Erectile Dysfunction and Infertility

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Erectile Dysfunction (ED) affects some 3 million men between the ages of 40 to 70. It is so common that half the men in this age group have some problem achieving or maintaining an erection; in most men, in fact, the problem may occur occasionally.

Erectile difficulties may be much more common than appreciated as a factor in infertility. The stress and the impact on spontaneity of intercourse at a specific and prescribed time may place tremendous strain on both partners. There are now many options for treatment.

Erectile dysfunction has been defined as the inability to obtain or maintain an erection for satisfactory sexual activity. This term has now largely displaced “impotence,” which has a deeply negative connotation, suggesting a social or moral failure. Few, if any, ED patients have reason to feel this way about themselves. Instead, they should feel empowered to receive a wide range of treatment options which offer a great deal of promise for those suffering from the physical and emotional consequences associated with erectile dysfunction.

It is true that, in the past, most cases of ED were thought to be the result of psychogenic factors. Today the reverse is true: ED is understood to be more often an effect of the body, not the mind. Atherosclerosis, vascular disease, diabetes, smoking, spinal cord injuries, anti-hypertensive drugs and certain anti-depressants account for approximately 70% of ED cases. For 20% to 30% of men, erectile dysfunction has secondary psychogenic effect known as performance anxiety.    In fact depression, anxiety and stress can all play a role in infertility associated with ED.

Physicians need to explore all the psychological, social and economic factors that can affect patients such as family stresses, the stress of infertility investigations, timing of intercourse around ovulation, loss of spontaneity and communication problems. All these are possible causes of ED in couples seeking to deal with infertility. When sexual activity or sperm collection is centred on ovulation, essential for conception, this obviously causes additional stress. In addition, cigarette smoking, alcohol or drug use and obesity can all contribute to erectile dysfunction.

Physiology of erectile dysfunction

The erectile function in males is dependant on a complex process of physiological (vascular, nerves and anatomical) and psychological factors that result in the flow of blood into the flaccid (soft) penis, distending the blood vessels and spongy tissue in the penis with blood and resulting in an erection. This blood flow may be diminished by medical conditions such as high blood pressure, diabetes and hardening of the arteries, often as a result of high cholesterol and smoking.

Nerve damage or trauma caused by such conditions such as spinal cord injuries multiple sclerosis, stroke, prostate or colon surgery may block communication between the brain to the penis resulting in erectile problems.

Causes of erectile dysfunction

As we have seen above, there are many causes of erectile dysfunction, some of which
may overlap.

Lifestyle: Smoking, alcohol, stress, obesity and anxiety may all contribute to ED.

Medications: Anti-depressants, hypertention (high-blood-pressure) treatments, certain diuretics (water pills), diabetic treatments and anti-cancer treatments, as well as some over-the-counter treatments.

Medical Causes: Diabetes, hypertension, high cholesterol, heart disease, spinal cord injuries, multiple sclerosis, prostatic or colon cancer, and depression are all medical causes.

Anxiety about erectile difficulties can aggravate the condition, resulting in a vicious circle with loss of libido under pressure to perform, particularly in situations where questions of infertility are involved. Communication is essential between both partners, as well as between the partners and their doctor and other caregivers. Often the man blames himself for any difficulties, putting pressure on himself and his performance – pressure that inevitably increases stress and anxiety, which further affects perfor-mance. Another response to this sort of pressure is denial or avoidance, which certainly will not help correct the situation.

Many men can be so overwhelmed by erectile difficulties that they become distanced from their partners. Frustrated and fearful, they avoid sexual contact. Their partner, in turn, may feel rejected unloved and unattractive, placing the relationship under even more stress. Many may deliberately remain silent, in order not to place additional pressure on their partner, even though talking about the issue may reduce the anxiety and stress associated with ED. Often, in fact, once the stress of infertility treatments are complete many men may regain their normal erectile function.

From the patient’s point of view, if you are experiencing erectile dysfunction, there are three simple steps to take:

Second, discuss the problem with your partner, as openly as you can. (Doctors have found that involving both partners is very useful in evaluating the optimum route to take.)

From the doctor’s point of view, the first step is rule out any medical causes, such as diabetes or high blood pressure. The next thing your doctor will do is recommend appropriate healthy life style changes. Reducing or (better still) quitting smoking, reducing alcohol excess, cutting back consumption of high-fat foods can all help reduce the risk of erectile difficulties. Finally, the physician may recommend a specific treatment or therapy.

There are currently three oral preparations available in Canada for the treatment of ED. Sexual stimulation is required for all the oral preparations and the use of any products with nitro is an absolute contra-indication, e.g. the Nitro sublingual tablet or patch or puffer used in cases of angina. The side-effect profile does not differ much between these treatments, with headaches, flushing and indigestion occurring in less than 10%.

1.   Viagra. This was the first preparation introduced, and is very effective, working in about one hour after ingestion. It should not be used more than once daily.

2.   Cialis. Sometimes known as “the weekender,” this product has the advantage of continuing to act over a period of 36 hours. It is not affected by food or moderate alcohol intake and coitus can occur any time within 36 hours, with somewhat less stress on the partner.

3.   Levetra. This is the newest preparation available. It works within 30 minutes, and lasts 4 to 6 hours. It is not affected by food or alcohol.

This method requires training and employs a vacuum constricting device, which consists of a vacuum pump, a closed plastic cylinder and a constriction ring. Placing the penis in the cylinder and pumping air out produces a vacuum, which draws blood into the erectile tissues. This results in an erection that is maintained as long as the constriction band remains at the base of the Penis. 

In this therapy involves injecting a drug through a fine needle into the side of the penis prior to attempting intercourse. Effects may last up 4 hours. Priapism (prolonged erection) is a side effect, which can usually be managed by taking smaller doses. Another disadvantage is lack of spontaneity, as the treatment requires planning and both partners must be trained to administer it.

Transurethral therapy involves inserting medication via a suppository with a special delivery system directly into the urethra of the penis. This requires training and direct stimulation of the penis.

The procedure involves inserting surgically implants of either semi-rigid malleable prosthesis or an inflatable (hydraulic) devices left permanently in place. This is an unlikely procedure for infertility patients, and is used only when all other methods fail.

When there is undue pressure on the couple for timely intercourse around ovulation, pre-freezing a sperm sample may relieve some of the stress associated with this timed and prescribed intercourse. The sample may be used as husband insemination (AIH) at the optimum time in the woman’s cycle.

Counselling, psychotherapy or behavioural therapy may be helpful for some patients in whom there is no physical cause, and may be useful in combination with or independently of medical treatment.

About the author: Dr. Norman Barwin is the immediate Past President of IAAC. He is the Director of the Broadview Infertility/PMS and Midlife Centre where he established the Andropause Clinic. He has been involved in a number of clinical studies on erectile dysfunction including a multi-centre study on Viagra. He teaches the Human Sexuality Course at the University of Ottawa.