Discussing reproductive health in spinal care, part II: fertility issues

Reproductive health is considered by the WHO to be one of the basic human rights, stating “it is the choice of each individual and couple, (…) to determine if they intend pregnancy, and if so, (…) the timing” [1]. Many diseases jeopardize reproductive health and as a result, fertility issues arise in several medical fields. Oncology care has been among the first to urge the need for discussing fertility, initially by running surveys among doctors and patients to expose the lack of discussion about fertility [2, 3], later by developing guidelines regarding the options for fertility preservation (FP) and the initiation of this topic in clinical practice, leading to a new field of “oncofertility” [4‐8]. In spinal care, patients are faced with potential hazards to fertility and reproduction as well [9]. For example, 44 % of all patients with cauda equina syndrome experiences sexual dysfunction (defined as any problem resulting in abnormal intercourse, ranging from, e.g., decreased penile or vaginal sensation to impotence or retrograde ejaculation), displaying that this group is potentially at high risk for in- or sub-fertility [10]. However, discussing reproductive health is far from first priority for spinal surgeons, which was shown in a recent survey among neurosurgeons, displaying only 26 % of neurosurgeons discuss sexual health with their patients [11]. The first article in English literature acknowledging decreased fertility in spinal cord patients was written in 1948 and discussed male patients with spinal cord injury (SCI) [12]. Apart from the more obvious reasons for sub- or infertility in men with SCI (e.g., erectile and ejaculatory dysfunction), semen quality was found to be greatly reduced. Three causes were proposed: lifestyle factors [e.g., elevated scrotal temperature, infrequency of ejaculation, recurrent urinary tract infections (UTI)], physiological factors secondary to SCI (e.g., hormonal environment) and alterations in seminal plasma [13, 14]. Currently, the latter is considered to be one of the main causes [15]. This is compatible with the findings of reduced sperm motility in the ejaculate of SCI men (and adequate number and morphology) versus normal sperm motility in their epididymis [14]. Several treatment options for men were introduced, including in vitro and in utero fertilization after ejaculation through vibratory stimulation or electro ejaculation [16]. Due to several case reports about quickly deteriorating semen quality after SCI, cryopreservation of sperm as soon as possible after injury was proposed by several authors [17‐19].

The focus on the male patient is striking when browsing through literature on SCI and fertility. Data on female fertility and SCI is scarce. Women with SCI however, do experience prolonged amenorrhoea after injury, which can take up to 9 months [20, 21]. To complicate matters, during this anovulatory phase, unpredictable ovulation might occur, which makes it even more important to properly consult patients on fertility, and contraception [20]. When menses has returned, fertility of SCI women is assumed to be similar to the general population. However, virtually no data on fertility rates in SCI women are available [22]. With regard to pregnancy and labour, several health risks are identified for SCI women [23, 24]. In a large study of 472 SCI women of which 14 % got pregnant after injury, complications like miscarriage, diabetes of pregnancy, prematurity and low birth weight (corrected for prematurity) were significantly more frequent after injury than before injury (75 % versus 50 %). In addition, women with SCI displayed higher rates of delivery by caesarian section (18 versus 8 %) [25]. Apart from consequences of the disease itself, surgical treatments might impose an additional risk on fertility, in particular for men. Anterior spinal surgery, especially the transperitoneal approach, may cause damage to the hypogastric plexus and therefore cause retrograde ejaculation [9]. In women, damage to the hypogastric plexus has the potential to reduce pain sensations of the uterus and seems not to affect fertility in that sense. One retrospective telephone study in 2007 showed no decreased fertility among women after anterior spinal surgery [26]. However, literature on fertility after spinal surgery in women is sparse and might therefore not be representative.

An important risk for deteriorating medullary cord function, and thereby possibly affecting fertility, is surgery on the spine for tumor, trauma or degenerative disease. In particular in those interventions in which the surgery is done because the medullary tract is already at risk by the disease, the chance to further damage the cord, is considerable.

In 2010, a guideline was released by the Consortium for Spinal Care Medicine stating that (options of) fertility should be discussed with all SCI patients [27]. In the same period, instruments on how to measure infertility in SCI patients were proposed [28]. Discussing fertility is now adapted as one of the essential elements of primary spinal care [29]. Despite the fact that the attention for reproductive health and fertility issues in spinal care patients is increasing, data about practice patterns for discussing fertility in spinal care is nonexistent.

