Evaluation and treatment of infertility in spinal cord injured men through rectal probe electroejaculation

Microsurgical Management of Male Infertility: Compelling Evidence That Collaboration with Qualified Male Reproductive Urologists Enhances Assisted Reproductive Technology (ART) Outcomes

A male factor plays a significant role in a couple's reproductive success. Today, advances in reproductive technology, such as intracytoplasmic sperm injection (ICSI), have allowed it to be possible for just a single sperm to fertilize an egg, thus, overcoming many of the traditional barriers to male fertility, such as a low sperm count, impaired motility, and abnormal morphology. Given these advances in reproductive technology, it has been questioned whether a reproductive urologist is needed for the evaluation and treatment of infertile and subfertile men. In this review, we aim to provide compelling evidence that collaboration between reproductive endocrinologists and reproductive urologists is essential for optimizing a couple's fertility outcomes, as well as for improving the health of infertile men and providing cost-effective care.

Sperm preservation by electroejaculation before anticancer therapy

BACKGROUND

This report presents a case where electroejaculation (EEJ) was used for semen cryopreservation (SCP), prior to gonadotoxic anti-cancer treatment in a 14-year old boy diagnosed with Hodgkins disease.

METHOD

Two sessions of EEJ were performed with an interval of 48 hours.

RESULTS

No complications were seen and the procedures resulted in nine frozen straws of motile spermatozoa.

CONCLUSION

EEJ is a safe and feasible procedure for SCP in an adolescent cancer patient who is unable to masturbate or use penile vibratory stimulation (PVS).

Electroejaculation in patients with spinal cord injuries: A 21-year, single-center experience

OBJECTIVES

To evaluate treatment results of electroejaculation in patients with spinal cord injuries and the additional value of repeated electroejaculation.

METHODS

We carried out a retrospective chart analysis of all spinal cord injury patients treated with electroejaculation at University Medical Center Utrecht, Utrecht, the Netherlands, from January 1994 to July 2015. Data were collected on the patients' demographics and medical history. We evaluated sperm quality according to World Health Organization standards, pregnancy and delivery rates.

RESULTS

A total of 230 electroejaculation procedures were carried out in 47 patients. In 227 of 230 electroejaculations (98.7%), an ejaculate could be obtained. In 169 of 230 (73.5%) electroejaculation procedures, it was possible to yield semen containing progressively motile spermatozoa. In 18 of 47 (38.3%) patients, no semen of sufficient quality could be yielded during the first electroejaculation. Repeated electroejaculation resulted in ejaculates containing progressively motile spermatozoa in seven of 18 (38.9%) of these men. Procreation was attempted through in vitro fertilization/intracytoplasmic sperm injection in 17 couples; of these, 14 of 17 (82.4%) couples achieved pregnancy.

CONCLUSIONS

In the majority of spinal cord injury patients treated with electroejaculation, it is possible to obtain semen that can be used for assisted reproductive technologies. Repeated electroejaculation should be considered when the first procedure fails.

Fertility treatment in spinal cord injury and other neurologic disease

Infertility in individuals with neurologic disorders is complex in etiology and manifestation. Its management therefore often requires a multimodal approach. This review addresses the implications of spinal cord injury (SCI) and other neurologic disease on fertility, including the high prevalence of sexual dysfunction, ejaculation disorders and compromised semen parameters. Available treatment approaches discussed include assisted ejaculation techniques and assisted reproductive technology including surgical sperm retrieval and intracytoplasmic sperm injection (ICSI).

Testicular sperm retrieval and intra cytoplasmic sperm injection provide favorable outcome in spinal cord injury patients, failing conservative reproductive treatment

STUDY DESIGN

Retrospective cohort analysis.

OBJECTIVES

The objective of this study was to determine the in vitro fertilization (IVF) outcome after testicular sperm extraction (TESE) in a group of spinal cord injury (SCI) male patients not compatible with conservative fertility treatment.

SETTING

University-affiliated medical center.

METHODS

Thirty two SCI patients (C2 to L2) were referred to IVF after repeated trials of electroejaculation (EEJ) or penile vibratory stimulation (PVS), and full andrological evaluation. Testicular sperm aspiration (TESA) was the method of choice for sperm extraction. Open TESE was performed only after a negative TESA attempt. Clinical pregnancy and live birth rates were determined.

RESULTS

A total of 106 testicular procedures were performed. Sperm was found in 95 cycles (89.6%). The average metaphase II (MII) oocyte number was 11.0±4.2, an average of 5.1±2.3 oocytes became normally fertilized after Intra Cytoplasmic Sperm Injection (ICSI) (fertilization rate 57.1%). On average, 2.7±1.2 embryos were replaced. The clinical pregnancy rate was 32/106 (30.2%) per cycle and 19/32 (59.3%) per couple. Live birth rate was 62.5% (20/32).

