1 Instituto de Reproducción CEFER (Centro Médico Teknon), Marquesa de Vilallonga, 08017 Barcelona and 2 Instituto Guttmann, Barcelona, Spain
![]() |
Abstract |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
Key words: ICSI/paraplegic/pregnancy/prostatic massage/spinal cord-injured
![]() |
Introduction |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
Case report |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
Neurological exploration after the spinal cord lesion that caused the paraplegia had been stable and was as follows: hypoesthesia below T12 and anaesthesia below L3, non-existent tendon reflex in lower extremities, and equivocal plantar reflex. Urologically, he had a neuropathic bladder, and the urodynamic study showed a hypoactivehyposensitive detrusor with negative reflexes, micturition by pressure with good flow and no post-urinary residue.
His libido was intact, but he did not have intercourse because he could not sustain an erection. Nor was penile vibratory stimulation successful. In order to obtain an erection he had used intracavernous injection of papaverine (the last time had been 2 years earlier) with unsatisfactory result. Sometimes, after micturition or when getting onto the examination couch from his wheelchair, a few drops of sticky, yellowish secretion came out. The physical examination was normal from the andrological perspective: testes of 1520 ml (measured with a Prader orchidometer); normal epididymis, vasa deferentia, penis and prostate. There was no venous return in the left spermatic cord. After urination, a drop of secretion was obtained which revealed 141 immotile and dead spermatozoa (stained with eosinnigrosine) on microscopic examination (x400) in 13 fields.
A fertility examination of the patient's 30-year-old wife revealed no relevant abnormalities.
The patient had undergone electroejaculation on five occasions, under general anaesthesia. He provided a report on semen quality obtained on two previous electroejaculations: (i) a volume of 1.5 ml was recovered, sperm count of 51.2x106/ml, 2.6% motile and 10% normal morphology; and (ii) volume 2 ml, sperm count of 49.9x106/ml; 1.3% motile but sperm morphology was not available.
In-vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) was also performed at another centre: eight oocytes were obtained, five in the metaphase II stage (MII); five embryos cleaved, three of which were transferred. Pregnancy was not achieved.
Prostatic massage and the related IVFembryo transfer cycle
Ovulation
The patient's partner was stimulated using gonadotrophin-releasing hormone analogues (GnRHa; Procrin ; Abbot, Madrid., Spain) and recombinant follicle stimulating hormone (rFSH; Gonal-F®, Serono, Barcelona, Spain). Ovarian response was monitored by means of a series of intravaginal echographic examinations and by measuring the plasma concentrations of 17-ß-oestradiol. Ultrasound-guided transvaginal follicular puncture was performed under sedation with propofol. From the 27 aspirated follicles, 19 oocytes were obtained 16 MII, two MI and one abnormal.
Collection of spermatozoa
The patient was placed in the prone position on the examination couch, resting only on his arms and feet. The kneechest position was not possible, as the patient's knee joints were ankylosed. Two Falcon (ref. 2001), tubes were prepared each with 2.5 ml of HEPES buffered HTF (human tubal fluid) supplemented with 0.3% human serum albumin (HSA). The prostaticvesicular and ampullae deferentiae massage was performed from lateral to mid-line. The hypotonic anal sphincter facilitated the massage and no discomfort was caused to the patient. An abundant secretion was easily collected from the glans. The total volume secreted was 6 ml containing a total number of 12.32x106 spermatozoa (6.24x106 with tails) and 8% with motility (8% graded + and ++; WHO, 1992); and 16% with normal morphology (Papanicolaou stain; WHO, 1992
).
Sperm preparation
Spermatozoa were prepared for ICSI using PureSperm (Scandinavian IVF Science®, Gothenburg, Sweden) 70% centrifuged at 270 g for 20 min and 0.162500x106 spermatozoa were obtained, 20% of which were motile (11% graded ++ and +++; 9% graded +). ICSI was performed using a Nikon® microscope, micromanipulators TM5 and ZM3 (Narishige Co. Ltd, Tokyo, Japan), home-made holding micropipettes and injecting micropipettes (Cook Australia, Queensland, Australia). The spermatozoa were obtained from a drop of 5% polyvinyl pyrrolidone in HTF.
Microinjection
Eighteen oocytes were microinjected at the 3 o'clock position with the polar body placed at 12 o'clock. Eighteen hours after microinjection there were 12 zygotes with two pronuclei (PN), one with 1 PN, three with 0 PN and two oocytes had degenerated. Embryos were individually cultured in vitro in HTF + 0.3% HSA drops under mineral oil and standard conditions until day 3.
Embryo transfer
Immediately before embryo transfer, assisted hatching was performed with Tyrode's acid solution, as is usual in all the embryo transfers in our laboratory. Because most of the oocytes had excessive granularity concentrated in the central part of the cytoplasm, we decided to transfer four embryos. Three of them derived from oocytes with excessive granularity. The four embryos (79 cells) were transferred after informing the couple about the risks of multiple pregnancy and receiving their consent. The woman was subjected to immunodepressive treatment with methylprednisolone (16 mg per day/4 days) starting from the day before embryo transfer. Thirteen days after embryo transfer plasma concentrations of ß-human chorionic gonadotrophin compatible with pregnancy were detected. The echogram showed three fetal sacs with positive heart beat. At the 32nd week of pregnancy, three healthy babies, two males and a female, were born by Caesarean section. They weighed 1800, 1600 and 1200 g respectively.
