Predictors of success in electroejaculation of spinal cord injured men

Clean intermittent catheterisation from the acute period in spinal cord injury patients. Long term evaluation of urethral and genital tolerance

Since its introduction by Lapides, clean intermittent catheterisation (CIC) has dramatically changed the urological management of spinal cord injury (SCI) patients. Since 1978 we have used CIC as a mode of drainage in the acute period, during the period of bladder retraining as a measurement of residual urine, and in some instances in the medium and long term. 12-14 Fr PVC catheters are used with lubricant. The objectives of this study were: first, in a population of 159 SCI patients (group 1), to evaluate the overall incidence of complications of CIC; Secondly to study two groups of patients: group 2 (n = 8) consisted of patients who had performed CIC for over 2 years before discontinuance; group 3 (n = 21) consisted of patients on CIC for over 5 years (mean length of use: 9.5 years). The reasons for acceptance of long term CIC, frequency of urinary tract infections, and rates of urethral strictures were evaluated. The analysis of group 1 showed a rate of lower urinary tract infection of 28% and of cytobacteriological infection of 60%. Chronic pyelonephritis was never observed and infection was always confined to the lower urinary tract which is in accordance with other studies. The rate of epididymitis and urethral stricture was 10% and 5.3% respectively. Sixty two per cent of group 2 remained incontinent, and 89% of group 3 showed a satisfactory degree of continence. The first factor for acceptance of long term CIC is continence, the second one is the ability to perform CIC independently. In group 3 we found a rate of urethral stricture of 19%, and of epidydimitis of 28.5%. These two complications (urethral tolerance and urethroprostatic infection) increased with the number of years on CIC. The method and the type of catheters used must also be considered. We need further studies of long term CIC in patients using non-reusable hydrophilic catheters from the acute period to see if these two complications can be prevented.

The influence of bladder management on fertility in spinal cord injured males

Male infertility is a well recognised problem following spinal cord injury. The techniques of vibration induced ejaculation and transrectal electroejaculation have significantly increased the likelihood of sperm retrieval in spinal cord injured males; however, the reproductive capacity remains markedly reduced due to poor semen quality. The Spinal Injuries Unit at Royal North Shore Hospital has developed a programme to achieve seminal emission and enhance fertility. This study analysed the results of the first sample obtained at stimulation in 70 spinal cord injured males with respect to procedure performed, neurological level, completeness of lesion, bladder management, infection, age and duration since injury. Our study demonstrated that bladder management and neurological level were significant factors affecting the presence of motile sperm. Individuals managing their neuropathic bladder by catheter (intermittent self-catheterisation, indwelling urethral or suprapubic catheter) had significantly enhanced semen quality compared to those voiding by reflex or straining. Differences were also noted within the catheter group itself with intermittent self-catheterisation achieving a higher percentage of motile sperm present.

Spermatogenesis and the pituitary-testicular hormone axis in rats during the acute phase of spinal cord injury

Male infertility frequently occurs after spinal cord injury (SCI). However, little is known about the acute effects of SCI on male reproductive function. This study evaluated the effects of SCI on spermatogenesis and testicular-pituitary function in rats 2 and 4 weeks after injury. Spinal cord injury was produced in rats by T9 spinal cord transection. Controls received similar surgery without transection. Complete spermatogenesis was seen 2 weeks after SCI; however, abnormalities were present in the seminiferous tubules. Hormone levels were similar in the two groups. Four weeks after SCI, incomplete spermatogenesis was noted in 3 of 9 rats, 4 others had delayed spermiation, and the last 2 had nonspecific regression of seminiferous epithelium. Serum testosterone levels were lower at 4 weeks in SCI rats than in controls, but testicular testosterone content was not. Plasma gonadotropin levels were similar in the two groups 4 weeks after SCI. Quantitative analysis revealed a 26 to 33% decrease in the number of spermatogenic cells in stage VII seminiferous tubules at 4 weeks in SCI rats (p < 0.01). This study demonstrated that qualitative and quantitative impairments of spermatogenesis occur during the acute phase of SCI in rats.