This study was designed to explore knowledge, attitude and practice patterns of neurosurgeons about discussing fertility with spinal care patients.

Fertility issues are not commonly discussed in spinal care: 88 % of respondents (almost) never consults his or her patient on this topic. Cauda equina syndrome is an exception in which 70 % of neurosurgeons discuss fertility issues. A quarter of responding neurosurgeons stated that they believe that they have the responsibility to discuss fertility issues with spinal care patients. Discussion is initiated significantly more often in male than in female patients, regardless of doctors’ sex or age. This study confirms that counseling on fertility leads to more referrals to fertility specialists. Merely 4.5 % of the responding neurosurgeons has ever referred a patient to a fertility specialist.

This is the first study focussing on the knowledge, attitude and practice patterns of neurosurgeons regarding discussing fertility. Twelve percent of neurosurgeons discuss fertility with their patients; a fairly low percentage when compared to figures from oncology care surveys (60–95 %). We hypothesized that a reason for this difference is the fact that oncofertility is a longer standing field and therefore oncologists are more aware of the importance of discussing fertility in their patient population. The earlier introduction of aforementioned oncology guidelines seems to play an essential part in this. Oncology care surveys show a slight increase of discussing fertility from 60 % before implementation of the guidelines [2, 4, 5], to 67–95 % afterwards [31, 32]. Since this study is performed after introduction of the Consortium guideline, one can merely guess what the results would have been before implementation.

In order to attain a high response rate, this questionnaire was kept as compact as possible. This, together with other proven effective strategies to increase response rate, such as a monetary incentive and using mail-based questionnaires instead of web-based ones [33, 34], yielded a response rate of 62 %. This is extremely high compared to similar surveys with response rates ranging from 15 to 37 % (mean 28 %) [31, 32, 35‐38]. However, it is likely that clinicians who are not interested in the topic of this survey, have declined invitations more often. Therefore, actual rates of discussing fertility may even be lower among the general clinician population. An important remark in this context is that only 2 % of neurosurgeons who returned the questionnaire indicated a lack of interest.

More than half of the responding neurosurgeons wishes to enhance their knowledge about FP. This percentage is lower than found among oncologists, of whom 87 % wish to gain more info on FP [37]. Merely 8 % of respondents are confident about their knowledge, as opposed to half of oncologists in a similar review [36].

Referrals to fertility specialists are rarely made (4.5 %); and, naturally, significantly more often by doctors discussing fertility with their patients. This contrasts sharply to figures from oncology surveys in which 47 to 82 % refers to a fertility specialist. Oncology studies identified the following positive doctor predictors for referring: female sex, favorable attitude, gynecology or pediatrics as specialty, high frequency of discussing fertility and easy access to fertility specialist [31, 35, 38]. In the present survey, no positive predictors for referring, apart from high frequency of discussing fertility, were found.

Fertility is discussed more often with men than with women, and as well up to a higher age with male patients. The latter is easily explained by the restricted reproductive age of women compared to men. The fact that neurosurgeons discuss fertility more often with male patients is in concordance with the current focus of spinal literature on male fertility. However, like stated before, the hypothesis that fertility is not affected in SCI women is not supported by constructive research. The need for research on fertility in SCI women is essential, as was already urged by DeForge in 2005 [22]. Unfortunately, no new studies about this topic have emerged since.

Interestingly, doctors discuss fertility up to a higher age with female patients when they feel more confident about their own fertility knowledge (up to 55 years versus up to 36 years). This could be due to the fact that: (1) doctors with more knowledge, have this knowledge because they believe FP options should be easily accessible for everyone and thus also for women with more advanced age, or because (2) doctors with little knowledge, do not know that discussing reproductive health might still be useful for women with more advanced age (e.g., >36 years).

This study shows that fertility is not routinely discussed in spinal care, and that referrals to fertility specialists rarely take place. There is disagreement about the responsibility the neurosurgeon has in initiating discussion about fertility issues. According to current guidelines and consensus however, part of good practice includes discussing fertility issues in spinal care patients. Results of this study match our expectation that there is still a lot to improve in this area, especially when compared to oncology care. We propose integration of education on fertility in the neurosurgical training program to create more awareness and to enhance knowledge on FP options among neurosurgeons. As displayed in previous studies, creating referring facilities could positively influence the number of referrals. More education will enable neurosurgeons to provide adequate information and care to the patient. In a general light, more research regarding the barriers to initiate discussion about fertility in clinical practice and regarding fertility in women with spinal cord problems is needed.