August 28th, 2010
Listen and listen hard...
This week, I refused to perform a vasectomy on a patient of mine. That is, until he saw a doctor about his sky-high blood pressure. Thirty years old and a father of three, he is a productive, hardworking member of society who just happened to never have seen a doctor as an adult. Unusual? Not at all.
Why does this happen? Is it because, in the words of Andy Rooney, that “death is a distant rumor to the young?” What is it about being young and male that instills this concept of immortality? For one thing, men do not have a monthly biological reminder of their health, similar to the female menstrual cycle. Second, the culture of men is imbibed with the “breadwinner” mentality that tends to equate illness with weakness. Lastly, men are terrible goaltenders of their own health. It is simply not on the radar of most men to think about their health unless something a) hurts, or b) is life threatening.
Lets delve into the last of these a bit as there is an interesting corollary to back this up. It is clear from many studies over the last century that married men uniformly outlive their single counterparts. In some studies, the difference in lifespan approached 10 years. Viewed another way, divorce affects a man’s health about the same as picking up a pack-a-day cigarette habit. So, it is clear that one of the best strategies to a longer life is to marry and stay married. If it is in your personality to gain immortality by this approach then so be it.
But that may not be the case of my patient, who in fact came back one week later for his vasectomy, feeling empowered, and with his blood pressure under perfect control. “And I thought the headaches that I had been getting were due to the stress I have been feeling.” He was a changed man, in control of his health for the first time in his life. He also understood the concept that life-threatening illnesses may be subtler than a broken bone.
After 17 years of caring for young men, it is clear to me that they are an incredibly underserved population. In fact, this is one the key points that I will make as an invited speaker to the Centers For Disease Control (CDC) upcoming summit on “Advancing Men’s Reproductive Health in the US” to be held in Atlanta next months. In my practice, I assume that men need help understanding how to take better care of themselves. I know that they would like to find out more about what health issues they may have inherited that can harm them, but they have trouble asking and knowing where to turn. Hence my practice motto: “The way to take great care of men is simple: just listen to them.” And listen quietly, as their voices are soft. Trust me, this hardly ever happens in the standard, 12-minute office visit that is currently de rigueur in this country.
Tags: men's health, sex drive, sexual health, testis cancer, testosterone, vasectomy
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August 22nd, 2010
Testosterone: About as complicated as it gets.
You may know what testosterone can do for your strength, but did you also know that it is a contraceptive? That’s right, taking any synthetic testosterone will reliably make you infertile.
I’ve discussed the reason for this in other posts, but I’ll explain it again. Essentially, the brain drives the testicle to make sperm and testosterone with two hormones, FSH and LH. Think of the testicle as an engine that won’t run without the “gas” provided by these hormones. How much is gas delivered depends on how much testosterone is sensed by the brain. If enough is testosterone is present, the signal to make more decreased. So, with anabolic steroids, the brain figures that there is plenty of testosterone around (it doesn’t ask from whence it came) and it reduces the “gas” (LH and FSH) to the testicle. Thus, natural testosterone levels fall along with sperm production.
Recently, it became clear to me that milder, over the counter supplements such as DHEA or androstenedione can also have this effect. These are not the same as testosterone but are the building blocks for testosterone production. Importantly, they are available as over the counter supplements that do not require a doctor’s prescription to take.
Last week, I saw a patient who wanted a vasectomy reversal to have more children. He wrote down that he was taking creatine and other protein supplements, but when pushed further, he admitted to using DHEA. Worried about his sperm production, I checked LH and FSH levels and they were extremely low. No gas to the testis. No sperm being made. Based on this, I told him that his sperm count will be low or zero after a vasectomy reversal. Since then, he stopped the supplements and will wait several months before having the surgery. Luckily, in many cases, the effects of synthetic testosterone supplements are reversible when they are discontinued.
But, there are also ways to increase testosterone levels and maintain fertility. This is an important part of my practice as I treat young men with low testosterone who may want kids later on. It involves using pills or injections that stimulate “natural” or bioidentical testosterone production from the testicle. One way is to give the LH hormone (hCG) to stimulate the testicle to make testosterone. Given by a small needle injection several times weekly, it does the trick. Another method is to give pills called clomiphene citrate or tamoxifen that stimulate natural LH and FSH production. Since these medications are not approved by the FDA for men in the US, it is important to discuss benefits and side effects thoroughly before using them.
