Turek On Men's Health » cancer

An Ounce of (Fertility) Prevention

Paul Turek, MD — Mon, 17 Oct 2011 15:00:19 +0000

Kokopelli, the ancient fertility symbol.

“I’ve been told that my cancer is now cured… how do I get my fertility back?

Patients ask me this question weekly all the time and I am glad to help. Some of the most satisfying medical moments I’ve had are associated with these patients.

But when I hear this call for help, it also reminds me how medicine has been remiss in preventing the infertility in the first place. We can do better and we can do it right now.

The topic of fertility preservation is the substance of my recent lecture at the annual meeting of the American Society of Reproductive Medicine (ASRM) in Orlando, Florida. This well-attended course focused on the prevention, treatment and restoration of male fertility in the setting of sterilizing treatments typical of cancer therapy.

The goal of my lecture was to review and update providers on current and future strategies for the preservation and restoration of male fertility. Here are some of the ideas discussed. I’ve also included a link to the lecture slides if you are so inclined.

Preserving Male Infertility

Sperm banking. A 200-year old technique that is the purest form of preventative medicine, it is vastly underutilized, not covered by insurance, and not routinely offered to many cancer patients before treatment. What gives? Here is where we need to do the most work in this field.
Sperm Harvest. For 15 years, it has been possible, nay routine, to harvest sperm from men who want children after having a vasectomy without reversing the vasectomy. This same technology is easily applied to men before, during and after sterilizing cancer treatments. One very successful example of this in my practice is fine needle aspiration “mapping” of testicles for sperm in cancer survivors. Indeed, no-touch, metabolic imaging for sperm may be the ultimate iteration of this concept.
Electroejaculation. Based on decades of successful use in spinal cord injured men, artificial stimulation of ejaculation can be a very effective way to bank sperm or restore fertility in men or post pubertal teens who have had nerve damage to reproductive organs from cancer surgery.
Shielding Sperm Production. Physical shields are routinely used to block the effects of aberrant X-rays from hurting sperm production during treatment. In animal models, hormonally induced shut down of sperm production can protect the testicle during the storm of chemotherapy as well.

Restoring Male Infertility

Stem cell transplantation. Currently possible in animal models, this involves taking the delicate testicle stem cells from either pre- or post-pubertal boys or men and freezing the cells before cancer treatment. Subsequently, the stem cells are thawed and replaced back into the testicle to restore sperm production after the cancer is cured.
Sperm Maturation in a Dish. A variant of the above, also demonstrated in animal models, this technique involves maturing stem cells harvested from the testicle before cancer treatment in the laboratory all the way to their final form: a sperm with a tail.
Sperm from Stem Cells. Yet another variant of the above that has been demonstrated in animals, this involves growing usable sperm from early, pluripotent stem cells such as embryonic or adult pluripotent stem cells. One example would be to take a skin biopsy from a sterile man, coercing them to become adult stem cells and then push those cells to sperm in a dish. Truly, a fantastic outcome of America’s investment in stem cell technology.

Fertility Restoration after Cancer: Current and Future Therapies by Paul J. Turek MD, FACS, FRSM Director, TheTurek Clinic, San Francisco (WARNING: Images in slides not appropriate for all audiences due to subject matter)

View more presentations from Dr. Paul Turek | The Turek Clinic

Cancer’s Second Hit

Paul Turek, MD — Mon, 15 Aug 2011 15:00:15 +0000

A holder of "two hit wonders" of a different kind

“This is as hard on me as having cancer was. The difference is that being infertile is not life threatening; having cancer is.”

These are the words of a young cancer survivor sitting in my office who is now dealing with infertility, a common consequence of cancer treatment. Yes, he is very happy to be alive. Yes, he is grateful for each new day and knows exactly what it feels like to look death in the face and skirt it. But, what is also clear is that the infertility hurts, hurts a lot, and hurts all over (again).

Surviving Cancer: The Numbers

Thankfully, surviving cancer is now quite common. Over 80% of childhood cancers are overcome and well over a million people in the U.S. are alive 25 years after cancer treatment. This means two things: 1) cancer defines quality of life among many of us, and 2) cancer and reproduction are bed partners in younger survivors.

The Effect of Infertility on Life

It is my belief that infertility affects a man’s quality of life as profoundly as cancer does. My patient’s statement is simply another reminder of this truth. But this is hard to prove, because the “tools” and “instruments” used to assess the impact of cancer on quality of life do not exist for infertility. And, for academic reasons, they are hard to compare mano e mano.

