Hope is a core value of children (Drawing courtesy Sophia Turek, age 7)

In quiet moment on the couch, I recently asked my 8-year old daughter what the word “hope” means to her. “If life were a meal, hope belongs in the steak,” she said.

The food metaphor didn’t surprise me, as with most kids her age, she thinks about it a lot. What did interest me was that, in her view, hope takes center stage. It’s not the cupcake for dessert. Or a sweet milk shake, or potato chips. To kids, hope is serious stuff, right smack in the middle of the main meal. Just a hunch, but I am convinced most adults would not put it there.

A Telling Telephone Call

He called from Kentucky. Having read about our recent research story about obtaining grant funding to build an artificial testicle, he wanted to know more. As a cancer survivor, he had no chance of fathering a child. He asked great questions about where the research was going and the expected time line for generating sperm from stem cells. I answered frankly as I am not a fan of dangling carrots or pipe dreams in front of others. He listened intently and thanked me kindly. I asked him to keep in touch, and that was that.

Little did he know such brief but meaningful conversations stokes my fire and fuels me to imagine, begin, execute and finish such far-fetched research projects.

Little did I know how that single, brief exchange also affected him. The next day, the Clinic received a new Yelp review (don’t get me started on this…just compare the visible reviews on the page with the invisible “filtered” accessed at the bottom). Curious, I read it. It blew me away. It went something like this (edited for brevity):

“H-O-P-E; that’s what Dr. Turek has given me; new found hope…..” After a 16-year nightmare with testicular cancer, once in 1996 and again in 2002, a good friend of mine forwarded me the most shocking, exciting, uplifting, inspiring article I had EVER read. I anxiously and carefully read it word for word, line for line, as I could not believe what my eyes were reading and my mind was comprehending. My instinct, was to call Dr. Turek’s office immediately as I was yearning for more information.”

“After talking with his office staff, a phone conference was scheduled for Dr. Turek and I within the next 3 days…Dr. Turek gave me “me” and he gave the rest of the testicular cancer world a vision that we never imagined possible… I will strive daily to do everything in my power to assist Dr. Turek in seeing this miracle discovery come to life. I will do whatever, whenever, whereever it takes to be a part of this life changing miracle. I am inspired, encouraged, and relieved with the hope of tomorrow for me and for others.”

For the first time in years, the man from Kenucky felt a ray of hope. And in some small way, his life is different today than yesterday.

Hope not Hype

So what is it about being an adult that takes the hope out of our “steak?” Why do long, strong doses of reality make it harder to dream the unimaginable? There is so much promise in hope that I, for the record, refuse to give it up. I agree with the old French Proverb that “hope is the dream of a soul awake.” You can expect more of the unimaginable out of me before my time is up on this good earth.

Related posts:

1. The Recipe for Man Made Sperm
2. The Artificial Testicle: Funded!
3. The Ins and Outs of Male Fertility Kits
4. The Secret Life of Varicoceles
5. Cancer’s Second Hit

Why Urology?

Admittedly, urology is a small, unusual and low-key medical specialty. In fact, for the longest time, my parents didn’t know exactly what I did as a doctor. I kind of like that about it. Feel free to choose a more glamorous, chest pounding, field like neurosurgeon or heart surgery if you like. I’ll stick with urology, thank you. It’s a fantastic balance of medicine and surgery, and involves the care of both adults and kids and men and women. All you have to do is get through six years of surgical training after medical school to join the crowd!

Spreading the Word

Since my time as a decorated professor at UCSF, I have been committed to getting students interested in our little corner of the medical world. This effort has resulted in the publication of a national curriculum for teaching urology to U.S. medical students now hosted on our leading society’s website. As popular as it has become, it is really an essential national resource for the field of urology as it slowly gets squeezed out of the tight, full schedules of medical students nationwide. For some reason, pharmacogenomics now matters more than prostate cancer in medical school.

Even with this under my belt, I felt that more was needed to get students turned on to our specialty. We needed to hear from real life urologists, both those in training and at the top of their game, and see why they chose this field. The field is ripe with superb mentors and I wanted to show them off. So, with the help of our national society, we recently created a short video in which urologists talk about why they chose this field. Well, “Why Urology?” has certainly hit the ground running,  and just garnered a national marketing award in its first several months of life!

