Paleo or Mediterranean? (Courtesy: forbesparkfriends.blogspot)

“Thou shouldst eat to live; not live to eat,” once said Socrates way back when. Sure he was smart, and probably brilliant. But how does one really “eat to live?”

Summer is just around the corner. And this one is gonna be different. For the first time in quite some time, you really want to avoid being both pale as a ghost and overweight for your first foray into the sun’s warmth. So, you search online using the terms “I need a diet plan” and retrieve (at last count) 106 million hits. Good luck finding that magic plan.

The Heritage Diets

So where do you start? Well, cavemen were pretty fit, running from woolly mammoths without cars, so why not start here? According to anthropologists who have studied our distant Neanderthal cousins, theirs was a foraging diet and consisted of fruits, non-starchy vegetables, lean meat, fish, nuts, and berries. They ate what they caught or found. No calorie counting and no measuring. Honestly, how different can our bodies really be from those of our ancestors 40,000 years ago? Welcome, the wildly popular Paleo diet, the choice of Homo Sapiens all over America.

One Paleo concept that makes great physiologic sense is the emphasis on protein. Protein is far more “thermal” than either fat or carbs so it is better at speeding up metabolism and inducing weight loss. It is also better at keeping you feeling “full” after eating than other food groups. So, if weight loss is a priority, and you don’t mind wearing a loin cloth, then going Paleo could be just right for you.

A close relative of the Paleo diet is the Mediterranean or Roman diet, already the cherished grub of a chunk of the world’s population. As another heritage diet favored by our ancestors, it also emphasizes the importance of tree nuts, fruits, vegetables and fish. However, this victual differs from Paleo in that it encourages generous amounts of olive oil and eating white meat instead of red meat. Oh, and don’t forget the regular consumption of wine. Go ahead and laugh, but the fact is that a very recent and well-performed trial comparing the Mediterranean to a simple-low fat diet resulted in a 30% reduction of heart attacks and strokes over 5-years. This, my friends, is the real deal in terms of a heart-healthy diet.

So Much Food, So Little Time

But how does a modern working stiff in America adhere to the principles of eating like our ancestors from 333 or even 33 generations ago? When was the last time you took a siesta during the workday? We need a path, a guiding principle, a way.

Some time back, I proposed precisely this to patients in the simplest terms I could imagine: pretend your body is a bank account and try to keep it empty, kind of like you do with your real bank account. Eat less (put less in), exercise more (take more out). And do this gradually, so you don’t go crazy counting calories.

But there are even better ways. One great example of this is the recent and very popular JumpStartMD program in the San Francisco Bay Area. This innovative approach combines real food strategies similar to the Paleo and Mediterranean diets, but also incorporates activity as well as behavioral changes to ensure that the job gets done. At JumpstartMD, being watched regularly by health care providers who monitor progress with wagging fingers doesn’t hurt either. But it’s all good, as the goal is to change your eating habits, slowly, and for the long haul. You know about “sustainability” in terms of energy and the environment, but how about applying it to your most valuable resource on this good earth: your health!

The post Mindful Eating appeared first on The Turek Clinic.

Used in Roman medicine…and maybe too much today? (Courtesy: Plamen Petkov)

Blasphemy! A surgeon who chooses not to operate? Precisely. Dr. John Duckett Jr, surgeon extraordinaire and personal role model, once told me: “It tries your patience, and you may go gray faster, but there are times you learn more by not operating.” I have followed his advice many times in my career, and our latest research is a direct result of this advice.

The Heck with That

Many men with azoospermia (the absence of ejaculated sperm) will actually have a few ejaculated sperm (cryptozoospermia) if you look hard enough. However, many clinicians simply don’t look hard enough to find these few good swimmers and others don’t believe that it’s worth looking.  “Heck with that stuff, just go to the testicle for sperm.”

