1 Reproductive Medicine Unit (RMU), Department of Obstetrics and Gynaecology, Centre Hospitalier Universitaire Vaudois (CHUV), 1011 Lausanne, 2 Laboratory of Andrology associated with the RMU, 1001 Lausanne and 3 Urology Department, CHUV, 1011 Lausanne, Switzerland
4 To whom correspondence should be addressed. Email: marysa.emery{at}chuv.hospvd.ch
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Abstract |
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Key words: anejaculation/counselling/ejaculation failure/IVF/oocyte retrieval
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Introduction |
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In cases of recognized ejaculatory difficulties, the following methods of sperm recovery for IVF have been reported: sex therapy (Jannini et al., 2002b; Elliott, 1993
), vibrostimulation (Elliott, 1993
; Saleh et al., 2003
), prostatic massage (Fahmy et al., 1999
; Hovav et al., 2000
), rectal probe electroejaculation (Ohl et al., 2001
; Hovav et al., 2002
), vasal sperm aspiration (Chiang et al., 2000
), percutaneous epididymal sperm aspiration (Lin et al., 1999
), and testicular sperm aspiration (Watkins et al., 1996
; Belker et al., 1998
). These techniques are, however, generally not put forth as emergency measures.
In our team, possible difficulties associated with sperm procurement are discussed with the patients on several occasions: during the initial medical consultations, during the pre-IVF counselling session with the nurses and/or counsellors, and in the andrology laboratory when the patient produces the first sperm sample for diagnostic purposes. If a problem is detected, the possibility of cryopreserving sperm for back-up use is discussed and carried out before initiating the treatment.
In the two following cases the oocyte retrieval followed pituitary down-regulation and ovarian stimulation. Both men had previously been able to obtain sperm samples by masturbation for analyses and former treatment but they failed on the day of oocyte retrieval.
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Case A |
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Case B |
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Discussion |
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In case A, the patient was taking fluoxetine (20 mg per day) and therefore the origin of his ejaculatory failure should be considered mixed: psychogenic and iatrogenic (Angst, 1998; Jannini et al., 2002a
). Clearly, the option to discontinue antidepressant medication to diminish the possible negative effect on ejaculation must be appraised in each specific situation.
If a patient has difficulty in producing a sperm sample by masturbation, the following non-invasive methods for facilitating sperm procurement can be proposed: help from the partner, sexual intercourse with a non-toxic condom (Elliott, 1993), the prescription of sildenafil (Tur-Kaspa et al., 1999
; Jannini et al., 2004
), penile vibration (Elliott, 1993
; Saleh et al., 2003
) and the viewing of a sexually stimulating video (van Roijen et al., 1996
). For patients having failed to produce a sample after a masturbation trial of over an hour, Tur-Kaspa et al. (1999)
reported the obtainment of sperm samples when they prescribed 50 mg sildenafil before a new attempt. Saleh et al. (2003)
collected data from 405 men with normal sexual functions who obtained a first sperm sample without difficulty but who were informed that the analysis of their semen was abnormal. When a second sample was requested 2 weeks later, 46/405 (11%) failed to obtain sperm by masturbation. The application of a mechanical vibration to the glans penis with a vibrator allowed nine of these 46 men (20%) to obtain a sample.
The invasive methods for obtaining sperm include vigorous massage of the prostate, rectal probe electroejaculation and surgical aspiration. These are generally employed after an attempt of sexual therapy and extensive explanations. One could question if they should also be applied in acute situations, as they often require anaesthetic procedures and operating room facilities. The ejaculation failure could furthermore be symptomatic of a repressed ambivalence concerning the wish for a child, a conflict within the couple, or an underlying psychiatric disorder. If so, invasive techniques should not be employed and psychological assistance to identify and work through the problem should be prescribed (Boivin and Kentenich, 2002).
Couples A and B had refused pre-IVF counselling, whereas 80% of the couples in our Unit accept this preventive and supportive measure (Emery et al., 2003). Both couples later acknowledged having had active difficulties in their marital relationship prior to the IVF, but had decided to present a unified front to the team in order to focus on the desired pregnancy. It is doubtful that mandatory counselling could have helped them to work out their marital problems (Hammer-Burns and Covington, 1999
; Boivin and Kentenich, 2002
; Strauss, 2002
), but it may have led to discussing sperm procurement problems.
In conclusion, ejaculation failure on the day of oocyte retrieval is a rare event, occurring in about one case in 500 retrievals in our Unit. If non-invasive methods to obtain a sperm sample fail, invasive techniques should be used with caution and within the scope of each team's experience. The cryopreservation of oocytes is unsuitable as it is still at an experimental stage, and resorting to donor sperm requires more consideration by the partners and cannot be carried out at such short notice. The main implements of prevention are the detection of sperm procurement problems before IVF, followed by an offer for psychological assistance and a firm recommendation for sperm cryopreservation before treatment.
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References |
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Submitted on February 19, 2004; accepted on June 3, 2004.