Male infertility following spinal cord injury: facts and fiction.

Traumatic spinal cord injury (SCI) resulting from motor vehicle and diving accidents, contact sports, and violence occurs to 8,000 to 10,000 Americans annually, who, depending on the severity of their spinal cord damage, face lives filled with unique medical, psychological, and social challenges. At present, there are more than one-quarter million survivors of SCI residing in the United States,[1] and although global statistics are not available, there are probably many million worldwide.

Within moments of sustaining an SCI, a person begins a lifelong process of education. Some of the knowledge these individuals gain comes though self-discovery; some of it is provided by peers whose time of injury, formal training, or self-discovery predates theirs; and some is provided by designated educators within the acute hospital and rehabilitation setting. Physical therapists (as well as other rehabilitation professionals) play a fundamental role in this education process, because they are among the first health care providers to treat the patients, often spend more continuous time with them than any other health care provider does, and commonly establish a trusting relationship with them lasting long after discharge from the hospital or rehabilitation setting. Because of this relationship, persons with SCI often rely on physical therapists as sources of information regarding their condition. This reliance places the physical therapist in a position of great responsibility to provide accurate, contemporary information. This is no easy task, because advances in medical management occur rapidly. and are sometimes reported in journals that are not widely read by physical therapists. Unless the physical therapist keeps abreast of current information, he or she could present months and outdated notions to persons with SCI.

Among the areas most often subject to gross misinformation is that of male fertility after SCI. Studies show that 80% of new injuries occur to men, and 82% occur to individuals between the ages of 16 and 45 years. Thirty percent of persons with SCI are married at the time of their injury, and 81% are still married 5 years after injury.[2] Persons with SCI are most often males of parenting age, and many seek information about how they can achieve fatherhood. Some of their questions include; "Will I be able to father a child?" "Can I achieve and maintain an erection?" "Will my semen quality get worse with the passage of time?" and Should I have my sperm frozen?"

Following an SCI, most men, but not women, experience fertility-related problems. Although women may become amenorrheic for Co to l@ months after injury,[3] they can conceive and bear children with nearly the same success rate as the general population.[4-6] During pregnancy, it is advised that a woman with SCI be well-monitored by a physician because (1) detection of some problems may be masked by impaired sensation, (2) complications unique to SCI may occur, such as autonomic dysreflexia or bladder dysfunction, and (3) women with SCI may have an increased incidence of early labor or babies with low birth weights.[6] In contrast to the relatively normal fertility experienced by women with SCI, most men with SCI experience impairments in fertility characterized by erectile and ejaculatory dysfunction and poor semen quality. This explains, in part, why only 1% of men with SCI have fathered children through sexual intercourse.[7] Exposure to these facts in isolation might deter men with SCI from ever seeking fatherhood, or might cause health care professionals to dissuade them from even trying. This article presents contemporary information about male fertility after SCI in a wider context. We will discuss common myths concerning factors that cause or influence infertility, and we will examine how men with SCI can approach biological fatherhood. This article is intended for professionals in the field of physical therapy but may be used as a source of information for those in other professions and health care fields and for persons with SCI and their loved ones.

Neurological Basis for Sexual Dysfunction in

Men With Spinal Cord injury Following an SCI, a man may experience impaired erection,[8] impaired ejaculation,[8] or impaired semen quality.[9] One or more of these conditions can impair his fertility, which, in a man, is usually defined as the ability to impregnate via sexual intercourse.[10] Understanding the alterations in erection, ejaculation, and semen quality that may occur in a man with SCI is important. These alterations cad vary depending on the neurological damage that has been sustained.

