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Ode to Ashley

Sunday, May 9th, 2010
A women for the ages.

A women for the ages.

I read a decade or so back that if you were to add up all of the jobs that a mother does over the course of a day, she would be earning an annual salary of $512,000. These occupations include: wife, partner, cook, nanny, cleaner, teacher, chauffeur, nurse, secretary and about 14 other jobs. Unbelievable but true. Happy Mother’s Day! Well, I have this and more. So, here is my “Ode to Ashley,” wife of 9 years and the mother of my daughters:

I have read all kinds of poetry,
And have been mesmerized by lines I’ve read.
I have viewed the wondrous symmetry
Of timeless pyramids and pharaohs dead.
But all such wonder pales with Ashley.

I have seen the grace of royalty,
And aged veterans who barely stand,
I have been shown the path of loyalty
By Mom, John, Gene…quiet not grand.
Though of these things, I have learned as much from Ashley.

I have opened bellies in those who wouldn’t recover,
And stabbed amoebic livers to drain and mend.
Watched feverish babies with typhoid die with mothers,
And I have loved and lost; got up and loved again.
Yet, about life, I have gleaned as much from Ashley.

I have seen the exquisite beauty of Vasari,
Heard Kovacevich, Richter, Miles and Coltrane.
For hours, walked the Hagia Sophia with Compari,
And surfed some beautiful green walls in rain.
But such beauty holds no candle to Ashley.

There is a special majesty in life,
But often hard to see from day to day.
But, if lucky in life, you may meet Ashley,
And see the spectrum of its beauty, its glorious array.

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The Curse of Women’s Urine

Sunday, April 25th, 2010
Estrogens and the manly man.

Estrogens and the manly man.

There must be something in the air… or water. The Bolivian President Evo Morales recently asserted publicly that hormones found in mass-produced foods are “feminizing” men. Speaking about chicken in Bolivia, which he believes are “loaded with feminine hormones,” he suggested that when men eat chicken “they are diverted from their nature as men.” So, is this how metrosexuals came to be?

But wait, the Vatican commented on this issue a year earlier, although they blamed female hormones from birth control pills for the increased estrogens in ground water. Pedro Castellvi, writing in the Vatican newspaper L’Osservatore Romano in 2009, stated: “we have sufficient data to affirm that one of the reasons for the not insignificant rise in male infertility in the west, is the environmental contamination caused by the pill.” Actually, it’s not the birth control pill itself but the urine from women taking the pill.

In fact, to date, the urine of women taking birth control pills has been blamed for worsening sperm counts in men, the growth of female sex organs in male fish, breast growth in young men and the early onset of puberty in young girls. What next?

Can I add a little balance to this discussion? First of all, exactly what is happening to men in Bolivia such that the President is not happy with them? Are they more civilized and less disruptive? Second, male infertility is not necessarily increasing in the western world; it may even be true that men have lower sperm counts now than a generation ago not because they are less fertile but because women are more fertile. Third, estrogens are found everywhere in the environment including in many plants (phytoestrogens) such as soy and legumes, and are not produced exclusively from the urine of women. Fourth, the intersex conditions that have been reported in many animal species tend to be caused by a very specific exposure at a very specific time point during fetal development and have been linked to pesticides, bisphenol A, dioxins and other environmental contaminants (xenoestrogens). Fifth, did we somehow forget about the worldwide obesity epidemic in humans and the fact that fat converts male hormones to female hormones? Lastly, there is little evidence that substantially increasing a man’s estrogen levels as an adult will dramatically alter anything, except maybe waist size and color preferences. Where the truth lies in all of this is currently unknown, but it is hard for me as a urologist to see how women’s urine could be blamed for so much.

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Handling The Truth

Sunday, March 28th, 2010
Patients can handle the truth...try them.

Patients can handle the truth...try them.

How would you react to a doctor who, instead of explaining the entirety of your medical options, simply said “trust me, this is the right choice.” Maybe that style of “care” worked a generation or two back, but today’s patients have access to any piece of medical information that their doctors do. Patients want to know as much as they can so they can make the best choices for themselves or their loved ones.

Why do I bring this up? Well, because I got a call the other day from a patient who was seeking for more information about his options for fatherhood after vasectomy. He had an older vasectomy, 25 years or so, and a wife who was 40 years old. He met with two doctors in other cities and asked them about vasectomy reversal and sperm retrieval with assisted reproduction. Both of these are options for vasectomized men. Both urologists said, “forget it!” The patient was stunned. He just wanted information to help him decide how he was going to approach the family building issue. Instead, he received no information, and, without asking, he was told what he should do. Forget it.

