TREATMENT OF INFERTILITY DUE TO ANEJACULATION IN THE MALE WITH ELECTROEJACULATION AND INTRACYTOPLASMIC SPERM INJECTION

Summary of the 2024 Update of the European Association of Urology Guidelines on Neurourology

BACKGROUND AND OBJECTIVE

Most patients with neurourological disorders require lifelong medical care. The European Association of Urology (EAU) regularly updates guidelines for diagnosis and treatment of these patients. The objective of this review is to provide a summary of the 2024 updated EAU guidelines on neurourology.

METHODS

A structured literature review covering the timeframe 2021-2023 was conducted for the guideline update. A level of evidence and a strength rating were assigned for each recommendation on the basis of the literature data.

KEY FINDINGS AND LIMITATIONS

Neurological conditions significantly affect urinary, sexual, and bowel function, and lifelong management is required for neurourological patients to maintain their quality of life and prevent urinary tract deterioration. Early diagnosis and effective treatment are key, and comprehensive clinical assessments, including urodynamics, are crucial. Management should be customised to individual needs and should involve a multidisciplinary approach and address sexuality and fertility. Lifelong monitoring and follow-up highlight the importance of continuous care for neurourological patients.

CONCLUSIONS AND CLINICAL IMPLICATIONS

The 2024 EAU guidelines on neurourology provide an up-to-date overview of available evidence on diagnosis, treatment, and follow-up for neurourological patients.

PATIENT SUMMARY

Neurological disorders very frequently affect the lower urinary tract and sexual and bowel function and patients need lifelong management. We summarise the updated European Association of Urology guidelines on neurourology to provide patients and caregivers with the latest insights for optimal health care support.

Diagnostic evaluation of sexual dysfunction in the male partner in the setting of infertility: a committee opinion

It is the responsibility of the clinician to assess for the presence of erectile dysfunction, ejaculatory dysfunction, or diminished libido in men presenting for evaluation of infertility. Referral to a reproductive urologist or other appropriate specialist with the requisite expertise in the evaluation and treatment of such conditions, including appropriate treatment of testosterone deficiency, is often warranted. This article replaces the article of the same name, last published in 2018.

Male Sexual Dysfunctions in the Infertile Couple-Recommendations From the European Society of Sexual Medicine (ESSM)

Introduction

Sexual dysfunctions (SDs) have been frequently reported among male partners of infertile couples due to psychogenic, relational and/or organic issues related with the inability to conceive. Likewise, male infertility (MI) could be a consequence of sexual dysfunctions.

Aim

To review the evidence on the prevalence and treatment of male SDs in men of infertile couples and provide clinical recommendations on behalf of the European Society of Sexual Medicine (ESSM).

Methods

The MEDLINE database was searched in September 2019 for randomized clinical trials (RCTs), meta-analyses and open-label prospective or retrospective studies investigating the presence of erectile dysfunction (ED) and/or ejaculatory dysfunctions (EjDs) and/or low sexual desire (LSD) in conjunction with infertility.

Main Outcome Measure

The panel provided statements on: (i) Prevalence and association between SDs and MI; (ii) Treatment of male SDs in men of infertile couples.

Results

ED has been reported in 9% to 62% of male partners of infertile couples, with severe impairment observed in only 1% to 3% of ED cases. Moreover, worse semen parameters have been associated with greater ED severity. Phosphodiesterase type 5 inhibitors (PDE5is) can be safely used to treat ED among patients seeking fatherhood. Male partners of infertile couples are at higher risk of premature ejaculation (PE). Retrograde ejaculation (RE) and anejaculation are a cause of MI and can be managed with electroejaculation (EEJ) or penile vibratory stimulation (PVS) or, alternatively, with oral treatments, however the latter with limited documented success. Low sexual desire has been reported by one third of men of infertile couples.

Conclusion

ED could significantly affect male partners of infertile couple; PDE5is should be suggested to ensure an effective and satisfactory sexual relationship of the couple. Anejaculation and RE should be considered as a possible cause of MI and treated accordingly. Low sexual desire is frequently reported among men of infertile couple and could be a symptom of other systemic conditions or psychological distress. Capogrosso P, Jensen CFS, Rastrelli G, et al. Male Sexual Dysfunctions in the Infertile Couple–Recommendations From the European Society of Sexual Medicine (ESSM). J Sex Med 2021;9:100377.

