data re

ﬂ

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-

operative

ndings, and the method of reconstruction.

During VR, microscopic identi

cation of sperm within

the intravasal

ﬂ

uid from the testicular end of the vas

deferens predicts the increased likelihood of VR success.

Patients with clear copious

ﬂ

uid and whole sperm have a

higher chance of sperm returning to the ejaculate and

therefore higher pregnancy rates after a VV.

The

intravasal

ﬂ

uid and sperm

ndings, the grading of which

was

rst described by the Vasovasostomy Study Group in

1991,

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

identi

ed in the vasal

ﬂ

uid.

5,16,18-20

The consistency of

the vasal

ﬂ

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

approximately 40%.

16,19

Covielloetal

showedthat intratesticulartestosteroneis

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.

23,24

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

safety pro

le, it remains a preferred method of testicular

salvage therapy for all patients desiring VR after prior

TST.

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.

Table 3.

Postoperative semen analyses of patent men

5; 83.3%)

Semen Parameters

Median (IQR)

Mean

Volume (mL)

2.2 (2.0-2.5)

2.3

0.7

Density (million/mL)

23 (15-28)

Motility (%)

20 (15-40)

Forward progression (1-4)

2.0 (2.0-2.5)

2.0

0.6

Total count (million)

46 (23-70)

Total motile count (million)

19 (4-31)

Abbreviations as in

Table 2

Table 2.

Baseline and follow-up hormone levels

Hormone

Baseline Hormone Levels

Follow-up Hormone Levels

Median (IQR)

Mean

Median (IQR)

Mean

LH (mIU/mL)

2 (1-4)

5 (4-5)

.08

FSH (mIU/mL)

5 (2-6)

7 (6-8)

.07

Total T (ng/dL)

249 (203-375)

347

260

563 (337-655)

570

336

.17

Free T (ng/dL)

6 (5-6)

10 (9-12)

.42

SHBG (nmol/L)

22 (14-35)

22 (19-36)

.06

Estradiol (ng/dL)

2 (2-4)

5 (2-7)

.09

FSH, follicle stimulating hormone; IQR, interquartile range; LH, luteinizing hormone; SD, standard deviation; SHBG, sex hormone binding

globulin; T, testosterone.

1338

UROLOGY 84 (6), 2014