Abstract
Erectile dysfunction (ED) is prevalent among males experiencing fertility challenges, yet attitudes towards actively treating ED in this group are under-researched. From a cohort of 1256 men with reproductive needs, 303 were identified with ED. The survey encompassed 296 respondents who correctly completed the second questionnaire, revealing that 50.3% sought ED treatment, with higher ED severity increasing the likelihood of seeking treatment. Infertile men were more likely to seek treatment than those with pregnancy loss (OR 3.18, 95% CI 1.74–5.83). Men with normal semen parameters were more open to ED therapy (OR 3.02, 95% CI 1.69–5.36), whereas those undergoing Assisted Reproduction Treatment were less inclined (OR 0.32, 95% CI 0.18–0.58). PDE-5 inhibitors (PDE-5Is) were preferred by 51.0% of those seeking treatment, with 29.7% of men with pregnancy loss and 60.1% of infertile men choosing PDE-5Is as their first option. Concerns included potential adverse effects of PDE-5Is on fetal health (78.7% of men with pregnancy loss) and on sperm quality (44.2% of infertile men). In conclusion, the different fertility requirements, semen parameters, and whether received ART are significant factors influencing the acceptance of treatment, PDE-5Is utilization among individuals in men with couple pregnancy loss is notably limited.
Supplementary Information
The online version contains supplementary material available at 10.1038/s41598-024-73328-5.
Keywords: Erectile dysfunction, Treatment seeking behavior, Reproductive health, Infertile, Couple pregnancy loss, Phosphodiesterase-5 inhibitors
Subject terms: Health care, Health occupations
Introduction
Erectile dysfunction (ED) is a prevalent condition affecting men worldwide, with significant implications for reproductive health and overall quality of life, represent a substantial challenge to the affected individual and their families1–3. Phosphodiesterase-5 inhibitors (PDE-5Is) had been proven to be an effective measure as first-line of ED treatment2–4. Nevertheless, apprehension regarding potential side effects, concerns about drug dependence, and perceptions related to masculinity and sexual performance often impede men from initiating treatment promptly and lead to premature cessation of PDE-5Is after commencement, thereby underscoring the intricacies inherent in the management of ED5,6. Moreover, cultural influences significantly impact treatment preferences, particularly evident in the preference of Asian men for traditional and complementary medicine remedies over PDE-5Is7–9.
Scholars are increasingly focusing on reproductive health, with a growing emphasis on sexual dysfunction among males facing fertility challenges: high rates of ED have been observed in such populations (for couple infertility 18.1% ~ 30.6% and for couple pregnancy loss 19.1% ~ 27.0%)10–12. The psychological ramifications of ED within this demographic should not be understated, the negative dynamics within a couple’s relationship and the mental strain resulting from decreased sperm quality, may contribute to heightened levels of depression and anxiety11,13–15. Despite sexuality significantly influences fertility, it is often overlooked in standard medical care protocols for fertility treatment16. There remains a need for deeper insights into the attitudes and preferences of men with fertility requirements towards active treatment interventions.
This underscores the necessity for an integrated approach to addressing both sexual and reproductive health concerns particularly for men desiring fatherhood, effective management of ED assumes added significance as it intersects with fertility outcomes and considerations for family planning17,18. Understanding the multifaceted nature of treatment attitudes and preferences among patients grappling with ED within the context of reproductive needs is imperative for tailoring interventions to meet their specific requirements and concerns. Despite the paramount importance of comprehending these attitudes, there remains a paucity of literature on the treatment preferences within this demographic.
The primary objective is to elucidate the attitudes of men with fertility needs towards the active treatment of ED, examining factors influencing their acceptance of intervention strategies. We also sought to investigate the preferences and concerns of these individuals regarding specific therapeutic modalities. Aim to offer valuable insights into the intricate interplay among ED, fertility, and treatment attitudes.
Methods
Survey methods and questionnaire
The survey was conducted between June 2021 and October 2021. In brief, the initial phase of our cross-sectional study conducted at the First Hospital of Jilin University, involved a descriptive analysis of the prevalence of ED within a cohort comprising 1,256 consecutive men with diverse fertility requirements (437 with couple pregnancy loss, 509 with couple infertility, and 310 with preconception care)12. This study constitutes a follow-up to the initial phase of a cross-sectional investigation. ED was diagnosed using a validated questionnaire International Index of Erectile Function-5 (IIEF-5) with a total score ≤ 21, identified 303 men with ED. Severity of ED was assessed according to the IIEF-5 scores as follows: a score of 17 to 21 indicates mild ED, a score of 12 to 16 indicates mild- moderate ED, and a score of 5 to 11 indicates moderate-severe ED19. After informing and obtaining consent from male survey respondents diagnosed with ED, questionnaires were required to be completed immediately and recalled on the spot. The questionnaire encompassed inquiries regarding the initiation of treatment, preference for treatment modalities, and knowledge/apprehensions concerning PDE-5Is. A schematic flow chart depicting the inclusion of patients in the study is presented in Fig. 1.
