The use of ICSI with fresh and cryopreserved electroejaculates from psychogenic anejaculatory men

Y. Hovav1,3, H. Yaffe1, B. Zentner2, M. Dan-Goor1 and M. Almagor1

1 Department of Obstetrics and Gynecology, Bikur Cholim Hospital and 2 IVF Unit, Hadassah Mount Scopus Hospital, Jerusalem, Israel


    Abstract
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
BACKGROUND: Electroejaculation has become an accepted form of semen procurement in men suffering from anejaculation. However, sperm in these ejaculates often exhibit low motility. In such cases, ICSI is offered to improve the possibility of successful pregnancy. Here we evaluate the fertilizing potential, using ICSI, of fresh and cryopreserved sperm obtained by transrectal electroejaculation from patients with psychogenic anejaculation. METHODS: A total of 25 men suffering from psychogenic anejaculation underwent 37 sessions of electroejaculation in combination with ICSI. In 17 patients fresh sperm (29 cycles, group I) was used, and in the other eight patients cryopreserved sperm (10 cycles, group II) was used. RESULTS: A total of 155 oocytes were injected with fresh sperm with a fertilization rate of 55% (85/155). The pregnancy rate was 10% (3/29) per cycle. A total of 94 oocytes were injected with frozen–thawed sperm with a fertilization rate of 50% (47/94). The pregnancy rate was 40% (4/10) per cycle. CONCLUSIONS: The fertilization and pregnancy rates with cryopreserved sperm from electroejaculation are at least as good as those of freshly obtained sperm. Therefore, when motile sperm is found in the thawed ejaculate, additional electroejaculation can be avoided.

Key words: anejaculation/cryopreservation/electroejaculation/fertilization rates/ICSI


    Introduction
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
The commonest cause of anejaculation is spinal cord injury, with other relatively uncommon causes including retroperitoneal lymph node dissection, diabetes mellitus, transverse myelitis and multiple sclerosis. Psychogenic anejaculation is a unique problem. Men who suffer from it are otherwise healthy individuals who cannot ejaculate even by masturbation, although they may have erections and nocturnal emissions.

Electroejaculation has been successfully used for sperm procurement in anejaculatory men desiring fertility. However, electroejaculation may alter semen quality (Brackett and Lynne, 2000Go). Electroejaculates from men with spinal cord injury often exhibit low sperm motility, decreased viability, reduced longevity of motility, poor cervical mucus penetration and compromised hamster oocyte penetration (Chung et al., 1995Go).

In a previous study, we demonstrated that the electroejaculates obtained from men with psychogenic anejaculation also show poor motility (Hovav et al., 1996Go). Despite these deficiencies, two studies have shown reliable cryopreservation characteristics of semen produced by electroejaculation (Buch and Zorn, 1993Go; Pardon et al., 1994Go), but there are no reports of clinical use of cryopreserved electroejaculates from men with psychogenic anejaculation.

In this study, we evaluated fertilization rates when performing ICSI in combination with cryopreserved electroejaculates from men with psychogenic anejaculation. The first pregnancies with these sperm are reported.


    Materials and methods
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
Patients
Between June 1998 and February 2001, 25 men with psychogenic anejaculation underwent electroejaculation followed by ICSI. Psychogenic anejaculation was diagnosed on the basis of lack of physical causes for the problem, presence of occasional nocturnal emissions and sexual relations without conscious ejaculations. Retrograde ejaculation was ruled out after urine examination. The levels of thyroid stimulating hormone, FSH, LH and prolactin were within the normal range. All the men were ultra-orthodox Jews and suffered from primary infertility of a duration ranging between 1–20 years. Psychotherapy and vibrator stimulation were suggested to all patients. Some were not responsive to the treatment and the others refused it. In the female spouses no infertility-related factors were identified.

Fresh sperm were used in 29 cycles (17 couples; group I). Cryopreserved sperm were used in 10 cycles (eight couples; group II). The age of the men (mean ± SD) was 31.9 ± 8.6 years (range: 24–50). The mean age of the women in group I and II was 29.4 ± 6.9 (range: 21–45) and 28.7 ± 7.3 years (range: 22–45) respectively.

