Sperm recuperation and cervical insemination in retrograde ejaculation

FERTILITY AND STERILITY

Vol. 49, No.5, May 1988 Printed in U.S.A.

Copyright © 1988 The American Fertility Society

Sperm recuperation and cervical insemination in retrograde ejaculation

Mario Brassesco, M.D.* Pedro Viscasillas, M.D.t Luisa Burrel, M.D.t Joaquin Calaf, M.D.t

Oswaldo Rajmil, M.D.:!: J. M. Pomerol Serra, M.D.:!: Francisco Morer Fargas, M.D.:!:

Human Reproduction Working Group, Universitat Autonoma, Barcelona, Spain

The importance of retrograde ejaculation in male infertility is difficult to estimate. The information from the literature barely refers to the incidence of this ejaculatory dysfunction, but recent publications seem to detect an increase in the number of cases identified. 1 ,2 This increase could be due to a higher incidence in radical pelvic surgery in young people, road accident injuries, the use of new drugs that act on the adrenergic system controlling ejaculation, or a change in the incidence of some evolutive forms of diabetes mellitus. In the infrequent complete form, the diagnosis is easily established through its major sign: aspermia. It is not possible, however, to exclude some minor forms where only part ofthe ejaculate is driven into the bladder, resulting in a diminution of both sperm volume and count. 1 Thus, when the volume of the ejaculate is repeatedly low, the patient should be asked to void after ejaculation. The identification of spermatozoa in the precipitate, after the urine has been centrifuged, leads to the diagnosis. The problem of infertility in these patients has been approached in different ways. Medical treatment with adrenergic substances with the aim of reversing the functional effects of the neuropathy have been of variable ef-

Received December 23, 1986; revised and accepted January 19,1988. * Reprint requests: Mario Brassesco, M.D., Semen Laboratory, Fundaci6 Puigvert, Institut d'Urologia, Cartagena 340-350, Barcelona 08025, Spain. t Department of Obstetrics and Gynaecology. Hospital Sant Pau. :\: Service of Andrology. Fundaci6 Puigvert. Vol. 49, No.5, May 1988

fectiveness. In the majority of the cases, the goal has been to recuperate motile spermatozoa from the bladder, either through spontaneous voiding or by catheterization. The toxicity of urine on the spermatozoa has been avoided by bladder washing, urine dilution, and or the administration of alkalinizing substances. In this article, we present our experience in the treatment of infertility in seven patients with retrograde ejaculation by a noninvasive method of sperm recuperation and insemination. MATERIALS AND METHODS

Retrograde ejaculation was identified by the demonstration of spermatozoa and fructose or citrate in the urine voided after ejaculation in 15 infertile patients with aspermia. In 8 of the patients, the number of sperm recuperated after masturbation and voiding was so low (lower than 1 X 106 ) that it would not allow for the preparation of a suitable sample for insemination, and these patients were excluded from the protocol. The present report is thus concerned with 7 patients affected by retrograde ejaculation and showing high amounts of spermatozoa in the urine. The age range was between 25 and 31 years and the ejaculatory dysfunction was secondary to a diabetic neuropathy in three patients, transurethral resection of the prostate (TUR) in two patients, and idiopathic hypertonus of the external sphincter (RES) in two patients. All of them had previously been treated with alpha-adrenergic drugs and had failed to obtain any degree of antegrade ejaculation. Brassesco et al.

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Figure 1 Evolution of urinary osmolarity (Osm), glucose (VG), and pH in relation to the timing of masturbation in a diabetic patient.

The existence of a female factor was ruled out by a complete physical examination, basal body temperature, hysterosalpingogram (HSG), and evaluation of the cervical mucus in the peri ovulatory period. One of the women presented a long follicular phase ovulatory pattern with a thermic rise around the 20th day of the cycle, and the insemination program was scheduled accordingly. In another case, the HSG showed the absence of one tube, according to the patient the salpingectomy had been performed during an appendectomy. The rest of the examinations confirmed the normality of all the factors studied. On the day of insemination, the patients were instructed to drink a solution of 4 gm of COaHNa in 250 ml of water. They were asked to void every 15 minutes, and the pH and osmolarity were measured in the urine collected. a In diabetic patients, where the urinary pH was low, the doses of bicarbonate and fluid were adjusted according to the response. When values of 300 to 500 mosm/kg and pH between 6.5 and 8 were reached, the patients were instructed to masturbate and void immediately after masturbation (Fig. 1).

