17June, 2024
Spinal cord injuries and male fertility
What is spinal cord injury?
Spinal cord injury is one of the devastating neurological conditions that involves central nervous system. It is defined as any damage to the spinal cord due to trauma or disease or degenerative conditions like cancer. It affects the injured person’s life in all aspects. It causes temporary or permanent disability in the affected parts of the body which are served by the spinal cord.
Who does it affect?
Spinal cord injuries are commonly seen in people who are at the peak of their reproductive period of life. It affects male more commonly than female in the ratio of 1:1 and 8:1 respectively. Males are four times more likely to sustain a spinal cord injury than females.
How common is spinal cord injuries and what it?
According to WHO, around 2.5 to 5 lakh people suffer from spinal cord injury globally. Annually, 40-80 cases occur per million population. Based on etiology, spinal cord injuries can be divided into
- Traumatic
- Non-traumatic
Traumatic injuries: Majority (90%) of spinal cord injury occurs due to trauma. The most common causes for traumatic spinal cord injury are road traffic accidents followed by falls, violence, sports and other causes.
Non-Traumatic injuries: It includes diseases or degenerative conditions or disorders such as cancers. The following are some of the lists of non-traumatic causes
- Injuries due to congenital diseases
- Compression due to tumours
- Vertebral spondylosis
- Vascular ischemia
How does spinal cord injuries affect male fertility?
Spinal cord injuries are commonly seen in young men, and it affects almost all aspect of their reproductive system. After the injury, most men experience impaired fertility. Their natural fertility rate falls to 5-10% post injury. Three major complications which can cause infertility in men are
- Erectile dysfunction
- Ejaculatory dysfunction
- Abnormal quality of semen
The degree of sexual dysfunction is variable and depends on the level and severity of the spinal cord injuries. Erectile dysfunction in SCI is mainly neurogenic but other causes of erectile dysfunction should also be evaluated.
Ejaculatory dysfunction: Ejaculation is dependent on spinal cord co-ordination and supraspinal input from the brain. Majority of the men have ejaculatory dysfunction after spinal cord injury. It is possible but it may be incomplete without techniques such as masturbation and/or non-vibro-stimulatory methods.
Semen abnormalities: In men with spinal cord injury, sperm production is usually normal, however the quality of semen is affected. Total sperm number is normal however, abnormal sperm motility and poor viability is observed. The change in the quality is seen as soon as 2 weeks post injury. Many factors affecting the quality of semen in SCI are interconnected. There are multiple theories for the abnormal semen motility in subjects with SCI such as increased scrotal temperature, anti-sperm antibodies, leukospermia and seminal plasma proteins and cytokines.
How to management erectile dysfunction in men with spinal cord injury?
As previously seen erectile dysfunction, ejaculatory dysfunction and semen abnormalities contribute to infertility in men with spinal cord injury. It can be treated with PDE5 inhibitors, intracavernous injections of alprostadil, intraurethral injections, penile prosthesis and vacuum constriction devices besides psychological counselling.
How to manage ejaculatory dysfunction in men with spinal cord injury?
Ejaculatory dysfunction: In spinal cord injury patients with anejaculation, penile vibratory stimulation is recommended as the first line of treatment. It is safe, cost effective and reliable method. The success rate was reported to be 86% for people with injury at or above T10. Patients who fail this method, should be referred for electroejaculation where electric current is delivered in a pattern of 5 seconds stimulation followed by 20 seconds rest. without sedation or general anaesthesia, this method can cause some discomfort for patients in some men.
For patients where electroejaculation is not possible, prostate massage is an alternative method. However, the yield of sperm is low when compared to penile vibratory stimulation or electroejaculation. When all the above method fail, surgical sperm retrieval should be considered as a last resort.
What are the fertility options for men with spinal cord injury?
The options of fertility in male with spinal cord injury include the following,
- Intravaginal insemination: It is least invasive and least expensive of all. The couple should be evaluated before determining optimal method. Female partner’s tubal and uterine pathology must be ruled out. She must be counselled about ovulation detection and timing of insemination. The success rate has been reported to be 40% from a multicentric study.
- Intrauterine insemination: It involves collection of semen from men affected by spinal cord injury usually by penile vibratory stimulation or electro ejaculation. The semen is processed to remove non-motile sperms. the processed semen is placed in the uterus. 3-6 cycles of IUI should be attempted before proceeding to other advanced ART techniques.
- Advanced ART techniques: IVF or ICSI is indicated in patients/ couples with no success with IUI. when number of of motile sperms is too low for conventional IVF, ICSI is suggested.
Conclusion:
Majority of men with spinal cord injury are young and experience fertility issues. The major issues leading to infertility in these men are erectile dysfunction, ejaculatory dysfunction and abnormal semen parameters. Even though the pregnancy outcomes are similar with spinal cord injured men and normal men, it is more invasive and expensive. Instead, ejaculate with enough motile sperm should be considered for IUI or intravaginal insemination. Before opting for surgical sperm retrieval, cost effective and safe methods such as penile vibratory stimulation or electroejaculation. Future research should focus on improving the semen quality in men with spinal cord injury and promoting natural ejaculation.
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