1 The Egyptian IVFET Centre, 3 Street 161, Hadaek El-Maadi, Maadi and 2 The Andrology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
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Abstract |
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Key words: ICSI/prostatic massage/psychogenic anejaculation/sperm retrieval
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Introduction |
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When fertility becomes the major issue for men with psychogenic or organic anejaculation, ejaculation can be induced by penile vibratory stimulation for self-insemination, intrauterine insemination, or assisted conception. In patients with spinal cord injuries, ejaculation rates ranged from 065.6% depending on the level of the lesion (Nehra et al., 1996; Brackett et al., 1998
). When penile vibratory stimulation is unsuccessful, electro-ejaculation is a relatively safe and non-invasive technique. However, it requires the use of specialized equipment and experience. With the exception of cases of spinal cord injury, general or spinal anaesthesia is mandatory (Ohl et al., 1992
). Conception has been reported when electro-ejaculation is combined with intrauterine insemination, or in-vitro fertilization (IVF) (Toledo et al., 1992
). Despite relatively high sperm counts, the semen obtained by electro-ejaculation usually reveals spermatozoa with low viability, poor survival, impaired cervical mucus penetration and poor fertilizing capability, in both organic (Denil et al., 1992
) and idiopathic anejaculation (Hovav et al., 1996
). In these patients intracytoplasmic sperm injection (ICSI) can offer a better chance of pregnancy (Denil et al., 1996
; Kiekens et al., 1996
).
In rare cases when electro-ejaculation fails, surgical retrieval of spermatozoa is the only alternative. Aspiration from the vas deferens is one method to retrieve spermatozoa in these cases. Successful pregnancy after vasal sperm aspiration combined with intrauterine insemination (Belker et al., 1994), IVF (Hovatta and von Smitten, 1993
) or ICSI (Hovatta et al., 1996
) has been reported.
In the Egyptian IVFET Centre we offer testicular sperm extraction combined with ICSI to selected patients with anejaculation. All patients have a per rectal examination and microscopic examination of the expressed prostatic secretion (EPS), as part of our routine andrology service. We observed that the EPS of some patients contained motile spermatozoa, and wished to investigate the use of this method for sperm retrieval in selected cases.
This paper reports our preliminary results with this simple method for sperm collection in three patients suffering from psychogenic anejaculation. The diagnosis of psychogenic anejaculation was based on the lack of a physical cause for the condition, the presence of nocturnal emissions, and existence of sexual relationships without ejaculation.
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Case reports |
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The couple presented to the Egyptian IVFET centre because their main concern was to conceive. The 23 year old wife had regular menstrual cycles with no abnormalities on general and pelvic examination. Routine laboratory tests including liver function and basal hormonal profile were normal. Transvaginal ultrasonography was unremarkable except for a single right ovarian cyst measuring 20 mm. Investigations for tubal patency were not done. Physical examination of the man revealed normal genitalia and no signs of endocrinological or neurological abnormalities. Per rectal examination revealed a mildly enlarged prostate. No nodules were palpated. The concentrations of testosterone, follicle-stimulating hormone (FSH), luteinizing hormone (LH) and prolactin were within normal limits. Urine analysis for glucose and protein was negative. Retrograde ejaculation was excluded after examination of a postcoital urine sample. Examination of the EPS at the clinic showed a few immotile spermatozoa. This finding encouraged us to attempt sperm retrieval using vigorous prostatic massage on the day of oocyte retrieval.
Due to financial constraints, a clomiphene citrate/human menopausal gonadotrophin (HMG) protocol was chosen for ovarian stimulation. The wife received clomiphene citrate 50 mg three times per day (Clomid®; Merrel-Dow SA, Neuilly-sur-Seine, France) for 5 days starting on day 2 of the cycle. HMG (Humegon®; Organon, Cidico, Egypt) 75 IU i.m. twice daily was given starting on day 5 of the cycle. Ovulation was monitored by transvaginal ultrasonography. Five follicles were seen, three in the right and two in the left ovary. When the leading follicle reached 18 mm, human chorionic gonadotrophin (HCG, Pregnyl®; Organon) 10 000 IU i.m. was given.
