How often are male factors involved?
About one-third of cases of infertility are caused by male factors alone. A combination of male and female factors causes about one-third of cases.

What causes male infertility?
The most common cause of male infertility is a varicocele (say: "var-ee-koh-seal"). This is when the veins in the scrotum (the skin "sack" that hangs beneath the penis) are dilated (enlarged) on 1 or both sides. This heats the inside of the scrotum and may affect sperm production. A blockage in a man's reproductive system may cause male infertility. Some medicines can also cause infertility.

Sometimes the cause of male infertility cannot be identified. In these cases, there may be an underlying genetic problem.

When should I see a doctor?
Usually, a couple should wait to see a doctor until after they've tried to get pregnant for a year. However, it's OK to see a doctor sooner, especially if the woman's age may be a factor.

Should men be checked for infertility?
Yes. It's important to identify and treat any correctable problems. In some men, a doctor's exam may find an underlying medical problem that is causing the infertility.

How is infertility evaluated?
Your doctor will obtain your medical history, examine you and test your semen at least twice. A semen analysis can tell your doctor about your sperm count and sperm quality. These are important parts of fertility. More testing may be needed, depending on the results of this first evaluation.

Is male infertility treatable?
More than one-half of cases of male infertility can be corrected. Treatment may help a couple get pregnant through normal sexual intercourse. Even if you can't get pregnant in this way, you may not need expensive or invasive treatments to get pregnant. If the man needs surgery to correct the problem that is causing his infertility, it can be an outpatient procedure. This means he doesn't have to stay in the hospital overnight.

ED is not only a common problem, particularly among older men, but also it is undertreated. A few years ago, the Massachusetts Male Aging Study of middle-aged and older men showed 35 percent of men ages 40 to 70 years had complete ED, which was strongly related to age, health status and emotional function. According to the American Medical Association (AMA), about 20 million American men, mostly older than 65, are affected. It is difficult to calculate an exact number because less than 10 percent seek treatment.

What causes ED?
Since an erection requires a precise sequence of events, ED can occur when any of the events is disrupted. The sequence includes nerve impulses in the brain, spinal column, and area around the penis, and response in muscles, fibrous tissues, veins, and arteries in and near the corpora cavernosa.

Damage to nerves, arteries, smooth muscles, and fibrous tissues, often as a result of disease, is the most common cause of ED. Diseases--such as diabetes, kidney disease, chronic alcoholism, multiple sclerosis, atherosclerosis, vascular disease, and neurologic disease--account for about 70 percent of ED cases. Between 35 and 50 percent of men with diabetes experience ED.

Also, surgery (especially radical prostate surgery for cancer) can injure nerves and arteries near the penis, causing ED. Injury to the penis, spinal cord, prostate, bladder, and pelvis can lead to ED by harming nerves, smooth muscles, arteries, and fibrous tissues of the corpora cavernosa.

In addition, many common medicines--blood pressure drugs, antihistamines, antidepressants, tranquilizers, appetite suppressants, and cimetidine (an ulcer drug)--can produce ED as a side effect.

Experts believe that psychological factors such as stress, anxiety, guilt, depression, low self-esteem, and fear of sexual failure cause 10 to 20 percent of ED cases. Men with a physical cause for ED frequently experience the same sort of psychological reactions (stress, anxiety, guilt, depression).

Other possible causes are smoking, which affects blood flow in veins and arteries, and hormonal abnormalities, such as not enough testosterone.

How is ED diagnosed?
Patient History: Medical and sexual histories help define the degree and nature of ED. A medical history can disclose diseases that lead to ED, while a simple recounting of sexual activity might distinguish between problems with sexual desire, erection, ejaculation, or orgasm.

Using certain prescription or illegal drugs can suggest a chemical cause, since drug effects account for 25 percent of ED cases. Cutting back on or substituting certain medications can often alleviate the problem.

Physical Examination: A physical examination can give clues to systemic problems. For example, if the penis is not sensitive to touching, a problem in the nervous system may be the cause. Abnormal secondary sex characteristics, such as hair pattern, can point to hormonal problems, which would mean that the endocrine system is involved. The examiner might discover a circulatory problem by observing decreased pulses in the wrist or ankles. And unusual characteristics of the penis itself could suggest the source of the problem--for example, a penis that bends or curves when erect could be the result of Peyronie's disease.

