Charles M. Lynne

Seminal reactive oxygen species and sperm motility and morphology in men with spinal cord injury

OBJECTIVE To assess the generation of reactive oxygen species and its relation to semen characteristics in men with spinal cord injury. DESIGN Cross-sectional study. SETTING Andrology laboratory at a tertiary care facility and research laboratory at a major medical center. PATIENT(S) Men with spinal cord injury and normal men. INTERVENTION(S) Collecting ejaculates from men with spinal cord injury by electroejaculation and vibratory stimulation and from normal men by masturbation. MAIN OUTCOME MEASURE(S) Measurement of reactive oxygen species before and after stimulation with 50 microM N-formyl-methionyl-leucylphenylalanine (FMLP) and 100 nM 12-myristate 13-acetate phorbol ester (PMA), white blood cell (WBC) concentration, sperm motility and morphology, and ejaculation method. RESULT(S) Compared with controls, levels of reactive oxygen species in men with spinal cord injury were significantly higher in unstimulated, f-MLP-stimulated, and PMA-stimulated specimens. The WBC concentration was significantly elevated in patients with spinal cord injury. Sperm motility in men with spinal cord injury was inversely related to the level of reactive oxygen species. The percentage of morphologically normal spermatozoa was significantly lower in men with spinal cord injury. Levels of seminal reactive oxygen species did not differ when comparing specimen type (antegrade versus retrograde) or method of ejaculation in men with spinal cord injury. CONCLUSION(S) Men with spinal cord injury had elevated levels of reactive oxygen species in their semen. Levels of reactive oxygen species were negatively correlated with sperm motility. Levels of reactive oxygen species were independent of the method of ejaculation or the type of specimen.

LOCAL ANESTHESIA FOR ULTRASOUND GUIDED PROSTATE BIOPSY: A PROSPECTIVE RANDOMIZED TRIAL COMPARING 2 METHODS

PURPOSE Since the introduction of prostate specific antigen (PSA) screening, asymptomatic men often undergo transrectal ultrasound guided prostate biopsy. This procedure may cause significant discomfort, which may limit the number of biopsies. We performed a randomized prospective study to compare periprostatic infiltration with 1% lidocaine with intrarectal instillation of 2% lidocaine gel before prostate biopsy. MATERIALS AND METHODS From October 1999 to July 2000, 150 men underwent prostate biopsy at the Miami Veterans Administration and Jackson Memorial Hospital. Experienced senior residents performed all biopsies. Patients were randomized into 2 groups depending on the method of anesthetic delivery. A visual analog scale was used to assess the pain score. Statistical analysis of pain scores was performed using the Student t test. RESULTS Ultrasound guided prostate biopsy was done in 150 cases. There was a statistical difference in the mean pain score after periprostatic infiltration and intrarectal instillation (2.4 versus 3.7, p = 0.00002) with patients receiving periprostatic infiltration reporting significantly less pain. CONCLUSIONS Men should have the opportunity to receive local anesthesia before ultrasound guided prostate biopsy with the goal of decreasing the discomfort associated with this procedure. Our prospective randomized study indicates that ultrasound guided periprostatic nerve block with 1% lidocaine provides anesthesia superior to the intrarectal placement of lidocaine gel.

AN ANALYSIS OF 653 TRIALS OF PENILE VIBRATORY STIMULATION IN MEN WITH SPINAL CORD INJURY

PURPOSE We evaluated ejaculatory response and semen quality in 653 trials of penile vibratory stimulation in 211 men with spinal cord injury, and compared results with low versus high amplitude vibratory stimulation. MATERIALS AND METHODS Low and/or high amplitude penile vibratory stimulation was performed 1 to 27 times in each patient, and antegrade and retrograde specimens of those who ejaculated were analyzed. RESULTS Significantly more patients ejaculated using high (54.5%) versus low (39.9%) amplitude stimulation. Using either amplitude the ejaculatory success rate was highest in men with injuries at C3 to C7, followed by T1 to T5, T6 to T10 and T11 to L3. While high amplitude stimulation increased the ejaculatory success rate in each group, the highest rate occurred in men with injuries at C3 to C7 (65.6%). Ejaculation was reliable, since most men who ejaculated did so during 100% of the trials and within 2 minutes of stimulation onset. Symptoms of autonomic dysreflexia were safely managed with nifedipine. All patients who ejaculated produced antegrade specimens. With the exception of ejaculate volume, which was significantly higher with high versus low amplitude stimulation, semen parameters were similar using both vibrator amplitudes. CONCLUSIONS Ejaculatory success is better while semen quality is similar using high versus low amplitude penile vibratory stimulation in men with spinal cord injury. This method may be considered first line treatment for anejaculation in men with spinal cord injury due to its safety, relative effectiveness, and relatively low investment of time and money.

