2.3. Fertility and Parenting
SCI Forum Reports
Fertility and Parenting
December 1, 1998
"There's a lot that goes on in the male to achieve unassisted fertility," said Ivan Rothman, a nurse practitioner in the Department of Urology. First, a man needs at least one testicle to produce sperm, and the structures necessary to get the sperm up and out of the body. Sperm travel from the testicles through the vas deferens to the seminal vesicles and the prostate. Ejaculation is necessary to get the sperm out of the urethra, and an erection is required for vaginal penetration. Sperm need to be motile, i.e., able to move from one place to another. Finally, the sperm must be capable of penetrating the ovum (egg) and fusing with its genetic material.
"In the general population, about 8-10% of cohabiting couples are infertile, defined as trying and failing to get pregnant for at least 12 months," Rothman said. In about 30% of couples, infertility is caused by a problem with the male; in 30%, with the female; and in 40%, the cause is unknown. Male factor infertility, which is Rothman's specialty, can be caused by a problem with any of the structures or processes described above. "SCI can have a profound effect on male fertility," he said.
"We frequently get men who come into our clinic soon after an SCI having been told they should have their sperm cryopreserved (frozen and stored in a medical facility) right away because things will only get worse as time goes on," Rothman said. "I don't know that the research supports that statement." While male fertility normally declines somewhat with age, female fertility declines 50% by age 40.
"Most of the fertility tests we do are much better at predicting failure to conceive than ability to conceive," Rothman said. "Occasionally a recently injured single man comes into our clinic wanting to know if he'll be able to reproduce in the future. We can do a semen analysis, and if things look very, very bad, I can talk definitively about his ability to conceive. But it's hard to say how good things are, and that's what people want to know. The best information we can give people is in a practical situation, when a couple is attempting conception, and we can tell them how this may work. A couple's goals drive the treatment plan."
During the infertility evaluation, men will be asked about their bladder management methods in order to determine their risk for lower genital tract infections, which can effect sperm motility. Infections or inflammations can be treated with antibiotics. Patients will have a blood test to measure whether they have normal levels of a follicle-stimulating hormone that stimulates the production of sperm in the testicles. Patients will be asked if they are able to ejaculate on their own or with the assistance of special equipment, and whether their semen is antigrade (going out of the penis) or retrograde (going back into the bladder), since this affects sperm quality and quantity.
If a patient cannot ejaculate on his own, Rothman usually starts him out with a vibrator because it is non-invasive, inexpensive, and safe. Held against the underside of the glans of the penis, the vibrator delivers high-intensity stimulation which produces a reflexive ejaculation. Although the first attempt takes place in the office in order to watch for autonomic dysreflexia, couples may bring the vibrator home for another try "because these kinds of interventions often work better at home," Rothman said.
Electroejaculation is a more invasive technique that may be tried if a vibrator is unsuccessful. A probe placed in the rectum sends an electrical current across the seminal vesicles and the prostate to try to cause a muscular contraction that results in ejaculation. This procedure is always done in the clinic with continuous blood pressure monitoring. The drug nefedipine may be given to patients to prevent autonomic dysreflexia. For patients with sensation, the procedure is done under general anesthetic.
When these methods fail, sperm may be removed directly from the testes with needle aspiration.
Semen is analyzed in the laboratory to determine sperm concentration, motility, and other factors that affect fertility. Depending on the results, treatments can be applied to the sperm to improve motility and increase their concentration, or to the patient to reduce inflammation or infection.
SCI does not affect a woman's fertility, said Brenda Houmard, MD, from the UW Fertility and Endrocrine Center, and "the current medical literature suggests that there are excellent outcomes for both mothers with SCI and their infants." In general, prenatal and labor and delivery care are changed little for women with SCI, with a few exceptions.
Because of the higher incidence of medical conditions and use of medications in women with SCI, pre-conception counseling is recommended for these women who are planning to get pregnant. Urinary tract infections (UTIs)-which in the general pregnant population carry significant risk for kidney infection with a resulting increase in maternal and fetal complications-are more prevalent among women with SCI due to incomplete bladder emptying and the use of catheters. Close monitoring and treatment of UTIs and preventive strategies such as minimizing residual urine volume and avoiding indwelling catheters are an important aspect of maternal care for women with SCI.
Autonomic dysreflexia can occur in response to labor and delivery and post-partum pain in women with lesions above T5-6 but can be successfully prevented or treated with epidural anesthesia.
Preterm labor is the biggest cause of perinatal morbidity and mortality in the normal population, Houmard said, "so we want to diagnose preterm labor early in all populations. We counsel all women to watch for signs such as uterine pressure and changes in discharge." Women with lesions below T10 often feel contractions, but women with lesions at any level can be taught to feel the uterus both for signs of preterm labor and for monitoring the contractions of full-term labor. Obstetricians may also increase the frequency of cervical checks to monitor for preterm labor in women with SCI, Houmard said.
Women with SCI may have a worsening of pressure sores, urinary incontinence, and constipation during pregnancy. Those with high lesions may have more breathing difficulties due to pressure from the enlarged uterus.
An initial evaluation for couples at the UW Fertility and Endocrine Center focuses on three main causes of infertility, Houmard said. Ovulation defects, or the inability to release an egg on a regular monthly basis, can be detected using a combination of menstrual history, basal body temperature charts, urinary ovulation detection kits, and the measurement of the hormone progesterone in the blood. Ovulatory problems account for about 10-15% of infertility cases.
