Turek On Men's Health » IVF

Reversing Vasectomy Reversal Thinking

Paul Turek, MD — Mon, 21 May 2012 15:00:17 +0000

My favorite drawing of the epididymovasostomy procedure (Courtesy: Netters Images)

You had your wings clipped and now you want more children. What’s a guy to do? Well that depends on who you ask. Your choices include vasectomy reversal or sperm retrieval and assisted reproduction (IVF – ICSI).

Doctors who perform IVF – ICSI might say that vasectomy reversals don’t work. Doctors who do vasectomy reversals say that they do. Other doctors fall in somewhere in the middle and say that “younger” vasectomies are reversible but “older” ones are not. Again, what’s a guy to do?

Facts about Fatherhood after Vasectomy

To get a handle on this, let’s start with the irrefutable facts of the case:

Where does conception occur? Vasectomy reversal allows for conception in the bedroom, whereas it occurs in a fluorescent-lit laboratory test tube with IVF – ICSI.
Who pays? If insurance does not cover either approach, then vasectomy reversal is always cheaper than IVF – ICSI.
Who gets procedures? Reversal involves surgery on the man but not the woman. IVF – ICSI involves procedures on both partners. Good to know if you like sharing such things.
How quickly can we get pregnant? Time to conception is generally faster with IVF – ICSI than vasectomy reversal.
What is the risk of twins? The chance of having twins or higher multiples is 1% with vasectomy reversal (i.e. sex) and 40% with IVF – ICSI.
What is the risk of birth defects? The chance of having a child with birth defects is twice as high (10% vs. 5%) with IVF – ICSI compared to sex.

The Problem of the Older Vasectomy

As I apprise patients of these facts in my daily practice, it recently occurred to me that the issue of the “older” this or that surfaces a lot. I have published research that speaks to relative performance of vasectomy reversal and IVF-ICSI with female partners who are less than 38 years old. I can also address the success of either approach in cases of older men. But there is much less information about the true reversibility of “older” (more than 15 year old) vasectomies. Is there any truth behind the statement that older vasectomies aren’t worth reversing? I really needed to answer this question and so I put my research hat on to do it.

Probably the biggest issue with the “older” vasectomy is that, just like a tire that is continually being filled, a physiological “blow out” of the system is more likely to be observed at reversal. It’s not dangerous or anything, but it does mean that a more “involved” procedure, termed epididymovasostomy, is needed at reversal to restore connectivity and fertility. And, by the way, the epididymovasostomy is one of the hardest microsurgical procedures to perform well on this good earth. So, knowing more about how often “blow outs” happen as vasectomies age could be very informative for doctors and patients alike.

For 25 years the prevailing thought among surgeons is that the rate of “blow outs” increases linearly as vasectomies age. Published algorithms and nomograms confirm the thinking that, given enough time, every vasectomy will “blow out” and need an epididymovasostomy instead of a vasovasostomy to restore sperm counts and fertility. And, as epididymovasostomy success rates are not as good as simpler procedures at reversal, this means that vasectomy reversal success rates should indeed fall with vasectomy age.

But what if it’s not true? What if the occurrence of “blow outs” does not rise along with vasectomy age? If true, then older vasectomies would be much more reversible than previously thought. And the return of sperm counts should be higher in older vasectomies than one would think. Voila, this is precisely what our new research shows and will be presented at our annual international urology meeting in Atlanta tomorrow. I guess that I agree with Don Miguel Ruiz when he said: “It is always better to ask then to make an assumption.” Stay tuned for the findings!

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.

The Essential Beginnings of a Vitamin

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

Petroglyphs and Paleo: Inspiration for Essential Beginnings

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

Do Vitamins Treat Cancer?

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

Do Vitamins Help Men Conceive?

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

The Idea of a Male Prenatal Vitamin

This study changed my worldview to the following:

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

The Essential Beginning

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

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

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

A Year Without Answers

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

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

This is a guest post from a patient who lives in Europe. He recently recontacted me about his experience with male infertility and how it affected him. Moved by his story and by his emotional fortitude, I asked him if he could share his remarkable journey with others.

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

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

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

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

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

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

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

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

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

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

Rise of the Instant Family

Paul Turek, MD — Mon, 09 Jan 2012 16:00:47 +0000

IVF: The elephant in the nursery room

Using sex to conceive, the chance of having twins or higher multiple births is about 1-2%. With assisted reproduction, including intrauterine insemination (IUI) in the office and in vitro fertilization (IVF) in the lab, the chance of twins, triplets or high order births ranges from 30-50%. That’s quite a big difference!

Twins have fascinated us for eons. They run in families but a twin gene has not been found. More twin babies grow up to be left handed than you’d expect, and identical twins built of the exact same genetic blueprint have similar brain wave patterns and may think the same, but have different fingerprints.

Since records have been kept starting in 1915, our multiple birth rate has been stable at 1-2% throughout most of the last century. IVF arrived in 1978 and is now 33 years old and is now performed over 120,000 times annually. One would expect it to affect our birth rate numbers at some point. Well, the data is in and it has.