![]() |
Discussion |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
Efficacy in obtaining spermatozoa
Vibratory stimulation is effective in 82.8% of patients with high neuronal lesions, above T10, and intact lower spinal reflex (Dahlberg et al., 1995). The efficacy of electroejaculation is 83% (Dahlberg et al., 1995
), and it is indicated when vibratory stimulation has failed or the neuronal lesion is low on the spinal cord. In SCI men, the efficacy of sperm extraction from the vasa deferentia, epididymis or testicles is expected to be 100%. In the case presented here, vibratory stimulation was not effective, whereas prostatic massage was as effective as electroejaculation, thus making testicular sperm extraction (TESE) unnecessary. We were previously unaware of the efficacy of prostatic massage in obtaining spermatozoa from these patients.
Simplicity, safety and cost
Vibratory stimulation can be performed at home (Beretta et al., 1989) but may cause hypertension and autonomic dysreflexia (Steinberger et al., 1990
). If retrograde ejaculation occurs (65% of patients; Ohl et al., 1996
), collection of spermatozoa from urinary alkalinization is required. Both electroejaculation and collection of spermatozoa via the seminal ducts or from the testes seem to be highly efficient protocols but, with or without general anaesthesia, are expensive and uncomfortable techniques. We consider prostatic massage as an ideal technique because of its simplicity and cheapness.
Quality of the semen obtained
Depending on the quality of the semen obtained, it is possible to perform artificial insemination or IVF-ICSI. Due to the poor quality of their semen sample, most SCI patients have to undergo ICSI cycles (Hultling et al., 1997; Quinn et al., 1998
), although repeating electroejaculation appears to improve semen quality (Ohl et al., 1996
) but leads to increasing patient annoyance. Electroejaculation often provides many more spermatozoa than surgical sperm retrieval, thus permitting semen cryostorage and multiple ICSI attempts. With the prostatic massage we were able to obtain as many spermatozoa as with electroejaculation and also to freeze them.
In conclusion, we consider prostatic massage to be useful for obtaining spermatozoa from SCI patients and even from patients with ejaculatory disorders of other aetiologies, although the efficacy of this technique can only be validated through experience with a large number of patients. The simplicity and safety of prostatic massage and the efficacy shown in this case encourages us to explore this option.
![]() |
Acknowledgments |
---|
![]() |
Notes |
---|
![]() |
References |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
Brindley, G. S. (1984) The fertility of men with spinal injuries. Paraplegia, 22, 337348.[ISI][Medline]
Bustillo, M. and Rajfer, J. (1986) Pregnancy following insemination with sperm aspirated directly from vas deferens. Fertil. Steril., 46, 144146.[ISI][Medline]
Chung, P.H., Yeko, T.R., Mayer, J.C. et al. (1995) Assisted fertility using electroejaculation in men with spinal cord injury a review of literature. Fertil. Steril., 64, 19.[ISI][Medline]
Dahlberg, A., Ruutu, M. and Hovatta, O. (1995) Pregnancy results from a vibrator application, electroejaculation, and a vas aspiration programme in spinal-cord injured men. Hum. Reprod., 10, 23052307.[Abstract]
Guttmann, L. and Walsh, J.J. (1971) Prostigmine assessment test of fertility in spinal man. Paraplegia, 9, 3951.[Medline]
Hultling, C., Rosenlund, B., Levi, R. et al. (1997) Assisted ejaculation and in-vitro fertilization in the treatment of infertile spinal-cord injured men: the role of intracytoplasmic sperm injection. Hum. Reprod., 12, 499502.[ISI][Medline]
Ohl, D.A., Menge, A. and Sonksen, J. (1996) Penile vibratory stimulation in spinal cord injured men: optimized vibration parameters and prognostic factors. Arch. Phys. Med. Rehabil., 77, 903905.[ISI][Medline]
Quinn, F.B., Saunders, D.M., Rutkowski, S.B. et al. (1998) The use of ICSI with electroejaculated sperm in spinal cord-injured (SCI) men. 16th World Congress on Fertility and Sterility, Abstracts, p. 457.
Rawicki, H.B. and Hill, S. (1991) Semen retrieval in spinal cord injured men. Paraplegia, 29, 443446.[ISI][Medline]
Steinberger, R.E., Ohl, D.A., Benett, C.J. et al. (1990) Nifedipine pretreatment for autonomic dysreflexia during electroejaculation. Urology, 36, 228231.[ISI][Medline]
Thomas, R.J.S., McLeish, G. and McDonald, I.A. (1975) Electroejaculation of the paraplegic male followed by pregnancy. Med. J. Aust., 2, 798799.
WHO (1992) Laboratory Manual for the Examination of Human Semen and SpermCervical Mucus Interaction. Cambridge University Press, Cambridge.
Submitted on November 6, 1998; accepted on February 7, 1999.