Laboratory Tests: Several laboratory tests can help diagnose ED. Tests for systemic diseases include blood counts, urinalysis, lipid profile, and measurements of creatinine and liver enzymes. Measuring the amount of testosterone in the blood can yield information about problems with the endocrine system and is indicated especially in patients with decreased sexual desire.

Other Tests: Monitoring erections that occur during sleep (nocturnal penile tumescence) can help rule out certain psychological causes of ED. Healthy men have involuntary erections during sleep. If nocturnal erections do not occur, then ED is likely to have a physical rather than psychological cause. Tests of nocturnal erections are not completely reliable, however. Scientists have not standardized such tests and have not determined when they should be applied for best results.

Psychosocial Examination: A psychosocial examination, using an interview and a questionnaire, reveals psychological factors. A man's sexual partner may also be interviewed to determine expectations and perceptions during sexual intercourse.

How is ED treated?
Most physicians suggest that treatments proceed from least to most invasive. Cutting back on any drugs with harmful side effects is considered first. For example, drugs for high blood pressure work in different ways. If you think a particular drug is causing problems with erection, tell your doctor and ask whether you can try a different class of blood pressure medicine.

Psychotherapy and behavior modifications in selected patients are considered next if indicated, followed by oral or locally injected drugs, vacuum devices, and surgically implanted devices. In rare cases, surgery involving veins or arteries may be considered.

Psychotherapy: Experts often treat psychologically based ED using techniques that decrease the anxiety associated with intercourse. The patient's partner can help with the techniques, which include gradual development of intimacy and stimulation. Such techniques also can help relieve anxiety when ED from physical causes is being treated.

Drug Therapy: Drugs for treating ED can be taken orally, injected directly into the penis, or inserted into the urethra at the tip of the penis. In March 1998, the Food and Drug Administration approved Viagra, the first pill to treat ED. Taken an hour before sexual activity, Viagra works by enhancing the effects of nitric oxide, a chemical that relaxes smooth muscles in the penis during sexual stimulation and allows increased blood flow.

While Viagra improves the response to sexual stimulation, it does not trigger an automatic erection as injections do. The recommended dose is 50 mg, and the physician may adjust this dose to 100 mg or 25 mg, depending on the patient. The drug should not be used more than once a day. Men who take nitrate-based drugs such as nitroglycerin for heart problems should not use Viagra because the combination can cause a sudden drop in blood pressure.

Additional oral medicines may soon be available to treat ED. Vardenafil and Cialis are being tested for safety and effectiveness. Both of these drugs work like Viagra by increasing blood flow to the penis. A third drug being tested, Uprima, works on the brain and nervous system to trigger an erection.

Oral testosterone can reduce ED in some men with low levels of natural testosterone, but it is often ineffective and may cause liver damage. Patients also have claimed that other oral drugs--including yohimbine hydrochloride, dopamine and serotonin agonists, and trazodone--are effective, but the results of scientific studies to substantiate these claims have been inconsistent. Improvements observed following use of these drugs may be examples of the placebo effect, that is, a change that results simply from the patient's believing that an improvement will occur.

Many men achieve stronger erections by injecting drugs into the penis, causing it to become engorged with blood. Drugs such as papaverine hydrochloride, phentolamine, and alprostadil (marketed as Caverject) widen blood vessels. These drugs may create unwanted side effects, however, including persistent erection (known as priapism) and scarring. Nitroglycerin, a muscle relaxant, can sometimes enhance erection when rubbed on the penis.

A system for inserting a pellet of alprostadil into the urethra is marketed as Muse. The system uses a prefilled applicator to deliver the pellet about an inch deep into the urethra. An erection will begin within 8 to 10 minutes and may last 30 to 60 minutes. The most common side effects are aching in the penis, testicles, and area between the penis and rectum; warmth or burning sensation in the urethra; redness from increased blood flow to the penis; and minor urethral bleeding or spotting.

Research on drugs for treating ED is expanding rapidly. Patients should ask their doctor about the latest advances.

