Turek On Men's Health » Testosterone

Diabetes Mellitus: The Infertility Triple Threat

Paul Turek, MD — Mon, 26 Mar 2012 15:00:55 +0000

Colors as possibility. Feathers in a kite shop, Beijing, China

Based on the feedback received from doctors reading the blog, we are introducing a new feature: Case of the Month. This Case of the Month is an actual patient from The Turek Clinic. It is presented to recognize American Diabetes Association Alert Day.

The Case of Male Infertility

He is a 31-year old who has been trying to conceive with his 28-year old wife for 2 years. During this time, he has noticed a lower sex drive and has had trouble ejaculating. His medical history is negative except for a 6-year history of diabetes mellitus that is well controlled with insulin injections. Exacerbated, he states “I really don’t know what’s happening to me!”

Upon further questioning, the sex drive issue started even before they were trying to conceive. Regarding ejaculation, the patient states that his erections are not very strong and, although he has the sensation of climax, nothing comes out of the penis with ejaculation. In fact, he is concerned that things might be “backing up” in his body with these symptoms.

A Short Review of Diabetes

First identified as a disease of “sweet urine” in ancient times, diabetes mellitus a metabolic disease characterized by high blood sugar (glucose) levels. It is one of the most common medical diseases in the U.S., affecting 26 million adults and children or about 8% of the population. Among those affected, about 15 million are people of reproductive age.

Normally, blood glucose levels are tightly controlled by insulin, a hormone produced by the pancreas. When the blood glucose rises, say after eating food, insulin is released to decrease the glucose level. In patients with diabetes, there is low or no production of insulin and therefore blood sugar levels are elevated. The sugars spill into the urine, hence the term “sweet urine.” Diabetes is currently a chronic medical condition that is not curable.

Can Diabetes Cause Infertility?

You bet. Diabetes causes male infertility in three ways:

Causes erectile dysfunction-by affecting the health of small blood vessels and lowering testosterone levels
Lowers sex drive-by lowering testosterone levels
Reduces ejaculate volume-by affecting the small nerves that control ejaculation and by lowering testosterone levels

Indeed, this patient had all three issues at the same time along with a low testosterone level. Fortunately, these symptoms are fairly easy to correct with oral medications:

Erectile dysfunction- Viagra, Cialis or Levitra can restore erections
Sex drive and low testosterone-Selective estrogen receptor modulators (i.e. off label use of clomiphene citrate) can correct testosterone deficiency
Ejaculate volume is low because it is emptying backwards into the bladder instead of forward into the penis. This can be treated with over the counter cold medication (alpha agonists) to restore the normal direction of ejaculate flow.

Sure enough, with this combination of pills, the infertility “hat trick” induced by diabetes was overcome and the patient was able to conceive naturally after several months. Another family holiday card on its way to The Turek Clinic this year!

Remember that about 1/3 of infertility is male driven. And diabetes is both a common and quite treatable cause of infertility. So, do yourself and your future family a favor and take the Diabetes Risk Test today.

Try Not Sitting

Paul Turek, MD — Mon, 27 Feb 2012 16:00:24 +0000

The chair: good for the eye, but bad for health

Have you heard about a new disease that affects almost half of Americans and is lethal if it goes unchecked? It’s called “sitting disease.” It’s real and it’s the new smoking.

The Chair as Enemy

Sitting is an example of a “sedentary” behavior. Either at work or at home as a couch potato, it is considered a “low fitness” activity. Some might argue that it should not even be considered an “activity” given how unfit it is for you. So, why is screen-watching so bad for you?

It’s because several recent studies on sitting, conducted in America and elsewhere, have all observed similar results. People who sit a lot have 50% higher rates of heart disease, diabetes and obesity. And, conversely, if people who sit a lot also take frequent small breaks like standing up to stretch or walk down the hall, they have smaller waists and improved sugar and fat metabolism than those who don’t take breaks. Could this explain the obesity epidemic in our country? Many think it does, and in both children and adults.

Another interesting finding from these studies is that the risk of disease with sedentary lifestyles is unrelated to overall exercise levels. The amount of time you spend sitting and the amount of time you exercise each have their own separate risk for heart disease. So, the cure for too much sitting isn’t more exercise, it’s less sitting.

