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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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You Are The Pill That You Eat

Tuesday, June 9th, 2009

Amber waves of grain, the stuff of our Neolithic ancestors

Amber waves of grain, the stuff of our Neolithic ancestors

At some point as we evolved, well after the Neolithic period, we started thinking that there must be a better way to get nutrients, something faster and more efficient, than through the food we have eaten for tens of thousands of years. Our fantasy of the future was encapsulated with TV shows like The Jetsons and Star Trek, where roast chickens and earl grey tea were produced by the touch of a button. Nowadays, grocery stores offer fruit smoothies, breakfast bars, energy drinks and microwave pizzas, so we can fuel up quickly and efficiently. Why sit down when you can eat while running? We take vitamins with the idea that we can rectify any potential deficiencies and even prevent illness, with the swallow of a pill. How simple, how easy, how efficient.

As a society, we are in love with “nutriceutical” supplements. About half of all adults take a multivitamin everyday and it is estimated that $75 billion worldwide is spent annually on nutriceuticals. And nonvitamin and nonmineral natural product use is so prevalent in the U.S. (40% of Americans) that the National Institutes of Health has even commissioned a new branch devoted entirely to the pursuit of complementary and alternative medicine research. This effort will undoubtedly unleash the true potential of alternative medicine. But let’s drill down on vitamins for a minute. What does the evidence really show? Well, it appears that taking vitamin supplements may not as beneficial as previously thought. Several major studies have now shown that vitamin supplements do little to prevent cancer and heart disease, while other studies report that vitamins and antioxidant supplements may actually increase cancer rates. One study concluded that folic acid supplements actually increased rates of precancerous colon polyps, and another study linked beta-carotene to higher lung cancer rates. Are vitamins then, failing us as supplements?

No one discounts the necessity of vitamins for our body’s function. Indeed, many diseases are associated with a deficiency in one or another vitamin. But we do place rather high expectations on vitamins. It’s rather narrow-minded of us to tout only a few particular nutrients in food and assign them letters of the alphabet, when many others may be just as essential to our primitive bodies, yet are unfamiliar to us intellectually. Vitamins do not exist in a void, but are part of a complex mixture of substances called food that is the real stuff of life. If anything, the fact that vitamins are getting an F in cancer prevention suggests that the way that they are absorbed in a pill is not the same as the way we extract them from whole foods that we eat.

My patients frequently ask me what supplements they should take to enhance their sexual health or fertility. The truth is that because sexual health is so thoroughly intertwined with overall health, I emphasize a whole-body approach. I don’t recommend a specific course of supplements, but antioxidants may have some value. If they wish to take a supplement, they may, but the important thing is that they get all nutrients necessary for their bodies to function optimally. The real solution to this is a well-balanced diet low in fat and sugar, emphasizing whole grains, fruits, and vegetables. That said, I do realize how resistant many people can be to changing their diet. If a patient feels they must take a supplement to compensate for poor eating habits, I steer them towards whole food supplements that contain a larger and more complex spectrum of nutrients than that found in traditional multivitamins. In all honesty however, I firmly believe in carrots from the earth and apples from trees, just like our Neolithic ancestors did.

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How Are Stem Cells Like Wine Grapes?

Wednesday, May 27th, 2009

Stem cells, like wine grapes, need tender nuturing to reach their potential.

Stem cells, like wine grapes, need tender nuturing to reach their potential.

Silicon Valley started in a small garage across the way from Stanford University by one man named Hewlett and another named Packard. There’s an historic plaque on that garage now, and a worldwide industry surrounds it. Stem cell research has just as much potential.

Last week, I mentioned that I was a believer, that I have seen things happen in stem cell research that others haven’t. Collaborating with Renee Reijo Pera, PhD at Stanford, we have been developing adult stem cells that would not involve embryos, or viruses, and that would not be rejected from the body. It all started when we put our heads together and thought hard about how sperm are made and how stem cells are grown. From this line of thinking, we concluded that the adult human testicle would be a great place to create a stem cell. Why? Because the first thing a developing embryo does as it begins to grow is to set aside cells and designate them as “germ” or reproductive cells. Much later on in fetal life, other tissues develop. So, germ cells are special and very closely related to embryonic stem cells; that is, they are very “stem like.”

