Electroejaculation in combination with in vitro fertilization and gamete micromanipulation for treatment of anejaculatory male infertility

Electroejaculation combined with intracytoplasmic sperm injection in patients with psychogenic anejaculation yields comparable results to patients with spinal cord injuries

OBJECTIVE

To evaluate sperm quality and fertility potential of men with psychogenic anejaculation treated by electroejaculation (EEJ) and intracytoplasmic sperm injection (ICSI). Treatment results were compared to spinal cord injured (SCI) patients treated similarly.

DESIGN

Retrospective clinical study.

SETTING

Academic tertiary referral fertility center.

PATIENT(S)

Couples with isolated psychogenic anejaculation or SCI.

INTERVENTION(S)

Electroejaculation and ICSI.

MAIN OUTCOME MEASURE(S)

Semen analysis, fertilization rate, implantation rate, pregnancy rate, delivery rate and safety of the procedure.

RESULT(S)

Fifteen patients diagnosed with psychogenic anejaculation underwent 40 EEJ/ICSI cycles. The semen retrieved was characterized by low motility (mean 10.7% ± 12.3%), normal volume (2.2 ± 1.9 mL) and normal count (25.1 ± 29.9 × 10(6)/mL), according to World Health Organization criteria. Results of EEJ/ICSI were compared with 22 SCI patients treated by 66 EEJ/ICSI cycles during the same period. Mean female age and the number of oocytes retrieved per cycle were similar between the groups. Similar semen parameters after EEJ were found between psychogenic and SCI patients. Fertilization rate was significantly lower in the psychogenic patients compared to SCI (47.0% and 57.0%, respectively). No significant differences were found regarding pregnancy rates (20% and 22.7%, respectively), implantation rate (10.2% and 11.6%, respectively) or delivery rates (15% and 18.2%, respectively).

CONCLUSION(S)

Sperm retrieved by EEJ is characterized by asthenospermia and normal count. In spite of the lower fertilization rate in psychogenic patients, combination of EEJ and ICSI gives adequate results to couples with psychogenic anejaculation similar to the results obtained for SCI patients. Current results give these couples a reasonable chance of pregnancy achievement.

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.

Influence of multiple transrectal electroejaculations on semen parameters and intracytoplasmic sperm injection outcome

OBJECTIVE

To compare semen parameters and intracytoplasmic sperm injection (ICSI) outcome in spinal cord-injured subjects who underwent single (group 1) or multiple (group 2) electroejaculations before ICSI.

DESIGN

Prospective, randomized, controlled study.

SETTING

Department of gynecology, obstetrics, and pediatric science in a reproductive medicine unit at a major Italian university.

PATIENT(S)

Thirty-four healthy women with a male partner with SCI who were seeking assisted reproduction services.

INTERVENTION(S)

Transrectal electroejaculation, controlled ovarian hyperstimulation, and ICSI.

MAIN OUTCOME MEASURE(S)

Sperm concentration, morphology, and motility and fertilization and pregnancy rates after ICSI.

RESULT(S)

Sperm was successfully retrieved in 94.1% of cases. In male subjects who underwent multiple electroejaculations, statistically significant improvements in sperm concentration and total sperm motility rate were observed. The overall fertilization rate was 63.6%. The number of oocytes retrieved and injected was comparable between the two groups. A total of nine clinical pregnancies were achieved. The pregnancy rate was statistically significantly higher in group 2 (n = 6/16; 37.5%) than in group 1 (n = 3/16; 18.75%).

CONCLUSION(S)

These data suggest that multiple electroejaculation has a positive effect on semen parameters and ICSI outcome.

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.

Vigorous prostatic massage: a simple method to retrieve spermatozoa for intracytoplasmic sperm injection in psychogenic anejaculation: case report

A simple, non-invasive method to retrieve spermatozoa from patients with anejaculation is described. Three patients with psychogenic primary anejaculation were referred for intracytoplasmic sperm injection (ICSI). On the day of oocyte retrieval, vigorous prostatic massage was done. Examination of the expressed prostatic secretion revealed a sufficient number of motile spermatozoa in cases 1 and 3. In case 1, only one poor quality oocyte was obtained and ICSI was unsuccessful. Spermatozoa were cryopreserved for future use. In case 2, no spermatozoa were retrieved by prostatic massage. A testicular biopsy was performed to retrieve spermatozoa for ICSI. Unfortunately no pregnancy resulted. In case 3, retrieved spermatozoa were successfully used for ICSI, and 19 ova were injected. Fertilization occurred in 10 of these; seven were cryopreserved and three embryos were transferred. Ultrasound scan has confirmed a singleton pregnancy, which is ongoing. We conclude that vigorous prostatic massage could be an effective method of sperm retrieval for assisted conception in selected patients with anejaculation.