Sperm retrieval by prostatic massage was performed on the day of oocyte retrieval. After cleaning the external genitalia with alcohol, the patient was placed in the knee-chest position. A per rectal examination was done and the prostate was palpated. The upper border of one lateral lobe was reached. The prostate was massaged vigorously by keeping firm pressure against the symphysis pubis while passing the pad of the index finger in a downward and medial direction in a rolling motion. The other prostatic lobe was palpated and the procedure repeated several times. The examination was well tolerated by the patient.
During the massage, the patient was asked to hold a sterile wide container below the external meatus to collect the drops of the EPS. Approximately 0.5 ml of secretion was aspirated from the container by a 30 gauge needle attached to a sterile 1 ml syringe containing 0.5 ml HEPES-buffered Earle's medium (catalogue no. 1034, Medicult, Copenhagen, Denmark). Microscopic examination of the drop showed a concentration of 5x106 spermatozoa/ml and 5% had sluggish motility; 70% of the sperm cells had abnormal morphology (World Health Organization, 1992). The contents of the syringe were transferred to a 5 ml Falcon tube (Becton Dickinson, Plymouth, UK). For washing, the tube was centrifuged at 300 g for 10 min. The supernatant was discarded, the pellet was resuspended in 0.3 ml of Ham's F10 medium (Gibco Laboratory, Grand Island, NY, USA) supplemented with 10% patient's serum and the wash was repeated. The sample was incubated in 5% CO2 at 37°C until used for micro-injection.
Transvaginal oocyte retrieval was performed 36 h after the HCG injection and yielded only one two-pronuclear (2PN) oocyte of poor quality. ICSI was carried out as previously described (Mansour, 1998). Unfortunately fertilization did not occur. Excess spermatozoa were cryopreserved for future use.
Case 2
A healthy 32 year-old male was referred for management of infertility and primary anejaculation. He had been married for 9 years, having intercourse weekly with normal libido and erection but no orgasm. He had never ejaculated while awake, even during trials of masturbation. He reported normal night emissions at an average of twice per month but despite multiple attempts was not able to collect semen with a spermicide-free condom during sleep. Previous trials of psychosexual counselling were met with resistance from both partners. Their main anxiety was to conceive. One previous trial of electro-ejaculation and intrauterine insemination (IUI) was performed in another centre but due to poor quality of semen no pregnancy occurred. The couple preferred not to repeat electro-ejaculation and IUI so ICSI was suggested.
Physical examination of the man showed normal genitalia and no signs of endocrinological or neurological abnormalities. Urine analysis for glucose and protein was negative. Retrograde ejaculation was ruled out after examination of a postcoital urine sample. The 30 year old wife had regular menstrual cycles. Her general and gynaecological examination was normal. Ovarian stimulation was performed using a desensitization long protocol as previously described (Mansour et al., 1996).
As in Case 1, sperm retrieval by prostatic massage was performed on the day of oocyte retrieval using the same technique. The EPS showed no spermatozoa. Surgical retrieval of testicular spermatozoa was therefore carried out on the same day by an open biopsy under local anaesthesia as previously described (Fahmy et al., 1997).
Nineteen oocytes were injected by ICSI as previously described (Mansour, 1998). After 24 h 11 oocytes showed two pronuclei (2PN). Six of the 2PN oocytes were cryopreserved and the rest were allowed to grow in vitro for 48 h, resulting in four embryos that were transferred. A subsequent pregnancy test was negative. Two months later, the cryopreserved 2PN oocytes were thawed. Unfortunately none of them divided and embryo transfer was cancelled.
