Turek On Men's Health » no scalpel vasectomy

A Dozen Funny Reasons for Vasectomy

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

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

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

Why do Men Get Vasectomies?

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

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

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

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.

I’ve Been Googled!

Paul Turek, MD — Sun, 12 Jun 2011 06:24:46 +0000

Lecture in the Palazzo Vecchio: Where do you go from here?

I’ve given countless lectures in innumerable countries over the last two decades, but I am most excited about the one I am giving next Wednesday. Google has asked me to speak to them during Men’s Health Week. Right down the road at the Googleplex in Mountain View, in the very heart of Silicon Valley.

The Google Invitation

I was enamored when asked to speak at the Palazzo Vecchio in Florence, beneath Vasari paintings. I was excited to lecture at the University of Istanbul and spend a day staring at the timeless space that is the Hagia Sophia. And I still jump at the chance to advise our government (the NIH) on matters of men’s health as I feel I may actually be influencing the direction of medical care in our country.

But an “ask” at Google, although not as architecturally or nationally historic, is still an important one, because I may, in some small way, directly influence health care attitudes and awareness among a group (young men) that I consider “medically underserved” for various reasons.

Google didn’t exist 14 years ago. Five years ago, the word “Google” was included as a verb in legendary and authoritative Oxford English dictionary. (“He’s been googling all day.”) Lately, I have the impression that Google may be taking over the earth as we know it. A lecture at Google therefore, offers not only the opportunity to bring medical awareness directly to men, but to a population of men who either are or will be primary “influencers” of other men.

Google Health

Although collectively they may understand all of the secrets of the digital universe, at the end of the day, Googlers still eat, sleep and procreate like the rest of us. Google Health, guided by the moniker “better health comes from better information,” is a recent health and wellness initiative at Google that has taken this quite seriously. It offers nifty tools for anyone to maintain their medical record, set personal goals, track progress with personalized tools, and share health information if they desire.

Personally, I think this is an excellent program for young men since, as a group, they 1) tend to feel immortal and 2) absolutely live for numbers and data. And what numerical trend in their lives is more important to realize and act upon than that suggested by their own bodies? It’s similar to the vintage Maserati with gauges that actually work.

Advice to Google on Sexual Health

My advice to them during Men’s Health Week is contained in a talk entitled “A Guy’s Guide to Maintaining Sexual Health.” What do I mean by sexual health? Issues with erections, sex drive, hormones, fertility, testis cancer, contraception and sexually transmitted diseases. Here are the main points that I’ll make:

Having sexual health issues is an easy way to keep from feeling truly immortal.
Most sexual health issues are easily treatable.
Sexual health is intimately tied to overall health
Therefore, a better understanding of sexual health issues will help you on the path toward immortality.

Remember, your body is the only place you have to live; don’t treat it as though you are renting it. I will see you on Wednesday.

The Secret Life of a Microsurgeon

Paul Turek, MD — Sat, 23 Apr 2011 15:09:50 +0000

Try doing this with suture much smaller than the finest human hair…

A recent study on hungover surgeons suggests that they are slower and sloppier after a night on the town. Get them toasted, let them sleep it off and they can’t perform surgery on par the next day. Not surprising findings, given the physical and mental demands of many surgeries. But quite alarming for patients who will quickly forgive a heart surgeon for having a terrible personality, but expect and demand that a surgeon be at the top of their game when operating.

Study of Sloshed Surgeons

Eight experienced surgeons and a bunch of medical students were treated to dinner in a restaurant and were instructed to drink until they felt intoxicated. They were then driven home and picked up again the next morning. Brought to a laboratory, they performed virtual reality (fake) surgeries at 9am, 1pm and 4pm. At 1pm, their skills were the worst, but at all three time points, they performed simulated surgeries below baseline, even though they were technically sober at the time of testing. So, surgeons are people too. The problem is that they wield scalpels.

As a microsurgeon, I shuttered when I read this study. It violates the mantra of centeredness that many of us adhere to religiously in practicing such a high art. And although any surgery can be challenging and take years to master, microsurgery places a unique demand on the surgeon: to fix things that are utterly invisible to the naked eye.

