Kevin McEleny
Kevin McEleny
Ph.D FRCS FRCS (Urol), Newcastle Hospitals

Erection and ejaculation: Getting sperm to the egg

Problems with erection

This is a key aspect of how people have children, but there are a few aspects that need to be mentioned:
How do men get erections? For a man to achieve an erection, three things need to occur all at the same time:

  • Men to be able to become sexually aroused
  • Their nervous system (the part of the brain that commands this to happen) has to be working
  • The blood supply that goes to the penis needs to be working normally

Also, because the brain plays a big part in what men find sexually arousing, there are many things that effect whether men can get and maintain an erection.

Not being able to achieve an erection: psychological and physical reasons

Age: Problems with erections become common as men get older but are also are more common in younger men with fertility issues. Older men are more likely to have a physical cause for their erection problems, (often called erectile dysfunction) but in younger men it is more likely to have a psychological cause

Hormones: Arousal can be affected by hormone problems, such as having a low testosterone, and this can make it harder for men to get an erection. As taking testosterone can severely effect sperm production it is extremely important that you don’t just start taking testosterone if you feel that your libido is low.

Nervous System Problems: Examples of nerve problems that can make it more difficult to get an erection include spinal cord injuries, having undergone pelvic surgery or having diabetes.

Blood Supply: Problems with the penis’s blood supply can be caused by smoking, hypertension (high blood pressure), high cholesterol, diabetes and certain medicines.

Stress: This is often because struggling to start a family is a stressful process. Anxiety about fertility can make it harder for men to get and maintain an erection. If this is the case then talking to a Fertility or Psychosexual Counsellor, a nurse or a urologist may be helpful.

Both sperm quality issues and erection problems are both very common male problems and it isn’t perhaps surprising that they can occur together in an unrelated way. It is important that if you are having erection problems that you discuss this with the fertility clinic staff or see your family doctor, as some potentially important physical problems can be ruled out by basic tests.

A man with erection and ejaculation problems

Getting tested

The risk factors that lead to problems with the blood supply of the penis are the same risk factors that can make it more likely that you could suffer a heart attack or stroke and so it is important that if you have problems with erections, that you discuss this with your family doctor, who will then perform certain tests to ensure that there are no physical reasons for problems with getting an erection. Your doctor may wish to check your blood pressure, cholesterol level and screen you for diabetes. It is recommended that a morning testosterone level be checked also.

Treating erection problems

In terms of lifestyle changes that can improve erection problems, it has been shown that regular exercise, losing weight if you are overweight, stopping smoking, and moderating your alcohol consumption can be helpful. You should discuss this with your GP or practice nurse though, particularly if you haven’t exercised for some time.

If there is a psychological reason for the erection problems, then your family doctor may refer you for psychosexual counselling and this can prove highly effective. Alternatively, your GP may prescribe medication to see if this improves your ability to get an erection, by increasing the blood supply to the penis. It is very important that you obtain the medication from a licensed chemist (pharmacist) and not through unofficial sources as it has been shown that some Internet-purchased medications can be contaminated with substances that are harmful. If the treatments don’t help, then other options are available.

Erection problems affect a high percentage of couples affected by fertility problems and to ensure that you get the problem assessed and treated, discuss it with a doctor so that important health issues can be checked out and you can get back to having a normal sexual relationship with your partner.

Problems with ejaculating

This is commonly seen in fertility clinics. Sometimes the problem can be that the man does not reach orgasm. Usually, this has a psychosexual cause and can be treated by counselling. Sometimes, it can be caused by a hormonal problem or by medications taken for other health reasons. 

Good health and exercise can prevent erection and ejaculation problems

If a man is able to achieve orgasm, but doesn’t ejaculate, this can be due to either the semen passing back up into the bladder (retrograde ejaculation); or due to no movement of semen through the male genital tract (anejaculation).

  • Retrograde ejaculation can be caused by nerve problems or surgery to the prostate gland/bladder neck.
  • Anejaculation can be caused by nerve problems or possibly certain medications.
Working closely with a specialist can help with these issues.
 

Testing in the Lab

If a man is able to achieve orgasm, but doesn’t produce any fluid, the fertility clinic will ask him to come in for a specialized semen test. In this test, he’ll be asked to produce a sample by masturbation and then a urine sample after that. The post-orgasm urine is examined under a microscope in the laboratory to see if sperms are present (normally they are not seen). If a man has retrograde ejaculation and significant numbers of sperms are present in the post-orgasm urine, then it may be possible to collect the sperm and store it for fertility treatment. In this situation the lab may also ask the man to take some medication prior to a further seen test to try and temporarily correct the retrograde ejaculation, to see if he’s able to ejaculate normally for the test. You can read more about different test here.

If no sperm is seen in the post-orgasm urine, then the diagnosis is anejaculation. Sometimes, this can be overcome by using special techniques for sperm recovery. If good quality sperm is present in the post-orgasm urine, then a pregnancy can be attempted in the partner by using intrauterine insemination (IUI), where the sperm are placed directly into the partner’s uterus during ovulation.

Sometimes the clinic will suggest other techniques to try and get men who are having problems to ejaculate. These include penile vibratory stimulation or electro-ejaculation which works best in men who have an intact ejaculation reflex i.e. the nerves that connect the male genital tract to the spinal cord are intact. If these ‘peripheral’ nerves are damaged because of say previous pelvic surgery, a pelvic fracture or due to diabetes, then surgical sperm retrieval may be necessary to recover sperm for fertility treatment with assisted reproductive technology (in-vitro fertilization and intracytoplastic sperm injection). These techniques are described in more detail elsewhere.​

Unless the ejaculation problem has a psychological basis or is caused by medication or a hormonal problem, it isn’t usually reversible. However, certain hormone issues need to be investigated and the fertility clinic or your family doctor should check that your levels of testosterone and other hormones, (prolactin and thyroid hormone) are normal. It is also important to check men with ejaculation problems for diabetes.

It can be very stressful to have fertility problems, and this can affect your sex life and your relationship. It is important that your partner and you discuss any problems that you are experiencing with your sex life and ask for help if you need it.