In the following section, we will briefly review the neurological basis for sexual dysfunction in men with SCI. Portions of this review are summarized from a chapter on this topic written by Martinez-Arizala and Brackett.[11]

Regulation of sexual function in the intact nervous system is via the autonomic nervous system (S-2 to S-4) parasympathetic and T-10 to T-11 sympathetic). The integration of a variety of visual, auditory, imaginative, tactile, and gustatory stimuli occurs in the hypothalamus, from which signals are relayed to the thoracolumbar sympathetic and parasympathetic spinal autonomic centers. These centers, in turn, provide the final neural outflow to the sexual organs. After SCI, the level of lesion and the degree of completeness of the injury (ie, the degree of retained function below the level of injury will be the major determinants of the degree and type of sexual dysfunction experienced. Sexual dysfunction may occur due to (1) failure of sympathetic outflow, (2) failure of parasympathetic output, (3) failure of somatic afferent and efferent neurotransmission, (4) psychological distress stemming from changes in body, image and feelings of inadequacy, or (5) a combination of these factors.

The supraspinal component of the motor pathways descends with the corticospinal tracts to the S-2 to S-4 segments of the sacral cord. The neural output from the hypothalamus to the sexual organs courses in the anterolateral columns to terminate in the intermediolateral cell columns of T-10 to L-3.[12] In men, the sympathetic output is primarily. responsible for regulating ejaculation,[13] although these spinal cord segments have also been shown to regulate the psychogenic component of penile erection. The parasympathetic spinal outflow originating from the S2 to S4 spinal segments is primarily responsible for mediating reflexogenic erection. The S-2 to S-4 spinal segments also contain other critical elements of the system, specifically the reflex are that receives sensory afferents from the genitals; the anterior horn cells that innervate striated muscles such as the external anal sphincter; and the perineal and pelvic-floor musculature, which are important in the process of ejaculation.

The bony (vertebral) level of injury. does not always correlate with the spinal cord (spinal segment) level of injury. In adults, the spinal cord ends at the L-1 to L-2 vertebral level (Fig. 1).[sup.14] Consequently, injuries at or below the L-1 vertebral level that damage the S-2 to S-4 parenchyma (the conus medullaris) will usually spare sympathetic spinal input to the sex organs but damage the lower motoneurons and the parasympathetic center located in the S-2 to S-4 spinal cord segments. Lesions above the L-1 vertebral level will interrupt the descending spinal cord pathways, yet spare the sacral components. Thus, in men with SCI, damage to the different spinal components of the nervous system that are responsible for mediating normal sexual function may produce loss of psychogenic erections (those produced by psychic stimuli), reflexogenic erections (those produced by, tactile stimulation of the penis), ejaculation, sensation of orgasm, fertility, or a combination of these.

The reported frequency of erection in men with SCI ranges from 54% to 95% of successful coitus, from 5% to 75% and of ejaculation, from 3% to 20%.[8,15,16] The incidence of successful impregnations in couples attempting conception via sexual intercourse has been uniformly dismal, with a reported range of 0% to 5%.[15] The low incidence of fertility cannot be entirely attributed to ejaculatory dysfunction. Brackett and colleagues[9,17,18] and others[19,20] have data that indicate that semen obtained from men with SCI by methods of assisted ejaculation is often of poor quality.

Methods of Assisted Ejaculation The majority of men with SCI are unable to ejaculate during sexual activity. This alone represents a major hurdle in their ability to impregnate their partner. To achieve biological fatherhood, most men with SCI require medically assisted ejaculation to obtain a semen sample, which is then used to inseminate the woman.

Anticholineserases Guttmann and Walsh[21] reported that the anticholinesterase drug prostigmine elicited spontaneous erections and ejaculations when intrathecally administered to 134 men with SCI. There was less likelihood of ejaculation if the lesion was between T-10 and L-4. Although the site of action for the drug was not defined in their study, the authors reported successful ejaculation in 58% of these men. This method has since been discontinued in clinical practice because severe side effects, including autonomic dysreflexia, were experienced by many of the men. Death from a cerebral hemorrhage occurred after the intrathecal injection of prostigmine in one man with C-6 quadriplegia.[21] Recently, a safer version of this method has been developed using subcutaneous administration of the short-acting reversible drug physostigmine, after pretreatment with N-butylhyoscine to reduce side effects.[22] This method had also been combined with masturbation or a vibrator[22-24] to successfully achieve ejaculation.

