Assisted reproduction technology in men with ejaculatory dysfunction with special reference to spinal cord injury

Abstract

Background: Men afflicted by spinal cord injury (SCI), myelomeningocele (MMC) and testicular cancer (TC) with retroperitoneal lymph-node dissection (RPLND) share the problem of infertility due mainly, but not exclusively, to neurologic impairment. This problem has historically been neglected, partly due to lack of effective treatment, partly due to lack of appreciation of the importance of sexual and procreational issues for rehabilitation outcomes and quality of life. With the recent significant development of assisted reproduction technology (ART), investigation of the effectiveness of such methods when applied to these patients is of highest relevance in a holistic rehabilitative context.

Aims: To evaluate the effectiveness of ART in infertile men with SCI, with particular reference to intracytoplasmic sperm injection (ICSI), and to compare it with previously published results using simpler methods. To evaluate the use of in vitro fertilization (IVF) and ICSI in men with an ejaculatory infertility after TC/RPLND. To investigate if spermatogenesis in men with MMC is sufficient for ART. To evaluate the anaesthesiological management of electroejaculation (EEJ) in patients at risk for autonomic dysreflexia (AD).

Patients and methods: Twenty-five couples with a SCI man underwent 53 ovum retrievals and 47 embryo transfers. Additionally, four frozen embryo replacements were carried out. (Papers I and III) Ten couples with a TC/RPLND man, with long-standing infertility due to anejaculation or retrograde ejaculation underwent EEJ under general anaesthesia (GA). The anterograde fraction was prepared and used for IVF. Additionally, one frozen embryo replacement was carried out. (Paper II) In nine men with MMC, retrieval of sperm was attempted by unassisted ejaculation, penile vibratory stimulation (PVS), EEJ in GA and/or testicular biopsy. (Paper IV) Thirty an ejaculatory SCI men and 15 men with anejaculation due to TC/RPLND underwent 87 EEJ procedures in GA with assisted mask ventilation in a day surgery setting. (Paper V)

Results: Sixteen clinical pregnancies were established in the couples with a SCI man, leading to 12 deliveries (10 singletons and 2 duplex). Ten of the pregnancies were established after conventional IVF and six after ICSI. Spermatozoa were recovered in nine of ten TC/RPLND men. Sperm quality was variable and conventional IVF was considered impossible in three cases. Altogether six IVF treatment cycles in six couples resulted in five pregnancies, of which four resulted in a delivery and one resulted in a spontaneous abortion. One additional pregnancy was achieved after transfer of cryopreserved embryos. The fertilization rate (FR) was 54% (33/61) and the cleavage rate was 97% (32/33). No complications relating to the procedure was encountered.

Two MMC men were able to achieve unassisted ejaculation. PVS was unsuccessful in the remaining seven subjects. In five subjects, EEJ yielded enough sperm to make ICSI possible. In one case, testicular biopsy revealed spermatogenesis. Thus, in six of nine MMC men, fatherhood seemed possible. All 87 EEJ procedures gave ejaculation of semen. Six episodes of hypertension occurred, all in subjects with SCI and a lesion at T6 or rostral. These episodes were successfully treated with calcium blockers. No adverse events occurred in the SCI group.

Conclusions: A cumulative delivery rate of about 50% can be expected with assisted ejaculation and IVF/ICSI in couples with a SCI man where home insemination has been unsuccessful. IVF/ICSI is the method of choice if home insemination fails, if EEJ in GA is required, if semen quality is poor, or if there are concurrent female infertility factors. A high cumulative delivery rate can also be expected from EEJ and IVF/ICSI in an ejaculatory men after TC/RPLND. Since semen retrieval in most instances requires EEJ in GA, IVF/lCSI is the method of choice. A sizeable proportion of men with MMC seems to have enough sperm for ICSI. The risk of severe hypertension and other complications from EEJ of SCI men in GA with assisted mask ventilation in a day surgery setting seems small, provided anaesthesia is managed by experienced staff. Our conclusion is that the safety of this procedure justifies its application in infertility treatment.