Male Health Topics
No topic is too embarrassing to discuss........
If you can't discuss these type of issues with me you have chosen the wrong doctor !
Erectile Dysfunction may be Early Warning Sign of Heart Troubles
By Peter Jaret : NY Times Article : March 1, 2008
In Brief
As if a blow to one’s masculinity weren’t bad enough. Researchers now say that for men over 40, having trouble getting or maintaining an erection is often a sign of something more worrying: cardiovascular disease. Indeed, there’s growing consensus that erection problems are a risk factor for heart disease, right up there with smoking and high blood pressure.
“The penis is the dipstick of the body’s health,” said Dr. Harry Fisch, director of the Male Reproductive Center at Columbia University Medical Center of New York Presbyterian Hospital. “If you’re able to have sex and healthy erections, it’s a good sign that your cardiovascular system is in good shape. If you can’t, it’s time to see your doctor.”
Impotence — or erectile dysfunction, as it’s sometimes called — was once deemed chiefly a psychological problem. When it occurs in men in their 20s and 30s, it often is. “But especially when men hit middle age, the main cause of erectile dysfunction is almost always vascular,” said Dr. Laurence Levine, professor of urology at Rush University Medical Center in Chicago. The same factors that can clog up arteries and lead to heart attacks and strokes — smoking, elevated cholesterol, inflammation and high blood pressure — also wreak havoc on the blood vessels that supply the penis. A flagging erection may be one of the earliest warning signs of trouble.
“The arteries in the penis are about one-third the size of one of the coronary arteries supplying the heart,” Dr. Levine explained. “When smaller blood vessels, such as the penile arteries, are compromised even a small amount, it can have a major effect on their capacity to dilate. And that will show up as a noticeable difference in the quality of an erection.”
When a man becomes aroused, the brain sends signals to the penis to release a chemical that rapidly widens blood vessels. Blood rushes in, causing an erection. Damage to those vessels can make them inflexible, limiting their ability to expand. When the damage gets bad enough, the spirit may be willing but the flesh unable.
Since men are all too aware when their erections begin to flag, erectile dysfunction may serve as a useful early warning sign of cardiovascular problems. In a British study that compared 207 men with heart disease with 165 healthy controls, investigators at Buckinghamshire Chilterns University College found that erectile woes can precede such problems as a heart attack or angina by up to five years.
“What you really worry about is the guy who goes online and gets Viagra, never knowing that the reason he’s having problems is that he’s got very high cholesterol levels and is diabetic,” said Dr. Wayne J. Hellstrom, professor of urology at Tulane University School of Medicine in New Orleans and co-author of a 2007 study that found that the more risk factors a man has for coronary artery disease, the greater his odds of having abnormal blood flow in his penis. The poorest blood flow showed up in men who already had coronary artery disease and diabetes.
To complicate matters, certain prescription drugs — including some high-blood-pressure medicines, cholesterol-lowering drugs, antidepressants and tranquilizers — can cause or worsen erection problems. “Twenty-five percent of erectile dysfunction may be related to medications,” said Dr. Kevin T. McVary, professor of urology at the Feinberg School of Medicine at Northwestern University in Chicago. Sometimes doctors can switch patients to a similar drug that doesn’t cause problems. But not always. “In that case we have to treat around the side effect, usually by prescribing a drug like Viagra,” Dr. McVary said.
In some men, getting high blood pressure and cholesterol under control, along with stepping up physical activity and shedding a few pounds, may be enough to improve erections. After participating in a program to lose weight and get more exercise, for example, one group of 55 obese men studied at the University of Naples in Italy significantly bettered their scores on a test called the International Index of Erectile Function.
Studies have shown that a diet abundant in fruits, vegetables, whole grains and fish, like that traditionally eaten in the Mediterranean region, may also help by reducing vascular inflammation. If a healthier diet means losing weight, all the better. “People with huge pot bellies typically have very low testosterone, the male hormone,” Dr. Fisch explained. “Visceral fat eats up testosterone. When men lose belly fat, their testosterone goes up.” So does their libido and, in some cases, the most obvious manifestation of it. Exercise is also important, he said, because it helps open up blood vessels.
Of course, diet and exercise are a tough sell when a simple pill can do the trick quickly. Treatment of impotence has undergone a revolution with the advent of Viagra and two similar drugs, Levitra and Cialis. All three work by blocking the breakdown of the chemical that causes blood vessels in the penis to widen. That in turn allows more of the chemical to build up, bolstering an erection.
Despite the happy images of smiling silver-haired couples in the ads, however, erectile dysfunction medications may not work for everyone. If blood vessels become too damaged, they can’t widen sufficiently. “As many as 30 percent of the men we see don’t get much improvement using these drugs,” Dr. Levine said. For some of them, exercise and weight loss may increase the pills’ effectiveness, as may lowering elevated cholesterol levels with cholesterol-lowering statin drugs.
The findings underscore the importance that men 40 and older see a doctor and treat cardiovascular risk factors if erection problems arise.
As for younger men, the latest findings are even more encouraging. Heeding the familiar advice to maintain a normal weight, get plenty of exercise and avoid smoking could well ensure sturdier erections for years to come. That’s potent motivation by any measure.
Published on February 29, 2008
Impotence Overview
An erection problem is the inability to get or maintain an erection that is firm enough for a man to have intercourse. You may be unable to get an erection at all, or you may lose the erection during intercourse before you are ready. If the condition persists, the medical term is erectile dysfunction.
Alternative Names
Erectile dysfunction; Impotence; Sexual dysfunction - male
Considerations
Erection problems are common in adult men. In fact, almost all men experience occasional difficulty getting or maintaining an erection. In many cases, it is a temporary condition that will go away with little or no treatment. In other cases, it can be an ongoing problem that can damage a man's self esteem and harm his relationship with his partner, and thus requires treatment.
If you have difficulty having or keeping an erection more than 25% of the time, it is considered a problem.
In the past, erection problems were thought to be "all in the man's mind." Men often were given unhelpful advice such as "don't worry" or "just relax and it will take care of itself." Today, doctors believe that when the problem is not temporary or does not go away on its own, physical factors are often the cause.
One way to know if the cause is physical or psychologic is to determine if you are having nighttime erections. Normally, men have 3 to 5 erections per night, each lasting up to 30 minutes. Your doctor can explain a test to find out if you are having the normal number of nighttime erections.
In most men, erection difficulties do not affect their sex drive.
Premature ejaculation (when orgasm comes on too quickly) is not the same as impotence. Together with your partner, you should seek counseling for this problem, which is usually due to psychological factors.
Male infertility is also quite different from impotence. A man who is unable to maintain an erection may be very capable of producing sperm that could fertilize an egg. An infertile man is usually able to maintain an erection, but he may be unable to father a child due to problems with sperm count or other factors.
Causes
An erection requires the interaction of your brain, nerves, hormones, and blood vessels. Anything that interferes with the normal process can become a problem. Common causes include:
Home Care
For many men, lifestyle changes can help:
If erection problems seem to be caused by a medication you are taking for an unrelated condition, consult your doctor. You may benefit from reducing the dose of the drug or changing to another drug that has the same result but not the same side effects. DO NOT adjust or discontinue medications without consulting your doctor first.
Talk to your health care provider if your erection problems are related to fear of recurring heart problems -- sexual intercourse is usually safe in these circumstances.
When to Contact a Medical Professional
Call your doctor if:
What to Expect at Your Office Visit
Your doctor will perform a physical examination, which will likely include checking your circulation, a rectal exam, a neurological exam, and an exam of your penis.
To help diagnose the cause of the problem, your doctor will ask medical history questions, such as:
There are many treatment options today. These include medicines taken by mouth, injections into the penis, vacuum devices, and surgery. In order to treat erectile dysfunction effectively, you must be aware of and comfortable with the possible side-effects and complications that may occur with each therapy.
Sildenafil (Viagra), vardenafil (Levitra), and tadalafil are medicines prescribed for mild-to-moderate erection difficulties caused by either physical or psychological problems. Although these medicines have become extremely popular, they are not "cure-alls," and they do not enhance erections if you are not impotent. And, they DO have side effects. These pills should not be used with certain other medications.
Men who take nitroglycerin for a heart condition (as either tablets, spray, or patches) should NOT take these medications. When taken with nitroglycerin, these drugs can significantly lower blood pressure. Some men have died from combining these drugs and nitroglycerin.
If pills do not work, other options are available. Testosterone may be prescribed by either skin patch or injection, especially if the problem is related to age. Alprostadil, injected at the penis or inserted as pellets, improves blood flow to the penis. This technique is usually more effective than medications taken by mouth.
For some patients, a vacuum pump or penile prosthesis (implant) may also be recommended or required.
Consult your health care provider to see if one of these treatments is right for you.
Drugs used for Erectile Dysfunction
By Peter Jaret
Dr. Laurence A. Levine is a professor of urology at Rush University Medical Center in Chicago. He is president of the Sexual Medicine Society of North America and the author of numerous research studies on erectile dysfunction.
Q. Are most men comfortable talking to their doctors about erection problems?
A. The Viagra era has certainly changed the embarrassment level. But many men still feel embarrassed, which is why I think it’s important for doctors to ask men over 40 about their sexual health as part of the routine “review of systems.” It’s especially important since erectile dysfunction can be an early sign of cardiovascular problems.
Q. What’s the connection between erectile dysfunction and cardiovascular disease?
A. When a man gets sexually aroused, the brain sends signals to the penis, where the release of certain chemicals causes blood vessels to dilate — turning a straw into a hose, if you will. The penis fills with blood, and you have an erection. A problem that affects the vascular system means that those blood vessels don’t dilate adequately. Problems with the vascular system often show up first as an inability to get or maintain erections.
Q. What percentage of men with erection problems turn out to have cardiovascular disease?
A. About 70 percent of men who have a cardiovascular event such as a heart attack or angina, when asked later, say that they were experiencing erectile dysfunction. When they’re asked how long they’d been experiencing erection problems, the average answer is about four years. Among men diagnosed with diabetes, almost 100 percent have been experiencing erectile problems. So erectile dysfunction can be a very useful warning sign.
Q. Can lifestyle changes recommended for preventing heart disease help improve erectile function?
A. That depends on the severity of the problem, how long it’s been a problem and a man’s age. A recent study in France looked at men who stopped smoking. After a year, 25 percent showed spontaneous improvement in their erections. Another recent study looked at obese men. It found that when they lost weight through a carefully monitored program of exercise and reduced calories, about one-third were having spontaneous erections after two years. That means they were getting erections without having to take drugs like Viagra.
Q. Can lowering blood pressure or cholesterol with medication improve erectile function?
A. The story here is a little less clear. We don’t have good evidence that lowering blood pressure improves erectile function. What it probably does is prevent progression. With diabetes, it’s very important to control blood sugar levels, because the diabetic process is known to cause vascular damage. Cholesterol-lowering drugs may help some men get spontaneous erections, but the stronger evidence relates to how well men with erectile dysfunction respond to Viagra, Levitra or Cialis. We did a study looking at men with elevated cholesterol who didn’t respond to Viagra. After we put them on Lipitor, a cholesterol-lowering drug, 60 percent were able to get erections.
Q. How do erectile dysfunction drugs work?
A. All three of the drugs on the market work to prevent the breakdown of the chemical that causes blood vessels in the penis to dilate. That allows more of the chemical to hang around and build up, so erections are better and last longer. After orgasm, blood vessels actually contract and the erection goes down. For men using these drugs, the refractory period, or bounce-back time — how long it takes before you can have an erection again — is also significantly shorter.
Q. Are there important differences among these drugs?
A. Viagra, Levitra and Cialis are each slightly different molecules, with slightly different effects and side effects. Viagra and Levitra usually last four to six hours, for instance, although there’s some evidence that they may last longer than that. Cialis can last as long as 36 hours. So you have a longer window of opportunity. Some men prefer that. Which drug is best? The answer is the one that works for you, with the fewest side effects.
Q. Are there dangers to overusing these drugs?
A. Despite early concerns, there is no evidence of a higher risk of heart attacks or blindness or acute hearing loss. In fact, erectile dysfunction drugs have actually been shown to lower heart attack rates in men taking them on a regular basis. That’s not surprising. Viagra was originally developed to treat angina, chest pain caused by cardiovascular disease. It didn’t prove to be particularly effective, so the study was stopped. But when the researchers asked the volunteers to give back the leftover drugs, they balked. The reason: their erections were so good. By dilating blood vessels, these drugs probably improve blood flow to the heart, which would protect heart muscle.
Q. Can men become dependent on erection drugs?
A. No. There is no evidence that people come to need more and more of them to get an erection, and no evidence of physical dependence. In fact, I often prescribe them to men with psychogenic erection problems, as a way to build confidence. After they become confident that they can have a normal erection, they don’t need the drugs any longer.
Q. Do erectile dysfunction drugs work for most men?
A. About 70 percent of the men in my practice respond. But if the vascular damage is too serious, even these drugs can’t help. In men who smoke, have elevated cholesterol, hypertension and diabetes — vasculopaths, I sometimes call them — the blood vessels in their penises are like lead pipes. They can’t dilate to cause an erection.
Q. What happens, then, if erectile dysfunction drugs fail?
A. Erection-inducing drugs can be injected directly into the penis, which creates higher levels and sometimes works when pills don’t. We train men to do this at home. For men who are uneasy about giving themselves a shot, there’s another approach that involves placing a tiny medication-containing pellet into the urethra. As the drug passes through the walls of the urethra, it causes blood vessels in the erectile tissue to dilate.
Another approach is the use of vacuum tubes, which have been around for more than a century. You put the penis inside a plastic tube, and a small pump draws the air out, pulling blood into the erectile tissue. Once the penis is erect, you slip a constriction band around the base of the penis and remove the tube and you’re ready for action. Clearly this is the least natural alternative, but it’s also the least expensive.
For highly motivated men, there’s the option of a penile prosthesis. Most of these are inflatable tubes implanted in the shaft of the penis, connected to a pump placed in the scrotal sack. With a squeeze of the pump, the prosthesis inflates and you have an erection. The penis looks normal in a flaccid state. The prosthesis doesn’t interfere with urination, sexual pleasure or orgasm. And our surveys of men and their partners say they’re very happy with the results. One downside is that you can have mechanical failures, which means having to replace the device. And there’s a very small risk of infection. Also, once you have a prosthesis implanted, you can never have an erection again without it.
Q. Can erectile dysfunction be prevented?
A. Men can certainly reduce the risk by maintaining good vascular health. The usual advice applies. Don’t become obese. And get lots of exercise. Exercise increases blood flow throughout the body, and what’s good for vascular health is good for the penis.
