Penile Vibratory Stimulation for Semen Retrieval in Men with Spinal Cord Injury: Patient Perspectives.

Spinal cord injury (SCI) is a catastrophic event with sequelae that are not often apparent. For the spinal cord injured man, the inability to become a biologic father because of reproductive dysfunction becomes a major negative factor in his self-esteem and a hindrance to his social rehabilitation. Approximately, 90% of men with SCI develop ejaculatory dysfunction and only 10% can ejaculate by masturbation or during sexual activity. It is only over the last 40 years that it has been possible to properly study and understand the various factors contributing to the problem. Advances have been made in governmental and societal attitudes that have led to improvements in the treatment and rehabilitation of persons with SCI and other disabilities. It is now possible to retrieve sperm reliably and safely from men with SCI. Although their semen quality is often impaired, there is a very reasonable chance for achieving biologic fatherhood using assisted reproductive techniques. Penile vibratory stimulation (PVS) is a safe, reliable, efficient, and cost-effective, method of sperm retrieval that will produce an ejaculate in up to 86% of the patients with a level of injury T10 or rostral, which accounts for approximately 80% of the SCI population. Some motile sperm will be present in 90% of these ejaculates. In approximately 75% of the ejaculates, there will be greater than 5 million motile sperm, allowing a couple to explore all the options available to a couple seeking help in conceiving a child. The Male Fertility Program of the Miami Project to Cure Paralysis is at the leading edge of basic and clinical research contributing to the management of infertility in men with SCI. This review will outline "how we got there" enabling us to recommend PVS as the first choice in assisting men with SCI to become biologic parents.

Seminal inflammasome activity in the adult varicocele.

Varicocele has been hypothesized to lead to seminal inflammation, which in turn interferes with sperm function. Thus, the aim of this study was to investigate the role of inflammatory cytokines in the pathogenesis of decreased semen quality observed in adult men with varicocele, and to determine if varicocelectomy corrects these potential alterations. A prospective study was carried out including fifteen control men without varicocele and with normal semen quality and 15 men with varicocele with surgical indication. Men with varicocele grades II or III underwent microsurgical subinguinal varicocelectomy. Controls collected one semen sample and men with varicocele collected one before and one 6 months after the surgery. Semen analysis, sperm function, and seminal lipid peroxidation levels were assessed. Seminal plasma inflammasome activity was evaluated by ELISA assays for IL-1ß, IL-18 and caspase-1 and by Western blotting for ASC (apoptosis-associated speck-like protein). Groups were compared by an unpaired Student's T test. Varicocelectomy samples were compared using a paired Student's T test (α = 5%). Men with varicocele had decreased semen quality, and increased seminal IL-1ß levels, when compared to control men. Varicocelectomy decreased levels of caspase-1, IL-18, and IL1ß. Thus, varicocelectomy improves sperm morphology and decreases seminal plasma inflammatory activity, after a six-month post-operative period.

Electroejaculation in men with spinal cord injury: a step-by-step video demonstration.

OBJECTIVE: To demonstrate the proper technique to perform electroejacuation (EEJ) in men with spinal cord injury (SCI) for the purpose of inducing ejaculation. DESIGN: A video demonstration of the proper technique to perform EEJ in men with SCI using the Seager model 14 electroejaculation machine. SETTING: Major university medical center. PATIENT(S): Men with SCI; institutional review board approval was obtained, and all subjects signed an informed consent form. INTERVENTION(S): Spinal cord injury occurs mostly in young men where the majority suffer from ejaculatory dysfunction. The method of choice to induce ejaculation in penile vibratory stimulation (PVS). PVS is successful in 86% of men with SCI whose level of injury is T10 or rostral. If PVS fails or the level is Caudal to T10, the patient is referred for EEJ. This video will demonstrate the proper technique for successful ejaculation using EEJ. Patients with history of autonomic dysreflexia or their level of injury is T6 or rostral are pretreated with 10-20 mg of nifedipine sublingually 10 minutes before stimulation. The patient is then placed in the lateral decubitus position. The bladder is emptied, and a buffer is instilled. An anoscopy is performed, and a rectal probe is placed. A current is delivered until an antegrade ejaculation is retrieved. A retrograde specimen is collected and examined for sperm identification. Patients with complete SCI (no sensory or motor function is preserved in sacral segments S4-S5) can undergo EEJ without anesthesia. Patients with incomplete SCI (significant nerve sparing or normal sensations) will experience pain during stimulation, and general anesthesia is recommended without the use of muscle relaxing agents. MAIN OUTCOME MEASURE(S): Successful ejaculation after performing EEJ in men with SCI. RESULT(S): Electroejacuation is successful in 95% of men with SCI and in nearly 100% if general anesthesia is used. Outcomes of in vitro fertilization or intracytoplasmic sperm injection after EEJ showed 37.5% pregnancy rate per cycle, 50.0% pregnancy rate per couple, 33.3% live birth rate per cycle, and 43.8% live birth rate per couple. No complications due to EEJ were observed in 953 trials, and none occurred in the patients presented in this video demonstration. CONCLUSION(S): Electroejacuation is a safe and reliable method for induction of ejaculation in men with SCI who fail a trial of PVS.