Pregnancy achieved by intracytoplasmic sperm injection using cryopreserved vasal-epididymal sperm from a man with spinal cord injury

Anejaculation and poor semen quality are two major causes of infertility in men with spinal cord injury (SCI). The poor motility of retrieved sperm usually has low fertilization potential and is thought to be unfavorable for cryopreservation. This report describes a pregnancy after intracytoplasmic sperm injection (ICSI) with cryopreserved vasal-epididymal sperm from a man with SCI and anejaculation. An attempt was made to obtain sperm through electroejaculation, but no motile sperm were found in two trials. Therefore, the subject underwent vasal aspiration. The retrieved sperm had a concentration of 26 x 10(6)/mL and a motility of 3%. ICSI was considered to be the best choice for the couple, but the wife did not become pregnant in the first cycle of treatment. A successful pregnancy was achieved by ICSI in the second cycle using frozen-thawed sperm, supernumerary in the previous cycle, with a density of 5 x 10(6)/mL and 1% motility. A set of healthy twins, one boy and one girl, were delivered via cesarean section at 36 weeks of gestation. Complementary to other assisted reproductive techniques, ICSI may provide men with SCI a greater opportunity to father children. The supernumerary sperm, regardless of quality, should be cryopreserved to avoid the necessity and risk of repeated assisted ejaculations and aspirations of the genital tract.

Approaches for obtaining sperm in patients with male factor infertility

OBJECTIVE

To describe methods of sperm retrieval for intracytoplasmic sperm injection (ICSI) in patients with male factor infertility and to review the clinical results using sperm from the different sources.

DESIGN

The literature on sperm-obtaining methods and ICSI was reviewed. Studies related to this topic were identified through MEDLINE.

RESULTS(S)

This review describes the evolution of sperm retrieval methods. Sperm can be obtained by microepididymal sperm aspiration (MESA), percutaneous sperm aspiration (PESA), and testicular sperm extraction (TESE), from patients with congenital absence of the vas deferens or acquired vas obstruction. When ICSI is performed with ejaculated, epididymal, or testicular sperm, good fertilization and pregnancy rates are achieved without significant differences among the various sperm sources. The original percutaneous sperm aspiration method has been modified slightly and yields successful results.

CONCLUSION(S)

Viable pregnancies can be achieved with ICSI by using not only ejaculated sperm, but also epididymal and testicular sperm. Microepididymal sperm aspiration, percutaneous sperm aspiration, modified percutaneous sperm aspiration, and testicular sperm extraction can be considered standard procedures to treat male factor infertility.

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.

Practical evolution and application of direct intracytoplasmic sperm injection for male factor and idiopathic fertilization failure infertilities

OBJECTIVE

To analyze the introduction of a new assisted fertilization technique for the treatment of severe male factor and idiopathic fertilization failure infertilities.

DESIGN

Retrospective analysis of 16-month clinical application of IVF-ET where insemination was performed solely by direct intracytoplasmic sperm injection.

SETTING

Clinical IVF-ET program.

PATIENTS

Ninety-two couples undergoing 105 cycles of sperm injection.

RESULTS

One hundred embryo transfers yielded 28 viable pregnancies (28%) from which eight normal deliveries have occurred to date. Complete cleavage arrest or fertilization failure occurred in four cycles, and one couple had all embryos cryopreserved. One thousand one hundred forty-three eggs were injected of which 173 (15%) degenerated. Four hundred seventy-nine of the surviving 970 eggs became normally fertilized (49%), and 381 of these zygotes (79.5%) developed suitably for cryopreservation or for transfer. Thirty-four of 310 embryos transferred implanted, yielding an implantation rate of 11%. Both testicular and epididymal sperm were used successfully to achieve fertilization and pregnancies, as was sperm retrieved by electroejaculation. Older women and couples suffering from prior idiopathic fertilization failure had a markedly poorer outcome.

CONCLUSIONS

These results confirm that the intracytoplasmic sperm injection technique is a successful form of assisted fertilization that can be applied to a wide range of couples at significant risk from fertilization failure.

Treatment by assisted conception of severe male factor infertility due to spinal cord injury or other neurologic impairment

PURPOSE

This retrospective study evaluated the pregnancy rates of 23 couples with male factor infertility due to traumatic spinal cord injury (N = 21), multiple sclerosis (N = 1) or transverse myelitis (N = 1).

