Sperm Retrieval
The two methods of sperm retrieval most commonly used are penile vibrostimulation (PVS) and the electroejaculation procedure (EEP). PVS is performed using a specialized vibrator placed on the penis to induce reflex ejaculation, whereas EEP uses a rectal probe to deliver electrical current to the periprostatic nerves, eliciting seminal emission. In the first months after injury, semen can only be attained by EEP, since PVS is not effective until spinal shock has resolved.
Author Year; Country Score Research Design Total Sample Size |
Methods | Outcome |
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Raviv et al. 2013; Israel Case control Level 3 N=32 (couples) |
Population: 32 couples with male partner with SCI referred to IVF after repeated trials of electroejaculation (EEJ) or penile vibratory stimulation (PVS) and full andrological evaluation; mean(SD) time since injury until assisted reproductive procedure 7.6(2.1) yrs, range 5–16; Patient subgroups: obstructive azoospermia (n=19), non-obstructive azoospermia (n=6), severe oligozoospermia (n=7). Treatment: Testicular sperm aspiration (TESA) for sperm extraction. Open testicular sperm extraction (TESE) was performed only after a negative TESA attempt. Outcome measures: clinical pregnancy and live birth rates. |
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Kathiresan et al. 2012; USA Case series Level 4 N SCI=444 N controls=61 |
Population: 444 men with SCI with no known causes of infertility other than SCI; level of injury: 176 cervical, 193 T1-T10, 70 T11-caudal; 115 complete, 126 incomplete. Controls: 61 able-bodied (AB) men, healthy with no history of infertility. Treatment: Retrospective chart review of Male Fertility Research Program participants from 1991 to 2011. Sperm retrieval methods included masturbation, penile vibratory stimulation (PVS), and electroejaculation (EEJ). Outcome measures: sperm retrieval method (masturbation, PVS, EEJ), semen volume, sperm concentration, sperm motility, total sperm count. |
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Qiu et al. 2012; China Pre-post Level 4 N SCI=26 N controls=16 |
Population: 26 infertile men with SCI (primary infertility present in 9), mean(SD) age 33.8(2.9) yrs, mean(SD) DOI 8.6(3.0) yrs (range 1-11 yrs), level of injury: C5-C6 (n=4), T2-T12 (n=22), mean(SD) yrs of infertility 6.8(4.2) yrs; Controls: 16 non-SCI fertile donors (all had previously fathered at least one child), mean(SD) age 32.9(2.1) yrs. Treatment: Collection of semen samples in SCI men using penile vibratory stimulation (PVS) (n=14), percutaneous vasal sperm aspiration (PVSA) (n=12); collection of semen samples in non-SCI donors all by masturbation (n=16). Outcome measures: sperm vitality and DNA integrity, sperm chromosomal aneuploidy. |
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Sonksen et al. 2012; Denmark Case control Level 3 N=140 |
Population: 140 SCI men with anejaculation and their healthy female partners (presenting for infertility treatment between 1988 and 2008); Age: SCI men (median 30 yrs, range 22–44), female partners (median 28 yrs, range 19–39 yrs); DOI: median 7 yrs (range 1–22), Level of lesion: C2 to T9. Treatment: Men who obtained antegrade ejaculation by penile vibratory stimulation (PVS) and had motile sperm in the ejaculate were offered the possibility of PVS combined with vaginal self-insemination at home. Couples were instructed to perform PVS and to instill the ejaculate intravaginally. Outcome measures: Pregnancy rate per couple, number of live births, total motile sperm count and time to pregnancies. |
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Brackett et al. 2009; USA Case series Level 4 N=500 |
Population: 500 men with SCI (3,152 semen retrieval procedures); mean(SD) age 34.1(0.4) yrs (range 17-63); mean (SD) DOI: 10.0(0.3) yrs; Level of injury: 203 cervical, 123 T1-T6, 150 T7-T12, 20 L1,4 unknown. Treatment: review of research data from Jan 1991 to Apr 2009 from SCI participants in a male fertility research program. Semen retrieval methods were performed according to ability: masturbation, if not then penile vibratory stimulation (PVS), if not then electroejaculation (EEJ). Outcome measures: semen retrieval methods: masturbation, PVS, EEJ; semen analysis: total sperm count, motility. |
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Hibi et al. 2008; Japan Post-test Level 4 N=8 |
Population: 8 participants with cervical SCI and neurogenic anejaculation (age 26-46 yrs, mean 35.6). Treatment: Retrograde vasal sperm aspiration (ReVSA). Outcome Measures: Presence of motile sperm. |