Proteomic insight of seminal plasma in spinal cord injured men submitted to oral probenecid treatment for improved motility.

OBJECTIVE: To observe the seminal plasma proteomic composition in men with spinal cord injury orally treated with probenecid, in order to observe pathways associated with increased sperm motility. STUDY DESIGN: Prospective study. SETTING: Miami Project to Cure Paralysis - University of Miami/Miller School of Medicine. PARTICIPANTS: Nine men with spinal cord injury, who agreed to participate in the study. INTERVENTION: Oral treatment with probenecid - 500 mg per day for one week, then 500 mg twice daily [1000 mg total] per day for three weeks. OUTCOME MEASURES: Semen analysis as per WHO 2010 guidelines, and seminal plasma proteomics analysis by LC-MS/MS. RESULTS: In total, 783 proteins were identified, of which, 17 were decreased, while 6 were increased after treatment. The results suggest a new pathway that could be treated by the decrease of biglycan after probenecid treatment. CONCLUSION: Oral treatment with probenecid is able to alter the seminal plasma proteome, in pathways that explain decreased innate immune response.

Evaluation of a re-engineered device for penile vibratory stimulation in men with spinal cord injury.

STUDY DESIGN: Cohort study OBJECTIVES: The purpose of this study was to evaluate the performance of a re-engineered device (Ferticare 2.0), which is replacing the previous standard (Ferticare 1.0) for penile vibratory stimulation in men with spinal cord injury. Most men with spinal cord injury are anejaculatory, requiring medical assistance to obtain their semen. Penile vibratory stimulation is generally recognized as the standard of care for semen retrieval in these anejaculatory men. SETTING: Major Research University in Miami, Florida, USA. METHODS: The Ferticare 2.0 device was applied to 15 men with spinal cord injury in a three-step protocol simulating normal use. Step 1: one device (2.5 mm amplitude, 100 Hz) was applied to the glans penis for 2 min. Step 2: If no ejaculation occurred, the amplitude was increased to 4.0 mm (100 Hz) and the device similarly applied. Step 3: If no ejaculation occurred, two devices, each 2.5 mm and 100 Hz were applied to the dorsum and frenulum of the glans penis. Participants at risk for autonomic dysreflexia were pretreated with sublingual nifedipine (20 mg), 15 min prior to stimulation. Blood pressure and other symptoms of autonomic dysreflexia were monitored. Participants answered a questionnaire about their experience with the device. RESULTS: Thirteen of 15 participants ejaculated with the device. No adverse events occurred. All participants commented they would recommend the device to other men with spinal cord injury. CONCLUSIONS: A re-engineered device, the Ferticare 2.0, is safe and effective for inducing ejaculation in men with spinal cord injury.

How long does it take a man to collect his semen specimen in a busy infertility clinic?

BACKGROUND: The duration of time required for male patients to collect their semen specimen heavily impacts the workflow of a busy infertility clinic. We analyzed this parameter to optimize the scheduling clinic space in the setting of growing male infertility practices. METHODS: Prospective observational study on men collecting semen specimens for fertility evaluation, sperm cryopreservation or vasectomy at a male infertility clinic. Duration of time required for semen collection by masturbation was measured. RESULTS: Patients were 136 men with a mean age ± standard deviation of 35.7±7.8 years (range, 18.8 to 62.5 years). Indications for semen collection were: evaluation for male factor infertility in 125 cases (92%), of which 12 (9%) underwent sperm cryopreservation; post-vasectomy evaluation in 7 cases (5%); and post vasoepididymostomy in 4 cases (3%). The median collection time was 11 minutes 57 seconds ± IQR 9 minutes 8 seconds to 17 minutes 5 seconds; and ranging from 3 minutes 9 seconds to 39 minutes 50 seconds. Patients accompanied by their female partner in the collection room were significantly more likely to take longer than 15 minutes compared to unaccompanied patients (P=0.012). Age and indication for semen collection were not associated with duration. CONCLUSIONS: Median collection time in our sample was 11 minutes 57 seconds, with significant variability across the sample. Patients accompanied by their female partners required significantly longer time to collect their sample, while age does not seem to have an impact.