CONCLUSIONS

TESA/E and IVF can provide excellent prognosis for SCI patients that cannot be treated by EEJ or PVS.

Electroejaculation With a Foley Catheter in the Bladder

Electroejaculation has been successfully used for sperm procurement in anejaculatory men desiring fertility. The electroejaculation procedure begins with complete catheterization of the bladder and instillation of an insemination medium into the bladder as a buffer. This step can minimize possible detrimental effects of urine on any retrograde ejaculate. The catheter is then removed. After the collection of the antegrade ejaculate, the bladder is catheterized again. Our objective was to evaluate the possibility of performing electroejaculation while the Foley catheter is instilled in the bladder. Eleven men with anejaculation underwent 22 procedures of rectal probe electroejaculation. Each patient underwent electroejaculation twice, once without the catheter instilled in the bladder (standard method) and once with it. The 2 methods, with and without the catheter, showed no significant differences in volume, concentration, motility, count, and total motility of the antegrade ejaculate. In retrograde ejaculate, there were no significant differences in the count, motility, and total motility. In addition, there was no difference in the total count and the total motility of both fractions in the 2 methods. In this study, we show that ejaculation can be achieved while the Foley catheter is instilled in the urethra without any detrimental effect on the sperm. Therefore, we recommend not removing the Foley catheter while performing electroejaculation.

Sperm chromosomal aneuploidy and DNA integrity of infertile men with anejaculation

PURPOSE

To explore sperm chromosomal aneuploidy, sperm membrane and DNA integrity in infertile patients with anejaculation.

METHODS

Semen samples were collected from 18 infertile men with spinal cord injury (SCI) by penile vibratory stimulation (PVS) and from 14 psychogenic anejaculation (PA) patients by percutaneous vasal sperm aspiration (PVSA). These semen samples as well as samples from 16 donors were analyzed using the hypo-osmotic swelling (HOS) test, the sperm chromatin dispersion (SCD) test and multi-color fluorescence in situ hybridization (FISH) with probes specific for chromosomes 13, 18, 21, X and Y.

RESULTS

There were significant differences in the percentages of motile sperm, normal morphologic sperm and sperm DNA fragmentation between the infertile men with SCI and the control group (P < 0.05 and P < 0.01). The sperm motility was significantly greater in the PA-PVSA group than in the SCI-PVS group (P < 0.01). The number of round cells per mL of semen obtained from the 18 SCI patients by PVS was between 1 and 8 million. The rate of sperm DNA fragmentation in the SCI-PVS group was higher than that of the PA-PVSA group (P < 0.05). The aneuploidy rates for the SCI patients were 2.4-fold higher for chromosomes 13, 18 and 21 and 2.2-fold higher for chromosomes X and Y than for patients in the control group (P < 0.0001).

CONCLUSIONS

The semen quality is poorer, sperm DNA fragmentation and sperm chromosomal aneuploidies are seen at a higher rate for SCI patients compared to healthy, fertile and normospermic men. Whether the difference in yield is due to increased scrotal temperature, genitourinary infection, or other reasons requires further study.

Blessé médullaire: prise en charge en andrologie

Les réactions sexuelles sont sous contrôle neurologique. Le traumatisme vertébromédullaire altère l’organisation neurologique et génère un dysfonctionnement sexuel. Les substances pharmacologiques actuelles permettent de rétablir la fonction érectile du blessé médullaire, première étape essentielle à la réorganisation d’une vie sexuelle. Le déclenchement de l’éjaculation est souvent difficile. Les techniques de stimulation périnéale isolées ou associées au traitement pharmacologique favorisent la réalisation d’éjaculation et permettent un recueil et une conservation du sperme. La possibilité d’obtenir une éjaculation au cours des rapports sexuels, chez le blessé médullaire, reste rare et sans véritable solution thérapeutique. Malgré l’altération de la qualité du sperme, les blessés médullaires conservent une possibilité de procréation pour 40 à 60 % des couples. Le recours à des techniques d’assistance médicale à la procréation est souvent nécessaire. La prise en charge des dysfonctionnements sexuels des blessés médullaires doit être intégrée dans un programme de rééducation et de réinsertion.

Semen parameters in men with spinal cord injury: changes and aetiology

AIM

To assess the changes in semen parameters in men with spinal cord injury (SCI) and the possible causes of these changes.

METHODS

The study included 45 subjects with SCI. Semen retrieval was done by masturbation (2), vigorous prostatic massage (n = 13), penile vibratory stimulation (n = 13) or electroejaculation (n = 17).

