Dear Dr G,

I am a 30-year-old man who is really stressed about parenthood.

My wife and I have been married for the last three years and we have been trying for a baby since day one.

During the last three years of festivities during balik kampung, I have been seeing my wife interrogated by well-meaning uncles and aunties about babies.

In truth, we have a dark secret that nobody in the family knows.

My wife had actually undergone medical examinations and was given an all-clear.

My semen analysis revealed my sperm quality being suboptimal is the real reason behind the delay in conceiving.

My approach in the last few years has been avoiding conversation.

However, I have decided to face the issues and hope to enhance my sperm quality in the years to come.

I have done some online searches and was horrified by how many recommendations for fertility enhancement in men.

I am somewhat confused and hope to put Dr G on the spot to debunk the myths.

First of all, can you confirm whether the type of clothing will influence the quality of sperms?

Will frequent ejaculations also cause male infertility?

Will a certain diet influence the sperm quality? What about alcohol intakes?

Lastly, I hear stress can reduce sperm counts? How is that possible?

Please help.

Yours truly,

Stressed Saiful

Male fertility is influenced by a wide range of biological, environmental, and lifestyle factors. In recent years, increased awareness about declining sperm quality has led to the spread of both scientifically supported information and widespread myths. Misunderstanding these factors can create unnecessary anxiety or cause men to overlook important habits that genuinely affect reproductive health.

One common myth is that wearing tight underwear or certain clothing completely destroys sperm production. In reality, the testes require a slightly cooler temperature than the rest of the body for optimal sperm development, and prolonged heat exposure can reduce sperm quality.

However, clothing alone is rarely a major cause of infertility. More significant contributors include frequent use of hot tubs or saunas, placing laptops directly on the lap for long periods, and extended sitting without movement. Addressing these habits can help maintain a healthier environment for sperm production.

There is also a belief that frequent sexual activity significantly lowers sperm quality. While very frequent ejaculation may temporarily reduce sperm concentration, the body continuously produces new sperm. For most healthy men, regular sexual activity does not harm fertility.

In fact, moderate ejaculation frequency may help reduce the accumulation of damaged sperm cells. Problems arise only when underlying health conditions or hormonal imbalances interfere with normal sperm production. Dietary myths are particularly common.

Some people assume that consuming specific “superfoods” or supplements can rapidly restore fertility. While nutrients such as zinc, selenium, omega-3 fatty acids, and antioxidant vitamins play important roles in sperm health, no single food or supplement can reverse fertility problems on its own. Sustainable improvement usually depends on long-term dietary patterns that support overall metabolic and hormonal health.

A balanced diet rich in fruits, vegetables, whole grains, lean proteins, and healthy fats provides the foundation for better reproductive function. Alcohol consumption is another area where misconceptions exist.

Moderate intake may not significantly impair fertility in otherwise healthy individuals, but chronic heavy drinking can reduce testosterone levels and interfere with sperm production.

Similarly, smoking is sometimes underestimated as a fertility risk. Scientific studies consistently link tobacco use to reduced sperm count, impaired motility, and increased oxidative damage. Quitting smoking can lead to gradual improvements in sperm quality over several months, as sperm production cycles renew.

Stress and sleep are often overlooked lifestyle factors. Many men believe psychological stress has little physical impact on fertility.

However, chronic stress can disrupt hormonal balance, particularly by increasing cortisol levels that may suppress testosterone production. Poor sleep further compounds this problem by affecting metabolic health, immune function, and cellular repair processes. Together, these factors can reduce the efficiency of sperm development and contribute to reduced fertility potential.

Physical activity is generally beneficial for reproductive health, but another myth suggests that more exercise is always better. Moderate exercise supports hormonal regulation, improves circulation, and helps maintain a healthy body weight. Excessive or extreme endurance training, however, can lead to hormonal suppression and increased oxidative stress.

Striking a balance between activity and recovery is therefore important for maintaining optimal sperm quality. Medical evaluation can play a critical role when lifestyle changes alone are insufficient. Conditions such as hormonal disorders, infections, or varicocele may require targeted treatment. Fertility specialists can provide semen analysis and personalised guidance based on individual health status.

Early intervention often improves outcomes and reduces the emotional burden associated with fertility challenges. Many myths about male fertility persist despite growing scientific knowledge about sperm health. While certain lifestyle factors do influence sperm quality, the effects are usually gradual and modifiable. By understanding the difference between misconceptions and evidence-based facts, men can take proactive steps to improve their reproductive health.

Sustainable lifestyle improvements, combined with appropriate medical care when needed, offer the best chance of overcoming obstacles and supporting fertility. The philosopher George Santayana once said: “Myth is the truth which is imagined”.

As far as the causes of male infertility, the myths are certainly widely imagined. Men who are ready to face both myths and truths about problematic male fertility often put Dr G on the spot for advice. His view is: “Healthy living is the only truth that is imaginable for healthy sperms.”

The post Male fertility: debunking the myths for a worried husband appeared first on George Lee.my.

Dear Dr G,

I read with interest the focus in the last few weeks on female impact on fertility. I guess you did not elaborate on the impact of men and fertility due to overwhelming importance of female factors.

