CONCLUSION

Preoperative medical testicular salvage therapy with CC

with or without hCG may improve the accuracy of the

decision for the best method of reconstruction, VV or EV,

therefore increasing the success of VR in patients with a his-

tory of TST. If managed appropriately, VR in men after TST

can have outcomes comparable with the general population.

References

Baillargeon J, Urban RJ, Ottenbacher KJ, et al. Trends in androgen

prescribing in the United States, 2001 to 2011.

JAMA Intern Med

2013;173:1465-1466

Mulligan T, Frick MF, Zuraw QC, et al. Prevalence of hypo-

gonadism in males aged at least 45 years: the HIM study.

Int J Clin

Pract

. 2006;60:762-769

Bassil N, Alkaade S, Morley JE. The bene

ts and risks of testosterone

replacementtherapy:a review.

TherClinRiskManag

.2009;5:427-448

Eisenberg ML, Lipshultz LI. Estimating the number of vasectomies

performed annually in the United States: data from the National

Survey of Family Growth.

J Urol

. 2010;184:2068-2072

Schwarzer JU. Vasectomy reversal using a microsurgical three-layer

technique: one surgeon

’

s experience over 18 years with 1300 pa-

tients.

Int J Androl

. 2012;35:706-713

Mui P, Perkins A, Burrows PJ, et al. The need for epi-

didymovasostomy at vasectomy reversal plateaus in older vasec-

tomies: a study of 1229 cases.

Andrology

. 2014;2:25-29

Liu PY, Swerdloff RS, Anawalt BD, et al. Determinants of the rate

and extent of spermatogenic suppression during hormonal male

contraception: an integrated analysis.

J Clin Endocrinol Metab

. 2008;

93:1774-1783

Roth MY, Ilani N, Wang C, et al. Characteristics associated with

suppression of spermatogenesis in a male hormonal contraceptive trial

using testosteroneand Nestorone(

) gels.

Andrology

. 2013;1:899-905

Manetti GJ, Honig SC. Update on male hormonal contraception: is

the vasectomy in jeopardy?

Int J Impot Res

. 2010;22:159-170

10.

Liu PY, Swerdloff RS, Christenson PD, et al; Hormonal Male

Contraception Summit Group. Rate, extent, and modi

ers of

spermatogenic recovery after hormonal male contraception: an in-

tegrated analysis.

Lancet

. 2006;367:1412-1420

11.

Jarow JP, Lipshultz LI. Anabolic steroid-induced hypogonadotropic

hypogonadism.

Am J Sports Med

. 1990;18:429-431

12.

Moss JL, Crosnoe LE, Kim ED. Effect of rejuvenation hormones on

spermatogenesis.

Fertil Steril

. 2013;99:1814-1820

13.

Katz DJ, Nabulsi O, Tal R, Mulhall JP. Outcomes of clomiphene

citrate treatment in young hypogonadal men.

BJU Int

. 2012;110:

573-578

14.

Depenbusch M, von Eckardstein S, Simoni M, Nieschlag E.

Maintenance of spermatogenesis in hypogonadotropic hypogonadal

men with human chorionic gonadotropin alone.

Eur J Endocrinol

2002;147:617-624

15.

Kessaris DN, Wasserman P, Mellinger BC. Histopathological and

cytopathological correlations of percutaneous testis biopsy and open

testis biopsy in infertile men.

J Urol

. 1995;153:1151-1155

16.

Lipshultz LI, Rumohr JA, Bennett RC. Techniques for vasectomy

reversal.

Urol Clin North Am

. 2009;36:375-382

17.

Sharma V, Le BV, Sheth KR, et al. Vasectomy demographics and

postvasectomy desire for future children: results from a contempo-

rary national survey.

Fertil Steril

. 2013;99:1880-1885

18.

Belker AM, Thomas AJ Jr, Fuchs EF, et al. Results of 1,469

microsurgical vasectomy reversals by the Vasovasostomy Study

Group.

J Urol

. 1991;145:505-511

19.