Vacuum Devices: Mechanical vacuum devices cause erection by creating a partial vacuum, which draws blood into the penis, engorging and expanding it. The devices have three components: a plastic cylinder, into which the penis is placed; a pump, which draws air out of the cylinder; and an elastic band, which is placed around the base of the penis to maintain the erection after the cylinder is removed and during intercourse by preventing blood from flowing back into the body.

One variation of the vacuum device involves a semirigid rubber sheath that is placed on the penis and remains there after erection is attained and during intercourse.

Surgery: Surgery usually has one of three goals:

     •  to implant a device that can cause the penis to become erect
     •  to reconstruct arteries to increase flow of blood to the penis
     •  to block off veins that allow blood to leak from the penile tissues

Implanted devices, known as prostheses, can restore erection in many men with ED. Possible problems with implants include mechanical breakdown and infection, although mechanical problems have diminished in recent years because of technological advances.

Malleable implants usually consist of paired rods, which are inserted surgically into the corpora cavernosa. The user manually adjusts the position of the penis and, therefore, the rods. Adjustment does not affect the width or length of the penis.

Inflatable implants consist of paired cylinders, which are surgically inserted inside the penis and can be expanded using pressurized fluid. Tubes connect the cylinders to a fluid reservoir and a pump, which are also surgically implanted. The patient inflates the cylinders by pressing on the small pump, located under the skin in the scrotum. Inflatable implants can expand the length and width of the penis somewhat. They also leave the penis in a more natural state when not inflated.

Surgery to repair arteries can reduce ED caused by obstructions that block the flow of blood. The best candidates for such surgery are young men with discrete blockage of an artery because of an injury to the crotch or fracture of the pelvis. The procedure is less successful in older men with widespread blockage.

Surgery to veins that allow blood to leave the penis usually involves an opposite procedure--intentional blockage. Blocking off veins (ligation) can reduce the leakage of blood that diminishes the rigidity of the penis during erection. However, experts have raised questions about the long-term effectiveness of this procedure, and it is rarely done.

Hope through research
Advances in suppositories, injectable medications, implants, and vacuum devices have expanded the options for men seeking treatment for ED. These advances have also helped increase the number of men seeking treatment. Gene therapy for ED is now being tested in several centers and may offer a long-lasting therapeutic approach for ED.

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) sponsors programs aimed at understanding the causes of erectile dysfunction and finding treatments to reverse its effects. NIDDK's Division of Kidney, Urologic, and Hematologic Diseases supported the researchers who developed Viagra and continue to support basic research into the mechanisms of erection and the diseases that impair normal function at the cellular and molecular levels, including diabetes and high blood pressure.

Points to remember
      •  Erectile dysfunction (ED) is the repeated inability to get or keep an erection firm
        enough for sexual intercourse.
     •  ED affects 15 to 30 million American men.
     •  ED usually has a physical cause.
     •  ED is treatable at all ages.
     •  Treatments include psychotherapy, drug therapy, vacuum devices, and surgery.

In the past, premature ejaculation was defined by the percent of times the man ejaculates during intercourse before his partner does. There is, however, a major problem with defining a man's ejaculatory control in terms of his partner's orgasmic frequency during intercourse. It has been clearly demonstrated that the majority of women (perhaps around 65%) are unable to orgasm with the stimulation of intercourse alone... never could and probably never will. For most women the vagina is significantly less sensitive than the clitoris, which is not always stimulated in most coital positions. A fair number of the roughly 35% of women who can make it during intercourse do so by combining clitoral stimulation with what they are experiencing vaginally. It is fortunate that some positions that work best for the woman are the same in which a man might exercise better control of his ejaculatory process.

"What is natural?" In nature the purpose of sex is procreation, and this process is accomplished by the deposit of sperm deep in the vagina, independent of the time it takes to do so (or, for that matter, the partner's satisfaction). Although averages stated vary a bit from study to study, it would appear safe to say that the average healthy male under 30, with steady vaginal thrusting, will ejaculate in 1 to 3 minutes, not 15 minutes as most men would wish.