Facts about Standing

What if you just stand up more? Could this help? You bet and here’s why:

There are roughly 639 muscles in the human body. 300 of them are used for balance when you stand still. Far fewer are needed to sit.
Standing instead of sitting for 4 hours daily burns an extra 200 calories a day
Standing improves your posture and reduces aches and stiffness.
By using large muscle groups, standing improves fat and sugar metabolism
And walking is even better than standing for overall health

The Cure for Sitting Disease

The good news is that this disease is curable and curing it can add years to your life.You know what to do at home: spend less time sitting in front of a screen, whether TV or computer. At work, here are some useful suggestions:

Get up more often throughout the day
Walk to talk to your colleague down the hall, don’t email
Hold walking staff meetings
Take a walk during your lunch break
Park farther away in the parking lot
Use ergonomically designed, elevated desks
Use slow treadmill-based desks

At this point, I’m afraid that I have to disagree with Albert Einstein when he said: “A table, a chair, a bowl of fruit and a violin; what else does a man need to be happy.”

The Testosterone Tipping Point

Paul Turek, MD — Mon, 06 Feb 2012 16:00:49 +0000

Sex and muscles are different when it comes to testosterone levels

Your car is not running well. It just doesn’t have the pick up it used to have. It’s low on gas so you fill it up, but it runs the same. OK, so it’s not the gas…it must be something else, so you begin looking for other causes. Yes, I’m an “old car guy,” but there is a point here.

Testosterone as Gasoline

Think of testosterone in your body as gasoline in your car. You need it to run and to run well. But a half tank of gas is just as good as a full tank, and topping off the gas tank is not going to help the car run any better. In other words, if you have enough gas—it’s not the problem.

When it comes to building muscle, it is clear that more testosterone is better. The higher the testosterone, the greater the anabolic effect. Weight lifters have known this for years. However, recent studies have shown that when it comes to sexual function, including erections and sex drive, the body may respond differently. More like a car does to gas: at some point adding more doesn’t help it run any better.

The Testosterone Plateau

There is a lot of scientific support for this idea. The most recent is from a European study of 2838 middle age and elderly men (yes, that’s ages 40-79) published last week. It examined the relationship between sexual function and male hormone levels in men who weren’t necessarily seeking care, typically referred to as a “community population.” Here are examples of the many prying questions that these men were asked:

How often do you think about sex?
How often do you attempt to have intercourse?
How frequently do you awake with a full erection?
Are you worried about your level of sexual desire?
Are you worried about your ability to have an erection?
How often do you perform self-stimulation?

What the study found was kind of expected: that testosterone levels correlated with overall sexual functioning in men. But the study also observed that there was a “plateau” effect of testosterone on sexual function. And this plateau occurred at 231 ng/mL (“normal” is 300-800ng/mL). In other words, sexual function worsened when testosterone levels fell below this point, but did not improve when levels increased above it. So, at least in these men, adding more gas to the tank would not necessarily help the car run better.

Notably, in six other clinical studies that have also examined this issue, a similar observation of plateauing testosterone levels was found. Not proof positive, but certainly suggestive of a true biological relationship.

Sexual Function is Not Muscle

So how does this percolate down into clinical practice? Well, I see men every day who have low energy and sex drive and poor erections and who feel “much older” than they feel they should for their age. Accompanying them is a lab report showing that their testosterone level is “low.” Maybe it’s 250 ng/mL, maybe 300 ng/mL. Although I believe that sexual function does not respond to testosterone like muscle does, I also understand that not all men are created equal, unlike assembly-line-built cars. In most cases, I respond “it’s not at all clear where your particular testosterone tipping point is, so lets get you above what you are now and see how you do.”

As with vintage cars, you really have to tinker with men to get them running right. And, it’s important to look beyond the gas issue to solve the problem of the poorly running machine. It’s our duty as good doctors not to just “top off the tank” and needlessly commit men to a life of testosterone replacement.

Your Hair or Your Hormones

Paul Turek, MD — Mon, 30 Jan 2012 16:00:25 +0000

Be nice to have Superman's hair…but at what price? (Courtesy; MovieBlog.com)

It’s the perfect drug for 40 million men in America who are going bald. Take it once a day to keep the hair on your head and shrink the prostate, which also commonly bothers men as they age. It’s a pill that has been used by at least 2 million reproductive age men over the last decade. But is it too good to be true?

The Best Hair Pill Yet

This magic pill is finasteride (trade names; Propecia, Proscar, Avodart). It represents a class of drug called the 5-alpha reductase inhibitors. These pills act as enzyme blockers: they prevent the male hormone testosterone from converting to its metabolite dihydrotestosterone (DHT). Although testosterone is responsible for a lot of our “male” features, DHT is more potent than testosterone for scalp hair and our internal reproductive organs (prostate, seminal vesicle). These drugs work by lowering DHT production and protect the gloriously youthful hair on our heads and the enviable ability to write your name in the snow while urinating.

And these drugs work well. More effective than topical or “rub in” medications, finasteride is great for what’s called “male pattern” hair loss which is due to a receding hairline or balding on the top of the head. In essence, it slows the growth phase of hair in these areas. However, it doesn’t treat hair loss on the sides or temple area.

