Male Fertility Following Spinal Cord Injury


In the United States, there are approximately 12,000 new cases of spinal cord injury (SCI) that occur each year. The majority of these injuries happen to men of reproductive age, between the ages of 16 and 30 years.

There are two main issues that men with SCI face concerning biological fatherhood:

1.)  Anejaculation – This is the inability to ejaculate during sexual intercourse, and it occurs in the majority of men with SCI.

2.) Poor semen quality – Men with SCI produce semen with lower numbers of sperm, lower percentages of moving sperm, increased counts of dead sperm (termed “necrospermia”), and sperm with higher levels of genetic material damage.

Erectile Function

Men with SCI often experience problems with erectile function, as the nerve pathways from the brain that control erections may be disrupted. Difficulties with erections may result in difficulty with ejaculation. Erectile function may be important for both fatherhood and sexual satisfaction. There are several treatment options when SCI decreases a man’s ability to achieve and/or maintain erections suitable for sexual intercourse: Vacuum erection devices, medications taken by mouth, medications injected into the penis, or surgery to place a penile implant.

Obtaining Sperm

Approximately 90% of men with SCI do not ejaculate normally. In these men, medical or surgical procedures are necessary to obtain sperm for fertilization. These sperm may be obtained by several means. Of note all of these should be done under the care of a physician to prevent complications, such as autonomic dysreflexia.

  • Masturbation: In men with SCI, masturbation may deliver a more intense stimulus to the penis than sexual intercourse, and thus may lead to ejaculation in some men.
  • Penile Vibratory Stimulation (PVS): A vibrator is applied to the head of the penis to stimulate an ejaculation. This can be done at home after training.
  • Electroejaculation (EEJ): A special probe is inserted into the rectum and an electrical current is applied until an ejaculation occurs. An anesthetic may be required depending on the individual patient sensation.
  • Surgical sperm extraction: Sperm can be directly retrieved from the testis or epididymis. This is known as Testicular Sperm Extraction (TESE).

Using Sperm for Fertility

Sperm obtained by the above methods may be used for paternity. Depending on the number of sperm obtained, and the method obtained, these sperm may be used for one of the following.

  • In-home insemination: The man produces a semen sample at home, and the couple uses a syringe to place the semen in the woman’s vagina at the time of ovulation. This is an option when relatively normal numbers of functional sperm are found in the ejaculate, generally 15×106 sperm/mL or more. While generally considered safe, in-home inseminations are done at the couples own risk. It is difficult to monitor these risks, since the couple is not in a medical setting.
  • Intrauterine Insemination (IUI): This is a procedure performed by a Gynecologist specializing in Female Fertility (“Reproductive Endocrinology and Infertility”, or REI Gynecologist).  A semen sample is processed by an Andrology lab and then, using a small plastic catheter, injected through the cervix and directly into the female uterus. This is an option when sperm counts are too small for in-home inseminations; generally 5-15×106 sperm/mL.
  • In Vitro Fertilization (IVF): This is a more involved procedure performed by a REI Gynecologist. Individual sperm are used to fertilize individual eggs from the female partner. The resultant embryos are then placed back into the female uterus for development.  This is typically done when small numbers of sperm are present, generally less than 5×106 sperm/mL, or when sperm are of a poor quality.