The Fertility Expert: Delaying Having Kids Is Impacting Your Future Children & Reducing Your Chances Of Parenthood By 90%! Masturbation Reduces Cancer Risk!

0:00:02 ♪ Dance through it all ♪
0:00:03 – From the director of The Greatest Showman
0:00:05 comes the most original musical ever.
0:00:07 – I want to prove I can make it.
0:00:08 – Proof to who?
0:00:09 – Everyone.
0:00:12 So, the story starts.
0:00:13 – Better Man.
0:00:15 Now playing in select theaters.
0:00:17 – Men need to understand the average age of the father
0:00:19 has gone up about three and a half years.
0:00:22 And with that, the chance of problems with the child
0:00:23 also can increase,
0:00:25 and that pregnancy becomes a lot riskier.
0:00:26 And this is why.
0:00:29 – Dr. Michael Eisenberg is an expert
0:00:31 in male sexual function and fertility
0:00:33 who’s helping us to learn the truth
0:00:35 about optimal sexual health.
0:00:36 – If you just look at all the data,
0:00:37 sperm counts are declining.
0:00:40 But low sperm counts is in low testosterone
0:00:41 could have devastating effects.
0:00:43 For example, men with lower semen quality
0:00:45 have higher risk of death.
0:00:46 – Wow.
0:00:47 – There’s a lot of really interesting questions
0:00:48 that need to be answered.
0:00:49 – Okay, let’s get into that.
0:00:51 Is there any evidence that the chemicals
0:00:53 in our environment are impacting our sperm count
0:00:54 and our testosterone levels?
0:00:55 – Yes.
0:00:57 It’s a chemical that’s in a lot of creams
0:00:58 and lotions that we use.
0:00:59 And then there’s a chemical that’s used
0:01:01 in the manufacturer of plastic,
0:01:02 and that could have pretty devastating effects.
0:01:05 And so don’t drink out of plastic water bottles.
0:01:06 – What about hair loss?
0:01:08 Couldn’t figure out if low testosterone
0:01:10 or high testosterone causes a receding hairline.
0:01:11 – Most men are not going to like this,
0:01:13 but it turns out that.
0:01:14 – If I’m sat down all day,
0:01:16 is that going to have an impact on my sperm count?
0:01:18 – There are studies that do support that.
0:01:19 I would say take breaks,
0:01:20 stand up to try and air out the area.
0:01:23 – What can I do to give myself the best possible chance
0:01:25 of increasing my fertility?
0:01:26 – So there’s a lot that we can do.
0:01:27 And usually we start with.
0:01:29 And then erectile dysfunction.
0:01:31 – Hundreds of millions of men all over the world
0:01:32 have trouble with erections,
0:01:33 but as long as you have a penis,
0:01:35 we can always make it hard.
0:01:37 For example, we can teach men to give themselves.
0:01:40 – Oh, I just got shivered down my body.
0:01:43 – But it probably works 80 to 90% of the time.
0:01:46 – Congratulations, Diary over CO gang.
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0:02:10 Thank you and enjoy this episode.
0:02:13 (upbeat music)
0:02:18 Dr. Michael Eisenberg,
0:02:22 why do you do what you do and what you do?
0:02:24 – It’s a pleasure to be here.
0:02:25 Certainly an honor.
0:02:28 I kind of see myself as a researcher
0:02:30 and advocate for men’s health,
0:02:31 and men’s reproductive health, sexual health.
0:02:34 And so, I think when I see patients in clinic,
0:02:36 that’s what I’m trying to do to try and understand
0:02:38 where they’re coming from and the issues they have
0:02:40 and find out ways that we can work
0:02:41 and improve them together.
0:02:43 And certainly from my research perspective,
0:02:46 I always wanna try and define what the issues are
0:02:51 and just improve our treatments that we have for men.
0:02:54 I am the director of male reproductive and sexual health
0:02:58 at Stanford or men’s health in the Department of Urology.
0:02:59 I have a joint appointment
0:03:01 in the Department of Obstetrics and Gynecology
0:03:03 because fertility is a team sport.
0:03:06 And so, I also help couples and I refer women
0:03:09 to the female side and just like I get lots of referrals
0:03:13 from them when we’re kinda worried about the male partner.
0:03:14 – When you say sort of reproductive health,
0:03:16 what are all the sort of things that fall
0:03:19 within that bucket or underneath that umbrella?
0:03:23 – So, I think, you know, reproductive health really,
0:03:25 I mean, I guess it’s sort of name implies
0:03:27 would be, you know, trying to have a baby.
0:03:28 But I think it’s so much more than that
0:03:30 because I think what we’re really learning
0:03:32 is that, you know, fertility is kind of a window
0:03:34 into future health.
0:03:36 Probably about 10% of the male genome
0:03:38 is devoted to reproduction.
0:03:40 And given there’s only about 25,000 genes in the body,
0:03:42 you know, it makes sense that some genes that are operating
0:03:46 and reproduction also operate in another organ system.
0:03:48 There was a study done where they took biopsies of men
0:03:50 that had trouble making sperm
0:03:52 and tried to sort of replicate these cells.
0:03:53 And they found that these cells had very high rates
0:03:55 of mutations in their DNA.
0:03:57 So you can imagine, you know, sort of for checks
0:03:59 and balances when we’re making sperm,
0:04:02 it makes sense if you can’t sort of faithfully replicate
0:04:04 your DNA, you know, there’s probably not,
0:04:05 there’s probably gonna be some blocks
0:04:06 where you can’t make a sperm, right?
0:04:08 If there’s gonna be mutations.
0:04:10 But also these men may be set up for other problems, right?
0:04:12 Like cancers or something like that.
0:04:13 If, you know, the body can’t, you know,
0:04:16 effectively replicate cells or DNA.
0:04:18 There could also be sort of hormonal links.
0:04:19 And that’s another thing that we commonly look at
0:04:22 more evaluating men with infertility.
0:04:25 Infertile men actually have lower testosterone levels
0:04:26 than fertile men.
0:04:29 So, you know, there’s also been studies
0:04:31 that show that men with lower testosterone levels
0:04:34 have, you know, sort of lower survival.
0:04:37 So it may be that, you know, kind of hormonal links
0:04:38 between fertility may kind of put men
0:04:41 on a different, you know, trajectory.
0:04:43 You know, another, I think very sort of important aspect
0:04:45 of reproduction, you know, there’s other kind of,
0:04:47 what I call sort of social factors
0:04:49 that are sort of at play.
0:04:51 You know, things that kind of necessarily
0:04:52 go with reproduction.
0:04:56 So like having a partner and having kids, hopefully.
0:04:57 And it turns out that those factors
0:05:01 actually are very important for health and longevity.
0:05:06 So like having a partner actually increases survival.
0:05:09 So if you like compare, sort of, if you have like,
0:05:11 you know, a man with a partner and a child,
0:05:13 if you then take away the partner,
0:05:15 the chance of that man dying goes up 60%.
0:05:18 And then if you take away just a child,
0:05:21 the chance of him dying goes up 60%.
0:05:23 But it turns out if they’re,
0:05:25 both of those things are absent,
0:05:27 that man has a three-fold higher risk of death
0:05:29 than somebody with a partner and a child.
0:05:33 So there’s really kind of this sort of important aspect,
0:05:35 I think, to health and reproduction,
0:05:37 I think, that men kind of need to understand.
0:05:39 And then obviously there’s also just a lot of,
0:05:41 you know, kind of intrinsic things that we do,
0:05:44 like lifestyle, behavior, obesity, smoking,
0:05:48 those are all very important for health as well.
0:05:50 So I think, you know, when I see these men for reproduction,
0:05:54 I really try and broaden it a little bit to overall health
0:05:55 because I think there’s certainly data
0:05:57 that as we improve a man’s health,
0:06:00 we’ll improve the reproduction and hopefully give them a baby,
0:06:03 but also, you know, improve their overall,
0:06:05 you know, survival, health, everything.
0:06:09 – So how many patients have you seen in your career,
0:06:12 if you had to hazard a guess roughly?
0:06:15 – Oh, I mean, I think it would probably be
0:06:17 in tens of thousands, I would guess,
0:06:20 maybe 20, 30,000.
0:06:22 – And how many years have you been working on this subject
0:06:25 of sort of male health, fertility, reproductive health,
0:06:26 all these kind of?
0:06:29 – About probably 10 to 15 years.
0:06:31 – It feels like the world has kind of turned
0:06:34 towards your work, more so in the last couple of years
0:06:35 than ever before.
0:06:39 It feels like you just so happen to be doing research
0:06:42 and educating people on a space that quite suddenly,
0:06:47 relatively suddenly has become really important to people.
0:06:49 And I was even looking at some of the data around
0:06:52 sort of testosterone replacement therapies
0:06:55 and how that’s just absolutely skyrocketed in recent times.
0:06:57 And also the conversation around fertility,
0:06:59 I was looking at the data around fertility,
0:07:01 how many people are searching out for information on it
0:07:04 and it skyrocketed over the last sort of five years.
0:07:06 And even in my circle of friends,
0:07:09 we weren’t talking about fertility or testosterone
0:07:13 or sperm count even two years ago.
0:07:15 Whereas this year, and in the last sort of 12 months,
0:07:18 it’s been a frequent topic of conversation.
0:07:21 Why is this, and is my assessment there accurate
0:07:24 and can that be supported with what you’re seeing?
0:07:25 – I mean, I think so.
0:07:27 Obviously, I guess I would say I’m biased
0:07:30 and that I think this is very interesting.
0:07:33 And I think there is a lot of momentum towards this.
0:07:35 There have been a lot of landmark studies suggesting
0:07:38 like you say declines in testosterone over time,
0:07:40 declines in sperm count over time.
0:07:43 And we can certainly talk about that a little bit more.
0:07:45 And I think with that,
0:07:47 there’s been really an explosion
0:07:49 in assisted reproductive technologies.
0:07:52 I’m familiar in the United States how that’s happening.
0:07:57 A few years ago, it was maybe about half percent
0:08:00 of all births in the US were conceived with IVF.
0:08:03 Now it’s about 2% and only increasing.
0:08:05 It used to be that insurance never covered it.
0:08:07 Now insurance commonly covers it.
0:08:09 And so with that, there’s just really been explosion
0:08:12 in the offerings, the number of cycles that are done.
0:08:15 In my particular area in Northern California,
0:08:18 it seems like every year a new IVF clinic is opening up
0:08:20 and you’re always worried and wondering
0:08:22 how could there be enough business to support it?
0:08:25 But instantly, all the patients,
0:08:27 all the slots are filled, they’re booked out for six months.
0:08:29 And I think there’s just tremendous amount of demand.
0:08:34 And I think to your point, the question really is why?
0:08:36 Is fertility declining?
0:08:39 Are more couples becoming reliant on IVF?
0:08:42 And I think, again, our sperm counts declining.
0:08:43 I think all those things are probably
0:08:47 kind of going together that’s leading to this.
0:08:49 And I think it’s something that we’re doing to ourselves.
0:08:51 Potentially, there’s some environmental exposure.
0:08:54 I think all these things are really interesting questions
0:08:55 that need to be answered.
0:08:57 – So let’s start with why then.
0:08:58 If we stay zoomed out a little bit
0:08:59 on some of the social factors,
0:09:04 that might be leading to infertility issues,
0:09:06 but also just correlated issues,
0:09:08 like things like testosterone and all of these things.
0:09:10 What are some of the broader social factors
0:09:14 that are causing IVF clinics to become so in demand now?
0:09:16 – Yeah, I mean, I think one of the big ones
0:09:18 would just be rising parental age.
0:09:25 There’s been sort of less data, I think,
0:09:27 on male age over time, at least here in the United States.
0:09:30 But a few years ago, there was a study done
0:09:34 where it showed that over the last maybe 30, 40 years,
0:09:35 the average age of the father
0:09:38 has gone up about three and a half years.
0:09:42 It used to be like in the ’70s, an older father,
0:09:44 and that would be considered over 40,
0:09:45 was maybe about 4% of births.
0:09:48 Now it’s probably 9%, 10% of births.
0:09:50 So I think there’s just a more delay.
0:09:53 And with that, infertility gets higher.
0:09:55 There’s usually a close correlation
0:09:57 between mother’s age and a father’s age.
0:10:00 And so, I think a lot of people are sort of familiar
0:10:03 as women get older, fertility goes down,
0:10:04 probably at a steeper rate.
0:10:06 But for men, the same thing happens.
0:10:08 Sperm counts get a little lower.
0:10:10 Testosterone gets a little lower.
0:10:12 Takes a little longer to conceive.
0:10:15 The chance of problems with the child also can increase.
0:10:17 I mean, the oldest father ever is 96.
0:10:20 So the biologic potential does persist,
0:10:22 but it certainly gets a little bit more difficult
0:10:24 and that pregnancy becomes a lot riskier.
0:10:27 – What is the rate of declining men and women
0:10:28 in terms of fertility?
0:10:31 – So I think, if your guests are looking
0:10:32 from an evolutionary standpoint,
0:10:34 peak fertility would probably be late teens,
0:10:35 early 20s, something like that.
0:10:39 And so for women, they’re born with a set number of eggs.
0:10:42 And so as soon as cycles start,
0:10:43 they continue to lose them over time.
0:10:48 And so usually we think about over 30, 35, 40.
0:10:50 Those are pretty big points where fertility
0:10:52 gets a little bit more challenging.
0:10:56 For men, the sperm counts do decline.
0:11:00 Why this sort of cut off, where we say older father is 40,
0:11:02 is sort of a constellation of sort of different risks.
0:11:03 The sperm counts get a little bit lower,
0:11:07 but the other thing that happens is every year,
0:11:09 we’re born with sort of sperm precursors,
0:11:11 or sperm stem cells in our body,
0:11:14 and they are constantly replicated every year.
0:11:15 And every time that happens,
0:11:17 there’s some chance of a mutation occurring.
0:11:19 So it turns out that every year,
0:11:22 we probably accumulate sort of two mutations in our DNA.
0:11:25 And so over time, that becomes a little riskier.
0:11:29 So for a 40-year-old is gonna have 20 more mutations
0:11:30 than a 30-year-old, for example.
0:11:33 So we have billions of base pairs of DNA in our body,
0:11:37 so the chance of 20 mutations making a difference
0:11:39 is probably pretty low.
0:11:42 But that’s at an individual level, at a population level,
0:11:44 that’s something that you may start to see.
0:11:48 And so for men, I think it is just sort of a slow, steady decline.
0:11:50 Again, probably in the ’30s, ’40s.
0:11:53 – Do you have the data on the oldest ever mother?
0:11:56 Are you the oldest ever woman to conceive a child?
0:12:00 – So with using like a donor egg,
0:12:03 I think it’s ’60s or even in the ’70s,
0:12:04 I think it’s been described before.
0:12:06 But I think with her own egg,
0:12:09 I think it’s late ’50s, early ’60s.
0:12:11 – Are you concerned about this as a macro trend?
