Assisted reproduction technology in men with ejaculatory dysfunction with special reference to spinal cord injury
Aims of the study
- To evaluate the effectiveness of advanced forms of assisted reproduction technology (ART), in men with SCI suffering infertility, with particular reference to intracytoplasmic sperm injection (ICSI), and compare it with previously published results using simpler methods.
- To evaluate the use of in vitro fertilication (IVF)/ICSI in men with anejaculatory infertility after RPLND to TC.
- To investigate if spermatogenesis in men with meningomyelocele (MMC) is sufficient for ART.
- To investigate if risk of autonomic dysreflexia and other complications during electroejaculation (EEJ) in general anesthesia (GA) are justifiable with regard to the purpose of the treatment.
- Using assisted ejaculation and IVF/ICSI, a cumulative delivery rate of around 50% can be expected in couples in which home insemination has been unsuccessful. ICSI allows treatment also in cases of extremely severe oligozoospermia or when only testicular sperm is available. Since IVF is more effective than IUI and the latter is ineffective unless performed in combination with hormonal stimulation of the woman, making it nearly as much invasive, IVF/ICSI is the method of choice if home insemination fails. IVF is strongly indicated if EEJ in GAA is required, the semen quality is poor or if there are concurrent female infertility factors.
- A high cumulative pregnancy rate can be expected from EEJ and IVF/ICSI in men that are anejaculatory after TC/RPLND. Since semen retrieval in most instances requires EEJ in GA, IVF/ICSI should be employed.
- A sizable proportion of men with MMC seems to have enough sperm for ICSI, retrievable by EEJ or TESE.
- The risk of severe hypertension and other complications from EEJ of SCI min in GA with assisted mask ventilation in a day surgery setting seems small, provided anesthesia is managed by experienced staff.
Research in the SCI field throughout the last decades has focused on topics mostly of theoretical interest. In the light of the extended life span of this group of patients, there is a need for a paradigm shift in the direction of patient-oriented applied research, based on the functional analyses of the physically impaired.
People with disability have the same demand as everybody else on society for information, community services, and health services. However, reproductive issues encountered by people with physical disabilities are different from those encountered by people without disabilities. Congenital disability is likely to affect sexual development to larger extent than acquired disability (Trollman et al, 1996). Disability, counselling of these men and women becomes important. It is necessary that the staff is knowledgable of all aspects of the infertility and sexology and that they can assist the patient soon after injury. This brings in a political aspect of the entire rehabilitation process after an injury that causes infertility. The disabled person has the right to information regarding reproduction that is comprehensive and accurate. Preconceived notion on the part of caregivers judging such couples less suitable as parents does not justify withholding information. As modern medical technology provides more options to treat infertility, it is the responsibility of society to make these services available for this category of patients.
A significant hurdle in pursuit of parenthood for couples with an SCI man is the lack of information and inadequacy of support regarding sexuality and fertility. Hence, information about the good prognosis for achieving pregnancy, and the excellent ability of these families to cope, must be disseminated to the primary caregivers.
It is important to stress that the primary objective of out infertility services is to help childless disabled persons to become parents. We have focused on the clinical outcome rather than on extensive diagnostics. The development of effective techniques for enabling people with physical disabilities to become parents serves as a powerful affirmation of the commitment of the rehabilitation team. This, in turn, leads to empowerment of the disabled individuals.
Karolinska Institutet 1998
Peter Sjöblom, docent Karolinska Institutet
Richard Levi, med dr, leg läkare