A man looking for his mojo.

Do you know why Sigmund Freud, esteemed psychoanalyst, had a vasectomy when he was 67 years old? How about William Butler Yeats, the famed writer, having his vasectomy at 69 years of age. Were they that sexually active and worried about conceiving? God bless them if this is true!

Hardly. Believe it or not, vasectomies were done in the roaring twenties and thirties in Austria by an endocrinologist named Steinach for physical and mental rejuvenation. “It revived my creative power,” wrote Yeats in 1937. This may be true as Yeats wrote a crop of poems during this period that rank with his best work. At that time, a vasectomy was considered the “holy grail” of perpetual youth. Steinach felt that by blocking sperm flow, male hormone production in the testis would improve.

The idea of hormonal rejuvenation really started in earnest with an acclaimed endocrinologist named Brown-Sequard who in 1889 injected himself with testicular extracts from rats and dogs. This led to the trend of “organotherapy” in which all sorts of animal organs were injected for every conceivable human illness. Sound familiar at all? It also led to serious and productive experimental research on the function of glands in the body.

The rejuvenating vasectomy was not an isolated claim to fame by Eugen Steinach from Vienna. He was nominated for a Nobel Prize six times for innovative studies that showed that male or female development depended almost entirely on the sex glands and their secretions. Give this theory a pinch of salt to incorporate modern genetics and is it true enough today.

What went wrong with Steinbach’s vasectomy idea was that he believed that narrow biologic principles could be used to treat the wide and complex condition of human sexuality. The funny thing is, almost 100 years later, we are still trying to figure out how to stay young forever.

And you thought this was old...

What do you own that is 600 million years old? Your old suit? That little league baseball glove? Your cologne? In fact, every man possesses something that old, and believe it or not, it’s a gene. Not the clothing kind, but the kind you keep in your genome, in your chromosomes. We’ve talked about the Y chromosome in this space but lets take a moment to focus on a single tiny gene.

Tucked away in every cell of your body is a gene called Boule, a piece of DNA critical for sperm production. A colleague of mine just announced that the Boule gene is present in every organism from insects like fruit flies, to sea urchins, roosters, fish and man. It is in invertebrates and vertebrates alike. That is, this tiny bit of DNA has remained essential for making sperm through 600 million years of evolution. Surely the oldest treasure you own.

But what’s really impressive about the Boule gene is that is has not changed over time. And change is the rule with every other known gene involved with reproduction in every species. In fact, evolution of reproductive traits is how a species diverges from other species. It gives each species its identity. And this change can be very rapid: in some fish, reproductive traits are observed to change in fewer than a dozen generations. So why would this one gene stay the same?

We think that the Boule gene has remained true over 600 million years because it is essential for reproduction. Boule is a “quality control” gene that ensures all goes well as sperm are made. Just as you would want your new car to be well inspected so it is safe to drive when you buy it, you want your sperm to be reproductively fit. In fact, if the Boule gene is removed, sperm production stops entirely. Not a single sperm is made in its absence. Now that’s control.

What’s also impressive about the Boule gene is that since it is linked to sperm production, it means that sperm are very, very ancient cells. Seems that nature sticks with what is tried and true and feels no need to experiment with magic potions or fairy dust to get the job done. Reminds me of what Einstein once said while reflecting on relativity and physics: “God does not play dice.” When it comes to reproduction, the Boule gene phenomenon suggests that he may take even fewer chances.

The beauty of a balsa wood board.

Up at dawn, and while waiting for a perfect, crumbling long board wave at Waikiki this past week, I recalled that Hawaiians live longer than the rest of Americans and wondered why. For some reason, life expectancy at birth in Hawaii is among the longest in the nation. Indeed, people born in Hawaii have a life expectancy of almost 81 years, at least three years longer than the US average. Why is this?

While watching rainbows appear and fade as early morning showers give way to the rising sun over Waikiki, I thought that it must be the fabulous and consistent climate. Then, as I saw surfers stream out to the break that I was tending before their workday started, I figured it must be that “island fitness” that pervades the tropics. Taking a large breath, I was reminded of the lack of air pollution and the sweet smell of jasmine, orchid and hibiscus flowers that blossom everywhere on the island. Could this be their secret?

