Turek On Men's Health

Assisted Reproduction: A Two-Edged Sword

Paul Turek, MD — Mon, 14 May 2012 15:00:28 +0000

Double-edged swords cut both ways.

Almost 2 decades ago, just about the time when my fellowship ended and I was starting on the faculty of UCSF, along came ICSI. Short for intracytoplasmic sperm injection, ICSI involves using a single sperm and manually injecting it into an egg. Voila, the egg fertilizes and becomes an embryo, and later, with the help of mother, a real live baby. No God or Darwin needed to decide on the chosen sperm; in one fell swoop, natural selection is replaced by the judgment of a laboratory technician.

How Good is ICSI?

Make no mistake, ICSI is good. It can go where IVF alone fails to go. The fact is that sperm from any organ can be used with ICSI to create a baby. My medical practice relies on it daily to help azoospermic men become biological fathers. ICSI is also popular. In the latest available data, it was used in 66% of 146,693 U.S. IVF cycles in 2010. That’s 96,817 times a year. Pretty popular by any measure.

The Downside of ICSI

Fortunately for science, the center that invented ICSI (accidentally by the way) has done a great job of following up on kids born with the technique. In fact, they were the first to report that children born with ICSI have higher rates of sex chromosomal issues when compared to naturally conceived children. Since then, concerns have been raised that ICSI kids may also be associated with higher rates of developmental delay and birth defects as well.

What has confused much of this story is our inability to decipher whether the added risk is due to the injection procedure itself or whether it is driven by the genetic risk introduced by infertile parents who require it to conceive. It’s a chicken-or-the-egg issue but in different garb.

The Latest and Greatest

The latest entry in this informational fray about ICSI and birth defects was published last week in the New England Journal of Medicine, the world’s most revered medical journal. An Australian study of 308,974 pregnancies and births over 16 years, both assisted and unassisted, found that birth defect rates were almost 2 fold higher in ICSI infants (9.9%) compared to naturally conceived (5.8%) children. The kinds of birth defects examined were not controversial and included heart, spinal, urinary tract, limb and cleft palate abnormalities, among others, but not minor defects unless they were disfiguring. This study was impressive for the following reasons:

1. It was robust. The sheer numbers of births examined was in excess of 300K+.
2. It was uniform. A single population registry available in Australia was used. Birth defects were clearly defined on a national level.
3. It was comprehensive. Detailed information on children was available from pregnancy to a child’s fifth birthday!
4. It was dissectable. Details and outcomes from various assisted reproduction treatments were available for analysis.
5. It was rigorous. State of the art analytic techniques were used to assess the findings.

One question I had when reading the paper was whether the analysis could help us figure out whether the birth defect risk stems from the ICSI technique or incoming parental risk that is brought to bear on offspring. Here are some observations from the paper that address this issue:

1. The rate of birth defects associated with treatments other than IVF and ICSI were not different from natural conception.
2. The risk of birth defects was also increased among infertile women who did NOT use IVF-ICSI.
3. The risk of birth defects was also increased among women who conceived naturally AFTER using assisted reproduction in the past.
4. Determining the role of paternal issues was not possible, as no information on paternal age or semen quality was included in this study.

In the absence of good information about paternal factors, these observations point out that maternal issues or the technique itself may play role in the higher rate of birth defect findings observed with ICSI.

A Changed World View

So, what to think now? Remember there are dozens of papers addressing this issue over the last 15 years. Given the variation in their quality, to date, I have withheld my opinion on the matter. However, with this study the balance has now shifted for me to truly believe that the birth defect rates are higher with IVF-ICSI than with natural conception. Our national fertility organization agrees. Clearly, the “sword” of ICSI cuts both ways.

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.”

It Takes Two to Tango

Paul Turek, MD — Mon, 30 Apr 2012 15:00:32 +0000

The genetic dance: adding spice to life.

