Award-winning urologist and men's health pioneer Dr. Paul Turek authors Turek on Men's Health, named one of Healthline's top men's health blogs of 2017 for the second consecutive year. Follow this blog and get the gamut of men's health issues, from infertility to vasectomy reversal azoospermia, ED & more.
Just a bunch of sperm peeps trying to figure out the future. That’s water not wine on the table.
It was about as spontaneous as meetings get. The academic equivalent of a “pick up” ball game. But it was attended by a who’s who in andrology in England and Ireland. And the topic was one that we never seem to think about in our busy lives as infertility care specialists: What is the future of male infertility?
A July Crowd
In attendance at the meeting, held at the famed Durrants Hotel in London, were urologists, gynecologists, endocrinologists, Ph.D. researchers, nutritionists, embryologists, psychologists, and industry experts. The meeting was organized by Dr. Jonathan Ramsay, a prominent London male fertility specialist, and we were also graced by the presence of a member of the British Parliament, Lord Robert Winston, who also happens to be a gynecology professor at Imperial College in London and a pioneering IVF clinician (IVF was invented in England). Surely a king’s table event loaded with a heavy-hitting brain trust in male infertility and sperm biology.
At the meeting we discussed the current status of male infertility care in Europe and the US, and also where it’s headed. Although disagreements were common, what struck me most was how much, and how often, we agreed on things. A summary of the current state of male infertility:
In the UK and the US, the vast majority of women but only a minority of infertile men receive medical care for their diagnosis.
For a variety of reasons, men have difficulty accessing infertility care.
Whether men admit it or not, the psychological impact of being infertile is great and likely on par with having cancer or other life-threatening illness.
Given that infertility is a “biomarker” of overall health, it is more important than ever that men receive proper medical care (and not just a semen analysis) when diagnosed with infertility.
Neither the public nor the rest of medicine fully appreciates the fact that evaluating male infertility provides a “window” into men’s overall health.
Although commonly used for 50 years, the semen analysis is a “blunt instrument” in the infertility evaluation. A “deeper dive” into sperm quality is essential to an improved understanding of male infertility.
We have not pursued “root cause” analyses of male infertility as diligently as we should. Research in this field is essential, as a better understanding of causes leads to more effective treatments.
IVF is now a big business in both countries and is used liberally as a “catch all” treatment in many cases of male infertility. But, unfortunately, it appears that the IVF sons of infertile men will also need IVF because the infertility is not “cured” but simply bypassed. This is not great news for the future of male infertility care.
The Crystal Ball
Moving forward, we all agreed that nothing beats good scientific research and well-performed randomized clinical trials to ensure that we offer the best possible solutions to male infertility. In addition, we felt that there is a great need to increase awareness of infertility as a life-altering and health-related disease amongst the public and within medicine. A driving sentiment felt throughout the meeting was that we must keep moving the needle and get infertile men the care that they not only need but also deserve. Good, better, best; never let it rest!
A vasectomy reversal is like sewing together a piece of spaghetti with a hole in the middle.
I see a lot of couples for vasectomy reversal procedures. As they gather information before proceeding, typically the partner, not the patient, fires off most of the questions. These queries come in two forms: questions directed at me and those having to do with the procedure.
The Dirty Dozen
Thank goodness that I’m a data-driven-doctor, because my patients are similarly inclined. Here are a dozen of the most common questions women ask me about their partners’ reversal procedure:
How long does it take? It depends on whether a straight connection (vasovasostomy) or bypass procedure (epididymovasostomy) is needed. Typically, 2 to 3.5 hours of surgery on a come-and-go basis.
How risky is it? I believe that paying attention to risk is essential to keeping a healthy man healthy. Performed under intravenous and local anesthesia, complications from anesthesia (heart or lung issues) or the procedure itself (bleeding, infection, chronic pain) occur in <1% of cases.
How painful is it? Men take an average 3-4 pain pills (total) after surgery, typically over the first 48 hours. Back to work at a desk job as soon as the pills stop. And, we’re studying a traditional Chinese herbal supplement to replace opiate pain pills after surgery.
How can we reach you after surgery? Uniquely, I keep in touch with patients using GetWellLoop, which connects us daily for 3 weeks after the procedure.
