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Erectile Dysfunction Radio Podcast
William Petok, PhD, joins the Erectile Dysfunction Radio Podcast to discuss how erectile dysfunction impacts couples dealing with infertility issues. Dr. Petok specializes in working with couples struggling with infertility, for whom building the family they desire is a challenge. He also has expertise working with individuals and couples who are experiencing sexual difficulties.
The Erectile Dysfunction Radio Podcast is dedicated to educating and empowering men to address erectile dysfunction, improve confidence, and enhance the satisfaction in their relationships. This podcast is hosted by certified sex therapist, Mark Goldberg, LCMFT, CST.
Transcript of Episode 5 – Erectile Dysfunction and Infertility
Mark Goldberg: We’re joined today by Dr. Bill Petok. He has an independent practice of psychology in Baltimore, in Severna Park, Maryland focused on the psychosocial aspects of reproductive health care as well as sexual function issues.
Welcome Bill, and thank you for joining us on today’s episode. Infertility is something that many couples do struggle with and it can have broad implications on a couple’s overall well-being, as well as particular implications for sexual function.
I think that’ll be a great segue talking about couples being in different places to ask you about some of the particular sexual implications, because I imagine if one partner is feeling down, feeling upset, and the other one feels energetic, hopeful and optimistic, their efforts to engage sexually may be impacted as well. Can you share a little bit about what you see in that realm?
Dr. Bill Petok: I certainly can. So most couples who are on infertility treatment in the early stages before they’re doing any interventions, are advised that there are fertile times in which they should have intercourse, and then there are non-fertile times where they will not be able to get pregnant.
It often happens that the focus of sexual activity is on that three to five day window, and then the rest of the month is ignored. Those of us who work on the mental health side and many, many medical providers who work in infertility will advise their patients that sex for procreative purposes is best during this time period, but that doesn’t preclude you from being sexually engaged with one another at other times.
Often what happens is couples get focused on that small window, and then the rest of the time they are not thinking about maintaining other aspects of their relationship, and of course, as you are well-aware sex is an important component of that. So there becomes this focus on it.
Another thing that frequently happens is, couples report they feel as though there’s someone else in the bedroom with them. The image of the doctor, or the nurse, or the treatment team, can be omnipresent. Most of us like to be sexually active, just with our partners, we don’t invite other people into the bedroom with us.
Mark Goldberg: Well said, Dr. Petok. [chuckle]
Dr. Bill Petok: Thank you. So that’s something that frequently gets reported. It feels like there’s somebody else there with us so we’re not able to enjoy ourselves.
Mark Goldberg: Sure. When we’re talking about erectile dysfunction and you conjure up that image of feeling like there is somebody else in the room.
Dr. Bill Petok: Yes.
Mark Goldberg: And the importance of desire, arousal, pleasure, the ability to relax, performance anxiety, can you share with our listeners a little bit about how this may particularly impact erectile dysfunction for a man who is in a relationship that is experiencing infertility?
Dr. Bill Petok: Well, a lot of guys will report they feel as though they are a delivery system, sex on demand. This may be, not for male factor but for female factor, where there’s this window and he gets a call and she says, “You have to come home now, because I’m in that window, where we have to do it tonight, because I’m in that window.”
So that’s an extra level of pressure. And if your guy has had shaky erections before, or has had even insignificant difficulty, the anxiety of feeling as though one has to perform could have an impact on the erection, there’s no doubt about it. So you see that as a potential developing factor.
Since about the early ’80s, there has been scientific literature on the interface between sexual dysfunction and infertility, and the statistics range all over the place. And keep in mind that IVF treatment only goes back to 1978. The first IVF baby is only 42 years old. So we’ve got a smaller window of studying what happens.
Nevertheless there have been ongoing reports, in fact I’m currently editing a book on the interface between infertility and sexual dysfunction.
We see an increasing amount of attention paid to this. As we begin to understand that we’re treating people who have robust lives that incorporate many different functions, sex being one of them, reproduction being one of them. If we just focus on one particular component, for example, the reproductive capacity, we’re forgetting about the whole person, and how those people interact with one another, and what they’re comfortable with and what gives them anxiety.
Mark Goldberg: Yeah, it is really complex, and like you pointed out, a man may have been struggling with erectile dysfunction to an extent before hitting this patch of infertility.
Dr. Bill Petok: Yes.
