Prostate biopsy

The first thing I have to point out is that each urologist’s routine may be slightly different. Different does not mean wrong. Most of the information I will present here is based on how I, personally, perform a prostate biopsy.

The reason we do a prostate biopsy is to evaluate the prostate for prostate cancer cells. We also get to look at the shape, contour, and size of the prostate using the ultrasound machine. This can be helpful when looking down the road at treatment options.

Your doctor will provide antibiotics for you to take before the procedure. You will also perform and enema before coming to the office. You will be instructed to stop all blood thinning medications. Typically, there is no need to fast prior to the procedure.

Once in the room you will undress from the waist down and lie on the exam table on your side facing away from the doctor. Your bottom will hang off the side of the table and you’ll bring your knees up toward your chest. Basically, you’ll be in a fetal position. In my office the procedure can be done with nitrous oxide medication to make you more comfortable. This is laughing gas at a low dose that you control to make yourself comfortable. It doesn’t knock you out, just takes the edge off.

The doctor will then perform a rectal exam and then insert the ultrasound probe into your anus. This will make you feel like you need to poop, which is a normal sensation. This can be painful for men with hemorrhoids, but is otherwise painless.

The next step is to numb the prostate. This is done by injecting a numbing medication, such as Marcaine, around the nerves of the prostate. During this portion you’ll feel a poke and some burning and pressure from the injection. This is similar to what you would experience with a dentist working on your tooth. Once this part is done, the rest is typically pain-free.

Next the doctor will take some pictures and some measurements of the prostate, looking for any suspicious areas.

The biopsies are then done in specific areas of the prostate, as well as any areas that looked abnormal on the ultrasound. Each time a biopsy is taken you will hear a loud clicking noise of the biopsy device. You should not feel any pain, but may feel some pressure.

After the biopsies are done the ultrasound is removed and the procedure is all done.

You should expect to have some blood in the urine, stool, and semen for a couple of days, though it can last up to a couple of weeks. If you experience high fevers, chills, nausea, vomiting, or an inability to urinate you should call your doctor immediately.

Your doctor should get results within about a week.

There should be no lasting side effects from the procedure. It does not cause impotence or problems with erections. It does not spread cancer. It does not cause cancer. I hope this information has been useful to you and helped to prepare you for your prostate biopsy if you are having one.

You can make an appointment to see me here.

What is PSA?

PSA is one half of prostate cancer screening, which should be performed annually in all men from age 50 to 70. In some men it should be started earlier if they have a strong family history of prostate cancer.

PSA stands for prostate specific antigen. It is an enzyme produced by the prostate tissue cells that is important in making semen less thick and gel-like.

When we talk about PSA for men we’re really referring to a blood test that measures the level of this enzyme floating around in your blood. The reason this test is important is that it can give us a clue as to your prostate health. Having a low PSA is never a bad thing, but having a high PSA could signal a problem.

There are several conditions that could cause your PSA to be high. The most important, of course, is prostate cancer. This is the whole reason we perform the test in the first place. We’re trying to detect prostate cancer early to make it more curable.

Prostate cancer isn’t the only issue that can cause a high PSA, though. Prostate inflammation or infection, which often has no symptoms, can cause an elevation. So can simply having a large prostate. Other things can also do it, such as a recent urine infection, urinary catheter, urinary retention, or camera exam of the bladder. If you ejaculate within 24 hours to the blood test, this can also cause a slight elevation of the PSA.

One of the things I mentioned that can increase your PSA is having a big prostate. This is important because as men age, their prostates grow. So it is normal and natural to see your PSA increase as you age. This is why what’s considered a “normal” PSA changes as you get older.

For a male in his 50s the PSA should be less than 2.5. In your 60s it should be less than 4.5. Once you’re in your 70s it should be less than 10.

It’s also important to keep an eye on the rate of change of the PSA as well. What I mean by this is that if you’re 60 and your PSA is 0.5, but next year it’s 1.2, and the following year it’s 3.5, that could be a problem. Even though that 3.5 is less than 4.5, the rapid increase in the PSA can hint at a problem.

When the PSA is high or is changing rapidly your doctor should refer you to a urologist. Your urologist will then suggest some additional testing. This could include some more specialized blood tests, such as a prostate health index score, a 4kscore, or free PSA percentage. Alternatively, a prostate MRI, a type of imaging scan, could be useful in select cases. Most commonly, though, the next step is a prostate biopsy, a test that samples the prostate tissue for cancer cells.