A relaxing evening luau with soothing traditional aloha music and dancing accompanied by light, aromatic, almost Mediterranean dinner fare suggested that reducing stress and eating well and in moderation may also have something to do with it. Witnessing the deep respect held for family elders, for the community at large, and for the beauty and health of their island must also contribute in some way to longevity.

And then it hit me. Balance. The backbone of many older cultures is that they have found and maintain a seemingly harmonious balance as a civilization. They are aligned with others as individuals, with nature and with their place as a society on this good earth. The stress of extremes is present but not pervasive in such self-realized cultures and this is obvious in the genuinely large smiles that greet you at every corner of the island. So, let me propose a formula for staying healthy: realize that it is not life’s moments themselves that define you, but how you choose to live them.

It doesn't get any better than this!

Legend has it that surfing began in the Hawaiian Islands hundreds of years ago. In the late 1800’s, it was introduced to the U.S. mainland by way of southern California. Duke Kahanamoku, an Olympic star in swimming from Hawaii, helped popularize the sport by traveling internationally and demonstrating his surfing style. He is credited with surfing the longest wave ever in 1917, at a break called Outside Castles in Waikiki. The 1000 meter long wave that he surfed is a record that has yet to be broken.

Surfing became known in the Santa Cruz area, at the northern edge of Monterey Bay, began in the early 1930’s, 30 years before the epic surfing movie “Endless Summer” was released. Even today, Santa Cruz is known throughout the world as a mecca for peeling point breaks, and is certainly one of the best surf spots in California.

I love surfing Santa Cruz waters. To me, it is really the pinnacle of pristine California coastal beaches, a place where you can still hear the driving surf guitar of Dick Dale and feel the relaxed atmosphere of surf living. Pelicans, sea otters and often dolphins join you as you play in the water. Just magic.

I surfed Pleasure Point this weekend with an old friend on two windless days. Warm, waist- to head-high surf launched from a southern swell beginning in New Zealand and entering Monterey bay in perfectly peeling corduroy sets. Poetry.

In my other life as a surgeon, a craft like many others, I have learned to appreciate and enjoy the smallest details in life. For details matter in surgery, let this be clear. But they are not the ends, only the means, to a much larger whole that they constitute. Witness the healing and restoration of patients after complex microsurgery.

Surfing is also rich with details. The size, pitch and break of the swell, the aura of the murmuring ocean and breaking tide. The contour, rail, and rocker of the hand shaped board, and the trim of the body on board as it silently cuts through water.  Like surgery, surfing reaches an almost spiritual realm not only through the sensations conveyed by innumerable associated details, but also through the sublime and intoxicating feeling that, at least for a moment, one is in control of life.

The spine: OK for shivers and tingling, but that's it.

I have a lot of patients in my practice who have broken their backs. Not figuratively by working so hard, but literally, by having spinal cord injuries. Some have been crushed by rolling logs, fallen from tall heights, been victims of shooting, dived into shallow pools or took an untoward jump while skiing or skateboarding. As a group, these men are impressive: imbibed with fortitude, perseverance, decisiveness and joie de vivre, they take nothing in life for granted. Live it hard, wring it dry, no regrets.

Their numbers are not insignificant either. Roughly 5,000-10,000 individuals experience spinal cord injury annually in the U.S. alone. And although you may think that cars have plenty of safety measures, they don’t, as the biggest cause of cord injury is motor vehicle accidents. Violence, recreational activities and workplace-related injuries round out the top four causes. And, of course, single, reproductive age men (ages 20-34 years old) are by far the most commonly affected.

I am reminded of these patients after a good friend, Dr. Stephen Seager, came over for dinner last week. A true Irish gentleman (“blended scotch before dinner and single malt after, no ice”) and world famous veterinarian, Dr. Seager invented the rectal probe electroejaculator in the early 1980s. I will leave it up to your imagination to wonder how this device works. But realize that this one doctor, through his invention and its popularization worldwide among male fertility specialists, has touched every spinal cord injured father from around the world over the past 30 years.

Seriously, the Seager Electroejaculator has revolutionized our ability to help men with spinal cord injury to conceive and become fathers. It takes advantage of the fact that ejaculation is governed by a spinal reflex (like sneezing) and it stimulates that reflex to happen. In fact, probably the only biological function that is not seriously affected in men who have broken their necks and cannot move any of their limbs (quadriplegic) is reproduction as this reflex generally remains intact.

