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Erectile Dysfunction

Erectile Dysfunction

Erectile Dysfunction (ED) is common and is defined as the inability to achieve or maintain an erection sufficient for satisfactory sexual performance. Erectile dysfunction is strongly age-related and affects as many as 30 million American men. While there is an estimated prevalence of all ages of about 10%, the prevalence rises to over 50% in men between 50 and 70 years of age. While ED is common, only a small percentage of men ever discuss this problem with a physician.

It’s important to listen to men with ED and make them feel comfortable with what can be a troubling symptom for them. ED may also occur with cardiovascular disease, neurological disorders, after pelvic surgery or trauma, with diabetes and as a consequence of certain medications used commonly. There are a number of treatments to treat ED including; hormone testing, non-invasive ultrasound measurement of blood flow, and trials of medicine and non-medicine treatments.

Here are some treatment options:

Changing Habits and Medications

Quitting smoking can be an important step in reducing the impact of impotence or eliminating it altogether. Small changes in prescription medication may also help improve erectile quality.

Hormone Medications

Irregular levels of sex hormones such as low levels of testosterone, excess prolactin, and excess estrogen cause some cases of ED. These conditions are usually treatable with excellent results.

Vacuum Devices

This treatment involves the use of an external vacuum device and one or more tension rings. The device works by inserting the penis into a plastic cylinder, which is then pumped to create a controlled vacuum. Once an adequate erection is produced, a tension band is slipped around the base of the penis to maintain the erection: the vacuum device is then removed. The erection-like state generally lasts long enough for a couple to have intercourse.

Injection Therapy

One of the newest forms of treatment involves the self-injection of medication into the side of the penis. The relatively painless injection produces erections of good quality for about 70-80 percent of patients. There are several injectable medications that, when used alone, help increase blood flow to the penis which promotes an erection.

Penile Prostheses

This treatment involves the surgical placement of a stationary or movable device into the two sides of the penis, allowing erections as often as desired. These implants come in two forms: an inflatable device and semi-rigid rods. This treatment is not recommended until other methods have been considered or tried first.

Surgical Treatment

This treatment is usually reserved for those patients whose blood flow has been blocked by an injury to the penis or pelvic area. Surgery is also used to correct ED caused by vascular blockages. The goal of this treatment is to correct a blockage of blood flow to the penis so that erections will occur naturally.

Oral Therapy

The mainstay of therapy for erectile dysfunction has consisted of very safe medications called PDE5 inhibitors. These medications include Viagra, Levitra, and Cialis. They are all similar but there are some important differences between them. They are typically quite effective and can be given at the initial visit as samples.

Professional Counseling

Because ED can result from a combination of psychological and physical factors, counseling can lessen anxiety, which in turn may reduce the impact and duration of the condition. This therapy is often used in combination with other treatments directed by a physician.

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Male Infertility

Male Infertility

When the word “infertility” is used most people think about female infertility. Infertility affects 15% of couples attempting pregnancy in the United States. In half of these cases, couples will have a male factor of infertility of about 25%.

Male infertility is due to low sperm count, blockages that prevent the delivery of sperm or abnormal sperm function. Illnesses, chronic health problems, injuries, lifestyle choices, and other factors can also be a factor in male infertility.


The main sign of male infertility is the inability to conceive a child. There may be no other obvious signs or symptoms. However, in some cases an underlying problem such as a hormonal imbalance, an inherited disorder or dilated veins around the testicle causes signs and symptoms.

