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

Reproductive characteristics and success rate of intracytoplasmic sperm microinjection in spinal cord injury infertile men: Retrospective cohort study

BACKGROUND

Thanks to modern methods of assisted reproduction (ART), parenthood has become an attainable goal for couples in which the male partner has experienced spinal cord injury (SCI).

OBJECTIVE

The aim of our study was to determine the success of the treatment of infertile patients with SCI with intracytoplasmic sperm injection (ICSI) of cryopreserved sperm obtained by the testicular sperm aspiration (TESA) procedure.

METHODS

In this retrospective study 156 infertile couples were included, in which the male partner is primarily infertile due to azoospermia. Infertile couples were divided into two groups. The first group (n= 82) includes men with SCI, and the second (n= 74) men with obstructive azoospermia (OA) as the cause of infertility. All infertile men were examined and processed in the diagnostic procedure, and based on the urological findings, surgical extraction of sperm from the testicles was indicated. Exclusion criteria were the age of women over 40 and men over 45.

RESULTS

We found that the quality of sperm was worse in the group with SCI, compared to the group with OA, but without statistical significance. Zenica and Johnsen score (p= 0.001; p= 0.000) showed worse semen characteristics in the group with SCI.     There were no significant differences in the average number of embryos (p= 0.698), pregnancy rates per cycle (p= 0.979) and pregnancy rates per embrio transfer (ET), clinical pregnancy rates per ET (p= 0.987) and delivery rates per ET (p= 0.804) in couples with SCI, compared to couples with OA.

CONCLUSION

Based on the results of this research, the TESA and ICSI procedures can be recommended as a successful method in the treatment of male infertility caused by azoospermia due to SCI.

Constructing and Validating a Network of Potential Olfactory Sheathing Cell Transplants Regulating Spinal Cord Injury Progression

The pathology of spinal cord injury (SCI), including primary and secondary injuries, primarily involves hemorrhage, ischemia, edema, and inflammatory responses. Cell transplantation has been the most promising treatment for SCI in recent years; however, its specific molecular mechanism remains unclear. In this study, bioinformatics analysis verified by experiment was used to elucidate the hub genes associated with SCI and to discover the underlying molecular mechanisms of cell intervention. GSE46988 data were downloaded from the Gene Expression Omnibus dataset. In our study, differentially expressed genes (DEGs) were reanalyzed using the "R" software (R v4.2.1). Functional enrichment and protein-protein interaction network analyses were performed, and key modules and hub genes were identified. Network construction was performed for the hub genes and their associated miRNAs. Finally, a semi-quantitative analysis of hub genes and pathways was performed using quantitative real-time polymerase chain reaction. In total, 718 DEGs were identified, mainly enriched in immune and inflammation-related functions. We found that Cd4, Tp53, Rac2, and Akt3 differed between vehicle and transplanted groups, suggesting that these genes may play an essential role in the transplantation of olfactory ensheathing cells, while a toll-like receptor signaling pathway was significantly enriched in Gene set enrichment analysis, and then, the differences were statistically significant by experimentally verifying the expression of their associated molecules (Tlr4, Nf-κb, Ikkβ, Cxcl2, and Tnf-α). In addition, we searched for upstream regulatory molecules of these four central genes and constructed a regulatory network. This study is the first to construct a regulatory network for olfactory ensheathing cell transplantation in treating SCI, providing a new idea for SCI cell therapy.

Effects of autonomic nervous system disorders on male infertility

The male reproductive functions are largely regulated by the autonomic nervous system. Male sexual behavior and fertility primarily depend on the normal function of the higher neural centers related to the autonomic nervous system, the hypothalamic-pituitary-gonadal axis, the autonomic nervous components within the spinal cord and spinal nerves, and certain somatic nerves in the pelvic floor. In this review article, we will summarize the role of the autonomic nervous system in regulating male reproductive capabilities and fertility, its impact on male infertility under abnormal conditions, including the role of drug-induced autonomic nervous dysfunctions on male infertility. The main purpose of this article was to provide an overview of the effects of autonomic nervous dysfunction on male reproductive function and shed light on the potential therapeutic target for male infertility.

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.

The impact of male factors and their correct and early diagnosis in the infertile couple's pathway: 2021 perspectives

PURPOSE

The current clinical practice in reproductive medicine should pose the couple at the centre of the diagnostic-therapeutic management of infertility and requires intense collaboration between the andrologist, the gynaecologist and the embryologist. The andrologist, in particular, to adequately support the infertile couple, must undertake important biological, psychological, economical and ethical task. Thus, this paper aims to provide a comprehensive overview of the multifaceted role of the andrologist in the study of male factor infertility.

METHODS

A comprehensive Medline, Embase and Cochrane search was performed including publications between 1969 and 2021.