What technique do you use? I’m a big fan of studying the masters who preceded me and taking their techniques to the next level. I apply whatever technique works best for each patient. Some keywords are: microscopic, modified 1-layer, formal 2-layer, invagination.
How much experience do you have performing these procedures? It’s my favorite thing to do, and I publish my results in peer-reviewed literature. Can’t get much more “authentic” and “valid” than that!
How many vasectomy reversals do you do? One to three cases weekly. As a measure of procedural complexity, the average age of vasectomies that I reverse is 15 years, and 17% of my cases have already failed vasectomy reversals with other surgeons. Call me “clean up.”
When can we have sex again? I like to keep things moving to keep them open. Two weeks until sex with straight connections and 3 weeks after a bypass procedure.
What’s the chance he’ll have a sperm count? Short answer: it depends, but it’s high. For vasectomies that were performed fewer than 15 years ago, return of motile sperm occurs in 90-100% of cases. For vasectomies that were performed fewer than 16 years ago, 75-90% of cases.
What’s the chance I’ll get pregnant?
Hard to accurately judge surgeon success using this metric because there’s another party involved here (the partner). However, 55-65% in the average case.
How quickly will I get pregnant? Great question. This depends as much on the female partner’s fertility potential as it does on the quality of the vasectomy reversal. With vasectomies performed <15 years ago, typically <1 year, but with reversals performed >16 years ago, typically 1-2 years.
Can he get another vasectomy afterwards? Tapping into the idea that men really love their vasectomies, I now offer a “One & Done” package that includes both a reversal and a subsequent vasectomy. Short answer: absolutely possible.
There are also less common but equally interesting questions I get asked. Two of them come to mind: “Do you cut yourself shaving?” (never!) and “How much sleep do you get before surgery?” (I love sleep). Both questions stem from real concern about the well-being of the partner having surgery. As Winnie the Pooh once said: “Some people care too much; I think it’s called love.”
The beauty of the ocean runs deep (Courtesy: Unsplash.com)
As a surfer, I find spending time on the ocean wonderfully intoxicating. The power and pitch of the waves, the size of swells, the shimmer of the sea, all magnificent to behold. But, what’s beneath the water’s surface is truly a whole other world; one even more marvelous than floating on top. And so it goes with men’s health.
Scratching the Surface
He came to see me because his vasectomy reversal had failed and he was wondering whether I could help him have kids. He had had a vasectomy and then a vasectomy reversal a decade or so later. The reversal had worked initially but over the last several years, while he was trying to conceive, his sperm count fell to zero. Not a single swimmer.
I think about several things when I see this: surgical failure of the reversal procedure with scar tissue causing re-blockage, changes in health (cancer, diabetes, obesity), testicular failure from illness or exposure (fevers, hot baths, solvents) and medications, to name a few. And since I have a habit of asking “why?” we now break the water’s surface and head into that deeper place where answers lie.
He was a picture of health. His reversal was done by a highly competent colleague and so I ruled out reversal failure. He was medication-free and had no bad health-related habits. I was really coming up empty handed…except for one thing: he mentioned that he was feeling more tired lately and has been having trouble with erections and a lower sex drive. His primary care physician measured his testosterone and it was low…really low. Low testosterone could explain the erection and sex drive issues and also poor sperm production.
His doctor suggested that he start on testosterone replacement. But the patient knew better: this might help his symptoms, but it would “turn off” sperm production. He didn’t follow that advice but asked for my help instead.
It is medically satisfying and usually correct when a set of symptoms can be ascribed to a single overarching diagnosis. But this didn’t happen until I reviewed the ream of laboratory data that he handed me during the visit.
Then I saw it. His blood counts have always been really high. For years. Thick blood. Hemochromatosis! A genetic condition that causes blood to sludge in the pituitary and reduce the signal strength for the testicle to make testosterone and sperm. We confirmed it with iron studies. He started donating blood, and I kickstarted his pituitary with medication, and, low and behold, both his sex life and sperm returned.
Being able to find and cure disease relies not only on powers of observation, but also the ability to listen (and trust) that what patients tell you is real and relevant. Only then, when the truth is laid bare on the table, does the hidden become obvious.
