An analysis of 653 trials of penile vibratory stimulation in men with spinal cord injury.

PURPOSE: We evaluated ejaculatory response and semen quality in 653 trials of penile vibratory stimulation in 211 men with spinal cord injury, and compared results with low versus high amplitude vibratory stimulation. MATERIALS AND METHODS: Low and/or high amplitude penile vibratory stimulation was performed 1 to 27 times in each patient, and antegrade and retrograde specimens of those who ejaculated were analyzed. RESULTS: Significantly more patients ejaculated using high (54.5%) versus low (39.9%) amplitude stimulation. Using either amplitude the ejaculatory success rate was highest in men with injuries at C3 to C7, followed by T1 to T5, T6 to T10 and T11 to L3. While high amplitude stimulation increased the ejaculatory success rate in each group, the highest rate occurred in men with injuries at C3 to C7 (65.6%). Ejaculation was reliable, since most men who ejaculated did so during 100% of the trials and within 2 minutes of stimulation onset. Symptoms of autonomic dysreflexia were safely managed with nifedipine. All patients who ejaculated produced antegrade specimens. With the exception of ejaculate volume, which was significantly higher with high versus low amplitude stimulation, semen parameters were similar using both vibrator amplitudes. CONCLUSIONS: Ejaculatory success is better while semen quality is similar using high versus low amplitude penile vibratory stimulation in men with spinal cord injury. This method may be considered first line treatment for anejaculation in men with spinal cord injury due to its safety, relative effectiveness, and relatively low investment of time and money.

Factors associated with the quality before freezing and after thawing of sperm obtained by microsurgical epididymal aspiration.

OBJECTIVE: To identify whether the cause, site of ductal obstruction, and characteristics of fluid aspirates are associated with the cryosurvival and fertility after thawing of sperm obtained during reconstruction of the excurrent ducts with microsurgical epididymal sperm aspiration, vasal sperm aspiration, or both. DESIGN: Prospective study. SETTING: Andrology center at a tertiary care institution. PATIENT(S): Men undergoing reconstruction of the excurrent duct and sperm aspiration (n = 42) or microsurgical epididymal sperm aspiration (n = 11). INTERVENTION(S): Sperm were tested for an association with the cause and site of obstruction. Fertilization and pregnancy rates after sperm aspiration and intracytoplasmic sperm injection (ICSI) were evaluated for fresh and frozen aspirates. MAIN OUTCOME MEASURE(S): Motile sperm count and percentage motility after thawing. RESULT(S): The motile sperm count before freezing was significantly higher in the caput epididymis than in the corpus. The motile sperm count before freezing was related inversely to the distance from the caput where the sperm were aspirated. Sperm from clear and opaque fluid aspirates had better percent motility than those from cloudy and creamy fluid aspirates. High fertilization and pregnancy rates were achieved using both fresh and frozen epididymal sperm. CONCLUSION(S): None of the factors studied was associated with cryosurvival of aspirated epididymal or vasal spermatozoa. Because motility is low after thawing, these specimens are best used with ICSI.

Seminal reactive oxygen species and sperm motility and morphology in men with spinal cord injury.

OBJECTIVE: To assess the generation of reactive oxygen species and its relation to semen characteristics in men with spinal cord injury. DESIGN: Cross-sectional study. SETTING: Andrology laboratory at a tertiary care facility and research laboratory at a major medical center. PATIENT(S): Men with spinal cord injury and normal men. INTERVENTION(S): Collecting ejaculates from men with spinal cord injury by electroejaculation and vibratory stimulation and from normal men by masturbation. MAIN OUTCOME MEASURE(S): Measurement of reactive oxygen species before and after stimulation with 50 microM N-formyl-methionyl-leucylphenylalanine (FMLP) and 100 nM 12-myristate 13-acetate phorbol ester (PMA), white blood cell (WBC) concentration, sperm motility and morphology, and ejaculation method. RESULT(S): Compared with controls, levels of reactive oxygen species in men with spinal cord injury were significantly higher in unstimulated, f-MLP-stimulated, and PMA-stimulated specimens. The WBC concentration was significantly elevated in patients with spinal cord injury. Sperm motility in men with spinal cord injury was inversely related to the level of reactive oxygen species. The percentage of morphologically normal spermatozoa was significantly lower in men with spinal cord injury. Levels of seminal reactive oxygen species did not differ when comparing specimen type (antegrade versus retrograde) or method of ejaculation in men with spinal cord injury. CONCLUSION(S): Men with spinal cord injury had elevated levels of reactive oxygen species in their semen. Levels of reactive oxygen species were negatively correlated with sperm motility. Levels of reactive oxygen species were independent of the method of ejaculation or the type of specimen.

