The AFA Blog

Performance enhancing drugs kill another career

by Ken Mosesian

I love baseball. Two of my proudest moments from my childhood were catching my first fly ball while playing center field, and having my hitting improve enough that the outfielders moved back to the fence when I came up to bat. 

We're lucky enough to have an MLB stadium (go Diamondbacks!) a short ride from our home on light rail. For me, there's nothing like cheering for your team on a beautiful Spring day, enjoying a hot dog and a beer at the ball park.  So when I read that Manny Ramirez chose to retire rather than face another suspension for testing positive to performance enhancing drugs for the second time, I was angry.

I've always seen baseball as "cleaner" than other sports. It's a romantic notion not grounded in reality, but it's one that I cling to. I wasn't just angry at Ramirez for "dirtying up" my sport, I was angry at him for throwing away a career that most people can only dream of. At the end of his career he was making $20 million a year playing baseball, and playing it well. One example: in 2004, he hit a league leading 43 home runs, and took Boston to its first World Series title in 86 years. 

This hits home for another reason. The AFA took the lead in creating MRHA - the male reproductive health alliance - with CDC, Men's Health Network, and the Society for the Study of Male Reproduction. One of the key issues we're working on is helping to raise awareness about the dangers that anabolic steroids and other so-called performance enhancing drugs pose to health in general and reproductive health in specific. Moreover, they can wreck your life as we saw this past week. 

Manny Ramirez is a prime example of what can happen when someone uses these drugs. Instead of talking about his 43 home runs in 2004, or hitting nearly .400 in 2008, he'll be remembered as a great player who threw it all away because of drugs. 

It's a shame on every level. Whether we like it or not, sports figures are heros to kids, and a lot of kids saw their hero fall. My hope is that they understand that it didn't have to be this way, and that they learn the lesson that Manny Ramirez didn't. 

Ken Mosesian

Executive Director

Radiation and sperm

by Craig Niederberger, M.D., F.A.C.S.

The horrific earthquake and tsunami in northern Japan remind us that no matter how powerful we become or careful we are, nature asserts itself in ways that we can’t imagine.  The nuclear engineers and technicians working to contain the radiation leaking from the damaged power plant in Fukushima are nothing short of heroic.  Radiation can cause all sorts of ills, from acute sickness to cancer and infertility.

In the testis, developing sperm cells are exquisitely sensitive to radiation.  Kyodo News reported that after an explosion at the Fukushima No. 2 reactor on March 15, radiation levels measured as high as 8,217 micro sievert or 0.8217 rem per hour.  (Micro sievert and rem are units of radiation dosage.)

Does that amount of radiation harm developing sperm cells?  I asked Marvin Meistrich, Ph.D., Professor of Experimental Radiation Oncology and the Florence M. Thomas Professor of Cancer Research at the University of Texas M. D. Anderson Cancer Center, a world’s expert in radiation and sperm.  Dr. Meistrich explained that sustained exposure to 20 rem of radiation over 4 weeks caused sperm counts to drop to 1/10th of their original amount.  At doses of 40-80 rem, sperm counts fell to about 1/100th of the starting number, and in some cases were wiped out entirely.  At 200 rem, that drop to zero sperm became permanent. For one-time doses, Dr. Meistrich explained that 15-20 rem caused a short-term fall in sperm count, and 400 rem or more resulted in permanent loss of sperm.

We know that radiation changes DNA, the sperm’s precious genetic cargo.  What we don’t know is what dose causes a harmful DNA change that damages a developing embryo or causes disease later in life.

The radiation leakage in Fukushima seems to be in the range at which damage to sperm occurs.  I can only hope that the workers at Fukushima and the people near the plants are aware of the dangers and take action to protect themselves.

BPA and sperm

by Craig Niederberger, M.D., F.A.C.S.

Bis-phenol A, or “BPA”, is everywhere.  It’s a chemical commonly found in plastic bottles, like those holding sodas and water.  It leeches out from the plastic container, and seeps into the drink.  To the body, it looks like the female hormone estrogen, and may throw male hormones out of whack.

Mounting evidence suggests that BPA is bad for sperm, slowing the soldiers and lowering their numbers. Look for “BPA Free” on bottles if you want your sperm to be the best that they can be.

