Turek On Men's Health » Testosterone

Try It, You’ll Like It?

Paul Turek, MD — Mon, 07 May 2012 15:00:09 +0000

The pill that started it all in 1998.

As if it’s not top of mind anyway, here’s an update on the state of erection pills. Another one was just approved by the FDA and will hit the streets soon. Its name: Stendra (avanfil). Who names these drugs anyway?

The PDE5i Drugs

This new pill works similarly to the holy triumvirate of Viagra, Levitra and Cialis; it is a full-fledged member of the phosphodiesterase inhibitor (PDE5i) family. In essence, they are like taking coffee for the penis. Stendra is the first such pill to be approved in the last decade and it will certainly be interesting to see how it fares in this field of household giants.

What These Pills Do for You

You may be curious to try one of these pills, even if you don’t need it. You may even have thought to open that email spam folder that says “Bigger, Better, Badder” for quite some time. What can expect when you take these pills? Well, it depends on why you are taking it.

Goal: Trying it for Kicks

All pharmaceutical grade, FDA-approved pills share benefit and risk. The same is true for the PDE5i’s. If you don’t really need any help with your erection, this is termed “recreational use.” In fact, this is more common than you might think. It is estimated that 1 in 5 men ages 18-30 years have tried one of these erection pills for fun. But we know even more. Men claim that the pills prevent sexual failure and improve sexual performance and stamina. And, these pills tend to be used with other recreational drugs and alcohol that can decrease erections. More concerning however, is the well-defined association between illicit drugs, PDE5is and an increase in unsafe sexual behavior and increased HIV transmission.

In the simplest scenario, when they are taken in isolation by healthy young men, there may be a shorter latency period (“down time”) between ejaculation and the next erection. Others observe that the time to ejaculation can be extended.

But, for the most part, a normal erection is a normal erection and these pills would not be expected to offer much benefit to men who don’t really need them. In such cases, the common side effects of these medications such as headaches, facial flushing, nasal stuffiness, upset stomach may be more evident.

Goal: Trying it for Special Situations

Some men need a little help with erections. They may have normal erections at times but at other times, it’s not quite up to speed. This is termed situational erectile dysfunction. Whether it’s early in the relationship, associated with condom use or because of scheduled sex needed to conceive, the associated stress can be a killjoy. For these men, the PDE5is can be man’s best friend since 90-95% of men will recover normal, on-demand erections. Again, if the PDE5is are not really “needed” the side effect profile of these agents can be bothersome and limit their use.

Goal: Trying it Because You Need it

It is for men with true erectile dysfunction that these pills are intended. For those unable to achieve or maintain an erection, these pills are a holy grail. In fact, from 60-85% of men with erectile dysfunction will respond to the PDE5is as first line therapy, a great achievement for any pill. Unfortunately, men in this category may also have associated medical conditions such as diabetes, cholesterol imbalance or heart disease that make medical supervision of patients mandatory. In addition, other medications, including statins (cholesterol lowering) drugs, diltiazem, Zoloft and protease inhibitors to name a few, can interact with PDE5is and affect drug metabolism and produce, at times, life-threatening side effects. Clearly, doctors need to be involved in determining whether or not a patient should consider PDE5is for erectile dysfunction.

The reason these drugs are so popular is obvious. In the words of the self-help author Wayne Dyer, men fully realize that “miracles come in moments. Be ready and willing.”

The Skinny on Obesity and Male Fertility

Paul Turek, MD — Mon, 09 Apr 2012 15:00:13 +0000

Whipped cream: an unnecessary evil.

You have often heard me say that sperm production is an engine that really wants to run hard and fast. And, that by not taking great care of yourself, sperm quality and fertility can suffer. Given that 1 in 3 Americans have it, one of the biggest elephants in the room is obesity. Now, the literature is oozing with new data that puts real live numbers to the obesity and fertility problem.

Obesity and Sperm

As discussed before in this forum, there appears to be a direct relationship between a man’s weight and not only his semen quality but also his fertility. However, a brand new study out of Paris has now put more meat on this bone. In this meta-analysis of 14 prior studies and 10,000 subjects, new facts were put forth on the obesity and infertility issue. Here they are in a nutshell:

Obese men are 42% more likely to have low sperm counts than men of normal weight.
Obese men are 81% more likely to be sterile (have no ejaculated sperm) than men of normal weight
For every 20 pound increase in a man’s weight there is a 10% increase in the chance of infertility

Is that enough fodder to make the changes you need to make? If not, then read on.

Fat and Male Fertility

Clearly, a large chunk of the obesity problem is related to diet. Junk in means waistlines out. In the first study of its kind published last week, researchers from Harvard collected semen samples from 99 mostly (71%) overweight or obese infertile men and assessed the fat intake in their diets over the previous year. Here is what they found:

Eating a lot of saturated fats was associated with lower sperm counts
Eating omega-3 polyunsaturated fats — the fats commonly found in fish and plant oils — was associated with better quality sperm

Of course complicating the study is the fact that most of the men were obese and all of them were infertile. Although the study included weight in the analysis, they did not consider conditions such as diabetes, heart disease, cholesterol issues and sedentary lifestyle that are associated with being overweight. Ultimately, such “details” have been known to kill a study over time. Regardless, dietary fats are now key suspects in the link between obesity and infertility. In other words, sperm are feeling the weight of obesity.