Mark Goldberg: Right. And these things can become very layered and compound pretty quickly for a lot of guys.
Dr. Bill Petok: Yeah.
Mark Goldberg: So another question I think that our listeners would be interested in is that when a couple is able to overcome this infertility challenge, they’re able to conceive and have a baby through any of the treatments available… will the sexual issues such as erectile dysfunction, resolve themselves in your experience? Or can the sexual dysfunction continue even after the initial trigger has been resolved?
Dr. Bill Petok: Well, I’m going to give you the classic answer which is, it just depends. It could resolve, the anxiety, the performance concerns could dissipate, we got pregnant, we’re having a kid, we don’t have to worry about that anymore, or they could continue. And a lot, I think depends on what were the pre-existing conditions.
A guy who’s got really good erections and has a strong sense of self and has a good sense of what is pleasurable, who develops some transient form of erectile dysfunction during infertility treatment, is probably more likely to recover quickly than a guy who had shaky erections, less self-confidence, was more concerned about sexual function after infertility treatment, depending about what the treatment is of course.
It’s going to run a wide range, which speaks to knowing who you’re working with well, and building in strategies of working with somebody, so that they don’t forget that sex for reproduction is just part of the reason we have sex. And that doing things which are pleasurable during the course of infertility treatment outside of that window is just as important.
Mark Goldberg: I imagine that listeners to this podcast can already appreciate your answer if it just depends, as we continually reinforce the message that this is complex. It’s complex and there’s no simple answer that’s going to apply for infertility.
Every person who finds themselves in that situation, every man who experiences ED during infertility treatments or during a process of not being able to conceive is different. His experience is going to be different, and how quickly he can resolve this ED is going to depend on a whole slew of factors. This is just being one of them.
Dr. Bill Petok: Yes, that’s correct.
Mark Goldberg: So to that end, Dr. Petok, what recommendations do you have for a man who develops significant erectile dysfunction during infertility treatments or during a period where he and his partner are trying to conceive and are not being successful?
Dr. Bill Petok: Well, I’d go back to that statement I made before that keeping in mind that sex for reproduction is just one of the reasons we have sex, and that staying connected on an emotional and physical level and other times than that fertile window would be important, that pleasuring for just that for pleasuring would be good.
We’ll sometimes recommend that people take a holiday from treatment. There’s a whole slew of things that people can do to take a holiday.
You don’t necessarily have to stop the treatment. You can’t today go to a motel as easily as you could 12 months ago, but go do something which is fun. Return to some of the things which were romantic in your earlier life together, things which were sexually arousing, things that gave you pleasure.
All of those sort of things would be useful. Taking that holiday from being focused on sex just for reproduction would be critical. And I wouldn’t overlook the use of some of the PDE5 inhibitors as a medical treatment for an erectile difficulty. There isn’t any data that suggest their use impairs sperm function, so you would be fine doing that. That might be a bit of a help during that time period.
Mark Goldberg: If I’m hearing you correctly, the process of infertility treatment can feel not sexy?
Dr. Bill Petok: That’s an understatement, Mark.
Mark Goldberg: Okay. I don’t want to oversell that, but obviously, it is filled with challenges. It can become a rigid road. It could feel routine like, “We have to get this done.”
Some of the recommendations that I hear you making are really about infusing the relationship with pleasure, leaning on earlier stages of the relationship where pleasure was more of the focus and infertility was not at the forefront.
We’re trying to call in some of those earlier experiences, as well as potentially talking to a medical provider about using a medication. That’s what you’re referring to with the…
Dr. Bill Petok: Yeah, and I guess the other thing is, if you’re in infertility treatment, asking the treatment team if they have somebody who is equipped. They should have somebody who’s equipped to deal with the mental health components of infertility, sexuality being part of it.
Most of us who work in the infertility field know something about sex because we know that sex is one of the reasons that people have fertility problems. Not everybody specializes in sexuality component, but clearly, reproductive endocrinologists and urologists who deal with this problem understand this difficulty and know and have good referral sources for mental health providers.
Mark Goldberg: So a man should not feel that’s something he cannot bring up with an endocrinologist or with any other fertility counselor or professional. This is certainly a well-known challenge of trying to conceive. A provider is likely going to be understanding, empathic, and will be able to help you get to the treatments that you need to help resolve that erectile dysfunction.
Dr. Bill Petok: That’s correct.
Mark Goldberg: So, Dr. Petok, can you share with us how common infertility issues are for couples?
