Posts Tagged ‘vasectomy reversal’

Freud’s Vasectomy

Sunday, July 25th, 2010
A man looking for his mojo.

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.

Surfing is Life

Monday, June 28th, 2010
It doesn't get any better than this!

It doesn't get any better than this!

Legend has it that surfing began in the Hawaiian Islands hundreds of years ago. In the late 1800’s, it was introduced to the U.S. mainland by way of southern California. Duke Kahanamoku, an Olympic star in swimming from Hawaii, helped popularize the sport by traveling internationally and demonstrating his surfing style. He is credited with surfing the longest wave ever in 1917, at a break called Outside Castles in Waikiki. The 1000 meter long wave that he surfed is a record that has yet to be broken.

Surfing became known in the Santa Cruz area, at the northern edge of Monterey Bay, began in the early 1930’s, 30 years before the epic surfing movie “Endless Summer” was released. Even today, Santa Cruz is known throughout the world as a mecca for peeling point breaks, and is certainly one of the best surf spots in California.

I love surfing Santa Cruz waters. To me, it is really the pinnacle of pristine California coastal beaches, a place where you can still hear the driving surf guitar of Dick Dale and feel the relaxed atmosphere of surf living. Pelicans, sea otters and often dolphins join you as you play in the water. Just magic.

I surfed Pleasure Point this weekend with an old friend on two windless days. Warm, waist- to head-high surf launched from a southern swell beginning in New Zealand and entering Monterey bay in perfectly peeling corduroy sets. Poetry.

In my other life as a surgeon, a craft like many others, I have learned to appreciate and enjoy the smallest details in life. For details matter in surgery, let this be clear. But they are not the ends, only the means, to a much larger whole that they constitute. Witness the healing and restoration of patients after complex microsurgery.

Surfing is also rich with details. The size, pitch and break of the swell, the aura of the murmuring ocean and breaking tide. The contour, rail, and rocker of the hand shaped board, and the trim of the body on board as it silently cuts through water.  Like surgery, surfing reaches an almost spiritual realm not only through the sensations conveyed by innumerable associated details, but also through the sublime and intoxicating feeling that, at least for a moment, one is in control of life.

One Child China

Sunday, June 13th, 2010
China: 5000 years old and on the move.

China: 5000 years old and on the move.

Just got back from China, from Beijing and Hong Kong to be exact. I lectured to several medical and academic institutions on where I believe men’s health is headed in the future. What I found was an audience eager to push the research frontiers in this field, however I also a sensed a lack of sufficient infrastructure to do this at the highest level. I paused for a moment to think about what was possible, since a monumental tidal wave of increased industrial productivity and change is occurring in China. For example, there are 1000 new cars being put on the road daily in Beijing alone! I sensed that when the might of China’s intellectual potential directs its energy toward medical research and innovation, the world will stand in utter awe at the prodigious output that will result.

Despite the fact that China’s culture is endowed with 5000 years of evolution and is responsible for helping to define human civilization, one thing really surprised me: its decision in 1979 to control its population by mandating a “One Child Only” policy. In the rest of the world, human reproduction is a basic right and for the most part, entirely unregulated. Under China law, families are allowed to have one child. After that, a vasectomy is performed on the male partner. Like it or not.

In addition to great control of population growth, the “One Child Only” policy has also led to the development of the wildly successful “No Scalpel Vasectomy” procedure. Now relatively common in the U.S., the “No Scalpel Vasectomy” is a quicker (10 minute), cleaner, less invasive and more comfortable innovation on a 100-year old American procedure.

But the curse of the “No Scalpel Vasectomy” is now being felt in China. Currently, it is difficult to find enough youth to fill jobs in urban areas within the massive and burgeoning Chinese economy. As a consequence, there has been a softening of the law such that couples that are both products of “one child” parents can now have two children. So can farmers, handicapped couples, and couples who work in “high risk” occupations like coal mining, heavy equipment operations and the like.

Even more fascinating is that infertile couples have a real reproductive edge over fertile couples under this law. How? Well, if they need assisted reproduction to help them conceive and they happen to have twins or triplets as a result (a 30-40% chance), they are not penalized for bearing “extra” children. Can’t help but think that this little known fact may partly contribute to the size of the massive, bustling IVF clinics that I visited in China last week. many of which are 4-10 times the size of U.S. clinics.

Handling The Truth

Sunday, March 28th, 2010
Patients can handle the truth...try them.

Patients can handle the truth...try them.

