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Vibratory stimulation for treatment of anejaculation in quadriplegic men
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Vibratory Stimulation for Treatment of Anejaculation in Quadriplegic Men Jon L. Pryor, MD, Suzanne C. LeRoy, RNC, MSN, Theodore C. Nagel, MD, Hugh C. Hensleigh, PhD ABSTRACT. Pryor JL, LeRoy SC, Nagel TC, Hensleigh HC. Vibratory stimulation for treatment of anejaculation in quadriplegic men. Arch Phys Med Rehabil 1995;76:59-64. • Sexual dysfunction and infertility are common problems following spinal cord injury. Most men with complete spinal cord lesions do not ejaculate during coitus. Vibratory stimulation applied to the frenulum of the penis in six quadriplegic male subjects produced ejaculates for intrauterine inseminations. Pregnancies occurred in five of the six partners. Vibratory stimulation is a relatively safe and effective means to produce an ejaculation in men with quadriplegia. © 1995 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation
Patients with spinal cord injuries (SCI) present with complicated medical as well as psychological problems. Changes in sex life and anxiety about fertility are predominant concerns during their course of rehabilitation. Anejaculation is expected for most of the 10,000 new patients each year with SCI: 70% of men with incomplete lower motor neuron lesions have ejaculatory function preserved as compared with only 5% of men with complete upper motor neuron lesions. 1 Management of the ejaculatory dysfunction of men with SCI is based on the successful initiation of seminal emission by stimulating intact neurons below the level of the SCI. Treatment has included chemical ejaculation (intrathecal neostigmine methylsulfate), 2-7 electroejaculation, and the use of vibratory stimulation. 3'8-t3 Because of the complex monitoring and profound side effects of chemically induced ejaculation, this method is no longer recommended. 2't4'15 Electroejaculation has been used increasingly in a clinical setting; however, vibratory stimulation results in fewer side effects, is cheaper, less cumbersome, and easier to use in select patients where the injury level is above the thoracolumbar emission center (between T10 and L3). 3'16-18 There is little data in the literature concerning this technique and the pregnancies that have resulted from its use. We report our technique of vibratory stimulation using the Brookstone Acuvibe 6002 Vibrator a and present reports on 6 quadriplegic men and resultant pregnancies in five of their partners. MATERIALS AND METHODS Subjects Six quadriplegic male subjects ranging in age from 30 to 35 years with injury levels at C4-7 presented for vibratory From the University of Minnesota Hospital and Clinic (Dr. Pryor), Departments of Urologic Surgery (Dr. Pryor, Ms. LeRoy) and Obstetrics and Gynecology (Drs. Pryor, Nagel, Hensleigh), Minneapolis, MN; and Reproductive Health Associates (Drs. Pryor, Nagel, Hensleigh), St. Paul, MN. Submitted for publication April 18, 1994. Accepted in revised form July 27, 1994. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. Reprint requests to Jon L. Pryor, MD, University of Minnesota Hospital and Clinic, Department of Urologic Surgery, Box 394 UMHC, 420 Delaware Street SE, Minneapolis, MN 55455. © 1995 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation 0003-9993/95/7601-304853.00/0
stimulation. Causes of their injury included diving, rodeo, motor vehicle, wrestling, logging, and baseball accidents. Length of time since injury ranged from 6 to 18 years. Then six partners were evaluated; five were ovulatory with normal tubal and uterine status. One partner was irregularly ovulatory and had an abnormal hysterosalpingogram and subsequent hysteroscopy and polypectomy. Protocol After a history and physical, preliminary laboratory evaluation, and informed consent, each patient had at least one trial vibratory stimulation procedure to determine seminal parameters, to rule out infection, and to determine the need for sympathomimetics. Vibrator and Method of Stimulation The vibrator (figs 1 and 2) was used on all patients (low speed-2,800 rpm and high speed-4,200 rpm). At high speed the amplitude measured (__) lmm from the center and at low speed measured (_+) 1.5mm from center. All procedures used 4,200 rpm and time from vibrator application to ejaculation varied from 5 to 45 minutes in our patient population. If stimulation required more than 5 minutes, vibratory stimulation and rest periods were alternated in 5-minute increments. No adverse effects were noted from the procedure. The Appendix outlines the method of stimulation used at the University of Minnesota for patients undergoing vibratory stimulation. Laboratory Preparations Semen analyses were performed on the antegrade and/ or retrograde specimens with morphologies determined by World Health Organization (WHO) Criteria 19 or Kruger's Strict Criteria 2° depending on the lab used (tables 1-6). The sperm preparations for insemination were performed on the antegrade, retrograde, or pooled sample, as indicated. The samples were prepared by the swim-up technique from washed samples using Hams F-10 or Biggers Whitten Whittingham medium supplemented with 6g/L human serum albumin or 8% maternal serum. In one patient (case 2), a Percoll gradient c was used to prepare the sample. Samples were evaluated after preparation; total progressively motile sperm (PMS) and total motility (%) were recorded. The Arch Phys Med Rehabil Vol 76, January 1995
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VIBRATORY STIMULATION IN QUADRIPLEGICS, Pryor
Fig 1--Brookstone Acuvibe 6002 Vibrator.
laboratory work was done in a university laboratory and in a private clinic laboratory. RESULTS A total of six quadriplegics in our clinic have used vibratory stimulation for ejaculation and subsequent intrauterine inseminations in their partners. Two partners have delivered healthy baby boys, one partner miscarried at 9 weeks gestation, and two others are doing well and expected to deliver in early 1994. A sixth patient and his wife have completed their second vibratory stimulation without conception and will resume vibratory stimulation in early 1994. Case 1. A 30-year-old man (C6-7 complete, secondary to a baseball accident in 1987) underwent 30 transelectrical stimulation (TES) procedures with a prior physician, using a rectal finger probe to induce ejaculation (3 specimens were without sperm, 27 specimens had retrograde evidence of 0.9 million to 895 million sperm/mL with 0 to 2% motility, and there were no antegrade ejaculates). Follicle stimulating hormone (FSH) and testosterone were reported as normal. The patient presented to our office in the spring of 1992 for vibratory stimulation. The patient's wife was ovulating normally without evidence of other factors contributing to infertility. Following this evaluation, they proceeded with vibratory stimulation. Table 1 outlines the semen parameters for each vibratory stimulation procedure. In July 1992, after taking ephedrine 50mg four times daily for 10 days, the patient complained of headaches and increased spasticity. He was switched to imipramine 25mg twice daily for 10 days before his next vibratory stimulation. After this patient declined nifedipine or any sympathomimetics, however he did take sodium bicarbonate as recommended. The latter specimens for intrauterine inseminations (4 and 5) were achieved with difficulty. On both occasions it took approximately 45 minutes with frequent rest periods to obtain the specimens, whereas it had previously taken 5 minutes. The patient's wife was administered clomiphene citrate before the fourth and fifth inseminations and also received human chorionic gonadotropin (hCG)10,000 United States Pharmacopeia (USP) units to trigger ovulation in the fifth cycle. She conceived in this cycle and had a singleton intrauterine pregnancy documented by transvaginal ultrasound, and subsequently delivered a healthy boy in July 1993. Case 2. A 30-year-old man (C4-5, incomplete, secondary to a wrestling accident in 1977) presented in June 1992. His hormone profile was consistent with hypogonadotropic hypogonadism (a normal FSH of 4IU/L and luteinizing hormone (LH) of 4IU/L, despite a low testosterone of 280ng/ dL). In July 1992, the patient underwent vibratory stimulation on two separate occasions after taking sodium bicarbonate only. Because these initial seminal parameters were good Arch Phys Med Rehabil Vol 76, January 1995
(table 2), no treatment was deemed necessary for his hypogonadotropic hypogonadism. In March 1993, after taking ephedrine 25mg four times daily for 10 days and sodium bicarbonate 650rag four times daily for 2 days, vibratory stimulation was undertaken with improved motility noted in the specimen. A trial sperm prep (Swim-Up) was done and an intrauterine insemination (IUI) was planned for the next vibratory stimulation attempt in conjunction with monitored ovulation of the patient's wife. She was ovulatory with a normal hysterosalpingogram. In April 1993, after imipramine 25mg twice daily for 10 days (a change in the sympathomimetic was undertaken in an effort to improve the seminal parameters) and sodium bicarbonate for 2 days before, vibratory stimulation was performed and IUI was done in a spontaneous cycle timed by an LH surge. The patient's wife conceived and had a singleton intrauterine pregnancy documented by transvaginal ultrasound and was due to deliver in January 1994. Attempts at follow-up were unsuccessful. Case 3. A 35-year-old man (C5-6, complete, secondary to a diving accident in 1975) presented in December 1991 for vibratory stimulation. His wife was ovulatory without evidence of other factors contributing to infertility. Table 3 outlines the semen parameters for each vibratory stimulation. In the first year he had four vibratory stimulation procedures and the specimen quality varied greatly. The patient was
/y
.7
/
j"
Fig 2 - - V i b r a t o r and method of stimulation.