Usefulness of the acrobead test in evaluating human acrosome function in fresh and cryopreserved sperm.

PURPOSE: Assays for the acrosome reaction are usually cumbersome and lack reproducibility. Accurate determination of acrosomal status is important in patients diagnosed with male infertility before proceeding with intrauterine insemination or in vitro fertilization. We determined the optimum capacitation time and acrosomal status of fresh semen specimens in normal fertile men with the Acrobead test, and whether the assay could be used to evaluate cryopreserved semen specimens. MATERIALS AND METHODS: Semen samples from 13 normal donors were divided, with half of the fresh ejaculate used for the Acrobead test and half cryopreserved for a minimum of 24 hours in liquid nitrogen before testing. Fresh and frozen specimens were prepared with the swim-up technique. Sperm concentration was adjusted to 4, 2, 1 and 0.5 x 10(6)/ml. in 4 wells of a 96-well tissue culture plate. Ten microl. polyacrylamide beads (1.5 x 10(6)/ml.) coated with anti-CD46 monoclonal antibodies (MH61 beads) were added to each well. The attachment of beads with acrosome reacted spermatozoa was scored after 0, 1, 3, 6 and 24 hours of incubation. Results were graded on a scale of 0 (no bead binding to the sperm) to 4 (complete attachment to the beads). Specimens with scores of at least 2 were considered normal. RESULTS: A score of at least 2 was noted in 3 of 13 fresh specimens (15.3%) at 1, 9 (69.2%) at 3, 11 (84.6%) at 6 and 13 (100%) after 24 hours. However, a significantly greater number of frozen specimens (8 of 13, or 62%) had a score of 2 or more at 1 hour of incubation and 100% bead attachment to sperm occurred at 3 hours. CONCLUSIONS: Our results indicate that in fresh semen specimens an incubation period of 6 to 24 hours can be used to screen individuals who present with normal sperm characteristics but have slow acrosome reactions. Early acrosome reaction observed in cryopreserved specimens indicates that these spermatozoa may have membrane damage and leakage of acrosome contents as a result of the freeze-thaw process. The Acrobead assay is a simple and objective test that can be used at a clinical andrology laboratory to evaluate the acrosomal status of fresh but not frozen human spermatozoa.

Effects of cancer on spermatozoa quality after cryopreservation: a 12-year experience.

OBJECTIVE: To determine whether type of cancer and response to treatment was related to prefreeze or post-thaw semen quality and to predict post-thaw sperm motility from prefreeze motility. DESIGN: Retrospective study. SETTING: Tertiary care institution. PATIENT(S): One hundred six cancer patients cryopreserving their semen specimens. INTERVENTION(S): Computer-assisted semen analysis was performed before and after cryopreservation on each patient specimen. MAIN OUTCOME MEASURE(S): The relationship of sperm motility and motion characteristics to type of cancer and patient's response to treatment. RESULT(S): Prefreeze and post-thaw semen quality did not differ between patients presenting with testicular cancer and Hodgkin's disease. Patients with leukemia or advanced soft tissue cancer had a higher prefreeze and post-thaw motility and higher total and motile sperm count than testicular and Hodgkin's disease patients. A prefreeze sperm motility of > or = 15% could predict a post-thaw motility of > 10%. CONCLUSION(S): Prefreeze or post-thaw semen quality in cancer patients is not affected (except the prefreeze motile sperm count within the testicular cancer patients) by the type of disease. Prefreeze motility can predict post-thaw motility. Cryopreservation of semen should be offered to cancer patients irrespective of the type of disease.

Effect of artificial stimulants on cryopreserved spermatozoa from cancer patients.

