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Electroejaculation in Combination with Intracytoplasmic Sperm Injection in Patients with Psychogenic Anejaculation Results in Lower Fertilization Rates
FERTILITY AND STERILITYt VOL. 69, NO. 3, MARCH 1998 Copyright ©1998 American Society for Reproductive Medicine Published by Elsevier Science Inc. Printed on acid-free paper in U.S.A.
Electroejaculation in combination with intracytoplasmic sperm injection in patients with psychogenic anejaculation results in lower fertilization rates Yedidya Hovav, M.D., Irit Kafka, M.D., Mary Dan-Goor, Ph.D., Haim Yaffe, M.D., and Miriam Almagor, Ph.D. Bikur Cholim Hospital, Jerusalem, Israel
Objective: To evaluate the outcome of intracytoplasmic sperm injection (ICSI) with sperm obtained by electroejaculation in men with psychogenic anejaculation. Design: Retrospective clinical study. Setting: In Vitro Fertilization Unit, Bikur Cholim Hospital, Jerusalem, Israel. Patient(s): Seven men with psychogenic anejaculation who underwent 16 sessions of electroejaculation in combination with ICSI. Intervention(s): Electroejaculation, ICSI. Main Outcome Measure(s): Semen analysis, ICSI, fertilization rates. Result(s): All patients had poor sperm motility. One hundred forty-seven oocytes were injected, with a fertilization rate of 27% (39/142). One ongoing pregnancy was achieved. Conclusion(s): Sperm obtained by electroejaculation have low motility and reduced fertilization potential. Nevertheless, ICSI should be offered to improve the possibility of successful pregnancy. (Fertil Sterilt 1998;69:561–3. ©1998 by American Society for Reproductive Medicine.) Key Words: Electroejaculation, ICSI, fertilization rates
Received May 27, 1997; revised and accepted October 1, 1997. Reprint requests: Yedidya Hovav, M.D., IVF Unit, Department of Obstetrics and Gynecology, Bikur Cholim Hospital, 5 Strauss Street, P.O. Box 492, Jerusalem, 91004, Israel (FAX: 972-2-6701-289). 0015-0282/98/$19.00 PII S0015-0282(97)00532-3
Electroejaculation has become an accepted form of semen procurement in anejaculatory men with spinal cord injuries. However, these electroejaculates exhibit low motility and poor sperm function. In a previous study (1), we demonstrated that the electroejaculates obtained from men with psychogenic anejaculation show poor motility. The sperm quality of patients with psychogenic anejaculation is similar to that of patients with spinal cord injuries, despite the fact that the former do not have a neurologic disorder and its complications. Therefore, it has been suggested that electroejaculation may have detrimental effects on sperm (2). We thus decided to evaluate fertilization rates when performing ICSI in combination with electroejaculation.
MATERIALS AND METHODS Patients Seven patients who had psychogenic anejaculation were evaluated for primary male factor infertility; a patient history was taken, a physical examination was performed, and serum hormone levels were determined. The diagnosis of psychogenic anejaculation was based on the lack of physical causes for the condition and on the presence of nocturnal emissions and the existence of sexual relationships without conscious ejaculations. The mean age of the patients was 29 years (range, 22– 41 years). All the patients were free of urinary tract infections and had occasional nocturnal emissions. Retrograde ejaculation was ruled out after urine examination. The 561
TABLE 1 Sperm characteristics after electroejaculation and ICSI fertilization rates. Patient no.
Total sperm count (3106)*
Motility (%)
Age of spouse (y)
No. of cycles
No. of oocytes fertilized/ no. of oocytes injected (%)
1 2 3 4 5 6 7
19.0 17.0 6.0 1.5 194.0 11.0 13.0
0.5 0.5 1.0 0.5 14.0 5.0 45.0
26 26 29 22 32 41 31
4 2 1 3 3 1 2
4/39 (10) 3/10 (30) 5/9 (55) 11/31 (35)† 8/29 (27) 1/6 (16) 7/18 (38)
* The total sperm count was calculated from the combination of antegrade and retrograde ejaculates. † A clinical pregnancy was achieved.