RESULTS

Available evidence indicates that a careful medical history and physical examination, followed by semen analysis, always represent the basic starting points of the diagnostic work up in male partner of an infertile couple. Regarding treatment, gonadotropins are an effective treatment in case of hypogonadotropic hypogonadism and FSH may be used in men with idiopathic infertility, while evidence supporting other hormonal and nonhormonal treatments is either limited or conflicting. In the future, pharmacogenomics of FSHR and FSHB as well as innovative compounds may be considered to develop new therapeutic strategies in the management of infertility.

CONCLUSION

To provide a high-level of care, the andrologist must face several critical diagnostical and therapeutical steps. Even though ART may be the final and decisive stage of this decisional network, neglecting to treat the male partner may ultimately increase the risks of negative outcome, as well as costs and psychological burden for the couple itself.

Male Sexual Dysfunction and Infertility in Spinal Cord Injury Patients: State-of-the-Art and Future Perspectives

Spinal cord injury (SCI) is a relevant medical and social problem. According to the World Health Organization, the commonly estimated worldwide annual incidence of SCI is 40 to 80 cases per million population. After the SCI experience, most men present with sexual dysfunction (erectile dysfunction (ED) and ejaculatory dysfunction), fertility problems (such as impaired spermatogenesis, abnormalities in sperm viability, motility, and morphology), and systemic disorders such as genitourinary infection and endocrine imbalances. The best options available for managing the ejaculatory disorders in patients suffering from SCI are penile vibratory stimulation (PVS) and electroejaculation (EEJ). Furthermore, the treatment of ED in SCI patients consists of medical therapies including phosphodiesterase 5 inhibitors (PDE5i), intracavernosal injections (ICI), vacuum erection devices (VEDs), and surgical as penile prosthesis (PP). This review provides a snapshot of the current evidence for the mechanisms of sexual dysfunction and infertility in SCI patients, discusses the best management strategies for these conditions, and offers our perspective on the direction of future research.

Management of male factor infertility: position statement from the Italian Society of Andrology and Sexual Medicine (SIAMS) : Endorsing Organization: Italian Society of Embryology, Reproduction, and Research (SIERR)

PURPOSE

Infertility affects 15-20% of couples and male factors are present in about half of the cases. For many aspects related to the diagnostic and therapeutic approach of male factor infertility, there is no general consensus, and the clinical approach is not uniform.

METHODS

In the present document by the Italian Society of Andrology and Sexual Medicine (SIAMS), endorsed by the Italian Society of Embryology, Reproduction, and Research (SIERR), we propose evidence-based recommendations for the diagnosis, treatment, and management of male factor infertility to improve patient and couple care.

RESULTS

Components of the initial evaluation should include at minimum medical history, physical examination, and semen analysis. Semen microbiological examination, endocrine assessment, and imaging are suggested in most men and recommended when specific risk factors for infertility exist or first-step analyses showed abnormalities. Full examination including genetic tests, testicular cytology/histology, or additional tests on sperm is clinically oriented and based on the results of previous investigations. For treatment purposes, the identification of the specific cause and the pathogenetic mechanism is advisable. At least, distinguishing pre-testicular, testicular, and post-testicular forms is essential. Treatment should be couple-oriented, including lifestyle modifications, etiologic therapies, empirical treatments, and ART on the basis of best evidence and with a gradual approach.

CONCLUSION

These Guidelines are based on two principal aspects: they are couple-oriented and place high value in assessing, preventing, and treating risk factors for infertility. These Guidelines also highlighted that male infertility and in particular testicular function might be a mirror of general health of a man.

Penile Vibratory Stimulation for Semen Retrieval in Men with Spinal Cord Injury: Patient Perspectives

Spinal cord injury (SCI) is a catastrophic event with sequelae that are not often apparent. For the spinal cord injured man, the inability to become a biologic father because of reproductive dysfunction becomes a major negative factor in his self-esteem and a hindrance to his social rehabilitation. Approximately, 90% of men with SCI develop ejaculatory dysfunction and only 10% can ejaculate by masturbation or during sexual activity. It is only over the last 40 years that it has been possible to properly study and understand the various factors contributing to the problem. Advances have been made in governmental and societal attitudes that have led to improvements in the treatment and rehabilitation of persons with SCI and other disabilities. It is now possible to retrieve sperm reliably and safely from men with SCI. Although their semen quality is often impaired, there is a very reasonable chance for achieving biologic fatherhood using assisted reproductive techniques. Penile vibratory stimulation (PVS) is a safe, reliable, efficient, and cost-effective, method of sperm retrieval that will produce an ejaculate in up to 86% of the patients with a level of injury T10 or rostral, which accounts for approximately 80% of the SCI population. Some motile sperm will be present in 90% of these ejaculates. In approximately 75% of the ejaculates, there will be greater than 5 million motile sperm, allowing a couple to explore all the options available to a couple seeking help in conceiving a child. The Male Fertility Program of the Miami Project to Cure Paralysis is at the leading edge of basic and clinical research contributing to the management of infertility in men with SCI. This review will outline “how we got there” enabling us to recommend PVS as the first choice in assisting men with SCI to become biologic parents.

