robert oates, m.d. - fertility in the spinal cord injured male
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Fertility in the Spinal Cord Injured Male
Robert D Oates, M.D.Boston Medical Center
Fortunately, I was one of the first in the country to learn about fertility issues in the man with a spinal cord injury and wrote a number of papers early in my career advancing this field. During my fellowship, we were just learning about how to help SCI men become fathers.
My Experience in this Field
I continue to have an incredible interest and desire to help – it is as rewarding as can be imagined to assist couples and watch them reach their goal of having children.
Being a Urologist is a crucial aspect of care – it is complete and does not just revolve around “sperm”.
My Experience in this Field
General medical and surgical history Medications, allergies ?
Level of injury Complete or incomplete ? Sensation in the genital and rectal area ? Autonomic dysreflexia – does that happen ?
Voiding regimen Intermittent catheterization ? Indwelling catheter ? Condom catheter ?
Bowel regimen
What is important to knowabout my medical history ?
Erectile function Spontaneous, reflex, how long do they last ? Are they sufficient for sexual satisfaction for both of you ? Any medications been tried: pills, injections ?
Ejaculation Does it happen at all ? What makes it happen ? If it happens, do you have autonomic dysreflexia ?
What is important to know about my sexual history?
Ejaculation is a reflex Stimulation must be present to make it fire off Stimulation comes from the brain (thoughts) and the penis Usually must have both
With a spinal cord injury: Either the stimulation from the brain cannot reach the reflex center because of the spinal cord injury
OR The stimulation from the penis cannot reach the reflex center because of the spinal cord injury
Why don’t I ejaculate?
Why don’t I ejaculate?
3 main phases:1. Stimulation: visual, tactile, cognitive
2. Emission: contraction of the SV & VA with flow of seminal fluid into the posterior urethra
3. Antegrade ejaculation: contraction of the periurethral musculature with forward flow of seminal fluid
Neurophysiology of Ejaculation
SV – seminal vesicles (glands in the pelvis that make most of the fluid in the ejaculate)VA – vasal ampullae (the end of the tubes in the pelvis that delivers the sperm up from the testes in the scrotum)
Emission Sympathetics (spinal level T10 ‐ L2)
Bladder neck closure Sympathetics (spinal level T10 ‐ L2)
Antegrade Ejaculation Somatics (spinal level S2 ‐ S4)
Integrated Reflex Control Center Spinal level T12 ‐ L1
Neurophysiology of ejaculation
Emission The first phase of the ejaculatory process where
the semen fluid flows into the urethra Sympathetics (spinal level T10 ‐ L2)
Neurophysiology of ejaculation
Bladder neck closure This prevents the semen from travelling
backwards into the bladder Sympathetics (spinal level T10 – L2)
Neurophysiology of ejaculation
Antegrade Ejaculation This is the rhythmic contraction of the muscles
around the urethra to move the semen forward out the end of the penis
Somatics (spinal level S2 ‐ S4)
Neurophysiology of ejaculation
Integrated Reflex Control Center This is the reflex center in the spinal cord that
controls the whole process Spinal level T12 ‐ L1
Neurophysiology of ejaculation
Tx depends on level of injury If above T12 / L1 – options include Penile vibratory stimulationRectal probe electroejaculation Testis tissue extraction
If below T12 / L1 – options includeRectal probe electroejaculation Testis tissue extraction
SCI: Ejaculatory Dysfunction Treatment (Tx)
A good first choice spinal cord must be active and reflexive
Stimulation activates reflex centerNormal forward semen flowPatients can be taught to do it after the first one in the office ! ! commercially available vibrator lessens medical intervention and cost
Penile Vibratory Stimulation
Successful in 60% of SCI men overall The semen can be used for:
depending on the sperm count and activity home insemination – can help you get pregnant at home intrauterine insemination – sperm are put into the uterus in‐vitro fertilization – the most complex, but sometimes necessary, tx
Some men may experience autonomic dysreflexia if the injury level is above T6 occasionally pretreatment with a medication is necessary why it is necessary to have the first one done in my office
important to make sure it is safe for you
Penile Vibratory Stimulation
Penile Vibratory Stimulation
Used when vibratory stimulation did not or would not work Indications: SCI men refractory to PVS RPLND (an operation for some men with testicular cancer) Multiple Sclerosis Diabetes Mellitus Transverse Myelitis
Rectal probe electroejaculation
Provides semen for adjunctive therapies IUI IVF ICSI
Rectal Probe Electroejaculation
} Depends uponsemen parameters
Not for home insemination
In office for patient with no rectal sensation / no dysreflexia In operating room if rectal sensation / dysreflexia Technique: only FDA approved equipment Only with fully trained physician I was one of the first in the world to learn in 1988 and helped
pioneer the use of electroejaculation in the US
Rectal Probe Electroejaculation
Stimulate to certain voltages and current densities Ejaculate is collected Used for appropriate indication depending upon: Sperm count Sperm activity
Typically collected and frozen for later use with IVF
Rectal Probe Electroejaculation
Depends upon sperm count and activityDepends upon female factors
Age, ovarian function, etc
Depends upon adjunctive treatment usedHome insemination, IUI, IVF
Pregnancy rates ‐ PVS & RPE
If these non‐invasive minimally invasive techniques do not work Direct sperm harvesting
Testis Epididymis
Used in conjunction with ICSI
Much more complex of a strategy Successful as last option
SCI: Refractory to PVS and RPE
Fatherhood is certainly possible in the SCI male It is important to understand the full complexity of
spinal cord injury Depending on the individual, important to try the simplest
approach first Move to the more complex as the situation dictates
The goal is a happy healthy family !!!
Summary
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