Low sperm count and beef.

There has been some recent evidence for low sperm counts in men whose mother's were exposed to more than 7 beef meals per week when pregnant. I believe that while the evidence is scant, it is there and the phenomenon may be related to the usage of growth hormone and other androgens in cattle. See attached link here.

On another related, and perhaps scarier note, pediatricians have been noting a rise in breast development in girls less than 10-11 years of age. These pediatricians have told me that they feel the problem comes from estrogen in industrial raised chicken and recommend that parents purchase hormone free chicken and other meat. Makes sense to me.

I have been purchasing Whole Foods brands as well as Stop and Shops organic brand.

Thanks

Dr S.

The IC Cocktail

When all else has failed and the patient with interstitial cystitis is still miserable with frequency and pelvic/perineal pain, you, as the treating physician, basically has 2 options. Option 1 is to refer them out to the "specialist." This my get the patients out of your hair, but it does not do the patient a service. The better approach is option 2: the IC cocktail instillation.

I use a compunded mixture of 2% lidocaine, 10,000 U Heparin, and 8.4% Sodium Bicarb. After confirming that the symptoms are not due to a UTI, I instill the mixture--a total of 12cc--by gravity into the bladder. I then have the patient hold the mixture in the bladder for 15 to 20 minutes, then void it out.

The most difficult part of the entire process is finding a pharmacy that can compound the above mixture. I use a pharmacy in NJ called Wedgewood. I think the are terrific and recommend them.

The majority of IC patients who are refractory to other forms of treatment, such as elavil, atarax, and elmiron, will repsond to the instillations.

That's it.

How to do an epididymal sperm aspiration.

I friend of mine, a urologist in OH, asked me how I do an epididymal sperm aspiration . Here is what I told him.

First, after taking proper informed consent, I take the patient into the OR and prep and drape the area. Local anesthesia with some light IV sedation is sufficient, typically. I do a perivasal cord block using the 3 finger technique, such as during a vasectomy. Then I wrap a sterile gauze pad around the testicle so that I can easily immobilize it with my left hand while keeping the skin overlying the testicle taught. I then infiltrate local under the scrotal skin and dartos and make a 1-2cm transverse scrotal incision, which I deepen with the knife and cautery until I get to the tunica vaginalis. of the testicle. After opening the tunica vaginalis, I roll the testicle so that the epididymis comes into the field. I then immobilize the epididymis by passing a 5-0 nylon suture through the tunic of the epididymis. At this point I am ready for the sperm retrieval,which is performed as follows.

After inspecting the head, body, and tail of the epididymis, I try to determine which area appears most dilated and which area has dilated tubules that appear full of milky white fluid. I then pass a 26G needle into the tubules at these areas and aspirate back and forth. If you hit sperm filled tubules, some milky white fluid will enter the needle/syringe. You then squirt the aspirate into a media filled petri dish and inspect in the microscope for the presence of sperm, most preferably motile sperm. If you have several million motile sperm, and the patient intends to proceed with IVF or ICSI, you are done. If the patient plans to proceed with IUI only, you'll need at least 5-10 million motile sperm. If you don't get this on the first pass, you continue the procedure by sequentially aspirating various portions of the epididymal head, body, and tail until you either have enough sperm or you can not get enough motile sperm. In cases where 1 side does not yield motile sperm in sufficient quantities, you must proceed to the other side.

That is how I do it. Some urologists do the entire procedure percutaneously, but I have found that sperm yields are not sufficient via the percutaneous approach. Just my own observation. Patients do quite well and do not have more post-op pain than with the percutaneous method. Patients that have the procedure performed on a Friday may return to work by Monday.

Any questions, ask me via the comment section.

Clomid and Male Fertility

I like clomid--AKA clomiphene citrate. It is a good drug and very effective for the right patient at the right time. Unfortunately, clomid is not indicated or approved for use in men and it is expensive. Clomid is indicated for use in infertile woman and is used to induce ovulation. Men don't ovulate. Prescribing clomid for men is difficult due to insurance coverage issues. Every time I write for clomid, I get a flurry of phone calls, first from the pharmacist who informs that the clomid is only for women, then from the patient who informs me that the pharmacist informed them that clomid is only for women, and then I get the phone calls back and forth to the insurance carrier as I try to get the medication covered for the patient. As you can imagine, prescribing clomid to men is a royal pain and I, therefore, really and truly only do it when it is indicated.

Here is when I think it works.

• Men with low AM testosterone and low sperm counts AND low or low normal FSH and LH levels.

Other male infertility specialists that I know and respect use clomid in other situations as well, such as for men with low testosterone and sperm counts but high/high normal FSH/LH levels. Personally, I don't do this, but they do and claim to have results.

When I have men on clomid, I like to check hormone levels, specifically testosterone and estradiol, every 2 or so weeks, at least until hormone levels stabilize. Why do I check estradiol levels? Testosterone can be converted to estradiol, which can then cause breast enlargement.

There you have it.

Thanks,

Dr S.