Human Reproduction, Vol. 14, No. 7, 1783-1784,
July 1999
© 1999 European Society of Human Reproduction and Embryology
Viagra for temporary erectile dysfunction during treatments with assisted reproductive technologies: Case report
1 IVF Unit, Department of Obstetrics and Gynecology, Barzilai Medical Center, Ben-Gurion University of the Neger, 78306 Ashkelon, Israel, and 2 Department of Obstetrics and Gynecology Chair A, University of Turin, 10100 Turin, Italy
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Abstract |
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During treatments with assisted reproductive technologies (ART), some men may have difficulties in producing spermatozoa on demand at the time of insemination, either for intrauterine insemination (IUI) or for in-vitro fertilization (IVF). This situation imposes tremendous stress on the couple and may cause cancellation of the treatment. Here we describe, for the first time, the use of sildenafil citrate (ViagraTM) for temporary erectile dysfunction in couples undergoing ART. The first case was a man who could not produce spermatozoa for the first IVF treatment after an exhausting trial for 12 h, despite the fact that he never had problems in providing sperm samples during previous IUI cycles. Using Viagra enabled him to provide spermatozoa, but the delay in oocyte insemination resulted in no embryonic development. This prompted us to be more alert to this option and to suggest the use of Viagra to men who had a history of erectile dysfunction during previous ART cycles. In these cases, the use of Viagra was planned in advance and it successfully solved any unpredictable erectile dysfunction on the day of insemination. Such cases emphasize the need to think in advance of this potential use of Viagra during ART.
Key words: erectile dysfunction/infertility/IVF/sildenafil citrate/viagra
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Introduction |
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During an assisted reproductive technology (ART) treatment, the female partner is the one who usually receives medication, undergoes ultrasound examinations, blood testing and operative procedures. The man, besides supporting his partner during this stressful treatment, is requested only to produce one or two sperm samples for intrauterine insemination (IUI) or in-vitro fertilization (IVF) (Tur-Kaspa et al., 1994
). Unfortunately, sometimes men fail this requirement. This failure confronts the couple with tremendous stress. It usually can be solved with time, or by audiovisual supports. Rarely, invasive procedures such as electroejaculation or epididymal or testicular sperm aspiration have been successfully implemented (Hovav et al., 1996; Vanderschueren et al., 1998). Occasionally, cancellation of these particular treatment cycles is required. For such cases freezing of spermatozoa as a back-up for the next cycle is recommended.
Sildenafil citrate (ViagraTM) has recently been successfully introduced for the treatment of erectile dysfunction in which there is no established organic cause (Boolell et al., 1996). Sildenafil citrate, a selective inhibitor of the type-V cGMP-specific phosphodiesterase enzyme, potently enhances the relaxant effect of nitric oxide on the human corpus cavernosum by increasing the value of cGMP in this tissue. Sexual stimulation is required in order to produce its pharmacological effect, since it has no direct relaxant effect on the corpus cavernosum (Ballard et al., 1998). Viagra has been shown not to affect sperm count of healthy donors.
We describe, for the first time, the use of Viagra during ART treatments for cases of temporary erectile dysfunction. We think that the early use of Viagra after failed attempts to produce spermatozoa lasting for 1–2 h should be considered. This may prevent both stress and frustration for the couple and a delay in the insemination, which may compromise the IVF/IUI results.
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Case report |
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Four men with temporary erectile dysfunction during IVF treatments were identified. One was a 36 year old man, who with a 32 year old woman was referred for an IVF treatment after failed cycles of ovarian stimulation with IUI because of unexplained secondary infertility of 3 years. The man never had difficulties in providing sperm samples on demand during the three previous IUI cycles. However, on the day of the egg retrieval he had temporary erectile dysfunction lasting for 12 h, which he attributed to the stress that he felt because of the IVF treatment.
After these exhausting trials to donate spermatozoa, we considered the possibility that Viagra might assist the first man described above to solve this unexpected problem. Indeed, 1 h and 10 h after taking 50 mg of the drug, he produced two sperm samples with a total of 70x106 motile spermatozoa. Eleven oocytes were collected and were inseminated by standard IVF procedure. After 18 h we observed two pronuclei in four oocytes, but no subsequent cleavage occurred in these fertilized eggs and, therefore, no embryo transfer was performed. The patient was not asked to produce two sperm samples but he probably felt he needed it for his own reassurance.