Here’s something most men are happy to hear: Sex is also good for your penis. In fact, men normally get two to seven spontaneous erections during the night — not because they’re having an erotic dream or their bladders are full. It’s a reflex. We’re designed to get erections so that blood flows into the erectile tissue to nourish it. Sometimes after prostate surgery, men stop having nocturnal erections, at least temporarily. The longer you don’t have them, studies show, the more likely you are to begin to lose length, girth and vascular tissue in the penis. For most men, that’s a pretty strong case for use it or lose it.
For Common Male Problem, Hope Beyond a Pill
By Lesley Alderman : NY Times Article : August 29, 2009
If you watch enough television, you’d think that treating erectile dysfunction was as effortless as popping a pill and then whirling your partner around the living room in a romantic dance. Correcting erectile dysfunction, alas, is not so simple — and it can be rather costly. One Viagra pill, for example, the most common way to treat erection problems, costs about $15.
Insurers can be chary of reimbursements. And despite the fact that E.D., as the dysfunction is known, becomes increasingly common after men reach 65, Medicare Part D does not cover drugs for it.
An estimated 30 million men in this country experience erectile dysfunction. Nearly a third of men in their 50s experience E.D., whereas more than half of those in their 60s have the problem.
If you’re hoping to have Viagra-aided sex twice a week, your bill for the entire year could run around $1,500. If you’re fortunate enough to have insurance that covers the medications, your co-pay will be on the high side, around $40 for a one-month supply of six to eight pills — bringing your annual bill to a more manageable $500 or so. There are no generic versions of E.D. meds yet.
Even among the name-brand drugs, which also include Cialis and Levitra, the medications do not work for about half of the men with E.D., says Dr. Ajay Nehra, professor of urology at the Mayo Clinic in Rochester, Minn. He is also president of the Sexual Medicine Society, an association of health care professionals.
And yet, as it turns out there are other treatments for E.D. And some of them are more cost-effective than the brand-name pills advertised on television.
“There is not a man out there that cannot be helped in some way with his E.D. — even if money is an issue,” says Dr. Andrew McCullough, an associate professor of urology and director of Male Sexual Health and Fertility at the Langone Medical Center at New York University.
The first step is to see a doctor who specializes in E.D. (usually a urologist) and have your overall health checked out. If your primary care physician can’t make a recommendation, contact the Sexual Medicine Society and ask for a referral.
In many of cases, E.D. is the sign of an underlying disorder like diabetes or hypertension. In fact, in younger men, erection problems are often the first symptom of cardiovascular disease.
“Erectile problems may show up about three years before a cardiovascular event such as a heart attack or stroke,” says Dr. Ira Sharlip, clinical professor of urology at the University of California, San Francisco.
That’s because plaque will start to clog the small arteries in the penis before the wider coronary arteries. Your doctor will also try to determine whether your E.D. is the result of a psychological issue, in which case he will refer you to a therapist. Depending on your policy, your insurer may cover a set number of visits. (One way for you to check on your own whether your issue may be psychological or physical is try the postage stamp test, also known as nocturnal penile tumescence test.)
By adopting healthier habits, you may be able to improve your overall well-being and restore your erectile function.
“There is increasing evidence that we can reverse erectile dysfunction with lifestyle changes,” says Dr. Drogo K. Montague, director of the Center for Genitourinary Reconstruction in the Glickman Urological and Kidney Institute at Cleveland Clinic.
In a recent study of men with E.D., or at risk for developing it, researchers in Italy found that the men could improve their erections by losing weight, improving their diet and exercising more frequently. After two years of significant lifestyle changes, 58 percent of the men had normal erectile function, according to the study, which was published in The Journal of Sexual Medicine in January.
But lifestyle changes, while basically free, can be difficult to make and may take months to take effect. In the meantime, your doctor will probably prescribe a phosphodiesterase type 5 inhibitor, also called a PDE-5 inhibitor, like Viagra, Cialis or Levitra. These drugs enhance the effects of nitric oxide, a chemical that helps to increase blood flow in the penis. The three drugs work in the same way, but differ in how quickly they take effect and how long they last. If the PDE-5 drugs don’t work for you, don’t give up quickly, says Dr. McCullough, who theorizes that “in over 40 percent of drug failures the problem is with the user, not the drug.” Dr. McCullough adds, “it’s important to take these medications as directed, like on a totally empty stomach, rather than a full one, and not less than 60 minutes before sex.”
If the pills don’t work for you, you might want to try self-administered injections of alprostadil, a drug that helps blood vessels expand and facilitates erections. Granted, this may sound onerous, but the shot, which is sold under the brand names Edex and Caverject, is done with a fine needle, feels no worse than a pinprick and produces an erection that can last up to four hours, according to doctors who recommend it.
The shots cost about $35 per injection and are covered by most insurers, but not by Medicare.
But ask your doctor about an injection that’s a cocktail of generic forms of alprostadil, papaverine and phentolamine.
Although this generic combination is not F.D.A.-approved as an E.D. treatment, doctors are legally free to administer it — and both Dr. Sharlip and Dr. McCullough recommend it.
“The generic injections clearly work the best,” Dr. Sharlip said, “and are usually less expensive.”
Another cost-effective option is a vacuum erection device or penis pump. It works like this: you place a tube on the penis and then pump the air out of the tube, which pulls blood into the penis. When the penis is erect, you then put a snug ring around the base to maintain the erection, which lasts long enough to have sex.
The cost for the device, which requires a prescription, can run from $300 to $600, but most insurers and Medicare will cover part of the cost and the device should last for years. Even if you spend $300 out of pocket and use the device once a week, you’ll be spending much less per year than on pills or injections. You can also buy a nonprescription pump online (even Amazon carries some) for as little as $30, Dr. McCullough said.
Finally, if all other treatments fail, you could consider getting penile implants, an effective and permanent solution for chronic E.D. The most common type of implant works through inflation: two cylinders are placed inside the penis and a fluid-filled reservoir is implanted under the abdominal wall or groin muscles; a pump and a deflation valve are placed inside the scrotum. To create an erection, you pump fluid from the reservoir into the cylinders. To deflate the penis, you press the release valve.
Most insurers and Medicare cover the surgery, so your out-of-pocket costs will be minimal. This might be the most cost-effective strategy of all since, according to Dr. Nehra, 80 percent of implants last 10 years.
Premature Ejaculation Overview
Premature ejaculation occurs when a man orgasms during intercourse sooner than he or his partner wishes.
Causes
Premature ejaculation is a common complaint. It is only rarely caused by a physical or structural problem.
Premature ejaculation early in a relationship is most often caused by anxiety and overstimulation. Other psychological factors such as guilt may also be relevant. The condition usually improves without formal treatment.
Symptoms
Ejaculation happens before the individual or couple would like (prematurely). This may range from before penetration to a point just after penetration, and may leave the couple feeling unsatisfied.
Signs and Tests
Abnormal findings are unlikely to be associated with the condition. Useful information is more likely to be obtained from interviewing the person or the couple.
Treatment
In general, practice and relaxation will help you deal with the problem. Some men try to distract themselves by thinking non-sexual thoughts (such as naming baseball players and records) to avoid becoming excited too fast.
Some helpful techniques include the following:
The "stop and start" method:
Local anesthetic creams may be applied to the penis to decrease stimulation. Decreased feeling in the penis may prolong the time before ejaculation. Condom use may also have this effect for some men.
Evaluation by a sex therapist, psychologist, or psychiatrist may be helpful for some couples.
Expectations (prognosis)
In most cases, the man is able to learn ejaculatory control through education and practice of the simple techniques outlined. Chronic premature ejaculation may be a sign of anxiety or depression, both of which could be helped by psychiatric intervention.
Complications
Infertility in Men Overview
Infertility is the inability of a couple to become pregnant after 12 months of unprotected intercourse.
Alternative Names
Low sperm count; poor sperm quality
Causes
Primary infertility is the term used to describe a couple that has never been able to conceive a pregnancy, after at least 1 year of unprotected intercourse.
Secondary infertility describes couples who have previously been pregnant at least once, but have not been able to achieve another pregnancy.
Causes of infertility include a wide range of physical as well as emotional factors. Approximately 30 - 40% of all infertility is due to a "male" factor such as retrograde ejaculation, impotence, hormone deficiency, environmental pollutants, scarring from sexually transmitted disease, or decreased sperm count. Some factors affecting sperm count are heavy marijuana use or use of prescription drugs such as cimetidine, spironolactone, and nitrofurantoin.
A "female" factor -- scarring from sexually transmitted disease or endometriosis, ovulation dysfunction, poor nutrition, hormone imbalance, ovarian cysts, pelvic infection, tumor, or transport system abnormality from the cervix through the fallopian tubes -- is responsible for 40 - 50% of infertility in couples.
The remaining 10 -30% of infertility cases may be caused by contributing factors from both partners, or no cause can be identified.
It is estimated that 10 - 20% of couples will be unable to conceive after 1 year of trying to become pregnant. It is important that pregnancy be attempted for at least 1 year. The chances for pregnancy occurring in healthy couples who are both under the age of 30 and having intercourse regularly is only 25 - 30% per month.
In addition to age-related factors, increased risk for infertility in men is associated with the following:
Symptoms
A complete history and physical examination of both partners is essential.
Tests for men may include:
Treatment »
Treatment depends on the cause of infertility. It may involve:
In-Depth Treatment »
Support Groups
Many organizations provide informal support and referrals for professional counseling. See infertility - support group.
Expectations (prognosis)
A cause can be determined for about 85- 90% of infertile couples.
Appropriate therapy (not including advanced techniques such as in vitro fertilization) allows pregnancy to occur in 50 - 60% of previously infertile couples.
Without any treatment intervention, 15 - 20% of couples previously diagnosed as infertile will eventually become pregnant.
Complications
Although infertility itself does not cause physical illness, the psychological impact of infertility upon individuals or couples affected by it may be severe. Couples may encounter marital problems, as well as individual depression and anxiety.
Calling Your Health Care Provider
Call for an appointment with your health care provider if you are unable to achieve a desired pregnancy.
Prevention
Because infertility is frequently caused by sexually transmitted diseases, practicing safer sex behaviors may minimize the risk of future infertility. Gonorrhea and chlamydia are the two most frequent causes of STD-related infertility.
Mumps immunization has been well demonstrated to prevent mumps and its male complication, orchitis. Immunization prevents mumps-related sterility.
Surprising Causes of Male Infertility
By Melinda Beck : WSJ : June 28, 2011
On average, the typical man makes about 1,000 sperm every heartbeat.
What do laptops, prolonged hot-tub and taking extra testosterone have to do with a man's sperm count? Melinda Beck debunks some myths and explains some science about fertility. Yet a number of lifestyle choices, environmental factors and chance events can sabotage the sperm: an adolescent groin injury, cigarette smoking, heavy drinking, intense cycling and even using a laptop directly on the lap.
Infertility, defined as the inability to conceive after one year of unprotected sex, affects one in six couples of childbearing age in the U.S. In 40% of cases, the problem is with the man; in 40% it's with the woman, and in 20%, something is amiss with both, say Zev Rosenwaks and Marc Goldstein, fertility experts at New York Presbyterian/Weill Cornell Medical College and co-authors of the 2010 book, "A Baby at Last!"
Since men contribute to infertility at least half the time, says Dr. Goldstein, couples investigating why they can't conceive should start with a simple sperm count.
About 70% of male infertility is treatable, he says, and in about 25% of cases, it could have been avoided with greater awareness of the lifestyle choices that can harm sperm.
Testosterone trouble. Smoking cigarettes, heavy alcohol drinking and using marijuana, cocaine and opioid painkillers can all lower the level of testosterone needed to make sperm or otherwise cut their quantity and quality. So can some commonly prescribed medications for high blood pressure, heart disease, stomach acid, gout, inflammatory bowel disease, enlarged prostates and baldness.
In many cases, alternative drugs exist that don't hamper fertility.
Even extra testosterone can lower a man's testosterone. As many body-builders know, taking testosterone and other anabolic steroids can build muscles but shrink testicles and halt sperm production because the brain thinks the body has plenty and stops making enough of its own. In most cases, normal sperm production resumes within a few months once men stop using the substances.
Exposure to large amounts of radiation can also make men permanently sterile. When getting an X-ray of any part of the body, men should always request a lead shield for their testicles, says Dr. Goldstein.
Keeping cool. Men trying to conceive should avoid hot baths, hot tubs and tight pants, since heating the testicles by even a few degrees can hamper or stop sperm production. Studies at Stony Brook University in New York have shown that resting a laptop on the lap can raise temperatures in the scrotum as much as 5 degrees Fahrenheit in an hour. Although most heat problems are temporary, researchers still urge men to use desks or tables instead.
Fertility Foes
Some things believed to affect men's sperm count, at least temporarily:
Some things believed to affect men's sperm count, at least temporarily:
Lifestyle choices Cigarettes, heavy alcohol or drug use, laptop placed on the lap
Activities Cycling in compression shorts, excessive exercise
Health issues Obesity, sexually transmitted diseases, groin injury
Environmental Some pesticides and industrial agents. Possible risks with certain plastic bottles
Certain prescription drugs
Tagamet (cimetidine) for ulcers
Propecia, Avodart (finasteride, dutasteride) for enlarged prostate, baldness
Inderal (propranolol) for heart disease, hypertension
Procardia, Cardizem (nifedipine, diltiazem) for angina, hypertension
Azulfidine (sulfasalazine) for bowel disease
Furadantin (nitrofurantoin) for urinary tract infections
Colchicine for gout
Most antiandrogens for enlarged prostate, cancer
Many chemotherapy drugs
Testosterone preparations
Source: J.K. Amory; Drugs of Today, 2007; WSJ reporting
An earlier Stony Brook study debunked one widely held belief, however. In comparing the scrotal temperatures of 97 men wearing either boxers or briefs, researchers found there was little difference.
Trauma. Men of all ages should take care to avoid trauma to the testes, in part to avoid rupturing the delicate ducts that carry sperm and keep them shielded from the body's immune system, which would otherwise attack them as foreign invaders. Once exposed, sperm trigger the formation of antisperm antibodies which hamper their ability to swim and fertilize an egg.
"That's why wearing a cup for playing sports is so important," says John Amory, a specialist in male reproductive medicine at the University of Washington. "It's not just to prevent pain."
Sexually transmitted diseases. Chlamydia, gonorrhea and other STDs can block those same ducts with inflammation and scar tissue, and they are rampant in the U.S., affecting up to half the population by age 35. Men with symptoms such as burning on urination or discharge from the penis should see a doctor as soon as possible to minimize long-term damage. Those with multiple sex partners should use condoms and be checked yearly for STDs, experts say.
Diet and exercise. Obesity can thwart a man's fertility in many ways: lowering libido, reducing sperm counts and disrupting hormone balance. This is in part because fat tissue produces estrogen, which lowers testosterone. Maintaining a healthy weight and diet can significantly increase a man's chance of conceiving a healthy baby, studies show.