Now What?

As a men’s health specialist, I am always searching for lifestyle changes that can improve male fertility and health. As you can imagine, I was ecstatic to publish the first paper linking hot baths to lower sperm counts, as this identified an easily modifiable lifestyle issue: just say no to tubs! Well, here, my friends, is another one: Losing weight and eating well. This is a good thing! Maybe not as easy to fix as getting out of tubs, but one that is also much more germane to a long and prosperous life. So try The Turek Clinic Weight Control Plan. I have heard nothing but good feedback.

Diabetes Mellitus: The Infertility Triple Threat

Paul Turek, MD — Mon, 26 Mar 2012 15:00:55 +0000

Colors as possibility. Feathers in a kite shop, Beijing, China

Based on the feedback received from doctors reading the blog, we are introducing a new feature: Case of the Month. This Case of the Month is an actual patient from The Turek Clinic. It is presented to recognize American Diabetes Association Alert Day.

The Case of Male Infertility

He is a 31-year old who has been trying to conceive with his 28-year old wife for 2 years. During this time, he has noticed a lower sex drive and has had trouble ejaculating. His medical history is negative except for a 6-year history of diabetes mellitus that is well controlled with insulin injections. Exacerbated, he states “I really don’t know what’s happening to me!”

Upon further questioning, the sex drive issue started even before they were trying to conceive. Regarding ejaculation, the patient states that his erections are not very strong and, although he has the sensation of climax, nothing comes out of the penis with ejaculation. In fact, he is concerned that things might be “backing up” in his body with these symptoms.

A Short Review of Diabetes

First identified as a disease of “sweet urine” in ancient times, diabetes mellitus a metabolic disease characterized by high blood sugar (glucose) levels. It is one of the most common medical diseases in the U.S., affecting 26 million adults and children or about 8% of the population. Among those affected, about 15 million are people of reproductive age.

Normally, blood glucose levels are tightly controlled by insulin, a hormone produced by the pancreas. When the blood glucose rises, say after eating food, insulin is released to decrease the glucose level. In patients with diabetes, there is low or no production of insulin and therefore blood sugar levels are elevated. The sugars spill into the urine, hence the term “sweet urine.” Diabetes is currently a chronic medical condition that is not curable.

Can Diabetes Cause Infertility?

You bet. Diabetes causes male infertility in three ways:

Causes erectile dysfunction-by affecting the health of small blood vessels and lowering testosterone levels
Lowers sex drive-by lowering testosterone levels
Reduces ejaculate volume-by affecting the small nerves that control ejaculation and by lowering testosterone levels

Indeed, this patient had all three issues at the same time along with a low testosterone level. Fortunately, these symptoms are fairly easy to correct with oral medications:

Erectile dysfunction- Viagra, Cialis or Levitra can restore erections
Sex drive and low testosterone-Selective estrogen receptor modulators (i.e. off label use of clomiphene citrate) can correct testosterone deficiency
Ejaculate volume is low because it is emptying backwards into the bladder instead of forward into the penis. This can be treated with over the counter cold medication (alpha agonists) to restore the normal direction of ejaculate flow.

Sure enough, with this combination of pills, the infertility “hat trick” induced by diabetes was overcome and the patient was able to conceive naturally after several months. Another family holiday card on its way to The Turek Clinic this year!

Remember that about 1/3 of infertility is male driven. And diabetes is both a common and quite treatable cause of infertility. So, do yourself and your future family a favor and take the Diabetes Risk Test today.

A Year Without Answers II

Paul Turek, MD — Mon, 19 Mar 2012 15:00:18 +0000

Rug design courtesy of Rex Ray, San Francisco

This is the second of two guest posts from a patient who lives in Europe. He recently recontacted me about his experience with male infertility and how it affected him. Moved by his story and by his emotional fortitude, I asked him if he could share his remarkable journey with others. The first post is from March 12th.

I had to face the fact that I was my own worst enemy. This was an epiphany for me. By becoming a negative person, spontaneity and creativity had left me, high and dry. And gone with it was the ability to problem solve. For me, once of the hardest things that I have ever had to do in my life was to admit that I was the root of the problem, that I was responsible. The epiphany was that because I was the problem, I could also be the agent of change. I could own this. The rebuilding of me had to start with me.

It was at that point that I reached out to a psychiatrist, Our talks helped me find my way back. Honestly, I never knew that these sides of my character even existed, and was even less aware that they would belch from my soul as they did. These sessions allowed me to vent my feelings and, over time, I felt better and better. It felt like I could take the 800-pound gorilla to the doctor’s office and leave it there. And, funny enough, the “gorilla” began shrinking in size with each session, almost to the point of becoming a small, friendly monkey. And although even cute little monkeys can be annoying, these sessions helped me enormously by providing tools and methods to help me better understand, accept and manage such strong feelings.

Modern societies of any culture, Western or Eastern, are not great at raising men to be in touch with their emotions. And realizing that you are infertile is a very hard blow to one’s manhood on many levels. One of the most concerning issues was worrying about what others were thinking or knew about my situation. Early on, it bothered me to think that they would find out. As I began to heal, however, I began to care less and less about what others thought. I simply can´t control other people’s minds and have no interest in doing so. I also realized that those who are close to me all know about the infertility and nothing has changed between us and how the view me as a person. The rest I leave in God’s grace.

