Turek On Men's Health » Azoospermia

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.

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 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.

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…

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

Your Hair or Your Hormones

Paul Turek, MD — Mon, 30 Jan 2012 16:00:25 +0000

Be nice to have Superman's hair…but at what price? (Courtesy; MovieBlog.com)

It’s the perfect drug for 40 million men in America who are going bald. Take it once a day to keep the hair on your head and shrink the prostate, which also commonly bothers men as they age. It’s a pill that has been used by at least 2 million reproductive age men over the last decade. But is it too good to be true?

The Best Hair Pill Yet

This magic pill is finasteride (trade names; Propecia, Proscar, Avodart). It represents a class of drug called the 5-alpha reductase inhibitors. These pills act as enzyme blockers: they prevent the male hormone testosterone from converting to its metabolite dihydrotestosterone (DHT). Although testosterone is responsible for a lot of our “male” features, DHT is more potent than testosterone for scalp hair and our internal reproductive organs (prostate, seminal vesicle). These drugs work by lowering DHT production and protect the gloriously youthful hair on our heads and the enviable ability to write your name in the snow while urinating.

And these drugs work well. More effective than topical or “rub in” medications, finasteride is great for what’s called “male pattern” hair loss which is due to a receding hairline or balding on the top of the head. In essence, it slows the growth phase of hair in these areas. However, it doesn’t treat hair loss on the sides or temple area.

Finasteride, Sex and Male Fertility

Although it may keep you looking like Clark Kent, many male infertility specialists, including myself, have concerns about finasteride. First, there is a 10% chance of sexual side effects that include erectile and ejaculatory dysfunction and lowering of sex drive. These issues can be subtle while on the pill but become very obvious when men stop it; many of my patients have noted a sexual “curtain being lifted” or “coming alive” after discontinuing the pill.

Second, there is an even more profound concern about finasteride among specialists: male infertility. Before it received FDA approval, the drug trials showed that it lowered ejaculate volume but did not change sperm count or motility on semen analysis testing (actual human fertility studies are not routinely required by the FDA). Now that it has been on the market for 10 years, though, impressive declines in semen quality have been observed and published with finasteride by many of us. This effect is not subtle either, as patients with complete sterility (azoospermia) have had recovery of their sperm counts after stopping finasteride!

There are several clues that this effect on fertility was possible. The rabbit studies done for FDA approval of the drug actually showed this effect. At 3 months, there was no effect on rabbit fertility. But, when followed longer, rabbits showed significant decreases in natural fertility. In addition, while I was writing a recent reproductive physiology chapter for Campbell-Walsh Urology, our leading urology textbook, I researched at what levels the 5-alpha reductase enzyme is found in the human testis and epididymis. Lo and behold, there are gobs of this enzyme in these important organs for sperm production and maturation, implying that the blocking agent finasteride would have an effect. So now what do we do?

At this point, controlled clinical trials are needed to prove this effect on fertility. For the time being, current thinking is that finasteride may not dramatically change sperm production in healthy men, but can impair semen quality in infertile men. Typically, the effects of medications on male infertility are reversible. So, to be proactive men should consider stopping the pill at least 6 months prior to trying to conceive. And, have confidence that she loves you just as much for other reasons. As Telly Savalas once said: “We’re all born bald, baby!”

A Dozen Funny Reasons for Vasectomy

Paul Turek, MD — Mon, 16 Jan 2012 16:00:38 +0000

Funny, but not the typical scene of a vasectomy at The Turek Clinic. Photo courtesy of the movie.

As a vasectomist, I realize that a vasectomy, that iconic way to stop family building in its tracks, is not simply a 10-minute procedure. In a man’s life, it is a significant cultural event. I dare you to describe a more personal, scary and misunderstood part of a man’s body with which to meddle. And, recall that men don’t give birth, so their bragging rights after a vasectomy are somewhat limited.

Why do Men Get Vasectomies?

