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.

Testosterone: About as complicated as it gets.

You may know what testosterone can do for your strength, but did you also know that it is a contraceptive? That’s right, taking any synthetic testosterone will reliably make you infertile.

I’ve discussed the reason for this in other posts, but I’ll explain it again. Essentially, the brain drives the testicle to make sperm and testosterone with two hormones, FSH and LH. Think of the testicle as an engine that won’t run without the “gas” provided by these hormones. How much is gas delivered depends on how much testosterone is sensed by the brain. If enough is testosterone is present, the signal to make more decreased. So, with anabolic steroids, the brain figures that there is plenty of testosterone around (it doesn’t ask from whence it came) and it reduces the “gas” (LH and FSH) to the testicle. Thus, natural testosterone levels fall along with sperm production.

Recently, it became clear to me that milder, over the counter supplements such as DHEA or androstenedione can also have this effect. These are not the same as testosterone but are the building blocks for testosterone production. Importantly, they are available as over the counter supplements that do not require a doctor’s prescription to take.

Last week, I saw a patient who wanted a vasectomy reversal to have more children. He wrote down that he was taking creatine and other protein supplements, but when pushed further, he admitted to using DHEA. Worried about his sperm production, I checked LH and FSH levels and they were extremely low. No gas to the testis. No sperm being made. Based on this, I told him that his sperm count will be low or zero after a vasectomy reversal. Since then, he stopped the supplements and will wait several months before having the surgery. Luckily, in many cases, the effects of synthetic testosterone supplements are reversible when they are discontinued.

But, there are also ways to increase testosterone levels and maintain fertility. This is an important part of my practice as I treat young men with low testosterone who may want kids later on. It involves using pills or injections that stimulate “natural” or bioidentical testosterone production from the testicle. One way is to give the LH hormone (hCG) to stimulate the testicle to make testosterone. Given by a small needle injection several times weekly, it does the trick. Another method is to give pills called clomiphene citrate or tamoxifen that stimulate natural LH and FSH production. Since these medications are not approved by the FDA for men in the US, it is important to discuss benefits and side effects thoroughly before using them.

Is normal testosterone important for your health? Absolutely. But, like a sword, it is a hormone with two sharp edges. And such instruments should be wielded with skill and balance.

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.

And you thought this was old...

What do you own that is 600 million years old? Your old suit? That little league baseball glove? Your cologne? In fact, every man possesses something that old, and believe it or not, it’s a gene. Not the clothing kind, but the kind you keep in your genome, in your chromosomes. We’ve talked about the Y chromosome in this space but lets take a moment to focus on a single tiny gene.

Tucked away in every cell of your body is a gene called Boule, a piece of DNA critical for sperm production. A colleague of mine just announced that the Boule gene is present in every organism from insects like fruit flies, to sea urchins, roosters, fish and man. It is in invertebrates and vertebrates alike. That is, this tiny bit of DNA has remained essential for making sperm through 600 million years of evolution. Surely the oldest treasure you own.

But what’s really impressive about the Boule gene is that is has not changed over time. And change is the rule with every other known gene involved with reproduction in every species. In fact, evolution of reproductive traits is how a species diverges from other species. It gives each species its identity. And this change can be very rapid: in some fish, reproductive traits are observed to change in fewer than a dozen generations. So why would this one gene stay the same?

We think that the Boule gene has remained true over 600 million years because it is essential for reproduction. Boule is a “quality control” gene that ensures all goes well as sperm are made. Just as you would want your new car to be well inspected so it is safe to drive when you buy it, you want your sperm to be reproductively fit. In fact, if the Boule gene is removed, sperm production stops entirely. Not a single sperm is made in its absence. Now that’s control.

What’s also impressive about the Boule gene is that since it is linked to sperm production, it means that sperm are very, very ancient cells. Seems that nature sticks with what is tried and true and feels no need to experiment with magic potions or fairy dust to get the job done. Reminds me of what Einstein once said while reflecting on relativity and physics: “God does not play dice.” When it comes to reproduction, the Boule gene phenomenon suggests that he may take even fewer chances.

The sound and the fury of an Italian in a hurry.

I am a Men’s Health specialist and a vintage car buff. On more than one early Sunday morning jaunt down the Pacific Coast Highway in an old Ghibli, I have reflected on how similar these two beasts are.

1. When they run, they run hard. Tune that old Italian just right and you are in for a sweet ride to the limit. That big, throaty V8 with all of those cams and chains sounds like all hell is breaking loose, but the torque and exhaust notes are true symphonies of power and might. Similarly, a young man is his prime is the definition of immortality, pushing physiology and productivity to seemingly boundless limits, even on the most tortuous of roads.

