Ahh Balls (The Testicle Edition)

“Ahh Balls” is an expression uttered quite a bit in my house. Apparently, it began with my father-in-law, Jack, who would use it somewhere between “gosh darn” and “oh shit” but always said it with a smile and a hint of irony. It’s the root of a lot of great Christmas and Father’s Day presents (a golfer always needs balls) at least one of which involved a box full of whiffle balls being dropped on his head. Our oldest daughter carried on the tradition last month when she gave these custom-printed tennis balls to my husband for his birthday. Jack passed away a few weeks ago at 91. He was a great guy—a varsity tennis player who spent summers as a cowboy and played guitar with the likes of Woodie Guthrie and the Clancy Brothers. And, he had a great sense of humor, so he would definitely have considered a newsletter about testicles with the title “Ahh Balls” to be a fitting tribute.

Where Have all the Sperm Gone?

A new book, with quite the alarmist title, has everyone worried about sperm counts. Count Down: How Our Modern World Is Threatening Sperm Counts, Altering Male and Female Reproductive Development, and Imperiling the Future of the Human Race was written by Dr. Shanna Swan, an epidemiologist at Mt. Sinai Hospital in NYC. Swan first made news in 2017 when she published a meta-analysis that found sperm counts in the Western world had fallen 59% between 1973 and 2011. In the book, Dr. Swan argues that if you project this decrease into the future, sperm counts hit zero by the year 2045 (though she acknowledges that such projections are risky).

There is little disagreement about whether sperm counts are dropping—it’s easy to collect and count the little swimmers. But the book has a lot of people debating what has caused it and whether it’s such a big deal.

Swan and others have focused on chemicals in our environment, specifically Phthalates, a type of chemical that is added to plastics to make them squishier and more flexible. Tests have shown that these chemicals do get into our bodies, at least in part by leaching from plastic containers into the food we eat. Swan says that these chemicals might trick our bodies into thinking we have more testosterone than we do. Testosterone production is like a thermostat, when it reaches its desired levels, it turns off, only turning back on when that level drops. So, if our bodies mistake other chemicals for testosterone, they could turn off production of this hormone, which would in turn impact sperm production. (It’s the same mechanism that leads to body builders who are doing steroids having super high-pitched voices; their bodies have stopped making testosterone which is responsible for male post-puberty sex characteristics.)

Swan—who also believes that these chemicals are responsible for higher rates of miscarriages and genital abnormalities—acknowledges that there are lifestyle factors (like diet, exercise, and smoking) that might also be at play, but still wants us to focus on environmental chemicals. She told USA Today: “The other lifestyle factors matter in a transient way. The reason I’m so focused on these early exposures to endocrine disruptors is because that’s never going to change, and it’s going to be passed on to later generations.” She’s calling on companies to rethink how they make chemicals and governments to better regulate chemicals and stop playing “whack-a-mole” where one chemical (like BPA) gets a lot of attention and is removed only to be replaced by another equally harmful one.

Not everyone agrees that there’s a direct connection between Phthalates and sperm production, however. Not surprisingly, the vinyl industry has taken umbrage. Vinyl Verified said on its website, “…a select number of competitive interests and agenda-driven activists have advanced a dishonest campaign to mislead consumers, and deny them their right to make their own decisions about vinyl.” (How many vinyl-adjacent decisions do you make every day?)

Others, without an interest in selling us siding or pleather pants, have said the research is not yet conclusive. Emily Oster, an economist who has written books to help non-scientists make sense of conflicting research on pregnancy and parenthood, explained in her newsletter (which you should subscribe to) that the research on Phthalate exposure has been mixed and depends on the methods authors use to measure it. And, she notes that we don’t yet know whether dropping sperm counts are impacting fertility. There are studies that show that older men who have lower sperm counts are no less likely to fertilize eggs through IVF. (Though in the harsh setting that is the female reproductive tract sperm count likely does matter.) Mostly, Oster says this doesn’t rank as something that we should spend too much time worrying about because the research is mixed and the elements within our control are few.

In a nutshell (see what I did there), it is definitely too early to be announcing the Phthalate-induced end of the human race and possibly even too early to suggest we all switch back to glass containers for storing our food (though I am tempted).

Prostate Cancer Screening Down in the Pandemic
(But it Might not be a Problem)

Trips to the doctor dropped in 2020 for obvious reasons. At the beginning of the pandemic, many offices were closed and even when they opened up, many of us stuck to video checkups if anything. As a result, cancer screenings—from mammography to colonoscopies to PSA tests for prostate cancer—have gone way down and there is a fear that we’ve missed out on early diagnosis for many patients.  

