Abstract
There is a complex interplay between male sexual dysfunction and male factor infertility, including ejaculatory dysfunctions which are the most common male sexual dysfunction. It is divided into four categories: premature ejaculation (PE), delayed ejaculation (DE), retrograde ejaculation (RE), and anejaculation/anorgasmia (AE). Unfortunately, some of these ejaculatory dysfunctions are less studied and not as well understood. Various pharmacologic treatments and surgical procedures can be offered for patients with ejaculatory dysfunctions seeking fertility. These include the off-label use of SSRIs (selective serotonin reuptake inhibitors) for PE, surgical (testicular sperm aspiration, testicular sperm extraction, and microsurgical epididymal sperm aspiration) and nonsurgical methods (medications, positive predictive value, and electroejaculation) for patients with RE and AE. The interaction between chemical impulses and the modulation of the ejaculation process in an individual patient is necessary to conclude the clinical status of the patient and feasibility of the available treatment techniques. Ultimately, this can help in deciding the best sperm retrieval technique to increase pregnancy outcomes.
7.1 Introduction
Ejaculatory dysfunction (EjD) is the most common sexual dysfunction in men [1,2]. The spectrum of EjD covers premature ejaculation (PE), delayed ejaculation (DE), retrograde ejaculation (RE), and a complete inability to ejaculate, also known as anejaculation (AE) [3]. Moreover, EjD can also lead to low-volume ejaculate, which may be a contributing male infertility factor in men seeking fatherhood. Several surgical and nonsurgical sperm retrieval methods are used to obtain sperm from the epididymis and/or testes in men with ejaculatory dysfunctions (Table 7.1). The selection of technique depends on the clinical scenario and feasibility.
Table 7.1 Summary of the medical and surgical treatment options in patients with concomitant infertility and ejaculatory dysfunction
| Type | Definition | Causes | Diagnosis | Treatments |
|---|---|---|---|---|
| Anejaculation/anorgasmia (AE) | Complete failure to attain emission despite adequate stimulation. | Anatomic, genetic, endocrine, infectious, and neurobiological factors, or it may be drug-induced | Post-orgasmic urinalysis: complete absence of antegrade ejaculation and a non-viscous, sperm-negative, and fructose-negative semen | Medical treatment |
| Behavioral: psychosexual counseling | ||||
| Pharmacological: cabergoline, alpha adrenoceptor agonists (pseudoephedrine) | ||||
| Procedural: penile vibratory stimulation (PVS), | ||||
| Electroejaculation (EEJ) | ||||
| Surgical treatment | ||||
| Testicular sperm aspiration (TESA) | ||||
| Testicular sperm extraction (TESE) | ||||
| Epididymal sperm aspiration (percutaneous or microsurgical): | ||||
| Retrograde ejaculation (RE) | Insufficient bladder neck resistance to the high pressures yielded by the ischiocavernosus and bulbospongiosus muscles during ejaculation, causing redirection of semen into the bladder | Medication (tamsulosin), surgical (transurethral resection of the prostate), retroperitoneal surgical resection and complications of diabetes | Urinalysis obtained immediately postcoital or post-orgasm with >10–15 sperm per high power field validates the presence of RE | Medical treatment |
| Pharmacological: pseudoephedrine; alpha agonists; Imipramine, (tricyclic antidepressant) | ||||
| Surgical treatment | ||||
| Young–Dees procedure: | ||||
| Abrahams procedure: | ||||
| Alloplastic spermatocele: | ||||
| TESA | ||||
| TESE | ||||
| Epididymal sperm aspiration (percutaneous or microsurgical): | ||||
| Premature ejaculation (PE) | Lifelong PE: ejaculation that always or nearly always occurs prior to or within about 1 minute of vaginal penetration Acquired PE: clinically significant reduction in latency time after penetration, often to about 3 minutes or less | Higher levels of education, presence of social phobia, relational difficulties, psychological factors such as stress, depression, guilt | Validated questionnaire: premature ejaculation profile (PEP), premature ejaculation diagnostic tool, or index of premature ejaculation if the patient has concomitant erectile dysfunction | Medical treatment |
| Behavioral: psychosexual counseling | ||||
| Pharmacological: selective serotonin reuptake inhibitors (SSRIs), phosphodiesterase 5 inhibitors (PDE5), and eutectic mixture of prilocaine and lidocaine Topical agents (Promescent®) | ||||
| Surgical treatment | ||||
| Penile hypoanesthesia via hyaluronic acid gel glans penis augmentation | ||||
| Selective dorsal nerve neurotomy |
7.1.1 Normal Ejaculatory Mechanism
The two important phases of normal ejaculation are emission and expulsion. These processes are mediated by somatic, sympathetic, parasympathetic, afferent, and efferent fibers. The first phase of ejaculation is emission, which consists of a peristaltic contraction of the smooth muscles in the seminal tract until the ejaculate reaches the prostate. Ejaculate is then deposited into the posterior urethra. The latter phase, expulsion, happens when the semen is forcefully and rapidly advanced through the urethra and then out the penis. Adequate propulsion of semen necessitates synchronized relaxation of the external urinary sphincter with accompanying bladder neck closure, rhythmic contractions of the striated muscles of the bulbospongiosus muscles and the pelvic floor [4]. The ejaculation process can be triggered in several ways, such as influences from various cortical stimuli as well as tactile stimulation of the glans penis [5].