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Kanto et al. 2008; Japan Case control Level 3 N = 56 |
Population: 22 men with SCI (age 21-41); data on 34 men with obstructive azoospermia was obtained retrospectively as control Treatment: Testicular sperm extraction (TESE); if unsuccessful, microdissection TESE was performed, followed by intracytoplasmic injection (ICSI) Outcome Measures: Fertilization; pregnancy. |
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Arafa et al. 2007; Eqypt Post-test Level 4 N=69 |
Population: Men with SCI; Age: mean 36.6 yrs, SD=18.34; Injury level: at or below T10 (n=34), above T10 (n=35); Time since injury: mean 11.03 yrs, SD=7.80; anejaculatory. Treatment: Prostatic massage thru the rectum to push the sperm out through the ejaculatory ductal system. Outcome Measures: Semen retrieval. |
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Brackett et al. 2007; USA Pre-post Level 4 N=297 |
Population: Men with SCI; Age: range 17- 60 yrs; Injury level: cervical (n=109), T1-T10 (n=131), T11 or below (n=45), unknown (n=12); Time since injury: range 0.2-44.6 yrs. Treatment: Penile vibratory stimulation using 1 vibrator, or if this failed, 2 vibrators applied to glans penis using sandwich method. Outcome Measures: Semen retrieval. |
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Soler et al. 2007; France Pre-post Level 4 N=158 |
Population: Men with SCI; Age: mean 29.5- 33.2 yrs; Level of injury: tetraplegia (group 1, n=55), paraplegia at or above T6 (group 2, n=52), paraplegia T7-T10 (group 3, n=23), paraplegia T11 and below (group 4, n=28); anejaculation, failed to respond to penile vibratory stimulation (PVS). Treatment: PVS and midodrine 7.5-30mg (tetraplegia) or 15-30mg (paraplegia) 30 to 120 mins before stimulation, ED was treated with PDE5i or intracavernosal prostaglandin injection. Outcome Measures: Number of ejaculations, blood pressure (BP), average dose for success. |
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Kolettis et al. 2002; USA Post-test Level 4 N=27 |
Population: Men with SCI (n=27), 9 couples; Injury level: cervical (n=10), thoracic (n=16), lumbar (n=1). Treatment: Electrical stimulation (12-18V, 400-600mA for 30 second bursts) followed by intrauterine insemination or IVF. Outcome Measures: Seminal parameters, ejaculation rates, cycle function, pregnancy rates. |
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Le Chapelain et al. 1998; France Case series Level 4 N=44 |
Population: Men with SCI; Age: mean 28.5 yrs, range: 19-49 yrs; Injury level: C4-L2, tetraplegia (n=17), paraplegia (n=22); Impairment: 8 complete, 9 incomplete. Treatment: Retrospective analysis of vibratory stimulation, electroejaculation or subcutaneous physostigmine (a reversible acetylcholine esterase antagonist) (at least 2 sessions). Outcome Measures: Ejaculation, conception, sperm count, motility. |
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Lochner-Ernst et al. 1997; Germany Post-test Level 4 N=219 |
Population: 219 men; 51 participants with tetraplegia, 161 with paraplegia; Mean time since injury: 11.9 yrs. Treatment: Supranuclear patients were treated by vibrostimulation. When this failed, further treatment was applied: physostigmine medication and vibrostimulation, electroejaculation, physostigmine with electroejaculation (EE), surgical approaches. Infranuclear patients were treated by EE. Outcome Measures: Semen retrieval and pregnancy success. |
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Lim et al. 1994; Australia Post test Level 4 N=12 |
Population: Men with SCI; Age: mean 31 yrs, range 21-36; Injury level: C4-L2; Time since injury: mean 8 yrs, range 1-24 Treatment: Assisted ejaculation (electroejaculation (EE) or penile vibratory simulation (PVS)) using balloon catheter to tamponade the bladder neck. Outcome measures: Antegrade ejaculation, semen analysis including volume, sperm concentration, morphology, percentage of motile sperm, adverse events, impact of catheter and lubrications on sperm. |
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Sonksen et al. 1994; Denmark Post-test Level 4 N=66 |
Population: Men with SCI and erectile dysfunction; Age: range 18-44 yrs; Time since injury: 0.6-39 yrs, Level of injury: C2- L1. Treatment: Vibrator (multicept ApS) and Relax (Nordic Light) vibrators. Different amplitudes were tested. Outcome Measures: Ejaculation responses. |
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Leduc et al. 1992; Canada Post-test Level 4 N=37 |
