We get a a lot of very special, personal and wonderful news from our patients at The Turek Clinic. Sometimes they are generous enough to share their stories with us. With their permission, we’d like to share their story here – in their own words.

Introducing Cole Michael!

“Here is our story! Please let me know how I can share it with future patients

My wife and I are thrilled to report that we just had our first baby boy!

“Cole Michael” was born on February 28th, 2012 weighing 8 lbs. 1 3oz. and measuring 21.5 inches long. Both mommy and baby are doing great.

Dr. Turek is an ‘angel’ from God that performed a miracle for me and my growing family. A brief history: I went through a divorce 4 years ago that left me with two beautiful boys, and a vasectomy. Shortly afterwards, I met the love of my life. After dating for 11 months we got engaged and decided that we wanted children of our own so I called up my urologist (the same one that performed the vasectomy) and scheduled the surgery to have everything undone.

He assured me that he had done this type of surgery before with enough success to have me commit to moving forward with him (you would think the one that closed it up could open it back up… I was so wrong)! The surgery was very painful; a lot of bruising and I had a huge hematoma that stretched from the top of my right hip bone down to the bottom of my buttocks. The recovery lasted two full weeks – I couldn’t get off the couch for the first week because the pain and swelling was so horrendous. But I kept saying to myself, ‘it will all be worth it if I can get viable sperm again.’ Needless to say, the surgery was unsuccessful and left me with residual amounts of pain, scaring, and a $7,500 bill to pay.

My fiancée and I were very disappointed and desperate to have the procedure done correctly. I went back to my doctor and expressed my deep concern of the outcome of the surgery and the only thing that he could recommend is that I should consult with Dr. Turek in San Francisco. Dr Turek specializes in fixing vasectomies that didn’t take the first time. He’s world renowned, and has an impressive track record of successful outcomes. I just wish he would have referred me from the start versus trying to perform it himself and leaving me nothing to show for it but a lot of pain.

So I took his advice and immediately went on The Turek Clinic Web site. I was very impressed and immediately scheduled a consultation with Dr. Turek. I told him my story: 4 year old vasectomy, with an 8 month old failed vasectomy reversal. Dr. Turek said, “This is my area of expertise. I like challenges so lets see what we can do.” And after going over his success rates it was clear that he is the one that should have been doing this procedure from the very start.

I had the surgery performed in January 2011, was married June 4th, 2011 and we had our first baby February 28, 2012. What an amazing blessing to be celebrating our first wedding anniversary ‘with’ our beautiful baby boy!

There are three things that make Dr Turek the leader in this type of procedure:

1. Pain management: It’s amazing when the surgery is done correctly the first time how much ‘less’ pain medicine is needed and how the recovery was expedited (I had very little swelling and only had to use the pain medicine for two days).
2. After care is unparalleled: Dr. Turek is there from surgery all the way up to conception and his staff are amazing. Constant support and communication through: office visits, email and phone calls.
3. Positivity! Dr Turek’s clinic gave my wife and I a feeling of hope and optimism from day one.

We feel so blessed to have Dr. Turek in our lives and its amazing to think how gifted his talents are to bring life to parents when at one time there was no hope. He is our angel!!”

Kind regards,
Mike and Rachel
Roseville, California

You can read more from our patients on our testimonials page.

Related posts:

1. The A through Z of Male Fertility in One Hour
2. Timing (And Position) Are Everything
3. Dr. Paul Turek, an Elsevier Author at AUA 2011
4. Dr. Paul Turek on TV Show ‘The Doctors’
5. How to Avoid Male Infertility

Introducing Cole Michael!

We get a a lot of very special, personal and wonderful news from our patients at The Turek Clinic. Sometimes they are generous enough to share their stories with us. With their permission, we’d like to share their story here – in their own words.

“Here is our story! Please let me know how I can share it with future patients

My wife and I are thrilled to report that we just had our first baby boy!

“Cole Michael” was born on February 28th, 2012 weighing 8 lbs. 1 3oz. and measuring 21.5 inches long. Both mommy and baby are doing great.