7.1.2 Pathophysiology
Multiple neurotransmitter systems at supraspinal and spinal regions are involved in the regulation of the ejaculatory reflex. A wide range of neurotransmitters, including dopamine, nitric oxide, oxytocin, adrenaline, c-aminobutyric acid, 5-hydroxytryptamine (5-HT), serotonin, and acetylcholine have a role, particularly in the central nervous system (CNS) [6–8]. The neurotransmitter that is most studied in the neurophysiology of ejaculation is 5-HT [9]. There are 14 different 5-HT receptor subtypes reported so far, each having a different function and neuroanatomical location [10]. The 5-HT1a somatodendritic autoreceptors that are present in the medullary and mesencephalic raphe nuclei are responsible for diminishing 5-HT release into the synapse via a negative feedback mechanism and decreasing ejaculatory latency [11, 12]. The 5-HT1b and 5-HT2c receptors, in contrast to the 5-HT1a autoreceptors, are located in the postsynaptic membrane, and they have been shown to extend ejaculatory latency. It is likely that the mechanism behind ejaculatory disorders is the change in levels of 5-HT or altered 5-HT receptor sensitivity in the ejaculatory regulating centers of the CNS [12].
7.1.3 Implications of EjD on Fecundity
Ejaculatory dysfunction is one of the major causes of male infertility and is a serious problem in young patients. Therefore, therapeutic management of EjD has become very crucial for couples wishing for a baby. Semen analysis is a crucial exam for the diagnosis of male infertility. An adequate volume of ejaculate is necessary to carry the male gametes into the reproductive tract of the female [13]. The 2010 World Health Organization (WHO) criteria consider 1.5 ml semen volume as the lower reference limit and ≥15 million sperm/ml is regarded as normal [14]. Ejaculatory dysfunction may impact the semen quality parameters by reducing volume, sperm count, and motility.
Retrograde ejaculation and anejaculation are common causes of EjD. The etiology and treatment of RE and AE in male infertility have been comparatively well studied [15, 16]. Men who have AE or RE in their reproductive phase due to any reason can lead to infertility. Spinal cord injury (SCI) is the major cause of neurogenic AE. Psychogenic erections need the supraspinal input to the cord with intact thoracolumbar roots, and therefore they are frequently lost with injuries to the thoracic spinal cord [17]. Therefore, some men with SCI can initiate reflexogenic erections. However, they cannot preserve them due to the absence of psychogenic erections [18]. Diabetes complications are also responsible for RE, with one series describing a prevalence of 32 percent [19]. Surgery and instrumentation are also reported as important factors causing AE. Both often lead to an incompetent bladder neck, with most men experiencing RE after transurethral resection of the prostate [20]. Alpha-receptor antagonists given for lower urinary tract symptoms can also cause RE [21].
7.1.4 Prevalence and Pregnancy Outcomes
Ejaculatory problems have been reported by 74.3 percent, 54.9 percent, and 30.1 percent of men aged 70–80, 60–69, and 50–59 years, respectively.[22]. Retrograde ejaculation contributes to 0.3–2 percent of male infertility [23, 24], whereas PE impacts up to 30 percent of the adult male population and is regarded as the most common sexual disorder in men [1]. Ejaculatory dysfunction-related infertility is one of the most serious problems for men seeking fatherhood. Erectile dysfunction is an important post-testicular cause of male infertility, and there have been major advances in our understanding of this disorder. However, if sexual intercourse is attained successfully without any ejaculate, the female partner will not be able to conceive. Hence, the establishment of management of EjD is increasingly important for couples wishing to conceive a child. The therapeutic approach to EjD-related male factor infertility is indicated when EjD is the main reason for having no children and if EjD is also accompanied by worsening of semen quality.