Seems reasonable enough. But, this approach dials up a whole new problem. If so few sperm are in the semen, then sperm production is also way, way down. Fewer apples on the ground mean fewer apples in the tree. So, “just going to the testicle” for sperm could mean a major pruning and usually requires complex and extensive surgical dissection of the testicle, just to find just a few sperm. And often, the surgery fails to find any sperm at all. Ever try to find a needle in a haystack? So, why not use the ejaculated sperm in the first place?

Putting the Knife Down

This week, we are presenting our latest research that says no to surgery at the annual meeting of the American Urological Association—a group of surgeons, no less. For this study, we decided to avoid operating on infertile testicles and simply plan to use as much ejaculated sperm as we could get. We had infertile men freeze consecutive semen samples until sufficient sperm were available for IVF-ICSI. Couples then proceeded to IVF-ICSI using a combination of fresh and frozen-thawed ejaculated sperm. What we learned surprised even us!

Every Sperm is Sacred

Here are the facts of our study to be presented on Tuesday:

• Men with very few ejaculated sperm have “usable” (motile) sperm in about one of every 2 ejaculates.
• On average, men with very few ejaculated sperm banked a little over 3 semen specimens before being “cleared” for IVF-ICSI without surgical backup.
• About 1/3 of men banked from 1-100 motile sperm; 1/3 banked 101-1000 sperm and 1/3 banked >1000 motile sperm per ejaculate.
• At the time of IVF-ICSI, 85% of men used either fresh ejaculate or banked sperm and required no testicular sperm retrieval. 15% needed surgery to procure enough sperm.
• At IVF-ICSI, 60% of eggs fertilized normally and 46% of women secured an ongoing pregnancy or live birth.

Bottom line: most men with very low ejaculated sperm counts can bank sperm and avoid surgery to become fathers. And this sperm works about as well as any other sperm you can throw at eggs. Ah, the words of Emily Dickinson ring so true:

Surgeons must be very careful
When they take the knife!
Underneath their fine incisions
Stirs the Culprit—Life!

The post Medicine Without Surgery appeared first on The Turek Clinic.

The truth about sperm chromosomes.

He came in to talk about a vasectomy reversal. “Doc, it’s been 15 years since my wings were clipped. Do my sperm still work? If I have kids, will they be ok?”

A Two-Sided Picture

Great questions! He was wondering whether being blocked so long from a vasectomy had fiddled with his sperm.  Somehow messed it up. I broke this question into 2 parts:

• What disease risk does he bring to kids as an older father?
•  What disease risk does he bring to kids having an older vasectomy reversed?

The Older Father

We’ve dealt with the older father issue before. Older fathers do bring issues to bear on their offspring. But, alas, the increased risk of transmitting heritable diseases in this way is quite low overall, much less than 5%, and there is nothing to test for in particular to know before you go. But this was not the meat of his questions to me.

The Older Vasectomy

The poignant issue here is whether sperm that are produced after prolonged obstruction with vasectomy might somehow be damaged or defective once the vasectomy is reversed. After all, how would a car engine to run if you put a cork in the exhaust for a while?

Well, I too was curious about this issue and published a neat study that addressed it a couple of years ago. In men undergoing vasectomy reversal, we tested the genetic fidelity of the sperm producing machinery after prolonged blockage. How good was the quality control process after being blocked for years? How did it compare with that of men of normal fertility who had not had a vasectomy?

Technically, what we sought to find out was how recombination errors during meiosis translate into chromosomal abnormalities in sperm. We found that the “factory” (testicle) and its “product” (ejaculated sperm after reversal) were both in remarkably good shape after prolonged blockage. In fact the genomic integrity of the sperm produced after reversal was no different than that of otherwise fertile men—you really couldn’t tell them apart. This was very encouraging and means that having a vasectomy should not lead to an increased risk of chromosomal diseases in offspring after reversal.

So, I told him that. “Sir, your sperm after reversal are fully the fellows they were before the your horses were reigned in.”

The post Fully the Fellows appeared first on The Turek Clinic.

The places the world takes us! Hoodoos at Bryce Canyon

The case of the month is an actual patient of The Turek Clinic. It is presented in honor of National Infertility Awareness Week.