Inability to obtain sperm for fresh IVF cycles: analysis and incidence of outcomes using a database from the United States

Background

Azoospermia is present in 10% of men presenting with infertility and surgical sperm retrieval rates for men with azoospermia due to spermatogenic dysfunction remain low. We investigated the incidence of failed fresh IVF cycles due to inability to obtain sperm and describe predictors for subsequent IVF.

Methods

A national IVF database was used to identify fresh IVF cycles in which there was failure to obtain sperm. Patient linkage was utilized to determine outcomes of subsequent IVF.

Results

243,291 fresh IVF cycles were identified; 719 (0.3%) listed “inability to obtain sperm” as reason for embryo non-transfer. Male infertility was a factor in 537 (75%) and ejaculation was the most common anticipated sperm source (414, 57%). 713 (99.2%) cycles resulted in retrieved oocytes, but only 627 (87.2%) cryopreserved oocytes. 265 (37%) of couples underwent subsequent IVF. On multivariable analysis, lack of initial oocyte cryopreservation (OR 0.34, p = 0.01) and male infertility (OR 0.14, p = 0.01) were associated with having no subsequent cycles. Partner sperm was used in 213 (80%) second cycles and sperm retrieval method was largely conserved (181/213, 85%). Embryos were transferred in 186 (70%) second cycles. Failed embryo transfers were due to repeat inability to obtain sperm in 5 (6%) cycles.

Conclusions

Failure to obtain sperm during fresh IVF is rare, but most affected couples will not pursue further cycles of IVF after their initial failed attempt.

Diagnostic evaluation of sexual dysfunction in the male partner in the setting of infertility: a committee opinion

It is the responsibility of the clinician to assess for the presence of erectile dysfunction, ejaculatory dysfunction, or diminished libido related to hypoandrogenism among men presenting with a primary complaint of infertility. Referral to a reproductive urologist or other appropriate specialist with requisite expertise in the evaluation and treatment of such conditions is often warranted.

Fertility in men with spinal cord injury

Young men comprise the overwhelming majority of men with spinal cord injury (SCI), the incidence of which has been growing over the years. Due to advances in physical medicine and rehabilitation, remarkable improvements in survival rates have been reported, leading to life expectancies similar to those of the general population. However, many sexual and reproductive functions may be impaired due to erectile or ejaculatory dysfunction and semen abnormalities, characterised by low-sperm motility or viability in SCI males who have not become parents yet. Nevertheless, fatherhood is still possible through the introduction of specialised medical management, by using various medical, technical and surgical methods for sperm retrieval in combination with assisted reproductive techniques. Erectile dysfunction can be managed by the use of phosphodiesterase-5 inhibitors, intracavernosal injections, vacuum devices and penile prostheses. Semen can be obtained from the vast majority of anejaculatory men by medically assisted ejaculation through the use of penile vibratory stimulation or electroejaculation and via prostate massage or surgical procedures. Despite impaired sperm parameters, reasonable pregnancy rates similar to those in able-bodied subfertile cohorts have been reported. However, future research should focus on the optimisation of semen quality in these men and on improving natural ejaculation.

Testicular sperm extraction for patients with spinal cord injury-related anejaculation: A single-center experience

OBJECTIVES

To present a single-center experience with testicular sperm extraction and intracytoplasmic sperm injection for fathering biological children in patients with ejaculatory dysfunction as a result of spinal cord injury.

METHODS

Testicular sperm extraction was carried out in 52 male patients with ejaculatory dysfunction as a result of spinal cord injury. We investigated sperm retrieval rates and pregnancy rates from medical records. Data on age, testicular volume, hormonal status (luteinizing hormone, follicle stimulating hormone and testosterone), and time since spinal cord injury were obtained and analyzed to detect potential associations with the presence of spermatogenesis.

RESULTS

Testicular sperm retrieval was achieved in 42 of 52 patients (80.7%). Intracytoplasmic sperm injection was carried out for 37 patients, and pregnancy was achieved in 32 (86.5%). The take-home baby rate was 70.2%. In the group with successful sperm extraction, testicular volume was significantly greater, time from spinal cord injury to extraction was significantly shorter, and serum luteinizing hormone and follicle-stimulating hormone levels were significantly lower. Serum follicle-stimulating hormone levels had the strongest association with feasibility of sperm retrieval by testicular sperm extraction. Furthermore, the sperm retrieval rates of patients injured within the preceding 12 years were significantly better than those injured longer before treatment (P = 0.045).