Although most men with male infertility do not notice symptoms here are some signs and symptoms associated with male infertility:

  • Difficulty with ejaculation or small volumes of fluid ejaculated
  • Pain, swelling or a lump in the testicle area
  • Reduced sexual desire
  • Recurrent respiratory infections
  • Abnormal breast growth (gynecomastia)
  • Decreased facial or body hair or other signs of a chromosomal or hormonal abnormality
  • Erectile dysfunction
  • A lower than normal sperm count

Medical Causes

Male infertility can be caused by a number of different health issues and medical treatments. Some may include:

  • Varicocele. A varicocele is a swelling of the veins that drain the testicle. It’s the most common reversible cause of male infertility. Varicoceles result in reduced quality of the sperm.
  • Ejaculation issues. Retrograde ejaculation occurs when semen enters the bladder during orgasm instead of emerging out the tip of the penis.
  • Certain medications. Long-term anabolic steroid use, cancer medications, certain antifungal medications, and other medications can impair sperm production and decrease male fertility.
  • Tumors. Cancers and nonmalignant tumors can affect the male reproductive organs. In some cases, surgery, radiation or chemotherapy to treat tumors can affect male fertility.

When to See a Doctor

You should see a doctor after one year of being unable to conceive a child with unprotected intercourse or if you start noticing signs and symptoms.

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Men who are in need of in vitro fertilization (IVF) fall into two general categories: Obstructed and Non-Obstructed patients. Obstruction is caused either by prior vasectomy or by conditions in which the outflow tubing of the testicles has been damaged or failed to form properly from birth.

Below is a list of common procedures done.

Testicular Sperm Extraction (TESE) and Micro Dissection TESE

In some cases, sperm is taken directly from the testicle for IVF. This occurs in men with very low sperm production who have no sperm in the ejaculation in which the cause is not from a blockage, called nonobstructive azoospermia. It also occurs in some men with epididymal scarring, previously failed vasectomy reversal and in some men with congenial blockages of the sperm ducts. TESE can be done with local anesthesia in an office or in a surgery center with many other anesthesia options.

Tissue that is extracted is immediately examined to determine the presence or absence of sperm. In so instances, multiple areas of the testis will need to be sampled in order to find adequate numbers of healthy sperm. In cases where only small “pockets” of sperm production may exist within the testis, a technique known as microdissection TESE would be performed. This procedure has been shown to allow for the detection of visible sperm in many previously untreatable men.

Microscopic Epididymal Sperm Aspiration (MESA)

In obstructed patients, sperm may be harvested surgically from the epididymis in the high numbers with high motility. This can be done in two ways. One way it can be done is through the skin, percutaneously or it can be done open surgically with the operating microscope. Usually, the open technique allows for a much greater harvest of sperm to be frozen but requires a minor surgery with a small scrotal incision. Recovery time, however, is very brief. The surgery takes about 30 minutes and is done as an outpatient. Once the sperm is cryopreserved, it can be used at any fertility center in the country.

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Vasectomy Reversal

When the vas deferens is divided at the time of vasectomy, sperm continue to be produced in the testicles on each side. Most of this sperm is either reabsorbed by the body or accumulates in the epididymis, the small gland located behind each testicle where sperm normally mature and gain the ability to swim.

The epididymis is a very fine, single tube that is prone to blockage when a long time interval has occurred between vasectomy and vasectomy reversal.

There are two possible operations that should be offered to complete a successful vasectomy reversal. Both operations are performed through small incisions in the scrotal area. The decision for which procedure to do will be decided at the time of surgery when the present fluid at the testicular side of the vasectomy site in the vas tube is examined.

Two Possible Operations

If there are sperm present at this site, a two-layer, microsurgical connection of the two ends of the vas will be performed. This is known as a vasovasostomy. If there are no sperm present, that means obstruction to the sperm flow has occurred in the epididymis. In this instance, a standard vasovasostomy will not be successful and the second option of surgery will be performed.

The second option of surgery consists of connecting the vas tubes to the epididymal tube in a location close to the testicle, thereby passing the blocked site in the epididymal tube. This is known as an epididymovasostomy.

As mentioned above the decision to perform which operation is made at the time of surgery. However, there are some factors that can help predict which operation will be necessary.