There are factors that influence how quickly a man will ejaculate. The younger the man, the more likely it is that he will ejaculate quicker. The more excited the man, the quicker he is likely to be, and related to this, the more novel and exciting the partner, the greater the tendency to orgasm rapidly. Also, the longer the time since his last ejaculation, the greater the loss of control. Furthermore, the more active and rapid the thrusting, the sooner he is likely to reach the point of ejaculatory inevitability - that point of no return. It also seems clear that the more worried or anxious the man, the shorter his fuse will be. In summary, the man at greatest risk of ejaculating quickly is the young man who is with a new partner after a long dry spell and is very excited, but very nervous, as he penetrates and thrusts steadily and rapidly.


Men have tried many things to slow themselves down. Makers of the desensitizing creams have made fortunes because men believe that if they numb the end of their penis they will last longer. However, most men are disappointed with these over-priced creams, as the ejaculatory reflex is much more complicated than just superficial nerve endings. Someone once said that our largest sex organ is not between our legs, but rather between our ears. There is a lot of complicated neurology between the end of a penis and the top of the man's brain! More recently, physicians have been prescribing medications that have been found to have ejaculatory retardation as a side effect, but as a behavioral therapist I have a problem with this. Even if such medication does work (and it often does not), it will "cure" nothing. The man can't take it for a lifetime, and in relying on the magic pill will never learn how to manage his ejaculatory process in a way to prolong the pleasure both he and his partner experience. Condoms might help (and should always be worn in the practice of safer sex), but in a long-term committed relationship, condoms may be a nuisance unless being worn for contraceptive purposes.


Unfortunately, much effort by well-intended sex therapists has been wasted, for many of my colleagues have not understood the dynamics of the natural ejaculatory response nor the important learning components of gaining better management of the process.

There is a series of step by step exercises "prescribed" by sex therapists called the start-stop method, but it is not simply starting and stopping that helps a man gain control. The man must focus in on his steady progression toward the inevitable, that point of no return. He must identify all the internal indicators that he is approaching that threshold where his body will automatically take over and propel him to orgasm. This requires relaxation and concentration. He cannot be thinking of his partner's response nor even looking at her body. He must stay within himself and feel his process unfolding. Then he must stop before reaching the point of ejaculatory inevitability. Typically the instructions are to start and stop four or five times before "letting go" and ejaculating. I always remind men to identify what that psychological/physical "letting go" really involves. The start-stop procedure works best with a committed and giving partner whom is willing to take the time to help. Typically the "homework" starts with manual stimulation with a dry hand.

Hypoactive sexual desire disorder: Men with this disorder have a persistent lack of sexual desire or appetite, absence of sexual fantasies and complete lack of interest in and avoidance of sexual contact with a partner. The National Institutes of Health estimates 15 million to 30 million American men do suffer from erectile dysfunction and need drugs to have sexual intercourse. It may be caused by boredom or unhappiness in a long-standing relationship or result from traumatic events in childhood or adolescence. Depression also may play a role. Possible physical causes include drug side effects and hormonal deficiencies. Sometimes, boosting abnormally low testosterone levels may help.

Male orgasmic disorders: Also called ejaculatory disorders, they include inhibited ejaculation (orgasm does not occur) and premature ejaculation (when ejaculation occurs before, during or soon after penetration and before the man desires). Inhibited orgasm is usually caused by a psychological disorder such as depression or anxiety, or use of substances like alcohol or drugs. The man's emotional state and feelings such as guilt, boredom or resentment also may play a role. The cause of premature ejaculation is unclear but is thought to result from a combination of psychological and physical factors. Both problems are typically treated with therapy that teaches the man and his partner techniques for either producing or slowing down orgasm. In some cases, premature ejaculation can be treated with small doses of an SSRI, an antidepressant such as Prozac®, Paxil® or Zoloft®, taken either daily, or one to two hours before a sexual encounter.