As a start, we studied how infertility affected men who were not necessarily cancer survivors. In 357 infertile couples, we looked at the “strain” (personal, social, sexual, and marital) caused by having a male factor infertility diagnosis. Importantly, these men underwent formal face-to-face interviews and filled out questionnaires as they were battling the infertility problem. In this way, the immediate impact of having the diagnosis was assessed in couples and not the memory of infertility, which is often softened by time.

What we learned was that infertile male partners had a lower personal and sexual quality of life compared to men without male infertility. Examples of how we defined personal issues are: lack of control, missing something in life, inability to meet life goals, or feeling defective. Examples of sexual issues are: level of sexual enjoyment, perceived attractiveness to partner, failure with sex because of fertility problems, and persistent thoughts of having a child during intercourse. I would wager that cancer affects personal and sexual quality of life in similar ways.

Infertility: An Owner’s Checklist

So, being infertile matters to men. And it matter a lot, sometimes more than anything else. What can you do about it? Here’s the checklist for surviving infertility:

Get information. It helps control of the situation. You need to “own” it.
Talk openly with your partner and trusted others. Get the support you need.
Keep the lines of communication open with your partner. This may be the most significant threat your relationship will ever see.
Keep doing the things that you do best. They are not likely the cause of infertility and can keep the routine in your life.
Take time to “blow off” stress through exercise, sports, yoga, massage or whatever works for you.
Maintain that critical balance as you tackle this issue like you have tackled others, and as you will tackle future issues.

The “Brick” Takes a Beating

Paul Turek, MD — Sat, 04 Jun 2011 06:36:45 +0000

Remember the huge "brick" cell phones from a couple of decades back?

While you were blabbing away, your cell phone took a hit this week. Basically cell phones were slammed from two sides. As much as any modern product, the cell phone is about as integrated as a piece of plastic can get into our lives. In 2002, 2% of Americans gave up their landlines for cell phones; in 2009, it was about 1/3 of cell phone users. Similar to Americans and their cars, there are countries in Europe where cell phones outnumber the population.

Cell Phones Cause Cancer

So what is the recent cell phone scuttlebutt? The World Health Organization (WHO) issued a press release this week that classified radiofrequency magnetic fields such as that generated by wireless cell phones as “possibly carcinogenic” (cancer causing). A group of 31 scientists from 14 countries met in rural France to review the published evidence linking cell phones and cancer. In a consensus statement, they felt that the risk of a brain cancer called glioma is 40% higher in individuals who use cell phones for > 30 minutes daily for 10 years. It was this data that drove the panel to label cell phones as possibly carcinogenic. For perspective, the pesticide DDT, coffee (acrylamide), alcoholic beverages and night shift work are also considered “possibly carcinogenic” by the WHO.

Cell Phones Reduce Male Fertility

About half a dozen studies involving 750 men have been published over the past 8 years that attempt to link cell phone use with impaired semen quality. Importantly, only semen quality, and not actual fertility, is commonly studied. For the most part, cell phone use in these studies is associated with lower sperm motility and lower sperm numbers. However, a recent Canadian-Austrian report from a couple of weeks ago also suggests that this effect may be hormonal in nature, since cell phones in this study were associated with worse semen quality but higher testosterone levels.

To one practiced in the art of male reproductive medicine, these studies are both curious and puzzling. One huge problem with “epidemiologic” studies is that they can only postulate an association between A and B, but do not prove causality or that A causes B. In the realm of cell phones, they tend to ignore major covariates such as life style issues (smoking, hot tubs, recreational drug use), occupational history and other sources of radiofrequency exposure such as radio towers, personal digital assistants (PDA), Bluetooth devices and computers that might also impact semen quality. But lets get even more basic: a single semen analysis does not a man make as semen quality in any individual can vary quite widely from day to day, season to season and even year to year. Just take a gander at our hot tub study and its effect on semen quality to get a small taste what these epidemiologic studies are up against in terms of bias.

What would be most convincing of a relationship between cell phones and male infertility or cancer would be mechanistic research that shows biological plausibility or causality of the link. This is difficult but essential, especially if what is at stake is a piece of plastic owned and coddled by 5 billion of our 6.9 billion human inhabitants on this good earth.

Eat, Sleep, Reproduce

Paul Turek, MD — Sun, 17 Apr 2011 05:50:36 +0000

This white paper is red hot.

It has been said that we, like many other living creatures, were put on this good earth to eat, sleep and reproduce. In a minimalist, animalistic and mechanistic way, everything else is we do to make the world a better place is icing on the cake. Of course, we have free will and we can choose not to do any or all of these organic functions. However, I personally have not met anyone who has successfully avoided all three.