 

The Story of Testosterone

by Craig Niederberger, M.D., F.A.C.S.

When you think of what makes up the inside of the testes, think spaghetti. Imagine a bunch of spaghetti noodles squished together. Inside of the noodles are the developing sperm cells. Between the noodles are cells called “Leydig cells” whose job it is to make the male hormone testosterone. They start with cholesterol, and churn out testosterone.

Not only is testosterone critical to the factory inside the spaghetti that makes sperm, it is important for many parts of the male body to work well. Adequate testosterone is needed for bone and muscle strength, and men with low testosterone may experience low sex drive, problems with mental focus and depression.

The relationship between testosterone and how the penis works is less clear. Men with low testosterone can get erections, but of course sex drive can be a problem. And if a man’s testosterone is low, correcting it may improve the performance of drugs like Viagra, Levitra and Cialis.

Total testosterone doesn’t tell you the whole story. Testosterone circulates in the blood in two forms. Testosterone that is either free or loosely bound to blood protein is called “bioavailable”, and as the name implies, is available for the cells to work. Testosterone that is bound to sex hormone binding globulin (“SHBG”, but also called androgen binding protein,) is blocked from acting in cells. Although many labs offer to measure free testosterone, often the most reliable way to measure bioavailable testosterone is to have the blood tested for albumin, sex hormone binding globulin and testosterone, and then to use a calculator for bioavailable testosterone. One is available on the International Society for the Study of the Aging Male’s web site, and another for iPhones and iPod touches can be found in the iTunes store. A man may have adequate total testosterone, but still suffer from the ravages of low testosterone levels if his bioavailable testosterone is low.

Testosterone levels rise and fall during the day, with a peak in the early morning, and the lowest point in the late afternoon. That’s why many a man’s sex drive is highest in the morning, and it’s time for a nap in the afternoon.

Testosterone is converted to dihydrotestosterone, which makes the hair fall out of your hair follicles if your family tree has male pattern baldness. Dihydrotestosterone also enlarges the prostate. Drugs like finasteride (Propecia and Proscar) and dutasteride (Avodart) block the conversion of testosterone to dihydrotestosterone.

All men have a little estrogen, the female hormone. An enzyme called “aromatase” converts testosterone to estrogen. If the estrogen level is too high, it may interfere with the working of testosterone.

One last important point about the making of testosterone: levels in the testis are twenty times greater than in the blood. So if a man is given testosterone, his blood levels may increase, but the pituitary tells the testis, “hey, there’s enough testosterone around, so stop making it.” As a result, testosterone levels in the testis fall, sperm stop being made, and the testes shrink. That’s why many body builders who take testosterone and other similar chemicals experience shrinking testes. Testosterone can be great for men with low levels later in life, but for men who want to have children, it can really work against sperm production.

 

Tighty whities and hot testes

by Craig Niederberger, M.D., F.A.C.S.

If you’re trying to conceive, do you need to change your underwear from boxers to briefs?

No doubt heat kills sperm.  The testes live outside of the abdomen for a good reason.  They need to be cool, about 4 degrees C cooler than body temperature.  Testes that don’t descend, a condition called “cryptorchidism,” have real problems making sperm.  Ovaries obviously don’t have this sensitivity to heat; they’re perfectly happy living in the abdomen.

The real question is: how much heat kills sperm?  Crossing your legs increases your scrotal temperature by about 1 degree C, and it’s difficult to imagine that every man who crosses his legs is going to have a hard time impregnating his wife.  Form fitting underwear, or briefs, raise it by a similar amount.  Putting a laptop on your lap increases your scrotal temperature by about 1.5 degrees C or so.

So you probably shouldn’t worry about wearing boxers or briefs, but stay away from cooking your testes in a jacuzzi or sauna while you’re trying to conceive.  Save that for stress reduction after the baby’s born.

How-To; Getting Sperm from the Testis

by Craig Niederberger, M.D., F.A.C.S.

This blog post was inspired by several patients who asked after I explained surgical sperm retrieval, if there was somewhere they could go for more information.  I realized that I hadn’t written about such a common issue.

Just as a carpenter has many ways to make a cabinet, a surgeon can tackle a problem in a number of ways.  And just as two cabinets may differ, different surgical problems demand different approaches.  Such is the case in retrieving sperm from the testis.