Case 3
A healthy 34 year old male had been married for 3 years. He was seen because of infertility and anejaculation. He is a religious orthodox, and has spent most of his life working in a mosque. He had a rigid upbringing. His sexual history revealed that he had primary anejaculation. He had no premarital sexual relations and did not masturbate. Unlike Cases 1 and 2, he had a low sex drive with infrequent sexual encounters occurring only once per month. Despite normal erections, he had never ejaculated while awake. He reported infrequent night emissions. Psychotherapy was suggested but was not accepted due to religious attitudes. Clinical examination showed no abnormalities except for a small left epididymal cyst. Aspiration of the cyst was negative for spermatozoa. The patient had previously had a testicular biopsy in another centre (which did not have cryopreservation facilities) that revealed normal spermatogenesis. Hormonal profile and urine analysis for glucose and protein were normal. Retrograde ejaculation was excluded after postcoital urine examination. His 20 year old wife had regular menstrual cycles. Her general and gynaecological examination and investigations showed no abnormality. Ovarian stimulation was performed using a desensitization long protocol as in Case 2.
Sperm retrieval by prostatic massage was done on the day of oocyte retrieval using the same technique as in Case 1. Approximately 0.5 ml of EPS was collected. Microscopic examination revealed a concentration of 2x106 spermatozoa/ml, 25% with sluggish motility and 95% of the sperm cells with abnormal morphology. Of the 20 oocytes collected by transvaginal ultrasound-guided follicular puncture, 19 had polar bodies and were injected. After 24 h 10 oocytes were 2PN. Five of the 2PN oocytes were cryopreserved and the rest were allowed to grow in vitro for 72 h. Five 8-cell embryos were seen, two were cryopreserved and three (one grade I and two grade II) embryos were transferred. A subsequent pregnancy test was positive and ultrasound examination revealed one embryonic sac with fetal echoes. The pregnancy is currently ongoing.
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Discussion |
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Following the use of ICSI with surgically retrieved spermatozoa to treat severe male factor infertility, continuous attempts to simplify the technique have been made. Microsurgical epididymal sperm aspiration (MESA) (Tournaye et al., 1994; Silber et al., 1994
) was superseded by percutaneous epididymal sperm aspiration (PESA) (Craft et al., 1995
) and testicular sperm extraction (TESE) (Devroey et al., 1994
). Open testicular biopsy has been replaced by needle biopsy in cases of obstructive azoospermia (Bourne et al., 1995
). Vigorous prostatic massage represents a further attempt to simplify the method of retrieval of spermatozoa for a proportion of patients with anejaculation. It eliminates the need for general anaesthesia and the use of sophisticated and expensive equipment.
All three couples were counselled about all other methods for sperm retrieval. Although electro-ejaculation is not yet available in our centre, they preferred to be treated by us. Successful sperm retrieval using prostatic massage was achieved in two out of the three patients in this series. Although the sperm count was low, it was adequate for ICSI, which resulted in one successful pregnancy. Cryopreservation of spermatozoa was done in both cases, allowing the possibility of future ICSI attempts.
In these case reports we tried this simple procedure on patients suffering from psychogenic anejaculation undergoing ICSI. However, we believe that it may be applied to other types of anejaculation. Prostatic massage can be done for couples already committed to ICSI before the patient is admitted to the operating theatre for more invasive techniques. If no motile spermatozoa are found, then vibratory stimulation, electro-ejaculation or surgical retrieval can be performed.
We realise that this method will not be appropriate for every patient. The procedure is facilitated by the patient standing and leaning over the examination table or lying in the knee-chest position, and this may be difficult in patients with spinal cord injury. More studies are needed to ascertain the proportion of men with spermatozoa in their prostatic secretion after massage, and which cases are most suitable for this technique.
In conclusion, we recommend this non-invasive and simple technique of prostatic massage for sperm retrieval for ICSI as a possible first-line management for selected patients suffering from infertility due to anejaculation.
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Notes |
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* Presented in part at the 15th annual conference of The European Society of Human Reproduction and Embryology, Tours, June 1999
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References |
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Submitted on January 28, 1999; accepted on May 6, 1999.