Love what you do, make a difference doing it and spread the word. These are the tenets of my life in medicine.

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1. The Expert in Each of Us

Kokopelli, the ancient fertility symbol.

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

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

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

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

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

Preserving Male Infertility

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

Restoring Male Infertility

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

Related posts:

1. Keeping the Family Jewels Shining
2. The Quiet After the The Storm of Cancer
3. How Are Stem Cells Like Wine Grapes?
4. The Orchid in the Arctic
5. The Recipe for Man Made Sperm

Google: Feels like college all over again…

Got a slice of Google life this week with a lecture and lunch on the Googleplex campus. Here’s the Google wrap up. Now, this is a company with great ingredients for a healthy work life: Yoga and massage classes, personal trainers, free bicycles, three squares a day, an on-site doctor, haircuts, car washes, dry cleaning, rubber exercise balls everywhere, and health and wellness lectures at lunch. In the words of CEO Eric Schmidt “The goal is to strip away everything that gets in our employees’ way.” Nothing like the corporate America of yesteryear. Truly, a very tasty wrap.

The Guy’s Guide to Maintaining Sexual Health Talk

My talk was well attended and, as far as I could tell, no one fell asleep. Maybe it’s because I kept up the pace. Or, maybe the young Googlers were riveted by my relatively disruptive philosophy how best to identify and care for men’s sexual health issues. If you just can’t wait for the YouTube video to be posted on Google Health in a week or two, here’s the meat of it:

• Young men are medically underserved in America.
• One problem that contributes to this is that their care is fragmented and reductionist in nature since it is provided by various doctors.
• One helpful solution would be to train more men’s health specialists who “own” all aspects of young men’s health.
• Another problem is that men do not have biological reminders, or biomarkers, of their health, unlike the menstrual cycle in women.
• Importantly, sexual health issues such as low sex drive, erectile dysfunction and infertility are intimately relatedto overall health. Examples:
  • Men with erectile function are twice as likely to have heart attacks later in life.
  • Men who are infertile are 2 to 3 times more likely to get testis and prostate cancer, respectively, later in life.
• Maintaining good overall health is a great way of optimizing sexual health. The reverse is also true.
• Sexual health issues should therefore be considered natural biomarkers of overall health for men.
• If we educate men about such natural biomarkers, then they may assume more “ownership” of their health and live healthier, productive and maybe longer lives.

Googlers Care

I have to admit the Googlers surprised me, right off the bat, at start of the talk. Watch the YouTube video and you’ll see. Not surprisingly, when I asked the audience how many of them get regular oil changes for their cars (not knowing that Google provides this service for them), most of them raised their hands. However, when I asked how many of them had been to a doctor in the past year for a personal checkup…again the majority raised their hands. More than I had ever seen among young men. This is a good sign, to see men taking equally good care of their bodies and their cars. I see this as a powerful first step for men to achieve “ownership” of their personal health and wouldn’t you know it, Googlers are leading the way. Happy Father’s Day.

The Talk:

Video -

Slides -
The Guy’s Guide To Maintaining Sexual Health By Paul J. Turek, MD

Related posts:

1. I’ve Been Googled!
2. Adding Hope to Health
3. Eat, Sleep, Reproduce
4. Freud’s Vasectomy
5. Where There’s Smoke

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.

Related posts:

1. Freud’s Vasectomy
2. The Age of Aquarius
3. The Ailing Male Pill
4. You Are The Pill That You Eat
5. The Condom Cha Cha

This white paper is red hot.

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

The Problem with Reproduction

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

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

The White Paper on Reproduction

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

White Paper Themes

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

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

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

Related posts:

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2. The Quiet After the The Storm of Cancer
3. Genome: Repair Thyself
4. Through the Looking-Glass
5. The Skinny on Holiday Cards

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.

Related posts:

1. Adding Hope to Health
2. The Quiet After the The Storm of Cancer
3. Keeping the Family Jewels Shining
4. Metabolomics: The Picture of Fatherhood
5. Babies…Naturally

Freed from the confines of the solitary.

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

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

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

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

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

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

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

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2. You Are The Pill That You Eat
3. Surfing is Life
4. Keeping the Family Jewels Shining
5. Where There’s Smoke

An international symbol of peace…or cancer?