Two things are still true after visiting these two doctors:

1. He still wants a family.

2. He knows no more than he did before about how to achieve this goal.

Now what is wrong with this picture? Patients do not necessarily depend on doctors for information; they can get that almost anywhere on the Web. However, they do depend on doctors for wisdom and knowledge–the interpretation of information as it applies to the patient. I believe that life is a journey, one that involves many forks in many roads. Some are chosen and others are not. In the end, there is a story, a memory, of the path that was taken. Making decisions about medical care is also part of the journey that we all take. As doctors, we are obliged to use our experience and wisdom to help patients face decisions and choices that affect their health, their budgets and often their very lives. A patient’s “trust” is earned and is not gifted to doctors. Be their trusted consultant, someone who they can rely on for good solid information and wisdom. Unlike what Col. Nathan R. Jessep says in A Few Good Men, patients can handle the truth.

In my discussion with this patient, I gave him the facts about each choice. Older vasectomies are less successful at being reversed than younger ones, but the results are still very respectable in the right hands. His wife’s age could influence his decision either way, especially if she has limited time left to have children. Pregnancies after reversals of older vasectomies occur later than those after younger vasectomies. Sperm retrieval and assisted reproduction

can be a faster, albeit more expensive, way to conceive. If more than one child is desired, then assisted reproduction can get very expensive compared to vasectomy reversal. No value judgments, just the facts. There are lots of ways to build families and patients armed with good informaton can decide which way is best for them.

It has always been my philosophy as a physician and surgeon to walk the walk with the patient. Even stepping into their shoes and taking the journey with them. This makes good sense in situations in which outcomes cannot be guaranteed. Sure, I will offer an opinion if they ask, “what would you do?” However, in my brief stay on this good earth, I have found that the educated consumer always makes the best choices.

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The Symphony of Surgery

Wednesday, November 25th, 2009
Tickle the ivories and delight the senses.

Tickle the ivories and delight the senses.

I spent an evening this past weekend listening to the mighty Berlin Philharmonic Orchestra, conducted by Sir Simon Rattle. Listening to their performance of Wagner, Schoenberg and Brahms left me utterly breathless. A magnificent musical experience. Why? Because every single musician thinks and responds incredibly quickly and appears to give their all to a whole that is far greater than the sum of the parts. The mastery of these technically demanding movements was superb and it was clear that this orchestra, led by a conductor filled with supreme passion, could turn on a dime at any moment.

Can a surgeon perform surgery like a world-class symphony performs music? Absolutely. While a resident in general surgery, I remember watching a pediatric heart surgeon name William Norwood at the Children’s Hospital of Philadelphia perform his own Norwood Procedure on children with malformed hearts. Dr. Norwood’s hypoplastic heart surgery on infants at the brink of death was exhilarating to behold. Appearing intense and focused, with no wasted movements of his ambidextrous hands, he could repair an aorta or pulmonary artery in a minute with either hand, throwing absolutely perfect sutures as rapidly as a sewing machine. All the while working on hearts the size of shrunken plums and veins slimmer than angel-hair pasta. A technical virtuoso. All while listening to Albinoni’s Adagio in G Minor.

Aside from sheer talent, what makes William Norwood and Sir Simon Rattle the giants that they are, is a vision of perfection and the ability to inspire the best from others. Helping others achieve more than they could otherwise is a key element of leadership, especially in the setting of complex team performances like heart surgery or Schoenberg movements.

Inspired by these maestros, I too strive for perfection in my corner of the medical world, that of reproductive microsurgery. I view vasectomy reversal surgery as a craft best done by artisans. The chance to lead a roomful of others, throw 300 knots all with equal precision into an organ the size of spaghetti, gauge biology like a painter eyeing a still life, and help to create new life as a result. There is art in all that we do. Have you found your canvas?

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Sex: Warts and All

Monday, October 12th, 2009
Life has its warts, just ask Letterman...

Life has its warts, just ask Letterman...

What is all this news about warts? Although incurable, genital warts (condyloma acuminata for the Greek among us) are the most common sexually-transmitted disease caused by a virus. The human papillomavirus (HPV) to be exact. Not to be confused with HSV that causes genital herpes. Less than 5% of those who have an HPV infection will actually develop visible warts, but either way, they may be infectious. The viral particles penetrate the skin through small abrasions in the genital area that may occur during sexual activity. When visible in men, warts are treated with chemicals such as podophyllin, interferon and trichloroacetic acid when small, and by liquid nitrogen or surgical excision when larger. Since they cannot be cured, the goal of treatment is to remove all visible lesions and theoretically to reduce the chances of transmission.

