Medsarticles. Medical Weblog

Finally, what of the end of his fertile period? Old father time is an archetype of the past, present and future. Men can father children in their 70s and it is less natural to cut off a man’s fertility than a woman’s, that will in any case fail. Post-vasectomy counselling is not as widely available as it should be and regrets can linger.

As a last insight, one man spoke about withdrawal, describing it as ‘Terrible, doctor.’ Then he thought a moment, and added, ‘Actually that is not quite true because we used it while I waited for the results of the specimens after vasectomy. That was really our last excitement.’ Excitement and terror are closely linked. Excitement is easy to admit. Terror less so, but what was shared here was a tinge of sadness for his lost reproductive powers.

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Mr and Mrs E., a wealthy Indian couple, had been trying to achieve a pregnancy since their arranged marriage two years previously. Mrs E. was frightened and withdrawn at her first visit to the infertility clinic at the hospital, but seemed to be somewhat relieved to find a female doctor present. Mr E. gave the history and spoke for her. They adhered to all the investigations and treatment regimes with precision. She was diagnosed as having polycystic ovarian disease, and underwent a year of gonadotrophin therapy to induce cycles of ovulation, but she still did not become pregnant. Only on one occasion did the doctor manage to examine Mrs E. on her own. She hinted at her despair about her failure to conceive, and at the lack of fun with sex, but her allegiance to her upbringing and to her husband prevented her from letting go of any of her own feelings.

Several times on visits to the hospital, tears would appear but they would be stifled by her husband’s words, ‘Don’t worry, she will be all right soon.’ They were both sad when it was agreed that treatment should stop, but the doctor was again told not to worry as they would be fine. The only treatment left to them was to consider in vitro fertilization, where the fertilizing power of the sperm could be studied as well as ovulation. This idea must have posed difficulties for Mr E. but he could not share them with any member of the clinic staff.

Several months elapsed before Mr E. telephoned to say that they would like a private referral to be admitted on to the assisted conception programme at a nearby centre: he asked for it to be done immediately because he had got his wife in the mood for it now. An offer to come and discuss it again was firmly but politely refused.

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Sometimes the ambivalence can be due to a conflict between what the woman wants and what she ought to do. She may be subject to the pressure of others and fear criticism. She may use the abortion clinic for permission to continue with the pregnancy.

Miss D. was 25 and lived with her boyfriend. She had become pregnant for the second time, having had an abortion at 19. The doctor asked, ‘You want an abortion?’ She said, ‘No, I don’t really.’ She went on to reel off a list of reasons, many of them financial, as to why she could not have a baby. The doctor pointed out that she had given some very reasonable reasons for requesting abortion but had not said anything about her own feelings. She continued in the same vein. Recognizing her defences, the doctor tried safer ground and asked how she felt about her previous abortion. She had felt awful afterwards, as she had wanted the baby but could not have it. She was only 19 then. And now? She felt she was the right age but she and her boyfriend were in debt and lived in one room. The doctor said it must be sad to have an abortion when you really want a baby. At this point she burst into tears. She agreed she wanted this baby but felt she could not have it in her present circumstances. She wanted more time to think. She came back a few days later. She had talked to her boyfriend who was delighted at the thought of having a baby, and her parents were going to help out with the money problems.

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Sterilization is only for those who are sure that they want no more children. This is the ultimate in medical interference. An operation, sometimes under general anaesthetic, involving deliberate damage to the internal or external genitalia. From this, there is no going back, and all patients are counselled that reversal operations rarely succeed. Some pain and discomfort is to be expected, and even laparoscopic techniques carry a risk of future gynaecological problems. The first decision each couple have to make is, which one for the ‘chop’? Even with the most loving, sexually compatible and stable couple, this can be a difficult decision. There is an element of self-sacrifice here, which may be denied, but is present, nevertheless. One will be damaged, deprived of the ability to make a child, and one will not. One will have to come to terms with this personal loss, which is very different to the couple accepting that there will be no more children in this unit. It is common for the after-effects of sterilization to resemble grief, muted and unconscious though this might be. Grief for the damage, for the ending of fertility, for the children who might have been, but now never will be. The aim of sterilization counselling is to help the couple understand these feelings, and to filter out those for whom the decision is pressurized, or ill understood.