Clinical Predictors of Vibrator-Assisted Ejaculation following Spinal Cord Injury: A Prospective Observational Study

Introduction  Infertility in men with spinal cord injury (SCI) occurs due to combination of factors like erectile dysfunction, ejaculatory failure, and semen abnormalities. Penile vibratory stimulation (PVS) is a known method of treatment for anejaculation. Predicting successful outcome of PVS depends on several clinical factors, which assess the intactness of the neural arc pertaining to the spinal ejaculation pattern generator. This study reports the clinical predictors for successful candidacy for a PVS trial in males with SCI. Methods  Twenty-three males with SCI, satisfying the inclusion criteria, were recruited in this prospective observational study. Participants underwent two trials of PVS with single high-amplitude vibrator. The clinical predictors recorded were neurological level, superficial abdominal reflex, cremasteric reflex, bulbocavernosus reflex, plantar reflex, ankle jerk, knee jerk, lower abdominal sensation, and hip flexor response. In addition, somatic responses during PVS were recorded and corelated. Participants who had successful ejaculation were "responders" and the others were termed as "nonresponders." Binary logistic regression analysis of the clinical parameters was done to compare responders against nonresponders. Results  Of the twenty-three males (mean age 33.2 ± 6.8 years) with paraplegia, all four persons with neurological level above T9 had successful ejaculation with PVS. Among all the clinical parameters in the study, presence of somatic responses showed statistical significance in predicting successful ejaculation ( p -value = 0.02). Conclusion  This study reports that in men with SCI, along with the level of injury, somatic responses and other clinical reflexes, should be considered concurrently to predict the outcome of vibrator assisted ejaculation.

From disability to fatherhood: Journey of serving soldiers with spinal cord injury

Background

Apart from neurological consequences, most distressing sequels of spinal cord injury (SCI) in men are erectile dysfunction, ejaculatory dysfunction and abnormal semen quality. Of these, ejaculatory dysfunction and poor semen parameters pose the biggest challenge to their biological fatherhood. Penile vibratory stimulation (PVS) and electroejaculation are first-line modalities for anejaculation, and surgical sperm retrieval (SSR) is adopted when other treatments fail. Sperms obtained using these techniques can be used for various fertility treatments for couples with spinal cord injured men. The aim of the study was to study the effectiveness of various modalities of sperm retrieval for assisted reproductive treatment in men with SCI.

Methods

It was a prospective observational study, wherein partners of 12 men with SCI presenting for subfertility underwent assisted reproduction after retrieving sperms via various modalities. The primary outcome was to assess efficacy of PVS in obtaining sperms and of SSR if PVS failed. The secondary outcome was to assess the pregnancy rate in their partners.

Results

PVS was successful in obtaining ejaculate in 7 of 12 men, and SSR was fruitful in 4 of 5 men. In vitro fertilization cycle for men who underwent PVS resulted in a pregnancy rate of 57.14% and 75% in couples for men who underwent SSR with an overall pregnancy rate of 58.33%.

Conclusion

With new cases of SCI occurring primarily in young men at the peak of their reproductive health, it is imperative that medical professionals involved with reproductive health should be aware of the various modalities to help them achieve biological paternity.

Spinal Cord Injury Causes Reduction of Galanin and Gastrin Releasing Peptide mRNA Expression in the Spinal Ejaculation Generator of Male Rats

Spinal cord injury (SCI) in men is commonly associated with sexual dysfunction, including anejaculation, and chronic mid-thoracic contusion injury in male rats also impairs ejaculatory reflexes. Ejaculation is controlled by a spinal ejaculation generator consisting of a population of lumbar spinothalamic (LSt) neurons that control ejaculation through release of four neuropeptides including galanin and gastrin releasing peptide (GRP) onto lumbar and sacral autonomic and motor nuclei. It was recently demonstrated that spinal contusion injury in male rats caused reduction of GRP-immunoreactivity, but not galanin-immunoreactivity in LSt cells, indicative of reduced GRP peptide levels, but inconclusive results for galanin. The current study further tests the hypothesis that contusion injury causes a disruption of GRP and galanin mRNA in LSt cells. Male rats received mid-thoracic contusion injury and galanin and GRP mRNA were visualized 8 weeks later in the lumbar spinal cord using fluorescent in situ hybridization. Spinal cord injury significantly reduced GRP and galanin mRNA in LSt cells. Galanin expression was higher in LSt cells compared to GRP. However, expression of the two transcripts were positively correlated in LSt cells in both sham and SCI animals, suggesting that expression for the two neuropeptides may be co-regulated. Immunofluorescent visualization of galanin and GRP peptides demonstrated a significant reduction in GRP-immunoreactivity, but not galanin in LSt cells, confirming the previous observations. In conclusion, SCI reduced GRP and galanin expression in LSt cells with an apparent greater impact on GRP peptide levels. GRP and galanin are both essential for triggering ejaculation and thus such reduction may contribute to ejaculatory dysfunction following SCI in rats.

