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.

Urologic Trauma

Isolated urologic injuries are uncommon after an MVA, such as Governor Corzines, but GU trauma does occur. I would not be surprised if the governor even had some. Here are some urologic injuries that he could have had, or might have.

• Kidney trauma: The kidneys are protected in their locations in the retroperitoneum, but can get injured in severe enough accidents. Renal traumas can range from minor bruises to fractured kidneys and major vascular tears. Seat belts, in general, would protect people from renal injuries.


• Ureters: The ureters carry urine from the kidneys into the bladder. Isolated ureter injury during blunt trauma--ie from an MVA--rarely, if ever happens. Sometimes in children involved in MVA, the connection of the kidney into the ureter can be disrupted. Seat belts can help prevent this.


• Bladder injuries: Bladder injuries are pretty common in MVA's and happen most frequently when the passenger/driver's bladder is full at the time of the accident. This causes the bladder to rupture and this can be life-threatening. Patients with pelvic fractures will often have bladder injuries, either as a result of bladder rupture or because a piece of the pelvic bone gets lodged into the bladder. Bone chips don't belong in the bladder and can cause recurrent UTI's. The lap portion of a seat belt can cause a bladder rupture.


• Urethral injuries: The urethra can get inured--severely--during an MVA. Injuries range from bruises to partial tears to complete disruptions. Complete disruption is very bad and men who have this injury will typically require many surgeries to correct the problem and can expect long-term disability, despite the best of care. The disability can be in the form of recurrent stricture disease and sexual dysfunction/ED. Urethral injuries are most often associated with pelvic fractures. Seat belts can prevent urethral injuries.

I wish the Governor of the Great State of NJ well and a speedy recovery.

The IU.

Treatment options for ED.

A patient asked me yesterday about the options to treat his ED. Here is, in essence, what I told him.

1: Medical Therapies: These are the PDE5 inhibitors, viagra, cialis, and levitra. All 3 work quite well, in general, and each have their own unique qualities. Some patients will respond well to one, but not to another. Similarly, some patients will experience side-effects with one agent, yet not another agent. In general, these medications are good first line therapies.

2: Injection therapies: This is a very effective form of treatment that works >90-95% of the time. It involves the man injecting a tiny needle into the base of his penis 10-15 minutes before he wishes to engage in sex. The injection is painless and most find men have no problem learning how to perform the injections. However, the majority of men who start to use injection therapy will ultimately discontinue it for a variety of reasons.

3: Penile implants: This is the most effective form of treatment for ED and the only one that allows for the patient's return to normal functioning. It involves the urologist placing a small pump into the scrotum via a small opening in the skin. When the man desires an erection, all he does is press on the pump and sterile water transfers into the penis and he gets a normal, firm erection that will stay up as long as he desires. Men who have this procedure done report the highest satisfaction levels, though it is the most invasive form of treatment and it has side-effects.

4: Other options: Other options exist, though they really do not work well or any better than placebo, so I don't recommend them.

Thanks,

Dr Schoor