The Problem with Reproduction

In the big picture, what exactly does it mean if we try to reproduce and are unable to? With women, age is a clear determinant of fertility. They are born with all the eggs they will ever have, and when they run out fertility is no longer possible.

However, with men, the system is entirely different. The healthy adult human male makes 1200 sperm/heartbeat right up until andropause (7^th to 8^th decade) with new sperm produced constantly. So, when young men can’t reproduce because sperm production has ground to a halt, one has to wonder why such an important organic function is compromised. And this has led to boatloads of research over the last several decades into its causes and treatments, to the benefit of both patients and science.

The White Paper on Reproduction

A white paper is an authoritative report that helps solve a problem. White papers try to educate readers and help people make decisions. And I am delighted to announce that a white paper has recently been produced by the NIH regarding the issues surrounding infertility. As you may recall from prior posts, we met several months back in the middle of winter at the NIH headquarters in Washington DC, with the charge of identifying key opportunities in science that will define way we examine reproductive health over the next decade. At this meeting, I led a session on how infertility relates to overall health in men and women. Well, ta da, we now have the official White Paper from this meeting for your review at: www.NICHD.NIH.gov/vision.

White Paper Themes

Here are some of the overall themes of the white paper. What is very satisfying for me is the fact that several of my initiatives were carried through to the white paper:

Overall health affects reproductive health, and reproductive health affects overall health.
Reproductive and sexual health is essential to our wellbeing and serves as a window to overall health in males and females
Reproductive research is the cornerstone of stem cell research and is central to the field of regenerative medicine
Fundamental and applied contraceptive research is critical to this initiative as half of pregnancies in the US are currently unintended and unwanted
A better understanding of human development is necessary to reduce the incidence of adult male and female infertility
The effects of infertility on quality of life should be examined more thoroughly in future studies
We need to develop a national database of prospectively collected reproductive health data (e.g., an NIH social health network).

Now it’s your turn. Do your country and me a favor and take a couple of minutes and glance at the white paper. Tell us if it’s on or off the mark. Send your comments to NICHDvision@mail.nih.gov. We need your opinion to help direct this science over the next decade.

Mice Sperm in a Dish

Paul Turek, MD — Sat, 09 Apr 2011 15:11:11 +0000

If they just would have included a photo of the finished product…

It’s not the mother load of discoveries in our field, but it’s pretty close. It tells us that the mother load is definitely out there…and within reach. Yup, the good news is that real. live, old-fashioned sperm were made in a dish… at least for mice.

The Holy Grail: Artificial Sperm

For the 55,000 reproductive age cancers survivors annually in the U.S. and a host of other men who are sterile due to injury, genetics, exposures and the like, this is good news. Despite the availability of utterly fantastic reproductive technologies like sperm mapping, in vitro fertilization and intracytoplasmic sperm injection, some men still do not have sperm to use them. The standard of care in reproductive medicine today is a sperm: a mature one, with a tail, and hopefully moving or at least alive.

And the sperm can come from anywhere. Often, men with no sperm in the ejaculate will have sperm within the reproductive organs such as the testicle or epididymis. These sperm work great to help them become fathers. But there are many other men do not have any sperm, anywhere, especially men with childhood cancers who were blasted with sterilizing treatments before they even reached puberty and made their first sperm. Clinically, I see these patients all the time and this is the crowd of men I am very motivated to help in my short time on this good earth.

The Finding: Functional Sperm for Mice

The recipe to produce functional sperm from stem cells precursors has eluded researchers for 50 years. There have been many false starts, including the last one in 2009 out of Newcastle that was published and then retracted from print by the editors one week later. But, a group from Yokohama City Japan nailed it and recently published functional mouse sperm from testis stem cell precursors.

From reading the paper, it is clear that it took several years of constant, diligent work to find the key ingredients to make it happen. In my opinion, the secret sauce was that our recent, vastly improved understanding of stem cell biology really enlightened the science. They took testicular tissue from newly born mice that contained only stem cells (no sperm, just sperm precursors) and put them in a jello-like environment. Getting them to grow was the trickiest part and finding the right food was also critical.

How is This Sperm Different?

What made this paper great was that the scientists made reproductively “competent” sperm. They took the artificially created sperm and used them with high technology approaches to create baby mice. Then, they let the baby mice grow up and mate. Remarkably, the offspring of these mated mice were normal. Can’t ask for much more from a sperm now can we? Many have tried, including some of my closest colleagues, but no one has gone this far before. Bravo!