Strenuous exercise may hurt fertility, though. Men who run more than 100 miles a week have lower sperm counts and testosterone levels.
Dr. Goldstein also advises male cyclists trying to conceive to ride for only 30 miles at a time—mainly to limit their time wearing tight bicycle shorts. And he recommends using a seat with a wide back rather than a hard, narrow one. "You want more of your weight on your sit bones," he says.
Environmental factors. Some pesticides, heavy metals and industrial agents also reduce sperm production. Less is known about the effects of bisphenol A (BPA), an estrogen-like compound found in some water bottles and other plastics, but some fertility experts tell their patients to avoid them.
Similarly, while the effects of electromagnetic waves on human sperm are not well studied, Dr.Goldstein advises men to not to carry their cellphones in their front pockets as a precaution.
Male Infertility : Are men overlooked at Infertility Centers?
By Laurie Tarkan : NY Times Article : May 2, 2008
In Brief:
With the advent of advanced reproductive technologies, fertility experts debate whether male infertility should even be treated.
Urologists believe varicose veins of the scrotum are the leading cause of male infertility, though the evidence is mixed on whether surgical repair raises pregnancy rates.
Infection is a common cause of infertility in men and often can be treated with antibiotics.
The aging of a female partner’s eggs should be carefully weighed against lengthy treatments like raising sperm count.
But for a semen specimen, most men are practically ignored when couples go to fertility centers. And depending on the infertility specialist offering treatment, that is either a good thing or a bad thing.
Urologists who specialize in infertility say they can treat a man with low sperm count and increase pregnancy rates, helping patients avoid costly and invasive in vitro fertilization. Reproductive endocrinologists, on the other hand, say that most male fertility treatments have not been shown to improve pregnancy rates and put patients through unnecessary risks and expense.
It is a debate that has been raging for at least 50 years in various forms surrounding almost every aspect of male infertility and its treatments.
In 1992, for example, an advance in I.V.F. called ICSI, for intracytoplasmic sperm injection, provided fuel for the reproductive endocrinologists’ view that most men do not need fertility-enhancing treatments. In the procedure, pronounced ICK-see, a single sperm is inserted directly into an egg. ICSI revolutionized treatment for men with severely low sperm counts. Reproductive endocrinologists say that trying to improve sperm count in most men is no longer necessary, because only a few healthy sperm are needed.
“That doesn’t take into account, however, the economic burden that puts on patients to undergo advanced reproductive technologies,” said Tracy L. Rankin, program director of male reproductive health at the National Institutes of Health.
ICSI and I.V.F. are expensive, rarely covered by insurance, and require women to get hormonal injections and have invasive procedures to remove eggs and transfer embryos. Urologists also point out that ICSI, like any technique that manipulates the egg, can damage it and raise the risk of genetic abnormalities, though it is not clear why.
Furthermore, ICSI does not guarantee pregnancy, said Dr. Marc Goldstein, professor and surgeon in chief of male reproductive medicine and surgery at Weill Medical College of Cornell University in New York. Still, the percentage of I.V.F. cycles using ICSI has risen sharply, to more than 57 percent in 2004 from 11 percent in 1995. And many centers perform it, even when there is no problem in the male partner.
“If you try to treat the underlying problem, you may not need I.V.F.,” said Dr. Harry Fisch, professor of clinical urology at Columbia University and the author of “The Male Biological Clock” (Simon and Schuster, 2004).
Male problems are believed to be either solely or partly responsible in about 40 percent of all infertility cases, with the most common cause of male infertility a varicocele, or swelling of a vein in the scrotum. A varicocele appears to raise the temperature of the testes, potentially damaging the developing sperm and rendering men less fertile. Varicoceles are more than twice as common in infertile men as in the general population — 35 percent compared with 15 percent.
Yet the research on surgical repair of varicoceles to correct male infertility is limited and conflicting.
“Whenever it has been studied in a controlled fashion, it’s been shown to have no impact on pregnancy rates,” said Dr. Sherman J. Silber, a urologist and the director of the Infertility Center of St. Louis. A former proponent of the surgery, he has stopped performing it. “Most urologists who specialize in infertility have a vested interest,” he said; the surgery is all they do, and “that’s the moneymaker.”
But many urologists say that they have many patients who have conceived a baby naturally after the surgery. The existing research is flawed, they say, because it included patients who did not have true varicoceles.
Dr. Ashok Agarwal, director of the Clinical Andrology Laboratory and Reproductive Tissue Bank at the Cleveland Clinic, performed an analysis of existing evidence, weeding out poor studies. Of 396 patients who underwent surgery, 33 percent had a pregnancy, compared with 15 percent of 174 control patients. “An 18 percent improvement is not only biologically significant; it is highly significant from a clinical point of view,” Dr. Agarwal wrote in an e-mail.
For couples who want more than one child, the prospect of improving sperm count might be appealing. “If you opt for assisted reproductive technologies,” Dr. Agarwal said, “you’re back there in three or four years to have another baby.”
But raising sperm count, whether through surgery, hormone treatments or lifestyle changes, takes time, a commodity many couples do not have, said Dr. Robert A. Greene, a reproductive endocrinologist and medical director of the Sher Institute for Reproductive Medicine of Northern California. It takes about three months for sperm to mature, so it will take at least that long for any treatment to raise sperm count. In most cases, it takes at least 6 to 12 months for changes to have an impact.
“Couples put off I.V.F. for a year or two waiting for sperm count to rise, while the woman’s age increases from 34 to 36 and her eggs are getting older,” Dr. Silber said.
In women in their mid-30s and older, time is of the essence. Based on national averages, the success of one cycle of I.V.F. using a fresh embryo drops from about 37 percent in women under 35 to about 20 percent in those 38 to 40. It drops further, to about 11 percent, in women in their early 40s. Most doctors would agree that if a woman is about 38 or older, the couple should go straight to I.V.F. with ICSI rather than seeking treatments to improve sperm count.
The bottom line is that a couple is likely to hear a convincing argument for whichever procedure is being offered by the specialist they see, making the decision about treatment difficult. Doctors can rattle off study results and success rates to support either side, but the devil is in the details. The research on all male treatments is limited and weak. Studies are small, not well controlled and of limited duration.
“The latest information is that basically, we don’t know,” Dr. Rankin said. A couple’s decision, in the absence of good hard data, comes down to their individual situation, the fertility factors of each partner, their finances, their age, their comfort with advanced reproductive technologies, and how many children they want.
Infertility in Men : Overview
Infertility is the inability to become pregnant after 12 months of unprotected sex (intercourse).
Alternative Names
Barren; Inability to conceive; Unable to get pregnant
Causes »
Primary infertility is the term used to describe a couple that has never been able to achieve a pregnancy after at least 1 year of unprotected sex.
Secondary infertility describes couples who have been pregnant at least once, but have not been able to achieve a pregnancy again.
Causes of infertility include a wide range of physical and emotional factors.
About 30 - 40% of all infertility is due to a "male" factor such as:
About 10 - 20% of couples will be unable to conceive after 1 year of trying to become pregnant. It is important that you try to get pregnant for at least 1 year.
The chances for a pregnancy in healthy couples who are both under the age of 30 and having sex regularly is only 25 - 30% per month. A woman's peak fertility occurs in her early 20s. As a woman ages beyond 35 (and especially after age 40), the likelihood of getting pregnant drops to less than 10% per month.
In addition to age-related factors, other infertility risks include:
Symptoms
A complete history and physical examination of both partners is essential.
Tests may include:
Treatment »
Treatment depends on the cause of infertility. It may involve:
In-Depth Treatment »
Support Groups
Many organizations provide informal support and referrals for professional counseling. See infertility - support group.
Outlook (Prognosis)
A cause can be determined for about 85- 90% of infertile couples.
Getting the right therapy (not including advanced techniques such as in vitro fertilization) allows pregnancy to occur in 50 - 60% of couples who were infertile.
Without any treatment, 15 - 20% of couples diagnosed as infertile will eventually become pregnant.
Possible Complications
Although infertility itself does not cause physical illness, it can have a major emotional impact on the couples and individuals it affects.
Couples may have problems with their marriage. Individuals may experience depression and anxiety.
When to Contact a Medical Professional
Call for an appointment with your health care provider if you are unable to get pregnant.
Prevention
Because sexually transmitted diseases (STDs) often cause infertility, practicing safer sex behaviors may minimize the risk. Gonorrhea and chlamydia are the two most common causes of STD-related infertility.
STDs often don't have symptoms at first, until PID or salpingitis develops. These conditions scar the fallopian tubes and lead to decreased fertility, infertility, or an increased risk of ectopic pregnancy.
Getting a mumps vaccine in men has been shown to prevent mumps and its complication, orchitis. The vaccine prevents mumps-related sterility.
Some forms of birth control, such as the intrauterine device (IUD), carry a higher risk for future infertility. IUDs are not recommended for women who have not already had a child.
If you are considering getting an IUD, carefully weigh the increased risk of infertility and the potential benefits with your partner and health care provider.
Getting diagnosed and treated early for endometriosis may decrease the risk of infertility.
Vasectomy : Safe, Simple and Little Used Form of Contraception
By Peter Jaret : NY Times Article : June 27, 2008
In Brief:
Vasectomies are safer and more cost-effective than tubal ligations, the sterilization technique for women, but remain relatively underused.
A new no-scalpel vasectomy technique significantly reduces complications.
The rate of unwanted pregnancies after vasectomy remains low; most of those pregnancies can be traced to patient error.
A tiny puncture and a little snip, done under local anesthetic — that’s essentially all there is to a vasectomy.
“Vasectomies are the safest, simplest, most cost-effective method of contraception we have,” said Dr. Edmund Sabanegh Jr., director of the Clinic for Male Fertility at the Cleveland Clinic Foundation.
They are also strikingly little-used. About 500,000 American men have the operation each year. More than twice as many women undergo tubal ligation for permanent contraception, even though that operation costs three to four times as much, requires general anesthesia and an abdominal incision, and carries a small but real risk of serious complications.
“There’s something about having a surgeon fiddling around down there with a scalpel that makes even tough guys squeamish,” said Dr. Marc Goldstein, director of the Center for Male Reproductive Medicine and Microsurgery at the Weill Medical College of Cornell University in New York.
And then there are the misconceptions that discourage many men from having vasectomies, especially the widespread and groundless worry that the procedure will lower testosterone levels and affect sexual performance.
Whatever the reasons in the United States, the situation is not the same among men everywhere. By the time they reach their 50s, roughly half of men in New Zealand have undergone vasectomies, according to Dr. Sabanegh, compared with fewer than one in six in the United States. In Canada, vasectomies outnumber tubal ligations.
Experts hope that recent advances in vasectomy techniques will ease some of the fears.
The chief advance is the no-scalpel vasectomy, a technique pioneered in China in the 1970s that has been steadily gaining popularity in the United States. In a traditional vasectomy, doctors make two half-inch incisions on either side of the scrotum to sever the vas deferens, the two narrow tubes that carry sperm from the testicles during ejaculation. The no-scalpel approach does away with the need for incisions.
In the new technique, doctors use their fingers to locate the vas deferens by feel through the thin skin of the scrotum.
“Once we’ve located the vas, we make a tiny poke-hole over it,” said Dr. Phillip Werthman, director of the Center for Male Reproductive Medicine and Vasectomy Reversal in Los Angeles. The hole can be gently expanded in a way that pushes blood vessels aside rather than cutting through them, so there is almost no bleeding. Using a hooked instrument, surgeons pull the vas through the hole, then cut it.
“A lot of men can’t even tell where the procedure was done afterwards, the hole we make is that small,” said Dr. Goldstein, who was the first Western doctor to travel to China to learn the technique. Compared with traditional techniques, no-scalpel vasectomies result in less bleeding, less postoperative pain and quicker recovery. They also require less time to perform — a little more than 10 minutes in the hands of an experienced surgeon.
Although the traditional incision method is still more widely used, that is likely to change as more and more medical schools teach the no-scalpel approach.
In another bid to win over squeamish males, some doctors have replaced the needles used to inject anesthesia into the scrotum with high-pressure jets that deliver painkillers through the skin.
“A lot of men’s biggest fear is that needle,” Dr. Werthman said, even though the actual needle used is so narrow that most men barely feel it. “Pressure injection takes the psychological edge off that,” he said, though many patients find the loud popping sound it makes unpleasant.
In the end, the success or failure of a vasectomy depends not on how surgeons reach the vas but how they block it. Many doctors use several methods to ensure that sperm don’t find another path. Along with cutting out a small section of the tube, they may burn the inner lining of the two remaining ends, clamp them and separate them.
With current techniques, the chance of an unwanted pregnancy occurring in the first year after a vasectomy is 1 in 1,000, Dr. Sabanegh said. Some of those failures are the fault of the patient, not the procedure. Because it can take several months for sperm remaining after a vasectomy to be washed out, men are counseled to use other contraception methods until tests show that their semen is free of active sperm. Many men don’t bother. In a 2006 study of 436 vasectomies, researchers at the Cleveland Clinic Foundation found that only three out of four returned for follow-up semen analysis, and only 21 percent followed the full instructions to continue to be tested until two specimens came up negative.
Panel Urges End To PSA Screening at Age 75
By Tara Parker-Pope : NY Times Article : August 5, 2008
In a move that could lead to significant changes in medical care for older men, a national task force on Monday recommended that doctors stop screening men ages 75 and older for prostate cancer because the search for the disease in this group was causing more harm than good.
The guidelines, issued by the U.S. Preventive Services Task Force, represent an abrupt policy change by an influential panel that had withheld any advice regarding screening for prostate cancer, citing a lack of reliable evidence. Though the task force still has not taken a stand on the value of screening in younger men, the shift is certain to reignite the debate about the appropriateness of prostate cancer screening at any age.
Screening is typically performed with a blood test measuring prostate-specific antigen, or PSA, levels. Widespread PSA testing has led to high rates of detection. Last year, more than 218,000 men learned they had the disease.
Yet various studies suggest the disease is “overdiagnosed” — that is, detected at a point when the disease most likely would not affect life expectancy — in 29 percent to 44 percent of cases. Prostate cancer often progresses very slowly, and a large number of these cancers discovered through screening will probably never cause symptoms during the patient’s lifetime, particularly for men in their 70s and 80s. At the same time, aggressive treatment of prostate cancer can greatly reduce a patient’s quality of life, resulting in complications like impotency and incontinence.
Past task force guidelines noted there was no benefit to prostate cancer screening in men with less than 10 years left to live. Since it can be difficult to assess life expectancy, it was an informal recommendation that had limited impact on screening practices. The new guidelines take a more definitive stand, however, stating that the age of 75 is clearly the point at which screening is no longer appropriate.
The task force was created by Congress and first convened in 1984 to analyze current medical research and to make recommendations about preventive care for healthy people. Its guidelines are viewed as highly credible and are often relied on by physicians in making decisions about patient care.