Dr. Turek is an ‘angel’ from God that performed a miracle for me and my growing family. A brief history: I went through a divorce 4 years ago that left me with two beautiful boys, and a vasectomy. Shortly afterwards, I met the love of my life. After dating for 11 months we got engaged and decided that we wanted children of our own so I called up my urologist (the same one that performed the vasectomy) and scheduled the surgery to have everything undone.

He assured me that he had done this type of surgery before with enough success to have me commit to moving forward with him (you would think the one that closed it up could open it back up… I was so wrong)! The surgery was very painful; a lot of bruising and I had a huge hematoma that stretched from the top of my right hip bone down to the bottom of my buttocks. The recovery lasted two full weeks – I couldn’t get off the couch for the first week because the pain and swelling was so horrendous. But I kept saying to myself, ‘it will all be worth it if I can get viable sperm again.’ Needless to say, the surgery was unsuccessful and left me with residual amounts of pain, scaring, and a $7,500 bill to pay.

My fiancée and I were very disappointed and desperate to have the procedure done correctly. I went back to my doctor and expressed my deep concern of the outcome of the surgery and the only thing that he could recommend is that I should consult with Dr. Turek in San Francisco. Dr Turek specializes in fixing vasectomies that didn’t take the first time. He’s world renowned, and has an impressive track record of successful outcomes. I just wish he would have referred me from the start versus trying to perform it himself and leaving me nothing to show for it but a lot of pain.

So I took his advice and immediately went on The Turek Clinic Web site. I was very impressed and immediately scheduled a consultation with Dr. Turek. I told him my story: 4 year old vasectomy, with an 8 month old failed vasectomy reversal. Dr. Turek said, “This is my area of expertise. I like challenges so lets see what we can do.” And after going over his success rates it was clear that he is the one that should have been doing this procedure from the very start.

I had the surgery performed in January 2011, was married June 4th, 2011 and we had our first baby February 28, 2012. What an amazing blessing to be celebrating our first wedding anniversary ‘with’ our beautiful baby boy!

There are three things that make Dr Turek the leader in this type of procedure:

1. Pain management: It’s amazing when the surgery is done correctly the first time how much ‘less’ pain medicine is needed and how the recovery was expedited (I had very little swelling and only had to use the pain medicine for two days).
2. After care is unparalleled: Dr. Turek is there from surgery all the way up to conception and his staff are amazing. Constant support and communication through: office visits, email and phone calls.
3. Positivity! Dr Turek’s clinic gave my wife and I a feeling of hope and optimism from day one.

We feel so blessed to have Dr. Turek in our lives and its amazing to think how gifted his talents are to bring life to parents when at one time there was no hope. He is our angel!!”

Kind regards,
Mike and Rachel
Roseville, California

You can read more from our patients on our testimonials page.

Related posts:

1. About Dr Turek

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:

1. My wife said: “the factory is closed,” so I’m here.
2. I was told that they broke the mold after they made me, but I want to make sure of it.
3. My wife said: “It’s your turn now.”
4. After this, I won’t ever have to say I’m sorry again.
5. I’m married! Condoms are sooo high school!
6. Have you seen the movie ‘One Fine Day?’ That’s why I’m here!
7. Every time I look at my wife, she gets pregnant.
8. Apparently, sacrificing some limbs just isn’t the same…
9. She told me: “Enough, get your wings clipped already!”
10. I was told that I can shoot the gun all I want and no one will get hit.
11. I heard that it’s easier than getting your teeth pulled out…
12. 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.

Related posts:

1. Freud’s Vasectomy
2. The Vasectomy Hoopla
3. Guide to Surviving the Holiday Season
4. Insider’s Guide to Vasectomy Reversal
5. Are Fathers Better Citizens?

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!

Related posts:

1. The Skinny on Holiday Cards
2. Guide to Surviving the Holiday Season
3. Recipe for Making a Walrus
4. Fertility from Sterility
5. Timing (And Position) Are Everything

Cleaning a set of these every week is one way to "busy your hands."