Another realization over the last year is that infertility is not a disability in life. It is in fact the way that I was created. It is part of me. It is who I am. And although I can’t change it easily like, say, losing weight or getting more exercise, I can certainly change how I view it. I can shape my future in any way that I wish. I am the master of me.

The road I took that year was no easy one, but I made it through the year. Leaving this behind me, I can now move forward in my life. I have faced the demons and have come to terms with my reality. I now look upon the future with renewed eyes and see a future filled with happiness despite the fact that I cannot have children.

Please let us know if you would like to continue a discussion of these issues in an on-line forum…

The Ins and Outs of Male Fertility Kits

Paul Turek, MD — Mon, 13 Feb 2012 16:00:38 +0000

A scene from Sperm Warfare based on our collection room (Courtesy: DavidRouda.com)

A man’s sperm count. One of the most misunderstood tests in all of medicine. Like naming stars in the sky to help order the universe, we assign “normal” ranges to the features of semen because we can. Unfortunately, except when there are no sperm in the semen (azoopermia) its power to predict male fertility is terrible. Given the choice, I’d take a past history of paternity over a semen analysis any day as a better predictor of a man’s fertility. But what do I know, I only do this for a living.

The Semen Analysis

In its most proper form, the semen analysis is collected at home or in a urologist’s office and evaluated in a certified medical laboratory, according to published standards. The amount of semen (volume), sperm count or concentration and the proportion of moving sperm (motility) are all rigorously assessed. When done right, the natural day-to-day variation in semen output and quality are minimized. But…you have to visit a urologist or hospital for this, and deal with the scheduling and embarrassment. And there’s the rub.

Home Male Fertility Kits

At-home fertility kits for men are not new. Dr Robert Glass at UCSF was working on this in the early 90’s before I arrived there. In the mid 2000’s, a kit called Fertell, quite popular in Europe, was introduced into the U.S., but bombed. Who knows why. Today, there are three kits battling it out in the market:

Micra Sperm Test: allows you to look at your own semen under a disposable microscope and do the counting yourself.
SpermCheck Fertility Check: assesses whether sperm counts are normal but does not look at sperm movement.
Spermeter: tests the count and motility of sperm.

For those skeptical about their partners or kids, there are even at-home kits to determine whether fluids or stains around the house or on clothing are actually semen:

Reactions to Home Male Fertility Kits

Personally, I like the idea of home sperm tests. Currently, in infertility medicine, the semen analysis is typically done only after an intensive (and expensive) evaluation of female fertility is performed. Given that male fertility is 30% of the problem, this seems too little and too late for me. But, what do men think of these tests? Here are some responses:

“I didn’t sign up for this when I was assigned testicles.”
“Give me the peace and quiet of the doctor’s office to my house anyday!”
“This could develop into the All-American pastime.”
“It will be a welcome change from counting sheep.”
“I’ll probably need to take repeated tests to ensure accuracy.”

The Ultimate Collection Room

Although it is no substitute for the real-deal semen analysis, home sperm kits may get men to real medical care earlier than they would otherwise. And to confirm the at-home findings, they would get the opportunity to collect in famous rooms such as ours, termed the masterbatorium and highlighted by Metropolis Magazine. This room has even inspired a play that has toured the west coast called “Sperm Warfare.” Come check it out…by appointment of course

The Testosterone Tipping Point

Paul Turek, MD — Mon, 06 Feb 2012 16:00:49 +0000

Sex and muscles are different when it comes to testosterone levels

Your car is not running well. It just doesn’t have the pick up it used to have. It’s low on gas so you fill it up, but it runs the same. OK, so it’s not the gas…it must be something else, so you begin looking for other causes. Yes, I’m an “old car guy,” but there is a point here.

Testosterone as Gasoline

Think of testosterone in your body as gasoline in your car. You need it to run and to run well. But a half tank of gas is just as good as a full tank, and topping off the gas tank is not going to help the car run any better. In other words, if you have enough gas—it’s not the problem.

When it comes to building muscle, it is clear that more testosterone is better. The higher the testosterone, the greater the anabolic effect. Weight lifters have known this for years. However, recent studies have shown that when it comes to sexual function, including erections and sex drive, the body may respond differently. More like a car does to gas: at some point adding more doesn’t help it run any better.

The Testosterone Plateau

There is a lot of scientific support for this idea. The most recent is from a European study of 2838 middle age and elderly men (yes, that’s ages 40-79) published last week. It examined the relationship between sexual function and male hormone levels in men who weren’t necessarily seeking care, typically referred to as a “community population.” Here are examples of the many prying questions that these men were asked:

How often do you think about sex?
How often do you attempt to have intercourse?
How frequently do you awake with a full erection?
Are you worried about your level of sexual desire?
Are you worried about your ability to have an erection?
How often do you perform self-stimulation?

What the study found was kind of expected: that testosterone levels correlated with overall sexual functioning in men. But the study also observed that there was a “plateau” effect of testosterone on sexual function. And this plateau occurred at 231 ng/mL (“normal” is 300-800ng/mL). In other words, sexual function worsened when testosterone levels fell below this point, but did not improve when levels increased above it. So, at least in these men, adding more gas to the tank would not necessarily help the car run better.

