Achieving Pregnancy in Situational Psychogenic Anejaculation in an Islamic Community - Two Case Repo...

Nader Salama

American Journal of Medical and Biological Research

Achieving Pregnancy in Situational Psychogenic Anejaculation in an Islamic Community - Two Case Reports and Literature Review

Nader Salama

Department of Urology, Alexandria faculty of Medicine, Alexandria, Egypt

Abstract

Introduction: Psychogenic anejaculation is a rare cause of male infertility. In this type of anejaculation, the patient cannot ejaculate while awake. Most cases of this disorder were reported in Jewish communities. In the present report, we describe the successful achievement of pregnancy in two Muslim men with situational psychogenic anejaculation. The treatment involved the simplest approach in one case but the highly technical procedure in the second case. Case presentation: Two men presented with situational psychogenic anejaculation and concern to conceive. Clinical examination, hormonal assay, urine analysis and ultrasound imaging identified irrelevant data in both. Psychosexual counseling was rejected by both men and penile vibration did not give a response in either. Case 1 succeeded to get sperm from masturbation-induced ejaculate. Case 2 got sperm after doing conventional testicular sperm extraction. The use of the retrieved sperms succeeded to attain pregnancy in both cases. However, the anejaculationdid not revert in either patient. Conclusion: Men from Islamic communities with strict religious upbringing have the possibility to have psychogenic anejaculation. This report confirms the good fertilizing potential of sperm and its capability of achieving pregnancy in men with psychogenic anejaculation. Men with this type of anejaculation are resistant to improvement even after their concern to conceive dissipates.

Cite this article:

  • Nader Salama. Achieving Pregnancy in Situational Psychogenic Anejaculation in an Islamic Community - Two Case Reports and Literature Review. American Journal of Medical and Biological Research. Vol. 3, No. 6, 2015, pp 149-151. http://pubs.sciepub.com/ajmbr/3/6/3
  • Salama, Nader. "Achieving Pregnancy in Situational Psychogenic Anejaculation in an Islamic Community - Two Case Reports and Literature Review." American Journal of Medical and Biological Research 3.6 (2015): 149-151.
  • Salama, N. (2015). Achieving Pregnancy in Situational Psychogenic Anejaculation in an Islamic Community - Two Case Reports and Literature Review. American Journal of Medical and Biological Research, 3(6), 149-151.
  • Salama, Nader. "Achieving Pregnancy in Situational Psychogenic Anejaculation in an Islamic Community - Two Case Reports and Literature Review." American Journal of Medical and Biological Research 3, no. 6 (2015): 149-151.

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1. Introduction

Natural pregnancy necessitates ejaculation inside the vagina to deposit sperm-containing semen. Men may face impediment about pregnancy due to inability to ejaculate, despite normal erection that is called anejaculation. This medical problem represents a rare etiology of male infertility accounting only for 2% of cases [1]. Anejaculation may be either organic or psychogenic.

Psychogenic anejaculation could be a cause of male infertility in 0.4-0.5% of cases [2]. It is usually diagnosed after exclusion of organic causes of anejaculation [3, 4]. It is less understood and studies investigating it are still few. It is not surprising that its management could be sometimes intricate. Besides, its prevalence is not clearly reported as it is often misjudged as delayed ejaculation [5]. Psychogenic anejaculation can take different forms. It can be generalized to happen with all types of sexual situations and situational to be encountered in some erotic situations (intercourse) and not the others (masturbation and/or nocturnal erotic dreams) [6]. The majority of cases of psychogenic anejaculation in the literature were reported from Jewish communities due to the strict orthodox upbringing [3, 4]. Research dealing with psychogenic anejaculation is totally absent in Islamic countries, except for one study which even missed any form of follow-up to the patients [7].

In this report, we describe the management of two patients with situational psychogenic anejaculation in an Islamic community to achieve pregnancy.

2. Case Reports

Case 1

35-year-old male patient, appointed as a lab technician, consulted us for inability to ejaculate intra-vaginally since he got married (4 months). He reported normal libido and erection but no orgasm. He was doing intercourse 2 times a week. He had a failure of defloration in the first two weeks of marriage during the honeymoon. He had an anxious personality. He was not masturbating, except for very rare occasions during which he ejaculated. He was looking for masturbation as a sin. He had no premarital sexual encounters. The patient has a strict religious upbringing. He reported wet dreams which on average were 3-4 per month. The patient was the middle son in 3-sons family. The 2 other brothers did not complain of any difficulty about ejaculation. He was nonsmoker or alcoholic. Physical examination did not reveal any abnormalities which could point to any cause of organic anejaculation [3, 4]. Fasting blood sugar was normal. Hormonal evaluation of total testosterone, free testosterone, luteinizing hormone, prolactin and estradiol showed normal levels. Trans-rectal and scrotal ultrasound examinations were done and did not show any abnormalities. The patient was asked to collect semen during masturbation for semen analysis. The semen testing identified normal sperm parameters, except for isolated asthenospermia (forward progression 23% & total motility 31%). Psychosexual counseling was suggested, but the patient refused because of his religious beliefs. Penile vibratory stimulation (Thrive, Thailand) was tried with no response. The patient was deeply worried about conception. The patient was, therefore, advised to collect the semen during masturbation at home in coincidence with the day of ovulation of the wife. The collection was done in a sterile container taken from our lab facility. The couple was then instructed to aspirate the semen in a syringe and inject it into the vagina. By this tactic, the wife got pregnant 2 months later. Pregnancy proceeded smoothly with the delivery of a healthy boy. Three months after delivery the intra-vaginal ejaculation was still not feasible. The patient missed the follow-up visits after that.