My wife and I have been married for more than a decade; we focused on our careers so that our offspring will have a better quality of life.

Although I often bank on my wife being 10 years younger than me to mitigate the impact of age-related infertility, I still cannot help but wonder about the negative implications of ageing and its effect on a man’s sperm quality.

As I venture into the fourth decade of my life, I hope to embark on the journey of parenthood with my wife this year.

Despite most doctors’ assurance of zero negative impact of my older sperm on the next generation, I still would like to put Dr G on the spot for his opinion.

Firstly, are there any changes in the quality of sperm in ageing men?

If so, what are the changes, and why?

What measures can a man take to improve the quality of his sperm?

Lastly, should I really be concerned with my ageing sperm above 40?

Yours truly,

Ageing Alan

Male fertility has long been considered relatively stable compared to female fertility, which declines more sharply with age.

However, growing scientific evidence shows that advancing paternal age is associated with gradual changes in sperm quality, reproductive outcomes, and potential risks to offspring health.

Research over the past few decades has demonstrated that several key semen parameters decline as men grow older. Studies have reported reductions in semen volume, sperm concentration, motility, and the proportion of normally-shaped sperm.

These changes often begin gradually after the mid-30s and may become more pronounced after the age of 40. Although many older men remain fertile, the probability of impregnation may decrease, and the time required to conceive can increase.

This decline is partly attributed to reduced efficiency of the testes and changes in hormonal regulation, particularly a gradual decrease in testosterone production.

One of the most significant age-related concerns involves the integrity of sperm DNA. As men age, sperm are more likely to exhibit DNA fragmentation and genetic mutations.

These changes are thought to result from cumulative exposure to environmental toxins, oxidative stress, and natural cellular aging processes.

Damage to sperm DNA can reduce fertilisation potential, impair embryo development, and increase the likelihood of miscarriage.

Some research also suggests a link between advanced paternal age and a higher risk of certain genetic or neurodevelopmental conditions in children, although the absolute risk remains relatively low.

Chronic illnesses such as diabetes, hypertension and obesity are associated with hormonal imbalance and increased oxidative stress, both of which can negatively affect sperm production and function.

Environmental exposure, including smoking, excessive alcohol consumption, and contact with pollutants or heat, may also contribute to declining fertility.

Thus, age-related fertility changes often reflect a combination of intrinsic biological factors and modifiable lifestyle influences.

Despite these challenges, there is strong evidence that certain measures can help improve sperm quality and fertility potential in older men. Adopting a balanced and nutrient-rich diet plays a central role in supporting reproductive health.

Nutrients such as zinc, selenium, omega-3 fatty acids, folate and vitamins C and E are particularly important for maintaining sperm motility and protecting DNA integrity.

Maintaining a healthy body weight is also crucial, as excess body fat can disrupt hormonal balance and reduce testosterone levels.

Regular moderate physical activity contributes positively to male fertility by improving cardiovascular health, metabolic function and hormonal regulation.

Exercise enhances blood flow, including to reproductive organs, and may help reduce inflammation and oxidative stress.

However, extremely intense or prolonged endurance training can have the opposite effect by suppressing testosterone and impairing sperm production.

Therefore, balanced exercise routines are generally recommended.

Lifestyle modifications such as quitting smoking, limiting alcohol intake and avoiding recreational drugs can lead to measurable improvements in sperm parameters over time.

These substances are known to impair sperm concentration, motility, and genetic quality.

Similarly, minimising exposure to excessive heat is important, as sperm production requires a temperature slightly lower than core body temperature.

Simple habits such as wearing loose-fitting clothing, avoiding frequent use of hot tubs or saunas, and reducing prolonged sitting can help maintain optimal testicular function.

Sleep quality and stress management also play important roles in reproductive health. Adequate sleep supports hormonal balance and overall cellular repair processes. Psychological well-being and lifestyle stability may therefore indirectly enhance fertility.

Medical evaluation is particularly important for older men who are attempting to conceive. Semen analysis, hormonal testing, and screening for conditions such as varicocele or reproductive tract infections can identify treatable causes of reduced sperm quality.

Management of chronic diseases and appropriate medical or assisted reproductive interventions may significantly improve the likelihood of successful conception.

While male fertility does not decline as abruptly as female fertility, advancing age is associated with measurable reductions in sperm quality and reproductive efficiency.

Biological ageing, increased DNA damage, hormonal changes and lifestyle factors all contribute to this process.

Nevertheless, many of these influences are modifiable. Through healthy nutrition, regular exercise, avoidance of harmful substances, stress reduction and appropriate medical care, older men can improve their reproductive health and enhance their chances of fatherhood.

Understanding these factors allows individuals and healthcare providers to make informed decisions about fertility planning in later life.

Legendary American actor Fred Astaire famously said: “Old age is like everything else. To make a success of it, you’ve got to start young.”

Older men hoping to make a success of parenthood often put Dr G on the spot for an opinion on their ageing sperm. His view is: “If you couldn’t start young, start now!”

The post The impact of ageing on male fertility appeared first on George Lee.my.

Dear Dr G,

I read with interest your explanation about getting the timing right for a successful pregnancy.

However, I was disappointed that you did not elaborate on how some couples face uncertainty when the woman has irregular periods.