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

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

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

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

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

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

Related posts:

1. Keeping the Family Jewels Shining
2. Genome: Repair Thyself
3. What we found: Male infertility and Cancer
4. Good Job Government!
5. The Quiet After the The Storm of Cancer

How many of these are chasing you?

Whenever I mention to the media that “stress” is bad for male fertility and men’s health in general, they show images of snarling, bumper-to-bumper traffic with heat shimmering off of the asphalt. Sure, that works for stress. But that is not the half of it.

Being stuck in traffic is a form of acute stress, similar to being told that your check bounced, you missed your deadline, or you’re late for that important business meeting for which you planned so hard. Going back 100,000 years, this is same stress associated with being chased by a rogue wooly mammoth. Either way, modern or ancient, the human body responds the same way: by stimulating adrenaline and activating the sympathetic (“fight or flight”) nervous system. Blood is directed to where it is needed most—the heart and muscles–and not to the penis. And the result is loss of sex drive, erections, and lower testosterone levels. Not a great state of affairs for general or sexual health. This response also explains why so many men who are fine with recreational sex hit the skids performance-wise during “scheduled sex” needed for baby making.

More worrisome than the effect of acute stress on health is that of long term or chronic stress. Although more subtle than acute stress, it is far more pervasive in our lives. Do you travel 50,000 air miles or more annually across time zones? Do you change shifts at work? Travel stress and changing work hours (circadian stress) are forms of chronic stress. Do you worry about your finances (financial stress) or workout too much (physical stress)? Is there someone seriously ill in the family or is your love life tanking (emotional stress)? Remember, your body is a very primitive organism and responds the same way to all forms of stress, with the “fight or flight” reaction, ready to run from the wooly mammoth.

So what are the consequences of chronic stress? Well, for both sexes, sex is the first casualty. Intimacy is a close second. Stress hormones lower testosterone production and, as a consequence, sex drive falls. Testosterone is also an important vitamin for mood, muscle mass, male fertility, kidney and bone function and these can also suffer. And must I mention one of the best-studied areas of stress: that of Type A personalities having the shortest “shelf life” on this earth? Is this you? Take the test and find out.

Even more novel is the latest news that humans (like animals) have “clock genes” that control daily, sleep-wake or circadian rhythms. And when these rhythms are upset, as with stress, cancer development is promoted.

My advice: Assess how many wooly mammoths are chasing you, even the small ones. Then, begin a regimen of stress reduction using regular exercise, acupuncture, yoga or massage to get that body of yours tired and relaxed.  In the words of Lily Tomlin “For fast-acting relief, try slowing down.”

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2. Baby Making Tips
3. Weighing Your Options
4. The Curse of Women’s Urine
5. Does Male Infertility Begin in the Womb?

Listen and listen hard…

This week, I refused to perform a vasectomy on a patient of mine. That is, until he saw a doctor about his sky-high blood pressure. Thirty years old and a father of three, he is a productive, hardworking member of society who just happened to never have seen a doctor as an adult. Unusual? Not at all.

Why does this happen? Is it because, in the words of Andy Rooney, that “death is a distant rumor to the young?”  What is it about being young and male that instills this concept of immortality? For one thing, men do not have a monthly biological reminder of their health, similar to the female menstrual cycle. Second, the culture of men is imbibed with the “breadwinner” mentality that tends to equate illness with weakness. Lastly, men are terrible goaltenders of their own health. It is simply not on the radar of most men to think about their health unless something a) hurts, or b) is life threatening.

Lets delve into the last of these a bit as there is an interesting corollary to back this up. It is clear from many studies over the last century that married men uniformly outlive their single counterparts. In some studies, the difference in lifespan approached 10 years. Viewed another way, divorce affects a man’s health about the same as picking up a pack-a-day cigarette habit. So, it is clear that one of the best strategies to a longer life is to marry and stay married. If it is in your personality to gain immortality by this approach then so be it.

But that may not be the case of my patient, who in fact came back one week later for his vasectomy, feeling empowered, and with his blood pressure under perfect control. “And I thought the headaches that I had been getting were due to the stress I have been feeling.” He was a changed man, in control of his health for the first time in his life. He also understood the concept that life-threatening illnesses may be subtler than a broken bone.