Case 2

31-year-old male working as an engineer sought medical advice for inability to conceive and ejaculate inside the vagina. This failed intra-vaginal ejaculation was primary. It was the reason to ask him divorce by the first wife. Recently, he re-married since 6 months. He had normal libido and erection. The couple reported doing are gular sexual activity every other day but the patient did not feel orgasm. The patient was the sole boy in the family. He was the older brother for 3 sisters. The first impression about him gave a shy personality. He was raised in a strict religious atmosphere. He was nonsmoker or alcoholic. He had no previous sexual experience and did not masturbate as he also considered this practice a sin and damaging for health. However, he reported wet dreams which were on average 4-5 per month. He further added that prolongation of the foreplay and the use of sensate focus therapy [8] did not improve his condition. Physical examination with special emphasis on the reproductive organs gave irrelevant data. Fasting blood sugar was normal. Hormonal profile including total testosterone, free testosterone, luteinizing hormone, prolactin and estradiol revealed no deviations from the normal ranges. Urine sample after intercourse did not reveal any sperms which may suggest the existence of retrograde ejaculation. Scrotal and trans-rectal sonographic check-up did not reveal any disorder.

Management of the patient started by convincing him to collect semen during masturbation, but he failed to ejaculate. The patient was then asked to collect semen by overnight application of a condom. However, he could not collect the semen in the condom. Next, vibratory stimulation of penis (Thrive, Thailand) was tried. No response, unfortunately, happened. As the main concern of the couple was to procreate and under strong family pressure, conventional testicular sperm extraction (TESE)-intracytoplasmic sperm injection (ICSI) was decided. TESE was done under light sedation. It was successful to retrieve a good number of motile sperms. The subsequent ICSI resulted into five good quality embryos. Three embryos were frozen while the other two embryos were transferred. A pregnancy test was positive after 2 weeks. The course of pregnancy was uneventful resulting into the delivery of a healthy boy and girl. Two years after delivery, the patient was still not able to ejaculate intra-vaginally although he and his wife have good sexual interrelationship.

3. Discussion

The aim of the present case study included 2 goals. The first goal was to report the existence of psychogenic primary anejaculation in the Islamic communities. Most of the studies investigating the psychogenic anejaculation were raised from Jewish communities due to the higher prevalence of this type of anejaculation among orthodox Jewish population [3, 4]. Psychogenic anejaculation, however, was also reported in Hindu and Christian families that follow orthodox religious traditions [9, 10]. The two patients under the current study were also kept under strict Islamic regulations. They had no sexual partners before marriage. They believed that masturbation is a sin. Talking about the sexual matter is still a cultural taboo in their community [11].The current case study is the first report that clearly documents the existence of psychogenic situational anejaculation among orthodox Muslim men.

Ejaculation as a final event during sexual activity is thought to need a certain level of sexual excitement [12]. It is supposed that the two patients in the current report did not reach the sufficient level of sexual excitation needed to trigger ejaculation. This may be related to their performance anxiety and spiritual circumstances which may expedite their psychogenic anejaculation. Furthermore, the two patients did not get orgasm. This agrees with Otani [13] who claimed that most cases of psychogenic anejaculation do not feel orgasm.

The second goal of the study was to verify the capability of sperm from the two reported men to achieve pregnancy. This was facilitated in the first patient through simple intra-vaginal self-insemination but using the highly technical TESE-ICSI in the second patient. The current study, therefore, confirms the previous studies reporting the good fertilizing competence of sperm in men with psychogenic anejaculation with subsequent pregnancy [3, 4, 10].

In the current case study, psychosexual counseling was not welcomed and even rejected by both patients. The main concern of the two patients was to conceive as soon as possible, but the counseling may take a long time. Both were asked most time from the families and friends when they will procreate? In addition, many people in this community are still thinking that going for psychological consultation means they are mentally unsound. This may add another stigma beside the stigma that they have delayed conceiving. Although psychosexual consultation is recommended by most researchers as an initial treatment modality of psychogenic anejaculation [8, 9], some studies claimed that this consultation is not able to revert the anejaculation [10, 14]. Penile vibratory stimulation was tried with both patients. However, it did not yield semen. This also coincides with other investigators who stated the uselessness of penile vibrator to get semen in some patients with psychogenic anejaculation [14].

The effectiveness of electroejaculation to get semen in patients with psychogenic anejaculation has been demonstrated in many studies [3, 4, 10]. In the present case study we did not use electrovibrator to get sperm from the second patient but we shifted directly to the conventional TESE. This was because 1) Electroejaculator needs anesthesia (spinal or general) making the technique costly and associated with possible side effects. Anesthesia may also add unnecessary emotional burden on the patient who was already anxious. In contrast, the TESE was done under light sedation. 2) Electroejaculator-retrieved semen has fairly compromised quality [3, 4].

4. Conclusion

We managed two Muslim men with situational psychogenic anejaculation who were unable to conceive. Men from Islamic communities with strict religious upbringing have the possibility to have psychogenic anejaculation. This report confirms the good fertilizing potential of sperm and its capability of achieving pregnancy in men with psychogenic anejaculation. Men with psychogenic anejaculation are difficult to get improved even after their concern to conceive fades.

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