The Case of the Month is an actual patient from The Turek Clinic. It is presented to highlight Infertility Awareness Week.

The Dance Begins

He is a 36-year old who has been trying to conceive with his 35-year old wife for 2 years. After 5 months of trying, the couple achieved a pregnancy she miscarried at 8 weeks. After trying for another 7 months, they conceived again and again lost the baby, this time at 9 weeks. The couple appears disheartened and broken as they tell the story in the office.

“I’m not sure what’s wrong with me…I can’t seem to carry a baby,” says the wife in tears. “My tests look great but for some reason, nothing lasts!” she continues. The husband then pipes in: “We checked on me after the first miscarriage and my sperm count was low. Could I be the problem?” Great question.

The Pregnancy Dance

Normally, the human sperm and egg meet in the fallopian tube soon after sex. Then, over the next several days, a highly orchestrated genetic dance begins. Within 2 days, the sperm molecularly “undresses” for the egg, revealing, in full nakedness, its genetic material. Inspecting the male genome, the egg surveys and corrects its imperfections, making it whole and usable. Based on how this dance goes, usually before day 3, the egg (now an 8 cell embryo) is compelled to make an executive decision: continue developing or stop the dance. This decision is probably the first of many quality control decisions the embryo makes as it develops and is highly dependent upon the acceptability of the sperm genome.

Sperm as Dance Partners

Can sperm contribute to early miscarriages? Yes they can.

And this is despite the fact that you may never see this on any list of presumed causes of pregnancy loss. Here are the ways in which this is thought to happen:

Imbalanced Sperm Chromosomes. The classic example is when chunks of genetic material are misplaced within sperm chromosomes. Termed Robertsonian translocations, imbalanced sperm chromosomes can be found in perfectly healthy men and packaged into perfectly healthy looking (e.g. morphologically normal) sperm. The only clue may be that the sperm concentration in the ejaculate is low (termed oligospermia). When the egg and sperm genomes marry after fertilization, embryonic development is affected by the abnormal chromosomal balance in sperm, and the dance ends when the partners trip over each other’s feet. Fortunately, a blood test termed a karyotype can detect this in a man’s blood and preimplantation genetic diagnosis can be used with assisted reproduction to select for normally balanced embryos that lead to successful pregnancies.

Sperm DNA Breaks. More subtle issues with sperm can also lead to miscarriages. While the genetic payload is being prepared and packed for shipping in each sperm well before ejaculation, there may be subtle alternations in packaging quality that allow for breakages to occur in the sperm DNA ladder. Termed sperm DNA fragmentation, this problem is also found in perfectly normal looking sperm at normal sperm concentrations and motilities. Ultimately, in the first few days of embryonic life, the egg in all of its wisdom may be unable to repair the breaks and fragments of sperm DNA and elects to stop developing. And the dance ends.

Unlike with chromosomal issues, poor DNA integrity can result from acquired rather than genetic causes. Such lifestyle factors include such as smoking, fevers, hot baths, illness, infections, medications (anti-depressants and Propecia), chemotherapy, radiation therapy, oxidant exposure (e.g. air pollution, solvents), older paternal age and the good ole’ varicocele, that bag of veins located above the testicle that overheats the factory through abnormal blood drainage pattern. Sperm DNA damage is also measurable through specialized sperm-based assays that detect DNA strand breaks. And unlike chromosomal issues, they may be correctable by lifestyle changes, improved health or by repairing anatomical issues (varicocele).

So, think of chromosomal imbalances as men with two left feet and fragmented sperm DNA as men with shoes on the wrong feet. Either way, the dance just isn’t as smooth as it should be and it just stops in its tracks.

Antibodies and Epigenetics. Of course, there may be other ways that sperm contribute to miscarriage. Men are generally “allergic” to their sperm and some may develop antibodies to their sperm as a result. What is not clear is whether these antibodies induce a reaction from the female host to “attack” the embryo containing these same male allergic proteins. Additionally, the way sperm DNA is “fingerprinted,” termed epigenetics, may also influence pregnancy progression although this science is still in its infancy.