They were a cute couple, a bit nervous and very excited. She was 20 years old and he was 24, and they appeared deeply in love. They had been trying to conceive for a while and, following a move to America, were told by their doctor that he was “shooting blanks.” I confirmed that he had azoospermia, that he was healthy and that there was no blockage present. The diagnosis was nonobstructive azoospermia. They proceeded with sperm mapping and I called him back 2 weeks later to tell him the results.

You Have Sperm

“Congratulations! You have several pockets of sperm in your left testicle that should be plenty for having a child of your own. This will require a fairly high level of technology (IVF-ICSI) and a relatively simple sperm retrieval procedure to work though.”

“Thank you SO much, doctor!” They responded with crackling, emotional voices.

Where Did You Go?

And that was that. Over the next several months, most couples hearing this news usually reconnect with me several times: once or twice to confirm that what I said was true and then again to plan the series of assisted reproductive events needed to have children. But with this lovely young couple…utter and complete silence.

You’re Kidding

Soon enough, the indelibly innocent and optimistic impression that this couple left on me faded with time. Over the years, I would often ask myself and my staff: “remember that lovely young couple? I wonder what happened to them.” As is often the case, infertility can single handedly shred an otherwise hardy relationship and leave it gasping for breath at the side of the road. A force of unmistakable power. I had hoped that this wasn’t what happened to them.

Fourteen years later, almost to the day, they showed up in my new North Beach digs looking as bright, cheerful and giddy as ever and none the worse for wear.  She was now 34 years old and he was a confident 38.

“We’re back, Dr. Turek!”

“I see,” I said, half smiling, half worried, trying to quickly calculate how many years it had been since we had done his sperm mapping and found sperm.

“Yup, we needed to settle into America, save some money, and we’re now ready to move forward.”

“So, you want to move forward with things?” I said hesitatingly as if I had just seen a ghost. This couple had the exact same sparkle in their eyes and jump in their step that I remembered from a decade and a half ago.

“Yes, sir. That’s right!”

Well what happened next must been influenced by the sacred, the celestial, or both. Testicular sperm were found just where we thought they were 14 years earlier. And she got pregnant with twins just as she always thought she would.

Hard to describe exactly what this couple has taught me about life, but my world is somehow different after meeting them. They have redefined the words “fortitude,” “stamina” and “resilience” for me. They have also shown me what the word “grace” looks like in action, as a verb and not a noun.  And to every one of the 8 million infertile couples in America, each with their own amazing journey, I honor you this week.

The post Climb Every Mountain appeared first on The Turek Clinic.

C’mon, be the Dad and muff the shot. (Courtesy: Cleveland Show wiki)

It’s tax day! Feeling powerless? It’s no wonder. In the words of Albert Einstein, certainly no mathematical slouch, “the hardest thing in the world to understand is income tax.”

Alas, you have done your best and the tax return is in. Time for a reward. What will it be: a new Tesla sedan, season tickets to the Giants, or a Diebenkorn Ocean Park painting?

Hardly! How about more like a dinner at In-n-Out burgers, a good movie, or some new tires for the car. Better yet, borrow from the coupon-clipping theme of the past, and go for a snip-n-save.

Vasectomy Economics

You worked hard, you saved hard, and you just missed “March Dadness” when your buddies got their vasectomies last month. Now’s your chance. Treat yourself to a 9-minute no-scalpel vasectomy and reap the economic rewards. Since you’re in tax mode, let’s break it down. Here is a simple cost-benefit analysis of getting your wings clipped compared to not having the nut-cut.

Vasectomy                        No Vasectomy

1. Value (to partner)       Priceless                              Worthless
2. Rug rats                          ++                                    (++++++)²
3. Contraception            “No worries”            “Did you pull out in time?”
4. Freedom                    Unbridled                              Shackled

Forget Economics

Putting aside the economics, there are other reasons for a vasectomy straight from the horse’s mouth:

“I have a penis without a conscience”
“I always ride bareback now.”
“My genes are not that great.”
“My first time for manscaping.”
“A whole day of Blockbuster movies!”
“My one chance to have bigger balls.”
“I needed a good third-hand tale.”