Population: 37 men with SCI; Age: mean 29.5 yrs, range 19-61; 15 cervical (9 complete, 6 incomplete), 22 thoracic (20 complete, 2 incomplete), Time since injury: range 3 months-23 yrs. Treatment: 10mg nifedipine for autonomic dysreflexia, 40mg butylbromure hyoscine subcutaneously to limit some of the parasympathetic side effects of physostigmine, and then 2-4mg physostigmine subcutaneously 30 mins later and followed by masturbation by female partner. Outcome Measures: Ejaculation responses, pregnancies. |
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Rawicki & Hill 1991; Australia Post-test Level 4 N=39 |
Population: 39 men; Injury level: C4-L5. Treatment: Electroejaculation (EE), vibration ejaculation (VE), and subcutaneous physostigmine (PS). Outcome Measures: Seminal emission, pregnancies, conception. |
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Beretta et al. 1989; Italy Post-test Level 4 N=102 |
Population: 102 men; Age: mean 25.6 yrs; Injury level: cervical-sacral lesions, above T11 (n=58), thoracolumbar lesions (n=36), sacral (n=8); Mean time since injury 6.1yrs. Treatment: Simple vibrator applied to the penis for ejaculatory response. 15 patients who wanted to conceive a child, received instruction in home use of vibrator. Outcome Measures: Ejaculation frequency, sperm quality. |
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Brindley et al. 1989; UK Post-test Level 4 N=8 |
Population: 7 SCI, 1 primary anorgasmia, Age: range 27-37 yrs; Level of injury: C5-T9, 5 complete; Time since injury: 2-15 yrs. Treatment: Implantation of radio-linked hypogastric plexus stimulator device. Outcome Measures: Seminal emission and erection (with use of implant). |
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Ohl et al. 1989; USA Post-test Level 4 N=48 |
Population: 48 men with SCI; mean age 31yrs, range 20-53 yrs; 15 cervical, 29 thoracic, 4 lumbar; YPI 4 months-34 yrs; 56% complete, 44% incomplete. Treatment: Rectal probe electroejaculation (EE). Outcome Measures: Semen retrieval and sperm quality. |
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Halstead et al. 1987; USA Post-test Level 4 N=12 |
Population: 12 men with SCI; Age: range: 23-38 yrs; Injury level: C5-C6 (n=4), T3-T12 (n=7), L1 (n=1); paraplegia (n=8), tetraplegia (n=4); Impairment grade: AIS A (n=7), b (n=1), C (n=3), D (n=1). Time since injury: range 0.5-18 yrs. Treatment: Rectal probe electroejaculation on 38 occasions. Outcome Measures: Ejaculation response and sperm quality. |
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Brindley 1984; England Post-test Level 4 N=81 |
Population: 81 men with SCI, mostly complete. Treatment: Application of a vibrator of 80 Hz and 2.5mm amplitude to the lower surface of the glans penis, electroejaculation (EE). Outcome Measures: Semen retrieval. |
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Chapelle et al. 1983; France Post-test Level 4 N=20 |
Population: Injury level: T6-L4; Time since injury: >6 months. Treatment: Physostigmine (PS) followed by intraspinal injection of neostigmine (ISN) (0.25-0.5mg) or PSC (2mg physostigmine sulfate injected 30min after 40mg Nbuthylhyocine) several weeks later. Outcome Measures: Ejaculation. |
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Brindley 1981; UK Post-test Level 4 N=89 |
Population: Men with SCI (n=84); Injury level: C6-L1 or below; ejaculatory failure. Treatment: Electro-ejaculation (EE) technique with glove-finger electrode. Outcome measures: Successful EE defined as: external success (liquid containing spermatozoa trickled from meatus), retrograde success (no external spermatozoa but at least 5×106 spermatozoa in urine), definite failure (no liquid at meatus or no external spermatozoa or < 5×106 spermatozoa in urine), external failure (no semen externally and no urine specimen provided), pain prevented (at the only attempt at EE, stimulation was less than strength needed for success due to pain). |
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Cechova et al. 2014 Czech Republic Post Test Level 4 N=20 |
Population: 20 males (mean age=30.8 years old, age range=20-44 years old); level of injury 13 cervical and 7 thoracic; average time since injury to PVS= 64 months; 7 patients had PVS for more than 3.5 years and 13 patients had PVS less than 3.5 years. Treatment: Participants were divided into two groups: Group 1 had 7 patients who were more than 3.5 years since their injuries and Group 2 had 13 patients who were less than 3.5 years since injury. PVS was performed using the Ferticare Multicept. Outcome Measures: Evaluate the effectiveness and safety of penile vibrostimulation (PVS), semen quality, sperm count, sperm motility, and further utilization of the ejaculate in men with SCI. |
