PVS was first described by Sobrero in 1965 [40] and is one of the simplest methods used for collection of sperm in SCI men.

EEJ is an alternative method for sperm collection and can be used for similar indications as PVS. EEJ is, however, much more invasive, as it requires medical intervention and the patient may require general or spinal anesthesia [30].

Electro-ejaculation as a technique was originally designed to assist in animal husbandry and was first described in the 1930s [43]. In humans, the technique was first described by Horne in 1948 [23] and became an established technique for assisted reproduction in the SCI patients in the late 1980s [44]. The first reported pregnancy as a result of electro-ejaculation was reported by an Australian group in 1975 [45], and later in Japan in 1992 [46].

Prior to the introduction of sperm retrieval techniques, donor semen was the only method of achieving pregnancy available to azoospermic men. The introduction of surgical sperm retrieval techniques revolutionized the management of sub-fertility in men with SCI. Men in whom no ejaculate can be obtained or whose ejaculate contains no viable sperm require more invasive forms of intervention: surgical sperm retrieval. Sperm can be obtained through various techniques from either the epididymis or testis by percutaneous aspiration, biopsy, or formal surgical exploration [33]. In SCI men, both testicular sperm aspiration (TESA) and testicular sperm extraction (TESE) are used for sperm extraction.

Our centre is based in Southport and Ormskirk National Health Service (NHS) Trust, Southport, Merseyside, United Kingdom. It is a district general hospital that provides secondary level care for the local population. The North West Regional Spinal Injury Unit is also based in the hospital. Assisted conception units with facilities for IVF, ICSI, and other advanced fertility techniques are located in regional tertiary centres. Our regional centre is based in Liverpool Women’s Hospital, 30 miles away.

This model, with a spinal injury unit and separate assisted conception unit being located in two different hospitals, is not unusual in the UK. However, it creates unique problems for the management of infertility in spinal cord injury patients. The challenge arises because the sperm retrieval is performed in the spinal unit and then the sperm specimen is transported to the assisted conception unit for analysis, cryopreservation and eventual treatment.

The management protocols for our patients have been established over the last 25 years and consist of an integrated pathway that includes referral, assessment, sperm collection and assisted conception for spinal patients undergoing fertility treatment. In the UK, assisted conception treatment of infertility is done under the guidance of the Human Fertilization and Embryology Authority (HFEA). The treatment protocols in our center fulfill the HFEA criteria [52].

Following surgical sperm retrieval, the specimen is immediately transported by car in G-Mops™ Plus (Vitrolife, Göteborg, Sweden) [52] culture medium to the assisted conception unit where the specimen is then assessed for sperm parameters and then cryopreserved. Post-thaw analysis is performed a few days later to confirm viability.

In our center, we only use cryopreserved sperm for the subsequent treatment, which is IVF/ICSI. We have not found any deterioration in the fertilization rates in the SCI patients compared to the sperm from the able-bodied men (Table 14.4).

The advantages of the model described include the following: (1) collection of sperm is done according to the suitability and convenience of the spinal injury patient, and (2) the outcome is not affected by either the level or type of injury. In addition, the assisted conception can be scheduled to suit the couple. Sperm collection and cryopreservation can also be done for single men for future use as well.

There are well-defined and significant differences in the seminal quality and the seminogram of the men with SCI, when compared to able-bodied, ambulant men, and this is proposed to be multifactorial. Typically, volume may be normal but frequently discolored—a condition known as “rusty pipe syndrome of unknown etiology.” [20]. Specimens of ejaculate from spinal patients typically have an increased count but have poor quality, specifically for motility and viability [25, 53]. Changes in seminal parameters occur as soon as two weeks after acute injury [54]. Early work in the field of SCI related fertility identified various factors thought to contribute to poor semen quality in SCI men, namely urinary tract infections, method of bladder management, static prostatic fluid, testicular hyperthermia and histological changes, hormonal alterations, presence of antibodies, and use of chronic medications [55]. Hirsch et al. [56] proposed that testicular failure and accessory sexual gland dysfunction may also be responsible for poor semen quality in spinal cord injury patients. Method of bladder drainage has been shown to influence the amount of motile spermatozoa with intermittent self-catheterization being the optimum method that is “sperm friendly.” [57]. Additionally, level of neurological insult is also important and demonstrates a linear relationship with caudal injuries demonstrating the most deleterious effects on motility [22].

The World Health Organization (WHO) criteria for assessment of semen are considered the gold standard for the assessment of semen analysis (Table 14.5) [58].

However, the same criteria cannot always be applied to the semen specimen obtained from a spinal injury patient because of the unique circumstances that apply to this patient cohort. These include the following: infrequent ejaculations, the need to keep the specimen from entering the bladder and the requirement to instill culture medium intravesically. The results from our center are described in Table 14.6, and when compared to the WHO reference limits (Table 14.5), it is obvious that all the parameters do not conform.