The Microcosm of Microsurgery

How demanding is microsurgery? Demanding enough that you would certainly not want your microsurgeon to rave all night before your procedure. In vasectomy reversal surgery, we routinely reconnect tubes that are less than 1/10th of a millimeter in size, slightly bigger than the absolute limit of human hand-eye coordination. For perspective, here are a variety of other dimensions in this subatomic universe:

Thickness, credit card 0.76 mm
Diameter, human egg 0.12 mm
Diameter, average human hair 0.1 mm
Diameter, human vas deferens opening 0.1 mm
Average thickness, plain sheet of paper 0.09 mm
Length, human sperm cell tail 0.04 mm
Limit of human motion 0.03 mm
Wavelength of light emitted by a carbon dioxide laser 0.0011 mm

What’s the Surgeon’s Secret?

The secret of expert surgeons is the same as that of any Olympic-caliber athlete. Natural skill and experience are assumed. If your outstretched hand has a visible tremor, you should probably avoid microsurgery. More importantly, however, are consistency and discipline, which are the true hobgoblins of great surgeons. With this Tao in mind, drinking binges are unacceptable for a master surgeon. Regarding coffee, its allowed, but just drink the same amount every day. Stay consistent. Play sports and keep fit but don’t expect to be Picasso if you’ve thrown a shoulder, your back or sprained a finger-playing ball. Pain diverts critical mental and neuromuscular energy away from the task at hand. Best to heed the words of Aristotle on this: “We are what we repeatedly do. Excellence… is not an act, but a habit.”

But should we define recommendations for alcohol use by surgeons before procedures as the study authors suggest? Fine with me. But what about pilots, school bus drivers and cabbies, to name a few other professions, who also take other’s lives in their hands?

That Azoospermic Feeling

Paul Turek, MD — Tue, 08 Feb 2011 06:09:48 +0000

Was Van Gogh Azoospermic?

At the beginning of the office visit, I like to ask men with no sperm in the ejaculate who are unable to conceive a simple question: “What crossed your mind when you first heard that you were azoospermic?” The answers varying greatly but are very telling:

“It must be a mistake.”
“I shouldn’t have joined that fraternity in college…”
“It wasn’t the best sample I’ve ever done.”
“I was simply and utterly devastated.”
“I was in shock and then got really depressed.”
“It changed my life…I always thought that I would be a father.”

The Meaning of Azoospermia

Azoospermia is the lack of sperm in the ejaculate. It can be due to a blockage in the system (obstruction) or failure of the testicles to make sperm (nonobstructive). The most common reason for blockage is a vasectomy. Other causes include infections, prior surgery, injury or congenital absence of certain reproductive tract organs. Failure to make sperm can be due to exposures (hot tubs), medications, varicocele, a history of undescended testicles, cancer and cancer treatment. However the largest chunk of men with poor sperm production have none of these issues. Instead, they have a subtle genetic cause: either they are missing genes on the Y chromosome or have other chromosomes harboring subtle alterations that do not otherwise affect their health or lives.

So, like Captain Renault in the movie Casablanca, most men with azoospermia are “shocked, shocked!” because they feel so normal in every other way. And the vast majority are normal (as normal as men can get) in every other way. Most of the things they worry about, like college indiscretions, are exposures that are entirely reversible with time. My response is usually to allay fear and guilt by saying: “This is not something that you have done to yourself; let’s see if we can do something about it at this point.”

Treating Azoospermia

In fact there is a whole lot that we can do with azoospermia. Men with blockages can often be unblocked with microsurgery, one of my favorite things to do. This gives them the chance to conceive naturally again. And most men with poor production as a cause of azoospermia will have pockets of sperm in the testicles that can be identified by techniques like sperm mapping and that can be used for high-technology pregnancies.

What I have learned after caring for hundreds of azoospermic men over two decades is that they really don’t care what their sperm counts are as long as they can be fathers. And once they are fathers, it is clear that that “azoospermic feeling” goes away, as it should.

The Low Down on Being Knocked Up

Paul Turek, MD — Sun, 19 Dec 2010 00:01:24 +0000

Vasectomy reversal: a sprinkle of art and architecture with biology.