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VIBRATORY STIMULATION IN QUADRIPLEGICS, Pryor Table 1: Case 1-Semen Parameters With Vibratory Stimulation Date 6/92 7/92
7/92 8/92 9/92 10/92 10/92
Volume
Count
Ante 1. l m L Retro 81 m L Ante 3.0mL Retro 10mL (Serum Swim-up) N/A N/A N/A N/A N/A
No sperm seen 30.5 million/mL (Combined ante/retro) 106 million/mL 35 million PMS 35 million PMS 32 million PMS 25 million PMS 34 million PMS 75 million PMS
Motility
Morphology
< 1%
N/A 16% normal (WHO)*
15% 15% 10% 15% 20% 10% 30%
IUI
52% normal (WHO) N/A N/A N/A N/A N/A
IUI IUI IUI IUI IUI
1~ 2! 31 41 5*
Abbreviations: ante, antegrade; retro, retrograde; PMS, progressively motile sperm; IUI, intrauterine insemination; N/A, not available. * W H O criteria for determining morphology. t All insemination preps used the Serum Swim-Up and are reported as PMS. All results are from a combination of the antegrade and retrograde ejaculates.
screened for an endocrinopathy in January 1993, and had normal hormones with an FSH of 5.9IU/L and a testosterone of 429ng/dL. In April 1993, his wife was on clomiphene citrate to regulate ovulation and conceived with her second IUI timed by an LH surge. An intrauterine pregnancy was documented by transvaginal ultrasound and she subsequently delivered a healthy boy in January 1994. Case 4. A 31-year-old boy (C7, complete, secondary to a rodeo accident in 1984) presented in the spring of 1993 for vibratory stimulation. He had a normal hormone profile. In May 1993, the patient underwent vibratory stimulation after taking sodium bicarbonate two days before the procedure. There was no antegrade ejaculate and no sperm were seen retrograde (table 4). In July 1993, after taking sodium bicarbonate for 2 days and ephedrine 50mg 3 hours before the procedure, vibratory stimulation produced an antegrade and retrograde specimen. An IUI was planned for the next cycle as the quality of the specimen was excellent. The patient's wife had ovulatory basal body temperatures, a normal hysterosalpingogram, and a normal endometrial biopsy. The patient was empirically treated with ciprofloxin 500mg twice daily for 1 week before the next procedure to cover any risk of infection. Sodium bicarbonate was taken 2 days before along with ephedrine 50mg 3 hours before the procedure. Vibratory stimulation was performed and an IUI was done on a spontaneous cycle timed by an LH surge. The patient's wife conceived on her first cycle. She delivered in April 1994. Case 5. A 31-year-old man (C4-6, complete, secondary
to a motor vehicle accident in 1982) presented in June 1993. The patient had normal hormones with an FSH of 3IU/L and a testosterone of 371ng/dL. Table 5 outlines the semen parameters for each vibratory stimulation procedure. The first vibratory stimulation produced an antegrade and retrograde ejaculate with an increased number of red blood cells noted by the lab. A urinalysis and culture showed increased numbers of red blood cells and 10,000 to 50,000 colonies of Staphlococcus species. He was subsequently treated with erythromycin for 2 weeks. His partner was ovulatory with a normal hysterosalpingogram and endometrial biopsy. In September 1993, the day after the partner's LH surge, vibratory stimulation produced an antegrade and retrograde ejaculate and an IUI was performed. Conception occurred with the first insemination, however the partner subsequently miscarried at 9 weeks gestation. This couple resumed vibratory stimulation in early 1994. Case 6. A 35-year-old men (C5-6, complete, secondary to a logging accident in 1978) presented in February 1992. The patient had normal hormones with an FSH of 6IU/L, LH of 10IU/L, and a testosterone of 322ng/dL. He underwent three vibratory stimulation procedures in 1992 and had a normal sperm penetration assay (SPA) with 42% penetration. His wife had irregular ovulation by basal body temperatures and an intrauterine filling defect was noted at the time of hysterosalpingogram. Subsequently, a hysteroscopy and polypectomy were performed and the wife was placed on clomiphene citrate to regulate ovulation. Two IUIs were done (September 1993 and November 1993) without conception,
Table 2: Case 2-Semen Parameters With Vibratory Stimulation Date
Volume
Count
Motility
Morphology
7/92
Ante 3.2mL Retro 32.5mL Ante 1.2mL Retro 42mL Ante 0.4mL Retro 60mL (Trial Swim-up Prep) 0.5mL Ante 2.1 mL Retro 110mL (Percoll Prep of antegrade) O.6mL
1,600 million/mL 58.5 million/mL 2,800 million/mL 11.5 million/mL 333 million/mL 2.6 million/mL
<2% < 1% <5% 0% 10% 0%
N/A N/A N/A 6% normal (WHO) 10% normal (Kruger's)* N/A
1.8 million PMS 90 million/mL 0.3 million/mL
35% 10% 0%
N/A N/A
1.7 million PMS
10%
7/92 3/93
4/93
IUI
IUI #1
* Kruger's Strict Criteria for determining morphology.