Distribution of Semen Parameters Among Adolescent Males Undergoing Fertility Preservation in a Multicenter International Cohort.

OBJECTIVE: To determine the distribution of semen parameters among adolescent and adult males presenting for fertility preservation. METHODS: A retrospective, cross-sectional cohort study of adolescent males age 11-19 who underwent semen analysis for fertility preservation at 3 centers in 2 countries with a comparison cohort of adult men presenting for fertility preservation. Prevalence of azoospermia and distribution of semen parameters was compared across groups. RESULTS: A total of 197 adolescents and 95 adults underwent semen analysis for fertility preservation. Azoospermia was present in 17 (8.6%) adolescents and 3 (3.2%) adults. There was decline in the prevalence of azoospermia with increasing age. After exclusion of patients with azoospermia, the adolescent and adult cohorts were comprised of 180 and 92 patients, respectively. Median age at presentation among adolescents vs adults was 16.5years (interquartile range [IQR] 15.2-17.6) and 30.8years (IQR 22.7-43.8), respectively. Median semen volume was 1.0mL (IQR 0.5-2.0) vs 2.5mL (IQR 1.5-3.5), P <.001. Median sperm concentration was 30million/mL (IQR 10-57) vs 39million/mL (IQR 14-57), P = .2. Median sperm motility was 39% (IQR 20-55) vs 45% (IQR 35-55), P = .01. Median total motile sperm count was 11million (IQR 1.4-33) for adolescents vs 29million (IQR 13-69) for adults, P <.001. CONCLUSION: Young adolescent males had higher prevalence of azoospermia and lower semen parameters compared to adults. In conjunction with physical examination, Tanner stage, and specific clinical context, these data can help to inform patients and their families about potential for fertility preservation, even in very young adolescent patients.

Effect of a formal oncofertility program on fertility preservation rates-first year experience.

BACKGROUND: A formal fertility preservation program was initiated at our institution in 2016 as part of a multi-disciplinary oncofertility initiative to improve the reproductive needs of oncologic patients. After 1 year of initial experience, we assessed sperm banking rates in men diagnosed with cancer, as well as examined the trends in the use of fertility preservation services. METHODS: We performed a chart review from 2011 to 2017 for men newly diagnosed with cancer, and for all men who underwent fertility preservation during that period of time at our institution. We assessed the rates of sperm banking among patients newly diagnosed with cancer, before and after the implementation of a standardized oncofertility program in 2016. The program includes nursing and physician education regarding indications of fertility preservation. Additionally, we evaluated the overall population undergoing sperm cryopreservation at our institution during the study period. RESULTS: From 2011 to 2016, 30 of 902 oncologic patients underwent sperm banking prior to their treatment (3.3% of total cancer patients). After the program was implemented, 42 of 218 patients underwent fertility preservation between June 2016 and August 2017 (19.3% of total cancer patients). In this group, patients' mean age was 30.14 years old (range, 13-69 years old), with 6 pediatric patients; 36 of the samples (85.7%) were obtained from masturbation. When viable sperm could not be obtained from ejaculation, patients underwent either testicular or epididymal sperm extraction (6 cases). Overall, 98 men used the formal fertility preservation service. Of these, 42 were cancer patients and 56 were non-cancer patients. Of the non-cancer patients, 17 banked sperm after varicocelectomy, 6 prior to vasectomy and 6 because of hypogonadism. CONCLUSIONS: Rate of sperm banking increased nearly six-fold after institution of a formal fertility preservation program, indicating the clinical need for such a program at academic institutions. Oncofertility is a relevant part of the care for oncologic patients, and should be considered as part of counseling before cancer treatment.

Oral probenecid improves sperm motility in men with spinal cord injury.