I ask most patients why they are considering a vasectomy. The responses vary, but can be very amusing. Here are a dozen of the funniest answers I’ve heard in my practice:

My wife said: “the factory is closed,” so I’m here.
I was told that they broke the mold after they made me, but I want to make sure of it.
My wife said: “It’s your turn now.”
After this, I won’t ever have to say I’m sorry again.
I’m married! Condoms are sooo high school!
Have you seen the movie ‘One Fine Day?’ That’s why I’m here!
Every time I look at my wife, she gets pregnant.
Apparently, sacrificing some limbs just isn’t the same…
She told me: “Enough, get your wings clipped already!”
I was told that I can shoot the gun all I want and no one will get hit.
I heard that it’s easier than getting your teeth pulled out…
My wife told me that it’s time for juice without seeds.

So, here’s to the most effective contraceptive ever developed and hats off to those men who chose the “emission impossible” way to an unburdened and unbridled sex life.

The Artificial Testicle: Funded!

Paul Turek, MD — Mon, 02 Jan 2012 16:00:01 +0000

Whole Earth Catalog: the old Google, according to Steve Jobs

It is the stuff of dreams in academic medicine: an NIH (National Institutes of Health) research grant. Get one of these and you’re pretty much assured of getting tenure and succeeding at any major U.S. university. It is the ultimate stamp of approval from the government and society that your thoughts and ideas have merit and value.

And I was just awarded one!

NIH Funds the Artificial Testicle

Yes, the federal grant that we submitted recently to build a human artificial testicle was funded. To be clear, this grant is not about creating a testicular implant for a man who is missing a real one. We did that a decade or so ago. This award is to develop a sperm making biological machine. I wrote it along with Dr. Connie John, CEO at MandalMed, Inc., a biotechnology company in the Bay Area. We now have a couple of years to create human artificial sperm in a dish, or more formally, a “bioreactor.” A fancy dish to be sure.

You’ve seen the posts on how successful this research has been in mice models using various stem cells as a starting point: embryonic stem cells, adult stem cells and early germ line (spermatogonial) stem cells. In labs all over the world, real, live, fertile sperm have been made in animal models from each of these stem cell precursors. Honestly, given this success over the past several years, surely we can figure out how to do the same in humans.

Why Do I Need NIH Funding?

Funny thing is, I am not in academic medicine anymore. No tenure to deal with and no need to prove anything to anyone but myself and to legions of loyal patients who depend on cutting edge innovation for their infertility care. Personally, feeling the suffering of patients with infertility is far more motivating than doing science for the sake of science, or for the sake of tenure.

Not to compare myself to Steve Jobs in any way, but I can’t help think one of his favorite mottos from the Whole Earth Catalog. This is what guided him in his quest to build a better computer for everyone: “Stay hungry; stay foolish.” It feels absolutely fabulous to be able to dream it, write it and finally to do it. The essence of science for the good of people.

Press Release

Effort to Build Artificial Testicle Awarded NIH Grant

Released: 1/9/2012 1:45 PM EST
Source: The Turek Clinic

Proposal to make human sperm from stem cells receives government funding

Newswise — SAN FRANCISCO, CA. January 9, 2012. Dr. Paul Turek, Director and Founder of The Turek Clinic, a men’s health medical practice, and Dr. Constance John, chief executive of MandalMed, Inc, a San Francisco-based biotech company, were recently awarded a Small Business Innovation Research (SBIR) grant from the National Institute of Environmental Health Sciences (NIEHS) of the National Institutes of Health (NIH) to construct an artificial human testicle and research how sperm are made from stem cells.

“Fertile sperm can be made from various stem cells in mice, but making human sperm from these same sources has been elusive,” says Turek, a practicing male infertility specialist in San Francisco. In this project, they will try to produce mature human sperm in a live laboratory model of a human testicle.

This work extends on previously published research by Dr. Turek on human testicular stem cells, the forerunners of sperm. Dr. John is an expert on human Sertoli cells, which critically nurture sperm as they develop in the testicle. “This grant is quite an honor and comes after several years working together on this idea,” notes Turek. “We have assembled a great group of scientists who are very committed to its success.”

A functioning artificial testicle has important implications for the field of reproductive biology. It could shed enormous light on the intricate details behind the mysterious and complicated process of spermatogenesis or sperm production. Even further, it could be used to later develop patient-specific, fertile sperm for men who simply do not make sperm due to genetic or acquired causes.