METHODS

Ovulation induction by clomiphene citrate or gonadotropins was used in combination with intrauterine insemination as an initial approach for assisted conception in all but one couple.

RESULTS

Six pregnancies occurred in 60 cycles of intrauterine insemination (mean of 2.6 cycles). In this group, the cumulative pregnancy rate was 26%. Six couples who failed after a total of 33 intrauterine insemination cycles (mean of 5.5 cycles), and 1 couple with no previous intrauterine insemination cycles, initiated 10 cycles of in vitro fertilization (mean of 1.4 cycles). In this group, five pregnancies occurred. The pregnancy rate was 71%.

CONCLUSION

We conclude that ovulation induction in combination with intrauterine insemination offers an effective initial therapy of severe male factor infertility due to spinal cord injury.

Micromanipulative and conventional insemination strategies for assisted reproductive technology

Micromanipulative techniques, such as subzonal insemination and direct intracytoplasmic sperm injection, are used when standard in vitro fertilization techniques have failed. These new approaches are currently under investigation in a variety of centers across the country. The projected results and the strengths and weaknesses of these techniques are reviewed.

Assisted ejaculation combined with in vitro fertilisation: an effective technique treating male infertility due to spinal cord injury

Infertility due to spinal cord injury (SCI) in males has been identified for decades as an area of major concern and techniques for assisted ejaculation are available. There has not been an overall consensus regarding which type of assisted procreation is the most appropriate for these couples. We describe here our experience from a programme based on assisted ejaculation combined with in vitro fertilization (IVF). Twelve couples have been treated so far and altogether 22 cycles with ovum pick-up have been completed. Fertilisation of the oocytes was obtained in 18 of these cycles. The overall oocyte fertilisation rate was 49%. Embryo transfer took place in 17 cycles, leading to seven clinical pregnancies. Four of the pregnancies are delivered or are ongoing, whereas three ended in first trimester spontaneous abortion. Thus our initial experience suggests that assisted ejaculation in combination with IVF is an effective option for these couples.

Treatment of male infertility and idiopathic failure to fertilize in vitro with under zona insemination and direct egg injection

OBJECTIVE

Failure to fertilize eggs in vitro may be countered by micromanipulation of gametes to place selected spermatozoa underneath the zona pellucida of the egg or directly into the egg, thereby improving chances of fertilization and production of viable embryos. Analysis of our clinical data for assisted fertilization was undertaken to assess those factors of relevance in this therapy, and a description of our procedures are given.

STUDY DESIGN

Retrospective analysis of 85 cycles (73 couples) of in vitro fertilization and embryo transfer performed at a private infertility clinic, in which micromanipulation for assisted fertilization was used to overcome either severe male factor infertility or idiopathic failure to fertilize, was performed.

RESULTS

In 60 cycles where only embryos from under zona insemination were available for uterine transfer, 15 singleton and two twin pregnancies occurred (28.3% viable pregnancy rate per transfer, 14.1% embryonic implantation). In 14 of these cycles embryos arose only after repeated under zona insemination adding more spermatozoa; this accounted for four of the singleton and one of the twin pregnancies (38.5% pregnancy rate, 22.2% embryonic implantation). No embryos arose from partial zona dissection performed in five cycles on sibling eggs. However, in 16 cycles conventional insemination yielded fertilization in six cycles, and mixed transfer of these embryos and sibling embryos from under zona insemination gave rise to one pregnancy from four transfers (pregnancy rate 25%, embryonic implantation 7.1%). Likewise, in nine cycles donor spermatozoa yielded fertilization in eight cycles, and mixed transfer with sibling embryos fertilized by under zona insemination with partner's spermatozoa gave rise to two pregnancies from five transfers (pregnancy rate 40%, embryonic implantation 15.8%). Fertilization and pregnancy rates did not differ whether couples suffered either from male factor infertility or from previous idiopathic fertilization failure. Direct egg injection of a single spermatozoon into 105 eggs gave an 88.6% egg survival and 32.3% fertilization. Mixed transfers with sibling embryos from conventional and under zona insemination yielded one triplet, one twin, and three singleton pregnancies.

CONCLUSIONS

Overall, a 24.7% (21/85) viable pregnancy rate per cycle initiated occurred when only embryos from assisted fertilization were available. This strongly indicates that assisted fertilization made a real contribution in cases where either insufficient spermatozoa were available for conventional insemination or in cases where previous fertilization failure had arisen. The wide range of seminal parameters were found to be unhelpful in defining chances of success with assisted fertilization.