PURPOSE: We determined whether cryopreserved sperm samples obtained from cancer patients before treatment respond to artificial motility stimulants and if this response is related to the extent of disease. MATERIALS AND METHODS: Pre-freeze distribution of disease stage in the different types of cancer and the percentage of the population with or without oligospermia before cryopreservation were examined. Cryopreserved semen samples from 17 cancer patients (10 with testicular cancer, 5 with Hodgkin's disease and 2 with other metastatic disease) were examined for a relationship between post-thaw sperm motion characteristics and patient age or status (survived versus died) and type of disease. Motion characteristics (curvilinear velocity, straight line velocity, average path velocity, linearity and amplitude of lateral head displacement) were analyzed on a computer assisted semen analyzer before (time 0), and 30 and 60 minutes after addition of a 2.5 mM. concentration of pentoxifylline and 2-deoxyadenosine. RESULTS: Post-thaw sperm motion characteristics were not correlated with patient age or status, whether they did or did not have oligospermia, or type of cancer. Compared to baseline values, sperm motion characteristics increased significantly after stimulation at time 0 (p < 0.02) and at 60 minutes (p < 0.05). Oligospermic or nonoligospermic specimens responded to the same extent with pentoxifylline and 2-deoxyadenosine. A negative correlation was noted between overall stage, and type of disease and motion characteristics. CONCLUSIONS: Sperm banking should be encouraged at cancer diagnosis regardless of semen quality. Artificial stimulation of sperm motility results in significant improvement in sperm motion characteristics.

Semen quality of spinal cord injured men is better when obtained by vibratory stimulation versus electroejaculation.

PURPOSE: Most spinal cord injured men require assisted ejaculation procedures to obtain semen, and the majority can achieve this result by vibratory stimulation or electroejaculation. We determined if semen obtained by vibratory stimulation differed in quality from that obtained by electroejaculation. MATERIALS AND METHODS: Between subjects and within subjects designs were used. Of 77 spinal cord injured men 23 underwent vibratory stimulation only, 44 electroejaculation only and 10 both procedures. Antegrade, retrograde and total ejaculates were analyzed in each subject for total sperm count, percent motile sperm and percent sperm with rapid linear motion. RESULTS: With vibratory stimulation compared to electroejaculation the percent motile sperm and percent sperm with rapid linear motion were significantly greater, whereas total sperm count was similar, in the antegrade specimens and total ejaculates. This finding was true for different groups of subjects as well as within a group of the same subjects. CONCLUSIONS: Semen obtained by vibratory stimulation is of better quality than that obtained by electroejaculation. In medical practices that include assisted ejaculation of spinal cord injured men, we recommend obtaining a specimen by vibratory stimulation. If that method fails electroejaculation should be performed.

Seminal plasma of spinal cord injured men inhibits sperm motility of normal men.

PURPOSE: Seminal plasma was investigated as a contributor to the poor sperm motility of spinal cord injured men. MATERIALS AND METHODS: Seminal plasma of spinal cord injured men was mixed with sperm of normal men and vice versa. Sperm motility was analyzed at 5 and 60 minutes after mixing. RESULTS: At 5 (but not 60) minutes seminal plasma from spinal cord injured men inhibited motility of sperm from normal men. Concomitantly, seminal plasma from normal men improved motility of sperm from spinal cord injured men. CONCLUSIONS: Seminal plasma of spinal cord injured men contributes to poor sperm motility.

Treatment by assisted conception of severe male factor infertility due to spinal cord injury or other neurologic impairment.

PURPOSE: This retrospective study evaluated the pregnancy rates of 23 couples with male factor infertility due to traumatic spinal cord injury (N = 21), multiple sclerosis (N = 1) or transverse myelitis (N = 1). METHODS: Ovulation induction by clomiphene citrate or gonadotropins was used in combination with intrauterine insemination as an initial approach for assisted conception in all but one couple. RESULTS: Six pregnancies occurred in 60 cycles of intrauterine insemination (mean of 2.6 cycles). In this group, the cumulative pregnancy rate was 26%. Six couples who failed after a total of 33 intrauterine insemination cycles (mean of 5.5 cycles), and 1 couple with no previous intrauterine insemination cycles, initiated 10 cycles of in vitro fertilization (mean of 1.4 cycles). In this group, five pregnancies occurred. The pregnancy rate was 71%. CONCLUSION: We conclude that ovulation induction in combination with intrauterine insemination offers an effective initial therapy of severe male factor infertility due to spinal cord injury.

The gastric augment single pedicle tube catheterizable stoma: a useful adjunct to reconstruction of the urinary tract.