Vibratory Stimulation Vibratory stimulation has been used to produce ejaculation in men with SCI.[25-27] A vibrator is placed on the base or glans of the penis, and stimulation is delivered until ejaculation is produced. The technique seems to work best in men with higher (T-10 or above) or incomplete lesions,[28,29] and its success is dependent on the presence of a neurologically intact lower and lumbosacral cord.[26] This technique works better with a high-amplitude vibrator (2.5 mm) versus a low-amplitude vibrator (less than 2.5 mm).[29,30 Amplitude refers to the peak-to-peak distance of the moving part of the vibrator, that is, how far the vibrating part is moving tip and down. When a high-amplitude vibrator is used on men with a neurologically intact lumbosacral cord, semen samples are obtained in Lip to 95% of men with SCI.[29]

Electroejaculation Electrostimulation via the rectum (termed "electroejaculation") was originally developed to procure semen from farm animals and endangered species for selective breeding, but has been modified and refined for use in humans.[19] This technique was first used in humans with SCI by Horne and colleagues[31] 1948. Refined in the 1980s, electroejaculation works by delivering electrical current through an electrode positioned on a probe placed within the rectum of the man.[19] When electrical current is applied, an ejaculation is often produced, sometimes accompanied by erection. The ejaculation may be antegrade @out the tip of the penis) or retrograde (into the bladder), or both. The sperm of the retrograde ejaculate can be obtained by draining the bladder contents with a catheter after ejaculation and then isolating the retrograde sperm via centrifugation.[32] Recent studies have shown that semen can be retrieved by electroejaculation in 85%[33] to 100%[34] of men with SCI. Of the three methods outlined, electroejaculation has been used most frequently because it is associated with a high success rate in obtaining semen and a low incidence of undesirable side effects.[19,20,35-37]

Semen Quality Since the advent of safe, reliable methods of obtaining ejaculate from men with SCI, data have accumulated on the condition of the semen. This section will summarize studies of the semen quality, of men after SCI.

Acute Versus Chronic Injuries Acutely injured men (those with injuries of less than 1 year) often query health care professionals about the current and future status of their semen quality. Only a few published reports have addressed the issue of semen quality of men injured less than 1 year, in part because men with SCI may not be physiologically or emotionally prepared to participate in assisted ejaculation procedures and in part because their recovery demands attention in so many other areas of rehabilitation and social reintegration. Nevertheless, one study showed that within the first 2, weeks of injury, semen could be obtained by electroejaculation and was of good quality.[38]

In contrast, Brackett et al (study in progress) have found inconsistent results in 15 newly injured men. In this study, vibratory stimulation or electroejaculation has been tried on each subject starting between 6 and 12 weeks postinjury, and continuing every 1 to 3 months for up to 24 months postinjury. To date, the following differences between ejaculates of men with acute and chronic SCI have been observed: (1) Semen often cannot he obtained by, assisted ejaculation of acutely injured subjects, in contrast to men injured 1 to 2 years or longer in whom semen can be obtained almost 100% of the time; (2) when semen is obtained from men with acute injuries, it is of tell lacking sperm, again in contrast to men with chronic injuries for whom at least some sperm are present 95% of the time; (3) when sperm are present in the ejaculates of acutely, injured men, the quality max, main dramatically, from month to month, in contrast to individuals with chronic injuries, for whom there is less monthly, variation in semen quality; and (4) the typical pattern of body movements (contraction of abdominal muscles below the level of injury, contraction of pelvic floor muscles, abduction of thighs, knee flexion, back arching) observed during the electroejaculation of men with chronic SCI is virtually absent in those with acute injuries.

Semen Quality The remainder of our article focuses on semen quality in men with chronic injuries (operationally defined as injuries of 1 year or longer). Using assisted ejaculation, semen can be obtained from the majority of chronically injured men with SCI. As of April 1996, we (NL Brackett and CM Lynne, unpublished data) have performed a series of 912, assisted ejaculation procedures on 185 chronically, injured anejaculatory men with SCI who participated as research subjects in studies of their semen quality. Ejaculates were obtained from all of these subjects, most of whom (95%) had sperm in their semen.