STUDY DESIGN: Prospective cohort study (twenty men with spinal cord injury [SCI]). OBJECTIVE: Determine if administration of oral probenecid results in improved sperm motility in men with SCI. SETTING: Major university medical center. METHODS: Twenty men with SCI were administered probenecid for 4 weeks (250 mg twice a day for 1 week, followed by 500 mg twice a day for 3 weeks). Semen quality was assessed at three time points: pre-treatment, post-treatment (immediately after the 4-week treatment), and follow-up (4 weeks after the last pill was ingested). RESULT(S): Probenecid was well-tolerated by all subjects. Sperm motility improved in each subject after 4 weeks of oral probenecid. The mean percent of sperm with progressive motility increased from 19% to 26% (P < 0.05). A more striking increase was seen in the mean percent of sperm with rapid linear motility, from 5% to 17%, (P <0.001). This improvement continued into the four week follow up period. Similar improvements were seen in the total motile sperm count (15 million, 28 million, and 27 million at pre-treatment, post-treatment, and follow-up, respectively). Sperm concentration was not significantly different at pre-treatment, post-treatment, and follow-up, (52 million, 53 million and 53 million, respectively). CONCLUSION: This study showed that administration of an oral agent (probenecid) known to interfere with the pannexin-1 cellular membrane channel, can improve sperm motility in men with spinal cord injury. It is the first study to report improved sperm motility after oral medication in men with SCI.

Policy on Posthumous Sperm Retrieval: Survey of 75 Major Academic Medical Centers.

OBJECTIVE: To evaluate the presence and content of policies on posthumous sperm retrieval at 75 major academic medical centers in the U.S. MATERIALS AND METHODS: We surveyed the top 75 major academic medical centers ranked for research in 2016 by U.S. News & World Report using a questionnaire-based telephone/web survey. We gathered data on the presence and content of posthumous sperm retrieval policies on the Internet. If not published, we contacted the legal counsel, the ethics and compliance offices, the urology department, as well as the infertility treatment center associated with each institution. In addition, we also surveyed members of the Society for Male Reproduction and Urology. RESULTS: We gathered data regarding posthumous sperm retrieval from 41 out of the 75 major academic medical centers. Of the 41 institutions, only 11 (26.8%) had policies regarding posthumous sperm retrieval. Out of those 11 centers, 4 required prior written consent, whereas the remaining 6 allowed for verbal or inferred consent from the surviving life partner. One policy prohibited the procedure. Five of the policies in this survey included a bereavement period. Of the 30 (73.2%) centers without policies, lack of legal guidance was cited as the most common barrier to policy adoption. CONCLUSION: Only a small proportion of major academic medical centers have policies on posthumous sperm retrieval. Medical centers can adopt individualized policies based on guidelines published by professional societies.

Reproductive Health of Men with Spinal Cord Injury.

Most men with spinal cord injury (SCI) are infertile due to a combination of erectile dysfunction, ejaculatory dysfunction, and abnormal semen quality. This article addresses issues that should be considered when managing the reproductive health of men with SCI. The authors present recommendations based on their decades of experience in managing the reproductive health of more than 1,000 men with SCI. Men with SCI face obstacles when pursuing sexual activity and/or biologic fatherhood. Hypogonadism and premature symptoms of aging may interfere with sexual function. Erectile dysfunction is prevalent in the SCI population, and treatments for erectile dysfunction in the general population are also effective in the SCI population. Most men with SCI cannot ejaculate with sexual intercourse. The procedures of penile vibratory stimulation (PVS) and/or electroejaculation (EEJ) are effective in obtaining an ejaculate from 97% of men with SCI. The ejaculate often contains sufficient total motile sperm to consider the assisted conception procedures of intrauterine insemination or even intravaginal insemination at home. If PVS and/or EEJ fail, sperm may be retrieved surgically from the testis or epididymis. Surgical sperm retrieval typically yields enough motile sperm only for in vitro fertilization with intracytoplasmic sperm injection. The majority of new cases of SCI occur in young men at the peak of their reproductive health. With proper medical management, these men can expect to experience active sexual lives and biologic fatherhood, if these are their goals. Numerous tools are available to physicians for helping these patients reach their goals.

Advances in the management of infertility in men with spinal cord injury.