Electroejaculation does not impair sperm motility in the beagle dog: a comparative study of electroejaculation and collection by artificial vagina

Sperm samples obtained by electroejaculation (EEJ) in men with anejaculatory infertility have a markedly lower quality than those obtained by normal ejaculation. An electrical effect of the EEJ procedure has been implicated by some investigators as a direct cause of low sperm quality. To determine whether the EEJ procedure causes direct sperm damage, we compared ejaculates obtained from dogs by EEJ and by artificial vagina (AV). In seven adult beagle dogs, semen was collected weekly, alternating between the two procedures. The average (antegrade) sample from AV had a volume of 2.6 ml., sperm concentration of 150.1 x 10(6) per ml., total sperm count of 381.7 x 10(6) and motility of of 26.3%. The average antegrade sample from EEJ had a volume of 1.8 ml., a concentration of 129.6 x 10(6) per ml., a total sperm count of 166.8 x 10(6) and a motility of 30.1%. Of these differences only the total sperm counts and the total motile sperm counts were statistically significant (p < 0.05). There were no significant differences between the antegrade motilities, total sperm counts (antegrade plus retrograde-381.7 versus 243.4 x 10(6), for AV and EEJ, respectively) or the total motile sperm counts from the two procedures (103.9 versus 78.0 x 10(6)). There were no differences in the average curvilinear velocity (VCL) measured by computer-assisted sperm motion analysis (56.9 mu. per second for AV, 47.4 mu. per second for antegrade EEJ specimens and 41.7 mu. per second for retrograde EEJ specimens). Since routine semen parameters between artificial vagina and electroejaculation did not differ in dogs, we conclude that the electroejaculation procedure is not responsible for the gross semen abnormalities reported in electroejaculation of anejaculatory men.

Electroejaculation using standard nerve stimulation equipment and Teflon-coated needles

We attempted transperineal needle electroejaculation using a Digistim nerve stimulator and Teflon-coated needles in 12 anejaculatory men. We obtained semen in 11 men. Five of the 12 men also underwent electroejaculation using a transrectal probe. Comparable semen parameters were obtained by transrectal probe and transperineal needles.

Simplified and objective assessment of spermatogenesis in spinal cord injured men by flow cytometry analysis

Deterioration of the germinal epithelium of the testis is a known sequela of spinal cord injury (SCI) that may influence the outcome of male reproductive rehabilitation efforts. Quantitative testicular biopsy, currently regarded as the standard of assessing the integrity of spermatogenesis, has not gained wide-spread clinical use because of its invasive nature and relative technical complexity. Alternatively, aspiration DNA flow cytometry analysis of the testis has offered a potential method of spermatogenic assessment that meets both the requirements of simplicity and objectivity. The objective of this study is to determine the capability of flow cytometry to assess spermatogenesis following SCI. Eleven SCI men underwent incisional testicular biopsy with the specimen simultaneously submitted for quantitative evaluation of the germinal epithelium by both quantitative histometry and DNA flow cytometry. The haploid percentage of cells showed highly significant levels of correlation with key micrometric parameters of the quantitative testicular biopsy: spermatid/tubule (p < 0.002) and the spermatid/Sertoli cell ratio (p < 0.0005). Since tissue procurement is accomplished less invasively for flow cytometry analysis, we recommend this method as the modality of assuring integrity of the germinal epithelium in candidates for reproductive rehabilitation.