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Exercise can boost potency by increasing your sense of well-being and your ability to handle stress. It also helps keep your arteries functioning well. So it’s important that you exercise regularly. Your doctor can help you plan an exercise program that will be safe and beneficial.

Ask him to focus on aerobic exercise—steady exercise over a prolonged period of time which increases your heart rate and makes your body produce more HDLs. Many activities qualify as aerobic exercise, including jogging, bicycling and walking briskly. To be really helpful, however, most of these exercises need to be done for 20 to 30 minutes at a time, at least three times a week. You don’t need to start out at this pace. Begin slowly and work your way up gradually. Exercise activities with a lot of stops and starts, such as handball, tennis and weight lifting, won’t do your arteries as much good as a less strenuous, but continuous workout. The key is to get your heart rate up to 80 percent of its maximum, and keep it there for 12 to 15 minutes. Ask your doctor what your maximum heart rate should be. Then, when you exercise, stop periodically to check your pulse to see what your rate is.

Faithfully following an exercise program for several months also tends to lower your blood pressure. Doctors know that high blood pressure is a major cause of clogged arteries, so lowering your blood pressure can help your arteries, your heart—and your erections.

Sometimes men who enjoy exercise believe that all they have to do to protect their health and their potency is work Out. Some people believe in the tooth fairy, too. The truth is that all the other elements of the potency program—diet, normal weight, normal blood pressure, no smoking and moderate use of alcohol, if any—are essential, too. If you jog five miles and then reward yourself with a double cheeseburger and fries, followed by a cigarette, your arteries are still susceptible to trouble.

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An implant will not change your personality. It will not make you the most popular guy on the block. It can’t be counted on to save a failing marriage.

Having an implant does not, by itself, make you feel aroused. What causes you to feel desire before surgery should have the same effect after the operation. By the same token, if you rarely feel sexual desire before getting an implant, that’s unlikely to change.

Implants are not magic problem-solvers. The prosthesis will not change lifelong sexual patterns. If you rarely had sex before your erection problem developed, the operation will not turn you into a sexual superman. By itself, an implant will not increase your sexual appetite or desire. The prosthesis doesn’t change behavior; it just enables you to have an erection and makes intercourse possible.

Implants produce a simulated erection which, although close in appearance to a natural erection, is not identical. The implants are placed in the corpora cavernosa (those two cylinders which run parallel along the length of the penis, and, in a natural erection, fill up with blood). The head of the penis, which is part of a separate and much more delicate area called the corpus spongiosum, does not become erect with any of the implants. And it’s not likely that a model with such a feature will be developed, because of this area’s small size, irregular shape and closeness to the urethra.

The implant erection usually is not quite as wide or as long as a naturally produced erection. An implant won’t increase the size of a man’s penis.

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Sometimes the best way to tell if you’ve found a professional who may be able to help is by what he or she does not do. The following are some warning signs. We suggest that you look elsewhere for your care if your doctor does any of the following things:

• He refuses or is unwilling to have your partner involved in diagnosis and treatment.

• He ignores your sexual problem or tries to change the subject every time you bring it up.

• He tells you to adjust to life without sex, or tells you that sex isn’t important.

• He fails to take a complete medical history specifically aimed at diagnosing impotence.

• He makes any automatic, unfounded assumptions about the cause of your problem. If your doctor tells you without giving you a thorough evaluation that your erection problems are caused by psychological difficulties or that you have a problem just because you’ve been working too hard, run, don’t walk, out of that office. Generally speaking, no one can assume the cause of your problem without a thorough evaluation specifically focused on your potency problem. Don’t let a well meaning but ignorant professional dissuade you from seeking all the help you need.

• He can’t tell you the success rates and the dangers of various treatments.