Finasteride, Sex and Male Fertility

Although it may keep you looking like Clark Kent, many male infertility specialists, including myself, have concerns about finasteride. First, there is a 10% chance of sexual side effects that include erectile and ejaculatory dysfunction and lowering of sex drive. These issues can be subtle while on the pill but become very obvious when men stop it; many of my patients have noted a sexual “curtain being lifted” or “coming alive” after discontinuing the pill.

Second, there is an even more profound concern about finasteride among specialists: male infertility. Before it received FDA approval, the drug trials showed that it lowered ejaculate volume but did not change sperm count or motility on semen analysis testing (actual human fertility studies are not routinely required by the FDA). Now that it has been on the market for 10 years, though, impressive declines in semen quality have been observed and published with finasteride by many of us. This effect is not subtle either, as patients with complete sterility (azoospermia) have had recovery of their sperm counts after stopping finasteride!

There are several clues that this effect on fertility was possible. The rabbit studies done for FDA approval of the drug actually showed this effect. At 3 months, there was no effect on rabbit fertility. But, when followed longer, rabbits showed significant decreases in natural fertility. In addition, while I was writing a recent reproductive physiology chapter for Campbell-Walsh Urology, our leading urology textbook, I researched at what levels the 5-alpha reductase enzyme is found in the human testis and epididymis. Lo and behold, there are gobs of this enzyme in these important organs for sperm production and maturation, implying that the blocking agent finasteride would have an effect. So now what do we do?

At this point, controlled clinical trials are needed to prove this effect on fertility. For the time being, current thinking is that finasteride may not dramatically change sperm production in healthy men, but can impair semen quality in infertile men. Typically, the effects of medications on male infertility are reversible. So, to be proactive men should consider stopping the pill at least 6 months prior to trying to conceive. And, have confidence that she loves you just as much for other reasons. As Telly Savalas once said: “We’re all born bald, baby!”

How is a Medical Visit Like A Ball Game?

Paul Turek, MD — Mon, 23 Jan 2012 16:00:30 +0000

The ultimate male bonding experience in 2012

The world came to San Francisco this weekend. The 49ers hosted the NFC Championship footba ll game at Candlestick Park and it was a day for ages. Friends clamored for tickets, taking seats at any price. Some bought tickets like they were playing the stock market: buy sooner if it rains, later if it doesn’t, or the day before, but not on game day. Not only tailgating, burgers and beer, but stories and tales all flowed freely. A perfect male-bonding experience.

The Culture of Men

As any ball game will convey, clearly the culture of men is fundamentally different from that of women. During my previous life as a decorated academic, my medical office was situated squarely in the middle of a women’s health center, complete with fake impressionist paintings on pink walls, flowers in cute vases and bathrooms with tampon dispensers. Magazines like “Shape,” “Woman’s World” and “O-The Oprah Magazine” covered the waiting room coffee tables. Simply not the best place for male DNA to visit, say nothing of being comfortable there.

The Turek Clinic as Man Cave

Having close to an allergic reaction to this, when I ventured out to create a men’s health clinic, I tried to replicate the ball game experience in a medical office. Here are the essential elements that I considered:

Street parking. For some reason, men prefer it; don’t ask me why.
Convenience. Ball games start on time and (generally) finish on time. Medical visits should also be on time. No long lines, no waiting.
One chance. There are no second chances in playoffs games. When helping men, do as much done as possible in a single office visit. Use follow-up phone appointments after that.
Personality. Sports teams have players and, as everyone knows, players have personality. Men want to know their doctor’s personality. It helps them to develop trust. Sure, a “power wall” of diplomas is nice, but how about hanging a balsa wood surf board in the lobby along with a stylized picture of a late 60s Maserati Ghibli. Men need to trust that their doctor is human and understands them.
Space. Ball games are often outdoors, often in chest-beating, cold weather. Bringing that outdoor feeling inside is important. Floor to ceiling windows facing the San Francisco Bay is perfect, with plenty of room to lounge around on Wi-Fi. And cover the coffee table with men’s magazines, a whole slew of them. Oh, also make sure that there’s ESPN or surfing movies on a large flat screen TV.
The Staff. Here’s where a medical office can beat a ticket taker at a ball game. Imagine being greeted first thing in the morning by a smiling face and an offer of coffee or tea. The essence of The Turek Clinic approach.
Long visits. Ball games take time. Medical office visits should too. Most men are nervous for the first several minutes of any doctor’s visit. Honestly, what can you expect to learn from a patient during that time? The book is just opening. This is precisely why I never understood the average, 12-minute doctor’s visit. Men need time to open up and relax. Not only that, I am convinced that listening to men is the secret to curing their ills.

