Author: Akash Kapadia, MD

What to Know About Testicular Mapping

Posted on July 12, 2023July 12, 2023 by Akash Kapadia, MD in Azoospermia, Low Testosterone, Male Fertility

While there’s plenty we don’t know, we have learned a lot about male fertility and reproduction over the past few decades. One of the most exciting areas of research and advancement has been in the management of male fertility concerns. Nonobstructive azoospermia was at one time considered difficult or impossible to treat, yet now, many men with no detectable sperm in their semen have become fathers. Today, there are several sperm extraction techniques available to these men, but most are invasive. As such, there has been a need for minimally invasive diagnostics to see whether sperm can be found in the testes.

This is where testicular mapping or FNA mapping comes into play. Testicular mapping is a highly effective, mildly invasive diagnostic procedure in which the testicles are mapped using fine needle aspiration. During the procedure, testicular tissue samples are removed and then analyzed to see if sperm is present. This has been a game-changer for patients that once only had the more invasive micro-TESE as their only option. The following information on testicular mapping should be of interest to men suffering from Azoospermia.

We expect to find sperm in about 50% of men with azoospermia
Over 30% of men are eventually able to become fathers as a result
It’s a Less-Invasive, similarly effective diagnostic option versus a Micro-TESE
It doesn’t reduce testosterone levels appreciably
Only a few physicians perform it around the US

Why a Second Procedure?

Knowing that testicular mapping is purely a diagnostic procedure, why wouldn’t we just use a micro-TESE that allows for both diagnosis and treatment? The answer is simple. About 50% of men with nonobstructive azoospermia do not have viable sperm in the testes. Both testicular mapping and micro-TESE are very good at identifying patients with viable sperm, but the micro-TESE does so in a much more invasive manner. That means that about 50% of our patients will have an unnecessarily invasive procedure that inhibits their lives and lifestyles and may even cause longer-term low testosterone.

Will It Hurt?

One of the best qualities of testicular mapping is how minimally invasive it is and how little the procedure hurts. To be sure, there will be some discomfort after the procedure as the anesthetic wears off. However, anesthesia is administered during the procedure, and patients do not feel appreciable discomfort. On the other hand, a micro-TESE can cause significant discomfort during the recovery period.

Is Micro-TESE a Bad Procedure?

While the above discusses the downsides of a micro-TESE versus testicular mapping, understand that these limitations are only in the diagnostic realm, and that is why Dr. Kapadia is one of the few urologic surgeons around the country to offer testicular mapping. However, as a sperm extraction procedure (something that testicular mapping cannot do), micro-TESE is the gold standard. If we know there is viable sperm in the testes, a micro-TESE is the most effective way to extract it and help our patients become fathers.

In short, working with Dr. Kapadia to optimize a diagnostic and sperm extraction plan can save time and discomfort in appropriate patients. Dr. Kapadia sees azoospermia patients from all over the southeast United States, and we look forward to scheduling a consultation with you to learn more about the diagnostic options that you may have.

When to Consider a Penile Implant for Erectile Dysfunction

Posted on June 28, 2023August 2, 2023 by Akash Kapadia, MD in Erectile Dysfunction, Penile Implants

Erectile dysfunction (ED) is the persistent inability to achieve or maintain an erection sufficient for sexual satisfaction. It is a prevalent condition affecting up to 30 million men in the United States and 150 million worldwide. ED can significantly impact a man’s quality of life and intimate relationships. Luckily, numerous treatment options exist for ED, which range in invasiveness and cost. These include oral phosphodiesterase type 5 (PDE5) inhibitors (e.g., sildenafil, tadalafil), intraurethral alprostadil, penile injections, and vacuum devices. However, if these methods fail to provide satisfactory results or are contraindicated due to medical conditions, a penile implant may be worth considering. However, it can also be regarded as a first-line treatment through shared decision-making. This article explores the circumstances under which patients could contemplate a penile implant as a treatment option for ED, discussing the procedure, benefits, and potential risks involved.

