Teodoro C. Aballa

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.

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.

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.

SERUM AND SEMEN PROSTATE SPECIFIC ANTIGEN CONCENTRATIONS ARE DIFFERENT IN YOUNG SPINAL CORD INJURED MEN COMPARED TO NORMAL CONTROLS

PURPOSE Recent investigations have indicated that factors within the seminal plasma may contribute to the condition of low sperm motility in men with spinal cord injury. To determine whether the prostate gland functions normally in these men we chose prostate specific antigen (PSA) as a marker of prostatic function, and compared serum and semen concentrations in spinal cord injured and healthy noninjured men. MATERIALS AND METHODS The study included 21 spinal cord injured men (mean age 33.3+/-1.2 years) and 22 noninjured normal men (mean age 30.3+/-1.5 years). Blood was obtained from subjects following at least 24 hours of abstinence from ejaculation and serum PSA was determined by modified enzyme immunoassay. Antegrade ejaculates from all subjects were frozen to -80 C, exactly 15 minutes after collection. Seminal plasma PSA was determined using Hybritech Tandem MP assay. RESULTS Mean serum PSA concentration was 1.20+/-0.19 ng./ml. in spinal cord injured and 0.69+/-0.07 ng./ml. in noninjured men (p<0.02). Mean seminal plasma PSA concentration was 0.59+/-0.11 mg./ml. in spinal cord injured and 1.29+/-0.15 mg./ml. in noninjured men (p<0.001). CONCLUSIONS Our findings of elevated serum and decreased seminal plasma PSA concentrations indicate that prostatic secretory dysfunction is present in men with spinal cord injury.

Semen quality in spinal cord injured men: Does it progressively decline postinjury?☆☆☆

OBJECTIVE To determine if semen quality of men with spinal cord injury (SCI) undergoes a progressive decline as a function of years postinjury. DESIGN A retrospective analysis of cross-sectional data. SETTING University-based research center. SUBJECTS Semen quality was examined in 638 specimens from 125 men with SCI. INTERVENTION Penile vibratory stimulation, electroejaculation, and masturbation were used as semen retrieval methods. Routine semen analysis was performed to evaluate semen quality. MAIN OUTCOME MEASURES Sperm concentration, total sperm count, and percent sperm motility were examined at 2-year intervals from men whose injuries had occurred 6 weeks to 26 years earlier. RESULTS No difference in any semen parameter was found as a function of time postinjury. CONCLUSIONS Semen quality in men with SCI does not progressively decline after the SCI. Men with SCI who are considering biologic fatherhood should be advised that the number of years after injury need not be a determinant in deciding when to start a family.

SEMEN RETRIEVAL IN MEN WITH SPINAL CORD INJURY IS IMPROVED BY INTERRUPTING CURRENT DELIVERY DURING ELECTROEJACULATION

PURPOSE Based on the findings of a previous study of pressure differentials in the external and internal urinary sphincters during electroejaculation we determined whether semen retrieval in men with spinal cord injury would be improved by interrupting current delivery during electroejaculation. MATERIALS AND METHODS We tested continuous versus interrupted current delivery in the same group of 12 men with spinal cord injury. Patients underwent a mean of 4 randomly assigned continuous or interrupted trials 4 to 8 weeks apart. Antegrade and retrograde semen parameters were analyzed per trial. Multiple trials of each method per patient were averaged and semen parameters by the continuous and interrupted methods were compared. RESULTS Interrupted delivery resulted in significantly greater mean antegrade volume versus continuous delivery (2 versus 0.9 cc). In this antegrade fraction mean total sperm count and mean total motile sperm was higher for interrupted (130 million and 35 million) versus continuous (79 million and 26 million, respectively) delivery. The mean retrograde total sperm count was 4-fold higher for continuous (120 million) versus interrupted (29 million) delivery. In the total ejaculate of the combined antegrade and retrograde fractions the mean total sperm count and mean total motile sperm were not significantly different for the 2 methods. CONCLUSIONS Each method resulted in a similar mean total sperm count and total motile sperm in the total ejaculate but a higher proportion of sperm was found in the antegrade fraction using the interrupted method. We recommend interrupted current delivery as the technique of choice when electroejaculation is performed to obtain sperm for fertilization.

