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Sexual and Reproductive Health

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
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.
  1. A total of 106 testicular procedures were performed. Sperm was found in 95 cycles (89.6%).
  2. Average metaphase II (MII) oocyte number was 11.0(4.2), an average of 5.1(2.3) oocytes became normally fertilized after Intra Cytoplasmic Sperm Injection (ICSI) (fertilization rate 57.1%).
  3. On average, 2.7(1.2) embryos were replaced. The clinical pregnancy rate was 32/106 (30.2%) per cycle and 19/32 (59.3%) per couple. The live birth rate was 62.5% (20/32).
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.
  1. Sperm retrieval method in SCI participants: masturbation (n=43), PVS (n=243), EEJ (n=158). Sperm retrieval method in AB control group: masturbation (n=61).
  2. 8.1% (43 of 528 SCI participants) retained ability to ejaculate by masturbation.
  3. Sperm motility was significantly higher in the SCI-masturbation group (36.9%) than the PVS group (25.9%) or EEJ group (15.0%), but lower compared with a control group of 61 non-SCI healthy men who collected their semen by masturbation (58.0%).
  4. The SCI-masturbation group had similar antegrade sperm concentration as the PVS group, and control group, but significantly higher than the EEJ group.
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.
  1. The rate of sperm DNA fragmentation was higher in the PVS group than in the percutaneous vassal sperm aspiration (PVSA) group.
  2. Aneuploidy rates for SCI patients were 1.5 to 1.6-fold higher for chromosomes 13, 18, and 21, and were 2.3- to 2.4-fold higher for chromosomes X and Y than for the control group.
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.
  1. Median total motile sperm count: 29 million (range 1–92 million).
  2. 60 of the 140 couples (43% pregnancy rate) achieved 82 pregnancies.
  3. 72 of the pregnancies resulted in live births with delivery of 73 healthy babies.
  4. Median time to first pregnancy was 22.8 months (range 6.0–98.4). No complications were reported.
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.
  1. Of the 500 men 9% could ejaculate by masturbation.
  2. Penile vibratory stimulation (PVS) was successful in 86% of patients with a T10 or rostral injury level.
  3. Electroejaculation (EEJ) was successful in most cases of failed PVS (91.9% responded to EEJ).
  4. Sperm obtained without surgical sperm retrieval, in 97% of patients completing the treatment algorithm.
  5. Total motile sperm counts exceeded 5 million in 63% of cases.
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.
  1. Motile sperm was recovered in all participants who underwent ReVSA (11 procedures total).
  2. The retrieved sperm concentration was 109.4(64.7) × 106/mL (range 31.2-156.3× 106/mL).
  3. The retrieved motility of sperm was 69.8% (16.8) (range 50-91%).
  4. Clinical pregnancies were achieved in 8 cases (7 couples).
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.
  1. TESE successfully retrieved sperm in 19 participants with SCI.
  2. ICSI resulted in a fertilization rate of 236 of 364 (64.8%) in SCI couples and 14/19 achieved pregnancy.
  3. In couples with obstructive azoospermia, ICSI resulted in a fertilization rate of 435 of 567 (77%) and 29/34 achieved pregnancy.
  4. Pregnancy rate was significantly higher for couples with SCI using fresh testicular sperm-ICSI compared to frozen-thawed sperm-ICSI
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.
  1. Semen retrieval by prostatic massage was successful in 22 men (31.9%).
  2. Semen retrieval by prostatic massage was higher for men with a SCI above T10 than below T10 (81.8% vs 18.2%).
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.
  1. 49% of all men ejaculate with 1 vibrator; 57% of men whose injury level was at or above T10 responded to 1 penile vibratory stimulation vs. only 15% with a level of injury at or below T11.
  2. Of failures with 1 vibrator, 22 % responded to penile stimulation with 2 vibrators.
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.
  1. Percentage successful ejaculation following midodrine was 64.6% (62%, 69%, 46%, and 79% in groups 1 to 4 respectively).
  2. Individuals with upper motor lesions above T10 and complete lesions had more success.
  3. Average dose required was 18.6mg.
  4. Midodrine induced mild increase in mean arterial BP (max. 10mmHg) and reduced heart rate with PVS in all patients.
  5. Individuals with tetraplegia have highest increase in SBP (more than 200mmHg in 20% of cases).
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.
  1. Ejaculation rates: 43/112 were antegrade ejaculations (38%), 24/112 were retrograde ejaculations, 45/112 were both antegrade and retrograde ejaculations (40%) and 2/112 were not able to ejaculate (2%).
  2. Pregnancy rate: 3/9 couples achieved pregnancy, 2 or which resulted in live births and both were twins.
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.
  1. 30/39 patients produced an ejaculation.
  2. Greater success rate among participants with tetraplegia (96%), then T1-T10 (73%), then T11-L2 (42%).
  3. Vibratory stimulation produced significantly higher volumes of sperm than electroejaculation, and better sperm quality.
  4. Among 10 couples who wanted children, 3 pregnancies resulted and 2 births of healthy children.
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.
  1. Vibrostimulation in supranuclear lesions was successful in 133 patients, and in 5 more after physostigmine injection.
  2. EE was successful in all 7 infranuclear lesions and in 4 supranuclear patients failing with vibrostimulation. 8 more supranuclear patients responded to EE and physostigmine.
  3. Surgical retrieval was applied in 27 patients.
  4. In 109 patients who wanted children, 73 pregnancies in 46 couples, leading to 54 births and 16 abortions.
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.
  1. Antegrade ejaculations were collected on all occasions.
  2. No urine contamination of sperm and no sperm were found in post-ejaculate urine.