Whether it’s amortization, appreciation, bubble or bust, a vasectomy is one of the few gifts that, in simple economics, keeps on giving.

The post Snip-n-Save appeared first on The Turek Clinic.

Butterscotch Plum (sideways). Courtesy: A.J. Russell, artist.

This is a guest post from a patient who lives in Europe. He has shared his remarkable journey about being infertile in the past. As I continue to be moved by his story and his fortitude, I asked him to write to us again. He is also the inspiration for the creation of The Turek Clinic Support Forum. 

The road to where I am today has been hard, actually more like a rollercoaster, fluctuating between hope and despair. The past year has been both the best and the scariest one of my life.

Being diagnosed with azoospermia and going to all ends of the earth to learn that I do not have sperm of my own is now a distant memory. I have since started a new journey that lasted precisely 9 months and promises to continue far beyond that.  God bless donor sperm.

I still remember the day it really hit me that I would in fact become a father. It was at the first ultrasound and I saw this 7-millimeter fetus and realized that this was really happening. That was, I think, the first moment I allowed myself to “feel” and be happy. I was once again filled with hope.

While she was pregnant, my wife asked me regularly about how I felt. What did I feel?  Did I feel any paternal feelings for the bun in the oven? I did not. At least not at first. The pregnancy was still very abstract for me. However, I soon realized that, early on, there is not much you can do or feel as a father since we do not have the same natural connection to the fetus as the mother. As time passed, though, I began to feel more and more for the little child. My feelings got stronger with each ultrasound. Once we hit 30 weeks of pregnancy, and I saw the 3D pictures of the fetus, a wave of emotions hit me. I remember loving her, really loving her at that point.

In November 2012 the apple of my eye, my darling daughter, was born. I can’t explain how I felt that day, my emotions were overwhelming. I could not wait for her to be born, to hold her in my arms, to kiss her or to watch her sleep. I had missed her even before she was born. The birth of a child is said to be a life-changing experience, which I did not believe before, but now I do. It changed me completely and stuff that was important to me isn’t any more… and other stuff is.

It has now been just over 4 months since she was born and every day I feel blessed to have her in my life. Her smiles, her laughter and grip on my finger all bring my world to a halt. The love I have for her is unlike anything I have ever felt.

So what are my feelings about having used a sperm donor? Honestly, I don’t think about it. It has no importance or relevance to me. Maybe it is dwarfed by what I now have. She is my precious little girl and I am her father. Nothing else matters. Nothing else is relevant. Nothing. I actually wonder why I didn’t take this path earlier than I did, but I guess it’s because you only make choices and take paths when you are ready to do so. The funny thing is, everyone who meets my daughter makes the same comment: “She looks just like you!” Funny how things work out.

The post A Year of Answers appeared first on The Turek Clinic.

Be careful out there! (Courtesy: patternsolutions.net)

How about an April Fools riddle: What 100-year old garment accessory lives less than an inch from your privates and is a leading cause of penile injury? Nope, not your stylish skivvies! It’s your pant zipper.

Zipper History

An American invention from 1913, the “hookless fastener” was first used on rubber boots and tobacco pouches. It took another several decades before the zipper landed on men’s trousers. Now, roughly 14 billion zippers are made worldwide every year and they can be found on everything, including ziplock bags.

Zippers Can Hurt

A brand new study now reveals the dark side of this neat little invention that conveniently speeds up the morning dress routine: the penile zipper injury. Here are the facts:

• There are about 2200 emergency room (ER) visits in the U.S. annually for penile zipper injuries
• Zippers are the 5th leading cause of penile injury
• Zippers surpass bicycles as a leading cause of penile injuries in men needing ER visits
• Falling toilet seat injuries are more common than zipper injuries in little boys (girls, don’t ask!)
• The female labia can also get caught in zippers; however the scrotum tops the labia for zipper attacks
• Penile zipper injury rates have remained stable over the past 8 years–Thank goodness!