Semen quality of spinal cord injured men is better when obtained by vibratory stimulation versus electroejaculation

PURPOSE Most spinal cord injured men require assisted ejaculation procedures to obtain semen, and the majority can achieve this result by vibratory stimulation or electroejaculation. We determined if semen obtained by vibratory stimulation differed in quality from that obtained by electroejaculation. MATERIALS AND METHODS Between subjects and within subjects designs were used. Of 77 spinal cord injured men 23 underwent vibratory stimulation only, 44 electroejaculation only and 10 both procedures. Antegrade, retrograde and total ejaculates were analyzed in each subject for total sperm count, percent motile sperm and percent sperm with rapid linear motion. RESULTS With vibratory stimulation compared to electroejaculation the percent motile sperm and percent sperm with rapid linear motion were significantly greater, whereas total sperm count was similar, in the antegrade specimens and total ejaculates. This finding was true for different groups of subjects as well as within a group of the same subjects. CONCLUSIONS Semen obtained by vibratory stimulation is of better quality than that obtained by electroejaculation. In medical practices that include assisted ejaculation of spinal cord injured men, we recommend obtaining a specimen by vibratory stimulation. If that method fails electroejaculation should be performed.

Seminal plasma of spinal cord injured men inhibits sperm motility of normal men.

PURPOSE Seminal plasma was investigated as a contributor to the poor sperm motility of spinal cord injured men. MATERIALS AND METHODS Seminal plasma of spinal cord injured men was mixed with sperm of normal men and vice versa. Sperm motility was analyzed at 5 and 60 minutes after mixing. RESULTS At 5 (but not 60) minutes seminal plasma from spinal cord injured men inhibited motility of sperm from normal men. Concomitantly, seminal plasma from normal men improved motility of sperm from spinal cord injured men. CONCLUSIONS Seminal plasma of spinal cord injured men contributes to poor sperm motility.

Anesthetic block of the dorsal penile nerve inhibits vibratory-Induced ejaculation in men with spinal cord injuries☆

OBJECTIVES [corrected] We investigated which nerve pathways are necessary to achieve ejaculation using penile vibratory stimulation (PVS) in men with spinal cord injury (SCI). METHODS Eight men with SCI were selected based on the presence of a bulbocavernosus reflex (BCR) and consistent antegrade ejaculation with PVS. Level of injury was cervical (4), upper thoracic (4), and lower thoracic (1). Mean age was 30.4 years (range 22 to 38). Usual responses to PVS included autonomic dysreflexia (4), erection (4), and consistent somatic responses such as abdominal contractions (8). Local anesthesia of the dorsal penile nerves (penile block) was achieved using 1% plain lidocaine injection. Effective penile block was confirmed by loss of the BCR. Two PVS ejaculation trials were performed: one trial during the penile block and one trial when the penile block had worn off. In 4 subjects, the bladder contents were analyzed for retrograde ejaculation. RESULTS With the penile block, ejaculation was inhibited in 100% of the subjects. None of the bladder washings demonstrated sperm, indicating absence of retrograde ejaculation. None of the subjects exhibited their usual erectile response, somatic responses, or signs of autonomic dysreflexia. After the penile block wore off, PVS induced ejaculation in all subjects. If subjects usually had erection, somatic responses, or signs of autonomic dysreflexia, these also returned. CONCLUSIONS Our data suggest that ejaculatory response to PVS in SCI men requires the presence of intact dorsal penile nerves.

Treatment for Ejaculatory Dysfunction in Men With Spinal Cord Injury: An 18-Year Single Center Experience

PURPOSE In what is to our knowledge the largest study of its kind to date we retrospectively reviewed the records of 3,152 semen retrieval procedures in a total of 500 men with spinal cord injury to make recommendations to the medical field on ejaculatory dysfunction treatment in this specialized patient population. MATERIALS AND METHODS We retrospectively studied data from 1991 to 2009 in the Miami Project to Cure Paralysis male fertility research program at our institution. We assessed the semen retrieval success rate and semen quality. RESULTS Of the 500 men 9% could ejaculate by masturbation. Penile vibratory stimulation was successful in 86% of patients with a T10 or rostral injury level. Electroejaculation was successful in most cases of failed penile vibratory stimulation. Sperm were obtained without surgical sperm retrieval, in 97% of patients completing the treatment algorithm. Total motile sperm counts exceeded 5 million in 63% of cases. CONCLUSIONS Sperm can be easily obtained nonsurgically from most men with spinal cord injury. Sufficient sperm are available for simple insemination procedures. A treatment algorithm based on our experience is presented.