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

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

Two things are still true after visiting these two doctors:

1. He still wants a family.

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

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

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

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

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

Adding Hope to Health

Sunday, March 7th, 2010
How about being happy and hopeful as well as healthy?

How about being happy and hopeful as well as healthy?

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

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

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

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

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

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

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

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

The Symphony of Surgery

Wednesday, November 25th, 2009
Tickle the ivories and delight the senses.

Tickle the ivories and delight the senses.

I spent an evening this past weekend listening to the mighty Berlin Philharmonic Orchestra, conducted by Sir Simon Rattle. Listening to their performance of Wagner, Schoenberg and Brahms left me utterly breathless. A magnificent musical experience. Why? Because every single musician thinks and responds incredibly quickly and appears to give their all to a whole that is far greater than the sum of the parts. The mastery of these technically demanding movements was superb and it was clear that this orchestra, led by a conductor filled with supreme passion, could turn on a dime at any moment.

Can a surgeon perform surgery like a world-class symphony performs music? Absolutely. While a resident in general surgery, I remember watching a pediatric heart surgeon name William Norwood at the Children’s Hospital of Philadelphia perform his own Norwood Procedure on children with malformed hearts. Dr. Norwood’s hypoplastic heart surgery on infants at the brink of death was exhilarating to behold. Appearing intense and focused, with no wasted movements of his ambidextrous hands, he could repair an aorta or pulmonary artery in a minute with either hand, throwing absolutely perfect sutures as rapidly as a sewing machine. All the while working on hearts the size of shrunken plums and veins slimmer than angel-hair pasta. A technical virtuoso. All while listening to Albinoni’s Adagio in G Minor.

Aside from sheer talent, what makes William Norwood and Sir Simon Rattle the giants that they are, is a vision of perfection and the ability to inspire the best from others. Helping others achieve more than they could otherwise is a key element of leadership, especially in the setting of complex team performances like heart surgery or Schoenberg movements.

Inspired by these maestros, I too strive for perfection in my corner of the medical world, that of reproductive microsurgery. I view vasectomy reversal surgery as a craft best done by artisans. The chance to lead a roomful of others, throw 300 knots all with equal precision into an organ the size of spaghetti, gauge biology like a painter eyeing a still life, and help to create new life as a result. There is art in all that we do. Have you found your canvas?

Are We Replacing Ourselves?

Tuesday, September 8th, 2009
Where are you? Green means high and red means low.

Where are you? Green means high and red means low.

When a couple decides to have children, they rarely, if ever, contemplate the effect this has on the nation. But population scientists do. The effect that birth rates have on society is critical—as basic as knowing whether a nation is sustaining their population or not. But, trying to figure out if birth rates are going up or down is also complex, not unlike taking our temperature by feeling our foreheads.

A good barometer of birth rate assesses the average number of births per woman, and is generally noted by country. For a country to sustain its population in the future, the replacement rate is 2.1, or 2.1 births to every woman. What has occupied the minds of population scientists over the past 20 years is the fact that birth rates have dropped around the world, especially in Europe, but also in China and Japan. Interestingly, many countries in Africa do not have this problem, with birth rates well above 4. 

Also notable is the fact that in the past 20 years, the population of the world has dropped, falling an average of 1% per year. You can imagine how much this issue has occupied the minds of population scientists who seek to explain the phenomenon. Contributing factors include changing attitudes about family size, the cost of raising a child and the wider availability of contraceptives. The birth rate may also be dropping because child mortality on the whole has dropped. Or, because women who choose to have children later create a temporary lull in the birth rate. One concern with population drops is that countries whose populations become too small may not be able to afford to support its infrastructure, causing economic decline. So, on the one hand, it’s expensive to raise a child. On the other, it’s also expensive not to.

A recent study however, does show a change in these trends. Fertility rates now show a recent increase in developed nations. For years it has been thought that for some reason, developed nations, including most of Europe, have steadily dwindling populations. But this may not actually be the case. For example, in the 1970s, the US fertility rate was at a low of 1.74; lately it’s been relatively stable at 2.05. It appears that children are still wanted in a modernized world.

It’s quite hard to see these trends in my daily medical practice, as I perform as many vasectomies as I do vasectomy reversals. It’s even harder to render an opinion when the information is so diffuse and generational. So, to population scientist, I am a professionally “neutral contributor” to fertility rates. Like to think I do more good than that though…

The Ailing Male Pill

Thursday, August 6th, 2009
What shape will the male pill take?

What shape will the male pill take?