7.2 Anejaculation/Anorgasmia
Anejaculation is identified as a complete absence of ejaculation despite adequate stimulation. Men commonly discontinue sexual interaction given exhaustion, partner request, or irritation [25]. An orgasm is defined as the climax of sexual arousal which is felt throughout the body, whereas ejaculation involves the release of sperm carrying fluid following sexual activity. There is a difference between orgasm and ejaculation, but most men will present with a complaint of combined inability to orgasm or ejaculate. Total AE is the situation in which the man is unable to ejaculate semen consciously with normal orgasm, either by masturbation or during intercourse. Anejaculation covers complete RE, anorgasmia, or failure of emission. Complete RE can occur because of any of the causes of AE, whereas DE is mostly due to a neurological reason with disruption of sympathetic nerves or output.
7.2.1 Prevalence
Anejaculation, anorgasmia, and DE are among the uncommon and least understood male sexual health dysfunctions. The estimated prevalence of AE/DE is approximately 1–4 percent of the male population [26–28].
7.2.2 Causes and Pathophysiology
Anejaculation is caused by anatomic, genetic, endocrine, infectious, and neurobiological factors, or it may be drug-induced. It may also be caused by psychosocial, relationship, or psychosexual problems. Any drug, medical disease, congenital abnormality, or surgical procedure that interferes with either the peripheral control or central control of ejaculation that includes sympathetic nerve supply to the seminal vesicles, bladder neck, vas deferens, or prostate, as well as the somatic efferent nerve supply to the pelvic region, can lead to AE and anorgasmia. From a medication standpoint, the most well-known drugs are from the antidepressant class (SSRIs), which enhance the amount of circulating 5-HT, an ejaculatory inhibitor [29]. Medical diseases include hypothyroidism and alcoholic or diabetic neuropathy [30], even cerebro-vascular accident (CVA) related to the impairment of orgasm [31], and low testosterone [32]. Anatomically, surgical procedures such as prostatectomy, transurethral resection of the prostate (TURP), bladder neck incision, retroperitoneal lymph node dissection (RPLND), or other pelvic or colorectal surgery and SCIs, which can damage pelvic nerves, may also cause DE [33, 34]. Patients who use serotonergic antidepressants frequently describe sexual dysfunction. Around seven-fold higher risk for AE has been observed in SSRI users [35]. The significant heterogeneity in the presentation of SSRI-related sexual dysfunction and its occurrence may indicate underlying genetic factors [36]. Aging can also lead to decreased penile sensitivity, which has been attributed to possible degenerative age-related or ultrastructural changes in the penile receptors [37,38], ultimately leading to progressive axonal sensory loss [39, 40].
7.2.3 Diagnosis
Diagnostic clues to AE are the complete absence of antegrade ejaculation and a non-viscous, sperm-negative, and fructose-negative post-orgasmic urinalysis [41].
7.2.4 Treatment
7.2.4.1 Nonsurgical: Behavioral-Psychosexual Therapy
Given the large psychosocial component of AE, referral to a sexual therapist can be important to assess and treat behavioral, relational, or psychological issues. Psychosexual therapy can be specifically helpful in primary inhibited orgasm [42] when it is not due to a medical disease, surgical side effects, or medication.
7.2.4.2 Medical
Cabergoline is a potent dopamine receptor agonist. It is thought to promote ejaculation by increasing dopamine neurotransmission. Cabergoline (0.5 mg twice/week) was tested for the treatment of anorgasmic men who were non-responders to the treatment for testosterone deficiency [43]. The authors found that 25 percent of men had improved orgasmic function. Bupropion (150 mg daily), which acts via blocking the reuptake of both norepinephrine and dopamine, is used as an agent in depressed men when SSRIs cause AE [44]. Testosterone replacement has been assessed as a potential treatment for anejaculation. However, exogenous testosterone treatment is contraindicated in men seeking fertility as it can change the natural balance of the hypothalamic–pituitary–gonadal axis, resulting in impaired spermatogenesis and possibly azoospermia. Other alternative treatments in EjD patients are electroejaculation (EEJ) [45] or penile vibratory stimulation (PVS) [46], especially for the treatment of AE in patients with SCI. An alpha-agonist, such as ephedrine (15–60 mg), pseudoephedrine (60–120 mg), imipramine (25–75 mg), and midodrine (7.5–22.5 mg max.), can be considered if an anejaculatory male is trying to achieve fertility [47]. Alpha agonists may change AE to RE, which helps in sperm retrieval from the urine.
