Clinical Conditions

Men with neurologic impairments in their sympathetic outflow, as in traumatic spinal cord injury (SCI), demyelinating neuropathies (multiple sclerosis), diabetes, and following retroperitoneal lymph node dissection (often for testis tumor), frequently have abnormalities or absence of seminal emission. Electroejaculation (EEJ) has been proven to be a safe and effective means to obtain motile sperm suitable for assisted reproductive techniques (intrauterine insemination or in vitro fertilization).

Electroejaculation (EEJ) is normally performed under general anesthesia, though for men with a complete spinal cord injury (SCI), anesthesia may not be necessary. To prevent autonomic dysreflexia, men with SCI, particularly above the level of T-5, are premeditated with 20mg of nifedipine, sublingually, 15 minutes prior to EEJ. The procedure begins by first catheterizing the patient in supine position and emptying the bladder completely. The use of Betadine and Surgilube is to be avoided because of their spermicidal effect. Instead, the urethra is lubricated with glycerin or, preferably, by instillation of 2 cc of 6% simulated human tubal fluid and plasmanate. The pH of the urine should be assessed to ensure its alkalinity (pH>6.5). Oral sodium bicarbonate may be used if necessary. Because retrograde ejaculation (backwards ejaculation into the bladder) occurs frequently in this procedure, an additional 10 cc of the simulated human tubal fluid and plasmanate is instilled into the bladder to help preserve any sperm inside the bladder. The catheter is then removed. Although it is possible to perform the procedure in lithotomy position, lateral decubitus position is preferred, as it allows easier access to both the penis and rectum.

The patient is put on his side with his thighs and knees slightly flexed. All pressure points are appropriately padded. A blood pressure cuff is applied to the patient's left arm for continuous blood pressure monitoring every 2 minutes. Digital rectal examination and anoscopy should be performed before and after the procedure to inspect the rectal ampulla and mucosa for any injury. In patients with SCI, it is not uncommon to find rectal mucosal abrasion, especially if they are being managed with a chronic digital bowel program. If anoscopic inspection is not performed prior to the EEJ, one could mistakenly attribute the rectal abrasion to be caused by the procedure. After proper inspection, a well-lubricated large rectal probe with horizontal electrode plates is introduced gently into the rectal ampulla, and is stabilized against the anterior rectal wall at the level of the seminal vesicles and prostate. Electrostimulation via the rectal probe may then begin.

The rectal probe is connected to an adjustable output power source and is capable of simultaneously recording the temperature of the probe through a thermistor. The amount of current and voltage needed depends on the patient's body habitus and the extent of his neurologic injury. In patients with incomplete SCI, the procedure may be limited by their tolerance to pain, as sensation may be present.

Rhythmic delivery of current is performed by manually turning the dial to increase the voltage delivery progressively for a few seconds. After a few initial stimulation, the voltage is reduced to zero. Voltage is then gradually increased until erection/ejaculation has occurred. The voltage at which the first erection/ejaculation occurs is noted and is then increased to a level 30% to 50% higher, depending on patient's tolerance and the rectal temperature which is constantly monitored and displayed. Ejaculation may be entirely retrograde. In these cases, sweating, piloerection, " goose bumps" on the things and buttocks, and erection may be the only signs that the patient is adequately stimulated and that ejaculation has occurred. The number of stimulation, the current, and the voltage necessary to produce a maximum erection are noted, as this information will be useful for subsequent procedure if needed. The ejaculate is collected directly into a cup containing 3 cc of human tubal fluid (HTF) buffer.

The probe temperatures as well as the number of stimulation required to achieve full erection and ejaculation are recorded. The ejaculate is then collected in a sterile wide-mouth plastic container. The numbers of stimulation and maximum voltage required may vary and ejaculation may be retrograde. If the probe temperature rises rapidly to above 40oC, we either change the rectal probe or suspend the stimulation until the temperature falls below 38oC.

Following electroejaculation, anoscopy is performed again prior to returning the patient in the supine position. The bladder is catheterized to collect the post-ejaculate urine, which is sent along with the ejaculate to the IVF laboratory for processing.

Currently, employing this technique, semen can be obtained in more than 90% of neurologically impaired men. More than 40% of the couples achieve pregnancy with IUI or IVF. Pregnancy rates are slightly better among couples in which the male partner had SCI (43%) or idiopathic anejaculation (33%) then those who had undergone retroperitoneal lymph node dissection (20%) or had diabetes (0%).