levels of testosterone, FSH, LH, and prolactin were within the normal range. The spouses ranged in age from 20 –38 years. In all the spouses, a medical history was taken, a physical examination was performed, and the ovulatory status was evaluated. A hysterosalpingogram was obtained before treatment. The ovulation induction, electroejaculation procedure, and semen preparation were performed as previously described (1). Oocytes were assessed for the presence of pronuclei 15–20 hours after injection. Embryos were assigned to one of three quality categories according to their morphology. For statistical analysis, the x test was used. 2
The electroejaculation procedure for the treatment of men who have psychogenic anejaculation was approved by the Helsinki Committee of Bikur Holim Hospital.
RESULTS We performed 16 cycles of ICSI with sperm retrieved by electroejaculation from seven men with psychogenic anejaculation (Table 1). Of the 142 oocytes that were injected, 39 (27%) were fertilized normally. Thirty-eight embryos were transferred. Twenty-three (59%) of the embryos were of good quality and 15 (39%) were of poor quality. One woman got pregnant and a healthy baby boy was delivered after an uneventful pregnancy. Our average ICSI fertilization rate during the study period was 42%, and the decrease in fertilization rate observed in patients with psychogenic anejaculation was statistically significant (P , 0.01).
DISCUSSION The aim of our study was to evaluate the fertilizing potential in ICSI of sperm obtained by transrectal electro562
Hovav et al.
Communications-in-brief
ejaculation from patients with psychogenic anejaculation. Previous studies (2, 5) demonstrated that electroejaculated sperm exhibited severe asthenospermia. This was the case in patients with spinal cord injuries as well as those who had undergone lymph node dissection and those who had psychogenic anejaculation (1). High fertilization rates are usually achieved with ICSI independent of semen parameters. However, in our study, ICSI fertilization rates after electroejaculation were significantly lower than those obtained after normal ejaculation. This may indicate that the electroejaculation procedure hampers the fertilizing capacity of sperm in ICSI. The electric current and the heat generated during the procedure might negatively affect sperm components to reduce both the fertilizing ability of the sperm within the oocyte and the development of the zygote. Similar findings recently have been reported in a patient with idiopathic anejaculation (3). Denil et al. (4) showed that in a patient who underwent electroejaculation because of previous retroperitoneal surgery, 6 of 10 oocytes were fertilized in ICSI but only 3 (30%) developed into embryos. Their observations support our suggestion that the electroejaculation procedure not only may decrease fertilization rates but also may induce arrest of embryonal development. Alternatively, the unsatisfactory sperm parameters may be related to several other negative effectors, such as the overproduction of oxygen radicals (5), the emission of immature sperm cells, or the presence of antisperm antibodies (6). Therefore, the option of epididymal or testicular fineneedle aspiration should be considered as a plausible alternative to transrectal electroejaculation to achieve higher rates of fertilization and pregnancy. References 1. Hovav Y, Shotland Y, Yaffe H, Almagor M. Electroejaculation and assisted fertility in men with psychogenic anejaculation. Fertil Steril 1996;66:620 –3. 2. Sikka SC, Wang R, Kukuy E, Walker CF, Hellstrom WJ. The detrimen-
Vol. 69, No. 3, March 1998
tal effects of electric current on normal human sperm. J Androl 1994; 15:145–50. 3. Kiekens C, Spiessens C, Duyck F, Vandenweghe D, Coucke W, Vanderschueren D. Pregnancy after electroejaculation in combination with intracytoplasmic sperm injection in a patient with idiopathic anejaculation. Fertil Steril 1996;66:834 – 6. 4. Denil J, Kupker W, Al-Hasani S, Schill T, Kuczyk M, Jonas U, et al. Successful combination of transrectal electroejaculation and intracyto-
FERTILITY & STERILITYt
plasmic sperm injection in the treatment of anejaculation. Reprod 1996; 11:1247–9. 5. Rajasekaran M, Hellstrom WJ, Sparks RL, Sikka SC. Sperm damaging effects of electric current: possible role of free radicals. Reprod Toxicol 1994;8:427–32. 6. Almagor M, Dan-Goor M, Hovav Y, Kafka I, Shotland. Antisperm antibodies in men with psychogenic anejaculation. Arch Androl. In Press.