RESULTS

The semen of men with SCI showed normal volume (2.3 +/- 1.9 mL) and sperm count (85.0 X 10(6) +/- 83.8 X 10(6)/mL) with decreased motility (11.6% +/- 0.1%), vitality (18.5% +/- 5.2%) and normal forms (17.5% +/- 3.4%), and pus cells has been increased (6.0 X 10(6) +/- 8.2 X 10(6)/mL). Total (13.4 +/- 9.9 vs. 7.1 +/- 6.8) and progressive (4.4 +/- 3.9 vs.2.2 +/- 2.1) motility were significantly higher in subjects with lower scrotal temperatures. There was no statistical significant difference between electroejaculation and penile vibratory stimulation groups as regards any of the semen parameters. Subjects'age, infrequent ejaculation, injury duration and hormonal profile showed no significant effect on semen parameters.

CONCLUSION

The defining characteristics of the seminogram in men with SCI are normal volume and count with decreased sperm motility, vitality and normal forms, and the increased number of pus cells. The most acceptable cause of the deterioration of semen is elevated scrotal temperature.

Prostatic massage: a simple method of semen retrieval in men with spinal cord injury

The aim of this study was to evaluate the efficacy of prostatic massage (PM) as a method for obtaining semen in men with spinal cord injury (SCI) and to evaluate the semen parameters in the semen samples obtained by this method. Sixty-nine patients with SCI underwent PM as a trial for semen retrieval. History taking, examination and hormonal assay analysis (follicle-stimulating hormone, luteinizing hormone, prolactin and testosterone) were performed in all patients. Patients were grouped as follows: group 'A' where sperm could be successfully retrieved by PM and group 'B' where no sperm could be retrieved. PM resulted in the production of prostatic secretion in 51 patients (73.9%) and no secretion was obtained in 18 patients. Spermatozoa were successfully retrieved in only 22 patients (31.9%). The semen analysis of the sperm-positive samples showed asthenoteratozoospermia with decreased vitality and increased number of leucocytes. Semen collection by PM was significantly higher in patients with an SCI level above T10. PM is a safe and simple outpatient clinic procedure that can be easily used to retrieve semen in men with SCI.

Current trends in the treatment of infertility in men with spinal cord injury

OBJECTIVE

To determine current use of penile vibratory stimulation (PVS), electroejaculation (EEJ), and intrauterine insemination (IUI) in treatment of infertility in men with spinal cord injury (SCI).

DESIGN

Prospective survey, retrospective chart review, and literature review.

SETTING

Major university medical center.

PATIENT(S)

Male SCI patients and female partners.

INTERVENTION(S)

A survey administered to professionals determined current treatment methods for infertility in couples with SCI male partners.

MAIN OUTCOME MEASURE(S)

Sperm retrieval methods, ejaculation success rates, total motile sperm (TMS), IUI application, and IUI outcomes.

RESULT(S)

Twenty-eight percent of surveyed professionals do not retrieve sperm from ejaculates of SCI patients, relying instead on retrieval from reproductive tissues. Reasons for not offering PVS or EEJ were lack of familiarity, training, or equipment. Thirty-four percent do not offer IUI to these couples. Chart review showed that semen could be retrieved by PVS or EEJ in 95% of patients. Fifty-three percent and 43% of trials had TMS >5 and >10 x 10(6), respectively. Of survey respondents performing IUI, 42% lacked enough data to estimate pregnancy rates (PRs) in these couples. Literature review showed IUI PRs between 9% and 18% per cycle and 30% and 60% per couple.

CONCLUSION(S)

Based on ejaculation success rates, TMS yields, and IUI outcomes, the methods of PVS, EEJ, and IUI warrant consideration in centers not currently offering these options for couples with SCI male partners.

Does repeated electro-ejaculation improve sperm quality in spinal cord injured men?

STUDY DESIGN

Retrospective analysis.

OBJECTIVES

To assess the effect of repeated electro-ejaculation on the sperm quality in spinal cord injured men.

SETTING

Regional Spinal Injuries Unit, Southport, UK and Hewitt Center for Reproductive Medicine, Liverpool, UK.

METHOD

Retrospective, observational study of men with spinal cord injuries undergoing repeated electro-ejaculation as a part of fertility treatment.

RESULT

There was no improvement in the volume, sperm concentration, motility or the total motile count in the successive antegrade and retrograde samples following repeated electro-ejaculations.

CONCLUSION

Electro-ejaculation is an invasive procedure and its use should be restricted to obtaining semen sample for carrying out assisted conception procedures only.