• He is quick to tell you, “If this treatment doesn’t work, nothing will!” If you hear this, bolt for the door! No knowledgeable professional will put you under such wholly uncalled-for stress. There are almost always alternative treatments that will help. If you decide on a particular course of action, find out about alternatives if your first attempt at a solution (preferably the least expensive and least complicated treatment) doesn’t work.

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Women have many of the same fears as men. And a wife or lover may be afraid that by talking about the problem she’ll find out that she is the problem—that she’s doing something that turns him off. And she may fear finding out that her husband does fine with other women. She also may be afraid that his health is the problem; she may resist talking about the difficulty hoping it will “cure” itself, so she’ll know he is physically okay And some women want to protect their husband’s feelings Sensing their partner’s reluctance to talk, they avoid the topic They don’t want to, as one woman says, “make him feel an^ worse than he already does.”

Our research indicates that women react to erection problems in a wide variety of ways. In many cases we looked at, the way a woman responded appeared to be greatly influence by the way she and her husband normally communicated. The more reassurance and love that was available on both sides and the more both were involved in solving the problem, the more manageable the sexual difficulty was. When there was less communication there was more opportunity for hurt feelings, self-doubt, blame and anger to fester—and erupt.

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There is no doubt that most cultures see the breast as a symbol of femininity and the loss of a breast is frequently mourned because of this. Surgeons try to be as conservative as possible but where the priority is longterm survival, and hopefully a cure, the cosmetics take a back seat. Losing a breast can cause a massive psychological reaction, so it is now a relatively common practice for the cancer surgeon to work with a plastic surgeon to reconstruct the breast at the time of the mastectomy. Nonetheless, many women notice a change in their sexual behavior after a mastectomy. This seems to be particularly true of women who rely a lot on breast and nipple stimulation for arousal or orgasm. Sensate focus exercises also come in handy here. The different touching techniques used on other areas of your body stimulate the erotic feelings that build towards orgasm. In the case of mastectomy, it takes the emphasis away from the breasts by discovering other parts of the skin that will give you a similar response.

The loss of a breast can also mean a loss of self-confidence and a reluctance to initiate sex. Rita was forty-two when her breast cancer was diagnosed. ‘I was devastated. I thought they must have put the wrong name on the mammogram. The whole ordeal felt like some terrible nightmare. Matthew and I

had always had a great sex life. We married late and I suppose we were making up for lost time or something. He was always a big breast man and he always said how much he loved the fact that I was well-endowed. When I heard I had to have a mastectomy I thought, “Well that’s it then, he won’t have any interest in me sexually any more. This will turn him right off.” The strange thing was that it was me who had the trouble with sex. I couldn’t bear to let him see me without a shirt on, and I would freeze if his hands went anywhere near my chest. He said it really didn’t matter to him, he was just so glad he still had me. He was so patient and so gentle, I don’t know how I would have coped on my own.’

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Being able to express our sexuality is one of those things we take for granted, provided everything is going well. If you have a current partner and your relationship is happy, if you both manage to orgasm most of the time and don’t worry when you don’t, if erections are never a problem, and you have matching libidos, then sexuality is probably not an issue.

As a matter of fact, when you consider the intricate blend of factors that need to combine to make it all happen … personalities, emotions, moods, blood vessels, nerves, hormones and muscles … it’s amazing that it works as often as it does.

But things can go wrong and when they do it can come as a huge surprise. For many people, developing a problem with their sexual function will force them to confront their attitudes and beliefs about sex in a totally new way. It can make you question the way you see yourself, your partner, and your relationship(s). On an even deeper level, a sexual difficulty can suddenly bring up all sorts of memories of the sexual anxieties and insecurities of childhood and adolescence.

It is not possible to talk about sexual problems without also dealing with relationship problems. Difficulties with sex always need to be seen in the context of the whole living situation. It’s a chicken and egg situation. Sexual problems can have an influence on the relationship and, if the relationship is in trouble, one way or another it will show up sexually. All sorts of factors can have an impact. Do you have time alone together? Do you have privacy or are you sharing a house with the in-laws? Are you frightened of getting pregnant? Is sex being used as part of a punishment and reward system? Do you resent your partner controlling the pursestrings and holding back money unless they get their way sexually?

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