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VIBRATORY STIMULATION IN QUADRIPLEGICS, Pryor Table 3: Case 3-Semen Parameters With Vibratory Stimulation Date
Volume
Count
12/91
Ante 0.35mL Retro 1.8mL Ante 4.3mL Retro 5 l mL Ante 5.8mL Retro 65mL Ante 2.8mL Retro 50mL Ante 0.7mL Retro 78mL Ante 4.5mL Retro 60mL (combined Swim-Up Prep)
No sperm seen 4.7 million/mL 50.5 million/mL 13 million/mL 0.24 million/mL 4.9 million/mL 5 sperm/50 hpf* 25 sperm/50 hpf 193 million/mL 14 million/mL N/A No sperm seen
6/92 11/92 12/92 2/93 3/93
4/93
Ante 2mL Retro 95mL (Swim-Up Prep)
Motility
Morphology
5% 0% 0% 0% 10% 0% 0% 10% 20%
N/A N/A 16% normal (WHO) N/A N/A N/A N/A N/A 9% normal (Kruger's) N/A
20 million PMS No sperm seen 1.02 million/mL 2.9 million PMS
5%
N/A N/A
15% 45%
IUI
IUI #1
IUI #2
* hpf = high powered field (40× objective).
although~specimen quality has been good (table 6). The patient resumed vibratory stimulation in early 1994. DISCUSSION An important concern of patients with SCI is their sexual and fertility status. Their fertility is complicated by erectile and ejaculatory dysfunction, deficiencies in spermatogenesis and genitourinary tract infections. Problems with spermatogenesis are common because of neurological denervation and are reflected in depressed seminal parameters--sperm motility and morphology are often markedly impaired secondary to increased scrotal temperatures, chronic infection, prolonged stasis, and lack of ejaculation.8'~8Testicular histology notes a range of spermatogenic abnormalities including tubular atrophy, spermatogenic arrest, and interstitial fibrosis.~ Interestingly, no direct correlation exists between these findings and level of injury, number of years since injury, or history of urinary tract infections. Vibratory stimulation of the penis was first applied to paraplegic men to induce emission and/or ejaculation by Comarr and was followed by others. 9-~2'~8'z~'22 Afferent impulses from the glans penis travel via the pudendal nerve to the sacral cord. An uninterrupted neural communication with the thoracolumbar cord must exist, so that the excitation in the sacral cord can move upwards and transmit impulses in the thoracolumbar sympathetics, resulting in emission and/ or ejaculation. For this technique to be successful, the injury level must be above the thoracolumbar "emission center" (between T10 and L3). ~5 Therefore, this technique is optimally used in quadraplegic men with a level of injury above
T10. However, lesions above the T7-1evel are often accompanied by signs and symptoms of autonomic dysreflexia (eg, sudden pounding headache caused by rapid increase in blood pressure, flushing, sweating, and cardiac arryrhmias) that can frequently be prevented by pretreatment with nifedipine 10 to 15 minutes before the procedure. 15 In the 6 months following injury in which the cord is not excitable (spinal shock), vibratory methods of stimulation, in general, will not work. ~5Brindley H found a 77% (48/62) chance of success in inducing ejaculation in patients who were more than 6 months from time of injury and who did not have damage between L2 and S 1. In patients whose ejaculatory dysfunction is neurological and not associated with bladder neck scarring, pharmacological manipulation with alpha-adrenergic sympathomimetic medications often partially or completely converts the patient to antegrade ejaculation, may increase sperm counts in previously low density antegrade ejaculates, and may develop retrograde ejaculation in previously azoospermic men with ejaculatory failure. 15 Since 1970, there have been 93 documented pregnancies and 49 live births through electroejaculation, subcutaneous neostigmine methylsulfate, or vibratory stimulation. Many of these patients had tried more than one method to induce ejaculation. Of patients using vibratory stimulation alone, we could find reports of only 38 pregnancies and 16 liveborn children. 14 In our series, we had the patient's spouse/partner evaluated before stimulation and actual insemination to optimize chances of success. We also found that good communication between the physicians, the patient, and his spouse/partner
Table 4: Case 4-Semen Parameters With Vibratory Stimulation Date
Volume
5/93
Ante 0 Retro 100mL Ante 0.27mL* Retro 125mL* Ante 0 Retro 55mL (Swim-Up Prep)
7/93 7/93
Count
Motility
Morphology
No sperm seen 600 million/mL 8 million/mL
20% 10%
24% normal (Kruger's) N/A
1.6 million/mL 7.5 million PMS
25% 75%
N/A
* Ephedrine 50mg was taken 3 hours before vibratory stimulation.
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IUI
IUI 1
VIBRATORY STIMULATION IN QUADRIPLEGICS, Pryor
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Table 5: Case 5-Semen Parameters With Vibratory Stimulation Date
Volume
Count
Motility
Morphology
6/93
Ante 20.0mL* Retro 60.0mL* Ante 2.0mL Retro 340.0mL (Swim-Up Prep)
30.5 million/mL 8 million/mL N/A 1.28 million/mL 1.33 million PMS
5% 2%
3% normal (Kruger's) N/A
10% 35%
N/A
9/93
IUI
IUI 1
* Increased numbers of red blood ceils found in antegrade and retrograde specimens.
to be important for timing of procedures, arrangement of laboratory facilities, and optimizing the woman's cycle. Some men may be able to remain in their wheelchair during the procedure; this is a simpler arrangement that eliminates the danger of failing off the table if muscle spasms occur with ejaculation. This decision must be made on an individual basis, individualized according to body size of patient, ease of specimen collection and quality of specimen achieved. The lithotomy position is preferable with patients who are unable to obtain specimens in their wheelchair. In our patient population, emission of semen occurred between 5 and 45 minutes after application of the vibrator. After one or more successful procedures these men learned to guide the practitioner performing the stimulation to the most productive vibration site. Increased anxiety and stress associated with infertility may cause increased difficulty producing specimens; patients need to be counseled about this possibility. Vibratory stimulation may also be done at home to "clear out" the system or for sexual needs of patients; however, it is imperative that the risk of autonomic dysreflexia be discussed with patients with lesions at T7 or above and that pretreatment with nifedipine be made available. Specimens for insemination should not be collected at home secondary to the risk of contamination and subsequent risk of infection if IUI is planned. When the ejaculate is to be used for insemination, appropriate alkalinization of the urine with sodium bicarbonate or acetazolamide (Diamox b) and increased hydration of the patient before semen collection are required, as urine is usually spermicidal because of its acidic pH and hyperosmolarity.~5 Antegrade ejaculation need not occur, as there are techniques for retrieving sperm and processing a retrograde ejaculate. This includes emptying the bladder via catheterization and instilling an appropriate buffered medium, or emptying the bladder both before ejaculation and immediately
after to recover the ejaculated fluid in as small a volume of urine as possible. The fluid is then washed and resuspended in appropriate buffer before artificial insemination or other assisted reproductive technology. It is essential to get the antegrade and retrograde samples to the lab for processing as soon as possible secondary to the deleterious effects of urine on sperm in retrograde ejaculates. With successive vibratory applications, the quality of the seminal parameters tends to improve. ~2"~8 Patients should be reminded that each cycle can be an emotional roller coaster and that persistence and patience are often needed. If there is increased stress, anxiety, or marital discord, counseling may be recommended. Adoption and donor insemination are alternatives that should be discussed early in the evaluation process in case a pregnancy does not occur and the couple desire to pursue other paths to having a family. Sexual needs also need to be addressed as there are many good treatments for erectile dysfunction that add greatly to the quality of life in this patients population. All patients in the case reports use vasoactive intracorporal pharmacotherapy or have spontaneous erections that are adequate for vaginal penetration. Although there was no attempt to document that the infants and fathers were genetically related, we are confident that these conceptions resulted from the ejaculates obtained by vibratory stimulation because of the timing of the insemination and our knowledge of their social history. Our unusually high success rate (83% of couples achieved pregnancies) is probably because of detailed review and treatment of both partners; and good communication between the andrologist, reproductive endocrinologist, and andrology lab, that resulted in recommendations for treatment of patient, partner, and semen specimens. Four of five patients achieving pregnancies had 1.3 to 7.5 million progressively motile sperm and three of five had counts as low as
Table 6: Case 6-Semen Parameters With Vibratory Stimulation Date
Volume
4/92 7/92
Unable to ejaculate Ante 3. l mL Retro 28mL Ante 2.4mL Retro 51.5mL (SPA 42% penetration) Ante 0.5mL Retro 55mL (Swim-Up Prep) 0.3mL Ante 0mL Retro N/A (Swim-Up Prep)
9/92*
9/93*
11/93"
Motility
Morphology
20% 20% < 10% 30%
N/A N/A N/A N/A
(Ante/retro combined) 0.93 million/mL
30%
N/A N/A
IUI 1
2.75 million PMS
70%
N/A 13 million PMS
35%
N/A
IUI 2
Count
1.5 million/mL 1.2 million/mL 10 sperm/13 hpf 5.5 million/mL
IUI
* All specimens were obtained after ephedrine was administered 25mg four times daily for 10 days.