My wife and I have been married for more than a decade.

We have grown used to the awkward questions from well-meaning relatives who expect my wife to be pregnant by now.

Although Artificial Reproductive Technology is available, we are determined to conceive as naturally as possible.

Doctors have ruled out polycystic ovarian syndrome (PCOS) and have attributed the issue to stress.

However, we were not offered any guidance on how to predict ovulation naturally.

First, why do some women have irregular periods, and how does this affect their chances of getting pregnant?

Are there ways to identify the fertile window for women with irregular periods?

Lastly, how can my wife regulate and improve her menstrual cycle?

Thank you in advance.

Yours truly,

Uncertain Eugene

Women who experience irregular menstrual cycles while trying to conceive may feel uncertain and frustrated. Unlike those with predictable monthly patterns, irregular cycles make it difficult to estimate when ovulation will occur and when the chances of pregnancy are highest.

However, understanding how fertility works and learning to observe the body’s natural signals can significantly improve the likelihood of conception. With patience, consistency and the use of complementary methods, it is possible to identify fertile periods and increase the chances of becoming pregnant, even when cycles vary in length.

Ovulation is the key event that determines fertility in any menstrual cycle. It is the moment when an ovary releases an egg that can be fertilised by sperm. The egg survives for about a day, but sperm can live inside the female reproductive tract for several days. As a result, the fertile window includes the few days before ovulation and the day ovulation occurs.

In regular cycles, this window can often be predicted by counting backwards from the expected start of the next period. In irregular cycles, however, ovulation may occur earlier or later than expected, or sometimes not at all.

Because of this unpredictability, relying only on calendar calculations is often ineffective. One helpful way to recognise approaching fertility is to pay attention to changes in cervical mucus.

Hormonal fluctuations throughout the cycle affect the amount and texture of this natural discharge. After menstruation, many women notice dryness or very little mucus. As oestrogen levels rise in preparation for ovulation, mucus usually becomes more noticeable and eventually clear. A clear, egg-white-like consistency is often a strong sign that ovulation is near and that the chances of pregnancy are highest.

Regular observation can provide valuable clues about the body’s reproductive rhythm, even when cycles are irregular. Another useful method is tracking basal body temperature, which is the body’s resting temperature measured immediately after waking. After ovulation, progesterone causes a slight but sustained rise in this temperature.

Although this rise confirms that ovulation has already occurred, charting temperature over several months can help identify patterns and estimate timing in future cycles. When combined with cervical mucus tracking, basal body temperature monitoring becomes more effective in predicting fertile days.

Ovulation predictor kits can also be especially helpful for women with irregular periods. These tests detect a surge in luteinising hormone in urine, which usually happens shortly before ovulation. Because irregular cycles may require longer monitoring, some women begin testing earlier and continue until a surge is detected.

When used alongside physical signs such as mild pelvic discomfort, increased sexual desire or slight breast tenderness, these kits can increase confidence in identifying fertile timing. Improving the chances of pregnancy involves more than identifying ovulation.

Having regular sexual intercourse during the suspected fertile window increases the likelihood that sperm will be present when the egg is released. Many healthcare professionals recommend intercourse every two to three days throughout the cycle for couples trying to conceive with irregular periods. This approach reduces the pressure of precise timing while still maximising opportunities for fertilisation.

Lifestyle factors also play an important role in supporting fertility. Maintaining a balanced diet, achieving a healthy body weight, managing stress and getting enough sleep can help regulate hormones.

Excessive exercise or sudden weight changes may disrupt ovulation, while ongoing stress can affect hormone production and menstrual regularity. Avoiding smoking, limiting alcohol intake and ensuring adequate intake of nutrients such as folic acid and iron can further support reproductive health.

Irregular cycles may be linked to underlying medical conditions such as hormonal imbalances, thyroid disorders or reproductive syndromes.

Healthcare providers may offer tests, treatments or medications to stimulate ovulation or regulate cycles, which can improve the chances of conception. Conceiving with irregular periods often requires persistence and a better understanding of the body’s signals. By combining careful observation, consistent tracking and healthy lifestyle habits, many women can identify their fertile windows and improve their chances of pregnancy.

Although the journey may sometimes feel uncertain, knowledge and proactive care can turn unpredictability into informed hope.

The post Understanding fertility with irregular menstrual cycles appeared first on George Lee.my.

Dear Dr G,

I am glad the whole CNY celebration is over.

As we venture into another Hari Raya, my wife and I cannot help but think about having another child.

I read with interest how you described the ideal timing for conception. Clearly, your focus was on women, when ovulation occurs within a small window, and how intercourse should be timed around that period.

On the other hand, I was disappointed that there was no mention of how the frequency of ejaculation should be incorporated into the timing of intercourse.

I am sure that certain days of abstinence should enhance the number and quality of sperm ejaculated. What I am uncertain about is the number of days or weeks of abstinence that will optimise sperm quality.

My wife consulted the gynecologist and was somewhat surprised by the advice. Instead of asking me to refrain from frequent ejaculations, the doctor actually asked us to engage in daily intercourse during the ovulation period.

