A man looking for his mojo.

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

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

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

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

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

China: 5000 years old and on the move.

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

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

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

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

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

Estrogens and the manly man.

There must be something in the air… or water. The Bolivian President Evo Morales recently asserted publicly that hormones found in mass-produced foods are “feminizing” men. Speaking about chicken in Bolivia, which he believes are “loaded with feminine hormones,” he suggested that when men eat chicken “they are diverted from their nature as men.” So, is this how metrosexuals came to be?

But wait, the Vatican commented on this issue a year earlier, although they blamed female hormones from birth control pills for the increased estrogens in ground water. Pedro Castellvi, writing in the Vatican newspaper L’Osservatore Romano in 2009, stated: “we have sufficient data to affirm that one of the reasons for the not insignificant rise in male infertility in the west, is the environmental contamination caused by the pill.” Actually, it’s not the birth control pill itself but the urine from women taking the pill.

In fact, to date, the urine of women taking birth control pills has been blamed for worsening sperm counts in men, the growth of female sex organs in male fish, breast growth in young men and the early onset of puberty in young girls. What next?

Can I add a little balance to this discussion? First of all, exactly what is happening to men in Bolivia such that the President is not happy with them? Are they more civilized and less disruptive? Second, male infertility is not necessarily increasing in the western world; it may even be true that men have lower sperm counts now than a generation ago not because they are less fertile but because women are more fertile. Third, estrogens are found everywhere in the environment including in many plants (phytoestrogens) such as soy and legumes, and are not produced exclusively from the urine of women. Fourth, the intersex conditions that have been reported in many animal species tend to be caused by a very specific exposure at a very specific time point during fetal development and have been linked to pesticides, bisphenol A, dioxins and other environmental contaminants (xenoestrogens). Fifth, did we somehow forget about the worldwide obesity epidemic in humans and the fact that fat converts male hormones to female hormones? Lastly, there is little evidence that substantially increasing a man’s estrogen levels as an adult will dramatically alter anything, except maybe waist size and color preferences. Where the truth lies in all of this is currently unknown, but it is hard for me as a urologist to see how women’s urine could be blamed for so much.

Where are you? Green means high and red means low.

When a couple decides to have children, they rarely, if ever, contemplate the effect this has on the nation. But population scientists do. The effect that birth rates have on society is critical—as basic as knowing whether a nation is sustaining their population or not. But, trying to figure out if birth rates are going up or down is also complex, not unlike taking our temperature by feeling our foreheads.

A good barometer of birth rate assesses the average number of births per woman, and is generally noted by country. For a country to sustain its population in the future, the replacement rate is 2.1, or 2.1 births to every woman. What has occupied the minds of population scientists over the past 20 years is the fact that birth rates have dropped around the world, especially in Europe, but also in China and Japan. Interestingly, many countries in Africa do not have this problem, with birth rates well above 4. 

Also notable is the fact that in the past 20 years, the population of the world has dropped, falling an average of 1% per year. You can imagine how much this issue has occupied the minds of population scientists who seek to explain the phenomenon. Contributing factors include changing attitudes about family size, the cost of raising a child and the wider availability of contraceptives. The birth rate may also be dropping because child mortality on the whole has dropped. Or, because women who choose to have children later create a temporary lull in the birth rate. One concern with population drops is that countries whose populations become too small may not be able to afford to support its infrastructure, causing economic decline. So, on the one hand, it’s expensive to raise a child. On the other, it’s also expensive not to.

A recent study however, does show a change in these trends. Fertility rates now show a recent increase in developed nations. For years it has been thought that for some reason, developed nations, including most of Europe, have steadily dwindling populations. But this may not actually be the case. For example, in the 1970s, the US fertility rate was at a low of 1.74; lately it’s been relatively stable at 2.05. It appears that children are still wanted in a modernized world.

It’s quite hard to see these trends in my daily medical practice, as I perform as many vasectomies as I do vasectomy reversals. It’s even harder to render an opinion when the information is so diffuse and generational. So, to population scientist, I am a professionally “neutral contributor” to fertility rates. Like to think I do more good than that though…

What shape will the male pill take?