Some situations that may warrant the consideration of a penile implant include:

Non-Responsiveness to Medications: If oral medications or other ED treatments do not produce the desired results, a penile implant may be a viable alternative.
Anatomical Abnormalities: Certain anatomical abnormalities, such as Peyronie’s disease (scar tissue formation in the penis) or severe congenital penile curvature, can coexist with refractory ED. In such cases, a penile implant can help overcome these physical limitations.
Underlying Medical Conditions: Individuals with medical conditions like diabetes, spinal cord injuries, or prostate cancer treatments (e.g., radical prostatectomy) may experience persistent ED that does not respond well to conservative treatments. A penile implant can offer a solution in these cases.

There are two primary types of penile implants: inflatable and malleable.

Inflatable Implants: This type consists of inflatable cylinders placed in the penis, a fluid-filled reservoir, and a pump. The cylinders fill with fluid by squeezing the pump in the scrotum, creating an erection. After intercourse, the liquid is transferred back to the reservoir, deflating the implant. The reservoir is typically placed within the pelvis through the same incision used to place the implant.
Malleable Implants: Malleable implants, also known as semi-rigid implants, consist of bendable rods inserted into the penis. They allow the individual to position the penis for sexual activity manually. Unlike inflatable implants, malleable implants do not require a pump or reservoir. However, the same level of natural flaccidity is not achieved with a malleable.

Penile implants offer several benefits for individuals with persistent ED:

Reliability: Penile implants provide a reliable and on-demand solution for achieving and maintaining erections.
Spontaneity: Unlike other treatment options that may require planning or timing, penile implants allow for spontaneous sexual activity.
Improved Satisfaction: Across multiple studies, penile implants have been shown to have up to a 90% patient and partner satisfaction rate. This high satisfaction rate makes sense as penile implants can restore sexual function and enhance overall well-being.

However, it is essential to consider the potential risks associated with penile implants, and discussing these factors with a physician is crucial before making a decision:

Infection: While rare, the risk of developing an implant infection is between 1 and 3%. Infection risk is higher in the following situations: replacement or revision of penile implant, immunosuppression, poorly controlled diabetes, and pre-existing infection anywhere else in the body. In case of penile implant infection, the device must be removed, the cavity washed out, and new placement.
Mechanical failure: As with any mechanical device, there is a chance of breakdown of the components over time, requiring reoperation. The risk of mechanical failure is 5% at five years after device placement.
Intraoperative complications: Complications during the operation are exceptionally rare. However, one notable complication is an injury to the urethra, which requires abandoning the surgery and waiting to place the implant when the urethra has healed.

When traditional treatment options for ED prove ineffective or unsuitable, a penile implant can be considered a viable solution. It offers individuals a reliable and on-demand method to regain sexual function, improving quality of life and intimate relationships. However, the decision to pursue a penile implant should be made after carefully considering the individual’s unique circumstances in consultation with Dr. Kapadia.

Debunking Common Vasectomy Myths

Posted on June 14, 2023August 2, 2023 by Akash Kapadia, MD in Vasectomy

Vasectomy is a safe, effective, and permanent method of male sterilization. Despite its widespread use, numerous misconceptions and myths surround this procedure. These misconceptions often deter men from considering a vasectomy. In this article, we aim to debunk some of the most common myths about vasectomies. By separating fact from fiction, we hope to clarify and enable men to make informed decisions about their reproductive health.

Myth 1: Vasectomy Is Immediately Effective

While vasectomy is an effective contraceptive method, it does not immediately render a man infertile. After undergoing a vasectomy, sperm will initially remain within the reproductive tract, which can potentially lead to pregnancy. It takes time and several ejaculations to fully clear the remaining sperm from the vas deferens and seminal vesicles. Men should continue using contraception until follow-up semen analysis in the office 8 to 16 weeks postoperatively demonstrates no sperm. Before this testing, men should perform at least 10 to 20 ejaculations.

Myth 2: Vasectomy Is Irreversible

Contrary to popular belief, vasectomy is not always irreversible. While the procedure is intended to be permanent, options are available for men who later decide to father children.
It is possible to restore fertility through a procedure called a vasectomy reversal, which is performed microscopically. Surveys suggest 2 to 6% of vasectomized men will ultimately seek reversal. It is important to know that this surgery is often expensive and not covered by insurance.

