ect the observation of a trend toward more men
presenting for VR after previous TST.
Prior TST may adversely affect the outcome of VR by
suppressing spermatogenesis, altering the intraoperative
ndings used to determine the method of reconstruction,
that is, VV vs EV. This effect is critical given that VR
success rates depend primarily on the following 3 factors:
interval time between vasectomy and VR, the intra-
ndings, and the method of reconstruction.
During VR, microscopic identi
cation of sperm within
uid from the testicular end of the vas
deferens predicts the increased likelihood of VR success.
Patients with clear copious
uid and whole sperm have a
higher chance of sperm returning to the ejaculate and
therefore higher pregnancy rates after a VV.
uid and sperm
ndings, the grading of which
rst described by the Vasovasostomy Study Group in
dictate whether to reconstruct with a VV or the
more technically dif
cult EV. The consensus recom-
mendations of numerous authors are that VV should only
be performed if whole sperm or sperm heads and tails are
ed in the vasal
The consistency of
uid, when coupled with the grading of vasal
spermatozoa, is another very important factor in the de-
cision for the method of reconstruction. After microsur-
gical VV, patency and pregnancy rates decline as the
obstructive interval increases; overall, patency after VV is
71%-97% with a 30%-76% pregnancy rate, depending on
the obstructive interval.
Patency rates for the current
techniques of intussuscepted end-to-side EV are approx-
imately 80% at the best, with a lower pregnancy rate of
maintained by concurrent low-dose hCG in a randomized
sample of 29 healthy volunteers with gonadotropin sup-
pression by exogenous testosterone. The maintenance of
spermatogenesis with the concurrent use of low-dose hCG
with TST was recently demonstrated by Hsieh et al.
this 2013 retrospective study, 26 young hypogonadal men
(mean age, 36 years) underwent treatment with exogenous
testosterone plus hCG 500 units intramuscularly every
other day. The hormone pro
le and semen analyses were
evaluated before and during therapy for a mean follow-up of
6.2 months. Testosterone signi
cantly increased to within
normal limits, however there were no differences in semen
parameters from baseline noted.
Finally, in another small
series of 13 patients with idiopathic hypogonadotropic
hypogonadism and azoospermia, spermatogenesis was qual-
itatively maintained by hCG alone after being induced by
gonadotropin-releasing hormone or combination hCG with
human menopausal gonadotropins.
Therefore, hCG has
been shown to be effective at reinitiating and maintaining
spermatogenesis in hypogonadotropic hypogonadal men
after, and even during, TST.
CC, a selective estrogen receptor modulator that in-
creases gonadotropin secretion via estrogen receptor
blockade in the hypothalamus and anterior pituitary, is
used off-label to treat male secondary hypogonadism.
Both CC and its isomer enclomiphene citrate, which is
currently being tested in clinical trials, improve hypo-
gonadotropic hypogonadism by increasing gonadotropin
secretion. The increased gonadotropins result in higher
endogenous testosterone through a positive LH effect,
and additionally may protect and potentially improve
spermatogenesis through a positive FSH effect.
Although data supporting the use of CC in this speci
population do not exist, CC remains a primary method of
testicular salvage therapy, or as an adjunctive treatment
concurrent with hCG, for spermatogenic recovery after
exogenous testosterone exposure. Because CC is a low-
cost generic medication with an excellent short-term
le, it remains a preferred method of testicular
salvage therapy for all patients desiring VR after prior
A testicular salvage therapy combination regimen of
both CC and hCG has not been previously reported in
the literature. In this study, the particular regimen used
represents the authors
current practice and is not a uni-
versally accepted method of testicular salvage therapy.
Postoperative semen analyses of patent men
Forward progression (1-4)
Total count (million)
Total motile count (million)
Abbreviations as in
Baseline and follow-up hormone levels
Baseline Hormone Levels
Follow-up Hormone Levels
Total T (ng/dL)
Free T (ng/dL)
FSH, follicle stimulating hormone; IQR, interquartile range; LH, luteinizing hormone; SD, standard deviation; SHBG, sex hormone binding
globulin; T, testosterone.
UROLOGY 84 (6), 2014