Men and Miscarriages: How Can They Help?

So, sperm matter when it comes to miscarriage. Because of this, my advice is:

See a men’s reproductive specialist if you’re having trouble with miscarriages. A good history and a simple physical exam can assess possible risk factors and lead to lifestyle changes.
Take great care of yourself. Stay healthy, avoid tobacco, exposure to smelly solvents, medications (when possible) and hot tubs and eat a diet rich in antioxidants.
If you’re stuck with airport food, consider taking antioxidants vitamins such as that found in a good male pre-natal supplement.
Similar to advice endlessly given to women, it may help to start when you’re young.

And when the tango begins, please be reminded of the power of the female egg: “Remember, Ginger Rogers did everything Fred Astaire did, but backwards and in high heels.” (Faith Whittlesey)

Why I Love Medicine-Redux

Paul Turek, MD — Mon, 23 Apr 2012 15:00:12 +0000

One great book–but patients also make a great read.

I was recently asked why I love medicine by a health care blog. They published what they could, but there is really more than my response to them revealed. I’d like to set the record straight.

We all grow up reading in school. A book is a pile of paper with words on it. But when viewed carefully and thoughtfully, it can stir the imagination, take you to faraway places and let you drift into the minds of others. In the words of Thomas Mann in Joseph in Egypt, books allow you to experience a barefoot walk “on the greenest of mosses.”

Patients are the Best Books

I first fell in love with medicine when I realized that patients, in a way, are like books. The look of their skin, the movement of their eyes, the tilt of their head, their posture and walk, they way they talk, how they shake your hand and what they tell you is all a part of their story. It is there for the reading.

In the field of men’s health, in which I specialize, I have come to realize that men are books that may be particularly difficult to open and read. Often the books are shut tight. They may even be locked. Maybe it’s cultural, maybe it’s the species, but this makes them hard to read. And, as a consequence, they barely or never get read (i.e. cared for).

My love for medicine grew further when I realized that the key to taking great care of men is figuring how to open the book. It’s there in all of its glory: you just need to figure out how to open it.

Secret #1

Here is a secret: You must be patient and you must listen. Men need to know that they can trust you, not only as a doctor, but also as a human being. Men need to know that you are on their side and honestly 12-minute office visits simply don’t cut it. By listening and observing, instead of dominating the conversation, you can take in the small signs that are otherwise missed, including the doorway conversations that can change everything.

Secret #2

But there’s another secret. Most women do not understand why a have a balsa wood surfboard hanging on the wall of my office. Guys get it. Having a real and palpable personality as a doctor helps patients trust you. And if they trust you, they start to relax. And if they relax, the book opens up, in all of its wonder and richness.

The stories of many famous lives have made great reading. But the stories of everyday lives make equally great books. The mystery, passion, sadness, joy, desires, struggles, hopes and dreams found in the best written books are far more illuminated and intense, magnified and distilled, in everyday life. As the artist Cezanne once said: “…there is a magnificent richness of color that animates nature.”

The Essential Beginnings of a Vitamin

Paul Turek, MD — Mon, 16 Apr 2012 15:00:57 +0000

Petroglyphs and Paleo: Inspiration for Essential Beginnings

Honestly, my opinion about nutritional supplements has evolved dramatically. Historically, the value of prenatal vitamins for women is well recognized and uncontested. For example, calcium keeps mom’s bones healthy as developing fetuses borrow mom’s calcium for their own bones. And iron prevents the anemia of pregnancy. Folic acid clearly prevents neural disorders and birth defects in children. No doubt, prenatal vitamins for women make sense.

Do Vitamins Treat Cancer?

