What is electroejaculation and when is it recommended for fertility treatment?

Electroejaculation for Male Infertility

Electroejaculation is a safe and effective sperm retrieval technique primarily indicated for men with aspermia (absence of ejaculation) or anejaculation due to spinal cord injury, retroperitoneal lymph node dissection, diabetes mellitus, or other neurogenic causes, and should be performed when less invasive methods like penile vibratory stimulation or sympathomimetic medications have failed. 1

What is Electroejaculation?

Electroejaculation (EEJ) is a procedure that uses low-current electrical stimulation delivered via a rectal probe to induce emission of semen in men who cannot ejaculate naturally. 2, 3 The technique directly stimulates the ejaculatory organs through the rectal wall, bypassing the need for intact neural pathways. 2, 4

Technical Aspects

• Anesthesia requirements: Non-spinal cord injury patients require general anesthesia, while those with complete spinal cord injuries above the level of sensation may not need anesthesia. 2, 5
• Stimulation parameters: Typical settings involve currents of 400-450 mA, voltages around 20-22 volts, and probe temperatures of approximately 35-36°C. 4
• Setting: Can be performed as an outpatient procedure in experienced centers. 6

Clinical Indications

Primary Indications (AUA/ASRM Guidelines)

For men with aspermia, electroejaculation may be performed as part of induced ejaculation strategies, with the choice depending on the patient's underlying condition and clinician experience. 1

The specific clinical scenarios include:

• Spinal cord injury: Most common indication, with ejaculate obtained in 98-100% of attempts and sperm present in 88% of patients. 3, 4
• Retroperitoneal lymph node dissection: Post-surgical anejaculation, with adequate sperm samples obtained in 87% of cases. 2
• Diabetes mellitus with ejaculatory failure: When sympathomimetic medications fail to restore ejaculation. 5
• Other neurogenic causes: Multiple sclerosis, extensive pelvic surgery, adult myelodysplasia. 2

When to Consider EEJ in Treatment Algorithm

The AUA/ASRM recommends that for men with retrograde ejaculation, first-line treatment should be sympathomimetic medications (pseudoephedrine 60-120 mg taken 120-150 minutes before ejaculation), with electroejaculation reserved for cases where medical therapy fails. 7, 1

For patients unable to ejaculate prior to gonadotoxic therapies (such as chemotherapy), electroejaculation or testicular sperm extraction should be considered for fertility preservation when standard ejaculation is not possible. 1

Expected Outcomes

Sperm Retrieval Success

• Ejaculate obtained: 98-100% success rate in obtaining an ejaculate. 3, 4
• Sperm presence: 83-88% of procedures yield sperm. 3, 4
• Adequate samples for insemination: 75% in spinal cord injury patients and 87% in post-RPLND patients produce samples with at least 10 million progressively motile sperm. 2

Critical Limitation: Poor Sperm Quality

A major obstacle to success is the severe asthenozoospermia (poor motility) and reduced functional quality of sperm obtained through electroejaculation. 2 Typical findings include:

• Motility: Usually below 5% in most cases, with antegrade specimens showing slightly better motility (mean 7%) than retrograde specimens (mean 4%). 4, 5
• Sperm count: Wide variation, with antegrade specimens containing mean counts of 478-698 million sperm. 4, 5
• Morphology: Generally poor in most cases. 3

Pregnancy Rates

The pregnancy outcomes vary significantly based on the assisted reproductive technique used:

• Intrauterine insemination (IUI): 28.6% pregnancy rate per couple, requiring multiple cycles. 3
• In vitro fertilization with intracytoplasmic sperm injection (IVF-ICSI): 68.75% pregnancy rate per couple, significantly superior to IUI. 3
• Overall pregnancy rate: 70% per couple when combining all assisted reproductive techniques in experienced centers. 3

Given the poor sperm motility typically obtained, advanced reproductive technologies (IVF-ICSI) offer higher success rates with fewer procedures compared to intrauterine insemination. 5, 3

Safety Profile

Common Side Effects

• Autonomic dysreflexia: Mild to minimal in most cases, occurring in approximately 19% of patients. 3, 4
• Rectal mucosal changes: Mild disruption possible. 4
• Bowel program disruption: Occasional occurrence. 6

Overall, electroejaculation is considered a safe procedure with only minor complications encountered in clinical practice. 2, 3

Important Considerations

• Pain management: Patients with low-level spinal cord injuries or intact sensation require analgesia or general anesthesia to complete the procedure. 4, 5
• Repeated stimulations: May improve sperm counts but can lead to deterioration in semen quality if performed too frequently (weekly intervals). 4

Clinical Pitfalls to Avoid

• Proceeding directly to surgical sperm extraction: Electroejaculation should be attempted before more invasive testicular sperm extraction in appropriate candidates, as it is less invasive and can be repeated. 1
• Using IUI when sperm quality is very poor: With motility typically below 5%, proceeding directly to IVF-ICSI rather than multiple failed IUI cycles may be more efficient and cost-effective. 3, 5
• Ignoring epididymitis: Active epididymitis has a negative impact on retrieval success and should be treated before attempting electroejaculation. 4
• Inadequate anesthesia in non-SCI patients: All patients without complete spinal cord injury above the level of sensation require general anesthesia. 2, 5