By his innovative thinking, Dr. Seager brings hope to every spinal cord injured patient who dreams of being a father. Personally, seeing my patients with their little children running around their wheelchairs, and the wide, grateful smiles on their faces is easily one of the most satisfying experiences I have had in my medical career.

China: 5000 years old and on the move.

Just got back from China, from Beijing and Hong Kong to be exact. I lectured to several medical and academic institutions on where I believe men’s health is headed in the future. What I found was an audience eager to push the research frontiers in this field, however I also a sensed a lack of sufficient infrastructure to do this at the highest level. I paused for a moment to think about what was possible, since a monumental tidal wave of increased industrial productivity and change is occurring in China. For example, there are 1000 new cars being put on the road daily in Beijing alone! I sensed that when the might of China’s intellectual potential directs its energy toward medical research and innovation, the world will stand in utter awe at the prodigious output that will result.

Despite the fact that China’s culture is endowed with 5000 years of evolution and is responsible for helping to define human civilization, one thing really surprised me: its decision in 1979 to control its population by mandating a “One Child Only” policy. In the rest of the world, human reproduction is a basic right and for the most part, entirely unregulated. Under China law, families are allowed to have one child. After that, a vasectomy is performed on the male partner. Like it or not.

In addition to great control of population growth, the “One Child Only” policy has also led to the development of the wildly successful “No Scalpel Vasectomy” procedure. Now relatively common in the U.S., the “No Scalpel Vasectomy” is a quicker (10 minute), cleaner, less invasive and more comfortable innovation on a 100-year old American procedure.

But the curse of the “No Scalpel Vasectomy” is now being felt in China. Currently, it is difficult to find enough youth to fill jobs in urban areas within the massive and burgeoning Chinese economy. As a consequence, there has been a softening of the law such that couples that are both products of “one child” parents can now have two children. So can farmers, handicapped couples, and couples who work in “high risk” occupations like coal mining, heavy equipment operations and the like.

Even more fascinating is that infertile couples have a real reproductive edge over fertile couples under this law. How? Well, if they need assisted reproduction to help them conceive and they happen to have twins or triplets as a result (a 30-40% chance), they are not penalized for bearing “extra” children. Can’t help but think that this little known fact may partly contribute to the size of the massive, bustling IVF clinics that I visited in China last week. many of which are 4-10 times the size of U.S. clinics.

The sound and the fury of an Italian in a hurry.

I am a Men’s Health specialist and a vintage car buff. On more than one early Sunday morning jaunt down the Pacific Coast Highway in an old Ghibli, I have reflected on how similar these two beasts are.

1. When they run, they run hard. Tune that old Italian just right and you are in for a sweet ride to the limit. That big, throaty V8 with all of those cams and chains sounds like all hell is breaking loose, but the torque and exhaust notes are true symphonies of power and might. Similarly, a young man is his prime is the definition of immortality, pushing physiology and productivity to seemingly boundless limits, even on the most tortuous of roads.

2. They run well, even when neglected. It is amazing how well a vintage Italian can run, even when it is not run as often as it likes. Likewise, men can abuse their bodies through bad diet, sleep deprivation, and workaholism for years and not look or feel the worse for wear. Incessant plowing over the bad roads of an uneven and untempered life only makes men stronger if it doesn’t stop them.

3. The metal bends quietly before it breaks. A vintage Italian can be pushed to the limit, a limit that is often unclear until it is reached. The crack may not be preceded by a creak in a well-oiled machine. This is just like many men; tough as nails until they fall; and when they fall, they fall hard…and fast.

4. Listen carefully as the gauges may not work. Although there are many spirited sounds emanating from an old Italian at speed, some are more ominous than others. To pick these up, you must listen carefully to get a better sense of things, as gauges don’t tell the whole story. Similarly, the messages of health can be subtle, and often unrealized and unreported by the driven male. If it doesn’t hurt, then it is unlikely to harm, and so it is ignored.

And this, I believe is the secret to taking great care of men. You must listen. Not only hear what is being said, but really listen. Open the hood, study the underside, and work the throttle. The messages may be subtle behind the sound and the fury, and only by listening will you truly understand how well that man or Maserati is running.

