The office evaluation of the infertile male involves a comprehensive history and physical structured to uncover all potential causes including congenital, medical, surgical, environmental, genetic, and psychosocial etiologies. The physical exam begins with the patient’s general appearance, body habitus, and progresses to the genital exam in which the testicles are examined for size, consistency, and location. Prior surgical scars, absence of the vas deferens, or the presence of varicoceles may be identifiable causes of infertility. The semen analysis is the cornerstone laboratory evaluation of the male undergoing an infertility workup. The semen is evaluated for several key parameters including volume as well as sperm concentration, number, motility, and form. An endocrine evaluation is indicated in men with oligospermia, azoospermia, or a history of physical examination findings suggestive of hormonal abnormalities including sexual dysfunction, decreased libido, or physical evidence of impair androgenization. Pending the initial workup genetic testing may be indicated.

About a year into Trump’s presidency, I sat on a flight home from Europe next to a twenty-year veteran of the US State Department. I asked him how things were going since Trump’s Secretary of State, Rex Tillerson, had taken charge. He hesitated for a minute but then explained that things weren’t going that well. Neither Trump nor Tillerson listened much to their career civil service professionals. Morale was as low as he’d ever seen it, several senior people had decided to take early retirement, and those remaining were often at odds with administration policies. He also said that because the State Department’s reputation had been tarnished because of Trump’s insulting and often isolationist foreign policies, it was having trouble recruiting young people to work there – a problem, he explained, that was creating a generational vacuum of expertise that would remain for years even after Trump was gone.

Donald J. Trump was sworn in as the forty-fifth president of the United States on January 20, 2017. How he won the presidency is the subject of this chapter. It is an important story for us because it foreshadows some of the leadership characteristics that he brought to the White House to launch his attack on the “deep state.” It’s also an important story because Trump’s election reflected a tipping point in American politics – a set of structural conditions and national anxieties that had developed gradually over several decades. Trump benefited from other tipping points once he became president, but this was the one that launched his startling rise to the presidency in the first place. Trump recognized and exploited this unique political opportunity to seize power.1 He was a maven whose inspirational promises and appeal to voters fit the times like a glove, enabling him to pursue his agenda for radical institutional change.

Upon leaving the Constitutional Convention in 1787, Benjamin Franklin is supposed to have been asked whether the framers had given us a monarchy or a republic. As legend has it, Franklin’s reply was short and sweet: “A republic, if you can keep it.” The principal difference between the two is the presence in a republic of free and fair elections – the institutional core of any democracy.

According to the old proverb, “An elephant never forgets.” Indeed, during severe drought in Africa, old elephants have been known to lead the herd to distant watering holes that they remember visiting only as calves sixty years earlier during previous dry spells. It’s ironic, then, that the Republican Party’s mascot is the elephant. The party used to be dedicated to traditional political norms and values, particularly those of civility and compromise.1 It also used to focus on economic and national security issues. Yet thanks to Donald Trump many in the party seem to have forgotten this. As a result, the party has embraced identity politics driven by anger, incivility, intolerance, and divisiveness. Trump alone was not responsible for this shift. For instance, figures like Patrick Buchanan, who twice sought the party’s presidential nomination, former Speaker of the House Newt Gingrich, and one-time vice presidential candidate Sarah Palin had been nudging the party in this direction for years, aided by the right-wing media. But Trump took this to unprecedented extremes that now dominate the party.2 The consequences have been dire.

America’s political institutions are the guardrails preventing our democratic system of government from plunging over the cliff into autocracy. But their durability and strength are not guaranteed, particularly when someone like the president of the United States – perhaps the most powerful person in the world – attacks them. Donald Trump laid siege to these institutions. Except for the Civil War, the damage Trump caused to the country’s guardrails was unprecedented. This book describes what happened and assesses the damage. But it also does something else that’s important.

The day after Donald Trump was elected president in 2016, I attended a panel discussion at the Brookings Institution in Washington DC. The panel included liberals, moderates, and conservatives. The moderator asked them why the election turned out as it did and what the Trump administration was likely to do during the next four years. The panelists offered a lot of different answers, and the debate was lively. But in the end, they all agreed on one thing. Given Trump’s promises to lay siege to the deep state, the next four years might be one of the toughest tests ever for America’s political institutions. They wondered how well the institutional guardrails of American politics and democracy would hold.