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men need to understand the average age of the father has gone up about three and a half years and with that the chance of problems with the child also can increase then that pregnancy becomes a lot riskier and this is why Dr Michael Eisenberg is an expert in male sexual function and fertility who's helping us to learn the truth about optimal Sexual Health if you just look at all the data sperm counts are declining but low sperm counts and low testosterone could have devastating effects for example men with lower semen quality have higher risk of death wow and there's a lot of really interesting questions that need to be answered okay let's get into that is there any evidence that the chemicals in our environment are impacting our sperm count now testosterone levels yes it's a chemical that's in a lot of creams and lotions that we use and then there's a chemical that's used in the manufacturer of plastic and that could have pretty devastating effects and so don't drink out of plastic water bottles what about paros couldn't figure out if low testosterone or high testosterone causes a receding hairline most men are not going to in like this but it turns out that if I'm sat down all day is that going to have an impact on my sperm C there are studies that do support that I would say take breaks stand up to try and air out the area what can I do to give myself the best possible chance of increasing my fertility so there's a lot that we can do and usually we start with and then erectile dysfunction hundreds of millions of men all over the world have trouble with directions but as long as you have a penis we can always make it hard for example we can teach men to give themselves ooh I just got shiver down my body but it probably works 80 to 90% of the time congratul ulations Dio gang we've made some progress 63% of you that listen to this podcast regularly don't subscribe which is down from 69% our goal is 50% so if you've ever liked any of the videos we've posted if you like this channel can you do me a quick favor and hit the Subscribe button it helps this channel more than you know and the bigger the channel gets as you've seen the bigger the guests get thank you and enjoy this episode [Music]
Dr Michael Eisenberg why do you do what you do and what you do it's a pleasure to be here certainly an honor um I kind of see myself as a researcher and advocate for Men's Health men's reproductive Health sexual health and so you know I think when I see patients in clinic that's what I'm trying to do to try and understand where they're coming from any issues they have and find out ways that we can you know work and improve them together and certainly from my research perspective I always want to you know try and Define what the issues are um and just improve our treatments that we have for men I am the director of male reproductive and Sexual Health at Stanford or Men's Health uh in the Department of Urology um I have a joint appointment in the department of obstetr and Gynecology because fertility is a team sport and so I also help you know couples and I refer women to the female side and just like I you know get lots of referrals from them you know when we're kind of worried about the male partner when you say sort of reproductive Health what what are all the sort of things that fall within that bucket or underneath that umbrella so I think you know reproductive Health really I mean I guess as it sort of name implies would be you know trying to have a baby um but I think it's so much more than that because I think what we're really learning is that you know fertility is kind of a window into future health probably about 10% of the male genome is devoted to reproduction um and given there's only about 25,000 genes in the body you know it makes sense that some genes that are operating in reproduction also operate in another organ system there was a study done where they took biopsies of men that had troubl making sperm and tried to sort of replicate these cells and they found that these cells had very high rates of mutations in their DNA so you can imagine you know sort of for checks and balances when we're making sperm it makes sense if you can't sort of faithfully replicate your DNA you know there's probably not there's probably going to be some blocks where you can't make a sperm right if there's going to be mutations but also these men may be set up for other problems right like cancers or something
like that if you know the body can't you know effectively replicate cells or DNA there could also be sort of hormonal links and that's another thing that we commonly look at when we're evaluating men uh with infertility um infertile Men actually have lower testosterone levels than fertile men so you know there's also been studies show that men with lower testosterone levels have you know sort of lower survival so it may be that you know kind of hormonal links between fertility May kind of put men on a different you know trajectory you know another I think very sort of important aspect of reproduction you there's other kind of what I call sort of social factors that are sort of at play um you know things that kind of necessarily go with reproduction so like having a partner um and having kids hopefully and it turns out that those factors actually are very important for Health and Longevity so um like having a partner actually increases survival so if you like compare sort of if you have like a you know a man with a partner and a child if you then take away the partner the chance of that man dying goes up 60 % and then if you take away just a child the chance of him dying goes up 60% but it turns out if there both of those things are absent that man has a three-fold higher risk of death than somebody with a partner and a child so there's really kind of this sort of important aspect I think to health and reproduction I think that men kind of need to understand and then obviously there's also just a lot of you know kind of um intrinsic things that we do like lifestyle Behavior obesity smoking those are all very important um for health as well um so I think you know when I see these men for reproduction I really try and broaden it a little bit to overall health because I think there's certainly data that you know as we improve a man's health we'll improve their reproduction um and hopefully give them a baby but also you know improve their overall you know survival Health everything so how many patients have you seen in your career if you had to Hazard a guess roughly oh I mean I think it would probably be mean tens of thousands I would guess maybe 20 30,000 and how many years have you been working on this subject of sort of male Health fertility uh reproductive
