Electroejaculation following retroperitoneal lymphadenectomy

Clinical review of ejaculatory dysfunction

BACKGROUND

Ejaculatory dysfunction (EjD) is a complex pathological condition compared to erectile dysfunction (ED). A definitive classification of EjD is not established, and treatment is often delayed. Owing to its association with infertility, EjD is a serious concern, particularly in men of reproductive age.

METHODS

The authors performed a literature search to identify the latest articles and overseas guidelines for review.

RESULTS

Our new classification categorizes men into two groups as follows: (1) men with inability to ejaculate (retrograde ejaculation, anejaculation, intravaginal ejaculatory dysfunction) and (2) men requiring an abnormal time for ejaculation (premature ejaculation, delayed ejaculation). In Japan, the number of men presenting with an inability to ejaculate is greater than those presenting with premature ejaculation. Pharmacotherapy is the first-line treatment for the management of these EjD patients. Behavioral therapy is added to pharmacotherapy depending on the case. Penile vibratory stimulation or electroejaculation is indicated in some men with retrograde ejaculation and anejaculation. In cases who hope for a baby, assisted reproductive technology should be simultaneously considered not to waste time.

CONCLUSION

It is important to distinguish between EjD and ED and accurately diagnose the type of EjD for optimal treatment of this condition.

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.

[Why and how to assess hypospermia?]

Hypospermia is a semen volume lower than 2 mL on at least two semen analyses. The etiologies of hypospermia are many and may be divided into two pathophysiologic sub-groups: disturbances of ejaculation reflex leading to partial retrograde ejaculation and seminal glands and ducts anatomic and functional anomalies. In this last pathologic mechanism, the mutations of CFTR gene, involved in many different forms of cystic fibrosis, represent a possible cause of hypospermia. The molecular anomaly of CFTR gene's screening is very important for the potential descendents and for the patient himself. It must be considered any time clinic and/or paraclinic context is evocative.

Update on medical treatment of ejaculatory disorders

Among the treatment modalities for ejaculatory disorders pharmacological treatment is the least invasive option. In this review, medical treatments for retrograde ejaculation (RE) and anejaculation (AE) are discussed systematically. Thirty-six studies dealing with patients with RE and 40 with AE evaluated the use of medical treatment and were included in this review. In addition four articles dealing with prostatic massage in anejaculatory patients were considered. Sperm quality in patients with retrograde and AE is often impaired. In patients with RE no differences in response to medical treatment could be detected between the different underlying diagnoses. Compared with ephedrine, imipramine and chlorpheniramine + phenylpropanalamine showed significantly higher reversal rates, while differences between the other treatments were not significant. Regarding the reversal of AE, the alpha agonistic drugs were significantly inferior to treatment with parasympathetic drugs. Of the different alpha agonistic medical treatments for the reversal of AE, milodrin showed significantly better rates than imipramine (p = 0.008), pseudoephidrine (p = 0.02) and ephedrine (p = 0.044), while all other treatments were not significantly different (p = 0.4). In conclusion, medical treatment for reversal of RE offers a realistic chance of conceiving offspring naturally and should be the treatment modality of first choice. In contrast, in AE, medical treatment cannot be recommended generally as treatment of first choice as it shows low overall success rates compared with electrovibration stimulation and electroejaculation. Under consideration of the mostly uncontrolled design of the majority of studies published, controlled clinical trials comparing different treatment options appear urgently warranted.

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.

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.

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.

Procreation after death or mental incompetence: medical advance or technology gone awry?

OBJECTIVE

To review our experience with semen retrieval in men who are incompetent or dead and to formulate general medical, legal, and ethical guidelines for practitioners.

DESIGN

Case series and literature review.

SETTING

Academic.

PATIENT(S)

Seven incompetent or neurologically dead individuals in whom sperm retrieval was requested.

INTERVENTION(S)

Electroejaculation.

RESULT(S)

Seminal emission was induced in the two men who underwent electroejaculation. Sperm suitable for cryopreservation was obtained in one of these men. Review of the legal and ethical implications of such procedures led to development of general guidelines for determining whether gamete retrieval should be performed when requested. Issues of procreational autonomy, consideration of the decedent's wishes, and assurance of the well-being of any new life created were considered most strongly in the formation of these guidelines.

CONCLUSION(S)

Although the retrieval of sperm from deceased or incompetent individuals may be achieved readily, it is incumbent upon the practitioner to consider the legal and moral implications of these procedures before proceeding.