What drives pregnancy rates after vasectomy reversal? Lots of things. The judgment and skill of the surgeon are critical as not all surgeons are the same. Two operations are possible during reversal surgery (vasovasostomy or epididymovasostomy) and choosing the correct one for each side of each patient involves deft surgical judgment. After the type of procedure is chosen, the skill comes in making it all work in some of the smallest organs in the body. To provide perspective, the suture used for this surgery is about 1/5 the size of a hair and is not easily visible to the human eye. The tubes to be reconnected are about 1/10 of a millimeter in diameter (100um) and can test the absolute limit of controllable hand motion (2-3 um). Doing this right takes training, experience, focus, control and good jazz in the operating room. The result is a “patency” rate, or sperm in the ejaculate.

But even with sperm returning to the ejaculate, the natural pregnancy rates are not the same as those in couples without a vasectomy reversal. Why? Think of it this way, you measure your surgeon by the patency rate, which is a technical issue. However, pregnancy rate is a biological outcome that involves many more variables. For example, we have published that female fertility potential is the single most important factor in pregnancy success after reversal. Since it can take up to a year after vasectomy reversal surgery to conceive, I recommend that female partners >35 years of age consider an evaluation of their fertility potential (i.e. get an answer to the question: “Do I have a year of time to conceive?”); I insist that women 37 years of age consider this evaluation and with a stern gaze, I very strongly recommend that women >40 years of age undergo this evaluation. I do this because my goals are aligned with those of patients: at the end of the day, my greatest reward is a holiday card with a kid in it.

Say that the sperm counts are good after reversal and the female partner is young. Why wouldn’t this couple conceive after reversal? Technically, a 30-year-old woman trying to conceive with an unvasectomized partner has a mean cumulative fecundity (pregnancy) rate at 1 year of about 85%. With a vasectomized and reversed male partner, this rate is about 65%. Not a huge difference but a real one.

To explain this, we need to introduce the immune system. Men who have a vasectomy essentially become “inoculated” to their sperm, similar to a mumps or flu vaccine. The immune system actively develops antibodies to sperm and this reaction eventually wears off with time. But, the immune system also has a fabulous memory, for which we are all grateful. Hence, at the time of vasectomy reversal, the immune system becomes inoculated again and antibodies to ejaculated sperm are generated. All things being equal, antisperm antibodies are likely the reason why pregnancy rates after vasectomy reversal are lower than expected. Since the immune response after reversal also wears off with time, this may also explain why it takes longer to conceive after vasectomy reversal.

What’s so incredible about all of this biological and surgical action and reaction, is that gobs of beautiful babies are more likely than not to be the result. Someone, somewhere has prioritized reproduction in the grand scheme of things. As Thoreau said: “Nature is full of genius, full of divinity; so that not a snowflake escapes its fashioning hand.” A toast to the beauty of biology.

The Condom Cha Cha

Paul Turek, MD — Mon, 13 Dec 2010 04:17:23 +0000

Sometimes doing the dance gets old…

It is hilarious and it happened again recently. I had just finished his quick and painless no scalpel vasectomy and was about to hand him his signed “diploma” (really) for “meritorious performance and uncommon bravery” when he said it. Just as the others had said it, with that screechy, high-pitched, Vienna Boy’s Choir voice: “Nice job doc; it didn’t hurt a bit!”

Even though it was made in jest, this comment suggests there is something about the culture of men that equates vasectomy with castration. The truth is that vasectomy is the most successful contraceptive available bar none and, unlike female oral contraceptives, requires virtually no compliance to maintain its effectiveness. It does not alter sex drive, erections, sensation, ejaculate volume or testosterone levels. In fact the way testosterone leaves the testis to supply the rest of the body is through an entirely different route (the bloodstream) than that taken by sperm (the vas deferens).

Nevertheless, something is removed, or different, after a vasectomy. Maybe it’s as simple as shooting blanks instead of having both barrels loaded. Maybe it’s the association of virility with the ability to sire offspring that defines Western culture, although you wouldn’t know this based on the meager birth rates in Western civilization of late. Maybe it’s the utter irreversibility of the decision to have a vasectomy performed. Whatever it is, it bubbles up and surfaces now and again in the gesture and guise of this faint, prepubertal voice.