Dr. Bill Petok: Sure. Mark, the data suggest that between 12% and 15% of couples will experience infertility in one form or another. And infertility is defined as having unprotected vaginal penetrative sex for 12 months without conception. It’s important to have that construct built around it, so we know what the definitions are.
Of the 12% to 15%, and we’re talking about primarily worldwide, not just United States statistics, of that amount, their breakdown is about 50% is female factor, about 40% is male factor, and another 10% is shared male and female.
So despite what people may glean from news reports or popular press, male factor infertility is almost as significant as female factor.
Mark Goldberg: Wow. So you’re saying that about 12% to 15% of couples are going to encounter a period of 12 months with intentionally trying to conceive through penetrative sex and will not be successful?
Dr. Bill Petok: That’s correct.
Mark Goldberg: Of that 12% to 15%, 40% of those couples will be experiencing that as a result of an issue with the male partner.
Dr. Bill Petok: That’s correct. It’s a big chunk, and like I said, popular press would have you believe that infertility is primarily a female problem, but it is significantly a male problem as well. And there are a number of reasons why the press doesn’t cover it in the same way.
Ultimately, every pregnancy takes place within a woman, and so a great deal of medical attention is directed at the female component of infertility.
Mark Goldberg: So it requires, generally speaking, both partners. Dr. Petok, can you share with us about some of the particulars of that 40%? What types of issues lead to male infertility or the male role in this process of infertility?
Dr. Bill Petok: Well, you could think about it in two ways. Two primary components. One has to do with production of sperm that are well functioning and the other is the delivery of those sperm so that they can fertilize an egg. It’s about the production and also the plumbing, if you will. And the production of sperm, as with the production of eggs, is a complex process which has got biological and hormonal components to it that are critical.
With one of those components malfunctioning, you could wind up with a lack of production or production of sperm which are inadequate for proper fertilization of an egg. And then the other side of that would be, there’s some way that the sperm can’t get to the egg.
Either it has difficulty transversing, making the transition from the testis to the seminal duct and out through the vas deferens and through the penis into the vagina or there is some other functional issue that’s causing lack of sperm production.
Testicles reside below the body on purpose because they need to be slightly cooler than the average body temperature to produce sperm. If you have, for example, something called a varicocele, which is a large amount of veins around the testicle, the heat from the blood in those veins can overheat the testis so that it can’t produce sperm properly.
As you can see, it’s a rather complex process.
Mark Goldberg: Yes, it sounds rather complex. And what I’m gathering from you Dr. Petok, is that there is the production end of the sperm, which can have a whole slew of problems as well as the delivery. And when you talk about delivery, and in particular around the podcast that we’re focusing on in sexual dysfunction, does that include instances of unejaculation, where a man may have trouble reaching ejaculation through penetrative sex or are we talking about… even with ejaculation, there’s particular challenges with the sperm being able to travel once it is in the woman?
Dr. Bill Petok: So you could have the unejaculation problems where the man does not ejaculate with penetrative sex. You could have retrograde ejaculation where the ejaculate goes, essentially, backwards and winds up in the bladder unable to get out of the penis and into the vagina and therefore into the uterus and able to fertilize an egg.
Those would be two issues. And of course, without the ability to penetrate, having an erectile dysfunction, you can’t deliver the goods, so to speak.
Mark Goldberg: So, Dr. Petok, can you inform myself and the listeners about what the primary treatments are for infertility?
Dr. Bill Petok: Well, let’s divide them into two categories. There’s the female side of things, which I’ll talk about second and then there’s the male side of things. There are such a wide variety of issues that could take place that have an impact on sperm production.
There could be hormonal issues, there could be exposure to toxins, we know that anybody who has a chemotherapy for cancer is likely to have impaired, if not destroyed, spermatogenesis, because of the toxic nature.
People are exposed to toxic chemicals, there’s even… well, there are problems with things such as marijuana smoking, because THC, the active ingredient in marijuana, has an effect which reduces sperm production. It is reversible in most cases but if a man has been smoking for a very long time and has built up high levels of THC in his testes, which is where they would reside, he’s going to have difficulty.
The same would be true for a man who uses steroids, anabolic steroids for weight lifting. What happens in that case is the brain gets a message that there’s plenty of testosterone on board and you don’t need to produce any more and production of testosterone is necessary for the production of sperm.
