A simple non-invasive method of spermatozoa retrieval from the bladder (SPERB) in patients with retrograde ejaculation

INTRODUCTION

Retrograde ejaculation (RGE) is the commonest cause of Aspermia.^[1] It is a type of ejaculatory dysfunction where semen is pushed retrograde into the urinary bladder instead of the normal antegrade flow into the urethra during ejaculation. The absence of antegrade ejaculation causes male infertility. It is a disheartening condition in men and distress to the couple as there is no antegrade ejaculation despite normal and sustained erection followed by the perception of ejaculation. Parnham and Serefoglu^[2] quoted the incidence of RGE as 0.3% to 2% of male infertile population. Many cumbersome and invasive methods were used in managing infertility in these men. We use a simple and non-invasive method for spermatozoa retrieval in these men from urinary bladder. Herein, we describe the detailed methodology and the case reports of spermatozoa retrieval from the bladder in patients diagnosed with retrograde ejaculation.

PHYSIOLOGY OF MALE SEXUAL FUNCTION

Male sexual function is a series of complex events that takes place involving psychological, neurogenic, vascular, and hormonal factors.^[3] With good libido and sexual stimuli in men, arousal and penile erection is achieved. This is followed by the two phases of events known as emission and ejaculation.

The process of emission takes places with the involvement of distal epididymis, vas deferens, seminal vesicles, prostate gland, prostatic urethra, and bladder neck. Stimuli mediated by the innervations form sympathetic nervous system initiates emission by the closure of bladder neck. Contents from the epididymis, vas deferens, seminal vesicles, prostate, and bulbourethral glands are then deposited into the prostatic urethra.^[4]

Ejaculation, also known as seminal emission is initiated by the presence of semen in the prostatic urethra. It is controlled by the coordinated neurological stimuli from T10-L2 (sympathetic fibres) to S2-S4 (somatic fibres).^[5] Highly coordinated neurological and muscular events aid in the process of ejaculation. The pelvic floor muscles around the urethra upon rhythmic contractions propels the ejaculate via the penile urethra and external meatus.^[6]

PATHOPHYSIOLOGY IN RETROGRADE EJACULATION

The events of sexual function like libido, arousal, and erection are normal in patients with retrograde ejaculation. The process of emission take place but due to inadequate closure of bladder neck, semen flows into the urinary bladder.^[7]

The semen deposited into the bladder is exposed directly to the acidic urine, which makes the spermatozoa either immotile or non-vital. In order to treat infertility, it is essential to isolate the spermatozoa from urine and retain spermatozoa motility and viability.

Etiology of retrograde ejaculation is given in Table 1.

Table 1 Etiology of retrograde ejaculation in men^[10,11]

DIAGNOSIS

High index of suspicion of retrograde ejaculation is raised when a male partner has good erection and achieves the sense of orgasm and ejaculation but there is aspermia/no antegrade ejaculation − dry orgasm. Eliciting the patient’s medical [Table 1] and surgical history is very essential in confirming the diagnosis with further investigations. History should also include the details of surgeries in bladder neck, spinal cord, urethra, neoplastic excision with irradiation in the pelvic floor.^[4] The chances of RGE is ruled out in men with painful antegrade ejaculation, as it could be due to pathologies in the ejaculatory duct.^[12]

The spermatogenesis is intact despite which the male remains infertile as there is only defective spermatozoa transportation.^[13,14] Final diagnosis of retrograde ejaculation can be elicited in men by detailed history taking and examination of post coital or post masturbatory urine for the presence of spermatozoa. The voided urine, upon macroscopic examination will appear cloudy,^[2] and plenty of immotile spermatozoa^[15] can be seen when viewed under the microscope.

Though spermatogenesis is usually unaffected in these men, exposure to the acidic pH of the urine in the bladder makes the spermatozoa immotile/non-vital.^[16] Hence, if the time of exposure of spermatozoa to urine is minimized, motile spermatozoa can be obtained and can be used for fertility treatment procedures which has evolved over a period of time. Cloudy urine has to be differentiated from milky urine (chyluria), which occurs in filariasis or trauma to the lymphatics of the genital tract.

Many methods have evolved in an attempt to recover motile spermatozoa in patients with retrograde ejaculation and one such method is spermatozoa retrieval from bladder (SPERB), which is described below. A detailed literature review pertaining to fertility management in these men is mentioned in Table 3.

SPERMATOZOA RETRIEVAL FROM THE BLADDER (SPERB) - A SIMPLE NON-INVASIVE TECHNIQUE

This novel technique involves a simple method of spermatozoa retrieval from the bladder in patients diagnosed with retrograde ejaculation. We coined the term “SPERB − Spermatozoa Retrieval from the Bladder.” SPERB is a simple, non-invasive and effective method of spermatozoa retrieval in men with retrograde ejaculation which we routinely perform in Department of Andrology & Reproductive Medicine, Chettinad Super Specialty Hospital, Chennai since 2009. The main principle of this technique is to reduce the time of contact of the spermatozoa with urine in the bladder, thereby retaining spermatozoa motility.

