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.

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.

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.

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.

China: 5000 years old and on the move.

Just got back from China, from Beijing and Hong Kong to be exact. I lectured to several medical and academic institutions on where I believe men’s health is headed in the future. What I found was an audience eager to push the research frontiers in this field, however I also a sensed a lack of sufficient infrastructure to do this at the highest level. I paused for a moment to think about what was possible, since a monumental tidal wave of increased industrial productivity and change is occurring in China. For example, there are 1000 new cars being put on the road daily in Beijing alone! I sensed that when the might of China’s intellectual potential directs its energy toward medical research and innovation, the world will stand in utter awe at the prodigious output that will result.

Despite the fact that China’s culture is endowed with 5000 years of evolution and is responsible for helping to define human civilization, one thing really surprised me: its decision in 1979 to control its population by mandating a “One Child Only” policy. In the rest of the world, human reproduction is a basic right and for the most part, entirely unregulated. Under China law, families are allowed to have one child. After that, a vasectomy is performed on the male partner. Like it or not.

In addition to great control of population growth, the “One Child Only” policy has also led to the development of the wildly successful “No Scalpel Vasectomy” procedure. Now relatively common in the U.S., the “No Scalpel Vasectomy” is a quicker (10 minute), cleaner, less invasive and more comfortable innovation on a 100-year old American procedure.

But the curse of the “No Scalpel Vasectomy” is now being felt in China. Currently, it is difficult to find enough youth to fill jobs in urban areas within the massive and burgeoning Chinese economy. As a consequence, there has been a softening of the law such that couples that are both products of “one child” parents can now have two children. So can farmers, handicapped couples, and couples who work in “high risk” occupations like coal mining, heavy equipment operations and the like.

Even more fascinating is that infertile couples have a real reproductive edge over fertile couples under this law. How? Well, if they need assisted reproduction to help them conceive and they happen to have twins or triplets as a result (a 30-40% chance), they are not penalized for bearing “extra” children. Can’t help but think that this little known fact may partly contribute to the size of the massive, bustling IVF clinics that I visited in China last week. many of which are 4-10 times the size of U.S. clinics.

This Da Vinci fetus is way past the critical window of exposure.

A relatively alarming study was published a couple of years ago that suggested that a pregnant woman’s behavior can determine the fertility of her unborn son. Sperm quality from 387 men was compared to beef consumption their mothers reported while pregnant with them. They found that the sons of “high beef consumers” (>7 beef meals/week) had sperm counts that were 24% lower than in men whose mothers ate less beef. Interestingly, sperm counts in the sons were not related to mother’s consumption of other meat or to the son’s consumption of meat. In essence, the author’s thought that estrogens in beef consumed by women may alter the testis development of their unborn sons and may adversely affect the son’s fertility. Similarly impressive decreases in semen quality have been described in the sons of women who smoked during pregnancy.

Sounds almost biblical, doesn’t it? I bring this up because of a point that I made in last week’s blog. In “The Curse of Women’s Urine,” I mentioned how xenoestrogens or environmental estrogens have been shown in animals to act at a very precise point in the developing male fetus and result in intersex conditions at birth or infertility as adults. Well, as the study of mothers’ beef intake reveals, the same issues may also exist in humans. As Aristotle once said: “At his best, man is the noblest of all animals; separated from law and justice he is the worst.”

Time for a quick lesson in biology. When do testicles develop in humans? Believe it or not, when male fetus in just 4 weeks old, the location where the future testis will be is organized (the urogenital ridge). Two weeks later, the primitive germ cells (sperm precursor cells) migrate to the urogenital ridge and set up what is to later become the testis. About 1-2 weeks after that, “sex cords” develop in the primitive testis, setting up the architecture of the mature organ. So, by 8-12 weeks of pregnancy, the human testis is virtually a complete organ, holding within it all of the potential it will ever have.

So the “critical window” of exposure for the human testis, that period in which even a potentially small exposure could wreak significant developmental and long lasting havoc, is about the time when women actually just realize that they are pregnant. The time of morning sickness and painful breasts.

So, does male infertility begin in the womb? Still not clear, really, as all studies have flaws. For example, in the study of beef eating pregnant women, the cohort of son’s whose sperm counts were so thoroughly examined were ALL fertile. That’s right, their wives were all pregnant. Oscar Wilde couldn’t have said it better when he said: “The pure and simple truth is rarely pure and never simple.”

Is faster better? Not always.

What is the most common sexual health problem affecting men? That’s easy, it’s erectile dysfunction, right? Nope. Try premature ejaculation. Hands down more common than erection issues, affecting 25-40% of men in the U.S.