Fig. 1.
Flow chart of respondents in a cohort of consecutive men with diverse fertility requirements.
Statistical analysis
Normal distribution results are expressed as mean and standard deviation, categorical data are presented as frequencies and percentages. Unpaired two-sided Student’s t-tests or Mann–Whitney U-test were used for comparisons of the two groups. Analysis of variance (ANOVA) or Kruskal–Wallis tests were employed for comparing continuous parameters among more than two groups, whereas categorical variables underwent comparison via the Pearson χ2 test. A multivariable logistic regression analysis was conducted to examine factors associated with the accepting attitude toward the ED intervention, the odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. A 2-sided P value was used, and significance was set at P < 0.05. Survey data were collected and analyzed using IBM SPSS statistical software version 22.0 (IBM).
Ethical approval
The present study received approval from the Institutional Review Board Ethics Committee of the First Hospital of Jilin University (approval No. 21K064-001). Informed consent was obtained from all participants in compliance with the Helsinki declaration and its amendments. All procedures were performed in accordance with relevant guidelines. This study is part of a registered clinical trial on ClinicalTrials.gov (NCT04941690). This study adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
Results
Characteristics of the respondents
The study participants were drawn from a cohort comprising 1256 men with varying fertility requirements. Within this cohort, 303 males were identified as experiencing ED based on the IIEF-5. Ultimately, the survey encompassed 296 respondents who correctly completed the second questionnaire, yielding an overall valid response rate of 97.6%. These respondents had a mean (SD) age of 33.85 (4.51) years and a mean (SD) body mass index (BMI) of 26.33 (3.65). Of the respondents, 115 (38.8%) were addressing couple pregnancy loss, 153 (51.7%) were managing couple infertility, and 28 (9.5%) were providing couple preconception care. Among them, 166 (56.1%) exhibited mild ED, 103 (34.8%) had mild to moderate ED, and 27 (9.1%) demonstrated moderate to severe ED. Table 1 presents the characteristics of the included respondents (Table 1).
Table 1.
Characteristics of the respondents.
| Variable | Respondentsa | P value | ||
|---|---|---|---|---|
| Overalla | Refuse all types of medical interventions | Active treatment-seeking | ||
| N = 296 | N = 147 (49.66%) | N = 149 (50.34%) | ||
| Age | 33.85 (4.51) | 33.39 (4.36) | 34.36 (4.61) | 0.062 |
| BMI | 26.33 (3.65) | 26.20 (3.44) | 26.46 (3.86) | 0.527 |
| Smoking | 127 (42.91%) | 61 (41.50%) | 66 (44.30%) | 0.712 |
| Drinking | 61 (20.61%) | 31 (21.09%) | 30 (20.13%) | 0.953 |
| Underlying diseases | 0.719 | |||
| Hypertension | 13 (4.39%) | 5 (3.40%) | 8 (5.37%) | |
| Diabetes | 7 (2.36%) | 3 (2.04%) | 4 (2.68%) | |
| Monthly household income | 0.508 | |||
| ~ 5000 | 82 (27.70%) | 45 (30.61%) | 37 (24.83%) | |
| 5000–7000 | 141 (47.64%) | 66 (44.90%) | 75 (50.34%) | |
| 7000 ~ | 73 (24.66%) | 36 (24.49%) | 37 (24.83%) | |
| Night shift | 65 (21.96%) | 28 (19.05%) | 37 (24.83%) | 0.202 |
| Education level | 0.990 | |||
| Junior school | 47 (15.88%) | 23 (15.65%) | 24 (16.11%) | |
| High school | 85 (28.72%) | 42 (28.57%) | 43 (28.86%) | |
| University | 164 (55.41%) | 82 (55.78%) | 82 (55.03%) | |
| Testis volume | 12.89 (2.98) | 13.01 (2.85) | 12.79 (3.11) | 0.530 |
| GAD-7 scores | 4.77 (3.26) | 4.53 (3.09) | 5.01 (3.39) | 0.202 |
| Reason for clinic visit | 0.030 | |||
| Pregnancy loss | 115 (38.85%) | 68 (46.26%) | 47 (31.54%) | |
| Infertile | 153 (51.69%) | 68 (46.26%) | 85 (57.05%) | |
| Preconception care | 28 (9.46%) | 11 (7.48%) | 17 (11.41%) | |
| Degree of ED | < 0.001 | |||
| Mild | 166 (56.08%) | 94 (63.95%) | 72 (48.32%) | |
| Mild to moderate | 103 (34.80%) | 48 (32.65%) | 55 (36.91%) | |
| Moderate to severe | 27 (9.12%) | 5 (3.40%) | 22 (14.77%) | |
| Undergoing ART | 109 (36.82%) | 66 (44.90%) | 43 (28.86%) | 0.006 |
| Abnormal Semen parameters | 201 (67.91%) | 113 (76.87%) | 88 (59.06%) | 0.002 |
a Mean (SD); n (%).