Take a moment to reflect this Independence Day (Courtesy: Unsplash.com)
You appreciate a nice cold glass of water. And you rely on a steady flow of electricity to your home and work. Many of us also admire how modern technology keeps us not only engaged and productive but also organized. But when is the last time you reflected upon the most precious natural resource in our country: Freedom! I think about this frequently and certainly every time I work with military families.
Costs of War
Estimates are that 6,900 U.S. troops have been killed in Iraq, Afghanistan and Pakistan since the Iraq War began in 2003. As a consequence, scores of families will fail to form or grow — we’re talking about infertility in its most disastrous and absolute form.
An additional 30,000 troops have been injured during these three military operations, and about 1 of every 20 injuries affected the male reproductive tract, causing near absolute infertility. Over a 12-year period ending in 2013, 1,367 men in our military had genital injuries in Iraq and Afghanistan, according to a recent military report. The most common injuries were to the scrotum, testicles and penis. Over 10% of men lost one or both testicles from these injuries. And, over 94% of men injured were in peak reproductive age of 35 years or younger. It’s hard to stay fertile when parts down there are missing or not working anymore.
Keeping the Jewels Safe
Thankfully, there are systems in place to protect not only the lives, but the fertility of our troops at war. The most notable of these are:
Sperm banking before deployment. This has long been encouraged by the Pentagon and now they are thinking about actually funding it.
Pelvic armor. Given the abundance of ground-level mines and improvised explosive devices (IEDs), the military now uses Kevlar underpants. There’s the PUG (protective undergarment) on the inside and a thicker POG (protective outer garment) worn over combat trousers.
Funding infertility care. In 2016, a bill passed in Congress that provides infertility treatment (up to 3 cycles of IVF) to disabled veterans.
There are some very special fertility doctors doing amazing work to preserve fertility in cases of catastrophic genital injuries.
Our servicemen not only put their own lives on the line, they also indirectly place their future families on that same line. As the award-winning American writer Cynthia Ozick once said, “We often take for granted the very things that most deserve our gratitude.” It is absolutely my honor to tend to the fertility needs of our military.
If you ask, most people think others have more sex than they do. They would also say that if given the choice, they would have sex more often than they actually do. And most think that the elderly have very little sex. But are these perceptions really grounded in fact? Hardly.
The Science of Sex
The formal study of human sexual habits is a relatively new science. Maybe it’s because sex is not a very easy subject to investigate unlike, say, tobacco use. Sex customs change with time and this tends to complicate things. In the sexually liberated 1960s, society went from not having sex to having it a lot. The 1970s brought along women’s liberation and the power of sexual choice. In the 1980s, as HIV surfaced, sex became less randy and more sensible or carefully considered. The 1990s brought the World Wide Web and the 2000s brought social media, both of which have changed the public view of sex and pornography. It’s tough to study a constantly moving target.
Some of the best snapshot data on sex among Americans comes from the Kinsey Institute’s 2010 national survey. Some of the key takeaway points are:
Those partnered or married tend to have more sex/month than those who are single.
The highest rates of sex are among married folk between the ages of 25-49 with almost half having sex from a few times monthly to at least once weekly.
The frequency of sex decreases with age among men and women, but not as much as you might imagine: Two-thirds of Americans over age 70 have sex regularly.
More or Less Sex?
What we don’t know much about is whether there are any trends in our sexual habits over time. Recently, a 15,000-person,30-year survey of British sexual practices was published that suggests that younger Brits are having less sex than in the past. Over the past 30 years, among those aged 16-44 years, the sexual frequency per month dropped from 4 times to 3 times among women and remained level at 3 times/month among men. They also found that:
The proportion of those reporting no sex in the past month increased over the 30-year study to about 29% of men and women.
The proportion of those reporting sex 10 times or more per month decreased from about 19% early on to 13% later on in the study.
Those 25 years old and older, and those married or partnered, had the steepest declines in sexual frequency.
So, what’s up with youth having less sex now than a generation ago? The study’s authors offered up explanations based on the concept that sex occurs during “downtime” in our lives. Essentially, today’s youth have less downtime for sex than before – possibly because of more “pressurized” lives, more exhaustion or more distractions from sex by digital age behaviors such as social media or online working or shopping. Easy access to pornography online may also play a role here but really hasn’t been studied.