Two patients told me that they were getting divorced this week. They came to the office and thanked me for all that I have done for them. They wished that the assisted reproductive technology had worked and given them children, but it didn’t. The relationships simply couldn’t tolerate the strain and gave way. Unfortunately this is not uncommon.

The Stress of Infertility

Don’t doubt for a minute that being infertile doesn’t have the same impact as having cancer. Very little can tear holes in the fabric of a relationship like infertility can. Add to this the romance of the holiday season and you have a recipe for potential disaster. Gathered families encircled by the howling laughter of children; smartly dressed kids at parties just learning to be polite; parents reveling in the enchantment written on the faces of children hearing holiday stories. To the infertile, its like having walking pneumonia—it just never seems to get better or go away.

Eight Ways to Reduce Your Holiday Stress

Maybe it’s not that bad. Maybe the holiday season is just more stressful. What can you do about it? Here are some tips for men as the holidays approach:

1. Take smaller steps. Stress and depression are like the flu: give them some time to run their course and pass through. You will make it, and you will be stronger because of it.
2. Make a plan. Spinning out of control without a plan for the problem can cause great anxiety. Simply agreeing to take the next month off and start again in the New Year can make all the difference in the world.
3. Enjoy each other. After all, you have found a soul mate that is going through the same experience. Give and get that big hug that can make all the difference in the world
4. Express yourself. Cry on her shoulder and not in a closet. Vent about that wicked day by journaling. A belly laugh or a primal scream is even better. Empathy is a very rich and particularly human experience with immense healing power.
5. Relieve your stress. Exercise, yoga, massage and acupuncture are fabulous ways for men to “vent” and relax. There is something about those endorphins that waft through the body after a long run…
6. Be mindful. Take your eyes off the Ipad and lose circular thoughts that lead to nowhere. Take note of the present. Quietly observe life. Breathe to relax. You are an organism, not a machine.
7. Try fasting. From emails, texts, news, stock quotes. Do you really think that you can keep up with the web growing at a rate of 7.3 million pages per day?
8. Busy your hands. There is enormous therapy to be found by working with your hands. In the words of Michael Crawford, author of Shop Class as Soulcraft: “Fixing things feels good.”

Related posts:

1. The Skinny on Holiday Cards
2. Fertility from Sterility
3. The Quiet After the The Storm of Cancer
4. Insider’s Guide to Vasectomy Reversal
5. Adding Hope to Health

What's inside of a coffee mug depends on how you look at it.

Do you think it is possible to have your own children with absolutely no sperm in the ejaculate?
Why yes. It happens on a daily basis in my practice.
Honestly, the word “sterility” has really lost much of its meaning nowadays with advances in reproductive technology.

The Affairs of Sperm

Azoospermia is the word used to describe the lack of any sperm in the ejaculate. It is a devastating thing for men to hear as they try to conceive. It comes in two forms: as a consequence of blockage in the sperm ducts outside the testis in the setting of normal sperm production in the testicle (i.e. vasectomy) or as a result of poorly functioning testicles and normal, open ducts beyond it. We routinely grab sperm from behind vasectomy sites to use with assisted reproduction to conceive. Finding sperm in men with poor sperm production, termed nonobstructive azoospermia, is a more complex matter.

One way to think about sperm production in men with poorly functioning testicles is to compare it to a mug with coffee in it. Say the mug is filled with ¼ cup of coffee. If you hold shake the mug, you may not see any coffee spill over the side. In this case, you might assume that the mug has no coffee inside. But, if you peer into the mug directly, you will see that there is actually coffee in the mug. Similarly, the testicle makes more sperm (coffee) than is found in the ejaculate (spilling over cup). There exists a threshold of sperm production, over which sperm shows up in the ejaculate and below which it will not. So, now you know the secret of making fathers out of “sterile” men with poorly functioning testicles.