So that’s the scary part. But what’s new? What’s relatively new is that it has become clear than certain subtypes of HPV cause only benign warts (types 6 and 11) while other subtypes can cause cervical cancer (types 16,18). Of course, any association with cancer thankfully leads to more research and the outcome of research thus far is the development of an HPV “vaccine”. Like many vaccines, this one does not cure HPV but simply prevents it. And, it must be given before exposure to the virus to be effective, ideally before sexual activity begins. To date, the vaccine (Gardasil, Merck & Co) is widely approved for use by young women in many countries including the U.S. and is being widely used to prevent HPV and hopefully cervical cancer.

But what about boys and men with HPV? Similar to women, it would not be expected that an HPV vaccine would have any effect once a man has HPV or warts. But what about vaccinating boys before they begin sexual activity, similar to girls?  Our FDA is considering precisely this question and now has some real information on which to base a decision.The data comes from Britain, where the vaccine has been already been approved for boys.

A very recent study now suggests that although it might be cost-effective to vaccinate girls in Britain, it appears not to be the case for vaccinating boys. This is based on the assumption that all girls would already be vaccinated. So, a “coed” vaccination campaign would double the cost of treatment but is likely not to double the results. Basically, the vaccine can prevent the infection quite well thank you, but it may not be worth the public health investment to offer it to boys. However, if the coverage of girls is low, then it may be worth vaccinating boys.

And so it goes. A story similar to that of contraception: If one partner is well protected, then the other may not need to be protected. So there you have it concerning HPV, warts and all.

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Happy Anniversary to Testis GPS

Tuesday, September 29th, 2009
FNA mapping: testicular "cartography" for male infertility

FNA mapping: testicular "cartography" for male infertility

It’s been 13 years. Certainly a significant amount of time for any recent tech start up, but also impressive for a medical procedure. It’s the 13th anniversary of the invention of fine needle aspiration mapping of the testis for sperm. Nine hundred cases and going strong and many families created along the way.

It all started in 1996. Infertile patients from around the globe asking me if there was anything, absolutely anything, that I could do beyond what was currently available to find sperm so that they could have a child. The in vitro technology was there, if we could just find sperm! Survivors of cancer, war injuries, brutal infections, chronic disease, spinal cord injury, cystic fibrosis and a myriad of other genetic syndromes all had a simple request: the opportunity to be biological fathers. They refused to accept what a simple testicular biopsy was telling them, that there was no sperm being produced in the factory and no chance of having their own sons and daughters.

Its times like these, pushed against the wall, when creativity surges and opportunity frees us from the restraints of the routine. For me, it came as a simple revelation: not all branches of an apple tree have apples. Or, in my field, not all prostate biopsies show cancer and not all testis biopsies show sperm. A single biopsy of a testicle in a man with no sperm in the ejaculate is simply not enough to say that he does not have any sperm and that he cannot become a father. We must look harder. And so out of this revelation, testis fine needle aspiration “mapping” was born, 13 years ago and going strong.

The details of the mapping procedure don’t matter except to say that it’s all a matter of sampling enough to reduce sampling error and, while doing so, being kind to patients. Too many biopsies can destroy a testis, but non-surgical, fine needle sampling is a kinder, gentler, and more informative way to learn more and to find sperm. Think of it as “GPS” for the testis or, as one patient put it, “testicular cartography.” And, once sperm are found, the world becomes our oyster in a reproductive sense.

Telling a leukemia survivor who was too young to bank sperm before he was hit with a wall of chemotherapy, radiation therapy or a bone marrow transplantation to just stay alive that he can now be a father because of some small pocket of sperm still alive in his mapped testis is a profoundly satisfying and motivating experience. Motivating enough for me to be thinking about the next new thing…

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A Short History of the Y Chromosome

Tuesday, September 22nd, 2009
The Y chromosome: diminutive but cool.

The Y chromosome: diminutive but cool.

Among the many chromosomes in a man’s body, the smallest one with the largest personality has to be the Y chromosome. With it, you are a male; without it, you are a female, with few exceptions. More than any other chromosome, it really defines who you are.

The Y chromosome controls other traits as well: hairy ears, tooth enamel, and stature to name a few. But for the longest time, the Y chromosome was also considered home to a lot of “junk DNA” that we thought had no purpose. We now know that much of this DNA has a purpose and that the Y is the home of many important male fertility genes.

Before its association with male fertility, the Y chromosome was widely considered a genetic black hole, a chromosome that evolved as a broken remnant of the X chromosome. We knew that the “maleness” gene was on the Y and a few other genes. However, since the Y chromosome has been fully undressed as a result of the human genome project, we now know that it is very unique, even special, and that it evolves in its own special way to keep men men.