The semen quality. of men with chronic SCI has been characterized in numerous studies.[9,17,18,20,32,39-45] In general, the semen contained normal numbers of sperm but low percentages of motile sperm. This is shown in Figures 2A and 2B from a study by Brackett et al[17] that compared the semen quality, of 66 men with SCI with that of men without SCI. This study also showed that the percentage of normally formed sperm was lower in the ejaculates of subjects with SCI than in the ejaculates of their uninjured counterparts (Fig. 2C). Most of the nonmotile sperm obtained from subjects with SCI are dead (as opposed to alive with an impaired motility mechanism, and the motile sperm die more quickly than those of men without SCI.[46]

Causes of Poor Sperm Motility The majority of studies report that men with SCI produce sperm ill normal lumbers but that the sperm are "fragile" (ie, have impaired motility and viability). This semen profile is uncommon in the general male population-fertile or infertile-and the reasons for this condition are unclear. That following have been hypothesized as causes of poor semen quality in men with SCI:

1. Lifestyle factors such as elevated scrotal temperature, methods of bladder management, and infrequency of ejaculation.

2. Physiological factors secondary to SCI such as an altered hormonal environment, leucocytospermia, and the time postinjury.

3. Seminal plasma factors, which regulate normal sperm motility. Lifestyle foctors:

Scrotal temperature. Because the semen profile of most men with SCI is uncommon in the general population, factors that are unique to their lifestyle have been investigated as possible causes of this condition. One hypothesis is that the poor quality of semen of men with SCI may be related to elevated scrotal temperature, either from a generalized scrotal thermoregulatory dysfunction or because of sitting for prolonged periods in a wheelchair. Wang[47] and Brindley[48] have reported higher scrotal temperatures in men with SCI who sit in wheelchairs than in men without SCI sitting in armchairs, and Brindley[48] found that higher scrotal temperatures were associated with fewer motile sperm in men with SCI. Conversely, Brackett et al[17] found no difference between men with and without SCI with respect to (1) oral temperature, (2) scrotal temperature, or (3) the difference between oral and scrotal temperatures. Additionally, no correlation was observed between these temperatures and the semen quality of men with SCI. Thus, the results of this study show no generalized scrotal thermoregulatory dysfunction in men with SCI. More importantly, a cohort of men with SCI who did not use a wheelchair for locomotion (ie, they walked with crutches) had semen quality as impaired as that of men who used wheelchairs.[17] Based on these studies, there appears to be no strong evidence to suggest that elevated scrotal temperature in men with SCI is a major contributor to their poor semen quality. Although it may improve the confidence of some men with SCI to use strategies to cool their scrotum, no published reports have determined that this treatment results in improved semen quality.

Infrequency of ejaculation. Infrequency of ejaculation is a lifestyle factor thought to adversely affect semen quality in men with SCI. In similar studies, Beretta et al[28] and Siosteen et al[49] instructed subjects to ejaculate using a vibrator at home for a time period ranging from 3 to 6 months. Semen quality was measured before and after this period. Although both groups of authors recommended weekly stimulations, actual ejaculation frequencies were not reported. Beretta and colleagues,[28] but not Siosteen and co-workers,[49] reported improved sperm motility following use of the vibrator. A study in progress by Brackett and colleagues in which ejaculate was obtained by vibration and electrical stimulation at the following intervals: 1, 2, and 3 days or 1, 2, 4, 8, 12, and 16 weeks. Stimulation intervals of less than 1 week and more than 12 weeks resulted in ejaculates with lower sperm concentration or lower sperm motility than those produced within 12 to 12-week intervals. Otherwise, there was no association between semen quality and frequency of ejaculation.

Bladder management. Methods of bladder management have been thought by some to cause impairments in semen quality. Ohl et al[50] found that the sperm motility of men with SCI who used intermittent catheterization was better than that of men who used alternate forms of bladder management; however, sperm motility was lower in men with SCI than in men without SCI.

