Infertility

• Are age 35 or older and have been trying to conceive for six months or longer
• Are over age 40
• Have irregular or absent periods
• Have very painful periods
• Have known fertility problems
• Have been diagnosed with endometriosis or pelvic inflammatory disease
• Have had multiple miscarriages
• Have undergone treatment for cancer

Men should talk to a doctor if they have:

• A low sperm count or other problems with sperm
• A history of testicular, prostate or sexual problems
• Undergone treatment for cancer
• Small testicles or swelling in the scrotum
• Others in your family with infertility problems

Causes.

All of the steps during ovulation and fertilization need to happen correctly in order to get pregnant. Sometimes the issues that cause infertility in couples are present at birth, and sometimes they develop later in life.
Infertility causes can affect one or both partners. In general:

• In about one-third of cases, there is an issue with the man
• In about one-third of cases, there is an issue with the woman
• In the remaining cases, there are issues with both the man and the woman, or no cause can be found

Risk Factors.

Many of the risk factors for both male and female infertility are the same. They include:

• Age – Women’s fertility gradually declines with age, especially in the mid-30s, and it drops rapidly after age 37. Infertility in older women is likely due to the lower number and quality of eggs, and can also be due to health problems that affect fertility. Men over age 40 may be less fertile than younger men.
• Tobacco use – Smoking tobacco or marijuana by either partner may reduce the likelihood of pregnancy. Smoking also reduces the possible effectiveness of fertility treatment. Miscarriages are more frequent in women who smoke. Smoking can increase the risk of erectile dysfunction and a low sperm count in men.
• Alcohol use – For women, there’s no safe level of alcohol use during conception or pregnancy. Alcohol use may contribute to infertility. For men, heavy alcohol use can decrease sperm count and motility.
• Being overweight- Among American women, an inactive lifestyle and being overweight may increase the risk of infertility. For men, sperm count also may be affected by being overweight.
• Being underweight Women at risk of fertility problems include those with eating disorders, such as anorexia or bulimia, and those who follow a very low-calorie or restrictive diet.
• Exercise issues A lack of exercise contributes to obesity, which increases the risk of infertility. Less often, ovulation problems may be associated with frequent strenuous, intense exercise in women who are not overweight

Prevention.

Some types of infertility aren’t preventable. But several strategies may increase your chances of pregnancy.

Couples Have regular intercourse several times around the time of ovulation for the highest pregnancy rate. Intercourse beginning at least five days before and until a day after ovulation improves your chances of getting pregnant. Ovulation usually occurs in the middle of the cycle — halfway between menstrual periods — for most women with menstrual cycles about 28 days apart

Men Although most types of infertility aren’t preventable in men, these strategies may help:

• Avoid drug and tobacco use and drinking too much alcohol, which may contribute to male infertility.
• Avoid high temperatures found in hot tubs and hot baths, as they can temporarily affect sperm production and motility.
• Avoid high temperatures found in hot tubs and hot baths, as they can temporarily affect sperm production and motility.
• Avoid exposure to industrial or environmental toxins, which can affect sperm production.
• Limit medications that may impact fertility, both prescription and nonprescription drugs. Talk with your doctor about any medications you take regularly, but don’t stop taking prescription medications without medical advice.
• Exercise moderately. Regular exercise may improve sperm quality and increase the chances for achieving a pregnancy.

Women For women, a number of strategies may increase the chances of becoming pregnant:

• Quit smoking. Tobacco has many negative effects on fertility, not to mention your general health and the health of a fetus. If you smoke and are considering pregnancy, quit now.
• Avoid alcohol and street drugs. These substances may impair your ability to conceive and have a healthy pregnancy. Don’t drink alcohol or use recreational drugs, such as marijuana, if you’re trying to get pregnant.
• Limit caffeine. Women trying to get pregnant may want to limit caffeine intake. Ask your doctor for guidance on the safe use of caffeine.
• Exercise moderately. Regular exercise is important, but exercising so intensely that your periods are infrequent or absent can affect fertility.
• Avoid weight extremes. Being overweight or underweight can affect your hormone production and cause infertility.

Diagnosis.

Before infertility testing, you

Tests for men Male fertility requires that the testicles produce enough healthy sperm, and that the sperm is ejaculated effectively into the vagina and travels to the egg. Tests for male infertility attempt to determine whether any of these processes are impaired.

You may have a general physical exam, including examination of your genitals. Specific fertility tests may include:

• Semen analysis.
• Hormone testing.
• Genetic testing.
• Testicular biopsy.
• Imaging.
• Other specialty testing.

Tests for women Specific fertility tests may include:

• Ovulation testing.
• Hysterosalpingography.
• Ovarian reserve testing.
• Other hormone testing.
• Imaging tests.

Infertility evaluation can be expensive, and sometimes involves uncomfortable procedures. Some medical plans may not cover the cost of fertility treatment. Finally, there’s no guarantee — even after all the testing and counseling — that you’ll get pregnant.

Treatment.

Common treatment options for premature ejaculation include behavioral techniques, topical anesthetics, medications and counseling. Keep in mind that it might take time to find the treatment or combination of treatments that will work for you. Behavioral treatment plus drug therapy might be the most effective course.

Behavioral techniques In some cases, therapy for premature ejaculation might involve taking simple steps, such as masturbating an hour or two before intercourse so that you’re able to delay ejaculation during sex. Your doctor also might recommend avoiding intercourse for a period of time and focusing on other types of sexual play so that pressure is removed from your sexual encounters.

