Erectile dysfunction (ED) is a relatively common problem in men being treated for fertility issues. Risk factors include higher rates of hypogonadism (low testosterone), which can affect sperm production as well as erectile function. The psychological stress of trying to coordinate intercourse with a woman’s ovulatory cycles can also contribute to a temporary problem with erections in men with fertility issues.
Other risk factors for ED include diabetes, medications (such as beta-blockers, diuretics, and antidepressants), obesity, tobacco use, excessive alcohol use, psychological factors (stress, anxiety, depression), prolonged bicycle riding, and heart disease.
Erectile Dysfunction Evaluation
A basic ED evaluation will generally start with a review of the degree of severity of the problem. This can be accomplished with simple questioning or with a more formal short questionnaire, such as the IIEF-5 (International Index of Erectile Function). Further evaluation typically includes a physical exam as well as a review of the man's medical history to look for any of the above mentioned risk factors. Hormone testing (e.g. free and total testosterone) is also often a part of an ED evaluation. More advanced testing exists such as penile doppler ultrasound and DICC (dynamic infusion cavernosometry) but these are infrequently used in routine clinical practice, and are usually reserved for men with more complex urologic problems.
Management of Erectile Dysfunction
The first step in managing ED should include an attempt to decrease or eliminate potentially reversible risk factors, such as cigarette smoking, excessive alcohol use, and prolonged bike riding. Tight blood sugar control can be beneficial in diabetic men, as can gradual weight loss in men with obesity. Stress, anxiety, and depression can be addressed with counseling and/or medications (such as antidepressants, anti-anxiety medications, etc.); however, these psychoactive medications can unfortunately have erectile (and ejaculatory) side effects as well.
Hypogonadism (Low Testosterone)
Low testosterone levels are a common cause of erectile dysfunction (as well as being a risk factor for abnormal semen parameters). Medications to increase endogenous testosterone production can improve erectile function in men with low testosterone, as well as increase the effectiveness of medications used to treat ED (see the links below for more information).
PDE-5 inhibitors are oral medications that can help to achieve or sustain an erection longer. Even young, otherwise healthy men often experience temporary erectile problems, especially under the stress of trying to conceive, and in such circumstances PDE-5 inhibitors can help. The use of these medications does not make a man dependent on them in the future for getting erections.
There are four types of PDE-5 inhibitors currently available:
1) Sildenafil (Viagra): 50 mg, 100 mg
2) Vardenafil (Levitra, Staxyn): 10 mg, 20 mg
3) Tadalafil (Cialis): 10mg, 20mg
4) Avanafil (Stendra): 50mg, 100mg, 200mg
I do not recommend going above the highest listed doses of these medications, though they can be split into lower dosage pills using a pill cutter. These medications should not be used in combination with each other.
None of these medications will give a man an erection by themselves. Rather, they work by increasing the ability to achieve and sustain an erection with normal sexual stimulation. All of these medications are going to work best if the man has plenty of sexual stimulation, is not rushed or stressed, is well rested, and is in a comfortable environment. There is also evidence that these medications may be more effective if testosterone levels are not lower than normal.
How PDE-5 inhibitors Work
Viagra, Levitra, and Staxyn work similarly, in that they are short-acting and achieve maximum blood concentration in about one hour. Therefore, these medications should be taken about an hour prior to anticipated sexual activity. Stendra has a faster time to maximum blood concentration (about fifteen to thirty minutes) and therefore should be taken about fifteen to thirty minutes prior to sexual activity. None of these medications should be taken more than once a day.
Cialis works a little differently in that it needs to be in your system for about an hour before it is effective, but then its blood levels stay elevated for twenty-four to thirty-six hours. (This is not the length of the erection, but rather the time frame for an enhanced ability to achieve and sustain an erection.) Cialis used in this manner should not be taken more than once every other day. Alternatively, Cialis is available in lower doses (2.5mg and 5mg) that can be used daily.
How to Use pde-5 inhibitors
It is best to start out with a lower dose of this type of medication and work up to the higher dose as needed. Sometimes multiple trials of a medication are needed before a medication is effective, as men get more comfortable with the medication and the stress of trying something new wears off. Some studies have suggested that a PDE-5 inhibitor should not be considered ineffective unless it has been tried on at least five or six separate occasions. Although none of the PDE-5 inhibitors has been shown to be more effective than any other, sometimes switching to another PDE-5 inhibitor may work if one type is not successful.