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Chehenesse et al. 2016; France Case Series Level 4 N=384 |
Population: 384 participants with SCI; level of injury C5-L4. Treatment: None. A retrospective analysis of a cohort of men with complete SCI. Outcome Measures: Successful ejaculation with PVS |
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Discussion
There are no RCT studies in this area. One of the largest studies of its kind (n=500 men with SCI) (Brackett & Ibrahim 2009) determined that semen could be obtained from most men with SCI without surgical procedures. The studies have mainly reported cumulative ejaculatory success rates and suitability of using techniques such as vibrostimulation, electroejaculation, subcutaneous physostigmine (a reversible acetylcholine esterase antagonist) and operative sperm retrieval for assisted reproduction (Dahlberg et al. 1995; Nehra et al. 1996; Brinsden et al. 1997; Chung et al. 1997; Lochner-Ernst et al. 1997; Le-Chapelain et al. 1998; Hibi et al. 2008; Kanto et al. 2008). Simple prostatic massage alone has been successfully used to obtain sperm in 32% of 69 men with SCI, typically those with lesions above the T10 level (Arafa et al. 2007).
When using PVS, the vibrator parameters of frequency and, in particular, amplitude, have been shown to be important variables to optimize outcomes. The application of a specialized vibrator, with settings of approximately 70-100 Hz with 2.5-3.5 mm amplitude (Brindley 1984; Sønsken et al. 1994; Ohl et al. 1997) on the penis (usually frenulum) produces antegrade, retrograde, and some mixed semen samples. Vibrostimulation worked most reliably in men with lesions above T10, those men with SCI who had a reflex hip flexion with scratching the soles of the feet and with injuries over 6 months in duration (Brindley 1984; Sønsken et al. 1994; Lochner-Ernst et al. 1997; Sønsken et al. 1997) or in patients with incomplete lesions (Taylor et al. 1999). Recent research has shown greater success with PVS in patients less than 3.5 years since injury vs. more than 3.5 years since injury (77% in comparison with 14%: Cechova et al. 2014). A retrospective chart review found that successful ejaculation with PVS was greater when any of the C5–T6 spinal segments was injured (50-67% success) and was less likely when lesions were more caudal (complete L4 injury of 2.6%, 12% when any of the sacral segments was injured: Chehenesse et al. 2016).
Vibrostimulation application for 30 sec to 20 minutes (most occurring in less than 3 min) resulted in ejaculation in 60% to 100% of patients (Beretta et al. 1989; Rawicki & Hill 1991; Sønksen et al. 1994; Rutkowski et al. 1995; Chung et al. 1997; Sønksen et al. 1997). Several recent studies have reported methods to “salvage” some of the ejaculatory failures with PVS. Brackett et al. (2007b) reported success in recovering semen in an additional 22% of men with SCI who failed on several occasions to respond to high amplitude PVS with 1 vibrator, as well as 38% of inconsistent responders, using a technique that sandwiched the glans penis between two vibrators presumably by increasing afferent input. PVS paired with midodrine has mixed results in producing ejaculation in men with SCI. Soler et al. (2007b) reported that 65% of 158 men who failed to respond to PVS alone were able to ejaculate when treated with midodrine (average dose of 18.7 mg) 30-120 minutes prior to applying PVS. They found antegrade ejaculation was more frequent in patients with complete (73%) and UMN (89%) lesions; moderate increases in blood pressure (MAP ~10mmHg) were induced by midodrine in comparison to VS alone, with 13 patients (11 with tetraplegia) recording systolic BP > 200mmHg. Midodrine plus PVS was well-tolerated and salvaged approximately 66% of cases that did not respond to PVS alone (Soler et al. 2007; Courtois et al. 2008). In contrast, a recent double‐blind, randomized, placebo-controlled study found no improvement in ejaculation success rates by PVS combined with midodrine vs. a placebo (Leduc et al. 2015). In a 12‐week, multicenter, double blinded, placebo‐controlled study; 418 men with SCI were randomized to vardenafil (n = 207) or placebo (n = 211) and ejaculation success was assessed using the International Index of Erectile Function (IIEF). The results of this study showed a significantly greater ejaculation success rate with vardenafil when compared to placebo (19% vs. 10%) (Giuliano et al. 2008).