The Instant Family

The Centers for Disease Control and Prevention (i.e., CDC) just published the information on twin births over the last 3 decades (1980-2009). Here are the key findings:

The twin birth rate rose 76% over this time, from 19/1000 births to 33/1000 births.
In 2009, 1/30 U.S. births was a twin compared to 1/53 babies 30 years ago. Among multiple births reported in 2009, 96% were twins.
Twin birth rates increased by 100% in women ages 35-39 years and by over 200% in women ages 40 years and older.
If the twinning rate had not changed, almost 1 million fewer babies would have been born over the last 30 years.

Since only about 1/3 of the rising twin rate can be ascribed to older moms in the study, this leaves the rise of IVF and fertility treatments as the only elephant left in the room.

An Epidemic of Multiples

Although convenient for many couples as the entire family is complete with a single birth event, the twinning epidemic has other implications. Here are some of them that concern the CDC:

Higher risk to moms health (eclampsia, gestational diabetes)
Higher rate of premature births
Less healthy, smaller sized babies (about half of twins)

When I see those twin strollers while walking down the street, I think “chock it up to technology changing the face of humanity yet again.” For the couple pushing those strollers, you will never seen bigger, or more tired, smiles. In the words of Josh Billings: “There are two things in life for which we are never truly prepared: twins.” But there is something to be said for getting the family built in one fell swoop.

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…

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.

Busy as Birds and Bees

Paul Turek, MD — Sat, 12 Mar 2011 16:04:21 +0000

Birds do it, bees do it. Even educated fleas do it…

I paused and peered over the microphone at the audience. My first words were “I thought you’d never ask.” And I mean’t it. My lecture at Stanford Universitywas not conceivable two decades ago. But last week was different.

The Most Common Genetic Disorder in America

The audience was filled with cystic fibrosis patients. Cystic fibrosis is a common inherited disorder that is due to a defective gene that results in abnormally thick and sticky mucus. The mucus builds up in lung passages and elsewhere and results in life-threatening lung infections and digestion problems. Cystic fibrosis is uniformly disabling and deadly.

In 1959, a child with cystic fibrosis survived an average of 6 months. In 2008 cystic fibrosis patients lived an average of 37.4 years. Recent data also shows that 40% of adults with cystic fibrosis are married or partnered. As they live healthier and longer, the minds of cystic fibrosis patients have naturally wandered to thoughts of the birds and the bees.

The Birds and the Bees: Fertility and Cystic Fibrosis

The Stanford Cystic Fibrosis Center asked me to speak about fertility and cystic fibrosis. Absolutely my honor. The fact that these patients are now old enough and strong enough to contemplate having children is a testament to advances in medical care and their personal fortitude. The message of my talk was that fertility is possible in both sexes and is even pretty close to normal in affected women. In fact, 240 American women with CF were pregnant in 2008. Men with cystic fibrosis tend to be missing parts of their reproductive tracts and require sperm retrieval(and their partners assisted reproduction) to become fathers.

Dying for What You Believe

As I was preparing my talk, I was overcome when I learned that simple childhood sniffles or sleepness nights can be life threatening to cystic fibrosis parents. The fabled nurturing instinct to care for their young, the sheer essence of parenthood, present throughout animaldom, can be a lethal reflex for cystic fibrosis parents. Add this to the normal heroic effort needed to raise children and your find yourself staring down the very definition of the words “commitment” and “courage.” That’s why I was honored, and frankly inspired, to speak that day and will be honored to speak again. Because, in the words of Lao Tzu, the ancient Taoist philosopher: “being deeply loved by someone gives you strength, while loving someone deeply gives you courage.”

The Skinny on Holiday Cards

Paul Turek, MD — Sat, 01 Jan 2011 18:20:54 +0000

The real meaning behind holiday cards for us.

“I want the holiday card with three of you on it” is what I tell my infertile patients at our first meeting in the office. Even if that visit occurs in February. In fact, this sums up much of what I think about infertility care:

The solution to infertility is a path that may take time to travel.
I will travel the path with them.
When all is said and done, I want what they want: a child for them.
They are part of The Turek Clinic family and not just clients.

It works. This holiday season, we received hundreds of cards, enough to fill a wall in the Clinic. And the notes that accompanied them were fabulous. One man apologized that he was remiss in getting a semen analysis done after his vasectomy reversal, but after receiving this card with a new baby in it, he knew that I would understand why. Another wrote that although he didn’t expect me to remember helping him back in 2001, looking at his son often reminds him of how lucky he was to have met me. Just as satisfying, the address on that envelope read “ The Turek Clinic Family.”

The paths that couples take to conceive are many and varied. They are influenced by wishes and dreams, strongly held beliefs, and the realities of age, timing and finances. Regardless, I do not tell couples which path to take, but after presenting them with all options, walk with them on the path that they choose.

