What is the fertility management protocol for men with spinal cord injuries?

Fertility Management Protocol in Spinal Cord Injury Men

Initial Assessment and Semen Retrieval

Men with spinal cord injury (SCI) require systematic fertility evaluation beginning with penile vibratory stimulation (PVS) as the first-line method for semen retrieval, followed by electroejaculation (EEJ) if PVS fails, with surgical sperm retrieval reserved only for cases where both methods are unsuccessful. 1

Semen Retrieval Hierarchy

• Penile vibratory stimulation should be attempted first, achieving successful semen retrieval in 67% of SCI men, and is less invasive than alternatives 2
• Electroejaculation should be the second-line approach when PVS fails, with a 97% success rate for obtaining semen 2
• Surgical sperm retrieval (testicular sperm extraction) should only be used when both PVS and EEJ fail, as it unnecessarily commits couples to the most expensive and invasive assisted reproductive technology (IVF/ICSI) 1

Concurrent Evaluations Required

• Both partners must undergo concurrent fertility assessment to avoid subjecting the female partner to unnecessary, costly, and invasive treatments 3, 4
• Obtain at least two semen analyses separated by 2-3 months to establish baseline sperm parameters 5, 4
• Measure FSH, LH, total testosterone, and thyroid function to identify correctable endocrine causes 5, 4

Expected Semen Parameters in SCI

Men with SCI typically demonstrate normal sperm concentrations (mean 110.4 M/mL) but severely impaired motility (mean 12.3%) and viability due to accessory gland dysfunction, leukocytospermia, and elevated pro-inflammatory cytokines in seminal plasma. 1, 6

• Sperm concentration usually remains normal or near-normal despite the injury 1, 7
• Motility is the primary abnormality, with most men showing values well below the 50% reference threshold 1, 7
• Leukocytospermia and elevated inflammatory markers are present in most SCI patients and contribute to poor sperm quality 1

Treatment Algorithm Based on Sperm Parameters

For Adequate Motile Sperm Count (>10 million total motile sperm)

• Intravaginal insemination (IVI) at home following vibroejaculation should be the first-line treatment, achieving a pregnancy rate of 22% per cycle 2
• This approach is the least invasive and most cost-effective option when sufficient motile sperm are present 1, 2

For Moderate Impairment

• Intrauterine insemination (IUI) with ovarian stimulation should be attempted for up to three consecutive cycles when total motile sperm count is >10 million but IVI has failed 5
• IUI following electroejaculation achieves pregnancy rates of 30% per cycle 2
• If no pregnancy occurs after three IUI cycles, progression to IVF/ICSI is indicated 5

For Severe Asthenozoospermia or Failed IUI

• IVF with intracytoplasmic sperm injection (ICSI) should be used when motility is severely impaired or after failed IUI attempts 5, 1
• ICSI directly overcomes the motility defect and achieves pregnancy rates of 19-43% per cycle in SCI populations 6, 2

Critical Management Pitfalls

Never prescribe exogenous testosterone to men with SCI desiring fertility, as it completely suppresses spermatogenesis through negative feedback on the hypothalamus and pituitary, causing azoospermia that may take months to years to recover. 5, 4, 8

Additional Pitfalls to Avoid

• Do not proceed directly to surgical sperm retrieval and IVF/ICSI without first attempting PVS or EEJ with IVI/IUI, as this is an alarming trend that unnecessarily subjects couples to the most invasive and expensive treatment 1
• Avoid delaying referral to assisted reproductive technology when medical therapies fail, as female partner age critically impacts fertility outcomes 5
• Do not use empiric medical therapies (antioxidants, vitamins, hormonal treatments) for idiopathic poor sperm quality in SCI, as these have questionable clinical utility and are outweighed by ART advantages 5, 8

Expected Outcomes

Overall pregnancy rates per couple reach 55-64% using this stepwise approach, with 18-22% pregnancy rates per cycle for home insemination methods and 19-43% per cycle for IVF/ICSI. 6, 2

• Seventeen pregnancies occurred in 31 couples (55% cumulative pregnancy rate) across 97 treatment cycles in one comprehensive series 2
• Twenty of 31 men (64%) successfully fathered at least one child using these protocols 6
• Home-based intravaginal insemination following vibroejaculation provides the highest pregnancy rate per cycle (22%) among non-IVF methods 2