If viagra stopes working, try adding a statin

"Atorvastatin said to improve sildenafil response in men with high cholesterol, ED.


MedWire (10/29, Albert) reported, "Atorvastatin therapy improves the response to sildenafil of men with erectile dysfunction (ED) and hypercholesterolemia," according to a study appearing in the International Journal of Impotence Research. Researchers in Iran "investigated whether addition of atorvastatin therapy to sildenafil treatment would improve erectile function in 131 men, aged 62.9 years on average, with ED and high cholesterol who were previously unresponsive to sildenafil." They found that subjects "taking atorvastatin had significantly greater improvements in [International Index of Erectile Function (IIEF-5)] score by week six than those taking placebo. By the end of the study, the average IIEF-5 score was 13.9 for patients in the atorvastatin group and 10.5 for those in the placebo group." "

Reprinted from the AUA Daily Scope

This is new for me and I plan to try it study it further for my own erectile dysfunction patients here in Suffolk County Long Island Urology practice.  Another approach for when the PDE5 inhihitors like viagra or cialis stop working for patients is to evaluate the man for low testosterone.

Dr Schoor

The Semen Analysis: What it can and cannot tell us about male infertility.

For most men, the fertility evaluation starts with a semen analysis and most of these men will have normal semen analyses.  Does this mean that they are fine?  Does it mean that they don't have a male factor--a condition that is preventing their sperm from fertilizing an egg?

The answer is no it does not.

The semen analysis is a very crude indicator of a man's true fertility potential.  In other words it is very possibl to have a serious male infertility factor yet have a normal semen analysis.  How is this possible?

The semen analysis looks at a number of measures.   These features are:

• Seminal fluid volume
• Seminal fluid pH ( a measure of acidity)
• Seminal fluid viscosity (a measure of liguidity)
• Sperm concerntration
• Sperm motility
• Sperm morphology ( a measure of the sperm's shape)

While an abnormality in one or more of these measures indicates that a male factor may exist, an analysis in which all these features are normal does not mean that such a condition is absent.

So why do it at all?

Because it is the best we have and it is a good place to start.  It is a good, though imperfect, screening tool.   Used this way, if several semen analyses are normal, then it is less likely that the man will have a male factor condition.

Of course, as in everything in medical practice, there are exceptions.  Men who smoke or who are exposed to other environmental toxicants can have normal semen analyses yet have sperm that do not function properly.  I have this also in men with testis tumors and occult diabetes (undiagnosed diabetes).  I have also seen this in men with varicoceles.

So how, in my opinion, should we counsel a couple with infertility.  I think it is reasonable to start with several semen analyses rathe than just one.  If 2 or 3 are normal and the man has no urologic complaints, than the couple may proceed with assisted reproduction aimed at the women.  However, if after several attempts at the lower cost assisted reproductive procedures, like artificial insemination, the woman is still not pregnant and the  next option is for the couple to proceed to in-vitro or ICSI, then I think referral to a urologist is reasonable and beneficial.  Often it is the urologist who uncovers a treatable and reversible male factor that was probably contributing to the couple's infertility problem.  At best, after correction of the male factor the couple can enjoy a natural, unassisted pregnancy.  At worst, the couple proceeds with in-vitro after a brief and inexpensive delay. 

Thanks,

Dr Schoor

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Sperm may play major role in HIV transmission, research suggests.

Re-printed from the AUA Daily Scope.


"HealthDay (10/26, Dotinga) reported that a paper appearing in the Journal of Experimental Medicine indicates that "sperm, not just semen, can transmit the virus that causes AIDS to immune cells in the body." Researchers at the University of Buenos Aires explained that the "virus attaches to the surface of sperm and can be transmitted to immune cells" by "passing through tiny abrasions in the vagina or anus or perhaps through another method." What's more, the "slightly acid environment, which they likened to that in the vagina after sexual intercourse, boosts the likelihood of infection of these cells." "

HIV is still a major problem and transmission is not fully understood.  Avoiding high risk sexual behaviors can go a long away to prevent spread of the disease.
 
Dr Schoor

Another reminder that the male factors still matter.

Re-printed from the AUA Daily Scope Newsletter.

Sperm donor unknowingly passes potentially deadly genetic heart condition to offspring.


The AP (10/21, Tanner) reports that a paper appearing in the Journal of the American Medical Association reveals that a "sperm donor passed on a potentially deadly genetic heart condition" -- hypertrophic cardiomyopathy -- "to nine of his 24 children, including one who died at age two from heart failure." The story has spotlighted the "importance of thoroughly screening sperm donors." At present, "voluntary sperm bank guidelines say donors should be required to provide a complete medical history to rule out those with infectious diseases or a family history of inherited diseases."

A number of centers also provide genetic testing for conditions like "cystic fibrosis and sickle cell traits," according to MedPage Today (10/20, Fiore). However, those conditions are "much less common than hypertrophic cardiomyopathy in the general population." Therefore, the researchers at Abbott Northwestern Hospital "suggest that an echocardiogram may be a good way to determine which patients should be excluded from donating sperm." They also recommended "recording donor information in a national, searchable database to easily identify and notify any affected offspring if a genetic disorder is found."

Perhaps rather than an expensive echochardiogram, we just start with a detailed history and physical exam.  His condition could have been initially detected by history then confirmed with more expensive testing.

Dr Schoor

Has the man become irrelevant in the age of assisted reproductive techniques?

With the incredible advances that have been made in assisted reproductive technologies directed at women, many patients and doctors alike ask me why should they bother with evaluating and treating male factor infertility at all.  As long as the man has a reasonable sperm count, they reason, the couple can have a baby using assisted techniques such as intra-uterine insemination (IUI), in-vitro-fertilization (IVF), or intracytoplasmic sperm injection (ICSI).  I think it is a reasonable question and one that is being asked with increasing frequency during this recent economic downturn.

True,  (ICSI) requires the presence of only one sperm, but while pregnancy and babies come from ICSI, the process, in comparison to natural pregnancy or even artificial insemination is, well, less-than-pleasant.  Here are some other reasons:

1. ICSI, IVF, and IUI are very expensive procedures.  Male factor therapies are inexpensive, in comparison.  IUI costs ~$1000 per attempt while IVF or ICSI costs ~$15000 per attempt.  A varicocele repair costs ~$3500 total (varicocele surgery is usually insurance covered, even in New York where insurance companies do not cover fertility services).
2. Correcting male factors enhances success rates for all the female directed procedures, including ICSI.  I suppose that if you were spending $20,000 per IVF attempt, you'd want to improve the odds of success as much as possible in your favor.
3. IUI, IVF, and ICSI procedures are safe, but are associated with potential serious risks that male factor risks do not possess.  Such risks include twinning, hyperstimulation syndrome, and laboratory specimen mix ups (wrong embryo implanted, yes it happens).  Male factor treatments are very safe and never associated with life-threatening side-effects. 
4. Male infertility is associated with certain life threatening health conditions in men, like testicular cancer & diabetes.  Often, an abnormal semen analysis is the only indication that such a condition exists.  Referral to a urologist could save his life.  Personally, I diagnosis 4 to 6 infertility patients per year with testicular cancer in my male infertility clinic in Long Island. When your baby is born, he or she will benefit from having dad around for a long time.  
5. While a couple's motivation to have a baby is high enough to propel them to undergo painful, stressful, and expensive female assisted reproductive procedures, they'd rather get pregnant the old fashioned way if at all possible.  Correcting male factor infertility can help couples achieve this goal.

So in my humble view, men and our sperm are still relevant and will remain so despite the truly amazing advances in female reproductive medicine.

Dr Schoor