0:12:13 Because if we play this forward,
0:12:16 it would lead us to assume that fertility
0:12:18 is gonna be an increasing problem for society.
0:12:21 – Yeah, I mean, I think very much so, right?
0:12:22 It’s existential.
0:12:24 I mean, as a disclaimer, obviously,
0:12:25 I’m in the fertility business.
0:12:29 So I do certainly care about this trend
0:12:31 and wanna make sure that we reverse it.
0:12:32 It’s a risk factor that we know about,
0:12:36 but I think the solution is not obvious, right?
0:12:40 Because asking couples to delay careers, education,
0:12:42 all that is very challenging.
0:12:44 I think some countries have tried to come up with
0:12:49 ways to support parenthood through leave
0:12:51 or other kind of programs like that.
0:12:55 Child care also becomes very important.
0:12:56 But even with those,
0:12:58 I think that there’s just sort of a perception.
0:13:01 It’s just, it’s not as easy as you’d think.
0:13:03 And it turns out actually that the return on investment
0:13:05 for some of these things,
0:13:08 having a child is so kind of important
0:13:10 for the health of a society, right?
0:13:12 There’s this concept called replacement rate.
0:13:14 That’s the number of children that need to be born
0:13:15 to a reproductive age woman
0:13:17 to maintain a population’s level.
0:13:20 Sort of this is kind of ignoring immigration.
0:13:23 So it turns out that you need about 2.1 children
0:13:25 per reproductive age woman
0:13:27 for a population level to stay the same.
0:13:29 So if in some societies, it’s lower.
0:13:32 Like in the US, it’s a little lower than that.
0:13:37 And some like Asian countries like Korea and Japan,
0:13:38 it’s lower than that.
0:13:39 And that’s really existential
0:13:43 because if you’re working population starts to decline,
0:13:47 the tax base, everything will really collapse.
0:13:49 And so from an economic standpoint, it makes sense.
0:13:52 If these are couples that want to have kids
0:13:54 and they, you know, these are wanted children,
0:13:57 you know, to try and invest in, you know,
0:13:59 allowing them to do that really makes sense
0:14:02 because, you know, it’ll kind of pay it back.
0:14:05 It is at a societal level.
0:14:06 – I read about in Hungary
0:14:08 that if you have four or more babies,
0:14:11 then you’ll pay knowing tax for the rest of your life
0:14:12 according to the prime minister.
0:14:13 It’s an article that I’d seen.
0:14:16 And I think this is speaks to a broader trend
0:14:20 of how there’s going to be a top-down approach
0:14:23 towards getting us to get back to having babies,
0:14:24 to stop the population collapse
0:14:26 and decline that you talked about.
0:14:29 Hungary’s prime minister has announced a raft of measures
0:14:31 aimed at boosting the country’s declining birth rate
0:14:33 and reducing immigration.
0:14:36 And one of them is that essentially you’ll be given a check
0:14:38 and you only have to pay that check back
0:14:40 if you don’t have four kids.
0:14:41 So for every kid you have,
0:14:44 25% of the money that you’re given is discounted.
0:14:45 And once you get to four kids,
0:14:47 you never have to pay income tax again,
0:14:50 which I thought was a really interesting idea.
0:14:52 But it’s a sign of things to come.
0:14:54 – Yeah, yeah, I mean, it’s fascinating, right?
0:14:55 I mean, I think that these, you know,
0:14:57 the economic ministers, prime ministers
0:14:59 are really thinking about things.
0:15:01 I’m sure they’ve looked at the numbers, right?
0:15:06 And realized that, you know, society really relies on,
0:15:07 you know, maintaining numbers.
0:15:10 And when, you know, when the population starts to slip,
0:15:11 could be a problem.
0:15:13 Yeah, I think that’s, it’s a very clever solution.
0:15:16 – Sperm quality.
0:15:20 Sperm quality I read is declining.
0:15:22 – Yeah, so that’s a very,
0:15:24 it’s interesting ’cause that’s such a controversial statement.
0:15:27 You know, I think there is a tremendous amount of data
0:15:28 that supports that.
0:15:30 A number of years ago, I was actually involved in a study
0:15:34 looking at data from a sperm bank here in the United States.
0:15:37 It was a sperm bank that was in the Northeastern U.S.
0:15:39 at a few locations.
0:15:40 And it wasn’t a lot of data.
0:15:43 It was just sort of a few years of data,
0:15:45 about like a little over maybe 10, 15 years.
0:15:48 But what we found is that actually if you looked at men
0:15:50 that were coming in to try and be donors,
0:15:52 because, you know, at these banks, they’re very selective.
0:15:55 So you have to have, you know, excellent sperm
0:15:58 that freezes well, that thaws well, really high numbers.
0:16:00 And, you know, they also look at your pedigree a little,
0:16:02 make sure there aren’t conditions around your family.
0:16:03 They’re like you to be fit.
0:16:06 You know, these are kind of things that are thought to,
0:16:08 you know, sort of make a better donor.
0:16:10 And when we looked at sort of the candidates
0:16:12 that came in over this really short period of time,
0:16:16 probably 10, 15 years, there was declines in, you know,
0:16:19 sperm counts, you know, the movement shape,
0:16:20 all these sort of parameters that we look at
0:16:22 when we’re talking about a semen analysis.
0:16:24 And what was interesting is that, you know,
0:16:26 when people have talked about declines in sperm count,
0:16:28 people have sort of attributed it to different things.
0:16:29 For example, people have talked about
0:16:31 the obesity epidemic, right?
0:16:34 And that maybe we’re more sedentary now than we used to be,
0:16:36 or, you know, environmental exposures or another thing.
0:16:38 There’s more chemicals now than it used to be,
0:16:41 or cell phone prevalence and things like that.
0:16:43 But, you know, over this short period of time,
0:16:44 where we did have, you know,
0:16:45 a lot of information on these men.
0:16:47 They filled out surveys, you know,
0:16:50 they filled out kind of rich family histories.
0:16:52 They filled out information about whether they drank a lot,
0:16:54 smoked a lot, things like that.
0:16:56 There’s really no differences in these men, you know,
0:16:57 from the beginning of the study to the end.
0:17:00 The only difference was that their sperm counts were lower.
0:17:03 So it was really, you know, kind of surprising,
0:17:04 very interesting.
0:17:06 And so, you know, other investigators have used studies
0:17:08 like that kind of pooled them all together
0:17:11 using kind of advanced statistical techniques
0:17:14 and found this decline over time, you know,
0:17:17 over the last maybe 20, 30, 40, 50 years.
0:17:21 So there is a preponderance of data that supports that.
0:17:25 So the counterargument that others have made is that,
0:17:26 you know, over that same period of time,
0:17:28 some of our techniques have changed, right?
0:17:31 We’re better at counting sperm now than we used to be,
0:17:33 you know, some of the different, you know,
0:17:35 tools that we use to measure sperm counts.
0:17:37 Some of the analyzers are better now than they used to be,
0:17:40 so we’re a little bit more precise than we used to be.
0:17:42 The other, you know, thing that these studies have done
0:17:44 is when they pool together data,
0:17:46 they assume that, you know, everybody’s the same.
0:17:47 Like, right, if we were both in the study,
0:17:50 they would assume that I’m like you, you’re like me.
0:17:52 But it turns out that there’s a lot of variation
0:17:53 based on, like, region.
0:17:55 So there was a study in the United States
0:17:56 where they looked at fathers,
0:17:59 so men that had kids at different regions of the country,
0:18:01 you know, like, had some in California, New York,
0:18:03 some in the Midwest.
0:18:04 And even though these were all fathers,
0:18:08 similar ages, the sperm quality was much different.
0:18:10 It turned out it was really high in New York.
0:18:11 I think California was next.
0:18:14 And the Midwest was a lot lower.
0:18:16 So, you know, again, why, you’d think that right in New York
0:18:19 would be kind of hustle, bustle, metropolis.
0:18:21 Maybe they would have some poor risk factors,
0:18:23 but it turns out they had the best sperm.
0:18:25 And so why that is is, you know, wasn’t certain,
0:18:27 but it just shows us that there’s a lot of variation
0:18:29 in semen quality from individuals.
0:18:31 So when you put things together,
0:18:33 sometimes it can be difficult to, you know,
0:18:34 to identify trends.
0:18:36 So ideally what we do is, you know,
0:18:39 I and my neighbor would give sperm maybe every year,
0:18:40 every five years, 10 years over time,
0:18:42 and you’d see what changed.
0:18:44 And those studies aren’t available.
0:18:46 So that’s sort of the criticism of these studies.
0:18:49 But again, if you just look at all the data,
0:18:51 if you compare studies from the, you know,
0:18:54 ’70s, ’80s, ’90s to today, sperm counts are lower.
0:18:56 – What is the current best guess
0:18:58 as to why sperm counts are lower?
0:18:59 – Yeah, I think that’s a million-dollar question.
0:19:01 Because, you know, we’ve talked about,
0:19:04 this is sort of an existential threat, right?
0:19:07 We need a, you know, I think any species
0:19:08 has sort of three main functions, right?
0:19:09 Eat, survive, reproduce.
0:19:11 You eat to survive, you survive, reproduce,
0:19:12 spread your DNA.
0:19:13 And so if you can’t do that,
0:19:15 it’s definitely gonna be an issue.
0:19:17 So, you know, I think that we’ve talked about, you know,
0:19:19 maybe obesity, I think we’re certainly different now
0:19:22 than we used to be, you know, in terms of walking around,
0:19:25 you know, sedentary behavior.
0:19:27 People have, you know, hypothesized different chemicals
0:19:29 in the environment are kind of leaching
0:19:31 into our food supply or water supply.
0:19:32 – Is there any evidence for that,
0:19:33 that the chemicals in our environment
0:19:35 are impacting our sperm count?
0:19:38 And our testosterone levels and things like that?
0:19:41 – Yeah, there are studies that do support that.
0:19:43 You know, there are certainly like preclinical studies,
0:19:45 you know, where you can actually, you know,
0:19:49 dose like rats and mice, these.
0:19:51 There’s also human studies where you can, you know,
0:19:53 compare sperm quality to, you know,
0:19:55 different sort of chemical traces in the blood
0:19:57 and see these correlations as well.
0:20:00 And then there’s a study called NHANES,
0:20:03 which is a study by our Centers for Disease Control,
0:20:07 where every year men and women are sort of surveyed,
0:20:09 they collect data on obesity, blood pressure,
0:20:10 things like that.
0:20:13 And they do collect data on sort of chemical exposures
0:20:15 for these, you know, select group of individuals
0:20:17 that kind of represent the whole population.
0:20:21 This has been done for the last, you know, many, many decades.
0:20:23 And so when we talk about obesity kind of rising
0:20:25 in prevalence in the United States,
0:20:26 it’s been, it’s based on that data.
0:20:29 This is kind of a rigorously sort of researched,
0:20:31 you know, group of individuals that’s selected every year.
0:20:35 And so those same studies collect data on testosterone
0:20:37 or estrogen for women and they collect it
0:20:38 on these different environmental chemicals
0:20:40 and do see these correlations.
0:20:42 I would say that not every study supports this,
0:20:45 but there are certainly a good number that do show
0:20:46 that there is this correlation,
0:20:50 that if you have higher exposure to some of these chemicals,
0:20:52 there’s higher risk of lower hormone levels.
0:20:55 – What are those chemicals and where do we find them?
0:20:59 ‘Cause I spoke to someone who was a urologist recently,
0:21:01 I think from NYU, and they were telling me
0:21:05 that things like the microplastics,
0:21:07 and I’m not particularly aware of what a microplastic is,
0:21:09 to be honest, but things like microplastics
0:21:11 in our environment are some of the chemicals
0:21:14 that are causing sperm quality to reduce.
0:21:16 Is there evidence to support that?
0:21:18 – There’s a lot of different chemicals
0:21:20 to be sort of concerned about or think about.
0:21:22 I think, you know, microplastics are one phthalates.
0:21:23 – What is the phthalate?
0:21:26 – A phthalate is, it’s a chemical that’s in a lot of like,
0:21:31 you know, different like creams and lotions that we use.
0:21:35 And so those also have been shown to affect androgen,
0:21:38 you know, and kind of endocrine function inside the body.
0:21:42 Bisphenol A is a, you know, a common chemical
0:21:44 that’s used in the manufacture of plastic.
0:21:45 And that’s also been found
0:21:47 to have these endocrine disrupting properties.
0:21:50 So that’s also been correlated with semen quality.
0:21:51 – Endocrine disrupting.
0:21:52 – Endocrine disrupting.
0:21:53 – What does that mean?
0:21:56 – So, you know, if you look at sort of pathways
0:21:59 for men and women, there’s, you know, hormones, right?
0:22:01 I’m making testosterone and that acts on my body
0:22:04 as I was a child to help make me a man.
0:22:06 Now it kind of helps, you know, keep me a man,
0:22:09 you know, with grow a beard, all those sorts of things,
0:22:11 giving me my deeper voice.
0:22:13 And so there’s some of these chemicals
0:22:14 that kind of mimic some of that action
0:22:16 or block some of that action.
0:22:19 And so if that happens, it can affect, you know,
0:22:23 normal development of, you know, boys or girls, you know,
0:22:25 maybe, you know, again, affects sort of semen quality.
0:22:27 If we think about sort of the origins of changes
0:22:30 in semen quality, some of it may be when we’re adults,
0:22:32 but some of it also could be during development,
0:22:34 you know, either when we’re developing inside
0:22:37 of our mothers or, you know, during puberty,
0:22:40 if something kind of affects the normal timing of that,
0:22:41 it could be, you know, again,
0:22:42 could have pretty devastating effects.
0:22:45 And so one theory for that is some of these chemicals
0:22:48 that affect these sort of biologic pathways,
0:22:50 these endocrine pathways involved in that.
0:22:53 – From the research you’ve seen on sort of these chemicals,
0:22:56 is there any changes that you’ve made in your own life
0:22:57 at all?
0:22:59 Anything that you, it’s kind of made you think differently
0:23:00 about the choices you make in your own life
0:23:02 with your kids, ’cause you’ve got three kids.
0:23:04 So you have an opportunity to kind of influence them
0:23:07 at an earlier stage than most of us can influence ourselves.
0:23:08 But…
0:23:11 – Yeah, so one thing that we do is I’ve thrown away
0:23:13 all plastic water bottles.
0:23:14 I would say I still use it
0:23:17 because I find them very convenient.
0:23:18 And I’m done with reproduction.
0:23:21 But certainly for the kids,
0:23:23 I make sure they don’t drink out of plastic water bottles.
0:23:27 So we have either glass or metal.
0:23:31 I do think there is data that that’s a very large exposure
0:23:32 that kids get.
0:23:36 And I think it’s fairly easy now to remove that.
0:23:38 – What is the data say about plastic bottles?
0:23:41 – If you look at exposures from that,
0:23:44 they just leach a tremendous amount with wash,
0:23:46 with water, it kind of sits there all day.
