Infrequent intercourse
Excessive intercourse or
masturbation
Poor timing in
relationship to ovulation
Premature withdrawal.
Sperm toxic lubricants
Sperm dysmotility
Idiopathic asthenospermia
Immotile cilia syndrome
(Kartagener's syndrome)
Protein carboxylmethylase
deficiency
Immunologic (antisperm
antibodies)
Idiopathic polyazoospermia
CHAPTER 5-A
The normal ejaculatory
respond consists of well timed neuromuscular events that result in the
expulsion of semen from urethra.
A decrease or absence of
fertility potential in the nerves or the muscle related to this phenomenon is
the result of anatomical abnormalities of the ejaculatory organs. Ejaculatory
dysfunction is uncommon and
account for
2%J ” ' ‘
(Dublin L1971—etiological
factor in 1294 cases of male infertility):
Rainbow of clinical causes
are:
Anejaculation u/
Retrograde ejaculation
Premature ejaculation
Ejaculatory duct
obstruction.
Anejaculation and
ejaculatory dysfunction are terms
used to describe male
infertility as inability to have ejaculation by neurological disease, traumatic
injury or as complication of surgery.
For diagnosis of proper
causes, understanding of physiology of ejaculation and etiology of each
disorder enable physician to select appropriate treatment.
Ejaculatory reflex is to
coordinate events initiated by cerebral integration of visual, auditory,
tactile and olfactory stimuli modulated by psychosocial cognitive processing.
Tactile stimuli to the
afferent receptors on the glans penis travel through the pudendal nerve from
the glans to the brain. The efferent neuronal pathways arise from thoracolumbar
spinal level ( T 10-L2) and travel through the sympathetic chain ganglia to the
hypogastric plexus, then through the pelvis (as the hypogastric nerve) and
terminate as postganglionic fibers on the prostate, vas deference, and seminal
vesicles.
Sympathetic stimulation
causes a concerted sequence of events-closure of the bladder neck prevents
retrograde ejaculation; and contraction of the prostatic musculature, ampulla
of the vas deference and seminal vesicle cause emission of the semen and
seminal fluid into the prostatic urethra.
As the urogenital
diaphragm opens, propulsion of semen through the urethra is then maintained by
rhythmic contraction of the bulbocavernosus, ischiocavernosus and the pelvic
floor muscles under the somatic motor control of the pudendal nerve (S2-S4).
Numerous short adrenergic
fibers are located throughout the wall of the vas deference.
Recently we have seen new
role of NO (Nitrus oxide) in male infertility as high concentration of NO is
found in epididymis, vas deference and seminal vesicle.
Most of the ejaculatory
dysfunctions are traumatic or iatrogenic.
Spinal cord injury
Trauma to posterior
urethra.
Retroperitoneal lymph node
dissection
Aortic aneurysectomy
(operation of aortic aneurysm)
Colorectal surgery
Sympathectomy.
Antihypertensive
Antipsychotics
Antidipressant
Others (Alcohol,
baclofen).
Diabetes mellitus
Multiple sclerosis
Bone marrow transplant.
Retarded ejaculation.
Traumatic
Spinal cord injuries (SCI)
may cause anejaculation in 90- 95 % sufferers.
Usually these male
population is young with average age of 25-30 years and mostly suffered by
vehicular or some accident followed by spinal injury and lead to anejaculation.
SCI make patients suffer
from variety of sexual function and abnormalities depending on level of injury
at cord site.
Men with complete upper
motor neuron lesion rarely ejaculate but most of them are capable of sufficient
erection for intercourse to satisfy spouse.
Men with incomplete upper
motor neuron disease mostly retain capability of ejaculation.
Men with complete lower
motor neuron decrease can ejaculate and have erection while incomplete lower
motor neuron lesion can maintain erection but only half can achieve
ejaculation.
In category of SCI
anejaculation, only few percentage; can go for pregnancy mostly they have to
take help of ART specialist and have go for test tube (IVF).
Iatrogenic
Surgical injury to
sympathetic nerves may result in retrograde ejaculation.
Retroperitoneal lymph node
dissection, incases of non- seminiferous testicular tumors, can sometime causes
anejaculation by accidental injury to sympathetic trunk or sometimes more
peripheral postganglionic sympathetic fibers disrupting the ejaculatory
mechanism.
Abdominal aorta aneurysm
surgery like aneurysmectomy can cause retrograde ejaculation.
Anterior resection for
colonic surgery sometimes causes injury to anterior hypogastric plexus and can
cause ejaculatory disturbance.
TURP (Transurethral
resection of prostate) can cause vesicle neck incompetence and retrograde
ejaculation incidence upto 90%.