Because of this subtle yet pervasive response to vasectomy that I have gleaned from patients, I now make it a point to counsel men before the procedure not only about what actually gets altered (fertility) with vasectomy but also what is preserved, which is essential maleness. In fact, many men feel liberated afterwards, not only from the anxiety of unwanted pregnancies but also from the “Condom Cha Cha” of their acne-filled youth to which they might prefer never to return.

I also discuss the fact that men should feel comfortable with the idea that vasectomy is a reasonable form of contraception for the “near future” as the idea of it being drop dead permanent can be seriously off-putting to many reasonable candidates. Simply stated, men’s lives are not filled with that many decisions that hold an equal weight of sheer permanence as that of vasectomy. This is also where the concept of sperm banking and sperm retrieval enter the conversation as ways to preserve or restore fertility after vasectomy. And, given the fact that 5-7% of U.S. men choose to have a vasectomy reversal in the U.S. alone is strong testament to men’s desire to continue to exercise reproductive choice in the face of what was previously understood to be a permanent decision.

So, my take on the shrill, jocular “thanks” occasionally offered after vasectomy is that it represents the well-informed response of the emancipated man who accepts that his manhood has nothing to do with how far his sperm travel.

Bringing It Home

Paul Turek, MD — Sun, 07 Nov 2010 05:46:28 +0000

It's the age of William Carlos Williams all over again.

The workday was winding down. I made a cup of tea and pulled up the dashboard on my computer to review the progress of my patients after surgery. Everyone was progressing beautifully…but one. He reported that his pain had increased over the last 2 days. So I called him on his cell phone:

“John, it’s Dr. Turek. You seem to be having more pain than before after your surgery. Is everything OK?”
“Dr. Turek?? Wow! Yes, everything is fine. I stopped my pain pills yesterday and also went back to work. I guess I pushed it a bit.”
“No problem, John. Just making sure.”

That, my friends, is the new face of great medical care. Taking care of patients in the moment, where they live. Your doctor watching over you when you need it the most.

It’s called Healthloop.com and what a great asset it is to my practice. Why? Because men simply don’t call. However, they will tell you what’s happening on a secure website when asked about how they are doing after surgery. In fact, they will even take the opportunity to “tweet” me on Healthloop when they might not know exactly how they should be doing.

The brainchild of a physician-colleague named Dr. Jordan Schlain, Healthloop is a medical work of art at the vanguard of a whole new field of medicine called “home-based care.” What’s revolutionary about this concept is that it helps patients stay at home, obviates travel to the doctor’s office, opens up new lines of communication and empowers patients. It is also a practical and inexpensive alternative to the vaunted “house call” of generations past. I offer it to every patient under my knife.

The time is now for remote monitoring—taking care of patients from afar. Aged patients are less mobile and harbor more chronic conditions that may just as well be watched from home. In addition, technology is now more widespread (Healthloop is web-based), miniaturized and portable than ever. Finally, there is a constant push to reduce healthcare costs and what better way to do that than by helping patients avoid doctor’s visits or even emergency room visits.

What I like most about home-based care is that it engages patients in self-care as never before. And with young men, the added communication with a provider is empowering. As John said: “Thanks, Dr. Turek…it’s nice to know that my body is healing normally after surgery.” The house call is back. William Carlos Williams would be proud.

The Age of Aquarius

Paul Turek, MD — Sun, 19 Sep 2010 02:11:58 +0000

Is this the dawning of the Age of Aquarius?

It really seems like the moon is in seventh house, and that Jupiter is aligned with Mars. Why? Because our government gets it and want to know how it can help.

Last week, I spoke at a stakeholder meeting about men’s reproductive health, held at the Centers for Disease Control (CDC) in Atlanta. You may have heard of the CDC, begun in 1946, as the American government’s disease surveillance unit. Answering to the executive branch of the government and not to Congress, the CDC has a storied history over the past 60 years, being integral to the worldwide eradication of smallpox and to the control of measles and rubella and more recently, HIV. And who can forget the role that the CDC played in identifying the cause of Legionnaires disease, toxic shock syndrome and SARS? Well now they are interested in men’s reproductive health. You gotta believe.

