Diagnosis of Partial Retrograde Ejaculation in Non-Azoospermic Infertile Men with Low Semen Volume

Abstract

In non-azoospermic patients with low semen volume (LSV), looking for partial retrograde ejaculation (PRE) by searching sperm in the postejaculatory urine (PEU) is required. The use of a retro-ejaculatory index (R-ratio) was suggested to define PRE, but none of the studies indicated a specific threshold above which PRE must be considered. Our objective was to propose a threshold value for the R-ratio as indicative of PRE in patients with LSV selected to be devoid of any known causes or risk factors for retrograde ejaculation or LSV. Among our data base (2000–2009) including 632 patients with PEU, 245 male patients from infertile couples who had had a first semen analysis with LSV (< 2mL) and a second semen analysis associated with PEU, were selected on the previous criteria. A prospective control group was randomly constituted (2007–2008) of 162 first consulting male patients from infertile couples, with a normal semen volume (≥ 2mL) on a first semen analysis and who accepted to collect PEU with their usual second semen analysis, selected on the previous criteria. To define an R-ratio threshold indicative of PRE, we used a ROC curve analysis and a regression tree based on a classification and regression tree (CART) algorithm. Of the 245 LSV patients, 146 still presented low semen volume (< 2 mL) on the second semen analysis. From the use of the CART algorithm, two low (1.5% and 2.8%) and two high R-values (7.1% and 8.3%) were defined, according to the lower reference limit for semen volume of 2.0 mL (WHO 1999) or 1.5 mL (WHO 2010) respectively. As only one or no patient with normal semen volume was observed above the two high R-values, we suggest an R-value higher than the range of [7.1–8.3]% as indicative of PRE until confirmation by a prospective multicenter study.

Male Sexual Dysfunctions in the Infertile Couple–Recommendations From the European Society of Sexual Medicine (ESSM)

“…In a case-control study comparing 245 infertile men with a semen volume < 2 ml with 162 infertile men with a semen volume > 2 ml, 6% vs. 7% had sperm in the post-ejaculatory urine sample and was diagnosed with RE. 64 In a retrospective cohort study, involving 920 infertile men, RE was found in four (4%) out of 96 of azoospermic subjects. 65 …”

“…In a case-control study comparing 245 infertile men with a semen volume < 2 ml with 162 infertile men with a semen volume > 2 ml, 6% vs. 7% had sperm in the post-ejaculatory urine sample and was diagnosed with RE. 64 In a retrospective cohort study, involving 920 infertile men, RE was found in four (4%) out of 96 of azoospermic subjects. 65 Regarding anejaculation, Punab et al 10 showed that, in a large prospective clinical-epidemiological study investigating causes of male infertility, anejaculation accounted for 1.2% of all causes.…”

“…Epidemiological studies of EjDs among infertile men are limited. Currently, three case-control studies 5 , 19 , 60 and six single-arm studies 17 , 22 , 40 , 61 , 62 , 63 have investigated PE among infertile men; one case-control 64 and one single-arm study 65 have looked at RE, while only one study have investigated the prevalence of anejaculation among infertile men 10 ( Table 3 ).…”

“… 4 Retrograde ejaculation Mieusset et al. 64 Case-control 245 infertile men with semen volume < 2ml and 162 infertile men with a semen volume > 2ml Post-ejaculatory urine test 15/245 (6%) of infertile men with semen volume < 2 ml had sperm in post-ejaculatory urine vs. 12/162 (7%) of infertile men with semen volume > 2 ml - 3 Lee et al. 65 Retrospective cohort 920 infertile men, 96 of them azoospermic Not specified 4/96 (4%) azoospermic men had RE Identification of specific causes of male infertility is presented 4 Anejaculation Punab et al.…”

“…Only two observational studies investigating RE among infertile men were available. Both suffer from selection bias, as one 64 selected patients based on ejaculate volume and the other 65 only reported RE among azoospermic men. Only one study investigated the prevalence of anejaculation in a cohort of unselected infertile men 10 There is a shortage of RCTs investigating the treatment of anejaculation in infertile men and thus LoE 1 is currently lacking.…”