“When you look at screening, you have a chance the screening will help you live longer or better, and you have the chance that screening detection and treatment will harm you,” said Dr. Ned Calonge, chairman of the task force and chief medical officer for the Colorado Department of Public Health and Environment. “At age 75, the chances are great that you’ll have negative impacts from the screening.”
It is estimated that one out of every three men 75 and older is now screened for prostate cancer, although some studies suggest the number is even higher. The Journal of the American Medical Association reported in 2006 that in a group of nearly 600,000 older men treated by the Veterans Administration, 56 percent of those ages 75 to 79 had been screened for prostate cancer. Given the large numbers of men over 75 who are being screened, even a small decline in testing may greatly reduce the number of prostate cancer cases detected.
Dr. Calonge said it was important that the guidelines not be viewed as “giving up” on older men. While the new rules should discourage routine testing of older patients, the recommendations will not prevent a man from seeking screening if he desires it, Dr. Calonge said. The new guidelines are not expected to alter Medicare’s current reimbursement for annual PSA screening of older men.
“There will be some men who would say, ‘Let’s do it anyway,’ and other men who say, ‘If we don’t need to do it, let’s not do it,’ ” Dr. Calonge said.
The guidelines focus on the screening of healthy older men without symptoms and will not affect treatment of men who go to the doctor with symptoms of prostate cancer, like frequent or painful urination or blood in the urine or the semen.
Studies of the value of prostate cancer screening for younger men have produced mixed results, but a major clinical trial under way in Europe will try to determine whether there is any value, in terms of longer life expectancy, to screening this group for prostate cancer. Those results may be published as early as next year.
While the verdict is still out on younger men, the data for older men are more conclusive, experts say. The American Cancer Society and the American Urological Association both say annual PSA screening should be offered to average-risk men 50 and older, but only if they have a greater than 10-year life expectancy.
Recently, Swedish researchers collected 10 years of data on men whose cancer was diagnosed after the age of 65 and found no difference in survival among those who were treated for the disease and those whose cancers were monitored but treated only if the cancer progressed. The finding suggests that for most men, stopping screening at 75 is a safe option.
“If someone has made it to the age of 75 and they don’t have an elevated PSA, the likelihood of them developing clinically significant prostate cancer in the last 10 to 15 years of their life is pretty low,” said Dr. Peter C. Albertsen, professor of urology at the University of Connecticut Health Center. “The downside risk begins to outweigh the upside at the age of 75.”
Some studies suggest that as many as half of men 75 and older have clinically insignificant prostate cancer that is unlikely to affect their health but may be found through a biopsy. If the disease is detected as a result of screening, the men may be actively treated with radiation or hormone therapies, or may endure the stress of “watchful waiting” to see if the disease progresses.
Treatments for prostate cancer can cause significant harm, rendering men incontinent or impotent, or leaving them with other urethral, bowel or bladder problems. Hormone treatments can cause weight gain, hot flashes, loss of muscle tone and osteoporosis.
“I’m very pleased the prevention task force has said, at least for the old guys, ‘Leave them alone because our evidence suggests it doesn’t help,’ ” said Dr. Derek Raghavan, director of the Cleveland Clinic Taussig Cancer Institute. “Taking an 80-year-old and telling him he has cancer and telling him he needs radiotherapy or surgery uses up medical resources and puts him at risk. It’s a step toward rational thinking.”
Screening Tests : Not Always Best Course
By Tara Parker-Pope
NY Times Article : August 12, 2008
Sometimes what you don’t know might end up being better for you.
For years patients have been told that early cancer detection saves lives. Find the cancer before the symptoms appear, the thinking goes, and you’ve got a better chance of beating the disease.
So it might have seemed surprising last week when a panel of leading medical experts offered exactly the opposite advice. They urged doctors to stop screening older men for prostate cancer, which will kill an estimated 28,600 men in the United States this year.
Their advice offered a look at the potential downside of cancer screening and our seemingly endless quest to detect cancer early in otherwise healthy people. In this case, for men 75 and older, the United States Preventive Services Task Force concluded that screening for prostate cancer does more harm than good.
“We’ve done a great job in public health convincing people that cancer screening tests work,” said Peter B. Bach, a pulmonologist and epidemiologist at Memorial Sloan-Kettering Cancer Center in New York City. “We’re uncomfortable with the notion that some screening tests work and others don’t. That seems mystifying to people.”
But the reality is that while some cancer screening tests — like the Pap smear for cervical cancer or mammography for breast cancer — clearly save lives, the benefits of other screening tests are less clear.
Studies of lung cancer screening, for instance, have failed to prove that it prolongs life. A mass screening for neuroblastoma in Japanese infants was halted after it became clear that the effort wasn’t saving children and worse, led to risky treatments of tumors that weren’t life threatening.
The case seemed stronger for screening for prostate cancer. By some measures, death rates from the disease in the United States have plummeted since the introduction of the screening test for prostate specific antigen, which detects levels of a protein that can signal prostate cancer.
The data, in fact, are highly misleading. The introduction of screening can trigger big statistical fluctuations that can be difficult to interpret. But if you look at prostate cancer statistics in the 1970s, long before screening was introduced, death rates have dropped only slightly since then. The small decline seems largely because of improvements in treatment, many experts say, though others point to early detection as the reason.
Whether there really is a measurable benefit from PSA screening for younger men won’t be known for a few more years, after data from two major clinical trials studying the test are reported.
How can it be that finding prostate cancer early doesn’t help save lives? For starters, a large percentage of prostate cancers aren’t deadly. They are slow growing and unlikely to result in any symptoms before the end of a man’s natural life expectancy. By some estimates, as many as 44 percent of the men who are treated for prostate cancer as a result of PSA testing didn’t need to be. Had they been left alone, they would have died of something else and never known they had cancer.
“Screening tests don’t only pick up life-threatening cancers, they pick up tumors that look identical to traditional tumors, but they don’t have the same biologic behavior,” said Dr. Barry Kramer, associate director for disease prevention at the National Institutes of Health. “Some are so slow growing they never would have caused medical problems in the person’s natural life span.”
In the case of PSA testing, the Preventive Services Task Force, an expert panel that makes recommendations about preventive care for healthy people, said there was not enough evidence to recommend for or against screening of younger men, although they urged doctors to advise men of all the risks and benefits of screening. But they did conclude that 75 is the age at which the risks clearly begin to outweigh the benefits, and the disease, if detected, would most likely not have a meaningful effect on life expectancy.
Another problem with determining the value of screening is that it results in “lead time bias.” For instance, someone diagnosed with lung cancer at the age of 65 may die at 67 and be remembered as a two-year survivor. If the same man had been diagnosed at 57 through screening and died at the age of 67, he would be known as a 10-year survivor. That sounds a lot better, but the reality is that diagnosis and treatment didn’t prolong his life. He died at 67 either way.
“Even a harmful screening test could appear on the surface as a helpful test,” Dr. Kramer said. “Because you measure survival from the date of diagnosis, even if the person dies of the same cause on the same day they would have without screening, it looks like survival was longer.”
Any screening test can lead to false positives, followed by invasive and risky tests. Large numbers of people often end up being poked, prodded and tested only to discover they’re fine.
Biopsies to detect prostate cancer get mixed reviews. Some men find them to be a minor discomfort; others say they were left in debilitating pain. Once cancer is found, surgery, radiation or hormone therapy, or “watchful waiting,” may be advised.
Treatments for prostate cancer can cause significant harm, rendering men incontinent or impotent, or with other urethral, bowel or bladder problems. Hormone treatments can cause weight gain, hot flashes, loss of muscle tone and osteoporosis.
“It’s just a needle stick, but the cascade of events that follows are fairly serious,” Dr. Bach said. “I think the burden is on medicine to try and generate some evidence that the net benefits are there before drawing that tube of blood.”
The problem with prostate screening is that some men are very likely to have been saved by early detection. But how many have been hurt?
“I’m a little worried we may look back on the prostate cancer screening era, after we learn results of clinical trials, and see that we’ve harmed a lot of people without doing them good,” said Dr. David Ransohoff, a professor of medicine and cancer screening researcher at the University of North Carolina at Chapel Hill. “By being so aggressive with so many people, did we do the right thing? I don’t know that it’s going to turn out that way.”
Regrets After Prostate Surgery
NY Times Health Column : August 27, 2008
One in five men who undergoes prostate surgery to treat cancer later regrets the decision, a new study shows. And surprisingly, regret is highest among men who opt for robotic prostatectomy, a minimally invasive surgery that is growing in popularity as a treatment.
The research, published in the medical journal European Urology, is the latest to suggest that technological advances in prostate surgery haven’t necessarily translated to better results for the men on which it is performed. It also adds to growing concerns that men are being misled about the real risks and benefits of robotic surgical procedures used to treat prostate cancer.
Of the 219,000 men in the United States who learn they have prostate cancer each year, nearly half undergo surgical removal of the gland, according to the National Cancer Institute.
Duke University researchers surveyed 400 men with early prostate cancer who had undergone either a traditional “open” surgical procedure or newer robotic surgery to remove the prostate. Overall, the vast majority of men were satisfied. However, 19 percent regretted their treatment choice. Notably, men who had undergone robotic surgery were four times more likely to regret their choice than men who had undergone the open procedure.
Researchers say the higher level of regret among robotic patients suggests that they had higher expectations for their recovery, possibly because the robotic procedure is widely touted as a more innovative surgery than traditional prostatectomy. Even among men who had the same scores on erectile function and other measures of post-surgery recovery, the robotic patients still reported a higher level of dissatisfaction and regret than other men.
Part of the problem may be that doctors who perform robotic prostatectomies commonly cite potency rates as high as 95 percent and above among their patients, giving patients an unrealistic view of life after surgery.
But the data are highly misleading. Researchers often define potency as simply being able to achieve an erection that is “adequate” for intercourse — but for many men, that definition doesn’t capture their ongoing struggle to return to a normal sex life. Earlier this year, researchers from George Washington University and New York University used a more realistic definition of potency, showing that after surgery, fewer than half of the men studied felt their sex lives had returned to normal within a year.
Another important finding of the new research showed that men were less likely to regret their choice shortly after surgery. The men who were long past surgery experienced more regret. That finding likely speaks to the fact that as time passes after surgery, men gain a more realistic view of lingering health and quality-of-life issues like erection problems and other changes in their sex lives.
The Duke researchers said that the study shows urologists need to communicate more carefully the risks and benefits of the treatment prior to surgery so that men have more realistic expectations of what to expect.
To learn more, read “Sex After Prostate Cancer,'’ a Well blog post that includes my column about the issue as well as numerous comments from men and women about the aftermath of prostate cancer treatment.
The Gleason Score : What Does This Mean?
The score is based on a pathologist’s microscopic examination of prostate tissue that has been chemically stained after a biopsy. Under a standard microscope, the cells can show in various patterns.
To determine a Gleason score, a pathologist assigns a separate numerical grade to the two most predominant architectural patterns of the cancer cells. The grade depends on how far the cells deviate from normal appearance. The numbers range from 1 (the cells look nearly normal) to 5 (the cells have the most cancerous appearance).
The sum of the two grades is the Gleason score. The lowest possible score is 2, which rarely occurs; the highest is 10. Scores of 2 to 4 are considered low grade; 5 through 7, intermediate grade; and 8 through 10, high grade.
High scores tend to suggest a worse prognosis than lower scores because the more deranged, high-scoring cells usually grow faster than the more normal-appearing ones.
Prognosis also depends on further refinements. In one example, a score of 7 can come in two ways: 4 plus 3 or 3 plus 4. With 4 plus 3, cancer cells in the most predominant category appear more aggressive than those in the second, suggesting a more serious threat than a 3-plus-4 score, in which cells in the most predominant group appear only moderately aggressive.
If you can't discuss these type of issues with me you have chosen the wrong doctor !
Erectile Dysfunction may be Early Warning Sign of Heart Troubles
By Peter Jaret : NY Times Article : March 1, 2008
In Brief
- For men over 40, erection problems may be an early sign of heart disease.
- A flagging erection may precede cardiovascular problems like a heart attack or angina by up to five years.
- Exercise, weight loss and lowering cholesterol may help improve erections.
- Erectile dysfunction drugs don’t work for up to 30 percent of men.
As if a blow to one’s masculinity weren’t bad enough. Researchers now say that for men over 40, having trouble getting or maintaining an erection is often a sign of something more worrying: cardiovascular disease. Indeed, there’s growing consensus that erection problems are a risk factor for heart disease, right up there with smoking and high blood pressure.
“The penis is the dipstick of the body’s health,” said Dr. Harry Fisch, director of the Male Reproductive Center at Columbia University Medical Center of New York Presbyterian Hospital. “If you’re able to have sex and healthy erections, it’s a good sign that your cardiovascular system is in good shape. If you can’t, it’s time to see your doctor.”
Impotence — or erectile dysfunction, as it’s sometimes called — was once deemed chiefly a psychological problem. When it occurs in men in their 20s and 30s, it often is. “But especially when men hit middle age, the main cause of erectile dysfunction is almost always vascular,” said Dr. Laurence Levine, professor of urology at Rush University Medical Center in Chicago. The same factors that can clog up arteries and lead to heart attacks and strokes — smoking, elevated cholesterol, inflammation and high blood pressure — also wreak havoc on the blood vessels that supply the penis. A flagging erection may be one of the earliest warning signs of trouble.
“The arteries in the penis are about one-third the size of one of the coronary arteries supplying the heart,” Dr. Levine explained. “When smaller blood vessels, such as the penile arteries, are compromised even a small amount, it can have a major effect on their capacity to dilate. And that will show up as a noticeable difference in the quality of an erection.”
When a man becomes aroused, the brain sends signals to the penis to release a chemical that rapidly widens blood vessels. Blood rushes in, causing an erection. Damage to those vessels can make them inflexible, limiting their ability to expand. When the damage gets bad enough, the spirit may be willing but the flesh unable.
Since men are all too aware when their erections begin to flag, erectile dysfunction may serve as a useful early warning sign of cardiovascular problems. In a British study that compared 207 men with heart disease with 165 healthy controls, investigators at Buckinghamshire Chilterns University College found that erectile woes can precede such problems as a heart attack or angina by up to five years.
“What you really worry about is the guy who goes online and gets Viagra, never knowing that the reason he’s having problems is that he’s got very high cholesterol levels and is diabetic,” said Dr. Wayne J. Hellstrom, professor of urology at Tulane University School of Medicine in New Orleans and co-author of a 2007 study that found that the more risk factors a man has for coronary artery disease, the greater his odds of having abnormal blood flow in his penis. The poorest blood flow showed up in men who already had coronary artery disease and diabetes.
