Successful Pregnancy Outcome in Retrograde Ejaculation – Interesting Case Report

Introduction

The new reproductive technologies, such as IVF ICSI, are becoming increasingly common, enabling infertile couples to become parents and create families. One of the rare cause of male infertility is ejaculatory dysfunction i.e., retrograde ejaculation which is characterized by absent or very low semen volume. It contributes to 0.3-2% of male infertility [1]. The combination of dry orgasm and issue with fertility make the condition distressing to both patient and their partner especially when trying to conceive [2]. The process of ejaculation requires complex co-ordinationand interplay between the epidiymides, vasa deferentia, prostate, seminal vesicles, bladder neck and bulbourethral glands [3]. Upon ejaculation, sperm are rapidly conveyed along the vas deferens and into the urethra via the ejaculatory ducts. From there, the semen progresses in an antegrade fashion in part maintained by coaptation of the bladder neck and rhythmic contraction of the periurethral muscles co-ordinated by a centrally mediated reflex. Any factor, which disrupts this reflex and inhibits the bladder neck (internal vesical sphincter) contraction, may lead to retrograde passage of semen into the bladder. Men with retrograde ejaculation have little to suggest a diagnosis in terms of symptoms beyond that of reduced ejaculation or dry orgasm. Post orgasm, many men will describe the passage of cloudy urine. This can be attributed to the mixing of semen in the bladder with urine. A number of men will present with fertility issues for the obvious reasons [4]. In the present case, there was a successful pregnancy in the patient after alkalization of the urine and washing with density gradient method and subsequently using it for ICSI.

Case Report

A 25 years old female came to our OPD with primary infertility. We had advised the hormonal profile and the ultrasound pelvis. Serum hormonal measurements were AMH: 10.95 ng/ml, Prolactin: 8.7 ng/ml, thyroid stimulating: 1.6 pg/ml. Ultrasound showed bilateral poly-cystic ovaries with normal uterus. The husband’s semen analysis showed Aspermia, with normal hormonal profiles FSH- 8.0 IU/ml, LH- 6.5 IU/ml, Total Testosternoe 450 ng/dL, Prolactin- 4.0 ng/ml, TSH- 2.6 pg/ml. USG scrotum with Doppler showed normal study. Urine analysis was done and showed a count of 12mill/ml and 20% rapid progressive motility. They were diagnosed as a case of Retrograde Ejaculation.

In view of the above diagnosis, we recommended IVF with ICSI to the couple. As PCO was diagnosed, we stimulated her ovaries with FSH 150 (hpHMG, Menopur; Ferring GmbH, Germany). After 11 days of stimulation, transabdominal scan showed 26-28 good follicles of 14mm size in both ovaries. After that daily subcutaneous injection of GnRH antagonist, 0.25 mg Cetrorelix (Cetrotide, Merck SeronoS.p.A, Italy), were added from day 9 to 11. When follicles reached 18 mm, Lupride 1mg (rhCG, Ovitrelle; Merck SeronoS.p.A, Italy) was given to trigger ovulation.

Transvaginal oocyte aspiration was performed before 36 hrs, under ultrasound guidance, using Wallace OPU needle and Cooks gamete buffer media. We retrieved 24 oocytes from both ovaries. The husband was advised to take alkaline solution 3 days prior to egg collection, (pH was monitored daily) and was advised to
masturbate after half emptying the bladder and then collect the urine sample. The urine sample was washed with density gradient method to retrieve the sperms which showed a sperm count of 12 mill/ml and 15% progressive motile. Oocytes were denuded and Intra Cytoplasmic Sperm Injection (ICSI) was performed in the laboratory in Cooks gamete media, in 22 mature oocytes. Embryos were further cultured in cleavage media. Twenty good embryos (15 grade A and 5 grade AB) were formed and were cryo-preserved in five straws on day 3, in view of OHSS.

FET preparation

GnRH agonist 0.5 mg Inj. Leuprolide Acetate (Lupride, Inca Sun Pharmaceutical Industries Ltd.)) was started one week post egg collection and reduced to half dose (0.25 mg) on day 2 of next cycle along with addition of 6 mg estradiol valerate (Progynova, Zydus Cadila Healthcare Ltd.,German Remedies) in divided doses. Transvaginal sonography for endometrial thickness was done on day 12 that was 8.8mm. GnRH agonist injection was stopped after the trigger injection of the patient and Tablet estradiol valerate was continued in the same dose. Progesterone suppositories 200 mg (Naturogest, Zydus Cadila Healthcare Ltd., German Remedies) twice daily were started. One straw of embryos were thawed on the embryo transfer day, Three Day 3 Embryos were transferred in the patient. After 14 days of luteal support, beta HCG was done which came positive. Ultrasound was done after 2 weeks of beta HCG that showed intrauterine single live pregnancy of 6 weeks.

Discussion

Infertility has been the major concern of patients with ejaculatory disorders resulting in aspermia [5]. A dry ejaculate (aspermia), may occur either because of an inability to transport semen (anejaculation) or because of an inability to ejaculate in an antegrade direction (retrograde ejaculation). The treatment of
aspermia varies with underlying etiology and includes medical therapy with sympathomimetics, urinary sperm retrieval, bladder neck reconstruction, prostatic massage, penile vibratory stimulation, electroejaculation, and surgical sperm retrieval [6]. Management needs to be tailored to the individual patient, and the
partner’s fertility status needs to be fully assessed beforehand and taken into account [1].

References

1. Jefferys A, Siassakos D, Wardle P. The management of retrograde ejaculation: a systematic review and update. FertilSteril. 2012; 97: 306-312.
2. Rowland D, McMahon CG, Abdo C, et al. Disorders of orgasm and ejaculation in men. J Sex Med. 2010; 7: 1668-1686.
3. Giuliano F, Clement P. Neuroanatomy and physiology of ejaculation. Annu Rev Sex Res. 2005; 16: 190-216.
4. Fedder J, Kaspersen MD, Brandslund I, et al. Retrograde ejaculation and sexual dysfunction in men with diabetes mellitus: a prospective, controlled study. Andrology. 2013; 1: 602-606.
5. Revenig L, Leung A, Hsiao W. Ejaculatory physiology and pathophysiology: assessment and treatment in male infertility. Translational Andrology and Urology. 2014; 3: 41-49.
6. Mehta A, Sigman M. Management of the dry ejaculate: a systematic review of aspermia and retrograde ejaculation. Fertil Steril. 2015; 104: 1074-1081.