After 17 years of caring for young men, it is clear to me that they are an incredibly underserved population. In fact, this is one the key points that I will make as an invited speaker to the Centers For Disease Control (CDC) upcoming summit on “Advancing Men’s Reproductive Health in the US” to be held in Atlanta next months. In my practice, I assume that men need help understanding how to take better care of themselves. I know that they would like to find out more about what health issues they may have inherited that can harm them, but they have trouble asking and knowing where to turn. Hence my practice motto: “The way to take great care of men is simple: just listen to them.” And listen quietly, as their voices are soft. Trust me, this hardly ever happens in the standard, 12-minute office visit that is currently de rigueur in this country.

Related posts:

1. Freud’s Vasectomy

Just say no.

Most couples in most countries will conceive within a year of trying. Families in the Ukraine take an average of 2.5 years, according to a new U.S. publication. Why? Radiation discharged from the ill-fated nuclear explosion at nearby Chernobyl in 1986 is the likely culprit. Male infertility is the consequence.

We know that sperm production is exquisitely sensitive to radiation, and we actually know how sensitive it is to this exposure. Believe it or not, this was demonstrated in a series of never-to-be-repeated experiments conducted in the 1960’s right here in America. Recall that this was the time of the Cuban Missile Crisis and extreme Cold War tension. The Walla Walla experiments in Washington state involved irradiation of 64 prisoners with various dose levels at Washington State Penitentiary to find the dose that would sterilize them. A similar, second set of prisoner experiments were also conducted at Oregon State Penitentiary during the same period. These studies on “volunteers” demonstrated two things: 1) prisoners do not have the free will to be considered for scientific experiments and 2) the testis is very sensitive to radiation.

How sensitive? Let’s use a chest X-ray for comparison (0.1 mSV). When 15 mSV (150 chest X-ray equivalents) of radiation was aimed at the testis, sperm counts fell. When 50 mSV (500 chest X-rays) were used, it caused temporary sterility. And after 500 mSV (5000 chest X-rays) of radiation, permanent sterility resulted.

So, it is not surprising that a nuclear explosion in the Ukraine occurring 24 years ago over a fallout area 1/3 as large as Iceland’s recent Eyjafjallajokull volcano (19,000+ square miles) might have an effect on human fertility in the surrounding area. Those exposed to radiation as children are now grown, have survived their thyroid cancers, and are trying to reproduce.

As a scientist and doctor, teacher, humanitarian and ethicist, I find this world an often frightfully complex place, mainly because of a failure to learn and grow from our mistakes. Haven’t we realized that good planets are hard to find? In the case of Chernobyl, and in the words of Alan Eddison:

Modern technology

Owes ecology

An apology

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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.

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How damaged is your genetic sheet metal?

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

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

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

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

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

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The best medicine for man is man…and good government

A couple sees a reproductive specialist for infertility. She gets a complete evaluation and he gets a semen analysis checked. It looks like his semen quality is low and they are recommended to pursue in vitro fertilization  (IVF) and intracytoplasmic sperm injection (ICSI) to conceive, the highest level of what is termed “assisted reproduction.” They try this at significant expense and it fails. They try again and it fails again. At this point, the man sees a urologist and, after a proper physical examination, he is told that he has a testis mass and is diagnosed with testis cancer.

The point: Male infertility can be a symptom of another medical condition.

The question: What would have happened to this man if they had successfully conceived with IVF-ICSI?

This scenario is not all that uncommon in our field. And it is why I gladly accepted the invitation to go Washington D.C. and consult with the National Institute of Health (NIH) last fall regarding where government research monies should be spent in the future in the field of male reproductive health. At that meeting, I suggested that we start calling infertility a medical disease, just like any other, and get men the medical care that they deserve. I expect several great grant initiatives to stem from this gathering and was honored to have participated in it.

This scenario is also why I am excited to have been more recently invited to join the Medical Advisory Board of the Cooperative Reproductive Medicine Network at the National Institute for Child Health and Diseases (NICHD) at the NIH. The RMN, established in 1989, is a cooperative effort of seven universities and the government and is charged with conducting and publishing high quality clinical research studies in reproductive medicine.  Thankfully, one of the areas of focus is on male infertility. So, I will be taking my “infertility as a disease” mantra to Washington quite a bit this year as I believe scenarios like the case outlined above should never happen in modern medicine.

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