However, with heart disease or cancer, the story is quite different. In 1998, the government set out to test herbal and other alternative health remedies to find the ones that work for cancer and other diseases. After spending $2.5 billion, the disappointing answer was that none of them help prevent or treat these diseases. As noted here several years ago, vitamins got an “F” for cancer. To top this off, newer data from just last month suggests that excess vitamins supplements may actually lead to an earlier death. Now what’s a guy to do?

Do Vitamins Help Men Conceive?

Thankfully, what is more encouraging is the value of antioxidant supplements for male infertility. In 2011, An august research group in England published a Cochrane Review that analyzed 34 studies of 3876 infertile couples using assisted reproduction to conceive. The meta-analysis found that the partners of men taking antioxidant supplements were 4-fold more likely to get pregnant and 4-fold more likely to give birth than couples in which the male partner was not taking supplements.

The Idea of a Male Prenatal Vitamin

This study changed my worldview to the following:

A large chunk of male infertility (maybe half) is due to what’s called “oxidative stress.”
Antioxidants are a good defense against oxidative stress.
The best antioxidants are found in the diet, and the Paleo diet appears to be the best.
Most men have terrible, antioxidant-poor, diets
If men ate more fruits and vegetables, maybe fertility would improve.
Barring this, men should view antioxidant supplements as prenatal vitamins.

The Essential Beginning

Motivated by this epiphany, I and several trusted colleagues, including fertility physicians and nutritionists, set forth to create a male prenatal supplement that would be better than eating airport food for fertility. We wanted it to be made in California and support the local economy, be certified-organic, and to reflect the latest findings in antioxidant research. It would contain vitamins, minerals and organics with high bioavailability, instead of just putting stuff on a label without regard to whether or not it is absorbed well by the body, like most other supplements. We wanted it to be available online, to avoid the middleman markup, and to be reasonably priced.

After a year of pretty intense work, it has arrived. It is called XY (your chromosomes, get it?). And not only that, we continued our research and developed an entire fertility product line for women all the way from pre-conception through breast-feeding with XX (women’s prenatal), Z (pregnant prenatal) and Z+ (post-natal and breast feeding).

Do all men need a male prenatal? Probably not, because as I said, nothing replaces a healthy antioxidant diet. But if you are like most of us, creatures of habit eating airport food and busting our chops to put food on the table daily, it is to you that I dedicate Essential Beginnings, XY.

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.

April Fools in Saudi Arabia?

Paul Turek, MD — Mon, 02 Apr 2012 15:00:17 +0000

Kings Castle, Riyadh, Saudi Arabia, during an evening stroll.

Had April Fools Day come weeks early half way around the world? The thought had crossed my mind just before harsh reality hit.

A Short Trip to Saudi Arabia

It was a long day and I had given several lectures the day before at a medical symposium in Riyadh and headed to King Khalid Airport with just under two hours of sleep. It was just after midnight and I was anxious to get on that long, polar flight home and see my family.

“Sir, your return flights have been cancelled,” said the airport attendant in broken English.

Thinking that exhaustion was affecting my hearing, I leaned over and politely said: “Excuse me?”

He repeated the sentence and then watched me in silence. Both flights. 18 hours. All gone.

A First World Human

In our particular “first world” culture, we are surrounded by, and have access to, lots and lots of things, including information. Much of what we need can be mailed to us from Amazon in neat little packages. We expect our food to arrive fast and hot. We like to place our coffee orders using 4 to 5 adjectives (“triple decafe soy latte”) like the brunch scene in Steve Martin’s LA Story. We also tend to live by written contracts and agreements. We sign for everything. And dammit, I’m sure there was something written somewhere that I could use to get back on these flights.

But I was not in America. I was in Saudi Arabia, where things are different. This is a place where handshakes and eye contact matter far more than a signature. And this has been true for thousands of years, since the time of Mesopotamia and Babylon. As a man named Richard kindly reminded me at the airport, the information age has been incredible, but unlike people, “the Internet does not care, only people do.”