Since sexual frequency is correlated not only with happiness but also health, the study of sexual habits can inform us about birth rates as well as overall population health.
You may never look at a plastic cup the same way again (courtesy: unsplash.com)
You may do it all the time, but not for academic reasons. Now they’re asking you to provide a semen sampleto see how it measures up. If you feel like you’re being singled out, don’t. Truth is, there’s a long history of looking at semen under a microscope. The Dutch lens maker van Leeuwenhoek first peered at sperm through a microscope over 300 years ago; he called them “animalcules” or “tiny animals.” So it may be comforting to know that you’re not the first to be asked to do this.
Sperm Tarot Reading
Sure, it may seem odd, but checking your semen is an important step in evaluating why you’re not able to conceive. For example, there’s a 5% chance that no sperm will be found – and that, my friend, changes things. So, here’s a primer on how to collect a semen sample.
Loving Plastic Cups
Let’s begin with some biology. Realize that ejaculation is a reflex,like a sneeze, and needs triggering to get the sample you want. This can be difficult for many men to do “by appointment” instead of recreationally. Face it, it’s entirely unromantic. In the words of friend and author Greg Wolfe, it’s essentially “making love to a plastic cup.”
But there’s more. Not only must ejaculation happen on schedule, but the semen must all be collected for examination. This is an entirely new experience for many, if not all, men. It often leads to what I call the “first-sample syndrome” in which half the semen is in the cup and the other half ends up…somewhere else. Long story short, your semen analysis may be for the first time you have to actually think about what you’re doing when you ejaculate.
It’s also important to understand that the longer you abstain from ejaculation before the “clinical” sample is offered, the older the sperm are. Sure, you may have more seminal fluid and more sperm in the fluid, but sperm motility or movement decreases dramatically. The ideal abstinence period before providing a semen sample to the lab is 2-3 days. This is the optimal for sperm count and motility. Oh, and keep the cup at body temperature by putting it in your shirt pocket, and try to drop it off within an hour or so of procurement, as sperm motility falls while in the cup.
Be aware that your semen quality is more likely to reflect lifestyle choices over the past 2-3 months than the past 2-3 days. For example, stopping alcohol, weed or tobacco use several days before your semen analysis is unlikely to give you a better sample if you’ve been sousing liberally for several months.
Finally, try not to use any lubrication when you collect the sample. Notoriously toxic to sperm are saliva, hand lotions, soaps, hospital-based lubricants (Surgilube, KY Jelly), water, soda, coffee or tea. Typically, vegetable oils and mineral oils are safe. In this case, staying “high and dry” is a good thing.
Bottom line is that there are lots of things that influence semen quality. So put your best foot forward take great care of yourself and follow these simple directions.
Think of your body as a petri dish for all kinds of things (Courtesy: Unsplash.com)
How many sexually transmitted infections (STIs) are there right now in the U.S.? Believe it or not, 110,000,000! That’s double the number of folks that get the flu each year. Talk about an epidemic! Not only that, but 20,000,000 new STIs are diagnosed each year. Fully half of these infections occur in 15- to 24-year-olds.
Unfortunately, most studies examining STIs and fertility focus on females and not males. But there is some knowledge about how STIs impact the fertility potential of men. Might be good to know which ones can impair male fertility, don’tcha think?
What Goes Around
A dozen or more STIs are known. Their incidence varies widely by geographic area. In the U.S., 8 common STIs and 2 rare, episodic ones merit discussion. Among them, 4 are caused by bacteria and are curable, 1 is a parasite (also curable) and 5 are viruses that aren’t curable but are controllable. Here are the Top 10 pesky little bugs.
Top 10 STIs in the U.S.
#1 HPV (human papilloma virus or condyloma; 14 million new cases annually). Alternatively called “venereal warts,” they are associated with cervical and penile cancers, but not male infertility. A preventative vaccine is available for teenagers.
#2 Chlamydia trachomatis (2.8 million cases). In women, chlamydia infections can block tubes and cause infertility. In men, blockages have not been demonstrated, but many studies show impaired sperm motility and DNA fragmentation either due to inflammation or anti-sperm antibodies.