A male birth control pill certainly sounds like a good idea. But after 25 years and millions of dollars of research, there’s still no pill. We put a man on the moon faster than we’ve invented a male pill.

The question isn’t really whether it can be done, because it can. The production of sperm is linked to testosterone levels in the body. When testosterone levels are too high, the body stops producing sperm. Witness the testis shrinking (atrophy) that occurs with anabolic steroid use. Such pills have been tested, and are successful. One problem, though, is that the ability of hormone-based male pills to work perfectly (which they really need to do) varies with a man’s ethnicity. Works for some, but not all. This issue alone may prove fatal for the male hormone pill.

Besides this, there is a litany of concerns regarding the physical side effects of a hormone-based male pill. Immediate concerns have been a big issue in past trials- adult acne, weight gain, moodiness and the like. But what about possible long term effects? The female contraceptive pill has been linked with higher rates of heart disease and breast and liver cancer in women. Although not completely comforting, at least we know these issues in women. But little to no research has addressed similar issues with long term “pill” use in men.

Despite all of this, there is still a healthy interest in a male birth control pill. Studies have shown that men in committed relationships are more interested than single men in a pill– no surprise here. Single men are interested in using condoms for the added bonus of protection against STDs. A male birth control pill might also be a better contraceptive alternative for men who want more control over family planning than that offered by vasectomy. That said, there is still the eternal question of whether or not a pill would sell successfully– would women, in the end, trust their partners to be consistent and compliant in taking the pill? The answer to this question varies from couple to couple, but to get a sense of things, ask yourself how often you fail to take something as simple and uneventful as a daily multivitamin to get an idea of the magnitude of this problem.

There simply aren’t enough options for male contraception on the market today. The main ones are abstinence, rhythm method, withdrawal, condoms, and vasectomy. Given this lineup, there is certainly room for more, and more reliable, contraceptives for men. One thing seems reasonable clear: given the safety and effectiveness of vasectomy, and fact that daily compliance is not needed to keep it effective, anything new has to be this good or better. How about a truly reversible vasectomy? Or a long term, implantable hormonal device? In the end, these are likely to become tasty alternatives to a male pill.

Barrier contraception faces stiff competition...

Hold on now. Wait a minute. Don’t get too excited. If you thought “pulling out” was a feeble and ineffective method of contraception for the reckless and unprepared, well it is. At least at first glance. But given that at least 38 million couples use it worldwide, coitus interruptus warrants a second look. 

Coitus interruptus, with its ancient yet undistinguished history, is very easily dismissed as an effective contraceptive because of the widely accepted belief that the pre-ejaculate contains sperm. There is actually no conclusive evidence that this is the case. No one has actually found sperm in pre-ejaculatory fluid. In addition, it is all-natural, organic, hormone- and side effect-free, and affordable. It needs no tool that nature hasn’t already given us, except rigorous and unerring self-control. Well, in fact this is the big downside. Who has rigorous and unerring self-control? We are men, not robots. Pulling out doesn’t protect you from sexually transmitted diseases, either.

That said, a recently published study has shown for the first time in the modern era that withdrawal is more effective a contraceptive than one might think. Maybe we should look at the pull-out with a little more respect. The withdrawal method, when used with perfect technique, has a 4% failure rate. This falls behind vasectomy (0.1%), birth control pills (0.3%), IUDs (0.6%), and condoms (2%), but not by much. The actual (real life) failure rate is likely somewhere between 15-25%, which is really not far behind the actual failure rate of condoms, at 10-18%.  So withdrawal is not that bad after all, only a little less effective than condoms. Perhaps men deserve a pat on the back for this. Well done. 

However, if this were a contraceptive pill, a 15% failure rate would send its inventors back to the drawing board. For coitus interruptus is inherently flawed, and women who seek more control over whether or not they become pregnant are more likely to reject this method over the long term. One study revealed that women of higher economic status and education are more likely to insist upon a more surefire method of contraception. It appears that women simply don’t trust men’s timing, their control, and perhaps even the male sense of responsibility when it comes to contraception. They want more control in the matter. What does this mean for a male contraceptive pill? More on that next week.

Thoughts as elemental as the ocean

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

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

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

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

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