A Primary Care Provider's Guide to Sexual Health for Individuals With Spinal Cord Injury

The collaboration with individuals regarding their sexual health is an important component of patient-centered health care. However, talking about sexual health in primary care settings is an area not fully addressed as a result of time limitations, medical task prioritization, awareness or knowledge deficit, and discomfort with the topic of sexuality. A critical shift in professional focus from disease and medical illness to the promotion of health and wellness is a prerequisite to address sexual health in the primary care setting. This article provides guidance for practitioners in primary care settings who are caring for persons with spinal cord injury. Clinicians should seize the opportunity during the encounter to reframe the experience of disability as a social construct status, moving away from the narrow view of medical condition and "find it, fix it" to a broader understanding that provides increased access to care for sexual health and sexual pleasure.

How to treat neurogenic bladder and sexual dysfunction after spinal cord lesion

Neurogenic bladder and sexual dysfunction after spinal cord lesions are highly prevalent. The treatment algorithm for neurogenic bladder is well described. Clean intermittent self-catheterisation associated with treatment of neurogenic detrusor overactivity is the gold standard. Goals of treatment are twofold: i) control risk factors to avoid upper urinary tract complications, and ii) improve quality of life by treating incontinence when feasible. Lower urinary tract dysfunction is still a major cause of complications and hospitalisation. Sexual dysfunction must be addressed and treated and is at the top of patient expectations one year after injury.

Topical Systematic and Synthetic Literature Review Regarding Men Sexual Dysfunctions after Spinal Cord Injury

Introduction Spinal cord injury (SCI) is a life-altering event usually associated with loss of motor and sensory, as well as with bladder, bowel and sexual, functions impairment. Recovering sexual function is one of the most important function tightly coupled with the life quality. In this respect, in the related literature can be found data regarding mainly: diagnosis/evaluation issues therapeutic/assistive-rehabilitative interventions (including connected to fertility troubles) and of psychological and or educational specific counseling, kind. Materials and methods.This paper presents a current systematic (of Preferred Reporting Items for Systematic Reviews and Meta-Analyses – PRISMA – type) and synthetic literature review on sexual dysfunctions and respected available management options in male subjects with SCI, using the following search keywords/ combinations of key words: “men”, “sexual dysfunction”/ “fertility” / “erectile dysfunction”/ “ejaculatory problems” / “sexual disorder“, “spinal cord injury”, “paraplegia”/ ”tetraplegia” /“paraplegic”/ ”tetraplegic”, “management”/ “treatment”, by interrogating international renown data bases: NCBI/PubMed, NCBI/PMC, Elsevier, PEDro and respectively, ISI Web of Knowledge/Science – to check whether the selected articles are published in ISI indexed journals – considering publications from January 2009 to June 2019, written in English, open access articles and being “fair”/“high” quality on our PEDro inspired, customized quality classification of the selected papers – the basic criterion, being the weighted citations number per year. Results. We have found initially 647 articles and eventually, after accomplishing the PRISMA stages (without meta-analysis), we have selected 16 articles matching all the above mentioned quest method’s requests (see further the figure representing our PRISMA type completed flow-diagram), covering (together with knowledge acquired from extra bibliographic resources, too). Conclusions. Sexual disfunctions after SCI are complex and strongly add to the severe and multimodal disability the affected people – in the case of our work: men – experience. Therefore, they worth being fathomed and periodically reappraised. Keywords: Spinal Cord injury (SCI), men sexual dysfunctions, systematic literature review, rehabilitation,

Evaluation of a re-engineered device for penile vibratory stimulation in men with spinal cord injury

STUDY DESIGN

Cohort study OBJECTIVES: The purpose of this study was to evaluate the performance of a re-engineered device (Ferticare 2.0), which is replacing the previous standard (Ferticare 1.0) for penile vibratory stimulation in men with spinal cord injury. Most men with spinal cord injury are anejaculatory, requiring medical assistance to obtain their semen. Penile vibratory stimulation is generally recognized as the standard of care for semen retrieval in these anejaculatory men.

SETTING

Major Research University in Miami, Florida, USA.

METHODS

The Ferticare 2.0 device was applied to 15 men with spinal cord injury in a three-step protocol simulating normal use. Step 1: one device (2.5 mm amplitude, 100 Hz) was applied to the glans penis for 2 min. Step 2: If no ejaculation occurred, the amplitude was increased to 4.0 mm (100 Hz) and the device similarly applied. Step 3: If no ejaculation occurred, two devices, each 2.5 mm and 100 Hz were applied to the dorsum and frenulum of the glans penis. Participants at risk for autonomic dysreflexia were pretreated with sublingual nifedipine (20 mg), 15 min prior to stimulation. Blood pressure and other symptoms of autonomic dysreflexia were monitored. Participants answered a questionnaire about their experience with the device.

RESULTS

Thirteen of 15 participants ejaculated with the device. No adverse events occurred. All participants commented they would recommend the device to other men with spinal cord injury.

CONCLUSIONS

A re-engineered device, the Ferticare 2.0, is safe and effective for inducing ejaculation in men with spinal cord injury.