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VIBRATORY STIMULATION IN QUADRIPLEGICS, Pryor
1.3 to 2.9 million progressively motile sperm on the day of intrauterine insemination. Three of five patients had 10% or less normal morphology by Kruger's Strict Criteria but still achieved pregnancies. Both laboratory staff reported similar subjective responses to the sperm preparations: the sperm samples were of very low quality, lots of debris, high round cell counts, and very low motility; the quality of antegrade and/or retrograde samples improved with each collection; and sperm preparations yielded samples for insemination with low numbers of sperm but with improved motility and little debris or round cells. Even with suboptimal semen parameters, pregnancies can be achieved when evaluation and treatment involves all members of the health care team. The vibratory stimulation technique has positive implications for the reproductive needs of patients with SCI and their partners, and should be discussed as a potential option for those desiring a pregnancy. Acknowledgment: We are grateful to Dennis Dykstra, MD, for reviewing the neurological histories of these patients. References 1. Shaban S. Treatment of abnormalities of ejaculation. In: Lipshultz L, Howards S, editors. Infertility in the male. 2nd ed. St. Louis: MosbyYear Book, 1991:409. 2. Amelar R, Dubin L. Sexual function and fertility in paraplegic males. Urology 1982;20:62-5. 3. Lipshultz L, Howards S, editors. Infertility in the Male 2nd ed. St. Louis: Mosby-Year Book, 1991:414. 4. Chapelle P, Jondet M, Durand J, Grossiord A. Pregnancy of the wife of a complete paraplegic by homologous insemination after an intrathecal injection of neostigmine. Paraplegia 1976; 14:173-7. 5. Chapelle P, Blanquart F, Puech A, Held JP. Treatment of anejaculation in the total paraplegic by subcutaneous injection of physostigmine. Paraplegia 1983;21:30-6. 6. Guttman L, Walsh J. Prostigman assessment test of fertility in spinal man. Paraplegia 1970;9:39-50.
7. Spira R. Artificial insemination after intrathecal injection of neostigmine in a paraplegic. Lancet 1956; 1:670-1. 8. Sarkarati M, Rossier A, Fam B. Experience in vibratory and electroejaculation techniques in spinal cord injury patients: a preliminary report. J Urol 1987; 138:59-62. 9. Comarr A. Sexual function among patients with spinal cord injury. Urol Int t970;25:134-68. 10. Brindley G. Electroejaculation: its technique, neurological implications and uses. J Neurol Psychiatr 1981;44:9-18. 11. Brindley G. Reflex ejaculation under vibratory stimulation in paraplegic men. Paraplegia 1981; 19:299-302. 12. Brindley G. The fertility of men with spinal injuries. Paraplegia 1984; 22:337-48. 13. Francois N, Lichtenberger J, Jouannet P, Desert JF, Maury M. L'ejaculation par le vibromassage chez le paraplegique a' propos de 50 cas avec 7 grossessnes. Ann Med Phys 1980;23:24-36. 14. Sonksen J, Biering-Sorensen F. Fertility in men with spinal cord or cauda equina lesions. Semin Neurol 1992; 12:106-14. 15. Murphy J, Lipshultz L. Abnormalities of ejaculation. Urol Clin North Am 1987; 14:583-96. 16. Newman H, Reiss H, Northrup J. Physical basis of emission, ejaculation and orgasm in the male. Urology 1982; 19:341. 17. Thomas A. Ejaculatory dysfunction. Fertil Steril 1983;39:445-54. 18. Szasz J, Carpenter C. Clinical observations in vibratory stimulation of the penis of men with spinal cord injury. Arch Sex Behav 1989;6:46174. 19. World Health Organization. WHO laboratory manual for the examination of human semen and sperm-cervical mucus interaction. New York: Cambridge University Press, 1992. 20. Menkveld R, Stander F, Kotze T, Kruger T, van Zyl J. The evaluation of morphological characteristics of human spermatozoa according to stricter criteria. Hum Reprod 1990;5:586-92. 21. Tarabulcy E. Sexual function in the normal and in paraplegia. Paraplegia 1972; 10:201-8. 22. Sobrero AJ, Stearns H, Blair JH. Technic for the induction of ejaculation in humans. Fertil Steril 1965; 16:765-7.
Suppliers a. Brookstone Acuvibe 6002 Vibrator, Brookstone Company, 5 Vose Farm Road, Peterborough, NH 03458. b. Diamox, Lederle Laboratories, Division of American Cyanamid Company, One Cyanamid Plaza, Wayne, NJ 07470. c. Percoll, Sigma, No. P1644, St. Louis, MO.
APPENDIX University of Minnesota Vibratory Stimulation Technique (1) In select patients, sympathomimetics (ephedrine or imipramine) is administered either 2 hours before procedure or 10 days before procedure if the patient is able to tolerate it. (2) Sodium bicarbonate 650mg four times daily starting 2 days before and morning of procedure. (3) Patient is to drink increased amounts of water in the moming of procedure. (4) Nifedipine 10mg sublingual is administered 10 to 15 minutes before procedure. (5) Lithotomy position (or wheelchair in select patients). (6) Dynamap (automatic sphygmomanometry). (7) Catheterize patient and empty bladder completely. (8) Rinse bladder with 15mL of culture media (Ham's F10 or BWW) with 0.6% (6g/L) albumin) then place 15mL of fresh media in bladder and remove catheter.
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(9) Vibrator to frenulum of penis until antegrade ejaculate or patient feels as if orgasm has occurred. Antegrade collected into specimen container 1. (10) Catheterize and rinse bladder with 20mL of culture media with albumin and collect it in specimen container 2. (11) Antegrade and retrograde specimens are sent to lab for sperm preparation. (12) If specimen quality is not optimal, consider change of sympathomimetic and repeat vibratory stimulation at another time. (13) Once optimal quality of specimens achieved proceed with intrauterine inseminations or other assisted reproductive technologies in conjunction with monitored ovulation of spouse or partner (full evaluation of female partner required before this).
