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

TST.

METHODS

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,

speci

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

pro

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

ﬂ

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

recorded.

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

1-tailed

value

.05.

RESULTS

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.

1336

UROLOGY 84 (6), 2014