Male infertility in spinal cord trauma

Every year there are 10 thousand new cases of patients victimized by spinal cord trauma (SCT) in the United States and it is estimated that there are 7 thousand new cases in Brazil. Eighty percent of patients are fertile males. Infertility in this patient group is due to 3 main factors resulting from spinal cord lesions: erectile dysfunction, ejaculatory disorder and low sperm counts. Erectile dysfunction has been successfully treated with oral and injectable medications, use of vacuum devices and penile prosthesis implants. The technological improvement in penile vibratory stimulation devices (PVS) and rectal probe electro-ejaculation (RPE) has made such procedures safer and accessible to patients with ejaculatory dysfunction. Despite the normal number of spermatozoa found in semen of spinal cord-injured patients, their motility is abnormal. This change does not seem to be related to changes in scrotal thermal regulation, frequency of ejaculation or duration of spinal cord damage but to factors related to the seminal plasma. Despite the poor seminal quality, increasingly more men with SCT have become fathers through techniques ranging from simple homologous insemination to sophisticated assisted reproduction techniques such as intracytoplasmic sperm injection (ICSI).

Fertility following spinal cord injury: a systematic review

STUDY DESIGN

Systematic review.

OBJECTIVES

To review systematically fertility of persons with spinal cord injuries (SCI) and their partners.

METHODS

Reports from six databases (1966-2003), selected annual proceedings (1997-2002) and manufacturer's information were screened against eligibility criteria. Searches covered female obstetrical issues, and the efficacy of vibration and electroejaculation for males, as well as advanced fertility (AF) treatments for partners of SCI males. Data were pooled from case-series reports on SCI males' ejaculation, and pregnancies and live births for partners of SCI males.

RESULTS

In all, 2,127 unique reports were evaluated, of which 66 reports were included. No studies investigated fertility in SCI females. Ejaculation interventions in the last decade resulted in response rates of 95% (95% confidence intervals (CI) 91%, 99%), with 100% response rate reported in several recent publications. A total of 13 studies (1993-2001) yielded pregnancy rates of 51% (95% CI 42%, 60%) in partners of SCI males. Of these, 11 studies (1993-2003) yielded live birth rates of 41% (95% CI 33%, 49%).

CONCLUSIONS

Fertility of SCI males is extensively studied. Semen for fertility purposes can generally be obtained using vibration and electroejaculation. AF techniques are increasing pregnancy rates. Research is needed to improve sperm quality. Freezing of sperm is unlikely to significantly improve fertility rates. Fertility of SCI females is addressed only in case reports and opinion articles. The opinion that female fertility is unaffected by SCI should be further investigated using appropriate research methodology.

Diagnosis and treatment of ejaculatory dysfunction

The normal ejaculatory process requires complex coordination and integration of neurologic, physiologic, anatomic, and psychologic events. An understanding of these processes is critical to evaluate properly and manage patients with ejaculatory dysfunction. With the advent of improved techniques to treat patients, some men with ejaculatory dysfunction are being offered the opportunity to reproduce. Further research on the ejaculatory process and associated dysfunctional states should continue to improve treatment for patients presenting with ejaculatory disorders.

Delayed timing of intrauterine insemination results in a significantly improved pregnancy rate in female partners of quadriplegic men

OBJECTIVE

To review pregnancy rates obtained with three protocols used during development of a successful therapy for infertility in couples in which the male partner had spinal cord injury.

DESIGN

Retrospective chart review.

SETTING

Private infertility center.

PATIENT(S)

Eleven quadriplegic men and their spouses undergoing intrauterine insemination.

INTERVENTION(S)

Protocol 1: Intrauterine insemination was performed 24 hours after the LH surge was detected in unstimulated cycles. Sperm were prepared by standard sperm washing. Protocol 2: Female partners were stimulated with clomiphene citrate and hCG. Sperm were inseminated 32-34 hours after hCG injection. Sperm preparation was by serum swim-up or density gradient preparation. Protocol 3: Identical to protocol 2, except the insemination was delayed to 38-40 hours after hCG injection.

MAIN OUTCOME MEASURE(S)

Pregnancy rates.

RESULT(S)

Five patients were enrolled into protocol 1 and underwent a total of 19 inseminations with no subsequent pregnancies. They then underwent protocol 2, but no pregnancies resulted from inseminations. Four of the original couples, along with six additional couples, underwent insemination in protocol 3. A total of 19 inseminations were performed, and 6 of the 10 patients (60%) became pregnant. The success of insemination at 38-40 hours after hCG administration was significantly better than that of the initial two protocols (P<.05). No differences were observed in sperm quality between protocol 2 and protocol 3. Overall, 73% (8 of 11) of the patients became pregnant.

CONCLUSION(S)

Intrauterine insemination 38-40 hours after the hCG injection results in an improved chance of pregnancy. These results indicate that many couples with spinal cord injury-associated male infertility can be treated with intrauterine insemination of sperm treated by serum swim-up, with a high probability of success.