What’s wrong with men’s reproductive health care in the U.S.? Well, in a sense, it doesn’t exist. Most men who are infertile do not get the care that they should; most male sexual health issues are verboten topics for public discourse; and men’s roles in family life and contraceptive planning are paltry at best.

It warms my heart to know that among all the government branches that could have taken men’s reproductive health seriously, the CDC has picked up the ball. After all, they are interested in assessing populations at-risk and controlling epidemics. And that is exactly the kind of thinking that will improve men’s reproductive health in the U.S., a condition that could certainly be termed an epidemic. A couple of years ago, I wrote an NIH grant (that was funded no less!) to help train male reproductive specialists at UCSF that began with the following sentence: “Men’s reproductive health is a large and underserved area of medicine in the U.S.” Amen.

This first-of-its-kind meeting was brimming with excitement. Attended by non-profits, academics, urologist thought leaders and numerous federal agencies, it was clear that the time had come to rethink the way we take care of young men. The definition of men’s reproductive health that guided the discussion was “the ability to have a responsible, satisfying and safe sex life and the capability to reproduce and the freedom to decide if, when and how often to do so.” In this context, awareness, public health, barriers to care, messaging, resources, engagement, and communication were terms addressed as if this topic were a true, national epidemic. In the words of Wallace Stevens: “Thought is an infection. In the case of certain thoughts, it becomes an epidemic.” For the good of a large chunk of our population, let’s hope that this issue goes viral.

The Man in the Mirror

Paul Turek, MD — Sun, 05 Sep 2010 04:50:57 +0000

For best fertility: look in the mirror

What is the most commonly asked question in my male fertility practice:

“What can I do to improve my sperm count?”

My answer:

“Treat your body like a temple; all things in moderation.”

I’m sure that this is a disappointing answer for many men, but it’s true. There are no tricks here. Here’s why: Unlike food or water, which we need to live from day to day and without which something will break down in our lives, sperm production is different.

The sperm making process, termed spermatogenesis, wants to run hard and fast—and all the time. The body is happiest making 1200 sperm/second in the normal healthy male. It would rather make sperm than not, given the chance. It is similar to the heart that wants to beat or to a self-winding watch.

So all one can really do is to try not to poison the sperm making process by unhealthy living. Fevers, illness, tobacco, hot tubs, obesity and poor eating habits are all examples of toxins or exposures that “sicken” the body and slow down sperm production. Stay healthy and sperm numbers should be just fine, thank you. A good reproductive body is a good healthy body.

Of course there are reasons to have low or no sperm counts that do not involve impaired sperm production, including vasectomy and lifelong or acquired blockages, but these are unusual. In addition, with infertility due to genetic causes, low sperm counts are likely the consequence of being handed fewer than normal numbers of testis stem cells, the cells that produce sperm. But even in cases of genetic infertility, the stem cells that are present are working their hardest to make as many sperm as possible. It just may not be enough sperm to get out of the testicle and into the ejaculate.

And yes, we have good ways of improving the sperm numbers in men with low sperm counts, but with these treatments we generally will not improve sperm counts to numbers that exceed those that the man would naturally have if he were healthy.

So, lifestyle and daily habits matter greatly for sperm production and fertility. I know it’s trite, but Michael Jackson was right: start with the man in the mirror.

Freud’s Vasectomy

Paul Turek, MD — Mon, 26 Jul 2010 03:06:14 +0000

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.

One Child China

Paul Turek, MD — Mon, 14 Jun 2010 05:08:59 +0000

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.

Handling The Truth

Paul Turek, MD — Sun, 28 Mar 2010 23:23:24 +0000

Patients can handle the truth…try them.

How would you react to a doctor who, instead of explaining the entirety of your medical options, simply said “trust me, this is the right choice.” Maybe that style of “care” worked a generation or two back, but today’s patients have access to any piece of medical information that their doctors do. Patients want to know as much as they can so they can make the best choices for themselves or their loved ones.

