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

Medial preoptic connections with the midbrain tegmentum are essential for male sexual behavior

The medial preoptic area appears to play a major role in the control of sexual behavior. Efferents from the medial preoptic area course through the medial forebrain bundle to pass through and/or terminate in the dorsolateral and ventral tegmentum of the midbrain. Bilateral lesions of the dorsolateral tegmentum eliminate mating behavior in male rats, reproducing the effect of bilateral medial preoptic lesions. Sexual behavior is also eliminated when a preoptic lesion on one side of the brain is combined with a lesion of the dorsolateral tegmentum on the other side of the brain. In other words, asymmetric brain damage which bilaterally destroys the preoptic connections with the dorsolateral tegmentum eliminates male sexual behavior, and we conclude that the connections between these two regions are essential for copulation

Alterations in activities of cyclic nucleotide systems and in β-adrenergic receptor-mediated activation of cyclic amp-dependent protein kinase during progression and regression of isoproterenol-induced cardiac hypertrophy

Initial and transient increases in the basal levels of cyclic GMP in the heart were noted prior to cardiac hypertrophy in rats administered isoprotenol. Increased levels of cyclic AMP-phosphodiesterase (in both the soluble and particulate fractions) and stimulatory modulator of cyclic GMP-dependent protein kinase, however, were associated with the progression, or the state, of cardiomegaly, with their levels returning to the control values upon regression of the hypertrophy. The levels of cyclic GMP phosphodiesterase in the soluble fraction were lower, whereas those in the particulate fraction were higher, in the hypertrophied heart than the control. In cardiac hypertrophy, the maximal activity ratio (−cyclic AMP/+cyclic AMP) of cyclic AMP-dependent protein kinase in the incubated minced heart caused by isoproterenol was lower, whereas the concentration of isoproterenol required to increase the activit ratio half-maximally was higher than controls; The reduced responsiveness to the drug, however, was reversed when the hypertrophy regressed. These observations, taken collectively, appear to suggest that the desensitization of the β-adrenergic mechanism seen in the cardiac hypertrophy produced by repeated administration of isoproterenol is associated with adaptive modifications in certain parameters of the cyclic nucleotide systems

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

Penile Vibratory Stimulation

Penile vibratory stimulation (PVS) is the application of a vibrator(s) to the penis in order to elicit a reflex ejaculation in men who are anejaculatory. Its main application in in the field of fertility management in men who have suffered a spinal cord injury (SCI) which results in neurogenic anejaculation. The method is described in detail. Sperm obtained via PVS may be used in various assisted conception methods or for at-home insemination in some cases. Pregnancy rates using this sperm are similar to those seen in non-injured men without SCI

Sperm Retrieval From the Bladder

In normal ejaculation, sperm exit the urethral meatus during orgasm (antegrade ejaculation), and very little, if any sperm enter the urinary bladder (retrograde ejaculation). Certain medical conditions, however, lead to retrograde ejaculation, and this condition may interfere with the man’s ability to initiate a pregnancy by sexual intercourse. If pregnancy is a goal, it may be necessary to retrieve sperm from the bladder for use in assisted conception procedures. This article will describe methods of retrieving sperm from the urinary bladder

Impact of Spinal Cord Injury

Although medical advances have greatly improved the prognosis for people who sustain spinal cord injury, it remains a major social and health-care problem. There are estimated 10,000–12,000 spinal cord injuries every year in the USA alone. More than a quarter of a million Americans are currently living with spinal cord injury, with many millions more worldwide. The cost of managing the care of patients with spinal cord injury is approximately $4 billion per year. The majority of spinal cord injury victims are young adults. Of them, more than 80% are men. As a result, young males constitute the largest part of this patient population. Reproductive function is essential for men with spinal cord injury, but unfortunately, less than 10% of them can father children without medical assistance. Infertility in male patients with spinal cord injury results from a combination of erectile dysfunction, ejaculatory dysfunction, and poor semen quality. As a result of advancements in assisted ejaculation techniques including electroejaculation and high-amplitude penile vibratory stimulation, semen can be safely obtained from nearly all men with spinal cord injury without resorting to surgical procedures; however, semen quality is poor in the majority of cases