Sexual Dysfunction and Infertility in the Male Spina Bifida Patient

Nanfu Deng; Nannan Thirumavalavan; Jonathan A. Beilan; Alexander J. Tatem; Mark S. Hockenberry; Alexander W. Pastuszak; Larry I. Lipshultz


Transl Androl Urol. 2018;7(6):941-949. 

In This Article

Treatment Strategies

Infertility treatments for men with spina bifida include pharmacological and surgical interventions each aimed at targeting a specific component of infertility. Here, we review the treatment options for spina bifida men whose infertility may have resulted from solely testicular dysfunction or a combination of erectile dysfunction, ejaculatory dysfunction, and decreased spermatogenesis.

Erectile Dysfunction

Men with spina bifida and erectile dysfunction typically have intact penile architecture and vasculature. Up to 75% of spina bifida men suffer from erectile dysfunction, primarily the ability to maintain erections.[27] The PDE5i sildenafil can improve erections in this patient population. In a randomized placebo-controlled study of 15 spina bifida men with erectile dysfunction, sildenafil 25 and 50 mg taken one hour before planned sexual activity led to significant improvements in erectile function sub-scores of the International Index of Erectile Function (IIEF) by 50% and 88%, respectively, when compared to a placebo.[37,38] Furthermore, of the 80% of men who responded to this therapy, mean erection duration while on 25 and 50 mg of the drug increased by 192% and 266%, respectively.[37] The mean frequency of erections while on 25 and 50 mg of the drug also improved by 61% and 96%, respectively.[37] With the improvements in erectile function while on sildenafil, the authors also observed increased sexual confidence in these men. Other PDE5is have not been studied specifically in this population, but no known contraindication exists to any PDE5i in this spina bifida patients. However, it is important to note that improving erectile dysfunction with pharmacological agents may not solve infertility as impotence in spina bifida men may also be associated with azoospermia.[19]

Ejaculatory Dysfunction, Including Retrograde Ejaculation

Ejaculatory dysfunction is a significant cause of infertility among spina bifida men. In instances of complete neurogenic failure of seminal emission, rectal probe electroejaculation under general anesthesia appears to be an effective method of collecting semen from which viable sperm can be isolated.[33] In a preliminary study by Reilly and Oates involving ten spina bifida men with ejaculatory dysfunction, rectal probe electroejaculation produced ejaculates in all the patients.[19] In a study by Hultling et al. evaluating the success of electroejaculation, the authors found that this method allowed 4 out of 7 men who were not able to achieve unassisted ejaculation to produce enough spermatozoa for assisted fertilization.[18] In addition, surgical retrieval of sperm from the male genitourinary tract, including the bladder, vas deferens, epididymis, and testicle, is also a valid option to collect sperm for assisted fertilization in those men suffering from retrograde ejaculation.[33]

Additionally, surgical interventions have been proposed to increase penile sensation aimed at facilitating erection and ejaculation in spina bifida patients. In cases of pudendal nerve dysfunction, Jacobs et al. performed ilioinguinal-to-dorsal-penile neurorrhaphy on two men with penile anesthesia and found that both men reported improved sensation to the penis and glans during intercourse at 24 months post-operation.[39] A similar procedure performed by Overgoor et al. on 30 spinal lesion patients with no baseline penile sensation, including 18 with spina bifida, found that 24 patients gained glans penis sensation following the TOMAX (TO MAX-imize sensation, sexuality and quality of life) procedure.[40,41] Compared to their pre-operative evaluations, these men reported better overall sexual function (P=0.022) and satisfaction (P=0.004) after the TOMAX procedure.[40]


ART involves manipulation of gametes or embryos to maximize the chances of successful fertilization or implantation. Today, various methods of ARTs are available to treat infertility, and they all require some level of baseline spermatogenesis, as sperm must be collected and isolated for fertilization from either the ejaculate or anywhere along the reproductive tract. With the advent of in vitro fertilization (IVF) in the 1970s, an embryo could be derived from two gametes in a controlled laboratory setting. Furthermore, intrauterine insemination (IUI) is another form of ART that has the potential to increase successful fertilization rates.[42]

The development of intracytoplasmic sperm injection (ICSI) in 1992 dramatically reduced the number and even quality of viable sperm required for successful fertilization.[33] Though outcomes after ART yield live births for males with significant spermatogenic defects, their outcomes specifically in spina bifida fathers have not been reported. In addition, ICSI is associated with increased incidence of congenital defects, multiple gestations leading to low birth weight and preterm infants, sex chromosome defects, and various epigenetic syndromes.[43] Children of fathers with spina bifida are also at increased risk of neural tube defects, making prenatal care imperative.[16] Whether ART specifically in the spina bifida male has any effect on the offspring is unknown.