An Old World Human

I wasn’t thinking about all of this at that moment in the airport. I am a surgeon and all I saw was bleeding. Something had to be done and done quickly as the flights were nearly boarding. Unfortunately, I was alone. No colleagues were with me nor available to call at 1 am. I briefly considered responding impulsively, with anger. But, having just spent the better part of a week in the middle of this remarkable country and remarkable people, I thought about it for a moment. The reality was that I was utterly and completely…powerless.

“I really need your help getting home today” I said softly, admitting this to them.

The attendant nodded. As I waited patiently, he moved quickly and grabbed his superiors and they put their heads together. Over the next half an hour, it was as if the seas had parted. After several minutes tapping away on a computer one of them looked up at me and said: “We can get you standby on one of your flights.”

I responded “that’s a great start, thank you” with an encouraging smile.

Several tense minutes later, another attendant looked up and said that my ticket had been restored. I smiled, shook their hands and said “Shukar” or thank you in Arabic.

I still have no idea why my ticket was cancelled. But having access to the world with a smart phone served me no purpose during that tense hour. Trusting in my fellow man, however, made all the difference. I will always remember this old and sturdy concept in our new and fragile world.

No related posts.

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…

A Year Without Answers

Paul Turek, MD — Mon, 12 Mar 2012 15:00:30 +0000

"Elemental" Courtesy of the Artist: A.J. Russell

This is a guest post 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 day we met with Dr. Turek was a week filled with hope and happiness. Almost a year earlier, on the same day, I went through a biopsy with the result that there were no sperm. So when we found out about Dr Turek, this really felt like the last chance, the last hope. Therefore the decision to travel across the world to see him was an easy one. The visit and procedure went well, but, again, the result from mapping showed no sperm. And no answer as to why this is.

It has been a year since I spoke with Dr. Turek about these results, a year characterized by disappointment, anger, sadness and worst of all, no answers. There were simply no answers to be found. Why me? Why now? What now? Literally a thousand questions ran through my head interfering with my daily life, keeping me up at night and affecting my relationships. I had never felt anything like this before.

I wanted so badly to not feel alone in this. I wanted someone to understood my plight, without me having to explain every small detail, because you can´t explain this feeling.

I needed to talk about it. I just couldn’t bury it. But, who was I going to talk to? And what would I talk about? I felt isolated as there appeared to be a big taboo regarding this topic. Anyone I spoke to told me focus on other things in life. But how are you supposed to do that when all you think about is the fact that you can’t have your own children? I knew no one with a similar experience who would step forward and talk about his experiences and feelings. Google searches were pointless, as the Internet does not care and information on coping is useless.

That year was best characterized by the feeling of being lost and trying to find my way in darkness without a map or light. I felt that I was in a deep, dark place, especially when I tried to look forward into the future.

Feeling alone, I began suppressing everything. All feelings, thoughts and discussions were avoided. I told my close family that I did not want talk about this matter anymore. It was a buried subject for me, never to see the light of day again. The reason for this was that talking about this issue within the family only made things worse. One problem with this approach was that the bright spots in my life also suffered along side. The subject became an 800-pound gorilla that, although ignored, never left the room. Maybe the gorilla was bigger than 800-pounds as the family dynamics changed greatly.

Then I became angry, sometimes uncontrollably. This was when I could see that I was approaching rock bottom. The slightest annoyance, comment or action sent me into a furious rage where I often exploded at whomever was next to me. Many times it was my wife, which led us to the brink of divorce. We were both tired of fighting and there appeared to no other solution to end the fighting but dissolving the marriage. This moment was a real eye opener for me.

What helped keep me going to some degree during this time was my job. As a futures trader, my work was very involving and in the moment. Believe it or not, it was also logical and predictable, in a mathematical sort of way. It could be explained and reasoned with and while doing it, I could leave all my troubles behind. But I couldn´t hide in my job forever.