Vibratory Stimulation for Treatment of Anejaculation in Quadriplegic Men Jon L. Pryor, MD, Suzanne C. LeRoy, RNC, MSN, Theodore C. Nagel, MD, Hugh C. Hensleigh, PhD ABSTRACT. Pryor JL, LeRoy SC, Nagel TC, Hensleigh HC. Vibratory stimulation for treatment of anejaculation in quadriplegic men. Arch Phys Med Rehabil 1995;76:59-64. • Sexual dysfunction and infertility are common problems following spinal cord injury. Most men with complete spinal cord lesions do not ejaculate during coitus. Vibratory stimulation applied to the frenulum of the penis in six quadriplegic male subjects produced ejaculates for intrauterine inseminations. Pregnancies occurred in five of the six partners. Vibratory stimulation is a relatively safe and effective means to produce an ejaculation in men with quadriplegia. © 1995 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation
Patients with spinal cord injuries (SCI) present with complicated medical as well as psychological problems. Changes in sex life and anxiety about fertility are predominant concerns during their course of rehabilitation. Anejaculation is expected for most of the 10,000 new patients each year with SCI: 70% of men with incomplete lower motor neuron lesions have ejaculatory function preserved as compared with only 5% of men with complete upper motor neuron lesions. 1 Management of the ejaculatory dysfunction of men with SCI is based on the successful initiation of seminal emission by stimulating intact neurons below the level of the SCI. Treatment has included chemical ejaculation (intrathecal neostigmine methylsulfate), 2-7 electroejaculation, and the use of vibratory stimulation. 3'8-t3 Because of the complex monitoring and profound side effects of chemically induced ejaculation, this method is no longer recommended. 2't4'15 Electroejaculation has been used increasingly in a clinical setting; however, vibratory stimulation results in fewer side effects, is cheaper, less cumbersome, and easier to use in select patients where the injury level is above the thoracolumbar emission center (between T10 and L3). 3'16-18 There is little data in the literature concerning this technique and the pregnancies that have resulted from its use. We report our technique of vibratory stimulation using the Brookstone Acuvibe 6002 Vibrator a and present reports on 6 quadriplegic men and resultant pregnancies in five of their partners. MATERIALS AND METHODS Subjects Six quadriplegic male subjects ranging in age from 30 to 35 years with injury levels at C4-7 presented for vibratory From the University of Minnesota Hospital and Clinic (Dr. Pryor), Departments of Urologic Surgery (Dr. Pryor, Ms. LeRoy) and Obstetrics and Gynecology (Drs. Pryor, Nagel, Hensleigh), Minneapolis, MN; and Reproductive Health Associates (Drs. Pryor, Nagel, Hensleigh), St. Paul, MN. Submitted for publication April 18, 1994. Accepted in revised form July 27, 1994. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. Reprint requests to Jon L. Pryor, MD, University of Minnesota Hospital and Clinic, Department of Urologic Surgery, Box 394 UMHC, 420 Delaware Street SE, Minneapolis, MN 55455. © 1995 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation 0003-9993/95/7601-304853.00/0
stimulation. Causes of their injury included diving, rodeo, motor vehicle, wrestling, logging, and baseball accidents. Length of time since injury ranged from 6 to 18 years. Then six partners were evaluated; five were ovulatory with normal tubal and uterine status. One partner was irregularly ovulatory and had an abnormal hysterosalpingogram and subsequent hysteroscopy and polypectomy. Protocol After a history and physical, preliminary laboratory evaluation, and informed consent, each patient had at least one trial vibratory stimulation procedure to determine seminal parameters, to rule out infection, and to determine the need for sympathomimetics. Vibrator and Method of Stimulation The vibrator (figs 1 and 2) was used on all patients (low speed-2,800 rpm and high speed-4,200 rpm). At high speed the amplitude measured (__) lmm from the center and at low speed measured (_+) 1.5mm from center. All procedures used 4,200 rpm and time from vibrator application to ejaculation varied from 5 to 45 minutes in our patient population. If stimulation required more than 5 minutes, vibratory stimulation and rest periods were alternated in 5-minute increments. No adverse effects were noted from the procedure. The Appendix outlines the method of stimulation used at the University of Minnesota for patients undergoing vibratory stimulation. Laboratory Preparations Semen analyses were performed on the antegrade and/ or retrograde specimens with morphologies determined by World Health Organization (WHO) Criteria 19 or Kruger's Strict Criteria 2° depending on the lab used (tables 1-6). The sperm preparations for insemination were performed on the antegrade, retrograde, or pooled sample, as indicated. The samples were prepared by the swim-up technique from washed samples using Hams F-10 or Biggers Whitten Whittingham medium supplemented with 6g/L human serum albumin or 8% maternal serum. In one patient (case 2), a Percoll gradient c was used to prepare the sample. Samples were evaluated after preparation; total progressively motile sperm (PMS) and total motility (%) were recorded. The Arch Phys Med Rehabil Vol 76, January 1995
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VIBRATORY STIMULATION IN QUADRIPLEGICS, Pryor
Fig 1--Brookstone Acuvibe 6002 Vibrator.
laboratory work was done in a university laboratory and in a private clinic laboratory. RESULTS A total of six quadriplegics in our clinic have used vibratory stimulation for ejaculation and subsequent intrauterine inseminations in their partners. Two partners have delivered healthy baby boys, one partner miscarried at 9 weeks gestation, and two others are doing well and expected to deliver in early 1994. A sixth patient and his wife have completed their second vibratory stimulation without conception and will resume vibratory stimulation in early 1994. Case 1. A 30-year-old man (C6-7 complete, secondary to a baseball accident in 1987) underwent 30 transelectrical stimulation (TES) procedures with a prior physician, using a rectal finger probe to induce ejaculation (3 specimens were without sperm, 27 specimens had retrograde evidence of 0.9 million to 895 million sperm/mL with 0 to 2% motility, and there were no antegrade ejaculates). Follicle stimulating hormone (FSH) and testosterone were reported as normal. The patient presented to our office in the spring of 1992 for vibratory stimulation. The patient's wife was ovulating normally without evidence of other factors contributing to infertility. Following this evaluation, they proceeded with vibratory stimulation. Table 1 outlines the semen parameters for each vibratory stimulation procedure. In July 1992, after taking ephedrine 50mg four times daily for 10 days, the patient complained of headaches and increased spasticity. He was switched to imipramine 25mg twice daily for 10 days before his next vibratory stimulation. After this patient declined nifedipine or any sympathomimetics, however he did take sodium bicarbonate as recommended. The latter specimens for intrauterine inseminations (4 and 5) were achieved with difficulty. On both occasions it took approximately 45 minutes with frequent rest periods to obtain the specimens, whereas it had previously taken 5 minutes. The patient's wife was administered clomiphene citrate before the fourth and fifth inseminations and also received human chorionic gonadotropin (hCG)10,000 United States Pharmacopeia (USP) units to trigger ovulation in the fifth cycle. She conceived in this cycle and had a singleton intrauterine pregnancy documented by transvaginal ultrasound, and subsequently delivered a healthy boy in July 1993. Case 2. A 30-year-old man (C4-5, incomplete, secondary to a wrestling accident in 1977) presented in June 1992. His hormone profile was consistent with hypogonadotropic hypogonadism (a normal FSH of 4IU/L and luteinizing hormone (LH) of 4IU/L, despite a low testosterone of 280ng/ dL). In July 1992, the patient underwent vibratory stimulation on two separate occasions after taking sodium bicarbonate only. Because these initial seminal parameters were good Arch Phys Med Rehabil Vol 76, January 1995
(table 2), no treatment was deemed necessary for his hypogonadotropic hypogonadism. In March 1993, after taking ephedrine 25mg four times daily for 10 days and sodium bicarbonate 650rag four times daily for 2 days, vibratory stimulation was undertaken with improved motility noted in the specimen. A trial sperm prep (Swim-Up) was done and an intrauterine insemination (IUI) was planned for the next vibratory stimulation attempt in conjunction with monitored ovulation of the patient's wife. She was ovulatory with a normal hysterosalpingogram. In April 1993, after imipramine 25mg twice daily for 10 days (a change in the sympathomimetic was undertaken in an effort to improve the seminal parameters) and sodium bicarbonate for 2 days before, vibratory stimulation was performed and IUI was done in a spontaneous cycle timed by an LH surge. The patient's wife conceived and had a singleton intrauterine pregnancy documented by transvaginal ultrasound and was due to deliver in January 1994. Attempts at follow-up were unsuccessful. Case 3. A 35-year-old man (C5-6, complete, secondary to a diving accident in 1975) presented in December 1991 for vibratory stimulation. His wife was ovulatory without evidence of other factors contributing to infertility. Table 3 outlines the semen parameters for each vibratory stimulation. In the first year he had four vibratory stimulation procedures and the specimen quality varied greatly. The patient was
/y
.7
/
j"
Fig 2 - - V i b r a t o r and method of stimulation.