Severing the ventral funiculus in chronic spinal cord injury has the most deteriorating effect on spermatogenesis in rats

Sexual dysfunction, following spinal cord injury (SCI), is highly dependent on the extent of injury. SCI disrupts the supraspinal innervation of the reproductive organs; resulting in structural and functional deficits. Relating the extent of SCI to these changes could eventually improve diagnoses and treatment planning of sexual dysfunction following SCI. In the present study, following chronic SCI of different severities (1/3 dorsal SCI (1/3 SCI), 2/3 dorsal SCI (2/3 SCI), and complete transection (Tx)) at T8 spinal level, histological changes of seminiferous tubules parameters in testis were examined. The diameter of seminiferous tubules (DST) and epithelial height of seminiferous tubules (HST) were significantly decreased in all SCI groups compared to control and sham. In addition, DST in 2/3 SCI and Tx groups and HST in Tx group were significantly decreased in comparison with 1/3 SCI animals. Nonetheless, the diameter of seminiferous tubules' lumen decreased significantly in 2/3 SCI and Tx compared to control, sham, and 1/3 SCI groups. Concerning cellular component, the number of spermatocytes and spermatids layers significantly decreased in both 1/3 and 2/3 SCI in comparison to normal. However, Tx had the most prominent deteriorating effect on these layers; indicating impairment in the process of spermatogenesis. These results show that the spinal tracts are part of the neural circuitries innervating the testis and responsible for their structural support. These tracts are mainly distributed between the lateral and ventral funiculi at T8 spinal level. Consequently, sparing ventral funiculi in the SCI prevents the severe decline in spermatogenesis.

Semen collection by trans-rectal digital stimulation and insemination campaign in goat

The overall purpose of this study was to describe a method of semen collection via trans-rectal digital massage (TDM) and to carry out a related fertility trial in Angora goat. Sixteen Angora bucks (ranging 1-4 years) and 28 nulliparous does (1-2 years) were used in this study. Semen samples were collected via trans-rectal massage from 85.71% of the bucks in multiple attempts (18/21). The mean values of volume, pH, mass motility, total motility, concentration, viability, abnormal spermatozoa rate and ejaculation time were 0.64 ± 0.09 ml, 6.3 ± 0.21, 2.7 ± 0.34, 58.18 ± 5.1%, 3.68 ± 0.31 × 10⁹ /ml, 71.38 ± 7.12%, 18.22 ± 2.48% and 3.4 ± 0.33 min respectively. Oestrus was detected with teaser buck and confirmed by using infrared thermography and ultrasonography (US). The success rate of synchronisation was found as 71.4% (20/28). On Day 21, pregnancy diagnosis was performed trans-rectally with US and the pregnancy rate was determined as 78.57% (11/14). TDM method of semen collection seems to be easily applicable to the buck and it could be a good alternative to collect semen as well as its use in artificial insemination campaign. Thermal monitoring is found to be a valuable tool to monitor the response to hormonal driven ovulatory synchronisation in Angora does during timed artificial insemination.

Telemetric monitoring of penile pressure during mating in rats after chronic spinal cord injury

In men with a spinal cord injury (SCI), erectile function, ejaculation, and fertility are severely impaired. The present study utilized a telemetric pressure transducer implanted into the corpus cavernosum of the penis to examine sexual function during awake mating behavior in a rat contusion model with a range of Infinite Horizon Impactor forces distributed between 150 and 215 kdyn. The mating behavior paradigm included examination of the counts, average pressure, and average duration for mounts, intromissions, and ejaculations. Male Wistar rats were mated with receptive females in 30-min sessions preinjury (sexual acclimation) and once per week for 6 wk beginning after a 2-wk recovery period post-SCI. All SCI animals had significant deficits in sexual function in the parameters measured. These deficiencies were more prevalent in a subset having less than 20% white matter sparing, likely a reflection of the extent of bilateral spino-bulbo-spinal sexual circuitry disruption at the lesion epicenter. The resulting discoordination of the autonomic and somatic reflex control of erection and ejaculation recorded using telemetry devices in an awake, behaving animal model provides an effective means of gauging sexual function deficits after SCI and could have utility for quantifying recovery after a therapeutic intervention.

Chronic Spinal Cord Injury Reduces Gastrin-Releasing Peptide in the Spinal Ejaculation Generator in Male Rats