0:23:49 So I think it’s a very,
0:23:52 I think in most plastic water bottles,
0:23:54 I want the plastic bottle industry to come after us.
0:23:59 But that’s a common way for individuals
0:24:00 to get exposed to it.
0:24:02 So I think if, again, if we’re saying
0:24:05 that’s one of the main touch points for plastics,
0:24:07 is usually through our kind of food and water supply,
0:24:11 then I think it’s easy to get rid of it if you can.
0:24:12 – Is there anything else?
0:24:16 I’ve read recently that heat has a role
0:24:17 in our sort of sperm quality.
0:24:21 So if we’re going into saunas or something,
0:24:23 or if we’re spending a lot of time under sunbathing,
0:24:26 then there’s science that suggests
0:24:28 that will lower our sperm count.
0:24:29 – Yeah, so that is right.
0:24:31 So, I mean, I think that, you know,
0:24:32 again, you can kind of look at this sort of
0:24:36 in a bigger sort of global warming kind of context.
0:24:37 And people have theorized that maybe
0:24:39 that could also play a role because,
0:24:41 you know, the testicles are outside the body
0:24:43 ’cause they need to be a few degrees cooler
0:24:44 for sperm production to occur.
0:24:47 So anything that warms them up can definitely be a problem.
0:24:50 So when I talk to patients in clinic, for example,
0:24:52 we do talk about sauna use, hot tub use,
0:24:55 some men bathe every day, like in a bath.
0:24:58 And those all can impact sperm production.
0:25:00 There have been studies that show that men that, you know,
0:25:02 use saunas on a regular basis,
0:25:04 they have lower sperm counts.
0:25:06 And then when you withdraw that exposure,
0:25:08 sperm counts will go back to normal.
0:25:11 One, you know, sort of interesting application of this
0:25:13 was to try and use this data or use that knowledge
0:25:15 to come up with a contraceptive.
0:25:18 So there was this weird sort of like trust kind of belt
0:25:21 that actually pushed the testicles up into the groin,
0:25:25 which actually turned out did reduce sperm counts to zero,
0:25:30 I think, and again, the few men that volunteered to do that.
0:25:32 But you can imagine,
0:25:35 I think most men are not gonna be too excited about that,
0:25:37 ’cause it’s probably pretty uncomfortable.
0:25:38 The other way that I’ve seen it
0:25:40 is I’ve had patients that have gotten sick,
0:25:42 certainly around COVID, that happen not infrequently.
0:25:45 Men would come in, you know, telling me that, you know,
0:25:47 they just got over a COVID infection
0:25:48 that where they had high fevers for, you know,
0:25:52 a few weeks, and then their sperm counts would be very low.
0:25:54 And then, you know, we wait a few months.
0:25:56 It takes about two to three months to make a sperm.
0:25:57 So we let one of those cycles
0:25:58 or two of those cycles go through
0:26:00 and their sperm counts came back.
0:26:02 I had a patient even before COVID,
0:26:06 like 41 year old guy, he had normal sperm count.
0:26:07 And then all of a sudden he measured
0:26:09 and the sperm count had gone to zero.
0:26:11 And it turns out he had a flu
0:26:13 with fevers about 102 degrees Fahrenheit
0:26:15 the week before.
0:26:18 And again, we let kind of sort of nature take his course.
0:26:19 He recovered and then his sperm counts
0:26:20 came back to baseline.
0:26:23 So we do see that as well.
0:26:25 – With that belt that you mentioned that,
0:26:28 it holds the sort of testicles closer to the body.
0:26:31 I’m guessing it’s doing that to heat them up, basically,
0:26:32 which reduces the sperm count.
0:26:35 Obviously then one would think about their boxer shorts.
0:26:38 We’re all wearing very tight boxer shorts these days.
0:26:40 That’s like in vogue or whatever.
0:26:42 So is there any studies to suggest
0:26:44 that boxer shorts can reduce sperm count
0:26:45 if they’re tight?
0:26:46 – So that’s like a very common,
0:26:48 that’s one of the most common questions I get,
0:26:50 like boxers versus briefs.
0:26:52 And that’s been studied a lot
0:26:53 ’cause that is a very common exposure.
0:26:55 I think I usually just tell men whatever’s comfortable.
0:26:58 I think it’s unlikely that any single layer
0:26:59 is gonna make a big difference.
0:27:01 Unless again, you have the specially designed underwear
0:27:04 that pushes testicles up into the groin.
0:27:06 But otherwise, as long as they’re outside the body,
0:27:07 it should be okay.
0:27:10 – What about mobile phones and technology?
0:27:13 Is there any link between fertility
0:27:14 and our use of technology,
0:27:16 specifically having these devices in our pockets
0:27:18 close to our genitals?
0:27:20 – That’s another common question that I get.
0:27:24 And that is certainly something that’s changed right now
0:27:27 versus 20, 30 years ago.
0:27:29 So there were some studies that initially showed
0:27:32 kind of this signal that men that use cell phones more
0:27:34 had lower sperm count.
0:27:36 But some of these studies were, they’re older
0:27:38 and you also worry about some of these
0:27:39 kind of confounding things.
0:27:41 It may be that people that use phones more
0:27:42 do other things more.
0:27:43 They may have more stress in their life
0:27:45 and other things that could affect semen quality.
0:27:47 So there was a clever study that was done
0:27:49 where they actually took a jaculate.
0:27:51 So it took sperm, put it in a cup
0:27:53 and put a cell phone next to it
0:27:56 and tried to measure changes in the quality of the sperm.
0:27:57 And they actually did find some.
0:27:59 They found higher rates of like DNA damage within the sperm
0:28:02 that was exposed to the phone versus not.
0:28:04 Kind of trying to control for temperature,
0:28:07 which we said is important for the health of the sperm.
0:28:09 – Wait, so they controlled for temperature?
0:28:11 – They controlled for temperature.
0:28:15 And just having the cell phone getting its signal
0:28:19 seemed to affect the DNA damage in sperm.
0:28:23 It wasn’t, it was a statistically significant difference.
0:28:25 It maybe would not be kind of a point
0:28:27 where we would get as worried clinically,
0:28:28 but it is a change.
0:28:29 So I think it’s something to think about.
0:28:33 I think that aside from that,
0:28:35 cell phones I think nowadays don’t get too hot.
0:28:38 So not as worried about heat, but whether this RF,
0:28:41 this radio frequency exposure may impact things
0:28:43 as a maybe a theoretical risk.
0:28:45 But again, there’s not a lot of concrete data.
0:28:48 So I think that, again, a lot of my patients do tell me
0:28:50 that they keep their, try and keep their cell phone
0:28:53 in their back pocket or front pocket to try and avoid that.
0:28:54 I think that’s fine.
0:28:57 – I’ve been having this conversation with my partner a lot.
0:28:59 She really believes that my cell phone
0:29:02 should never be slid under my genitals,
0:29:04 which I sometimes do when I’m like,
0:29:05 I don’t know when I’m in a car or something
0:29:07 or when I’m on the sofa.
0:29:08 I don’t know when I’ve got my hands full.
0:29:10 I’ll just grab it and I’ll kind of like slide it
0:29:15 between my legs and she’ll reach in and pull it out
0:29:16 and say, and I think, because she’s concerned
0:29:18 about those four kids that we want to have.
0:29:20 – And you, I think she cares about you too.
0:29:23 – Yeah, to be fair, she’s not someone
0:29:25 that’s going to read PubMed and read about the studies,
0:29:27 but it’s just a feeling she has.
0:29:30 And I always refuted it and thought, now there’s no way.
0:29:31 There’s no way because they would have tested it.
0:29:33 And the test seems so easy.
0:29:35 You get sperm, you put it in a little thing.
0:29:38 You put the phone on top of it, send it some text messages,
0:29:40 connect to the wifi, the Bluetooth,
0:29:42 and see how the sperm get on.
0:29:44 I didn’t realize there was a study associated with it.
0:29:47 – Yeah, I think laptops also can do that too,
0:29:49 but they also have a little more heat associated with it.
0:29:50 So a similar study was done in laptops
0:29:54 where they had sperm put it next to a laptop
0:29:55 and they controlled for temperature
0:29:57 until the same pattern.
0:30:00 Again, sort of the wifi signal can also affect
0:30:03 again, sperm DNA damage and sperm quality.
0:30:07 But also, laptops can get warm too, right?
0:30:09 Some of the batteries, some of the moving parts within
0:30:10 can heat up too.
0:30:13 And it also just serves as almost like insulation
0:30:14 if you put it over your lap.
0:30:17 So I do talk to patients about that as well,
0:30:19 to maybe use like a pillow or something else
0:30:22 just to try and shield yourself a little bit.
0:30:24 – Wouldn’t we see a sort of big difference
0:30:26 between hot countries and cold countries
0:30:28 or sort of warm countries and sperm counts then?
0:30:31 So if I’m in sort of sub-Saharan Africa,
0:30:33 I’m assuming my sperm count will be pretty low
0:30:35 ’cause I’m gonna be swearing all day.
0:30:38 So I think that the other sort of element to that though
0:30:41 is that there are differences in populations.
0:30:43 And I think that that has not been well described.
0:30:47 But if you compare, again, we talked about California
0:30:49 and New York, the Midwest and the United States,
0:30:52 but people have also compared like Denmark,
0:30:55 which they have a lot of sort of problems with reproduction.
0:30:57 So they’ve really studied it very, very aggressively.
0:30:59 And if you compare them to other countries nearby
0:31:02 or other countries in Europe, it’s much different.
0:31:06 And so one possibility could be exposures
0:31:08 and what these men are doing, what they’re exposed to.
0:31:09 But the other could be, again,
0:31:12 there could be some genetic components.
0:31:14 But one interesting thing about sort of on that same line
0:31:19 is that sperm quality does vary based on time of year.
0:31:21 So during the hotter months, it does go down a little bit,
0:31:22 not meaningfully.
0:31:25 And then during the cooler months, it goes up a little bit.
0:31:28 But the other thing is that we don’t spend,
0:31:30 some of us do, I guess, or some of us don’t,
0:31:32 but not spend all your time outdoors, right?
0:31:36 And sometimes during the cooler months,
0:31:38 you’re kind of bundled up inside.
0:31:39 And during the warmer months,
0:31:41 you may be in cool air conditioning.
0:31:45 – Did you say that Denmark has had a problem with sperm count?
0:31:47 – Yes, yeah.
0:31:51 So in the United States, I said that about 2% of births
0:31:52 are conceived with IVF.
0:31:54 In Denmark, it’s about 10%.
0:31:54 – Wow.
0:31:57 – And it’s actually, they’ve, again,
0:31:59 they have really a crisis of reproduction there.
0:32:02 So they’ve really done some really good research
0:32:03 on semen quality.
0:32:06 And it’s estimated that only about 25% of Danish men
0:32:08 have normal semen quality.
0:32:10 – Have they figured out why?
0:32:11 – That’s what they’re looking into.
0:32:12 They have lots of theories.
0:32:15 And again, I think, again, it goes to many of these
0:32:16 same topics that we talked about,
0:32:20 whether it’s environmental exposures on mothers,
0:32:24 or again, pubertal boys, or adults as well.
0:32:26 So they are trying to figure it out,
0:32:28 but it is, it’s also one of the countries
0:32:31 where the fertility rate is below replacement.
0:32:32 So it’s definitely an issue.
0:32:36 – One would assume that it’s some kind of environmental factor.
0:32:37 I guess it could be some other social factor,
0:32:39 but one would assume that it’s some kind of
0:32:42 environmental factor.
0:32:44 – Yeah, some people have postulated during World War II,
0:32:45 they’re very isolated.
0:32:48 And so potentially there were some chemical exposures
0:32:50 that have just kind of persisted and remained
0:32:51 in the population.
0:32:54 And it’s kind of tough to work through that,
0:32:55 but it’s not known.
0:32:58 If I’m sat down all day,
0:33:00 is that gonna have an impact on my sperm count as well?
0:33:03 Because of the heat generated from me just sitting here.
0:33:06 And/or if I’m a cyclist,
0:33:10 or someone that’s doing sat down on my testicles,
0:33:11 doing something warm.
0:33:14 – People have looked at sort of different occupations
0:33:15 where you sit a lot.
0:33:18 And there are associations like drivers,
0:33:20 taxi drivers, truck drivers,
0:33:22 they certainly can have changes in sperm count,
0:33:24 probably due to heat.
0:33:26 Again, I think it could be a combination
0:33:27 of sort of sitting all day is also,
0:33:30 from probably other health standpoints is not great.
0:33:32 And cycling too,
0:33:35 people have looked at sort of peak athlete cyclists
0:33:37 and there are differences in semen quality.
0:33:41 But peak cyclists, they do a lot to their body.
0:33:44 And so it’s possible that there could be other effects too,
0:33:47 but looking at men that sort of recreationally cycle too.
0:33:49 I think that the number that I use,
0:33:51 there’s a study that showed,
0:33:53 if you cycle over five hours a week,
0:33:55 there can be lower sperm counts.
0:33:58 So I talked to men about that when they do cycle,
0:34:01 more than that, potentially taking breaks,
0:34:03 trying to stand up if we think the mechanism is heat
0:34:06 to try and sort of circulate out the area
0:34:08 to spend some time out of the saddle if possible.
0:34:11 – What about men with big thighs?
0:34:12 – Yeah.
0:34:14 Well, I think obesity is an issue.
0:34:16 There’s certainly a strong correlation
0:34:18 between body mass index and semen quality.
0:34:21 So as men get bigger, sperm counts go down.
0:34:24 And so heat is certainly one of the possible mechanisms
0:34:27 for that, just kind of insulating that area,
0:34:29 warming things up can kind of do it.
0:34:33 Obesity also affects the kind of hormonal axis as well.
0:34:35 So that also maybe at play too,
0:34:39 because there’s kind of a normal simulation
0:34:40 that’s given by your pituitary and your brain
0:34:44 that tells your testicles to make sperm, make testosterone.
0:34:47 And some of that’s also affected by obesity as well.
0:34:48 So it’s probably a combination,
0:34:51 but that is something I do think about when I see,
0:34:53 in my patients and we do talk about sort of heat exposures
0:34:57 as well and see if there’s a different sort of strategies
0:35:00 they can use to try and allow more circulation in the area.
0:35:04 – Is there a link between sperm counts
0:35:06 and alcohol consumption?
0:35:07 – I think it depends is what I would say.
0:35:11 So in general, for most kind of moderate use,
0:35:13 I would say kind of a drink a day.
0:35:17 And some people think that no amount of alcohol is safe,
0:35:18 but probably if you look at these studies,
0:35:20 looking at maybe a drink or two a day,
0:35:23 probably doesn’t correlate too strongly with semen quality.
0:35:25 But it seems like there are some studies
0:35:27 that say that when men get to three a day,
0:35:31 so maybe 20 a week, there can be lower quality in semen.
0:35:34 And there was also another study that we did looking at,
0:35:37 to see if some men are more susceptible to alcohol intake.