This is a different kind of care as it encourages healthy, informed patient decisions. It is also empowering to couples because, whether they know it or not, they are best suited to make decisions about their lives. And couples want to make the best decisions, but the lack of accurate and helpful information about choices often hinders this process. I have found that this approach creates enormously and mutually strong and satisfying bonds with patients in a currently fragmented health care system. Reading a few Yelp reviews will convince you of this.

I don’t know who said this but it fits the bill here: “Good friends are like stars…. You don’t always see them, but you know they are always there.” Receiving so many holiday cards at The Turek Clinic is a magnificent reminder of this.

Babies…Naturally

Paul Turek, MD — Sat, 14 Aug 2010 15:35:08 +0000

The magic bullet? You decide.

In my daily fertility practice, while trying to help couples to conceive, I’ve noticed a trend lately. Patients are less interested in using high levels of “assisted reproduction” to have children. In particular, they would like to avoid in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI), the Cadillac of all techniques. Even before they meet me, they have decided against it. Not all couples, mind you, but certainly more than before.

Briefly, IVF-ICSI is a busy month for women. It involves stimulating them with daily, injectable hormones during the first half of the menstrual cycle to generate more eggs than normal within the ovary. Ovulation of eggs is induced by injection of a second hormone, which is closely followed by egg retrieval using needle aspiration under anesthesia. Retrieved eggs are then stripped of their cell coats in a dish and a single sperm is individually injected into each egg by an embryologist. The criteria for choosing sperm are: good looking and hopefully moving. Eggs then become embryos in a Petri dish and are transferred back to the female reproductive tract three to five days later, depending on how they develop. Extra embryos can be frozen for future use. A pregnancy test is obtained two weeks later.

As a male fertility specialist whose practice mantra has been “treat the male, cure the disease,” I find this trend very interesting. Assisted reproduction is almost always an option for couples, but I have spent a good deal of time publishing research showing that classic male infertility treatments such as varicocele repair and vasectomy reversal are very cost-effective ways to conceive compared to more expensive techniques like IVF-ICSI. On the other hand, these techniques are the only option for many men with azoospermia, or the absence of ejaculated sperm, and I am glad that it exists for this.

I wrote down what patients said when I asked them why IVF-ICSI is not an option on the table for them and here are some of the responses:

“It seems pretty invasive and unnatural.”
“Isn’t it relatively new?” (IVF is 32 years old, ICSI is 18 years old)
“Who selects the sperm?” (Since it is not God or Darwin)
“Wasn’t ICSI developed as an experimental mistake?” (Yes)
“How do we know that those are our eggs and our sperm? (Rare)
“It’s only a single try at having children.” (Maybe two)
“Isn’t there an issue with higher birth defects and syndromes in babies” (Very likely)
“Are our children going to be infertile?” (Unknown)
“We’d prefer to have the hope of trying every month at home.”
“IVF-ICSI is too expensive”

What I think is happening is that as IVF-ICSI is being offered to consumers more often than ever (currently 1-2% of U.S. babies are born from these techniques), patients are becoming better educated about the technology and are making more informed, personal choices. My gut also says that good, old-fashioned sex has a strong following among infertile couples as a way to conceive. In the words of Woody Allen in Annie, “that was the most fun I’ve ever had without laughing.”

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.

Once Upon a Time in Barcelona

Paul Turek, MD — Thu, 26 Mar 2009 16:12:03 +0000

The Sagrada Familia, A Gaudi inspired sand castle-like cathedral in the center of Barcelona Spain

While in Barcelona recently, meandering through the Parc Guell and Sagrada Familia, the weight of what happened earlier that day hit me. I reveled, as anyone might, in the outlandish works of Gaudi, but a part of me remained sober, due to my participation in a debate at a men’s health conference. By the end of it, I realized that men in this country simply don’t get the treatment they deserve.

Are infertile men better served by fixing their infertility problem, or bypassing the problem and using IVF instead to build a family? My opponent was a well-known men’s health specialist from Germany. We butted heads on a variety of issues. But we strongly agreed that although some cases of infertility may not be treatable, all cases merit a thorough evaluation. This is because the cause of infertility could be an underlying medical problem with serious ramifications. Infertility can be a window into a man’s future health. Men not only deserve such an evaluation, they are owed it.

To provoke my opponent and cause a little drama, I said that IVF was the worst thing to happen to men’s health in the U.S in the last thirty years. Most infertile men in America receive only a semen analysis, and never get a proper examination. I estimated that only ten to twenty percent of U.S. men with infertility receive a formal urologic evaluation. The fact is that most infertile men stateside simply get no real medical care.

My audience’s visible disbelief at these statements revealed the huge divide between socialist health care systems in Europe and our own. In Germany and Spain, it is not simply advised, but mandated that both infertile partners receive a full workup, prior to considering treatment. Why pay through the nose for IVF when you may not need it? I had no idea that European countries’ approach to men’s health was so progressive. Surely, for the sake of men’s health, a similar mandate is a fundamental and worthwhile goal of any proposed national health care package in America.

What we found: Male infertility and Cancer