Electroejaculation in spinal cord injury patients: simplified new equipment and technique

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.

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.

Necrospermia and chronic spinal cord injury

OBJECTIVE

To determine whether improvement in quality of semen over 4 consecutive days of electroejaculation in men with chronic spinal cord injury (SCI) was consistent with epididymal necrospermia.

DESIGN

Prospective study of a random sample of men with SCI.

SETTING

A southeastern Australian SCI management center in collaboration with the specialist andrology service of a university-based department of obstetrics and gynecology in a tertiary referral hospital.

PATIENT(S)

Nine men with chronic spinal cord injury.

INTERVENTION(S)

Semen samples were obtained by using electroejaculation, and testicular biopsy samples were obtained by using fine-needle tissue aspiration.

MAIN OUTCOME MEASURE(S)

Semen analysis was performed according to World Health Organization criteria. Testicular biopsy and electron microscopy were done by using standard techniques.

RESULT(S)

During up to 4 days of consecutive-day electroejaculation, sperm motility and viability in semen obtained from men with chronic SCI increased by an average of 23% on days 2 and 3. The severity of the degenerative changes and the numbers of spermatozoa affected on day 1 became less marked by day 4. The changes were not present in late spermatids obtained from testicular biopsies.

CONCLUSION(S)

The asthenospermia of chronic SCI is similar to epididymal necrospermia and can be improved by consecutive-day electroejaculation.

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.

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.

A simple technique to prevent retrograde ejaculation during assisted ejaculation

The aim of this study was to develop a technique which would prevent retrograde ejaculation in chronic spinal cord injured (SCI) patients undergoing vibration and electroejaculation procedures. A balloon catheter was used to tamponade the bladder neck in 12 patients who underwent 100 assisted ejaculation procedures. Antegrade ejaculations were collected on all occasions with no incidences of urine contamination and no sperm were seen in post ejaculatory urine. Silicone catheters had minimal effects on sperm motility and viability. All lubricant gels were found to adversely affect sperm quality and were not used.

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.

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.

Prostatic intraepithelial neoplasia: a premalignant lesion

Putative premalignant changes in the prostate have been recognized for a number of years. A variety of synonyms have been given to the most commonly described lesion, characterized by proliferation and dysplasia of the normal two cell layers lining prostatic acini and ductules; prostatic intraepithelial neoplasia (PIN) is the term most often used. A premalignant prostatic lesion should have morphologic features similar to invasive carcinoma (CA), a spatial association with microinvasive cancer arising from the lesion, and should occur at a greater frequency, severity and extent in organs harboring CA. Most definitively, progression from the premalignant lesion into CA should be observed over time. PIN fulfills all but the last of these requirements. High grade PIN is cytologically indistinguishable from prostate carcinoma (CAP). The major differentiating feature between PIN and CAP is the presence, although frequently disrupted, of the basal cell layer in the former. We have studied the basal cell layer in PIN using antibodies to high molecular weight cytokeratins and have found a correlation between PIN grade and the percent disruption of the basal cell layer. The cells making up PIN are phenotypically similar to those of CAP. We have used a variety of markers including cytokeratins, vimentin and the lectin Ulex euroapaeus to demonstrate this similarity. Additionally, we and others have noted decreased PIN immunoreactivity with antibodies directed against prostate specific antigen (PSA) and prostatic acid phosphatase. Other investigators have noted additional phenotypic similarities between PIN and CAP, including the ABH and Lewis antigens. PIN incidence and grade correlate well with the presence of CAP elsewhere in the prostate.(ABSTRACT TRUNCATED AT 250 WORDS)

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.