ED: Erectile Dysfunctions.
ART: assisted reproduction treatment.
BMI: body mass index.
Significant are in value [bold].
Attitudes of the males with fertility requirements toward active treatment of erectile dysfunctions and associated factors
The baseline characteristics of the study population were comparable across the two groups: the Refuse all types of medical interventions group and the Active treatment group (Table 1). Among the 296 males with ED, 50.3% (149/296) opted for continuing active treatment. Specifically, for males with couple pregnancy loss, this proportion was 40.9% (47/115), for male with couple infertile it was 55.6% (85/153), and 60.7% (17/28) for male with couple preconception care, groups did not differ on most demographic characteristics (Supplemental Table 1). Of them, 43.4% (72/166) of males with mild ED sought active treatment, for male with mild to moderate ED it was 53.4% (55/103), while for male with moderate to severe ED it was 81.5% (22/27). Within this cohort, 36.8% (109/296) received assisted reproduction treatment (ART) during the study enrollment, among these, 39.4% (43/109) sought active treatment for ED, whereas among those not undergoing ART, the proportion was 56.7% (106/187). All study participants underwent fertility assessments, where abnormal semen parameters referred to men with impaired sperm counts, motility, morphology, or sperm DNA fragmentation. Notably, the majority of males with normal semen parameters (64.2%, 61/95) pursued active treatment for ED, while this proportion was lower at 43.8% (88/201) among males with abnormal semen parameters (Table 1).
A multivariable logistic regression model was used to estimate factors associated with the accepting attitude toward the ED intervention, the results are shown in Table 2. Severity of ED may be an important correlate of treatment-seeking, our data suggests that as the severity degree of ED rises, the proportion of males with ED who request active treatment is also increased in sequence in mild ED (reference), mild to moderate ED (OR, 1.99; 95% CI, 1.15–3.46; P = 0.014), and moderate to severe ED (OR, 6.89; 95% CI, 2.32–20.47; P < 0.001). The proportion of males with ED who request active treatment was higher in couple infertile (OR, 3.18; 95% CI, 1.74–5.83; P < 0.001) than that in couple pregnancy loss. Those with normal semen parameters were more willing to accept therapy for ED than men with impaired semen parameters (OR, 3.02; 95% CI, 1.69–5.36; P < 0.001). In addition, males received ART are usually more reluctant to accept therapy for ED (OR, 0.32; 95% CI, 0.18–0.58; P < 0.001) than those males ART was not performed.
Table 2.
Related factors of active treatment of erectile dysfunction in men with reproductive needs.
| Variable | Respondentsa | OR (95%CI) | P value | |
|---|---|---|---|---|
| Refuse any types of medical interventions (N = 147) | Active treatment-seeking (N = 149) | |||
| Reason for clinic visit | ||||
| Pregnancy loss | 68 (46.26%) | 47 (31.54%) | 1 [Reference] | NA |
| Infertile | 68 (46.26%) | 85 (57.05%) | 3.18 [1.74–5.83] | 0.000 |
| Preconception care | 11 (7.48%) | 17 (11.41%) | 2.21 [0.87–5.58] | 0.095 |
| Degree of ED | ||||
| Mild | 94 (63.95%) | 72 (48.32%) | 1 [Reference] | NA |
| Mild to moderate | 48 (32.65%) | 55 (36.91%) | 1.99 [1.15–3.46] | 0.014 |
| Moderate to severe | 5 (3.40%) | 22 (14.77%) | 6.89 [2.32–20.47] | 0.000 |
| Undergoing ART | ||||
| No | 81 (55.10%) | 106 (71.14%) | 1 [Reference] | NA |
| Yes | 66 (44.90%) | 43 (28.86%) | 0.32 [0.18–0.58] | 0.000 |
| Semen parameters | ||||
| Abnormal | 113 (76.87%) | 88 (59.06%) | 1 [Reference] | NA |
| Normal | 34 (23.13%) | 61 (40.94%) | 3.02 [1.69–5.36] | 0.000 |
a Mean (SD); n (%).