Variably called early ejaculation, or early or rapid climax, it is defined as male ejaculation earlier than the subject or his partner desires. It used to be defined as ejaculation within 2 minutes of sexual intercourse, until it was realized that 75% of men ejaculate within 2 minutes in over half of their sexual encounters. What the definition really implies is that is some element of poor control over ejaculation that is stressful and may result in interpersonal difficulty.

Is this a medical disorder? In some cases, yes. Think of ejaculation as a reflex, like sneezing. There is a point of no return and this is what comes too soon in men with early ejaculation. The problem has two forms: lifelong and recent. The former is believed to result from low levels of the neurotransmitter serotonin (5HT) that normally modulates the ejaculation reflex. The recent form does not have as clear a biological basis, but may occur from psychological stress or from the need to overcome an erection problem.

The good news is that there are treatments available, and more treatments being reviewed by the FDA. Currently, the most effective treatments are pills called SSRIs, which elevate 5-HT levels and include anti-depressants such as Prozac, Zoloft, Celexa, and Lexapro. A newer form of SSRI drug, called Priligy, is now available in nine countries but has still not been FDA approved in the states. Also, a metered-dose aerosol spray has been developed to increase time to ejaculation by numbing the skin on the penis and decreasing sensation. Maybe this will help. Unfortunately, with all drug treatments for this condition, when the drugs are stopped, the issue generally returns.

What I find interesting is that companies are vigorously trying to drum up sympathy and attention for premature ejaculation as a widespread medical disorder, when in many cases it may be only an occasional annoyance that does not need constant treatment. Treatment might be perfect for a few men with debilitating disease, but it appears that they are trying to create and market a whole new category of disease. Good idea: create a “huge unmet need,” an epidemic that is perfect for a blockbuster, quality of life drug. Well what about a pill for shyness, or talking too fast? Where does it end? The larger issue here might be the “medicalization” of our daily lives in which there is a healthy and wide variation of normal.

Do I believe that some men have debilitating early ejaculation? You bet, and I see them every day. Do I think that a pill will treat this issue? Sure, for many, but only while you take it. Will blockbuster pills be the cure-all for early ejaculation? No way. The cure will come with more holistic treatment, by empowering men through behavioral changes that teach them to control and “own” the problem. Works superbly for my patients, pill or no pill.

Throwing a wrench in the machinery of sperm production...

I have to admit, the testis “mapping” procedure that I developed some years ago has truly been a workhorse technique for my male infertility practice. And for the practices of other male reproductive specialists around the world as well. Creating fertility from sterility. I bring it up again because it is gathering more attention in the press as this week we recently published another paper that highlights its utility—this time in cancer survivors.

In a related study from 2002, we published that the majority of men who had been exposed to chemotherapy for cancerous or non-cancerous disease and who were “sterile” afterwards have sperm in the testis that can be safely used for fatherhood with assisted reproduction. Fine needle aspiration (FNA) mapping was employed in this study and its potential to help cancer survivors to conceive was convincingly demonstrated. The recent paper expands that group of men to include those who received not only chemotherapy and radiation therapy but also a relatively extreme treatment for certain cancers termed bone marrow transplantation.

Let’s back up a minute for a biology lesson. How does chemotherapy affect a man’s fertility? Well, the basis of its effectiveness in curing cancer is that chemotherapy preferentially kills rapidly dividing cells more than slowly dividing cells. In general, cancer cells divide more rapidly than do normal body cells. The term for this difference in cell susceptibility is “therapeutic index”. Unfortunately, sperm are also produced very rapidly (about 1200 sperm are made every heartbeat) and therefore sperm precursor cells are also very sensitive to the effects of chemotherapy. Think of sperm production as a rapidly turning set of gears and chemotherapy as a wrench being thrown into them. Ka-chunk! Machine comes to a loud and crashing halt. Sperm production is over, or tremendously slowed down. The same action is true for radiation therapy treatment.

Now, imagine not just one small wrench being thrown into the gears, but a huge wrench (or many wrenches) being suddenly thrown into the machine of sperm production. The result? More damage to the sperm-making machinery and a much higher chance of sterility. This is the essential difference between the patients from the 2002 paper on mapping and the most recent one. The cancer survivors in this week’s paper got blasted with the heaviest doses of chemotherapy imaginable, and topped off with a dollop of radiation therapy just to be sure. Hard to believe, but they also had usable pockets of sperm in their testicles. And normal babies as a result.

So, with techniques like FNA sperm mapping, there continues to be hope and good news about fertility after the storm of cancer treatment has passed.

Bacchus is no longer a role model...

