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Authors Wincze, JP
Review Date November 2015
Citation Fertility and Sterility 2015; doi:10.1016/j.fertnstert.2015.07.1155 (Epub ahead of print)
Men with no known medical factors may experience difficulty with conception due to erectile dysfunction (ED), premature ejaculation (PE), or delayed ejaculation (DE). The psychosocial components of these disorders may be overlooked during fertility care due to physician inexperience with non-medical factors and/or the patient’s reluctance to disclose details of his sexual functioning.
To provide a comprehensive discussion of the assessment and treatment of psychosocial contributions to the male sexual dysfunction that impacts on fertility.
The method is not described; the article appears to be a focused review of the literature.
The biopsychosocial model considers biological, psychological and social factors that contribute to one’s health. When a couple is attempting conception changes may occur in their usual approach to sexual activity. The goal of sexual activity may change from mutual satisfaction to conception only, activity may become scheduled in line with ovulation, and there may be pressure to conceive as soon as possible; these factors may adversely affect the sexual functioning and experience of both men and women.
ED is clinically defined as the inability to acquire and maintain an erection sufficient for penetrative sexual activity for a minimum duration of 6 months on at least 75% of occasions. It must also cause significant stress for the individual; this is more likely in younger men.
The most prevalent sexual dysfunction experienced by men, ED is estimated to affect 10% of men aged 35 years or younger and 50% of men aged over 60 years.
Biological factors, psychosocial factors, or a combination of both may contribute to ED. Younger men experiencing ED when attempting to conceive are more likely to be experiencing performance anxiety rather than related medical factors. In this situational ED, men typically experience ED with their partner but not during private masturbation.
The quality of the couple’s relationship and the behaviour of the partner is often overlooked in ED treatment. Some partners may feel ED is a reflection of their man’s feelings for them or the intensity of their desire to conceive may indirectly place pressure on their partner. Couples focused on conception may also overlook the importance of creating a stimulating environment for sexual activity to occur.
Individual, partner/relationship and environmental factors need to be considered. Where ED is strongly associated with pressure to conceive, treatment of performance anxiety is the most likely option to manage ED. Sensate focus is a procedure designed to help men focus on the sensations and process of sex rather than on penis activity and the outcome of sex. Couples are educated to remove blame, increase sexual communication, and to explore sexual activity other than penis-vaginal intercourse until performance anxiety has decreased.
PE is defined as a condition in which a man consistently ejaculates within approximately 1 minute of vaginal penetration and before the man wishes it to occur.
Prevalence rates of PE vary greatly in the literature, most likely due to varying definitions and measurement tools. Conservative estimates suggest 1-3% of men experience PE.
Limited potential biological factors have been identified (e.g. disturbances in serotonergic neurotransmission, different cortical evoked potential) and there have been many psychological factors explored but none have been validated with quality research. It’s likely that worry over PE can lead to performance anxiety and subsequent ED.
Couples need accurate and normative information about PE, and should be encouraged to adopt a flexible behavioural approach to sexual relations. Sex needs to be positioned as a pleasurable activity no matter how quickly the man ejaculates, and that the female’s orgasm can precede or follow penis-vaginal intercourse.
DE is the persistent difficulty or inability to achieve ejaculation in spite of sufficient stimulation; it can be present in both partnered and solo sexual activity. In couples attempting conception, surgical sperm harvesting may be necessary in cases where the male partner cannot ejaculate under any circumstances.
DE is thought to be less prevalent then ED or PE as a presenting problem. Estimates are difficult to obtain due inconsistent definitions and research approaches but it is generally agreed to occur in <1%-3% of the male population.
Many biological (e.g. certain pharmacologic agents and diseases) and psychological factors (e.g. performance anxiety, idiosyncratic masturbatory styles) have been identified as potential contributors to DE.
The management of DE is similar to that of ED and PE: providing accurate information and removing blame, and the use of senate focus to reduce performance anxiety. If idiosyncratic masturbatory practices are contributing to DE, masturbation retraining to a style more resembling the sensations of penis-vaginal intercourse may be useful.
This article demonstrates the importance of considering psychosocial factors when providing care to men with sexual dysfunction who are in a couple where conception is being attempted. Patients are likely to benefit from the provision of accurate and reassuring information, addressing issues of performance anxiety, and suggestions about the importance of a sexually stimulating environment. When sexual problems predate the fertility issue and/or when there appear to be complex psychological or relationships issues, patients should be referred to a sex therapist.
Points to Note
- Men with no known medical factors may experience difficulty with conception due to erectile dysfunction (ED), premature ejaculation (PE), or delayed ejaculation (DE).
- There are multiple potential biological and psychosocial factors that contribute to ejaculatory dysfunction in men attempting conception with a partner.
- Patients are likely to benefit from the provision of accurate and reassuring information, addressing issues of performance anxiety, and suggestions about the importance of a sexually stimulating environment.
- This is a literature review conducted by a single author with a method not described; it is possible that the review is significantly biased by the single reviewer’s own perceptions and interests.
- The application of biopsychosocial theory in this article lacked sufficient consideration of social factors around heteronormative relationships in Western countries (e.g. the social construction of ‘masculinity’).