Here are some factors that would favor the ability to perform a vasovasostomy:

  1. Time from vasectomy < 10 years
  2. Vasectomy performed higher in the scrotum away from the epididymis
  3. The presence of a small “pea-sized” lump at the vasectomy area


It should be noted that the findings at the time of surgery may not be the same on each side. This means that it may be possible for a vasovasostomy on one side and an epididymovasostomy on the other side.

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Surgical Treatment for Infertility in Men

Surgical Treatment for Infertility in Men: Varicocele Ligation, Vasectomy Reversal, Transurethral Resection of the Ejaculatory Duct, Sperm Retrieval and IVF/ICSI techniques


Surgery is  an option to treat male Infertility and is sometimes required to treat conditions associated with infertility.  Following are surgical treatments available to men for who are experiencing infertility problems that are preventing them from successfully conceiving a child with their partner.


Varicocele Ligation


Surgical ligation is one of the most common treatments for the treatment of male infertility and repairing the varicocele is a relatively simple surgical procedure.  Usually done by a Urologist, a Varicocele Ligation begins with an incision being made in the skin above the scrotum, down to the testicular veins and then tied off with sutures. Patients can leave the hospital the same day but about 20 percent of surgical ligation patients have an overnight stay at the hospital.  Recovery period for a surgical ligation is two to three weeks.


Vasectomy Reversal


Vasectomies are considered a permanent form of contraception however,  advances in microsurgery have improved the success of vasectomy reversal procedures.  A Vasectomy Reversal Surgery reconnects the male reproductive tract after a vasectomy.  Vasovasostomy, also known as Vasectomy Reversal, is a procedure where the cut ends of the vas deferens are stitched back together in two layers.  When the epididymis is inflamed or scarred and is blocking the sperm from reaching the vas deferens, a patient may need a Vasoepididymostomy.  In this procedure, the surgeon will bypass the blockage and stitch the vas deferens to the epididymis in two layers.


Transurethral Resection of the Ejaculatory Duct


Transurethral Resection of the Ejaculatory Duct  is a method to treat ejaculatory duct obstruction and this procedure may help couples who want to conceive naturally and avoid assisted reproductive technologies such as IVF/ICSI.  This procedure is usually done on an outpatient basis.  It is performed endoscopically by inserting instruments into the patient’s penis.  Dye is injected into the seminal vesicle, the surgeon resets the duct, removes the obstruction, and reconnect.  The dye will flow freely through the duct if the procedure is successful.  The procedure removes the ejaculatory duct obstruction and opens the ejaculatory ducts which allows for the normal flow of ejaculate and improvement of semen parameters.


Sperm Retrieval and IVF/ICSI Techniques


There are several methods available for Sperm Retrieval also known as Sperm Extraction.  Depending on the reasons why a patient does not have enough sperm in their ejaculate will determine the right method for them.. Once the patient meets with their doctor to discuss their fertility problems,the doctor will determine the best method based on the patients individual case.


Following are some of the most common methods available for Sperm Retrieval for In Vitro Fertilization (IVF) and Intracytoplasmic Sperm Injection (ICSI):


Percutaneous Epididymal Sperm Aspiration (PESA)


PESA requires a needle to be inserted into the epididymis and sperm is withdrawn.  This procedure is used to find sperm when there is no sperm found in the male partners ejaculate.  The procedure can be performed using a local anesthetic with a quick recovery time.


Testicular Sperm Extraction (TESE)


TESE is a surgical biopsy of the testis.  The surgery is performed using a local anesthetic and a small cut is made in the scrotum where a small portion of the tissue is removed to extract a few viable sperm cells  This method is usually used when there is evidence of an obstruction.


Microsurgical testicular sperm extraction (Micro-TESE)


Micro-TESE surgery is the opening of the outer cover of the testicle and examining the inside of the testis under an operating microscope.  This procedure is performed in an operating room under local anesthesia.  More of the testis is examined however, less testicular tissue is removed.  Also this procedure causes less damage to the structure inside the testicle and causes fewer blood supply problems caused by tiny blood vessels being cut. This procedure appears to increase the number of sperm that can be retrieved.



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