I turned the corner at rock bottom when I realized that if I did not start controlling my emotions and start being honest with myself, my life as I knew it would change dramatically. It was on that day, a very cold one in December, that I realized that I was just too exhausted to continue to fight with myself and others. I couldn’t bear to face another year continuing on the same as the last. So, I stopped lying to myself and began to face the reality of my emotions.”

The second and final part of this guest series will be available Monday, March 19th.

Patient Testimonial: Dr. Turek, “The Miracle Worker!”

Paul Turek, MD — Thu, 08 Mar 2012 20:33:46 +0000

We get a a lot of very special, personal and wonderful news from our patients at The Turek Clinic. Sometimes they are generous enough to share their stories with us. With their permission, we’d like to share their story here – in their own words.

Introducing Cole Michael!

“Here is our story! Please let me know how I can share it with future patients

My wife and I are thrilled to report that we just had our first baby boy!

“Cole Michael” was born on February 28th, 2012 weighing 8 lbs. 1 3oz. and measuring 21.5 inches long. Both mommy and baby are doing great.

Dr. Turek is an ‘angel’ from God that performed a miracle for me and my growing family. A brief history: I went through a divorce 4 years ago that left me with two beautiful boys, and a vasectomy. Shortly afterwards, I met the love of my life. After dating for 11 months we got engaged and decided that we wanted children of our own so I called up my urologist (the same one that performed the vasectomy) and scheduled the surgery to have everything undone.

He assured me that he had done this type of surgery before with enough success to have me commit to moving forward with him (you would think the one that closed it up could open it back up… I was so wrong)! The surgery was very painful; a lot of bruising and I had a huge hematoma that stretched from the top of my right hip bone down to the bottom of my buttocks. The recovery lasted two full weeks – I couldn’t get off the couch for the first week because the pain and swelling was so horrendous. But I kept saying to myself, ‘it will all be worth it if I can get viable sperm again.’ Needless to say, the surgery was unsuccessful and left me with residual amounts of pain, scaring, and a $7,500 bill to pay.

My fiancée and I were very disappointed and desperate to have the procedure done correctly. I went back to my doctor and expressed my deep concern of the outcome of the surgery and the only thing that he could recommend is that I should consult with Dr. Turek in San Francisco. Dr Turek specializes in fixing vasectomies that didn’t take the first time. He’s world renowned, and has an impressive track record of successful outcomes. I just wish he would have referred me from the start versus trying to perform it himself and leaving me nothing to show for it but a lot of pain.

So I took his advice and immediately went on The Turek Clinic Web site. I was very impressed and immediately scheduled a consultation with Dr. Turek. I told him my story: 4 year old vasectomy, with an 8 month old failed vasectomy reversal. Dr. Turek said, “This is my area of expertise. I like challenges so lets see what we can do.” And after going over his success rates it was clear that he is the one that should have been doing this procedure from the very start.

I had the surgery performed in January 2011, was married June 4th, 2011 and we had our first baby February 28, 2012. What an amazing blessing to be celebrating our first wedding anniversary ‘with’ our beautiful baby boy!

There are three things that make Dr Turek the leader in this type of procedure:

Pain management: It’s amazing when the surgery is done correctly the first time how much ‘less’ pain medicine is needed and how the recovery was expedited (I had very little swelling and only had to use the pain medicine for two days).
After care is unparalleled: Dr. Turek is there from surgery all the way up to conception and his staff are amazing. Constant support and communication through: office visits, email and phone calls.
Positivity! Dr Turek’s clinic gave my wife and I a feeling of hope and optimism from day one.

We feel so blessed to have Dr. Turek in our lives and its amazing to think how gifted his talents are to bring life to parents when at one time there was no hope. He is our angel!!”

Kind regards,
Mike and Rachel
Roseville, California

You can read more from our patients on our testimonials page.

