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Human Sexuality



Infertility means you cannot make a baby (conceive).

Infertility is grouped into two categories:

  • Primary infertility refers to couples who have not become pregnant after at least 1 year of unprotected sex (intercourse).
  • Secondary infertility refers to couples who have been pregnant at least once, but never again.

Alternative Names

Inability to conceive; Unable to get pregnant


A wide range of physical and emotional factors can cause infertility. Infertility may be due to problems in the woman, man, or both.


Female infertility may occur when:

  • A fertilized egg or embryo does not survive once it sticks to the lining of the womb (uterus)
  • The fertilized egg does not attach to the lining of the uterus
  • The eggs cannot move from the ovaries to the womb
  • The ovaries have problems producing eggs

Female infertility may be caused by:

  • Autoimmune disorders, such as antiphospholipid syndrome (APS)
  • Cancer or tumor
  • Clotting disorders
  • Diabetes
  • Growths (such as fibroids or polyps) in the uterus and cervix
  • Birth defects that affect the reproductive tract
  • Excessive exercising
  • Eating disorders or poor nutrition
  • Use of certain medications, including chemotherapy drugs
  • Drinking too much alcohol
  • Obesity
  • Older age
  • Ovarian cysts and polycystic ovary syndrome (PCOS)
  • Pelvic infection or pelvic inflammatory disease (PID)
  • Scarring from sexually transmitted infection or endometriosis
  • Thyroid disease
  • Too little or too much hormones


Male infertility may be due to:

  • A decrease in sperm count
  • Sperm being blocked from being released
  • Sperm that do not work properly

Male infertility can be caused by:

  • Environmental pollutants
  • Being in high heat for prolonged periods
  • Birth defects
  • Heavy use of alcohol, marijuana, or cocaine
  • Too little or too much hormones
  • Impotence
  • Infection
  • Older age
  • Cancer treatments, including chemotherapy and radiation
  • Scarring from sexually transmitted diseases, injury, or surgery
  • Retrograde ejaculation
  • Smoking
  • Use of certain drugs, such as cimetidine, spironolactone, and nitrofurantoin

In healthy couples under age 30 who have sex regularly, the chance of getting pregnant is about 25 - 30% per month.

A woman's peak fertility occurs in her early 20s. After age 35 (and especially 40), the chances that a woman can get pregnant drops considerably.


The main symptom of infertility is the inability to become pregnant. Specific symptoms depend on what is causing the infertility.

Infertility can cause many painful emotions in one or both partners.

Exams and Tests

When you should seek treatment for infertility depends on your age. It is recommended that women under 30 should generally try to get pregnant on their own for 1 year before seeking testing.

Infertility testing involves a complete medical history and physical examination of both partners.

Blood and imaging tests will be done. In women, this may include:

  • Blood tests to check hormone levels, including progesterone and follicle stimulating hormone
  • Checking body temperature first thing in the morning to check if the ovaries are releasing eggs
  • FSH and clomid challenge test
  • Hysterosalpingography (HSG)
  • Pelvic ultrasound
  • Laparoscopy
  • Luteinizing hormone urine test (ovulation prediction)
  • Thyroid function tests

Tests in men may include:

  • Sperm testing
  • Testicular biopsy (rarely done)


Treatment depends on the cause of infertility. It may involve:

  • Education and counseling
  • Fertility treatments such as intrauterine insemination (IUI) and in vitro fertilization (IVF)
  • Medicines to treat infections and clotting disorders
  • Medicines that help the woman grow and release eggs from the ovaries

It is important to recognize and discuss the emotional impact that infertility has on you and your partner, and to seek medical advice from your health care provider.

You can increase your chances of becoming pregnant each month by having sex at least every 3 days before and during ovulation. It is especially important to do so 72 hours before ovulation begins.

Ovulation occurs about 2 weeks before the next menstrual cycle (period) starts. If a woman gets her period every 28 days, the couple should have sex at least every 3 days between the 10th and 18th day after the period starts.

Support Groups

See: Infertility - support group

Outlook (Prognosis)

As many as 1 in 5 couples diagnosed with infertility eventually become pregnant without treatment.

More than half of couples with infertility become pregnant after treatment, not including advanced techniques such as in vitro fertiliziation (IVF).

Possible Complications

Infertility can have a big emotional impact on you and your partner.

Depression, anxiety, and marriage problems may occur.

When to Contact a Medical Professional

Call for an appointment with your health care provider if you are unable to get pregnant.


