Georgie Kovacs interviewed Dr. Paul Gittens, one of the country’s leading specialists in sexual function for men and women, hormone replacement, male infertility and wellness. He is a board certified urologist, fellowship trained specifically in sexual medicine and male infertility. He is also a clinical associate professor in obstetrics and gynecology and founded the Centers for Sexual Medicine in Philadelphia and New York City.
Georgie: I appreciated hearing how empathetic your approach was at the recent Endo summit. At the ASRM conference last year, I heard data shared about men’s health. The information relayed was that men only go to a doctor if their mother, wife or sister recommend them to go. They have issues that they don’t want to deal with or don’t know how to deal with them.
While I often talk about a lack of awareness around women’s health, there’s a different aspect to look at for men’s health. There’s such a societal pressure for what men could or should be. I believe that impacts what men might seek help for. Given these dynamics, I thought it would be important to hear your wisdom.
Dr. Gittens: I totally agree. The physician at ASRM was correct in his statement. Most men don’t pay attention to their health until it’s really too late. This goes back to how men are socialized. When they’re younger, they’re taught to be tough and ignore aches and pains. And then as they grow older, in their teens and twenties, they feel like they’re indestructible. Then in their thirties and forties, they’re consumed with a career. In their fifties they realize that they maybe should have gone to a physician or paid attention to aches and pains. At that point, they’re fearful of undergoing exams and having issues like cancer or high blood pressure or diabetes.
Women are introduced to physicians a lot earlier than men. They’re introduced to their gyn and family practitioner a lot earlier than men which may mean they’re more comfortable than men.
Georgie: before we dive in further, I thought it would be helpful to give a little color around what you do to help men.
Dr. Gittens: I’m a board-certified urologist and have a clinical associate professorship in OB/GYN. Going through residency, I found that there was a need to treat men for sexual dysfunction. One of the main reasons was that, at that time, no one paid any attention to it. I had a personal experience where, as a resident, I was following a patient for prostate cancer. He had had surgery. One of my attendees came into the room and said, “your prostate cancer is healed. Your PSA is low. I operated on you and your cancer is non-existent.”
After he left the room, as a resident you’re taking notes and running around and I’m in the room by myself and the man started crying. I couldn’t understand why. After talking to him for about 20 minutes he told me that he was obviously ecstatic that his prostate cancer was removed but he suffered from low libido and erectile dysfunction. It was really disruptive for his relationships at home.
I took that experience and furthered my understanding in sexual health for both men and women.
Georgie: I didn’t know about that experience. Thanks for sharing that. It’s amazing how the little things that happen to us in life can lead in many ways.
Dr. Gittens: now my practice is varied. I treat men with erectile difficulties: low testosterone, problems with ejaculation and orgasm. We have a special program for sexual health after prostate cancer. Another large part of my practice is male infertility, which I also did a fellowship in.
Georgie: I have firsthand understanding of how the medical process works. I know there are urologists who treat men but that there are also specialties. Talk to us about the medical journey that men face when they have an issue and have to search for answers, especially with the cultural taboo that may factor in.
Dr. Gittens: if a man has any sexual dysfunction or male infertility, it’s a blow to who they feel they are as a person. It can affect their self-esteem. There are high rates of depression. It can affect their sexual and emotional relationships. It takes a lot for a male to feel comfortable enough to find help.
Usually, the first thing they’ll do is go on the internet. They search for terms related to their condition. After that, they’ll probably go to their urologist or primary care doctor. There are some issues with the system. Our traditional medical system doesn’t provide as much patient interaction. That’s part of the business of medicine. Oftentimes, they’ll go to their primary care doctor and speak for 5-10 minutes and then are rushed out. Then they may go to another PCP or urologist without the underlying problem being addressed.
I often see patients after they’ve seen 3-4 physicians. They’re tired of being shuffled around. We work through things pretty slowly to get to the bottom of the problem.
Georgie: what are some of the most common conditions that you tend to see in your practice?
Dr. Gittens: erectile difficulties with men. Erectile dysfunction (which I like to call erectile difficulties) is the inability to have an erection that allows a man to complete having intercourse. We break that down to a couple of different phases: initiation and maintenance. The causes of that vary. I see men that have had high blood pressure, diabetes, cardiovascular disease. It could be medication, neurological problems and even stress. These can all contribute to erectile dysfunction.
