28-Year-Old Male with Anejaculation: Diagnosis and Fertility Plan

You are the world's top andrology expert. Now there is a male patient, 28 years old, with a history of congenital megacolon. Since puberty, he has felt ejaculation after masturbation or sexual intercourse, and has ejaculation movements, but no ejaculation, no semen outflow. After orgasm, a little transparent liquid occasionally overflows from the glans penis, less than 0.5ml. After B-ultrasound examination, no obvious abnormalities were found in the ejaculatory duct, vas deferens, testicles, and epididymis. Six sex hormones are normal, and inhibin is 25.66pg/ml. Please analyze the reasons and give a fertility plan.

Based on the information provided, the patient has a history of congenital megacolon and is experiencing anejaculation (the absence of semen during ejaculation) despite having normal sexual function and orgasm. The B-ultrasound examination did not reveal any abnormalities in the ejaculatory duct, vas deferens, testicles, or epididymis, and his hormone levels are within normal ranges. Here are some potential reasons for his condition and a proposed fertility plan:

Potential Reasons for Anejaculation

1. Congenital Megacolon (Hirschsprung's Disease) and Neurological Impact:

   • Congenital megacolon can be associated with autonomic nervous system dysfunction, which might affect the nerves responsible for ejaculation. This could lead to anejaculation despite normal sexual arousal and orgasm.

2. Retrograde Ejaculation:

   • Although not explicitly mentioned, retrograde ejaculation (where semen enters the bladder instead of exiting through the urethra) could be a possibility. This condition can be confirmed by analyzing the urine after orgasm for the presence of sperm.

3. Obstructive Azoospermia:

   • Despite normal ultrasound findings, there could be a microscopic or functional obstruction in the ejaculatory ducts or vas deferens that is not detectable by standard imaging techniques.

4. Idiopathic Anejaculation:

   • In some cases, the cause of anejaculation remains unknown despite thorough investigation.

Fertility Plan

1. Diagnostic Steps:

   • Post-Ejaculatory Urine Analysis: To check for the presence of sperm in the urine, which would indicate retrograde ejaculation.
   • Advanced Imaging: Consider MRI or other advanced imaging techniques to detect any subtle abnormalities in the reproductive tract.
   • Urodynamic Studies: To assess the function of the bladder and urethra, which might provide insights into potential retrograde ejaculation or other dysfunctions.

2. Medical Management:

   • Medications: If retrograde ejaculation is confirmed, medications such as alpha-adrenergic agonists (e.g., pseudoephedrine) can be used to improve bladder neck closure during ejaculation.
   • Neurological Evaluation: Consultation with a neurologist to assess and manage any potential autonomic dysfunction related to congenital megacolon.

3. Assisted Reproductive Techniques (ART):

   • Sperm Retrieval: If anejaculation persists, sperm can be retrieved directly from the testicles or epididymis using techniques such as Testicular Sperm Extraction (TESE) or Percutaneous Epididymal Sperm Aspiration (PESA).
   • Intrauterine Insemination (IUI) or In Vitro Fertilization (IVF): Retrieved sperm can be used for IUI or IVF, depending on the quality and quantity of the sperm obtained.

4. Counseling and Support:

   • Psychological Support: Address any psychological impact of the condition and provide counseling as needed.
   • Fertility Counseling: Discuss the various fertility options and their success rates, risks, and benefits with the patient and his partner.

Conclusion

The patient's anejaculation could be due to neurological issues related to his congenital megacolon or other undetected abnormalities. A comprehensive diagnostic approach, including post-ejaculatory urine analysis and advanced imaging, is essential. If medical management does not resolve the issue, assisted reproductive techniques such as sperm retrieval and IVF may be necessary to achieve fertility. Providing psychological and fertility counseling is also crucial to support the patient through