7.2.4.3 Penile Vibratory Stimulation
In PVS, a vibrator is placed against the penis and then supraphysiological mechanical stimulation is applied to induce ejaculation. Although PVS is a comparatively safe and low-cost alternative, it needs at least one intact lumbosacral spinal cord segment (above T10) [48]. There are various methods of applying PVS: (1) placing one FertiCare personal device (Multicept, Denmark) to the frenulum or dorsum of the glans penis; (2) placing the glans penis between two FertiCare devices; and (3) placing the glans penis between two vibrating surfaces of a Viberect-X3 device (Reflexonic LLC, Frederick, USA). The above devices are specific vibrators available for patients with SCI. These vibrators have the capacity to deliver an amplitude of 2.5 mm, also known as “high-amplitude vibrators.” It has been found that these high-amplitude vibrators can significantly increase ejaculatory success rate compared to lower-amplitude vibrators (96 percent vs. 32 percent ejaculatory success rate, respectively) [49].
7.2.4.4 Electroejaculation
Electroejaculation is a technique to collect semen to analyze and potentially freeze or store sperm or immediately process semen for artificial insemination. This technique was developed originally by veterinary specialists. During the procedure, a mild electric current is utilized to induce an ejaculation under anesthesia or in the absence of anesthesia (for men with SCI). Electroejaculation permits men unable to ejaculate to conceive a child. Several conditions lead to AE, including SCI, multiple sclerosis, radical abdominal and pelvic surgeries, and diabetes. Electroejaculation may be successful in obtaining ejaculate from men with all types of SCI, and from men who do not have deficit of major elements of the ejaculatory reflex arc. Any other situations that impact the ejaculatory mechanism of the peripheral and/or central nervous system, including surgical nerve injury, may also be treated successfully with EEJ.
Electroejaculation is generally performed transrectally (rectal probe EEJ). The probe is placed in the dorsal lithotomy position or lateral decubitus. Antegrade ejaculation is collected during stimulation, and the retrograde fraction is captured via postprocedural catheterization. Patients are usually prepared through emptying the bladder and inserting a sperm-friendly medium (solution) into the bladder prior to the procedure. Many men (including some men with SCI) may need general anesthesia for EEJ due to significant discomfort and potentially severe side effects, mainly originating from autonomic dysreflexia.
Special care must be taken during this procedure to monitor rectal temperature in order to prevent rectal mucosal burns. Anoscopy is generally performed immediately before and after EEJ. Monitoring of the rectal mucosa in this manner is highly recommended. This technique is also recommended for AE patients who failed to ejaculate with PVS and those taking sedatives and narcotics, males with past pelvic surgery/trauma or peripheral neuropathy, and men with significant genital, perineal, or pelvic edema.
7.2.5 Surgical Techniques
The most common surgical procedure employed for the management of EjD-related infertility is known as surgical sperm retrieval (SSR). This is based on the extreme progression in the techniques of ART (intracytoplasmic sperm injection, in vitro fertilization [IVF], sperm cryopreservation). Patients with RE or AE who fail to ejaculate or have insufficient spermatozoa within ejaculates under nonsurgical treatments could be directed for SSR. Anejaculation is not usually linked to defective spermatogenesis. Therefore, testicular sperm aspiration (TESA) and extraction (TESE) are routinely used SSR procedures. Testicular sperm aspiration is a needle aspirate collected from seminiferous tubules which contains both immature and mature sperm, both motile and non-motile. It is easy to perform without oral or conscious sedation. A study reported 61.4 percent pregnancy rate using TESA with cryopreservation [50]. The TESE procedure requires making a small incision in the testis to examine the presence of sperm in the tubules. It is usually performed in the operating room with sedation, but can also be performed with local anesthetic alone. A study demonstrated that the pregnancy outcome was 86.5 percent using this technique for couples in whom the male partner was suffering from EjD [51].
