Making babies after SCI.
Spinal-cord injuries (SCIs) typically happen to young people who are in the midst of their child-bearing years. As a result, questions regarding fertility are emotionally powerful and often raised early post-injury. Almost universally, young people fear SCI means never having and raising children.For most able-bodied couples, the fertilization process is relatively uncomplicated. The man ejaculates the sperm into the woman's vagina during sexual intercourse. The sperm travels through the woman's cervix, uterus, and fallopian tubes where the sperm fertilizes an egg that has been released from the ovary.
For people with SCI, however, what might be an uncomplicated and natural process is most often extremely complex and emotionally stressful.
Although I have discussed fertility in previous columns (February 1996, February 1999, and May 2004), having a child is an important priority for many people. Thus, it seems appropriate to review the current issues surrounding fertility after injury. New medications and reproductive technologies are continually being developed. As a result, pregnancies and childbirth are not uncommon in relationships where one individual has an SCI.
Male Fertility
Twenty-five years ago, many of the fears regarding infertility were justified. Physicians and health professionals discouraged people with SCI from thinking about having children. Producing a child seemed doubtful and improbable. In response, some hospitals began programs to freeze semen shortly after injury. Even surrogate mothers and male sperm donors were considered an option.
The idea of sperm banking persisted for many years. A sense of urgency was involved in preserving sperm after the initial injury. If possible, clinicians rushed to retrieve a sample even on the day of injury. Today research has demonstrated the idea of preserving sperm early after injury is unnecessary.
The vast majority of men with all levels of SCI experience difficulties in the attempt to have a child through the impregnation of an egg during sexual intercourse. These problems, called male-related factors, are typically associated with erectile dysfunction, ejaculatory dysfunction, poor semen quality, or a combination of them all. Any disturbance or interruption in any of these aspects can lead to reproductive problems.
Although men with SCI have normal numbers of sperm, the percentage of motile sperm tends to be lower than in men without SCI. In general, men with SCI have been shown to have approximately 20% of motile sperm as compared to 70% in those who do not have an injury. "Motility" refers to the sperm's ability to swim and ultimately fertilize the egg. It is the most widely used measure of semen quality.
Research studies have demonstrated this lower percentage of sperm motility for men with SCI does not correlate with level of injury, age, time postinjury, or frequency of ejaculation. As a result, scientists are turning their attention to biochemical explanations for these changes in the sperm of men with SCI. Today's studies are looking at how the body stores sperm in the seminal vesicles and how the biochemical make up of the semen (the liquid that carries the sperm) may be harmful to healthy sperm.
The ejaculation process is one of the most perplexing sexual issues facing a man after injury. The primary issue involved in male infertility after SCI is this problem related to ejaculation--a neuromuscular mechanism impacted by the injury. As a result of this biological interruption, semen is unable to be expelled from the urethra during intercourse or masturbation.
Given these sexual difficulties, men with SCI must often use techniques other than intercourse to impregnate the female's egg. These include masturbation, the use of penile vibratory stimulation or a rectal probe, called electroejaculation. Although electroejaculation is the least preferred, it is the most effective with up to an 83% success rate. In contrast, vibratory stimulation is usually tolerated well except for dysreflexia in men with injuries above T10. In general, however, any of these techniques can be used to obtain the semen sample.
Most recently, there has been some discussion of newer medications that might stimulate ejaculation. Such medications are currently being used in sexual health clinics for men who have difficulty reaching orgasm and ejaculating. One medication, oxytocin, has not been used with men who have SCI but may prove beneficial. As is often the case, further research with men who have SCI is necessary.
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After obtaining the sample and determining the quality of the semen, the couple can attempt pregnancy with various fertility procedures. These currently available include intra-vaginal insemination, intra-uterine insemination (IUI), in-vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), and intracytoplasmic sperm injection (ICSI).
Until more is understood, there is little a man with SCI can do to improve his sperm quality. Maintaining good health, getting regular exercise, keeping a healthy diet, and reducing secondary complications such as skin and bladder infections are probably the key factors.
Female Fertility
For women with SCI, the situation is very different than for men. In general, injuries of the spinal cord have little effect on female fertility. For women desiring to have a child, the outlook is extremely positive--although possible complications need to be closely monitored.
Immediately after injury, 44-58% of women have a temporary disruption of their menstrual cycles. Menstruation usually returns within six months postinjury. Neither the level nor the completeness of the injury appear to be associated with the interruption of menstrual cycles. In a small percentage of women with SCI, there are also changes in cycle length, duration and amount of flow, and amount of menstrual pain.
Birth Control
The issue of birth control can be somewhat problematic for women with SCI. Condoms, which are often recommended, provide contraception as well as diminish the risk of transmission of sexually transmitted diseases.
A diaphragm may be another acceptable option if the individual has adequate hand dexterity or a cooperative partner.
Oral contraception is associated with increased incidence of thromboembolism and must be prescribed with caution in women with SCI. In addition, the birth control pill has recently been associated with lower testosterone levels in women, thus diminishing sexual desire.
Pregnancy
Pregnant women with SCI have an increased risk of urinary tract infections (UTIs), leg edema, autonomic dysreflexia (AD), constipation, thromboembolism, and premature birth.
Since functioning of the uterus arises from the T10-12 levels, women with lesions above T10 may not be able to perceive uterine contractions or fetal movements. It may be difficult to differentiate between pregnancy-induced hypertension and AD. For some women, dysreflexia may be the only clinical manifestation of labor.
During the second and third trimesters, pregnant women may have difficulty performing tractional tasks they previously completed independently. Transfers may require a caregiver's assistance, and a power wheelchair may be necessary for mobility.
Nevertheless, in spite of the precautions and possible side effects, many women with SCI choose pregnancy and have successful deliveries. For the most part, they experience it in a positive manner and deliver via cesarean section.
Where to Start
The first step for a couple considering having a child is to contact a fertility specialist who has experience with people with SCI. For men, this is often a urologist specializing in male-factor fertility problems. For women, locating an obstetrician with a supportive attitude, an accessible office, and experience in SCI can be difficult.
In spite of the challenges, there are more and more experienced physicians throughout the country. Attitudes have changed, and you should expect a physician who will support you throughout this process. Your local rehabilitation hospital, outpatient clinic, or independent living center should be able to point you in the right direction.
Contact: ducharme@bu.edu.
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| Title Annotation: | sexuality and SCI |
|---|---|
| Author: | Ducharme, Stanley |
| Publication: | PN - Paraplegia News |
| Date: | Nov 1, 2008 |
| Words: | 1247 |
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