Spinal cord injury (SCI) causes sexual dysfunction, including anejaculation in men. Likewise, chronic mid-thoracic contusion injury impairs ejaculatory reflexes in male rats. Ejaculation is controlled by a spinal ejaculation generator (SEG) comprised of a population of lumbar spinothalamic (LSt) neurons. LSt neurons co-express four neuropeptides, including gastrin-releasing peptide (GRP) and galanin and control ejaculation via release of these peptides in lumbar and sacral autonomic and motor nuclei. Here, we tested the hypothesis that contusion injury causes a disruption of the neuropeptides that are expressed in LSt cell bodies and axon terminals, thereby causing ejaculatory dysfunction. Male Sprague Dawley rats received contusion or sham surgery at spinal levels T6-7. Five to six weeks later, animals were perfused and spinal cords were immunoprocessed for galanin and GRP. Results showed that numbers of cells immunoreactive for galanin were not altered by SCI, suggesting that LSt cells are not ablated by SCI. In contrast, GRP immunoreactivity was decreased in LSt cells following SCI, evidenced by fewer GRP and galanin/GRP dual labeled cells. However, SCI did not affect efferent connections of LSt, cells as axon terminals containing galanin or GRP in contact with autonomic cells were not reduced following SCI. Finally, no changes in testosterone plasma levels or androgen receptor expression were noted after SCI. In conclusion, chronic contusion injury decreased immunoreactivity for GRP in LSt cell soma, but did not affect LSt neurons per se or LSt connections within the SEG. Since GRP is essential for triggering ejaculation, such loss may contribute to ejaculatory dysfunction following SCI.

Activity-Based Training Alters Penile Reflex Responses in a Rat Model of Spinal Cord Injury

INTRODUCTION

Multisystem functional gains have been reported in males with spinal cord injury (SCI) after undergoing activity-based training (ABT), including increases in scoring of sexual function and reports of improved erectile function.

AIM

This study aims to examine the effect of daily 60-minute locomotor training and exercise in general on sexual function in a rat SCI contusion model.

METHODS

Male Wistar rats received a T9 contusion SCI. Animals were randomized into 4 groups: a quadrupedal stepping group (SCI + QT), a forelimb-only exercise group (SCI + FT), a non-trained harnessed group (SCI + NT), and a home cage non-trained group (SCI + HC). The 2 non-trained groups were combined (SCI) post hoc. Daily training sessions were 60 minutes in duration for 8 weeks. Urine samples were collected during bi-weekly 24-hour metabolic cage behavioral testing. Latency, numbers of penile dorsiflexion, and glans cupping were recorded during bi-weekly penile dorsiflexion reflex (PDFR) testing. Terminal electromyography (EMG) recordings of the bulbospongiosus muscle (BSM) were recorded in response to stimulation of the dorsal nerve of the penis (DNP).

OUTCOMES

ABT after SCI had a significant effect on PDFR, as well as BSM EMG latency and burst duration.

RESULTS

SCI causes a significant decrease in the latency to onset of PDFR. After 8 weeks of ABT, SCI + QT animals had a significantly increased latency relative to the post-SCI baseline. BSM EMG response to DNP stimulation had a significantly decreased latency and increase in average and maximum amplitude in SCI + QT animals. SCI animals had a significantly longer burst duration than trained animals. Time between PDFR events, penile dorsiflexion, glans cupping, and urine testosterone were not affected by ABT.

CLINICAL IMPLICATIONS

ABT has a positive influence on sexual function and provides a potential therapy to enhance the efficacy of current sexual dysfunction therapies in the male SCI population.

STRENGTHS AND LIMITATIONS

Several significant small improvements in sexual function were found in a clinically relevant rat model of SCI using a readily available rehabilitative therapy. The limited findings could reflect insensitivity of the PDFR as a measure of erectile function.

CONCLUSIONS

These results indicate that task-specific stepping and/or loading provide sensory input to the spinal cord impacting the neural circuitry responsible for sexual function. Steadman CJ, Hoey RF, Montgomery LR, et al. Activity-Based Training Alters Penile Reflex Responses in a Rat Model of Spinal Cord Injury. J Sex Med 2019; 16:1143-1154.

Neural Control and Physiology of Sexual Function: Effect of Spinal Cord Injury

Objective: To present the current understanding of normal anatomy, physiology, sexual physiology, pathophysiology and the consequential sexual changes and dysfunctions following a spinal cord injury (SCI). Methods: Narrative review of the latest literature. Results: Peripheral innervations of the pelvis involve 3 sets of efferent neurons coordinated though the pelvic plexus (somatic, thoracolumbar sympathetic, and sacral parasympathetic), and these are under cerebral descending excitatory and inhibitory control. SCI, depending on the level of lesion and completeness, can alter this cerebral control, affecting the psychological and reflexogenic potential for genital arousal and also ejaculation and orgasm. During arousal, nitric oxide is the main neurotransmitter for smooth muscle relaxation in both male and female erectile tissue. In men, erection, ejaculation, and orgasm are under separate neurological control and can be individually affected by SCI. Conclusions: Since sexual function is rated amongst the highest priorities by individuals living with SCI, methods employed to affect the neurological changes to maximize sexual neurophysiology prior to initiating medical therapies including paying attention to sexual sensate areas and visceral signals with mindfulness techniques, practicing body mapping, and sexual stimulation of sensate areas to encourage neuroplasticity. Attention should be paid to the biopsychosocial sexual contexts within which persons with SCI live to maximize their sexual and fertility rehabilitation.