7.3 Retrograde Ejaculation
Retrograde ejaculation is specified as substantial propulsion of seminal fluid from seminal vesicles into the bladder via the posterior urethra. It can occur because of structural or functional disruption of the ejaculation process, such as insufficient bladder neck resistance to the high pressures yielded by the ischiocavernosus and bulbospongiosus muscles during ejaculation, causing backward redirection of semen into the bladder [52]. The function of the bladder neck can be impacted by post-traumatic anatomical disruption via surgery (i.e., TURP) or pelvic fracture, or through processes modifying the nerve input to the sphincter. It can also be affected by alteration into the neuroreceptors within the bladder neck. Therefore, RE can either be partial or complete based on the severity of the neurological injury. Surgical injury to the nerves affecting the ejaculatory function is also a risk of RE, with the most common being spine, colorectal, and retroperitoneal surgeries [53, 54]. However, the introduction of the nerve-sparing RPLND technique has made this pillar of testicular cancer therapy less detrimental to patients’ ejaculatory function [55]. Retrograde ejaculation is the most common cause for EjD in the absence of antegrade ejaculation, and contributes to 0.3–2 percent of male infertility [23,24].
7.3.1 Prevalence
Retrograde ejaculation is both under-recognized and common in diabetic men, with one study reporting a prevalence of 32 percent [19]. It is responsible for only 0.3–2 percent of infertility, despite being a common type of ejaculatory dysfunction [47]. Also, RE was the observed cause in 18 percent of azoospermic men; however, as a source of infertility it was only implicated in 0.7 percent [4,56].
7.3.2 Causes and Pathophysiology
Various medications, such as alpha-receptor antagonists (e.g., tamsulosin), antipsychotics, antidepressants, and other sympatholytics, surgical procedures (TURP), and complications of diabetic peripheral neuropathy can cause RE. It has been observed that the incidence is likely rising as an effect of increasing rates of diabetes, bladder neck surgery for malignancies, and the use of α-receptor antagonists [57]. Surgical injury to the nerves influencing ejaculatory function also pose the risk of RE, with the most common being spinal surgery, retroperitoneal and colorectal and other radical pelvic surgeries [53,54]. Moreover, the most common reason for RE is a history of RPLND for the treatment of testicular cancer, especially in patients in infertility clinics. Notably, the evolution of the surgical template for RPLND has resulted in important modifications to save the ejaculatory functions [13,15].
7.3.3 Diagnosis
Diagnosis is by urinalysis performed on a urine sample that is obtained immediately after ejaculation. In cases of RE, the specimen will carry an abnormal level of sperm. Anejaculation can often be confused with RE, especially in case of orgasmic AE. They share some fundamental etiology – urinalysis is employed to distinguish between them. A physical exam of the genitals is also used to ensure that there are no anatomical abnormalities. The urine will be assessed for the presence of semen. If there are no sperm in the urine, it may be due to injury to the prostate as a result of prior radiation therapy or surgery. The most useful assessment of RE is the evaluation of postcoital urine samples or post-orgasm. A finding of >10–15 sperm per high power field validates the presence of RE [58]. The post-ejaculatory urine sample is collected from patients undergoing a semen analysis. The sample is investigated for the number, morphology, and presence of sperm.
7.3.4 Pregnancy Outcomes
Jefferys et al. have examined several studies using a variety of artificial insemination techniques with the obtained sperm (IVF, ICSI, and intrauterine insemination [IUI]). Overall, the pregnancy rate per cycle was 15 percent, and the live birth rate was 14 percent [47]. The pregnancy rate per cycle was increased to 44.4 percent after successful treatment of RE [59].
7.3.5 Treatment
7.3.5.1 Nonsurgical Techniques (Medical)
Treatment of pharmacologic RE requires discontinuing the offending drug if desirable and medically safe. For other etiologies of RE, medical therapies are first-line in spite of the lack of robust studies supporting their use. Alpha agonists such as pseudoephedrine have been utilized off-label to stimulate more robust bladder neck contraction. In a recent prospective trial of 20 men with complete or partial RE dosed with 60 mg pseudoephedrine every 6 h the day before semen analysis and two additional doses on the day of semen analysis, 70 percent of patients showed improvement in semen parameters such as ejaculate volume, percentage of total spermatozoa in urine, total sperm count in antegrade ejaculate, percentage of total motility, and total motile count in antegrade ejaculate [60]. The tricyclic antidepressant imipramine (25 mg twice/day) has also been employed alone and in combination with an alpha-agonist, with mild success [47,61].