Couples with a spinal cord injured male partner require assisted ejaculation techniques to collect semen that can then be further used in various assisted reproductive technology methods to achieve a pregnancy. The majority of men sustaining a spinal cord injury regardless of the cause or the level of injury cannot ejaculate during sexual intercourse. Only a small minority can ejaculate by masturbation. Penile vibratory stimulation and electroejaculation are the two most common methods used to retrieve sperm. Other techniques such as prostatic massage and the adjunct application of other medications can be used, but the results are inconsistent. Surgical sperm retrieval should be considered as a last resort if all other methods fail. Special attention must be paid to patients with T6 and rostral levels of injury due to the risk of autonomic dysreflexia resulting from stimulation below the level of injury. Bladder preparation should be performed before stimulation if retrograde ejaculation is anticipated. Erectile dysfunction is ubiquitous in the spinal cord injured population but is usually easily managed and does not pose a barrier to semen retrieval in these men. Semen analysis parameters of men with spinal cord injury are unique for this population regardless of the method of retrieval, generally presenting as normal sperm concentration but abnormally low sperm motility and viability. When sperm retrieval is desired in this population, emphasis should be placed on initially trying the simple methods of penile vibratory stimulation or electroejaculation before resorting to more advanced and invasive surgical procedures.

Towards Understanding Male Infertility After Spinal Cord Injury Using Quantitative Proteomics.

The study of male infertility after spinal cord injury (SCI) has enhanced the understanding of seminal plasma (SP) as an important regulator of spermatozoa function. However, the most important factors leading to the diminished sperm motility and viability observed in semen of men with SCI remained unknown. Thus, to explore SP related molecular mechanisms underlying infertility after SCI, we used mass spectrometry-based quantitative proteomics to compare SP retrieved from SCI patients to normal controls. As a result, we present an in-depth characterization of the human SP proteome, identifying ∼2,800 individual proteins, and describe, in detail, the differential proteome observed in SCI. Our analysis demonstrates that a hyper-activation of the immune system may influence some seminal processes, which likely are not triggered by microbial infection. Moreover, we show evidence of an important prostate gland functional failure,i.e.diminished abundance of metabolic enzymes related to ATP turnover and those secreted via prostasomes. Further we identify the main outcome related to this fact and that it is intrinsically linked to the low sperm motility in SCI. Together, our data highlights the molecular pathways hindering fertility in SCI and shed new light on other causes of male infertility.

Inhibin B is lower and anti-Müllerian hormone is similar in serum of men with spinal cord injuries compared to controls.

Men with spinal cord injury have a unique semen profile characterized by normal sperm concentration but abnormally low sperm motility and viability. The purpose of our study was to determine if new diagnostic information could be obtained for this population by measuring serum concentrations of inhibin B and anti-Müllerian hormone. These hormones, as well as follicle stimulating hormone, luteinizing hormone, and testosterone, were measured in 30 men with spinal cord injury and 15 age-matched control subjects. Serum concentrations of inhibin B and testosterone were significantly lower in the spinal cord injury group compared to the control group. A statistically significant negative relationship was observed between serum concentrations of inhibin B and follicle stimulating hormone in both the spinal cord injury group and the control group, and between inhibin B and luteinizing hormone in the spinal cord injury group only. A significant positive relationship was also observed between inhibin B and sperm concentration in the spinal cord injury group. Although serum concentrations of inhibin B were significantly lower in the spinal cord injury group than in controls, inhibin B and anti-Müllerian hormone serum concentrations did not provide an additional diagnostic tool for male infertility in this population. This is the first study to determine serum concentrations of inhibin B and anti-Müllerian hormone in men with spinal cord injury.

Involvement of the inflammasome in abnormal semen quality of men with spinal cord injury.

OBJECTIVE: To study the mechanism leading to elevated semen cytokines in men with spinal cord injury (SCI) and to understand if inflammasome pathways are involved in this process. To investigate inflammasome components and end-product cytokines in semen of SCI and control subjects. DESIGN: Prospective study. SETTING: Major university medical center. PATIENT(S): Men with and without SCI (n = 28 per group). INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Seminal plasma concentrations of caspase-1, interleukin (IL) 1ß, and IL-18 were quantified by ELISA. Caspase-1 in sperm fractions and apoptosis-associated speck-like protein containing a caspase activation and recruitment domain (ASC) in seminal plasma and sperm fractions were identified by Western blot. Localization of proteins in sperm was accomplished by immunocytochemistry. RESULT(S): ASC, caspase-1, IL-1ß, and IL-18 concentrations were elevated in the seminal plasma of SCI subjects compared with control subjects. ASC and caspase-1 were elevated in sperm cells of SCI subjects. Immunocytochemistry revealed that ASC was located in the acrosome, equatorial segment, and midpiece, and caspase-1 in the midpiece. CONCLUSION(S): This study provides the first evidence of ASC in human semen and demonstrates the involvement of inflammasome proteins in semen of men with SCI. These findings suggest an immunologic basis for abnormal semen quality in men with SCI.