2. They run well, even when neglected. It is amazing how well a vintage Italian can run, even when it is not run as often as it likes. Likewise, men can abuse their bodies through bad diet, sleep deprivation, and workaholism for years and not look or feel the worse for wear. Incessant plowing over the bad roads of an uneven and untempered life only makes men stronger if it doesn’t stop them.

3. The metal bends quietly before it breaks. A vintage Italian can be pushed to the limit, a limit that is often unclear until it is reached. The crack may not be preceded by a creak in a well-oiled machine. This is just like many men; tough as nails until they fall; and when they fall, they fall hard…and fast.

4. Listen carefully as the gauges may not work. Although there are many spirited sounds emanating from an old Italian at speed, some are more ominous than others. To pick these up, you must listen carefully to get a better sense of things, as gauges don’t tell the whole story. Similarly, the messages of health can be subtle, and often unrealized and unreported by the driven male. If it doesn’t hurt, then it is unlikely to harm, and so it is ignored.

And this, I believe is the secret to taking great care of men. You must listen. Not only hear what is being said, but really listen. Open the hood, study the underside, and work the throttle. The messages may be subtle behind the sound and the fury, and only by listening will you truly understand how well that man or Maserati is running.

Synthetic cells: true science or fashion vinyl?

Believe it or not, science has now claimed to have made “synthetic life.” Life created from non-living substances. J Craig Venter and colleagues, after a decade of work, produced a man-made version of the entire DNA content (genome) of a bacteria (adding in a couple of harmless “watermarks” to track it) and inserted it into the shell of another bacteria after removing its DNA. And, lo and behold, the artificial genome starting making proteins and the man-made bacteria began to replicate.

You may remember Craig Venter as the man in corporate biotech a decade back who challenged the U.S. government in a race to completely encode the entire human genome. The Human Genome Project was completed in 2003 and jointly announced. This is a beautiful thing but Venter wanted to “own” and patent the human genome and charge others for using it as a resource whereas the U.S. government insisted that it be made publicly available, which it is.

Is this really synthetic life? No. Essentially, Venter performed the equivalent of gutting a computer and then entirely reprogramming it. Is this an important scientific achievement? Absolutely, a tour de force, since technology has been limiting this work for years. Recently, however, there has been a 100-fold increase in the length of genetic material that can be manufactured from raw chemicals in the lab. Without a doubt, science has been dreaming about this kind of work for three decades and recombinant DNA technology is an early product of this movement.

So, an entirely “artificial cell” was not produced by Venter, as the control station was man-made, but the rest of the cell was not. My only hope is that this is not just another “pleather” (plastic and leather) product in our lives. As Lily Tomlin said: “[even] vinyl leopard skin is becoming an endangered synthetic.” On the contrary, this work may have advance science sufficiently to begin the manufacture of designer cells, good or bad, that can clean up oil spills, dynamite and waste water, dispose of nuclear waste and deliver antibiotics, chemotherapy, testosterone or Viagra to hard to reach but important areas of the body.

This Da Vinci fetus is way past the critical window of exposure.

A relatively alarming study was published a couple of years ago that suggested that a pregnant woman’s behavior can determine the fertility of her unborn son. Sperm quality from 387 men was compared to beef consumption their mothers reported while pregnant with them. They found that the sons of “high beef consumers” (>7 beef meals/week) had sperm counts that were 24% lower than in men whose mothers ate less beef. Interestingly, sperm counts in the sons were not related to mother’s consumption of other meat or to the son’s consumption of meat. In essence, the author’s thought that estrogens in beef consumed by women may alter the testis development of their unborn sons and may adversely affect the son’s fertility. Similarly impressive decreases in semen quality have been described in the sons of women who smoked during pregnancy.

Sounds almost biblical, doesn’t it? I bring this up because of a point that I made in last week’s blog. In “The Curse of Women’s Urine,” I mentioned how xenoestrogens or environmental estrogens have been shown in animals to act at a very precise point in the developing male fetus and result in intersex conditions at birth or infertility as adults. Well, as the study of mothers’ beef intake reveals, the same issues may also exist in humans. As Aristotle once said: “At his best, man is the noblest of all animals; separated from law and justice he is the worst.”

Time for a quick lesson in biology. When do testicles develop in humans? Believe it or not, when male fetus in just 4 weeks old, the location where the future testis will be is organized (the urogenital ridge). Two weeks later, the primitive germ cells (sperm precursor cells) migrate to the urogenital ridge and set up what is to later become the testis. About 1-2 weeks after that, “sex cords” develop in the primitive testis, setting up the architecture of the mature organ. So, by 8-12 weeks of pregnancy, the human testis is virtually a complete organ, holding within it all of the potential it will ever have.

