MANAGEMENT OF INFERTILITY IN THE PARAPLEGIC
BY
DR PETER H C LIM
AM, MB,BS, MMed(Surg), D.Urol(Lond), FICS,
Head & Senior Consultant Urological Surgeon,
Division of Urology,
Dept of Surgery,
Toa Payoh Hospital,
Singapore 1129.

SPINAL CORD INJURY & FERTILITY:
------------------------------
              The low fertility of paraplegic men has been
pointed out as a major source of marital dissatisfaction
(David et al, 1977). This may be caused by difficulties at
sexual intercourse eg. mechanical problems, muscle spasms &
autonomic hyperreflexia. The latter is characterised by a
rapid & prolonged increses in blood pressure at times of
sexual excitement causing a terrible headache, flushing &
sweating. Urological help to solve impotence is often
required by way of education, pyscho-sexual counselling for
both the patient & his partner, the use of erectile
dysfunction aids, penile implants etc.
                The most important factor for impaired
fertility in the male is poor semen quality. They often
demonstrate impaired testicular biopsies, with semen showing
decreased numbers and motility when obtained.  The
pathophysiology of this damage may be related to neurogenic,
systemic or local factors exacerbated by increased time since
injury.
              Ejaculatory failure is the other major
impediment to achieving good fertility potential in these
patients. Through ordinary sexual means (i.e. manual, oral or
vaginal stimulation) about 8% of paraplegics can reach
ejaculation (Zeitlin et al, 1957). The best rate of approx.
10% is with lower thoracic & lumbar cases, and the lowest
rate of approx. 4% is with cervical cases. The figure rises
to around 70% successful ejaculation if the Electro-vibrator
is used (Brindley, 1981a). With another method i.e. the
Electro-ejaculator, the success rate reported by Brindley was
42 out of 92 with antegrade ejaculation & another 14 with
definite retrograde ejaculation. The various studies reviewed
suggest that early treatment might obtain good quality semen
which can be used for insemination or frozen for later use.
In the chronic phase of injury, repeated ejaculations may
lead to improvement of semen quality (Brindley, 1982). For
example, within the 14 couples who used Brindley's vibratory
ejaculation or electroejaculation at home, 4 wives are
pregnant to date (Brindley, 1981b). Some patients may respond
to one form of stimulus while failing with another. The best
techniques would appear to be those which can be used
repeatedly, frequently, & with minimal side effects -
preferably in an outpatient setting (vida supra).  Vibratory
or electroejaculatory techniques are relatively easy to
perform, & stimulus withdrawal can occur quickly in the case
of side effects such as autonomic dysrrefexia.
              Since not all spinal cord injured males can be
ejaculated perticularly in those with lesions involving the
segments of T-10 to L-2, such patients may be candidates for
vasal aspiration or alloplastic spermatoceles combined with
in-vitro-fertilisation techniques.



REFERENCES:
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David, A, Gur, S & Razin, R (1977): Survival in marriage in
the paraplegic couple-psychological study. Paraplegis,
15:198-201.

Zeitlin,A B, Cottrell, T L & Lloyd, F A (1957): Sexology of
the paraplegic male. Fertil. Steril., 8:337-344.

Brindley, G S (1981a): Reflex ejaculation under vibratory
stimulation in paraplegic men. Paraplegia, 19:300-303.

Brindley, G S (1982): Sexual functioning & fertility in
paraplegic men. In "Clinical Practice in Neurology". Ed:T.B.
Hargreave. Springer Verlag, Berlin.

Brindley, G S (1981b): Electroejaculation-its techniques,
neurological implications & uses. J. Neurol. Neurosurg.
Psychiat., 44:9-18