The most important thing to understand about PSA is that it isn’t a perfect test. A high PSA doesn’t mean there is cancer. Don’t panic if your PSA is high, but definitely see a urologist.

I hope that this information on PSA has been helpful and allows you to better understand your blood. If you’re ever unsure of what your next step should be, see a urologist for more information. It’s better to be safe than sorry.

You can make an appointment to see me here.

Prostate Cancer Screening

In 2020, approximately 170,000 men will be diagnosed with prostate cancer in the United States. We’ve gotten better at detecting it and treating it, but prostate cancer still accounts for nearly 5% of all cancer deaths. Screening may help to address this problem.

To start off I should explain what screening means. Screening is testing to detect a possible health problem before someone has signs or symptoms. For example, when you turn 50 you should have a screening colonoscopy to look for colon cancer. If someone has blood in their stool the colonoscopy is no longer a screening test, but a diagnostic test. The difference is having symptoms vs no symptoms. Prostate cancer rarely has symptoms, but sometime will have back pain, bone pain, blood in the urine, or difficulty with urination.

When it comes to screening for prostate cancer the key concept is called “shared decision-making.” The doctor should explain why you might consider doing screening or skipping screening. Basically, you should understand the plusses and minuses of screening and you can then decide if it sounds right for you or not.

Prostate cancer screening involves two simple tests. The first is a digital rectal exam where the doctor puts one finger in your rectum to feel the prostate. The exam checks for any lumps or bumps called nodules that may be present. The second test is a PSA blood test. PSA is a protein that is made by normal prostate cells. When prostate cancer is present the number of prostate cells increases rapidly. More cells means a higher PSA value. However, a PSA rise can also happen normally. As a man ages, the PSA value will naturally rise as the prostate gets bigger, so it’s important to understand that there are normal ranges of PSA based on age. For men if their 50s the PSA should be less than 2.5. In their 60s it should be less than 4.5. And in their 70s it should be less than 10.

If either of these tests is abnormal then you should be referred to a urologist for further evaluation.

Now let’s talk about who should be screened for prostate cancer. The American Urologic Association, the biggest influencer on urologic care recommends screening in men aged 55 to 70. Most doctors start at age 50, which is reasonable since that’s also the age several other screening tests start. There are some special cases to consider though.

Men whose prostate cancer risk is above average may consider beginning screening at an earlier age. These risk factors including being black, having a family history of prostate cancer at an early age, or certain other cancers in first-degree relatives that developed at a young age. Men over 70 in excellent health may consider continued screening. Any men who have an estimated lifespan less than 10 years should not be screened. The reason for this is that these men are more likely to die from their other medical problems than from prostate cancer.

To summarize, you should consider prostate cancer screening if you are healthy between the ages of 50 and 70. Testing will include a rectal exam and a blood test. If either of these is abnormal you should see a urologist.

If you’d like an appointment to discuss your health click here.

How to Optimize Male Fertility


The most important part of getting pregnant is the sex. It sounds silly, but the first thing you need to do is make sure you’re doing it right. Make sure that you’re having unprotected vaginal intercourse and then neither partner is using any type of contraception or birth control. Penis in the vagina.


Timing matters, too. Women are not equally fertile every day of the month. The most fertile time is immediately during ovulation or when the egg in the female is passing toward the uterus. When there’s no egg ready there’s no way to create a baby. Intercourse daily in the two to three days prior to ovulation and through the days following ovulation increases fertility. Your gynecologist can better help you understand and track ovulation, but many kits and apps are available online and at the pharmacy that track you daily temperature. A very slight rise in your temperature, when measured at the same time each day, can signal the start of ovulation.

Cervical Contact

After ejaculation the female should prop her pelvis up on a pillow for 15 minutes to maximize the contact of the semen with the cervix.

Focus on the Boys

Once you’ve got the timing down you need to focus on the balls. There’s a reason the testicles are in a sack instead of instead the belly. Sperm develops best when at a temperature slightly lower than body temperature. To help, make sure you avoid tight-fitting underwear. Stick to boxers or commando. Definitely avoid hot tubs and hot baths as well. Those high temperatures can kill off your sperm.