So is a visit to The Turek Clinic the same as attending a NFC playoff game? Probably not. But it is about as comfortable as men will ever be in a doctor’s office. And they will remember this comfort and trust in the doctor. And if they remember, instead of quietly suffering through another problem in the future, they will reach out and call again. And that is the key to great care for men.

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.

The Wall of Holiday Cards

Paul Turek, MD — Mon, 26 Dec 2011 16:00:32 +0000

The Turek Clinic Team and the wall of holiday cards

I always tell grateful patients that the kindest thing that they can do for me is to send a holiday picture of the family. We have a wall in the clinic that is dedicated to this once a year event.

Well, you have outdone yourselves this year! The wall is full of cards and The Turek Clinic Team loves it. We received cards with photos of little kids, bigger kids, ultrasound photos of kids yet to be, dreams of kids and much more. Each telling their own story. What a way to fuel the fire of desire to continue to do what we can to help build families all over the world. Magical. So, thanks and

Have A GREAT Holiday!

Recipe for Making a Walrus

Paul Turek, MD — Mon, 12 Dec 2011 16:00:06 +0000

Being kissed by a grateful, one ton walrus…

How do you help a 2700 lb Walrus conceive? Very carefully. In fact, only a handful of walruses have conceived in captivity over the last century. In the U.S., it is 10 to be exact. But Holley Muraco, a zoologist at Six Flags Discovery Kingdom in Vallejo, has changed all that.

Now a Published Recipe

Holley’s recipe for helping captive walruses to conceive will be published in a major scientific journal, and I am proud to have had a part in this.

Posted here about a year ago, Holley watched the mating patterns and hormonal levels of walruses over 7 years. She cleverly figured out that the male walruses in U.S. zoos, among the few species that breed seasonally, are not fertile at the same time that the female walruses are fertile. She attributed it to a breakdown in the normal breeding signals that are intricately tied to day-night rhythms in the arctic. California is simply not the same as the North Pole, where these animals have evolved over thousands of years. Right next door to Santa. In essence, when it comes to fertility, captive walruses are like ships passing in the night.

The Critical Observation

Nobody in history had observed walrus mating patterns like Holley has done. It’s no surprise either because walruses live in the arctic cold and breed underwater in bone chillingly cold seas. Her observations led her to a great idea: to hormonally shift the male walrus so that he achieves his peak fertility window exactly when the female walrus is fertile (which is once a year). Holley asked me for advice about drugs, doses and timing based on my experience with human male infertility. Ended up working splendidly with a walrus conception achieved naturally, without the fancy help of assisted reproduction!

The Outcome

From these early efforts, the pup that was expected this past May made it to full term, but was stillborn. It took several days for the unbelieving mother to give up the pup–an incredibly sad time. But, now it is possible for her to get pregnant again, as several other captive walruses around the country already are, after following the new recipe. This reminds me of how truly privileged I am because I have the opportunity to help couples conceive every day by helping nature do what it does best.

Press Release

Six Flags discovery kingdom Biologists Successful in Helping Walrus Conceive

Scientific breakthroughs beneficial in better understanding of walrus reproduction

VALLEJO, Calif. – January 19, 2012 – After several years of research, Six Flags Discovery Kingdom recently reached a scientific breakthrough with the conception of one of its Pacific walruses. In the last 80 years only 11 calves have been born in U.S. facilities. The results of the park’s groundbreaking efforts, lead by marine mammal reproductive specialist Holley Muraco, have now been published in the Journal of Andrology.

In this study, the breakthrough formula for walrus conception is revealed. By watching the mating patterns and hormonal levels of walruses over a seven-year period, it was determined that male walruses, one of the few species that breed seasonally, were not fertile at the same time as the female walruses.

The team was comprised of Muraco, Discovery Kingdom marine mammal trainers and staff veterinarians with fertility expertise provided by Dr. Paul Turek, a men’s health and infertility specialist, founder of The Turek Clinic in San Francisco and co-author of the study.

“We simply moved his fertile window to coincide with her fertile window, and let the usual magic happen,” said Muraco.

With Turek’s help, the Six Flags team hormonally shifted the male walrus’s fertile window to coincide with the females.

“When Holley asked me to help with the hormonal approach to moving the male walrus fertile window from spring to fall, I thought ‘let’s try what works with infertile men’ and sure enough, it worked,” said Dr. Turek.

What came to light was that the mating signals of walruses are crossed because their day-night circadian rhythms are different in captivity than in the wild.

“In essence, when it comes to fertility, captive walruses are like ships passing in the night,” said Muraco. “Reproduction in walruses is seasonal and is tied to light-dark cycles. Those cycles aren’t the same in California as they are in the Arctic.”