We are somewhat confused and are wondering whether such frequency will deplete the sperm and defeat the purpose of fertility.

We are keen to put Dr G on the spot for some clarification.

Is frequent ejaculation good or bad for the quality of sperm? Would frequent ejaculation increase or decrease the overall number of sperm?

Apart from the numbers, what other parameters should be measured for better sperm quality?

Regards,

Frequent Freddie

The relationship between ejaculation frequency and sperm quality becomes clearer when we examine detailed quantitative data on specific sperm parameters such as motility, morphology, DNA integrity, and viability. These aspects of sperm quality are crucial because they directly influence the ability of sperm to reach, penetrate, and successfully fertilise the egg.

One of the most studied parameters is sperm motility, particularly progressive motility, which refers to the ability of sperm to move forward. Research consistently shows that shorter abstinence periods are associated with higher motility. For example, studies comparing one day versus three to five days of abstinence have reported increases in progressive motility of approximately 5 to 15% age points with shorter intervals. In contrast, when abstinence exceeds seven days, motility begins to decline more noticeably, and in some cases, progressive motility has been observed to drop below 20 % after extended periods of 10 to 14 days. This decline is thought to result from oxidative stress and ageing of sperm during storage in the epididymis.

Sperm DNA integrity is another critical factor that has gained attention in recent years. The DNA fragmentation index (DFI), which measures the proportion of sperm with damaged DNA, tends to increase with longer abstinence. Studies have shown that DFI can be reduced by as much as 20 to 30% when ejaculation occurs daily or every other day, compared with longer abstinence periods. Lower DNA fragmentation is associated with higher fertilisation rates, better embryo development, and a reduced risk of miscarriage, highlighting the importance of frequent ejaculation in maintaining genetic quality.

Morphology, or the structural normality of sperm, appears to be less sensitive to ejaculation frequency but still shows some variation. Research indicates that the percentage of morphologically normal sperm may improve slightly, often by a few percentage points, with shorter abstinence intervals. Although these changes are generally modest, they can still contribute to overall fertility, especially in individuals with borderline semen parameters.

Sperm viability, which refers to the proportion of live sperm cells, is also influenced by ejaculation frequency. Studies comparing short and long abstinence periods have found that viability can be 5 to 10% higher with shorter intervals. This finding is consistent with the idea that prolonged storage leads to cellular ageing and reduced membrane integrity, making sperm less likely to survive the journey through the female reproductive tract.

In addition to these parameters, biochemical markers of sperm function provide further insight. Reactive oxygen species (ROS), which can damage sperm membranes and DNA, tend to accumulate with longer abstinence. Frequent ejaculation helps reduce ROS levels, thereby protecting sperm from oxidative damage. Similarly, mitochondrial activity, which powers sperm movement, has been shown to be higher in sperm obtained after shorter abstinence, contributing to improved motility.

Taken together, these data reinforce the concept that sperm quality is optimised with moderate ejaculation frequency. While longer abstinence increases sperm count, it often does so at the expense of motility, DNA integrity, and overall cellular health. Conversely, shorter intervals between ejaculations promote the production of fresher, more functional sperm, even if the total number is slightly reduced.

A deeper examination of sperm quality parameters demonstrates that frequent ejaculation has measurable benefits beyond simple sperm count. Improvements in motility, DNA integrity, viability, and cellular function all contribute to a higher likelihood of successful fertilisation. These findings support clinical recommendations that emphasise regular ejaculation, particularly during the fertile window, as a key strategy for enhancing reproductive outcomes. An American motivational speaker, Marie Forleo, once said: “Success doesn’t come from what you do occasionally, it comes from what you do consistently.” Dr G is often put on the spot for his view on whether ejaculation frequency enhances reproductive outcomes. His verdict: “Consistency is the only way to optimise outcome!”

The post Ejaculation frequency, sperm quality: How often is best for male fertility? appeared first on George Lee.my.

Dear Dr G

First of all, Gong Xi Fa Cai, and happy new year to your family and all readers who are celebrating.

My wife and I are newlyweds and are contemplating starting a family soon. We are a bit superstitious, and our Feng Shui master has informed us that our Zodiac signs would be complemented perfectly by having a Horse baby.

During the Chinese New Year, we have received various tips from well-meaning uncles and aunties on ways to enhance pregnancy. You wouldn’t believe some of the suggestions, including specific timing and positions for sexual intercourse to ensure the perfect union of egg and sperm. Some even suggested that certain timings are ideal for conceiving a boy or a girl.

Although we believe in and will follow some of the tips suggested, I am still keen to hear from an expert. Therefore, I am hoping to put Dr G on the spot for some clarifications.

Firstly, why is the timing of intercourse crucial for a successful pregnancy?

What is the scientific basis for such timing?

Can sexual position and post-coital position enhance the chances of pregnancy?

Lastly, are there any other tips to ensure we have a Horse baby?

Regards

Timing Tim

The timing of sexual intercourse plays a central role in enhancing fertility because human conception depends on a very narrow biological window. Unlike many other processes in the body, the opportunity for fertilisation each month is limited to a few days surrounding ovulation. Understanding this timing allows couples to maximise their chances of conceiving naturally, without unnecessary stress or overly complicated interventions.