So now, all we have to do is replicate this in humans, something that I have been pursuing for several years with colleagues. What is so uplifting for me about this paper is that it seems that making human sperm in a dish is really more evolutionary than revolutionary science. I better go buy some more of that midnight oil….

A Primer on Radiation

Paul Turek, MD — Sat, 26 Mar 2011 17:22:32 +0000

Are we at risk of nuclear fallout from Japan?

We are all concerned for the Japanese after their recent, unheard of, triple cataclysm of earthquake, tsunami and nuclear meltdown. The catastrophe was horrendous and the photo-footage of the disaster is mind numbing and knee buckling. And next on our minds, occurring on the heels of the Haiti earthquake is what’s next for Japan: infectious disease epidemics and, even more frightening, nuclear fallout. Although I’ve addressed the issue of the Chernobyl nuclear fallout on male infertility in prior posts, it’s fresh in our minds again after “3-11” in Japan.

Radiation is scary. You can’t see it but you know it’s there. It’s like the adult version of ghosts for kids. Technically, radiation is a simple form of matter or energy like any other and was first defined in the 19th century when Bavarian professor Wilhelm Roentgen discovered X-rays. Nuclear radiation, like X-rays, is a form of “ionizing radiation,” which is energy that strips orbiting electrons from atoms forming charged particles called ions and creating molecules called “free radicals.” These substances are damaging to living systems, as they don’t behave as their neutral counterparts do, and generally mess up the physics and chemistry of life.

The First List: Typical Radiation Exposure

We are all exposed to radiation every day as it a part of the normal environment in which we live. In fact, if you are interested in calculating your annual exposure to radiation, click on this EPA website. You’d be amazed at what actually contributes to our radiation exposure every day: breathing air at different altitudes, airplane flights, luminous watch dials, irradiated (sterilized) food, watching TV, using a computer, having teeth with porcelain fillings or crowns or a wearing plutonium pacemaker to name a few. For perspective, here is a list of radiation levels from just living and breathing and also from common medical procedures:

2.5 mSv= Annual natural exposure to radiation
1 mSv= Chest X ray
2 mSv= Head CT scan
3 mSv= Screening mammography
25-50 mSv= Full body CT scan

The Second List: Radiation Exposure and Disease

100 mSv= Radiation dose causing temporary loss of sperm counts
500 mSv= Radiation dose causing permanent male sterility
170 mSv= Average per person exposure to radiation in the Ukraine in the year of the Chernobyl meltdown (1986)
30 mSv= Average exposure in the Ukraine two years after Chernobyl (1988)
1000 mSv= (Single dose) causes non-fatal, temporary radiation sickness (nausea, vomiting, low white blood cell count)
1000 mSv= (Accumulated dose) significant increased risk of cancer, premature aging
10,000 mSv= (Single dose) fatal radiation sickness

The Third List: Japanese Radiation Levels

400 mSv/hour= Peak radiation levels at the Fukushima nuclear power plant, March 14, 2011
173-181 mSv= Range of exposures of three nuclear plant workers
20-50 mSv= Radiation levels in tainted milk from Japan
5-10 mSv= Radiation levels in tainted spinach from Japan
Unclear= Radiation levels in canola and chrysanthemum greens
Unclear= Levels of radioactive iodine in Tokyo tap water

The Anti Radiation Diet

We are certainly concerned for the Japanese in their time of need. Should we also be concerned about nuclear fallout 5000 miles away? All federal agencies and most experts feel we shouldn’t be. However, if that answer is just not good enough, consider the anti-radiation diet:

Miso soup
Kelp (natural iodine helps prevent the uptake of iodine-131)
Brassica vegetables (rutabaga, turnips, cabbage, sprouts, cauliflower and broccoli)
Beans and lentils
Potassium, calcium and mineral rich foods
High nucleotide content foods (yeast, sardines, liver, anchovies, mackerel)
A good multivitamin supplement enriched with antioxidants

The Solitary Life

Paul Turek, MD — Sun, 24 Oct 2010 05:00:42 +0000

Freed from the confines of the solitary.

He called me from rural northern California and the phone conversation went something like this:

“Er… hello. I…I was wondering if you could help me.”
“Sure, sir, how can I help you?”
“Well…I’m single and haven’t dated in 20 years, but would really like to.”
“I’m not so sure that I am the one to ask on matters like that!”
(Laughs nervously) “I just haven’t had the nerve to date anyone.”
“If you are worried about your erections, I can certainly help with that.”
“No…no…it’s more that I’m worried that they will find out…” (goes quiet)
“Find out what, if I may ask?”
“Well, that I only have one ball left” said the Solitary Man.

