Archive for the ‘Uncategorized’ Category

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.

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.

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.

The Vasectomy Hoopla

Monday, April 20th, 2009

Thoughts as elemental as the ocean

Thoughts as elemental as the ocean

These are times fraught with uncertainty. A sunny day isn’t just a sunny day anymore; it’s evidence of global warming. America has been at war for almost a decade, trusted financial institutions are folding and our economy appears to be on the verge of collapse. It seems only natural that people would look at our unstable world, ask themselves dark-night-of-the-soul type questions, and choose what is right for them.

In the last several months, since the scope of our financial crisis has made itself known, there has been a spike in the number of vasectomies being performed. Some Planned Parenthoods are reporting that vasectomies are on the rise, up thirty percent from the same period last year. Several doctors have also made the same observation. The New York Times recently attributed the increase to the bleak outlook of America’s economy. They postulate that men are reacting out of fear that they can’t afford a child. This is too simplistic a conclusion. A man’s life is long, as is the ability to reproduce, and can easily outlast a financial deep freeze. And people don’t stop wanting children simply because they are expensive. The desire to procreate runs too deep; as deep as the need to eat.

There could be other reasons for the increase, if in fact there really is an increase. For one thing, reproductive impulses move with the seasons. It has been observed that, like most of nature, human reproduction is seasonal. It is widely accepted in the scientific community that birthrates swing up and down as the year progresses, with more babies born in the spring. Just like lambs. Despite our seeming transcendence of the animal world, reproductive urges remain firmly guided by biology. We could simply be seeing a downswing in this urge at this time.

It’s also possible that the new year, especially this one, gave people a desire to make a fresh start, and are putting their plans into action while they feel motivated. No doubt there will be a lull in vasectomy business when everyone runs off for vacation in the summer. Mai-tai or vasectomy? You choose.

One observation that throws a wrench in the New York Times’ argument is that right now, in my practice, I am seeing a surge of interest in vasectomy reversals. With these couples, just as with men seeking vasectomies, there is a level of urgency. Across the board, I hear the same thing from both groups — it’s now or never.

I am inclined to think that the grim reality of the recession, the wars, the rise in global temperature (will that affect sperm production?) — threats such as these crystallize thoughts and focus actions, helping us to clarify in our minds what we truly want. I think men are simply putting into action what they were already planning to do, while it is still possible. Whether it’s a man who seeks a vasectomy before he’s laid off, or a couple who thinks the clock is ticking just a little louder, times like these can reveal to people what is truly, fundamentally important to them.

Spring, Bicycling, Sex and You

Monday, April 13th, 2009

The beauty of a Campagnolo derailleur

The beauty of a Campagnolo derailleur

The warm breath of spring is here, and on it rides the cyclists. I join their ranks, happily. As a teenager in Connecticut, I spent my summers at a bicycle shop working on European models that gleamed amongst the dust motes. I joined a cycling club, wrote stories about races, and deified the movie Breaking Away, a coming-of-age film filled with dreamy Italian bicycles. With the extra money I earned mowing lawns, I bought a beautiful Raleigh racing bike with gorgeous Italian gears and toured rural New England, feeling like I was one of the scrappy townies in the movie. And so my love affair with bicycles began.

It took a while before the honeymoon was over. About twelve years ago, Dr. Irwin Goldstein reported the first case of erectile dysfunction (ED) in an avid cyclist. Other reports followed, and an “epidemic” ensued, despite very few verified cases of bicycling-induced erectile dysfunction. The current understanding is that the saddle (bicycle seat to you laymen), compresses the blood vessels and nerves in the perineum, the area between the scrotum and anus. This cuts off circulation in the penis, and decreases sensitivity. It has been reported that the pressure on the perineum when a man sits on a bicycle is sevenfold that of sitting in chairs. Currently, it is believed that adult men who ride a road bike for more than three hours a week have a seventy percent increased risk of getting ED, and five percent of cyclists will develop bicycle seat impotence. However, the exact risk factors (besides seat time) that predispose men to this problem are not understood.

So now we have a public health paradox. While bicycling is great exercise for your cardiovascular system, it may be detrimental to men’s sexual health. What is good to know is that the Feds are now involved with this issue, specifically the National Institute of Occupational Safety and Health (NIOSH). This is a good thing, as it means that more studies will be forthcoming that will focus on preventing bicycle seat impotence. From what we know now, the safest saddles appear to be those that force men to sit back, keeping the pressure off of the perineum. Noseless saddles may be better too. Gel saddles may be better than foam ones, and split rail or cutout saddles, which have a depression or gap down the middle of the seat, are probably safer. For now, if any pelvic numbness occurs while bicycling, change the saddle so it doesn’t occur anymore. Keeping your pelvis happy may also keep your sex life going.

Once Upon a Time in Barcelona

Thursday, March 26th, 2009

The Sagrada Familia, A Gaudi inspired sand castle-like cathedral in the center of Barcelona Spain

The Sagrada Familia, A Gaudi inspired sand castle-like cathedral in the center of Barcelona Spain

While in Barcelona recently, meandering through the Parc Guell and Sagrada Familia, the weight of what happened earlier that day hit me. I reveled, as anyone might, in the outlandish works of Gaudi, but a part of me remained sober, due to my participation in a debate at a men’s health conference. By the end of it, I realized that men in this country simply don’t get the treatment they deserve.