0:35:42 So there are some East Asian men and women
0:35:44 that have a mutation in one of the enzymes
0:35:47 that’s used to metabolize alcohol.
0:35:49 And so they accumulate what’s called acetaldehyde,
0:35:51 which is a toxin actually.
0:35:52 And so when they drink, they flush.
0:35:54 I don’t know if you have any friends that have this,
0:35:59 but we hypothesize that when you have this large load
0:36:02 of this chemical in your body that leads to flushing,
0:36:05 headache, dizziness, maybe it also affects semen quality.
0:36:07 And it turns out that it does.
0:36:10 So for these men that have this mutation,
0:36:12 when they drink, their sperm movement
0:36:14 goes down a little bit.
0:36:17 So it turns out that there’s actually a reasonable number
0:36:18 of men on earth that have this.
0:36:21 It’s probably in some populations up to 50%,
0:36:25 like in Taiwan, it’s very common in Japan,
0:36:28 men with Chinese and Vietnamese ancestry.
0:36:30 So I think it’s something to be aware of.
0:36:31 And I think usually men do know
0:36:33 if they flush when they drink,
0:36:35 it’s probably because they have this mutation
0:36:37 and aldehyde dehydrogenase too.
0:36:40 So for those men, I think that it’s probably better
0:36:44 to avoid alcohol or just to sort of be aware
0:36:47 because it can affect semen quality.
0:36:50 If I came into your clinic and I said,
0:36:55 Dr. Michael, I’m trying to have a kid with my partner
0:36:57 and I want to make sure that everything I’m doing
0:37:00 is giving me the best chance of having a kid.
0:37:02 What’s the list of things?
0:37:04 ‘Cause this is basically where I am in my life now.
0:37:06 I’m 31 years old.
0:37:07 I want to have a kid.
0:37:08 I ideally want to have four of them.
0:37:09 I’m thinking about the time.
0:37:11 My partner’s the same age as me.
0:37:14 We’re almost identical in age and she’s 31.
0:37:18 So we’ve got, we want to have these kids before 40 ideally.
0:37:19 So I kind of need to get-
0:37:20 – Get going. – Get going.
0:37:21 You know what I mean?
0:37:26 So what can I do to give myself the best possible chance
0:37:28 of increasing my fertility, my sperm count
0:37:30 so that we have those four kids
0:37:32 that I want over the next nine years?
0:37:33 – Was the four a number?
0:37:35 It was something you came up with before
0:37:36 that tax incentive or?
0:37:40 (both laughing)
0:37:41 – Yeah, we are planning to move to Hungary.
0:37:44 So it was really, it’s really about tax avoidance.
0:37:46 It’s not that I want kids.
0:37:48 No, I come from a family of four.
0:37:51 So for some reason, I’ve always had four in my head.
0:37:52 I think she’s fine with it as well.
0:37:55 I think we’ve chatted and she’s happy with four to six.
0:37:56 – No, it’s a good number.
0:37:58 – Not had six signed off, but four for sure.
0:38:00 What would you say to me then?
0:38:02 – So I think, you know, we look at, you know,
0:38:06 your overall health, you know, to see any risk factors
0:38:08 he had, obviously we’re talking about saunas, hot tubs,
0:38:10 buying out, you know, how you exercise.
0:38:14 But there’s things that you do that are not, you know, good.
0:38:15 Look at, you know, if any medical conditions
0:38:17 that you have, surgeries that you’ve had,
0:38:19 some of those can put men at risk for that.
0:38:21 If there’s any medications you’re on,
0:38:23 there can be medications that affect it.
0:38:25 And then we’ll do an exam.
0:38:28 So we’re gonna have to do that here for the cameras.
0:38:29 – I’m down.
0:38:31 (both laughing)
0:38:33 – Yeah, I do have a California medical license.
0:38:36 But so, you know, we wanna make sure we look
0:38:38 at the size of the testicles, make sure all the other
0:38:40 structures are where they’re supposed to be.
0:38:41 You know, one of the basic evaluations
0:38:43 will be a semen analysis.
0:38:45 So we’ll measure how much comes out,
0:38:45 look at how many sperm there are,
0:38:48 look at how many are moving, look at their shape as well.
0:38:50 And then usually we also check hormones as well.
0:38:52 So we’ll check testosterone.
0:38:53 Again, sort of this very male hormone.
0:38:54 The testicle does two things.
0:38:55 It makes sperm, makes testosterone.
0:38:57 So we check that.
0:38:58 And then usually we check some other hormones
0:39:00 involved in the kind of hormonal axis
0:39:02 that controls reproduction.
0:39:03 And that’s usually what we start.
0:39:04 And again, fertility is a team sport.
0:39:08 So it encourages your partner to also get evaluated as well.
0:39:10 And we’d see, you know, depending on kind of sperm counts,
0:39:13 usually then we’re able to sort of counsel about,
0:39:15 you know, how likely you are to be able to achieve,
0:39:16 you know, those four kids.
0:39:19 But, you know, again, if you’re kind of thinking about four,
0:39:22 I would agree that you should get started.
0:39:24 – Fertility issues.
0:39:26 We tend to think of it, I think there’s a stereotype
0:39:29 that it’s typically the woman who has the fertility issue.
0:39:30 And the man is okay.
0:39:32 And I think if you, when I looked at the data,
0:39:35 that’s kind of supported this idea that couples assume
0:39:38 it’s the woman that has the fertility issue.
0:39:39 Is that a misconception?
0:39:40 – It’s a huge misconception.
0:39:42 Yeah, so absolutely.
0:39:44 I think that, you know, in United States
0:39:46 and other countries too, I think usually, you know,
0:39:48 women are kind of the gatekeeper of fertility.
0:39:51 Everybody assumes that that’s where the issue lies.
0:39:53 But if you actually look at, you know, the data,
0:39:55 probably about half the time there’s a male factor
0:39:56 contributing.
0:39:59 And, you know, this sort of stereotype is so prevalent
0:40:01 that probably at least a quarter of the time
0:40:03 in the United States, the man’s never evaluated.
0:40:05 And he could be, you know, one of the issues.
0:40:08 So some couples may go to IVF, you know,
0:40:10 for the lone reason of, you know, again,
0:40:12 low sperm count and the man would never evaluate it.
0:40:14 And maybe there is a condition that we can improve.
0:40:16 Maybe he’s on a medicine, maybe, you know,
0:40:18 he’s going to the jacuzzi every day, you know,
0:40:21 something like that that we be able to reverse.
0:40:23 – You mentioned testosterone would be one of the things
0:40:24 that you would measure if you were trying to make sure
0:40:25 that my fertility was good.
0:40:29 Male testosterone decline.
0:40:31 This is another hot topic.
0:40:33 He talked about it at the start of this conversation.
0:40:35 Is it true that male testosterone is declining
0:40:38 and how much has it declined to buy?
0:40:41 – Yeah, so again, study from this NHANES,
0:40:43 this CDC, you know, measuring men every year
0:40:45 for the last several decades.
0:40:47 If, you know, there’s data that shows
0:40:50 that testosterone levels have gone down over time.
0:40:53 You know, people have also looked at, you know,
0:40:57 other cohorts of men, you know, from the 2000s and ’90s, ’80s,
0:40:58 and there’s just a progressive decline
0:41:01 in average testosterone levels over that amount of time.
0:41:03 So, you know, the amounts, you know,
0:41:05 kind of vary 50 to 100 points,
0:41:06 but, you know, generally these are, you know,
0:41:08 meaningful, measurable amounts.
0:41:11 In addition to sort of these kind of cohort changes
0:41:13 where if you kind of, you know, look at the average
0:41:16 four-year-old now versus, you know, 10 years ago,
0:41:18 our testosterone levels change too.
0:41:19 So I would say that I usually tell men
0:41:22 after the age of 20, your testosterone’s gonna go down
0:41:24 maybe about a percentage point every year.
0:41:26 So as we get older, testosterone does go down.
0:41:28 And there’s things, again, that can affect that trajectory.
0:41:30 You know, men that get more obese,
0:41:31 that also affects testosterone level.
0:41:34 A portion of all of our testosterone’s converted to estrogen.
0:41:36 A lot of that conversion happens in, you know,
0:41:38 adipose tissue or fatty tissue.
0:41:41 So the more kind of extra tissue there is in the body,
0:41:43 the more that conversion will happen.
0:41:45 And so your, you know, effective testosterone levels
0:41:46 will be lower.
0:41:48 – What about movement and exercise?
0:41:51 Does that have an impact on our testosterone levels
0:41:52 in a significant way?
0:41:53 – Yeah, I mean, I think that, you know,
0:41:56 the more walking you do, the more active you are,
0:41:58 we’ve looked at that as well.
0:42:00 You know, step count is directly correlated
0:42:01 to testosterone.
0:42:04 And you don’t have to take 20,000 steps a day.
0:42:06 You know, 4,000, 8,000 steps a day, you know,
0:42:08 just kind of walking around, you know,
0:42:10 sort of reasonable amounts that can make a big difference.
0:42:13 And I think that, you know, activity is important.
0:42:15 It probably also helps stave off obesity a little bit as well
0:42:17 as another mechanism.
0:42:19 – Okay, so I’m a Manchester United fan right now
0:42:20 and we’re losing a lot.
0:42:21 – I thought you guys had turned it around.
0:42:24 – Yeah, I thought so too, until last week.
0:42:26 Okay, so if you’re supporting a team
0:42:28 that is losing your testosterone levels,
0:42:30 likely going to be lower.
0:42:32 – Well, I think this is sort of an acute thing.
0:42:35 Maybe, we could do that experiment, right?
0:42:36 – When does that research come from that?
0:42:39 If your team wins, your testosterone increases?
0:42:41 – I don’t remember, that study is pretty old.
0:42:44 I think that even predated my training,
0:42:45 but I do remember reading that.
0:42:46 I think that was one of the articles
0:42:48 that get picked up by the newspaper.
0:42:50 – Okay, of course.
0:42:52 Why does testosterone matter?
0:42:54 – Well, I think testosterone is very important
0:42:56 for, you know, a lot of things.
0:42:59 I think it’s important for our quality of life.
0:43:02 So energy level, sex drive, mood, sleep, concentration,
0:43:03 all those things are very important.
0:43:05 When testosterone gets very low,
0:43:07 it also has a lot of health implications.
0:43:10 So muscle health, bone health, heart health.
0:43:13 So we do want to keep our levels in a normal range
0:43:16 because I think it kind of helps us
0:43:19 with our function and our life and happiness.
0:43:22 – How does it impact our sort of muscles and bones?
0:43:25 I don’t really understand what testosterone is doing.
0:43:26 I kind of think of it as the chemical
0:43:27 that kind of makes you a man.
0:43:29 I know women have testosterone too,
0:43:31 but I just think of it as the chemical
0:43:33 that makes my beard grow and my voice deep.
0:43:34 – Yeah, well, that’s what it’s doing.
0:43:35 But it’s anabolic.
0:43:36 It does help kind of grow.
0:43:38 It helps with bone turnover
0:43:41 and kind of keeps sort of the strength of the bone.
0:43:44 So men that have very low testosterone levels
0:43:45 have, you know, frailer bones,
0:43:48 higher risks of osteopenia, osteoporosis.
0:43:53 So, you know, I think it helps with muscle growth,
0:43:55 bone turnover, bone strength.
0:43:58 So I think all those things are important.
0:44:00 They usually don’t get into those problems
0:44:02 unless men are very, very low.
0:44:04 I would say that, you know, I don’t know you,
0:44:06 but, you know, the average testosterone levels
0:44:07 are probably 300 to 900.
0:44:10 I would guess probably on the higher end of that.
0:44:13 But, you know, when men are low,
0:44:14 probably less than 200, 100.
0:44:16 That’s where we start to worry more about, you know,
0:44:18 bone health, muscle health.
0:44:20 And so I think that there is some wiggle,
0:44:23 but when you get kind of lower than sort of the normal ranges,
0:44:26 kind of the 300 range, that’s when some men do develop,
0:44:27 you know, some of the symptoms
0:44:29 of lower energy levels, sex drive problems,
0:44:29 things like that.
0:44:33 – So low testosterone typically means lower sex drive?
0:44:34 – It can.
0:44:37 It’s one of the common symptoms that we see with that.
0:44:39 – Does that mean that if I just take loads of testosterone,
0:44:41 my sex drive is going to go back up?
0:44:43 – You know, over the last probably 10 to 20 years,
0:44:46 the number of prescriptions of testosterone written in the US
0:44:49 have kind of gone up almost at an exponential rate.
0:44:52 And because people did think of it sort of as a kind of
0:44:55 an anti-aging kind of rejuvenation therapy.
0:44:56 And so there was hope that it would help people.
0:44:58 But if you look at some of the randomized trials,
0:45:00 if a man has a normal testosterone level
0:45:02 and you give him testosterone,
0:45:03 it may not help him that much.
0:45:05 Even men that have kind of a lowish testosterone,
0:45:07 like we talked about sort of this 300 cut point.
0:45:09 So I’ve had plenty of patients,
0:45:11 testosterone of 250, let’s say.
0:45:15 So we talk about risks and benefits of being on testosterone.
0:45:16 We’ll try them on it.
0:45:17 And, you know, a lot of men do feel better,
0:45:18 but not everybody.
0:45:19 Some men say I don’t feel any,
0:45:20 you know, doc, I don’t feel any different,
0:45:24 even though we get his levels, you know, from 250 to 500.
0:45:26 And so then it’s probably not worth, you know,
0:45:28 to be on a medicine every day if it’s not helping you.
0:45:29 I’m not worried about his bone health, you know,
0:45:32 we’ll check some other measures to make sure that’s okay.
0:45:33 So then it’s not, you know, again,
0:45:34 when you look at risks and benefits,
0:45:35 it’s probably not worth it.
0:45:38 But there are certainly some men who do see improvement.
0:45:41 – So is testosterone hurting some people?
0:45:43 They’re testosterone treatments.
0:45:45 Does it actually have an adverse effect
0:45:48 if you take it basically when you don’t need to?
0:45:49 – I mean, even when you do need to,
0:45:51 I think it could sometimes cause issues.
0:45:54 Yeah, there are certainly side effects to testosterone.
0:45:57 You know, one of the big things that I see in my practice
0:45:59 is how testosterone impacts sperm production.
0:46:02 It actually was tested as a contraceptive
0:46:03 by the World Health Organization
0:46:06 because it does lower sperm counts in most men,
0:46:08 I would say 90% of men.
0:46:10 Now it doesn’t do 100%,
0:46:12 so it’s not that great of a contraceptive yet.
0:46:14 They’re kind of working on some other ways to tweak it.
0:46:17 But I have plenty of patients that come in, you know,
0:46:19 some of them suspect that testosterone is the issue,
0:46:20 some don’t know.
0:46:21 I remember one couple in particular,
0:46:23 they came in as a couple together,
0:46:25 you know, we measured his sperm count, it was zero.
0:46:27 We started talking about risk factors
0:46:28 and he was on testosterone.
