I am 39 and just got married. My problem is I am having difficulty ejaculating or reaching an orgasm. I really would like to impregnate my wife, but I just cannot. Do you have any suggestions?

-- Robert

Problems with impotence include difficulty with erection, failure to maintain the erection, difficulty achieving orgasm, or ejaculatory disturbances. Each of these problems can stem from a variety of causes. Your doctor can help you determine just what is happening in your case.

Difficulty achieving erection can reflect problems with either the nervous system or the blood vessels. This can be due to diabetes, lumbar-sacral disk disease, multiple sclerosis or certain types of prostate or bowel surgery. After an evaluation, your physician may prescribe Viagra to help you achieve and maintain an erection.

Psychologic factors may also come into play. If you have no difficulty achieving an erection and orgasm with masturbation, the problem may be psychological, and you should consider counseling.

Failure to ejaculate can indicate retrograde ejaculation, caused by a weakness of the muscles that close off the opening to the bladder during ejaculation. When this muscle sphincter fails, the semen take the wrong path; they enter the bladder rather than escaping through the urethra. This is best treated by a procedure to recover sperm from the bladder. The sperm can be used for insemination or IVF and ICSI (sperm injection). For more information on this condition, see my previous column, No Semen Comes Out during Intercourse.

If an irreversible neurologic cause is identified, sperm can be retrieved by a procedure called electroejaculation. While the patient is under anesthesia, his prostate is stimulated with an electrical current and a semen specimen retrieved for insemination. Alternatively, sperm can be retrieved directly from the testicle and used for ICSI during an IVF procedure.