A Multidisciplinary Approach to Sexual and Fertility Rehabilitation: The Sexual Rehabilitation Framework

Many studies have identified improvement in sexual function as a priority for persons with spinal cord injury (SCI). Due to the various secondary sensory, motor, and autonomic consequences following SCI and due to the complexity of sexuality per se, this area can be overwhelming to many health care professionals. The literature indicate that sexual and fertility rehabilitation must be addressed in a biopsychosocial manner and include various disciplines. The multidisciplinary utilization of a Sexual Rehabilitation Framework (SRF) allows the medical and/or psychosocial factors that impede or improve sexual and reproductive function to be examined. The SRF is a user-friendly and simplified way to proactively address the major biopsychosocial areas of sexuality and to create a plan of action for the person with SCI. It is an adjunct tool to the full sexual history, and it encourages all disciplines involved in SCI rehabilitation to address the issue of sexual function in the same manner as they would other activities of daily living. Eight areas are included in the SRF: sexual drive/interest, sexual functioning, fertility and contraception, factors associated with the condition, motor and sensory influences, bladder and bowel influences, sexual self-view and self-esteem, and partnership issues. The use of the SRF is encouraged in both inpatient and outpatient settings. Multidisciplinary or interdisciplinary team work is encouraged in sexual and fertility rehabilitation to move clinicians toward providing proactive and comprehensive care for individuals with SCI or other chronic disabilities.

Oral probenecid improves sperm motility in men with spinal cord injury

STUDY DESIGN

Prospective cohort study (twenty men with spinal cord injury [SCI]).

OBJECTIVE

Determine if administration of oral probenecid results in improved sperm motility in men with SCI.

SETTING

Major university medical center.

METHODS

Twenty men with SCI were administered probenecid for 4 weeks (250 mg twice a day for 1 week, followed by 500 mg twice a day for 3 weeks). Semen quality was assessed at three time points: pre-treatment, post-treatment (immediately after the 4-week treatment), and follow-up (4 weeks after the last pill was ingested).

RESULT(S)

Probenecid was well-tolerated by all subjects. Sperm motility improved in each subject after 4 weeks of oral probenecid. The mean percent of sperm with progressive motility increased from 19% to 26% (P < 0.05). A more striking increase was seen in the mean percent of sperm with rapid linear motility, from 5% to 17%, (P <0.001). This improvement continued into the four week follow up period. Similar improvements were seen in the total motile sperm count (15 million, 28 million, and 27 million at pre-treatment, post-treatment, and follow-up, respectively). Sperm concentration was not significantly different at pre-treatment, post-treatment, and follow-up, (52 million, 53 million and 53 million, respectively).

CONCLUSION

This study showed that administration of an oral agent (probenecid) known to interfere with the pannexin-1 cellular membrane channel, can improve sperm motility in men with spinal cord injury. It is the first study to report improved sperm motility after oral medication in men with SCI.

Fertility and sexuality in the spinal cord injury patient

BACKGROUND

After a spinal cord injury, patients have different perceptions of sexuality, sexual function, and potential for fertility. These changes can greatly impact quality of life over a lifetime.

PURPOSE

The purpose of this workgroup was to identify common evidence based or expert opinion themes and recommendations regarding treatment of sexuality, sexual function and fertility in the spinal cord injury population.

METHODS

As part of the SIU-ICUD joint consultation of Urologic Management of the Spinal Cord Injury (SCI), a workgroup and comprehensive literature search of English language manuscripts regarding fertility and sexuality in the spinal cord injury patient were formed. Articles were compiled, and recommendations in the chapter are based on group discussion and follow the Oxford Centre for Evidence-based Medicine system for levels of evidence (LOEs) and grades of recommendation (GORs).

RESULTS

Genital arousal, ejaculation, and orgasm are significantly impacted after spinal cord injury in both male and female SCI patients. This may have a more significant impact on potential for fertility in male spinal cord injury patients, particularly regarding ability of generate erection, semen quantity and quality. Female patients should be consulted that pregnancy is still possible after injury and a woman should expect resumption of normal reproductive function. As a result, sexual health teaching should be continued in women despite injury. Pregnancy in a SCI may cause complications such as autonomic dysreflexia, so this group should be carefully followed during pregnancy.

CONCLUSIONS

By understanding physiologic changes after injury, patients and care teams can work together to achieve goals and maximize sexual quality of life after the injury.

Sexual concerns after Spinal Cord Injury: An update on management

BACKGROUND

Spinal Cord Injury (SCI) causes neurological impairment with resultant neurogenic sexual dysfunction which can compound preexisting psychological and medical sexual concerns. Understanding these concerns is important in managing the lifelong needs of persons with SCIs.

OBJECTIVES

To provide an overview of the impact of SCI on sexuality along with a framework for treatment of sexual concerns. To briefly review male infertility and its treatments and pregnancy in females after SCI.

METHODS

Interdisciplinary literature review and synthesis of information.