Preventing sexually transmitted infections (STIs), such as gonorrhea and chlamydia, may reduce your risk of infertility.

Maintaining a healthy diet, weight, and lifestyle may increase your chances for getting pregnant and having a healthy pregnancy.

Take a prenatal or multivitamin containing folate before and during pregnancy. This lowers your risk for miscarriage and developmental problems in the baby.


Jose-Miller AB, Boyden JW, Frey KA. Infertility. Am Fam Physician. 2007;75(6):894-856.

Lobo RA. Infertility: etiology, diagnostic evaluation, management, prognosis. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM eds. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2007: chap 41.

Speroff L, Fitz M, eds. Clinical Gynecologic Endocrinology and Infertility. 7th ed. Philadelphia, Pa; Lippincott Williams & Wilkins; 2005.

Brassard M, Melk YA, Baillargeon JP. Basic Infertility Including Polycystic Ovary Syndrome. Medical Clinics of North America. Sept 2008;92(5).

Erection problems


An erection problem is when a man cannot get or keep an erection that is firm enough to have intercourse. You may be unable to get an erection at all. Or, you may lose the erection during intercourse before you are ready.

If the condition continues, it is called erectile dysfunction.

Alternative Names

Erectile dysfunction; Impotence; Sexual dysfunction - male


Erection problems are common in adult men. Almost all men sometimes have trouble getting or keeping an erection.

In many cases, the problem goes away with little or no treatment. In other cases, it can be an ongoing problem. If you have trouble getting or keeping an erection more than 25% of the time, it is a problem.

An erection problem that does not go away can damage your self-esteem and harm your relationship with your partner. It needs to be treated.

In the past, erection problems were thought to be "all in the man's mind." Men often were given unhelpful advice such as, "don't worry," or "just relax and it will take care of itself." Today, doctors believe that physical factors often cause erection problems.

One way to know if the cause is physical is whether you have nighttime erections. Normally, men have 3 to 5 erections per night. Each erection lasts for up to 30 minutes. Your doctor can tell you how to find out whether you are having the normal number of nighttime erections. If you have erections in the morning, this can also mean that there is not a physical cause.

Erection problems usually do not affect a man's sex drive.

Having an orgasm too quickly (premature ejaculation) is not the same as impotence. Get counseling with your partner for this problem.

Male infertility is also different from impotence. A man who cannot keep an erection may be able to produce sperm that can fertilize an egg. A man who is infertile can usually keep an erection, but he may not be able to father a child due to problems with sperm.


An erection involves your brain, nerves, hormones, and blood vessels. Anything that interferes with these normal functions can lead to problems getting an erection.

Common causes of erection problems include:

  • Diseases such as diabetes, high blood pressure, heart or thyroid conditions, poor blood flow, depression, or nervous system disorders (such as multiple sclerosis or Parkinson's disease)
  • Medicines, including blood pressure medications (especially beta-blockers), heart medications (such as digoxin), some peptic ulcer medications, sleeping pills, and antidepressants
  • Nerve damage from prostate surgery
  • Nicotine, alcohol, or cocaine use
  • Poor communication with your partner
  • Repeated feelings of doubt and failure
  • Spinal cord injury
  • Stress, fear, anxiety, or anger
  • Unrealistic sexual expectations, which make sex a task instead of a pleasure

Erection problems become more common with age. However, they can affect men at any age. Physical causes are more common in older men. Emotional causes are more common in younger men.

Low levels of testosterone can lead to erection problems. They may also reduce a man's sex drive.

Home Care

For many men, lifestyle changes can help:

  • Cut down on smoking, alcohol, and illegal drug use.
  • Get plenty of rest and take time to relax.
  • Exercise and eat a healthy diet to keep good blood circulation.
  • Use safe sex practices to prevent HIV and STDs.
  • Talk openly to your partner about sex and your relationship. If you cannot do this, counseling can help.

Couples who cannot talk to each other are likely to have problems with sexual intimacy. Men who have trouble talking about their feelings may find it hard to share their anxiety about sexual performance. Counseling can help both you and your partner.

See also:

  • Erection problems - aftercare
  • Kegel exercise - self-care

When to Contact a Medical Professional

Call your doctor if:

  • The problem does not go away with lifestyle changes
  • The problem begins after an injury or prostate surgery
  • You have other symptoms, such as low back pain, abdominal pain, or a change in urination

If erection problems seem to be caused by a medication you are taking, talk to your health care provider. You may need to lower the dose or change to another drug. DO NOT change or stop taking any medications without first talking to your health care provider.