I may see men with low libido, which is just not having the urge to have intercourse. That is probably the second most common thing.
The third most common thing I see in the office is male infertility. If a couple is trying to conceive, the male or female may not have gotten a workup. We can do a semen analysis and see low sperm count or other problems.
Georgie: I know some people say, “why not just take Viagra”? It sounds like there are some underlying things men can do. I’d love to hear your thoughts around the medication and other options to support men.
Dr. Gittens: erectile dysfunction is not like breaking your arm. If you break your arm, everyone is healed in a similar way. Erectile dysfunction has so many different pathways. There are vascular pathways (blood pressure, cardiovascular issues), neurological components (Alzheimer's, parkinsons, stroke), hormonal issues (low testosterone, thyroid problems) medications (antidepressants, anti-psychotics, too much alcohol, recreational drugs). Another category used to be called “psychological.” Instead of psychological issues, I like to call this an adrenaline (epinephrine) mediated. When adrenaline increases, blood flow goes to the arms and legs for fight or flight. Anxiety due to previous failures or relational stress can cause blood to flow away from the penis.
PD5s, such as Viagra and Cialis are the most common medications and can be helpful. But with all of those pathways, there are many other options to help with ED. Hormonal pathways, such as increasing testosterone or balancing the thyroid. For some of the other pathways, you have to comb through those medications and find the ones that are contributing to the issue. If it’s a psychiatric medication, you have to partner with mental health care providers. Stroke is highly correlated to ED. We encourage better diets, losing weight, developing healthier lifestyles.
Going back to the types of therapies, there are a number that we use. Some are FDA approved, like Viagra and Cialis. We use core wave therapy, which is low-intensity wave therapy which can rehabilitate the penis. This provides better volume and rigidity. We use PRP. There are pumps and injectable therapy. As a last resort, we can surgically implant into the penis with a scrotum pump. There are tons of therapies out there but it starts with looking at an individual, figuring out what’s wrong with them.
We do ultrasounds of the blood flow to and from the penis. Armed with all of the information, we come up with an individual plan tailored to each person.
Georgie: what would you recommend to men when they are having these challenges? Should they first go to their PCP and then get recommended to a specialist? What is the path?
Dr. Gittens: first, they have to want to be helped. There are a lot of men out there who have a problem and don’t know where to go. They’re nervous about talking about it. First, being comfortable with a physician they can talk to. Then, finding a physician who takes this seriously. I take sexual health just as seriously as if someone had cancer. Maybe find a physician who was fellowship trained in this or has a practice that focuses on erectile difficulties.
In the sexual medicine society, there is a list of physicians that focus on sexual health. That would be a good place to start.
Georgie: you mentioned that the first step is wanting to get help. If they’re struggling, what would you say about handling the emotional state a man comes in with when trying to seek help?
Dr. Gittens: when an individual is looking for help, find a practice that takes a multidisciplinary approach. For example, in my practice with men that have a high adrenaline mediated ED, I have a network of psychologists and psychiatrists I can access to help with treatment. I also work with pelvic floor therapists. I have a number of things in place that provide the broadest range of treatment.
Talk to your primary care doctor. If they’re uncomfortable with treating the problem, ask for a referral. Be your own advocate. Find someone who is willing to help you and has the same desire for a good outcome as you do.
Georgie: at the Endo Summit when you presented you spoke a lot about how even clinicians are often uncomfortable talking to their patients about sexual health. Maybe you can elaborate a bit on that.
Dr. Gittens: as physicians, we’re not trained to talk about sexual intimacy at all. Most of our college years are in the library. In medical school, we study basic science and anatomy and physiology. Then, in residency, you focus on your field. Urology is mostly surgical as well as prostate cancer and kidney stones. Where is sexual health in our training? It’s not there.
When a patient goes to the office, the physician wants to use all of the tools they’ve been taught to use: medications and surgery. But there is an aspect that is missing. The physician has to be comfortable enough or have had the training to talk about these personal issues.
I’ve heard this so many times. A patient goes to an office and complains about sexual dysfunction. Defensively, a clinician may say, “well, you’re too old you don’t need to have intercourse” or “go read this book.” They may not have the right tools. Physicians want to be heroes and save the day. When they don’t have the tools, they may become self-conscious and say things that put patients in a position where they have to help themselves.