Abnormalities in the uterine cavities or blockages in the fallopian tubes can be diagnosed using an X ray test called a hysterosalpinogram that uses an injected dye. The third focus of the evaluation is male factor infertility due to abnormalities in ejaculation or semen quality.
"If clearly identified causes of infertility are found, we take steps to correct the defect," Houmard said. If no cause is identified, fertility treatments may still be undertaken to improve the likelihood of conception each cycle.
Intrauterine insemination is typically used when there is low semen volume or low sperm count. After semen is extracted using one of the methods described earlier, sperm are washed in the lab, concentrated, and placed into the uterus using a small catheter inserted through the cervix, "getting the sperm one step closer to where it needs to be for fertilization," Houmard said. This method can be used with the natural menstrual cycle or in combination with medication to stimulate ovulation. Results are generally good for mild to moderate male factor infertility, Houmard said, "with up to a 10-14% chance of pregnancy per cycle, yielding a 40-50% chance of pregnancy in one year."
In vitro fertilization (IVF) is the fertilization of an egg with sperm in a culture dish outside the body. First, the woman receives ovulatory medications that stimulate egg development. Eggs are collected via needle aspiration through the vagina using ultrasound guidance. Sperm collected from the male partner are placed with the egg to allow for fertilization. An embryo develops for several days in the culture dish and is placed back in the uterus. Depending on the age of the woman, there is about a 25% pregnancy rate per cycle.
Intracytoplasmic sperm injection (ICSI, pronounced "ik-see") involves injecting a single sperm directly into an egg under microscopic guidance. Since it requires only one sperm per egg, this method can bring the fertility rate up to normal levels for cases in which the male partner has a very low sperm count.
"The overall message here is that fertility is a definite possibility and should be an expectation for both males and females who have prior SCI," Houmard said.
Costs of infertility services range from $600-700 for an initial evaluation to $6,000-7,000 for each cycle of IVF treatment. Costs will be greater if methods to collect semen require anesthesia or surgery. "In general, most insurance plans don't pay a lot of money for infertility evaluation or treatment, and the vast majority of patients are paying out of pocket," Houmard said.
For the rest of the evening, a panel of SCI consumers and spouses discussed their experiences with conception, pregnancy, and parenting. Steve, who has T2 paraplegia, was warned that his fertility would probably suffer due to his spinal cord injury. Although they were prepared to adopt, he and his wife, Beth, had two children naturally. They have been trying for a third child for several years and are now being treated at the UW Fertility and Endocrine Center for sperm motility and ovulation problems.
When Gary sustained a C5 incomplete injury 25 years ago he was told he would never have children. "I believed that for ten years," he said. But after getting married he and his wife, Karen, decided to explore fertility options before choosing adoption. Gary's sperm were obtained using vibratory ejaculation, and Karen, who was put on clomid, became pregnant with twins through artificial insemination.
Laura, who has T7-8 complete paraplegia, was told she wouldn't have any problems with fertility after her injury 19 years ago and became pregnant with her daughter without difficulty four years ago. Because Laura has no sensation below her injury, she had private birth classes with the labor and delivery nurses at the hospital where she delivered.
After his C4 complete injury 13 years ago, Mark thought he'd never want to have children. But he changed his mind after marrying Lisa, and they went to the UW Urology Clinic for evaluation and treatment. Mark's sperm were removed using direct aspiration from the vas deferens. After three pregnancies and miscarriages, Lisa carried her fourth pregnancy to term and delivered a boy. One year later they tried again and got pregnant with twin boys.
The panelists recommended that couples expecting a baby make arrangements before delivery to get help from family and friends. Mark was frustrated by his inability to help with the babies or household work due to his high level injury. "It eats at you-she was doing all the work," he said. "The only thing I could do was keep working and bringing in money." When Mark's wife Lisa was pregnant with the twins, she ended up on bed rest in the hospital. Their son was one year old at the time. "It was hard for Mark," Lisa said. "My sister basically moved in."
When Gary's twins were three months old, his wife went back to work and he stayed home to provide full-time child care. "You find ways to deal with problems," he said. "I used a pillow in my lap to carry them. When they started to roll, I used a strap. The babies learned to lie still on my lap." When they started walking, they taught themselves how to ride between his legs. "We went everywhere, each boy holding on to a leg. They're very adaptable." At seven years old, the twins now help him with daily tasks, putting his wheelchair in and out of the car and helping him dress. "It's totally natural for them to help," he said.
Kids quickly learn what their disabled parent's limitations are, so it's important to develop a voice control method early in life, Gary said. "I try to keep my voice level at all times. If I do need to warn or stop them, I deepen my voice, and they respond right away."
Steve recommended that people plan ahead and even consult an occupational therapist to work on skills that can help with baby care, such as how to hold a baby against you using a snugly. "Try different equipment and practice with other people's kids," he suggested. Many obstacles can be overcome with a little creativity. After Mark accidentally rolled over one of his twins, "we put jingle bells on them," Lisa said.
Adapting to children's changing development is an ongoing issue for parents with SCI. "My needs for adaptation changed every time my daughter's development changed," Laura said. Now her daughter is four, and behavioral issues are more of a problem than the mechanical issues of infancy, such as carrying or lifting a baby. "The biggest challenge in my life has been parenting, not being paralyzed," she said.