The achievement of pregnancies using assisted reproductive technologies for male factor infertility after retroperitoneal lymph node dissection for testicular carcinoma

OBJECTIVE

To evaluate the success of electroejaculation with assisted reproductive technologies (ART) in anejaculate men after retroperitoneal lymph node dissection (RPLND) for testicular cancer.

DESIGN

Retrospective clinical study.

SETTING

Tertiary care, university-affiliated IVF program.

PATIENTS

Anejaculate men after RPLND, spouses.

INTERVENTIONS

Electroejaculation, microsurgical sperm aspiration, various assisted reproductive technologies.

MAIN OUTCOME MEASURES

Sperm density and motility, fertilization rate, pregnancy rate (PR).

RESULTS

Compared with patients not receiving chemotherapy, patients who received chemotherapy had diminished average sperm densities and motilities (63 x 10(6) and 20% versus 101 x 10(6) 32%, respectively); decreased fertilization rates per cycle for IVF and intracytoplasmic sperm injection (ICSI) (11% versus 26%, respectively); lower PRs per cycle of hMG-IUI and IVF (14% versus 60% and 8% versus 50%, respectively). No pregnancies were achieved with natural cycle-IUI, clomiphene citrate-IUI, or GIFT. Two couples progressed to intracytoplasmic sperm injection with one achieving the successful delivery of healthy twins. The overall PR per cycle was 22%.

CONCLUSIONS

Patients receiving chemotherapy had decreased sperm densities, motilities, fertilization, and PRs for each modality used. Rectal probe electroejaculation with ART can help anejaculate men after RPLND achieve biologic paternity. An early move to the more aggressive therapies (hMG-IUI, IVF, ICSI) is supported.

Preservation of function in genitourinary cancers: psychosexual and psychosocial issues

GU cancers are commonly associated with treatment-related sexual dysfunction, varying from mild to severe. For the clinical oncologist, it is important to be aware that sexual problems or sexual dysfunction may occur as a result of any aspect of cancer and cancer treatment. Sexual function is sensitive to the effects of trauma, both physical and emotional. This is particularly the case for patients whose cancer affects their genitals. Despite some commonalities of psychosocial and psychosexual issues in GU patients across diagnostic categories, GU patients do not present as one distinct, homogeneous group. GU neoplasms, with the exception of bladder cancer, affect mostly men. Men and women tend to differ in their ways of dealing with emotional distress and physical illness. While the man may typically do well using denial as a defense and may not want to discuss his feelings about his diagnosis and treatment, his partner may suffer if her way of coping is oriented toward communicating thoughts and feelings about the situation. Another important difference in this population is related to age and developmental differences. Testicular cancer typically is diagnosed in young men between the ages of 15 and 34 (46). The patients often still live with their parents or have just formed families of their own. In contrast, prostate cancer is diagnosed in older men, who are at a completely different stage in their lives when they have to deal with this challenge. Developmental stage at the time of diagnosis and treatment is an important variable in adaptation to cancer (47). Since GU malignancies and their treatments directly or indirectly affect sexual organs and sexual functioning, issues of sexual body image and identity as men or women are frequent concerns for GU patients. This is most obviously the case for men facing penectomy or orchiectomy. Similarly, women undergoing cystectomy with its simultaneous removal of uterus, ovaries, and parts of the vaginal wall face issues regarding their femininity as well as doubts about future sexual functioning. However, body image concerns are not limited to these two groups but may affect any cancer patient. The experience of having lost all hair due to chemotherapy, bearing of surgical scars, lost or altered functioning, and just the realization of having had cancer may change the way a patient feels about his/her body permanently.(ABSTRACT TRUNCATED AT 250 WORDS)

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.

Laparoscopic implantation of electrodes for stimulation of the hypogastric nerve and the vas deferens in dogs

The minimal invasiveness of laparoscopy prompted us to investigate its use for placement of electrodes for stimulation of the hypogastric nerve and the vas deferens. In an acute canine model, pressure changes in the vas deferens secondary to electrostimulation were recorded. The laparoscopic approach included four ports. Monopolar cuff electrodes were placed around the hypogastric nerve and the vas deferens, and the leads of both were pulled through the abdominal wall. After multiple percutaneous stimulations (20 mAmp., 20 Hz. and 200 microsecond pulse width), the abdomen was opened through a midline incision to check the position of the electrodes. Electrostimulation was repeated with the abdomen open. Electrostimulation of both the hypogastric nerve and vas deferens resulted in marked pressure rises in the vas. These increases were similar in response to both surface and percutaneous stimulation. We thus believe that laparoscopic implantation of electrodes followed by percutaneous preliminary stimulation of the superior hypogastric plexus or the vas deferens may be a viable future approach to anejaculation.

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.