In trying to get stronger and become more manly, a man could be destroying another form of manliness which is being able to conceive. So the other part would be some form of blockage. One of the more common forms is something called CBAVD. Which is Chronic Bilateral Absence of the Vas Deferens. The vas deferens is a duct which gets the sperm out of testis into the ejaculatory duct and then into the penis, so that it can be flushed into the vaginal barrel. But if you don’t have a vas deferens, you may be producing viable sperm but it can’t get out.
We have new treatments which are quite remarkable. The treatments are microsurgical techniques, which allow a surgeon to extract sperm either from the vas, where it may be stuck, or directly from the testicle. These procedures are done under anesthesia, under the microscope and by highly trained individuals.
Quite remarkably, it is able to extract sperm directly from a testicle, freeze it or use it immediately in a fresh state to fertilize an egg, with a procedure known as ICSI, which is short for Intracytoplasmic Sperm Injection. And what happens in this process, and you can watch videos of this on the internet, it’s really quite remarkable.
A single egg is held in a pipette under the microscope, and a single sperm is placed in a much thinner pipette, and that thin pipette with the single sperm is placed through the outer coating of the egg, the zona pellucida, to the interior of the egg and the sperm is injected into that egg, the pipette is withdrawn, the zona pellucida heals over and you get a high rate of fertilization like this.
So many people refer to that as a treatment for male factor infertility.
Mark Goldberg: Yeah. So it sounds like it’s quite a cutting edge type of intervention. When we go back to that 40% being caused by male, and it sounds like men can have a pretty active role in resolving the infertility. Like you pointed out, Dr. Petok, I would have imagined that primarily the man is asked to ejaculate into a cup, and the rest happens on the female partner side.
But just hearing about what some of the implications are, this could be… I understand it’s a microsurgery, but it still can involve a little bit more than ejaculating into a cup and could require more of the male partner?
Dr. Bill Petok: Well, and in fact, IUI, which is what you’re talking about, intrauterine insemination, is one way of delivering… if there’s a delivery issue, you can’t get the sperm out, then you’re going to have to go in and extract it, if you can, if it’s there.
IUI would be helpful under circumstances where there are other issues that impede sperm from connecting with an egg. So, for example, there may be antibodies which attack the sperm when they enter the vaginal barrel and prevent it from going through the cervix. So, IUI would go through the vaginal barrel with a flexible catheter and place sperm directly into the uterus.
Many people do ICSI now, any reproductive endocrinologist does ICSI, as a matter of course, because traditional IVF places eggs in a petri dish, and place sperm in that petri dish, and hopes that they get together, which they typically do. But with ICSI, you see it happening under the microscope, so you know you’ve got a fertilized egg. It’s a higher-tech, more cost, but more effective.
Mark Goldberg: It sounds like there are a number of excellent treatments out there?
Dr. Bill Petok: Yes.
Mark Goldberg: And couples have a lot of things open to them now. Can you share a little bit about the stress that couples experience, going through this process?
Dr. Bill Petok: Absolutely. This is true for both men and women, but probably more so for women. The sort of mindset, as we grow up, is that we will… for those of us who are heterosexual, we will grow up, go to school, get a career, find a mate and have a family.
Today, even if we’re not heterosexual, technology allows us to have families, especially with the use of gestational carriers and egg donors, for gay men. And gay women have been doing this for years, with just sperm donors.
That’s the mindset, that’s what we expect to happen, and when that doesn’t happen, the sense of failure, embarrassment, shame, self-blame. We could go on and on about what kinds of things people think, both men and women, about this failure to conceive, this infertility, and so it can be quite stressful. And that’s just the diagnosis, and then you talk about the treatments.
As you could imagine from my description of what sperm extraction looks like, with these microsurgical techniques, it’s not exactly the sort of thing we wake up in the morning and think about that would be just great.
In fact, probably when I was talking about that surgical procedure, many men listening sort of pinched their legs together, because the thought of someone cutting your testicle open to get sperm out is not exactly comforting.
Mark Goldberg: I will acknowledge, I had a similar reaction upon hearing that, as well. [chuckle]
Dr. Bill Petok: Yes, yeah. Well, you’re not alone. So, there’s the stress of that, and then of course, there’s the stress of, “Will this work?”
And then, there is the overriding stress of, “What this will cost?” You know, infertility treatments are not inexpensive. The average IVF cycle in the United States costs between $12,000 and $15,000. If you throw in ICSI and other treatments, you’re talking upwards of $20,000.