To complicate matters, certain prescription drugs — including some high-blood-pressure medicines, cholesterol-lowering drugs, antidepressants and tranquilizers — can cause or worsen erection problems. “Twenty-five percent of erectile dysfunction may be related to medications,” said Dr. Kevin T. McVary, professor of urology at the Feinberg School of Medicine at Northwestern University in Chicago. Sometimes doctors can switch patients to a similar drug that doesn’t cause problems. But not always. “In that case we have to treat around the side effect, usually by prescribing a drug like Viagra,” Dr. McVary said.
In some men, getting high blood pressure and cholesterol under control, along with stepping up physical activity and shedding a few pounds, may be enough to improve erections. After participating in a program to lose weight and get more exercise, for example, one group of 55 obese men studied at the University of Naples in Italy significantly bettered their scores on a test called the International Index of Erectile Function.
Studies have shown that a diet abundant in fruits, vegetables, whole grains and fish, like that traditionally eaten in the Mediterranean region, may also help by reducing vascular inflammation. If a healthier diet means losing weight, all the better. “People with huge pot bellies typically have very low testosterone, the male hormone,” Dr. Fisch explained. “Visceral fat eats up testosterone. When men lose belly fat, their testosterone goes up.” So does their libido and, in some cases, the most obvious manifestation of it. Exercise is also important, he said, because it helps open up blood vessels.
Of course, diet and exercise are a tough sell when a simple pill can do the trick quickly. Treatment of impotence has undergone a revolution with the advent of Viagra and two similar drugs, Levitra and Cialis. All three work by blocking the breakdown of the chemical that causes blood vessels in the penis to widen. That in turn allows more of the chemical to build up, bolstering an erection.
Despite the happy images of smiling silver-haired couples in the ads, however, erectile dysfunction medications may not work for everyone. If blood vessels become too damaged, they can’t widen sufficiently. “As many as 30 percent of the men we see don’t get much improvement using these drugs,” Dr. Levine said. For some of them, exercise and weight loss may increase the pills’ effectiveness, as may lowering elevated cholesterol levels with cholesterol-lowering statin drugs.
The findings underscore the importance that men 40 and older see a doctor and treat cardiovascular risk factors if erection problems arise.
As for younger men, the latest findings are even more encouraging. Heeding the familiar advice to maintain a normal weight, get plenty of exercise and avoid smoking could well ensure sturdier erections for years to come. That’s potent motivation by any measure.
Published on February 29, 2008
Impotence Overview
An erection problem is the inability to get or maintain an erection that is firm enough for a man to have intercourse. You may be unable to get an erection at all, or you may lose the erection during intercourse before you are ready. If the condition persists, the medical term is erectile dysfunction.
Alternative Names
Erectile dysfunction; Impotence; Sexual dysfunction - male
Considerations
Erection problems are common in adult men. In fact, almost all men experience occasional difficulty getting or maintaining an erection. In many cases, it is a temporary condition that will go away with little or no treatment. In other cases, it can be an ongoing problem that can damage a man's self esteem and harm his relationship with his partner, and thus requires treatment.
If you have difficulty having or keeping an erection more than 25% of the time, it is considered a problem.
In the past, erection problems were thought to be "all in the man's mind." Men often were given unhelpful advice such as "don't worry" or "just relax and it will take care of itself." Today, doctors believe that when the problem is not temporary or does not go away on its own, physical factors are often the cause.
One way to know if the cause is physical or psychologic is to determine if you are having nighttime erections. Normally, men have 3 to 5 erections per night, each lasting up to 30 minutes. Your doctor can explain a test to find out if you are having the normal number of nighttime erections.
In most men, erection difficulties do not affect their sex drive.
Premature ejaculation (when orgasm comes on too quickly) is not the same as impotence. Together with your partner, you should seek counseling for this problem, which is usually due to psychological factors.
Male infertility is also quite different from impotence. A man who is unable to maintain an erection may be very capable of producing sperm that could fertilize an egg. An infertile man is usually able to maintain an erection, but he may be unable to father a child due to problems with sperm count or other factors.
Causes
An erection requires the interaction of your brain, nerves, hormones, and blood vessels. Anything that interferes with the normal process can become a problem. Common causes include:
- Diseases and conditions such as diabetes, high blood pressure, heart or thyroid conditions, poor circulation, low testosterone, depression, spinal cord injury, nerve damage (for example, from prostate surgery), or neurologic disorders (such as multiple sclerosis or Parkinson's disease)
- Medications such as blood pressure medications (especially beta-blockers), heart medications (such as digoxin), some peptic ulcer medications, sleeping pills, and antidepressants
- Nicotine, alcohol, or cocaine
- Poor communication with your partner
- Stress, fear, anxiety, or anger
- Unrealistic sexual expectations, which make sex a task rather than a pleasure
- "Vicious cycle" of doubt, failure, or negative communication that reinforces the erection problems
Home Care
For many men, lifestyle changes can help:
- Cut down on smoking, alcohol, and illegal drugs.
- Get plenty of rest and take time to relax.
- Exercise and eat a healthy diet to maintain good circulation.
- Use safe sex practices, which reduces fear of HIV and STDs.
- Talk openly to your partner about sex and your relationship. If you are unable to do this, counseling can help.
If erection problems seem to be caused by a medication you are taking for an unrelated condition, consult your doctor. You may benefit from reducing the dose of the drug or changing to another drug that has the same result but not the same side effects. DO NOT adjust or discontinue medications without consulting your doctor first.
Talk to your health care provider if your erection problems are related to fear of recurring heart problems -- sexual intercourse is usually safe in these circumstances.
When to Contact a Medical Professional
Call your doctor if:
- Self-care measures do not resolve the problem and you continue having difficulty with erections -- effective treatments are available
- You suspect that a medication is causing the problem
- The problems begin after an injury or prostate surgery
- You have other symptoms like low back pain, abdominal pain, or change in urination
What to Expect at Your Office Visit
Your doctor will perform a physical examination, which will likely include checking your circulation, a rectal exam, a neurological exam, and an exam of your penis.
To help diagnose the cause of the problem, your doctor will ask medical history questions, such as:
- Have you been able to achieve and maintain erections in the past?
- Is the difficulty in achieving erections or maintaining the erection?
- Do you have erections during sleep?
- How long have you had difficulty with erections?
- What medications are you taking (including prescription medications, over-the-counter medications, recreational drugs)?
- Do you smoke? How much each day?
- Do you use alcohol? How much?
- Have you recently had surgery?
- Have you ever had vascular surgery or other treatments for your blood vessels?
- Are you depressed?
- Are you afraid or worried about something?
- Are you experiencing a lot of stress?
- Has your energy level decreased?
- Are you sleeping well each night?
- Are you afraid of sexual activity because of physical problems?
- Have there been any recent changes in your life?
- What other symptoms do you have?
- Have you noticed changes in sensations in your penis?
- Do you have any problems with urination?
- Urine analysis
- Blood tests, including CBC, metabolic panel, hormone profile, PSA
- Penile ultrasound (to evaluate for blood vessel or blood flow problems)
- Nocturnal penile tumescence (NPT) to test if you are having nighttime erections and rigidity monitoring (Rigiscan)
- Neurological testing
- Psychometric testing
There are many treatment options today. These include medicines taken by mouth, injections into the penis, vacuum devices, and surgery. In order to treat erectile dysfunction effectively, you must be aware of and comfortable with the possible side-effects and complications that may occur with each therapy.
Sildenafil (Viagra), vardenafil (Levitra), and tadalafil are medicines prescribed for mild-to-moderate erection difficulties caused by either physical or psychological problems. Although these medicines have become extremely popular, they are not "cure-alls," and they do not enhance erections if you are not impotent. And, they DO have side effects. These pills should not be used with certain other medications.
Men who take nitroglycerin for a heart condition (as either tablets, spray, or patches) should NOT take these medications. When taken with nitroglycerin, these drugs can significantly lower blood pressure. Some men have died from combining these drugs and nitroglycerin.
If pills do not work, other options are available. Testosterone may be prescribed by either skin patch or injection, especially if the problem is related to age. Alprostadil, injected at the penis or inserted as pellets, improves blood flow to the penis. This technique is usually more effective than medications taken by mouth.
For some patients, a vacuum pump or penile prosthesis (implant) may also be recommended or required.
Consult your health care provider to see if one of these treatments is right for you.
Drugs used for Erectile Dysfunction
By Peter Jaret
Dr. Laurence A. Levine is a professor of urology at Rush University Medical Center in Chicago. He is president of the Sexual Medicine Society of North America and the author of numerous research studies on erectile dysfunction.
Q. Are most men comfortable talking to their doctors about erection problems?
A. The Viagra era has certainly changed the embarrassment level. But many men still feel embarrassed, which is why I think it’s important for doctors to ask men over 40 about their sexual health as part of the routine “review of systems.” It’s especially important since erectile dysfunction can be an early sign of cardiovascular problems.
Q. What’s the connection between erectile dysfunction and cardiovascular disease?
A. When a man gets sexually aroused, the brain sends signals to the penis, where the release of certain chemicals causes blood vessels to dilate — turning a straw into a hose, if you will. The penis fills with blood, and you have an erection. A problem that affects the vascular system means that those blood vessels don’t dilate adequately. Problems with the vascular system often show up first as an inability to get or maintain erections.
Q. What percentage of men with erection problems turn out to have cardiovascular disease?
A. About 70 percent of men who have a cardiovascular event such as a heart attack or angina, when asked later, say that they were experiencing erectile dysfunction. When they’re asked how long they’d been experiencing erection problems, the average answer is about four years. Among men diagnosed with diabetes, almost 100 percent have been experiencing erectile problems. So erectile dysfunction can be a very useful warning sign.
Q. Can lifestyle changes recommended for preventing heart disease help improve erectile function?
A. That depends on the severity of the problem, how long it’s been a problem and a man’s age. A recent study in France looked at men who stopped smoking. After a year, 25 percent showed spontaneous improvement in their erections. Another recent study looked at obese men. It found that when they lost weight through a carefully monitored program of exercise and reduced calories, about one-third were having spontaneous erections after two years. That means they were getting erections without having to take drugs like Viagra.
Q. Can lowering blood pressure or cholesterol with medication improve erectile function?
A. The story here is a little less clear. We don’t have good evidence that lowering blood pressure improves erectile function. What it probably does is prevent progression. With diabetes, it’s very important to control blood sugar levels, because the diabetic process is known to cause vascular damage. Cholesterol-lowering drugs may help some men get spontaneous erections, but the stronger evidence relates to how well men with erectile dysfunction respond to Viagra, Levitra or Cialis. We did a study looking at men with elevated cholesterol who didn’t respond to Viagra. After we put them on Lipitor, a cholesterol-lowering drug, 60 percent were able to get erections.
Q. How do erectile dysfunction drugs work?
A. All three of the drugs on the market work to prevent the breakdown of the chemical that causes blood vessels in the penis to dilate. That allows more of the chemical to hang around and build up, so erections are better and last longer. After orgasm, blood vessels actually contract and the erection goes down. For men using these drugs, the refractory period, or bounce-back time — how long it takes before you can have an erection again — is also significantly shorter.
Q. Are there important differences among these drugs?
A. Viagra, Levitra and Cialis are each slightly different molecules, with slightly different effects and side effects. Viagra and Levitra usually last four to six hours, for instance, although there’s some evidence that they may last longer than that. Cialis can last as long as 36 hours. So you have a longer window of opportunity. Some men prefer that. Which drug is best? The answer is the one that works for you, with the fewest side effects.
Q. Are there dangers to overusing these drugs?
A. Despite early concerns, there is no evidence of a higher risk of heart attacks or blindness or acute hearing loss. In fact, erectile dysfunction drugs have actually been shown to lower heart attack rates in men taking them on a regular basis. That’s not surprising. Viagra was originally developed to treat angina, chest pain caused by cardiovascular disease. It didn’t prove to be particularly effective, so the study was stopped. But when the researchers asked the volunteers to give back the leftover drugs, they balked. The reason: their erections were so good. By dilating blood vessels, these drugs probably improve blood flow to the heart, which would protect heart muscle.
Q. Can men become dependent on erection drugs?
A. No. There is no evidence that people come to need more and more of them to get an erection, and no evidence of physical dependence. In fact, I often prescribe them to men with psychogenic erection problems, as a way to build confidence. After they become confident that they can have a normal erection, they don’t need the drugs any longer.
Q. Do erectile dysfunction drugs work for most men?
A. About 70 percent of the men in my practice respond. But if the vascular damage is too serious, even these drugs can’t help. In men who smoke, have elevated cholesterol, hypertension and diabetes — vasculopaths, I sometimes call them — the blood vessels in their penises are like lead pipes. They can’t dilate to cause an erection.
Q. What happens, then, if erectile dysfunction drugs fail?
A. Erection-inducing drugs can be injected directly into the penis, which creates higher levels and sometimes works when pills don’t. We train men to do this at home. For men who are uneasy about giving themselves a shot, there’s another approach that involves placing a tiny medication-containing pellet into the urethra. As the drug passes through the walls of the urethra, it causes blood vessels in the erectile tissue to dilate.
Another approach is the use of vacuum tubes, which have been around for more than a century. You put the penis inside a plastic tube, and a small pump draws the air out, pulling blood into the erectile tissue. Once the penis is erect, you slip a constriction band around the base of the penis and remove the tube and you’re ready for action. Clearly this is the least natural alternative, but it’s also the least expensive.
For highly motivated men, there’s the option of a penile prosthesis. Most of these are inflatable tubes implanted in the shaft of the penis, connected to a pump placed in the scrotal sack. With a squeeze of the pump, the prosthesis inflates and you have an erection. The penis looks normal in a flaccid state. The prosthesis doesn’t interfere with urination, sexual pleasure or orgasm. And our surveys of men and their partners say they’re very happy with the results. One downside is that you can have mechanical failures, which means having to replace the device. And there’s a very small risk of infection. Also, once you have a prosthesis implanted, you can never have an erection again without it.
Q. Can erectile dysfunction be prevented?
A. Men can certainly reduce the risk by maintaining good vascular health. The usual advice applies. Don’t become obese. And get lots of exercise. Exercise increases blood flow throughout the body, and what’s good for vascular health is good for the penis.
Here’s something most men are happy to hear: Sex is also good for your penis. In fact, men normally get two to seven spontaneous erections during the night — not because they’re having an erotic dream or their bladders are full. It’s a reflex. We’re designed to get erections so that blood flows into the erectile tissue to nourish it. Sometimes after prostate surgery, men stop having nocturnal erections, at least temporarily. The longer you don’t have them, studies show, the more likely you are to begin to lose length, girth and vascular tissue in the penis. For most men, that’s a pretty strong case for use it or lose it.
For Common Male Problem, Hope Beyond a Pill
By Lesley Alderman : NY Times Article : August 29, 2009
If you watch enough television, you’d think that treating erectile dysfunction was as effortless as popping a pill and then whirling your partner around the living room in a romantic dance. Correcting erectile dysfunction, alas, is not so simple — and it can be rather costly. One Viagra pill, for example, the most common way to treat erection problems, costs about $15.
