Based on the limited data available, patients in the pre-
sent study had TST discontinued and were started on CC
25 mg daily with or without hCG 3000 units subcuta-
neously every other day for testicular salvage therapy.
Two of 6 patients (33.3%) underwent TESA to assess for
spermatogenesis before VR. Based on our early experi-
ence, we propose the following preoperative management
algorithm (
Fig. 1
). If interested in VR, it is recommended
to directly inquire regarding a patient
s use of TST to
assess the risk of gonadotropin suppression. If the history
is suggestive of gonadotropin suppression, then the
physical examination during the initial encounter should
include an assessment of testicular volume coupled with a
hormone pro
le including total and free testosterone, LH,
and FSH levels. If testicular volumes are low and gonadal
suppression is con
rmed, discontinuation of TST is rec-
ommended with transition to CC with or without hCG
for a duration of 3 months (ie, testicular salvage). After
3 months, the patient should have another clinic visit for
a repeat physical examination and hormone pro
le. In
men with an uncertain response to therapy (eg, persis-
tently soft, small testes, or no improvement in the labo-
ratory assessment of hypogonadotropic hypogonadism),
an in-of
ce TESA may be considered to de
determine the presence of spermatogenesis. After the
examination and hormone pro
le improve, or if a TESA
is positive for active spermatogenesis, one can proceed to
microsurgical VR in the standard fashion. As with every
VR, the option remains for concurrent cryopreservation
of sperm, particularly when a successful outcome is less
Although the sample size was small, the results
observed in this case series are promising and suggest that
outcomes using this preoperative strategy for patients with
previous TST may approach those seen in the general
population. After 9 VVs and 3 EVs were performed, with
2 of 6 patients (33.3%) undergoing at least 1 EV, the men
demonstrated an overall patency of 83.3% after a median
follow-up of 6.4 months, with 100% patency among men
undergoing at least 1 VV. Remarkably, pregnancy was
achieved by 50% during the short follow-up period. The
results in the present case series compare quite closely
with a recently published, large, contemporary series of
1229 VRs where the rate of at least 1 EV was 33%, and
the overall patency rate was 84% after a median
obstructive interval of 10 years.
Limitations of the study include its retrospective nature,
small sample size, and that all cases were performed at a
single institution in an urban setting. Additionally,
without a control arm, it is possible that some patients may
have naturally achieved return of spermatogenesis over
which would make the actual bene
t of a 3-month
course of medical testicular salvage therapy not entirely
certain. Because previous TST dose, usage, and compli-
ance were not available for all patients, speci
c conclu-
sions regarding the exact exogenous testosterone exposure
in the study population cannot be made. For all these
reasons, the results must be cautiously interpreted in this
context, and the recommendations for preoperative
management herein should be used in centers of excel-
lence by physicians already experienced with using
testicular salvage therapy. The exact best regimen of
testicular salvage therapy cannot be fully elucidated from
this small cohort in the present study. These limitations in
a study such as this reinforce the dire need for multi-
centered prospective data for the treatment of male
fertility. We have demonstrated a proof of concept that
men with suppression of their hypothalamic pituitary
gonadal axis, potentially resulting in decreased spermato-
genesis from exogenous testosterone use, can have sper-
matogenic recovery before VR and achieve favorable
outcomes compared with other larger contemporary series.
Figure 1.
Algorithm for preoperative evaluation and treatment of men desiring vasectomy reversal after testosterone sup-
plementation therapy (TST). hCG, human chorionic gonadotropin; TESA, testicular sperm aspiration.
UROLOGY 84 (6), 2014