  3. Silicone catheters had minimal effect on sperm motility and viability.
  4. Lubricant gels adversely affect sperm quality.
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.
  1. Similar ejaculation responses when using frequencies of 80-100Hz and amplitude of 1mm.
  2. At 100Hz and 2.5mm amplitude there were significantly higher ejaculation rates than amplitude of 1mm.
  3. Ejaculation occurred in 58/66 men (88%).
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.
  1. 54% of cases resulted in antegrade ejaculation.
  2. 46 samples showed mean normal count but low motility rate (28%).
  3. Fresh unwashed sperm artificial insemination performed in 6 couples with 3 successful pregnancies.
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.
  1. Semen obtained from 21 of 24 men with a lesion at T8 or above, and from 4 of 11 men with lesions below T10.
  2. 8 pregnancies from 6 couples.
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.
  1. Penile vibrators triggered ejaculation in 72 patients (70.5%).
  2. 11 other patients showed ‘weak’ ejaculation with poor contractions of perineal muscles.
  3. Stimulation ranged from 30 sec-20 min. Of 15 ‘home-use’ patients, increase in sperm concentration and steep decrease in abnormal spermatozoa over 3 months.
  4. 6 couples had homologous artificial insemination, 3 pregnancies resulted.
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).
  1. Post-implant, all patients achieved external emission of semen, volume between 1-5ml in 4 patients, only a drop or two drops in 3 patients (but good quantities obtained later).
  2. 5 pregnancies (2 live births) in the partners of 4 patients. Implants functioned for years without deterioration in performance.
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.
  1. 10 million sperm obtained in 71% of participants (n=34).
  2. Age and interval since injury had no effect on outcome.
  3. Higher success among participants with paraplegia (90% ejaculated successfully) and in those using intermittent catheterization for bladder management compared to cervical or lumbar patients (successful ejaculation in 60% and 50%, respectively).
  4. Indwelling urethral catheters and high pressure reflex voiding had a negative impact on EE results.
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.
  1. Antegrade ejaculation occurred in 9 patients with improvement in % motility and total live sperm count on repeated stimulations in 5 patients.
  2. Significant retrograde ejaculation occurred in 1 patient.
  3. Sperm acceptable for artificial insemination from 4 patients.
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.
  1. Required duration <20min (usually <3min) in 48/81 men with SCI.
  2. Vibrator failed in 19/81 who lacked reflex hip flexion on scratching soles of feet and in 14 others. Vibrator failed in 11/12 men with injuries <6 months duration.
  3. From 21/34 men for whom the vibrator failed, semen cold be obtained by electroejaculation (EE).
  4. 11 pregnancies reported. 9 healthy children born.
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.
  1. Initial PS application successful in 5/20 patients. 3 patients successful in subsequent tests. 12 not successful.
  2. Only successful if T12-L2 segments are intact.
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).
  1. EE technique resulted in external success in 43% of men, retrograde success in 17% of men, and definite failure in 24% of men, with remaining 16% uncertain due to external failure without urine confirmation or being prevented by pain.
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.
  1. Ejaculation was achieved in 11 (55 %) patients [9 (82%) of patients with cervical SCI & 2 (18%) patients with thoracic SCI]
  2. Success rate of PVS in patients less than 3.5 years since injury was 77 % in comparison with 14 % in patients over 3.5 years since injury.
  3. When comparing semen quality in first and second PVS, total sperm count and number of sperm with progressive motility increased.
  4. Fertilization was not successful despite high sperm concentration (213 x 106/ml). The plan is to use it in vitro fertilization. In 1 patient the ejaculate was successfully used for fertilization.
  5. Autonomic dysreflexia during PVS occurred in 7 patients, in 6 with cervical and 1 patient with thoracic SCI. Symptoms of autonomic dysreflexia resolved within three minutes.
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
  1. Successful ejaculation with PVS was reported in 47.4% of patients
  2. Ejaculation success with PVS was high when any of the C5–T6 spinal segments was injured (50-67% success).
  3. Ejaculation success with PVS decreased when lesions were more caudal, reaching a minimum for the subsample with complete L4 injury of 2.6% versus a minimum of 12% when any of the sacral segments was injured.

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. 1995Nehra et al. 1996Brinsden et al. 1997Chung et al. 1997Lochner-Ernst et al. 1997Le-Chapelain et al. 1998Hibi et al. 2008Kanto 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 1984Sønsken et al. 1994Ohl 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 1984Sønsken et al. 1994Lochner-Ernst et al. 1997Sønsken 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. 1989Rawicki & Hill 1991Sønksen et al. 1994Rutkowski et al. 1995Chung et al. 1997Sønksen 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. 1995Lochner-Ernst et al. 1997Shieh 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. 1988Lucas et al. 1991Brackett et al. 2002Elliott & 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. 2005Claydon 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. 1983Leduc 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. 1989Sønksen et al. 1994Le Chapelain et al. 1998; Brackett et al. 2007b, 2009; Kathiresan et al. 2012Qiu et al. 2012Sønksen 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 1984Halstead et al. 1987Ohl et al. 1989Lochner-Ernst et al. 1997Le Chapelain et al. 1998Kolettis 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.

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