Emad Ibrahim, M.D., HCLD

Male Fertility Following Spinal Cord Injury

The research is focused on understanding and improving the impairments to male fertility which occur following spinal cord injury (SCI). Following SCI, most men, but not women, experience impaired fertility. Specifically, most men with SCI are anejaculatory, and some experience erectile dysfunction. Although their semen may be obtained by medically-assisted ejaculation procedures, in most cases, semen quality is impaired, specifically, sperm motility and viability are abnormally low, although sperm numbers tend to be normal.

Our research is focused on determining the cause of impaired semen quality in men with SCI. Our studies have shown that factors secondary to SCI are not responsible for impaired semen quality in men with SCI. For example, the condition is not due to scrotal thermoregulatory dysfunction, the method or frequency of ejaculation, the number of ensuing years post-injury, or hormonal alterations. Our recent evidence indicates that the problem is related to the seminal plasma. For example, seminal plasma of men with SCI inhibits sperm motility of able-bodied men. In addition, sperm motility is much higher in men with SCI before the sperm mix with seminal plasma. Substances within the seminal plasma are abnormal in men with SCI, including elevated reactive oxygen species, decreased prostate specific antigen (a marker of prostate function) and decreased fructose (a marker of seminal vesicle function). The semen of men with SCI contains an abnormally high number of non-spermatozoon cells, most of which are leukocytes. Our research showed significantly higher concentrations of pro-inflammatory cytokines in the seminal plasma of men with SCI. In-vitro neutralization of these cytokines led to improvement of sperm motility. In collaboration with our colleagues in the Miami Project to Cure Paralysis we detected higher levels on the inflammasome components in semen and sperm cells of men with SCI. We recently published the data of our pilot study using oral probenecid to improve motility in men with SCI which is considered the first published oral medication to treat this condition. Our current studies are aiming at determining the best dosage regimen and duration to enhance the effect of oral probenecid.  In collaboration with distinguished neuroscience researchers from the Miami Project to Cure paralysis, our program is investigating novel therapeutic agents targeting the inflammasome complex in animal models with the goal of developing new therapeutic modalities to treat reproductive dysfunction in this population. Our ultimate goal is to develop therapies to normalize semen quality in men with SCI, so that chances of biological fatherhood are increased.

In addition to our investigation of sperm and seminal plasma, we are studying methods to improve semen retrieval and semen processing for assisted conception procedures. Recent improvements treating male infertility in the general population have led to a problem for men with SCI. Often, their ejaculates are not examined as a source of sperm for assisted reproductive technology (ART). Instead, sperm are retrieved surgically from their testes or epididymes as a first line treatment for anejaculation. This development has resulted in many centers performing expensive and invasive ART to overcome the low sperm numbers typically obtained with surgical sperm retrieval. Our research is focused on optimizing non-surgical methods of obtaining sperm from men with SCI. By maximizing the total motile sperm available for ART, couples have a wider range of options for pursuing assisted conception. Our research is leading the field by establishing standards of care for treatment of infertility in men with SCI.

We developed an educational program comprised of didactic classes and live workshops aiming at teaching health care professional dealing with patients with SCI on the optimal methods of management of reproductive function in men with SCI. Through this program and the developed educational video that over 100 practitioners worldwide learned the techniques of penile vibratory stimulation (PVS) and electroejaculation (EEJ) with the goal of spreading the knowledge of these simple techniques to avoid using surgical sperm extraction as the first choice for ART in couples with a male with SCI.

Educational Workshops Sponsored by PVA Grant.