Electroejaculation and assisted reproductive technologies in the treatment of anejaculatory infertility

OBJECTIVE

To determine the efficacy of electroejaculation in combination with assisted reproductive technology (ART).

DESIGN

Case series.

SETTING

University fertility program.

PATIENT(S)

One hundred twenty-one consecutive couples seeking treatment of anejaculatory infertility.

INTERVENTION(S)

Electroejaculation with IUI, or gamete intrafallopian transfer or IVF.

MAIN OUTCOME MEASURE(S)

Pregnancy and pregnancy outcome.

RESULT(S)

Fifty-two couples became pregnant (43%), 39 by IUI alone (32.2%). Cycle fecundity for IUI was 8.7%. No difference in cycle fecundity was seen among ovarian stimulation protocols (clomiphene citrate, 7.6%, hMG, 13.2%, and natural cycle, 11.2%). Pregnancy was unlikely when the inseminated motile sperm count was <4 million. Female management protocol and etiology of anejaculation did not affect results. Patients undergoing IVF had higher cycle fecundity (37.2%) than did those undergoing IUI. The rates of spontaneous abortion and multiple gestations were 23% and 12%, respectively.

CONCLUSION(S)

Electroejaculation with stepwise application of ART is effective in treating anejaculatory infertility. Intrauterine insemination with the least expensive monitoring protocol should be used for most couples, because use of more expensive monitoring did not improve results. It is cost-effective to bypass IUI and proceed directly to IVF in men who require anesthesia for electroejaculation and in those with a total inseminated motile sperm count < 4 million.

Reflexes and somatic responses as predictors of ejaculation by penile vibratory stimulation in men with spinal cord injury

STUDY DESIGN

Retrospective chart review.

OBJECTIVE

To identify factors in addition to level of injury (LOI) that may predict ejaculation by penile vibratory stimulation (PVS) in spinal cord injured males.

SETTING

Major urban medical school and teaching hospital.

MATERIALS AND METHODS

Presence of a bulbocavernosus response (BCR) and a hip flexor response (HR) before PVS (n=123 patients), and somatic responses during PVS (n=204 trials performed on a subset of 44 patients) were evaluated for their frequency of occurrence on trials with and without ejaculation.

RESULTS

Overall ejaculation success rates for cervical, T1-T6, and T7-T12 LOI were 71%, 73%, and 35%, respectively. Eighty per cent of patients who were positive for both BCR and HR ejaculated with PVS, while only 8% of patients who were negative for both BCR and HR ejaculated with PVS. For cervical injuries, BCR and HR were no more predictive of ejaculation by PVS than LOI alone. T1-T6 patients were more likely to ejaculate when at least one reflex was present. T7-T12 patients with no BCR were unlikely to ejaculate by PVS. Except for abdominal contractions, somatic responses were not present in the majority of PVS trials. When they were present, however, they occurred in a high percentage of ejaculation trials: withdrawal response (hip flexion, knee flexion and thigh adduction) (90%), piloerection (84%), extremity spasms (83%), thigh abduction (80%), and thigh adduction (72%).

CONCLUSION

We recommend that patients with cervical injuries initially undergo PVS. Patients with T1-T6 LOI with at least one reflex present, and patients with T7-T12 LOI with both reflexes, or only BCR present, may undergo PVS. Certain somatic/autonomic responses, when seen, may help in deciding whether to continue with a given trial, or give a repeat trial, of PVS.

SPONSORSHIP

The Miami Project to Cure Paralysis and the State of Florida Specific Appropriations.

Canine model of infertility after spinal cord injury: time course of acute changes in semen quality and spermatogenesis

PURPOSE

We established a canine model of subfertility after spinal cord injury and examined the time course of acute changes in semen quality and spermatogenesis after spinal cord injury.

MATERIALS AND METHODS

Seven dogs underwent surgical T7 spinal cord injury. Six dogs were used as controls. Electroejaculation and testicular fine needle aspiration were performed at baseline and twice weekly for 3 weeks after spinal cord injury. Semen quality change was examined by standard semen analysis. Spermatogenesis was assessed by flow cytometry of testicular fine needle aspiration in all dogs as well as by testicular histology at study conclusion in 4 controls and 4 spinal cord injured dogs.

RESULTS

No significant changes in spinal cord injured dogs were noted before 3 weeks after injury. From baseline to 3 weeks after injury certain changes were evident in spinal cord injured dogs. Mean antegrade sperm motility decreased from 62.9% to 20.1% (p = 0.008), mean total sperm (antegrade plus retrograde total sperm) decreased from 423 to 294 x 106 which was not statistically significant, and the incidence of testicular haploid cells decreased from 75.6% to 48.3% (p = 0.028). No significant change in any parameter was present in control dogs. The mean number of mature spermatids per cross-sectional tubule on final testicular histology was significantly decreased in spinal cord injured dogs compared with controls (13.6 versus 43.9, p = 0.02).