Physiological factors:

Endocrine dysfunction. A normally functioning hypothalamic-pituitary-gonadal (HPG) axis is required for normal sperm production. A disturbance in this axis could lead to problems in semen quality. Several studies have examined the endocrine status of men with SCI, with some studies showing normal levels of testosterone (T), luteinizing hormone (LH), follicle-stimulating hormone (FSH), and prolactin (PH) and with other studies showing these levels to be abnormal.[7.9,51-53] Until recently, however, none of these studies correlated endocrine findings with the semen quality of men with SCI. This was done by Brackett et al[9] who found that mean serum levels of LH and FSH were lower but T and Prl were similar in men with SCI compared with men without SCI who were normospermic. Importantly, no association was observed between the serum levels of these hormones and semen quality, except that subjects with SCI who had elevated FSH (n=5) were azoospermic (no sperm in their semen).

Cardiovascular function. Normal blood flow to the gonads is required for normal sperm production. Although no studies have examined scrotal or testicular blood flow in men with SCI, several authors[54-57] have reported that men with tetraplegia lose vasomotor function and vascular tone and have lower cardiac output and stroke volume compared with men without SCI. These changes result in part from poor return of venous blood from the lower extremities and in part from atrophy of the heart and diminished size of the left ventricular chamber. Men with paraplegia do not seem to sustain the same systemic alterations of blood flow as men with tetraplegia.[55] Clearly, further investigation is required to determine whether there are alterations in gonadal blood flow in men with SCI and whether such changes are related to impaired semen quality.

Stress. Among the more novel explanations for infertility in men with SCI is that damage to the nervous system might be associated with stress-related factors. Studies of men without neurologic impairment have demonstrated undesirable effects of physiological stress on male fertility.[58-61] Recent reports[62-64] have shown that immune function in experimental animals is immediately suppressed after chemical or surgical ablation of their sympathetic nervous system. Preliminary evaluation of immune function in humans with tetraplegia has shown similar immune dysfunction, with the type of immune deficits mirroring stress-induced immune deficits.[65] These studies showed that acute and chronic stress from physical activity and fatigue modify the endocrine status of young asymptomatic men in the following ways. Stress from physical overtraining yields an intensity-dependent inhibition of androgen and gonadotropin secretion characterized by transitory lowering of free (ie, non-sex hormone-bound) testosterone (FT) levels and the Ft:cortisol ratio (FTCR) for up to 24 hours following cessation of exercise.[66-69] Intense physical activity may also alter the pulsatile release of hormones from various aspects of the HPG-axis.[70-71] Several authors have reported concomitant decreases of LH and FT following exercise,[72-74] the mechanism of this suppression being attributed to a postexercise decrease in the hypothalamic release of GnRH (gonadotropin-releasing hormone.[59,69-74] Testosterone levels are lower in trained than untrained men,[58 75] a deficiency attributed to stress-induced dysfunction of the HPG axis.[58]

Leucocytospermia. Leucocytospermia (excessive numbers of white blood cells [WBC] in the ejaculate) is observed in many men with SCI. This condition is thought to contribute to poor semen quality, because studies of men without SCI indicate that leucocytospermia is associated with defects in the semen profile, including (1) reductions in the volume of the ejaculate and in sperm concentration and sperm motility and (2) loss of sperm function as a result of oxidative stress, [76,77] or the secretion of cytotoxic cytokines.[78] In studies of men with SCI, electrical current administered in vivo (via electroejaculation and in vitro decreased sperm motility and increased the formation of reactive oxygen species (ROS).[79,80] Reactive oxygen species are unstable, reactive molecules that can cause toxicity or death to cells of the body, including sperm cells. Reactive oxygen species include hydrogen peroxide, the superoxide anion, and the hydroxyl radicals. Leucocytospermia may indicate the existence of a reproductive tract infection (RTI). In men with SCI, antibiotic treatment of an RTI does not result in improved sperm motility, although it does lower the number of WBC present in the semen.[50]