Myth 3: Vasectomy Is Painful

Many men avoid vasectomy for fear of pain and discomfort during the procedure. However, vasectomy is a relatively quick and straightforward surgical procedure. Most vasectomies are performed using local anesthesia, which numbs the area and significantly reduces pain. The process typically takes 15-30 minutes and involves making a small incision in the scrotum to access the vas deferens. Some men may experience mild discomfort or soreness post-surgery, but this can be managed with over-the-counter pain relievers and ice packs.

Myth 4: Vasectomy Increases the Risk of Prostate Cancer

In the past, men with vasectomies were believed to have a greater risk of developing prostate cancer. However, numerous studies have investigated this association, and the overall scientific evidence does not support a causal link between vasectomy and prostate cancer.

Myth 5: Sex Will Not Be as Pleasurable After a Vasectomy

Many men express concern that undergoing a vasectomy will reduce their sexual pleasure. However, it’s important to understand that vasectomy only interrupts the delivery of sperm during ejaculation. Vasectomy does not affect any of the nerves in the penis, so sensitivity or pleasure will remain unchanged. It also does not affect testosterone production, libido, or the ability to achieve and maintain an erection. Further, the freedom from worrying about unplanned pregnancies may make sex even more pleasurable for both partners.

Myth 6: Men Who Undergo Vasectomy Ejaculate Less

It is a common misconception that a vasectomy will reduce a man’s semen volume. However, the testicles contribute only about 5% of your semen volume. The remaining 95% is produced by the prostate and seminal vesicles, unaffected by a vasectomy.

Vasectomy remains a highly effective and reliable option for men seeking permanent sterilization. We hope to encourage men to make informed decisions about their reproductive health by dispelling common myths surrounding vasectomies. Men considering a vasectomy must consult a healthcare professional who can provide personalized information and address concerns.

Research Suggests That THC Use Has an Effect on Fertility

Posted on May 24, 2023June 1, 2023 by Akash Kapadia, MD in Male Fertility

As if the number of fertility-issue-causing concerns wasn’t long enough, recent (2021) research¹ has shown that regular consumption of THC, the psychoactive compound of marijuana, is potentially harmful to male fertility. The study showed that in current and past human users, marijuana had a significantly higher risk of abnormal sperm morphology versus non-users. Semen volume was also lower in current and past users.

Another study² conducted on non-human subjects (rhesus macaque monkeys), giving them daily THC, showed the testes of the animal subjects reduced in size and increased fragmentation of DNA. These associations were directly correlated to increased use.

Continue reading “Research Suggests That THC Use Has an Effect on Fertility” →

Comparing Micro-TESE and FNA Mapping / Testicular Mapping

Posted on May 10, 2023June 1, 2023 by Akash Kapadia, MD in Azoospermia

Non-obstructive Azoospermia is a concerning condition for any man. There are physical implications, of course, in that there’s no sperm in the semen, and the man cannot become a biological father. However, psychological considerations can also make azoospermia defeating. Many men find it very difficult to learn that the only option is relatively invasive microscopic surgery called MicroTESE which carries a 50% or less chance of finding sperm.

For most men, an alternative to the costly and invasive MicroTESE is a minimally invasive procedure known as testicular mapping (fine needle aspiration mapping). Unfortunately, there are very few reproductive urologists (male fertility specialists) around the United States, including Dr. Kapadia, who perform testicular mapping for azoospermia. As such, Dr. Kapadia sees patients from all over the US who are interested in this procedure.

Continue reading “Comparing Micro-TESE and FNA Mapping / Testicular Mapping” →

Nitric Oxide and Its Role in Erectile Dysfunction

Posted on April 26, 2023April 28, 2023 by Akash Kapadia, MD in Diet, Erectile Dysfunction, Supplements

Several potential issues can cause or worsen erectile dysfunction. Many of these are discussed on our website. However, some are less discussed yet worthy of mention and attention; one such potential cause is a deficiency in nitric oxide. Nitric oxide, or NO, is a gas molecule that most cells in the body produce. It is an integral part of how our body functions and plays a role in activating the enzymes in blood vessels that, among other things, help make a normal erection. As we age, however, the body produces less nitric oxide (which is the case for many essential bodily functions).

While the prevalence of erectile dysfunction continues to be researched, studies have shown that about 20% of the United States male population and 50% of those aged 40 to 70 years may suffer from moderate ED. Greater than 60% of men over 70 may suffer as well. This data is from the early 2000s, and the obesity epidemic, for example, has significantly worsened so those prevalence figures may be even higher.

