Male Fertility and Insemination

Men with SCI are less likely to become biological fathers than men in the general population for a number of reasons. Erections may be absent or not firm enough for penetration, thus sperm often needs to be retrieved via penile vibrostimulation (PVS) or electroejaculation procedures (EEP), and inserted via at-home, or intravaginal, semination. Once semen has been retrieved, sperm quality and motility are often degraded or of lower quality. However, male fertility rates have been much improved since the advent of assistive reproductive technologies like in vitro fertilization (IVF) and intracytoplasmic injection (ICSI). In general, the amount of assistive reproductive technology required is directly related to the difficulty of retrieving semen and to the motility of the sperm in the semen retrieved.

Discussion

Pregnancy rates of partners of men with SCI, although somewhat dependent on sperm quality and motility, have been improved over recent years with usage of assisted reproductive technology (ART). Men with SCI have a good chance (>50%) of becoming biological fathers when they have access to specialized clinics and care.

An overall stepwise approach to using ART and fertility post-SCI might look like the following:

• A clinical assessment of degree of neurological impairment, physical health, bladder management, fertility history, blood work (female) and risk factors (e.g., is Autonomic Dysreflexia induced by sexual activity)
• Sperm retrieval – ejaculation is less common in men with SCI, so sperm retrieval methods are usually tried from least to most invasive – penile vibratory stimulation (PVS), electroejaculation procedure (EEP), surgical retrieval of sperm (e.g., vasal aspiration, microsurgical epididymal sperm aspiration (MESA), testicular sperm extraction (TESE))
• Assessment of semen quality (analysis of sperm motility, i.e., swimming ability)
• Insemination method based on sperm motility and least to most invasive/expensive:
  • At home (intercourse or vaginal insemination)
  • Intrauterine insemination – washed, concentrated sperm directly into the uterus via a catheter around the time of ovulation in an office procedure
  • In vitro fertilization (IVF) – eggs are retrieved from ovaries and fertilized by sperm in a laboratory, the resulting embryos are cultured and directly transferred to the uterus in an office/clinic/hospital procedure
  • IVF + Intracytoplasmic sperm injection (ICSI) – a single, healthy sperm is injected directly into a mature egg often to treat severe male factor infertility.

Multiple cycles of any/all of the above procedures may be tried based on the wishes of the person, the invasiveness of the sperm retrieval, the quality and motility of the sperm, and cost of insemination options.

Pregnancy rates have been reported using either pregnancy rate per couple or pregnancy rate per insemination method. Reported as per couple, there has been considerable improvement in recent rates due to better technology. The most recent and largest studies report a pregnancy rate range from 25-85%, with many studies achieving 50-65% success once all fertility options and procedures have been employed (Cito et al. 2020; Kanto et al 2009; Kathiresan et a. 2011; Leduc et al. 2012; Bechoua et al. 2013; Dahlberg et al. 1995; Heruti et al. 2001; Hultling et al. 1994; 1997; Shieh et al. 2003; Sonksen et al. 2012, 1997; Brinsden et al. 1997; Schatte et al. 2000; Nehra et al. 1996, Ohl et al. 2001, Brackett et al. 1995).

The number of attempts/cycles varied greatly, with pregnancy unlikely to occur after 5 attempts of any method (recognizing that some couples advanced on the continuum of increasing ART). The chance of pregnancy per cycle for intrauterine insemination is <15%, whereas for IVF/ICSI 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).

Normal and total fertilization rates of fresh semen samples were significantly lower in SCI groups (46% and 50% success rates) than non-SCI controls (71% and 75% success; p<0.01) though there were no significant differences between SCI and non-SCI controls in pregnancy, miscarriage, or live births per cycle (Cito et al. 2020). While fresh semen samples are preferred, cryopreserved semen samples have been used successfully for IVF technology. Multiple gestations were more frequent with IVF/ICSI.

There are a number of kinds of surgical sperm retrieval (i.e., sperm aspiration) that are minimally invasive and used for IVF/ICSI, and mitigate some of the semen quality and sperm motility issues in men with SCI. They use fine needles and local anesthetic to extract sperm directly from the testicle (Testicular Sperm Aspiration -TESA), the tube behind the testicle (Percutaneous Epididymal Sperm Aspiration – PESA) or from the sperm duct (Vasal Sperm Aspiration – VSA) (Johns Hopkins, 2026). One case-control study 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 non-SCI controls with obstructive azoospermia (Kanto et al. 2009). The use of retrograde vasal sperm aspiration has also shown to be a reliable method for consistent sperm retrieval such that a high pregnancy rate and cryopreservation of excess sperm for future use was possible (Hibi et al. 2008).

Conclusion

Men with SCI have a good chance of becoming biological fathers with access to specialized care utilizing reproductive assisted technology, as supported by level 3 (Kanto et al. 2009; Cito et al. 2020), level 4 (Brackett et al. 1995; Dahlberg 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 et al. 2008; McGuire et al. 2011; Kathiresan et al. 2011; Leduc 2012), and level 5 evidence (Bechoua et al. 2013)

There is level 3 evidence (Kanto et al. 2009) that testicular sperm extraction followed by intracytoplasmic injection is an effective way to induce pregnancy, with fresh sperm giving better results than frozen-thawed sperm.