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Quantitative Assessment of Retrograde Ejaculation Using Semen Analysis, Comparison With a Standardized Qualitative Questionnaire, and Investigating the Impact of rhBMP-2

Study Design. This was a prospective study evaluating the incidence of retrograde ejaculation (RE) after anterior lumbar interbody fusion (ALIF) based on laboratory analysis of semen and urine. Objective. The purpose of this study was to investigate the incidence of RE based on quantitative semen analysis and to compare the rate with that identified using a standardized qualitative questionnaire administered by telephone. Summary of Background Data. RE is a specific sexual dysfunction in which semen passes into the bladder during ejaculation. It has long been a known possible complication of ALIF associated with injury to the superior hypogastric plexus occurring during access to the anterior lumbar spine. Although reported in multiple studies, there is no standardized assessment for RE and many studies do not describe the methods by which it was assessed. Recently, there has been increased interest in ALIF-related RE with respect to the use of recombinant human bone morphogenetic protein (rhBMP-2). However, how RE was diagnosed remains loosely defined. One possible assessment of RE is to analyze semen and urine after ejaculation. Methods. Forty-one male patients undergoing ALIF with posterior pedicle screw instrumentation and fusion at L4–L5 and/or L5–L1 consented to participate in the study. The subjects went to a cryobank for preoperative semen and postejaculatory urine analysis. They returned to the cryobank 3 to 6 months after surgery for repeat testing. The semen analysis consisted of ejaculate volume, total sperm count, concentration, and motility, whereas the urine test reported postejaculatory voided urine for spermatozoa. Postoperatively, patients were called by the principle investigator who conducted an interview based on a standardized questionnaire (completed for 36 patients). Patients were considered to have RE based on the questionnaire if they reported less or no ejaculate fluid. These results were compared with those from the laboratory testing to evaluate the value of the questionnaire in assessing RE. rhBMP-2 was used in 21 of the cases. The incidence of RE was compared in these patients versus those in whom rhBMP-2 was not used. Results. Four patients (9.8%) were diagnosed with RE based on the laboratory analysis, 2 of which resolved spontaneously. Based on the questionnaire, 15 (41.7%) patients reported having RE, including the 4 that were confirmed by laboratory testing. Of the 21 patients treated with rhBMP-2, 2 (9.5%) were diagnosed with RE, 1 of which resolved. Of the 20 patients treated without rhBMP-2, 2 (10.0%) had RE, 1 of which resolved. Conclusion. This study suggests that use of a questionnaire tends to overestimate the incidence of RE as compared with the quantitative semen and urine analysis. Contrary to recent studies using retrospective qualitative review, in this small group with quantitative analysis, use of rhBMP-2 was not related to an increased incidence of RE, with a rate of approximately 10% in both patients receiving, and those not receiving, rhBMP-2. Further study of a larger group using preoperative semen and urine analysis, postoperative standard questionnaire and postoperative semen analysis should be pursued to further investigate the occurrence of RE and to possibly assist in developing and validating a questionnaire for RE assessment.