Notably, in six other clinical studies that have also examined this issue, a similar observation of plateauing testosterone levels was found. Not proof positive, but certainly suggestive of a true biological relationship.

Sexual Function is Not Muscle

So how does this percolate down into clinical practice? Well, I see men every day who have low energy and sex drive and poor erections and who feel “much older” than they feel they should for their age. Accompanying them is a lab report showing that their testosterone level is “low.” Maybe it’s 250 ng/mL, maybe 300 ng/mL. Although I believe that sexual function does not respond to testosterone like muscle does, I also understand that not all men are created equal, unlike assembly-line-built cars. In most cases, I respond “it’s not at all clear where your particular testosterone tipping point is, so lets get you above what you are now and see how you do.”

As with vintage cars, you really have to tinker with men to get them running right. And, it’s important to look beyond the gas issue to solve the problem of the poorly running machine. It’s our duty as good doctors not to just “top off the tank” and needlessly commit men to a life of testosterone replacement.

Your Hair or Your Hormones

Paul Turek, MD — Mon, 30 Jan 2012 16:00:25 +0000

Be nice to have Superman's hair…but at what price? (Courtesy; MovieBlog.com)

It’s the perfect drug for 40 million men in America who are going bald. Take it once a day to keep the hair on your head and shrink the prostate, which also commonly bothers men as they age. It’s a pill that has been used by at least 2 million reproductive age men over the last decade. But is it too good to be true?

The Best Hair Pill Yet

This magic pill is finasteride (trade names; Propecia, Proscar, Avodart). It represents a class of drug called the 5-alpha reductase inhibitors. These pills act as enzyme blockers: they prevent the male hormone testosterone from converting to its metabolite dihydrotestosterone (DHT). Although testosterone is responsible for a lot of our “male” features, DHT is more potent than testosterone for scalp hair and our internal reproductive organs (prostate, seminal vesicle). These drugs work by lowering DHT production and protect the gloriously youthful hair on our heads and the enviable ability to write your name in the snow while urinating.

And these drugs work well. More effective than topical or “rub in” medications, finasteride is great for what’s called “male pattern” hair loss which is due to a receding hairline or balding on the top of the head. In essence, it slows the growth phase of hair in these areas. However, it doesn’t treat hair loss on the sides or temple area.

Finasteride, Sex and Male Fertility

Although it may keep you looking like Clark Kent, many male infertility specialists, including myself, have concerns about finasteride. First, there is a 10% chance of sexual side effects that include erectile and ejaculatory dysfunction and lowering of sex drive. These issues can be subtle while on the pill but become very obvious when men stop it; many of my patients have noted a sexual “curtain being lifted” or “coming alive” after discontinuing the pill.

Second, there is an even more profound concern about finasteride among specialists: male infertility. Before it received FDA approval, the drug trials showed that it lowered ejaculate volume but did not change sperm count or motility on semen analysis testing (actual human fertility studies are not routinely required by the FDA). Now that it has been on the market for 10 years, though, impressive declines in semen quality have been observed and published with finasteride by many of us. This effect is not subtle either, as patients with complete sterility (azoospermia) have had recovery of their sperm counts after stopping finasteride!

There are several clues that this effect on fertility was possible. The rabbit studies done for FDA approval of the drug actually showed this effect. At 3 months, there was no effect on rabbit fertility. But, when followed longer, rabbits showed significant decreases in natural fertility. In addition, while I was writing a recent reproductive physiology chapter for Campbell-Walsh Urology, our leading urology textbook, I researched at what levels the 5-alpha reductase enzyme is found in the human testis and epididymis. Lo and behold, there are gobs of this enzyme in these important organs for sperm production and maturation, implying that the blocking agent finasteride would have an effect. So now what do we do?

At this point, controlled clinical trials are needed to prove this effect on fertility. For the time being, current thinking is that finasteride may not dramatically change sperm production in healthy men, but can impair semen quality in infertile men. Typically, the effects of medications on male infertility are reversible. So, to be proactive men should consider stopping the pill at least 6 months prior to trying to conceive. And, have confidence that she loves you just as much for other reasons. As Telly Savalas once said: “We’re all born bald, baby!”

How is a Medical Visit Like A Ball Game?

Paul Turek, MD — Mon, 23 Jan 2012 16:00:30 +0000

The ultimate male bonding experience in 2012

The world came to San Francisco this weekend. The 49ers hosted the NFC Championship footba ll game at Candlestick Park and it was a day for ages. Friends clamored for tickets, taking seats at any price. Some bought tickets like they were playing the stock market: buy sooner if it rains, later if it doesn’t, or the day before, but not on game day. Not only tailgating, burgers and beer, but stories and tales all flowed freely. A perfect male-bonding experience.

The Culture of Men

As any ball game will convey, clearly the culture of men is fundamentally different from that of women. During my previous life as a decorated academic, my medical office was situated squarely in the middle of a women’s health center, complete with fake impressionist paintings on pink walls, flowers in cute vases and bathrooms with tampon dispensers. Magazines like “Shape,” “Woman’s World” and “O-The Oprah Magazine” covered the waiting room coffee tables. Simply not the best place for male DNA to visit, say nothing of being comfortable there.