The Incredible (Renewable?) Egg

Paul Turek, MD — Mon, 05 Mar 2012 18:32:47 +0000

The human egg: a thing of beauty…now a renewable resource?

It’s hard to keep up anymore; things are changing so quickly in fertility medicine. Just in the last week, a Harvard researcher discovered stem cells in the human ovary and a 66 year old just became a mom to twins in Switzerland. There goes the rug, being pulled out from under our scientific feet yet again.

Testicular Stem Cells

A couple of years ago, we published a paper confirming the presence of cells in adult men that were long though to exist: testicular stem cells. These are “multipotent” cells unlike most other cells in the body: they not only renew themselves, but they can also become sperm and may even be coaxed into becoming other organs in the body. The really convenient thing is that they are not derived from embryonic stem cells (a political minefield) a fact that makes them prime candidates for stem cell-based treatments in the future.

The Dogma About Eggs and Ovaries

But eggs are not sperm. Sperm are made constantly throughout a man’s life, like blood cells, and therefore it makes sense that there are stem cells running the show. However, for at least as long as I have been in medicine, it has been thought that women are born with all of the eggs they will ever have, some 1-2 million, and lose them throughout life, most obviously through monthly ovulation, until they are gone. The basket empties of eggs somewhere in the 40’s for most women, about 10 years before menopause. This lack of new egg production has led to the belief that, unlike within the testicle, adult stem cells do not exist in the ovary.

Ovarian Stem Cells

But Dr. Jonathan Tilly at Harvard thinks otherwise. He believes that women indeed have adult stem cells in the ovary that might be able produce new eggs during a woman’s lifetime. And maybe even after her traditional reproductive window has closed.

Dr. Tilly first showed this in mice and published it in 2004. He recently extended this work to women by locating an incredibly scare biological resource: fresh ovaries donated by Japanese women undergoing sex change procedures. Within this tissue, he found cells that showed classic stem cell characteristics using genetic markers. But this only means that they “look” like stem cells. To prove that they can “act” like real stem cells, he isolated these cells in a Petri dish and watched them turn into real, live, immature eggs. More convincingly, he then transplanted them into mice and they continued to develop into even more mature eggs, passing through meiosis in some cases which is a characteristic process occurring only in eggs and sperm.

So what are the implications of this technologically mind-bending work? Hard to know, but down the line it may mean that women may be able to make new eggs when we thought that they couldn’t. Maybe their baskets never really empty of eggs and that their fertility can be extended beyond what we now think is possible.

Regarding the 66 year old women who just had twins…it’s not clear to me how many genetic parents were involved, how long it took, and how heroic the effort was, but I can guarantee you that she will have her hands way too full for the next several years to keep up with this science.

Try Not Sitting

Paul Turek, MD — Mon, 27 Feb 2012 16:00:24 +0000

The chair: good for the eye, but bad for health

Have you heard about a new disease that affects almost half of Americans and is lethal if it goes unchecked? It’s called “sitting disease.” It’s real and it’s the new smoking.

The Chair as Enemy

Sitting is an example of a “sedentary” behavior. Either at work or at home as a couch potato, it is considered a “low fitness” activity. Some might argue that it should not even be considered an “activity” given how unfit it is for you. So, why is screen-watching so bad for you?

It’s because several recent studies on sitting, conducted in America and elsewhere, have all observed similar results. People who sit a lot have 50% higher rates of heart disease, diabetes and obesity. And, conversely, if people who sit a lot also take frequent small breaks like standing up to stretch or walk down the hall, they have smaller waists and improved sugar and fat metabolism than those who don’t take breaks. Could this explain the obesity epidemic in our country? Many think it does, and in both children and adults.

Another interesting finding from these studies is that the risk of disease with sedentary lifestyles is unrelated to overall exercise levels. The amount of time you spend sitting and the amount of time you exercise each have their own separate risk for heart disease. So, the cure for too much sitting isn’t more exercise, it’s less sitting.