Insurers can be chary of reimbursements. And despite the fact that E.D., as the dysfunction is known, becomes increasingly common after men reach 65, Medicare Part D does not cover drugs for it.
An estimated 30 million men in this country experience erectile dysfunction. Nearly a third of men in their 50s experience E.D., whereas more than half of those in their 60s have the problem.
If you’re hoping to have Viagra-aided sex twice a week, your bill for the entire year could run around $1,500. If you’re fortunate enough to have insurance that covers the medications, your co-pay will be on the high side, around $40 for a one-month supply of six to eight pills — bringing your annual bill to a more manageable $500 or so. There are no generic versions of E.D. meds yet.
Even among the name-brand drugs, which also include Cialis and Levitra, the medications do not work for about half of the men with E.D., says Dr. Ajay Nehra, professor of urology at the Mayo Clinic in Rochester, Minn. He is also president of the Sexual Medicine Society, an association of health care professionals.
And yet, as it turns out there are other treatments for E.D. And some of them are more cost-effective than the brand-name pills advertised on television.
“There is not a man out there that cannot be helped in some way with his E.D. — even if money is an issue,” says Dr. Andrew McCullough, an associate professor of urology and director of Male Sexual Health and Fertility at the Langone Medical Center at New York University.
The first step is to see a doctor who specializes in E.D. (usually a urologist) and have your overall health checked out. If your primary care physician can’t make a recommendation, contact the Sexual Medicine Society and ask for a referral.
In many of cases, E.D. is the sign of an underlying disorder like diabetes or hypertension. In fact, in younger men, erection problems are often the first symptom of cardiovascular disease.
“Erectile problems may show up about three years before a cardiovascular event such as a heart attack or stroke,” says Dr. Ira Sharlip, clinical professor of urology at the University of California, San Francisco.
That’s because plaque will start to clog the small arteries in the penis before the wider coronary arteries. Your doctor will also try to determine whether your E.D. is the result of a psychological issue, in which case he will refer you to a therapist. Depending on your policy, your insurer may cover a set number of visits. (One way for you to check on your own whether your issue may be psychological or physical is try the postage stamp test, also known as nocturnal penile tumescence test.)
By adopting healthier habits, you may be able to improve your overall well-being and restore your erectile function.
“There is increasing evidence that we can reverse erectile dysfunction with lifestyle changes,” says Dr. Drogo K. Montague, director of the Center for Genitourinary Reconstruction in the Glickman Urological and Kidney Institute at Cleveland Clinic.
In a recent study of men with E.D., or at risk for developing it, researchers in Italy found that the men could improve their erections by losing weight, improving their diet and exercising more frequently. After two years of significant lifestyle changes, 58 percent of the men had normal erectile function, according to the study, which was published in The Journal of Sexual Medicine in January.
But lifestyle changes, while basically free, can be difficult to make and may take months to take effect. In the meantime, your doctor will probably prescribe a phosphodiesterase type 5 inhibitor, also called a PDE-5 inhibitor, like Viagra, Cialis or Levitra. These drugs enhance the effects of nitric oxide, a chemical that helps to increase blood flow in the penis. The three drugs work in the same way, but differ in how quickly they take effect and how long they last. If the PDE-5 drugs don’t work for you, don’t give up quickly, says Dr. McCullough, who theorizes that “in over 40 percent of drug failures the problem is with the user, not the drug.” Dr. McCullough adds, “it’s important to take these medications as directed, like on a totally empty stomach, rather than a full one, and not less than 60 minutes before sex.”
If the pills don’t work for you, you might want to try self-administered injections of alprostadil, a drug that helps blood vessels expand and facilitates erections. Granted, this may sound onerous, but the shot, which is sold under the brand names Edex and Caverject, is done with a fine needle, feels no worse than a pinprick and produces an erection that can last up to four hours, according to doctors who recommend it.
The shots cost about $35 per injection and are covered by most insurers, but not by Medicare.
But ask your doctor about an injection that’s a cocktail of generic forms of alprostadil, papaverine and phentolamine.
Although this generic combination is not F.D.A.-approved as an E.D. treatment, doctors are legally free to administer it — and both Dr. Sharlip and Dr. McCullough recommend it.
“The generic injections clearly work the best,” Dr. Sharlip said, “and are usually less expensive.”
Another cost-effective option is a vacuum erection device or penis pump. It works like this: you place a tube on the penis and then pump the air out of the tube, which pulls blood into the penis. When the penis is erect, you then put a snug ring around the base to maintain the erection, which lasts long enough to have sex.
The cost for the device, which requires a prescription, can run from $300 to $600, but most insurers and Medicare will cover part of the cost and the device should last for years. Even if you spend $300 out of pocket and use the device once a week, you’ll be spending much less per year than on pills or injections. You can also buy a nonprescription pump online (even Amazon carries some) for as little as $30, Dr. McCullough said.
Finally, if all other treatments fail, you could consider getting penile implants, an effective and permanent solution for chronic E.D. The most common type of implant works through inflation: two cylinders are placed inside the penis and a fluid-filled reservoir is implanted under the abdominal wall or groin muscles; a pump and a deflation valve are placed inside the scrotum. To create an erection, you pump fluid from the reservoir into the cylinders. To deflate the penis, you press the release valve.
Most insurers and Medicare cover the surgery, so your out-of-pocket costs will be minimal. This might be the most cost-effective strategy of all since, according to Dr. Nehra, 80 percent of implants last 10 years.
Premature Ejaculation Overview
Premature ejaculation occurs when a man orgasms during intercourse sooner than he or his partner wishes.
Causes
Premature ejaculation is a common complaint. It is only rarely caused by a physical or structural problem.
Premature ejaculation early in a relationship is most often caused by anxiety and overstimulation. Other psychological factors such as guilt may also be relevant. The condition usually improves without formal treatment.
Symptoms
Ejaculation happens before the individual or couple would like (prematurely). This may range from before penetration to a point just after penetration, and may leave the couple feeling unsatisfied.
Signs and Tests
Abnormal findings are unlikely to be associated with the condition. Useful information is more likely to be obtained from interviewing the person or the couple.
Treatment
In general, practice and relaxation will help you deal with the problem. Some men try to distract themselves by thinking non-sexual thoughts (such as naming baseball players and records) to avoid becoming excited too fast.
Some helpful techniques include the following:
The "stop and start" method:
- This technique involves sexual stimulation until the man recognizes that he is about to ejaculate. The stimulation is then removed for about thirty seconds and then may be resumed. The sequence is repeated until ejaculation is desired, the final time allowing the stimulation to continue until ejaculation occurs.
- This technique involves sexual stimulation until the man recognizes that he is about to ejaculate. At that point, the man or his partner gently squeezes the end of the penis (where the glans meets the shaft) for several seconds, withholding further sexual stimulation for about 30 seconds, and then resuming stimulation. The sequence may be repeated by the person or couple until ejaculation is desired, the final time allowing the stimulation to continue until ejaculation occurs.
Local anesthetic creams may be applied to the penis to decrease stimulation. Decreased feeling in the penis may prolong the time before ejaculation. Condom use may also have this effect for some men.
Evaluation by a sex therapist, psychologist, or psychiatrist may be helpful for some couples.
Expectations (prognosis)
In most cases, the man is able to learn ejaculatory control through education and practice of the simple techniques outlined. Chronic premature ejaculation may be a sign of anxiety or depression, both of which could be helped by psychiatric intervention.
Complications
- Very early ejaculation, occurring prior to entry into the vagina, may prohibit a desired pregnancy.
- A continued lack of ejaculatory control may lead to sexual dissatisfaction on the part of either or both partners and may be a factor in sexual tension or discord in the relationship.
Infertility in Men Overview
Infertility is the inability of a couple to become pregnant after 12 months of unprotected intercourse.
Alternative Names
Low sperm count; poor sperm quality
Causes
Primary infertility is the term used to describe a couple that has never been able to conceive a pregnancy, after at least 1 year of unprotected intercourse.
Secondary infertility describes couples who have previously been pregnant at least once, but have not been able to achieve another pregnancy.
Causes of infertility include a wide range of physical as well as emotional factors. Approximately 30 - 40% of all infertility is due to a "male" factor such as retrograde ejaculation, impotence, hormone deficiency, environmental pollutants, scarring from sexually transmitted disease, or decreased sperm count. Some factors affecting sperm count are heavy marijuana use or use of prescription drugs such as cimetidine, spironolactone, and nitrofurantoin.
A "female" factor -- scarring from sexually transmitted disease or endometriosis, ovulation dysfunction, poor nutrition, hormone imbalance, ovarian cysts, pelvic infection, tumor, or transport system abnormality from the cervix through the fallopian tubes -- is responsible for 40 - 50% of infertility in couples.
The remaining 10 -30% of infertility cases may be caused by contributing factors from both partners, or no cause can be identified.
It is estimated that 10 - 20% of couples will be unable to conceive after 1 year of trying to become pregnant. It is important that pregnancy be attempted for at least 1 year. The chances for pregnancy occurring in healthy couples who are both under the age of 30 and having intercourse regularly is only 25 - 30% per month.
In addition to age-related factors, increased risk for infertility in men is associated with the following:
- Multiple sexual partners (increases risk for sexually transmitted diseases)
- Sexually transmitted diseases
- History of orchitis or epididymitis
- Mumps
- Varicocele
- A past medical history that includes DES exposure (men or women)
- Long-term (chronic) disease such as diabetes
Symptoms
- Inability to produce viable sperm.
- A range of emotional reactions by either or both members of the couple. In general, such reactions are greater among childless couples. Having at least one child tends to soften these painful emotions.
A complete history and physical examination of both partners is essential.
Tests for men may include:
- Semen analysis -- the specimen is collected after 2 to 3 days of complete abstinence to determine volume and viscosity of semen and sperm count, motility, swimming speed, and shape.
- Postcoital testing (PCT) to evaluate sperm-cervical mucus interaction through analysis of cervical mucus collected 2 to 8 hours after the couple has intercourse.
- Biopsying the testicles (rarely done).
- Serum hormonal levels (blood tests) for either or both partners.
Treatment »
Treatment depends on the cause of infertility. It may involve:
- Simple education and counseling
- Highly sophisticated medical procedures such as in vitro fertilization
In-Depth Treatment »
Support Groups
Many organizations provide informal support and referrals for professional counseling. See infertility - support group.
Expectations (prognosis)
A cause can be determined for about 85- 90% of infertile couples.
Appropriate therapy (not including advanced techniques such as in vitro fertilization) allows pregnancy to occur in 50 - 60% of previously infertile couples.
Without any treatment intervention, 15 - 20% of couples previously diagnosed as infertile will eventually become pregnant.
Complications
Although infertility itself does not cause physical illness, the psychological impact of infertility upon individuals or couples affected by it may be severe. Couples may encounter marital problems, as well as individual depression and anxiety.
Calling Your Health Care Provider
Call for an appointment with your health care provider if you are unable to achieve a desired pregnancy.
Prevention
Because infertility is frequently caused by sexually transmitted diseases, practicing safer sex behaviors may minimize the risk of future infertility. Gonorrhea and chlamydia are the two most frequent causes of STD-related infertility.
Mumps immunization has been well demonstrated to prevent mumps and its male complication, orchitis. Immunization prevents mumps-related sterility.
Surprising Causes of Male Infertility
By Melinda Beck : WSJ : June 28, 2011
On average, the typical man makes about 1,000 sperm every heartbeat.
What do laptops, prolonged hot-tub and taking extra testosterone have to do with a man's sperm count? Melinda Beck debunks some myths and explains some science about fertility. Yet a number of lifestyle choices, environmental factors and chance events can sabotage the sperm: an adolescent groin injury, cigarette smoking, heavy drinking, intense cycling and even using a laptop directly on the lap.
Infertility, defined as the inability to conceive after one year of unprotected sex, affects one in six couples of childbearing age in the U.S. In 40% of cases, the problem is with the man; in 40% it's with the woman, and in 20%, something is amiss with both, say Zev Rosenwaks and Marc Goldstein, fertility experts at New York Presbyterian/Weill Cornell Medical College and co-authors of the 2010 book, "A Baby at Last!"
Since men contribute to infertility at least half the time, says Dr. Goldstein, couples investigating why they can't conceive should start with a simple sperm count.
About 70% of male infertility is treatable, he says, and in about 25% of cases, it could have been avoided with greater awareness of the lifestyle choices that can harm sperm.
Testosterone trouble. Smoking cigarettes, heavy alcohol drinking and using marijuana, cocaine and opioid painkillers can all lower the level of testosterone needed to make sperm or otherwise cut their quantity and quality. So can some commonly prescribed medications for high blood pressure, heart disease, stomach acid, gout, inflammatory bowel disease, enlarged prostates and baldness.
In many cases, alternative drugs exist that don't hamper fertility.
Even extra testosterone can lower a man's testosterone. As many body-builders know, taking testosterone and other anabolic steroids can build muscles but shrink testicles and halt sperm production because the brain thinks the body has plenty and stops making enough of its own. In most cases, normal sperm production resumes within a few months once men stop using the substances.
Exposure to large amounts of radiation can also make men permanently sterile. When getting an X-ray of any part of the body, men should always request a lead shield for their testicles, says Dr. Goldstein.
Keeping cool. Men trying to conceive should avoid hot baths, hot tubs and tight pants, since heating the testicles by even a few degrees can hamper or stop sperm production. Studies at Stony Brook University in New York have shown that resting a laptop on the lap can raise temperatures in the scrotum as much as 5 degrees Fahrenheit in an hour. Although most heat problems are temporary, researchers still urge men to use desks or tables instead.
Fertility Foes
Some things believed to affect men's sperm count, at least temporarily:
Some things believed to affect men's sperm count, at least temporarily:
Lifestyle choices Cigarettes, heavy alcohol or drug use, laptop placed on the lap
Activities Cycling in compression shorts, excessive exercise
Health issues Obesity, sexually transmitted diseases, groin injury
Environmental Some pesticides and industrial agents. Possible risks with certain plastic bottles
Certain prescription drugs
Tagamet (cimetidine) for ulcers
Propecia, Avodart (finasteride, dutasteride) for enlarged prostate, baldness
Inderal (propranolol) for heart disease, hypertension
Procardia, Cardizem (nifedipine, diltiazem) for angina, hypertension
Azulfidine (sulfasalazine) for bowel disease
Furadantin (nitrofurantoin) for urinary tract infections
Colchicine for gout
Most antiandrogens for enlarged prostate, cancer
Many chemotherapy drugs
Testosterone preparations
Source: J.K. Amory; Drugs of Today, 2007; WSJ reporting
An earlier Stony Brook study debunked one widely held belief, however. In comparing the scrotal temperatures of 97 men wearing either boxers or briefs, researchers found there was little difference.