The Turek Clinic as Man Cave

Having close to an allergic reaction to this, when I ventured out to create a men’s health clinic, I tried to replicate the ball game experience in a medical office. Here are the essential elements that I considered:

Street parking. For some reason, men prefer it; don’t ask me why.
Convenience. Ball games start on time and (generally) finish on time. Medical visits should also be on time. No long lines, no waiting.
One chance. There are no second chances in playoffs games. When helping men, do as much done as possible in a single office visit. Use follow-up phone appointments after that.
Personality. Sports teams have players and, as everyone knows, players have personality. Men want to know their doctor’s personality. It helps them to develop trust. Sure, a “power wall” of diplomas is nice, but how about hanging a balsa wood surf board in the lobby along with a stylized picture of a late 60s Maserati Ghibli. Men need to trust that their doctor is human and understands them.
Space. Ball games are often outdoors, often in chest-beating, cold weather. Bringing that outdoor feeling inside is important. Floor to ceiling windows facing the San Francisco Bay is perfect, with plenty of room to lounge around on Wi-Fi. And cover the coffee table with men’s magazines, a whole slew of them. Oh, also make sure that there’s ESPN or surfing movies on a large flat screen TV.
The Staff. Here’s where a medical office can beat a ticket taker at a ball game. Imagine being greeted first thing in the morning by a smiling face and an offer of coffee or tea. The essence of The Turek Clinic approach.
Long visits. Ball games take time. Medical office visits should too. Most men are nervous for the first several minutes of any doctor’s visit. Honestly, what can you expect to learn from a patient during that time? The book is just opening. This is precisely why I never understood the average, 12-minute doctor’s visit. Men need time to open up and relax. Not only that, I am convinced that listening to men is the secret to curing their ills.

So is a visit to The Turek Clinic the same as attending a NFC playoff game? Probably not. But it is about as comfortable as men will ever be in a doctor’s office. And they will remember this comfort and trust in the doctor. And if they remember, instead of quietly suffering through another problem in the future, they will reach out and call again. And that is the key to great care for men.

Are Fathers Better Citizens?

Paul Turek, MD — Mon, 21 Nov 2011 16:00:01 +0000

What wouldn't you give to help one of these? (Source: Leonardo Da Vinci, 1468)

As a surfer, I remember charging pretty big walls of cold, wintery Northern California water with the goal of getting a fast, albeit short, adrenaline-stoked ride. Years ago on Thanksgiving, I was pummeled by a big swell to the point that I wondered whether I would make it out of the water alive. But once I married and had kids, the risk element of waves larger than a single story high became less attractive to me. It wasn’t worth it. Too much at stake. Does fatherhood also reduce other types of risky behavior?

Fatherhood is Transforming

It apparently does. It is well known that fatherhood can be “transformative” or “tempering” for men. But what shape that transformation takes has not been studied very much, despite the fact that unattached men are considered by some to be a source of society’s ““suffering” or “instability.” Loose cannons so to speak.

Fatherhood and High Risk Behavior

A newly published study has tackled this issue. It addressed the changing patterns of crime and substance abuse in new fathers, as these behaviors can threaten both health and society. Specifically, the study asked whether men are less likely to drink, use tobacco or commit crimes after they become fathers. In other words, do tough guys straighten out after having kids?

The authors followed over 200 men ages 12 to 31 who demonstrated high rates of juvenile delinquency in a metropolitan area. They were assessed annually for self-reported acts of crime and court records were reviewed for arrests. Self-reported rates of beer, wine, hard liquor, tobacco and marijuana use were documented, as were co-habitation, marital status and age at first fatherhood. And remarkably, this study was conducted over 19 years!

It has been previous shown that marriage itself and getting older can reduce men’s negative behavior, but this study clearly demonstrated a real association between fatherhood by itself and reduced crime and substance abuse patterns. And, the effects were large and long lasting. Of note, these changes were greater amongst the older men in the group (late 20’s and 30s) and were distinct from those changes expected as men age. Lastly, unlike marriage, cohabitation alone was not shown to reduce risky behavior in young men.

A Golden Opportunity to Help Men Help Themselves

Why is this important? One reason is because it suggests that first fatherhood may present a real opportunity to improve the health and behavior of young men. God knows that there are not many opportunities to do this with those who consider themselves otherwise immortal. New fathers might be more willing to hear messages and make life style changes when they are holding what might be their noblest work in their arms. And these changes in behavior could affect the health of the individual, his children and his family. After all, and I am not sure who said this, “A baby will make love stronger, days shorter, nights longer, bankroll smaller, home happier, clothes shabbier, the past forgotten, and the future worth living for.”

Guide to Surviving the Holiday Season

Paul Turek, MD — Mon, 14 Nov 2011 16:00:30 +0000

Cleaning a set of these every week is one way to "busy your hands."

Two patients told me that they were getting divorced this week. They came to the office and thanked me for all that I have done for them. They wished that the assisted reproductive technology had worked and given them children, but it didn’t. The relationships simply couldn’t tolerate the strain and gave way. Unfortunately this is not uncommon.