Sperm from a Rock

Of course, it’s not quite that simple. There is one more layer of complexity here. Poorly functioning testicles may not make sperm evenly throughout their substance. In many cases, there are “pockets” or “islands” of sperm within a sea of otherwise empty tissue. Clinically, this makes sperm retrieval more difficult and has pushed this technology to a high art.

To find sperm, fertility specialists use several sophisticated approaches in men with nonobstructive azoospermia. The traditional testis biopsy works about 30% of the time to find sperm and, as a consequence, is no longer the de rigueur technique for this problem. Fine needle aspiration “mapping”, which I invented about 15 years ago, is easily twice as good as a biopsy in finding sperm and much less invasive. Lastly, “microdissection” of the testis another alternative and involves an all-out surgical assault on the testicle to find sperm making it the most invasive approach.  The elegance and complication rates for these approaches vary widely, but their intent is the same: to find enough sperm to allow biological fatherhood. Importantly, when expertly performed, these techniques will find sperm in the majority of cases. For the remainder, there is hope as even newer “no touch” scanning technologies are on the horizon…

Related posts:

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

Beauty (and results) are in the eye of the practiced beholder…

Something like 25,000 American men a year want more children after having a vasectomy. The more popular of two options for fatherhood after vasectomy is a vasectomy reversal; the other choice is sperm retrieval for men and in vitro fertilization (IVF, “test tube baby”) for their partners. Even though it is a surgical procedure that is technically quite challenging and not generally covered by medical insurance plans, clearly reversals have a major leg up on high-tech, IVF conceptions: you can do what you do best and do it at home, the old-fashioned way, to conceive.

Who Does Vasectomy Reversals?

Among the 10,000 or so practicing urologists in the U.S., maybe 5-10% of them are interested in performing vasectomy reversals and far fewer than 1% are fellowship trained microsurgeons who specialize in this procedure. So, how do you decide to whom you should go to have this done?

Deciding on a Surgeon

Not all doctors are same. If you didn’t know this before, you heard it here first. Some are average run-of-the-mill, some are better, and others are truly gifted and talented at what they do. And the difference between an average doctor and a great doctor is the quality of the product. Did you actually get what you asked for, or what you expected to get?

You can read all over the Internet about ways to choose your reversal surgeon. These parcels of advice are helpful and may lead you to find a good surgeon instead of an average one. But if you want the highest quality surgeon, here are six key issues to consider as you search and shop:

1. Does the surgeon enjoy doing vasectomy reversals? I’ve met countless surgeons who are pleasant enough in or out of the office but who are simply miserable in the operating room. I can’t explain why. Personally, reversals are my favorite thing to do (at work). It is a craft and an art form of the highest caliber, the elixir of a surgical life.  A surgeon who loves what he does will do a better job of it.
2. Does the surgeon pay attention to details? I can’t recall who said this, but life really is in the details. And microsurgery, performed at 1/25 normal scale, is the ultimate detail-oriented surgical procedure. Has the surgeon gotten all of your details? How about your medications? Habits? Your partner’s issues? How neat is their office? How comprehensive and detail-oriented are the staff?
3. How long will you have to wait to get the procedure done? You may think that if you have to wait a long time to get the reversal performed that the surgeon is very busy at doing reversals. Honestly, it could mean that (s)he doesn’t operate very much or that (s)he spends a lot of time out of the office or doing other procedures. In other words, reversals may not be a priority for the surgeon (see #1 above). Or, the office itself may be disorganized (see #2 above). The better way to assess “busy” is to look them in the eye and ask them how many vasectomy reversal cases they do each year.
4. What are your surgeon’s success rates? You see success rates of surgeons on every website. And they all look the same and are all very high. What does this mean? How do you decide? Frankly, many surgeons quote the published rates of other surgeons, kind of like selling “knock offs” instead of the real thing. This may be fine for buying purses but not for vasectomy reversals. Peer-reviewed and journal-published data is an excellent measure of quality: it is the certified seal of authenticity. So, ask that simple question: Has the surgeon published their success rates in trade journals?
5. How many reversals does the surgeon perform annually? Do Olympic athletes or concert musicians win competitions through talent alone? Of course not. It’s all about the training. Similarly, a good predictor of reversal success is surgical volume or the number of cases. Volume means practice and practice makes perfect. This is true for almost all surgical procedures in medicine and is also true with reversals.
6. Does your surgeon want what you want? You don’t really want a reversal, you really want a kid, right? And you don’t want to sell that old car or mortgage a property to get it. Let’s say that the cost matters a lot for you. If IVF is covered by insurance and a reversal is not, then IVF may be the cheaper way to go. In this case, the surgeon should not keep giving the hard sell for vasectomy reversal. There are several paths to fatherhood. Make sure that your surgeon shares your goals. For me, it’s the holiday card that matters the most.