When vibrostimulation fails, obtaining semen by electroejaculation (Taylor et al. 1999) is a possibility, particularly for people with lower lesions (Ohl et al. 2001). Since an ejaculate was almost always attainable by penile vibratory stimulation or electroejaculation, the need for surgical aspiration was rare but reported (Dahlberg et al. 1995; Lochner-Ernst et al. 1997; Shieh et al. 2003). Retrograde ejaculation of semen into the bladder, which frequently accompanies EEP and affects sperm quality, can be prevented by simply applying a technique of gentle bladder neck tamponade (Lim et al. 1994) using a non-toxic all-silicone Foley catheter and the balloon filled with 10mls of saline. Controlling severity of autonomic dysreflexia with nifedipine allowed for better sperm retrieval using electroejaculation technique (VerVoort et al. 1988; Lucas et al. 1991; Brackett et al. 2002; Elliott & Krassioukov 2006). Electroejaculation is considered more invasive and painful than penile vibratory stimulation for men with incomplete SCI, and patients prefer penile vibratory stimulation if sperm quality was equal between the two techniques (Ohl et al. 1997). Vibrostimulation has been shown to also induce pronounced levels of autonomic dysreflexia (Sheel et al. 2005; Claydon et al. 2006), especially in men with tetraplegia with increases of +70-90mmHg in mean arterial pressure (SBP ~190±20mg, DBP ~130±10mg, SBP ~150±10mg), reduced heart rate (–5-10 bpm) and cardiac arrhythmias. This requires careful monitoring during vibratory stimulation and screening for safe home use as AD was often silent in nature.
The use of physostigmine injections alone or in conjunction with both vibrostimulation and electroejaculation has largely dropped out of use since the mid-1990s (Chapelle et al. 1983; Leduc et al. 1992). An implantable hypogastric nerve stimulator (radio-controlled) was also successful in yielding semen with sperm (not necessary all motile), but has not undergone further development (Brindley et al. 1989).
Operative sperm retrieval should be reserved for those men who fail conservative sperm retrieval methodology. Operative retrieval commits a couple to expensive higher-level interventions such as intracytoplasmic sperm injection (ICSI), where a single sperm is injected directly into the egg to force fertilization. Such high level interventions with operative sperm retrieval, i.e. using fresh testicular sperm (Kanto et al. 2008) or aspirated retrograde vasal sperm (Hibi 2008) in an ICSI cycle, do result in better conception rates per cycle from the male SCI population. However, decisions regarding method of retrieval and insemination must also include a cost benefit ratio (Ohl et al. 2009).
Conclusion
There is level 4 evidence (Beretta et al. 1989; Sønksen et al. 1994; Le Chapelain et al. 1998; Brackett et al. 2007b, 2009; Kathiresan et al. 2012; Qiu et al. 2012; Sønksen et al. 2012) that semen retrieval may be assisted by vibrostimulation in men with lesions above T10.
There is level 4 evidence (Soler et al. 2007b) that Midodrine may be an effective and safe adjunct to penile vibratory stimulation in men not responding to penile vibratory stimulation alone who are not at risk for significant autonomic dysreflexia.
There is level 4 evidence (Brindley 1984; Halstead et al. 1987; Ohl et al. 1989; Lochner-Ernst et al. 1997; Le Chapelain et al. 1998; Kolettis et al. 2002) that semen retrieval may be assisted by electroejaculation in men who failed vibrostimulation.
There is level 4 evidence (Brindley et al. 1989) that surgical aspiration may be used to retrieve sperm if vibrostimulation and electroejaculation are not successful.
There is level 4 evidence (Arafa et al. 2007) that prostatic massagethru the rectum to push the sperm out through the ejaculatory ductal system is one technique to retrieve semen in some men and is more successful with lesions above T10.
There is level 4 evidence (Lim et al. 1994) that the use of a balloon catheter to tamponade the bladder neck may be effective in obtaining antegrade samples in men who normally deliver retrograde samples.
There is level 4 evidence (Hibi et al. 2008) that retrograde vasal sperm aspiration can retrieve sperm of sufficient motility to afford pregnancy.
There is level 3 evidence (Kanto et al. 2008) 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.