Trauma. Men of all ages should take care to avoid trauma to the testes, in part to avoid rupturing the delicate ducts that carry sperm and keep them shielded from the body's immune system, which would otherwise attack them as foreign invaders. Once exposed, sperm trigger the formation of antisperm antibodies which hamper their ability to swim and fertilize an egg.
"That's why wearing a cup for playing sports is so important," says John Amory, a specialist in male reproductive medicine at the University of Washington. "It's not just to prevent pain."
Sexually transmitted diseases. Chlamydia, gonorrhea and other STDs can block those same ducts with inflammation and scar tissue, and they are rampant in the U.S., affecting up to half the population by age 35. Men with symptoms such as burning on urination or discharge from the penis should see a doctor as soon as possible to minimize long-term damage. Those with multiple sex partners should use condoms and be checked yearly for STDs, experts say.
Diet and exercise. Obesity can thwart a man's fertility in many ways: lowering libido, reducing sperm counts and disrupting hormone balance. This is in part because fat tissue produces estrogen, which lowers testosterone. Maintaining a healthy weight and diet can significantly increase a man's chance of conceiving a healthy baby, studies show.
Strenuous exercise may hurt fertility, though. Men who run more than 100 miles a week have lower sperm counts and testosterone levels.
Dr. Goldstein also advises male cyclists trying to conceive to ride for only 30 miles at a time—mainly to limit their time wearing tight bicycle shorts. And he recommends using a seat with a wide back rather than a hard, narrow one. "You want more of your weight on your sit bones," he says.
Environmental factors. Some pesticides, heavy metals and industrial agents also reduce sperm production. Less is known about the effects of bisphenol A (BPA), an estrogen-like compound found in some water bottles and other plastics, but some fertility experts tell their patients to avoid them.
Similarly, while the effects of electromagnetic waves on human sperm are not well studied, Dr.Goldstein advises men to not to carry their cellphones in their front pockets as a precaution.
Male Infertility : Are men overlooked at Infertility Centers?
By Laurie Tarkan : NY Times Article : May 2, 2008
In Brief:
With the advent of advanced reproductive technologies, fertility experts debate whether male infertility should even be treated.
Urologists believe varicose veins of the scrotum are the leading cause of male infertility, though the evidence is mixed on whether surgical repair raises pregnancy rates.
Infection is a common cause of infertility in men and often can be treated with antibiotics.
The aging of a female partner’s eggs should be carefully weighed against lengthy treatments like raising sperm count.
But for a semen specimen, most men are practically ignored when couples go to fertility centers. And depending on the infertility specialist offering treatment, that is either a good thing or a bad thing.
Urologists who specialize in infertility say they can treat a man with low sperm count and increase pregnancy rates, helping patients avoid costly and invasive in vitro fertilization. Reproductive endocrinologists, on the other hand, say that most male fertility treatments have not been shown to improve pregnancy rates and put patients through unnecessary risks and expense.
It is a debate that has been raging for at least 50 years in various forms surrounding almost every aspect of male infertility and its treatments.
In 1992, for example, an advance in I.V.F. called ICSI, for intracytoplasmic sperm injection, provided fuel for the reproductive endocrinologists’ view that most men do not need fertility-enhancing treatments. In the procedure, pronounced ICK-see, a single sperm is inserted directly into an egg. ICSI revolutionized treatment for men with severely low sperm counts. Reproductive endocrinologists say that trying to improve sperm count in most men is no longer necessary, because only a few healthy sperm are needed.
“That doesn’t take into account, however, the economic burden that puts on patients to undergo advanced reproductive technologies,” said Tracy L. Rankin, program director of male reproductive health at the National Institutes of Health.
ICSI and I.V.F. are expensive, rarely covered by insurance, and require women to get hormonal injections and have invasive procedures to remove eggs and transfer embryos. Urologists also point out that ICSI, like any technique that manipulates the egg, can damage it and raise the risk of genetic abnormalities, though it is not clear why.
Furthermore, ICSI does not guarantee pregnancy, said Dr. Marc Goldstein, professor and surgeon in chief of male reproductive medicine and surgery at Weill Medical College of Cornell University in New York. Still, the percentage of I.V.F. cycles using ICSI has risen sharply, to more than 57 percent in 2004 from 11 percent in 1995. And many centers perform it, even when there is no problem in the male partner.
“If you try to treat the underlying problem, you may not need I.V.F.,” said Dr. Harry Fisch, professor of clinical urology at Columbia University and the author of “The Male Biological Clock” (Simon and Schuster, 2004).
Male problems are believed to be either solely or partly responsible in about 40 percent of all infertility cases, with the most common cause of male infertility a varicocele, or swelling of a vein in the scrotum. A varicocele appears to raise the temperature of the testes, potentially damaging the developing sperm and rendering men less fertile. Varicoceles are more than twice as common in infertile men as in the general population — 35 percent compared with 15 percent.
Yet the research on surgical repair of varicoceles to correct male infertility is limited and conflicting.
“Whenever it has been studied in a controlled fashion, it’s been shown to have no impact on pregnancy rates,” said Dr. Sherman J. Silber, a urologist and the director of the Infertility Center of St. Louis. A former proponent of the surgery, he has stopped performing it. “Most urologists who specialize in infertility have a vested interest,” he said; the surgery is all they do, and “that’s the moneymaker.”
But many urologists say that they have many patients who have conceived a baby naturally after the surgery. The existing research is flawed, they say, because it included patients who did not have true varicoceles.
Dr. Ashok Agarwal, director of the Clinical Andrology Laboratory and Reproductive Tissue Bank at the Cleveland Clinic, performed an analysis of existing evidence, weeding out poor studies. Of 396 patients who underwent surgery, 33 percent had a pregnancy, compared with 15 percent of 174 control patients. “An 18 percent improvement is not only biologically significant; it is highly significant from a clinical point of view,” Dr. Agarwal wrote in an e-mail.
For couples who want more than one child, the prospect of improving sperm count might be appealing. “If you opt for assisted reproductive technologies,” Dr. Agarwal said, “you’re back there in three or four years to have another baby.”
But raising sperm count, whether through surgery, hormone treatments or lifestyle changes, takes time, a commodity many couples do not have, said Dr. Robert A. Greene, a reproductive endocrinologist and medical director of the Sher Institute for Reproductive Medicine of Northern California. It takes about three months for sperm to mature, so it will take at least that long for any treatment to raise sperm count. In most cases, it takes at least 6 to 12 months for changes to have an impact.
“Couples put off I.V.F. for a year or two waiting for sperm count to rise, while the woman’s age increases from 34 to 36 and her eggs are getting older,” Dr. Silber said.
In women in their mid-30s and older, time is of the essence. Based on national averages, the success of one cycle of I.V.F. using a fresh embryo drops from about 37 percent in women under 35 to about 20 percent in those 38 to 40. It drops further, to about 11 percent, in women in their early 40s. Most doctors would agree that if a woman is about 38 or older, the couple should go straight to I.V.F. with ICSI rather than seeking treatments to improve sperm count.
The bottom line is that a couple is likely to hear a convincing argument for whichever procedure is being offered by the specialist they see, making the decision about treatment difficult. Doctors can rattle off study results and success rates to support either side, but the devil is in the details. The research on all male treatments is limited and weak. Studies are small, not well controlled and of limited duration.
“The latest information is that basically, we don’t know,” Dr. Rankin said. A couple’s decision, in the absence of good hard data, comes down to their individual situation, the fertility factors of each partner, their finances, their age, their comfort with advanced reproductive technologies, and how many children they want.
Infertility in Men : Overview
Infertility is the inability to become pregnant after 12 months of unprotected sex (intercourse).
Alternative Names
Barren; Inability to conceive; Unable to get pregnant
Causes »
Primary infertility is the term used to describe a couple that has never been able to achieve a pregnancy after at least 1 year of unprotected sex.
Secondary infertility describes couples who have been pregnant at least once, but have not been able to achieve a pregnancy again.
Causes of infertility include a wide range of physical and emotional factors.
About 30 - 40% of all infertility is due to a "male" factor such as:
- Decreased sperm count
- Environmental pollutants
- Hormone deficiency
- Impotence
- Retrograde ejaculation
- Scarring from sexually transmitted disease
- Heavy marijuana use
- Use of prescription drugs such as cimetidine, spironolactone, and nitrofurantoin
- Abnormal egg transport from the cervix through the fallopian tubes (causes 40 - 50% of infertility in couples)
- Hormone imbalance
- Ovarian cysts
- Pelvic infection
- Poor nutrition
- Problem with ovulation
- Scarring from sexually transmitted disease or endometriosis
- Tumor
About 10 - 20% of couples will be unable to conceive after 1 year of trying to become pregnant. It is important that you try to get pregnant for at least 1 year.
The chances for a pregnancy in healthy couples who are both under the age of 30 and having sex regularly is only 25 - 30% per month. A woman's peak fertility occurs in her early 20s. As a woman ages beyond 35 (and especially after age 40), the likelihood of getting pregnant drops to less than 10% per month.
In addition to age-related factors, other infertility risks include:
- Anovulatory menstrual cycles
- Autoimmune disorders, such as antiphospholipid syndrome (APS)
- Clotting disorders (thrombophilia)
- Defects of the uterus (myomas) or blockage of the cervix
- Eating disorders (women)
- Endometriosis
- Exposure to the drug diethylstilbestrol (DES)
- History of orchitis or epididymitis in men
- Long-term (chronic) disease such as diabetes
- Pelvic inflammatory disease (PID)
- Many sexual partners
- Mumps (men)
- Sexually transmitted diseases
- Varicocele (men)
Symptoms
- A range of emotions by either or both members of the couple. In general, such reactions are greater among childless couples. Having at least one child tends to soften these painful emotions.
- Inability to become pregnant
A complete history and physical examination of both partners is essential.
Tests may include:
- Blood hormone levels
- Cervical mucus to detect ovulation
- Endometrial biopsy
- Hysterosalpingography (HSG)
- Laparoscopy
- Luteinizing hormone urine test
- Pelvic exam
- Postcoital testing (PCT)
- Progestin challenge
- Semen analysis
- Serum progesterone
- Temperature first thing in the morning to check for ovulation (basal body temperature)
- Testicular biopsy (rarely done)
Treatment »
Treatment depends on the cause of infertility. It may involve:
- Education and counseling
- Medical procedures such as in vitro fertilization
- Medicines to treat infections and clotting disorders, or promote ovulation
In-Depth Treatment »
Support Groups
Many organizations provide informal support and referrals for professional counseling. See infertility - support group.
Outlook (Prognosis)
A cause can be determined for about 85- 90% of infertile couples.
Getting the right therapy (not including advanced techniques such as in vitro fertilization) allows pregnancy to occur in 50 - 60% of couples who were infertile.
Without any treatment, 15 - 20% of couples diagnosed as infertile will eventually become pregnant.
Possible Complications
Although infertility itself does not cause physical illness, it can have a major emotional impact on the couples and individuals it affects.
Couples may have problems with their marriage. Individuals may experience depression and anxiety.
When to Contact a Medical Professional
Call for an appointment with your health care provider if you are unable to get pregnant.
Prevention
Because sexually transmitted diseases (STDs) often cause infertility, practicing safer sex behaviors may minimize the risk. Gonorrhea and chlamydia are the two most common causes of STD-related infertility.
STDs often don't have symptoms at first, until PID or salpingitis develops. These conditions scar the fallopian tubes and lead to decreased fertility, infertility, or an increased risk of ectopic pregnancy.
Getting a mumps vaccine in men has been shown to prevent mumps and its complication, orchitis. The vaccine prevents mumps-related sterility.
Some forms of birth control, such as the intrauterine device (IUD), carry a higher risk for future infertility. IUDs are not recommended for women who have not already had a child.
If you are considering getting an IUD, carefully weigh the increased risk of infertility and the potential benefits with your partner and health care provider.
Getting diagnosed and treated early for endometriosis may decrease the risk of infertility.
Vasectomy : Safe, Simple and Little Used Form of Contraception
By Peter Jaret : NY Times Article : June 27, 2008
In Brief:
Vasectomies are safer and more cost-effective than tubal ligations, the sterilization technique for women, but remain relatively underused.
A new no-scalpel vasectomy technique significantly reduces complications.
The rate of unwanted pregnancies after vasectomy remains low; most of those pregnancies can be traced to patient error.
A tiny puncture and a little snip, done under local anesthetic — that’s essentially all there is to a vasectomy.
“Vasectomies are the safest, simplest, most cost-effective method of contraception we have,” said Dr. Edmund Sabanegh Jr., director of the Clinic for Male Fertility at the Cleveland Clinic Foundation.
They are also strikingly little-used. About 500,000 American men have the operation each year. More than twice as many women undergo tubal ligation for permanent contraception, even though that operation costs three to four times as much, requires general anesthesia and an abdominal incision, and carries a small but real risk of serious complications.
“There’s something about having a surgeon fiddling around down there with a scalpel that makes even tough guys squeamish,” said Dr. Marc Goldstein, director of the Center for Male Reproductive Medicine and Microsurgery at the Weill Medical College of Cornell University in New York.
And then there are the misconceptions that discourage many men from having vasectomies, especially the widespread and groundless worry that the procedure will lower testosterone levels and affect sexual performance.
Whatever the reasons in the United States, the situation is not the same among men everywhere. By the time they reach their 50s, roughly half of men in New Zealand have undergone vasectomies, according to Dr. Sabanegh, compared with fewer than one in six in the United States. In Canada, vasectomies outnumber tubal ligations.
Experts hope that recent advances in vasectomy techniques will ease some of the fears.
The chief advance is the no-scalpel vasectomy, a technique pioneered in China in the 1970s that has been steadily gaining popularity in the United States. In a traditional vasectomy, doctors make two half-inch incisions on either side of the scrotum to sever the vas deferens, the two narrow tubes that carry sperm from the testicles during ejaculation. The no-scalpel approach does away with the need for incisions.
In the new technique, doctors use their fingers to locate the vas deferens by feel through the thin skin of the scrotum.
“Once we’ve located the vas, we make a tiny poke-hole over it,” said Dr. Phillip Werthman, director of the Center for Male Reproductive Medicine and Vasectomy Reversal in Los Angeles. The hole can be gently expanded in a way that pushes blood vessels aside rather than cutting through them, so there is almost no bleeding. Using a hooked instrument, surgeons pull the vas through the hole, then cut it.
“A lot of men can’t even tell where the procedure was done afterwards, the hole we make is that small,” said Dr. Goldstein, who was the first Western doctor to travel to China to learn the technique. Compared with traditional techniques, no-scalpel vasectomies result in less bleeding, less postoperative pain and quicker recovery. They also require less time to perform — a little more than 10 minutes in the hands of an experienced surgeon.
