7).
- 44. Lee R, Li PS, Goldstein M, Tanrikut C, Schattman G, Schlegel PN. A decision analysis of treatments for obstructive azoospermia. Hum Reprod. 2008;23(9):2043–9. pmid:18556680
- 45. Meng MV, Greene KL, Turek PJ. Surgery or assisted reproduction? A decision analysis of treatment costs in male infertility. J Urol. 2005;174(5):1926–31; discussion 1931. pmid:16217347
- 46.
Statistics AB o. Consumer price index, Australia. ABS; 2025. https://www.abs.gov.au/statistics/economy/price-indexes-and-inflation/consumer-price-index-australia/latest-release
- 47.
BelgiumNBo. Consumer price index (2013=100) 2025 [cited 2025 April 7]. https://stat.nbb.be/Index.aspx?DataSetCode=NICPHISTO
- 48.
Office FS. Consumer price index: Germany, months, individual consumption by purpose (COICOP 2-5-digit hierarchy). 2025. Accessed 2025 April 7. https://www-genesis.destatis.de/datenbank/online/statistic/61111/table/61111-0004
- 49.
Statistics SDo. Consumer Price Index (CPI), 2024 as base year 2025. Accessed 2025 April 7. https://tablebuilder.singstat.gov.sg/table/TS/M213752
- 50.
Statistics Usb. Consumer Price Index for All Urban Consumers (CPI-U) 2025. https://data.bls.gov/dataViewer/view/timeseries/CUSR0000SAM
- 51. Fishel S. First in vitro fertilization bab—this is how it happened. Fertility and Sterility. 2018;110(1):5–11.
- 52. Yan J, Wu K, Tang R, Ding L, Chen Z-J. Effect of maternal age on the outcomes of in vitro fertilization and embryo transfer (IVF-ET). Sci China Life Sci. 2012;55(8):694–8. pmid:22932885
- 53. Goldhaber-Fiebert JD, Brandeau ML. Evaluating cost-effectiveness of interventions that affect fertility and childbearing: how health effects are measured matters. Med Decis Making. 2015;35(7):818–46. pmid:25926281
- 54. Amanvermez R, Tosun M. An Update on Ovarian Aging and Ovarian Reserve Tests. Int J Fertil Steril. 2016;9(4):411–5. pmid:26985328
- 55. Jimbo M, Kunisaki J, Ghaed M, Yu V, Flores HA, Hotaling JM. Fertility in the aging male: a systematic review. Fertil Steril. 2022;118(6):1022–34. pmid:36509505
- 56. Johnson SL, Dunleavy J, Gemmell NJ, Nakagawa S. Consistent age-dependent declines in human semen quality: a systematic review and meta-analysis. Ageing Res Rev. 2015;19:22–33. pmid:25462195
- 57. Nusbaum DJ, Marks SF, Marks MBF, Burrows PJ, Zollman R, Samplaski MK. The effect of male age over 50 years on vasectomy reversal outcomes. Urology. 2020;145:134–40.
- 58.
World Bank Group. World Bank country and lending groups. https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups