Male infertility in spinal cord trauma

Sexuality, Intimacy, and Reproductive Health after Spinal Cord Injury

Spinal cord injury (SCI) is a life-altering event often accompanied by a host of anxiety-provoking questions and concerns in the minds of affected individuals. Questions regarding the ability to resume sexual activity, partner's satisfaction as well as the ability to have biological children are just a few of the unknowns facing patients following the devastating reality that is SCI. As a result of advances in SCI research over the last few decades, providers now have the knowledge and tools to address many of these concerns in an evidence-based and patient-centered approach. SCI can impair multiple components involved in sexual function, including libido, achieving and maintaining an erection, ejaculation, and orgasm. Many safe and effective fertility treatments are available to couples affected by SCI. Finally, learning to redefine one's self-image, reinforce confidence and self-esteem, and feel comfortable communicating are equally as important as understanding functionality in regaining quality of life after SCI. Thus, this review aims to highlight the current state of SCI research relating to sexual function, reproductive health, and the search for meaning.

Spinal cord injury and male infertility-a review of current literature, knowledge gaps, and future research

Spinal cord injury (SCI) affects nearly half a million new patients worldwide, with 17,700 in the US each year, and disproportionately impacts young males of reproductive age. Almost every aspect of male reproduction is affected by SCI, resulting in: erectile, endocrine and sexual dysfunction, decreased sperm motility despite an often-normal count, and abnormal semen emission and ejaculation. The aim of this review is to focus on how SCI impacts testicular spermatogenesis, sperm function, semen quality, and overall fecundity while discussing what is not known, and future avenues for research.

Advances in the management of infertility in men with spinal cord injury

Couples with a spinal cord injured male partner require assisted ejaculation techniques to collect semen that can then be further used in various assisted reproductive technology methods to achieve a pregnancy. The majority of men sustaining a spinal cord injury regardless of the cause or the level of injury cannot ejaculate during sexual intercourse. Only a small minority can ejaculate by masturbation. Penile vibratory stimulation and electroejaculation are the two most common methods used to retrieve sperm. Other techniques such as prostatic massage and the adjunct application of other medications can be used, but the results are inconsistent. Surgical sperm retrieval should be considered as a last resort if all other methods fail. Special attention must be paid to patients with T6 and rostral levels of injury due to the risk of autonomic dysreflexia resulting from stimulation below the level of injury. Bladder preparation should be performed before stimulation if retrograde ejaculation is anticipated. Erectile dysfunction is ubiquitous in the spinal cord injured population but is usually easily managed and does not pose a barrier to semen retrieval in these men. Semen analysis parameters of men with spinal cord injury are unique for this population regardless of the method of retrieval, generally presenting as normal sperm concentration but abnormally low sperm motility and viability. When sperm retrieval is desired in this population, emphasis should be placed on initially trying the simple methods of penile vibratory stimulation or electroejaculation before resorting to more advanced and invasive surgical procedures.

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.

Male fertility following spinal cord injury: an update

Spinal cord injury (SCI) occurs most often in young men at the peak of their reproductive health. The majority of men with SCI cannot father children naturally. Three major complications contribute to infertility in men with SCI: erectile dysfunction, ejaculatory dysfunction, and abnormal semen quality. Erectile dysfunction can be managed by regimens available to the general population, including oral administration of phosphodiesterase-5 (PDE-5) inhibitors, intracavernosal injections, vacuum devices, and penile prostheses. Semen may be obtained from anejaculatory men with SCI via the medically assisted ejaculation methods of penile vibratory stimulation (PVS) or electroejaculation (EEJ). Sperm retrieval is also possible via prostate massage or surgical sperm retrieval. Most men with SCI have abnormal semen quality characterized by normal sperm concentrations but abnormally low sperm motility and viability. Accessory gland dysfunction has been proposed as the cause of these abnormalities. Leukocytospermia is evident in most SCI patients. Additionally, elevated concentrations of pro-inflammatory cytokines and elevated concentrations of inflammasome components are found in their semen. Neutralization of these constituents has resulted in improved sperm motility. There is a recent and alarming trend in the management of infertility in couples with SCI male partners. Although many men with SCI have sufficient motile sperm in their ejaculates for attempting intrauterine insemination (IUI) or even intravaginal insemination, surgical sperm retrieval is often introduced as the first and only sperm retrieval method for these couples. Surgical sperm retrieval commits the couple to the most advanced, expensive, and invasive method of assisted conception: in vitro fertilization with intracytoplasmic sperm injection (IVF/ICSI). Couples should be informed of all options, including semen retrieval by PVS or EEJ. Intravaginal insemination or IUI should be considered when indicated.

Testicular sperm retrieval and intra cytoplasmic sperm injection provide favorable outcome in spinal cord injury patients, failing conservative reproductive treatment

STUDY DESIGN

Retrospective cohort analysis.

