Male Fertility After Spinal Cord Injury

this is Pam Lauer I'm a nurse practitioner at Craig Hospital and today we're going to talk about male fertility after spinal cord injury as always every person before or after spinal cord injury is different and may have specific issues with fertility or just your overall medical status and it's important for you to visit with your health care provider before using this information so what we're going to talk about today is hopefully what you want to know about fertility what problems there can be in spinal cord injury how a jack ulation can happen both before and

after spinal cord injury how we could help to get to an ejaculation after spinal cord injury what's different about the sperm and then other issues that might affect fertility so after spinal cord injury about 90% of injured guys cannot father children by sexual intercourse alone but what is important and I think one of the main takeaways from this discussion is that it is absolutely still possible to father children after spinal cord injury and we'll talk about how women however after spinal cord injury are able to conceive and deliver babies with close to the same fertility

rates as the general population so what are the problems after spinal cord injury there are two main issues the first one is that most men after spinal cord injury don't ejaculate during intercourse so the sperm can't get where they need to go the second issue is that sperm motility which is how fast the sperm swim and sperm viability which is how long they live is lower after spinal cord injury so in normal ejaculation when you're sexually excited there are some tubes that contain the sperm in the testes that are called the vas deferens and those

squeezed that sperm into the back of the urethra then there's fluid from the seminal vesicles which is kind of near the prostate that mixes with the sperm to make semen and then at climax or orgasm there's a signal sent to the spinal cord that then tells the muscles at the base of the penis to start to contract and to push that semen forward and up and out of the penis to work that process needs the spinal cord to have an intact ejaculation reflex and that occurs typically in the lumbar spine so that's the main spinal

ejaculatory Center however there are other areas of the spinal cord t10 to l2 that controls some of that pushing forward of the sperm and expulsion which is getting the sperm out of the penis is actually in the sacral region so generally above t10 you're gonna have what we call an intact spinal reflex that still doesn't mean that below t10 you can't father children it just may not have an intact reflex so your options may be a little different so how would we get the semen if you're not able to ejaculate on your own again masturbation

about 10% of men can achieve ejaculation with masturbation or intercourse and we're talking about hand stimulation here the next option is vibratory stimulation to the penis there's electroejaculation prostate massage which isn't done as often because really the amount of sperm that we get from the prostate massage is very inconsistent whether we're gonna get it at all and then how much we actually get and then there are more advanced fertility options such as percutaneous epididymal sperm aspiration testicular sperm aspiration and testicular sperm extraction and we'll talk about all these options the first option that we're going

to talk about is penile vibratory stimulation this is a very simple procedure where we apply a vibrator to the the head of the penis that causes that ejaculation reflex to be stimulated the reason that I want to talk about this first is that is a very safe procedure relatively very low risk it can cause autonomic dysreflexia and a rubbing or abrasion of the penis or swelling of the head of the penis however the vibratory stimulation in those patients that we just talked about are above t10 so they have that intact ejaculation reflex have about 86

percent success that this is going to work even below t10 there's a still a fifteen percent success rate which isn't significant but still is worth trying especially if there's a reflex called the bulb o cavernosa sri flex that's present so if that's if that's present then this is definitely something that we should consider trying vibratory stimulation is less expensive than a lot of the options for fertility after spinal cord injury if it's safe and doesn't cause significant autonomic dysreflexia then it can be done at home especially if the sperm motility is good and that can

be a very personal experience that you and your partner can be a part of there's better sperm motility with vibratory stimulation than there is with eej and very little what we call retrograde ejaculate which is where the sperm actually goes back into the bladder instead of coming out of the penis so there are different types of vibrators that we use you can use something as simple as a wand massager all the way up to the more expensive vibrators that have actually been built for spinal cord injury itself the Furtick hair which is the one that

you see on the upper left is the most statistically effective and was built for spinal cord injury so studies were done showing that the amplitude of 2.5 and frequency somewhere about a hundred hundred and ten were most effective so again this is the vibrator that is 86% effective with the use of one or two fiber echt is another option although it's a little less statistically effective at about 71 to 77 percent however the vibrate is quite a bit cheaper at this point it can be the by Brecht I think can be somewhat harder to use

and a little bit more difficult to collect the specimen into it into a cup and it takes about twice as long to get the ejaculation with the vibrant as it does to the Ferda care the technique is that you apply the Furtick air if you're going to use this one or a wand massager to the top of the penis for about two minutes and if it's not effective you just you look at the skin and you look to see if there's any problems before you try it again at times we have to use one fair

to care on the top and one on the bottom to get an ejaculation and you can continue repeat that we try not to go longer than about 10 minutes again you can have significant autonomic dysreflexia during this procedure so it is something that I would really recommend trying with your practitioner if they have these options so that you can monitor the first time how high the blood pressure gets and what you may need to do to manage the blood pressure at home if this is something that you're going to be doing at home such as

the application of Nitra bid appointment or some in some cases an oral medication can be used before you start using the vibrator the next option if vibratory stimulation is not effective is electroejaculation electroejaculation is where a small probe is inserted into the rectum and sends a little electrical signal near the prostate and causes ejaculation if a patient doesn't respond to vibratory stimulation this is an option if you can find this in your area it is not effective to achieve a Jack Y elation about ninety-five percent of the time it typically won't work in what we