Side Effects of PDE-5 Inhibitors
Men who stop using PDE-5 inhibitors because of side effects is low, but occasionally bothersome side effects can occur. Sometimes switching to another PDE-5 inhibitor will decrease or eliminate the side effects.
Some of the more common potential side effects include:
2) Headache (pre-treatment with acetaminophen or ibuprofen may help)
3) Heartburn or acid reflux (consider pre-treatment with antacid medications if this is a problem)
4) Nasal congestion
5) Temporary blue/green color in vision, or other visual changes
6) Back discomfort (primarily seen with Cialis)
If you experience any severe side effects, stop taking the medication and seek immediate medical help.
Prolonged erections (priapism) that last more than three to four hours are rare with oral PDE-5 inhibitors, but in the event that this happens, the man should be seen in the emergency room as soon as possible. If not treated promptly, priapism can lead to penile damage and scar tissue formation due to a lack of blood flow to the area.
Nitrates: Dangerous to Use with PDE-5 Inhibitors
Nitrates are medications that relieve heart disease-related chest pain (angina) by increasing blood flow to the heart. Examples of nitrate medications include Dilatrate, Isordil, Nitro-Dur, Nitrolingual, Nitrostat, and ISMO. Nitrates can also be abused as illegal drugs, and are sometimes called “poppers” (amyl nitrate, butyl nitrite). When used together, PDE-5 inhibitors can have severe negative interactions with nitrates, and can dangerously drop blood pressure to the point of being life-threatening.
Never use PDE-5 inhibitors if you use nitrates. If you have a history of heart disease, chest pain, or nitrate use in the past, or if you need multiple medications to control blood pressure, always get clearance from your primary care doctor or cardiologist before using these medications.
Impact on Fertility
Some small studies have suggested that PDE-5 inhibitors may be detrimental to sperm quality. However, these findings have not been confirmed by larger controlled studies, and I currently do not think that there is much evidence of a significant negative impact on semen parameters. If a man is having trouble even getting his sperm into the female reproductive tract due to erection issues, then this is a much bigger problem than any borderline changes in his sperm quality.
Muse is the brand name for a small pellet, resembling a grain of rice, that is inserted into the tip of the penis. The medicine (alprostadil) is then absorbed through the urethra into the penis, where it directly increases blood flow, thereby improving erectile function.
Muse should be given for the first time in a doctor’s office to assess how a particular man responds to it. Prolonged erections are more common with Muse than with PDE-5 inhibitors, and any erection that lasts more than three to four hours should be promptly evaluated in the emergency room, for if it is left untreated, it can cause irreversible scarring of the penis. Muse is generally considered to be stronger than the PDE-5 inhibitors in the treatment of ED, but less strong than penile injections.
Biochemically active agents can be injected directly into the penis using a small needle and syringe. Single agents (such as alprostadil) can be injected, as well as combinations of injectable medications (such as Trimix). These medications increase penile blood flow and enhance erectile function. These are the strongest medications for the treatment of ED.
Penile injections should be given for the first time in a doctor’s office to assess how a particular man responds to this treatment. Again, prolonged erections (priapism) are more common with injections than with PDE-5 inhibitors, and any erection that lasts more than three to four hours should be promptly evaluated in the emergency room to avoid irreversible scarring of the penis.
Vacuum Erection Device
Mechanical vacuum erection devices (VEDs) pull blood into the penis, and then an obstructive band is placed around the base of the penis to hold the blood in to maintain an erection. Although these devices can be effective for erections, they are not often used in men of fertility age, as comfort of use and satisfaction rates can be less than ideal. Some men may also experience some blockage of sperm flow with ejaculation due to the compressive ring around the penis.
Couples Sex Therapy
Sometimes couples experience psychological or relationship-related issues that interfere with effectively completing sexual intercourse. This can be a long-standing problem, or it may have developed with the added stress of trying to conceive a child. In these circumstances, working with a well-trained sex therapist can help to both relieve stress and more effectively perform timed intercourse.
For guidance on finding a local sex therapist, consult the website of the American Association of Sexuality Educators, Counselors and Therapists, at www.aasect.org.