#3 Trichomonas vaginalis (1.1 million cases) has no proven association with male fertility but this flagellated parasite has been linked to lower sperm motility. Treatable with antibiotics.
#4 Gonorrhea (820,000 cases) is a bacterial infection that causes nasty urethritis and potentially epididymitis which could lead to interruption or blockage of sperm flow during ejaculation and result in male sterility.
#5 Herpes simplex virus (HSV, 776,000 cases) causes painful genital pimples but has no well described association with male infertility. Its effect on developing babies in infected mothers is profound, however.
#6 Syphilis (55,400 cases). Early infections are marked by genital ulcers followed by neurological symptoms if untreated. Before the age of antibiotics, it was a common cause of dementia. There is no reported toxic effect of syphilis on sperm, but if untreated, infertility can result from inflammation, scarring and blockage of the epididymis and testis.
#7 HIV (41,400 cases) is associated with reduced semen quality and male infertility, but really only if the infection progresses to the point of weight loss and immunodeficiency.
#8 Ureaplasma urealyticum and Mycoplasma (common) are tiny bacteria that cling to sperm and may impair sperm motility and function. They are typically found in <1% of asymptomatic infertile men.
#9 Zika virus (rare) can be transmitted sexually during epidemics with devastating effects on fetal development but no clear effects on male fertility. However, Zika-infected male mice have been shown to be vulnerable to testicular infections and sterility.
#10 Ebola virus (very rare) is transmitted sexually and that can cause problems much worse than fertility, including death.
So, that’s the scoop on STIs and male infertility. Some are feared and others simply frightening. Remember, you and your partners carry your entire sexual history with you during every encounter. The best way to prevent this cause of male infertility is to practice safe sex. Every time. Treatment is good, but prevention is ideal.
There’s a lot to learn outside these pages (Courtesy: Unsplash.com)
Is it my imagination or does every new electronic device, be it an alarm clock, cooking widget or cell phone, come with a 100-page owner’s manual? No more learning by simple intuition or reason nowadays. According to Malcolm Bradbury, the digital age is different: “We don’t have reason; we have computation. We don’t have a tree of knowledge; we have an information superhighway.” Is what you learned of love and relationships in school a good manual for how things actually work? What didn’t they tell you in Sex Ed class?
What It Is
Sex drive has its ups and downs. Although teenagers think of sex every 3 minutes, one might expect that as we age, and life gets complicated, thoughts of sex occur less often. One great way to keep your sex drive healthy is to stay healthy. And disconnect (you guessed it!) from your digital devices.
Penis size varies, but yours is likely normal. Let’s go over the facts. The average length of a flaccid (limp) penis is 3.5 inches and the average length of an erect penis is 5 inches. Also, the length of the flaccid penis doesn’t predict the length of the erect penis, as there are “growers” and “showers.” Not only that, penis size does not correlate with hand or foot size or race, height or weight.
The penis can be curved. Most “normal” penises curve a little. A “straight” penis has a 15-degree curve or less in any direction. That’s a little less than 5 minutes past the hour on a clock. Of some concern are penises that have an increasing curvature, or a curvature associated with a painful erection.
Men lose their erections. One of my men’s health practice’s “emergencies” are men who have their first failed erection. I see them right away as they are quite concerned that something bad is happening to them. It is: they need to take better care of themselves. The penis has a mind of its own and is very clued into a man’s health and stress levels.
Excessive masturbation is harmful. A whole lot of animals masturbate. The genitals are built for use. If it were harmful, we and other species would have gone extinct a long time ago. Having said that, excessive masturbation can interfere with having a healthy sexual relationship with a partner.
Don’t ignore pain, lumps and bumps. Testicular cancer is the most common cancer in young men. And it’s curable. So, cop a feel down there once a month and let someone like me know if you feel something different.
When it comes to love and sex, education — whether through manuals or schooling — is not the same as real life. In the words of Neil Gaiman: “You don’t get explanations in real life. You just get moments that are absolutely, utterly, inexplicably odd.”
