Fertility outcomes after electroejaculation in men with spinal cord injury

Ten thousand new cases of spinal injury occur annually in the United States. More than 80% of these patients are men, and 80% of these newly injured men are 18 to 45 years of age (1). Less than 15% of these men retain ejaculatory function after their injury (2). Anejaculatory men require electroejaculation when vibratory stimulation fails. Significant complications are rare, and electroejaculation is well tolerated by most men (3). Sperm retrieval is successful in more than 90% of cases, but pregnancy rates with IUI are disappointing—7% to 14% per cycle (4 ‐ 8). Use of IVF, with or without ICSI, would probably improve pregnancy rates. We report our experience with electroejaculation in men with spinal cord injury. We obtained institutional review board approval for our study. All patients undergoing electroejaculation were evaluated by history and physical examination by one of two investigators. All patients who underwent electroejaculation had failed to ejaculate with vibratory stimulation. Electroejaculation was performed without anesthesia in an office setting except in sensate patients, in whom general anesthesia was used. Our early technique consisted of 30-second bursts of stimulation at 12 to 18 V and current of 400 to 600 mAmp. We later used a method that consists of dialing up the voltage progressively starting at low levels, dialing up briefly and back down. Voltage usually did not exceed 14 to 18 V, and the current did not exceed 600 mAmp. Blood pressure was monitored throughout the procedure. Rectal examination was done to check for bleeding and heating of the rectal wall (3). Between 1983 and 2001, 27 patients underwent 112 electroejaculation procedures. One hundred ten procedures (98%) produced some ejaculate. Complications, all of which were self-limited, occurred during 36 electroejaculation attempts (32%). The initial prep median total motile sperm count and motility per procedure were 6 10 6 and 7%, respectively. Thirty-nine (35%) electroejaculation attempts yielded an initial prep total motile sperm count of at least 5 10 6 , and 28 cycles (25%) yielded no motile sperm. Nine couples desired to have children. Twenty-five cycles of IUI were performed, some with superovulation; these attempts resulted in one pregnancy (rate, 4% per cycle) but no live birth. Initial and final prep total motile sperm counts were 12.8 10 6 and 3 10 6 , respectively, and motility was 19% and 21%, respectively, for the IUI cycles. Three cycles of IVF were performed, resulting in one twin pregnancy and the birth of one set of twins. Two cycles of IVF-ICSI were performed, resulting in one twin pregnancy and the birth of one set of twins. Total pregnancy and live delivery rates for IVF cycles were both 40% per cycle (Table 1). Ejaculatory dysfunction is a rare cause of male infertility and accounts for approximately 2% of cases (3). Sperm can be successfully retrieved from most anejaculatory men with spinal cord injury by using vibratory stimulation or electroejaculation. If sperm cannot be retrieved by these techniques, vasal aspiration or testicular sperm extraction may be required (9 ‐12). The poor quality of semen obtained by electroejaculation from men with spinal cord injury has been attributed to prolonged abstinence, antisperm antibodies, heat from the procedure, and reactive oxygen species (13, 14). No corrective therapy is currently available, and advanced fertility techniques are required to circumvent this problem.