Infertility
Vasectomy Reversal Outcomes in Men
Previously on Testosterone
Supplementation Therapy
Robert M. Coward, Douglas A. Mata, Ryan P. Smith, Jason R. Kovac, and Larry I. Lipshultz
OBJECTIVE
To report considerations for preoperative management and outcomes of vasectomy reversal (VR)
in men with a history of testosterone supplementation therapy (TST).
METHODS
A retrospective review of men on TST before VR from 2010 to 2013 was performed. For in-
clusion, patients were required to have baseline and follow-up hormone levels as well as post-
operative semen analyses. Preoperative use of medical testicular salvage therapy and testicular
sperm aspiration (TESA), intraoperative
f
ndings, and pregnancies were also analyzed.
RESULTS
Six of 265 men who underwent VR had prior TST and met inclusion criteria. Median age was
39 years with a median obstructive interval of 7.5 years. Median duration of TST was 9 months
before discontinuation and transition to testicular salvage therapy with clomiphene citrate with
or without human chorionic gonadotropin for a median of 2.8 months. At baseline, decreased
luteinizing hormone (median, 2 mIU/mL), follicle stimulating hormone (median, 5 mIU/mL),
and total testosterone (median, 249 ng/dL) were observed. Two men (33%) with uncertain re-
covery of spermatogenesis based on physical examination and hormone response underwent
preoperative testicular sperm aspiration con
f
rming the presence of sperm. Nine vasovasostomies
and 3 epididymovasostomies were performed. Patency was 83% after a median follow-up of
6.4 months and was 100% in men undergoing at least 1 vasovasostomy. Spontaneous pregnancy
was achieved by 50% during the follow-up period.
CONCLUSION
Testicular salvage medical therapy may play a role in the preoperative management of VR in men
with prior TST. VR after TST can have outcomes comparable to those in the general
population.
UROLOGY
84: 1335
e
1341, 2014.
Ó
2014 Elsevier Inc.
U
se of testosterone supplementation therapy
(TST) has become increasingly common among
younger men.
1
Idiopathic biochemical hypo-
gonadism, de
f
ned by a total testosterone level
<
300 ng/
dL, is observed in just over a third of all men aged
45-54 years.
2
The diagnosis of hypogonadism and its
treatment with TST has grown remarkably in recent years,
as testosterone prescriptions have increased over 500%
since 1993.
3
The age group with the most rapid rate of
increased utilization is men aged 40-49 years, with
testosterone prescriptions increasing more than 4.2-fold
between 2001 and 2011. In 2011, this equated to a total
prevalence of 2.3% in this age group alone.
1
Men undergo vasectomy at an average age of 31 years,
4
whereas the average age for vasectomy reversal (VR) is
41 years.
5,6
Some men within this window will be diag-
nosed with hypogonadism and treated with TST. Nearly
all men will have some degree of suppression of sper-
matogenesis during treatment with TST. Exogenous
testosterone typically results in atrophy of the germinal
epithelium in normal men with varying degrees of sup-
pression of spermatogenesis, including azoospermia,
within several months.
7,8
The level of suppression is
partly dependent on the type of testosterone preparation,
with topical preparations typically displaying a smaller
degree of suppression of gonadotropins and thus sper-
matogenesis than injectable or implantable testosterone
preparations.
9
Sperm concentrations usually recover to
pretreatment levels after the cessation of TST; however,
recovery could take up to 2 years,
10
and permanent
detrimental effects to spermatogenesis are possible.
11,12
The use of TST before VR may impact vasal
fl
uid
f
nd-
ings by suppressing spermatogenesis, which could compli-
cate intraoperative decision making on the method of
Financial Disclosure:
Larry Lipshultz is a paid consultant, advisor, speaker, and
clinical trial investigator to Eli Lilly and Company. He is a clinical investigator, meeting
participant, and speaker to Endo Pharmaceuticals. He is also a meeting participant and
speaker to P
f
zer. He is a clinical trial investigator and speaker to Auxilium Pharma-
ceuticals. The remaining authors declare that they have no relevant
f
nancial interests.
From the Department of Urology, University of North Carolina School of Medicine,
Chapel Hill, NC; the Scott Department of Urology, Baylor College of Medicine,
Houston, TX; the Department of Biochemistry and Cell Biology, Wiess School of
Natural Sciences, Rice University, Houston, TX; and the Department of Urology,
School of Medicine, University of Virginia, Charlottesville, VA
Address correspondence to: Robert M. Coward, M.D., 2113 Physicians Of
f
ce
Building, CB#7235, 170 Manning Drive, Chapel Hill, NC 27599-7235. E-mail:
mcoward@med.unc.edu
Submitted: February 6, 2014, accepted (with revisions): June 16, 2014
ª
2014 Elsevier Inc.
All Rights Reserved
0090-4295/14
1335