Time postinjury, freezing sperm. Men with SCI often question whether their semen quality will deteriorate over time. After 1 to 2 years postinjury, during which time semen collection and quality are inconsistent (see "Acute Versus Chronic Injuries" section), there is no association between semen quality and number of years postinjury.[20] Mallidis et al[38] recommend freezing sperm shortly after injury, but this recommendation is not universally agreed on. Padron et all[45] have shown that freezing does not damage sperm from men with SCI any more than sperm from men without SCI; however, the quality of thawed sperm is almost always worse than that of fresh sperm (ie, total motile sperm is less, and the quality, of the motility is worse). Although it may be advantageous sometimes to freeze sperm for use in assisted reproductive procedures, there is no evidence to support routinely, freezing sperm from the majority of men with SCI.

Methods of ejaculation. Brackett et al[81] found that sperm motility was higher (but not normal) when obtained by vibratory stimulation as compared with electroejaculation. Whether this difference is due to a beneficial effect of vibration stimulation or a damaging effect of electroejaculation is not known. Evidence suggesting that electroejaculation affects sperm motility is offered by studies showing the damaging effects of electrical current on sperm motility[79,80,82] and by a study showing that the biochemical constituents of electroejaculates of men with SCI differ from those of masturbated ejaculates from noninjured men.[44] Evidence against electroejaculation's effects is offered by a study showing that the sperm motility of neurologically intact dogs was no different when collected by electroejaculation versus an artificial vagina.[83]

Seminal plasma factors:

Alterations in normal seminal plasma composition may alter normal sperm motility.[84] As the constituents of seminal plasma from electroejaculates of men with SCI differ from those of men without SCI,[44] it is possible that abnormalities within the seminal plasma are responsible for compromised sperm motility. Evidence for this idea is presented by Brackett et al,[18] who showed that the seminal plasma of men with SCI (collected by vibratory stimulation) inhibited the motility of sperm taken from men without SCI. Additionally, there is evidence that sperm from the epididymis of men with SCI (ie, sperm that has not yet been mixed with seminal plasma) has normal motility.[85,86]

Summary of Issues Relating to Semen Quality

The causes of poor semen quality in men with SCI have yet to be fully understood, although the following are clear:

1. Most men with SCI have very similar semen profiles, despite the differences in the level and extent of their spinal cord lesions.

2. Lifestyle factors alone (ie, scrotal hyperthermia, infrequent ejaculations, bladder management) do not seem to account for the poor semen quality.

3. Secondary physiological factors alone do not seem to account for the problem: (1) Some hormones of the HPG-axis are disturbed, but are not correlated with semen quality, (2) the time postinjury, is not an influencing factor in semen quality (after 1-2 years postinjury), and (3) the method of collection may affect semen quality but does not account for the large difference in semen quality between men with and without SCI.

4. Seminal plasma of men with SCI may contribute to poor sperm motility.

Given these pieces of the puzzle, we hypothesize that the semen problems of men with SCI may be the result of a disturbance of their autonomic nervous system (ANS), because the common denominators in this condition are (1) all of the patients have an SCI and (2) the organs controlling semen quality are under the control of the ANS. Although this hypothesis seems simplistic, it represents a shift in the focus of this problem from lifestyle factors to the role of the nervous system in the production and maintenance of normal semen quality. Little is known about the role of the nervous system in the control of normal semen quality. The poor semen quality in men with SCI raises questions about this role that warrant further investigation.

Assisted Reproductive Techniques

Some of the same assisted reproductive techniques (ART) available to infertile couples with a male partner without SCI may be used to assist couples with malefactor infertility secondary to SCI. The decision of which technique to attempt should be made in conjunction with a physician (urologist or obstetrician/gynecologist) who is specialized in treating these couples. In addition to the man's semen quality, other factors that influence the selection of an ART include the health of the female partner, the ages of the partners, whether the couple can financially., afford the procedure, how quickly they want children, and the couple's emotional stability in dealing with possible conception failures. The following section reviews the available techniques in assisting men with SCI to become fathers. Further details about ART have been published elsewhere.[87]