CONCLUSIONS

Testicular sperm extraction and intracytoplasmic sperm injection seem to provide favorable results for patients with ejaculatory dysfunction as a result of spinal cord injury. However, early testicular sperm extraction is recommended, because sperm retrieval becomes more difficult with time from spinal cord injury.

Should sperm be cryopreserved after spinal cord injury?

In spinal cord injured (SCI) patients, three main factors may cause infertility: erectile dysfunction, ejaculatory dysfunction and impaired semen quality. This letter aims to discuss how we can manage SCI patients’ fertility in accordance with patient-centred care. For such SCI patients aged 20 to 40, having children represents hope for the future. Furthermore, it is a way to rebuild a life after the spinal injury and must be seen as an important part of the rehabilitation program. We suggest that sperm cryopreservation may contribute to patient-centred care management of SCI patients’ fertility, although there is no scientific evidence that cryopreservation will improve fertility outcome after SCI. Indeed, sperm cryopreservation is an affordable and simple technique in specialised centres with trained staff. Here, a protocol to manage SCI patients’ fertility is discussed: we propose PVS for sperm banking to all SCI patients after the phase of spinal shock during the rehabilitation program. If live sperm are retrieved, they are frozen and stored; however, if no live sperm are retrieved, electroejaculation and/or surgical sperm extraction are proposed only for patients who desire biological fatherhood. Prospective studies on the evolution of semen parameters, ejaculatory dysfunction, post-infectious obstructions and spermatogenesis impairment in chronic SCI patients are urgently needed to provide robust data for the evidence-based management of SCI patients’ fertility. Even if use rates are expected to be low, sperm banking may be a simple and affordable preventative measure for selected male SCI patients.

Sperm banking and the cancer patient

The current concepts, recommendations, and principles of sperm banking as it pertains to the comprehensive care of young men of reproductive age with cancer are reviewed. Obstacles to sperm banking are addressed as well as future directions for fertility-preserving technologies. All cancer therapies-chemotherapy, radiation, and surgery-are potential threats to a man's reproductive potential. In addition, cancer itself can impair spermatogenesis. Thus, sperm cryopreservation prior to initiating life-saving cancer treatment offers men and their families the best chance to father biologically related children and should be offered to all men with cancer before treatment. Better patient and provider education, as well as deliberate, coordinated strategies at comprehensive cancer care centers are necessary to make fertility preservation for male cancer patients a priority during pretreatment planning.

Differential transcriptomic profile in spermatozoa achieving pregnancy or not via ICSI

Basic sperm analysis is limited as a method of estimating pregnancy. This study’s objective was use of microarray technology to differentiate the gene expressions of spermatozoa that achieved pregnancy in an intracytoplasmic sperm injection (ICSI)cycle in an oocyte donation programme with those that did not achieve pregnancy. A study of nested cases and controls was designed to evaluate fresh and frozen spermatozoa from infertile males undergoing ICSI with donor oocytes. The global genome expression of pooled samples from each group (achieving pregnancy versus those that didn’t, from fresh or frozen spermatozoa)was compared using microarray analysis. The level of expression of some of the transcripts from fresh spermatozoa was shown to differ for those that achieved pregnancy versus those that didn’t. Additionally, exclusively expressed transcripts were identified for both outcome groups. Analysis of frozen spermatozoa didn’t reveal differential expression, but exclusively expressed transcripts were detected. Lists of the transcripts were systematically analysed using different databases in order to provide information about them and their relationship with male fertility. The results revealed profound differences between the expression profiles of spermatozoa that resulted in pregnancy versus those that didn’t. These differences may explain ICSI failure associated with male factor infertility.

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.

Midodrine for the treatment of organic anejaculation but not spinal cord injury: a prospective randomized placebo-controlled double-blind clinical study