Is normal testosterone important for your health? Absolutely. But, like a sword, it is a hormone with two sharp edges. And such instruments should be wielded with skill and balance.
Tags: anabolic steroids, azoospermia, erections, male infertility, men's health, reproduction, sex drive, sexual health, testosterone, vasectomy reversal
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August 14th, 2010
The magic bullet? You decide.
In my daily fertility practice, while trying to help couples to conceive, I’ve noticed a trend lately. Patients are less interested in using high levels of “assisted reproduction” to have children. In particular, they would like to avoid in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI), the Cadillac of all techniques. Even before they meet me, they have decided against it. Not all couples, mind you, but certainly more than before.
Briefly, IVF-ICSI is a busy month for women. It involves stimulating them with daily, injectable hormones during the first half of the menstrual cycle to generate more eggs than normal within the ovary. Ovulation of eggs is induced by injection of a second hormone, which is closely followed by egg retrieval using needle aspiration under anesthesia. Retrieved eggs are then stripped of their cell coats in a dish and a single sperm is individually injected into each egg by an embryologist. The criteria for choosing sperm are: good looking and hopefully moving. Eggs then become embryos in a Petri dish and are transferred back to the female reproductive tract three to five days later, depending on how they develop. Extra embryos can be frozen for future use. A pregnancy test is obtained two weeks later.
As a male fertility specialist whose practice mantra has been “treat the male, cure the disease,” I find this trend very interesting. Assisted reproduction is almost always an option for couples, but I have spent a good deal of time publishing research showing that classic male infertility treatments such as varicocele repair and vasectomy reversal are very cost-effective ways to conceive compared to more expensive techniques like IVF-ICSI. On the other hand, these techniques are the only option for many men with azoospermia, or the absence of ejaculated sperm, and I am glad that it exists for this.
I wrote down what patients said when I asked them why IVF-ICSI is not an option on the table for them and here are some of the responses:
- “It seems pretty invasive and unnatural.”
- “Isn’t it relatively new?” (IVF is 32 years old, ICSI is 18 years old)
- “Who selects the sperm?” (Since it is not God or Darwin)
- “Wasn’t ICSI developed as an experimental mistake?” (Yes)
- “How do we know that those are our eggs and our sperm? (Rare)
- “It’s only a single try at having children.” (Maybe two)
- “Isn’t there an issue with higher birth defects and syndromes in babies” (Very likely)
- “Are our children going to be infertile?” (Unknown)
- “We’d prefer to have the hope of trying every month at home.”
- “IVF-ICSI is too expensive”
What I think is happening is that as IVF-ICSI is being offered to consumers more often than ever (currently 1-2% of U.S. babies are born from these techniques), patients are becoming better educated about the technology and are making more informed, personal choices. My gut also says that good, old-fashioned sex has a strong following among infertile couples as a way to conceive. In the words of Woody Allen in Annie, “that was the most fun I’ve ever had without laughing.”
Tags: Assisted Reproduction, azoospermia, FNA mapping, genetics, IVF, IVF-ICSI, male infertility, reproduction, sexual health, sperm, sperm count, TESE, women's health
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August 8th, 2010
Spoon bending power to heal.
Can prayer heal? Does touch matter in medicine? Long considered a nonrational part of Western medicine, these “lighter side” topics are now receiving close attention and study.
I am reminded about distant healing on the anniversary of the death of a medical school classmate and friend Dr. Elisabeth Targ. As a psychiatrist, daughter of a parapsychologist and niece of chess champion Bobby Fischer, she was not only bright, but also a bit paranormal herself. As a child, she played hide-and-seek with friends and would attempt to use clairvoyance to find them. She was also expected to call out her Christmas presents before opening them. As a trained scientist, she performed some of the best studies showing the effect of prayer or “distant healing” on extending the survival of AIDS and breast cancer patients.
In her study of how prayer can heal, Dr. Targ used scientific methods to determine whether “intention” from others 1500 miles away could help treat medical ills. In small studies of AIDS patients before current treatments were developed, she showed that they could live longer and spend less time in the hospital with distant healing. Her papers are in no way definitive and are highly criticized, but to date remain the best and most scientific attempts the world has seen in the last 150 years to define the potential of faith to heal.