Although the traditional incision method is still more widely used, that is likely to change as more and more medical schools teach the no-scalpel approach.
In another bid to win over squeamish males, some doctors have replaced the needles used to inject anesthesia into the scrotum with high-pressure jets that deliver painkillers through the skin.
“A lot of men’s biggest fear is that needle,” Dr. Werthman said, even though the actual needle used is so narrow that most men barely feel it. “Pressure injection takes the psychological edge off that,” he said, though many patients find the loud popping sound it makes unpleasant.
In the end, the success or failure of a vasectomy depends not on how surgeons reach the vas but how they block it. Many doctors use several methods to ensure that sperm don’t find another path. Along with cutting out a small section of the tube, they may burn the inner lining of the two remaining ends, clamp them and separate them.
With current techniques, the chance of an unwanted pregnancy occurring in the first year after a vasectomy is 1 in 1,000, Dr. Sabanegh said. Some of those failures are the fault of the patient, not the procedure. Because it can take several months for sperm remaining after a vasectomy to be washed out, men are counseled to use other contraception methods until tests show that their semen is free of active sperm. Many men don’t bother. In a 2006 study of 436 vasectomies, researchers at the Cleveland Clinic Foundation found that only three out of four returned for follow-up semen analysis, and only 21 percent followed the full instructions to continue to be tested until two specimens came up negative.
Panel Urges End To PSA Screening at Age 75
By Tara Parker-Pope : NY Times Article : August 5, 2008
In a move that could lead to significant changes in medical care for older men, a national task force on Monday recommended that doctors stop screening men ages 75 and older for prostate cancer because the search for the disease in this group was causing more harm than good.
The guidelines, issued by the U.S. Preventive Services Task Force, represent an abrupt policy change by an influential panel that had withheld any advice regarding screening for prostate cancer, citing a lack of reliable evidence. Though the task force still has not taken a stand on the value of screening in younger men, the shift is certain to reignite the debate about the appropriateness of prostate cancer screening at any age.
Screening is typically performed with a blood test measuring prostate-specific antigen, or PSA, levels. Widespread PSA testing has led to high rates of detection. Last year, more than 218,000 men learned they had the disease.
Yet various studies suggest the disease is “overdiagnosed” — that is, detected at a point when the disease most likely would not affect life expectancy — in 29 percent to 44 percent of cases. Prostate cancer often progresses very slowly, and a large number of these cancers discovered through screening will probably never cause symptoms during the patient’s lifetime, particularly for men in their 70s and 80s. At the same time, aggressive treatment of prostate cancer can greatly reduce a patient’s quality of life, resulting in complications like impotency and incontinence.
Past task force guidelines noted there was no benefit to prostate cancer screening in men with less than 10 years left to live. Since it can be difficult to assess life expectancy, it was an informal recommendation that had limited impact on screening practices. The new guidelines take a more definitive stand, however, stating that the age of 75 is clearly the point at which screening is no longer appropriate.
The task force was created by Congress and first convened in 1984 to analyze current medical research and to make recommendations about preventive care for healthy people. Its guidelines are viewed as highly credible and are often relied on by physicians in making decisions about patient care.
“When you look at screening, you have a chance the screening will help you live longer or better, and you have the chance that screening detection and treatment will harm you,” said Dr. Ned Calonge, chairman of the task force and chief medical officer for the Colorado Department of Public Health and Environment. “At age 75, the chances are great that you’ll have negative impacts from the screening.”
It is estimated that one out of every three men 75 and older is now screened for prostate cancer, although some studies suggest the number is even higher. The Journal of the American Medical Association reported in 2006 that in a group of nearly 600,000 older men treated by the Veterans Administration, 56 percent of those ages 75 to 79 had been screened for prostate cancer. Given the large numbers of men over 75 who are being screened, even a small decline in testing may greatly reduce the number of prostate cancer cases detected.
Dr. Calonge said it was important that the guidelines not be viewed as “giving up” on older men. While the new rules should discourage routine testing of older patients, the recommendations will not prevent a man from seeking screening if he desires it, Dr. Calonge said. The new guidelines are not expected to alter Medicare’s current reimbursement for annual PSA screening of older men.
“There will be some men who would say, ‘Let’s do it anyway,’ and other men who say, ‘If we don’t need to do it, let’s not do it,’ ” Dr. Calonge said.
The guidelines focus on the screening of healthy older men without symptoms and will not affect treatment of men who go to the doctor with symptoms of prostate cancer, like frequent or painful urination or blood in the urine or the semen.
Studies of the value of prostate cancer screening for younger men have produced mixed results, but a major clinical trial under way in Europe will try to determine whether there is any value, in terms of longer life expectancy, to screening this group for prostate cancer. Those results may be published as early as next year.
While the verdict is still out on younger men, the data for older men are more conclusive, experts say. The American Cancer Society and the American Urological Association both say annual PSA screening should be offered to average-risk men 50 and older, but only if they have a greater than 10-year life expectancy.
Recently, Swedish researchers collected 10 years of data on men whose cancer was diagnosed after the age of 65 and found no difference in survival among those who were treated for the disease and those whose cancers were monitored but treated only if the cancer progressed. The finding suggests that for most men, stopping screening at 75 is a safe option.
“If someone has made it to the age of 75 and they don’t have an elevated PSA, the likelihood of them developing clinically significant prostate cancer in the last 10 to 15 years of their life is pretty low,” said Dr. Peter C. Albertsen, professor of urology at the University of Connecticut Health Center. “The downside risk begins to outweigh the upside at the age of 75.”
Some studies suggest that as many as half of men 75 and older have clinically insignificant prostate cancer that is unlikely to affect their health but may be found through a biopsy. If the disease is detected as a result of screening, the men may be actively treated with radiation or hormone therapies, or may endure the stress of “watchful waiting” to see if the disease progresses.
Treatments for prostate cancer can cause significant harm, rendering men incontinent or impotent, or leaving them with other urethral, bowel or bladder problems. Hormone treatments can cause weight gain, hot flashes, loss of muscle tone and osteoporosis.
“I’m very pleased the prevention task force has said, at least for the old guys, ‘Leave them alone because our evidence suggests it doesn’t help,’ ” said Dr. Derek Raghavan, director of the Cleveland Clinic Taussig Cancer Institute. “Taking an 80-year-old and telling him he has cancer and telling him he needs radiotherapy or surgery uses up medical resources and puts him at risk. It’s a step toward rational thinking.”
Screening Tests : Not Always Best Course
By Tara Parker-Pope
NY Times Article : August 12, 2008
Sometimes what you don’t know might end up being better for you.
For years patients have been told that early cancer detection saves lives. Find the cancer before the symptoms appear, the thinking goes, and you’ve got a better chance of beating the disease.
So it might have seemed surprising last week when a panel of leading medical experts offered exactly the opposite advice. They urged doctors to stop screening older men for prostate cancer, which will kill an estimated 28,600 men in the United States this year.
Their advice offered a look at the potential downside of cancer screening and our seemingly endless quest to detect cancer early in otherwise healthy people. In this case, for men 75 and older, the United States Preventive Services Task Force concluded that screening for prostate cancer does more harm than good.
“We’ve done a great job in public health convincing people that cancer screening tests work,” said Peter B. Bach, a pulmonologist and epidemiologist at Memorial Sloan-Kettering Cancer Center in New York City. “We’re uncomfortable with the notion that some screening tests work and others don’t. That seems mystifying to people.”
But the reality is that while some cancer screening tests — like the Pap smear for cervical cancer or mammography for breast cancer — clearly save lives, the benefits of other screening tests are less clear.
Studies of lung cancer screening, for instance, have failed to prove that it prolongs life. A mass screening for neuroblastoma in Japanese infants was halted after it became clear that the effort wasn’t saving children and worse, led to risky treatments of tumors that weren’t life threatening.
The case seemed stronger for screening for prostate cancer. By some measures, death rates from the disease in the United States have plummeted since the introduction of the screening test for prostate specific antigen, which detects levels of a protein that can signal prostate cancer.
The data, in fact, are highly misleading. The introduction of screening can trigger big statistical fluctuations that can be difficult to interpret. But if you look at prostate cancer statistics in the 1970s, long before screening was introduced, death rates have dropped only slightly since then. The small decline seems largely because of improvements in treatment, many experts say, though others point to early detection as the reason.
Whether there really is a measurable benefit from PSA screening for younger men won’t be known for a few more years, after data from two major clinical trials studying the test are reported.
How can it be that finding prostate cancer early doesn’t help save lives? For starters, a large percentage of prostate cancers aren’t deadly. They are slow growing and unlikely to result in any symptoms before the end of a man’s natural life expectancy. By some estimates, as many as 44 percent of the men who are treated for prostate cancer as a result of PSA testing didn’t need to be. Had they been left alone, they would have died of something else and never known they had cancer.
“Screening tests don’t only pick up life-threatening cancers, they pick up tumors that look identical to traditional tumors, but they don’t have the same biologic behavior,” said Dr. Barry Kramer, associate director for disease prevention at the National Institutes of Health. “Some are so slow growing they never would have caused medical problems in the person’s natural life span.”
In the case of PSA testing, the Preventive Services Task Force, an expert panel that makes recommendations about preventive care for healthy people, said there was not enough evidence to recommend for or against screening of younger men, although they urged doctors to advise men of all the risks and benefits of screening. But they did conclude that 75 is the age at which the risks clearly begin to outweigh the benefits, and the disease, if detected, would most likely not have a meaningful effect on life expectancy.
Another problem with determining the value of screening is that it results in “lead time bias.” For instance, someone diagnosed with lung cancer at the age of 65 may die at 67 and be remembered as a two-year survivor. If the same man had been diagnosed at 57 through screening and died at the age of 67, he would be known as a 10-year survivor. That sounds a lot better, but the reality is that diagnosis and treatment didn’t prolong his life. He died at 67 either way.
“Even a harmful screening test could appear on the surface as a helpful test,” Dr. Kramer said. “Because you measure survival from the date of diagnosis, even if the person dies of the same cause on the same day they would have without screening, it looks like survival was longer.”
Any screening test can lead to false positives, followed by invasive and risky tests. Large numbers of people often end up being poked, prodded and tested only to discover they’re fine.
Biopsies to detect prostate cancer get mixed reviews. Some men find them to be a minor discomfort; others say they were left in debilitating pain. Once cancer is found, surgery, radiation or hormone therapy, or “watchful waiting,” may be advised.
Treatments for prostate cancer can cause significant harm, rendering men incontinent or impotent, or with other urethral, bowel or bladder problems. Hormone treatments can cause weight gain, hot flashes, loss of muscle tone and osteoporosis.
“It’s just a needle stick, but the cascade of events that follows are fairly serious,” Dr. Bach said. “I think the burden is on medicine to try and generate some evidence that the net benefits are there before drawing that tube of blood.”
The problem with prostate screening is that some men are very likely to have been saved by early detection. But how many have been hurt?
“I’m a little worried we may look back on the prostate cancer screening era, after we learn results of clinical trials, and see that we’ve harmed a lot of people without doing them good,” said Dr. David Ransohoff, a professor of medicine and cancer screening researcher at the University of North Carolina at Chapel Hill. “By being so aggressive with so many people, did we do the right thing? I don’t know that it’s going to turn out that way.”
Regrets After Prostate Surgery
NY Times Health Column : August 27, 2008
One in five men who undergoes prostate surgery to treat cancer later regrets the decision, a new study shows. And surprisingly, regret is highest among men who opt for robotic prostatectomy, a minimally invasive surgery that is growing in popularity as a treatment.
The research, published in the medical journal European Urology, is the latest to suggest that technological advances in prostate surgery haven’t necessarily translated to better results for the men on which it is performed. It also adds to growing concerns that men are being misled about the real risks and benefits of robotic surgical procedures used to treat prostate cancer.
Of the 219,000 men in the United States who learn they have prostate cancer each year, nearly half undergo surgical removal of the gland, according to the National Cancer Institute.
Duke University researchers surveyed 400 men with early prostate cancer who had undergone either a traditional “open” surgical procedure or newer robotic surgery to remove the prostate. Overall, the vast majority of men were satisfied. However, 19 percent regretted their treatment choice. Notably, men who had undergone robotic surgery were four times more likely to regret their choice than men who had undergone the open procedure.
Researchers say the higher level of regret among robotic patients suggests that they had higher expectations for their recovery, possibly because the robotic procedure is widely touted as a more innovative surgery than traditional prostatectomy. Even among men who had the same scores on erectile function and other measures of post-surgery recovery, the robotic patients still reported a higher level of dissatisfaction and regret than other men.
Part of the problem may be that doctors who perform robotic prostatectomies commonly cite potency rates as high as 95 percent and above among their patients, giving patients an unrealistic view of life after surgery.
But the data are highly misleading. Researchers often define potency as simply being able to achieve an erection that is “adequate” for intercourse — but for many men, that definition doesn’t capture their ongoing struggle to return to a normal sex life. Earlier this year, researchers from George Washington University and New York University used a more realistic definition of potency, showing that after surgery, fewer than half of the men studied felt their sex lives had returned to normal within a year.
Another important finding of the new research showed that men were less likely to regret their choice shortly after surgery. The men who were long past surgery experienced more regret. That finding likely speaks to the fact that as time passes after surgery, men gain a more realistic view of lingering health and quality-of-life issues like erection problems and other changes in their sex lives.
The Duke researchers said that the study shows urologists need to communicate more carefully the risks and benefits of the treatment prior to surgery so that men have more realistic expectations of what to expect.
To learn more, read “Sex After Prostate Cancer,'’ a Well blog post that includes my column about the issue as well as numerous comments from men and women about the aftermath of prostate cancer treatment.
The Gleason Score : What Does This Mean?
The score is based on a pathologist’s microscopic examination of prostate tissue that has been chemically stained after a biopsy. Under a standard microscope, the cells can show in various patterns.
To determine a Gleason score, a pathologist assigns a separate numerical grade to the two most predominant architectural patterns of the cancer cells. The grade depends on how far the cells deviate from normal appearance. The numbers range from 1 (the cells look nearly normal) to 5 (the cells have the most cancerous appearance).
The sum of the two grades is the Gleason score. The lowest possible score is 2, which rarely occurs; the highest is 10. Scores of 2 to 4 are considered low grade; 5 through 7, intermediate grade; and 8 through 10, high grade.
High scores tend to suggest a worse prognosis than lower scores because the more deranged, high-scoring cells usually grow faster than the more normal-appearing ones.
Prognosis also depends on further refinements. In one example, a score of 7 can come in two ways: 4 plus 3 or 3 plus 4. With 4 plus 3, cancer cells in the most predominant category appear more aggressive than those in the second, suggesting a more serious threat than a 3-plus-4 score, in which cells in the most predominant group appear only moderately aggressive.