ED: Erectile dysfunctions.
ART: Assisted reproduction treatment.
Significant are in value [bold].
Attitudes of males with fertility requirements towards PDE-5Is and associated concerns
Among male patients seeking active treatment, although 98.6% (147/149) of the respondents indicated familiarity with at least one of the PDE-5Is, only 51.0% (76/149) opted for PDE-5Is as their preferred therapy. Men with various fertility requirements show various attitudes towards PDE-5Is. Notably, PDE-5Is was selected as the first choice for ED therapy only in 29.7% (14/47) of males with couple pregnancy loss. Conversely, for couples facing infertility, this preference rose to 60.1% (51/85), and for those seeking preconception care it reached 64.8% (11/17). Moreover, the utilization of traditional Chinese medicine, acupuncture, or herbal remedies as the initial ED therapy was significantly more prevalent among males experiencing pregnancy loss within couples compared to those facing infertility (70.3% vs. 39.9%) (Fig. 2).
Fig. 2.
Acceptance of different treatment options in men who actively seek erectile dysfunction treatment.
For respondents who opted not to pursue PDE-5Is as their initial treatment for ED, various fertility considerations give rise to distinct concerns and apprehensions. Among males with couple pregnancy loss, the foremost worry (78.7%, 26/33) revolves around the potential adverse effects of PDE-5Is on fetal development. Conversely, for those with couple infertility, the primary concern (44.2%, 15/34) is whether PDE-5Is exert negative effects on human spermatogenesis, followed closely by apprehensions regarding potential detrimental impacts on fetal development (38.2%, 13/34) (Fig. 3).
Fig. 3.
The main concerns among those respondents refuse phosphodiesterase-5 inhibitors.
Discussion
Erectile dysfunction (ED) remains a prevalent condition among men with diverse fertility needs, constitutes a complex ailment that impacts not solely sexual function, but also reproductive health and outcomes. However, given the infrequent inclusion of inquiries into sexual activity within routine infertility assessments, it is plausible that their prevalence may be underestimated17. The elevated incidence of ED among men with reproductive requirements appears primarily attributable to psychological factors20. Specifically, apprehension regarding performance, characterized by mild subjective concern and subsequent autonomic arousal dysfunction, may initiate initial challenges and subsequently exacerbate anxiety and sexual dysfunctions within a self-perpetuating cycle21. Most ED males did not actively seek treatment, studies have shown that the average time from the discovery of ED to the first treatment is 4.3 months6,22.
Our study, encompassing 296 men of different fertility needs with ED, sheds light on the attitudes towards active treatment and the factors influencing these inclinations within this population. Our findings reveal a notable inclination towards active treatment among men with ED, with 50.3% of respondents expressing a desire to pursue intervention, it is similar to prior Asian studies22,23. Interestingly, the severity of ED emerged as a significant determinant, with a progressive increase in treatment-seeking behavior observed from mild to moderate to severe ED. This was in accordance with the previous studies’ findings in the general population24,25. This underscores the perceived impact of ED severity on the quality of life and underscores the importance of addressing this condition comprehensively. Furthermore, the existence of ED may impair fertility through a diminishment in the frequency of effective vaginal intercourse18. Our investigation underscores the impact of men with varying reproductive requirements on the preference for ED treatment, find that men with infertility exhibiting a greater propensity towards seeking active intervention for ED compared to those experiencing couple pregnancy loss.
The declined semen quality inflicted considerable psychological and physical burden on individuals with fertility requirements13–15,20. Semen parameters emerged as a noteworthy factor influencing treatment-seeking behavior in the present study, men with normal semen parameters displaying a higher likelihood of seeking ED treatment compared to those with abnormal parameters. This association underscores the interplay between sexual function and fertility potential, in situations where ED and diminished sperm quality coincide, the predominant inclination among men is to prioritize addressing sperm-related issues over sexual function concerns. Highlight the need for a comprehensive assessment of male reproductive health in the management of ED.
