Friday, August 08, 2008

Low Volume Ejaculate: A Rational Approach That Maximizes Success

Some men have infertility that is associated with low volume ejaculates. Often these men do not realize that they have less than the normal amount of ejaculate fluid because they have no basis of comparison. Other times, men will report that over time, the amount of fluid ejaculated has decreased over time. Some report having "dry" orgasms, a condition known as aspermia.

Ejaculation and orgasm are different entities. Orgasm is the pleasurable sensation that typically, but not always, occurs with ejaculation. Ejaculation is the physical release of seminal fluid from the penis. Seminal fluid contains 3 things: sperm, prostate fluid, and seminal vesical fluid. Sperm--or the testicular component--makes up the smallest contribution by volume. Men rarely if ever notice a decrease in ejaculate fluid volume from a testicular bloackage, such as after a vasectomy.

Normally fertile men have ejaculate volumes of 2.5ml or greater. Volumes between 2ml and 2.5ml are in an equivical range and are rarely associated with any abnormalities or male factors. Volumes less than 2.0ml are definitely low and when detected should prompt the urologist-male infertility specialist to investigate.

Low volume ejaculates are caused by 3 disorders: ejaculatatory dysfunction, genital tract obstructions, or congenital anomalies. An evaluation can typically differentiate one of these disorders from another.

Ejaculatory disorders are caused by:
  • neurological diseases, e.g. multiple sclerosis, autonomic neuropathies, authonomic dysreflexia, spinal cord injury.
  • Diabetes, is causes a combination of neurologic and autonomic nervous system problems
  • Prior surgeries; can cause retrograde ejaculation, aspermia, or both
  • Medications; some can cause retrograde ejaculation, aspermia or both
Genital Obstructions are caused by:
  • Prostate cysts
  • inflammatory disorders
  • Infections
  • Scars from prior surgeries
Congenital anomalies
  • Seminal vesical aplasia (absence)
  • CBAVD (absence of the vas deferens)
A detailed history, physical exam, laboratory assessment, and semen analysis can alert the physician to the possibility that a genital tract obstruction might exist. When low volume ejaculate infertility is encountered, an experienced male fertility specialist can use their knowledge of the causes to develop a evidence based plan of evaluation and treatment.

When the patient history fails to uncover any reversible disorder or obvious cause for the problem, such as an offending medication, a spinal cord lesion, or CBAVD, a thorough diagnostic work-up is indicated. Here's how I proceed:
  1. Repeat semen analysis with a post-ejaculate urine analysis (PEUA). The PEUA is essential for diagnosing retrograde ejaculation, a common, often reversible, and treatable disorder in which the sperm get deposited into the bladder after ejaculation rather than in the normal direction of flow.
  2. If PEUA negative, proceed with a TRUS, which is a prostate sonogram. This test can determine if the seminal vesicals are present or absent or if there is a prostate cyst. It can also at times determine if the ejaculatory duct is dilated. The TRUS is not 100% accurate for determining whether or not a blockage is present and can have many false positive and negative results. If the TRUS is positive or equivocal, and I am considering a procedure to correct ejaculatory duct obstruction--a procedure called the TURED--I recommend that the patient have the following:
  3. A Testis biopsy. This procedure is definitive and can differentiate between a disorder of sperm production versus sperm ductal obstruction. One can also harvest and freeze any sperm found after a biopsy, circumstances permitting. If the biopsy is consistent with obstruction or blockage, and the TRUS findings and SA/PEUA findings are consistent with ejaculatory duct obstruction, then:
  4. I have a discussion with the patient and partner about further treatment options. These options include referral for IVF-ICSI and a sperm retrieval procedure to obtain sperm or proceeding with a TURED--a minimally invasive procedure that can un-block the ejaculatory ducts and restore fertility in affected men.
  5. Perform the TURED. When the diagnosis is correct and the blockage is in a location that can be reached by the procedure, the results of the TURED can be dramatic. Azoospermic patients can go from zero sperm to normal (>20 million sperm) within days of the procedure.
Low volume ejaculate can be a difficult diagnostically. With a rational and evidence based approach, a high number of men can be helped with few side-effects. And best of all, these procedures are typically covered by insurance plans.

Any questions, contact me.