Slowly Back Off

Just in case you find yourself trying to undress after that rare drunken stupor or assembling yourself following a listless sleep and get your member zipped, here’s what to do: back down the zipper slowly. If still stuck, add some mineral or vegetable oil. Use a cotton swab to help back the skin out. And although conceptually attractive, kissing it really doesn’t help.

You might as well be prepared for that zipper attack, as you and your privates will share a long life with them. In the words of comedian George Burns: “First you forget names, then you forget faces. Next you forget to pull your zipper up and finally, you forget to pull it down.”

The post Zip-a-Dee-Doo-Dah appeared first on The Turek Clinic.

William Penn. Humble Quaker, thought leader and founder of Pennsylvania (Courtesy: Atwater-Kent Museum)

The case of the month is an actual patient of The Turek Clinic.

“I thought for sure that I never wanted kids. They broke the mold when they made me,” he told me. But then, he met the woman he never thought he would meet. “She changed everything. Nothing was the same after her,” he said with a wide, intoxicating smile.

A Perfect Record

He came in to talk about a vasectomy reversal. He had the vasectomy 11 years prior. No unexpected loads, no muddied waters, no Craignancies in his past. A perfect record capped off with a vasectomy.

As is my habit, I took a good long history and performed a physical exam on him. As a guy who crosses his t’s and dots his i’s, I also checked his reproductive hormones, since he had not conceived in the past. Just making sure that things are a “go” for a new launch. Vasectomy reversal microsurgery is certainly a pleasure for me to perform, but it’s more important that it’s the right choice for the patient.

A Man’s Intuition

A week after his visit, we talked on the phone. Something didn’t sit right with me. His testicular volume, a great measure of sperm output, was a little low. And, although his testosterone level was normal, his follicle stimulating hormone (FSH) was on the high side. Maybe sperm production wasn’t completely normal. Maybe it was non-existent. In either case, a vasectomy reversal might NOT be the way to go, as I couldn’t reassure him of a robust sperm count after the procedure. Best to be sure the engines are ready for the launch.

The Biological Truth

“What are you saying Doc?”
“Well, you might not be fertile after a vasectomy reversal. Your engine’s not running well.”
“How do you know for sure?”
“Right now it’s a strong hunch, but instead of investing time and money in a reversal, I’d suggest looking closer at the engine to see how well it’s running.”
“How do we do that?”
“Lets ‘map’ the puppies and see what’s going on.”

I am a firm believer in following instincts. And although surgeons can be good, maybe even great, they are always, and I mean always, trumped in the end by biology.

Sure enough, testicular mapping showed that sperm production was present but in only very low amounts. So low that there was no way he would have had sperm in the ejaculate after a reversal. Fast-forward 3 months: we performed a testicular sperm retrieval instead of a vasectomy reversal and his wife went through in vitro fertilization and ICSI and they conceived first shot. Point is that even if you have a big hammer, not everything is a nail. In the words of William Penn: “Sense shines with a double luster when it is set in humility.”

The post Biology Always Wins appeared first on The Turek Clinic.

Go ahead! Have a heart! (Courtesy: San Francisco Medicine magazine)

What makes you feel like a good citizen? Is it giving blood? Coaching your kid’s team? Volunteering at a school or shelter? Church work? Voting? Recycling? What is it that makes you feel part and parcel of the wide, wide world around us?

I asked this question of myself recently. As a doctor, quite naturally I thought of helping people. I am a big fan of the “smallest things make the biggest difference:” opening doors for others and helping the elderly cross the street. But what struck the most resonant chord with me was my commitment to the little free clinic that could right here in San Francisco.

It Stole My Heart

The full story behind my devotion to Clinic by the Bay is being published this week in San Francisco Medicine magazine. It’s funny how such large commitments begin so innocently.

It was during a busy cystoscopy clinic at the Veterans Affairs Hospital. Vets in half buttoned medical gowns were meandering all around. And there was Janet Reilly, oblivious yet focused: “Hi, Paul… I really need you to help me get medical professionals, especially retired ones, to volunteer in a free clinic.”