Schiff J, Chan P, Li PS, et al. Outcome and late failures compared in

4 techniques of microsurgical vasoepididymostomy in 153 consec-

utive men.

J Urol

. 2005;174:651-655; quiz 801

20.

Smith RP, Khanna A, Kovac JR, et al. The signi

cance of sperm

heads and tails within the vasal

ﬂ

uid during vasectomy reversal.

Indian J Urol

. 2014;30:23-27

21.

Coviello AD, Matsumoto AM, Bremner WJ, et al. Low-dose human

chorionic gonadotropin maintains intratesticular testosterone in

normal men with testosterone-induced gonadotropin suppression.

J Clin Endocrinol Metab

. 2005;90:2595-2602

22.

Hsieh TC, Pastuszak AW, Hwang K, Lipshultz LI. Concomitant

intramuscular human chorionic gonadotropin preserves spermato-

genesis in men undergoing testosterone replacement therapy.

J Urol

2013;189:647-650

23.

Kaminetsky J, Hemani ML. Clomiphene citrate and enclomiphene

for the treatment of hypogonadal androgen de

ciency.

Expert Opin

Investig Drugs

. 2009;18:1947-1955

24.

Kaminetsky J, Werner M, Fontenot G, Wiehle RD. Oral enclomi-

phene citrate stimulates the endogenous production of testosterone

and sperm counts in men with low testosterone: comparison with

testosterone gel.

J Sex Med

. 2013;10:1628-1635

EDITORIAL COMMENT

Increased awareness about potential links between hypogonadism

and metabolic syndrome, sexual dysfunction, mood disorders, and

physical

tness in men leads to dramatic increase in utilization of

testosterone replacement therapy (TRT).

Some of the men

treated with TRT either never had children or remarry and decide

to have children with their new spouses.

TRT by lowering serum

luteinizing hormone (LH) and follicle-stimulating hormone

(FSH) can lead to suppression of spermatogenesis. When human

chorionic gonadotropin (hCG) was given with TRT, no sup-

pression of spermatogenesis was observed providing convincing

evidence that it is not TRT per se causing spermatogenic sup-

pression but decrease in serum LH and FSH levels as a result of

TRT. As no reliable method exists at this point to predict which

men will suppress their sperm production while on TRT, it is wise

to stop TRT to allow for LH and FSH recovery before vasectomy

reversal for at least 3-6 months. However, if such an approach is

necessary in men who have normal LH and FSH levels despite

TRT is an area of debate. From a purely physiological perspective,

if LH and FSH are within normal range then it would be unlikely

that suppression of spermatogenesis would occur with normal LH

and FSH levels despite of TRT.

The choice of anastomosis during vasectomy reversal depends

on the presence of sperms in the testicular end of vas, thus it is

paramount that spermatogenesis is optimized before an attempt

at reconstruction. The authors present their experience with 6

men who wished vasectomy reversal after TRT. Based on few

published observational studies using clomiphene citrate and/or

hCG to restore normal pituitary function in men with sup-

pression of LH and FSH after TRT, authors used 25 mg with or

without hCG 3 times a week to restore spermatogenesis. It is

reassuring to notice that within minimum of 3 months of

therapy with clomiphene citrate and/or hCG, sperms were

identi

ed in all 6 subjects. In addition, results of vasectomy

reversal seem to re

ﬂ

ect the type of anastomosis, with bilateral

vasoepididymostomy resulting in azoospermia on follow-up

semen analysis despite the presence of nonmotile sperms in

epididymal

ﬂ

uid rather than the medical treatment used.

This article brings an important issue of inherited risks of

spermatogenic suppression in some if not all men on TRT. Lack

of a control arm makes it unclear if any form of therapy other

than stopping TRT and following FSH and LH is indeed

necessary; hence, additional studies with larger numbers of

subjects are needed.

Clomiphene citrate and hCG treatments add additional cost

and the need for injections in addition to not being Food and

Drug Administration

approved treatments for male infertility.

1340

UROLOGY 84 (6), 2014