And so it goes. A man is his mid-40’s diagnosed with testicular cancer in his 20’s and cured by removal of his right testicle. And now, after leading a solitary life for 25 years, he wants his sex life back. Surely, losing a testicle wouldn’t affect a man that much.

An unusual story? Not at all. In 1996, I led the study team that investigated the safety of using a newly designed testicular implant in boys and men who had never had, or had lost, a testicle. At this time, the FDA required extensive safety data on all new implants because of the cancer scare associated with leaking breast implants in the past. That same scare led to the pulling of all kinds of implants off the market, including a tried and true testis implant that had a perfect track record. Several years later, collaborating with 14 university medical centers nationwide, I published the research that showed that the new testis implant was entirely safe and it became the first (and still only) FDA-approved implant to replace this organ.

Proving that it was safe is only half the story though. It was also effective, very effective. What does that mean? For the study, we had men complete validated psychological questionnaires, termed “instruments,” that addressed confidence, self-esteem and body image before and after implant placement. We asked questions that no one had ever asked these men before. And what we learned was impressive: Men felt better about themselves, were more confident, and felt whole again. And these gains translated into real changes in their lives, both socially and professionally.

I recently placed the testicle implant that I had designed and studied into The Solitary Man. I put it right where his original testicle was before it was removed and placed it in less than an hour. He went home the same day and I saw him again 3 weeks after the procedure.

If it weren’t for the Pendelton wool shirt and boot jeans, I might not have recognized him; he was a changed man. He had a grin from ear to ear, a deep sparkle in his eye and a new bounce in his step. I asked him how he was doing and he responded, almost wet eyed: “I’m dating again.” Miracle? No. Magic? Yes.

Weed Worries

Paul Turek, MD — Sun, 17 Oct 2010 14:25:22 +0000

An international symbol of peace…or cancer?

A good rule to follow in medicine when evaluating whether research should be translated into clinical care is “reproducibility.” Good research, that is research that is likely to end up as “true fact” in the long run, is reproducible…not just by the original researchers, but also more importantly by others in the field. In med speak, where the number of syllables matters greatly, we call this “independent confirmation.”

The legalization of pot has been in the news quite a bit lately, especially in California. So hasn’t interesting research linking pot use to testis cancer. I have been tracking this research since 2009 when a study first associated pot use with higher testis cancer rates. Clinically, it suggests that pot use is a “risk factor” for testis cancer. Recently, another research group has confirmed this finding in different men in a different place. Independent confirmation. Two for two. Now that gets my attention.

Testis cancer is the most common cancer in young men ages 15-35. Of real concern is that the rates of testis cancer are rising 3-6% annually since the 1970’s in the US and even faster in Europe. It is usually caught early and is highly curable, but it should be avoided at all costs. It brings along with it other multi-syllable words like “orchiectomy” (testis removal), “chemotherapy,” “radiotherapy,” “infertility,” and “hypogonadism” (low testosterone) which are all as ugly as they sound. Currently, there are few known risk factors for testis cancer except a history of an undescended testicle or other condition resulting in abnormal testis development, a family member with testis cancer, being Caucasian, and possibly infertility. Sooner rather than later, we may need to add chronic or frequent pot use to the list.

How much pot is risky? Both studies showed that long-term pot use (greater than 10 years or since adolescence) and greater than once weekly users had twice the rate of testis cancer as nonusers. In the more recent study, daily marijuana use tripled the risk of testis cancer. And the strength of these links held strong when other lifestyles issues such as alcohol and tobacco use were considered.

How does pot increase the risk of testis cancer? Not clear really, but pot does contain potential “carcinogens” (another big word) like tobacco and can alter testosterone balance. Both of these can unfavorably alter the testis environment in a critical way.

At this point, being the prevention guy that I am, I recommend stashing the sweet Lucy, junking the joint, cutting the grass, pitching the pot, winging the weed, burying the bammy and heaving the hemp. It’s just not worth it.

Where There’s Smoke

Paul Turek, MD — Sat, 11 Sep 2010 07:00:16 +0000

All smokers eventually quit…

Smoking is bad for men’s fertility. Not unexpected, you might add, since 1000 smokers die each day around the world from smoking related diseases. But what else is new? A lot. And this matters because 25 million men in America smoke. Along with 21 million women. Any other condition this common would certainly be considered a frightening epidemic.