About Paul Turek, MD
Paul Turek, MD is founder of The Turek Clinic and a former professor and endowed chair at the University of California San Francisco. As a men’s reproductive health expert, he has pioneered innovative techniques for treating male infertility, including Testicular Mapping. In addition to his appointment to the Cooperative Reproductive Network Advisory Board, Dr. Turek sits on the Advisory Board for the Men’s Health Network, Fertile Hope and is President-Elect of the Society of Male Reproduction and Urology. He is Chief Medical Officer at MandalMed, Inc, and is also Past-President of the American Society of Andrology and of the Northern California Urology Society and is an Editorial Board member of several journals including Systems Biology in Reproductive Medicine, the Asian Journal of Andrology and the International Brazilian Journal of Urology.

A complete biography of Dr. Turek is available on Wikipedia at http://en.wikipedia.org/wiki/Paul_J._Turek.

About The Turek Clinic
The Turek Clinic, founded in 2008, is a men’s reproductive health practice specializing in male infertility, vasectomy, vasectomy reversal, varicocele repair, and other minimally invasive procedures using innovative and cutting-edge techniques. For more information, visit www.TheTurekClinic.com, www.TurekVasectomy.com, or Dr. Turek’s blog (here).

About MandalMed, Inc.
MandalMed is a privately held biotechnology company located in San Francisco- the home of more bioscience companies than any other region in the world. MandalMed’s mission is to develop pharmaceutical products of worldwide significance. Areas where there is a great need for better treatments, including cancer and neurological conditions, are the targets of MandalMed’s research and development programs. For more information, see www.MandalMed.com.

The Wall of Holiday Cards

Paul Turek, MD — Mon, 26 Dec 2011 16:00:32 +0000

The Turek Clinic Team and the wall of holiday cards

I always tell grateful patients that the kindest thing that they can do for me is to send a holiday picture of the family. We have a wall in the clinic that is dedicated to this once a year event.

Well, you have outdone yourselves this year! The wall is full of cards and The Turek Clinic Team loves it. We received cards with photos of little kids, bigger kids, ultrasound photos of kids yet to be, dreams of kids and much more. Each telling their own story. What a way to fuel the fire of desire to continue to do what we can to help build families all over the world. Magical. So, thanks and

Have A GREAT Holiday!

Guide to Surviving the Holiday Season

Paul Turek, MD — Mon, 14 Nov 2011 16:00:30 +0000

Cleaning a set of these every week is one way to "busy your hands."

Two patients told me that they were getting divorced this week. They came to the office and thanked me for all that I have done for them. They wished that the assisted reproductive technology had worked and given them children, but it didn’t. The relationships simply couldn’t tolerate the strain and gave way. Unfortunately this is not uncommon.

The Stress of Infertility

Don’t doubt for a minute that being infertile doesn’t have the same impact as having cancer. Very little can tear holes in the fabric of a relationship like infertility can. Add to this the romance of the holiday season and you have a recipe for potential disaster. Gathered families encircled by the howling laughter of children; smartly dressed kids at parties just learning to be polite; parents reveling in the enchantment written on the faces of children hearing holiday stories. To the infertile, its like having walking pneumonia—it just never seems to get better or go away.

Eight Ways to Reduce Your Holiday Stress

Maybe it’s not that bad. Maybe the holiday season is just more stressful. What can you do about it? Here are some tips for men as the holidays approach:

Take smaller steps. Stress and depression are like the flu: give them some time to run their course and pass through. You will make it, and you will be stronger because of it.
Make a plan. Spinning out of control without a plan for the problem can cause great anxiety. Simply agreeing to take the next month off and start again in the New Year can make all the difference in the world.
Enjoy each other. After all, you have found a soul mate that is going through the same experience. Give and get that big hug that can make all the difference in the world
Express yourself. Cry on her shoulder and not in a closet. Vent about that wicked day by journaling. A belly laugh or a primal scream is even better. Empathy is a very rich and particularly human experience with immense healing power.
Relieve your stress. Exercise, yoga, massage and acupuncture are fabulous ways for men to “vent” and relax. There is something about those endorphins that waft through the body after a long run…
Be mindful. Take your eyes off the Ipad and lose circular thoughts that lead to nowhere. Take note of the present. Quietly observe life. Breathe to relax. You are an organism, not a machine.
Try fasting. From emails, texts, news, stock quotes. Do you really think that you can keep up with the web growing at a rate of 7.3 million pages per day?
Busy your hands. There is enormous therapy to be found by working with your hands. In the words of Michael Crawford, author of Shop Class as Soulcraft: “Fixing things feels good.”