61
VIBRATORY STIMULATION IN QUADRIPLEGICS, Pryor Table 1: Case 1-Semen Parameters With Vibratory Stimulation Date 6/92 7/92
7/92 8/92 9/92 10/92 10/92
Volume
Count
Ante 1. l m L Retro 81 m L Ante 3.0mL Retro 10mL (Serum Swim-up) N/A N/A N/A N/A N/A
No sperm seen 30.5 million/mL (Combined ante/retro) 106 million/mL 35 million PMS 35 million PMS 32 million PMS 25 million PMS 34 million PMS 75 million PMS
Motility
Morphology
< 1%
N/A 16% normal (WHO)*
15% 15% 10% 15% 20% 10% 30%
IUI
52% normal (WHO) N/A N/A N/A N/A N/A
IUI IUI IUI IUI IUI
1~ 2! 31 41 5*
Abbreviations: ante, antegrade; retro, retrograde; PMS, progressively motile sperm; IUI, intrauterine insemination; N/A, not available. * W H O criteria for determining morphology. t All insemination preps used the Serum Swim-Up and are reported as PMS. All results are from a combination of the antegrade and retrograde ejaculates.
screened for an endocrinopathy in January 1993, and had normal hormones with an FSH of 5.9IU/L and a testosterone of 429ng/dL. In April 1993, his wife was on clomiphene citrate to regulate ovulation and conceived with her second IUI timed by an LH surge. An intrauterine pregnancy was documented by transvaginal ultrasound and she subsequently delivered a healthy boy in January 1994. Case 4. A 31-year-old boy (C7, complete, secondary to a rodeo accident in 1984) presented in the spring of 1993 for vibratory stimulation. He had a normal hormone profile. In May 1993, the patient underwent vibratory stimulation after taking sodium bicarbonate two days before the procedure. There was no antegrade ejaculate and no sperm were seen retrograde (table 4). In July 1993, after taking sodium bicarbonate for 2 days and ephedrine 50mg 3 hours before the procedure, vibratory stimulation produced an antegrade and retrograde specimen. An IUI was planned for the next cycle as the quality of the specimen was excellent. The patient's wife had ovulatory basal body temperatures, a normal hysterosalpingogram, and a normal endometrial biopsy. The patient was empirically treated with ciprofloxin 500mg twice daily for 1 week before the next procedure to cover any risk of infection. Sodium bicarbonate was taken 2 days before along with ephedrine 50mg 3 hours before the procedure. Vibratory stimulation was performed and an IUI was done on a spontaneous cycle timed by an LH surge. The patient's wife conceived on her first cycle. She delivered in April 1994. Case 5. A 31-year-old man (C4-6, complete, secondary
to a motor vehicle accident in 1982) presented in June 1993. The patient had normal hormones with an FSH of 3IU/L and a testosterone of 371ng/dL. Table 5 outlines the semen parameters for each vibratory stimulation procedure. The first vibratory stimulation produced an antegrade and retrograde ejaculate with an increased number of red blood cells noted by the lab. A urinalysis and culture showed increased numbers of red blood cells and 10,000 to 50,000 colonies of Staphlococcus species. He was subsequently treated with erythromycin for 2 weeks. His partner was ovulatory with a normal hysterosalpingogram and endometrial biopsy. In September 1993, the day after the partner's LH surge, vibratory stimulation produced an antegrade and retrograde ejaculate and an IUI was performed. Conception occurred with the first insemination, however the partner subsequently miscarried at 9 weeks gestation. This couple resumed vibratory stimulation in early 1994. Case 6. A 35-year-old men (C5-6, complete, secondary to a logging accident in 1978) presented in February 1992. The patient had normal hormones with an FSH of 6IU/L, LH of 10IU/L, and a testosterone of 322ng/dL. He underwent three vibratory stimulation procedures in 1992 and had a normal sperm penetration assay (SPA) with 42% penetration. His wife had irregular ovulation by basal body temperatures and an intrauterine filling defect was noted at the time of hysterosalpingogram. Subsequently, a hysteroscopy and polypectomy were performed and the wife was placed on clomiphene citrate to regulate ovulation. Two IUIs were done (September 1993 and November 1993) without conception,
Table 2: Case 2-Semen Parameters With Vibratory Stimulation Date
Volume
Count
Motility
Morphology
7/92
Ante 3.2mL Retro 32.5mL Ante 1.2mL Retro 42mL Ante 0.4mL Retro 60mL (Trial Swim-up Prep) 0.5mL Ante 2.1 mL Retro 110mL (Percoll Prep of antegrade) O.6mL
1,600 million/mL 58.5 million/mL 2,800 million/mL 11.5 million/mL 333 million/mL 2.6 million/mL
<2% < 1% <5% 0% 10% 0%
N/A N/A N/A 6% normal (WHO) 10% normal (Kruger's)* N/A
1.8 million PMS 90 million/mL 0.3 million/mL
35% 10% 0%
N/A N/A
1.7 million PMS
10%
7/92 3/93
4/93
IUI
IUI #1
* Kruger's Strict Criteria for determining morphology.