The menstrual cycle is typically around 28 days, although it can vary from person to person. Ovulation, the release of an egg from the ovary, generally occurs about 14 days before the next menstrual period. Once released, the egg remains viable for fertilisation for only about 12 to 24 hours. In contrast, sperm can survive within the female reproductive tract for up to five days under optimal conditions. This difference creates what is known as the fertile window, which includes the five days leading up to ovulation and the day of ovulation itself. Intercourse during this window significantly increases the likelihood that sperm will be present when the egg is released.

Rather than attempting to predict ovulation with absolute precision, many healthcare professionals recommend having sexual intercourse regularly throughout the fertile window. Engaging in intercourse every one to two days during this period helps ensure that viable sperm are consistently available. This approach reduces the risk of missing ovulation due to slight variations in cycle timing, which are common even in individuals with otherwise regular cycles. It also avoids the pressure of trying to time intercourse to a specific hour, which can sometimes create anxiety and negatively affect the experience.

Several natural signs can help identify the approach of ovulation. One of the most reliable indicators is a change in cervical mucus, which becomes clear, stretchy, and egg-white-like during the fertile phase. This type of mucus supports sperm survival and movement. In addition, ovulation predictor kits, which detect a surge in luteinizing hormone, can provide a more precise indication that ovulation is likely to occur within the next 24 to 36 hours. Some individuals also track basal body temperature, although this method is more useful for confirming ovulation than predicting it.

Despite the availability of scientific information, many myths about timing intercourse for conception continue to circulate. One common misconception is that specific sexual positions can significantly increase the chances of pregnancy. In reality, there is no strong scientific evidence to support this claim, as sperm are capable of reaching the cervix quickly regardless of position. Similarly, the belief that a person must remain lying down or elevate their hips after intercourse to aid conception is largely unsupported; while it may seem logical, it has not been proven to meaningfully affect outcomes.

Another widespread myth is that couples should abstain from intercourse for several days before ovulation to “build up” sperm count. Although sperm concentration can increase slightly with abstinence, longer gaps between intercourse can actually reduce overall chances by missing parts of the fertile window. Regular intercourse, rather than infrequent but strategically timed encounters, is generally more effective. There is also a misconception that ovulation always occurs on day 14 of the cycle. While this may be true for some individuals, many experience natural variations, and relying strictly on this assumption can lead to mistimed efforts.

Additionally, some people believe that conception is only possible on the exact day of ovulation. This overlooks the fact that sperm can survive for several days, making intercourse in the days leading up to ovulation equally, if not more, important. Another persistent myth is that stress alone can completely prevent pregnancy. While extreme stress may influence hormonal balance, everyday stress is unlikely to be the sole cause of difficulty conceiving. However, reducing stress can still be beneficial for overall well-being and relationship health.

In conclusion, enhancing fertility through the timing of sexual intercourse is largely about understanding and working with the body’s natural reproductive cycle while avoiding common misconceptions. By focusing on the fertile window, maintaining regular intercourse, and relying on evidence-based methods rather than myths, couples can significantly improve their chances of conception. This approach emphasises consistency, accurate knowledge, and a balanced perspective, helping to reduce unnecessary anxiety and promote a more informed and confident journey toward pregnancy.

English philosopher Francis Bacon once said: “To choose time is to save time.” Couples in a hurry to get pregnant for a preferred zodiac baby often put Dr G on the spot for the perfect conception timing. His response is: “As time is running out, better waste no time and gallop into the bedroom with good timing!”

The post Galloping to conception: Beating the clock for a Horse baby appeared first on George Lee.my.

Dear Dr G,

I am a 55-year-old man who is not in the best of health.

I was diagnosed with high cholesterol and high blood pressure during the pandemic.

Due to a sedentary lifestyle and family history, my most recent blood tests also revealed that I have diabetes.

Naturally, I was started on a range of medications to control these conditions.

Unfortunately, after starting these medications, I began to experience problems with my erections.

I explained to my doctors how the erectile issues were affecting my relationship with my wife and asked whether my medications could be reduced to improve rigidity.

The doctors assured me that the erectile weakness was caused by the underlying diseases and not necessarily by the medications they prescribed.

They explained that the way forward was to control my diet and exercise, and in the meantime to take medication to enhance erections.

I was somewhat surprised to discover that the blue pills have actually been around for nearly three decades.

I was even more surprised to learn that there are several options to choose from.

The doctors tried to explain how differences in drug mechanisms can result in varying effects and side effects.

I must admit that I do not fully understand all of them.

Can you explain the different types of medications for erectile dysfunction?

How are they taken? How quickly do they work?

And how long do they last?

Lastly, do they all have the same side effects?

Regards,

Choosing Choo

The phosphodiesterase-5 (PDE5) inhibitors sildenafil, vardenafil, udenafil, tadalafil and avanafil are closely related drugs used primarily to treat erectile dysfunction.

Although they share the same mechanism of action by enhancing nitric oxide–mediated increases in cyclic GMP to promote smooth muscle relaxation and penile blood flow, their pharmacokinetic differences strongly influence clinical efficacy, onset and duration of action, and side-effect profiles.