Fertility from Sterility

Paul Turek, MD — Mon, 07 Nov 2011 16:00:55 +0000

What's inside of a coffee mug depends on how you look at it.

Do you think it is possible to have your own children with absolutely no sperm in the ejaculate?
Why yes. It happens on a daily basis in my practice.
Honestly, the word “sterility” has really lost much of its meaning nowadays with advances in reproductive technology.

The Affairs of Sperm

Azoospermia is the word used to describe the lack of any sperm in the ejaculate. It is a devastating thing for men to hear as they try to conceive. It comes in two forms: as a consequence of blockage in the sperm ducts outside the testis in the setting of normal sperm production in the testicle (i.e. vasectomy) or as a result of poorly functioning testicles and normal, open ducts beyond it. We routinely grab sperm from behind vasectomy sites to use with assisted reproduction to conceive. Finding sperm in men with poor sperm production, termed nonobstructive azoospermia, is a more complex matter.

One way to think about sperm production in men with poorly functioning testicles is to compare it to a mug with coffee in it. Say the mug is filled with ¼ cup of coffee. If you hold shake the mug, you may not see any coffee spill over the side. In this case, you might assume that the mug has no coffee inside. But, if you peer into the mug directly, you will see that there is actually coffee in the mug. Similarly, the testicle makes more sperm (coffee) than is found in the ejaculate (spilling over cup). There exists a threshold of sperm production, over which sperm shows up in the ejaculate and below which it will not. So, now you know the secret of making fathers out of “sterile” men with poorly functioning testicles.

Sperm from a Rock

Of course, it’s not quite that simple. There is one more layer of complexity here. Poorly functioning testicles may not make sperm evenly throughout their substance. In many cases, there are “pockets” or “islands” of sperm within a sea of otherwise empty tissue. Clinically, this makes sperm retrieval more difficult and has pushed this technology to a high art.

To find sperm, fertility specialists use several sophisticated approaches in men with nonobstructive azoospermia. The traditional testis biopsy works about 30% of the time to find sperm and, as a consequence, is no longer the de rigueur technique for this problem. Fine needle aspiration “mapping”, which I invented about 15 years ago, is easily twice as good as a biopsy in finding sperm and much less invasive. Lastly, “microdissection” of the testis another alternative and involves an all-out surgical assault on the testicle to find sperm making it the most invasive approach. The elegance and complication rates for these approaches vary widely, but their intent is the same: to find enough sperm to allow biological fatherhood. Importantly, when expertly performed, these techniques will find sperm in the majority of cases. For the remainder, there is hope as even newer “no touch” scanning technologies are on the horizon…

The Secret Life of Varicoceles

Paul Turek, MD — Mon, 26 Sep 2011 15:00:19 +0000

Celsus, an expert at heat and varicoceles.

What’s squishy, worm-like, fills the space in the scrotum above your left testicle, can ache after a run and wreak havoc on your fertility? No it’s not your Johnson; it’s a varicocele. A very-what? A vari-ko-seal.

What is a Varicocele?

Varicoceles are dilated, tortuous veins that drain the testosterone-rich blood from the testicles. They come in three sizes: small, medium and large and are diagnosed on physical examination, generally by a specialist. Varicoceles exist when blood travels in the wrong direction through these veins. Normally, blood leaves the testicle and travels uphill to drain to the upper back, near the kidney. This is a long way to go and it’s all uphill. Since we stand as a species, good ol’ gravity, clearly our enemy as we age, acts over time here too and pulls the blood back down the veins and causes it to pool around the testicle.

Developing at puberty in active boys, varicoceles are an evolutionary consequence of man’s upright posture. Our quadriped ancestors and pets do not get them. They are common, occurring in one in every six adult men, and are generally nothing to worry about as they are often asymptomatic.

Why Do Varicoceles Matter?