If husband wants to have
antegrade ejaculation he has to go for medical therapy rather than to go for
surgery and can take medicine like Terazocin, Finasteride.
Sometimes undiagnosed
urethral stricture can cause retrograde ejaculation.
Surgery like Y-V
urethroplasty of the vesicle neck, for high outflow, tract resistance and
ureterovesical reflux in childhood must be investigated for presence of
retrograde ejaculation because they may now be in reproductive age group in
present scenario.
Congenital
Congenital absence of vas
and seminal vesicle is most common cause of azoospermia when we see low volume
ejaculate (<1 ml) and usually this semen is acidic. Rare circumstances are
congenital mullerian duct cyst. Childhood surgery for bladder extrophy,
epispadias. Sometimes urethral valves or myelodysplasia can cause anejaculation
or retrograde ejaculation.
Nowadays, in era of high
tension which reflects in hypertension and runs towards success, sometimes
causes severe depression and those to males have to go for consultation and
take medicine for antihypertension and antidepressant.
Agents associated with
impaired ejaculation:
Alcohol
Amitryptyline
Baclofen
Bethanidine
Chlordiazepoxide
Chlorimipramine >
Chlorpromazine
Chlorprothixene
Clomipramine
EPAC (Epsilone Animo
Caproic acid)
Guanethidine sulfate
Haloperidol
Hexamethionin
Imipramine hydrochloride
Methadone
Naproxen
Pargyline
Perphenazine
Phenelzine sulfate
Phenoxybenzamine
hydrochloride
Phenotamine
Prazosin hydrochloride
Reserpine
Thaizides
Thioridazine
Trifluoperazine
hydrochloride.
Agents used to achieve
seminal emission and/or antegrade ejaculation:
Bromopheniramine meleate
Chlorpheniramine
Ephedrine sulfate
Imipramine hydrochloride
Phenylpropanolamine
Pseudoephedrine
hydrochloride
While prescribing these
drugs to the patients we have to be careful of their sexual activity.
Metabolic and Systemic Disease
Patients with Diabetes
mellitus usually suffer from autonomic neuropathy with erectile dysfunction,
and some of them also suffer from retrograde ejaculation. This problem is very
common in young patients with juvenile onset DM.
Multiple sclerosis, a
demylenating disease, may be associated with anejaculatation or premature
ejaculation.
Inflammatory
Urogenital inflammation
involving the ejaculation ducts may cause partial or complete obstruction.
Chronic prostatitis have
shown ejaculatory duct obstruction, possibly associated with premature
ejaculation.
Prolonged catheterization
may induce an inflammatory reaction that can obstruct the orifice of the
ejaculatory ducts at the level of verumontanum.
Other inflammatory lesion,
such as advanced tuberculosis and gonococcal urethritis may be associated with
bilateral vassal and epididymal scarring.
Numerous psychological
conditions may be associated with functional disorder of ejaculation.
Some of them are as
follows:
Subconscious sadistic
feeling towards partner
Performance anxiety
Fear of sexually
transmitted disease
Illicit situation where the
need to perform quickly
Unresolved marital problem
Olfactory improper
sensation
Disfigurement of spouse
Uncomfortable position.
Psychodynamic bases of
ejaculatory incompetence (retarded ejaculation):
Fear of unwanted pregnancy
Consideration of religious
orthodoxy
Lack of sexual desire
Fear of congenital anomaly
in potential offspring
Distorted body image.
May be of myogenic or
neurogenic origin and should be in back of mind when volume of an ejaculate is
small and acidic (very few sperm seen microscopically).
Presence of sperm in
catheterized post-ejaculatory urine sample can diagnose this condition.
Characteristically
nocturnal emissions is present in these cases and indicate that ejaculatory
reflex is present and problem is psychological.
Ejaculatory dysfunction
disorder is not difficult to diagnose if one is keen to see the existence of
the differential.
So many times etiologies
can provide important sources of information in this disorder.
Anejaculation is complete
absence of antegrade ejaculation.
This category of patients
may experience sometime normal or decrease orgasm with contraction but nothing
to ejaculate.
Normally what ever teacher
had taught us regarding history taking will solve the problem because history
is mostly evident in all types of cases.
If semen analysis is not
done in these cases as there is no ejaculate, post-orgasm urine analysis shows
non viscous there is fructose negative sperm negative sample.
Retrograde ejaculation is
established when post-intercourse or masturbation urine analysis shows
spermatozoa under microscopic vision.
Ideally for all retrograde
ejaculate sample, whole content of bladder is centrifuged and then semen sample
(sediments) again suspended in 1 ml of media before microscopic examination
should be and motility parameters.
According to MASTERS and
JOHNSON premature ejaculation is the condition where there is inability to
control or sustain ejaculation for a sufficient length of time during
intravaginal containment to satisfy female in at least 50% of coital events.
