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Male Fertility and Resulting Pregnancy

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Unfortunately, after SCI, semen quality declines necessitating assistive reproductive technologies to compensate for the alterations (Elliott 2003). Pregnancy rates are lower than the general population but have been much improved since the advent of in vitro fertilization (IVF) and intracytoplasmic injection (ICSI).

Table 17: Fertility and Resulting Pregnancy

Discussion

Pregnancy rates of partners of men with SCI, although somewhat dependent on sperm motility, are improved consistently with higher levels of reproductive assisted technology. Fertility rates improve progressively with the use of assisted reproductive technology (ART) and more advanced techniques, as follows:

  • At home (intercourse or vaginal insemination)
  • Intrauterine insemination
  • In vitro fertilization (IVF)
  • IVF + intracytoplasmic sperm injection (ICSI)

Reports have varied in their description of pregnancy rates, using either pregnancy rate per couple or pregnancy rate per insemination method. In general, reported as per couple, there has been considerable improvement in rates over the last 20 years due to better technology (Brinsden et al. 1997; Schatte et al. 2000). In collation of reports by many authors, there appears to be an average 30-50% pregnancy rate and a 40% live birth rate (Beretta et al. 1989; Hultling et al. 1994; Dahlberg et al. 1995; Chung et al. 1997; Hultling et al. 1997; Heruti et al. 2001; Sheih et al. 2003; Giulini et al. 2004). Cumulative pregnancy rates could go as high as 80% (Sheih et al. 2003). The number of attempts varied greatly, with pregnancy unlikely to occur after 5 attempts of any method (recognizing that some couples advanced on the continuum of increasing ART).  Cycle fecundity rate (chance of pregnancy per cycle) for intrauterine insemination is <15%, whereas for IVF/ICSI it is between 25-40%.  In one study, it was felt that delayed timing of intrauterine insemination resulted in significantly improved pregnancy rates in female partners of men with tetraplegia (Pryor et al. 2001). While fresh semen samples were preferred, cryopreserved semen samples were used successfully for IVF technology. Cryopreservation of embryos to be replaced at a later date is also useful (Buch & Zorn 1993).  Multiple gestations were more frequent with IVF/ICSI. Testicular aspiration has been used less commonly, since it commits the man and his partner to IVF/ICSI procedures. One case control study however, found that pregnancy rates among couples using testicular aspirated sperm from males with SCI, were comparable to the rates among couples using the same procedure from able-bodied controls with obstructive azoospermia (Kanto et al. 2008).  The use of retrograde vasal sperm aspiration has also shown to be a reliable method for consistent sperm recovery such that a high pregnancy rate and cryopreservation of excess sperm for future use was possible (Hibi 2008).

Estimates of the feasibility of and effort required to pursue biological fatherhood after SCI are emerging. This cumulative evidence and substantial clinical experience suggest starting with an appropriate clinical assessment of neurological impairment, physical health, bladder management and risk factors for the man (i.e. autonomic dysreflexia), as well as fertility history and blood work for the female partner. Assessment of sperm retrieval methods follows with evaluation of the resultant semen samples retrieved.  Female intervention is determined by her fertility factors and by the quality of semen available. The least invasive and least expensive insemination options are pursued after weighing invasiveness and risk of sperm retrieval and semen quality. Men with SCI stand a good chance (>50%) of becoming biological fathers when they have access to specialized clinics and care.

Conclusion

There is level 3 (Kanto et al. 2008) and level 4 evidence (Buch and Zorn 1993; Hultling et al. 1994; Brackett et al. 1995; Dahlberg et al. 1995; Pryor et al. 1995; Nehra et al. 1996; Brinsden et al. 1997; Chung et al. 1997; Hultling et al. 1997; Sønksen et al. 1997; Taylor et al. 1999; Schatte et al. 2000; Heruti et al. 2001; Ohl et al. 2001; Shieh et al. 2003; Hibi 2008, McGuire et al. 2011; Kathiresan et al. 2011; Leduc 2012) that men with SCI have a good chance of becoming biological fathers with access to specialized care utilizing reproductive assisted technology.

  • Men with SCI should have realistic expectations of becoming a biological father.

    Depending on semen quality and female factors, a progression from intravaginal insemination to assisted techniques such as intrauterine insemination, in vitro fertilization (IVF) to IVF plus intracytoplasmic sperm injection (ICSI) is recommended.

    At home intravaginal insemination has revealed pregnancy rates of 40-50%.