Wednesday, September 28, 2011

Doctor, why can't I ejaculate ?

Many men ( and gynecologists as well !) confuse erectile dysfunction and ejaculatory problems. Dr Rupin Shah is the male infertility specialist ( andrologist) at our clinic. This excellent article dispels a lot of myths about this common problem, which is commonly misunderstood and improperly treated.

Anejaculation is the inability to ejaculate semen despite stimulation of the penis by intercourse or masturbation. It can be very distressing to a couple trying for a child - especially when it's not diagnosed properly. Most gynecologists are not comfortable dealing with the infertile man and will often just refer him to a urologist or andrologist. Please remember that this is a very real problem - it's NOT " all in your head " !

Since it's not a common problem, and is often confused with erectile dysfunction, let me describe this is in more detail. The man has normal libidio; gets aroused; gets an erection; and gets an orgasm, but no semen spurts out from the erect penis. After the orgasm, he loses the erection.

Anejaculation is a diagnosis which is best made by the patient himself. However, it's often difficult for the patient to explain what's happening to the doctor, hence this creates a lot of confusion. Please go step by step.

Do you have normal sexual desire ?
Do you get a good erection ?
Do you feel an orgasm ?
Do you lose the erection after your orgasm ?

It can be especially difficult for men who have never experienced an orgasm to describe their problem accurately.

It's easy to confuse some conditions with anejaculation. The commonest is called retrograde ejaculation. In this case, the semen goes backwards into the urinary bladder, rather than forward through the erect penis. In this case, the post orgasm urine is cloudy and turbid; and if this is sent to the lab for examination, the doctor will find sperm in the urine.

Men with a very low volume ejaculate ( for example, those with an absent vas deferens) will also have difficulty in making the right diagnosis. Though they do ejaculate semen, the volume is so small that they sometimes feel that they do not have any ejaculate at all !

What causes anejaculation?

Anejaculation may be situational or total.

(a) Situational anejaculation - in this condition the man is able to ejaculate in some situations but not in others. Typically, situational anejaculation is stress-induced and occurs selectively in the infertility clinic or at the time of ovulation or egg pick-up during an IVF (In Vitro Fertilization) cycle. Thus, a man who is able to ejaculate at home may be unable to do so in the clinic because he is self conscious and anxious. Similarly, some men become tense when they know they have to give a semen sample and hence usually fail "on demand” even though they are able to ejaculate on other occasions. Another common type of situational anejaculation when a man can ejaculate during intercourse but is unable to collect a sample by masturbation because he is not accustomed to do so.

(b) Total anejaculation – in this condition the man is never able to ejaculate semen consciously, either during intercourse or by masturbation, at home or in the clinic. Total anejaculation is further divided into anorgasmic anejaculation and orgasmic anejaculation.

Anorgasmic Anejaculation - these men never reach orgasm in the waking state (either by masturbation or by intercourse), and hence do not ejaculate. However, nocturnal emissions are usually present. There is no physical defect. This failure to reach orgasm is sometimes due to psychological inhibitions. Alternatively, some men need a high amount of stimulation before they reach orgasm and do not get this stimulation during intercourse or masturbation.

Orgasmic Anejaculation - these men reach and experience orgasm but they do not ejaculate semen, either because there is failure of emission of semen (due to a block in the tubes or damage to the nerves) or because there is retrograde ejaculation (flow of semen back into the bladder due to weakness of the bladder neck).

How is anejaculation treated ?

Situational anejaculation can often be prevented or treated by simple measures. The semen collection room in an infertility clinic should be in a quiet, discreet location and there should not be a queue of men waiting to use it! If you find the clinic environment is unfavorable discuss it with the doctor and ask if you can bring the semen sample from home (if you stay close by) or from a nearby hotel room.

What to do if you cannot give a semen sample

Sometimes Viagra helps. Viagra by itself does not facilitate ejaculation. However, if you are having difficulty getting an erection, Viagra could help you with that, thus making it easier to masturbate. If you anticipate having difficulty giving a semen sample (based on past experience) on the day of egg pick-up you could request your doctor to collect and freeze your semen beforehand on a day when you are relaxed. In fact, some centres routinely freeze a semen sample from all couples undergoing IVF (In Vitro Fertilization) since unexpected failure to collect semen, due to the stress of IVF (In Vitro Fertilization), is quite common.

If you have difficulty masturbating, but can ejaculate during intercourse, do not be disturbed. Many men are unable to masturbate. Discuss this with your doctor and arrange to collect the semen at home by coitus interruptus. This means having intercourse till the moment when ejaculation is about to happen. Withdraw the penis at that moment and catch the semen in the collection beaker. If that does not work, you can request your doctor for a non-spermicidal non-toxic condom made of silastic. You can buy one from our Online
! This would allow you to have full intercourse and ejaculate into the condom from which the semen is then collected. NOTE: Condoms that are routinely available are coated with a chemical that kills sperm and should not be used for collecting semen.

Finally, some men with situational anejaculation are just not able to collect a sample when required. Discuss this with your doctor beforehand. He will teach you how to use a vibrator to stimulate the penis and collect a sample. A couple of practice sessions should be done before the actual day of collection.

Anorgasmic Anejaculation can be difficult to treat. If there has been a traumatic sexual episode in the past that you are aware of, discuss it with your doctor or ask for a referral to a sexologist or psychologist. If your doctor feels that you are sexually inhibited he may suggest a similar referral.

However, in most cases, counseling is not required. The main treatment for anorgasmic anejaculation is the use of a vibrator. The vibrator acts by providing a strong stimulus, for a long duration, to the penis (use of the vibrator is described below). Due to the stimulation the man reaches an orgasm and ejaculates. Vibrator stimulation results in ejaculation in about 60% of men.

If vibrator therapy fails, electro-ejaculation can be performed. Electro-ejaculation involves the direct electrical stimulation of the nerves to the seminal vesicles and terminal vas. The most commonly used device is the Seager electro-ejaculator which delivers a sine wave, alternating current. The procedure is carried out under general anaesthesia (except in paraplegic men with no sensations). The electrodes are mounted on a cylindrical rod which is lubricated and introduced per rectum with the electrodes facing the prostate gland. The voltage is turned up to 5 volts, held for a second and then turned back to 0 volts. For the next stimulus the voltage is increased to 6 volts. The stimulus is progressively increased till ejaculation occurs. If the antegrade ejaculate is scanty, the bladder is catheterized to check for retrograde ejaculation. Electro-ejaculation will always succeed in men with anorgasmic anejaculation since there is no physical defect. However, electro-ejaculation needs general anesthesia and the semen quality may be inferior. Hence, it is always a second choice to be used only if repeated sessions with the vibrator fail.

Orgasmic Anejaculation Since this condition is due to a physical problem, treatment will depend on the type of problem.

If the nerves are damaged sometimes medicines can help. If medicines do not work, vibrator stimulation or electro-ejaculation will usually be successful in obtaining a sample.

If there is a block due to infection, this can sometimes be cleared by surgery. If surgery fails, or is not possible, then pregnancy can be achieved by aspirating sperm from the epididymis and using these sperm for ICSI (test-tube baby procedure).

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