Talk to your health care provider if your erection problems have to do with a fear of heart problems. Sexual intercourse is usually safe for men with heart problems.

Call your doctor right away or go to an emergency room if the medication you are taking for erection problems gives you an erection that lasts for more than 4 hours.

What to Expect at Your Office Visit

Your doctor will perform a physical exam, which may include:

  • Checking your blood flow (circulation)
  • An exam of your penis and rectum
  • An exam of your nervous system

To help find the cause of the problem, your doctor will ask medical history questions such as:

  • Have you been able to get and keep erections in the past?
  • Are you having trouble getting an erection, or keeping erections?
  • Do you have erections during sleep?
  • How long have you had trouble with erections?
  • What medications are you taking (including prescription medications, over-the-counter medications, and recreational drugs)?
  • Do you smoke? How much each day?
  • Do you use alcohol? How much?
  • Have you recently had surgery?
  • Have you ever had surgery or other treatments for your blood vessels?
  • Are you depressed?
  • Are you afraid or worried about something?
  • Are you experiencing a lot of stress?
  • Has your energy level decreased?
  • Are you sleeping well each night?
  • Are you afraid of sexual activity because of physical problems?
  • Have there been any recent changes in your life?
  • What other symptoms do you have?
  • Have you noticed changes in feeling to your penis?
  • Do you have any problems with urination?

Tests that may be done include:

  • Blood tests, including:
    • Complete blood count
    • Hormone profile
    • Metabolic panel
    • PSA
  • Nerve testing
  • Nocturnal penile tumescence (NPT) to check for normal nighttime erections
  • Penile ultrasound to check for blood vessel or blood flow problems
  • Psychometric testing
  • Rigidity monitoring
  • Urine analysis


The treatment may depend on the cause of the problem. Talk to your health care provider about the best way to treat your erection problem.

There are many treatment options today, including:

  • Injections into the penis
  • Medicines inserted into the urethra
  • Medicines taken by mouth
  • Surgery
  • Vacuum devices

Ask your health care provider about the possible side effects and complications of each treatment.

Sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis) are medicines called phosphodiesterase-5 (PDE5) inhibitors. They work only when you are sexually aroused. They usually start to work in 15 to 45 minutes.

These drugs can have side effects, which can range from muscle pain and flushing to heart attack. Do not use these drugs with medications such as nitroglycerin. The combination can cause your blood pressure to drop. Some men have died after taking these drugs with nitroglycerin.

Use PDE5 inhibitors with caution if you have any of the following conditions:

  • Recent stroke or heart attack
  • Severe heart disease, such as unstable angina or irregular heartbeat (arrhythmia)
  • Severe heart failure
  • Uncontrolled high blood pressure
  • Uncontrolled diabetes
  • Very low blood pressure

If pills do not work, other treatment options include:

  • Testosterone replacement using skin patches, gel, or injections into the muscle -- if your testosterone level is low.
  • A medicine called alprostadil, injected into the penis or inserted into the urethra, improves blood flow to the penis. This usually works better than medications taken by mouth.
  • A vacuum device can be used to pull blood into the penis. A special rubber band is then used to keep the erection during intercourse.
  • Some men may need a penis implant (prosthesis).

Many herbs and dietary supplements are marketed to help sexual performance or desire. However, none of these supplements have been profen effective for treating erectile dysfunction, and they may not always be safe.


Heidelbaugh JJ. Management of erectile dysfunction. Am Fam Physician. 2010;81:305-312.

Qaseem A, Snow V, Denberg TD, et al. Hormonal testing and pharmacologic treatment of erectile dysfunction: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2009;151:639-649.

Inhibited sexual desire


Inhibited sexual desire (ISD) refers to a low level of sexual interest. A person with ISD will not start, or respond to their partner's desire for, sexual activity.

ISD can be primary (in which the person has never felt much sexual desire or interest), or secondary (in which the person used to feel sexual desire, but no longer does).

ISD can also relate to the partner (the person with ISD is interested in other people, but not his or her partner), or it can be general ( the person with ISD isn't sexually interested in anyone). In the extreme form of sexual aversion, the person not only lacks sexual desire, but may find sex repulsive.

Sometimes, the sexual desire is not inhibited. The two partners have different sexual interest levels, even though both of their interest levels are within the normal range.

Someone can claim that his or her partner has ISD, when in fact they have overactive sexual desire and are very demanding sexually.