Related posts:

1. The Low Down on Being Knocked Up
2. Handling The Truth
3. Adding Hope to Health
4. The Secret Life of a Microsurgeon
5. The Vasectomy Hoopla

A surfing mentor in Panama: Victor Martinez

They stood on their boards in waist high waves within a couple minutes of my surf lesson. It was magic to see the look on their faces as their arms were wildly gesticulating in the white water. All half dozen of them. Even chilly 60-degree water didn’t seem to matter.

Teaching is fun. And this was certainly a highlight of my week spent in Outer Cape Cod with two-dozen relatives from Connecticut and New Hampshire. Great weather, 80+ degree-days, and the warm sand and grassy bluffs typical of east coast beaches.

An Academic Life

I certainly learned a thing or two about teaching while training as a resident at the University of Pennsylvania for six years and then again during my tenure as a full time faculty member at the University of California San Francisco for almost fifteen years. My experience teaching college and medical school students, residents and fellows has led to a relatively simple teaching philosophy, the secrets to which are below:

• Teachers are born and not made. More work than talent is needed to be a great teacher.
• Plant the seed of knowledge and let it grow. Don’t try to plant the whole tree. Curiosity is incredibly fertile soil.
• Be an example, or mentor, to those taught. Practice what you preach and your teaching will have far more impact.
• Take some time to put on the student’s shoes (figuratively of course) to better understand from whence they come and to optimally stimulate learning.
• Analogies work wonders. Bring home points with everyday examples.
• Storytelling is better than almost any other media imaginable for information retention. (If you haven’t guessed yet, this is precisely the modus operandi of this blog)

Teaching Urologists

From the Cape, I am off to New Orleans to teach an annual board review course to 600 urologists. This teaching scenario presents its own unique challenges including conveying an abundance of critical information (enough to fill a book) in a very short time frame (an hour). My goal: keep it short, keep it sweet, tell some stories and make it memorable. I’ll post the lecture slides this week and see what you think.

Related posts:

1. Adding Hope to Health
2. Where There’s Smoke
3. The Condom Cha Cha
4. Giving Up the Gavel
5. The Skinny on Holiday Cards

Google: Feels like college all over again…

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

The Guy’s Guide to Maintaining Sexual Health Talk

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

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

Googlers Care

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

The Talk:

Video -

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

Related posts:

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

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

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

The Google Invitation

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

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

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

Google Health

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

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

Advice to Google on Sexual Health

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

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

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

Related posts:

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

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

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

Study of Sloshed Surgeons

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

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

The Microcosm of Microsurgery

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

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

What’s the Surgeon’s Secret?

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

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

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If I could only draw like this surgeon could…

It’s the age of “green” no doubt about it. Houses, cars, and even lifestyles with small carbon footprints are part of a larger deeper, planetary respect. You may know of green pencils (from recycled newspapers), sugar cane paper and, of course, green books. But, did you know that the ultimate green book is one that has been around for 54 years and has a huge worldwide following in medicine?

The Netter Green Books are a veritable medical bible that has now been revised for the first time in five and half decades. I am honored to be one of its new editors. Giddy as I write this, Volume One, The Reproductive System, was just sent to me and it is absolutely glorious. Have a look on Amazon and you’ll see.