RESULTS

The average age at SCI is increased, thus persons with SCIs may have preexisting sexual concerns. Sexual activity and satisfaction are decreased after SCI. Psychogenic sexual arousal is related to remaining sensation in the T11-L2 dermatomes. Orgasm occurs in approximately 50% of persons with SCIs with all injuries except subjects with complete lower motor neuron (LMN) injuries affecting the lowest sacral segments A structured approach to treatment including assessing preinjury function, determining the impact of injury, education, assessing and treating iatrogenic sexual dysfunction and treatment of concomitant problems is recommended. Basic and advanced methods to improve sexual arousal and orgasm are discussed and treatment of anejaculation and issues associated with pregnancy and SCI are reviewed.

CONCLUSIONS

Sexual satisfaction is impaired after SCI; however, education and new therapies can improve responsiveness. Future research is warranted to improve sexual function and fertility potential in persons with SCIs.

Improvement of Sexual and Reproductive Function in Men with Spinal Cord Lesion

SUMMARY – The aim of the review is to establish sexual and reproductive functions in men with spinal cord lesion (SCL). Many sexual and reproductive dysfunctions may be found in these patients including individual’s low self-esteem, delay of orgasm, erectile or ejaculatory disorder and abnormalities of semen, which are characterized by lower sperm motility or viability. Owing to improvements in physical medicine and rehabilitation, the focus has been shifted from keeping patients alive towards ensuring the quality of life and improvements of sexual dysfunctions and later reproduction. Erectile dysfunction can be treated by using phosphodiesterase-5 inhibitors, intracavernosal injections, vacuum devices and penile prostheses. Semen can be retrieved from anejaculatory patients by medically assisted methods utilizing penile vibratory stimulation, electroejaculation, prostate massage, or surgically. Although there is low chance for pregnancy in natural way in most of SCL patients, fatherhood is possible through the introduction of assisted medical management. By use of various medical, technical and surgical procedures for sperm retrieval combined with assisted reproductive methods, high pregnancy rates have been reported comparable to those in able-bodied subfertile patients. Nevertheless, future studies are needed to improve semen quality and methods of assisted ejaculation in patients with SCL.

Evaluation of sexual and fertility dysfunction in spinal cord-injured men in Jamaica

INTRODUCTION

Sexual dysfunction and infertility are common in males with traumatic spinal cord injuries (SCIs). The objective of this study was to determine the prevalence of sexual dysfunction and infertility in males with traumatic SCI managed in Jamaica, as well as the therapeutic options offered.

CASE PRESENTATION

A cross-sectional study including males with traumatic SCI managed at the Sir John Golding Rehabilitation Centre, Kingston, Jamaica was carried out between 1 January and 31 December 2015. Sexual function was measured with the International Index of Erectile Function Questionnaire, and further information on social history, fertility desires and treatment options offered were collected. Data were analyzed using Stata 12 for Windows (College Station, TX, USA). The mean age of patients at the time of study was 38.8±15.3 years (range 19-71) with a mean duration of injury of 3.7±2.4 years (range 1.3-15.6). Of 45 patients with traumatic SCI surveyed, 90.7% had erectile dysfunction, with 62.8% being classified as severe and 73.3% of men were unable to ejaculate. Treatment for erectile and ejaculatory dysfunction was offered in only two patients, respectively. Most (71.1%) patients indicated that they wanted to have children in the future, however, no one had been referred for assisted reproductive techniques.

DISCUSSION

Men with traumatic SCI have high rates of severe erectile and ejaculatory dysfunctions, but have preserved interests in maintaining fertility. Adherence to guidelines for sexual education for men with traumatic SCI in Jamaica and the Caribbean is needed.

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.

Sexual dysfunction in medical practice

PURPOSE OF REVIEW

Sexual dysfunction is associated with many medical disorders. Lack of recognition of sexual dysfunction commonly occurs in medical practice. The impact of unrecognized sexual dysfunction affects quality of life, which in turn affects the recovery from medical illness. This article reviews the recent literature regarding sexual dysfunction in medical practice published in PubMed, Clinical key, Scopus, Google scholar from November 2014 to May 2016.

RECENT FINDINGS

New findings suggest that sexual dysfunction is associated with most of the disorders affecting various systems. Sexual dysfunction associated with medical disorders, apart from having effects on patients, also has impact on spouses. Sexual dysfunction may also be a predictor of future major adverse event. Prevelance of sexual dysfunction in various major illness is in the range of 20-75%. Phosphodiesterase-5 inhibitors which are first line drugs to treat erectile dysfunction cause no increase in myocardial infarction or death.

SUMMARY

Sexual functioning is impaired in neurological, endocrinal, cardiovascular, pelvic, dermatological, and other disorders. Stroke, epilepsy, traumatic brain injury, and other neurological disorders cause significant impairment in sexual functioning. Though exact correlation between androgen and sexual functioning cannot be made, androgen plays important role various phases of sexual cycle in both men and women. Diabetes has impact on all the phases of sexual cycle. Hypertension, as well as certain drugs used to treat hypertension also causes sexual dysfunction, judicious use of hypotensive drugs is recommended.