OBJECTIVES

The objective of this study was to determine the in vitro fertilization (IVF) outcome after testicular sperm extraction (TESE) in a group of spinal cord injury (SCI) male patients not compatible with conservative fertility treatment.

SETTING

University-affiliated medical center.

METHODS

Thirty two SCI patients (C2 to L2) were referred to IVF after repeated trials of electroejaculation (EEJ) or penile vibratory stimulation (PVS), and full andrological evaluation. Testicular sperm aspiration (TESA) was the method of choice for sperm extraction. Open TESE was performed only after a negative TESA attempt. Clinical pregnancy and live birth rates were determined.

RESULTS

A total of 106 testicular procedures were performed. Sperm was found in 95 cycles (89.6%). The average metaphase II (MII) oocyte number was 11.0±4.2, an average of 5.1±2.3 oocytes became normally fertilized after Intra Cytoplasmic Sperm Injection (ICSI) (fertilization rate 57.1%). On average, 2.7±1.2 embryos were replaced. The clinical pregnancy rate was 32/106 (30.2%) per cycle and 19/32 (59.3%) per couple. Live birth rate was 62.5% (20/32).

CONCLUSIONS

TESA/E and IVF can provide excellent prognosis for SCI patients that cannot be treated by EEJ or PVS.

Sperm chromatin condensation, DNA integrity, and apoptosis in men with spinal cord injury

OBJECTIVES

To evaluate the effect of cord injury on (1) sperm parameters and (2) DNA chromatin status.

DESIGN

Case-control study.

SETTING

Data were collected from men referred to Research and Clinical Center for Infertility, Yazd, Iran.

PARTICIPANTS

Thirty infertile men with the presence of any level of spinal cord injury (SCI) were compared with 30 healthy donors with definite fertility and normal sperm parameters.

INTERVENTIONS

Not applicable.

OUTCOME MEASURES

Sperm chromatin integrity was assessed using aniline blue (AB), chromomycin A3 (CMA3), toluidine blue (TB), and acridine orange (AO) assays. The rate of apoptotic spermatozoa was evaluated with terminal deoxynucleotidyl transferase-mediated dUTP nick-end labelling (TUNEL) staining.

RESULTS

Sperm concentration, motility, and morphology in men with SCI were significantly decreased compared with control group (P < 0.05). In addition, with regard to cytochemical staining and TUNEL test, the rate of reacted spermatozoa was increased significantly in SCI group when compared with the controls (P < 0.05). The majority of AB, TB, AO, and CMA3-reacted spermatozoa were higher than the "cut-off" value in men with SCI, as were the number of apoptotic spermatozoa stained with TUNEL.

CONCLUSION

Results showed that SCI disturbs sperm parameters, nuclear maturity, and DNA integrity of spermatozoa. Therefore, the production of spermatozoa with less condensed chromatin and more apoptotic rate increases after cord injury and this may be one possible cause of infertility following SCI.

Infertility in men with spinal cord injury: research and treatment

Spinal cord injury (SCI) occurs most often to young men. Following SCI, most men are infertile due to a combination of erectile dysfunction, ejaculatory dysfunction and semen abnormalities. Erectile dysfunction may be treated by the same therapies that are used in the general population. Similarly, the same treatments that are effective to assist conception in couples with non-SCI male factor patients are effective in assisting conception in SCI male-factor patients. The most apparent differences in male-factor symptoms between SCI and non-SCI patients are the high occurrences of anejaculation and atypical semen profiles in men with SCI. Methods available to assist ejaculation in men with SCI include penile vibratory stimulation and EEJ. Use of surgical sperm retrieval as the first line of treatment for anejaculation in men with SCI is controversial. Most men with SCI have a unique semen profile characterized by normal sperm concentration, but abnormally low sperm motility. Toxic substances in the semen contribute to this problem. Despite impaired sperm parameters, pregnancy outcomes using sperm from men with SCI are similar to pregnancy outcomes using sperm from non-SCI men. Future studies should focus on improving natural ejaculation and improving semen quality in these men.

Long-term potency after early use of a vacuum erection device following radical prostatectomy

OBJECTIVE

To evaluate the long-term potency after radical prostatectomy (RP) with the early use of a vacuum erection device (VED), and reasons for sexual inactivity and long-term attrition and maintenance of sexual activity, as RP is one of the most common treatments for prostate cancer but erectile dysfunction (ED) is a common side-effect.