Synthetic cells: true science or fashion vinyl?

Believe it or not, science has now claimed to have made “synthetic life.” Life created from non-living substances. J Craig Venter and colleagues, after a decade of work, produced a man-made version of the entire DNA content (genome) of a bacteria (adding in a couple of harmless “watermarks” to track it) and inserted it into the shell of another bacteria after removing its DNA. And, lo and behold, the artificial genome starting making proteins and the man-made bacteria began to replicate.

You may remember Craig Venter as the man in corporate biotech a decade back who challenged the U.S. government in a race to completely encode the entire human genome. The Human Genome Project was completed in 2003 and jointly announced. This is a beautiful thing but Venter wanted to “own” and patent the human genome and charge others for using it as a resource whereas the U.S. government insisted that it be made publicly available, which it is.

Is this really synthetic life? No. Essentially, Venter performed the equivalent of gutting a computer and then entirely reprogramming it. Is this an important scientific achievement? Absolutely, a tour de force, since technology has been limiting this work for years. Recently, however, there has been a 100-fold increase in the length of genetic material that can be manufactured from raw chemicals in the lab. Without a doubt, science has been dreaming about this kind of work for three decades and recombinant DNA technology is an early product of this movement.

So, an entirely “artificial cell” was not produced by Venter, as the control station was man-made, but the rest of the cell was not. My only hope is that this is not just another “pleather” (plastic and leather) product in our lives. As Lily Tomlin said: “[even] vinyl leopard skin is becoming an endangered synthetic.” On the contrary, this work may have advance science sufficiently to begin the manufacture of designer cells, good or bad, that can clean up oil spills, dynamite and waste water, dispose of nuclear waste and deliver antibiotics, chemotherapy, testosterone or Viagra to hard to reach but important areas of the body.

A women for the ages.

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

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

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

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

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

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

This Da Vinci fetus is way past the critical window of exposure.

A relatively alarming study was published a couple of years ago that suggested that a pregnant woman’s behavior can determine the fertility of her unborn son. Sperm quality from 387 men was compared to beef consumption their mothers reported while pregnant with them. They found that the sons of “high beef consumers” (>7 beef meals/week) had sperm counts that were 24% lower than in men whose mothers ate less beef. Interestingly, sperm counts in the sons were not related to mother’s consumption of other meat or to the son’s consumption of meat. In essence, the author’s thought that estrogens in beef consumed by women may alter the testis development of their unborn sons and may adversely affect the son’s fertility. Similarly impressive decreases in semen quality have been described in the sons of women who smoked during pregnancy.

Sounds almost biblical, doesn’t it? I bring this up because of a point that I made in last week’s blog. In “The Curse of Women’s Urine,” I mentioned how xenoestrogens or environmental estrogens have been shown in animals to act at a very precise point in the developing male fetus and result in intersex conditions at birth or infertility as adults. Well, as the study of mothers’ beef intake reveals, the same issues may also exist in humans. As Aristotle once said: “At his best, man is the noblest of all animals; separated from law and justice he is the worst.”

Time for a quick lesson in biology. When do testicles develop in humans? Believe it or not, when male fetus in just 4 weeks old, the location where the future testis will be is organized (the urogenital ridge). Two weeks later, the primitive germ cells (sperm precursor cells) migrate to the urogenital ridge and set up what is to later become the testis. About 1-2 weeks after that, “sex cords” develop in the primitive testis, setting up the architecture of the mature organ. So, by 8-12 weeks of pregnancy, the human testis is virtually a complete organ, holding within it all of the potential it will ever have.

So the “critical window” of exposure for the human testis, that period in which even a potentially small exposure could wreak significant developmental and long lasting havoc, is about the time when women actually just realize that they are pregnant. The time of morning sickness and painful breasts.

So, does male infertility begin in the womb? Still not clear, really, as all studies have flaws. For example, in the study of beef eating pregnant women, the cohort of son’s whose sperm counts were so thoroughly examined were ALL fertile. That’s right, their wives were all pregnant. Oscar Wilde couldn’t have said it better when he said: “The pure and simple truth is rarely pure and never simple.”