Facts about Standing

What if you just stand up more? Could this help? You bet and here’s why:

There are roughly 639 muscles in the human body. 300 of them are used for balance when you stand still. Far fewer are needed to sit.
Standing instead of sitting for 4 hours daily burns an extra 200 calories a day
Standing improves your posture and reduces aches and stiffness.
By using large muscle groups, standing improves fat and sugar metabolism
And walking is even better than standing for overall health

The Cure for Sitting Disease

The good news is that this disease is curable and curing it can add years to your life.You know what to do at home: spend less time sitting in front of a screen, whether TV or computer. At work, here are some useful suggestions:

Get up more often throughout the day
Walk to talk to your colleague down the hall, don’t email
Hold walking staff meetings
Take a walk during your lunch break
Park farther away in the parking lot
Use ergonomically designed, elevated desks
Use slow treadmill-based desks

At this point, I’m afraid that I have to disagree with Albert Einstein when he said: “A table, a chair, a bowl of fruit and a violin; what else does a man need to be happy.”

It’s in the Steak

Paul Turek, MD — Tue, 21 Feb 2012 16:00:48 +0000

Hope is a core value of children (Drawing courtesy Sophia Turek, age 7)

In quiet moment on the couch, I recently asked my 8-year old daughter what the word “hope” means to her. “If life were a meal, hope belongs in the steak,” she said.

The food metaphor didn’t surprise me, as with most kids her age, she thinks about it a lot. What did interest me was that, in her view, hope takes center stage. It’s not the cupcake for dessert. Or a sweet milk shake, or potato chips. To kids, hope is serious stuff, right smack in the middle of the main meal. Just a hunch, but I am convinced most adults would not put it there.

A Telling Telephone Call

He called from Kentucky. Having read about our recent research story about obtaining grant funding to build an artificial testicle, he wanted to know more. As a cancer survivor, he had no chance of fathering a child. He asked great questions about where the research was going and the expected time line for generating sperm from stem cells. I answered frankly as I am not a fan of dangling carrots or pipe dreams in front of others. He listened intently and thanked me kindly. I asked him to keep in touch, and that was that.

Little did he know such brief but meaningful conversations stokes my fire and fuels me to imagine, begin, execute and finish such far-fetched research projects.

Little did I know how that single, brief exchange also affected him. The next day, the Clinic received a new Yelp review (don’t get me started on this…just compare the visible reviews on the page with the invisible “filtered” accessed at the bottom). Curious, I read it. It blew me away. It went something like this (edited for brevity):

“H-O-P-E; that’s what Dr. Turek has given me; new found hope…..” After a 16-year nightmare with testicular cancer, once in 1996 and again in 2002, a good friend of mine forwarded me the most shocking, exciting, uplifting, inspiring article I had EVER read. I anxiously and carefully read it word for word, line for line, as I could not believe what my eyes were reading and my mind was comprehending. My instinct, was to call Dr. Turek’s office immediately as I was yearning for more information.”

“After talking with his office staff, a phone conference was scheduled for Dr. Turek and I within the next 3 days…Dr. Turek gave me “me” and he gave the rest of the testicular cancer world a vision that we never imagined possible… I will strive daily to do everything in my power to assist Dr. Turek in seeing this miracle discovery come to life. I will do whatever, whenever, whereever it takes to be a part of this life changing miracle. I am inspired, encouraged, and relieved with the hope of tomorrow for me and for others.”

For the first time in years, the man from Kenucky felt a ray of hope. And in some small way, his life is different today than yesterday.

Hope not Hype

So what is it about being an adult that takes the hope out of our “steak?” Why do long, strong doses of reality make it harder to dream the unimaginable? There is so much promise in hope that I, for the record, refuse to give it up. I agree with the old French Proverb that “hope is the dream of a soul awake.” You can expect more of the unimaginable out of me before my time is up on this good earth.

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