The Y chromosome, and its neighbor the X chromosome, evolved into “sex” chromosomes hundreds of millions of years ago. This is important because many species do not have a chromosome for each sex like we do. Some species become male or female based simply on the environment in which they find themselves. Imagine that! A boy in the Artic but a girl in the Caribbean. At first, the original sex chromosomes probably evolved as a pair of two X chromosomes. Then, 150 million years ago, the Y chromosome made its break from the X chromosome. Basically, it stopped associating with it and this led to our current X-Y system of sex determination. I guess this is when men really became men.

As it works now, the single Y chromosome has no partner with which to swap genes when sperm are made (at a normal rate of 1200 sperm/heartbeat!) This “swap meet” of genes that occurs when new sperm are formed is an important repair process for the 22 other chromosomes and is absolutely critical for our evolution as a species. In fact, this is the source of our evolution. So, now that the Y chromosome has become isolated and less of a team player, is it doomed to extinction? More importantly, are men are doomed to extinction?  

So how does the Y chromosome survive and repair itself, living alone in isolation while the world is changing around it? Well, we now know that it manages very well on its own, thank you. And this has probably been true for about 5 million years. Although it no longer swaps genes with the X chromosome, from which it came, the human Y chromosome is able to swap genes with itself to discard bad genes. It’s called gene conversion and no other chromosome does it. Just the Y. How uniquely male.

Basically, essential Y chromosome genes are arranged in a series of eight “palindromes,” or mirror image sequences, each of which folds like a hairpin in which its two arms come together. Then the “DNA checkers” compare the two arms for any differences and convert a mutation back to the correct sequence, thus saving the Y’s genes from mutational decay. So, the older “junk DNA” thought to exist on the Y chromosome is now known to represent DNA that it critical for its survival. One man’s junk is another man’s treasure. And so it goes, the Y lives on, and men do too.

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The Agents of Erection

Monday, August 24th, 2009
The biochemistry is complex; the result is simple.

The biochemistry is complex; the result is simple.

Subtle, efficient, and powerful, Viagra is a first-line agent of erection, along with its accomplices, Cialis and Levitra. True, there are other agents out there, such as penile implants and injections, but these three, the triumvirate of pills, are the go-to agents, because they work so well for so many people.

Viagra wasn’t so much invented as happened upon. Its ability to restore erections was discovered as a side effect of a clinical trial targeted towards treating heart disease. Viagra was supposed to reduce anginal chest pain by increasing blood flow to the heart. It turned out that Viagra did increase blood flow, but to a different organ. After the trial, when the company asked the test subjects to return the extra pills, the patients refused because their erections were so much better. And so the agents of erection were born.

Viagra, Cialis, and Levitra all work the same way–sort of like coffee for the penis. Similar to coffee, which works by preventing the breakdown of the energy molecule ATP, thus increasing metabolic energy, these agents inhibit an enzyme that breaks down a different energy molecule (cGMP) that is found in the penis. This energy molecule causes the arteries of the penis to dilate which is how erections begin. Because cGMP is not being broken down, more cGMP is available, and for a longer period of time. More cGMP equals more blood to the penis. Cue the Love Boat theme.

These medications, as a class called PDE5 inhibitors, are not aphrodisiacs and are no replacement for sexual stimulation. In other words, the traditional rules of engagement still apply. They can take up to one hour to start working, during which time foreplay and intimacy is important for a good experience. All three medications work equally well, with Cialis having the longest effect. Aside from the usual side effects from most pills that include headaches and upset stomach, the major concern with these medications is that they can have dire consequences if one is also taking certain heart or blood pressure medications, namely nitrate-containing medications and alpha-blockers. Dangerously low drops in blood pressure can result, leading to strokes and heart attacks.

These first-line agents of erection are intended for mild to moderate cases of erectile dysfunction. Because this disease is frequently a harbinger of other medical problems such as diabetes and heart disease that you should really know about, a thorough evaluation by a doctor should be performed before it is prescribed. So for health’s sake, please resist the temptation to purchase them from your email spam folder and see a doctor; although embarrassing at first, you’ll be happier in the long run.

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Baby Making Tips

Wednesday, August 19th, 2009
The most fun he ever had without laughing

The most fun he ever had without laughing

You might have “practiced” the art of baby making for quite a while. But have you actually tried to make a real baby? What does it mean when a couple says they’re “trying”, besides jettisoning the condoms, scheduling free time, and practicing your “sore throat” voice for calling in sick to work. No one teaches you the nitty gritty of baby making in sixth grade sex ed classes. So, here are some of the finer points.

