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Sexual and Reproductive Health

Male Fertility

Male fertility after SCI is often compounded by the difficulties of erectile dysfunction, as well as retrograde ejaculation or anejaculation. Ejaculation is a complex process involving coordinated activity of the sympathetic (smooth muscle) and somatic (striated muscle) nervous system controlling prostate and seminal vesicles, bladder neck/sphincter, pelvic floor and urethra. Few men with SCI are able to ejaculate with partner sexual practices alone and require medical assistance to obtain sperm. This sperm is then used for intravaginal/intrauterine insemination or other assisted reproductive technology (ART) interventions. Although most of the male fertility studies describe issues of retrieval, sperm quality, reproductive technology, pregnancy and live births within a single study, the tabled studies have been sorted into the topics of sperm retrieval, sperm quality and pregnancy based on the primary focus of the paper, although overlap does occur.

Author Year; Country
Dates included in the
Total sample size
Level of evidence
Type of study
DeForge et al. 2005;
CanadaReviewed published and
unpublished articles
between 1966 and 2003N=66Level of evidence
Jadad Scale – RCTs
Newcastle-Ottawa Scale –
Non RCTsType of studies
Not specifiedAMSTAR=7
Methods: Literature search for published
and unpublished studies from databases and
selected annual proceedings, of any
research design or language, that enrolled
male, adult/adolescent populations with SCI
reviewing fertility interventions with pre- and
post-intervention fertility measures
Interventions included electrical and
vibrational stimulation, testicular biopsy,
intracytoplasmic sperm injection (ICSI) and in
vitro fertilization (IVF).
Outcome measures included sperm quality
and pregnancy and live birth rates.
CINAHL, Cochrane Central Register of
Controlled Trials, SocioFile, and PsycINFO.
1. Systematic review restricted to male
fertility post-SCI, as there were no caseseries studies investigating fertility
issues such as pregnancy rates, live
births and complications or obstetrical
management issues in females after
2. Ejaculation interventions in the last
decade resulted in response rates of
95% (95% confidence intervals (CI)
91%, 99%), with 100% response rate
reported in several recent publications.
3. A total of 13 studies (1993–2001)
yielded pregnancy rates of 51% (95% CI
42%, 60%) in partners of SCI males. Of
these, 11 studies (1993–2003) yielded
live birth rates of 41% (95% CI 33%,
49%), an improvement overtime.
4. Reproductive success limited by
prevailing low semen quality in SCI
5. Sperm freezing would probably not
enhance fertility unless the sperm were
to be frozen almost immediately after
Patki et al. 2008;
Reviewed published
articles from PubMed and
Medline, dates not
N=not stated
Level of evidence
Methodological quality not
Type of studies
Not described
Method: Searched using the key words:
spinal cord injuries, fertility, sexual
dysfunction, and spermatogenesis, for
articles on the effects of SCI on semen
parameters that may contribute to poor
motility and poor viability.
Databases: PubMed and Medline
1. The distinguishing character of poor
semen quality in men with SCI is
abnormal sperm motility and viability, not
the sperm count which remains
comparable to the age-matched
population. The cause of this
asthenozoospermia appears be
multifactorial, but not related to time since
injury, elevated scrotal temperature,
method of bladder management or
method of ejaculation.
2. Although abnormal hormonal levels in
urine and blood have been reported in
many studies, this does not seem to be
the primary cause of infertility because
equal numbers of studies report normal
3. 2 studies reported a decrease in sperm
motility in men with SCI associated with
elevated scrotal temperatures. However,
a more recent study contradicted this,
finding no correlation between scrotal
temperature and semen parameters.
4. Men with SCI have elevated levels of
reactive oxygen species in semen which
is associated with a decrease in fertility.
5. Seminal plasma from men with SCI
decreases sperm motility
6. Axonemal defects and abnormalities of
flagella were identified in the majority of
patients with SCI.
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