The study was approved by the Institutional Review Boards in Bikur Cholim and Hadassah Hospitals.

Electroejaculation, sperm preparation and cryopreservation
A total of 37 procedures of electroejaculation were performed under general anaesthesia while the patients were placed in lateral decubitus, as previously described (Hovav et al., 1996Go), with the use of the Seager Model 14 Electroejaculator (Dalzell Medical System, The Plains, VA, USA). The procedures were done at Bikur Cholim Hospital without any complications. Sperm procurement was successful in all patients. The antegrade and retrograde portions of the ejaculate were assessed for sperm concentration and motility according to the World Health Organization guidelines for semen analysis (World Health Organization, 1999Go).

When fresh sperm was used, both antegrade and retrograde samples were prepared for ICSI by washing twice (1800 g, 5min) in medium IVF-50. The remaining sperm were frozen for further treatment.

For sperm cryopreservation, the antegrade sample was diluted 1:1 (v/v) in TEST-YOLK buffer with glycerol (Irvine Scientific, Santa Ana, CA, USA) and the retrograde ejaculate was concentrated by 5 min centrifugation at 1800 g followed by suspension of the pellet in TEST-YOLK buffer. Aliquots of 0.1–0.2 ml were frozen in liquid nitrogen as previously described (Hovav et al., 1996Go).

Ovarian stimulation, ICSI and embryo transfer
Controlled ovarian stimulation was obtained by administration of GnRH agonist (Decapeptyl CR; Ferring, Malmo, Sweden) in the midluteal phase with subsequent administration of FSH (Metrodin; Teva, Kfar-Sava, Israel).

Follicular development and the concentrations of estradiol and progesterone in blood were monitored. HCG (10 000 IU; Teva) was injected to achieve oocyte maturity; 36–38 h thereafter, transvaginal oocyte retrieval was performed. ICSI was carried out essentially as previously described (Palermo et al., 1995Go). Two to four good quality embryos were transferred into the uterine cavity 48–72 h after ICSI was performed.

Clinical pregnancy was established when a positive fetal heartbeat was determined by sonography.

Statistical analysis
Statistical analysis was performed by using the {chi}2 test.


    Results
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
In group I, the mean volume of the electroejaculates was 1.2 ml (range: 0.5–2.0). The mean total sperm concentration was 23.1 ± 23.3x106/ml with 8.67 ± 8.71% motile and in only four cases was the forward progression satisfactory. In three cases there was no motility at all. A total of 155 oocytes were injected and 85 were fertilized normally (55%). When motile sperm were injected, the fertilization rate was 74/121 (61%). From a total of 29 cycles, 49 embryos were transferred and three pregnancies were achieved (10% per cycle).

After thawing the ejaculates, motile sperm with moderate forward progression were found in nine out of 10 cycles (group II). In this group, of the 94 oocytes that were injected, 47 (50%) were fertilized normally. When frozen–thawed motile sperm were injected, the fertilization rate was 47/82 (57%) (Table IGo). There were no statistical differences in fertilization rates between the two groups. A total of 21 embryos were transferred and four pregnancies were achieved (40% per cycle). Two of them were full term (one following the transfer of frozen–thawed embryos). One is an ongoing pregnancy, and one resulted in a premature delivery at 25 weeks. Due to the low number of pregnancies, no statistical comparisons were made between the two groups.


View this table:
[in this window]
[in a new window]
 
Table I. The outcome of electroejaculation-ICSI with freeze–thawed sperm
 

    Discussion
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
The aim of our study was to evaluate the fertilizing potential in ICSI of cryopreserved sperm obtained by transrectal electroejaculation in patients with psychogenic anejaculation.

In the majority of our patients, the problem of psychogenic anejaculation seems to be related to their strict orthodox education, in which sex is considered abhorrent and taboo. Therefore, any indulgence in the subject was absolutely forbidden.