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

A total of 18 men older than 19 years with spinal cord injury was evaluated for fertility potential with testing of semen obtained by rectal probe electroejaculation. After fertility testing, including sperm penetration assay, semen cryopreservation and sperm antibody status, 6 of the 18 men proceeded with their partners to use rectal probe electroejaculation in efforts to conceive. Sperm was obtained in 16 of 18 cases. Average ejaculate total sperm count (306 million) was good but motility (22%) was poor. Adequate sperm retrieval after processing yielded a normal sperm penetration assay in 4 of 16 cases (25%) in which sperm were obtained. Favorable semen cryopreservation (greater than 33% of pre-freeze motility noted after thaw) was present in 5 of 16 cases (31%). Live births were achieved in 2 of 6 couples attempting conception. Despite the typically poor sperm motility noted in electroejaculates, rectal probe electroejaculation can result in pregnancies from couples involving spinal cord injured men. The sperm penetration assay data indicate that pregnancy should be achievable in at least 25% of spinal cord injured couples. Achieving these conceptions requires a team approach involving a urologist/andrologist, gynecologist/reproductive endocrinologist and a sperm-processing laboratory.

Pituitary-testicular and pituitary-thyroid axes in spinal cord-injured males

Thirty spinal cord-injured (SCI) males were studied for evaluation of their pituitary-testicular and pituitary-thyroid axes using combined luteinizing hormone-releasing hormone (LHRH) and thyrotropin-releasing hormone (TRH) tests and electroejaculated semen analyses. Thirty age-matched normal male volunteers served as controls. There were four subjects with low serum triiodothyronine (T3) levels, one with elevated serum follicle-stimulating hormone (FSH) level, eight with elevated serum testosterone levels, and 11 with elevated serum prolactin levels. There were significantly elevated luteinizing hormone (LH) responses to LHRH in SCI subjects when compared with normal controls. There were 16 (53.3%) SCI subjects who had exaggerated and/or prolonged LH responses. Among them, six subjects also had elevated FSH responses. There were eight and four subjects whose thyrotropin (TSH) and prolactin responses to TRH were exaggerated, respectively. Marked impaired motility was observed in 56 electroejaculated semen samples from 16 SCI subjects. There was a significant correlation between LH and total sperm count. Our data suggest that there is a reduced central dopaminergic tone in SCI subjects.

Fertility of spinal cord injured males: effect of genitourinary infection and bladder management on results of electroejaculation

Thirty-eight men undergoing electroejaculation (EEJ) procedures for anejaculatory infertility were examined for the presence or absence of infection in urine and semen. In 29 spinal cord injury patients, a high incidence of infected urine and infected semen (41% and 56%, respectively) was seen, in contrast to patients with normal bladder function (0% and 11%). Urinary infection was associated with slightly lower sperm quality and lower pregnancy rates (10% vs 30% in the presence of sterile urine). Semen infection had no effect on sperm counts or pregnancy rates. If intermittent self-catheterization (ISC) was used to empty the neurogenic bladder, slightly better sperm quality was seen, the total failure rate was less, and much better pregnancy rates (44%) resulted than for patients using an alternative bladder management (7%). Antibiotics did not reduce the incidence of urine or semen infection, but did improve sperm counts slightly. Continuous prophylaxis was associated with bacterial resistance to many oral antibiotics and had no advantage over a short course of antibiotics prior to the procedure. Despite the above associations, the sperm quality in our patient population was never normal compared with that of men who ejaculate normally. We conclude that the low sperm quality seen in electroejaculation specimens from spinal cord injured males is not due entirely to infection or to the type of bladder management. Short courses of antibiotics, instead of continuous antibiotic prophylaxis, may be beneficial. Intermittent catheterization is superior to other methods of neurogenic bladder management in maintaining the fertility of spinal cord injured men.