Anejaculation is a rare cause of infertility and adversely affects the general sense of well-being and perception of sexual life satisfaction. Evidence to support effective and noninvasive treatment for this ejaculatory disorder is lacking. This study aimed to evaluate the efficacy and safety of midodrine (alpha(1)-adrenergic receptor agonist) for the treatment of organic anejaculation but not spinal cord injury (SCI). A total of 128 patients were randomly assigned to oral midodrine 7.5-15 mg per day in a stepwise approach (group 1, n=64), or a similar regimen of placebo (group 2, n=64). They underwent a complete physical examination, echocardiography, 12-lead electrocardiogram, transrectal ultrasonography, complete blood count and blood chemistry. Hormonal assays included serum levels of luteinizing hormone, follicle-stimulating hormone, prolactin and testosterone. To rule out other sexual dysfunction, patients also completed the International Index of Erectile Function questionnaire. Psychiatric disorders were excluded by appropriate tests. Outcome measure was reversal of the anejaculation. None of the patients in the placebo group achieved antegrade or retrograde ejaculation. At the end of study, antegrade, retrograde and antegrade+retrograde ejaculation occurred in 18 (29.5%), 8 (13.1%) and 9 (14.8%) patients in midodrine group, respectively (all P=0.01). The most and least favorable responses were among patients with multiple sclerosis and bilateral sympathectomy, respectively. Midodrine improved ejaculation function in a dose-dependent manner. Four participants (6.3%) in midodrine group discontinued this study for reasons of adverse events. In patients with organic anejaculation but without SCI midodrine can reverse anejaculation in more than 50% of patients. Further studies are needed, however, for the evaluation of different treatment regimens in anejaculation therapy.

Medical and surgical management male infertility

Male infertility is the result of a variety of highly treatable conditions. The critical step in treating male infertility is to evaluate properly every male partner of an infertile couple and to generate the proper treatment strategy. There are many medical and surgical options that can help most couples overcome male factor infertility. Male infertility can most easily be broken down into problems of sperm production (testicular dysfunction) and problems of sperm transport (obstruction). When applicable, medical therapies are used as an initial strategy to improve sperm production or as a preliminary therapy to boost production transiently in anticipation of a surgical sperm retrieval attempt. A range of surgical options is available to correct varicoceles, reconstruct the obstructed system, or retrieve sperm for assisted reproduction.

Intracytoplasmic sperm injection--an assisted reproduction technique that should make us cautious about imprinting deregulation

OBJECTIVE

Due to the extensive use of intracytoplasmic sperm injection (ICSI) in assisted reproduction, not only among couples with severe male factor infertility problems, but to a broader scale, a lot of concern has been raised regarding the safety of the method and its implications in epigenetic control and imprinting dysregulation. This review means to provide a comprehensive report of the published scientific data, outline putative associations between ICSI and epigenetic control, and suggest measures to improve the current state of affairs and reach more scientifically consolidated results.

METHODS

This review was conducted by studying a broad spectrum of articles dealing with the subject of epigenetic control and its relation with ICSI. We tried to view the two subjects as parallel procedures that occur in the organism and by delineating the molecular and biochemical steps that comprise them make suggestions about putative associations between ICSI and epigenetic control.

CONCLUSIONS

No hard evidence presented at the moment can prove or disapprove ICSI's implications in epigenetic control. Nevertheless, we take the view that more comprehensive, long-term, and properly designed studies are imperative to be applied on a large-scale basis. We urge cautiousness, since the welfare of our progeny is what is at stake.

Male fertility and sexual function after spinal cord injury

Spinal cord injury has an enormous impact upon the sexual relationship of a man and his partner. Erection may be partial or absent, orgasm altered or impossible, and fertility severely impaired. New understanding of the physiology of sexual function and improved treatment can enable most cord-injured men to achieve erections suitable for sexual satisfaction. Modern methods of sperm collection and fertility treatment mean that many can also be fathers. The best results are obtained by a team approach involving rehabilitation and reproductive medicine clinicians, nurses, spinal cord injury specialists and counselors with the cord-injured man and his partner. Erections can be achieved by drugs, such as sildenafil, that block phosphodiesterase 5, prolonging the action of nitric oxide with resultant smooth muscle relaxation. Intracavernosal prostaglandin E1 and mechanical systems, such as vacuum pumps and constriction rings, are also effective. Sexual gratification can be promoted in the context of an understanding relationship in which the cord-injured person can gain pleasure from pleasing his partner and also from his partner's exploration of erotogenic areas not affected by the spinal cord injury. An emphasis on the broader view of sexuality in relationships allows for a continuance and strengthening of bonds between the couple. Vibration ejaculation or electroejaculation can be used to collect semen. For a limited period in the acute phase, usually for about 6-12 days after injury, normal semen can be obtained by electroejaculation from some cord-injured men. With chronic spinal cord injury the semen is of variable quality. Some patients have necrospermia, which may be improved by regular ejaculation. Others have poor quality semen or spermatogenic disorders and, in this situation, in vitro fertilization techniques must be used to achieve parenthood. Trials of assisted ejaculation help individualize cost-effective management of the infertility.