Although we always suspected that smoking impairs sperm quality and quantity, two papers published this week shed light on ways in which this could occur. Mechanistic in design, this research approached the problem from different angles and each made unique observations.

One study compared the integrity of sperm DNA in smokers and nonsmokers. As background, realize that a sperm’s job is to deliver a neatly packaged DNA payload to the egg during what is called fertilization. The egg then molecularly “undresses” the sperm DNA and decides over the next day or two whether that genetic payload is of high enough quality or integrity to proceed down the pathway toward becoming an embryo and then a fetus. If not, an executive decision is made by the fertilized egg to stop dividing and call it a day. Protamines are molecules that protect the DNA in sperm so that it remains neatly packaged, and in this study, the smoker’s sperm had significantly disrupted protamine protein levels compared to the sperm of non-smokers. That explains the sperm quality problem: smoking poisons sperm.

A second study took a different look at smoking and infertility. It assessed the impact of maternal smoking habits during early pregnancy on male fetal development. Based on the examination of miscarriages, they found that number of testicular stem cells that are destined to become sperm later in life in the male fetuses of mothers who smoked was half of that of their nonsmoking counterparts. And this observation held true when other social drugs like caffeine and alcohol were taken into account. Fewer stem cells in the developing testicle could mean fewer sperm and a higher risk of infertility in adult sons. This might explain a sperm quantity issue in some infertile men–in men who don’t even have to smoke to have the problem.

So ditch the coffin nails and let your life burn bright in other ways. There are many ways to have your breath taken away. As Woody Allen said: “Remember, if you smoke after sex, then you are doing it too fast.”

Genome: Repair Thyself

Paul Turek, MD — Mon, 22 Mar 2010 05:02:15 +0000

How damaged is your genetic sheet metal?

Imaging parking your car at home after work and all the nicks and scratches are removed while you sleep, before heading to work the next day. All shiny and new, polished even, while you sleep. Believe it or not, this is normally what happens to your genes and chromosomes on a minute-to-minute basis. DNA mismatch repair is a constant and vigilant process, occurring in all cells of the body. Why the biologic vigilance? Well, It keeps us whole, healthy and cancer free.

About 11 years ago, we published a paper showing for the first time that infertile men can’t repair the errors normally encountered in their DNA as well as normal men. This was startling news in part because it implied that infertile men may be more likely to develop other problems later in life, including cancer. Why cancer? Because the development of cancer has been associated with the inability to normally repair the frequent daily errors that occur to one’s DNA as the body’s cells divide and renew.

Today, however, we know much more. We know that testis cancer is 3-fold more likely to occur in previously infertile men than in fertile men as they age. And our latest research has shown that prostate cancer, thought to be a disease exclusive to older men, occurs more seriously and more commonly in previously infertile men.

So what does this mean? Is male infertility the first sign of a larger problem in our species? It is the ultimate medical problem of a species trying to reproduce? Well, honestly it isn’t entirely clear. However, to me it indicates that male infertility should certainly be considered an insurable and real medical condition that should be taken as seriously as a heart attack. Even more worrisome is the issue of whether the use of sperm from severely infertile men is putting their offspring at even higher risk of medical issues than that experienced by their fathers.

So do not ignore the infertility issue when it strikes and get that male partner evaluated by a specialist. Teach him to perform testicular self-examination, a simple maneuver performed once monthly in the shower that has far more potential to extend his life than even exercising or weight control. Educate him about prostate cancer so that he does not ignore the powerful screening tools available to find it early. The age of innocence is over. The warning signs are now clear; get men the care that they deserve.

Your DNA Barcode

Paul Turek, MD — Mon, 22 Feb 2010 02:03:04 +0000

Can we be DNA barcoded like a soup can in a grocery store?

How many of you would take a blood test to learn exactly how long you will live? How about whether or not you will become demented? Since the Human Genome Project ended, the genes and mutations associated with a vast array of diseases are being discovered daily and it is pretty easy to just put them on “chip” and make them available to the public.

Don’t get me wrong; gene testing already has already improved our lives. Such tests can clarify a diagnosis and better direct care, while others allow families to avoid having children with life-threatening or disabling conditions. They can be used to prevent disease before it happens, as with monitoring and removal of colon growths among those who have a gene for familial polyposis, and can diagnose common iron-storage diseases early enough to treat them and prevent them from becoming fatal. They can also help to positively identify murderers two decades after the crime.