Particularly when the objective is pregnancy, ED imposes heightened psychological stress on men15. Stress/distress and anxiety/depression frequently manifest within couples undergoing ART procedures26. Sexual dysfunction exhibited a higher prevalence among males undergoing ART procedures27. The impact of ART on treatment preferences for ED is also noteworthy, with individuals undergoing ART demonstrating a reduced inclination towards active treatment for ED. Solve fertility problems is the predominant treatment demand in these populations. Under ART circumstances, these patients may even solve fertility problems without sexual intercourse. Frequent gynecological examinations and procedures during ART may constrain sexual activity, also potentially contributing to this phenomenon. The complex interplay between medical interventions and patient perceptions, warranting further exploration to elucidate the underlying mechanisms and optimize treatment strategies in this subgroup.
With regard to treatment, PDE-5Is was still the first choice for ED treatment among men who chose active treatment. International consensus had recommended PDE-5Is as a first-line drug for the management of male infertility with coexisting ED unless the patient has contraindications or significant drug side effects3,18,24. However, variations in treatment preferences were observed across different fertility requirements in the present study. Although there is no direct evidence that potential injuries caused by the PDE-5Is to progeny health28. Some respondents felt that given the lack of robust evidence, it would be premature to judge the treatments as safe, lack of evidence and safety concerns play a prominent role in the choice of treatment options for ED. This may reflect the heightened importance of sexual function in the context of fertility treatments and the desire for holistic management of progeny health concerns. Given the psychosocial distress commonly associated with sexual dysfunction and male fertility issues, numerous patients opt to investigate alternative treatments, are frequently marketed as means to enhance overall well-being and holistic health29. Although the available data concerning the efficacy of Chinese herbal medications, acupuncture, mind–body practices, and faith-based healing in improving male fertility are either limited or inconclusive30,31, these treatments garnering preference among men with pregnancy loss subgroups. Recent literature indicates that PDE-5Is have the potential to enhance specific parameters of male sperm beyond their known effects on smooth muscle relaxation and penile erection32. Concerns regarding the potential adverse effects of PDE-5Is on fetal health and sperm quality were also evident in the present study, highlighting the importance of addressing patient apprehensions and providing tailored counseling to mitigate anxieties.
One of the principal strengths of our study lies in its holistic approach to elucidating the complexities of erectile dysfunction (ED) from the standpoint of male reproductive health. By incorporating a substantial cohort of men with diverse reproductive needs, we were able to capture a broad spectrum of perspectives and experiences. This comprehensive approach not only underscores the significance of ED within the context of reproductive health but also contributes to the development of rational treatment strategies for men with reproductive concerns. Moreover, the inclusion of multivariable logistic regression analysis facilitated the identification of key factors associated with treatment-seeking behavior for ED, thereby enriching our understanding of the complex interplay between demographic, and clinical variables in shaping patient preferences and attitudes towards intervention. Additionally, the exploration of treatment preferences and concerns among respondents provides valuable insights into the real-world dynamics of ED management, highlighting the importance of patient-centered care and shared decision-making in optimizing treatment outcomes. Despite these insights, our study is not without limitations. Firstly, this study investigates the potential postponement of treatment for ED among men with reproductive aspirations, examining the concerns that may contribute to such delays. Consequently, the study participants were deliberately chosen from a cohort of men with reproductive needs. It is recognized that analogous treatment delays and associated concerns may also exist within the broader male population. However, additional research is required to further explore and validate this phenomenon. Additionally, variations in lifestyle and religious beliefs can significantly impact the treatment preferences of patients with erectile dysfunction (ED). This study represents the first investigation into treatment attitudes among men with ED within a reproductive population. However, the cross-sectional survey did not account for these characteristics. Furthermore, due to conservative perspectives on sexuality prevalent in Asia, particularly in China, female-related factors were excluded from the study. The omission of these variables diminishes the robustness of the evidence presented, underscoring the need for further research to examine these dimensions more comprehensively.
In conclusion, our study underscores the multifaceted nature of ED within the context of male reproductive health, emphasizing the need for personalized approaches that take into account the severity of ED, fertility status, and patient preferences. Future research endeavors should focus on elucidating the long-term outcomes of ED interventions in men undergoing fertility treatments and exploring novel therapeutic modalities to optimize sexual and reproductive health outcomes in this population.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
The authors thank the patients for their active engagement in the study.
Author contributions
XW Y and QW, designed and conceived the study; QW, TT, XY Z and HW, collected the Data; XW Y and HW, performed the statistical analysis; XW Y and QW, drafted the article. All authors read, revised and commented on the article and approved the final version before submission.
Funding
This study was supported by the Department of Finance of Jilin Province (Grant No. JLSWSRCZX2021-034).
Data availability
The entirety of the data supporting this article is accessible in textual format, figures, tables, and references. Upon request, additional breakdowns of this data will be promptly provided by the corresponding author.
Declarations
Competing interests
The authors declare no conflict of interest.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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