This is not inexpensive, and many states don’t mandate treatment for infertility. Maryland, where we are, happens to be one of the mandated states, and so up to three cycles are mandated to be covered by insurance. But in many states, that is not the case, so you’re paying out of pocket for the cost of treatment, and depending upon your financial circumstances, that could be quite stressful.
Mark Goldberg: So it sounds like there are a number of issues that are going to impact both individuals and couples.
Dr. Bill Petok: Correct.
Mark Goldberg: Stepping all the way back to their early years schema of what life is supposed to look like.
Dr. Bill Petok: Yeah.
Mark Goldberg: Through the treatment period, the financial cost, the concern, the fear, the worry, potential disappointment of treatment not working.
Dr. Bill Petok: Correct.
Mark Goldberg: Do you see unique patterns, or particular patterns, in terms of the ways couples interact, or struggle to interact, struggle to engage and connect, when they’re going through this process?
Dr. Bill Petok: Probably the most significant pattern is that usually neither party is in the same place as the other party, at the same time. That can cause stress, because if I’m down and my spouse is in a more hopeful period, she may wonder what’s wrong with me, why am I not more hopeful, or vice versa.
But, of course, individuals go through these things individually, and if someone has been identified as the major problem area, whether it be male or female, they may take on an extra burden of stress, and guilt, and worry, and their partner may say, “Don’t worry, we’ll be able to work things out.”
As you’re well aware, telling somebody not to worry is an ineffective strategy. Doesn’t work, people tend to worry, anyway.
Mark Goldberg: Another thing that you pointed out, which is fascinating, is how young the field of infertility treatment really is, and that data is still being collected. We don’t really know to what extent the implications are for sexual dysfunction that stems during this period, as well as during the treatments.
Dr. Bill Petok: Correct.
Mark Goldberg: We’re continually learning, but it’s fair to assume that it could have a role, and maybe even a significant role, in a sexual dysfunction, like erectile dysfunction?
Dr. Bill Petok: It could. Let me just add one thing. The field of IVF is only 42 years old. Infertility treatment has been going on further than that, the first artificial insemination took place in 1884, in Philadelphia, at Thomas Jefferson University, a doctor by name of William Pancoast did that.
Turned out the wife of one of his residents was unable to conceive, and they determined that it was a male-factor problem. This speaks to the zeitgeist of the times, the doctor looked around at his residents and picked the one that he presumed would be the best looking, and had him produce a specimen which he was going to transfer.
The woman was not told this was going to take place, and she was anesthetized, she was knocked out, basically, so she didn’t know whose semen was being used to artificially inseminate her.
The scientific report didn’t come up for 25 years later, and so we get this notion that the use of donors is a secret which must be kept. The thinking at the time was a child knowing that they were donor-conceived would be unable to bond with their parents, and of course, this was long before Bowlby had developed attachment theory, it was somebody’s idea. I
It’s led to a feeling that secrecy is important in reproductive medicine, and that’s changed over the last 25 or 30 years. We now know that there is no shame in being donor-conceived, we now know that children who are the product of donor conception bond very well with the people who raise them. Those are their parents, the donor was just that, a donor. But I’ve gotten off on a tangent…
Mark Goldberg: Yes. The field has developed, and infertility certainly has been a challenge, historically.
Dr. Bill Petok: Yes.
Mark Goldberg: But you’re saying treatment began already… documented treatment began in the 1800s, late 1800s?
Dr. Bill Petok: Late 1800s.
Mark Goldberg: But IVF is really more in the past 40 some odd years.
Dr. Bill Petok: Yeah, 42 years was the first baby, right.
Mark Goldberg: Well, Dr. Petok, I want to thank you very much for your time. This has been extremely informative, I have no doubt that our listeners are going to learn a tremendous amount from this podcast.
Certainly, about infertility treatments, the potential challenges they bring to sexual engagement, and the importance of infusing a relationship with pleasurable activities.
Dr. Bill Petok: I hope that’s the overall message. I want to thank you, Mark, for inviting me to do this. Of course, male factor infertility has been a special interest of mine for many years, and it’s a pleasure to be able to speak to your audience about this.
Mark Goldberg: Thank you, we look forward to having you again on the podcast, in the future. Thank you very much.
Dr. Bill Petok: You’re more than welcome.
Learn more about Dr. Bill Petok on his website.
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