Electro-ejaculation of a complete paraplegic followed by pregnancy

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.

Male infertility and erectile dysfunction in spinal cord injury: a review

OBJECTIVE

To review the pathophysiology, evaluation, and management of erectile dysfunction and infertility in spinal cord injury (SCI).

STUDY SELECTIONS

Studies that covered various treatment options and their contraindications, complications, or side effects, including sildenafil (Viagra), intracavernosal injection therapy, topical medications and a urethral delivery system, a vacuum erection device, and penile prostheses. Other studies covered the effects of SCI on reproduction: spermatogenesis and testicular function, and seminal constituents. In addition, assisted reproductive techniques were compared: external vibratory stimulation, electroejaculation, testicular sperm aspiration, and intracytoplasmic sperm injection.

CONCLUSION

Goal-directed therapy is the mainstay of treatment of erectile dysfunction in men with or without SCI. The choice of therapy is often defined more by the needs of the patient's sexual relationship than by his erectile dysfunction. The majority of men with SCI are infertile because of a combination of ejaculatory dysfunction, impaired spermatogenesis, and poor semen quality. Although many technological advances have evolved to overcome ejaculatory dysfunction, the sperm density, motility, and function remain poor. Until these parameters are improved, men with SCI will have to pursue more financially and emotionally taxing procedures. Further studies to elucidate the cellular and molecular mechanisms of diminished sperm quality are needed. Addressing the issues of erectile dysfunction and male infertility may help to preserve the relationship between the patient and his partner.

Contribution of the assisted reproductive technologies to fertility in males suffering spinal cord injury

This study reviews 19 couples referred between 1990 and 1997 for fertility treatment for anejaculatory infertility in the male partner following spinal injury. Using sperm obtained by assisted ejaculation procedures, 14 of the 19 patients (74%) achieved at least 1 pregnancy. Pregnancy rates per treatment cycle were 12.0% for timed intrauterine insemination, 38.9% for gamete intra-Fallopian transfer and 19.2% for intracytoplasmic sperm injection followed by uterine embryo transfer. Choice of the appropriate assisted reproduction treatment to match the available semen quality results in a high level of success in such patients.

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.

Ejaculatory failure

Although anejaculation is a relatively uncommon occurrence in the general population, over 12,000 new cases are reported annually. Anejaculation may result from spinal cord injury (SCI), retroperitoneal lymph node dissection (RPLND), diabetes mellitis, transverse myelitis, multiple sclerosis, or psychogenic disorders. At least 30% of men with this problem are or will be married and many will seek help to remedy their infertile state. The evolution of technique and instrumentation over the least 30 years has made electroejaculation an accessible and acceptable form of therapy. Recent successes in inducing ejaculation by means of rectal probe electrostimulation or vibratory stimulation combined with assisted reproductive techniques, such as zygote intrafallopian transfer (ZIFT), gamete intrafallopian transfer (GIFT), and in vitro fertilization (IVF), have provided these men a means of producing their own biologic offspring.

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.

The combined use of vibrostimulation and in vitro fertilization: successful pregnancy outcome from a retrograde specimen obtained from a spinal cord-injured male

While pregnancies have been documented through the independent use of the vibrator method, from other methods of procuring ejaculate from spinal cord injured men, and from artificial insemination using a retrograde specimen, we believe that this is the first case report of a live birth resulting from a retrograde ejaculate obtained by vibration from a spinal cord-injured male whose partner underwent in vitro fertilization. Vibrostimulation may well be successful in the two-thirds of men whose spinal cord lesions are at the T10 neurological level and above, who have an intact bulbocavernosus reflex and anal tone but no pain or temperature sensation of the genitalia. Blood pressure monitoring, prevention of autonomic dysreflexia, alkalinization, dilution and infection control of urine, and retrograde specimen retrieval are all important techniques to ensure patient safety and optimal ejaculates. The timing of ovulation and insemination is the crucial factor for the partner of a SCI male whose sperm quality is poor. A complete gynecological workup, including studies of tubal patency, should be done before embarking on a series of artificial inseminations. Stimulation of ovulation and well-timed inseminations should optimize the chance of conception. Depending on semen analysis, female partner factors, and emotional and financial costs, IVF can appropriately be either an early or a final option.

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.

Neurological correlations of ejaculation and testicular size in men with a complete spinal cord section

This study was of 135 patients with a complete spinal cord section suffered from loss of ejaculation. The spinal cord injuries were classified following the upper and the lower limits of the lesion. The volume of the testes of the patients and of 13 normal control subjects were measured. Physostigmine allowed 75 patients to ejaculate and 15 of them procreated. The possibility of ejaculation after physostigmine mainly depended on the integrity of the T12-L2 metamers. The testicular volume was significantly smaller in patients with a lesion including the T12 metamer than in patients with a lesion sparing the T12 metamer. Six patients with a lesion including the T12 metamer had testicular atrophy. This suggests that T12 segment plays a role in testicular function in paraplegic patients.

Rectal probe electrostimulation in the treatment of anejaculatory spinal cord injured men

This paper reviews our experience with rectal probe electroejaculation (RPE) which is part of a larger effort to determine the correlates of successful ejaculation and fertility in SCI men. RPE is performed in the outpatient clinic using specially designed rectal probes. Over the past 18 months, we have attempted RPE on 38 occasions in 12 subjects (eight paraplegics and four quadriplegics) with an age range of 23-38 years and 0.5-18 years since onset of injury. Anterograde ejaculation occurred in nine subjects with improvement in percent motility and total live sperm count on repeated stimulations in five subjects. Significant retrograde ejaculation occurred in one person and sperm acceptable for artificial insemination (AI) was obtained from four subjects. The major side effects were mild dysreflexia (three subjects) and disruption of a normal bowel program (one subject). We conclude that RPE is a safe, relatively brief outpatient procedure and, with repeated stimulations, has a good potential for producing sperm acceptable for AI in selected patients.

Ejaculatory stimulation in spinal-cord injured men

Anejaculation is a common problem among spinal-cord injured (SCI) men. Only 1-20 per cent of SCI men can ejaculate. Methods of ejaculatory stimulation are needed to obtain sperm for artificial insemination purposes. The methods of stimulation heretofore used include intrathecal neostigmine, rectal probe electro-ejaculation, vibratory stimulation of the penis, and subcutaneous physostigmine. Ejaculatory ability increased to as much as 58 per cent using these techniques, but complications such as nausea and vomiting, elevated blood pressure, and headaches have been reported. The mechanisms of action of these techniques are poorly understood; they are believed to stimulate either reflex spinal ejaculatory centers or efferent peripheral nerves from these centers. The studies with these techniques often fail to use scientific methods of evaluation and are deficient in characterizing the subject population, description of stimulator and technique utilized, definition and presentation of "success" and/or complications observed. The criteria by which future studies of ejaculatory stimulation should be measured are suggested.

Electroejaculation for recovery of semen after retroperitoneal lymph node dissection: case report

Electroejaculation with a rectal probe was used successfully for semen recovery 8 years after bilateral suprarenal hilar lymph node dissection for stage IIB embryonal cell cancer. An adequate ejaculate was obtained in relation to total sperm count, motility and normal morphology. Prior use of sympathomimetic drugs, including imipramine and ephedrine, was unsuccessful in producing an ejaculation. Electrostimulation via a rectal probe seems to be a useful technique for semen recovery in the patient with anejaculation after retroperitoneal lymph node dissection.

Infertility in spinal-cord injured male

Sterility in spinal-cord injured (SCI) men is believed to be caused by ejaculatory dysfunction, genital ductal blockage secondary to infection, and/or impaired spermatogenesis. Semen from SCI men demonstrates diminished numbers of motile, morphologically normal sperm. Testicular biopsies demonstrate impaired spermatogenesis. Leydig and Sertoli cells appear to be normal. Endocrine evaluations reveal normal testosterone levels with an adequate Leydig cell reserve. Luteinizing hormone (LD) and follicle-stimulating hormone (FSH) levels are normal or high with normal or exaggerated stimulation responses. Acute depressions in testosterone, FSH, and LH levels can be seen following SCI, most markedly in quadriplegics. A normal hypothalamic-pituitary-testicular axis is implied by these findings, indicating a primary hypogonadism. Causes of impaired spermatogenesis may include local testicular temperature elevations, nondrainage of the reproductive tract, antisperm antibodies, and recurrent genitourinary infections. Treatment of infertility involves removal of these offending factors, and research is needed to correlate the impaired spermatogenesis with these factors.

Reproductive biology of paraplegics: results of semen collection, testicular biopsy and serum hormone evaluation