CONCLUSIONS

In the canine model tested the dogs readily survived spinal cord injury, electroejaculation was effective for obtaining ejaculate and fine needle aspiration allowed serial examination of spermatogenesis. Three weeks after spinal cord injury but not before 3 weeks sperm motility and spermatogenesis were significantly decreased. However, at the same point this decrease in spermatogenesis was not yet reflected in the total ejaculated sperm count.

Seminal vesicle aspiration in spinal cord injured men: insight into poor sperm quality

PURPOSE

In men with spinal cord injury poor quality semen is seen when performing electroejaculation and penile vibratory stimulation. We determined whether sperm stasis within the seminal vesicles is a potential cause of this problem.

MATERIALS AND METHODS

Seminal vesicle aspiration was performed immediately before electroejaculation or penile vibratory stimulation in men with aspermia secondary to spinal cord injury. Sperm count and quality of seminal vesicle aspiration and subsequent ejaculation were compared with historical ejaculated counts, ultrasound findings and patient characteristics.

RESULTS

Mean total number of right plus left seminal vesicle sperm plus or minus standard deviation was 511 +/- 960 x 10(6). Mean total number of sperm obtained by seminal vesicle plus electroejaculation or penile vibratory stimulation was 918 +/- 1,261 x 10(6). Average motility and viability of the seminal vesicle aspirated sperm were 1.3 and 3.2%, respectively. Average motility of the ejaculated sperm was 26.4% after seminal vesicle aspiration versus 16.3% in previous ejaculation induction procedures performed in the same patients. Seminal vesicle aspirated sperm represented 66% of the total number of sperm obtained during the session and was equal to 49% of the sperm obtained at previous electroejaculation or penile vibratory stimulation sessions. The period of abstinence correlated only with ejaculate count (simple regression p = 0.009). No other clinical characteristics had any effect on sperm count or quality.

CONCLUSIONS

Large numbers of poor quality sperm are present within the seminal vesicles of spinal cord injured men and these sperm comprise a large portion of the specimens collected by electroejaculation or penile vibratory stimulation. This phenomenon is independent of the period of abstinence, implicating disordered storage of sperm due to spinal cord injury rather than infrequent ejaculation. The large number of senescent sperm within the seminal vesicles appears to be a primary cause of poor sperm quality in spinal cord injured men.

Leukocytes in semen from men with spinal cord injuries

OBJECTIVE

To assess the leukocyte populations in semen samples from men with spinal cord injuries (SCIs) and their relation to sperm motility.

DESIGN

Cross-sectional study.

SETTING

A joint spinal cord injury and fertility clinic at an academic tertiary referral center for fertility treatment and a university-based department of immunology.

PATIENT(S)

Nine men with chronic SCIs and seven healthy sperm donors as controls.

INTERVENTION(S)

Semen samples were obtained by electroejaculation from men with SCIs and by masturbation from donors.

MAIN OUTCOME MEASURE(S)

Leukocyte populations determined by immunohistochemical techniques, bacteriologic assessment of urine, and sperm density and motility.

RESULT(S)

The most cellular specimens were antegrade specimens obtained from men with SCIs and coexisting urinary tract infections. The highest proportion of leukocytes occurred in retrograde samples from men with SCIs and urinary tract infections. The most predominant leukocytes in all specimens were granulocytes. Infection increased the number of T cells and the degree of cell activation. There was no significant correlation between leukocyte populations and total motile sperm counts.

CONCLUSION(S)

Increased numbers of leukocytes in semen samples from men with SCIs are the result of urinary tract infections. The reduced sperm motility seen in men with SCIs does not correlate with the numbers of leukocytes; therefore, other factors also contribute to the semen abnormalities in these patients.

Birth after electroejaculation coupled to intracytoplasmic sperm injection in a gun-shot spinal cord-injured man

We describe the case of a man who, after a gun-shot wound, has become paraplegic. As a consequence of his spinal cord injury he developed infertility due to incomplete erection and anejaculation. After several unsuccessful penile vibratory stimulation attempts, it was possible to achieve ejaculation by means of transrectal electrostimulation. However, the total sperm motility count, the percentage of normal sperm morphology, and the vitality and hypo-osmotic swelling test scores were rather low, and in particular viability was strikingly decreased during sperm preparation. These parameters further decreased following electroejaculate, forcing us to use intracytoplasmic sperm injection instead of conventional in vitro fertilization for the treatment cycle. A normal pregnancy was achieved which resulted in birth of a healthy girl on 1st January 1997.

