Sexology of elderly man with secondary infertility.

Atif A. Katib et al. touched a very sensitive field of everyday andrological work–up. The manuscript gives an overview to almost all possible causes of secondary infertility [1]. Compared to primary infertility, patients are rather young, usually healthy, slim, without chronic diseases and with normal libido, erectile and ejaculation function. The semen quality diminishes with age. In elderly men, healthy lifestyle recommendations are more often insufficient because comorbidities are so advanced. In this case, only pharmacological or surgical treatment is a way of choice. However, pharmacology and surgery carry other side effects, such as influencing semen, sexual drive, sexual function and fertility potential. Unfortunately, in many cases, the only way is assisted reproduction technology (ART).

Varicocelectomy improves the semen quality but statistically does not improve the rate of pregnancy. Microsurgical techniques give the highest rate of success without serious complications [2]. However, when performing varicocelectomy in elderly men, one must always keep in mind that the time of existing varicoceles is much longer than in younger patients, so expected positive effect in improving semen quality could be worse.

Sexological aspects in these patients are issues which cannot be just solved in one or two questions. It is not enough to ask “Do you have sexual intercourse?” After a few failures resulting from erectile dysfunction, many elderly males do not initiate or respond to sexual attempts from their partners, even when they want to have a child. The definitions of infertility enclose a time frame (1–5 years) but there are no details concerning “regular unprotected sexual intercourse” or “being sexually active” [3]. The frequency of intercourse in young men could be a few per day; in elderly men it could be a few per month or even a few per year, even if sexual activity is perceived as a marker of “good health” [4]. In these conditions, with poor semen quality, it is very difficult to conceive. Information regarding how many sexual intercourses occurred within the last 4 weeks which were finalized with semen deposition in the vagina is crucial to initially define how high the probability of becoming pregnant is.

Sexological consultation should be seriously considered in every patient with secondary infertility. The impact on sexual behaviour is not only determined by the level of testosterone, obesity or heart insufficiency, but also by frailty, lack of trust, intimacy, sexual desire or arousal [5]. During an interview with a couple who appears in the office due to secondary infertility, never assume that they have normal, regular active sexual life without any disturbances. Do not focus on semen analysis and treating low testosterone level. Appropriate counseling and treatment of erectile and/or ejaculation dysfunction [6] combined with effective treatment of metabolic, hormonal [7] and cardiovascular diseases could reach success and avoid ART. It is worth to underline that treatment of secondary infertility in aging males cannot be reduced only to a urologist or an andrologist. The broad team of specialists mentioned by the authors, including a sexologist or sexological psychotherapist, is required for the proper care of these unique patients.

The most important message to take home from the article is that elderly men who suffer from secondary infertility have much more multifactoral and extensive histories of diseases, traumas, surgeries, sexological problems and many more years of bad lifestyle habits (smoking, alcohol, drugs, etc.) than younger men. This makes diagnosis and treatment more difficult compared to patients with primary infertility. The future challenge for reproductive medicine is to help them, especially if we take into account elongating time of life and the increasing problem of infertility.