Since 1990 we have used stomach for bladder augmentation and continent urinary diversions in 73 patients, of whom 15 received a gastric tube catheterizable stoma and are the subject of this report. The gastric tube receives its blood supply from the same vascular pedicle as the gastric patch and, therefore, it can be moved anywhere along with the patch. The tube is then reimplanted in the reservoir or bladder following the Mitrofanoff principle and brought to the skin as a catheterizable stoma. Patient age ranged from 12 to 60 years. Three patients underwent augmentation cystoplasty and 12 received a composite gastrointestinal continent reservoir (in 10 a prior bowel conduit was detubularized and used as part of the reservoir). The appendix was either previously removed (10 patients) or not suitable as a catheterizable limb (4). All patients are continent. Catheters used to empty the reservoir varied from 12F to 18F. Complications included an early traumatic perforation of the tube in 1 patient, distal stenosis in 1 and mucosal redundancy in 1. Of these patients 2 required revision. Two patients had mild peristomal skin irritation without ulceration. Anatomical and technical aspects of this procedure are presented. In summary, we believe the gastric augment single pedicle tube to be a useful tool for the reconstructive urologist, which in select cases may obviate the need for additional bowel anastomosis to create a tapered intestinal catheterizable limb.

Scrotal and oral temperatures are not related to semen quality of serum gonadotropin levels in spinal cord-injured men.

Scrotal temperature, oral temperature, and the difference between oral and scrotal temperature were measured in spinal cord-injured subjects (SCI) and non-injured subjects as controls. We statistically correlated these measures to semen quality and serum gonadotropin levels in both groups. No difference was found between SCI and control subjects on any temperature measurement. Mean sperm motility, mean sperm morphology, and mean serum gonadotropin levels were significantly lower in SCI compared to control subjects, but these measures were not correlated to scrotal temperature, oral temperature, or the difference between oral and scrotal temperature in SCI or control subjects. These data indicate that: 1) there is not a generalized scrotal thermoregulatory dysfunction in SCI men; 2) scrotal temperature does not appear to contribute to poor semen quality in SCI men; and 3) elevated gonadotropin levels are not related to elevated scrotal temperatures in SCI men, as has been reported in non-injured, infertile men.

Semen of spinal cord injured men freezes reliably.

The objectives of the present study were to: 1) determine the effect of cryopreservation on the percent and the grade of motility of sperm from spinal cord injured (SCI) men and 2) determine which method of freezing yields the best post-thaw motility in sperm from SCI men. Antegrade semen samples were obtained from 9 SCI subjects and 10 age-matched healthy control subjects. Motility in fresh samples was determined and cryopreservative medium was added to each sample. Aliquots of each sample were frozen according to three methods: 1) liquid nitrogen vapor only (V); 2) vapor for 12 minutes followed by submersion into liquid nitrogen (V+N2); and 3) direct submersion into liquid nitrogen (N2). Samples were frozen for 1 week, then thawed. The post-thaw percent and grade of motility was determined. The mean percent motility of fresh samples for SCI subjects (21.0%) was significantly lower than for control subjects (55.7%). After thawing, the mean percent drop in motility for V, V+N2, and N2 for controls was 65.2%, 73.5%, and 79.4%, respectively, and for SCI subjects, it was 64.7%, 74.5%, and 81.6%, respectively. There was no statistically significant difference between control and SCI subjects by method of freezing. Vapor only as a freezing method was superior to all other methods for retention of sperm motility in both control and SCI subjects. We conclude that the semen of SCI men may be frozen reliably and that their sperm retain motility similar to that of normal men. Vapor only, being the most gentle method used, gives the best recovery of sperm motility in either group.

Transurethral polytetrafluoroethylene injection in female patients with urinary continence.

We present our results with the use of transurethral injection of polytetrafluoroethylene (Teflon) in 128 female patients with moderate to severe urinary incontinence from 1964 to 1991. Of the patients 60% had undergone previous surgical treatment for the incontinence. The etiologies included stress incontinence, neurogenic bladder, congenital anomalies, trauma and others. More than 73% of the patients improved (54.3% were totally dry). The failure rate was 27%. Complications were minimal. Urinary tract infection and temporary urinary retention occurred in 7 and 6 patients, respectively. Mean followup was 31 months. This study demonstrates that transurethral polytetrafluoroethylene injection is a useful treatment of moderate to severe urinary incontinence in female patients. Polytetrafluoroethylene is particularly useful for patients with failed previous incontinence procedures and poor surgical candidates. Failures are more likely in patients with periurethral fibrosis secondary to a previous urethral operation.