Georgie: my takeaway from that is that if anyone goes to a clinician and doesn't feel cared for, they shouldn’t give up but should find a place where they’re heard and listened to. If people are already in emotional distress about this and then have this experience, it could be easy to give up.
Dr. Gittens: I have many patients who feel better even after a first meeting, simply because they feel validated and heard. People carry this weight around. When they’re finally able to talk to someone who understands and listens, it can alleviate that burden.
Half of what I do is just listening carefully to patients.
Georgie: so, we’ve covered erectile difficulty. Now, let’s talk about number two: low libido.
Dr. Gittens: erectile difficulty absolutely impacts low libido. ED can increase depression and decrease feelings of self-worth, which erodes the desires for intercourse. Often, by fixing the erectile difficulties, we can increase libido.
Other issues that lead to lower libido are hormonal issues. As men age, they lose about 10% of their testosterone per decade. Where you start from matters. You can have issues with libido and erections.
Also, there are other pathways to libido that people don’t recognize. Dopamine is important for libido. We promote exercise to increase dopamine. There are studies for men and women who have higher libido from exercise.
Norepinephrine can increase libido. The important thing is to do the right testing and finding a plan for each patient.
Georgie: so, it seems like ED and low libido can be intertwined.
Dr. Gittens: I also see men who have good erectile function and low libido. We do hormonal panels and physical exams and then place them on medications if needed. The combination of increasing activities and lifestyle can make a positive difference. Higher muscle mass can increase testosterone. Decreasing stress can increase libido. Getting enough sleep can increase libido.
Georgie: the third area that you mentioned is male infertility.
Dr. Gittens: infertility in general - about 15% of couples have trouble conceiving. If you know 100 couples, 12-13 of them will have fertility issues. It’s extremely common. If you plug it in on the internet, infertility literature is primarily on female infertility. Not much on men. But if you look at the data, you’ll see that men actually account for about ⅓ of fertility (women account for ⅓ and ⅓ is from combined factors).
Even with a lot of emphasis on female infertility, men can contribute just as much. When you look at the data, men are hardly tested until the very end. The typical scenario is that a couple is having problems conceiving, a woman sees her gyn and gets referred to a fertility specialist, they do hundreds of thousands of dollars worth of tests and THEN they address men. Semen analysis: count may be low, motility may be low or issues with morphology. So, after a lot of money and time, attention then shifts to men.
There are a number of causes of male infertility: hormonal causes, physical issues (problems with testicle itself or veins), chronic illness, sexual problems, genetic problems, environmental issues.
My job is to rule all of those things out and either increase sperm count so they can have a natural conception or get their sperm counts to a point where they can go through IVF or IUI.
Another set of patients come in with no sperm count at all. My job is to do surgery where we go into the testicle and remove the sperm that’s present that doesn’t come into the semen analysis. This can be passed onto an IVF team so a couple can have a child.
Georgie: it does seem to be that women are looked at first and undergo a battery of tests. Often, late in the game, the men are looked at. I know there are start-ups now that are focusing on at-home testing for male fertility and more. Perhaps you can discuss the dynamic, though, of testing women first.
Dr. Gittens: it goes back to how men and women are different when it comes to healthcare. Women in general are exposed to the healthcare system a lot earlier than men. That dialogue they have with their primary doctor happens earlier.
Personally, the first time I saw a physician outside of immunizations was when I was in high school and needed an exam. After that, I hadn’t seen a physician for a long time. The access to healthcare is different. That’s a main driver.
There also isn’t a lot of education about male infertility: that it exists and that it is common. When couples are looking for reasons, the feeling is “it’s her,” even though that’s obviously not true.
When a patient goes to their physician, it’s female-focused and on trying to figure out why she has a problem. Doctors don’t really look at the male. That’s why you have seen these start-ups to promote testing for male infertility. The issue with start-ups that offer at-home semen analyses is that they only look at one factor. There’s also a margin of error in the tests.
You should come in for tests. This way, a physician can quickly address the issue in what could be a very simple fix.
Georgie: what are some other things that impact sperm count and what can be done to help it?
Dr. Gittens: in order to make sperm and testosterone, there’s a hormonal access that has to be intact. If you look at males that have fertility issues, a number of them will have lower testosterone. Testosterone is used by the sperm to mature. By carefully replacing testosterone (using medications that naturally increase testosterone), you can increase sperm count.