What made Elisabeth Targ a unique force in her field is that she refused to speculate about how or why distant healing works. She had a simple goal: to define the existence (or not) of the effect. Her boyfriend, Mark Comings, however is more daring in this regard. A theoretical physicist, he suggested that if we actually live in an eight-dimensional universe instead of the accepted three dimensions, then we might be more interconnected than we currently understand, and this could explain how a healer in Santa Fe could influence a patient in San Francisco. Sadly, Elisabeth died at age 41 years of a brain tumor. Ironically, it was the same kind of tumor that she was studying with distant healing treatment.
What about the role of touch in medicine? Clearly, patients who visit doctors for terrifyingly short visits feel that the visit is incomplete without a physical exam. The doctor’s visit is just not the same as that with your accountant, lawyer or financial advisor. The laying on of hands is a special part of the medical relationship and has been for millennia. In fact, there is good science to show that the physical exam is not as good at disease detection as a good patient history. What needs more study is what makes touch so special, almost medicinal, in the doctor’s office. Can it cure disease? I wish that my friend Dr. Targ were around for this one. She might be able to help us decide whether, in the words of Diane Ackerman: “touch seems to be as essential as sunlight.” My view as a men’s health specialist is that if it has the potential to heal, then use it, regardless of whether we understand why or how it works.
Tags: alternative medicine, complementary medicine, evolution, male infertility, men's health, reproduction, sexual health, vasectomy reversal, vitamins, women's health
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August 1st, 2010
Just say no.
Most couples in most countries will conceive within a year of trying. Families in the Ukraine take an average of 2.5 years, according to a new U.S. publication. Why? Radiation discharged from the ill-fated nuclear explosion at nearby Chernobyl in 1986 is the likely culprit. Male infertility is the consequence.
We know that sperm production is exquisitely sensitive to radiation, and we actually know how sensitive it is to this exposure. Believe it or not, this was demonstrated in a series of never-to-be-repeated experiments conducted in the 1960’s right here in America. Recall that this was the time of the Cuban Missile Crisis and extreme Cold War tension. The Walla Walla experiments in Washington state involved irradiation of 64 prisoners with various dose levels at Washington State Penitentiary to find the dose that would sterilize them. A similar, second set of prisoner experiments were also conducted at Oregon State Penitentiary during the same period. These studies on “volunteers” demonstrated two things: 1) prisoners do not have the free will to be considered for scientific experiments and 2) the testis is very sensitive to radiation.
How sensitive? Let’s use a chest X-ray for comparison (0.1 mSV). When 15 mSV (150 chest X-ray equivalents) of radiation was aimed at the testis, sperm counts fell. When 50 mSV (500 chest X-rays) were used, it caused temporary sterility. And after 500 mSV (5000 chest X-rays) of radiation, permanent sterility resulted.
So, it is not surprising that a nuclear explosion in the Ukraine occurring 24 years ago over a fallout area 1/3 as large as Iceland’s recent Eyjafjallajokull volcano (19,000+ square miles) might have an effect on human fertility in the surrounding area. Those exposed to radiation as children are now grown, have survived their thyroid cancers, and are trying to reproduce.
As a scientist and doctor, teacher, humanitarian and ethicist, I find this world an often frightfully complex place, mainly because of a failure to learn and grow from our mistakes. Haven’t we realized that good planets are hard to find? In the case of Chernobyl, and in the words of Alan Eddison:
Modern technology
Owes ecology
An apology
Tags: azoospermia, conception, fertility restoration, male infertility, men's health, radiation, reproduction, sexual health, sperm count, testicle, testis cancer
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July 25th, 2010
A man looking for his mojo.
Do you know why Sigmund Freud, esteemed psychoanalyst, had a vasectomy when he was 67 years old? How about William Butler Yeats, the famed writer, having his vasectomy at 69 years of age. Were they that sexually active and worried about conceiving? God bless them if this is true!
Hardly. Believe it or not, vasectomies were done in the roaring twenties and thirties in Austria by an endocrinologist named Steinach for physical and mental rejuvenation. “It revived my creative power,” wrote Yeats in 1937. This may be true as Yeats wrote a crop of poems during this period that rank with his best work. At that time, a vasectomy was considered the “holy grail” of perpetual youth. Steinach felt that by blocking sperm flow, male hormone production in the testis would improve.
The idea of hormonal rejuvenation really started in earnest with an acclaimed endocrinologist named Brown-Sequard who in 1889 injected himself with testicular extracts from rats and dogs. This led to the trend of “organotherapy” in which all sorts of animal organs were injected for every conceivable human illness. Sound familiar at all? It also led to serious and productive experimental research on the function of glands in the body.