Continue reading “Nitric Oxide and Its Role in Erectile Dysfunction” →

Should You Drink Less if You Have BPH?

Posted on April 12, 2023April 28, 2023 by Akash Kapadia, MD in BPH, Diet

While benign is in the name, it sure doesn’t feel like it to patients suffering from Benign Prostatic Hyperplasia (BPH). At first, many patients think they may have prostate cancer. They are relieved to learn that most cases of symptomatic lower urinary tract symptoms are not caused by a malignancy but rather this ubiquitous normal part of the aging process. However, BPH only tends to get worse as the cells in the prostate continue to grow. The result is often nocturia, in which the patient wakes for a visit to the bathroom multiple times each night, often causing disrupted sleep and constant daytime fatigue. As such, many patients think that reducing their water intake will solve the issue.

Ultimately, drinking fewer fluids to try to avoid the symptoms of BPH doesn’t work and may be counterproductive. For one, it is critically important that you stay hydrated for continued health. This is not just the health of your urinary system, but every bodily function depends on proper hydration. Even mild dehydration has significant physical and psychological consequences. Further, dehydration can make your lower urinary tract symptoms worse. Lack of fluid intake can cause bladder irritation as the urine is more concentrated. The result? You guessed it! An urge to urinate more frequently. It can also cause significant kidney issues that, once again, can create problematic urinary symptoms.

Continue reading “Should You Drink Less if You Have BPH?” →

Could How You Grow Your Hair Be Causing ED?

Posted on March 15, 2023April 28, 2023 by Akash Kapadia, MD in BPH, Erectile Dysfunction

One of the most concerning issues that male patients discuss with their friends or physicians is hair loss. For many, hair is a sign of virility, and despite the inevitability of male pattern, baldness, which ultimately comes down to genetics, we still fight for that hair tooth and nail. It’s no wonder that hair restoration has grown to be such a huge industry and is rife with therapies that work and others that many claim to be effective but don’t have much data to support the assertion. From micro-needling rollers to caffeine ointment, red light therapy, various essential oils, and medication, there’s an overwhelming amount of information to process and seemingly impossible decisions to make.

Enter Finasteride

Finasteride is a drug known as a five alpha reductase inhibitor. Its main claim to fame is the very effective blockage of dihydrotestosterone (DHT (finasteride blocks upwards of 90% of DHT in the prostate and 70% in the blood)). DHT is essential to the normal workings of our bodies and is instrumental in developing male characteristics. However, excess DHT on our scalp later in life can cause hair follicles to shrink and ultimately die. By controlling the DHT systemically via the oral intake of finasteride or locally through topical applications, we see some of the very best hair regrowth results of any therapy.

It’s worth understanding that finasteride was not developed as a treatment for hair loss but rather to slow the growth of the prostate to fight a natural process known as benign prostatic hyperplasia (BPH) that affects most men later in their lives. However, it soon became clear that men taking this drug grew more hair on their scalps, and you have the ubiquitous drug we are used to hearing about today.

The Side Effects of Finasteride

For all its benefits, Finasteride has some potentially significant side effects. They mostly revolve around the effects of very low DHT, including low libido, reduced general function, depression in some, and even erectile dysfunction. These effects seem more pronounced when finasteride is taken orally, but the topical version can also be problematic. Younger men seem to have greater side effects than their older counterparts. As such, if you are currently using finasteride therapy for hair loss and having difficulty maintaining an erection, you may wish to speak to Dr. Kapadia to understand more about the systemic effects that both the oral drug and, to a lesser extent, topical application can cause.

What Is the Answer?

If you look up the recommended dosages of oral finasteride, you may be shocked to see how varied they are. Dosages from .5 mg up to 5 mg are routinely prescribed. Why so much variance? We all react differently to finasteride; no single dosage makes sense for every patient. However, as with most drugs, we strongly encourage working with your primary care physician, urologist, and hair loss specialist, to take the minimum effective dose. This helps ensure the drug can take effect while minimizing its potential, side effects, and considerations. This dosage can, of course, be modified to find a sweet spot. And patients should be aware of how their body reacts in the days and weeks after changing their dosage.