What you weigh affects how your sperm play. And your fertility. Overweight men tend to have lower semen volumes, less sperm and more oddly shaped sperm. The same is also true for men who are too thin. So, along with the many other health hazards associated with obesity, add poor semen quality to the list.

Obesity in both sexes is known to be associated with heart disease, diabetes, hypertension, and metabolic syndrome among other nasty conditions that can shorten your life. Typically, obesity is measured with BMI or body mass index, which looks at weight in relation to height. Not a perfect measure, but reasonably accurate. Using this tool, the ideal BMI for men (and women) is considered to be 20-25. A Danish study of 1600 men showed that overweight men with a BMI > 25 had a 22% lower sperm concentration compared with healthy weight men. Interestingly, a BMI of <20 was also associated with poor semen quality. For optimal sperm production, then, it helps to be not too fat and not too thin.

But what about fertility? Is it also affected by obesity? Yup. Another recent study showed that for every 20-pound increase in a man’s weight, there is a 10% increase in the chance of infertility. And this remained true when other factors that might influence the results were accounted for, including obesity status of the women, the man’s age, cigarette smoking, alcohol intake, and solvent and pesticide exposure. In addition, obesity was associated with infertility in both older and younger men.

So what is it about weight that influences men’s sperm production and fertility? One theory is that sex hormone metabolism is altered by changes in weight. Sex hormones are the “fuel” for the engine (testis) to make sperm. Obesity increases fat stores and fat converts male hormones (testosterone) into female hormones (estrogens). Too much estrogen in men is bad for sperm production. Another theory posits that normal 2-degree difference in testis temperature relative to the body is lost with obesity, as excessive fat provides too much insulation and results in overheating. On the other hand, when a man is too thin, he may take on a “catabolic” metabolic state. With a body in “starvation mode,” fertility is not the first thing on its mind and sperm production and fertility suffer.

So, is the epidemic of obesity the reason why sperm counts have been falling in Western countries over the last 50 years? Maybe. But this problem is unique in that it is utterly and entirely preventable. Eat well and in moderation, sleep well and treat your body like a temple. You used to it for your own health; now do it for the health of your future family.

Making the world a better place with modern technology.

In this forum, I’ve already talked about how erections occur and also about pills used to treat erectile dysfunction in men. But what if they don’t help? What comes after the pill?

There are about 30 million men in the U.S. affected by erectile dysfunction. For 20% or more of men, common prescription therapies – Viagra, Levitra or Cialis – are not effective. For these men, we have many things “up our sleeves” to help. Before reviewing this cornucopia of cures, I really need to emphasize again the idea that erectile dysfunction may be a message that your body is not perfectly healthy. Think of it as a loud noise coming from under the hood of the car. It may run fine if you keep going, but you never know. Similarly, medical conditions such as high blood pressure, heart disease, high cholesterol, diabetes and low testosterone are important “loud sounds” that are associated with erectile dysfunction; they should be treated first and foremost. Often, by treating these illnesses, not only will erections improve, but you might live better and longer too.

Ok, so your cholesterol is fine. How then can erections be improved? Well the answer may be to “go local.” Local therapies attempt to improve erections by going to the source to treat the problem: the penis itself. Help the big guy out without involving the rest of the body. Penile salves, creams and urethral pills are available in many forms and are often compounded by pharmacies. One of these is a pill (MUSE) that is inserted just inside the urethra (the urine tube within the penis) and is absorbed by the penis to stimulate an erection. A little unconventional, but very effective in some men.

Although more difficult to imagine, local therapy can also involve injecting the side of the penis with highly active erectogenic agents such as papaverine, phentolamine and prostaglandins. Not the most palatable way to get an erection, but highly effective for the vast majority of men who fail to respond to pills. A more inviting alternative is based on recent developments in transdermal technology and involves delivering the same three medications in a clear gel into the urethra (TriMix Gel). Rub it in for a minute or two and you are up and running.

Available for 30 years now, penile vacuum pumps will also work in the majority of men. By creating 6 atmospheres of negative suction pressure around the penis, these mechanical devices draw blood directly into the penis. Once filled, a rubber ring is placed around the base of the penis to keep the blood in and away you go. But please don’t keep the ring on too long (more than 45 minutes) as bad things could happen…

In the most resistant cases, surgical implants may be needed to resurrect the erection.  Reliable and realistic, implants are the most invasive kind of local therapy and are effective in virtually all men. They can be rigid but bendable, inflatable, antibiotic coated and can have other neat widgets and gadgets. But they do require surgery, which distinguishes them from other treatments. They are also irreversible in the sense that they permanently alter penile anatomy, rendering ineffective most other treatments discussed here. So, let it be known that “vee have vays” of getting those erections back in case the pill doesn’t work.