PATIENTS AND METHODS

We identified 141 sexually active patients who underwent RP at Cleveland Clinic Foundation. Patients were offered various non-oral treatment options to prevent ED and were also motivated for early penile rehabilitation. At 5 years 62% remained sexually active, of whom 71% had natural erections sufficient for intercourse without assistance, 8.5% were still using sildenafil, 10% were using combined therapy (sildenafil plus VED). At 5 years 38% (43/113) men were sexually inactive. The reasons included loss of interest in 17 (40%), cardiovascular/neurological diseases in 18 (42%), hormonal therapy in three (7%), loss of partner in three (7%) and two had other surgery. The natural rate of erections for sufficient vaginal penetration without an erection aid were preserved and maintained in the early-prophylaxis group, and almost 60% of them had used a VED as early prophylaxis.

CONCLUSION

Despite current phosphodiesterase-5 inhibitor treatments for ED, VED is becoming recognized again as having a primary role in early penile rehabilitation in many patients, specifically those treated for prostate cancer.

Vacuum erection devices revisited: its emerging role in the treatment of erectile dysfunction and early penile rehabilitation following prostate cancer therapy

INTRODUCTION

Vacuum erection devices (VEDs) are becoming first-line therapies for the treatment of erectile dysfunction and preservation (rehabilitation) of erectile function following treatment for prostate cancer. Currently, there is limited efficacy of the use of phosphodiesterase type 5 inhibitors in elderly patients, or patients with moderate to severe diabetes, hypertension, and coronary artery disease.

AIM

The article aims to study the role of VED in patients following prostate cancer therapy.

RESULTS

Alternative therapies such as VED have emerged as one of the primary options for patients refractory to oral therapy. VED has also been successfully used in combination treatment with oral therapy and penile injections. More recently, there has been interest in the use of VED in early intervention protocols to encourage corporeal rehabilitation and prevention of postradical prostatectomy veno-occlusive dysfunction. This is evident by the preservation of penile length and girth that is seen with early use of the VED following radical prostatectomy. There are ongoing studies to help preserve penile length and girth with early use of VED following prostate brachytherapy and external beam radiation for prostate cancer. Recently, there has also been interest in the use of VED to help maintain penile length following surgical correction of Peyronie's disease and to increase penile size prior to implantation of the penile prosthesis.

CONCLUSION

VEDs can be one of the options for penile rehabilitation after prostate cancer therapy.

Measurement of sexual functioning after spinal cord injury: preferred instruments

BACKGROUND/OBJECTIVE

To determine the utility of certain instruments to assess sexuality and fertility after SCI, an expert panel identified key areas to study and evaluated available instruments. These were rated according to certain predefined criteria.

METHODS

The authors divided sexual issues into male and female sexual function, male reproductive function, and female reproductive function. The instruments that have been used most frequently to measure these aspects of sexual function over the past 5 years were identified by expert consensus. Finally, these instruments were subjected to a critical review.

RESULTS

The Female Sexual Function Index (FSFI), measurement of vaginal pulse amplitude (VPA), the International Index of Erectile Function (IIEF), and the measurement of ejaculatory function and semen quality were considered appropriate measures to assess sexual responses and reproductive function after SCI. There were no measures identified to assess female reproductive function.

CONCLUSIONS

For clinical trials aiming to improve sexual function after SCI, the FSFI or the IIEF is currently preferred. Although VPA is an appropriate means to assess female sexual responses, it is only useful for laboratory studies and is too invasive for use in clinical trials. For assessment of male fertility potential, assessment of ejaculatory capacity and semen analysis are recommended.

Assessment of nuclear DNA integrity of epididymal spermatozoa following experimental chronic spinal cord injury in the rat

Infertility is considered as one of the major problems associated with spinal cord injury (SCI). However, the exact underlying mechanism is still unknown. Therefore, the main objective of this experimental study was to evaluate the effect of chronic SCI on sperm parameters as well as chromatin integrity and DNA of spermatozoa aspirated from cauda epididymis of rats. Forty-five adult Wistar rats were divided into three groups - SCI, sham, and control. Following laminectomy, SCI was induced onto exposed dura matter (T10). The sham group underwent laminectomy of T10 only, while the control rats were not exposed to any type of injury or medication. The cauda epididymal sperms were aspirated after 8 weeks for analysis of sperm parameters and sperm chromatin integrity with aniline blue (AB), chromomycin A3 (CMA3), sodium dodecyl sulphate (SDS), and acridine orange (AO) tests. The sperm progressive motility and normal morphology of SCI rats were significantly changed when compared with other groups (p < 0.05). In addition, AB as well as CMA3 tests were insignificantly increased in the SCI group when compared with the sham and control groups. However, SDS and AO tests were significantly changed in SCI samples when compared with the sham and control groups (p < 0.001). The results showed that chronic SCI in rat disturbs sperm parameters as well as nuclear maturity and DNA integrity of sperms. Therefore, sperm chromatin structure is compromised in SCI animals as revealed by chromatin structural probes. These alterations may reduce the fertility potential of the male gamete following SCI.