The Stress of Infertility

Don’t doubt for a minute that being infertile doesn’t have the same impact as having cancer. Very little can tear holes in the fabric of a relationship like infertility can. Add to this the romance of the holiday season and you have a recipe for potential disaster. Gathered families encircled by the howling laughter of children; smartly dressed kids at parties just learning to be polite; parents reveling in the enchantment written on the faces of children hearing holiday stories. To the infertile, its like having walking pneumonia—it just never seems to get better or go away.

Eight Ways to Reduce Your Holiday Stress

Maybe it’s not that bad. Maybe the holiday season is just more stressful. What can you do about it? Here are some tips for men as the holidays approach:

Take smaller steps. Stress and depression are like the flu: give them some time to run their course and pass through. You will make it, and you will be stronger because of it.
Make a plan. Spinning out of control without a plan for the problem can cause great anxiety. Simply agreeing to take the next month off and start again in the New Year can make all the difference in the world.
Enjoy each other. After all, you have found a soul mate that is going through the same experience. Give and get that big hug that can make all the difference in the world
Express yourself. Cry on her shoulder and not in a closet. Vent about that wicked day by journaling. A belly laugh or a primal scream is even better. Empathy is a very rich and particularly human experience with immense healing power.
Relieve your stress. Exercise, yoga, massage and acupuncture are fabulous ways for men to “vent” and relax. There is something about those endorphins that waft through the body after a long run…
Be mindful. Take your eyes off the Ipad and lose circular thoughts that lead to nowhere. Take note of the present. Quietly observe life. Breathe to relax. You are an organism, not a machine.
Try fasting. From emails, texts, news, stock quotes. Do you really think that you can keep up with the web growing at a rate of 7.3 million pages per day?
Busy your hands. There is enormous therapy to be found by working with your hands. In the words of Michael Crawford, author of Shop Class as Soulcraft: “Fixing things feels good.”

Fertility from Sterility

Paul Turek, MD — Mon, 07 Nov 2011 16:00:55 +0000

What's inside of a coffee mug depends on how you look at it.

Do you think it is possible to have your own children with absolutely no sperm in the ejaculate?
Why yes. It happens on a daily basis in my practice.
Honestly, the word “sterility” has really lost much of its meaning nowadays with advances in reproductive technology.

The Affairs of Sperm

Azoospermia is the word used to describe the lack of any sperm in the ejaculate. It is a devastating thing for men to hear as they try to conceive. It comes in two forms: as a consequence of blockage in the sperm ducts outside the testis in the setting of normal sperm production in the testicle (i.e. vasectomy) or as a result of poorly functioning testicles and normal, open ducts beyond it. We routinely grab sperm from behind vasectomy sites to use with assisted reproduction to conceive. Finding sperm in men with poor sperm production, termed nonobstructive azoospermia, is a more complex matter.

One way to think about sperm production in men with poorly functioning testicles is to compare it to a mug with coffee in it. Say the mug is filled with ¼ cup of coffee. If you hold shake the mug, you may not see any coffee spill over the side. In this case, you might assume that the mug has no coffee inside. But, if you peer into the mug directly, you will see that there is actually coffee in the mug. Similarly, the testicle makes more sperm (coffee) than is found in the ejaculate (spilling over cup). There exists a threshold of sperm production, over which sperm shows up in the ejaculate and below which it will not. So, now you know the secret of making fathers out of “sterile” men with poorly functioning testicles.

Sperm from a Rock

Of course, it’s not quite that simple. There is one more layer of complexity here. Poorly functioning testicles may not make sperm evenly throughout their substance. In many cases, there are “pockets” or “islands” of sperm within a sea of otherwise empty tissue. Clinically, this makes sperm retrieval more difficult and has pushed this technology to a high art.

To find sperm, fertility specialists use several sophisticated approaches in men with nonobstructive azoospermia. The traditional testis biopsy works about 30% of the time to find sperm and, as a consequence, is no longer the de rigueur technique for this problem. Fine needle aspiration “mapping”, which I invented about 15 years ago, is easily twice as good as a biopsy in finding sperm and much less invasive. Lastly, “microdissection” of the testis another alternative and involves an all-out surgical assault on the testicle to find sperm making it the most invasive approach. The elegance and complication rates for these approaches vary widely, but their intent is the same: to find enough sperm to allow biological fatherhood. Importantly, when expertly performed, these techniques will find sperm in the majority of cases. For the remainder, there is hope as even newer “no touch” scanning technologies are on the horizon…

An Ounce of (Fertility) Prevention

Paul Turek, MD — Mon, 17 Oct 2011 15:00:19 +0000

Kokopelli, the ancient fertility symbol.

“I’ve been told that my cancer is now cured… how do I get my fertility back?

Patients ask me this question weekly all the time and I am glad to help. Some of the most satisfying medical moments I’ve had are associated with these patients.

But when I hear this call for help, it also reminds me how medicine has been remiss in preventing the infertility in the first place. We can do better and we can do it right now.

The topic of fertility preservation is the substance of my recent lecture at the annual meeting of the American Society of Reproductive Medicine (ASRM) in Orlando, Florida. This well-attended course focused on the prevention, treatment and restoration of male fertility in the setting of sterilizing treatments typical of cancer therapy.

The goal of my lecture was to review and update providers on current and future strategies for the preservation and restoration of male fertility. Here are some of the ideas discussed. I’ve also included a link to the lecture slides if you are so inclined.

