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Retrograde ejaculation: a more convenient method for artificial insemination
Europ. J. Obstet. Gynec. reprod. Biol,, 14 (1982) 175-178 Elsevier Biomedical Press
175
Case report
Retrograde
ejaculation: a more convenient for artificial insemination
method
N. Garcea, A. Caruso, S. Campo and P. Siccardi Clinica Ostetrica e Ginecologica, Universitci Cattolica de1 Sacro Cuore, Large A. Gemelli, 8, I - 00168 Roma, Italia Accepted
for publication
19 July 1982
GARCEA, N., CARUSO, A., CAMPO, S. and SICCARDI, P. (1982): Retrograde ejaculation: a more convenient method for artificial insemination. Europ. J. Obstef. Gynec. reprod. Biol., 14/3, 175-178. A case of retrograde ejaculation not responding to medical treatment is described in which the problem of sterility was overcome by artificial insemination. The semen was collected from urine after coitus by previous alkalinization with 1.63 g NaHCO, once daily. Pregnancy occurred at the 4th insemination during the 1st treatment cycle. This technique seems to be the most suitable for artificial insemination in cases of retrograde ejaculation. retrograde
ejaculation;
artificial
insemination,
husband;
urine alkalinization
Introduction Retrograde ejaculation into the bladder is an anomaly rarely involving the young. The pathogenesis, related to partial or total relaxation of the internal bladder sphincter, determines a partial or total retrograde passage of semen to the bladder at the moment of ejaculation. The etiology is most frequently related to congenital anomalies (congenital bladder neck, diverticulum) or to lesions in the peripheral nervous system even as far as the bladder. Frequent causes are traumatic lesions, juvenile diabetes or thoraco-lumbar sympathetic surgery. The cause is unknown in some patients. Diagnosis is simple: these men have a regular orgasm without ejaculation. The urinary sediment test after sexual intercourse reveals the presence of many spermatozoa. Medical treatment almost always leads to transitory improvements (Greene and Kelais, 1968; Stewart and Bergant, 1974; Stokamp et al., 1974; Andaloro and Dube, 1975; Thiagarajah et al., 1978). No cases of pregnancy following medical treatment have been described in the literature (Kapetanakis et al., 1978). The artificial insemination technique has resulted in some pregnancies but repeated insemination was necessary. Since the majority of techniques employed to retrieve semen from the bladder require the use of a catheter, a large number of artificial inseminations becomes not only fastidious but also dangerous to the patient. In some instances patients had to stop insemina002%2243/82/WOO-00/$02.75
Q 1982 Elsevier Biomedical
Press
176
tions due to the occurrence of cystitis (Fisher and Coats, 1954). Thus, an insemination technique not requiring bladder catheterization is preferable. Quite recently anterograde ejaculation by simple masturbation with full bladder has been obtained in two patients (Crich and Jequier, 1978). However, this may not be possible in all patients. Good results employing other techniques have been described in some particular cases (Lim and Rodrigues Pereira, 1979). Case report Our patient was a seemingly healthy 30-yr-old man with an unexceptional past history except for recurrent meningitis in early childhood, which had apparently subsided. Urography showed incontinence of the internal vesical sphincter, and a conically enlarged prostatic urethra. The patient had come to the doctor’s attention since, due to lack of ejaculation during otherwise normal sexual intercourse, the couple was sterile. Urinary sediment examinations showed a sufficient number of apparently normal spermatozoa, with poor motility and poor vitality probably due to vesical acidity. After 2 yr of unsuccessful medical treatment, the couple submitted to artificial insemination. Urine was previously alkalinized according to the technique of Glezerman et al. (1976). For convenience, this technique was modified by reducing administration of bicarbonate to a single dose of 1.63 g in the morning, thereafter monitoring the rise in urinary pH. Results (Fig. 1) showed that one dose of bicarbonate in the morning leads to a rise in urinary pH which lasts for at least 5 h (7th to 12th h after intake). Following spontaneous urination after sexual intercourse sperm were retrieved by removing the supematant of urine. Thus, 0.2-0.3 cc of sperm without any preparation was introduced into the cervical canal; this procedure is used since the interval of 30 min, incubation with glucose at 5%,
URINARY
pH
ADMINISTRATION
AFTER OF
ORAL NaHC03 (gr.1.63)
Na HCOs
n
a 7 _-PH
Fig. 1. Time required to obtain rise in urinary pH. The open and closed squares, triangles and circles, indicate (for convenience in one scheme only) five different experiments in different days. The arrows indicate the hour of administration of NaHCO,.