Peyronie's disease: Thought to affect about 1 percent of men usually between the ages of 40 and 60, Peyronie's disease is characterized by the formation of a hard, fibrous layer called plaque under the skin on one side of the penis. This disorder usually starts out as an inflammation, leading to a hardened scar that causes the penis to bend sharply when erect. If hardening occurs on both sides, indentations and shortening may result. The scarring or hardening can make erections painful and intercourse difficult or impossible. The bent or misshapen appearance of the penis can lead to emotional distress, which in turn worsens any sexual difficulties. Doctors are not sure what causes Peyronie's disease. But in many cases, the condition resolves itself. A physician will usually monitor the man closely for about a year, watching the plaque development and checking erectile function. Medications that might help to alleviate plaque buildup include topical vitamin A, collagenase ointment, B-complex vitamins or calcium channel blockers. If these treatments don't work and the condition doesn't go away on its own, surgery may be necessary. Surgeons have developed various techniques for removing the plaque without affecting penile function.

Dyspareunia: Men who experience dyspareunia, or pain during intercourse, usually have an underlying problem such as prostatitis (inflammation of the prostate gland) or some kind of nerve damage.

Erection begins with sensory or mental stimulation, or both. Impulses from the brain and local nerves cause the muscles of the corpora cavernosa to relax, allowing blood to flow in and fill the spaces. The blood creates pressure in the corpora cavernosa, making the penis expand. The tunica albuginea helps trap the blood in the corpora cavernosa, thereby sustaining erection. When muscles in the penis contract to stop the inflow of blood and open outflow channels, erection is reversed.

Men's bodies, including their penises, go through physical changes as they grow.
Some penises are straight, some point up, and some point down, some curve to the left, some curve to the left.
Some grow bigger, some don't. The size of a fellow's penis is probably genetically determined.

What is the prostate gland?
The prostate is a gland that lies just below a man's urinary bladder. It surrounds the urethra like a donut and is in front of the rectum. The urethra is the tube that carries urine out of the bladder, through the penis and out of the body. Your doctor may check your prostate by putting a finger into your rectum to feel the back of your prostate gland.

The prostate gland makes a fluid that provides nutrients for sperm. This fluid makes up most of the ejaculate fluid. We do not yet know all of the ways the prostate gland works.

What causes prostatitis?
Prostatitis is divided into categories based on cause. Two kinds of prostatitis, acute prostatitis and chronic bacterial prostatitis, are caused by infection of the prostate. Some kinds of prostatitis might be caused when the muscles of the pelvis or the bladder don't work correctly.

How is prostatitis treated?
The treatment is based on the cause. Your doctor may do a rectal exam and test urine samples to find out the cause.

An antibiotic is used to treat prostatitis that is caused by an infection. You might have to take antibiotics for several weeks or a few months. If prostatitis is severe, you might have to go to a hospital for treatment with fluids and antibiotics.

What if my prostatitis is not caused by infection?
Because we do not understand what causes prostatitis without infection, it can be hard to treat. Your doctor might try an antibiotic to treat a hidden infection. Other treatments are aimed at making you feel better. Nonsteroidal anti-inflammatory medicines, such as ibuprofen (two brand names: Advil, Motrin) or naproxen (one brand name: Aleve), and hot soaking baths may help you feel better. Some men get better by taking medicines that help the way the bladder or prostate gland work.

Can prostatitis be passed on during sex?
Sometimes prostatitis is caused by a sexually transmitted organism, such as chlamydia. Most cases are caused by infections that are not sexually transmitted. These infections can't be passed on to sexual partners.

Can prostatitis come back?
Men who have had prostatitis once are more likely to get it again. Antibiotics may not get into the prostate gland well. Small amounts of bacteria might "hide" in the prostate and not be killed by the antibiotic. Once you stop taking the antibiotic, the infection can get bad again. If this happens, you might have to take antibiotics for a long time to prevent another infection. Prostatitis that is not caused by infection is often chronic. If you have this kind of prostatitis, you might have to take medicine for a long time.

Should I have my prostate gland taken out if I have prostatitis?
Prostatitis can usually be treated with medicine. Most of the time, surgery is not needed.

Does prostatitis cause cancer?
Although prostatitis can cause you trouble, it does not cause cancer. There is a blood test some doctors use for prostate cancer. It is called the prostate-specific antigen (PSA) test. If you have prostatitis, your PSA level might go up. This does not mean you have cancer. Your doctor will treat your prostatitis and may check your PSA level again.