One reason this important observation took some time to figure out is because walruses live in the Arctic cold and breed underwater in bone-chillingly cold waters where few scientists have dared to go. Therefore, due to this inaccessibility, little is known of the walrus reproduction in the wild.

Additionally, it appears that the method used is generalizable to walruses in other facilities, as the Six Flags team has since helped walruses in other parks to conceive as well. The findings have proven significant; today, there are only 17 walruses in North American facilities, three of viable breeding age that reside in the Six Flags park.

“It’s a great feeling when we are able to improve the fertility of other species through natural methods,” said Dr. Turek, “as this is what we try to do in our clinics as much as we can.”

About Six Flags Entertainment Corporation

Six Flags Entertainment Corporation is the world’s largest regional theme park company with approximately $1.0 billion in revenue and 19 parks across the United States, Mexico and Canada. For more than 50 years, Six Flags has entertained millions of families with world-class coasters, themed rides, thrilling water parks and unique attractions including up-close animal encounters, Fright Fest and Holiday in the Park.

About Paul Turek, MD

Paul Turek, MD is founder of The Turek Clinic and a former professor and endowed chair at the University of California San Francisco. As a men’s reproductive health expert, he has pioneered innovative techniques for treating male infertility, including Testicular Mapping. In addition to his appointment to the Cooperative Reproductive Network Advisory Board, Dr. Turek sits on the Advisory Board for the Men’s Health Network, Fertile Hope and is President-Elect of the Society of Male Reproduction and Urology. He is Chief Medical Officer at MandalMed, Inc, and is also Past-President of the American Society of Andrology and of the Northern California Urology Society and is an Editorial Board member of several journals including Systems Biology in Reproductive Medicine, the Asian Journal of Andrology and the International Brazilian Journal of Urology.

A complete biography of Dr. Turek is available on Wikipedia at http://en.wikipedia.org/wiki/Paul_J._Turek.

About The Turek Clinic

The Turek Clinic, founded in 2008, is a men’s reproductive health practice specializing in male infertility, vasectomy, vasectomy reversal, varicocele repair and other minimally invasive procedures using innovative and cutting-edge techniques. For more information, visit www.TheTurekClinic.com, http://www.turekvasectomy.com or right here on Dr. Turek’s blog, http://www.TurekOnMensHealth.com/.

Why is Awake the New Sleep?

Paul Turek, MD — Mon, 28 Nov 2011 16:00:01 +0000

Sleeping Beauty definitely gets enough sleep (Source: Disney)

It was no surprise to me to read a recent study that showed that when Stanford men’s basketball players got more than 10 hours of sleep nightly, their on-court performance improved dramatically. They ran faster sprints, took more accurate shots and were less fatigued. Another example of more sleep translating into improved awake performance.

Facts About Sleep Deprivation

According to a recent national survey and the American Academy of Sleep Medicine, here are the current facts about sleep:

Adults should get 7-9 hours of sleep nightly.
Short sleep is defined as less than 6 hours of sleep.
Almost half (48%) of Americans say that they are not great sleepers.
More than 35% of Americans get less than 7 hours of sleep.
On average, “good” sleepers get 1-hour more sleep every night than poor sleepers.
13% say that they never get a good night’s sleep.
1 in 20 Americans have fallen asleep at the wheel while driving in the past month.
1 in 5 Americans have sex less often or have lost interest in sex because they are too sleepy.
In general, we sleep one hour less every night with each passing generation.

Sleep as Oxygen

During sleep, body temperature falls, muscles relax, the heart beats more slowly, blood pressure and pulse rate fall, and breathing slows. Clearly, sleep is more than simply rest and relaxation. It is a time of growth, recuperation and repair. Losing sleep may not physically kill you like being oxygen-deprived, but short sleep patterns are linked to depression, obesity, heart disease, loss of sex drive, attention disorders and a higher likelihood of developing a work-related disability. One Swedish study even showed that sleep deprived people look tired and less healthy and therefore less attractive to others.

Not only that, it’s not that easy to bounce back after losing sleep. The impairments caused by sleep-deprivation remain even after sleeping in for a day. Full recovery after sleep deprivation may take several nights of extended sleep.

So why does our society applaud those who stay up working all night rather than sleeping? Sleep deprivation is no badge of honor; it’s a threat to your health. Maybe this is why the Guinness Book of World Records refuses to recognize any record claims for lack of slumber. In my view, sleep ranks up there with nutrition and exercise as important pillars for a healthy, long and fulfilling life.

Are Fathers Better Citizens?