563
Electroejaculation in combination with intracytoplasmic sperm injection in patients with psychogenic anejaculation results in lower fertilization rates Yedidya Hovav, M.D., Irit Kafka, M.D., Mary Dan-Goor, Ph.D., Haim Yaffe, M.D., and Miriam Almagor, Ph.D. Bikur Cholim Hospital, Jerusalem, Israel
Objective: To evaluate the outcome of intracytoplasmic sperm injection (ICSI) with sperm obtained by electroejaculation in men with psychogenic anejaculation. Design: Retrospective clinical study. Setting: In Vitro Fertilization Unit, Bikur Cholim Hospital, Jerusalem, Israel. Patient(s): Seven men with psychogenic anejaculation who underwent 16 sessions of electroejaculation in combination with ICSI. Intervention(s): Electroejaculation, ICSI. Main Outcome Measure(s): Semen analysis, ICSI, fertilization rates. Result(s): All patients had poor sperm motility. One hundred forty-seven oocytes were injected, with a fertilization rate of 27% (39/142). One ongoing pregnancy was achieved. Conclusion(s): Sperm obtained by electroejaculation have low motility and reduced fertilization potential. Nevertheless, ICSI should be offered to improve the possibility of successful pregnancy. (Fertil Sterilt 1998;69:561–3. ©1998 by American Society for Reproductive Medicine.) Key Words: Electroejaculation, ICSI, fertilization rates
Received May 27, 1997; revised and accepted October 1, 1997. Reprint requests: Yedidya Hovav, M.D., IVF Unit, Department of Obstetrics and Gynecology, Bikur Cholim Hospital, 5 Strauss Street, P.O. Box 492, Jerusalem, 91004, Israel (FAX: 972-2-6701-289). 0015-0282/98/$19.00 PII S0015-0282(97)00532-3
Electroejaculation has become an accepted form of semen procurement in anejaculatory men with spinal cord injuries. However, these electroejaculates exhibit low motility and poor sperm function. In a previous study (1), we demonstrated that the electroejaculates obtained from men with psychogenic anejaculation show poor motility. The sperm quality of patients with psychogenic anejaculation is similar to that of patients with spinal cord injuries, despite the fact that the former do not have a neurologic disorder and its complications. Therefore, it has been suggested that electroejaculation may have detrimental effects on sperm (2). We thus decided to evaluate fertilization rates when performing ICSI in combination with electroejaculation.
MATERIALS AND METHODS Patients Seven patients who had psychogenic anejaculation were evaluated for primary male factor infertility; a patient history was taken, a physical examination was performed, and serum hormone levels were determined. The diagnosis of psychogenic anejaculation was based on the lack of physical causes for the condition and on the presence of nocturnal emissions and the existence of sexual relationships without conscious ejaculations. The mean age of the patients was 29 years (range, 22– 41 years). All the patients were free of urinary tract infections and had occasional nocturnal emissions. Retrograde ejaculation was ruled out after urine examination. The 561
TABLE 1 Sperm characteristics after electroejaculation and ICSI fertilization rates. Patient no.
Total sperm count (3106)*
Motility (%)
Age of spouse (y)
No. of cycles
No. of oocytes fertilized/ no. of oocytes injected (%)
1 2 3 4 5 6 7
19.0 17.0 6.0 1.5 194.0 11.0 13.0
0.5 0.5 1.0 0.5 14.0 5.0 45.0
26 26 29 22 32 41 31
4 2 1 3 3 1 2
4/39 (10) 3/10 (30) 5/9 (55) 11/31 (35)† 8/29 (27) 1/6 (16) 7/18 (38)
* The total sperm count was calculated from the combination of antegrade and retrograde ejaculates. † A clinical pregnancy was achieved.
levels of testosterone, FSH, LH, and prolactin were within the normal range. The spouses ranged in age from 20 –38 years. In all the spouses, a medical history was taken, a physical examination was performed, and the ovulatory status was evaluated. A hysterosalpingogram was obtained before treatment. The ovulation induction, electroejaculation procedure, and semen preparation were performed as previously described (1). Oocytes were assessed for the presence of pronuclei 15–20 hours after injection. Embryos were assigned to one of three quality categories according to their morphology. For statistical analysis, the x test was used. 2
The electroejaculation procedure for the treatment of men who have psychogenic anejaculation was approved by the Helsinki Committee of Bikur Holim Hospital.