The fact is, though, that varicoceles are not always innocent. In an odd way, they remind me of my dog Pretzel (my daughter named him) who will sit at your side all day when you’re home, but will grab that half eaten burger off the table as soon as nobody’s looking. Although varicoceles don’t cause cancer, they can hurt and they can cause male infertility. Also, a few others think that varicoceles can cause testosterone levels to drop.

The discomfort they cause is again due to gravity. It is usually mild and is worsened with physical activity and relieved by lying down, which neutralizes the effect of gravity. So, men can have varicocele pain after a long day of standing, but it never hurts in the morning upon awakening.

It’s role in male infertility actually dates back to the 1^st century AD. Celsus, a Greek physician, described them in De Medicina: “The veins are swollen and twisted over the testicle, which becomes smaller than its fellow, in as much as nutrition has become defective.” In reality, 40% of men who are having trouble conceiving their first child will have a varicocele, a rate almost three times higher than in the general population.

How varicoceles cause infertility is not entirely clear, but the most popular theory is that warm blood from the body that is flowing downhill into the scrotum heats up the testicles to the point that sperm production and quality are affected. Basically, the factory (testicle) is overheated and the workers aren’t putting out as many, or as good, a product.

Away with Thee, Varicocele

Fortunately, there are several ways to treat varicoceles and they work well to relief the pain and to improve semen quality. My favorite is to spend an hour with the patient and an operating microscope and tie off all of the enlarged veins. This stops the reverse flow of blood. Elegant, simple and safe. I do this a lot. In fact, varicocele is the single most correctable abnormality found among infertile men.

So, if you find yourself having trouble conceiving with an abnormal semen analysis and just can’t figure out why its happening, see a specialist as you might just be the average guy with a varicocele.

Fitting Into Your Genes

Paul Turek, MD — Mon, 19 Sep 2011 15:00:31 +0000

Change is the engine of evolution, and the source of infertility

“Why Me? I take great care of myself.”

I often hear this common question from men with low or no sperm counts who are unable to conceive. In fact, they usually are taking great care of themselves. The fact is, many cases of male infertility are actually genetic and have more to do with the cards that they were dealt.

“But my brothers, sisters and cousins all have kids…!”

Here where is gets a little complicated, as not all genetic traits are handed down the same way. There’s autosomal recessive and dominant, sex-linked, sex-limited, Mendelian and non-Mendelian, and even polygenetic and epigenetic. The thinking implied by this comment is Mendelian, which one of only a few ways to pass genetic traits along. The way infertility occurs is not necessary like that of heart disease or high blood pressure.

Genes and You

What is that saying? “Clothes make the man.” A more modern (and accurate) way of saying this is that “Genes make the man.” And with male infertility, it is becoming quite clear that genes matter a whole lot.

For 50 years, as men were evaluated for infertility, clinicians would simply use the term “unexplained” or “idiopathic” to describe much of what they saw. As the Y chromosome was found to have important genes for “maleness”, interest turned toward this chromosomal location to explain infertility as well. Then, in the mid-1990s, a colleague of mine discovered an area on the Y chromosome that could explain why a chunk of men had low or no sperm counts. Now, it is clear that the Y chromosome is central to normal male fertility.

It is thought that between 500 and 1000 genes are involved with sperm production. This is a reasonably big lot of the estimated 25,000 genes that exist in the human genome. However, currently, fewer than 50 genes have been definitively linked to male infertility. Some of these are on the Y chromosome, but many are not, making the story even more complex than originally thought.

My Answer to “Why Me?”

My long answer to the question “Why me?” revolves around the concepts that 1) there are two different genetic evolutions in the body, and 2) that your genes may be new to you and may not be handed down like clothes. It goes something like this:

Eggs and sperm (also called “gametes”) are responsible for the vast bulk of human evolution. They have a very long term view of where our species is going.
As a consequence, genes in our gametes constantly mutate and change, as change is the engine of evolution. Genetic change in our gametes is expected, nay necessary, for our proper evolution. They mutate rapidly and frequently.
On the contrary, genes in the rest of the body exist to support the work of the gametes, for the good of the species. So, the rate genetic mutations in this system is much lower. As the rocket (body) for the payload (gametes) the body must run fast, hard and true.
Given this setup, with evolutionary pressure high in gametes, new mutations occur far more commonly there than in the rest of the body.
Another way of looking at this is that if every mutation that occurred in our gametes was made manifest in our bodies, we would look entirely different from one generation to the next. Luckily, this isn’t the case, because the quality control “filter” is so good.
But it does explain why there is a lot more genetic change affecting infertility than one might expect.