Most of the time, taking sperm directly from the testis is necessary when a man has azoospermia, where no sperm is found in the ejaculate.  Azoospermia takes two basic forms, obstructive and non-obstructive.  As the name implies, obstructive azoospermia is due to a blockage in the tubes and structures that convey sperm from the testis to the outside world.  In the best case, a surgeon can fix the errant anatomy, allowing a couple to conceive children without further ado.  But because the tubes are so tiny, sometimes the tubes can’t be reconnected with surgery, and the alternative is to take sperm from the testis for it to be used in in-vitro fertilization.

The other form of azoospermia, non-obstructive, arises when the factory making sperm in the testis isn’t working quite right.  Sometimes, the cells starting sperm are missing entirely, a condition known as “Sertoli cell only syndrome”.  Occasionally, sperm may be rolling along their assembly line, a process that takes two to three months to complete, and stop mid-production.  When that happens, it’s called “maturation arrest”.  But frequently, sperm can be found in small amounts in the testis and can be retrieved using surgery.

Because it isn’t mature, sperm from the testis can only be used with in-vitro fertilization and intra-cytoplasmic sperm injection.

How can a surgeon remove sperm?  He or she can take it from the testis itself, or the epididymis, the tiny coiled tube lying on the back of the testis where sperm mature.  The surgeon can insert a needle into the testis or epididymis, he or she may make one or several small incisions into the testis or use microsurgery to retrieve sperm from either the testis or epididymis.  In the case of obstructive azoospermia, it doesn’t seem to matter which technique is used.  There’s plenty of sperm wherever it’s sought, and any method will do to retrieve it.  When a man has obstructive azoospermia, I usually recommend taking a small piece from the testis, as the sperm may be frozen and is good for a number of in-vitro fertilization cycles so that the man doesn’t need to go through a procedure for every cycle, and can be there for his wife during her procedures.

We’ve found that frozen sperm is just as good as fresh.  in fact, the chances for fertilization are the same for fresh and frozen sperm, and the chance for pregnancy may even be a little better for frozen sperm than for fresh.

Frozen sperm should literally last forever.  It’s in liquid nitrogen, which is so cold that the building blocks making sperm don’t decay.  Freezing sperm gives a couple time to plan when in-vitro fertilization is done.

When he has non-obstructive azoospermia, a man’s options are more limited.  A surgeon can use the operating microscope to comb through the testis looking for areas that may contain sperm, a procedure known as “microsurgical testis sperm extraction“.  Other techniques include making several small incisions in the testis or piercing the testis with a needle in a dozen or so different spots.  When a man has non-obstructive azoospermia, I usually recommend microsurgical testis sperm extraction.  More areas of the testis can be examined, and I can see the places that most likely contain sperm.

We’ve observed that prescribing a man with non-obstructive azoospermia clomiphene citrate for a few months before surgical retrieval seems to increase the chance to retrieve sperm.  In many men, sperm appears in the ejaculate and surgery isn’t needed.  If a couple has a few months, taking clomiphene before surgical sperm retrieval might be a good idea.

In short, a surgeon has many ways to retrieve sperm when necessary.  The choice depends on the preference of the surgeon and the couple, and what’s going on inside the testis.  I’ve listed the surgical techniques available, and my typical recommendations.

Bacon Cheeseburgers and Other Health Foods

By Harry Fisch, MD

Okay, I’m not totally serious. I’m not recommending bacon cheeseburgers on a daily basis.  I’m using this icon of fatty food to make a point: foods high in fat are not the enemy.  

The past decade has seen a remarkable sea change in the medical and scientific consensus about the alleged dangers of fat in our diet.  In part, this is from a re-evaluation of old research, such as that done in the '60s in Africa. Vanderbilt University scientist George Mann, MD, found that Masai tribesman in Kenya and Tanzania who lived primarily on red meat and whole milk were also very lean, had extremely low cholesterol levels, and were virtually free of heart disease.

