Sexual Health

Sexual health is a critical and often underappreciated component of fertility care. Even when sperm production, hormonal balance, and reproductive anatomy are optimized, sexual function and ejaculatory performance can be the factor that limits conception.

In fertility practice, assessing sexual health means more than asking if intercourse is occurring. It involves systematic evaluation of erectile function, ejaculatory disorders, libido, pain during intercourse, psychosexual factors, and the interplay between sexual dysfunction and systemic illness.

This module provides fertility clinicians, reproductive endocrinologists, and urologists with a structured framework for diagnosing, managing, and integrating sexual health in comprehensive fertility care.

Erectile Function & Its Role in Fertility

• Physiology of erection: The neurovascular cascade—pelvic nerves, nitric oxide signaling, vascular engorgement, venous occlusion.

• Etiologies of erectile dysfunction (ED) in fertility patients: vascular disease (diabetes, hypertension), endocrine causes (hypogonadism, thyroid disease), medication effects, psychological factors, pelvic trauma or surgery.

• Impact on fertility: Inability to maintain or achieve erection prevents intercourse; even with ART, sexual dysfunction can delay or complicate timing.

• Assessment tools: Standardized questionnaires (e.g. IIEF), nocturnal penile tumescence testing, duplex Doppler ultrasound.

• Management options in fertility settings:

  • Phosphodiesterase-5 inhibitors (PDE5i) — safe use in fertility patients

  • Intracavernosal injections or intraurethral agents when needed

  • Vacuum erection devices or penile prosthesis in refractory cases

  • Treat underlying causes (e.g. vascular risk, hormone therapy, neural injury)

Ejaculation & Ejaculatory Disorders

• Normal ejaculatory pathway: Sperm transport from epididymis → vas deferens → ejaculatory ducts → urethra.

• Common ejaculatory dysfunctions:

  • Premature ejaculation: may reduce semen deposition or lead to anxiety about intercourse timing

  • Delayed ejaculation or anejaculation: complete absence or severe delay in ejaculation

  • Retrograde ejaculation: semen enters the bladder rather than exiting

  • Painful ejaculation / dysejaculation: associated with prostatitis or urethral pathology

• Diagnostic evaluation:

  • Detailed sexual history (onset, consistency, context)

  • Post-ejaculatory urine analysis (for retrograde sperm)

  • Anatomical imaging (ejaculatory duct obstruction, cysts)

  • Neurologic assessment (diabetes, spinal injury, medication side effects)

• Treatment strategies:

  • Pharmacologic agents (such as sympathomimetics, tricyclics) to improve antegrade ejaculation

  • Sperm retrieval via PESA/MESA or testicular extraction when ejaculation is unobtainable

  • Behavioral techniques and counseling for psychogenic causes

Libido, Hormones & Sexual Desire

• Sexual desire is tightly connected to hormonal milieu, psychological state, and relational factors.

• Hypogonadism, thyroid dysfunction, hyperprolactinemia, and other endocrine disorders often manifest with low libido.

• Medication side effects (SSRIs, anti-hypertensives, opioids) are frequent contributors to libido suppression.

• In fertility patients, optimizing sexual desire is essential to maintain consistent intercourse or sexual activity aligned with fertility cycles.

• Approach:

  • Full hormonal panel (testosterone, SHBG, LH/FSH, prolactin, thyroid)

  • Medication review and possible substitution

  • Psychosexual counseling, sex therapy, couple’s therapy as adjuncts

Pain, Discomfort, and Anatomical Issues

• Although less common, painful intercourse (dyspareunia), penile curvature (Peyronie’s disease), penile lesions, and urethral stricture can impede sexual function.

• Evaluation:

  • Physical genitourinary exam, penile Doppler studies, ultrasound

  • Inquiry about penile plaques, curvature during erection, prior trauma or surgery

• Management:

  • Medical therapy (e.g., collagenase, pentoxifylline)

  • Surgical correction for curvature or strictures

  • Topical therapies or pain management when indicated

Psychological & Relational Factors

• Infertility itself places emotional strain; sexual performance may suffer under pressure, anxiety, depression, or relationship stress.

• Psychosexual dysfunction often coexists with medical causes and must be addressed in tandem.

• Fertility programs must integrate psychological assessment, sex counseling, and mental health support into standard care.

Integration of Sexual Health into Fertility Protocols

• Baseline screening: Every fertility patient should receive a structured sexual health questionnaire as part of the initial intake.

• Multidisciplinary collaboration: Close interaction between reproductive endocrinologists, urologists/andrologists, psychologists, and sex therapists.

• Coordination with ART scheduling: Treatments or interventions for sexual dysfunction should be timed to avoid delays in fertility cycles.

• Follow-up monitoring: Track sexual function outcomes over treatment—improvements, side effects, durability.