Previous studies, in men suffering from spinal cord injuries, showed favourable cryopreservation (post-thaw motility was >33% of original pre-freeze motility) in five of 16 (31%) electroejaculates. The average original motility preserved was 21% as compared with ~50% motility preservation in control groups (Buch and Zorn, 1993Go).

Pardon et al. reported no differences in mean percentage drop in post-thaw motility between electroejaculates and the control group (Pardon et al., 1994Go).

In our study, the pregnancy rate with fresh electroejaculate (group I) was only 10.5% per cycle. Schalte et al. reported similar results in ICSI with sperm obtained by electroejaculation from men with spinal cord injury (pregnancy rate of 15% with electroejaculation compared with 39% using normal ejaculated sperm) (Schalte et al., 2000Go).

These findings suggest that electroejaculation may affect sperm function. The higher pregnancy rate observed when sperm were cryopreserved after electroejaculation suggests the possibility that the process of freezing–thawing constitutes a form of selection. Sperm that retain their motility after thawing may have been less affected by the electroejaculation procedure. Obviously, this speculation should be validated by further experience with frozen electroejaculates.

Our results indicate that the fertility potential of cryopreserved electroejaculated sperm is similar to that of freshly obtained electroejaculated sperm. We therefore suggest that with the use of frozen–thawed sperm samples, the frequency of transrectal electroejaculation procedures may be lowered.

We conclude that since electroejaculation in patients with psychogenic anejaculation requires general anaesthesia and might be associated with side-effects as well as tremendous emotional stress, the use of cryopreserved electroejaculates may lessen the risks and burden of the patients and provide reasonable chances of pregnancy.

At present, not many physicians perform electroejaculation. The possibility of performing electroejaculation electively, without being confined to the timing of oocyte retrieval and cryopreserving the ejaculate, could simplify the procedure and make the co-operation between units easier.


    Notes
 
3 To whom correspondence should be addressed at: Male Fertility Unit, Department of Obstetrics and Gynecology, Bikur Cholim Hospital, Strauss 5, Jerusalem 91004, Israel. E-mail: spl113{at}netvision.net.il Back

Submitted on July 3, 2001; resubmitted on September 13, 2001


    References
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
Brackett, N.L. and Lynne, C.M. (2000) The method of assisted ejaculation affects the outcome of semen quality studies in men with spinal cord injury: a review. Neuro Rehabilitation, 15, 89–100.[Medline]

Buch, J.P. and Zorn, B.H. (1993) Evaluation and treatment of infertility in spinal cord injured men through rectal probe electroejaculation. J. Urol., 149, 1350–1354.[ISI][Medline]

Chung, P.H., Yeko, T.R., Mayer, J.C., Sanford, E.J. and Maroulis, G.B. (1995) Assisted fertility using electroejaculation in men with spinal cord injury—a review of the literature. Fertil. Steril., 64, 1–9.[ISI][Medline]

Hovav, Y., Shotland, Y., Yaffe, H. and Almagor, M. (1996) Electroejaculation and assisted fertility in men with psychogenic anejaculation. Fertil. Steril., 66, 620–623.[ISI][Medline]

Palermo, G.D., Cohen, J., Alikani, M., Adler, A. and Rosenwaks, Z. (1995) Intracytoplasmic sperm injection: a novel treatment for all forms of male factor infertility. Fertil. Steril., 63, 1231–1240.[ISI][Medline]

Pardon, O.F., Brackett, N.L., Weizman, M.S. and Lynne, C.M. (1994) Semen of spinal cord injured men freezes reliably. J. Androl., 15, 266–269.[Abstract/Free Full Text]

Schalte, E.C., Orejuela, F.J., Lipshultz, L.I., Kim, E.D. and Lamb, D.J. (2000) Treatment of infertility due to anejaculation in the male with electroejaculation and intracytoplasmic sperm injection. J. Urol., 163, 1717–1720.[ISI][Medline]

World Health Organization (1999) Laboratory Manual for the Examination of Human Semen and Semen–cervical Mucus Interaction, 4th edn, Cambridge University Press, New York.

accepted on October 24, 2001.