Preserving Male Infertility

Sperm banking. A 200-year old technique that is the purest form of preventative medicine, it is vastly underutilized, not covered by insurance, and not routinely offered to many cancer patients before treatment. What gives? Here is where we need to do the most work in this field.
Sperm Harvest. For 15 years, it has been possible, nay routine, to harvest sperm from men who want children after having a vasectomy without reversing the vasectomy. This same technology is easily applied to men before, during and after sterilizing cancer treatments. One very successful example of this in my practice is fine needle aspiration “mapping” of testicles for sperm in cancer survivors. Indeed, no-touch, metabolic imaging for sperm may be the ultimate iteration of this concept.
Electroejaculation. Based on decades of successful use in spinal cord injured men, artificial stimulation of ejaculation can be a very effective way to bank sperm or restore fertility in men or post pubertal teens who have had nerve damage to reproductive organs from cancer surgery.
Shielding Sperm Production. Physical shields are routinely used to block the effects of aberrant X-rays from hurting sperm production during treatment. In animal models, hormonally induced shut down of sperm production can protect the testicle during the storm of chemotherapy as well.

Restoring Male Infertility

Stem cell transplantation. Currently possible in animal models, this involves taking the delicate testicle stem cells from either pre- or post-pubertal boys or men and freezing the cells before cancer treatment. Subsequently, the stem cells are thawed and replaced back into the testicle to restore sperm production after the cancer is cured.
Sperm Maturation in a Dish. A variant of the above, also demonstrated in animal models, this technique involves maturing stem cells harvested from the testicle before cancer treatment in the laboratory all the way to their final form: a sperm with a tail.
Sperm from Stem Cells. Yet another variant of the above that has been demonstrated in animals, this involves growing usable sperm from early, pluripotent stem cells such as embryonic or adult pluripotent stem cells. One example would be to take a skin biopsy from a sterile man, coercing them to become adult stem cells and then push those cells to sperm in a dish. Truly, a fantastic outcome of America’s investment in stem cell technology.

Fertility Restoration after Cancer: Current and Future Therapies by Paul J. Turek MD, FACS, FRSM Director, TheTurek Clinic, San Francisco (WARNING: Images in slides not appropriate for all audiences due to subject matter)

View more presentations from Dr. Paul Turek | The Turek Clinic

Ways to Naturally Boost Testosterone

Paul Turek, MD — Tue, 11 Oct 2011 15:00:28 +0000

Sunset or sunrise? You choose.

Honestly, it seems like testosterone is to blame for everything these days. The epidemic of low testosterone has been linked to economic recession, wars, bank failures and even global warming. Ok, so maybe I am exaggerating, but many men feel (or are told) that their testosterone levels are the root cause of much of the way they feel. Leaving aside causality and association, what can you do about it?

Testosterone and You

I am the first one to say that testosterone is important for a healthy, long life. Clearly, men with low levels, termed hypogonadism, do not live as long as men with normal testosterone levels. I understand too, what testosterone isn’t and can’t do.

So, I am entirely empathetic to patients who ask: “Doc, what can I do to naturally increase my testosterone levels?” Forget about expensive gels, creams, injections, pellets or patches of testosterone that have side effects. They want to know what they can do, on their own, to improve their testosterone balance. As a big fan of self-empowerment, I dedicate this post to these men.

Lifestyle Changes to Improve Testosterone Balance

Lose weight. Fat converts testosterone to female hormones called estrogens. Less fat means less circulating female hormone levels.
Exercise. Although it is true that while you exercise, testosterone levels may be lower, exercise stimulates muscle recovery and growth through increased testosterone at rest.
Don’t overtrain. Rest between exercise sessions allows testosterone to work its magic.
Get good sleep. Poor sleep habits stress the body as a whole and stress reduces testosterone levels. Perpetual jet lag is no place to be.
Eat smart and cut the alcohol. Eat healthy meals regularly; skipping is not allowed. Also cut down on alcohol as it tends to impair testosterone production and increase conversion to estrogens.

Dietary Supplements That Improve Testosterone Balance

Get zinc. Zinc is a co-factor for testoterone production. Oysters, peanuts, chicken, lamb and (how timely) pumpkin seeds are excellent source.
Get vitamin B. This vitamin is also a co-factor for making testosterone. Bananas, avocados, watermelon, eggs and raspberries are excellent sources.
Control cholesterol. Eat plenty of monounsaturated fats, as found in fish, yogurt, almonds, and olive oil.
Eat garlic. Some evidence suggests that allicin within garlic can help improve testosterone balance. Watch your breath, though.
Herbal remedies: Tongkat ali, Catuaba bark-Muira pauma, Mucuna pruriens, Tribulus, Yohimbine and Ginseng. You know my opinion on these so take at your own risk.

Medical Treatments that Improve Testosterone Balance

If all else fails, see a specialist, as there are excellent prescription medications that can boost your body’s testosterone production, which is not the same as testosterone replacement. Clomiphene citrate, tamoxifen and human chorionic gonadotropin (hCG) are not anabolic steroids, but nor are they FDA approved in the U.S. for this purpose. But they are drugs that either convince the brain to send more gas (luteinizing hormone, LH) to the testicles to make more of your own testosterone, or directly provide the LH to stimulate testicles to make it. Unlike anabolic steroids, they encourage bioidentical (read: “your own”) testosterone production and do not impair fertility or shrink testicles.