The wall went up. How could I possibly add any more to my schedule? My days at UCSF were chock full of teaching, research, grants, clinics, committees and travel. And then there was the young family. As an academic surgeon, I was spinning at tortuously high rpm, barely holding things together and here was yet another demand on my time.

But her dream was clear. She wanted to start a volunteer-powered, free clinic for the working uninsured in San Francisco, a population of about 63,000 at the time. I emailed her back later that same day and said “Count me in.”

Why I Said Yes

I have always been interested in medical volunteerism, but this was not exactly how I pictured myself getting involved as a professional. During training, I had volunteered in fantastically needy and faraway places like Dakar, Senegal and always imagined going back to the Third World again, when I could offer more expertise and wisdom. But this proposal was different: it awakened me to the opportunities to help in my own backyard. And that’s why her offer was so compelling to me. I didn’t have to fly 16 hours to another continent and leave my family for weeks at a time to help others.

Volunteering is really quite possible in smaller, less disruptive, doses and nearer to home, where I live. It’s really the same giving feeling, just spread evenly over everyday life.

Looking Back

Since I became involved during the Clinic’s planning stages 7 years ago, I have never looked back. As a Founding Board member and Chair of the Medical Advisory Board, my involvement has only deepened with time. Why did I become, and why do I remain, involved with Clinic by the Bay? Honestly, because it feels good to give back in an understated, everyday way. And every single one of the following matters deeply to me:

• Providing the gift of better health
• Giving back in your own backyard.
• Helping fellow citizens in an incredibly fundamental way
• Making the community a better place
• Doing what you love to do
• Coming home to your family with a big smile on your face

I know I keep repeating the words attributed to that dotty-old-cigar-smoking-Brit Winston Churchill, but they still ring true for me: “You make a living by what you get; you make a life by what you give.”

The post A Good Citizen appeared first on The Turek Clinic.

Eastern Medicine is much easier than pulling these…(Courtesy: deviantart.com)

This week’s post is written by noted Bay Area acupuncturist Anca Sira, founder of Ama Wellness Center in San Rafael, California, She has a special interest in Eastern medicine treatments for infertility.

The man sitting in my waiting room for his acupuncture appointment looked about as excited as he would getting a root canal. I think it’s because men somehow think that if they are getting acupuncture for infertility that I will be putting needles in their penis. Not true. Probably the other reason that men don’t like to come in is because of the bigger “I don’t like to go to doctors” issue. Once we start, though, they soon figure out that acupuncture is nothing like a root canal.

Why Am I Here?

We start by talking about whatever floats the guys boat and then slip in the how’s the sperm question, which will result in a look down at the floor and mumbling of the answer before we happily go back to whatever was more distracting, like cars.  In some way or another, our conversation progresses to encompass the following points:

• Chinese or Eastern medicine has a several thousand-year history of focusing on male sexual health, especially given China’s long-standing male-centered society.
• Chinese medicine is not only all-natural, it is holistic, meaning it treats the whole body. The intake visit is a “State of your Health” visit that focuses on diet, cravings, sweat, sleep, and the big one–stress.
• Eastern medicine treatments include acupuncture, herbs, and dietary & lifestyle changes.
• Typically stress, anxiety and circulatory issues affect male fertility and acupuncture can help.  Recent studies also show improved sperm motility right after acupuncture.
• Herbal formulas may improve semen quality, including sperm counts, morphology and ejaculate volume.

So the moral of the story… yeah, acupuncture can help with sperm issues if you can get a man to go. Or maybe we need to couch it a different way: Think of it as though you are the dictator and your sperm is your army. They act on your orders to make progeny, and what you eat and do to enable your army determines their strength and ability to overcome adverse conditions. Well the less you do, the weaker the forces. Likewise, the more you do, the stronger the army. So acupuncture is a programmatic way to strengthen the army, build the forces and conquer the golden egg.  So cowboy up!

The post Pins and Needles appeared first on The Turek Clinic.