Treatment of Retrograde Ejaculation
For men with retrograde ejaculation seeking fertility, start with pseudoephedrine 60-120 mg taken 120-150 minutes before sexual activity, as this sympathomimetic agent shows the highest success rates for converting retrograde to antegrade ejaculation. 1
First-Line Pharmacologic Treatment
The American Urological Association recommends sympathomimetic medications as first-line therapy for retrograde ejaculation in men desiring fertility 1:
Pseudoephedrine 60-120 mg taken 120-150 minutes prior to ejaculation is the most effective single agent, with success rates of approximately 48% for converting complete retrograde ejaculation to antegrade ejaculation 1, 2
Imipramine 25-75 mg daily is an alternative first-line option, with success rates of approximately 38% when used alone 1, 2
Combination therapy with both pseudoephedrine and imipramine achieves the highest success rates at 61.5% for converting complete retrograde ejaculation, and should be used when monotherapy fails 2
Dosing Specifics
For imipramine, use a cycle-dependent dosing regimen: start at 25 mg daily and increase to 50 mg daily for 7 days prior to planned ejaculation or expected ovulation of the female partner 3. This approach successfully induced antegrade ejaculation in all 11 patients in one study, with two achieving spontaneous pregnancy 3.
For pseudoephedrine, the standard dose is 120 mg twice daily, though the optimal timing is 120-150 minutes before sexual activity 1, 2.
Medication-Induced Retrograde Ejaculation
If retrograde ejaculation is medication-induced (such as from alpha-1 blockers used for lower urinary tract symptoms), attempt dose reduction or medication substitution before adding sympathomimetics 1. Alpha-1 blockers, particularly tamsulosin and silodosin, commonly cause ejaculatory dysfunction including retrograde ejaculation 4.
Adjunctive Fertility Measures
When medical therapy is successful in producing antegrade ejaculation but sperm quality remains suboptimal, or when sperm retrieval from urine is necessary 1:
Alkalinize the urine to preserve sperm viability using oral medications or by adding sperm wash media into the bladder prior to ejaculation 1, 5
Perform urethral catheterization after ejaculation to retrieve sperm from the bladder for assisted reproductive techniques 1, 5
Traditional methods of hydration and urine alkalinization allow successful recovery of fertile sperm even in men of advanced reproductive age 6
Assisted Reproductive Techniques
When medical therapy fails to convert retrograde to antegrade ejaculation, proceed to assisted reproductive techniques 1:
Intrauterine insemination (IUI) using sperm harvested from alkalinized urine 6
In vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) using sperm retrieved from urine 6
Penile vibratory stimulation or electroejaculation as alternative sperm retrieval methods 1
Etiology-Specific Considerations
Success rates vary by underlying cause 7, 2:
Diabetic patients: Medical therapy shows promising results, with combination therapy achieving 61.5% success in complete retrograde ejaculation 2
Post-retroperitoneal lymph node dissection: Imipramine shows better efficacy (42.8% success) than ephedrine (12.5% success) in this population, as most patients have loss of emission rather than true retrograde ejaculation 7
Common Side Effects
Minor side effects occur in approximately 50% of patients on imipramine, including dizziness, weakness, nausea, or sweating, but major side effects are rare 3. These are generally well-tolerated and do not require discontinuation of therapy 3.