If a man has a pituitary lesion, it can inhibit hormonal responses. There are also some physical causes. Men may have had bilateral hernia repairs, which can cause obstruction of sperm. Some men have dilated veins in their scrotum. That can cause excess heat and oxidation, which lowers sperm count and motility. Chronic illnesses, such as fevers and any illnesses can lower sperm counts. There are toxins. Marijuana use and cigarettes or alcohol in some men can lower sperm counts. Also, genetics. Some men have particular genetic abnormalities which prevent them from either having sperm or having normal parameters that we look for in the semen analysis.
Georgie: one of the things that drives me is knowing that anything is possible. Somehow there’s a way to solve for a given challenge. You mentioned the “no sperm count” situation. I’d love for you to educate on us what happens if it is discovered that a man doesn’t have sperm count. Some say surgery. Some say it may not work. What are the realistic odds?
Dr. Gittens: 99% of the time, there is hope. When we look at no sperm count, my job is to figure out if it’s a problem with obstruction (the sperm isn’t coming out) or the factory (the production of sperm)? I’ll talk about the first one first.
In terms of obstruction, in order for sperm to travel from the testicles to the outside world, they have to get through a lot of tubes and area. If something is wrong with the transit system, then the semen analysis may not show any sperm. If there’s a problem with the vas deferens, the tube that carries the sperm to the prostate, or if there have been hernia repairs, it can obstruct sperm. Those are usually home run cases. With a physical exam and hormonal testing, we can go into the testicle itself and extract sperm and, from there, a couple can get IVF. Obstruction is almost never a problem for conception.
When it comes to manufacturing, it’s a little different. The way I explain it to my patients is: think of the testicle like a bucket of water. When the bucket overflows, we see that in the semen analysis. For some men, the bucket never overflows, so you don’t see it in the ejaculate. Then, we have to go directly into the bucket to release the sperm that can then be used for IVF. We use hormonal therapy to increase water in the bucket. Then, we go in and extract the sperm. There are conditions, genetic conditions, where there’s nothing we can do. It’s usually called a Y micro-deletion. On the Y chromosome, a certain area is just responsible for making sperm. If you have a deletion in that one arm on the chromosome, those are some of the only cases where we’re not able to do anything. That is fairly rare. The hope after that is something like donor sperm or adoption.
There are a lot of issues around this. Some men have had chemotherapy for cancer. In those situations, it just depends on what type of chemo they’ve used and for how long. Even in those cases, we can maximize the patient by placing him on hormone therapy and then going directly into the testicle. This can be very successful with IVF.
Georgie: what about vasectomy reversals? I’ve heard statements like, “oh, it was a bad reversal.” Maybe you can talk about that.
Dr. Gittens: there are about 500,000 men that undergo vasectomies every year. That’s the separation of the vas deferens. There are procedures that you can do. If a couple is interested in having a child after a vasectomy, their two options are to undergo IVF or to reconnect the tubes.
When we look at which patients are going to be more successful in terms of other patients for that surgery, we look at how long they’ve had their vasectomy. If you’ve had a vasectomy a year ago, you have a higher chance of success than if you had a vasectomy 20 years ago. That can also dictate the prognosis or success of a vasectomy reversal. Other things we look for are nodules. When we look into the vasectomy reversal, you have to look at who’s performing the surgery. For instance, in my training, we did microsurgical training. We use a large microscope and practice this 2-3 times a week. You only get that training if you’re doing a fellowship in urology or sexual medicine.
You need to choose the right patients and use the right surgical technique. Our success rate is really high but I also have treated a lot of men and done a lot of vasectomy reversal surgeries.
If you’ve had a failed reversal, you can go to a surgeon that will perform a redo reversal. Or you can go through IVF.
Georgie: I’d recommend that everyone go check out information from Dr. Gittens on his website. Men and women can benefit from learning about common conditions that are fixable.
What is some wisdom you would impart to make sure that men are optimizing their sexual health?
Dr. Gittens: everyone needs to be their own advocate. I’m a big believer in that. If you have a problem, don’t give up. You may see a physician that doesn’t give you the best advice. It’s up to you as an individual to go out and search for someone that is going to take care of your problem, whatever it might be.
Georgie: what would you say is your greatest hope for men’s health?
Dr. Gittens: men’s health is such a big topic. It starts when boys are young. It’s important that we instill in our young boys that we don’t have to be the tough guys. If something’s wrong, they need to talk about it. We also need to educate older men as well. By doing that, men’s health will improve.