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Clinical Case of the Month Treatment of Infertility

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Clinical Case of the Month Treatment of Infertility Spinal Cord (1999) 37, 89 ± 95 ã 1999 International Medical Society of Paraplegia All rights reserved 1362 ± 4393/99 $12.00 http://www.stockton-press.co.uk/sc Clinical Case of the Month Treatment of infertility J Sùnksen*,1, DA Ohl2, H Momose3, FT Rocha4, TEP Barros4 and F Biering-Sùrensen5 1Department of Urology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark, 2Department of Surgery, Section of Urology, University of Michigan, Ann Arbor, Michigan, USA; 3Department of Urology, Hoshigaoka Koseinenkin Hospital, Osaka, Japan; 4Spinal Injury Unit, University of SaÄo Paulo, SaÄo Paulo, Brazil; 5Centre for Spinal Cord Injured, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark Keywords: spinal cord injuries; ejaculation; fertility; spermatozoa Introduction The ability to ejaculate and semen quality is severely concentration of 404 million per ml with a motility rate impaired in the majority of men with spinal cord injury of 27%. The percentage of sperm with normal (SCI) and, consequently, pregnancies caused by SCI morphology was 62%. men without medical intervention are rare.1±3 The The couple entered a home fertility programme of most common methods to induce ejaculation in SCI PVS combined with vaginal self-insemination. They men are penile vibratory stimulation (PVS)4±7 and were carefully instructed at the outpatient clinic to electroejaculation (EEJ).8±11 perform PVS by themselves. The time of ovulation was In this case, we present a common fertility identi®ed by monitoring basal body temperature. The treatment situation with an SCI man and his wife. ejaculate was collected by the partner into a non- spermicidal container. A 10 ml syringe was then used Case presentation to instill the ejaculate intravaginally. No pregnancy occurred following eight cycles of home insemination. A 32-year-old C5 incomplete tetraplegic man and his Intrauterine insemination (IUI) was then performed. 35-year-old wife seeking treatment for infertility were Prior to IUI the wife was thoroughly evaluated by admitted to our clinic. Before the spinal cord injury 4 hystero-salpingography and assessment of ovulation years previously, he had normal ejaculatory function. and found normal. Before insemination by IUI, After the injury it was not possible to obtain clomiphene citrate (Pergotime) was used in a dose of ejaculation by sexual stimulation or masturbation. 100 mg per day on days 3 ± 7. Vaginal ultrasound Serum hormonal analyses of follicle-stimulating hor- examination was used for ovulation timing. When the mone, luteinizing hormone, prolactin, estradiol and leading follicle reached 18 mm in diameter, human testosterone were within normal limits. Orchiodometry chorionic gonadotropin (hCG, Profasi) 5000 IU was revealed normal testicular size on both sides. PVS was administered subcutaneously to induce ovulation. then performed with a new medical grade vibrator Intrauterine insemination was then performed 38 h (Figure 1) which has been developed for this purpose. following the hCG-injection. No pregnancies were A vibratory amplitude of 2.5 mm and a frequency of achieved during a total of six cycles of IUI. Before 100 Hz was used as previously described.4 The center IUI the semen obtained by PVS was processed by the of the vibrator knob was applied to the preputial Percoll-technique and the total number of motile frenulum and held in the same position until antegrade sperm used for the IUI cycles ranged from 30 ± 200 ejaculation occurred after 40 s of stimulation. The million (median 85). ejaculate was collected in a non-spermicidal container. The couple was then oered in-vitro insemination Due to the potential risk of autonomic dysre¯exia the (IVF). Prior to IVF the female partner was treated blood pressure was monitored during the procedure with a gonadotropin releasing hormone analogue and no signi®cant increase in the blood pressure was (GnRH, buserelin, Suprefact) followed by stimulation seen. A diagnostic raw semen analysis of the antegrade with human menopausal gonadotropins (Humegon) ejaculate was performed immediately following the according to a long protocol. Human chorionic procedure and showed a volume of 3.4 ml and a sperm gonadotropin was given 36 h before oocyte aspiration and a maximum of two embryos were transferred into the uterine cavity 48 h following the oocyte aspiration. Correspondence: J Sùnksen, Dept. of Urology, Rigshospitalet, University of Copenhagen, 9 Blesclamvei, DK-2100, Copenhagen, A total of four IVF cycles were performed. All cycles Denmark resulted in fertilization with a cleavage rate of 80% Treatment of infertility JSùnksenet al 90 Figure 1 Ferti care1 personal (Multicept, Rungsted, Den- Figure 2 Seager