Why do I bring this up? Well, because I got a call the other day from a patient who was seeking for more information about his options for fatherhood after vasectomy. He had an older vasectomy, 25 years or so, and a wife who was 40 years old. He met with two doctors in other cities and asked them about vasectomy reversal and sperm retrieval with assisted reproduction. Both of these are options for vasectomized men. Both urologists said, “forget it!” The patient was stunned. He just wanted information to help him decide how he was going to approach the family building issue. Instead, he received no information, and, without asking, he was told what he should do. Forget it.

Two things are still true after visiting these two doctors:

1. He still wants a family.

2. He knows no more than he did before about how to achieve this goal.

Now what is wrong with this picture? Patients do not necessarily depend on doctors for information; they can get that almost anywhere on the Web. However, they do depend on doctors for wisdom and knowledge–the interpretation of information as it applies to the patient. I believe that life is a journey, one that involves many forks in many roads. Some are chosen and others are not. In the end, there is a story, a memory, of the path that was taken. Making decisions about medical care is also part of the journey that we all take. As doctors, we are obliged to use our experience and wisdom to help patients face decisions and choices that affect their health, their budgets and often their very lives. A patient’s “trust” is earned and is not gifted to doctors. Be their trusted consultant, someone who they can rely on for good solid information and wisdom. Unlike what Col. Nathan R. Jessep says in A Few Good Men, patients can handle the truth.

In my discussion with this patient, I gave him the facts about each choice. Older vasectomies are less successful at being reversed than younger ones, but the results are still very respectable in the right hands. His wife’s age could influence his decision either way, especially if she has limited time left to have children. Pregnancies after reversals of older vasectomies occur later than those after younger vasectomies. Sperm retrieval and assisted reproduction

can be a faster, albeit more expensive, way to conceive. If more than one child is desired, then assisted reproduction can get very expensive compared to vasectomy reversal. No value judgments, just the facts. There are lots of ways to build families and patients armed with good informaton can decide which way is best for them.

It has always been my philosophy as a physician and surgeon to walk the walk with the patient. Even stepping into their shoes and taking the journey with them. This makes good sense in situations in which outcomes cannot be guaranteed. Sure, I will offer an opinion if they ask, “what would you do?” However, in my brief stay on this good earth, I have found that the educated consumer always makes the best choices.

Adding Hope to Health

Paul Turek, MD — Mon, 08 Mar 2010 05:06:03 +0000

How about being happy and hopeful as well as healthy?

The couple had been trying to conceive for 5 years unsuccessfully. The tension and anxiety in the relationship was palpable and strained. They had spent well into the 5 digits to have a child with test tube baby technology (IVF) and yet were still not pregnant. His vasectomy reversal had also failed them. And they were going to try one more time, just once, with me, before calling it quits.

When he came to me for care, he was frankly depressed. Out of money and full of debt, close to losing his job in this economy and in a strained relationship hanging on by a thread, he sat across from me. He looked terrible. “Can you help?” he asked me.

Well I did help. I reversed his vasectomy again and it worked. Fast-forward 9 months and a birth announcement arrives in the office from the couple with a long personal note of thanks on the back. But one line really struck me:

”Looking at her, sleeping quietly, I see her future as an astronaut, the President, a doctor, a lawyer or anything else that she wants to be. She can be or do anything!”

Absolutely unbridled hope and enthusiasm was infusing a mind once filled with almost unfathomable despair. All this change, nine months and one baby ago. Wow!

Talk about a biological drive. Reproduction easily ranks up there with breathing and eating. Not for everyone of course, but for many. I am quite sure that if you surveyed infertile couples about their quality of life with infertility, as has been done in patients with cancer, you would find these diagnoses equally impactful. I have no doubt many of my patients would give up five healthy years of their life to have a child. Maybe even 10. Just because it cannot be assessed by a blood pressure cuff, a blood test, or a scar does not make infertility any less important an affliction.

And yet, despite its profound impact, its ability to tear apart relationships, crush self-esteem and slow down an otherwise productive couple to a grinding halt, infertility is not really considered a disease in many societies, including ours.

Want a more productive and healthier society? Cure infertility. And what about something else that this world could use a lot more of, as expressed by my patient: the resurrection of those elemental feelings that lead us to live good lives and to make the world a better place for those who will follow us.