A study of a large medical claims database found that screenings for prostate cancer dropped 56% by the peak of the pandemic in April. Another study, of a large group practice in Massachusetts, found that PSA screenings in 2020 decreased 48 percent in March, 83 percent in April, and 67 percent in May compared with the same months in 2019, but by June they were back to pre-pandemic rates.

Some doctors are concerned. Neal Shore, a urologist and Medical Director, Carolina Urologic Research Center, told media outlets, “…as a physician treating men with cancer on a daily basis, [it] makes me concerned that prostate cancer may not be detected in its earlier stages when outcomes are typically better for the patient.” Dr. Mitchell H. Sokoloff, a  professor of urology at UMASS in Worcester, agrees. He usually sees patients who are referred for biopsies after a high PSA test and is worried because these visits are down 25% in his practice.  

But the truth is there has been a debate for years about whether regular PSA tests are worthwhile. Prostate-specific antigen (PSA) is a protein produced by tumors in the prostate tissue that can be detected in the blood. The test, which looks for elevated PSA levels in the blood, was initially developed to screen for recurrence in men who had already had prostate cancer, but in 1994 it was approved for widespread screening (much to the chagrin of its inventor). Prostate cancer death has gone down since the test but there are other factors such as improved treatment that could also be at work.

The problem is that PSA can be produced by non-cancerous tumors or cancerous tumors that are so slow growing, they would never become life-threatening even without treatment. By some accounts, the test is wrong 80% of the time (78% false-positive rate plus some false- negatives). On a population level this means we spend billions of dollars on a test that may be wrong more often than it is right. And, on a personal level, it means that many men are faced with unnecessary worry and disturbing choices about whether to treat or simply live with a cancer that may never cause a problem.

The American Urological Association stopped recommending universal PSA screenings in 2013. At this point, most medical organizations suggest men in their 50s talk to their doctors about whether they should test. Men who have risk factors—including race (prostate cancer rates are higher in Black men though we don’t know why), a family history of prostate cancer before the age of 65, or the BRCA1 and BRCA2 gene—may want an annual PSA test. Interestingly, experts agree that it doesn’t usually pay to screen men over 70 for this slow-growing cancer. 

For a number of years medical organizations were also recommending that men get an annual digital rectal exam (where a doctor inserts a finger into the anus to feel the size and shape of the prostate) as another way to check for prostate cancer. I actually remember when General Norman Schwarzkopf, fresh from his Desert Storm fame and his own cancer diagnosis, was on the Today Show as the face of this new screening recommendation. But as of 2018, this is no longer recommended because of a lack of evidence that it was useful.

In years to come, researchers will undoubtedly use the pandemic testing slowdown to determine how many prostate cancer cases that would have been detected were not and follow the outcomes of those patients. Hopefully, that will give us a better answer to the question of whether and when to get screened. In the meantime, people between the ages of 50 and 70 with prostates should find out what their doctor recommends.

Can Probiotics Make Your Balls Bigger?

A male health vlogger and founder of a supplement brand has gotten a lot of hits on a video in which he claims he grew his testicles over a two week period by taking probiotics—and then offered to sell viewers just the right pill for a mere $45 a bottle. I’m highly skeptical of his one-man study results but not ready to tell him “that’s not how it f**king works.”

As Mel Magazinepoints out, there is at least one study in mice that shows drinking water laced with Lactobacillus reuteri had a positive impact on their testicles. They made more sperm and had larger testicles than their peers who were given the same diet but plain old water. It’s not clear if their testicles actually grew from their starting point but it does appear that they staved off atrophying which happens to mice and men as they age. Their bodies make less testosterone which leads to some shrinkage and a drop in sperm count. In short, the rodents on probiotics had testicles of mice half their age.

There’s no way of knowing yet if these results translate into humans with testicles though lactobacillus—which is found in yogurt, sauerkraut, and Kombucha, as well as tons of probiotic supplements on the market—has some proven results in helping with digestion and fungal infections like yeast. I haven’t quite figured out why the vlogger and the 1.3 million people who watched his video are so eager for bigger balls though I fear it’s related to the dangerous misconception that bigger is better when it comes to all things masculine. Still, a couple of probiotic capsules or an extra yogurt for breakfast probably can’t hurt.