Reflexes and somatic responses as predictors of ejaculation by penile vibratory stimulation in men with spinal cord injury

Study design: Retrospective chart review.Objective: To identify factors in addition to level of injury (LOI) that may predict ejaculation by penile vibratory stimulation (PVS) in spinal cord injured males.Setting: Major urban medical school and teaching hospital.Materials and methods: Presence of a bulbocavernosus response (BCR) and a hip flexor response (HR) before PVS (n=123 patients), and somatic responses during PVS (n=204 trials performed on a subset of 44 patients) were evaluated for their frequency of occurrence on trials with and without ejaculation.Results: Overall ejaculation success rates for cervical, T1–T6, and T7–T12 LOI were 71%, 73%, and 35%, respectively. Eighty per cent of patients who were positive for both BCR and HR ejaculated with PVS, while only 8% of patients who were negative for both BCR and HR ejaculated with PVS. For cervical injuries, BCR and HR were no more predictive of ejaculation by PVS than LOI alone. T1–T6 patients were more likely to ejaculate when at least one reflex was present. T7–T12 patients with no BCR were unlikely to ejaculate by PVS. Except for abdominal contractions, somatic responses were not present in the majority of PVS trials. When they were present, however, they occurred in a high percentage of ejaculation trials: withdrawal response (hip flexion, knee flexion and thigh adduction) (90%), piloerection (84%), extremity spasms (83%), thigh abduction (80%), and thigh adduction (72%).Conclusion: We recommend that patients with cervical injuries initially undergo PVS. Patients with T1–T6 LOI with at least one reflex present, and patients with T7–T12 LOI with both reflexes, or only BCR present, may undergo PVS. Certain somatic/autonomic responses, when seen, may help in deciding whether to continue with a given trial, or give a repeat trial, of PVS.Sponsorship: The Miami Project to Cure Paralysis and the State of Florida Specific Appropriations.Spinal Cord (2001) 39, 514–519.

Pregnancy outcomes by intravaginal and intrauterine insemination in 82 couples with male factor infertility due to spinal cord injuries

OBJECTIVE To report our centers pregnancy rates (PR) by intravaginal insemination (IVI) or intrauterine insemination (IUI) in 82 couples with male partners with spinal cord injuries. DESIGN Retrospective analysis. SETTING Major medical center. PATIENT(S) Male patients with spinal cord injuries and their female partners. INTERVENTION(S) Intravaginal insemination and IUI. MAIN OUTCOME MEASURE(S) Pregnancy and live birth outcomes. RESULT(S) Overall, 31 of the 82 couples (37.8% PR) achieved 39 pregnancies. Sperm were obtained by masturbation, penile vibratory stimulation, or electroejaculation in 4 men (4.9%), 42 men (51.2%), and 36 men (43.9%), respectively. Intravaginal insemination, performed mostly at home by selected couples, was undertaken in 45 couples, 17 of whom (37.8% PR) achieved 20 pregnancies. Intrauterine insemination was performed in 57 couples, 14 of whom (24.6% PR) achieved 19 pregnancies, with a cycle fecundity of 7.9%. Eighteen and 21 live births occurred by IVI and IUI, respectively. CONCLUSION(S) The methods of IVI and IUI are reasonable options for this patient population. These methods warrant consideration before proceeding to assisted reproductive technologies (ART).

Semen Quality Remains Stable During the Chronic Phase of Spinal Cord Injury: A Longitudinal Study

PURPOSE In a longitudinal study we examined changes in semen quality with time during the chronic phase of spinal cord injury. MATERIALS AND METHODS Included in this study were 87 men with spinal cord injury who underwent 2 or more semen retrieval procedures with a minimum of 3 years between the first and last procedures. Patients were selected from our database of 500 with spinal cord injury who were volunteers enrolled in the Male Fertility Research Program of the Miami Project to Cure Paralysis from January 1, 1991 through April 31, 2009. Semen was collected by masturbation, penile vibratory stimulation or electroejaculation. Semen analysis was done according to WHO criteria. We used a statistical generalized linear mixed model to analyze changes in sperm concentration, total sperm count, total motile sperm count and sperm motility with time. RESULTS Mean patient age was 30.1 years (range 16 to 48) and mean time after injury at the initial sperm retrieval procedure was 7.1 years (range 1 to 26). Sperm concentration decreased slightly with time but all other parameters were unchanged, including total sperm count, indicating a stable, null pattern in measures with time. CONCLUSIONS Semen quality does not show clinically significant progressive changes during years after injury in men with spinal cord injury. This information is relevant for urologists who counsel these patients on family planning. Also, routine sperm freezing for fertility preservation is not indicated in this patient population.