Are infertile men better served by fixing their infertility problem, or bypassing the problem and using IVF instead to build a family? My opponent was a well-known men’s health specialist from Germany. We butted heads on a variety of issues. But we strongly agreed that although some cases of infertility may not be treatable, all cases merit a thorough evaluation. This is because the cause of infertility could be an underlying medical problem with serious ramifications. Infertility can be a window into a man’s future health. Men not only deserve such an evaluation, they are owed it.

To provoke my opponent and cause a little drama, I said that IVF was the worst thing to happen to men’s health in the U.S in the last thirty years. Most infertile men in America receive only a semen analysis, and never get a proper examination. I estimated that only ten to twenty percent of U.S. men with infertility receive a formal urologic evaluation. The fact is that most infertile men stateside simply get no real medical care.

My audience’s visible disbelief at these statements revealed the huge divide between socialist health care systems in Europe and our own. In Germany and Spain, it is not simply advised, but mandated that both infertile partners receive a full workup, prior to considering treatment. Why pay through the nose for IVF when you may not need it? I had no idea that European countries’ approach to men’s health was so progressive. Surely, for the sake of men’s health, a similar mandate is a fundamental and worthwhile goal of any proposed national health care package in America.

What we found: Male infertility and Cancer

Thursday, March 19th, 2009
The genetic complexity of sperm and precursor cells when the chromosomes are painted is similar to that of constellations of planets and stars, and look very similar.

The genetic complexity of sperm and precursor cells when the chromosomes are painted is similar to that of constellations of planets and stars, and look very similar.

So what did we find?

The study showed that men who are infertile have a much higher risk (3 times) of developing testis cancer later in life than the average citizen. And this was based on some serious number crunching. We worked from a huge database of over 51,000 infertile couples who sought care over a 22 year period in California.  The male partners were cross referenced with a California cancer registry to figure out who among them developed testis cancer as they got older. Among infertile couples in whom the male partner was not the reason for infertility, the future risk of testis cancer was the same as in the general population. However, among infertile men who were themselves the cause of the infertility, the risk of future testis cancer was 3 times higher.

So what does this really mean? Well, first of all, it confirms studies from Europe that have suggested the same thing is happening there. This confirmation in a U.S. based study is important, because the rate of testis cancer in many European countries is much higher than it is in the U.S. It also implies that there may be a connection of some kind between male infertility and testis cancer.

But what kind of connection could exist between male infertility and testis cancer? Well, environmental exposures might link these two conditions. However, the kinds of substances that could do this are still unclear. Estrogenic compounds such as bisphenol A, phthalates and pesticides have garnered much press lately as they alter sexual development in animals, but have not been definitively linked either to testis cancer or human infertility.

The connect, I think, may be even more basic: it probably involves genes and gene mutations. About 10 years ago, we and others reported that severely infertile men have more trouble than other men in properly repairing the daily breaks and kinks that occur in everyone’s DNA with daily use. Because faulty DNA repair is clearly associated with cancer in humans, this led us to surmise back then that infertile men with faulty DNA repair might have a higher risk of cancer later in life.  And voila! The results from the recent research appear to support this idea. 

For the time being, the risk holds only for testis cancer, but who know what future research will show? Based on this, I recommend that all infertile men certainly be evaluated by a urologist with a good history and physical examination. They should also be taught testicular self examination as a screening tool to detect testis cancer.

Infertility as a window into men’s health?  As a shift in thinking, it certainly does shine a new light on the problem.

 

Male Infertility and Cancer Later On

Saturday, February 28th, 2009

Every day I try my best to help men who walk through our clinic doors achieve the full potential of their reproductive and sexual health.  That covers a lot of ground mind you, from counseling on sexual dysfunction, to testing, to actual surgeries like a vasectomy.  I also see lots of patterns.  The one that kept bothering me – like an itch I couldn’t quite scratch – was the fact I kept seeing infertile men who had other medical issues that, at first blush, seemed unrelated.   It wasn’t just a patient here or there, it was all the time.

But the common wisdom has been that male infertility is a benign condition.  It is something that occurs in otherwise healthy men, making it harder for them to have a baby, but has no other real health implications. 

What we are taught often causes us to look something and see it in only one dimension, when in fact if it were turned slightly differently we would see that there is a completely other side to it.  In medicine, breaking out from what is taught, from what is ‘common wisdom,’ is particularly hard because we are a consensus-driven fraternity where the truth can take years to uncover and even then is often inconclusively viewed.  You don’t – at least I can’t – just one day see something and suddenly shift the paradigm in your head.

So it took some time for the light bulb to finally go on for me.  But when it did, it was an “aha” moment.  What if, instead of being a benign condition, infertility was a “window” into men’s health?  What if we could look at it as a signal that other conditions could occur or might happen, that are just as important, later in life?  If that were the case, could we use it as an early-warning tool to help prevent future disease? 

That insight became the hypothesis for a series of studies that I and several of my colleagues at UCSF Medical Center – Thomas J. Walsh, Mary  Croughan, Michael Schembri, June M. Chan (a really incredible team that any researcher would be proud to share a challenge with) – put together to understand the link between male infertility and other diseases.  The team was meticulous in the design and implementation of the study, and the results were nothing short of astounding. 

The results will take some time to explain, so I’ll save them for my next posting.