Dear Dr G,

I read with interest your articles in the last few weeks on premature ejaculation.

Truthfully, I do not experience any issues of early ejaculation, however my sex life has taken a curious turn lately with some ejaculatory disorder.

I was recently diagnosed with hypertension and diabetes, and was started on blood pressure and diabetic medications.

Since the diagnosis and treatment of my conditions, I have noticed the amount I ejaculate is diminishing significantly over the last few months. 

Don’t get me wrong, the erection, libido and even the climax is satisfactory, however I don’t seem to be able to produce any semen.

My wife commented on the reduction in semen and thought I don’t get so aroused anymore during sex. In fact, I was accused of faking my orgasm.

Although I already have two wonderful children, and having ejaculation is definitely not for having more children.

However, I am just curious why I am no longer producing any semen?

I went to the doctor and was diagnosed with retrograde or dry ejaculation.

Therefore, I would like to put Dr G on the spot for the mystery of my missing sperms.

First of all, can you tell me how much an average man ejaculates?

Is it normal to have less sperm as men age? 

How common is retrograde ejaculation and how is the diagnosis made?

Once diagnosed, what treatment is available for my condition.

Regards,

Faking Frederick

The World Health Organisation (WHO) outlines the average volume of ejaculate for men at 3.7ml, roughly equivalent to three-quarter of a teaspoon. The normal ejaculation volume in a man after a few days of abstinence actually ranges from 2-6 ml. However, this varies greatly with mood, state of arousal, physical health and the interval of prior ejaculation. The low volume of ejaculation in a man is called hypospermia. This is generally defined as a total ejaculation volume of less than 1.5ml. 

It is common to assume that ejaculation volume declines with age as do the rest of the sexual parameters, including libido and erectile rigidity. The age related decline starts in any decade of the men’s life and gradually over a five to 10 years interval. On the other hand, the sudden decline in the emission semen volume is more likely to be associated with certain medical conditions.

The complete absence of the emission of semen can be caused by retrograde ejaculation or “dry orgasm”. This occurs when the semen that is supposed to be propelling forward is directed backwards to the urinary bladder. The normal reproductive physiology requires the bladder sphincter to contract prior to ejaculation, prohibiting the mixture of urine and semen. The semen is then forced to exit the urethra through the penile opening. When the bladder sphincter does not function properly, retrograde ejaculation can occur.

The malfunction of bladder sphincter is generally caused by the derangement of the nerve supply to the bladder neck. The most common cause of pelvic nerve destruction is diabetes, causing retrograde ejaculation.

Other neurological causes of retrograde ejaculation can be multiple sclerosis and spinal cord injuries, resulting in the backflow of semen in addition to erectile dysfunction. Other non-neurological factors causing derangement of sphincter include prostate operations such as TURP, which destroy the bladder neck to overcome obstructions.

The other common aetiology of low ejaculate is the side effects of certain medications. The use of prostate and blood pressure medications, such as alpha-blockers are well recognised to relax the bladder neck resulting in retrograde ejaculation. Other groups of medications such as antidepressants and antipsychotics are also known to cause dry orgasm. The incidence of drug induced retrograde ejaculation is a common manifestation of men with low semen volume, which is completely reversible. 

The diagnosis of retrograde ejaculation requires a simple urinalysis obtained shortly after sexual climax. In the cases of retrograde ejaculation, the urine will contain copious amounts of sperms, which can be identified by microscopic examinations. In fact, for men facing the challenges of male-factor infertility related to ejaculatory dysfunction, the retrieval of the live sperms from the urine can often be used for IVF fertilisation.

The treatment of retrograde ejaculation usually depends on the cause. The cessation of medications such as antidepressants and alpha-blockers are usually effective in reversing the bladder neck dysfunctions. Other neurological and surgical causes of retrograde ejaculation may also be treated with medications such as tricyclic antidepressants and antihistamines like chlorphenamine. However, the success rates of such intervention are not so favourable.

Apart from the issues of infertility, the diminished or absence of ejaculation in men pose no threat to health whatsoever. Although retrograde ejaculation may just be a bit of a nuisance for some men, others may have significant frustration when facing such sexual dysfunction. Understanding the pathophysiology of retrograde ejaculation is crucial to avoid certain medications and nerve destructions that interfere with the intricate control of the forward propulsion of semen. Apart from disease awareness, open communication with a partner is also important to avoid misunderstanding of “faking an orgasm”.