What is the management pathway for infertility in spinal cord injury patients?

Management Pathway for Infertility in Spinal Cord Injury Patients

Men with spinal cord injury should undergo systematic evaluation starting with penile vibratory stimulation (PVS) for semen retrieval, progressing to electroejaculation (EEJ) if PVS fails, followed by intrauterine insemination (IUI) as first-line assisted reproduction, reserving in vitro fertilization with intracytoplasmic sperm injection (IVF/ICSI) only for couples who fail simpler approaches. 1

Initial Assessment and Counseling

Fertility Evaluation

• Assess three major complications contributing to infertility: erectile dysfunction, ejaculatory dysfunction, and abnormal semen quality 1
• Evaluate level and completeness of spinal cord injury as this impacts ejaculatory function and treatment success 2
• Distinguish between upper motor neuron (UMN) and lower motor neuron (LMN) lesions as UMN lesions respond better to vibratory stimulation while LMN lesions typically require electroejaculation 2
• Screen for genitourinary infections and endocrine abnormalities which commonly affect fertility in this population 3

Patient Education

• Inform couples that 88% of men with SCI have sperm present in ejaculate when appropriate retrieval methods are used 2
• Explain that sperm concentrations are typically normal but motility and viability are abnormally low due to accessory gland dysfunction, leukocytospermia, and elevated pro-inflammatory cytokines 1
• Discuss realistic pregnancy rates: 55-70% cumulative pregnancy rate per couple with comprehensive management 2, 4

Stepwise Management Algorithm

Step 1: Erectile Dysfunction Management

• Initiate phosphodiesterase-5 (PDE-5) inhibitors as first-line therapy for erectile dysfunction 1
• Progress to intracavernosal injections, vacuum devices, or penile prostheses if oral medications fail 1

Step 2: Semen Retrieval

First-Line: Penile Vibratory Stimulation (PVS)

• Attempt PVS first in men with UMN lesions above T10 as this achieves 67% success rate for semen retrieval 4
• Perform PVS in clinical setting initially to monitor for autonomic dysreflexia, particularly in lesions above T6 2
• Use low-current stimulation to minimize side effects while maximizing ejaculatory response 2

Second-Line: Electroejaculation (EEJ)

• Proceed to EEJ if PVS fails or in men with LMN lesions achieving 97-98.6% success rate for obtaining ejaculate 2, 4
• Use rectal probe with low-current stimulation of ejaculatory organs 2
• Expect sperm presence in 88% of patients when EEJ is successful 2
• Monitor for minor side effects which occur in approximately 19% of patients but are generally well-tolerated 2

Alternative: Prostate Massage or Surgical Sperm Retrieval

• Reserve surgical sperm retrieval only for men who fail both PVS and EEJ as it commits couples to the most invasive and expensive assisted reproduction (IVF/ICSI) 1

Step 3: Assisted Reproductive Technology

First-Line: Intravaginal Insemination (IVI) or Intrauterine Insemination (IUI)

• Attempt IVI at home following successful vibroejaculation achieving 22% pregnancy rate per cycle 4
• Progress to IUI with ovulation induction (clomiphene citrate or gonadotropins) if IVI fails, achieving 26-30% pregnancy rate per cycle 4, 5
• Perform mean of 2.6-5.5 IUI cycles before considering more advanced techniques 5
• Use antegrade ejaculate preferentially as it demonstrates significantly better sperm count, motility, and morphology compared to retrograde samples 2

Second-Line: In Vitro Fertilization with Intracytoplasmic Sperm Injection (IVF/ICSI)

• Reserve IVF/ICSI for couples who fail IUI after adequate trials (typically 3-6 cycles) 1, 4
• Expect 68-71% pregnancy rate per couple with IVF/ICSI in this population 2, 5
• Perform mean of 1.4 cycles to achieve pregnancy in successful couples 5

Critical Pitfalls to Avoid

Premature Use of Advanced Techniques

• Never introduce surgical sperm retrieval as first-line therapy despite the alarming recent trend, as many men have sufficient motile sperm for IUI or even intravaginal insemination 1
• Avoid bypassing simpler, less invasive, and less expensive options that have proven efficacy 1

Inadequate Semen Quality Assessment

• Recognize that leukocytospermia is present in most SCI patients and elevated pro-inflammatory cytokines contribute to poor motility 1
• Consider neutralization of inflammatory constituents which has resulted in improved sperm motility in research settings 1
• Distinguish between antegrade and retrograde ejaculate quality as this impacts treatment planning 2

Incomplete Evaluation

• Screen for accessory gland dysfunction as the proposed cause of abnormal semen parameters 1
• Assess for genitourinary infections which are common and treatable causes of impaired fertility 3

Expected Outcomes

Overall Success Rates

• Cumulative pregnancy rate of 55-70% per couple with comprehensive, stepwise management 2, 4
• Overall pregnancy rate of 18% per cycle across all assisted reproduction attempts 4
• Live birth rate resulting in 14 live births from 17 pregnancies in specialized fertility clinic series 4

Team-Based Approach

• Utilize specialized fertility clinic with multidisciplinary team including spinal cord injury specialists, urologists, and reproductive endocrinologists 2, 4
• Provide comprehensive client-focused approach with education, fertility assessment, and range of semen retrieval and assisted reproduction options 4