One real problem is that many commercialized gene tests are targeted to healthy people who might be at high risk because of a strong family medical history for a disorder. Unfortunately, because of how complex we are as biological organisms, the tests give only a “probability” for developing the disorder. That means that some people who carry a mutation may never develop the disease. Another limitation is the possibility of laboratory errors. What this means is that the tests are not perfect and could be wrong.

And what happens to your job prospects and health (or life) insurance rates when it is learned through genetic testing that you might develop a significant disease? Well…nothing. Because of the federal GINA Law (Genetic Information Nondiscrimination Act) passed in May 2008, insurance companies and employers cannot discriminate on the basis of information derived from genetic tests. So, genetics has now been added to the list of characteristics first embodied by the Civil Rights Act of 1964, that states that U.S. employers cannot discriminate according to race, color, national origin, sex, or religion. And this is good.

So, go ahead and take the “23 and Me” “DeCode” or “Navigenics” genomic screens if you so desire. Get to know your DNA barcode. Maybe you will get an idea of what may be around the corner for you. And maybe, just maybe, you will take better care of yourself knowing more about your genes. Just understand that many in the medical community feel that uncertainties surrounding test results, the current lack of available treatment options, the tests’ potential for provoking anxiety and social stigmatization could outweigh the benefits of testing. You know the saying: “Too much information…”

No related posts.

For the Good of the Hood

Paul Turek, MD — Mon, 01 Feb 2010 05:06:59 +0000

Do you agree with the Ancients on the good of the hood?

To circumcise or not. A loaded subject to be sure. The practice of male circumcision is ancient, likely far older than the biblical account of Abraham in Genesis. The Jewish faith, but not that of the Greeks or Romans, routinely recommended circumcision of newborn males. In the past century, it became “medicalized” as a preventative procedure only to be debunked in the last decade. Well, it may be now a procedure on the rise once again.

Circumcision is the removal of some or all of the foreskin or prepuce from the penis. The august American Academy of Pediatrics continues to recommend that circumcision is medically unnecessary, that it lacks any proven benefit, and that it should not be performed routinely in neonates. Maybe that is why the incidence of neonatal circumcision in the U.S. has continued to decline, from 80% in the 1960’s to 60% in 1996, to 55% of boys in 2001.

Why should circumcision be avoided? Issues of neonatal pain, behavioral changes and the potential for loss of sexual sensitivity from removal of the prepuce are age-old arguments for its discontinuation. However, a military study showing that there is a higher rate of urinary tract infections (UTIs) in non-circumcised boys and the fact that penile cancer tends to occur almost exclusively in uncircumcised men has kept the procedure alive and well.

In a somewhat radical departure from earlier recommendations, public health officials are now arguing that circumcision of men is a key weapon in the fight against human immunodeficiency virus (HIV) in Africa. Three recent, large, controlled studies have shown that circumcision reduces infection rates by 50 to 60% among heterosexual African. These studies stem from 3 different parts of the continent: South Africa, Uganda, and Kenya. In fact, two of the three clinical trials were stopped early because of overwhelmingly positive results. Experts now estimate that more than 3 million lives could be saved in sub-Saharan Africa alone if the procedure becomes widely used. And there is more recent data showing that the incidence of Herpes virus and HPV (Human Papilloma Virus) may also be reduced in circumcised men.

How circumcision prevents HIV transmission is not completely understood, but it is believed that the foreskin acts as a reservoir for HIV-containing secretions, increasing the contact time between the virus and target cells in the foreskin.

The problem with HIV and circumcision is that it is much more than a simple “behavior-based” intervention and this may ultimately be its biggest obstacle to wide acceptance. Changing social mores and behavior is one thing, but the “cold, hard steel” aspect of this public health initiative may not survive in the long run. If you don’t live in Africa, a clean penis and a clean life may be all that’s needed to replace the knife.

The Quiet After the The Storm of Cancer

Paul Turek, MD — Sun, 17 Jan 2010 23:38:36 +0000

Throwing a wrench in the machinery of sperm production…

I have to admit, the testis “mapping” procedure that I developed some years ago has truly been a workhorse technique for my male infertility practice. And for the practices of other male reproductive specialists around the world as well. Creating fertility from sterility. I bring it up again because it is gathering more attention in the press as this week we recently published another paper that highlights its utility—this time in cancer survivors.

In a related study from 2002, we published that the majority of men who had been exposed to chemotherapy for cancerous or non-cancerous disease and who were “sterile” afterwards have sperm in the testis that can be safely used for fatherhood with assisted reproduction. Fine needle aspiration (FNA) mapping was employed in this study and its potential to help cancer survivors to conceive was convincingly demonstrated. The recent paper expands that group of men to include those who received not only chemotherapy and radiation therapy but also a relatively extreme treatment for certain cancers termed bone marrow transplantation.