Maybe it’s true that clothes make the man, but with male fertility it is also true that the clothes were newly purchased and not hand-me-downs.

Insider’s Guide to Vasectomy Reversal

Paul Turek, MD — Tue, 06 Sep 2011 15:00:17 +0000

Beauty (and results) are in the eye of the practiced beholder…

Something like 25,000 American men a year want more children after having a vasectomy. The more popular of two options for fatherhood after vasectomy is a vasectomy reversal; the other choice is sperm retrieval for men and in vitro fertilization (IVF, “test tube baby”) for their partners. Even though it is a surgical procedure that is technically quite challenging and not generally covered by medical insurance plans, clearly reversals have a major leg up on high-tech, IVF conceptions: you can do what you do best and do it at home, the old-fashioned way, to conceive.

Who Does Vasectomy Reversals?

Among the 10,000 or so practicing urologists in the U.S., maybe 5-10% of them are interested in performing vasectomy reversals and far fewer than 1% are fellowship trained microsurgeons who specialize in this procedure. So, how do you decide to whom you should go to have this done?

Deciding on a Surgeon

Not all doctors are same. If you didn’t know this before, you heard it here first. Some are average run-of-the-mill, some are better, and others are truly gifted and talented at what they do. And the difference between an average doctor and a great doctor is the quality of the product. Did you actually get what you asked for, or what you expected to get?

You can read all over the Internet about ways to choose your reversal surgeon. These parcels of advice are helpful and may lead you to find a good surgeon instead of an average one. But if you want the highest quality surgeon, here are six key issues to consider as you search and shop:

Does the surgeon enjoy doing vasectomy reversals? I’ve met countless surgeons who are pleasant enough in or out of the office but who are simply miserable in the operating room. I can’t explain why. Personally, reversals are my favorite thing to do (at work). It is a craft and an art form of the highest caliber, the elixir of a surgical life. A surgeon who loves what he does will do a better job of it.
Does the surgeon pay attention to details? I can’t recall who said this, but life really is in the details. And microsurgery, performed at 1/25 normal scale, is the ultimate detail-oriented surgical procedure. Has the surgeon gotten all of your details? How about your medications? Habits? Your partner’s issues? How neat is their office? How comprehensive and detail-oriented are the staff?
How long will you have to wait to get the procedure done? You may think that if you have to wait a long time to get the reversal performed that the surgeon is very busy at doing reversals. Honestly, it could mean that (s)he doesn’t operate very much or that (s)he spends a lot of time out of the office or doing other procedures. In other words, reversals may not be a priority for the surgeon (see #1 above). Or, the office itself may be disorganized (see #2 above). The better way to assess “busy” is to look them in the eye and ask them how many vasectomy reversal cases they do each year.
What are your surgeon’s success rates? You see success rates of surgeons on every website. And they all look the same and are all very high. What does this mean? How do you decide? Frankly, many surgeons quote the published rates of other surgeons, kind of like selling “knock offs” instead of the real thing. This may be fine for buying purses but not for vasectomy reversals. Peer-reviewed and journal-published data is an excellent measure of quality: it is the certified seal of authenticity. So, ask that simple question: Has the surgeon published their success rates in trade journals?
How many reversals does the surgeon perform annually? Do Olympic athletes or concert musicians win competitions through talent alone? Of course not. It’s all about the training. Similarly, a good predictor of reversal success is surgical volume or the number of cases. Volume means practice and practice makes perfect. This is true for almost all surgical procedures in medicine and is also true with reversals.
Does your surgeon want what you want? You don’t really want a reversal, you really want a kid, right? And you don’t want to sell that old car or mortgage a property to get it. Let’s say that the cost matters a lot for you. If IVF is covered by insurance and a reversal is not, then IVF may be the cheaper way to go. In this case, the surgeon should not keep giving the hard sell for vasectomy reversal. There are several paths to fatherhood. Make sure that your surgeon shares your goals. For me, it’s the holiday card that matters the most.