Paul Turek, MD — Mon, 21 Nov 2011 16:00:01 +0000

What wouldn't you give to help one of these? (Source: Leonardo Da Vinci, 1468)

As a surfer, I remember charging pretty big walls of cold, wintery Northern California water with the goal of getting a fast, albeit short, adrenaline-stoked ride. Years ago on Thanksgiving, I was pummeled by a big swell to the point that I wondered whether I would make it out of the water alive. But once I married and had kids, the risk element of waves larger than a single story high became less attractive to me. It wasn’t worth it. Too much at stake. Does fatherhood also reduce other types of risky behavior?

Fatherhood is Transforming

It apparently does. It is well known that fatherhood can be “transformative” or “tempering” for men. But what shape that transformation takes has not been studied very much, despite the fact that unattached men are considered by some to be a source of society’s ““suffering” or “instability.” Loose cannons so to speak.

Fatherhood and High Risk Behavior

A newly published study has tackled this issue. It addressed the changing patterns of crime and substance abuse in new fathers, as these behaviors can threaten both health and society. Specifically, the study asked whether men are less likely to drink, use tobacco or commit crimes after they become fathers. In other words, do tough guys straighten out after having kids?

The authors followed over 200 men ages 12 to 31 who demonstrated high rates of juvenile delinquency in a metropolitan area. They were assessed annually for self-reported acts of crime and court records were reviewed for arrests. Self-reported rates of beer, wine, hard liquor, tobacco and marijuana use were documented, as were co-habitation, marital status and age at first fatherhood. And remarkably, this study was conducted over 19 years!

It has been previous shown that marriage itself and getting older can reduce men’s negative behavior, but this study clearly demonstrated a real association between fatherhood by itself and reduced crime and substance abuse patterns. And, the effects were large and long lasting. Of note, these changes were greater amongst the older men in the group (late 20’s and 30s) and were distinct from those changes expected as men age. Lastly, unlike marriage, cohabitation alone was not shown to reduce risky behavior in young men.

A Golden Opportunity to Help Men Help Themselves

Why is this important? One reason is because it suggests that first fatherhood may present a real opportunity to improve the health and behavior of young men. God knows that there are not many opportunities to do this with those who consider themselves otherwise immortal. New fathers might be more willing to hear messages and make life style changes when they are holding what might be their noblest work in their arms. And these changes in behavior could affect the health of the individual, his children and his family. After all, and I am not sure who said this, “A baby will make love stronger, days shorter, nights longer, bankroll smaller, home happier, clothes shabbier, the past forgotten, and the future worth living for.”

Humanizing Medspeak

Paul Turek, MD — Mon, 31 Oct 2011 15:00:33 +0000

A humanizing force: The book in my white coat

“Doctor, could you speak to me in plain English, please?!”

I rarely hear this in my men’s health practice. It’s likely because I am aware that Medspeak, or the language of medicine, is a second tongue, and a very foreign one to boot.

The Language of Medicine

There are 750 muscles, 206 bones, 428 named nerves and 60,000 miles of named and unnamed arteries and veins in the adult human body. Add to this all known body organs and physiological and molecular pathways and it becomes clear that the first two years of medical school involves learning 20,000 new vocabulary words, the equivalent of an entirely new language. Suddenly, sweating becomes diaphoresis, vomiting becomes emesis and red becomes erythematous. Throw in normal physiology and disease states in the second two years of medical school, and you have another 20,000 word vocabulary lesson. For some reason, patients now ambulate, visualize, articulate and masticate when the rest of us walk, see, talk and chew. That’s two whole languages to be learned in 4 years.

The Beauty of Medspeak

The vocabulary of medicine can be elegant, efficient and sound oh-so beautiful with all those Latin words. There is something poetic and mellifluous about the word “vestigial” which is a leftover structure with no current function, like the appendix. Another example: I recently hurt my thumb after my 7-year old daughter’s ace tetherball serve. Presenting my black and blue thumb to my favorite orthopedic surgeon, he said: “A minor bruise to your flexor pollicis longus and brevis muscles.” Just sort of rolls off your tongue. Felt better already.

The Vagaries of Medspeak

But Medspeak can also dehumanize. In the field of men’s health, I hear the words “idiopathic epididymitis” all the time. That’s eleven syllables of Medspeak in just 2 words. Sounds impressive but what does it really mean? How’s this: “unexplained scrotal pain that is not due to cancer or other badness.” When put in front of another word, “essential” also means unexplained. Admittedly, Medspeak can make even the vague and unknown sound official.

When commenting on written Medspeak, the late author-doctor Michael Crichton wrote: “I don’t agree… that medical writing is inept. I argue that it is actually a highly skilled, calculated attempt to confuse the reader.” Agreed. When used excessively or carelessly, it is dehumanizing and can change the moment and direction of a patient’s life.