The next problem, and a big one at that, was how to take adult stem cells and “reprogram” them to become embryonic-like stem cells. This took the better part of four years to figure out. And, like your grandmother’s great apple pie, the secret is in the recipe. Indeed, we found that just the right combination of feeder layers (a layer of cells in a petri dish which help the stem cells to develop) and bathing solutions were instrumental in nurturing these rare testis stem cells to become embryonic-like in a laboratory dish. I developed a lot of respect and a certain fondness for these rare and special cells through this process of discovery. The care lavished on them reminds me of winemakers and their finicky pinot noir vines, which require the right conditions and care to produce their transcendent fruit. Both require a delicate touch.

So, slowly, with persistence, we were able to generate a very “stem like” adult germ cell in a dish starting from a testicle. We showed that, like a real embryonic stem cell, this cell could begin to form the different layers of the body, including nerve, in a dish. What is still not clear from all of this work is exactly what kinds of body tissues can be made from this cell. Can we make an entire heart? How about a clavicle? Or can we just make sperm? This is what the next four years of research are for. In any case, this discovery may help to bypass the whole moral debate surrounding embryonic stem cells. There would also be no viruses to worry about, nor tissue rejection issues to dodge, because your body would simply be rebuilding itself.

Understand that this research is still in its infancy, but it’s a whole new world of medicine, where whole organs may be regrown, and sight and fertility restored. With more time, this kind of research may be as earthshaking as the discovery of antibiotics a century ago. Stem cell research is likely to be even more transformative than this. May the wonder and awe from scientific discovery never end.

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No Sex? Get Some Sleep!

Friday, May 1st, 2009

The Exquisite Woman Right Next to You..

The Exquisite Woman Right Next to You..

As a men’s health specialist, I get to hear a lot of things that men wouldn’t tell their best friends. And a very common occurrence is their confession that they have lost some of their sex drive. “My partner is great and I used to want sex ALL the time, now it barely enters my mind” is what I hear most.

The first thing to realize is that if you do not have the sex drive that you had when you were 18 years old, maybe its because you aren’t 18 anymore. Maybe the 10 to 20 years of aging that has occurred since then has taken a small toll. You are now older and wiser, having survived wars, financial distress and maybe even children, and you could be a bit less frisky as a result.

That reminds me of two memorable patients who represent different ends of this spectrum. Both in their late 30’s, one answered my survey question about how often they have sex by writing “twice daily, every day” and the other wrote “by appointment only.” This just goes to show that we are all built differently and we all age differently. Neither is really clinically out of the normal range. Blame comments in the locker room, Hollywood films, or Internet porn, but men often feel like their sex drive should not change with age. Tough for men to talk about and therefore tough for them to gauge. However, it is well understood by sex therapists that men aren’t always in the mood. Sometimes the History Channel looks way better.

It may not be for any lack of love or Barry White records. However, if it has been several weeks since you last took your wristwatch off, so to speak, then the real issue behind your lack of sex drive may be your level of sleeplessness and stress. If you aren’t well rested, you probably aren’t feeling too frisky. You’re probably cranky. Believe it or not, this is a very common reason why sex lives are compromised. Being anxious puts your nervous system, once part of the animal kingdom, into a primitive “fight-or-flight” response, and buries the sex drive. Relaxation though, stimulate several appetites, including degustory and sexual.

For a robust sex life, both of you need energy, relaxation, and time. The mind is the largest sexual organ, and turning off the amygdala, the portion of your brain that handles fear and worry, will allow that quiet, sensitive part of your brain that handles sex drive to kick into gear. Think seriously about turning off the TV or computer earlier in the evening, and swap out dozing in front of the TV for more restful sleep in bed. Think hard about improving how much quality rest you actually get, not necessarily to have more sex, but simply to sleep; the sex will follow. Make dates with your partner so you can focus solely on each other and forget the usual distractions. Take her to a funny movie, and laugh (or cry) together. But make the time, make it important, and catch some zzzs. Revving up your sex life can be as simple as that.

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