So the “critical window” of exposure for the human testis, that period in which even a potentially small exposure could wreak significant developmental and long lasting havoc, is about the time when women actually just realize that they are pregnant. The time of morning sickness and painful breasts.

So, does male infertility begin in the womb? Still not clear, really, as all studies have flaws. For example, in the study of beef eating pregnant women, the cohort of son’s whose sperm counts were so thoroughly examined were ALL fertile. That’s right, their wives were all pregnant. Oscar Wilde couldn’t have said it better when he said: “The pure and simple truth is rarely pure and never simple.”

Caetano Veloso, a masterful, otherworldly voice and an eye on the potential of youth

Had a wonderful evening out with my wife last night at a Caetano Veloso concert at Masonic Hall on Nob Hill in San Francisco. Caetano Veloso is Brazil’s equivalent of Frank Sinatra and is endowed with an absolutely otherworldly voice and reigns from Bahia. He is an historically important figure having led the Bossa Nova and Tropicalia movements in the late 1960’s. He plays it all: Jazz, pop, world beat, folk and ballad styles with an Ellingtonian understanding of harmonic richness.

As the Rolling Stone once said: “He’s a sublime and seductive melodist, a curious musician capable of taking sharp left turns, a historian whose compositions tie past and present together…at once upholding tradition and transcending it.” I have been a fan of his since the mid-1990’s, having seen him perform both in Brazil and in San Francisco. He is now 67 years old, and was simply outstanding again last night.

So how does one get this good? I think I discovered his secret last night, listening to him for the umpteenth time. In addition to his obvious musical gifts, he is at once historically grounded and very modern. And he is a fan of youth. His following remains a generation or two younger than he, and time and again he connects them to their past and to the future. It’s really a form of wisdom that he brings to music.

It is precisely this balance that I seek to achieve in the field of men’s health. Lets forget the stylistic aspects of Caetano Veloso that would be pretty difficult to match. But, bringing the wisdom of old fashioned medicine into the modern age has a certain timeless value. Making it a point not to forget that what has mattered in the doctor-patient relationship since the beginning of time, including trust, communication and empathy also still counts.  And leading the way with original and creative ideas that result in more innovative, efficient and personalized care is undoubtedly “modern.”

Caetano Veloso’s band is always filled with youthful musicians, all in their 20s or 30s. Surely he knows that youth have their ears to the ground and possess an uncanny sense of future…of their future.  Youth holds creativity, brilliance and fire, all forces strong enough to move mountains. Youths take paths that are characteristically unchartered, often “left turns,” and make decisions untainted and undaunted by experience. This all fits in nicely with my philosophy about taking care of men: “Want to take great care of men? Just listen to them.” I move with them just as I move with Caetano.

Did Warhol know about the "cola limit?"

How much coffee or tea do you consume everyday? Since many of us buy Slurpee sized cups of coffee in the morning, you should break those down into units of 8 ounce cups. How about cans of soda and in particular colas? Might be a good idea to keep track of this for a moment, as a recent study of 2,554 young Danish man has suggested that excessive cola intake could lead to lower sperm counts.

For comparison, the average young Danish military recruit consumes about 1 cup of coffee and 1 can of soda daily. This is in addition to about a half of cup of tea and 2 small chocolate bars (why not, Danish chocolate is yummy). This intake was associated with normal semen quality. However, the semen quality of young Danish men who consume more than 2 liters (2.1 quarts) of fizzy colas daily had a 30% less ejaculated sperm than men who drank no colas.

Interestingly, although colas are a weak source of caffeine (ounce for ounce, colas have 65% of the caffeine in coffee) there were no strong correlations between any amount of caffeine intake (even up to 7 cups of coffee a day!) and semen quality in these men. So, it is not likely that caffeine is the issue.

So what is the issue among those men who drink colas in excess? Well, the same issue as those who drink almost anything in excess—they have unhealthier lifestyles than those who consume in moderation. More burgers, more smoking, more alcohol, and fatter.

So, does drinking cola make men infertile? I doubt it, as the average sperm counts in men from all different levels of cola intake in the study were all normal by established fertility standards. Plus, fertility was not actually studied in these men, only a single semen sample. And even a good man can have a bad day.

There is a deeper truth running through this though. And you have heard this from me before. To be the best that you can be reproductively (and in life), do all things in moderation and treat your body like a temple.

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

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

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

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

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

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