0:46:29 And I said, well, the best thing to do
0:46:31 would be to stop testosterone.
0:46:34 And for his work, I’m gonna tell you what he did,
0:46:36 but for his work, he really couldn’t stop it.
0:46:39 So there’s some other medicines we were able to add
0:46:42 while he continued to the testosterone.
0:46:45 And then they ended up with triplets shortly thereafter.
0:46:48 So I think that, you know, men need to be aware of it
0:46:50 because that’s, you know,
0:46:51 certainly one of the big risk factors,
0:46:54 least of reproductive age men is this risk to fertility.
0:46:59 – So it can impact my sperm count negatively.
0:47:01 I saw a quote from you that said,
0:47:03 if we take a hundred of my infertile patients
0:47:04 that I see in the clinic,
0:47:06 at least five of those men will be infertile
0:47:08 because they’re on testosterone therapy.
0:47:11 One in 20 infertile men are that way
0:47:15 because of testosterone as it relates to infertility.
0:47:16 One of the things that I’ve always worried about
0:47:21 is if I take testosterone, then my hair would fall out.
0:47:24 – Yeah, so that can definitely happen.
0:47:28 So, you know, hair loss, breast growth, acne,
0:47:29 those can all occur.
0:47:31 I would say those are things that we can monitor.
0:47:33 So, you know, one thing I always tell men
0:47:35 is that we’re not trying to get them to superhuman, right?
0:47:36 We’re just trying to get you to normal.
0:47:38 So I think if we monitor it closely,
0:47:40 most men, you know, will do okay.
0:47:42 Again, there’s some other therapies that we can do
0:47:46 for men that have side effects, you know, from those things.
0:47:48 It can also affect the thickness of the blood,
0:47:50 something called a hematocrit or we count the number
0:47:51 of red blood cells in the body.
0:47:53 It can increase that number.
0:47:55 So if it gets too high, that can be an issue.
0:47:57 So that’s another number that we follow.
0:48:01 There used to be a concern about higher rates of heart attack
0:48:02 and stroke with testosterone.
0:48:05 So there were some studies done, you know,
0:48:08 about maybe 10 year, five, 10 years ago that suggested that,
0:48:10 but a really large trial just came out
0:48:13 with about 5,200 men.
0:48:15 Half of them randomized to testosterone, half not.
0:48:16 And there was actually no difference
0:48:19 in the risk of cardiovascular disease.
0:48:21 So I think that’s something that we can probably put to bed.
0:48:22 The other thing that men worried about
0:48:25 is increase the risk of prostate problems.
0:48:26 Prostate cancer, prostate growth,
0:48:28 and you know, that same trial also showed
0:48:30 that from a prostate standpoint,
0:48:32 probably not a lot of risk as well.
0:48:34 – Do you have many men coming to you
0:48:37 to talk to you about hair loss and balding?
0:48:40 – Some men do, I think one of the ways
0:48:42 that men talk to me about it is one of the common medications
0:48:44 for that is finasteride or, you know,
0:48:46 solving the trade name propitia.
0:48:49 And so they want to understand some of the risks of that.
0:48:53 And so, you know, when that medicine was approved
0:48:55 for a hair loss, they, you know, again,
0:48:57 ’cause people are gonna take it
0:48:59 are usually in their reproductive age,
0:49:01 they did randomized placebo-controlled trials
0:49:02 to look at semen quality.
0:49:05 And it turns out that it didn’t meaningfully impact things.
0:49:07 Maybe it went down a little, but not a lot.
0:49:11 But in sort of post, you know, analyses of some of this,
0:49:13 and now seeing lots of patients coming in,
0:49:15 we do see men that aren’t finasteride.
0:49:17 Some of them are more susceptible.
0:49:19 And so one of the interesting thing about trials
0:49:20 is there’s, you know, kind of inclusion
0:49:21 and exclusion criteria, right?
0:49:23 Not everybody can be in it.
0:49:26 And so if men had sperm counts that were too low,
0:49:28 they weren’t invited to be in these trials.
0:49:30 So for men that, you know, don’t have as much reserve
0:49:32 as others, I think they may be more susceptible.
0:49:35 So that’s one of the risk factors, finasteride.
0:49:37 You know, the other thing in addition to reproductive health
0:49:39 is sexual health that I deal with a lot.
0:49:41 And there’s also a concern that finasteride
0:49:43 impacts sexual function in men too.
0:49:44 So, you know, we have these discussions.
0:49:45 I’ve had some men that come in
0:49:48 after having been on finasteride
0:49:51 and have, you know, different issues with sexual desire,
0:49:53 low libido, or erectile dysfunction.
0:49:55 And so then we, you know, work through an algorithm
0:49:57 to try and improve that as well.
0:49:58 – This is one of the things I think about a lot,
0:50:01 ’cause I don’t wanna have a receding hairline,
0:50:03 and I also don’t wanna have an air operation
0:50:04 or anything like that.
0:50:06 But when I hear about some of these
0:50:09 testosterone replacement therapies and such,
0:50:11 my big concern is that if I take testosterone,
0:50:12 maybe not now, ’cause I’m, you know,
0:50:14 probably don’t need it right now,
0:50:16 but maybe when I’m a little bit older,
0:50:18 which is when I assume one would start taking it,
0:50:20 maybe when I’m about 50-ish.
0:50:21 – On average, but there are younger men
0:50:23 that are on it as well.
0:50:24 – For what reason?
0:50:26 Just because they’re low on,
0:50:28 what’s the sort of symptoms
0:50:29 that have caused them to take it?
0:50:30 – Well, I think there’s, you know,
0:50:32 with all things, there’s a bell-shaped curve.
0:50:33 So some men are a little bit lower.
0:50:35 Some have genetic conditions.
0:50:37 You know, there are some more nefarious
0:50:39 testosterone prescribers.
0:50:41 So even though men have a normal level,
0:50:42 they’re offered testosterone to kind of get
0:50:45 in these kind of testosterone clinics.
0:50:47 And some men, you know, if you kind of look at data,
0:50:51 maybe 10 to 20% of, you know,
0:50:54 high school athletes have experimented with testosterone,
0:50:55 and if you stay on that too long,
0:50:57 it can really shut down your own axis.
0:51:00 So if you take exogenous testosterone,
0:51:02 so like testosterone injections or gels,
0:51:04 your body stops making it.
0:51:05 And the longer you’re on it,
0:51:08 the less likely your body’s able to sort of restart.
0:51:10 And so for some of these men, you know,
0:51:13 poor choices or, you know, whatever,
0:51:14 they’ve been on testosterone for a while,
0:51:16 and they can’t ever stop.
0:51:18 – I don’t know if you’ve ever had me experience in it,
0:51:20 because I know you focus predominantly on male health,
0:51:22 but I’ve had a long conversation
0:51:25 about contraceptive pills with my partner,
0:51:28 because she was on, she said this publicly before,
0:51:30 that she was on a contraceptive pill for a long time.
0:51:31 And then, and everyone’s relationship
0:51:33 with contraception is different.
0:51:35 But after taking it for seven or eight years,
0:51:39 she came off it and her period didn’t happen.
0:51:41 Didn’t occur.
0:51:44 So she really struggled with that for a while previously.
0:51:45 And it made me really, you know,
0:51:47 I eliminated the fact that when we start messing
0:51:50 with the chemical balances of our body using pills
0:51:51 and injections and other things,
0:51:54 we could do pretty long-term
0:51:56 and/or permanent damage to ourselves.
0:51:58 And there’s no real such thing as a free lunch
0:52:01 is there in biology and chemistry.
0:52:02 – Yeah, I think that’s what it comes down to.
0:52:04 I think a lot of people have said that if they tried
0:52:06 to get the pill approved now,
0:52:09 it would be a much different process
0:52:12 and unlikely to succeed for those kinds of reasons.
0:52:17 If I have low testosterone and I come to see you,
0:52:20 what is the typical way
0:52:24 of getting a testosterone replacement therapy?
0:52:25 Is it a pill?
0:52:27 Is it an injection that I have to take?
0:52:30 I know that it’s quadrupled according to the data
0:52:33 in the US since the 2000s, which is staggering.
0:52:36 But how are people taking testosterone?
0:52:38 – So there’s lots of different ways it can be taken.
0:52:39 I think one thing, you know, again,
0:52:41 we talk about all the risks.
0:52:43 So fertility would certainly be a big one.
0:52:45 So if you come in in your thirties, you know,
0:52:47 I’d ask you about your reproductive intent.
0:52:49 So if you have a low testosterone,
0:52:51 you’re interested in having four kids.
0:52:53 I wouldn’t start you on testosterone directly.
0:52:55 There’s some off-label things, you know,
0:52:57 so medicines that we kind of repurpose
0:52:59 to help increase your body’s own testosterone
0:53:01 that we would start with.
0:53:03 But assuming that, let’s say you’re in your sixties,
0:53:05 you’re not interested in fertility.
0:53:07 Then, you know, there’s gels or patches
0:53:10 that you put on every day, testosterone, gel or patch.
0:53:12 ‘Cause that can work well, probably 10 to 20% of men
0:53:14 don’t absorb testosterone that well through the skin.
0:53:16 The other thing to be aware of is that there’s a risk
0:53:20 of like transference, like to your partner,
0:53:21 to anybody that kind of touches your skin.
0:53:24 So if you have young kids, just to sort of be aware of.
0:53:26 But as long as, you know, you put it on, let it dry,
0:53:28 put clothes on over it, it’s not a big risk.
0:53:31 You know, again, and also have to be,
0:53:33 I guess mindful of laundry as well.
0:53:35 So, you know, gels, patches are one.
0:53:38 There’s injections that you can do every,
0:53:41 usually one to three weeks on average.
0:53:43 There’s testosterone pellets.
0:53:45 So these are pellets that have testosterone.
0:53:47 They’re kind of slow release.
0:53:49 So they’re just injected.
0:53:51 We kind of implant them under the skin,
0:53:52 usually in the hip area.
0:53:55 And those last probably three to six months.
0:53:56 There’s longer acting injections.
0:53:58 So those are very common in Europe.
0:54:00 They’re kind of gaining steam in the US,
0:54:04 but those are injections that last probably 10 weeks or so.
0:54:06 And then there’s a new oral therapy.
0:54:09 So there’s an oral form of testosterone
0:54:10 that’s available as well.
0:54:12 – I was quite confused on this subject of hair loss
0:54:14 and testosterone, ’cause I couldn’t figure out
0:54:19 if low testosterone causes me to bold
0:54:20 and have a receding hairline,
0:54:23 or if it’s high testosterone that causes me to bold
0:54:26 and have a receding hairline, or if it’s both.
0:54:27 – I mean, it could be both.
0:54:30 I think usually we think about it as higher levels.
0:54:32 – Okay, it’s funny ’cause I’ve wondered before
0:54:34 whether me doing a lot of exercise,
0:54:37 which is I guess increasing my testosterone levels,
0:54:41 is gonna accelerate my bolding and receding hairline.
0:54:42 – Anything that’s good for your heart
0:54:43 should be good for your hairline.
0:54:45 So I would exercise, I think that’s good.
0:54:47 – But what if I’m doing like iron man’s
0:54:49 and 1,000 miles runs and all that kind of thing,
0:54:52 which you see in certain groups?
0:54:53 – So I don’t know that it,
0:54:56 I do think it’s possible to over exercise.
0:54:57 I don’t know if it’ll affect your hairline,
0:54:59 but you know, I think–
0:55:01 – My testosterone levels?
0:55:02 – It can affect testosterone levels.
0:55:03 I do think that it’s, you know,
0:55:07 when you kind of exercise at the point of exhaustion,
0:55:10 you know, we do see declines in sperm counts as well.
0:55:12 So hormone levels can certainly be affected.
0:55:15 – As my cortisol goes up, so my testosterone,
0:55:17 I guess goes down.
0:55:19 – Can go down, sometimes.
0:55:20 – Interesting.
0:55:21 What about penis size?
0:55:23 I heard you did some pretty landmark research,
0:55:26 which suggests that the length of a man’s penis
0:55:30 is increasing decade over decade in terms of men
0:55:31 that are being born and boys
0:55:33 that are going through puberty.
0:55:38 – Yeah, so this study also got a lot of attention.
0:55:40 So, you know, similar to how we have tracked
0:55:44 testosterone levels over time or sperm counts over time,
0:55:45 you know, for different reasons,
0:55:47 investigators have measured penile length,
0:55:48 you know, to kind of give normative data
0:55:50 across different populations,
0:55:52 to understand how different surgeries or conditions
0:55:55 may affect penile length.
0:55:58 So, you know, we looked at, you know, all the studies
0:56:00 and there were dozens.
0:56:02 And so we kind of pooled all that together.
0:56:04 This was tens of thousands of men
0:56:07 and just looked at sort of average penile length over time.
0:56:08 And so, you know, again,
0:56:10 based on some of the data on semen quality,
0:56:13 we would have expected things to get shorter over time.
0:56:15 And also ’cause we’re more obese now,
0:56:17 you know, the way that penises are measured
0:56:18 is you kind of pull the penis on stretch
0:56:21 and use a tape measure, some sort of ruler measuring device.
0:56:24 So if there’s kind of more gut, you know, more fat,
0:56:26 in theory, the length should be a little bit shorter
0:56:28 now than it used to be.
0:56:31 But it turns out, at least when you measure a rec penile length,
0:56:34 that penises are longer now than they used to be.
0:56:37 And so over the, you know, past 30 years or so,
0:56:40 they’ve probably gone up about 25%.
0:56:41 – Why?
0:56:43 – I mean, it’s a good question.
0:56:45 I think one hypothesis we had,
0:56:47 kind of looking at sort of different endocrine, you know,
0:56:50 abnormalities and changes in puberty,
0:56:52 is that if men go through puberty
0:56:54 or boys go through puberty earlier,
0:56:57 that tends to correlate with longer penis length.
0:56:59 And so if we are shifting puberty,
0:57:02 again, through these different environmental exposures,
0:57:04 maybe that is leading to, you know,
0:57:05 changes in general development.
0:57:07 And this may be one of the consequences of it.
0:57:12 – Does this have any upstream implications for sex?
0:57:15 – I think that, well, the numbers we’re talking about
0:57:20 shouldn’t be, you know, kind of enough
0:57:21 to make a big, big difference.
0:57:24 You know, people, as this study came out,
0:57:26 we talked about, you know, very enterprising patients
0:57:29 kind of reaching out, sending emails.
0:57:30 Some people hypothesized that this was
0:57:32 kind of natural selection.
0:57:33 So it’s hard to know.
0:57:35 But again, it’s a very short period of time.
0:57:37 So it’s hard to believe that there’s, you know,
0:57:39 that’s kind of the play.
0:57:41 – Do you have many people that come into your practice
0:57:43 that are struggling with erectile dysfunction?
0:57:45 – Yeah, so that’s another very common condition we see.
0:57:47 You know, if you look at men over the age of 40,
0:57:49 over half have some trouble with erection.