It’s also important to remember that finasteride may not cause erectile dysfunction and that aging is making it more difficult for you to achieve and maintain an erection during intercourse. In this situation, we can work with you to develop an erectile dysfunction treatment plan, including medication like sildenafil (generic Viagra) or tadalafil (generic Cialis), or for more severe erectile function, problems, course of injections, or even a penile implant.

Most importantly, speak to us about this and any other erectile function issues he may have. While it may feel awkward to have that conversation, we’ve helped thousands of men with the same problem, and want you to rest, assured that it is nothing to be ashamed of. Ultimately, erectile function can be achieved, no matter how bad your condition.

Male Infertility and Testicular Heat

Posted on February 22, 2023February 22, 2023 by Akash Kapadia, MD in Male Fertility

You probably heard it at some point in your life – stay away from those “tighty whiteys.” It may seem like a trivial piece of advice that was never fully explained to you as a child or young adult. However, it is a warning rooted in excellent science and can make a difference in a man’s fertility.

To understand precisely how the proper function of the testicles makes a difference in male fertility, we need to understand more about the anatomy. There is a good reason why the testicles hang outside of the body exactly the way they do – for temperature regulation. Sperm production and quality are most efficient at several degrees below average body temperature – around 93 degrees Fahrenheit.

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Why Can It Take So Long to Regain Erectile Function After Prostatectomy

Posted on February 8, 2023February 8, 2023 by Akash Kapadia, MD in Erectile Dysfunction

In the early days of radical prostatectomy, the anatomy of the prostate remained poorly understood. Erectile dysfunction occurred in all men who underwent a prostatectomy in those times. However, with an improved anatomic description of the prostate several decades ago, we began understanding the erectile nerves that envelop the prostate gland. This led to the advent of a procedure known as a nerve-sparing radical prostatectomy, which is now performed most often robotically. Despite taking great care in sparing the erectile nerves with the incredible 3-D visualization of robotic technology, virtually all men still get erectile dysfunction temporarily. Many fortunately regain erectile function over the period of months to a year. This is not to say that the nerve-sparing feature of the surgery is not essential. Quite the opposite. However, it has become evident that the involvement of other structures during surgery contributes to ED.

How Long Does Erectile Dysfunction Last After Prostatectomy?

Despite the nerve-sparing nature of the surgery, most patients experience ED that lasts beyond the physical recovery time after a prostatectomy. We expect most patients to regain erectile function in one to 12 to 18 months. That is considered the goal; for some, it can take up to two years. Up to 50% of patients may never regain erectile function and will need to consider alternative treatment options.

What Can Be Done?

For patients that require a prostatectomy to address fast-growing or aggressive prostate cancer, the best option is to visit a urologist and men’s health specialist like Dr. Kapadia, who has a specific program for patients with post-prostatectomy impotence. Our program follows a stepwise approach to address the two most common and disruptive concerns a man will face after a prostatectomy – ED and urinary incontinence. The first phase starts soon after cancer treatment and will include daily 5mg Tadalafil, generic Cialis, or Sildenafil, generic Viagra, on demand. If necessary, we may move on to injection therapies and other proven rehabilitative options. For most, this will improve erectile function satisfactorily; however, for some, we may need to continue to the restoration phase of treatment if we do not see results within the first year to 18 months. That said, we don’t give up because everyone’s anatomy is different, and there is no linear improvement in erectile dysfunction. Learn more about Dr. Kapadia’s post-prostatectomy rehabilitation and restoration program.

The Long-term Solution

For those who have not regained satisfactory erectile function after 12-18 months, there is a good chance that the dysfunction will not reverse. At this point, it is time to discuss an inflatable penile prosthesis, also known as a penile implant. Penile implants carry a very high satisfaction rate for couples and represent an elegant solution to a complex problem. The implant is completely customized to a man’s anatomy and provides a natural-appearing erection. Most importantly, the sensation, the ability to climax, and urination are completely unchanged. This means a man can enjoy a full and normal sex life with their partner.

For more information, we encourage you to contact our office to explore erection rehabilitation options after prostatectomy. If you are experiencing erectile dysfunction for any reason, we can discuss the possibility of a penile prosthesis.

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