Can a man attempting conception safely use Promescent (lidocaine topical spray) for premature ejaculation without affecting fertility?

Can Men Attempting Conception Safely Use Promescent?

Men attempting conception should avoid using Promescent (lidocaine topical spray) because it has demonstrated direct cytotoxic effects on human sperm, significantly reducing motility, forward progression, and viability in laboratory studies. 1

Critical Fertility Concerns with Promescent

Direct Sperm Toxicity

• In vitro studies demonstrate that Promescent causes statistically significant decreases in sperm motility, forward progression, and viability when exposed to normal human sperm samples. 1
• The cytotoxic impact occurs even with brief exposure, suggesting that residual medication on the penis at the time of intercourse could impair the sperm's ability to reach and fertilize an egg. 1
• While sperm DNA fragmentation was not significantly affected, the reduction in motility and viability alone is sufficient to compromise fertility potential. 1

Clinical Context

• Premature ejaculation affects up to 39% of men, creating significant overlap between men seeking PE treatment and those attempting conception. 1
• The timing of this concern is particularly relevant since couples trying to conceive are having frequent, timed intercourse during fertile windows. 1

Alternative Treatment Options During Conception Attempts

First-Line Alternatives: Oral SSRIs

• Daily paroxetine 10-40 mg provides the greatest ejaculatory delay (8.8-fold increase) and has no evidence of adverse effects on male fertility or birth outcomes. 2, 3
• Other compatible daily SSRIs include sertraline 25-200 mg, fluoxetine 5-20 mg, or citalopram 20-40 mg. 2
• Importantly, even methotrexate, leflunomide, and mycophenolate—drugs discontinued in women before pregnancy—show no increased risk for birth defects when used by men attempting conception, making SSRIs an even safer choice. 4

On-Demand SSRI Options

• Paroxetine 20 mg taken 3-4 hours before intercourse provides effective ejaculatory delay with less systemic exposure than daily dosing. 3
• On-demand dosing may be preferred for couples with infrequent sexual activity or concerns about daily medication. 3

Behavioral Approaches

• Combining behavioral and pharmacological approaches is more effective than either modality alone (Moderate Recommendation, Evidence Level Grade B). 4, 2
• Behavioral strategies can be implemented without any fertility concerns and should be emphasized during conception attempts. 4

Important Caveats About Topical Anesthetics Generally

When Topical Agents Might Be Considered

• If a couple absolutely requires topical treatment and cannot use oral medications, lidocaine-prilocaine cream (not Promescent spray) applied 20-30 minutes before intercourse with thorough washing before penetration may minimize sperm exposure. 4, 3
• The condom should be used during the waiting period, then removed, and the penis must be washed clean of all residual anesthetic before vaginal penetration to prevent both partner numbness and sperm exposure. 4, 3

Limitations of This Approach

• Even with washing, microscopic residue may remain and contact sperm during ejaculation. 4
• Prolonged application (30-45 minutes) causes loss of erection due to excessive numbness in a significant percentage of men. 4, 3
• Partner vaginal numbness from residual anesthetic is a frequent complaint that limits acceptability. 4, 3

Practical Management Algorithm

Step 1: Assess Comorbidities

• If erectile dysfunction coexists with premature ejaculation, treat the ED first, as PE often improves when ED is effectively managed. 4, 2, 3

Step 2: Initiate Fertility-Compatible Treatment

• Start daily paroxetine 10-20 mg as first-line therapy during conception attempts. 2, 3
• Combine with behavioral techniques for optimal outcomes. 4, 2

Step 3: Adjust Based on Response

• If partial response, consider combining daily low-dose SSRI with on-demand dosing. 3
• If SSRIs are contraindicated or not tolerated, consider alpha-1 adrenoceptor antagonists (limited evidence but no fertility concerns documented). 4, 2

Step 4: Avoid Promescent Entirely

• Do not use Promescent spray during any conception attempt period due to documented sperm toxicity. 1
• Resume Promescent only after conception is confirmed and the couple is no longer attempting pregnancy. 1

Key Counseling Points

• Patient and partner satisfaction—not just ejaculatory latency—is the primary treatment outcome, so the temporary switch from topical to oral therapy should be framed as optimizing both PE control and fertility. 4, 2, 3
• SSRIs require 1-2 weeks to reach full efficacy with daily dosing, so treatment should begin before the fertile window. 2
• Common SSRI side effects include nausea, dry mouth, decreased libido, and ejaculation failure, but these are generally acceptable given the fertility benefit. 3
• Patients should avoid sudden cessation of daily SSRIs to prevent withdrawal syndrome; taper when discontinuing. 4