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

nitively

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

certain.

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

time,

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

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