Objectives. To determine the outcomes for vasectomy reversal performed after at least 10 years of obstruction. Methods. We performed a retrospective review of three surgeons' experience with microsurgical vasectomy reversal for obstructive intervals of at least 10 years. Results. The overall pregnancy rate was 37%. The patency/pregnancy rate for an obstructive interval of 10 to 15, 16 to 19, and 20 or more years was 74%/40%, 87%/36%, and 75%/27%, respectively. The overall ongoing/delivered rate was 35%. The ongoing/delivered rates equaled the pregnancy rates, except in the 16 to 19-year group, for which the ongoing/delivered rate was 27%. Assuming a live delivery rate per cycle of 25% for intracytoplasmic sperm injection (ICSI), the delivery rate for vasectomy reversal would not be exceeded until an obstructive interval of at least 20 years. Assuming a live delivery rate of 28.6% per cycle for ICSI with obstructive azoospermia, the delivery rate for vasectomy reversal would not be exceeded until an obstructive interval of at least 15 years. Conclusions. Even after prolonged obstructive intervals, vasectomy reversal offers better or comparable success rates to ICSI. For each center, depending on their success rates, a threshold obstructive interval exists at which ICSI surpasses vasectomy reversal. Depending on their wishes, couples who have an obstructive interval that exceeds this threshold may be better served by ICSI. As with all infertile couples, close collaboration between the urologists and gynecologists is essential to provide the most appropriate care. © 2002, Elsevier Science Inc.