The fertility and urological status of 30 male paraplegics between 20 and 47 years old with lesions between the T2 and L3 levels were examined by studying serum hormone levels (estradiol-17 beta, testosterone, prolactin, and follicle-stimulating and luteinizing hormones), sperm and semen characteristics via testicular biopsy and rectal probe electrostimulation, and urodynamic evaluation. Of the patients 13 had reflexic, 4 hyperreflexic and 13 areflexic bladders. Nine of the 13 patients with reflexic and all 4 with hyperreflexic bladders had a positive external sphincter electromyogram with detrusor-sphincter dyssynergia. When catheters were not used to collect semen during rectal probe electrostimulation, retrograde semen flow into the bladder was the rule. A total of 22 patients could tolerate rectal probe electrostimulation, while 6 who could not were injured at the T12 level or lower. Seminal emissions were obtained from 35 to 42 studies in these 22 patients. Total sperm count was variable; in 22 studies it was greater than 20 million. Progressive motility usually was low; 77 per cent of the patients had less than 20 per cent motility. Of 13 biopsy specimens obtained 6 suggested normal testicular morphology, with tubule atrophy and spermatogenic activity only mildly reduced in 6 of the remaining 7. Serum testosterone and luteinizing hormone values were significantly higher (p less than 0.05) among the paraplegic patients than among intact male volunteers of the same age range. Other serum hormone levels were unchanged. Outcome of rectal probe electrostimulation and biopsy did not relate to the number of years of patient injury. Thus, the principal deterrent to the use of semen collected by rectal probe electrostimulation from paraplegics for artificial insemination resides in a predominantly low sperm motility. Suggestions for improvement of motility include 1) great care to minimize or prevent urinary tract infections, 2) selection of medications for urinary tract care that do not compromise sperm survival and 3) prevention of sperm stagnation in lower tract storage sites, perhaps by use of periodical rectal probe electrostimulation.

Initiation of erection and semen release by rectal probe electrostimulation (RPE)

Instrumentation and methodology are described for rectal probe electrostimulation (RPE) in human males to elicit erection and allow semen collection. This system virtually eliminates shock hazard; the simultaneous monitoring of current, voltage and impedance ensures reliability and repeatability. It was tested with 8 neurologically intact subjects, and 12 paraplegic patients with lesions between T4 and L2. Platinum electrodes delivered current (density never exceeding 0.37 mA per mm. at the electrode) at frequencies of 60 Hz, 20 Hz, and 0.25 Hz. Erection was elicited repeatably in only 1 of the intact subjects, and no seminal emissions or ejaculations occurred. Discomfort prevented current delivery beyond levels even 50 per cent of those safely acceptable. Six of 10 paraplegic patients (2 others had penile implants) developed erections with 20 Hz; the other 2 frequencies were much less effective. The extent of RPE-induced penile tumescence varied directly with electrode surface area and applied current intensity. Discomfort was minimal. Retrograde seminal emission in 5 of the 12 paraplegics was verified by post-stimulation recovery of sperm via voiding or bladder irrigation via catheter. Although motility was very low, 4 of 8 recovered bladder-urine/seminal fluid specimens indicated sperm counts and morphology consonant with use in artificial insemination. Thus, RPE, if combined with techniques to allow antegrade semen collection, may be a useful technique for spinal cord-injured men who, as part of their sexual rehabilitation, are interested in siring children.

Deep scrotal temperature and the effect on it of clothing, air temperature, activity, posture and paraplegia

Two new techniques for measuring deep scrotal temperature are described. Paraplegic men in wheelchairs have deep scrotal temperatures averaging about 0.9 degrees C higher than normal sitting men, and those whose scrotal temperatures are very high usually lack motile spermatozoa. In the author, deep scrotal temperatures at constant air temperature are 0.5 degrees C lower wearing boxer shorts than wearing Y-fronts, and 1.2 degrees C lower wearing scrotal slit underpants than wearing boxer shorts; they are 1.6 degrees C lower sitting with thighs apart than sitting with thighs together, and 0.5 degrees C lower running than sitting with thighs apart. From such observations, means of lowering paraplegic deep scrotal temperatures can be designed.

Electroejaculation: its technique, neurological implications and uses

An improved technique for electroejaculation is described, with the results of applying it to 84 men with spinal injuries and five men with ejaculatory failure from other causes. Semen was obtained from most patients, but good semen from very few. Only one pregnancy has yet been achieved. The technique has diagnostic applications.

Alternatives to orchiopexy

With improved surgical techniques orchiopexy has become possible in patients with cryptorchidism who previously were forced to alternatives, including no treatment at all, a trial of hormonal therapy or orchiectomy. However, the mere presence of a testis in the scrotum may not benefit some patients, that is neither enhancing fertility nor reducing malignancy. A prosthesis may provide comparable appearance and psychologic support. No treatment is indicated in cases of severe mental retardation, ejaculatory failure (as with the prune belly syndrome) and certain endocrine syndromes. Hormonal therapy, helpful in bilateral prepubertal cases, also may be useful in certain endocrine disorders. Orchiectomy is indicated in unilateral cases with severe neurogenic disturbances that preclude ejaculation, in prepubertal patients with 1 abdominal testis and in postpuberal boys with unilateral cryptorchidism at any site. If risk versus benefit is assessed for each patient these alternatives may be better for him than orchiopexy.