While I was a resident at the University of Pennsylvania years ago, a college friend who trained with me gave me a small book of poems to carry around. I opened it during those rare, quiet moments that can happen while on call. The book was by William Carlos Williams, a noted doctor-poet. Dr. Williams fully understood the two edged sword of Medspeak when he noted: “It is not what you say that matters but the manner in which you say it; there lies the secret of the ages.”

Your DNA Barcode

An Ounce of (Fertility) Prevention

Paul Turek, MD — Mon, 17 Oct 2011 15:00:19 +0000

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.

Fertility Restoration after Cancer: Current and Future Therapies by Paul J. Turek MD, FACS, FRSM Director, TheTurek Clinic, San Francisco (WARNING: Images in slides not appropriate for all audiences due to subject matter)

View more presentations from Dr. Paul Turek | The Turek Clinic

Ways to Naturally Boost Testosterone

Paul Turek, MD — Tue, 11 Oct 2011 15:00:28 +0000

Sunset or sunrise? You choose.

Honestly, it seems like testosterone is to blame for everything these days. The epidemic of low testosterone has been linked to economic recession, wars, bank failures and even global warming. Ok, so maybe I am exaggerating, but many men feel (or are told) that their testosterone levels are the root cause of much of the way they feel. Leaving aside causality and association, what can you do about it?

Testosterone and You

I am the first one to say that testosterone is important for a healthy, long life. Clearly, men with low levels, termed hypogonadism, do not live as long as men with normal testosterone levels. I understand too, what testosterone isn’t and can’t do.

So, I am entirely empathetic to patients who ask: “Doc, what can I do to naturally increase my testosterone levels?” Forget about expensive gels, creams, injections, pellets or patches of testosterone that have side effects. They want to know what they can do, on their own, to improve their testosterone balance. As a big fan of self-empowerment, I dedicate this post to these men.

Lifestyle Changes to Improve Testosterone Balance

Lose weight. Fat converts testosterone to female hormones called estrogens. Less fat means less circulating female hormone levels.
Exercise. Although it is true that while you exercise, testosterone levels may be lower, exercise stimulates muscle recovery and growth through increased testosterone at rest.
Don’t overtrain. Rest between exercise sessions allows testosterone to work its magic.
Get good sleep. Poor sleep habits stress the body as a whole and stress reduces testosterone levels. Perpetual jet lag is no place to be.
Eat smart and cut the alcohol. Eat healthy meals regularly; skipping is not allowed. Also cut down on alcohol as it tends to impair testosterone production and increase conversion to estrogens.

Dietary Supplements That Improve Testosterone Balance

Get zinc. Zinc is a co-factor for testoterone production. Oysters, peanuts, chicken, lamb and (how timely) pumpkin seeds are excellent source.
Get vitamin B. This vitamin is also a co-factor for making testosterone. Bananas, avocados, watermelon, eggs and raspberries are excellent sources.
Control cholesterol. Eat plenty of monounsaturated fats, as found in fish, yogurt, almonds, and olive oil.
Eat garlic. Some evidence suggests that allicin within garlic can help improve testosterone balance. Watch your breath, though.
Herbal remedies: Tongkat ali, Catuaba bark-Muira pauma, Mucuna pruriens, Tribulus, Yohimbine and Ginseng. You know my opinion on these so take at your own risk.

Medical Treatments that Improve Testosterone Balance

If all else fails, see a specialist, as there are excellent prescription medications that can boost your body’s testosterone production, which is not the same as testosterone replacement. Clomiphene citrate, tamoxifen and human chorionic gonadotropin (hCG) are not anabolic steroids, but nor are they FDA approved in the U.S. for this purpose. But they are drugs that either convince the brain to send more gas (luteinizing hormone, LH) to the testicles to make more of your own testosterone, or directly provide the LH to stimulate testicles to make it. Unlike anabolic steroids, they encourage bioidentical (read: “your own”) testosterone production and do not impair fertility or shrink testicles.

You should try to optimize testosterone balance naturally, as these behaviors are generally healthy and good for a long and happy life.

The Secret Life of Varicoceles

Paul Turek, MD — Mon, 26 Sep 2011 15:00:19 +0000

Celsus, an expert at heat and varicoceles.

What’s squishy, worm-like, fills the space in the scrotum above your left testicle, can ache after a run and wreak havoc on your fertility? No it’s not your Johnson; it’s a varicocele. A very-what? A vari-ko-seal.

What is a Varicocele?