In classical case this
happens before or immediately upon vaginal penetration and typically by
emission and ejaculation is followed by loss of erection.
In milder variety chief
complaint of patients will be like inadequate intravaginal endurance prior to
ejaculation and usually it is of male concern only.
This is dual history
diagnosis after consultation of both partners.
Mostly this diagnosis is
evidence based as we have to depend on laboratory findings in cases where we
see small ejaculate, azospermia and fructose negative sample.
Difficulty arises in
diagnosis when there is unilateral or partial block or sometimes only
functional blocks may give false report form normal site.
Local examination can
diagnose thick palpable cord. TRUS (Transrectal sonography) sometimes may show
cyst.
Suspicion of ejaculatory
duct obstruction should arise when physician sees normal report of gonadotropins
with normal size testis with small volume ejaculate with fructose absent and
physician must investigate this type of patients and eventually we achieve good
report with correction of problem.
TRUS may show enlargement
of seminal vesicle or distension of intraprostatic ejaculatory ducts.
Vasography is radiological
demonstration of blockage but we believe that it should be planned before
surgical repair scheduled.
Alternative diagnostic
modality is chromopertubation like method in which (vas deferens) instillation
of indigo carmine dye for followed by examination of catheterized urine is
presence of dye in it but this methods will not elicit the exact site of
blockage.
Newer diagnostic technique
in form of MRI is equivocal important for very good visualization of seminal
vesicle and prostate but with TRUS we get the same results.
Therapeutic evaluation and
causal treatment is given according to etiology.
As we have already
mentioned that numerous pharmacological drugs ejaculatory dysfunction can
cause, after proper sorting of the drug either switch over to another molecule
or it may require stoppage of drug also.
Routinely a normal
treatment in patients with retrograde ejaculation will be to advise patients to
do intercourse with full bladder and they will ejaculate antegrade.
In patients without
neurological or bladder neck scarring form of ejaculatory dysfunction will be
benefited with sympathomimetic drugs—sometimes single drug is not sufficient
and we have to give combination of drugs also.
Much success will be seen
in patients with retroperitoneal lymph node dissection. Results show conversion
of retrograde to antegrade ejaculation, increase in sperm counts in previously
low sperm density in patients with ejaculatory failure.
Alpha-adrenergic
sympathomimetic agents act through increased closure pressure at the internal
urinary sphincter via release of norepinephrine from the terminal nerve endings
and stimulation of adrenergic receptor sites.
Drugs like imipramine
hydrochloride, a tricyclic antidepressant, blocks their uptake of
norepinephrine at nerve terminals, potentiating the adrenergic activity.
Imipramine possesses
anticholinergic and direct smooth muscle relaxant property and should be used
in patients with some neurological, gastrointestinal and cardiac disease.
In patients with
anejaculation, physician can use injectable (hCG) human chorionic gonadotropins
and it will lead to nocturnal emission, which can be collected in
non-spermicidal condom, and used for AIH.
People had tried low dose
of phenothiazines for use in premature ejaculation and found very good result
in form of satisfaction to both patient as well as partner because it has got
property of anxiolitic and mood elevation.
Phenoxybenzamine can be
used in patients who do not want to procreate and just want to delay
ejaculation.
Word sounds like not hear
about this type of ejaculation until one sees only ejaculation of semen from
urethra not the chemical
Exactly this is very new
and very old method of getting ejaculation from previously spinal cord injured
man.Guttmann first reported
use of intrathecal injection of neostigmine in patients with spinal cord
injury; drug, an inhibitor of acetylcholine esterase has been found to reduce
spasticity and to heighten sexual function in some patients.
60 % of patients found to
be erectile for several hours and many found dribbling ejaculation of semen for
couple of days with or without accompanying erection. The ejaculation occurs
either antegrade or retrograde depending on status of bladder neck function.
The best result is seen
with intrathecal injection of neostigmine in patients with incomplete lesion of
cord while least success will be seen in patients with lesion from T10 to L4, i.e.
origin of sympathetic outflow responsible for emission.
You will be surprised that
till today why we are not trying to use this wonderful drug in our patients to
get fantastic results. Because of its tremendous side effects like autonomic
dysreflexia, transient loss of bowel and bladder function, muscular weakness.
Serious hypertensive crisis may require continuous cardiac monitoring and
nitroprusside—a vasodilator and sometime hospitalization.
Chappell had used
subcutaneous Physostigmine as it crosses blood-brain barrier. It does not
require intrathecal administration.
Use of both drugs is
abandoned because of its side effects.
So one should think of new
chemical use for chemical ejaculation.
Yes at present, physicians
are using intracavernous injection of agents like Papaverine and Phentolamine
or Prostaglandin El for the treatment of premature ejaculation.