177
SEMINAL
FLUID
AFTER URINE
ELIMINATION
Fig. 2. Scheme showing the various methods used to retrieve and to examine tion. The thicker the arrow, the better quality of the semen
the sperm before insemina-
A .I.H PREGNANCY
II II
TEST
+
I
I”‘I”“I”“I’“‘I”“I”“I’“‘I”“I”” 1
5’
10
15
20 DAY
OF
25 MENSTRUAL
30
35
40
CYCLE
Fig. 3. Time sequence of insemination in our experiment. The 4 arrows indicate the days on which A.I.H. was performed. The small arrow indicates the day on which the pregnancy test became positive (+ ).
and centrifugation made the quality of the semen poor (Fig. 2). Insemination was repeated every 3-4 days. At the fourth insemination and adequate thermic increase conception occurred (Fig. 3). Cesarian section became necessary at full-term due to acute fetal suffering. A live female child was born. She weighed 2250 g, and was small for date. The child is now over 12 mth old.
At present, homologous artificial insemination means available to solve the problem of infertility Sperm retrieval from spontaneous urination
(AIH) seems to be the only valid in cases of retrograde ejaculation. after sexual intercourse with no
178
increase in vesical urinary pH provides semen of variable quality. Thus repeated insemination is necessary and pregnancy may be difficult to achieve (Hotchkiss et al., 1955; Walters and Kaufman, 1959; Bourne et al., 1971). Furthermore, hotel-like surroundings in a medical laboratory would be necessary. The technique of increasing pH using a nutrient medium and buffer by means of vesical catheterization prior to sexual intercourse bothers the patient and often induces severe cystitis which makes further insemination impossible. Considerable improvement was made following the use of techniques in which semen was frozen in aliquots for later use. However the quality of the semen becomes impaired and repeated insemination is often necessary. The method of Glezerman appears to overcome all these problems if it is adapted to suit the particular patient as in the present case. This is important as intake of bicarbonate might be distasteful or even induce inflammation of the gastric mucosa. Furthermore, as it is impossible to predict the number of inseminations needed, the requisites of the couple should also be taken into consideration. With a single dose of bicarbonate in the morning and insemination in the evening this procedure becomes easily acceptable and bearable. Centrifugation, as suggested by Glezerman, is not necessary and should be avoided as it partially deteriorates the quality of the sperm. It appears from the literature and the present report that only two cases have been successfully treated with this technique, that of Glezerman et al. (1976) and ours. Results were excellent in both cases. After the first cycle of treatment the problem of infertility was overcome in both couples and conception occurred.
Andaloro, V. and Dube A. (1975): Treatment of retrograde ejaculation with bromopheniramine. Urology, 5, 520. Boume, R.B., Kretzschamar, W.A. and Esser, J.H. (1971): Successful artificial insemination in a diabetic with retrograde ejaculation. Fertil. Steril., 22, 275. Crich, J.P. and Jequier, A.M. (1978): Infertility in men with retrograde ejaculation: the action of urine on sperm motility, and a simple method for achieving antegrade ejaculation. Fertil. Steril., 30, 572. Fisher, I. and Coats, E. (1954): Sterility due to retrograde ejaculation of semen. Obstet. Gynec., 4, 352. Glezerman, M., Lunenfeld, B., Potashnik, G., Oelsner, G. and Beer, R. (1976): Retrograde ejaculation: pathophysiologic aspects and report of two successfully treated cases. Fertil. Steril., 27, 796. Greene, L.F. and Kelalis, P.P. (1968): Retrograde ejaculation of semen due to diabetic neuropathy. J. Urol., 98, 693. Hot&kiss, R.S., Pinto, A.B. and Kleegman, S. (1955): Artificial insemination with semen recovered from the bladder. Fertil. Steril., 6, 37. Kapetanakis, E., Rao, R. and Scommegna, A. (1978): Conception following insemination with a freeze-preserved retrograde ejaculate. Fertil. Steril., 29, 360. Lim, H.T. and Rodrigues Pereira, A. (1979): Successful artificial insemination in a case of retrograde ejaculation. Europ. J. Obstet. Gynec. reprod. Biol., 9, 247-248. Stewart, B.H. and Bergant, J.A. (1974): Correction of retrograde ejaculation by sympathomimetic medication: preliminary report. Fertil. Steril., 25, 1073. Stockamp, K., Schreiter, F. and Altwein, J.E. (1974): Adrenergic drugs in retrograde ejaculation. Fertil. Steril., 25, 817. Thiagarajah, S., Vaughan, E.D., Jr. and Kitchin, J.D. (1978): Retrograde ejaculation: successful pregnancy following combined sympathomimetic medication and insemination. Fertil. Steril., 30, 96. Walters, D. and Kaufman, MS. (1959): Sterility due to retrograde ejaculation of semen. Amer. J. Obstet. Gynec. 78, 274.