Alternative Names

Sexual aversion; Sexual apathy; Hypoactive sexual desire


ISD is a very common sexual disorder. Often it occurs when one partner does not feel intimate or close to the other.

Communication problems, lack of affection, power struggles and conflicts, and not having enough time alone together are common factors. ISD also can occur in people who've had a very strict upbringing concerning sex, negative attitudes toward sex, or traumatic sexual experiences (such as rape, incest, or sexual abuse).

Illnesses and some medications can also contribute to ISD, especially when they cause fatigue, pain, or general feelings of malaise. A lack of certain hormones can sometimes be involved. Psychological conditions such as depression and excess stress can dampen sexual interest. Hormonal changes can also affect libido.

Commonly overlooked factors include insomnia or lack of sleep, which lead to fatigue. ISD can also be associated with other sexual problems, and sometimes can be caused by them. For example, the woman who is unable to have an orgasm or has pain with intercourse, or the man who has erection problems (impotence) or retarded ejaculation can lose interest in sex because they associate it with failure or it does not feel good.

People who were victims of childhood sexual abuse or rape, and those whose marriages lack emotional intimacy are especially at risk for ISD.


The primary symptom is lack of sexual interest.

Exams and Tests

Most of the time, a medical exam and lab tests will not show a physical cause.

However, testosterone is the hormone that creates sexual desire in both men and women. Testosterone levels may be checked, especially in men who have ISD. Blood for such tests should be drawn before 10:00 a.m., when male hormone levels are at their highest.

Once physical causes have been ruled out, interviews with a sex therapy specialist may be helpful to reveal possible causes.


Treatment must be targeted to the factors that may be lowering sexual interest. Often, there may be several such factors.

Some couples will need relationship or marital therapy before focusing on enhancing sexual activity. Some couples will need to be taught how to resolve conflicts and work through differences in nonsexual areas.

Communication training helps couples learn how to talk to one another, show empathy, resolve differences with sensitivity and respect for each other's feelings, learn how to express anger in a positive way, reserve time for activities together, and show affection, in order to encourage sexual desire.

Many couples will also need to focus on their sexual relationship. Through education and couple's assignments, they learn to increase the time they devote to sexual activity. Some couples will also need to focus on how they can sexually approach their partner in more interesting and desirable ways, and how to more gently and tactfully decline a sexual invitation.

Problems with sexual arousal or performance that affect sexual drive will need to be directly addressed. Some doctors recommend treating women with either cream or oral testosterone, often combined with estrogen, but there is no clear cut evidence yet. There are studies underway looking at the possible benefit of testosterone supplementation for women with decreased libido.

Outlook (Prognosis)

Disorders of sexual desire are often difficult to treat. They seem to be even more challenging to treat in men. For help, get a referral to someone who specializes in sex and marital therapy.

Possible Complications

When both partners have low sexual desire, sexual interest level will not be a problem in the relationship. Low sexual desire, however, may be a sign of the health of the relationship.

In other cases where there is an excellent and loving relationship, low sexual desire may cause a partner to feel hurt and rejected. This can lead to feelings of resentment and make the partners feel emotionally distant.

Sex is something that can either bring a relationship closer together, or slowly drive it apart. When one partner is much less interested in sex than the other partner, and this has become a source of conflict, they should get professional help before the relationship becomes further strained.


One good way to prevent ISD is to set aside time for nonsexual intimacy. Couples who reserve time each week for talking and for a date alone without the kids will keep a closer relationship and are more likely to feel sexual interest.

Couples should also separate sex and affection, so that they won't be afraid that affection will always be seen as an invitation to have sex.

Reading books or taking courses in couple's communication, or reading books about massage can also encourage feelings of closeness. For some people, reading novels or watching movies with romantic or sexual content also can encourage sexual desire.

Regularly setting aside "prime time," before exhaustion sets in, for both talking and sexual intimacy will improve closeness and sexual desire.


Bhasin S, Basson R. Sexual dysfunction in men and women. In: Kronenberg HM, Melmed S, Polonsky KS, Larsen PR, eds. Williams Textbook of Endocrinology. 11th ed. Philadelphia, Pa: Saunders Elsevier; 2008:chap 19.

Shafer LC. Sexual disorders and sexual dysfunction. In: Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 1st ed. Philadelphia, Pa: Mosby Elsevier; 2008:chap 36.

Clayton AH, Hamilton DV. Female sexual dysfunction. Psychiatr Clin North Am. 2010;33:323-338.