Treatment of infertility in men with spinal cord injury

Most men with spinal cord injury (SCI) are infertile. Erectile dysfunction, ejaculatory dysfunction and semen abnormalities contribute to the problem. Treatments for erectile dysfunction include phosphodiesterase type 5 inhibitors, intracavernous injections of alprostadil, penile prostheses, and vacuum constriction devices. In anejaculatory patients who wish to father children, semen retrieval is necessary. Penile vibratory stimulation is recommended as the first line of treatment. Patients who fail penile vibratory stimulation can be referred for electroejaculation. If this approach is not possible, prostate massage is an alternative. Surgical sperm retrieval should be considered as a last resort when other methods fail. Most men with SCI have a unique semen profile characterized by normal sperm count but abnormally low sperm motility. Scientific investigations indicate that accessory gland dysfunction and abnormal semen constituents contribute to the problem. Despite abnormalities, sperm from men with SCI can successfully induce pregnancy. In selected couples, the simple method of intravaginal insemination is a viable option. Another option is intrauterine insemination. The efficacy of intrauterine insemination increases as the total motile sperm count inseminated increases. In vitro fertilization and intracytoplasmic sperm injection are options in cases of extremely low total motile sperm count. Reproductive outcomes for SCI male factor infertility are similar to outcomes for general male factor infertility.

SPERM MOTILITY FROM THE VAS DEFERENS OF SPINAL CORD INJURED MEN IS HIGHER THAN FROM THE EJACULATE

PURPOSE Recent evidence suggests that the seminal plasma of spinal cord injured men contributes to their distinctive semen profile of normal sperm concentration but low sperm motility and viability. This finding indicates that sperm in these men may be normal before exposure to the seminal and prostatic fluids. To investigate this question we compared vas aspirated to ejaculated sperm in 12 men with spinal cord injury and 14 healthy, age matched controls. MATERIALS AND METHODS Ejaculate was collected by penile vibratory stimulation or electroejaculation in spinal cord injured men and by masturbation in controls. Sperm was aspirated via microsurgery from 1 hemisectioned vas deferens in spinal cord injured men and during routine elective vasectomy in controls. Ejaculated and aspirated specimens were compared. RESULTS In men with spinal cord injury mean vas aspirated sperm motility and viability plus or minus standard error of mean were significantly higher than mean ejaculated sperm motility and viability (54.4% +/- 5.0% and 74.1% +/- 5.3% versus 14.1% +/- 2.6% and 26.1% +/- 4.9%, respectively). In controls mean vas aspirated sperm motility and viability were not significantly different from mean ejaculated sperm motility and viability (77.5% +/- 5.2% and 88.9% +/- 2.5% versus 74.3% +/- 5.2% and 85.0% +/- 3.5%, respectively). CONCLUSIONS In spinal cord injured men sperm motility and viability were significantly higher before contact with seminal fluids. Although aspirated sperm from men with spinal cord injury generally had lower motility and viability than that of controls, implying that epididymal or testicular factors may also have a part, the greatest decrease was observed in the ejaculate. Further study of infertility in these men should focus on prostatic and seminal vesicle factors.

Endocrine Profiles and Semen Quality of Spinal Cord Injured Men

We characterized endocrine profiles and semen quality in spinal cord injury subjects using noninjured normal and infertile subjects as controls. Compared to normal controls, spinal cord injury subjects had lower serum levels of luteinizing hormone and follicle-stimulating hormone. Subjects with spinal cord injuries between the T8 and T10 levels had a higher incidence of hormone outliers compared to subjects with injuries at other levels. Sperm motility and per cent normal sperm morphology were lower in spinal cord injury subjects compared to normal controls but not to infertile control subjects. Spinal cord injury subjects with elevated follicle-stimulating hormone levels were azoospermic. We conclude that endocrine abnormalities are likely to accompany spinal cord injury but may not be the sole mechanism contributing to impairments in semen quality.