Antisperm antibodies in men with psychogenic anejaculation

Antisperm autoantibodies were determined in 16 men suffering from psychogenic anejaculation who underwent assisted reproduction treatments. Blood and semen samples were collected after transrectal electroejaculation and antisperm antibodies in serum and on the surface of motile spermatozoa were measured using the direct and indirect immunobead binding test. Five men (31%) were found positive for antisperm antibodies. The majority of antibodies were directed against the sperm heads. Surface antibodies were mainly IgA isotype whereas serum antibodies were IgG isotype. These results suggest that psychogenic anejaculation might be associated with increased incidence of antisperm autoimmunity.

Pregnancy after assisted ejaculation procedures in men with spinal cord injury

OBJECTIVE

To present the results of fertility treatment in 28 men with spinal cord injury (SCI) and their partners.

DESIGN

Retrospective analysis.

SETTING

University hospital outpatient clinic and home.

PATIENTS

Twenty-eight anejaculatory men with SCI and their partners seeking treatment for infertility.

INTERVENTION

Penile vibratory stimulation and electroejaculation as semen retrieval methods. Assisted reproductive techniques used: vaginal self-insemination at home, intrauterine insemination, in vitro fertilization with or without intracytoplasmic sperm injection.

MAIN OUTCOME MEASURES

Ejaculation rate; sperm count and motility; pregnancy rates.

RESULTS

All of the men were able to ejaculate either by penile vibratory stimulation (79%) or electroejaculation (21%). Median total sperm count was 65 million (range, 0.1 to 480) with a median motility of 13% (range, 1% to 60%). Overall, 9 of 28 couples (32%) achieved 10 pregnancies (4 self-insemination, 3 intrauterine insemination, 1 in vitro fertilization, and 2 intracytoplasmic sperm injection).

CONCLUSIONS

An ejaculation rate of 100% was achieved using penile vibratory stimulation as a first treatment option with electroejaculation as a second option. Motivated couples with adequate semen quality may be offered penile vibratory stimulation combined with self-insemination at home. Together with intrauterine insemination or fertilization techniques used in vitro, the pregnancy rate per treatment cycle for SCI couples may approach that of natural procreation in healthy and fertile couples.

Correlation between semen parameters of electroejaculates and achieving pregnancy by intrauterine insemination

OBJECTIVE

To investigate whether any parameter in the routine semen analysis of electroejaculates is correlated with success in achieving pregnancy by IUI.

DESIGN

Retrospective observational study.

SETTING

An Assisted Reproductive Program at a tertiary care university center.

PATIENT(S)

Twenty-seven anejaculatory men with spinal cord injury (n = 24) or history of retroperitoneal lymph node dissection (n = 3), thirteen of whom attempted conception with their wives.

INTERVENTION(S)

Anejaculatory men underwent rectal probe electroejaculation and electroejaculates were used for IUI.

MAIN OUTCOME MEASURE(S)

Statistical correlation of semen parameters between electroejaculates that resulted in pregnancy and those that did not.

RESULT(S)

Seven pregnancies resulted from 56 IUIs using electroejaculates (pregnancy rate = 12.5% per IUI). The total motile sperm count and percentage of normal morphology were significantly higher in the specimens that resulted in pregnancies than those that did not. However, there was no statistically significant difference observed in pH, sperm concentration, or percentage of motility between the two groups. Swim-up techniques used to process electroejaculates significantly improved the motility of the specimens. No pregnancy occurred beyond the fifth IUI attempt. Repeated electroejaculation and duration of spinal cord injury had no effect on the quality of the ejaculates.

CONCLUSION(S)

The total motile sperm count and the percentage normal morphology of electroejaculates correlate with success in achieving pregnancy by IUI. Because repeated electroejaculation does not improve quality of ejaculate, the initial semen analysis of electroejaculates is not only useful in counseling couples undergoing such treatment program but should be planned for use as an inseminate.

Testicular aspiration of sperm for intracytoplasmic sperm injection: an alternative treatment to electro-emission: case report

The quantity and quality of spermatozoa produced by electro- or vibro-ejaculation in spinal cord injury patients is often poor, thus advanced reproductive techniques are required if pregnancy is to be achieved. On other occasions no spermatozoa are obtained. We present a successful case of pregnancy achieved using spermatozoa aspirated directly from the testicle combined with intracytoplasmic sperm injection in an in vitro fertilization cycle. We propose this as an alternative to electroejaculation in selected patients.

Electroejaculation and assisted fertility in men with psychogenic anejaculation

OBJECTIVES

To evaluate sperm characteristics and fertility potential in ejaculates obtained after electroejaculation in men with psychogenic anejaculation.