0:57:51 So very, very common.
0:57:54 Hundreds of millions of men all over the world are afflicted.
0:57:57 We don’t talk about this much.
0:58:01 What is the cause of this?
0:58:03 And are you seeing it increase over time?
0:58:05 The prevalence of erectile dysfunction?
0:58:07 – I mean, I think, you know, the rates are going up.
0:58:09 And I think, you know, the risk factors, you know,
0:58:12 are the same risk, largely the same risk factors
0:58:14 that affect heart disease.
0:58:17 So, you know, diabetes, obesity, high blood pressure,
0:58:20 high cholesterol, you know, minority of these conditions
0:58:22 can be caused by low-testosterone.
0:58:25 Sometimes the outcomes of, you know, surgical treatment
0:58:27 for pelvic cancers as well.
0:58:29 But by and large, it’s vascular.
0:58:31 Just, it’s a blood flow issue.
0:58:34 – ‘Cause I used to think it was more of like a,
0:58:37 like a hormonal thing or a psychology thing.
0:58:41 Like, you know, sexual anxiety or some kind of, you know,
0:58:42 change to our testosterone levels
0:58:46 is causing us to struggle with getting erections now.
0:58:47 We were saying it’s about…
0:58:50 – So I think, you know, psychogenic used to be thought of,
0:58:51 like you’re saying, used to be thought of
0:58:54 as the kind of the primary etiology.
0:58:56 And maybe for some, you know, populations,
0:58:58 it could be a little bit more common,
0:59:01 but generally for most men, sort of all comers,
0:59:04 it’s gonna be a blood flow issue, vascular, organic cause.
0:59:07 – And how would you go about treating erectile dysfunction?
0:59:09 – So there’s a lot we can do.
0:59:12 We do wanna, you know, kind of reverse anything that we can,
0:59:14 kind of understand where the man’s coming from,
0:59:16 find out if there’s, you know, new relationship
0:59:17 or other kind of factors.
0:59:19 You know, for men, like, you know,
0:59:21 suggesting that we do, like, kind of suspect
0:59:25 the psychogenic component, work with sex therapist as well.
0:59:28 But for other men, you know, I always like to be very positive.
0:59:29 It’s like to say, you know, as long as you have a penis,
0:59:31 we can always make it hard.
0:59:32 So there’s a lot that we can do.
0:59:37 So usually we start with pills, like Viagra, Cialis.
0:59:38 – Does that work for people?
0:59:40 – It works probably 60 to 70% of the time.
0:59:42 So that does work well.
0:59:43 Even for men with a psychogenic cause,
0:59:46 sometimes it can kind of help reset the system a little bit,
0:59:47 you know, convince them in their body
0:59:49 that everything is working well.
0:59:50 – Like a placebo effect.
0:59:52 – Well, it’s, I think, to some extent,
0:59:54 but even more than that, cause it does work.
0:59:55 It does help.
0:59:57 And then I think once they kind of regain that confidence,
0:59:59 if there was some sort of traumatic event,
1:00:03 traumatic relationship, it could help improve things.
1:00:04 Pills aren’t enough where they don’t like those
1:00:06 or they have side effects from those.
1:00:07 There’s other therapies.
1:00:09 So there’s medicines you can actually put
1:00:12 in the tip of the penis, like a gel or a suppository.
1:00:16 We can teach men to give themselves injections in the penis.
1:00:18 – Ooh, I just got shivered in my body.
1:00:22 There’s certainly a kind of a psychological sort of fear
1:00:24 of that, but it does work well.
1:00:26 Probably works 80 to 90% of the time.
1:00:29 There is something called a vacuum erection device.
1:00:31 So it’s like a plastic cylinder.
1:00:34 Put over the penis, it sucks blood into the penis,
1:00:35 kind of treats it like a balloon.
1:00:38 And then you put a band at the base to trap blood inside.
1:00:39 And there’s even surgeries we can do
1:00:40 to put a device inside the penis.
1:00:43 So whenever a man wants to be hard, he can be hard.
1:00:46 – I didn’t know there was surgery you could do.
1:00:47 – There’s a surgery.
1:00:48 – Mm-hmm.
1:00:49 – Do you put some…
1:00:51 – So there’s two main flavors of it.
1:00:54 There’s, or forms, maybe that’s a better term.
1:00:56 There’s one called a malleable.
1:00:56 So it’s bendable.
1:00:59 So it kind of puts this sort of bendable metal,
1:01:03 it’s a metal core with sort of a plastic kind of covering.
1:01:04 So when they don’t want to have sex,
1:01:07 you bend it down when you’re ready for sex, you bend it up.
1:01:09 Or there’s inflatable versions.
1:01:11 So whenever you’re ready for sex,
1:01:13 there’s basically a pump that goes in the scrotum
1:01:16 and you just pump it up and moves fluid into the cylinders
1:01:17 and you’ll get a rigid erection.
1:01:21 – Is that increasing in popularity?
1:01:25 – I think that it’s made by a few manufacturers
1:01:29 in the US or in the world.
1:01:31 And so I think the data is not as freely available.
1:01:34 I mean, in my practice, I’ve seen more and more of it.
1:01:36 We’re seeing more patients come in.
1:01:39 I also say that my practice is getting a little bit more
1:01:41 mature with time as I get older.
1:01:45 And so naturally, more patients kind of hear
1:01:47 about these different things, but it does work well.
1:01:49 I always say it’s a self-selected population, right?
1:01:51 We don’t hold men down and force them to get it,
1:01:52 but generally they’re very happy.
1:01:55 Probably 90% of men are very happy.
1:01:57 They’d recommend it to their friends,
1:02:00 partners are very happy, recommend it to other couples.
1:02:03 – And you just press a button and you get like a, you can…
1:02:04 – It’s a pump right now.
1:02:08 They are working actually on either a fob or like a phone app
1:02:10 that’ll kind of automatically inflate it
1:02:12 to make it easier for patients.
1:02:13 – I had no idea.
1:02:15 It sounds like sci-fi or something.
1:02:16 It sounds like it’s…
1:02:19 It sounds like something you might see on like a YouTube video
1:02:21 that people are working on in like 20, 30 years time.
1:02:26 But to know that men have that installed now is amazing.
1:02:30 – Yeah, I mean, it’s very common.
1:02:32 The youngest patient I put it in is about 20.
1:02:33 The oldest is in his 80s.
1:02:37 – What was the, is it seen as like a last option
1:02:40 in that menu of options that you presented there
1:02:42 where like the first option is probably Viagra.
1:02:45 And in terms of popularity, is it a last port of call?
1:02:47 – I think for a lot of men, it’s the most aggressive,
1:02:49 but some men don’t want to do like,
1:02:51 you had a reaction to the injection.
1:02:53 I think that’s a very common reaction.
1:02:56 There are certainly some advantages to it compared to others.
1:02:57 You know, for Viagra, for example,
1:02:59 even though it’s obviously the easiest, it’s a pill,
1:03:01 you know, there’s some side effects with it.
1:03:03 And there’s also, you know, a lag time, right?
1:03:04 You have to take the pill, wait an hour,
1:03:07 wait 30 minutes, something like that.
1:03:10 Whereas just, you know, the penile prosthesis,
1:03:12 you know, if you just pump it up,
1:03:13 it’s ready to go in seconds.
1:03:15 So it can be very spontaneous.
1:03:19 So patients like that, you know, some patients don’t,
1:03:20 you know, they have other medications
1:03:21 so they can’t take pills.
1:03:23 They don’t like some of the other
1:03:25 kind of intermediate options that we have.
1:03:28 – Shockwave therapy for erections.
1:03:30 Does that work and what is it?
1:03:33 – So the idea is that, is kind of the name implies
1:03:35 you’re sending shockwaves into the penis.
1:03:38 And the energy is induces kind of some micro trauma,
1:03:42 which induces new blood vessel growth is the hypothesis.
1:03:45 And so, you know, the hope is that with,
1:03:47 you know, getting better blood vessel,
1:03:48 better blood flow into the penis
1:03:51 can improve the quality of erections.
1:03:53 So there have been some studies that do show benefit.
1:03:55 It’s still considered experimental
1:03:57 because I think the data is not yet conclusive.
1:03:59 But I think for men with milder forms
1:04:01 of erectile dysfunction, it can help, you know,
1:04:04 maybe the men that are on Viagra or sometimes on Viagra,
1:04:06 maybe we can get them off those pills.
1:04:10 But I think we need more data to kind of understand
1:04:13 really the kind of the best target population for it.
1:04:15 – You talk about pelvic floors as well.
1:04:18 When we typically think about pelvic floors,
1:04:20 we tend to think of women, you know,
1:04:23 things like these Kegel exercises that people talk about.
1:04:26 But is it important for us to think about that
1:04:29 as a man as well, our sort of pelvic floor strength
1:04:31 and our pelvic floor muscles?
1:04:32 – I think in some conditions,
1:04:34 I think if you’re not thinking about it, it’s probably okay.
1:04:36 You’re not having a lot of problems.
1:04:37 But it can be a trigger for some men.
1:04:40 So that can be an etiology of some different
1:04:42 problems with urination.
1:04:44 You’d see men with very tight, you know,
1:04:46 pelvic floors and they have a lot of urgency to urinate.
1:04:48 They urinate frequently.
1:04:51 It can also lead to scrotal pain sometimes as well.
1:04:52 ‘Cause there’s a lot of muscles
1:04:53 as you’re kind of pointing out in the area.
1:04:56 And sometimes if they’re under tension,
1:04:58 if they’re not, you know, properly kind of trained
1:05:01 and they can kind of trigger some other areas.
1:05:05 And so for some of these different conditions,
1:05:07 we do kind of work with pelvic floor physical therapists
1:05:09 to train patients, you know, how to, you know,
1:05:11 again, relax the area, strengthen the area,
1:05:13 increase flexibility of some of those muscles,
1:05:14 which can help.
1:05:17 – Is it plausible that doing pelvic floor exercises
1:05:19 will improve one’s sex life?
1:05:23 – I mean, I think that unless we’re treating a problem,
1:05:26 I would be very hesitant, you know,
1:05:29 one of my favorite things is the enemy of good is better.
1:05:32 So if things are good, you know, to try and get better,
1:05:34 you know, there’s always going to be,
1:05:35 like you said, there’s no free lunch,
1:05:36 there’s always some trade-offs.
1:05:39 So I think if you work on kind of over-strengthening
1:05:40 the pelvic floor, it could lead
1:05:42 to some of these other dysfunction.
1:05:44 So you don’t want to end up with a floor
1:05:46 that’s too tight or too tense.
1:05:48 – Is there any correlation between these things,
1:05:50 like your pelvic floor strength, your testosterone,
1:05:54 your sperm count and a variety of the different cancers
1:05:57 that we see in men, things like testicular cancer
1:05:59 and prostate cancer?
1:06:04 – So I think with pelvic floor kind of strength,
1:06:06 I think I usually kind of think about that
1:06:09 as separate from cancer risk.
1:06:10 But for testis cancer, you know,
1:06:13 one of the risk factors for that is some men are born
1:06:15 without testicles in their scrotum.
1:06:18 So that’s a risk factor and so-called undescended testicle,
1:06:21 low sperm counts are associated with testicular cancer.
1:06:24 There is one study I know of years ago that looked at,
1:06:25 you know, comparing sort of sexual health
1:06:27 to prostate cancer risk found that men
1:06:29 that ejaculated more frequently
1:06:31 had lower risk of prostate cancer.
1:06:33 The thought was that, you know, there was inflammation
1:06:36 that you’re kind of clearing out by frequent ejaculations.
1:06:39 I think the study had men ejaculating 30 times a month
1:06:40 and showed a lower risk.
1:06:45 So that’s a lot, but that was one study that said,
1:06:47 at least it’s not dangerous to ejaculate more frequently.
1:06:49 But it’s not something that I generally recommend to men
1:06:50 to lower their risk.
1:06:53 – Look, if we talk about testicular cancer then,
1:06:56 what are the common symptoms of testicular cancer?
1:06:59 – Yeah, so usually it tends to be relatively asymptomatic.
1:07:02 I think that, you know, the classic symptom would be
1:07:05 a firm painless mass that men find in the scrotum.
1:07:07 So, you know, there used to be,
1:07:09 there are screening guidelines,
1:07:12 even though our preventative services task force thinks
1:07:14 that, you know, the utility of doing it
1:07:16 for, you know, reproductive age dementia,
1:07:19 their scrotums may lead to more anxiety
1:07:21 than actually, you know, finding testis cancer
1:07:22 ’cause it’s such a rare cancer.
1:07:25 So it’s more likely a man’s gonna just worry themselves
1:07:27 than actually, you know, diagnose an early cancer.
1:07:30 But the recommendation used to be that you would,
1:07:32 you know, once a month in the shower,
1:07:34 kind of feel yourself and if you feel something new
1:07:35 or something abnormal, you know,
1:07:37 bring it to your doctor’s attention.
1:07:39 Okay, I certainly see a lot of men with this concern
1:07:41 and do an exam say, you know, that’s normal
1:07:43 or if there’s something that we’re worried about,
1:07:45 we’ll kind of dive a little deeper.
1:07:47 – What is the demographic that’s most likely
1:07:49 to get testicular cancer?
1:07:50 Is it something that affects young people
1:07:52 as well as older people?
1:07:53 – It’s usually mostly a cancer of young men.
1:07:56 So I would say probably twenties to 40
1:07:58 is usually that kind of the prime demographic.
1:08:00 – Why is it a cancer of young men?
1:08:03 Is there any sort of physiological reason for that?
1:08:05 – Well, I mean, it’s a, you know, reproductive age cancer.
1:08:07 So that’s the prime reproductive years.
1:08:09 So it’s possible that it kind of correlates
1:08:13 with, you know, sperm counts declining with older ages.
1:08:14 There is another slight increase
1:08:17 for men in their fifties and sixties.
1:08:19 But again, it’s such a, it is a very rare cancer.
1:08:21 So I usually kind of quote,
1:08:23 probably one in a hundred thousand men
1:08:25 are gonna be diagnosed with it.
1:08:26 – So one in a hundred thousand?
1:08:28 – It’s pretty, it’s fairly uncommon.
1:08:30 – But prostate cancer is more common.
1:08:31 – Prostate cancer is more common.
1:08:33 Yeah, so that, you know, in the United States
1:08:36 probably at least 200,000 men every year.
1:08:38 Some studies say that, you know,
1:08:39 if you live long enough,
1:08:41 everybody will be diagnosed with prostate cancer.
1:08:43 But again, most men with prostate cancer
1:08:45 die of heart disease just like every other man
1:08:46 in this country.
1:08:48 So most men, you know, with prostate cancer
1:08:50 die with it, not of it.
1:08:51 So usually it’s a slower growing disease,
1:08:53 although there’s some that are more aggressive
1:08:55 and that’s why we screen for it and treat it.
1:08:58 – I read a stat that it affects one out of every seven men,
1:08:59 prostate cancer?