175
Case report
Retrograde
ejaculation: a more convenient for artificial insemination
method
N. Garcea, A. Caruso, S. Campo and P. Siccardi Clinica Ostetrica e Ginecologica, Universitci Cattolica de1 Sacro Cuore, Large A. Gemelli, 8, I - 00168 Roma, Italia Accepted
for publication
19 July 1982
GARCEA, N., CARUSO, A., CAMPO, S. and SICCARDI, P. (1982): Retrograde ejaculation: a more convenient method for artificial insemination. Europ. J. Obstef. Gynec. reprod. Biol., 14/3, 175-178. A case of retrograde ejaculation not responding to medical treatment is described in which the problem of sterility was overcome by artificial insemination. The semen was collected from urine after coitus by previous alkalinization with 1.63 g NaHCO, once daily. Pregnancy occurred at the 4th insemination during the 1st treatment cycle. This technique seems to be the most suitable for artificial insemination in cases of retrograde ejaculation. retrograde
ejaculation;
artificial
insemination,
husband;
urine alkalinization
Introduction Retrograde ejaculation into the bladder is an anomaly rarely involving the young. The pathogenesis, related to partial or total relaxation of the internal bladder sphincter, determines a partial or total retrograde passage of semen to the bladder at the moment of ejaculation. The etiology is most frequently related to congenital anomalies (congenital bladder neck, diverticulum) or to lesions in the peripheral nervous system even as far as the bladder. Frequent causes are traumatic lesions, juvenile diabetes or thoraco-lumbar sympathetic surgery. The cause is unknown in some patients. Diagnosis is simple: these men have a regular orgasm without ejaculation. The urinary sediment test after sexual intercourse reveals the presence of many spermatozoa. Medical treatment almost always leads to transitory improvements (Greene and Kelais, 1968; Stewart and Bergant, 1974; Stokamp et al., 1974; Andaloro and Dube, 1975; Thiagarajah et al., 1978). No cases of pregnancy following medical treatment have been described in the literature (Kapetanakis et al., 1978). The artificial insemination technique has resulted in some pregnancies but repeated insemination was necessary. Since the majority of techniques employed to retrieve semen from the bladder require the use of a catheter, a large number of artificial inseminations becomes not only fastidious but also dangerous to the patient. In some instances patients had to stop insemina002%2243/82/WOO-00/$02.75
Q 1982 Elsevier Biomedical
Press
176
tions due to the occurrence of cystitis (Fisher and Coats, 1954). Thus, an insemination technique not requiring bladder catheterization is preferable. Quite recently anterograde ejaculation by simple masturbation with full bladder has been obtained in two patients (Crich and Jequier, 1978). However, this may not be possible in all patients. Good results employing other techniques have been described in some particular cases (Lim and Rodrigues Pereira, 1979). Case report Our patient was a seemingly healthy 30-yr-old man with an unexceptional past history except for recurrent meningitis in early childhood, which had apparently subsided. Urography showed incontinence of the internal vesical sphincter, and a conically enlarged prostatic urethra. The patient had come to the doctor’s attention since, due to lack of ejaculation during otherwise normal sexual intercourse, the couple was sterile. Urinary sediment examinations showed a sufficient number of apparently normal spermatozoa, with poor motility and poor vitality probably due to vesical acidity. After 2 yr of unsuccessful medical treatment, the couple submitted to artificial insemination. Urine was previously alkalinized according to the technique of Glezerman et al. (1976). For convenience, this technique was modified by reducing administration of bicarbonate to a single dose of 1.63 g in the morning, thereafter monitoring the rise in urinary pH. Results (Fig. 1) showed that one dose of bicarbonate in the morning leads to a rise in urinary pH which lasts for at least 5 h (7th to 12th h after intake). Following spontaneous urination after sexual intercourse sperm were retrieved by removing the supematant of urine. Thus, 0.2-0.3 cc of sperm without any preparation was introduced into the cervical canal; this procedure is used since the interval of 30 min, incubation with glucose at 5%,
URINARY
pH
ADMINISTRATION
AFTER OF
ORAL NaHC03 (gr.1.63)
Na HCOs
n
a 7 _-PH
Fig. 1. Time required to obtain rise in urinary pH. The open and closed squares, triangles and circles, indicate (for convenience in one scheme only) five different experiments in different days. The arrows indicate the hour of administration of NaHCO,.