First of all, your chances of conceiving decrease if the two of you are under stress. Frequent travelling, major life changes, a long sickness, being vetted for the Supreme Court, running a start up with a gazillion hours weekly, are terrible for getting one “in the mood.” If the body is under stress, it’s in the primitive “fight or flight” response, and it’s not exactly in the mood to reproduce. So to improve your chances, decrease your stress level by eating well, sleeping well, staying healthy and relaxed, and treating your body right. If you are chronically overworked, you may consider decreasing or delegating your responsibilities. If this isn’t possible, force your body to relax with exercise, yoga, massage or acupuncture. Also, quit smoking, drink no more than two glasses of alcohol daily and avoid hot tubs and hot baths (showers are fine).

Like many things in life, timing is everything. Eighty percent of pregnancies occur when sex takes place before or during ovulation, which is the time when a woman’s ovary releases an egg for fertilization. But how to tell when ovulation is occurring? The most accurate way would be with an “ovulation predictor kit” purchased at any drugstore. Like a pregnancy test, it uses urine to determine if ovulation is about to occur. The old-fashioned method, which also works well, would be to pay attention to her basal body temperature. To do this, she should take her temperature first thing in the morning, for a string of consecutive days during the middle of her monthly cycle. There should be a dip in her temperature, followed by a rise. This indicates ovulation.

Once you know that the egg is on its way, intercourse is best performed every other day. Men need time between ejaculations to “reload”, and daily intercourse may not give a man enough time to do so (sorry guys). As for the act itself, studies have shown that no particular position is best. Research is suggesting that the two of you can bend yourselves into pretzels, if desired, with no effect on your chances of conceiving or on the gender of the child.

Baby making is a special experience. And, it’s fun! As Woody Allen said in the movie Annie Hall, ”…sex is the most fun I ever had without laughing.” If you think about it, what I am suggesting is that you and your partner make it a habit to take the best care of yourselves, just as you are going to take the best care of your child. Set the example for the new family and enjoy the ride!

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Pop Quiz on Men’s Sexual Health

Monday, June 22nd, 2009

Did the artist Roy Lichtenstein truly understand women?

Did the artist Roy Lichtenstein truly understand women?

Ok, you have been reading about men’s health on this blog for months. Now it’s time for a little quiz. Number two pencil’s out?

1. True or False: Real men don’t cry or express emotion.

False. Ever see Marlon Brando in Streetcar Named Desire, yelling Stella’s name in the streets? Too bad that men who cannot express their feelings are portrayed as monsters on film. Think of Arnold Schwarzenegger in the Terminator. Or Al Pacino in the Godfather (part two), where he has his brother killed with barely a trace of emotion. Simply not true. Real men feel but often they are not able to recognize and name the feelings. In any case, expressing feelings is as primitive and important as eating.

2. True or False: A healthy man always wants sex.

Tricky, but false. Testosterone influences a man’s libido, and men, on average, have a higher libido than women. When women state that “men always want to have sex,” it’s an exaggeration. According to the Kinsey Institute, 54% of men think about sex every day, or several times a day, but 46% think about it a few times per month, a few times per week, or less. Remember, stress also affects sexual desire. Men may not think about sex as much when they are older compared to when they were younger in part because of how much more complicated and stressful their lives have become.

3. True of False: A man who is good in bed should be able to keep it up for 45 minutes straight.

False. This would be fun it were true all the time. But actually, every man is different. In this case, it’s time to bury that competitive streak or any issues of inadequacy, because this expectation is a bit high. Although drug makers warn us on TV about erections lasting for several hours (which in fact can be painful), the average erection lasts 15 to 30 minutes. The average time to sexual climax in U.S. men is 7- 9 minutes, believe it or not.

4. True or False: I had five hours of sleep, worked a 9 hour day, then came home, helped with dinner, and worked on a pet project. Exhausted, I went to bed, and my lady love wanted sex. There must be something wrong with me if I don’t feel like it.

False. I wrote about this previously. Wanting to have sex is linked with stress and also sleeping well. This means between 6.5 and 7.5 hours of sleep each night. According to sleep researchers, the people that live the longest also sleep about that much. It’s well known that sleep deprivation has a direct impact on libido, and in some cases, on erectile function.

5. True or False: When I have sex with a woman, I need to attend to her needs before attending to mine.

True and False. It is gentlemanly and attentive to respond and pay attention to what a woman wants, but to tell the truth, women’s libido’s are a funny, wily thing. Only 26% of women in a committed relationship climax every time they have sex. Men often put themselves under undue pressure to give their partner an orgasm when it may cause more stress than satisfaction. Some advice: Take care of yourself and let her take care of herself.

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