The rejuvenating vasectomy was not an isolated claim to fame by Eugen Steinach from Vienna. He was nominated for a Nobel Prize six times for innovative studies that showed that male or female development depended almost entirely on the sex glands and their secretions. Give this theory a pinch of salt to incorporate modern genetics and is it true enough today.
What went wrong with Steinbach’s vasectomy idea was that he believed that narrow biologic principles could be used to treat the wide and complex condition of human sexuality. The funny thing is, almost 100 years later, we are still trying to figure out how to stay young forever.
Tags: alternative medicine, babies, complementary medicine, conception, contraception, erections, libido, men's health, no scalpel vasectomy, sex drive, sexual health, testicle, testosterone, vasectomy, vasectomy reversal, Viagra
Posted in sexual health, testosterone, vasectomy | 2 Comments »
July 18th, 2010
And you thought this was old...
What do you own that is 600 million years old? Your old suit? That little league baseball glove? Your cologne? In fact, every man possesses something that old, and believe it or not, it’s a gene. Not the clothing kind, but the kind you keep in your genome, in your chromosomes. We’ve talked about the Y chromosome in this space but lets take a moment to focus on a single tiny gene.
Tucked away in every cell of your body is a gene called Boule, a piece of DNA critical for sperm production. A colleague of mine just announced that the Boule gene is present in every organism from insects like fruit flies, to sea urchins, roosters, fish and man. It is in invertebrates and vertebrates alike. That is, this tiny bit of DNA has remained essential for making sperm through 600 million years of evolution. Surely the oldest treasure you own.
But what’s really impressive about the Boule gene is that is has not changed over time. And change is the rule with every other known gene involved with reproduction in every species. In fact, evolution of reproductive traits is how a species diverges from other species. It gives each species its identity. And this change can be very rapid: in some fish, reproductive traits are observed to change in fewer than a dozen generations. So why would this one gene stay the same?
We think that the Boule gene has remained true over 600 million years because it is essential for reproduction. Boule is a “quality control” gene that ensures all goes well as sperm are made. Just as you would want your new car to be well inspected so it is safe to drive when you buy it, you want your sperm to be reproductively fit. In fact, if the Boule gene is removed, sperm production stops entirely. Not a single sperm is made in its absence. Now that’s control.
What’s also impressive about the Boule gene is that since it is linked to sperm production, it means that sperm are very, very ancient cells. Seems that nature sticks with what is tried and true and feels no need to experiment with magic potions or fairy dust to get the job done. Reminds me of what Einstein once said while reflecting on relativity and physics: “God does not play dice.” When it comes to reproduction, the Boule gene phenomenon suggests that he may take even fewer chances.
Tags: azoospermia, conception, fertility, fertility preservation, fertility restoration, male infertility, men's health, reproduction, sexual health, sperm, sperm count, stem cells, testicle, testosterone
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July 11th, 2010
The beauty of a balsa wood board.
Up at dawn, and while waiting for a perfect, crumbling long board wave at Waikiki this past week, I recalled that Hawaiians live longer than the rest of Americans and wondered why. For some reason, life expectancy at birth in Hawaii is among the longest in the nation. Indeed, people born in Hawaii have a life expectancy of almost 81 years, at least three years longer than the US average. Why is this?
While watching rainbows appear and fade as early morning showers give way to the rising sun over Waikiki, I thought that it must be the fabulous and consistent climate. Then, as I saw surfers stream out to the break that I was tending before their workday started, I figured it must be that “island fitness” that pervades the tropics. Taking a large breath, I was reminded of the lack of air pollution and the sweet smell of jasmine, orchid and hibiscus flowers that blossom everywhere on the island. Could this be their secret?
A relaxing evening luau with soothing traditional aloha music and dancing accompanied by light, aromatic, almost Mediterranean dinner fare suggested that reducing stress and eating well and in moderation may also have something to do with it. Witnessing the deep respect held for family elders, for the community at large, and for the beauty and health of their island must also contribute in some way to longevity.
And then it hit me. Balance. The backbone of many older cultures is that they have found and maintain a seemingly harmonious balance as a civilization. They are aligned with others as individuals, with nature and with their place as a society on this good earth. The stress of extremes is present but not pervasive in such self-realized cultures and this is obvious in the genuinely large smiles that greet you at every corner of the island. So, let me propose a formula for staying healthy: realize that it is not life’s moments themselves that define you, but how you choose to live them.
