Thursday, 11 October, 2007

Trans-rectal Electro-ejaculation (TREE)

Trans-rectal electroejaculation (TREE) technique is used to collect semen from men who are unable to ejaculate. The technique has been used in animals since 1930s and in man since 1948 onwards. The aim of trans-rectal electroejaculation (TREE) is to directly stimulate the seminal vesicles. There are selected groups of patients for whom trans-rectal electroejaculation (TREE) is recommended. The majority of spinal cord injuries are among young men. About 5% of these men are likely to achieve pregnancies with their partners without assistance. The loss of fertility in these men is due to a decline of sperm quality, impotence and ejaculatory failure. About 50% of them may able to achieve ejaculation with the use of penile vibrators. Men who are unable to ejaculate by other means, should be offered rectal electroejaculation. Sexual dysfunction is common in insulin dependent diabetics. Trans-rectal electroejaculation (TREE) may be advised for men who are unable to achieve erection and ejaculation. Men with multiple sclerosis who are unable to achieve erection and ejaculation will also benefit from TREE. Men who are impotent and or unable to ejaculate because of psychosexual problems may be offered rectal electroejaculation after failed psychosexual treatment.

The procedure is performed as a day case surgery usually under a short general anesthesia. However, in men with spinal cord injury (SCI) it may be performed without anesthetics (although about 5% of these men may require a general anesthesia. The procedure takes about 15 minutes. The man usually lies on his right side. A metal or plastic tube (proctoscope) is lubricated and inserted into his rectum to inspect the lining of the rectum (see picture). A special probe is inserted into the rectum, the probe is attached to an electric stimulation power unit through which electric stimulation is delivered(see picture). The power is increased gradually until ejaculation occurs. At the same time an assistant will apply massage to the prostate gland and milk the urethra to obtain the ejaculate. At the end of the procedure, another proctoscope is inserted to check for any burn injury in the rectum caused by the hot rectal probe. Like any surgical procedure there are a few potential problems. Autonomic hypereflexia (very high blood pressure) is a potentially severe complication to any spinal cord injured man. Because the normal defenses which protect against a sustained high blood pressure during orgasm are lost. This can have serious consequences such as brain hemorrhage. For this reason, SCI men are usually given pills to lower their blood pressure before they undergo trans-rectal electroejaculation (TREE). Other problems that may occur include burn injury and complications associated with the general anesthesia.

After sperm preparation the fresh sperm is then used for treatment such as insemination, IVF or ICSI depending upon the sperm count and quality. Alternatively the semen sample is frozen for future use. Treatment options will depend upon the sperm count and quality. Other factors such as the fertility of the female partner and the duration of infertility, etc. will also influence the treatment options available. The options include the following:

Intrauterine insemination (IUI)

Intrauterine insemination (IUI) with washed and prepared sperm. This will be advised if the sperm problem is mild and the female partner is young, has regular menstrual cycles and ovulation, and has healthy patent Fallopian tubes. A pregnancy rate of 5-10% per treatment cycle is expected, depending on many factors such as the woman’s age and treatment cycle number, etc.

IVF (In Vitro Fertilization)

In-vitro fertilization (IVF) is usually advised if the female partner is 35 years or older, has blocked or damaged Fallopian tubes or severe endometriosis and the male partners sperm count or quality is not suitable for IUI.

ICSI (Intra-cytoplasmic Sperm Injection)

Intracytoplasmic sperm injection (ICSI) is advised when there is a severe sperm problem, i.e. sperm is not suitable for standard IVF treatment.

Recent advances in assisted conception such as IVF and ICSI have made it possible to achieve pregnancies and live births with ejaculate containing just a few sperm.

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