Model 11 Electroejaculator and rectal mark) vibrator developed to induce ejaculation in men with probe (Dalzall USA Medical Systems, The Plains, VA, spinal cord injuries. The amplitude and frequency may be set USA). The rectal probes used during the electroejaculation at the recommended 2.5 mm and 100 Hz, or according to procedure are generally 3 cm in diameter with either a individual requirements. The options available include transverse or a longitudinal arrangement of the electrodes. amplitudes between 1.0 ± 3.5 mm and frequencies between Alternating current (0 ± 50 V/0 ± 1000 mA) is used to perform 70 ± 110 Hz the electrical stimulaton (median number of oocytes aspirated per cycle was dure. Virtually 100% of SCI men ejaculate with EEJ ten, range 5 ± 14). A singleton pregnancy (still on- versus 60% to 80% with PVS. Dr Sùnksen, the lead going) was achieved after the fourth attempt of IVF. discussant of this case, should be congratulated for Following Percoll-technique, the total number of determining the importance of the vibratory amplitude motile sperm used for the IVF cycles ranged from and increasing PVS ejaculation rates to this range.4 It 28 ± 180 million (median 112). is because of his work that we have seen success with PVS and in recent years shifted our emphasis to PVS Comments by Dr Ohl as our primary procedure . Despite the fact that PVS works in a smaller This case presentation represents a very common percentage of the cases, it should always be tried situation we see at the University of Michigan. Many ®rst. Patient acceptance is substantially higher for PVS of my comments regarding management are based on over EEJ and there is a suggestion of better sperm our program's experience in EEJ but I believe the quality and function with PVS as well.12 Electro- comments are valid since similar sperm problems are ejaculation is reserved for PVS failures. In the very seen in both EEJ and PVS. rare event that EEJ and PVS both fail to cause seminal The initial evaluation of this patient and his spouse emission, surgical extraction of sperm can be prior to the initial PVS was correct. It was a limited considered, and I believe that ejaculation induction evaluation. Unfortunately, many men with SCI failure is the only acceptable reason for surgical sperm seeking infertility treatment at our center have extraction in the SCI population. Once adequate already undergone extensive unnecessary evaluation, sperm quality is demonstrated, attempts at pregnancy sometimes including invasive procedures such as can then proceed. testicular biopsy and vasogram. Spinal cord injured While I am not totally adverse to home insemina- menshouldbetreatedthesameasanymanwithan tion, I believe that success with this procedure will be infertility problem ± a `sperm count' should be extremely low, for two main reasons. The ®rst is obtained prior to invasive testing. Therefore, history, related to the insemination route. We have reported on physical exam and hormonal assays are all that functional abnormalities of the sperm obtained by should be performed prior to proceeding with EEJ13 and these functional abnormalities have also ejaculation induction. been veri®ed in men undergoing PVS. These defects The next question to consider is which type of include poor survival in incubation and cervical mucus ejaculation procedure to perform ± EEJ or PVS. transport. Home insemination success requires that Electroejaculation is clearly a more reliable proce- these fragile sperm survive the hostile vaginal Treatment of infertility JSùnksenet al 91 environment and also traverse the cervical mucus to associated with multiple births and disappointment of get into the uterus, tasks that the functional multiple failures of IVF. abnormalities may not allow. In the University of Michigan program, multiple initial attempts of Comments by Dr Momose physician-performed vaginal inseminations resulted in no pregnancies. With intrauterine delivery of sperm, Two diculties must be overcome by SCI men who the pregnancy rate immediately rose to greater than desire to father their own children; one is to obtain 30% per couple. semen and the other is successful insemination. The Secondly, I believe that patient-directed home most common procedures used to obtain semen are ovulation timing is suboptional. In this couple, basal PVS or EEJ. In general, PVS should be preferred as body temperature charting was the primary method the ®rst choice for SCI men as it is less invasive and used. Since SCI sperm also has decreased motility the eciency of over 75% is equal to EEJ. The longevity,14 ovulation timing is of the utmost presented case, a C5 incomplete tetraplegic man, is importance. The delivery of sperm should be likely to be burdened with neurogenic bladder performed as close to the time of ovulation as dysfunction of upper motor neuron
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