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VIBRATORY STIMULATION IN QUADRIPLEGICS, Pryor Table 3: Case 3-Semen Parameters With Vibratory Stimulation Date
Volume
Count
12/91
Ante 0.35mL Retro 1.8mL Ante 4.3mL Retro 5 l mL Ante 5.8mL Retro 65mL Ante 2.8mL Retro 50mL Ante 0.7mL Retro 78mL Ante 4.5mL Retro 60mL (combined Swim-Up Prep)
No sperm seen 4.7 million/mL 50.5 million/mL 13 million/mL 0.24 million/mL 4.9 million/mL 5 sperm/50 hpf* 25 sperm/50 hpf 193 million/mL 14 million/mL N/A No sperm seen
6/92 11/92 12/92 2/93 3/93
4/93
Ante 2mL Retro 95mL (Swim-Up Prep)
Motility
Morphology
5% 0% 0% 0% 10% 0% 0% 10% 20%
N/A N/A 16% normal (WHO) N/A N/A N/A N/A N/A 9% normal (Kruger's) N/A
20 million PMS No sperm seen 1.02 million/mL 2.9 million PMS
5%
N/A N/A
15% 45%
IUI
IUI #1
IUI #2
* hpf = high powered field (40× objective).
although~specimen quality has been good (table 6). The patient resumed vibratory stimulation in early 1994. DISCUSSION An important concern of patients with SCI is their sexual and fertility status. Their fertility is complicated by erectile and ejaculatory dysfunction, deficiencies in spermatogenesis and genitourinary tract infections. Problems with spermatogenesis are common because of neurological denervation and are reflected in depressed seminal parameters--sperm motility and morphology are often markedly impaired secondary to increased scrotal temperatures, chronic infection, prolonged stasis, and lack of ejaculation.8'~8Testicular histology notes a range of spermatogenic abnormalities including tubular atrophy, spermatogenic arrest, and interstitial fibrosis.~ Interestingly, no direct correlation exists between these findings and level of injury, number of years since injury, or history of urinary tract infections. Vibratory stimulation of the penis was first applied to paraplegic men to induce emission and/or ejaculation by Comarr and was followed by others. 9-~2'~8'z~'22 Afferent impulses from the glans penis travel via the pudendal nerve to the sacral cord. An uninterrupted neural communication with the thoracolumbar cord must exist, so that the excitation in the sacral cord can move upwards and transmit impulses in the thoracolumbar sympathetics, resulting in emission and/ or ejaculation. For this technique to be successful, the injury level must be above the thoracolumbar "emission center" (between T10 and L3). ~5 Therefore, this technique is optimally used in quadraplegic men with a level of injury above
T10. However, lesions above the T7-1evel are often accompanied by signs and symptoms of autonomic dysreflexia (eg, sudden pounding headache caused by rapid increase in blood pressure, flushing, sweating, and cardiac arryrhmias) that can frequently be prevented by pretreatment with nifedipine 10 to 15 minutes before the procedure. 15 In the 6 months following injury in which the cord is not excitable (spinal shock), vibratory methods of stimulation, in general, will not work. ~5Brindley H found a 77% (48/62) chance of success in inducing ejaculation in patients who were more than 6 months from time of injury and who did not have damage between L2 and S 1. In patients whose ejaculatory dysfunction is neurological and not associated with bladder neck scarring, pharmacological manipulation with alpha-adrenergic sympathomimetic medications often partially or completely converts the patient to antegrade ejaculation, may increase sperm counts in previously low density antegrade ejaculates, and may develop retrograde ejaculation in previously azoospermic men with ejaculatory failure. 15 Since 1970, there have been 93 documented pregnancies and 49 live births through electroejaculation, subcutaneous neostigmine methylsulfate, or vibratory stimulation. Many of these patients had tried more than one method to induce ejaculation. Of patients using vibratory stimulation alone, we could find reports of only 38 pregnancies and 16 liveborn children. 14 In our series, we had the patient's spouse/partner evaluated before stimulation and actual insemination to optimize chances of success. We also found that good communication between the physicians, the patient, and his spouse/partner
Table 4: Case 4-Semen Parameters With Vibratory Stimulation Date
Volume
5/93
Ante 0 Retro 100mL Ante 0.27mL* Retro 125mL* Ante 0 Retro 55mL (Swim-Up Prep)
7/93 7/93
Count
Motility
Morphology
No sperm seen 600 million/mL 8 million/mL
20% 10%
24% normal (Kruger's) N/A
1.6 million/mL 7.5 million PMS
25% 75%
N/A
* Ephedrine 50mg was taken 3 hours before vibratory stimulation.
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IUI
IUI 1
VIBRATORY STIMULATION IN QUADRIPLEGICS, Pryor
63
Table 5: Case 5-Semen Parameters With Vibratory Stimulation Date
Volume
Count
Motility
Morphology
6/93
Ante 20.0mL* Retro 60.0mL* Ante 2.0mL Retro 340.0mL (Swim-Up Prep)
30.5 million/mL 8 million/mL N/A 1.28 million/mL 1.33 million PMS
5% 2%
3% normal (Kruger's) N/A
10% 35%
N/A
9/93
IUI
IUI 1
* Increased numbers of red blood ceils found in antegrade and retrograde specimens.
to be important for timing of procedures, arrangement of laboratory facilities, and optimizing the woman's cycle. Some men may be able to remain in their wheelchair during the procedure; this is a simpler arrangement that eliminates the danger of failing off the table if muscle spasms occur with ejaculation. This decision must be made on an individual basis, individualized according to body size of patient, ease of specimen collection and quality of specimen achieved. The lithotomy position is preferable with patients who are unable to obtain specimens in their wheelchair. In our patient population, emission of semen occurred between 5 and 45 minutes after application of the vibrator. After one or more successful procedures these men learned to guide the practitioner performing the stimulation to the most productive vibration site. Increased anxiety and stress associated with infertility may cause increased difficulty producing specimens; patients need to be counseled about this possibility. Vibratory stimulation may also be done at home to "clear out" the system or for sexual needs of patients; however, it is imperative that the risk of autonomic dysreflexia be discussed with patients with lesions at T7 or above and that pretreatment with nifedipine be made available. Specimens for insemination should not be collected at home secondary to the risk of contamination and subsequent risk of infection if IUI is planned. When the ejaculate is to be used for insemination, appropriate alkalinization of the urine with sodium bicarbonate or acetazolamide (Diamox b) and increased hydration of the patient before semen collection are required, as urine is usually spermicidal because of its acidic pH and hyperosmolarity.~5 Antegrade ejaculation need not occur, as there are techniques for retrieving sperm and processing a retrograde ejaculate. This includes emptying the bladder via catheterization and instilling an appropriate buffered medium, or emptying the bladder both before ejaculation and immediately
after to recover the ejaculated fluid in as small a volume of urine as possible. The fluid is then washed and resuspended in appropriate buffer before artificial insemination or other assisted reproductive technology. It is essential to get the antegrade and retrograde samples to the lab for processing as soon as possible secondary to the deleterious effects of urine on sperm in retrograde ejaculates. With successive vibratory applications, the quality of the seminal parameters tends to improve. ~2"~8 Patients should be reminded that each cycle can be an emotional roller coaster and that persistence and patience are often needed. If there is increased stress, anxiety, or marital discord, counseling may be recommended. Adoption and donor insemination are alternatives that should be discussed early in the evaluation process in case a pregnancy does not occur and the couple desire to pursue other paths to having a family. Sexual needs also need to be addressed as there are many good treatments for erectile dysfunction that add greatly to the quality of life in this patients population. All patients in the case reports use vasoactive intracorporal pharmacotherapy or have spontaneous erections that are adequate for vaginal penetration. Although there was no attempt to document that the infants and fathers were genetically related, we are confident that these conceptions resulted from the ejaculates obtained by vibratory stimulation because of the timing of the insemination and our knowledge of their social history. Our unusually high success rate (83% of couples achieved pregnancies) is probably because of detailed review and treatment of both partners; and good communication between the andrologist, reproductive endocrinologist, and andrology lab, that resulted in recommendations for treatment of patient, partner, and semen specimens. Four of five patients achieving pregnancies had 1.3 to 7.5 million progressively motile sperm and three of five had counts as low as
Table 6: Case 6-Semen Parameters With Vibratory Stimulation Date
Volume
4/92 7/92
Unable to ejaculate Ante 3. l mL Retro 28mL Ante 2.4mL Retro 51.5mL (SPA 42% penetration) Ante 0.5mL Retro 55mL (Swim-Up Prep) 0.3mL Ante 0mL Retro N/A (Swim-Up Prep)
9/92*
9/93*
11/93"
Motility
Morphology
20% 20% < 10% 30%
N/A N/A N/A N/A
(Ante/retro combined) 0.93 million/mL
30%
N/A N/A
IUI 1
2.75 million PMS
70%
N/A 13 million PMS
35%
N/A
IUI 2
Count
1.5 million/mL 1.2 million/mL 10 sperm/13 hpf 5.5 million/mL
IUI
* All specimens were obtained after ephedrine was administered 25mg four times daily for 10 days.