1:09:00 – Yes.
1:09:03 – Okay, so what is a prostate?
1:09:06 – So prostate is, it’s a walnut shaped organ.
1:09:08 It’s just underneath the bladder.
1:09:10 So the way that we’re shaped is we have our bladder
1:09:12 which fills with urine from our kidneys
1:09:14 and then we urinate out the urethra, you know,
1:09:16 out the penis.
1:09:19 And so the prostate’s just at that kind of intersection
1:09:22 between the urethra and the bladder.
1:09:25 And it really has a function in reproduction.
1:09:28 So it produces about 20% of the fluid of our ejaculate
1:09:31 and it produces a lot of the different chemicals
1:09:34 and sugars that support and protect the sperm
1:09:36 in the female reproductive tract.
1:09:39 So after reproduction, it doesn’t really have a lot of,
1:09:40 you know, benefit.
1:09:41 Mostly it just causes issues
1:09:43 ’cause it gets bigger with age.
1:09:44 So it leads to urinary symptoms.
1:09:46 And then obviously it’s a cancer risk
1:09:47 as well as we get older.
1:09:50 – Okay, so we typically get prostate cancer
1:09:52 once we’ve stopped using the prostate.
1:09:54 – For reproduction, yes.
1:09:56 – So does it have a role outside of reproduction?
1:09:59 I guess ’cause it’s a gland that might be regulating hormones
1:10:02 long after we’re using it for reproduction reasons.
1:10:04 – It doesn’t really have any useful benefit.
1:10:06 If we could find a way to remove the prostate
1:10:08 without causing any complications,
1:10:10 that’d probably be a reasonable thing to do.
1:10:12 But unfortunately, every treatment we have
1:10:14 does have some side effects
1:10:16 just given where it is anatomically.
1:10:17 It’s right by a lot of the structures
1:10:20 that are important for erections and for reproduction.
1:10:21 – So when people have prostate treatment
1:10:23 because they’ve got a prostate cancer,
1:10:25 are they getting their prostate removed?
1:10:26 – Some men get it removed.
1:10:28 Some men have radiotherapy
1:10:30 to sort of kill all the prostate cells.
1:10:32 And there’s other kind of energy therapies
1:10:35 that are delivered like high-frequency ultrasound
1:10:37 can sometimes be delivered.
1:10:38 There’s also something called cryotherapy
1:10:40 where you can freeze the prostate.
1:10:40 You know, usually these are done
1:10:42 in kind of targeted fashions
1:10:44 where you can look at the prostate,
1:10:46 look at MRI imaging of the prostate,
1:10:47 look at biopsy patterns
1:10:48 to try and figure out where the cancer is.
1:10:51 So usually the whole gland is treated,
1:10:53 but sometimes I think newer modalities
1:10:56 are trying to just treat a particular portion.
1:10:59 – How often do you think we should get our prostate checked
1:11:02 and what are the symptoms that we should be looking for?
1:11:04 – From sort of a urinary standpoint,
1:11:06 I think that if urination bothers you,
1:11:08 you should talk to your primary care doctor
1:11:10 or your urologist about it.
1:11:11 If you’re waking up at night,
1:11:12 if you feel like you have to pee too frequently,
1:11:14 if it burns to pee, things like that.
1:11:18 So that sometimes is due to prostate enlargement,
1:11:19 prostate issues.
1:11:21 It could also be due to a tight pelvic floor as well.
1:11:23 From a cancer standpoint,
1:11:25 usually we check blood tests called the PSA,
1:11:27 prostate-specific antigen.
1:11:30 And there’s different screening guidance that’s made.
1:11:33 Usually you start men in their 50s or so
1:11:36 and screen every year or two until a man turns 70.
1:11:38 Some of the guidance or some of the screening patterns
1:11:40 will vary based on family history,
1:11:43 which is a very strong predictor of cancer risk.
1:11:45 – Is there anything I can do or is there any research
1:11:49 that gives me advice on how to treat my body in such a way
1:11:52 where I reduce my risk of prostate cancer?
1:11:55 – You know, we talked about some of these risks
1:11:57 for erectile dysfunction, right?
1:11:59 Like obesity, diabetes.
1:12:01 I think those same things can also play a risk
1:12:04 in a lot of these prostate conditions too.
1:12:07 So good diet, exercise, maintaining good body weight.
1:12:09 I think all those are important.
1:12:11 – Avoiding drinking water before bed.
1:12:12 – Well, that’ll help with, you know,
1:12:13 sometimes waking up at night.
1:12:16 So for some men that are most bothered by, you know,
1:12:19 so-called nocturier or waking up at night to urinate,
1:12:21 I think, you know, trying to dehydrate yourself.
1:12:23 You know, saying I’m not gonna drink any fluid
1:12:26 after seven o’clock at night or six o’clock at night
1:12:28 so that you’re more likely to get, you know, a full night’s
1:12:31 sleep, you know, waking up once at night is not that unusual,
1:12:33 but if it becomes a little bit more frequent, you know,
1:12:35 that’s one strategy that some men use.
1:12:38 – Okay, so reducing my water consumption at night time
1:12:40 isn’t gonna reduce my chance of having prostate cancer.
1:12:41 – Right. – Okay, fine.
1:12:43 What about spicy foods?
1:12:46 – So I think in a similar way that can also affect
1:12:47 some of the symptoms.
1:12:48 It shouldn’t affect your prostate cancer risk.
1:12:50 – It’s just a symptom thing.
1:12:50 Ah, okay.
1:12:54 Is there any studies that show ways that we can reduce
1:12:57 our prostate risk that aren’t just the sort of health
1:13:00 in what sort of lifestyle related things?
1:13:02 Is there anything linked to, I don’t know,
1:13:05 other parts of our lifestyle, like our use of technology
1:13:08 or alcohol consumption or anything at all?
1:13:08 – Not to my knowledge.
1:13:11 I think that, you know, Asian orange,
1:13:14 the defoliant that was used during Vietnam War,
1:13:17 that was found to be a risk factor for prostate cancer.
1:13:19 So I don’t know why you would,
1:13:21 but try and avoid Asian orange.
1:13:24 But otherwise, there are not a lot of modifiable risk factors,
1:13:25 other than the ones that we talked about.
1:13:28 I think that, you know, cancer risk goes up with obesity,
1:13:29 you know, thought to be due to different things,
1:13:31 but maybe inflammation and things like that.
1:13:33 So I think kind of living a healthy life,
1:13:36 I think hopefully we’ll keep you on a healthy trajectory.
1:13:37 – I’m the first person to lean into new tools
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1:14:37 What are the most important things
1:14:39 that we haven’t talked about,
1:14:40 that patients come into your clinic
1:14:42 and speak to you about,
1:14:45 as it relates to reproductive health,
1:14:47 hormones, everything in between?
1:14:50 – Well, another condition that I see men for a lot
1:14:51 is something called Peyronie’s disease,
1:14:53 which is a curvature of the penis.
1:14:57 So the way erections work is everything swells.
1:14:59 There’s sort of these kind of tough tissue layers
1:15:01 in the penis that trap blood inside,
1:15:04 and sometimes scar tissue can form on those layers
1:15:07 for different reasons, it’s thought maybe microtrauma.
1:15:09 Some men do remember sort of a traumatic sexual episode
1:15:12 that leads to an injury and scar formation,
1:15:14 and you can imagine that there’s scar tissue in there,
1:15:19 everything will not kind of expand in a uniform fashion.
1:15:20 So you can get a curvature deviation.
1:15:25 So some of these men have 90 degree curves to their penis,
1:15:27 and so whether it goes up or down,
1:15:30 it can make sex pretty challenging.
1:15:32 And so that’s another condition we see.
1:15:34 I think it’s important for men to know,
1:15:36 I think, again, it’s just similar to erectile dysfunction,
1:15:39 I think men are sometimes a little bit reticent
1:15:41 to talk about some of these conditions,
1:15:42 but it’s fairly common,
1:15:44 probably five to 10% of men are affected,
1:15:46 and there are effective treatments for this as well.
1:15:49 So I think just as sort of a public service announcement,
1:15:51 if men are suffering from this,
1:15:52 again, talk to your doctor
1:15:55 ’cause there are treatments that we can offer.
1:15:57 – Okay, so let’s conclude then.
1:15:59 If I wanna make sure that my sperm count remains
1:16:02 very, very high, so I can have those four kids,
1:16:04 and I wanna make sure my testosterone levels
1:16:07 remain at a healthy sort of balance,
1:16:10 let’s say, is it sort of 4,500?
1:16:12 It’s mg milligrams, is it?
1:16:13 – Yeah, about nanograms per deciliter.
1:16:15 – Okay, nanograms per deciliter.
1:16:17 Wanna keep it in that sort of healthy range,
1:16:19 and I wanna have rock art erections.
1:16:20 – Okay.
1:16:23 – So that I can have the four kids that I mentioned.
1:16:25 What is the advice that you would give
1:16:28 that is broadly applicable to everybody
1:16:30 without you having to run my blood tests
1:16:31 and all those things.
1:16:33 And this is really a conclusive point.
1:16:34 The first one that I’ve heard is about
1:16:36 sort of lifestyle and dietary choices.
1:16:39 Is there anything that I definitely shouldn’t be eating
1:16:42 if I’m trying to become optimal in these three areas?
1:16:44 – Again, people have looked at sort of different diets
1:16:48 which can affect health and reproductive health,
1:16:48 more specifically.
1:16:51 So I think generally healthy foods are a good idea.
1:16:53 Whole grains, fruits, vegetables,
1:16:55 usually the control group for all these
1:16:56 is like a Western diet,
1:17:00 like processed foods, fast food, things like that,
1:17:02 foods that have a lot of fat, high calorie,
1:17:05 those, and some of them also the packaging has
1:17:07 some of these same kind of chemicals
1:17:08 that we talked about earlier.
1:17:09 So I think trying to avoid some of those,
1:17:10 I think is a good idea.
1:17:12 – Sugar?
1:17:13 – Sugar’s okay.
1:17:15 – Okay.
1:17:16 – Unless again for a high calorie foods
1:17:18 or things to try and avoid.
1:17:21 If you have any medical conditions,
1:17:23 I think that trying to get those treated.
1:17:26 Sometimes men do worry that if you’re taking a pill
1:17:28 for something, it may affect your fertility.
1:17:31 But I think just generally being healthy,
1:17:32 anything that’s good for your heart
1:17:33 is gonna be good for fertility.
1:17:35 So I think it’s a good idea to get that treated.
1:17:38 There is a study out of Japan
1:17:39 that I always quote about this.
1:17:41 So this was a study that looked at all patients
1:17:43 that came in with male infertility
1:17:45 and tried to figure out who they helped, right?
1:17:47 And so they wanted to see if they could predict
1:17:49 who was likely to benefit from a urologic concentration
1:17:50 and who was not.
1:17:53 And so they looked at baseline sperm count
1:17:55 that wasn’t predictive of who was gonna benefit.
1:17:57 Baseline testosterone level wasn’t, age wasn’t.
1:17:59 Some men had this condition called a varicoseal,
1:18:01 which has dilated veins in the scrotum.
1:18:04 So about 15% of all men have them.
1:18:06 Infernal men, maybe about 40% have them.
1:18:08 So, you know, the testicles are outside the body
1:18:10 like we talked about and having larger veins
1:18:12 impairs normal temperature regulation.
1:18:14 And so if you fix those,
1:18:15 it turns out most of those men
1:18:18 are gonna improve their sperm count.
1:18:19 But the other really interesting finding
1:18:20 is that they also found that men
1:18:24 that had a comorbidity treated had improvements.
1:18:26 So the data they provided is men
1:18:28 that had high blood pressure.
1:18:29 If they got that under control,
1:18:32 their sperm counts went up about 25%.
1:18:34 So, you know, a lot of times, you know,
1:18:36 the first time men see the doctor,
1:18:37 men don’t go to the doctor a lot, right?
1:18:38 Unless there’s a problem, right?
1:18:42 Unless they’re in pain or some other, you know, condition.
1:18:44 So sometimes my patients,
1:18:45 the first time I’ve ever seen anybody
1:18:47 is seeing me to try and have a baby.
1:18:50 And so it’s an opportunity to, you know,
1:18:52 make them take a little bit more ownership of their health.
1:18:53 You know, if they’ve never had a blood pressure check,
1:18:55 check that blood sugar, cholesterol,
1:18:57 all those things are, you know,
1:18:58 ways to improve their health or opportunities
1:19:00 to improve reproductive health,
1:19:01 but, you know, overall health as well.
1:19:04 So I think that’s another thing to be kind of mindful of.
1:19:07 – What about depression then, our mental health
1:19:10 and the role that that will have on our fertility,
1:19:13 our erectile performance and all of those things?
1:19:14 Is there correlation there?
1:19:15 – There’s strong correlation, yeah.
1:19:17 So I think we do see a strong correlation
1:19:19 between erectile dysfunction and depression.
1:19:22 You know, if you look at men with erectile dysfunction,
1:19:24 I think up to 20%, it, you know,
1:19:26 may have some form of depression.
1:19:29 And we sometimes worry that some of the treatments
1:19:32 can also, you know, exacerbate sexual dysfunction,
1:19:34 but I think trying to get men on a better path is important.
1:19:36 I think it’s also important to work,
1:19:38 you know, again, with a therapist as well, you know,
1:19:40 so that you kind of attacking these things
1:19:42 from multiple, you know, multiple angles.
1:19:44 You know, generally most of these medicines,
1:19:45 you know, probably have not been tested,
1:19:48 you know, in terms of reproductive health.
1:19:49 There’s some studies that say that
1:19:51 some of these may affect semen quality,
1:19:53 but I think those studies are limited.
1:19:55 So I think, you know, generally
1:19:56 if men are on these medicines, we’re not sure,
1:19:59 and I think it’s helping them, you know,
1:20:02 we try and sort of, you know, carry on and persevere,
1:20:03 ’cause I do want them to get the benefit
1:20:05 of some of these therapies.
1:20:08 – What about childhood trauma and the role that plays?
1:20:11 You must see that show up in your practice.
1:20:13 – Yeah, I mean, I think it certainly can affect
1:20:14 sexual health, you know, pretty profoundly.
1:20:17 I think, you know, when you do suspect, you know,
1:20:19 kind of this sort of psychogenic component,
1:20:21 I think, you know, we do, I try and be, again,
1:20:23 like talked about very optimistic about options
1:20:26 that are available, but working with the therapist,
1:20:28 working with a sex therapist to come up
1:20:30 with sort of a good sort of strategy and plan
1:20:32 to kind of get, you know, men through, you know,
1:20:35 some of these issues so they can have, you know,
1:20:36 a fulfilling sex life.
1:20:38 – Anything else that I need to do
1:20:40 to improve these things, top-line things?
1:20:44 So lifestyle, you know, we’ve talked about food,
1:20:46 exercise we’ve talked about as well,
1:20:49 as a way to improve at least our testosterone levels.
