Spinal cord injury wreaks havoc on the male reproductive system. I was fortunate to be one of the first clinicians in the US to be actively involved in the treatment of infertility in the spinal cord injured male and authored some of the first papers detailing the application and results of penile vibratory stimulation and rectal probe electroejaculation. My experience is second to none in New England and I love helping my SCI couples get pregnant. We start with the simplest techniques (oftentimes quite successful) and move to the most complex strategies only as we have to. Fatherhood in the SCI male is absolutely possible.

1. Fertility in the Spinal Cord Injured Male
Robert D Oates, M.D.
Boston Medical Center

2. Fortunately, I was one of the first in the
country to learn about fertility issues in
the man with a spinal cord injury and
wrote a number of papers early in my
career advancing this field. During my
fellowship, we were just learning about
how to help SCI men become fathers.
My Experience in this Field

3. I continue to have an incredible interest
and desire to help – it is as rewarding as
can be imagined to assist couples and
watch them reach their goal of having
children.
Being a Urologist is a crucial aspect of
care – it is complete and does not just
revolve around “sperm”.
My Experience in this Field

4.  General medical and surgical history
 Medications, allergies ?
 Level of injury
 Complete or incomplete ?
 Sensation in the genital and rectal area ?
 Autonomic dysreflexia – does that happen ?
 Voiding regimen
 Intermittent catheterization ?
 Indwelling catheter ?
 Condom catheter ?
 Bowel regimen
What is important to know
about my medical history ?

5.  Erectile function
 Spontaneous, reflex, how long do they last ?
 Are they sufficient for sexual satisfaction for both of you ?
 Any medications been tried: pills, injections ?
 Ejaculation
 Does it happen at all ?
 What makes it happen ?
 If it happens, do you have autonomic dysreflexia ?
What is important to know
about my sexual history?

6.  Ejaculation is a reflex
 Stimulation must be present to make it fire off
 Stimulation comes from the brain (thoughts) and the penis
 Usually must have both
 With a spinal cord injury:
 Either the stimulation from the brain cannot reach the reflex center
because of the spinal cord injury
OR
 The stimulation from the penis cannot reach the reflex center
because of the spinal cord injury
Why don’t I ejaculate?

7. Why don’t I ejaculate?

8. 3 main phases:
1. Stimulation: visual, tactile, cognitive
2. Emission: contraction of the SV & VA with flow of seminal fluid into
the posterior urethra
3. Antegrade ejaculation: contraction of the periurethral musculature
with forward flow of seminal fluid
Neurophysiology of Ejaculation
SV – seminal vesicles (glands in the pelvis that make most of the fluid in the ejaculate)
VA – vasal ampullae (the end of the tubes in the pelvis that delivers the sperm up from the testes in the scrotum)

9.  Emission
 Sympathetics (spinal level T10 ‐ L2)
 Bladder neck closure
 Sympathetics (spinal level T10 ‐ L2)
 Antegrade Ejaculation
 Somatics (spinal level S2 ‐ S4)
 Integrated Reflex Control Center
 Spinal level T12 ‐ L1
Neurophysiology of ejaculation

11. Emission
 The first phase of the ejaculatory process where
the semen fluid flows into the urethra
 Sympathetics (spinal level T10 ‐ L2)
Neurophysiology of ejaculation

12. Bladder neck closure
 This prevents the semen from travelling
backwards into the bladder
 Sympathetics (spinal level T10 – L2)
Neurophysiology of ejaculation

13. Antegrade Ejaculation
 This is the rhythmic contraction of the muscles
around the urethra to move the semen
forward out the end of the penis
 Somatics (spinal level S2 ‐ S4)
Neurophysiology of ejaculation

14. Integrated Reflex Control Center
 This is the reflex center in the spinal cord that
controls the whole process
 Spinal level T12 ‐ L1
Neurophysiology of ejaculation

15. Tx depends on level of injury
 If above T12 / L1 – options include
 Penile vibratory stimulation
 Rectal probe electroejaculation
 Testis tissue extraction
 If below T12 / L1 – options include
 Rectal probe electroejaculation
 Testis tissue extraction
SCI: Ejaculatory Dysfunction
Treatment (Tx)

16. A good first choice
 spinal cord must be active and reflexive
Stimulation activates reflex center
Normal forward semen flow
Patients can be taught to do it
 after the first one in the office ! !
 commercially available vibrator
 lessens medical intervention and cost
Penile Vibratory Stimulation

17.  Successful in 60% of SCI men overall
 The semen can be used for:
 depending on the sperm count and activity
 home insemination – can help you get pregnant at home
 intrauterine insemination – sperm are put into the uterus
 in‐vitro fertilization – the most complex, but sometimes necessary, tx
 Some men may experience autonomic dysreflexia
 if the injury level is above T6
 occasionally pretreatment with a medication is necessary
 why it is necessary to have the first one done in my office
 important to make sure it is safe for you
Penile Vibratory Stimulation

18. Penile Vibratory Stimulation

19.  Used when vibratory stimulation did not or would not work
 Indications:
 SCI men refractory to PVS
 RPLND (an operation for some men with testicular cancer)
 Multiple Sclerosis
 Diabetes Mellitus
 Transverse Myelitis
Rectal probe electroejaculation

20. Provides semen for adjunctive therapies
 IUI
 IVF
 ICSI
Rectal Probe Electroejaculation
} Depends upon
semen parameters
Not for home insemination

21.  In office for patient with no rectal sensation / no dysreflexia
 In operating room if rectal sensation / dysreflexia
 Technique: only FDA approved equipment
 Only with fully trained physician
 I was one of the first in the world to learn in 1988 and helped
pioneer the use of electroejaculation in the US
Rectal Probe Electroejaculation

22.  Stimulate to certain voltages and current densities
 Ejaculate is collected
 Used for appropriate indication depending upon:
 Sperm count
 Sperm activity
 Typically collected and frozen for later use with IVF
Rectal Probe Electroejaculation

23.  Depends upon sperm count and activity
 Depends upon female factors
Age, ovarian function, etc
 Depends upon adjunctive treatment used
Home insemination, IUI, IVF
Pregnancy rates ‐ PVS & RPE

24.  If these non‐invasive minimally invasive techniques do not work
 Direct sperm harvesting
 Testis
 Epididymis
 Used in conjunction with ICSI
 Much more complex of a strategy
 Successful as last option
SCI: Refractory to PVS and RPE

25.  Fatherhood is certainly possible in the SCI male
 It is important to understand the full complexity of
spinal cord injury
 Depending on the individual, important to try the simplest
approach first
 Move to the more complex as the situation dictates
 The goal is a happy healthy family !!!
Summary