There is some evidence that antioxidants can also improve your sperm parameters. Taking a fertility supplement may help, though results are certainly not guaranteed. The supplement I recommend to my patients is ConceptionXR from Theralogix. They are not paying me to say this.

Beware the Toxins

More obvious is to make sure you avoid any toxic exposures. This can include chemical at work or home. Metalworking, welding, farming, and painting may expose people to chemicals that can damage sperm. The most common toxic exposures come from smoking, drugs, and alcohol. If you’re trying to get pregnant it’s the perfect time to quit smoking. Drugs, especially, marijuana can lower sperm counts and decrease motility. Sperm quality also appears to drop in direct relation to amount and frequency of alcohol consumption. Time to kick all these bad habits.

Lifestyle Changes

And it’s time to get to the gym. You need to move, ideally a minimum of 30 minutes of cardio per day. Also sleep; 6 hours or more per day. And de-stress. Relax, meditate. Get acupuncture. Get a massage. Relax.

Lastly, eat healthy. Ideally, go vegan. At a minimum cut back on meat and dairy consumption. A healthy body makes healthier sperm.

You can definitely improve your chances with some lifestyle changes.  Remember that in the end it’s all about more sperm and healthy sperm.

Testosterone – Does it Help or Hurt Fertility?


Testosterone is a male hormone that is extremely important in general health and fertility. Testosterone can affect energy levels, sex drive, metabolism, erections, and fertility.

The key to understanding testosterone and fertility is to understand where testosterone is produced and how it works in the testicles. There are two main types of cells in the testicles, Leydig cells and Sertoli cells. Leydig cells make testosterone. Sertoli cells make sperm. When the Leydig cells make testosterone, it is in response to a signal from the brain that is carried by luteinizing hormone, or LH. The LH tells the Leydig cells to make more testosterone. When there is enough testosterone LH turns off. When testosterone is low LH turns back on. The amount of testosterone is very high in the testicle because that’s where it is made. Once it gets to the rest of the body it gets diluted. Testosterone levels in the testicle are about one thousand times higher than in the blood. The Sertoli cells that make sperm require this very high concentration of testosterone to produce the sperm cells. When testosterone is low the Sertoli cells can’t make sperm.

Many people, doctors included, see this relationship and think, “Great, if I give this guy more testosterone he’ll make more sperm!” Unfortunately, it doesn’t work this way. When you get testosterone through injections, creams, or other ways it shuts down the body’s natural testosterone production.

What happens in the brain

What happens is that the brain sees the testosterone and decides that no more LH is needed, so LH turns off. When LH is turned off the testicles don’t make any more testosterone. In the blood, the testosterone levels remain normal because of the testosterone he’s taking. But in the testicle, the testosterone level is the same as the blood, which is way too low. Remember, it’s supposed to be one thousand times higher than the blood! Because of this the Sertoli cells stay turned off, and no sperm are made.

How to boost testosterone without testosterone

Alternative options that turn up the LH system are available. Those medications, such as HCG and Clomid, can cause testosterone levels to go up in a more natural way. This allows the Sertoli cells to ramp up sperm production.

Not everyone on testosterone will have infertility, but it can be a major contributing factor. In general, it should not be used to treat infertility.

Treatments for Male Factor Infertility

Hormone therapy

Testosterone should not be given as an infertility treatment. It will only make the problem worse as it will completely shut down sperm production. Instead, for men with hormone abnormalities medications such as human chorionic growth hormone (or HCG) or Clomid. These treatments can help to jump start your body’s natural production of testosterone, which can then bump up sperm production.

Retrograde ejaculation

If you are found to have semen that is passing into the bladder instead of out of the penis there may be several options based on the cause of this problem. Most commonly medications cause this issue. Stopping the medication may fix the problem. The biggest culprit is Flomax or other medications for an enlarged prostate. Prostate surgeries, such as TURP, can also cause this problem. Some men will have success using Sudafed to help push the semen in the right direction. Otherwise a washing of the urine may provide enough sperm for artificial insemination of the female partner.

Vasectomy reversal

This is obviously for men with a prior vasectomy. Success rates vary but depend primarily on how long ago the vasectomy was performed. This surgery involves reconnecting the ends of the vas deferens or plugging the vas deferens directly into the epididymis.