Functional characteristics of sperm obtained by electroejaculation

Sperm obtained by electroejaculation in 32 anejaculatory men were examined for functional characteristics. Raw specimens showed high sperm counts but motility averaged only 11%. Average viability was 10% for antegrade and 5% for retrograde fractions. Bovine cervical mucus penetration was normal (30 mm. or more in 30 minutes) in only 24% of the electroejaculation samples but it was normal in all of the donor samples tested. Processed sperm motility averaged 30% with 71% forward progression. At 20 hours patient samples retained 46% of the original motility, while donor controls retained 81%. In the hamster egg penetration assay patient sperm penetrated 14% of the oocytes while donor sperm penetrated 40%. Therefore, we identified 4 characteristics of sperm obtained by electroejaculation: 1) low viability, 2) poor survival after overnight incubation, 3) moderately impaired cervical mucus penetration and 4) moderately poor fertilizing capability as measured by the hamster egg penetration assay. Poor sperm survival and impaired function may explain the low pregnancy rates from insemination with electroejaculated sperm.

Quantitative testicular biopsy in spinal cord injured men: comparison to fertile controls

Spermatogenic abnormalities have been reported in the majority of spinal cord injured men on routine testicular biopsy. However, given the interim advances in their urological and rehabilitative care, a quantitative assessment of the germinal epithelium after spinal cord injury and comparison of these parameters to normal controls are warranted. Incisional testicular biopsy was performed in 14 spinal cord injured men. Quantitative micrometric techniques were applied to assess spermatogenesis and the results were compared to a normative data base of testicular biopsies previously obtained from a group of 15 fertile volunteers. From a minimum of 10 randomly selected round seminiferous tubules per subject the mean number of Sertoli cells, mature spermatids, tubular diameter and tubular wall thickness were determined in both groups and statistically analyzed. In the spinal cord injury group the mean number of spermatids per tubule was significantly lower and the mean number of Sertoli cells per tubule was significantly higher than in fertile controls (p less than 0.05). Moreover, the mean Sertoli cell-to-spermatid ratio per seminiferous tubule was significantly higher in the spinal cord injury group and discriminated between spinal cord injured men and controls, with a sensitivity of 93% and specificity of 100% (p less than 0.0001). Half of the spinal cord injury group showed a mean tubular spermatid density of less than 10. Compared to the fertile population, spinal cord injured men show significant differences in quantitative parameters of the germinal epithelium that may contribute to the reproductive dysfunction.

Male infertility following spinal cord injury

Ejaculatory dysfunction and poor semen quality are responsible for male infertility following spinal cord injury (SCI). Techniques which have been used to obtain semen include intrathecal neostigmine, subcutaneous physostigmine, direct aspiration of sperm from the vas deferens, vibratory stimulation and electroejaculation. Vibratory stimulation and electroejaculation are most widely used in the United States and have a 50-90% success rate at obtaining semen. Poor semen quality following SCI has been attributed to stasis of semen, testicular hyperthermia, urinary tract infections, sperm contact with urine, possible changes in the hypothalamic-pituitary axis, chronic use of various medications and possible sperm antibodies. The outlook for having a child following SCI continues to improve with advancements in obtaining and processing sperm and assisted reproductive technologies.

Electroejaculation following retroperitoneal lymphadenectomy

Transrectal electroejaculation was performed in 24 men who were anejaculatory from retroperitoneal lymphadenectomy. Of the men 23 had undergone retroperitoneal lymphadenectomy because of testis cancer. Seminal emission was achieved in all patients. In 21 patients greater than 10 x 10(6) progressively motile sperm with normal morphology were obtained. The average sperm count and motilities obtained were 289 x 10(6) and 18%, respectively, for the antegrade fractions, and 2,051 x 10(6) and 13%, respectively, for the retrograde fractions. Of the 3 azoospermic failures 2 had chemotherapy-induced testicular damage and 1 had carcinoma in situ of the remaining testis. A total of 19 couples underwent artificial insemination with electroejaculated sperm. There were 7 pregnancies achieved in 74 insemination cycles (36.8% of the couples conceived for a 9% cycle fecundity). Routine semen parameters could not predict which couples would be successful in achieving pregnancy. There were 2 first trimester spontaneous abortions. Five healthy children have been born. Electroejaculation is an excellent treatment for anejaculation that persists following retroperitoneal lymph node dissection.