Semen quality in men who sustained a spinal cord injury during the prepubertal period.

PURPOSE: There are limited reports regarding the semen quality of men who sustained a spinal cord injury during the prepubertal period. We performed a retrospective chart review of 533 subjects with spinal cord injury to identify those injured during the prepubertal period and to characterize the semen quality of this population. To our knowledge this study is the first to formally evaluate semen parameters in this small but important subgroup of spinal cord injured subjects. MATERIALS AND METHODS: A retrospective chart review was performed of all spinal cord injured subjects enrolled in the MFRP (Male Fertility Research Program) from 1991 through 2011. Prepubertal subjects were defined as those who sustained a traumatic spinal cord injury at or before the age of 11.9 years. Data collection included neurological level and completeness of injury, sexual responses, hormone profiles and semen quality. RESULTS: Of 533 subjects 7 met the criteria for this study. Age at injury ranged from 4.4 to 11.9 years. Three subjects, injured before age 9 years, were azoospermic. One subject injured at age 10 years had a subnormal total sperm count, while those injured at age 11.9 years had normal total sperm counts, comparable to those of our subjects who sustained spinal cord injuries as adults. In most ejaculates with sperm, sperm motility was subnormal and comparable to that of subjects injured as adults. CONCLUSIONS: Spinal cord injury before the age of 9 years appears to interfere with spermatogenesis. In subjects injured near the age of 12 years semen quality in adulthood appears to be similar to that of subjects injured as adults.

Infertility in men with spinal cord injury: research and treatment.

Spinal cord injury (SCI) occurs most often to young men. Following SCI, most men are infertile due to a combination of erectile dysfunction, ejaculatory dysfunction and semen abnormalities. Erectile dysfunction may be treated by the same therapies that are used in the general population. Similarly, the same treatments that are effective to assist conception in couples with non-SCI male factor patients are effective in assisting conception in SCI male-factor patients. The most apparent differences in male-factor symptoms between SCI and non-SCI patients are the high occurrences of anejaculation and atypical semen profiles in men with SCI. Methods available to assist ejaculation in men with SCI include penile vibratory stimulation and EEJ. Use of surgical sperm retrieval as the first line of treatment for anejaculation in men with SCI is controversial. Most men with SCI have a unique semen profile characterized by normal sperm concentration, but abnormally low sperm motility. Toxic substances in the semen contribute to this problem. Despite impaired sperm parameters, pregnancy outcomes using sperm from men with SCI are similar to pregnancy outcomes using sperm from non-SCI men. Future studies should focus on improving natural ejaculation and improving semen quality in these men.

Male sexual dysfunction and infertility associated with neurological disorders.

Normal sexual and reproductive functions depend largely on neurological mechanisms. Neurological defects in men can cause infertility through erectile dysfunction, ejaculatory dysfunction and semen abnormalities. Among the major conditions contributing to these symptoms are pelvic and retroperitoneal surgery, diabetes, congenital spinal abnormalities, multiple sclerosis and spinal cord injury. Erectile dysfunction can be managed by an increasingly invasive range of treatments including medications, injection therapy and the surgical insertion of a penile implant. Retrograde ejaculation is managed by medications to reverse the condition in mild cases and in bladder harvest of semen after ejaculation in more severe cases. Anejaculation might also be managed by medication in mild cases while assisted ejaculatory techniques including penile vibratory stimulation and electroejaculation are used in more severe cases. If these measures fail, surgical sperm retrieval can be attempted. Ejaculation with penile vibratory stimulation can be done by some spinal cord injured men and their partners at home, followed by in-home insemination if circumstances and sperm quality are adequate. The other options always require assisted reproductive techniques including intrauterine insemination or in vitro fertilization with or without intracytoplasmic sperm injection. The method of choice depends largely on the number of motile sperm in the ejaculate.