The samples obtained under these conditions were immediately centrifugated, the urine discarded, and the pellet resuspended in normal seminal plasma. The preparation was incubated at 37°C for 5 minutes and then checked for sperm count, morphologic features, and motility. Total sperm count and percentage of active motile sperm are presented in Table 1. The insemination days were chosen according to the previous basal body temperature (BBT) records of the wife. The most frequent ovulatory day was considered day 0, and the inseminations were scheduled for days -2, 0, and +2. The convenience of the day was confirmed by the optimal characteristics of cervical mucus. The inseminations were performed every other day until recording a rise in BBT. The inseminations were carried out with the cervical cup design by Finkester and Semm (WISAP, Portio adapter 8029, Sauerlach, Germany).

RESULTS Pregnancy was achieved in all cases treated. This means that, among the 15 patients complaining from infertility, 7 achieved a pregnancy. In 6 patients, pregnancy took place before the fourth month of insemination. In the seventh couple, the sixth month of treatment was reached without achieving pregnancy, despite the quality of the sample used for insemination. In order to rule out any female disturbance previously undetected, a thorough check-up of all factors, including hormonal determinations, endometrial biopsy, and laparoscopy, were performed without any positive findings. The patient became pregnant on the first insemination cycle after laparoscopy. All pregnancies reached term uneventfully. In

Table 1 Seminal and Obstetric Data in the Eight Pregnancies Obtained Patient

Etiology

1 2 3 3a 4 5 6

Diabetes Diabetes HES HES TUR Diabetes TUR HES

7 a

Sperm no.

Active motility (+++)

xu!'

%

82 112 202 100 58 80 60 60

25 30 50 40 15 30 20 30

Cycle

Delivery

Sex

wks

3 1 8 2 2 3 4 3

39 42 40 39 40 41 40 40

F F M F F M M F

In patient no. 3, pregnancy has been obtained on two occasions.

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seven cases, delivery took place spontaneously by vaginal route. In one case, in which amnionitis was suspected after premature rupture of the membranes, a cesarean section was performed. All newborns, five girls and three boys, were normal and healthy, birth weight was between 2900 and 4030 gm, and no malformations were detected. Couple number 3 has already achieved another pregnancy by the same technique. DISCUSSION

The goal in the management of infertility due to retrograde ejaculation has been the recovery of seminal material in adequate conditions to perform artificial insemination. At present, 19 pregnancies have been reported using different recovery methods. 4- 6 Our series represents the largest both in the number of patients considered and the number of pregnancies obtained. Both aspects require detailed discussion. Retrograde ejaculation is probably an infrequent cause of infertility, being related to other major urologic dysfunctions. 2 It is then logical to expect the number of cases discovered by a reproductive medicine group bound to a urologic institution to be higher than that found in a mainly female-oriented institution. The importance of such equilibrated groups, where andrologists and gynecologists share the management of the infertile couple, should not be overlooked. It is also true that the cases were selected restrictively and only those patients showing a reasonable degree of sperm recovery were allowed to enter the study. Moreover, we have been fortunate in having "pure" male factor cases, since the study of the

Vol. 49, No.5, May 1988

wives failed to show any major disturbance, as has been ascertained by the pregnancies obtained. We have no doubt that the high level of efficiency obtained in this series cannot be expected from wider use of this technique. SUMMARY

Seven infertile patients with retrograde ejaculation, in which spermatozoa could be recuperated from the postejaculation urine, were admitted to a sperm recuperation and cervical insemination program. A noninvasive method for sperm recuperation based on urine alcalinization and serial controls to time masturbation has been used. Insemination has been timed according to BBT charts and cervical mucus characteristics. Pregnancy has been obtained in the seven couples after one to eight treatment cycles. REFERENCES 1. Thomas AJ: Ejaculatory disfunction. Fertil Steril 39:445,

1983 2. Schienen C, Hupe H: Retrograde ejaculation. Urologe [A] 16:108, 1976 3. Mahadevan M, Leeton J, Trouson A: Non·invasive method of semen collection for successful artificial insemination in a case of retrograde ejaculation. Fertil Steril 36:243, 1981 4. Scammell GE, Stedroussea J, Dempsey A: Successful pregnancies using human serum albumin following retrograde ejaculation: a case report. Fertil Steril 37:277, 1982 5. Colpi HM, Sommadossi L, Zanolla A: Infertility caused by retrograde ejaculation: a successfully treated case. Andrologia 15:592, 1983 6. Brande PR, Ross LD, Bolton VN, Ockenden K: Retrograde ejaculation: a non invasive method for sperm recuperation from postejaculatory urine. Br J Obstet Gynaecol 94:76, 1987

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