Oh how we like to count and order things… (courtesy: Unsplash.com)
We humans like to count and label things. We order the stars above us into constellations. We organize time into hours, minutes and seconds. We name the colors of the rainbow. We track how many steps we take with widgets on our wrists. Maybe it gives us a sense of control over our big, wide world. Or maybe it helps us feel like we belong. Regardless, we do the same when it comes to male fertility.
We Count Sperm, Too
Semen analysis is another example of how we like to order our world. We have normal values, means and averages, and reference ranges for everything sperm-related, including total number, movement and shape. Does this have real value? Absolutely. Our ability to order the world is fundamental to how we think about things. And this weird habit of ours has certainly helped us to better evaluate and treat male infertility.
Let’s break down the Greek-derived terms given to sperm numbers so it makes more sense:
High sperm concentration
>100 million sperm/mL
Normal sperm concentration
15-100 million sperm/mL
Low sperm concentration
<15 million sperm/mL
Very few sperm present
Sperm on spun semen only
No sperm present
0 sperm in ejaculate
Every Sperm is Sacred
Now, here’s where the ordering and the science goes a little soft on us. Note the following 5 truths about ejaculated sperm numbers:
There is no known association of polyspermia with male infertility. The more the merrier it seems.
Having a normal sperm count does not mean you’re fertile. It means that you’re more likely to be fertile. Take a “deeper dive” into sperm counts and you will discover that at least 25% of men with normal sperm counts are infertile. It’s a quality issue, not just quantity.
Having a low sperm count increases the probability of being infertile but does not necessarily mean that you are. Perfectly normal babies are conceived by men with low sperm counts, precisely because women don’t need “normal” numbers to get the job done.
Men with low numbers of ejaculated sperm, which are often nearly impossible to find unless you look really hard, need not fear. A very small number of sperm can do a very good job of making babies with assisted reproduction (IVF-ICSI).
Having no sperm in the ejaculate is pretty much the only guarantee of male infertility. Many of these cases are due to blockage and can be corrected. Others are due to impaired sperm production, which although generally not correctable, does not necessarily preclude a man from having children. Pregnancy is possible using small numbers of testicular sperm and IVF-ICSI.
So, ordering our thoughts about sperm has led to a better understanding of the root causes of male infertility. But sperm counts are by no means the whole story, only a small part of it. For conception is a performance with many acts, actors and actresses that involves miracles as much as science.
Sex therapy was born in the 1960s, with the work of pioneering researchers Dr. William Masters and Virginia Johnson. They showed us that many intimacy problems could be cured with a combination of education, whole-body massage and applying specific techniques. They understood that some issues with sex are relationship independent, while others involve both partners. New couples have adjustment problems around who initiates, what is done and when. Couples with children may be exhausted and torn between prioritizing children over each other, leading to fights and feelings of relational doom. And, older couples deal with change of life, medications and diseases that can affect their closeness, desire and ability to perform. Throughout life, our sex lives are shaped and changed, and Masters and Johnson first led us to understand this.
Most doctors don’t get a stitch of sex therapy training in medical school. That means that the advice they offer is limited to their own experience in solving sex problems.
This is where a sex therapist comes in. They won’t suggest a threesome to spice up your sex life, but they will bring perspective to things, suggest a path forward, and provide you with tools to make it happen.
Breaking Down the Swing
Here are the most common reasons to see a sex therapist:
Mismatched sex drive is very common. In about two-thirds of cases, men want more sex than women, but in one-third, it’s the other way around. Either way, it can be problematic. Changes in sex drive can also be addressed.
Organic erection problems due to age or ill health are best treated by a physician. However, situational or stress-related ED, which is more of an unreliable but not truly faulty erection, is best addressed with sex therapy.
Early or premature ejaculation is the most common sexual issue in young men, and it’s curable with therapy. No pills, sprays or creams needed. The same is true for delayed or late ejaculation. Just a matter of relearning the swing.
People avoid sex for many different reasons. They can be religious or cultural, stem from neglect or abuse, or be caused by porn addiction or body image issues. Sexual aversion is also common among cancer survivors and among women following pregnancy.
In cases of sexual addiction or fetishes, sex therapy can be very helpful in providing perspective on the behaviors, thoughts and feelings surrounding sexual urges.
Things can get confusing in periods of coming out or during changes in gender identity. Nice to have a pillar of support during these trying times.