Fertility following spinal cord injury: a systematic review
We read this article by DeForge et al 1 with interest and congratulate the eminent authors for an extensive indepth systematic review about fertility in spinal cord injury (SCI). It is generally accepted that ejaculatory dysfunction and poor sperm quality are the two main reasons for the high infertility rates in SCI men. In recent times, the advancement in semen retrieval techniques has improved this outcome marginally. Vibroejaculation and electroejaculation are the two most commonly used
... niques. Although authors have quoted 86% ejaculation response rates from the pooled data of studies using both the methods, the high rates appear to be due to high success rates with electroejaculation. In our study 2 using vibroejaculation, the ejaculation rates were 50% despite having used the optimum parameters and technique as described by Sonsken et al. 3 This, however, matches well with the success rate of 60% quoted in a meta-analysis of 10 studies by Beckerman et al. 4 It is possible that some of our failures could be due to retrograde ejaculation. We did not check for this phenomenon as it was felt that the semen analysis of the ejaculate mixed with urine would be inaccurate measure of sperm quality. Authors, based on the studies by Ohl et al 5 and Siosteen et al, 6 state that too frequent ejaculations (ie once a week) cause the sperm quality to fall off. Siosteen 6 performed repeated PVS in 16 men for 4-6 months in an uncontrolled study and noted an increase in volume, fructose level and acid phosphatase levels suggesting an improved function of seminal vesicles and prostate. However, he did not observe any significant improvement in motility or morphology. Conversely, Brindley 7 has shown a progressive increase in sperm motility with repeated electro-ejaculation and Francois et al 8 helped to increase the motility of a man with repeated electro-ejaculations from 0 to 30%. We have reported data from a randomised controlled study, which clearly shows a statistically significant improvement in morphology (P ¼ 0.02) and forward progression (P ¼ 0.03) in semen samples of spinally injured men repeatedly vibroejaculating once a week for 12 weeks. 2 Unfortunately, the translation of this improved semen quality into improved fertility still remains to be seen. A scientific paper on this subject describing the further analysis of this study is N et al. Fertility following spinal cord injury: a systematic review. Spinal Cord 2005; 43: 693-703. 2 Hamid R, Bywater H, Patki P, Knight S, Shah P, Craggs M. The effects of repeated ejaculations on the quality of sperms following spinal cord injury. Eur Urol Suppl 2004; 3: 136. 3 Sonksen J, Biering-Sorensen F, Kristensen JK. Ejaculation induced by penile vibratory stimulation in men with spinal cord injuries. The importance of the vibratory amplitude. Paraplegia 1994; 32: 651-660. 4 Beckerman H, Becher J, Lankhorst GJ. The effectiveness of vibratory stimulation in anejaculatory men with spinal cord injury. Review article. Paraplegia 1993; 31: 689-699. 5 Ohl DA, Bennett CJ, McCabe M, Menge AC, McGuire EJ. Predictors of success in electroejaculation of spinal cord injured men. J Urol 1989; 142: 1483-1486. 6 Siosteen A, Forssman L, Steen Y, Sullivan L, Wickstrom I. Quality of semen after repeated ejaculation treatment in spinal cord injury men. Paraplegia 1990; 28: 96-104. 7 Brindley GS. Physiology of erection and management of paraplegic infertility. In: Hargreave TB (ed). Male Infertility. Berlin: Verlag Springer 1983, pp 261-279. 8 Francois N, Maury M, Jouannet D, David G, Vacant J. Electro-ejaculation of a complete paraplegic followed by pregnancy. Paraplegia 1978; 16: 248-251.