Because their mechanism is identical, variations in absorption rate, half-life, selectivity and metabolism largely determine how each drug performs in real-world treatment.

Sildenafil, the first drug in this class, has a relatively rapid onset of action.

Peak plasma concentration is typically reached in about one hour.

Its half-life of up to five hours produces a therapeutic window of roughly four to six hours.

Clinical trials consistently show that sildenafil improves erectile function in a majority of patients, with response rates commonly around 60–80% in the general population.

Response rates are lower in individuals with diabetes or post-prostatectomy erectile dysfunction.

Because sildenafil also inhibits PDE6 in the retina, visual disturbances such as blue-tinted vision and increased light sensitivity are common side effects.

Systemic vasodilation can also cause headache, flushing, nasal congestion, dizziness and heartburn.

Due to its short half-life, these side effects are usually transient and resolve within several hours.

Vardenafil has pharmacokinetic properties similar to sildenafil but is slightly more potent and more selective for PDE5. Peak levels occur within about one hour, and the half-life is approximately four to five hours, providing a slightly longer duration of action than sildenafil. Efficacy studies show that vardenafil performs particularly well in more challenging patient populations, including men with diabetes and those who did not respond adequately to sildenafil.

Because of its improved selectivity, visual disturbances occur less frequently.

Adverse effects are similar to others in the class and include headache, flushing, rhinitis and dyspepsia.

Tadalafil differs significantly due to its long half-life of approximately 17.5 hours. This allows efficacy for up to 36 hours after a single dose. The extended duration supports both on-demand dosing and daily low-dose therapy. Clinical trials show high efficacy comparable to other PDE5 inhibitors. The prolonged effect improves spontaneity and satisfaction, as sexual activity does not need to be precisely timed.

However, tadalafil’s pharmacokinetics also explain its distinctive side effects. Because it inhibits PDE11 in skeletal muscle, muscle aches and lower back pain occur more frequently than with other drugs.

Headache, flushing and nasal congestion may also occur and can last longer due to the extended half-life.

Udenafil occupies an intermediate position between shorter-acting agents and tadalafil. It has a half-life of about 11 to 13 hours, with peak levels reached in one to two hours. Clinical studies indicate that udenafil has efficacy comparable to sildenafil and tadalafil. It is often preferred by patients who want longer action without effects lasting more than a day.

The side-effect profile is similar to the class overall, with headache and flushing being most common.

Visual disturbances are relatively uncommon due to improved selectivity. The intermediate half-life means that side effects usually resolve within half a day.

Avanafil represents the newest generation of PDE5 inhibitors. It is characterised by rapid absorption and high selectivity for PDE5. Peak plasma levels occur within 30 to 45 minutes. Some patients experience effects as early as 15 minutes.

Its half-life of about five hours produces a duration similar to sildenafil and vardenafil.

High selectivity reduces off-target effects.

Clinical trials show efficacy comparable to earlier drugs, with faster onset and improved tolerability.

Visual disturbances and muscle pain are less common. Headache and flushing remain the most frequently reported side effects.

Because of its rapid onset and favourable side-effect profile, avanafil is often considered a convenient option for on-demand use.

The pharmacokinetic differences among PDE5 inhibitors strongly influence their clinical performance.

Shorter half-life drugs such as sildenafil and vardenafil provide reliable short-term efficacy with transient side effects.

Tadalafil offers prolonged efficacy along with longer-lasting adverse effects. Udenafil provides an intermediate duration of action. Avanafil prioritises rapid onset and improved selectivity.

The post Choosing the right pill for erectile dysfunction appeared first on George Lee.my.

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”. 

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Dear Dr G,

I AM emailing in desperation, as a middle-aged man recently diagnosed with prostate cancer.

In view of my age, the specialist persuaded me to undergo the robotic operation.

The surgeon counselled me on the potential complications of the operation.

Since the cancer was stage one, the doctor also mentioned various other options including external beam radiation and active monitoring.

He also mentioned that as the tumour is low grade in nature, I have some time to consider my options.

The most obvious consideration I am taking into account is my erection, as I have a young wife.

Although my wife assured me cancer elimination is a priority, whatever decision I make has to take into account our sexual activities.

I would like to put Dr G on the spot for some opinion.

First of all, why are prostate cancer cases on the rise these days?

Can you tell me what is the correlation between prostate cancer and erectile dysfunction?

What are the impacts of prostate cancer treatment on erectile functions?

What is the best way to preserve erectile functions before interventions?

I also heard about penile rehabilitation. What exactly is that and how do I do it?

Please help.

Yours truly,

Rehabilitate Romeo

The prostate is a gland located just below the bladder, closely surrounded by nerves and blood vessels vital for erectile function. Public awareness of prostate cancer and the utilisation of the Prostate Specific Antigen (PSA) for screening have become more prevalent in the last two decades.

Media coverage of prominent figures affected by prostate cancer, such as the Singapore Prime Minister, has also encouraged men to present younger with early disease that is suitable for radical intervention. Treatments for prostate cancer, though lifesaving, can disrupt these delicate structures.