Transurethral resection of ejaculatory ducts

This procedure is for men who have an obstruction of the ejaculatory ducts into the prostate. Often times this is due to the formation of a cyst in that area. In this procedure a camera is passed down the penis to the level of the ducts. A special loop is then used to carve away the obstructed section.

Testicular sperm extraction

Several procedures fall under this category. The difference is where the sperm are taken from and how they are retrieved. In general, the sperm can be retrieved in the office using a needle that goes through the skin or under anesthesia by opening the skin and going straight into the testicle. The sperm can be taken from either the testicle itself or the epididymis. These are all relatively quick and simple procedures with minimal recovery.

Understanding Male Hormones

As part of your infertility work-up you may have bloodwork done, to check out your hormone levels. This should always be done in men who have abnormal findings on their semen specimen.

Common Tests

The common tests are testosterone, estradiol, luteinizing hormone (or LH), follicle stimulating hormone (or FSH), and prolactin.

LH, FSH, and prolactin are made in a portion of the brain called the pituitary. Those hormones then control functions elsewhere in the body. LH primarily causes the production of testosterone in the testicles. A low LH could cause a low testosterone level. FSH primarily causes the production of sperm in the testicles. A low FSH could cause a low sperm count. A high prolactin can sometimes indicate a small tumor in the pituitary that then causes low LH and FSH levels and creates infertility.

The Importance of Testosterone

Testosterone is vitally important for male fertility. Testosterone helps men maintain a normal activity level, sexual interest and function, and metabolism. Most importantly, testosterone levels in the testicles help in sperm production. Low testosterone levels can impair sperm production. It can also cause erectile dysfunction. Low testosterone can occur due to problems with LH production or a problem in the testicle with testosterone production. It can also occur in men who are using testosterone supplementation with patches, gels, creams, and injections.

What About Estrogen?

Estradiol, a form of estrogen, is important in the regulation of male libido, erectile function, and sperm production. When estrogen levels are high it acts kind of like the Kryptonite of testosterone. Most important to infertility is that high estradiol level in men can cause impaired sperm production. A common cause of this is excess body fat. Testosterone is converted to estrogen in fat cells, so if you have too many fat cells you can end up with low testosterone and high estradiol ratio. When this happens you may have decreased sperm production resulting in infertility.

What Next?

If your hormone levels are abnormal your doctor may recommend additional tests such as a brain MRI, additional bloodwork, scrotal ultrasound, or testicular biopsy.

How to give a good semen specimen for analysis

Most of the time the semen specimen is collected at the lab, though sometimes they will ask you to collect the specimen at home and then bring it in. If that’s the case then make sure you get the specimen to the lab within 60 minutes and keep it close to your body to keep if near body temperature. If it’s collected at the lab, then you just have to show up ready.

When collecting your specimen, preparation is key. To make sure you give a good sample make sure that you abstain from ejaculation, sex or masturbation, for 3 to 5 days prior. Too short and the sample may be smaller than normal. Too long and it may be stale.

Do your best to avoid getting any lubricant into the specimen. Particularly, you should avoid any lubricant that is oil-based. Stick to the water-based products.

Make sure you collect the entire specimen in the cup. The total volume is important, so if you get half of it on your hands, or the floor, the specimen will be low quality.

Finally, you should always be asked to provide two specimens, typically 2-4 weeks apart. This is especially true if the first test had any abnormal findings. For the second specimen, follow the same instructions.

For help understanding your results, check out this post.

Good luck! And have fun.

The Basics of Infertility

What is infertility?

Infertility is defined as the inability to conceive between two partners despite unprotected intercourse for 12 months. 84% of couples will conceive within 12 months, 92% within 2 years.

There is also a difference between those men and women who have previously had children and those who have not. Primary infertility is when an individual has never had a child. Secondary infertility is when an individual has previously had a child. Certain conditions are more likely to cause primary and secondary infertility.

Once a couple has been determined to suffer from infertility an evaluation of both the male and female is indicated. 50% of the time a female factor is identified. 20% only a male factor is identified. And 30% of the time there is an issue with both partners.