It seemed to us that earlier use of Viagra in this case might have prevented the delayed insemination and possibly avoided losing a chance to conceive in that particular cycle. Thus, we searched among our patients for men who had a history of previous temporary erectile dysfunction during ART treatments and who would, therefore, possibly benefit from earlier use of Viagra in an IVF cycle.
The second man was 41 years old who produced spermatozoa for previous IUI only after ~5 h of attempts. The third was a 45 year old man, who repeatedly could not produce spermatozoa on the morning of nine previous oocyte retrieval procedures, but could produce spermatozoa only on the evening before. Because of that, the sperm sample was kept in medium until the next morning. He underwent testicular sperm extraction (TESE) once because of his inability to produce spermatozoa for IVF. The fourth man was 35 years old, and was able to provide a sperm sample, but only after 2 h of attempts. Each of these men was advised to use 50 mg of Viagra 1 h before they attempted to produce a sperm sample for IVF or IUI treatment.
The second and third men used Viagra for the first time at the next IVF treatment, and produced a sperm sample with no difficulty. The fourth man felt a great relief of pressure because of this potential solution to his difficulties. Due to these feelings he easily succeeded in providing a sperm sample without having to take the drug.
A significant delay of the insemination procedure for both IVF and IUI may compromise the results of these treatments. The first case we described here clearly demonstrated it. Since a mature oocyte can be fertilized for 12–24 h, prolonged pre-incubation of oocytes before insemination adversely affects their chance of fertilization and of developing into an embryo. If we had thought about using Viagra earlier for the first man in this series, it is possible that the outcome of this IVF cycle may have been successful. This experience prompted us to offer the use of Viagra to men who experienced temporary erectile dysfunction during ART treatments. The drug did assist them in producing spermatozoa on demand mainly by its pharmacological effect.
During IUI or IVF treatments, men are requested only to produce one or two sperm samples (Tur-Kaspa et al., 1994). Unfortunately, some men may have difficulties in producing spermatozoa on demand at the time of insemination. The problem can usually be solved with time, or by audiovisual supports. Sometimes, invasive procedures such as papaverin injection, electro-ejaculation or epididymal or TESE have been implemented successfully (Hovav et al., 1996; Vanderschueren et al., 1998). Occasionally, cancellation of these particular treatment cycles is required. For such cases, freezing of spermatozoa as a back-up for the next cycle is recommended.
If no contraindications exist, Viagra for temporary erectile dysfunction during ART seems to be a simple and cost-effective method of assisting these men to produce spermatozoa on demand. This will save the need for surgical procedures in most cases. Here we recommend, for the first time, the use of Viagra after failed trials of >1 h to produce spermatozoa, or planning the use of Viagra in advance for men with such a history. This may prevent stress and frustration for the couple and a delay in the insemination, which may compromise the IVF/IUI results.
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Viagra was used successfully with 4 additional patients, for a total of 8 men.
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Notes |
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To whom correspondence should be addressed
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References |
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TopAbstractIntroductionCase reportNote added in proofReferences |
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Ballard, S.A., Gingell, C.J., Tang, K. et al. (1998). Effects of Sildenafil on the relaxation of human corpus cavernosum tissue in vitro and on the activities of cyclic nucleotide phosphodiesterase isozymes. J. Urol., 159, 2164–2171.[Web of Science][Medline]
Boolell, M., Gepi-Attee, S., Gingell, J.C. and Allen, M.J. (1996) Sildenafil, a novel effective oral therapy for male erectile dysfunction. Br. J. Urol., 78, 257–261.[Web of Science][Medline]
Hovav, Y., Shotland, Y., Yaffe, H. and Almagor, M. (1996) Electroejaculation and assisted fertility in men with psychogenic anejaculation. Fertil. Steril., 66, 620–623.[Web of Science][Medline]
Tur-Kaspa, I., Maor, Y., Levran, D. et al. (1994) How often should infertile men have intercourse to achieve conception? Fertil. Steril., 62, 370–375.[Medline]
Vanderschueren, D., Spiessens, C., Kiekens, C. et al. (1998) Successful treatment of idiopathic anejaculation with electroejaculation after microsurgical vas aspiration. Hum. Reprod., 13, 370–371.
Submitted on January 4, 1999; accepted on March 19, 1999.
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