7.3.5.2 Surgical Techniques
Sperm retrieval can be done by nonsurgical methods in certain conditions. In men with persistent RE or if sperm within antegrade ejaculates are not enough for artificial insemination despite medical therapy, the recovery of retrograde ejaculates from the bladder via catheterization is possible [62]. The process starts with complete catheterization of the bladder and then instillation of an insemination buffer medium into the bladder. This step can derogate possible damaging effects of urine on retrograde ejaculate. The catheter is then removed. After collecting the antegrade ejaculate, the bladder is catheterized again. Surgical intervention utilizing collagen injection at the bladder neck has been reported with variable success rates; it has not been established as a treatment modality [63].
Surgical procedures for patients with RE for the restitution of normal ejaculation are the Young–Dees operation [64] and the Abrahams technique [65]. All other surgical techniques that can be used in patients with RE or AE in whom spermatozoa cannot be retrieved otherwise are aimed solely at sperm recovery (e.g., Wagenknecht alloplastic spermatocele [66–68], Brindley reservoir [69], recovery of epididymal microsurgical vas deferens aspiration [70], or epidydimal and testicular spermatozoa [MESA/TESA/TESE][71] for ART). Notably, these procedures are not routinely performed for patients with PE due to their invasiveness and complication rates, which are considerably higher than for traditional sperm retrieval procedures.
The Young–Dees operation is a type of bladder neck reconstruction to change RE into antegrade ejaculation. It could be the appropriate option for bladder neck incompetence at the time of ejaculation. The procedure decreases the caliber of the bladder neck, increases the deep urethra proximally, and supports the new bladder neck with trigonal muscle. This procedure can be considered when treatments such as sympathomimetic drugs and sperm retrieval from the urine for insemination are not successful. The rate of success for this operation is 80 percent [72]. The Abrahams technique was specifically used for patients with RE following Y-V plasty of the bladder during childhood. The procedure involves a transvesical approach to rebuilding the internal sphincteric mechanism.
Wagenknect et al. [67, 68] generated alloplastic spermatocele from a silicone elastomer. An alloplastic spermatocele is a container for sperm. This container can be punctured to collect the contents, which can be used to artificially inseminate the female partner. This is an effective method to retrieve fertile sperm from men suffering from EjD. The patient group includes men who are suffering from uncorrectable obstruction of the ejaculatory ducts, congenital hypoplasia or aplasia of the vas deferens, and inability to ejaculate for psychological or physiological reasons. The Brindley reservoir is another type of container used for the collection of sperm. It is sutured to the vas deferens for sperm retrieval and assisted conception.
Microsurgical epididymal sperm aspiration (MESA) requires dissection of the epididymis under the operating microscope and incision of an epididymal tubule. Fluid spills from the tubule and pools in the epididymal bed. This fluid is then collected. In TESA, spermatozoa are aspirated from a testicle by inserting a needle and aspirating tissue and fluid with negative pressure. Lastly, TESE is a surgical biopsy of the testis, which can be done with the aid of a microscope to enhance the sperm retrieval rate. The aspirated/biopsied tissue is then treated in the embryology laboratory and the sperm cells are extracted to use for assisted conception.
7.4 Premature Ejaculation
Premature ejaculation is an incompletely understood condition that impacts up to 30 percent of the adult male population and is regarded as the most common sexual disorder in men [1]. The vagueness surrounding PE is partially due to the challenges associated with accurately defining and classifying the clinical condition among patients [73]. Based on the International Society for Sexual Medicine (ISSM) 2014 criteria[74], PE can be classified into two categories: lifelong PE is defined as the ejaculation that always or nearly always occurs prior to or within about one minute of vaginal penetration; acquired PE is defined as the clinically significant reduction in latency time after penetration, often to about three minutes or less. Premature ejaculation does not directly lead to infertility, but coexists in around one-third of ED patients [75]. Moreover, PE due to hypoactive sexual desire may be an outcome of hidden hypogonadism that extends to reduced semen quality [76]. Premature ejaculation is mainly a sexual dysfunction and unlikely to be a major contributing factor to male infertility.
7.4.1 Prevalence
Premature ejaculation is one of the most common male sexual disorders and has been estimated to occur in around 4–39 percent of men in the general population [2,77–79].
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