DESIGN

Retrospective clinical study.

SETTING

In Vitro Fertilization Unit, Bikur Cholim Hospital, Jerusalem, Israel.

PATIENTS

Twenty men with psychogenic anejaculation who underwent 55 sessions of electroejaculation and their spouses.

INTERVENTIONS

Electroejaculation, assisted reproduction technologies.

MAIN OUTCOME MEASURES

Semen analysis, IVF, intracytoplasmic injection (ICSI), fertilization rates, and pregnancy rates.

RESULTS

In all patients, sperm density and motility rates were unsatisfactory (98 +/- 127 x 10(6) with 14.6% +/- 15% motility in the antegrade portions and 42 +/- 42 x 10(6) with 9.7% +/- 15.6% motility in the retrograde samples). Intrauterine inseminations performed in eight couples did not result in a pregnancy. Four couples underwent IVF-ET treatments. Two pregnancies were achieved with overall success rates of 22% per cycle. Five couples were treated using the ICSI procedure. Although good quality embryos were transferred, none of the treatments resulted in a pregnancy.

CONCLUSIONS

Psychogenic failure to ejaculate may be treated by electroejaculation. However, the average motility of the sperm obtained is diminished. The combination of electroejaculation with IVF, including the ICSI procedure, should improve chances of fertilization and pregnancy in these cases.

Penile vibratory stimulation in spinal cord injured men: optimized vibration parameters and prognostic factors

OBJECTIVE

To study the efficacy of penile vibratory stimulation (PVS) with optimized vibration parameters in spinal cord injured (SCI) men and to examine prognostic factors for success.

DESIGN

Case series.

SETTING

University hospital outpatient clinic.

PATIENTS

Thirty-four consecutive SCI men seeking fertility treatment.

INTERVENTION

PVS with optimized vibration parameters to induce reflex ejaculation.

MAIN OUTCOME MEASURES

Ejaculatory response; semen analysis.

RESULTS

Antegrade ejaculation was seen in 65% of patients. High rates were seen in lesions above T10 (81%) and in presence of hip flexion and bulbocavernosus reflexes (77%). Of men with lesions above T10, those with a penile prosthesis had lower ejaculation rates (40% vs 90%). Average total sperm counts were 968 million, with 26% motility.

CONCLUSIONS

High rates of ejaculation are seen with optimized vibration parameters, especially in men with lesions above T10 and intact lower spinal reflexes. A penile prosthesis may impair success with PVS.

Artificially stimulated ejaculation in the brain dead patient: a case report

Cutaneous vibratory stimulation and rectal probe electroejaculation are highly successful methods of obtaining semen in the anejaculate patient. We report a case in which spermatozoa were retrieved in a brain dead man by artificially stimulated ejaculation. The specimen was cryopreserved to be used at a later date in combination with assisted reproductive techniques.

Sperm-damaging effects of electric current: possible role of free radicals

The generation of reactive oxygen species (ROS) and sperm damage was evaluated in (a) samples obtained during electroejaculation (EE) of men with spinal cord injury and (b) in electrolyzed HAM's F-10 medium subjected to electric current in vitro. Chemiluminescence data showed a significant increase in ROS in the ejaculates (6 x 10(7) photons/ml) collected immediately after EE and in the electrolyzed medium (3 to 7 x 10(6) photons/ml) when compared to the control (4 to 7 x 10(4) photons/ml). Incubation of normal human sperm with the electrolyzed medium resulted in a significant threefold decrease in percent motility and a twofold decrease in percent viability. Sperm subjected to direct electric stimulation in vitro exhibited a significant twofold decrease in percent motility and percent viability. Superoxide dismutase (SOD) activity decreased significantly in sperm subjected to direct electric current in comparison to the control or the sample incubated with electrolyzed medium. These studies indicate that in vitro and in vivo electrical stimulation generate reactive oxygen species and affect SOD activity, which in part are responsible for decreased sperm motion and viability.

Greatly improved sperm motility from vas deferens sperm retrieval: a case for accessory gland related subfertility in spinal cord injured man. Case report

When sperm motility from vibratory or electroejaculates of spinal cord injured men reveals consistently poor motility (< 10%), one should consider accessory gland factors as a potential cause. Herein, we report the case of a 22 year old paraplegic male who consistently had motility of 1-2% on electroejaculates. He was evaluated in the office with vas deferens sperm retrieval, which revealed a 0.4 ml volume, 9 million/ml density, and 67% motility. We suggest that this significant percent motility differential can only be explained by an accessory gland factor impacting negatively upon this individual's fertility. We propose vas deferens sperm retrieval as a potentially diagnostic and therapeutic procedure in similar cases.