Varicoceles are dilated, tortuous veins that drain the testosterone-rich blood from the testicles. They come in three sizes: small, medium and large and are diagnosed on physical examination, generally by a specialist. Varicoceles exist when blood travels in the wrong direction through these veins. Normally, blood leaves the testicle and travels uphill to drain to the upper back, near the kidney. This is a long way to go and it’s all uphill. Since we stand as a species, good ol’ gravity, clearly our enemy as we age, acts over time here too and pulls the blood back down the veins and causes it to pool around the testicle.

Developing at puberty in active boys, varicoceles are an evolutionary consequence of man’s upright posture. Our quadriped ancestors and pets do not get them. They are common, occurring in one in every six adult men, and are generally nothing to worry about as they are often asymptomatic.

Why Do Varicoceles Matter?

The fact is, though, that varicoceles are not always innocent. In an odd way, they remind me of my dog Pretzel (my daughter named him) who will sit at your side all day when you’re home, but will grab that half eaten burger off the table as soon as nobody’s looking. Although varicoceles don’t cause cancer, they can hurt and they can cause male infertility. Also, a few others think that varicoceles can cause testosterone levels to drop.

The discomfort they cause is again due to gravity. It is usually mild and is worsened with physical activity and relieved by lying down, which neutralizes the effect of gravity. So, men can have varicocele pain after a long day of standing, but it never hurts in the morning upon awakening.

It’s role in male infertility actually dates back to the 1^st century AD. Celsus, a Greek physician, described them in De Medicina: “The veins are swollen and twisted over the testicle, which becomes smaller than its fellow, in as much as nutrition has become defective.” In reality, 40% of men who are having trouble conceiving their first child will have a varicocele, a rate almost three times higher than in the general population.

How varicoceles cause infertility is not entirely clear, but the most popular theory is that warm blood from the body that is flowing downhill into the scrotum heats up the testicles to the point that sperm production and quality are affected. Basically, the factory (testicle) is overheated and the workers aren’t putting out as many, or as good, a product.

Away with Thee, Varicocele

Fortunately, there are several ways to treat varicoceles and they work well to relief the pain and to improve semen quality. My favorite is to spend an hour with the patient and an operating microscope and tie off all of the enlarged veins. This stops the reverse flow of blood. Elegant, simple and safe. I do this a lot. In fact, varicocele is the single most correctable abnormality found among infertile men.

So, if you find yourself having trouble conceiving with an abnormal semen analysis and just can’t figure out why its happening, see a specialist as you might just be the average guy with a varicocele.

What Testosterone Isn’t

Paul Turek, MD — Mon, 12 Sep 2011 15:00:17 +0000

Testosterone: a molecule for life

I see a lot of patients who think that their testosterone levels should be higher for various reasons. I would like to set the record straight.

Even I have been heard to say that it is the “elixir of a man’s life.” Indeed, testosterone is one seriously important molecule throughout men’s lives. In the womb, it determines anatomic maleness. And during puberty, when another splash of testosterone hits boys and sticks for good, I don’t have to tell you what it does: feeds the growth spurt, cracks the voice, encourages hair growth, acne, stronger muscles and is the ultimate governor of teenage thought and action.

Testosterone in Adults

Testosterone in men is essential for health and well-being. First isolated in 1935, it is an anabolic hormone in that it generally induces growth. And it does this all over the body. In the brain, it influences sex drive, assertiveness, mood, energy and some aspects of thinking and verbal memory. In the heart, it helps dilate the arteries, which is good. Testosterone increases muscle strength and maintains normal bone density. It also reduces belly fat. In the kidney, it stimulates a hormone called erythropoietin that keeps blood counts normal. It also strengthens the immune system and helps blood to clot. In the male sexual organs, normal testosterone levels are important for erections and sperm production. So, it’s about as close to an “elixir” as any single circulating molecule in our bodies.

A List of What Testosterone Isn’t

Testosterone is not as vital to us as oxygen. For the record, here is what testosterone isn’t or doesn’t do:

It is not a common reason for erectile dysfunction (<6% of cases).
It is not a common cause for low sex drive.
It will not help you get more dates or make you a sex machine.
It will not magically make you a muscle man.
It will not magically cause weight loss or reduce fat. This requires a diet and exercise program.
It will not help you live forever; it falls with age.
It does not cause prostate cancer or liver cancer.
It is not higher during periods of stress; in fact, stress lowers testosterone levels.
It is generally lower in athletes than non-athletes.
It does not by itself cause baldness. Baldness is mainly genetic.
It does not get lower the more you masturbate.
It will not make you taller or your hands bigger as an adult.
More testosterone will not solve all of your problems.

What’s absolutely key to testosterone management is that there are symptoms present in association with low levels. In such cases, the benefits of treatment are clear. Think of testosterone as oil in your car: it helps everything work better, but when a problem occurs, it is usually something else that has gone wrong.