You should try to optimize testosterone balance naturally, as these behaviors are generally healthy and good for a long and happy life.

How to Avoid Male Infertility

Paul Turek, MD — Mon, 03 Oct 2011 15:00:51 +0000

Advice as you carve up the roads of life…

Some day, you may want kids…or you may not. It’s not on the top of your mind now as it’s still early in the relationship and you are in that wonderful phase of discovery with your partner. If this is your station then read on because, in the words of Ben Franklin, “an ounce of prevention is worth a pound of cure”.

A Short List of Things To Avoid

Male infertility is either handed to you (genetic) or is a consequence of life on this earth (acquired). You can’t do much about the former, but you can have some say in the latter. Here is a list of common acquired reasons for male infertility organized by severity. Try to avoid these exposures or conditions if you can, and well in advance of family building. Also enclosed are the slides from a very popular lecture on this topic that I first gave to infertility specialists at the American Society of Reproductive Medicine.

Definite Risk of Male Infertility

Anabolic steroids
Testosterone replacement
Opiate pain medication (codeine, hydrocodone, Demerol)
Hot baths, tubs
Smoking
Recreational drugs
Cancer chemotherapy
Radiation
Chronic fevers

Probable Risk of Male Infertility

Overweight (BMI >30)
Stress (physical, emotional, financial)
Excessive alcohol consumption
Finasteride (prostate and hair loss medication)
Varicocele
Pituitary (brain) tumors
Ketoconazole (antiandrogen)
Cimetidine (anti-ulcer)
Spironolactone (blood pressure medication)
Calcium channel blockers (blood pressure medication)
Azathioprine (for autoimmune disease)
Industrial toxins (BPA, PCBs)
Testis cancer

Possible Risk of Male Infertility

Pesticides
Sexually transmitted disease
Diabetes mellitus
Herbal supplements (estrogenic)
Heavy metal exposure (lead, arsenic, cadmium, mercury)
Anti-depressants (SSRI)
Sulfa-based drugs (sulfasalazine, sulfamethoxasole, nitrofurantoin)
Colchicine (anti-gout)
Excessive X-ray exposure
Biologic response modifiers (TNF-alpha blockers for autoimmune disease)
HMG-CoA Inhibitors (cholesterol drugs)

Remember sperm production is an engine that wants to run fast. Avoiding the above risk factors can help it run free and easy. As the ever quotable Franklin also said: “A little neglect may breed great mischief…for want of a nail the shoe was lost.”

Acquired Disorders of Spermatogenesis By Paul J. Turek MD, Professor and Endowed Chair in Urology Education, Department of Urology, University of California San Francisco and Director of the The Turek Clinic

View more presentations from Dr. Paul Turek | The Turek Clinic

What Testosterone Isn’t

Paul Turek, MD — Mon, 12 Sep 2011 15:00:17 +0000

Testosterone: a molecule for life

I see a lot of patients who think that their testosterone levels should be higher for various reasons. I would like to set the record straight.

Even I have been heard to say that it is the “elixir of a man’s life.” Indeed, testosterone is one seriously important molecule throughout men’s lives. In the womb, it determines anatomic maleness. And during puberty, when another splash of testosterone hits boys and sticks for good, I don’t have to tell you what it does: feeds the growth spurt, cracks the voice, encourages hair growth, acne, stronger muscles and is the ultimate governor of teenage thought and action.

Testosterone in Adults

Testosterone in men is essential for health and well-being. First isolated in 1935, it is an anabolic hormone in that it generally induces growth. And it does this all over the body. In the brain, it influences sex drive, assertiveness, mood, energy and some aspects of thinking and verbal memory. In the heart, it helps dilate the arteries, which is good. Testosterone increases muscle strength and maintains normal bone density. It also reduces belly fat. In the kidney, it stimulates a hormone called erythropoietin that keeps blood counts normal. It also strengthens the immune system and helps blood to clot. In the male sexual organs, normal testosterone levels are important for erections and sperm production. So, it’s about as close to an “elixir” as any single circulating molecule in our bodies.

A List of What Testosterone Isn’t

Testosterone is not as vital to us as oxygen. For the record, here is what testosterone isn’t or doesn’t do:

It is not a common reason for erectile dysfunction (<6% of cases).
It is not a common cause for low sex drive.
It will not help you get more dates or make you a sex machine.
It will not magically make you a muscle man.
It will not magically cause weight loss or reduce fat. This requires a diet and exercise program.
It will not help you live forever; it falls with age.
It does not cause prostate cancer or liver cancer.
It is not higher during periods of stress; in fact, stress lowers testosterone levels.
It is generally lower in athletes than non-athletes.
It does not by itself cause baldness. Baldness is mainly genetic.
It does not get lower the more you masturbate.
It will not make you taller or your hands bigger as an adult.
More testosterone will not solve all of your problems.

What’s absolutely key to testosterone management is that there are symptoms present in association with low levels. In such cases, the benefits of treatment are clear. Think of testosterone as oil in your car: it helps everything work better, but when a problem occurs, it is usually something else that has gone wrong.