call a cauda equina injury which is below l1 where the end of the spinal cord typically is and it becomes that kind of horse's tail of nerves going into the sacrum most of the ejaculation in eej is retrograde which means back into the bladder so this is something that cannot be done at home because it's a it's a expensive piece of machinery sometimes it can be a little bit hard to find someone that has it and again with that retrograde ejaculation we may have to spin down the urine to get the sperm that can be

used it can be a little uncomfortable some people say it feels like a little bit of cramping other times it you know it can be it can be painful some people don't feel like it is painful with people that are incomplete sometimes this is something that has to be done under anesthesia with the eej there's less motility which means how fast they swim of the sperm and less overall sperm count as compared to vibratory stimulation now depending on the motility and how much of the forward ejaculation we get this the semen could still possibly use

for either vaginal insemination or intrauterine insemination which is where the sperm is put right into the uterus by a provider other options if these aren't working or more into advanced fertility one of the options is called percutaneous epididymal sperm aspiration and this is where sperm is pulled right from the epididymis which is that tube that stores the sperm this is usually done by a fertility specialist called a reproductive endocrinologist so the sperm has not mixed with the fluid at this point so the motility is usually really good but the problem with these procedures are that

you can't obviously can't do this at home you don't get much sperm per procedure and it would be useful for advanced fertility such as in-vitro fertilization or if there aren't many sperm interest cytoplasmic sperm injection which is the name for that is is it C is the short term where they take one sperm into one egg for fertilization but these are procedures that have to be done in an office and again are more of an advanced fertility this can cause scar tissue development so can't be repeated often another option is to take the sperm directly

from the testes so sperm array needle is inserted right into the testicle and sperm in an other tissue is sucked out again this is done with a fertility specialist and because the sperm hasn't mixed with the fluid it also has the higher motility same thing applies in this situation though that we're not gonna get quite enough for vaginal or your during insemination but this would be useful for advanced fertility as such as IVF another option is is actually making an incision into the testes and examining the tubules to see if there's any sperm there and

that the sperm can be removed directly from the source this would be done either in the office or in an operating room and would be useful for advanced fertility so semen analysis what's different about sperm that come from a spinal cord injured man the sperm or the semen may not look normal sometimes it's brownish times it's even reddish in color again most specimens or most ejaculations will have a lot of sperm in them but they're not moving very quickly and then they don't live quite as long however it's important to know that there's nothing genetically

wrong with the sperm if the ejaculation does have sperm in it even after spinal cord injury the total number of modal sperm is still more than 5 million 75% of times so there is still a definite possibility if we can get an ejaculation that it would be potentially useful if the specimen has like more than 20 million motile sperm badger insemination will probably work well but even over 10 million we still would consider trying vaginal insemination and we're talking about 10 million per milliliter intrauterine insemination which is where the the sperm is and semen is

put directly into the uterus usually has to have about 5 million or more motile sperm so why do the sperm swim slower we know that there are other cells in the ejaculation that aren't usually there we know that because the sperm is a different color and then we look at the set the semen and we notice that there are other cells in there some of the cells are leukocytes which are white blood cells there are typically not any red blood cells in the ejaculation but some of the leukocytes can cause inflammation that are what make

the environment for the sperm bad or hostile and that can cause them to slow down there was a study done at Miami project to cure paralysis where they looked at the sperm and the ejaculation and when they took the sperm from egg spinal cord injured man and added it to the seminal fluid or the fluid that gets ejaculated of a non injured man and that sperm sped up and then they took the sperm from a non injured guy and added it to the seminal fluid of a spinal cord injured guy and it slowed down so

this was evidence that it's actually the fluid that is hostile that slows the sperm down and not the sperm itself there are other things that can affect sperm motility in spinal cord injury one is bladder management intermittent catheterization is the best or allows the best motility sphincter atomy is another option that is that is good about 25% motility suprapubic would be next on the list and then indwelling catheter would have the worst motility of the group the method of ejaculation as we already talked about can affect the sperm motility we're like vibratory stimulation would have

better motility than eej and then we just talked about how the seminal plasma itself affects the sperm motility testosterone supplementation can actually cause the testes themselves to turn off the production of sperm so testosterone supplementation is used when someone doesn't have enough testosterone naturally produced now this usually does happen more in spinal cord injured guys but usually right when they're first injured and then it usually will come back up to normal in a few months but guys that have that have low testosterone later on sometimes we'll go on testosterone supplementation to bring them back up

to normal levels so even if this is used to bring you back up to a normal level it most often will shut off your production of sperm it can actually even completely stop the sperm production in the testes this will happen with use of medical testosterone or anabolic steroids as well so when a guy who's been on testosterone supplements is trying to achieve fertility he'll need to come off the supplement for at least three months in some rare cases it can take up to a year for the testes to start producing sperm again there are

some recent studies that show that there are some medications that you can take if you absolutely have to stay on testosterone supplements that can preserve some of the sperm production and sperm quality this is where you would do hcg injections with or without something clomid Pierre this could be talked about with an advanced fertility specialist if you're not producing any sperm whatsoever so in summary what I really want you to take away from this presentation is that fertility is absolutely possible after spinal cord injury it may be a little more difficult to get the ejaculation

but it is absolutely possible vibratory stimulation is recommended for injuries above t10 it's the cheapest safest option and in some cases we'll give you the option to do this at home advanced fertility may not be needed but there are options available for you after spinal cord injury to have children thanks for listening