Pelvic floor exercisesWeak pelvic floor muscles might impair your ability to delay ejaculation. Pelvic floor exercises (Kegel exercises) can help strengthen these muscles.
To perform these exercises:

• Find the right muscles. To identify your pelvic floor muscles, stop urination in midstream or tighten the muscles that keep you from passing gas. These maneuvers use your pelvic floor muscles. Once you’ve identified your pelvic floor muscles, you can do the exercises in any position, although you might find it easier to do them lying down at first.
• Perfect your technique. Tighten your pelvic floor muscles, hold the contraction for three seconds, and then relax for three seconds. Try it a few times in a row. When your muscles get stronger, try doing Kegel exercises while sitting, standing or walking.
• Maintain your focus. For best results, focus on tightening only your pelvic floor muscles. Be careful not to flex the muscles in your abdomen, thighs or buttocks. Avoid holding your breath. Instead, breathe freely during the exercises.
• Repeat 3 times a day. Aim for at least three sets of 10 repetitions a day

The pause-squeeze technique

Your doctor might instruct you and your partner in the use of a method called the pause-squeeze technique. This method works as follows:

• Begin sexual activity as usual, including stimulation of the penis, until you feel almost ready to ejaculate.
• Have your partner squeeze the end of your penis, at the point where the head (glans) joins the shaft, and maintain the squeeze for several seconds, until the urge to ejaculate passes.
• Have your partner repeat the squeeze process as necessary.

By repeating as many times as necessary, you can reach the point of entering your partner without ejaculating. After some practice sessions, the feeling of knowing how to delay ejaculation might become a habit that no longer requires the pause-squeeze technique.

If the pause-squeeze technique causes pain or discomfort, another technique is to stop sexual stimulation just prior to ejaculation, wait until the level of arousal has diminished and then start again. This approach is known as the stop-start technique.

Condoms

Condoms might decrease penis sensitivity, which can help delay ejaculation. “Climax control” condoms are available over the counter. These condoms contain numbing agents such as benzocaine or lidocaine or are made of thicker latex to delay ejaculation. Examples include Trojan Extended, Durex Performax Intense and Lifestyles Everlast Intense.

Medications

Topical anesthetics Anesthetic creams and sprays that contain a numbing agent, such as benzocaine, lidocaine or prilocaine, are sometimes used to treat premature ejaculation. These products are applied to the penis 10 to 15 minutes before sex to reduce sensation and help delay ejaculation.
A lidocaine-prilocaine cream for premature ejaculation (EMLA) is available by prescription. Lidocaine sprays for premature ejaculation are available over-the-counter.
Although topical anesthetic agents are effective and well-tolerated, they have potential side effects. For example, some men report temporary loss of sensitivity and decreased sexual pleasure. Sometimes, female partners also have reported these effects.

Oral medications Many medications might delay orgasm. Although none of these drugs are specifically approved by the Food and Drug Administration to treat premature ejaculation, some are used for this purpose, including antidepressants, analgesics and phosphodiesterase-5 inhibitors. These medications might be prescribed for either on-demand or daily use, and might be prescribed alone or in combination with other treatments.

• Antidepressants. A side effect of certain antidepressants is delayed orgasm. For this reason, selective serotonin reuptake inhibitors (SSRIs), such as escitalopram (Lexapro), sertraline (Zoloft), paroxetine (Paxil) or fluoxetine (Prozac, Sarafem), are used to help delay ejaculation Of those approved for use in the United States, paroxetine seems to be the most effective. These medications usually take five to 10 days to begin working. But it might take two to three weeks of treatment before you’ll see the full effect. If SSRIs don’t improve the timing of your ejaculation, your doctor might prescribe the tricyclic antidepressant clomipramine (Anafranil). Unwanted side effects of antidepressants might include nausea, perspiration, drowsiness and decreased libido.
• Analgesics. Tramadol (Ultram) is a medication commonly used to treat pain. It also has side effects that delay ejaculation. Unwanted side effects might include nausea, headache, sleepiness and dizziness.
  It might be prescribed when SSRIs haven’t been effective. Tramadol can’t be used in combination with an SSRI.
• Phosphodiesterase-5 inhibitors. Some medications used to treat erectile dysfunction, such as sildenafil (Viagra), tadalafil (Cialis, Adcirca) or vardenafil (Levitra, Staxyn), also might help premature ejaculation. Unwanted side effects might include headache, facial flushing and indigestion. These medications might be more effective when used in combination with an SSRI.

Potential future treatment

Research suggests that several drugs that might be helpful in treating premature ejaculation, but further study is needed. These drugs include:

• Dapoxetine. This is an SSRI that’s often used as the first treatment for premature ejaculation in other countries. It’s not currently available in the United States.
• Modafinil (Provigil). This is a treatment for the sleeping disorder narcolepsy.
• Silodosin (Rapaflo).This drug is normally a treatment for prostate gland enlargement (benign prostatic hyperplasia).

Counseling

This approach involves talking with a mental health provider about your relationships and experiences. Sessions can help you reduce performance anxiety and find better ways of coping with stress. Counseling is most likely to help when it’s used in combination with drug therapy.
With premature ejaculation, you might feel you lose some of the closeness shared with a sexual partner. You might feel angry, ashamed and upset, and turn away from your partner.
Your partner also might be upset with the change in sexual intimacy. Premature ejaculation can cause partners to feel less connected or hurt. Talking about the problem is an important step, and relationship counseling or sex therapy might be helpful.