In patients on
psychological therapy and with psychological impotence on physicians are
finding very good results with intracavernous injection but still it will
require more number of patients for the study.
Premature ejaculation
rarely affects fertility unless it occurs before vaginal penetration; sometime
we collect even permute ejaculate and use it for AIH. Standard method of
management in this type of case requires more of counseling and sex therapy.
Prime motto of counseling
is to increase pre ejaculatory time.
Physicians try 'squeeze
technique' in which patients has to compress penis before sensation of
ejaculation; and second is to avoid sexual thought while intercourse; sometime
use of local anesthetic agents like xylocaine at urethra.For bladder neck,
scarring surgical correction will solve problem of retrograde ejaculation.
Congenital cystic lesion
of the ejaculatory ducts have been managed by Transurethral unroofing or
resection of the verumontanum to relieve obstruction.
If patients present with
both, ejaculatory duct as well as epididymal obstruction, surgical correction
can be done in form of transurethral resection of the ejaculatory duct and
vasoepididymostomy.
Microsurgical repair of
vassal obstruction is associated with higher pregnancy rates.
Challenging surgery is
when we have to go for vasoepididymal anastomosis as epididymis has little or
no muscular support of its delicate mucosa.
The epididymides have an
important role in acquisition of sperm motility and fertilizing capacity and it
is true that greater length of exposure of sperm in epididymis greater the
chances of fertility.
Microsurgical sperms
combined with ART is nowadays trends in case of vas block because of
tuberculosis or even after failed vasoepididymal anastomosis.
Microepididymal sperm
aspiration (MESA) is boon to the group of patient with congenital absence of
vas.
If reader looks at the
history of vibro, stimulator has been used for the male who are neurologically
normal but there is anejaculation.
Normally it is a
sympathetic event of the efferent neuronal pathways arising from spinal level
T10 to 12.
This is very useful
technique for the patients with spinal cord injury because penile vibratory
stimulation mandates an intact neurotical and anatomical apparatus below the
level of neurological deficit.
Most of the time physician
can get successful ejaculation if there is active central and peripheral
neuroaxis below the T10 level.
In patients with
retroperitoneal lymphadectomy, penile vibrostimulation is not useful because
sympathetic pathways are surgically interrupted.
First, physician have to
evacuate the bladder before vibrostimulation either in supine or relaxed
sitting position. If this is a case of retrograde ejaculation then we have to
fill bladder with 30 ml of buffer media probably with Ham flO and leave
indwelling catheter before stimulation.
The tip of the vibrator is
placed on the undersurface of the glans penis, compressed lightly, and moved
from side to side.
When you reach the trigger
point you wills see sudden enhancement of tumescence or an increase in
abdominal or lower extremity spasticity.
When the threshold level
of activation is reached, the ejaculatory sequence is initiated and there is
final increase in corporeal tumescence and rigidity often noted.
Although the ejaculatory
and erectile spinal reflexes are distinct but there is some neural communication
does exist to explain the erectile augmentation that occurs just before
ejaculation.
Semen proper through the
urethra is collected in sterile container and sent to laboratory for ICSI and
future preservation for next cycle.
The main side effect of vibratory
stimulation is autonomic dysreflexia but it wanes off shortly after removing
stimulator.
Rectal electroejaculation
is in veterinary science and very old in practice.
People are trying
different modes of stimulation like with finger electrode probe stimulation.
Most common indication for
this is spinal cord injury and usually in patients with paraplegia, is with
retroperitoneal lymphadectomy.
Less commonly, this can be
used in cases of myelodysplasia, diabetic neuropathy, multiple sclerosis.
In this technique,
retrograde ejaculation occurs most frequently. So physician has to fill the
bladder with sufficient amount of buffer media to collect the viable sperms.
Different sizes of probes
are available for stimulation at level of peri-prostatic plexus in order to
stimulate neuronal activity for ejaculation.
Physician may encounter
rectal mucosa, minor burns and some times rectal perforation, which might
require colostomy.
Best way to get good
quality sperms after retrograde ejaculation is bladder enrichment with buffer
media to make urine at least 200-300 mosm/L; usually urine is 366 msom/ L and
at this pH, sperm loses its motility.
Physician can advice
patient to take more sodium bicarbonate or acetazolamide for several days.
Sperm cryopreservation is
done prior to surgical procedures for testicular carcinoma or retroperitoneal
lymph node dissection.
Retrograde ejaculate are
preserved for future ICSI procedure.
Post thaw sample use of
Pentoxifylline and PAF (platelets activating factor) enhance the motility.
* Advancement in
sperm retrieving and processing techniques will make ART very easy for
ejaculatory dysfunctional males.