Radical prostatectomy can potentially cause nerve damage during surgery, which is a major cause of post-operative erectile dysfunction (ED). External beam radiotherapy or brachytherapy can also damage the blood vessels and nerves involved in erection. Lastly, Androgen Deprivation Therapy (ADT), which lowers testosterone, reduces libido and erectile capacity, leading to sexual dysfunction even in the absence of structural nerve damage.

Between 30–80% of men after radical prostatectomy experience ED, depending on surgical technique, patient age, and baseline function. Radiotherapy can also result in up to 50% of men developing ED within 5 years post-treatment. Nearly all men experience reduced libido and erectile function within months of hormonal therapy.

The improvement of medical technology and surgical techniques in recent years has evolved to give clinicians an advantage in identifying and protecting the neurovascular bundle responsible for the erectile and sexual functions of men. Despite the introduction of such “nerve-sparing” radical prostatectomy, the rate of erectile dysfunction can still be at best 14% and in some series as high as 100% in men after the operation.

Of course, the post-operative erectile function recovery is quite variable. Factors that may influence the return of sexual function include age, baseline sexual ability before the operation, and preoperative state of health.

Clearly, men who had problems such as diabetes, smoking, hypertension, and dyslipidemia would expect poorer outcomes in sexual performance after the operation. Although the terminology of “rehabilitating” the penis from “wrongdoing” is somewhat misleading, the notion of penile rehabilitation is essentially to prevent irreversible structural and functional damage.

This is achieved by forcefully enhancing the circulation and hence oxygenation of the tissues to facilitate recovery from the surgical insults. It is generally agreed that the first four weeks following the operation are non-beneficial for rehabilitating the penis. It is also well recognised that the window of responsiveness ranges from one to twenty-four months.

Apart from the recovery of erectile rigidity, some studies have even demonstrated benefits of sensory recovery and penile length that had been compromised after cancer operations. The regime utilised to rehabilitate the penis is very variable. This can range from daily doses of medications such as the blue pills to daily use of penile vacuum pumps and the injections of medications.

Besides, data is also emerging on the use of shock waves aiming to generate new vasculature of the penis to restore functions. Although many trials have demonstrated success, the exact dosage, interval of rehabilitation, and the long-term benefits of penile rehabilitation are generally unknown.

The detection of prostate cancer at early stages often ensures higher chances of oncological outcomes with radical surgery, especially in younger men with aggressive disease.

Undoubtedly, the trauma of surgery itself often leaves men with adversities such as erectile dysfunction and incontinence. Although the concept of penile rehabilitation may be in its early stages of research, it offers potential hope for men to regain functioning manhood after a hard time dealing with surgery.

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Dear Dr G,

I am a 66-year-old man starting a new relationship. Despite entering my later years, I refuse to slow down and engage in my career and exercise regularly to stay healthy.

Like many people today, I was invited to play pickleball. To my surprise, I love the game, and I’ve caught the love bug with a young lady 30 years my junior.

The relationship has been going well for six months. We are even discussing having a child together. I must confess, we are sexually active and often do not use contraception, yet she is not pregnant.

Concerned, I consulted doctors to assess my fertility and the risks of fathering a child at my age. I was discouraged by a gynaecologist who highlighted concerns about the risks to the child due to my paternal age, despite my girlfriend being healthy.

I value your opinion, Dr G. Does sperm quality deteriorate with age? What are the chances of fathering a child in one’s sixties and beyond? What risks exist for a woman in her thirties and forties having a baby? Similarly, what risks are there to the child when a man of my age fathers a child?

Surely everyone has heard of how Mick Jagger continues to father children at his age without challenges, as I aspire to breed like him.

Regards,

Breeding Brat

The most significant prognostic factor in pregnancy is a woman’s age.

Egg quality diminishes over time, and by 43, the egg supply dwindles. Even with Assisted Reproductive Technology, successful pregnancy rates for women at 44 are around 1.6%.

Advancing maternal age increases risks to both mother and child, including diabetes, placenta previa, and preeclampsia for the mother. The child faces risks of genetic disorders, low birth weight, premature delivery, and miscarriage. Miscarriage rates for women at 40 can be as high as 34%, rising to 53% by 45.

While male fertility declines with age, older men can still father children into their 60s, 70s, and 80s. Unlike women, who experience menopause, men typically produce sperm throughout life. However, recent studies highlight risks associated with older fathers.

The offspring of men over 40 face increased risks of miscarriage, autism, and birth defects. Though the overall risk is low, older men are more likely to father children with disorders like achondroplasia. Children of older fathers are also more prone to mental health issues such as schizophrenia, ADHD, and depression. Studies also suggest offspring of older fathers may face male infertility in the future.

Despite statistics against having children at an older age, most babies are born healthy with prenatal screening technology. Indeed, Mick Jagger, at 73, announced that his 29-year-old girlfriend Melanie Hamrick gave birth to a healthy child.

Although Mick Jagger is well-known for fathering children at advanced ages, other celebrities have followed suit. Al Pacino fathered a son at 83 with Noor Alfallah in 2023. Robert De Niro became a father again at 79 in 2023, welcoming a daughter with girlfriend Tiffany Chen.

At 73, Charlie Chaplin also had his youngest child, fathering 11 children in total. Rod Stewart seemed young when he became a father for the eighth time at 66 in 2011.

