Ejaculation Problems: Which Ones Affect Fertility

Two of them. Retrograde ejaculation, where semen passes backwards through the bladder neck into the bladder instead of out, and anejaculation, where no semen is released at all. Both block delivery, and in most cases the sperm is still there to be collected.

Premature ejaculation and delayed ejaculation are different. They can be distressing and they are worth treating, but they do not in themselves stop semen reaching the vagina, and no source on this page shows them reducing the chance of conception.

So the first useful thing is to know which of these you have — and that is settled by a test, not by guessing from symptoms.

A urine sample given straight after orgasm — but the finding has to clear a threshold rather than merely exist. Sperm in that sample points to semen having gone backwards into the bladder only where there is enough of it, and the figure reported in the literature is 10 to 15 sperm per high-powered field. That is what separates retrograde ejaculation from true anejaculation, and it cannot be told from the outside, because both look like a dry or nearly dry orgasm.

The threshold matters because a trace is close to normal. A review of ejaculatory dysfunction by Gray and colleagues calls the test controversial for that reason: some sperm turns up in post-ejaculation urine in 65% of fertile men, versus 73-90% of infertile men. So if you have been told you have retrograde ejaculation because sperm were seen in your urine, the question to ask is how many, not whether.

The AUA/ASRM guideline puts it as Statement 53, a Clinical Principle: "Clinicians should obtain a post-orgasmic urinalysis for males with aspermia after retroperitoneal lymph node dissection and reduced volume ejaculate who are interested in fertility." Worth reading that carefully — the formal recommendation is narrow, covering that specific surgical setting, and it is graded as a Clinical Principle rather than resting on trial evidence. The broader point stands regardless: this is the test that distinguishes the two, and it is a urine sample.

What prompts it is usually the semen analysis itself: low or absent ejaculate volume is the finding that raises the question. The AUA/ASRM guideline asks for a reproductive history and one or more semen analyses at the initial evaluation (Statement 2). There is more on the volume finding in low semen volume and on the test itself in how to prepare for a semen analysis.

The EAU groups the causes of retrograde ejaculation as neurogenic — spinal cord injury, cauda equina lesions, multiple sclerosis, autonomic neuropathy, Parkinson's disease, diabetes, retroperitoneal lymphadenectomy, and prostate, colorectal or anal surgery; anatomical, including urethral stricture and bladder neck resection after prostate surgery; pharmacological, including alpha-1 blockers, antipsychotics, antidepressants, some antihypertensives and thiazide diuretics; and endocrine, including hypothyroidism, hypogonadism and raised prolactin.

That a drug class can cause this is a reason to tell your prescriber you are trying to conceive. It is not a reason to stop a medicine you have been prescribed. Whether an alternative exists, and whether it is safe to switch, is a decision for the person who prescribed it.

The honest answer is that the figures vary a lot, and the reason is that they come from small single-setting series rather than population studies.

• At fertility clinics. Reported prevalence is 0.3-2% of men attending (EAU 2025).
• With diabetes. The EAU cites one controlled comparison in which retrograde ejaculation was found in 34.6% of diabetic men, a series of 57 men with type 1 diabetes in which the rate was at least 8.8%, and a series of 54 diabetic men with sexual dysfunction in which it was 6%. Read that range as meaning diabetes makes it materially more likely, not as a number.
• After prostate surgery. In a study of 5,276 men after transurethral resection of the prostate, 68% reported retrograde ejaculation afterwards. The EAU notes the incidence has fallen as less invasive techniques have come in.
• Anejaculation. Rare. The EAU cites a prevalence of 0.14% of the general population in Kinsey's data, with spinal cord injury, diabetes and multiple sclerosis as the commonest causes.

If diabetes is the background here, it is worth reading male fertility and diabetes alongside this, because the same autonomic neuropathy that causes retrograde ejaculation also causes erectile dysfunction.

Usually yes, and the routes have names. This is the part of the page that matters most if you have just been told you have anejaculation.

For anejaculation, including after spinal cord injury, the EAU puts penile vibratory stimulation first. It works by evoking the ejaculation reflex, which needs an intact lumbosacral segment of the cord. A systematic review and meta-analysis of 45 studies covering 3,851 men found that in complete spinal cord injury, ejaculation occurred with masturbation or intercourse in 11.8% (n = 1,161), with vibratory stimulation in 47.4% (n = 597) and with an acetylcholinesterase inhibitor before masturbation in 54.7% (n = 309); in incomplete injury the corresponding figures were 33.2%, 52.8% and 78.1%, though the last of those rests on 32 men (Chehensse 2013, Human Reproduction Update).

If vibratory stimulation fails, electroejaculation is next, and if that fails or cannot be done, sperm can be retrieved surgically from the testis or epididymis. Adding midodrine to vibratory stimulation in 158 men with spinal cord injury who had already failed stimulation alone produced ejaculation, antegrade or retrograde, in 102 of 158 men (65%) — but 16 developed intense autonomic dysreflexia needing treatment, which is why this is done in a unit equipped for it rather than opportunistically (Soler 2008, Journal of Sexual Medicine).

For retrograde ejaculation, the sperm is in the bladder, so it is recovered from urine. The AUA/ASRM guideline sets out the options as sympathomimetics, with or without alkalinisation of the urine and catheterisation, induced ejaculation, or surgical sperm retrieval (Statement 34). Once sperm is in hand, it is used in insemination or ICSI. A dedicated page covers whether retrograde ejaculation is a problem in more detail.