Analysis of limited fertility in intracytoplasmic sperm injection of sperm obtained by electroejaculation

Background and Aims:  We correlated findings in semen from patients with ejaculatory dysfunction with results of in vitro fertilization using their electroejaculated sperm. Methods and Results:  Electroejaculation was carried out in six patients with the above-mentioned criteria for a total of eight times. Sperm was obtained in six attempts. Intracytoplasmic injection of these sperm was performed in 156 eggs. Sixty-seven eggs were fertilized; most of these were injected with motile sperm. Two women became pregnant, both after injection with motile sperm. As previously reported, electroejaculated sperm showed low motility and a low fertilization rate, but even motile sperm had a low fertilization rate. Conclusion:  The results of the present study suggest the importance in fertilization of undetermined factors in addition to sperm motility. (Reprod Med Biol 2004; 3: 9-12).

Disorders of ejaculation

The physiology of ejaculation includes emission of sperm with the accessory gland fluid into the urethra, simultaneous closure of the urethral sphincters, and forceful ejaculation of semen through the urethra. Emission and closure of the bladder neck are primarily alpha-adrenergically mediated thoracolumbar sympathetic reflex events with supraspinal modulation. Ejaculation is a sacralspinal reflex mediated by the pudendal nerve. The most common ejaculation disorder is premature ejaculation, but there is little agreement regarding the definition of this disorder or its etiology, diagnosis, and treatment options. Premature ejaculation is in fact classically considered psychogenic in nature. However, recent data have demonstrated that prostatic inflammation/infection has been found with high frequency in premature ejaculation, suggesting a role of prostatic pathologies in the pathogenesis of some cases of failure of ejaculatory control. Rarer disorders are emission and ejaculation failure and urine contamination of semen. The new use of diagnostic procedures and the availability of pharmacological aids place this topic in the mainframe of medical sexology.

Spinal cord injury medicine. 4. Optimal participation in life after spinal cord injury: physical, psychosocial, and economic reintegration into the environment

This learner-directed module on spinal cord injury (SCI) presents a variety of perspectives of the process of personal and environmental adaptation for reintegration. Adaptation is unique to each person and does not predictably follow stages. Models used for understanding the process include biopsychosocial, ICIDH-2 (International Classification of Functioning, Disability and Health), and sector divisions of the environment. Home modification requires home (intermediate environment) evaluation and sociospatial behavioral mapping for planning and appropriation of remodeling in proportion to functional need and use. Options for access to the natural environment include specialized wheelchairs, climbing rigging, kayaks, and sail boats. Sports participation with adaptations is expanding and includes a larger variety of organizations and leagues. Economic needs are effectively anticipated with development of a life care plan. Procreative options to overcome infertility after SCI include vibratory stimulation for ejaculation, intravaginal insemination, intrauterine insemination, in vitro fertilization, and intracytoplasmic sperm injection. Approaches to requests for withdrawal of life-sustaining care include depression screening, pain evaluation, and assistance in accomplishment of person centered goals. Overall, community reintegration after SCI is continually improving because of better acceptance, accessibility, and technology for building adaptations.

OVERALL ARTICLE OBJECTIVES

(a) To review models and theories of medical intervention and disablement and (b) to demonstrate their application in rehabilitation practice by designing unique treatment plans that meet patient person-centered goals.

Pregnancy achieved following ICSI from a man with Klinefelter's syndrome and spinal cord injury

Klinefelter's syndrome and spinal cord injury are major causes of male infertility. Intracytoplasmic sperm injection (ICSI) is a relatively new method of assisted reproduction. A testicular biopsy was obtained from a patient with the double complications of non-mosaic 47,XXY Klinefelter's syndrome and spinal cord damage, and motile spermatozoa were collected. ICSI was then performed. Of the four sperm-injected oocytes, three became fertilized and cleaved. Two embryos were implanted, resulting in a single pregnancy with visible evidence of a heartbeat appearing at 6 weeks gestation. The pregnancy is now entering its 20th week. To the best of our knowledge, this is the first case of a pregnancy resulting from the sperm of a patient with double complications.

Ejaculatory physiology and dysfunction

The sequence of events encompassing ejaculation has been well described. Multiple disease processes can result in ejaculatory dysfunction. Evaluation and subsequent treatment of ejaculatory dysfunction is possible using behavioral, mechanical, and medical and surgical modalities. Further elucidation of ejaculation is now taking place at the molecular level.