In addition, a newly critical light has been shed on some research that seemed to support the hypothesis that eating lots of saturated fat raises your risk for cancer and heart disease. In 1953, physiologist Ancel Keys published an influential paper titled "Atherosclerosis, a Problem in Newer Public Health." He compared fat intake and the rate of heart disease in 6 countries: the United States, Canada, Australia, England, Italy and Japan. He found a correlation: nations with high levels of fat intake also had high levels of heart disease.  

Turns out, however, that Keys pulled a fast one. First of all, he “cherry-picked” his data. Statistics about fat intake and heart disease were actually available for 22 countries.  If you analyze all 22, the apparent link between fat consumption and heart disease disappeared. For example, the death rate from heart disease in Finland was 24 times that of Mexico, even though fat-consumption rates in the two nations were similar.

The other problem with Keys’ study is one that frequently bedevils researchers: correlation is not causation. In other words, maybe fat had little to do with the high rates of heart disease in the US, which had the highest level of fat intake of all.  Maybe it was the fact that US citizens didn’t exercise very much, or smoked a lot, or ate a lot of something else that was bad for the heart.

That “something else” is now generally agreed to be refined carbohydrates such as white sugar, white flour and high-fructose corn syrup.   This has led to a number of smart approach low carb diets such as that espoused by the late Robert Atkins, MD.  Recent research suggests that if you want to lose weight, you’re better off on a low-carb diet than a low-fat diet. When people on low-carb diets have been compared head-to-head with those on low-fat diets, the low-carb dieters typically scored significantly better on markers of heart disease, including both LDL and HDL cholesterol and triglycerides.

 The key idea in all of this is that your body makes fat from carbohydrates. It works like this: when you eat carbs (particularly starches and sugar), your blood sugar level rises. This triggers the release of insulin, which, in turn, signals the liver to start converting excess blood sugar to triglycerides, or fat.

So what’s the bottom line?  If you’re trying to lose weight, then I think a low-carb approach makes sense, combined, of course, with exercise.  If you’re already at a good weight and are otherwise healthy, then stay away from processed foods and unnecessary carbs, but relax and eat what you want with moderation. I like the advice of writer Michael Pollen:  "Eat food. Not too much. Mostly vegetables." His point is to eat normal food, the kind your grandmother was likely to cook — not stuff that’s full of added sugars and other ingredients.

I also think Julia Child had the right idea. She suggested that we all have an imaginary shelf labeled “Indulgences” which contained things like “the best butter, jumbo-sized eggs, heavy cream, marbled steaks, sausages, and gooey chocolate cakes.”  These are not “everyday” foods, she once wrote, but for special occasions, and “when that occasion comes, we can enjoy every mouthful.” Amen. And bon appétit!

Photo: Bricck

The New WHO

by Craig Niederberger, M.D., F.A.C.S.

A first test of male fertility is the semen analysis.  You do your thing, and a technician counts the sperm, sees how they’re moving, what they look like and whether they’re alive.  For decades, the World Health Organization has published criteria for these numbers to alert a man that he might have a problem when it comes to impregnating a woman.  Until recently, the numbers were a consensus of expert opinion, but in the latest edition, the WHO criteria changed substantially.

What the WHO is currently doing is to dispense with expert opinion, and just lay the numbers out for all to see.  Table II from the paper shows the numbers for men from couples who conceived within a year.  Take sperm concentration, for example.  For centile 5, the sperm concentration is 15 million per ml.  That means that only 5% of couples where the man had 15 million/ml sperm or less conceived within a year.  For centile 50, the concentration was 73 million/ml, meaning that 50% of couples conceived within a year when the sperm concentration was up to that number.  You get the idea.

The problem is that people like cutoffs, and in the latest edition, the WHO chose centile 5 as the line in the sand.  It’s a good number for thinking that below it, couple infertility likely involves the male.  But keep in mind that at centile 10, only 10% of couples conceived within a year.  In other words, having sperm numbers above the centile 5 cutoff doesn’t guarantee that the sperm are trouble free.

Frankly, I think the WHO numbers are most useful to get a ballpark idea of how fertility may be related to what’s inside the semen.  I prefer the approach David Guzick and colleagues took, where they applied a statistical method called Classification and Regression Tree (CART) analysis to sperm, which gives two cutoffs in a “green light, yellow light, red light” fashion.  For example, CART analysis came up with 13.5 million/ml and 48 million/ml for sperm concentration.  At 13.5 million/ml sperm or less, the “red light,” couple infertility likely involves the male.  At 48 million/ml or more, your sperm probably are “green light” good to go.  Between 13.5 million/ml and 48 million/ml, the “yellow light,” sperm may or may not be the problem.  You can find the Guzick CART cutoffs here.