177
SEMINAL
FLUID
AFTER URINE
ELIMINATION
Fig. 2. Scheme showing the various methods used to retrieve and to examine tion. The thicker the arrow, the better quality of the semen
the sperm before insemina-
A .I.H PREGNANCY
II II
TEST
+
I
I”‘I”“I”“I’“‘I”“I”“I’“‘I”“I”” 1
5’
10
15
20 DAY
OF
25 MENSTRUAL
30
35
40
CYCLE
Fig. 3. Time sequence of insemination in our experiment. The 4 arrows indicate the days on which A.I.H. was performed. The small arrow indicates the day on which the pregnancy test became positive (+ ).
and centrifugation made the quality of the semen poor (Fig. 2). Insemination was repeated every 3-4 days. At the fourth insemination and adequate thermic increase conception occurred (Fig. 3). Cesarian section became necessary at full-term due to acute fetal suffering. A live female child was born. She weighed 2250 g, and was small for date. The child is now over 12 mth old.
At present, homologous artificial insemination means available to solve the problem of infertility Sperm retrieval from spontaneous urination
(AIH) seems to be the only valid in cases of retrograde ejaculation. after sexual intercourse with no
178
increase in vesical urinary pH provides semen of variable quality. Thus repeated insemination is necessary and pregnancy may be difficult to achieve (Hotchkiss et al., 1955; Walters and Kaufman, 1959; Bourne et al., 1971). Furthermore, hotel-like surroundings in a medical laboratory would be necessary. The technique of increasing pH using a nutrient medium and buffer by means of vesical catheterization prior to sexual intercourse bothers the patient and often induces severe cystitis which makes further insemination impossible. Considerable improvement was made following the use of techniques in which semen was frozen in aliquots for later use. However the quality of the semen becomes impaired and repeated insemination is often necessary. The method of Glezerman appears to overcome all these problems if it is adapted to suit the particular patient as in the present case. This is important as intake of bicarbonate might be distasteful or even induce inflammation of the gastric mucosa. Furthermore, as it is impossible to predict the number of inseminations needed, the requisites of the couple should also be taken into consideration. With a single dose of bicarbonate in the morning and insemination in the evening this procedure becomes easily acceptable and bearable. Centrifugation, as suggested by Glezerman, is not necessary and should be avoided as it partially deteriorates the quality of the sperm. It appears from the literature and the present report that only two cases have been successfully treated with this technique, that of Glezerman et al. (1976) and ours. Results were excellent in both cases. After the first cycle of treatment the problem of infertility was overcome in both couples and conception occurred.
Andaloro, V. and Dube A. (1975): Treatment of retrograde ejaculation with bromopheniramine. Urology, 5, 520. Boume, R.B., Kretzschamar, W.A. and Esser, J.H. (1971): Successful artificial insemination in a diabetic with retrograde ejaculation. Fertil. Steril., 22, 275. Crich, J.P. and Jequier, A.M. (1978): Infertility in men with retrograde ejaculation: the action of urine on sperm motility, and a simple method for achieving antegrade ejaculation. Fertil. Steril., 30, 572. Fisher, I. and Coats, E. (1954): Sterility due to retrograde ejaculation of semen. Obstet. Gynec., 4, 352. Glezerman, M., Lunenfeld, B., Potashnik, G., Oelsner, G. and Beer, R. (1976): Retrograde ejaculation: pathophysiologic aspects and report of two successfully treated cases. Fertil. Steril., 27, 796. Greene, L.F. and Kelalis, P.P. (1968): Retrograde ejaculation of semen due to diabetic neuropathy. J. Urol., 98, 693. Hot&kiss, R.S., Pinto, A.B. and Kleegman, S. (1955): Artificial insemination with semen recovered from the bladder. Fertil. Steril., 6, 37. Kapetanakis, E., Rao, R. and Scommegna, A. (1978): Conception following insemination with a freeze-preserved retrograde ejaculate. Fertil. Steril., 29, 360. Lim, H.T. and Rodrigues Pereira, A. (1979): Successful artificial insemination in a case of retrograde ejaculation. Europ. J. Obstet. Gynec. reprod. Biol., 9, 247-248. Stewart, B.H. and Bergant, J.A. (1974): Correction of retrograde ejaculation by sympathomimetic medication: preliminary report. Fertil. Steril., 25, 1073. Stockamp, K., Schreiter, F. and Altwein, J.E. (1974): Adrenergic drugs in retrograde ejaculation. Fertil. Steril., 25, 817. Thiagarajah, S., Vaughan, E.D., Jr. and Kitchin, J.D. (1978): Retrograde ejaculation: successful pregnancy following combined sympathomimetic medication and insemination. Fertil. Steril., 30, 96. Walters, D. and Kaufman, MS. (1959): Sterility due to retrograde ejaculation of semen. Amer. J. Obstet. Gynec. 78, 274.