There are published figures, and they need their denominators and their ranges attached or they mislead.

A systematic review of 34 studies, most of them observational, reported that centrifuging and resuspending post-ejaculation urine gave a 15% pregnancy rate per cycle, with individual studies ranging from 0 to 100%. The Hotchkiss method — emptying the bladder by catheter before ejaculation and instilling a small volume of fluid to make it survivable for sperm — gave 24% per cycle, again with a 0 to 100% range across studies. On restoring forward ejaculation rather than retrieving sperm, sympathomimetics were pooled at 28% effective, antimuscarinics alone at a pooled 22% and the two combined at a pooled 39% (Jefferys 2012, Fertility and Sterility; figures as summarised in EAU 2025).

Those 0 to 100% ranges are the tell. The review's own conclusion is that the literature "is insufficient to allow firm comparisons between interventions", and that treatment should therefore be tailored to the individual. The AUA/ASRM statements covering the same ground are graded Expert Opinion, not evidence-based recommendations. So the right reading is that pregnancies do happen by these routes, and that nobody can tell you which route is best from the published evidence.

The EAU adds one practical caveat about the drug route: the effect of sympathomimetics diminishes over time.

Not on the evidence retrieved here. Conception needs semen deposited in the vagina, and in premature ejaculation it normally still is — the timing within intercourse changes, not the destination. The situation where it would matter for conception is the specific one where ejaculation happens before penetration, and no study cited on this page measured conception rates according to premature ejaculation, so that is a mechanical inference rather than a finding.

It is also more commonly reported than it is diagnosed, which matters if you are trying to work out whether you have it. In two large cross-sectional surveys, overall self-reported prevalence of premature ejaculation was 19.8% and 25.8%; when the same complaints were sorted by the Waldinger classification, the prevalence of lifelong premature ejaculation was 2.3% and 3.18%, and the prevalence of acquired premature ejaculation 3.9% and 4.48%. The EAU attributes the gap to the measurement — a single yes-or-no question inflates the figure. Both surveys found that men with acquired premature ejaculation were more likely to seek treatment than men who had always had it.

In the Indian community data, 19.4% of 211 men surveyed in four villages of Kaniyambadi block, Vellore district reported premature ejaculation (Vivekanandan 2019, Indian Journal of Psychological Medicine).

Delayed ejaculation has a prevalence of around 3% among sexually active men, with an estimated prevalence of about 1% for lifelong delayed ejaculation and about 4% for acquired. The EAU is candid that the epidemiology is unclear because the definitions are uncertain.

On treatment, the EAU's summary of evidence is blunt: there is not enough evidence to support a definitive treatment for delayed ejaculation, at evidence level 3. A survey of what practitioners actually prescribe recorded several drugs in use, but the EAU notes no proven efficacy or superiority for any of them, because the placebo-controlled randomised comparative trials have not been done. Vibratory stimulation is used as an adjunct.

Anorgasmia is the perceived absence of orgasm, and it can give rise to anejaculation. The EAU cites psychological factors as responsible for around nine in ten cases of anorgasmia, a figure resting on one cited source and an estimate rather than a measurement. Where a medicine is suspected — antidepressants are the usual candidate — that is a conversation with the prescriber. Hormonal causes including hypogonadism and prostate conditions are checked rather than assumed.

Most men who look this up do not go on to ask anyone. That is the pattern the Indian community data shows, and it shows why.

In the Vellore survey of 211 men, premature ejaculation was associated with guilt about masturbation, with the belief that nocturnal emission was the cause, and with anxiety and depression; erectile dysfunction was associated with worry about loss of semen and with the belief that the problem was a punishment. The authors' own conclusion was that sexual misconception is a significant problem in rural Indian communities and that it needs addressing in primary and secondary care (Vivekanandan 2019).

None of those beliefs is true, and none of them is what the test measures. The test that settles retrograde ejaculation is a urine sample given after orgasm. The appointment is with a urologist or an andrologist, and the AUA/ASRM guideline asks for both partners to be assessed at the same time (Statement 1). If the concern is whether an erection is the problem instead, that is a different question with a different answer — see whether erectile dysfunction is a fertility issue.

This is a field with confident writing built on thin data. The gaps are worth naming.

• That any one retrieval method is better than another. The review that produced the 15% and 24% figures per cycle states explicitly that the literature is insufficient for firm comparisons between interventions, and its studies ranged from 0 to 100% per cycle.
• That any drug reliably treats delayed ejaculation. The EAU rates the evidence for a definitive treatment at level 3 and records that the controlled trials have not been done.
• That sympathomimetics keep working. The EAU notes the effect diminishes over time, and that many of the studies of these drugs in retrograde ejaculation were small or were case reports.
• That premature ejaculation treatment improves conception. Not measured in anything cited here. Nor was the reverse — no retrieved study compared conception rates in men with and without premature ejaculation.
• An Indian figure for retrograde ejaculation. Not found. The diabetes estimates here come from European and North American series with denominators in the tens, and the Indian data cited on this page is a 211-man survey of one rural block, which measured erectile and premature ejaculation but not retrograde ejaculation.
• That nine in ten cases of anorgasmia are psychological. That figure appears in the EAU text attributed to one source. It has not been corroborated in anything retrieved here.