Let’s back up a minute for a biology lesson. How does chemotherapy affect a man’s fertility? Well, the basis of its effectiveness in curing cancer is that chemotherapy preferentially kills rapidly dividing cells more than slowly dividing cells. In general, cancer cells divide more rapidly than do normal body cells. The term for this difference in cell susceptibility is “therapeutic index”. Unfortunately, sperm are also produced very rapidly (about 1200 sperm are made every heartbeat) and therefore sperm precursor cells are also very sensitive to the effects of chemotherapy. Think of sperm production as a rapidly turning set of gears and chemotherapy as a wrench being thrown into them. Ka-chunk! Machine comes to a loud and crashing halt. Sperm production is over, or tremendously slowed down. The same action is true for radiation therapy treatment.

Now, imagine not just one small wrench being thrown into the gears, but a huge wrench (or many wrenches) being suddenly thrown into the machine of sperm production. The result? More damage to the sperm-making machinery and a much higher chance of sterility. This is the essential difference between the patients from the 2002 paper on mapping and the most recent one. The cancer survivors in this week’s paper got blasted with the heaviest doses of chemotherapy imaginable, and topped off with a dollop of radiation therapy just to be sure. Hard to believe, but they also had usable pockets of sperm in their testicles. And normal babies as a result.

So, with techniques like FNA sperm mapping, there continues to be hope and good news about fertility after the storm of cancer treatment has passed.

Keeping the Family Jewels Shining

Paul Turek, MD — Sat, 02 Jan 2010 18:47:05 +0000

Heirlooms for the species.

As a living, breathing being on this good earth, we tend to take things for granted. The ability to have offspring can be one of them. That is, until the day that a serious medical condition like cancer rears it ugly head and puts childbearing at risk. In addition to the sterilizing effect of cancer treatments, the mad rush to treat the disease often marginalizes efforts to preserve fertility. Fire all the canons and check for collateral damage later.

Fertility preservation seeks to protect men, adolescents and children from a common, serious and impactful side effect of cancer treatment: infertility. The goal of fertility restoration is to empower patients who are cured and potentially infertile to bear children. These related fields have burgeoned recently because medical care is now shifting from curing cancer to improving the quality of life among survivors. And without a doubt, for many, fertility is a key quality of life issue at some point. Thankfully, exciting new methods of restoring fertility have already been developed and even newer technologies are under study.

Classic techniques for fertility preservation in men include gonadal shielding and sperm banking. Gonadal shielding uses lead-based devices to protect the testicles from being struck directly by sterilizing radiation treatment. Sperm banking is the process of freezing healthy sperm before cancer treatment begins for later use to conceive. But there is more. For patients who are too young to bank sperm, for those who have precious little time to bank sperm, or for those who have no ejaculated sperm to bank, testis sperm retrieval by biopsy (TESE) or needle aspiration (TESA) for banking is now possible before cancer treatment. In fact, in some cases of testis cancer, it is possible to remove only the cancerous nodule instead of the whole testis, or to freeze sperm from the testicle after it is surgically removed. These are now routine ways to preserve fertility in men.

Fertility restoration for men has also seen real advances lately. Sperm “mapping” is an innovation that I developed for men who survive cancer treatment but have no sperm in the ejaculate. It non-invasively and non-surgically deciphers whether there are small numbers of mature sperm in the testis, too few to get into the ejaculate, but usable nonetheless. In men who sustain nerve injury from cancer surgery and who are unable to ejaculate, a special medical instrument can produce an ejaculate for fertility purposes in a process termed electroejaculation. Techniques such as these are valuable tools to help men deemed “sterile” after cancer treatment to become fathers.

One of the most exciting areas of fertility restoration involves stem cell technology. Yes, the “promise” that we have all heard about stem cells curing disease will likely find its way into the fertility field as well. In pre-pubertal boys with cancer, ejaculated sperm is not present. Despite this, it may be possible to freeze the early stem cells from the testicles of boys before sterilizing treatment. After thawing, these “adult” stem cells may later be used to create sperm after further growth in a Petri dish or after transplantation back into the same individual. Also on the horizon is our ability to take skin cells from a sterile man, convert them into an embryonic-like stem cells and then “drive” these cells to become mature sperm in a dish–a true “artificial testicle.” So, with the belief that hope can cure misery, the world of science has taken fertility research from science fiction to reality. Not convinced? Stay tuned!