CASE REPORT

A 32-year-old gentleman and his wife, a 27-year-old lady, married for around 3 years visited us with history of primary infertility. The female partner had regular menstrual cycles. Upon eliciting detailed sexual history, male partner revealed that he has no antegrade ejaculation and no night emission despite having orgasm. Uro-genital examination was found to be normal.

Considering the history, provisional diagnosis was made as retrograde ejaculation. Our method of SPERB was performed to confirm the diagnosis. Examination of post masturbatory urine revealed the presence of occasional motile and immotile spermatozoa. The test was repeated and the later showed similar spermatozoa parameters.

Since the spermatozoa numbers were very less, ICSI (Intra Cytoplasmic Sperm Injection) was the treatment of choice for this couple. Controlled ovarian hyperstimulation was done and oocyte retrieval was performed. Spermatozoa were recovered by the above-described method on the day of oocyte retrieval, and the motile spermatozoa obtained was used for ICSI. Details of the ART cycle are mentioned in Table 2.

Table 2 ART outcome

On the third day after ICSI, 05 cleavage stage embryos (03–8 cell grade 1 and 02–6 cell grade 1) were obtained. The rate of fertilization and cleavage was normal. Considering the age of the female partner, type of infertility and quality of embryos, a fresh transfer of 02–8 cell grade 1 embryos was performed. The remaining embryos are cryopreserved. Two weeks from the embryo transfer, serum β hCG levels was assessed and was found to be 579.2 mIU/ml. A healthy live baby boy was born at term by elective Caesarean section.

LITERATURE REVIEW OF MANAGEMENT OF RGE

Upon reviewing the literature in detail (Table 3), it is clear that many methods have evolved over a period of time in managing patients with retrograde ejaculation. But, most of these methods are invasive, cumbersome, and have lot of drawbacks and a majority of them have been withdrawn from current practice.

Table 3 Management of retrograde ejaculation − Literature review

DISCUSSION

The percentage of men with retrograde ejaculation among the infertile men ranges from 0.3% to 2%.^[2] The incidence of azoospermia and aspermia in our center is 10% and 0.3% respectively.

History taking plays a significant role in suspecting and diagnosing this condition. A detailed medical, surgical, and sexual history is important to identify the cause of an ejaculation. Patient’s inability to have an antegrade ejaculation despite having orgasm^[3] and passing cloudy urine^[2] after the sense of ejaculation due to mixing of semen and urine in the bladder are the key points to diagnose and to suspect retrograde ejaculation.

The final diagnosis of retrograde ejaculation is made by identifying spermatozoa in the post coital/masturbatory urine. In these patients with normal spermatogenesis, plenty of immotile spermatozoa can be seen. As there is mixture of semen with urine in the bladder, the acidic pH of urine renders the spermatozoa immotile/non-viable.^[16]

Isolation of motile spermatozoa is essential in these patients to treat infertility. Many methods have been employed for isolation of motile spermatozoa from patients diagnosed with retrograde ejaculation.

The treatment options vary largely from non-invasive to invasive methods, based on the etiology.^[17] Most of the methods used were either invasive or unpleasant to the couple seeking treatment. A detailed description of methodology used with their pros and cons are tabulated in Table 3.

SPERB, is a simple yet novel technique and is non-invasive. Spermatozoa retrieval from the bladder is done at ease just by instructing the patients to follow simple instructions. Emptying the bladder and voiding the post coital/masturbatory urine into the media acts as a buffer and reduces the acidic pH of residual urine thereby maintaining spermatozoa motility.

Among men with aspermia, SPERB method is effective in diagnosing retrograde ejaculation. The treatment method for infertility was based on the spermatozoa concentration and motility. ICSI is preferred when the recovered spermatozoa numbers are very few.

Pandiyan et al.^[31] introduced SPERB method in another institution and in the year 1998 presented and published the clinical outcome of using spermatozoa retrieved by this method as an abstract. Spermatozoa recovery was done in 06 patients diagnosed with retrograde ejaculation and the spermatozoa concentration and motility was suitable enough for performing intrauterine insemination. Since all the patients reported with primary infertility and had no female factor infertility, intrauterine insemination was offered and 04 pregnancies and live births were obtained.

CONCLUSION

Spermatozoa retrieval in men diagnosed with retrograde ejaculation can be performed by simple and non-invasive methods. Achieving fatherhood by natural conception is not possible in the absence of antegrade ejaculation. SPERB is a simple and easy method to retrieve motile spermatozoa and use it for fertility treatment. The choice of fertility treatment need not be restricted to higher treatment methodologies; a simple IUI should also be considered when the retrieved spermatozoa concentration and motility are favorable.