Tags: healthy eating, longevity, men's health, reproduction, sexual health, women's health
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June 28th, 2010
It doesn't get any better than this!
Legend has it that surfing began in the Hawaiian Islands hundreds of years ago. In the late 1800’s, it was introduced to the U.S. mainland by way of southern California. Duke Kahanamoku, an Olympic star in swimming from Hawaii, helped popularize the sport by traveling internationally and demonstrating his surfing style. He is credited with surfing the longest wave ever in 1917, at a break called Outside Castles in Waikiki. The 1000 meter long wave that he surfed is a record that has yet to be broken.
Surfing became known in the Santa Cruz area, at the northern edge of Monterey Bay, began in the early 1930’s, 30 years before the epic surfing movie “Endless Summer” was released. Even today, Santa Cruz is known throughout the world as a mecca for peeling point breaks, and is certainly one of the best surf spots in California.
I love surfing Santa Cruz waters. To me, it is really the pinnacle of pristine California coastal beaches, a place where you can still hear the driving surf guitar of Dick Dale and feel the relaxed atmosphere of surf living. Pelicans, sea otters and often dolphins join you as you play in the water. Just magic.
I surfed Pleasure Point this weekend with an old friend on two windless days. Warm, waist- to head-high surf launched from a southern swell beginning in New Zealand and entering Monterey bay in perfectly peeling corduroy sets. Poetry.
In my other life as a surgeon, a craft like many others, I have learned to appreciate and enjoy the smallest details in life. For details matter in surgery, let this be clear. But they are not the ends, only the means, to a much larger whole that they constitute. Witness the healing and restoration of patients after complex microsurgery.
Surfing is also rich with details. The size, pitch and break of the swell, the aura of the murmuring ocean and breaking tide. The contour, rail, and rocker of the hand shaped board, and the trim of the body on board as it silently cuts through water. Like surgery, surfing reaches an almost spiritual realm not only through the sensations conveyed by innumerable associated details, but also through the sublime and intoxicating feeling that, at least for a moment, one is in control of life.
Tags: complementary medicine, men's health, microsurgery, sexual health, vasectomy reversal, vitamins
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June 20th, 2010
The spine: OK for shivers and tingling, but that's it.
I have a lot of patients in my practice who have broken their backs. Not figuratively by working so hard, but literally, by having spinal cord injuries. Some have been crushed by rolling logs, fallen from tall heights, been victims of shooting, dived into shallow pools or took an untoward jump while skiing or skateboarding. As a group, these men are impressive: imbibed with fortitude, perseverance, decisiveness and joie de vivre, they take nothing in life for granted. Live it hard, wring it dry, no regrets.
Their numbers are not insignificant either. Roughly 5,000-10,000 individuals experience spinal cord injury annually in the U.S. alone. And although you may think that cars have plenty of safety measures, they don’t, as the biggest cause of cord injury is motor vehicle accidents. Violence, recreational activities and workplace-related injuries round out the top four causes. And, of course, single, reproductive age men (ages 20-34 years old) are by far the most commonly affected.
I am reminded of these patients after a good friend, Dr. Stephen Seager, came over for dinner last week. A true Irish gentleman (“blended scotch before dinner and single malt after, no ice”) and world famous veterinarian, Dr. Seager invented the rectal probe electroejaculator in the early 1980s. I will leave it up to your imagination to wonder how this device works. But realize that this one doctor, through his invention and its popularization worldwide among male fertility specialists, has touched every spinal cord injured father from around the world over the past 30 years.
Seriously, the Seager Electroejaculator has revolutionized our ability to help men with spinal cord injury to conceive and become fathers. It takes advantage of the fact that ejaculation is governed by a spinal reflex (like sneezing) and it stimulates that reflex to happen. In fact, probably the only biological function that is not seriously affected in men who have broken their necks and cannot move any of their limbs (quadriplegic) is reproduction as this reflex generally remains intact.
By his innovative thinking, Dr. Seager brings hope to every spinal cord injured patient who dreams of being a father. Personally, seeing my patients with their little children running around their wheelchairs, and the wide, grateful smiles on their faces is easily one of the most satisfying experiences I have had in my medical career.
Tags: Assisted Reproduction, erections, fertility restoration, male infertility, men's health, paraplegia, quadriplegia, reproduction, sexual health, sperm count, spinal cord injury
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