While science makes late fatherhood possible, it raises ethical and practical questions about whether a father can actively parent and support the child into adulthood. How will the child cope with the potential loss of a parent at a young age? What societal support systems exist for elderly fathers and their families?

When a man of”certain seniority” faces potential parenthood again, should he leap in joy or shiver in fear?

In response, Dr G says that “it’s all right letting yourself go, as long as you can get yourself back.”

Some ageing men aspire to breed like Mick Jagger, and the same principle applies: letting go is fine if one has the stamina and will to regain life after parenthood!

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Dear Dr G,

I email you with a heavy heart, as I have discovered that our childlessness is my fault. My wife and I have been married for five years and despite an active sex life, we have not conceived a child.

We visited a fertility specialist and found that the issue lies with me. Until I underwent a semen analysis, I was unaware of male-factor infertility.

To my surprise, my ejaculation contains no sperm. I don’t understand why I seem normal in the bedroom; in fact, I consider our sex life quite healthy. I don’t understand why it is fruitless.

The doctor explained the problem might be due to blockages in the sperm ducts or damage to the sperm-producing cells. I eventually agreed to try IVF and underwent an operation to retrieve sperm for a test-tube baby.

I must confess I have no idea about ART, PESA, MESA, and TESE. After all the attempts, I was told I have Spermatogenesis Arrest.

In simple terms, I can never father a child in my life. I would like to put Dr G on the spot for clarifications on my seedless outcome.

How common is male-factor infertility? How do you differentiate between obstructive and non-obstructive problems?

What exactly is Spermatogenesis Arrest? Why is this happening to me? Is there really no light at the end of the tunnel?

Regards,

Arrested Development Andy

Dear Andy,

Infertility is defined as the inability of couples to conceive after one year or more of active sex without contraception. The World Health Organization (WHO) estimates 60 to 80 million couples are affected, often considered just the tip of the iceberg. Contrary to the common belief that infertility is predominantly a female problem, male infertility accounts for up to 40% of all cases. Since the late 20th century, the declining quality of semen has become apparent. A 1992 study revealed the number of sperm has declined by 1% per annum since 1938. This is echoed by studies worldwide showing declines not just in sperm counts, but also in motility, morphology, and seminal volumes in the male population.

Azoospermia, or the absence of sperm in ejaculate, can affect up to 3% of all males. The causes of azoospermia can be divided into acquired or congenital and further differentiated into obstructive and non-obstructive. The most common acquired obstructive azoospermia is vasectomy. Besides surgery, sexually transmitted infections or trauma to the genitalia can cause scarring, leading to azoospermia. Non-obstructive azoospermia can also be acquired or congenital. Infections like mumps can destroy sperm-producing cells in the testicles, and men born with genetically derived Spermatogenesis Arrest can also end up with male-factor infertility. The hope for fathering a child for a man with non-obstructive azoospermia is very slim.

Men with obstructive azoospermia can overcome infertility with ART (Artificial Reproductive Technology). PESA (Percutaneous Epididymal Sperm Aspiration), MESA (Microscopic Epididymal Sperm Aspiration), and TESE (Testicular Exploration Sperm Extraction) are the main surgical techniques to retrieve trapped sperm. Following sperm retrieval, creating embryos with IVF (in-vitro fertilisation) and subsequent baby delivery is usually a matter of time. In the absence of sperm during retrieval operations, biopsies are taken to identify the causes. In some cases, Spermatogenesis Arrest is identified.

Spermatogenesis Arrest refers to the disruption or cessation of the process by which sperm cells (spermatozoa) are formed within the seminiferous tubules of the testes. This arrest can occur at various stages of sperm development, leading to a reduced or complete absence of mature sperm in the semen. Spermatogenesis Arrest refers to the interruption of this process at a specific developmental stage: early maturation arrest, stopping at the spermatogonial or primary spermatocyte stage; or late maturation arrest, stopping at the spermatid stage, before final transformation into mature sperm.

Spermatogenesis Arrest can be due to intrinsic testicular defects or external factors that disrupt the testicular microenvironment. Genetic causes such as Y-chromosome microdeletions (AZFa, AZFb, AZFc regions) and mutations in genes involved in germ cell development (e.g., SYCP3, TEX11) are well recognised.

Other causes include hormonal imbalances, undescended testicles, trauma, chemotherapy, or mumps orchitis. Treatments such as hormonal therapy using Gonadotropins (hCG, FSH) for hypogonadotropic hypogonadism and anti-oestrogens (clomiphene citrate) are used in selected cases.

Lifestyle changes, such as ceasing smoking, alcohol, heat exposure, and toxin avoidance, can also improve spermatogenesis in mild cases. However, when sperm retrieval procedures yield no mature sperm for in-vitro insemination, the hope for ART treatment is slim.

Male infertility is a real struggle for many, as society assumes all sexually mature men to be fertile while the guilt of infertility is often shouldered by women. Childbearing is clearly not just a matter of sex, but a multifactorial issue of the overall well-being of couples.

Men with Arrested Development of Sperm Maturation often put Dr G on the spot for an opinion, and he is sorry to say: “Spermatogenesis Arrest clearly poses challenges of adversity, failure, and heartache even science.”

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