RESULTS We performed 16 cycles of ICSI with sperm retrieved by electroejaculation from seven men with psychogenic anejaculation (Table 1). Of the 142 oocytes that were injected, 39 (27%) were fertilized normally. Thirty-eight embryos were transferred. Twenty-three (59%) of the embryos were of good quality and 15 (39%) were of poor quality. One woman got pregnant and a healthy baby boy was delivered after an uneventful pregnancy. Our average ICSI fertilization rate during the study period was 42%, and the decrease in fertilization rate observed in patients with psychogenic anejaculation was statistically significant (P , 0.01).
DISCUSSION The aim of our study was to evaluate the fertilizing potential in ICSI of sperm obtained by transrectal electro562
Hovav et al.
Communications-in-brief
ejaculation from patients with psychogenic anejaculation. Previous studies (2, 5) demonstrated that electroejaculated sperm exhibited severe asthenospermia. This was the case in patients with spinal cord injuries as well as those who had undergone lymph node dissection and those who had psychogenic anejaculation (1). High fertilization rates are usually achieved with ICSI independent of semen parameters. However, in our study, ICSI fertilization rates after electroejaculation were significantly lower than those obtained after normal ejaculation. This may indicate that the electroejaculation procedure hampers the fertilizing capacity of sperm in ICSI. The electric current and the heat generated during the procedure might negatively affect sperm components to reduce both the fertilizing ability of the sperm within the oocyte and the development of the zygote. Similar findings recently have been reported in a patient with idiopathic anejaculation (3). Denil et al. (4) showed that in a patient who underwent electroejaculation because of previous retroperitoneal surgery, 6 of 10 oocytes were fertilized in ICSI but only 3 (30%) developed into embryos. Their observations support our suggestion that the electroejaculation procedure not only may decrease fertilization rates but also may induce arrest of embryonal development. Alternatively, the unsatisfactory sperm parameters may be related to several other negative effectors, such as the overproduction of oxygen radicals (5), the emission of immature sperm cells, or the presence of antisperm antibodies (6). Therefore, the option of epididymal or testicular fineneedle aspiration should be considered as a plausible alternative to transrectal electroejaculation to achieve higher rates of fertilization and pregnancy. References 1. Hovav Y, Shotland Y, Yaffe H, Almagor M. Electroejaculation and assisted fertility in men with psychogenic anejaculation. Fertil Steril 1996;66:620 –3. 2. Sikka SC, Wang R, Kukuy E, Walker CF, Hellstrom WJ. The detrimen-
Vol. 69, No. 3, March 1998
tal effects of electric current on normal human sperm. J Androl 1994; 15:145–50. 3. Kiekens C, Spiessens C, Duyck F, Vandenweghe D, Coucke W, Vanderschueren D. Pregnancy after electroejaculation in combination with intracytoplasmic sperm injection in a patient with idiopathic anejaculation. Fertil Steril 1996;66:834 – 6. 4. Denil J, Kupker W, Al-Hasani S, Schill T, Kuczyk M, Jonas U, et al. Successful combination of transrectal electroejaculation and intracyto-
FERTILITY & STERILITYt
plasmic sperm injection in the treatment of anejaculation. Reprod 1996; 11:1247–9. 5. Rajasekaran M, Hellstrom WJ, Sparks RL, Sikka SC. Sperm damaging effects of electric current: possible role of free radicals. Reprod Toxicol 1994;8:427–32. 6. Almagor M, Dan-Goor M, Hovav Y, Kafka I, Shotland. Antisperm antibodies in men with psychogenic anejaculation. Arch Androl. In Press.
563