The evaluation

The evaluation of women is typically performed by an obstetrician/gynecologist or reproductive endocrinologist. A thorough history of risk factors, such as surgeries, chemical exposures, STDs, will be conducted. Routine bloodwork, including hormone levels, are checked. An examination is also performed. Additional testing, such as an x-ray study to evaluate the female reproductive tract, called a salpingogram, may be performed. The goal is to figure out if there is a hormone issue or physical issue.

Men go through a similar evaluation with interview questions and blood work. The key difference, and most important test for men, is the semen analysis.

Semen analysis

The semen analysis will give you information about the volume, number of sperm, and how normal those sperm look and move.

In general, male infertility falls into one of several groups. Men who have low semen volume, men who have low sperm counts, men who have no sperm, men who have abnormal sperm.

For more information on understanding your semen analysis check out this post.


Depending on the type of fertility your physician may make various recommendations. These may range from supplements, to surgeries, assisted reproductive techniques, like IVF, or even adoption.

Understanding Your Semen Analysis

This is what a typical semen analysis report looks like. If you provided a good specimen and had the same findings on two separate specimens then these results should be accurate. I also have some information for you on the basics of infertility.

The semen analysis

semen analysis

The first thing to understand is that semen and sperm are different things. Sperm are the little swimmers that penetrate the egg for fertilization. Semen is the entire liquid that is produced with ejaculation. Not all semen will have sperm, but all sperm is in semen (for the most part).


The first thing we see is the color. Certain discolorations could suggest blood or infection. Certain foods and medications can also cause a change in color. An abnormal color may mean some additional tests are needed, such as PSA testing, urine testing, or culture of the semen.


Next is volume. This is the total amount of fluid you produced when you ejaculated into the cup. A high volume means nothing. A low volume usually, though not always, means that the fluid is being blocked or going in the wrong direction. If you have a low volume your doctor will often ask you to repeat the test and then collect your urine to see if the semen is passing into your bladder instead of out of the penis. This could be due to some nerve problems, medications, or surgeries.


Liquefaction is how rapidly the semen gel turns into a liquid. Infections and dehydration can cause abnormal liquification. This process relies on certain enzymes in the semen, so if those enzymes are abnormal due to genetic issues that could be another cause.


The pH of the semen should be greater than 7.2. A high pH could indicate infection. A low pH could indicate blockage of the seminal vesicles. An abnormal pH affects the sperm and the enzymes in the semen.


Viscosity of the semen can relate to infection or oxidative stress. It’s a measure of how thick or watery the semen is. Oxidative stress is when too many free radicals, or damaging particles, are present in the semen. If this is the case for you your doctor may recommend antioxidants such as vitamin C or E. When the semen is too thick it can inhibit the movement of sperm.

Sperm concentration

Sperm concentration is very important. When low this could mean that the sperm are being blocked from getting from the testicle to the penis, or that the testicles aren’t making enough sperm. You may hear the terms oligospermia and azoospermia. Oligospermia is a low sperm concentration and azoospermia is no sperm.

Sperm total count

The total count is the concentration multiplied by the volume. It gives a sense of the overall picture. Gallons of semen with no swimmers is useless, just like a drop of semen with millions of swimmers is useless.

Sperm motile count

The motile count is the sperm concentration multiplied by the volume multiplied by the percent motility. Along with the percent motility, these values give us a sense of how well the sperm you have are functioning. Having swimmers is good, but if they aren’t moving they aren’t useful. Low motility can be related to varicocele, diet, excessive heat to the scrotum (like hot tubs), obesity, and certain toxins.


Progression tells us how well the moving sperm swim. Are they moving in straight lines or just swimming in circles? If they can’t progress forward they’ll never find the egg to bind and penetrate. Poor progression can be due to abnormal genetics, smoking, and varicocele.


When the sperm clump together abnormally this is called agglutination. The sperm want to be free solo swimmers, but when they’re stuck together they can’t move. It’s like trying to run a three-legged race. Most commonly this clumping is due to anti-sperm antibodies, which occur when the body’s immune system targets the sperm.


The final component is the morphology, or how normal do the sperm look. Sperm with abnormal heads aren’t able to penetrate the outer layer of the egg. These sperm are also frequently found to contain abnormal DNA. Abnormal morphology can be due to abnormal genetics of the male, which cannot be fixed. Other causes can include toxic exposures and increased temperature, both of which can be improved. Depending on the findings on your analysis your doctor may ask for additional tests or recommend additional procedures.