Who is Frank Netter?

Arguably the finest medical illustrator of the human body since Da Vinci, Dr. Frank Netter’s career as a medical illustrator began in the 1930′s. As a surgeon in training at NYU, he learned by cramming his notebooks with pictures, not words. His professors discovered this talent and offered to pay him for his art and helped to fund his medical education. Near the end of his career, his incredibly detailed, lifelike renderings of the human body in watercolor led the New York Times to hail him as “The Medical Michelangelo.”

How to Update a Masterpiece

Physicians old and young have looked at these images time and again for five decades, seeing in them comfortable sources of clear and clinically succinct information. The privilege of editing this monumental tomb has been both daunting and revealing. Dr. Netter’s art is utterly timeless, highly exact and informed to the point of being prescient. How do you improve on a masterpiece? On the other hand, medicine has change dramatically over the past half century and really demands that entirely new knowledge be revealed.  Similar to restoring a Michelangelo painting or translating a Nabokov novel, editing this volume highlighted to me both the vast changes in medicine and the timelessness of Dr. Netter’s art.  I chose to let the art do the talking and wrote text to frame it with context, clarification and modern clinical relevance.

Medicine as Art

I come from a family of painters and, as a surgeon, rather fancy myself a craftsman of sorts. This may be why I so enjoyed working with great artists such as Carlos Machado and Tiffany deVanzo who illustrated this volume. As a team, we were able to tackle such complex concepts as ejaculatory duct obstruction, microsurgery and the genetics of sex determination and convey them as medical art. Indeed, some of the figures we proposed for the new Netters took several months to get just right.

Just as challenging for me was my duty to examine the authority of current scientific knowledge. Although I have written and published 60 or more textbook chapters to date, for the first time and for this book, I would constantly ask myself whether what I had written is true not only now, but would be for the next 50 years, until the next edition is written. Trying to tell the difference between what we really know and what we really don’t is a daunting but intensely fulfilling task. My admiration and respect for the wondrously rich and intricate, baffling yet logical, and powerful but delicate workings of the human body have grown in unimaginable ways from this effort. Such are he “soft whisperings” of beauty of which Kahlil Gibran speaks.

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

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

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

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

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

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

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Sometimes doing the dance gets old…

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

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

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

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

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

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

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Father knows best… but he may need some help!

Honestly, I have a lot to be thankful for in November. A wedding anniversary, the birthdays of both daughters, and a restful holiday all in one month. Seeing the chocolate covered smiles on my young daughters as they inhaled birthday cake recently reminded me of something: My work involves turning men into fathers every day. Be it through lifestyle changes, medical treatments, vasectomy reversals or sperm retrievals, babies are born and the wonderful thank you notes that pour into the office are constant reminders of this.

Funny thing is, when a newly minted father looks me in the eye and asks “Any advice on being a Dad?” it is difficult to know what to say. Besides spouting the usual keywords like “love, fairness and consistency,” I find that it’s all so very personal, isn’t it? In fact, after our two daughters were born (one now 7 and the other 2), I actually asked my wife a similar question (as told in a recent limerick at their birthday party):

I remember asking Ashley,
With a voice somewhat ghastly,
“How do you raise girls?!?”

You see, boys are more straight-forward.
Toss them a truck, glove or sword,
And they’ll run until they’re silly,
Occasionally fiddling with their willy.

But girls are different to be sure.
Their love of pink just has no cure.
Their carriage, dance and elocution,
Suggest an entirely different evolution.

Then came Sophia, wise beyond her years,
A beauty towering above her peers,
A joker, a sport, a musician, an angel,
I am counting the hearts that she will mangle.

And then there’s Vanessa, mystic goddess with dimples,
Whose world is clear-cut and oh so simple.
Yet, behind the pacifier there lurks a smile,
That portends a woman of substantial guile.

“You raise them the same.” Ashley said to me.
“But you’ll turn to butter when they want things…you’ll see.”

So readers, help me out. What are the three most important traits of a good father?

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