Authors' objectives:

This report focuses on two questions: (1) issues related to fertility, pregnancy rates, and live births in persons with spinal cord injury (SCI), and (2) issues related to male impotence post-SCI.

Authors' results and conclusions: A total of 2,420 bibliographic records were retrieved. After duplicate records were removed, 2,082 unique items remained. An additional 46 potentially relevant studies were identified through conference abstracts or were nominated by manufacturers. A total of 2,128 reports were evaluated against the eligibility criteria. In total, 122 reports were included in the systematic review: 66 of the reports examined fertility and 56 reports examined sexual dysfunction in individuals with SCI. The 122 studies included 6,668 individuals, ranging in age from 16 years to 81 years, of which 78% of the studies reported 100% male participation, with 6% reporting all female participation. The complete spectrum of SCI severity was included across the studies. The majority of studies included in this review used a non-comparative study design (61%) to address the question under consideration. The quality of reporting of the 122 studies included was less than optimal. For example, of the 75 non-comparative studies, none of them reported on all the quality items we used to evaluate their reports. No studies were found that investigated fertility in females after SCI. For male fertility, ejaculation interventions in the last decade resulted in an overall ejaculation response rate of 95% (random effects pooled estimate: 0.95 [95% C.I. 0.91, 0.99]). Data from 13 studies over the past 10 years documenting pregnancy rates indicate rates of 51% (random effects pooled estimate: 0.51 [95% C.I. 0.42, 0.60]). Data from the 11 studies over the past 10 years documenting livebirth rates indicate live birth rates of 41% (random effects pooled estimate: 0.41 [95% C.I. 0.33, 0.49]). We found eight reports that examined the phenomena of sexual arousal in response to physical and cognitive stimulation in women. These papers describe the separate roles of physical reflex and cognitive pathways in the sexual response in SCI females, but did not test treatment methods for dysfunction. Several interventions (i.e., behavioral, topical agents, intraurethral Alprosatadil, intracavernous injections, vacuum tumescence devices, penile implants, sacral stimulators, and pharmacological) have been used to evaluate male sexual dysfunction. We identified one study that demonstrated improvement in penile rigidity in 10 SCI males before and after biofeedback, followed by home perineal muscle training exercises. Three non-comparative case-series studies and one controlled trial examined the use of topical vasodilators for erectile dysfunction in 53 SCI males, all demonstrating low efficacy or tolerability. Two case-series studies involving 30 SCI males describe the use of intraurethral Alproatadil for SCI male erectile dysfunction with high tolerability but low efficacy. Eight noncomparative case series involving 263 SCI males using intracavernous penile injections of vasodilating agents described poolable efficacy data along with side-effect profiles. The injection technique was highly efficacious, with a 90% satisfactory erection response rate (random effects pooled estimate: 0.90 [95% C.I. 0.83, 0.97]) and was well tolerated when appropriate precautions were taken. Only two case series involving 50 males examined vacuum tumescence devices. Although well tolerated, only a select group chose to use these devices; those that did choose to use them reported a high level of satisfaction. Nine studies, of which two were RCTs and seven were case-series studies, evaluated Viagra in 627 SCI males. Although less efficacious than injections, Viagra resulted in a 79% successful erectile function (random effects pooled estimate: 0.79 [95% C.I. 0.68, 0.90]). In addition, Viagra was well tolerated and often preferred by SCI males. Finally, five case-series studies examined the efficacy and morbidity of penile implants in 363 male SCI subjects, and demonstrated a high satisfaction rate but also had a much higher complication rate than the other treatment options.

Authors' recommendations: Apart from case reports and opinion pieces, there is a paucity of literature regarding fertility and pregnancy in SCI females. There is a relatively large body of evidence regarding males with SCI. Using vibration and electroejaculation, most SCI males can produce semen for fertility purposes. The level of invasiveness is likely more of a factor than either the choice or the order of these two interventions. Vibration should be tried at least on all upper motor neuron injuries first, with electroejaculation reserved for those individuals in whom vibration failed and those with lower motor neuron injuries. Advanced fertility techniques can increase pregnancy rates for an SCI male to above 50% per couple. Freezing of sperm, unless done in the first one or two weeks after SCI, and even if done earlier, is unlikely to make a significant improvement in SCI fertility rates and therefore is not widely practiced. Penile injection, Viagra, and vacuum devices can help most erectile function problems in SCI males, making the need for penile implants less common. These interventions positively affect sexual activity at least in the short-term. Long-term sexual adjustment has not been examined.

Authors' methods: Systematic review

Project Status: Completed

URL for project: http://www.ahrq.gov/clinic/tp/sexlsptp.htm

Year Published: 2004

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: United States

Organisation Name: Agency for Healthcare Research and Quality

Contact Address: Center for Outcomes and Evidence Technology Assessment Program, 540 Gaither Road, Rockville, MD 20850, USA. Tel: +1 301 427 1610; Fax: +1 301 427 1639;

Contact Name: martin.erlichman@ahrq.hhs.gov

Contact Email: martin.erlichman@ahrq.hhs.gov

Copyright: Agency for Healthcare Research and Quality (AHRQ)