reconstruction, and, therefore, may impair postoperative
patency and pregnancy rates.
There is currently no available data for the management
of exogenous testosterone-suppressed spermatogenesis in
vasectomized men seeking VR. The vasectomized patient
represents a particularly dif
cult patient in whom to assess
spermatogenesis, and therefore the serum testosterone and
gonadotropins, represents the most accurate initial
assessment. Medical testicular salvage therapy to recover
spermatogenesis in hypogonadotropic hypogonadal men
may be accomplished with clomiphene citrate (CC)
and/or human chorionic gonadotropin (hCG).
If doubt
persists whether spermatogenesis has recovered after
treatment with testicular salvage therapy, a testicular
sperm aspiration (TESA) in the of
ce may be performed.
Although TESA is more invasive, it can provide a de
itive demonstration of spermatogenesis and represents a
particularly helpful diagnostic test for the dilemma of un-
certainty of active spermatogenesis in patients with
obstructive azoospermia secondary to vasectomy.
VR outcomes after TST and considerations for pre-
operative management have not been previously re-
ported. Because of the increased diagnosis and treatment
of androgen de
ciency, we hypothesize that a growing
proportion of men desiring VR will have been treated
with TST. Because the effects of exogenous androgens
adversely impact spermatogenesis,
we postulated that
the use of TST may play a factor in VR outcomes. We
also sought to retrospectively describe a method of
testicular salvage therapy to potentially reinitiate sper-
matogenesis as well as a method to assess for the presence
of spermatogenesis before VR.
In this study, we describe the results of a retrospective
case series of the VR outcomes in men previously on TST
with a goal to demonstrate a proof of concept of a pre-
operative evaluation and treatment strategy using medical
management with testicular salvage therapy, and TESA
in select cases, to increase the success rate of VR after
After obtaining institutional review board approval, a retro-
spective chart review was conducted of consecutive VR cases
performed in a large academic urology practice. All surgeries
were performed by a single fellowship-trained microsurgeon
between December 2009 and May 2013. Patients were included
in the study if a history of prior TST was identi
ed during the
obstructive interval between vasectomy and VR. All patients
must have had 2 separate hormone pro
les along with post-
operative semen analysis data available. Patients were excluded
if any of these criteria were not met.
Preoperative data collected included demographics, length of
obstructive interval, and the formulation and length of time of
TST. Because TST for all patients was prescribed by an outside
facility before the patients presenting for evaluation for VR,
c prescription details including dose, usage and compli-
ance, and improvements in symptoms and testosterone levels
while on TST were not available for all patients and was
therefore not included for analysis. Baseline laboratory values
assessed included total testosterone level, calculated free
testosterone level, luteinizing hormone (LH) level, follicle
stimulating hormone (FSH) level, estradiol level, and sex hor-
mone binding globulin level. After TST was discontinued, pa-
tients underwent medical testicular salvage therapy with CC
25 mg daily, with or without hCG 3000 units subcutaneously
every other day. Both CC and hCG were recommended to all
patients, with some patients taking both as recommended and
others taking only CC because of patient factors such as cost
considerations. It should be noted that this particular combi-
nation regimen of off-label medications has not been previously
reported in the literature and only represents the authors
practice. The regimen and the length of time on medical
testicular salvage therapy were recorded. Patients returned for a
secondary physical examination and laboratory assessment
before VR.
After approximately 3 months of testicular salvage therapy, if
the recovery of spermatogenesis was clinically uncertain based
on the subjective changes in testicular volume or in the hor-
monal pro
le, patients underwent TESA before VR. TESA was
performed as an of
ce-based procedure with local anesthesia on
a single testicle with a single entry passage of the needle. After
administration of a spermatic cord block and subcutaneous skin
block with 1% lidocaine, an 18-ga 1.5-inch needle primed with
sperm wash media and
xed to a
ne needle aspirate piston
syringe was passed into the testicular parenchyma and moved in
and out with a sawing motion approximately 5 times while
holding the vacuum suction on the piston syringe. The aspirate
was then examined on a slide by a certi
ed andrologist with a
phase microscope at 40 times magni
cation for the determina-
tion of active spermatogenesis.
After the secondary preoperative assessment con
rmed an
improvement in the physical examination and the hormonal
le or a positive TESA was performed, all patients underwent
microsurgical VR by a single fellowship-trained microsurgeon
with either a 2-layered vasovasostomy (VV) or intussuscepted
end-to-side epididymovasostomy (EV), techniques of which were
previously described in detail.
Intraoperative data abstracted
included the methods of reconstruction and the characteristics of
the intravasal
uid (including its consistency and the presence or
absence of sperm or sperm parts). Results of postoperative semen
analyses and the achievement of pregnancy were similarly
Data were analyzed by computation of appropriate descriptive
summary statistics with measures of dispersion reported as
interquartile range (IQR) owing to the small sample size.
Comparisons between groups were performed using the Student
test. The threshold for statistical signi
cance was de
ned as a
Retrospective chart review identi
ed a total of 265 pa-
tients who underwent VR between December 2009 and
May 2013. Of those, 10 patients (2.7%) had a docu-
mented history of TST. After 4 patients were excluded
for incomplete data, a total of 6 patients were included for
analysis (
Table 1
). Median age at VR was 38.5 years
(IQR, 36.8-40.5 years), with a median obstructive inter-
val of 7.5 years (IQR, 5.5-8.8 years). All 6 men had
previously fathered children before their vasectomy.
UROLOGY 84 (6), 2014