A lot of people, including doctors and fertility specialists, are confused about the new WHO cutoffs.  Expect a little consternation about them for a bit.

WHO Table II Distribution of values, lower reference limits and their 95% CI for semen parameters from fertile men whose partners had a time-to-pregnancy of 12 months or less

N Centiles 2.5 (95% CI) 5 (95% CI) 10 25 50 75 90 95 97.5 Semen volume (ml) 1941 1.2 (1.0–1.3) 1.5 (1.4–1.7) 2 2.7 3.7 4.8 6 6.8 7.6 Sperm concentration (106/ml) 1859 9 (8–11) 15 (12–16) 22 41 73 116 169 213 259 Total number (106/Ejaculate) 1859 23 (18–29) 39 (33–46) 69 142 255 422 647 802 928 Total motility (PR + NP, %)* 1781 34 (33–37) 40 (38–42) 45 53 61 69 75 78 81 Progressive motility (PR, %)* 1780 28 (25–29) 32 (31–34) 39 47 55 62 69 72 75 Normal forms (%) 1851 3 (2.0–3.0) 4 (3.0–4.0) 5.5 9 15 24.5 36 44 48 Vitality (%) 428 53 (48–56) 58 (55–63) 64 72 79 84 88 91 92

*PR, progressive motility (WHO, 1999 grades a + b); NP, non-progressive motility (WHO, 1999 grade c).

Keeping Your Package Safe

By Harry Fisch, MD

As every guy knows, the penis and testicles are not very well protected from the vagaries of life. If the testicles didn’t have to be cooled to below body temperature for maximum efficiency, nature surely would have tucked them up inside the body somewhere safe and sound, the way a woman’s ovaries are. But, no … we have to deal with the fact that our crucibles for our genetic legacy are, literally, swinging in the wind and subject to injury from any number of sources.

Here are a few ways to help protect yourself:

• Wear a jock strap or hard cup during contact sports
• Buy a bicycle seat that has a groove or cut-out area down the center to reduce pressure on the nerves and arteries feeding the penis and scrotum
• Wear a seat belt (one lesser-known source of testicular injury is car accidents)

If you do have the unfortunate luck of sustaining a blow to your testicles, you should use some kind of scrotal support (i.e. jock strap) and apply ice packs to the groin as quickly as possible to reduce swelling; reapply every 3-4 hours afterwards for the first 12 hours or so. An anti-inflammatory pain medicine (i.e. ibuprofen) may be helpful. If swelling or tenderness are not reduced within 24 hours, or if you pass blood in your urine, see a doctor. If a blood vessel is leaking, it may need to be surgically repaired. Blood in the scrotum, or distended veins in the scrotum, can raise the temperature of the testicles and reduce, or stop, the production of sperm. This is definitely not a part of the body you want to take chances with!

Timing Sex

by Craig Niederberger, M.D., F.A.C.S.

If you’re trying to get pregnant, something useful to know is how often to have sex.  Sperm counts peak at two to three days after ejaculation, meaning, after you have sex (or masturbate,) the swimmers will be most abundant two to three days later.  Sperm live for about 48 hours in the female reproductive tract, so the optimum timing is sex every other day.

However, don’t freak out if you have an especially romantic weekend with a little extra frequent activity, or get caught up and miss a few days.  Stressing out about sex is counter productive, as stress itself can result in poorer sperm quality.

I’m often asked when during the month (or cycle) a couple should try to conceive.  Studies show that conception usually happens up to six days before, and ending on, ovulation.  The big problem is that most tests for ovulation show the event after it happens.  So a good plan is start having sex every other day after menstruation ends, and keep going until the next menstruation.

So, soldier on.  Have sex every other day.  Doctor's orders.

Craig Niederberger, M.D., F.A.C.S. is a highly published author and editor, and head of the Department of Urology, University of Illinois at Chicago. His blog, Male Health, and other writings will be syndicated on this page for The American Fertility Association's readership