1:20:50 – Yeah.
1:20:52 – Sleep, I guess, might be important.
1:20:53 – Sleep’s important too.
1:20:55 Sleep’s interesting because it’s,
1:20:56 what’s called a U-shaped association.
1:21:00 So it’s possible to get too much sleep.
1:21:02 So, you know, you probably want sort of an ideal amount,
1:21:04 probably seven to nine hours is usually,
1:21:06 that’s been associated with better semen quality
1:21:07 for men that get less.
1:21:09 Semen quality tends to be a little lower.
1:21:11 For men that get too much sleep.
1:21:13 You know, again, for men that have, you know,
1:21:15 are able to sleep 12, 13, 14 hours a day.
1:21:17 There may be other things going on there.
1:21:19 Maybe there’s some underlying depression or something.
1:21:21 Those men tend to have lower semen quality.
1:21:24 But, you know, I think sleep, I think, is certainly important.
1:21:26 There’s also been studies looking at weight loss as well.
1:21:29 You know, I think it’s obviously easy to say, lose weight,
1:21:33 but it’s not always as straightforward to do.
1:21:35 But there was, you know, a nice study
1:21:36 that came out a few years ago,
1:21:40 where men were randomized to, you know, weight loss program,
1:21:44 a very low calorie diet, 800 calories a day for a few weeks.
1:21:47 And then they lost, you know, weight.
1:21:49 And then they fall them for the rest of the year.
1:21:51 And so this is important because
1:21:53 men that were able to keep weight off
1:21:56 were able to maintain the benefits of their sperm count
1:21:58 versus men that were, you know,
1:21:59 kind of fell off the exercise routine.
1:22:02 They ended up gaining back, you know, their weight
1:22:04 and then their sperm counts declined again.
1:22:06 One of these arms actually also had one of these, you know,
1:22:08 hot GLP-1 analogs as well.
1:22:10 And so men that were on those
1:22:12 that kind of helped them keep their weight loss
1:22:14 were also able to maintain sperm count.
1:22:16 So patients do ask about that a lot, you know.
1:22:17 – I was just gonna ask about,
1:22:18 obviously as the impact’s exploded
1:22:21 and there’s many other forms of this sort of GLP-1
1:22:23 sort of fat loss injections.
1:22:26 I was wondering if that had any consequences on fertility.
1:22:29 – So again, there’s only one study that did study it
1:22:31 and it did seem to show benefit.
1:22:32 So it doesn’t cause any harm.
1:22:34 As long as you maintain weight loss with it,
1:22:36 you know, you do seem to see improvement.
1:22:38 You know, in contrast, you know,
1:22:41 some men also ask about like bariatric surgery,
1:22:42 which, you know, again, may be declining a little now
1:22:45 with these, you know, very effective medications.
1:22:46 But interestingly–
1:22:47 – Sorry, bariatric surgery?
1:22:50 – Bariatric sort of like gastric bypass.
1:22:52 I don’t know if this is popular in Europe
1:22:56 or the United Kingdom, but for some obese individuals,
1:22:57 there are surgeries that can be done
1:23:00 to help sort of reroute intestinal absorption.
1:23:02 So you can lose weight with that.
1:23:03 There’s also something–
1:23:04 – I’ve even been the gastric band thing.
1:23:06 – Yeah, there’s gastric bands too.
1:23:08 Yeah, so there’s different ways that’s been done.
1:23:09 And so with all those,
1:23:12 actually it tends to decrease sperm
1:23:15 sort of right paradoxically.
1:23:17 So you would think that if you lost weight,
1:23:19 your sperm counts would improve.
1:23:21 But it turns out with these surgeries,
1:23:23 sperm counts actually declined.
1:23:25 Some of them, some actually men went from
1:23:27 a reasonable sperm count to zero.
1:23:28 So the thought was that, you know,
1:23:31 it’s the trauma of a surgery potentially.
1:23:33 You know, there are, you know,
1:23:35 some vitamins and minerals are important too.
1:23:38 So, you know, without that normal absorption
1:23:40 that occurs in the intestines,
1:23:42 that could also lead to infertility.
1:23:44 You know, that was sort of a concern
1:23:46 and we were wondering if that same thing
1:23:48 would happen with, you know, these newer medications.
1:23:49 But it doesn’t seem like it.
1:23:52 So again, the GLP1 analog seem like they’re safe,
1:23:54 safe form of weight loss,
1:23:56 at least when we’re looking at semen quality as an outcome.
1:23:57 – What about supplementation?
1:24:02 Is there any supplements one might recommend?
1:24:03 I guess it’s difficult for you to recommend supplements,
1:24:06 but are there any of the sort of vitamins and minerals
1:24:07 that are typically deficient in people
1:24:10 that have infertility issues?
1:24:11 – So I think there is some data
1:24:13 that antioxidants can improve fertility.
1:24:15 So it’s sort of a very broad group.
1:24:17 Of things that have been tested.
1:24:19 – Berries and stuff, is that?
1:24:20 – Yeah, dark berries.
1:24:22 Yeah, those certainly can have a lot.
1:24:23 But, you know, I usually tell, you know,
1:24:24 patients to take a multivitamin,
1:24:27 they do make special mill fertility blends.
1:24:29 Like if you were to look it up on the internet
1:24:30 or Amazon or other platforms,
1:24:32 there are special fertility blends
1:24:34 that have kind of, some of them have,
1:24:36 you know, looked at the data and try and pick out,
1:24:38 you know, specific supplements
1:24:39 that are thought to be more beneficial.
1:24:42 Coenzyme Q is a powerful antioxidant
1:24:43 that has shown some benefit for fertility.
1:24:45 So I think that’s something else
1:24:47 that, you know, try and empower patients
1:24:47 and they can do that too.
1:24:49 And that can help.
1:24:51 – Protein, does that play a role in fertility
1:24:52 or testosterone?
1:24:54 – I think, you know, again, sort of part of a balanced meal
1:24:56 and part of a balanced sort of diet,
1:24:57 I think it’s important.
1:24:58 – What’s your mission from here on?
1:25:00 What are you gonna do for the next 10 years?
1:25:02 If you had to, as it I guess, what are you gonna do?
1:25:04 Is it more of the same or are you gonna,
1:25:07 are you interested in changing focus at all slightly?
1:25:09 Or are you gonna just continue to do research
1:25:10 on these subjects?
1:25:12 What’s your big sort of decade mission?
1:25:14 – Yeah, I mean, this really gets me up in the morning.
1:25:16 And this is the stuff that I like to do,
1:25:17 like late at night as well.
1:25:18 I mean, I really am passionate about this,
1:25:20 trying to understand, you know,
1:25:22 why we see this link between fertility and health,
1:25:24 why sperm counts are declining.
1:25:25 ‘Cause I think the more we understand about it,
1:25:28 we can, you know, hopefully mitigate some of these risks.
1:25:30 I also like to hopefully, you know,
1:25:33 through, you know, information channels
1:25:34 and platforms like this, you know,
1:25:37 hopefully engage more of the community
1:25:39 to try and come up with some therapies,
1:25:40 you know, for male fertility.
1:25:42 I think, you know, we talked about some of the things
1:25:44 that can be done, but there’s no, you know,
1:25:45 and in the United States,
1:25:47 there’s the Food and Drug Administration
1:25:49 that sort of oversees all, you know, therapeutics.
1:25:52 And there’s no FDA-approved therapy for male fertility,
1:25:54 which is really a shame, especially ’cause, you know,
1:25:56 again, we have this data that it’s becoming
1:25:59 more prevalent, existential, right, as a species.
1:26:00 So it’d be nice if there was some
1:26:03 to try and get more engagement from the scientific community,
1:26:06 from the pharmaceutical community,
1:26:08 to try and, you know, see that opportunity.
1:26:10 Because I think that’ll be very important for, you know,
1:26:11 for our fields.
1:26:13 But again, you know, I think, like you said,
1:26:14 sort of more of the same in some ways,
1:26:17 but I think trying to understand some of these questions
1:26:20 in a lot more detail so that we can really help these men.
1:26:22 – Is there, of all the subjects we’ve discussed today,
1:26:25 is there a particular part of it that concerns you the most?
1:26:27 – Well, I think, you know,
1:26:29 when we’re talking about sperm counts declining,
1:26:32 I do worry that that is a barometer of health.
1:26:34 And so it may be that, you know,
1:26:35 in addition to men’s reproductive health,
1:26:38 just our overall health is declining.
1:26:39 You know, when we look at sort of
1:26:40 the health of fathers over time,
1:26:43 we’ve seen, you know, fathers are getting a little older.
1:26:44 You know, we talked about that.
1:26:47 But, you know, with that comes more comorbidities, right?
1:26:50 Higher rates of hypertension, hyperlipidemia,
1:26:51 you know, other things.
1:26:53 And that sometimes can’t have
1:26:55 sort of transgenerational impacts.
1:26:57 So like a father that has high blood pressure,
1:26:59 or, you know, is obese,
1:27:02 that child is, you know, a slightly higher risk
1:27:03 of having some other issues later on.
1:27:05 So trying to understand that again,
1:27:08 if there’s maybe opportunities to try and figure out
1:27:09 what in that sperm is a little different,
1:27:11 maybe we can turn that switch off
1:27:13 to try and, you know, prevent that.
1:27:14 I think those are all things.
1:27:16 I don’t want to be alarmist about this.
1:27:18 These risks are all very, very low.
1:27:20 But I think there’s a lot of opportunities.
1:27:22 You know, I think one of the reasons I got into it, I think,
1:27:25 is because male reproductive health was really wide open.
1:27:27 So I think there’s still a lot of opportunities
1:27:28 to try and improve it.
1:27:32 – What would you say to a man that’s listening to this,
1:27:35 that’s struggling with any of the things we’ve discussed?
1:27:39 What is your closing message for them?
1:27:41 – Well, I think I would just try and be optimistic
1:27:42 and hopeful.
1:27:43 I think there’s a lot that we can do.
1:27:45 I think that, you know, it takes a lot of bravery,
1:27:47 you know, to go in and see doctors about some of this thing
1:27:50 and some of these, you know, different issues,
1:27:52 but, you know, it’s what we’re used to dealing with.
1:27:54 And I think there’s, you know,
1:27:55 plenty of options that are available.
1:27:58 So I would just encourage them to, you know, talk to friends,
1:28:01 but, you know, men talk to their primary care doctor,
1:28:03 talk to their urologist, come see a urologist.
1:28:05 You have a very broad platform.
1:28:06 So I think if there’s a couple struggling,
1:28:07 they’ve only seen gynecologists,
1:28:09 I would encourage them to maybe see, you know,
1:28:11 male reproductive specialists as well,
1:28:13 to try and get some other perspectives.
1:28:15 – We have a closing tradition on this podcast
1:28:17 where the last guest leaves a question for the next,
1:28:19 not knowing who they’re leaving it for.
1:28:21 The question that’s been left for you is a tricky one.
1:28:26 It is, what’s one thing you would do to change the world?
1:28:29 – I guess one thing that I would do to change the world,
1:28:34 I guess, it’s certainly out of our conversation,
1:28:38 was that I would make, try and make policy
1:28:42 that all governments would pay for infertility services.
1:28:46 So that this is a universal benefit for all of humanity.
1:28:48 I think that would certainly help open up the doors
1:28:51 for a lot of people that don’t have resources for it,
1:28:53 kind of hesitant to use it.
1:28:55 And hopefully that would, again,
1:28:57 solve some of the issues that we talked about
1:28:59 from a demographic standpoint.
1:29:01 – What would that do for humanity?
1:29:03 Would it be having more kids, I guess,
1:29:07 would be happier in our relationships, potentially?
1:29:08 – I mean, yeah, I think it could do all that.
1:29:12 I think that, I guess from a father standpoint,
1:29:16 having a child, again, increases longevity,
1:29:17 decreases cardiovascular risk,
1:29:21 increasing from a sort of societal perspective,
1:29:24 having, getting into that replacement level,
1:29:26 sort of maintain population.
1:29:29 I think that’s, again, existential for a society,
1:29:32 increase the tax base and all the other things
1:29:34 that are associated with that and the workforce.
1:29:36 It’s very difficult in politics now,
1:29:38 certainly in the United States.
1:29:40 There’s a lot of issues that are going on,
1:29:43 but making policy that really affects everyone,
1:29:44 I think, would be very profound.
1:29:48 And I think there’s be a lot of benefit to that.
1:29:53 – Dr. Michael Eisenberg, thank you so much for your time.
1:29:54 And thank you for the work that you’re doing
1:29:58 because you’re helping to,
1:30:00 ultimately to create families
1:30:03 and to also alleviate a lot of the stress and anxiety
1:30:06 and worry and concern people have
1:30:07 about their reproductive health.
1:30:10 And I think it’s an incredible service to humanity
1:30:11 to be doing that.
1:30:12 And especially at the time when we’re in,
1:30:15 where it feels like it’s more needed than ever before.
1:30:18 And frankly, the direction of travel isn’t fantastic
1:30:19 as it relates to some of these big issues
1:30:22 like testosterone and fertility.
1:30:25 And, but it’s really important for people like you
1:30:28 that have the information that are doing the research
1:30:31 to not just keep it in the lab
1:30:32 and not just keep it on PubMed
1:30:34 where it’s very hard for people like me to access it
1:30:37 ’cause we can’t bloody read PubMed.
1:30:39 So thank you for making the decision
1:30:40 which you actually don’t have to do
1:30:41 to come out and speak on these subjects
1:30:43 in a way that’s really accessible
1:30:45 and inspiring and empowering for people
1:30:48 because I think that’s gonna do a tremendous world of good.
1:30:49 So thank you.
1:30:50 – Thank you, my pleasure.
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1:30:52 How many of you started thinking
1:30:54 about your long-term health when you hit 30?
1:30:58 For me, this was a wake-up moment of me thinking to myself,
1:30:59 okay, I probably need to start paying
1:31:01 a little bit more attention now.
1:31:03 I already felt a change in myself when I hit 30
1:31:06 with things like my metabolism, my energy levels.
1:31:09 So this year is no different.
1:31:10 Zoe, which is a company I’ve invested in
1:31:13 but also a company that are a sponsor of this podcast,
1:31:16 helps me to make smarter food choices
1:31:17 all based on their world-leading science
1:31:19 and my own test results.
1:31:21 If I’m ordering food,
1:31:23 I know how to make my takeaway so much smarter
1:31:26 by adding things like a side of vegetables to eat first
1:31:29 or choosing the option with the most fiber.
1:31:31 Zoe helps me to make that choice.
1:31:32 It guides me and coaches me.
1:31:34 It’s my personalized nutrition coach
1:31:36 that I have on me 24/7.
1:31:38 And to help you start your Zoe journey
1:31:40 and start making smarter food choices,
1:31:43 I’m giving you guys 10% off when you join Zoe now.
1:31:46 All you’ve got to do is use code CEO10
1:31:47 at the checkout when you sign up.
1:31:50 Enjoy and let me know how you get on.
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