A male birth control pill certainly sounds like a good idea. But after 25 years and millions of dollars of research, there’s still no pill. We put a man on the moon faster than we’ve invented a male pill.

The question isn’t really whether it can be done, because it can. The production of sperm is linked to testosterone levels in the body. When testosterone levels are too high, the body stops producing sperm. Witness the testis shrinking (atrophy) that occurs with anabolic steroid use. Such pills have been tested, and are successful. One problem, though, is that the ability of hormone-based male pills to work perfectly (which they really need to do) varies with a man’s ethnicity. Works for some, but not all. This issue alone may prove fatal for the male hormone pill.

Besides this, there is a litany of concerns regarding the physical side effects of a hormone-based male pill. Immediate concerns have been a big issue in past trials- adult acne, weight gain, moodiness and the like. But what about possible long term effects? The female contraceptive pill has been linked with higher rates of heart disease and breast and liver cancer in women. Although not completely comforting, at least we know these issues in women. But little to no research has addressed similar issues with long term “pill” use in men.

Despite all of this, there is still a healthy interest in a male birth control pill. Studies have shown that men in committed relationships are more interested than single men in a pill– no surprise here. Single men are interested in using condoms for the added bonus of protection against STDs. A male birth control pill might also be a better contraceptive alternative for men who want more control over family planning than that offered by vasectomy. That said, there is still the eternal question of whether or not a pill would sell successfully– would women, in the end, trust their partners to be consistent and compliant in taking the pill? The answer to this question varies from couple to couple, but to get a sense of things, ask yourself how often you fail to take something as simple and uneventful as a daily multivitamin to get an idea of the magnitude of this problem.

There simply aren’t enough options for male contraception on the market today. The main ones are abstinence, rhythm method, withdrawal, condoms, and vasectomy. Given this lineup, there is certainly room for more, and more reliable, contraceptives for men. One thing seems reasonable clear: given the safety and effectiveness of vasectomy, and fact that daily compliance is not needed to keep it effective, anything new has to be this good or better. How about a truly reversible vasectomy? Or a long term, implantable hormonal device? In the end, these are likely to become tasty alternatives to a male pill.

The Vasectomy Hoopla

Monday, April 20th, 2009

Thoughts as elemental as the ocean

Thoughts as elemental as the ocean

These are times fraught with uncertainty. A sunny day isn’t just a sunny day anymore; it’s evidence of global warming. America has been at war for almost a decade, trusted financial institutions are folding and our economy appears to be on the verge of collapse. It seems only natural that people would look at our unstable world, ask themselves dark-night-of-the-soul type questions, and choose what is right for them.

In the last several months, since the scope of our financial crisis has made itself known, there has been a spike in the number of vasectomies being performed. Some Planned Parenthoods are reporting that vasectomies are on the rise, up thirty percent from the same period last year. Several doctors have also made the same observation. The New York Times recently attributed the increase to the bleak outlook of America’s economy. They postulate that men are reacting out of fear that they can’t afford a child. This is too simplistic a conclusion. A man’s life is long, as is the ability to reproduce, and can easily outlast a financial deep freeze. And people don’t stop wanting children simply because they are expensive. The desire to procreate runs too deep; as deep as the need to eat.

There could be other reasons for the increase, if in fact there really is an increase. For one thing, reproductive impulses move with the seasons. It has been observed that, like most of nature, human reproduction is seasonal. It is widely accepted in the scientific community that birthrates swing up and down as the year progresses, with more babies born in the spring. Just like lambs. Despite our seeming transcendence of the animal world, reproductive urges remain firmly guided by biology. We could simply be seeing a downswing in this urge at this time.

It’s also possible that the new year, especially this one, gave people a desire to make a fresh start, and are putting their plans into action while they feel motivated. No doubt there will be a lull in vasectomy business when everyone runs off for vacation in the summer. Mai-tai or vasectomy? You choose.

One observation that throws a wrench in the New York Times’ argument is that right now, in my practice, I am seeing a surge of interest in vasectomy reversals. With these couples, just as with men seeking vasectomies, there is a level of urgency. Across the board, I hear the same thing from both groups — it’s now or never.

I am inclined to think that the grim reality of the recession, the wars, the rise in global temperature (will that affect sperm production?) — threats such as these crystallize thoughts and focus actions, helping us to clarify in our minds what we truly want. I think men are simply putting into action what they were already planning to do, while it is still possible. Whether it’s a man who seeks a vasectomy before he’s laid off, or a couple who thinks the clock is ticking just a little louder, times like these can reveal to people what is truly, fundamentally important to them.