I can’t think of two ways of conceiving a child that could be more different. Now, I’m not referring to sex positions that might be more likely to produce a boy or girl. No, this is not a discussion of missionary vs. doggie, or cowgirl vs. kneeling lotus, or quarter moon vs. full moon at the time of rapture. Rather, this is about whether after having had a vasectomy and now wanting to conceive again, one should give it a go in the bedroom or in the laboratory. It was Woody Allen who said in Annie Hall that sex “is the most fun I’ve ever had without laughing.” So, what’s a guy to do, reverse the vasectomy or proceed with sperm retrieval and use in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI)?

Life Is in the Details

Let’s look closely at the choices in front of us. A vasectomy reversal is a 2-3 hour microsurgical procedure on the male partner with very few if any complications and a restriction of no sex for three weeks (probably the hardest part) after the procedure. When performed by expert reproductive surgeons, sperm returns to the ejaculate in 75%-100% of cases and attempts to conceive start pretty much right away and can be attempted monthly in the comfort of your own home.

IVF-ICSI requires several weeks of intensive hormonal injections for the female partner to drum up not just one egg (the usual number) but as many as possible. Then, procedures are performed on both partners: the female gets the entire cluster of generated eggs removed by needle aspiration from the ovary and the male undergoes a procedure by needle or incision to remove sperm from behind the vasectomy either in the testis or epididymis. The procured eggs and sperm then meet in a petri dish, but not randomly like God or Darwin may have intended. Instead, a trained embryologist chooses the sperm and injects one sperm directly into each egg. The fertilized eggs are then watched for up to a week in the laboratory and their quality assessed regularly as they develop as embryos. Uniquely, they can be biopsied and the genetic content of each embryo assessed for sex, chromosomal alterations and even specific genetic disorders if desired. Then, the (usually single) embryo is transferred back to the female partner in a second smaller procedure weeks later. That’s it. There’s no “was it as good for you as it was for me?” banter or anything.

How to Start a Life?

Here are some thoughts to consider in deciding which baby route to choose:

• Where does conception occur? Bedroom vs. laboratory, your choice.
• How much do we want to know about our fetus? Your guess is as good as mine vs. full genomic sequencing.
• How many children do we want? Monthly attempts at home vs. multiple IVF cycles.
• How much can we afford? Reversals are about half the price or less than an IVF cycle. Insurance covering IVF may even out this difference.
• Which has the higher pregnancy rate? Tough one to answer, but in the setting of healthy partners with good surgeons and good IVF technology, probably even-Steven.
• How soon will we be pregnant? Another tough one to answer, as many factors involved. All in, IVF is probably a few months faster.
• Risk of twins or triplets? With sex it’s 2% and with IVF it’s a 20-30% chance.
• Risk of birth defects? 25% higher with IVF than with sex. Malformations of the eye, heart and genitals are the most commonly observed defects.

Clearly, the decision to pursue IVF or vasectomy reversal is a complex one, stirring up all kinds of deeply held notions and emotions about love and life. Sex and natural selection are now being challenged by science and genetics. Luck and fate now compete with knowledge and determinism. And pure chance now faces the forces of statistics and probability. It’s enough to challenge the centuries-old view, as stated by Sidney Poitier, that: “So much of life, it seems to me, is determined by pure randomness.”