Approximately, 10% of men with SCI can ejaculate during intercourse, and pregnancy has resulted from this method.[88] When participating in any sexual activity, men with SCI with a T-6 or higher level of injury should be cautious for signs of autonomic dysreflexia, which include sweating above the level of lesion, hypertension, severe headache, and slowing of the heart rate. Often, however, some facial flushing is all that may be observed. The symptoms of autonomic dysreflexia can usually be prevented by taking 20 to 40 mg of the calcium channel antagonist, nifedipine, by mouth about 45 minutes prior to ejaculation. If ejaculation is not possible during intercourse, men with SCI may try to ejaculate with a vibrator - usually called a "massager" - which can be purchased in a drugstore. The vibrator is placed on the head or the shaft of the penis. With this method, care must be taken to (1) avoid autonomic dysreflexia and (2) not damage the skin of the penis. At the point of ejaculation, the semen can be collected in a cup and then inserted into the partner's vagina using a syringe (without a needle). If these methods fail, a couple can seek medical assistance, during which the semen collection is attempted by medical personnel who typically use vibratory stimulation or electroejaculation. The ejaculate can then be used for intrauterine insemination (IUI), in vitro fertilization (IVF), or gamete intrafallopian transfer (GIFT). These methods vary in their success rate and expense, with IUI representing the least expensive and least successful method and GIFT being the most expensive and most successful. If these methods fail due to a very low number of motile sperm produced by the male, the procedure of intracytoplasmic sperm injection (ICSI) may be combined with IVF or GIFT, or both, to increase the chance of pregnancy. With ICSI, only a few motile sperm are required, which may be isolated from the ejaculate or taken from the epididymis or testicles of the man.[89,90]

Only a few investigators have reported pregnancy rates (pregnancies/number of couples attempting pregnancy) or fecundity rates (pregnancies/number of pregnancy attempts) in couples with male-factor infertility secondary to SCI or other neurologically based anejaculation. One report[91] advised using IVF as the method of first choice in these couples. Brackett et al[32] recommended that, in men who are able to produce even a few million motile sperm, IUI (in combination with ovulation induction of the female partner) ought be attempted up to four times. If pregnancy is not achieved after four IUI attempts, IVF or GIFT should be attempted. With this regimen, Brackett et al[32] have achieved a cumulative pregnancy rate of 49% (26% for an IUI group and 71% for an IVF/GIFT group).

Hope for Fatherhood by Men With

Spinal Cord injury

Although SCI renders many, men incapable of easily, impregnating their female partners by vaginal intercourse, current technology can assist many to become biological fathers. Thus, when a man with SCI asks "What are my chances of becoming a father?" an appropriate response is "With some help, it is very possible." The first step is to have a semen evaluation by, professionals trained to obtain and analyze sperm from a man with SCI. There are approximately 200 physicians in the United States who are trained to perform this service. Our Male Fertility Research Program has evaluated the semen of IS men with SCI and has provided assistance to some of these men who wished to become fathers. Thus far, @O couples have opted to pursue parenthood by these methods. Of these 30 couples, 13 couples have delivered children and the female partners in 3 couples are currently pregnant. Treatment of 2 other couples led to pregnancies that terminated by miscarriage. Thus, our pregnancy success rate is 60% (18 pregnancies/30 couples). This rate is higher than rates reported at some other centers[91-95] but may be biased by the relatively low number of couples treated to date. Conversely, the fecundity and pregnancy rates in all fertility programs of this type are limited by the current state of technology, technology, that is undergoing widespread research and constant clinical improvement. This bodes well for future efforts at achieving high(er) rates of biological fatherhood for couples in which the male partner has an SCI. The urology, department of a medical school at a major university is a good place to start a search for information about centers with expertise in treating male-factory, infertility secondary to SCI.

The important message contained in this article is that biological fatherhood is possible in men with SCI. Thus, a newly injured man with SCI who is recovering in the intensive care or rehabilitation setting ought never be given the message: "You will never become a father." Until his sperm is thoroughly evaluated - and this usually will not happen until he is discharged from the rehabilitation setting - the possibility of biological fatherhood remains very much alive for men with SCI.

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