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VIBRATORY STIMULATION IN QUADRIPLEGICS, Pryor
1.3 to 2.9 million progressively motile sperm on the day of intrauterine insemination. Three of five patients had 10% or less normal morphology by Kruger's Strict Criteria but still achieved pregnancies. Both laboratory staff reported similar subjective responses to the sperm preparations: the sperm samples were of very low quality, lots of debris, high round cell counts, and very low motility; the quality of antegrade and/or retrograde samples improved with each collection; and sperm preparations yielded samples for insemination with low numbers of sperm but with improved motility and little debris or round cells. Even with suboptimal semen parameters, pregnancies can be achieved when evaluation and treatment involves all members of the health care team. The vibratory stimulation technique has positive implications for the reproductive needs of patients with SCI and their partners, and should be discussed as a potential option for those desiring a pregnancy. Acknowledgment: We are grateful to Dennis Dykstra, MD, for reviewing the neurological histories of these patients. References 1. Shaban S. Treatment of abnormalities of ejaculation. In: Lipshultz L, Howards S, editors. Infertility in the male. 2nd ed. St. Louis: MosbyYear Book, 1991:409. 2. Amelar R, Dubin L. Sexual function and fertility in paraplegic males. Urology 1982;20:62-5. 3. Lipshultz L, Howards S, editors. Infertility in the Male 2nd ed. St. Louis: Mosby-Year Book, 1991:414. 4. Chapelle P, Jondet M, Durand J, Grossiord A. Pregnancy of the wife of a complete paraplegic by homologous insemination after an intrathecal injection of neostigmine. Paraplegia 1976; 14:173-7. 5. Chapelle P, Blanquart F, Puech A, Held JP. Treatment of anejaculation in the total paraplegic by subcutaneous injection of physostigmine. Paraplegia 1983;21:30-6. 6. Guttman L, Walsh J. Prostigman assessment test of fertility in spinal man. Paraplegia 1970;9:39-50.
7. Spira R. Artificial insemination after intrathecal injection of neostigmine in a paraplegic. Lancet 1956; 1:670-1. 8. Sarkarati M, Rossier A, Fam B. Experience in vibratory and electroejaculation techniques in spinal cord injury patients: a preliminary report. J Urol 1987; 138:59-62. 9. Comarr A. Sexual function among patients with spinal cord injury. Urol Int t970;25:134-68. 10. Brindley G. Electroejaculation: its technique, neurological implications and uses. J Neurol Psychiatr 1981;44:9-18. 11. Brindley G. Reflex ejaculation under vibratory stimulation in paraplegic men. Paraplegia 1981; 19:299-302. 12. Brindley G. The fertility of men with spinal injuries. Paraplegia 1984; 22:337-48. 13. Francois N, Lichtenberger J, Jouannet P, Desert JF, Maury M. L'ejaculation par le vibromassage chez le paraplegique a' propos de 50 cas avec 7 grossessnes. Ann Med Phys 1980;23:24-36. 14. Sonksen J, Biering-Sorensen F. Fertility in men with spinal cord or cauda equina lesions. Semin Neurol 1992; 12:106-14. 15. Murphy J, Lipshultz L. Abnormalities of ejaculation. Urol Clin North Am 1987; 14:583-96. 16. Newman H, Reiss H, Northrup J. Physical basis of emission, ejaculation and orgasm in the male. Urology 1982; 19:341. 17. Thomas A. Ejaculatory dysfunction. Fertil Steril 1983;39:445-54. 18. Szasz J, Carpenter C. Clinical observations in vibratory stimulation of the penis of men with spinal cord injury. Arch Sex Behav 1989;6:46174. 19. World Health Organization. WHO laboratory manual for the examination of human semen and sperm-cervical mucus interaction. New York: Cambridge University Press, 1992. 20. Menkveld R, Stander F, Kotze T, Kruger T, van Zyl J. The evaluation of morphological characteristics of human spermatozoa according to stricter criteria. Hum Reprod 1990;5:586-92. 21. Tarabulcy E. Sexual function in the normal and in paraplegia. Paraplegia 1972; 10:201-8. 22. Sobrero AJ, Stearns H, Blair JH. Technic for the induction of ejaculation in humans. Fertil Steril 1965; 16:765-7.
Suppliers a. Brookstone Acuvibe 6002 Vibrator, Brookstone Company, 5 Vose Farm Road, Peterborough, NH 03458. b. Diamox, Lederle Laboratories, Division of American Cyanamid Company, One Cyanamid Plaza, Wayne, NJ 07470. c. Percoll, Sigma, No. P1644, St. Louis, MO.
APPENDIX University of Minnesota Vibratory Stimulation Technique (1) In select patients, sympathomimetics (ephedrine or imipramine) is administered either 2 hours before procedure or 10 days before procedure if the patient is able to tolerate it. (2) Sodium bicarbonate 650mg four times daily starting 2 days before and morning of procedure. (3) Patient is to drink increased amounts of water in the moming of procedure. (4) Nifedipine 10mg sublingual is administered 10 to 15 minutes before procedure. (5) Lithotomy position (or wheelchair in select patients). (6) Dynamap (automatic sphygmomanometry). (7) Catheterize patient and empty bladder completely. (8) Rinse bladder with 15mL of culture media (Ham's F10 or BWW) with 0.6% (6g/L) albumin) then place 15mL of fresh media in bladder and remove catheter.
Arch Phys Med Rehabi! Vol 76, January 1995
(9) Vibrator to frenulum of penis until antegrade ejaculate or patient feels as if orgasm has occurred. Antegrade collected into specimen container 1. (10) Catheterize and rinse bladder with 20mL of culture media with albumin and collect it in specimen container 2. (11) Antegrade and retrograde specimens are sent to lab for sperm preparation. (12) If specimen quality is not optimal, consider change of sympathomimetic and repeat vibratory stimulation at another time. (13) Once optimal quality of specimens achieved proceed with intrauterine inseminations or other assisted reproductive technologies in conjunction with monitored ovulation of spouse or partner (full evaluation of female partner required before this).