Health all these kind of about probably 10 to 15 years it feels like the world has kind of turned towards your work more so in the last couple of years than ever before it feels like you you just so happen to be doing research and educating people on a space that quite suddenly relatively suddenly has become really important to people and I was even looking at some of the data around sort of testosterone replacement therapies and how that's just absolutely skyrocketed in recent times and also the conversation around fertility I was looking at the data around fertility how many people are searching out for information on it and it's skyrocketed over the last what five years and even in my circle of friends we weren't talking about fertility or testosterone or sperm count even two years ago whereas this year and then last sort of 12 months it's been a frequent topic of conversation why is this and is my assessment there accurate and can that be supported with what you're seeing I mean I think so I you know obviously I guess I would say I'm biased and that I think this is um you know very interesting and I think you know there is a lot of momentum towards us you know there have been a lot of landmark studies suggesting like you say declines in testosterone over time uh declines in sperm count over time and we can certainly talk about that um a little bit more and I think with that you know um there's been really an explosion in assisted reproductive Technologies you know I'm familiar you know in the United States how that's happening you know a few years ago it was you know maybe about half percent of all bursts in the i in the US were conceived with IVF now it's about 2% and only increasing you know it used to be that insurance never covered it now Insurance commonly covers it and so with that there's just really been explosion in the offerings the number of cycles that are done you know and in my particular area in Northern California you know it seems like every year a new IVF Clinic um is opening up and you're always worried and wondering how could there be enough business to support it but instantly you know all the patients you know all the slots are filled they're booked out for six months and I think there's just tremendous amount of demand and I think that you
know I think to your point you know the question really is why you know is is fertility declining are more couples becoming riing on IVF um and I think you know again our sperm counts declining I think all those things are probably kind of going together um that's leading to this and I think it's you know it's something that we're doing to ourselves potentially there's some environmental exposure I think all these things are you know really interesting questions that that need to be answered so let's start with why then if we stay zoomed out a little bit on some of the social factors that might be leading to um infertility issues but also just correlated issues like things like testosterone and all of these things what are some of the broader social factors that are causing IVF clinics to become so in demand now yeah I mean I think one of the big ones would just be uh Rising parental age um you know uh there's been sort of less data I think on male age over time at least here in the United States but um you know a few years ago there was a study done where it showed that over the last maybe 30 40 years the average age of the father has gone up about three and a half years um it used to be like in the 70s you know the an older father and that would be considered over 40 was maybe about 4 % of bursts now it's probably 9 10% of bursts so I think there's just more delay and with that um you know infertility gets higher there's usually a close correlation between you know a mother's age and a father's age and so you know I think a lot of people are sort of familiar as women get older um you know fertility goes down probably at a steeper rate but for men the same thing happens you know sperm counts get a little lower testosterone gets a little lower takes a little longer to conceive you know the chance of problems with the CH the child also can increase I mean the oldest father ever is 96 so the biologic potential does persist um but it certainly gets a little bit more difficult in that pregnancy becomes a lot riskier what is the rate of decline in men and women um in terms of fertility so I think you know if your guest you're looking from an evolutionary standpoint you know Peak fertility probably be late teens early
20s something like that and so for women you know they're born with a set number of eggs and so as soon as you know Cycles start they continue to lose them over time and so usually we think about you know over 30 35 40 you know those are pretty big points where fertility gets a little bit more challenging for men you know we the the sperm counts do decline you know why this sort of cut off where we say older father is 40 is sort of a constellation of sort of different risks you know the sperm counts get a little bit lower but the other thing that happens is every year um you know we're born with sort of sperm precursors or sperm stem cells in our body and they are constantly replicated every year and every time that happens there's some chance of a mutation occurring so it turns out that you know every year we probably accumulate sort of two mutations in our DNA and so over time you know that becomes a little riskier so for like a 40-year-old is going to have 20 more mutations than a 30-year-old for example so we have you know billions of base pairs of DNA in our body so the chance of you know 20 you know mutations making a difference is probably pretty low um but you know that's at an individual level at a population level that's something that you may start to see and so for men I think it is just sort of a slow steady decline you know again probably in the 30s 40s do you have the data on the oldest ever mother are you the oldest ever woman to conceive a child so with uh using like a donor egg I think it's 60s or even even in the 70s I think it's been described before but I think with her own egg I think it's late 50s early 60s are you concerned about this as a macro Trend because if we play this forward it would lead us to a assume that fertility is going to be an increasing problem for society yeah I mean I think very much so right it's existential I mean you know as a disclaimer obviously I'm in the fertility business so um you know I do certainly care about this trend and want to make sure that we reverse it it's a risk factor that we know about but I think you know the the solution is not obvious right because asking couples to delay careers education all that is very challenging you know I think some countries have try to come up with you
know ways to support you know Parenthood you know through leave or you know other kind of programs like that child care also becomes uh you know very important um but even with those I think that um there's just sort of a perception it's just it's not as easy as you'd think and it turns out actually that you know the return on investment for some of these things you know having a child is so kind of important for the health of a society right there's some there's this concept called replacement rate that's the number of children that need to be born to a reprodu age women to maintain a population's level sort of this is kind of ignoring immigration so it turns out you need about 2.1 children per reproductive age women for a population level to stay the same so if you in some societies it's lower like in the US it's a little lower than that and some um like Asian countries like Korea JP Japan it's lower than that and that's really existential because if you know if your working population starts to decline um you know tax Spas everything you know will really collapse and so from an economic standpoint it makes sense if these are couples that want to have kids and they you know these are wanted children you know to try and invest in you know allowing them to do that really makes sense because you know it'll it'll kind of pay it back it is at a societal level I read about in Hungary that if you have four or more babies then you'll pay no income tax for the rest of your life according to the Prime Minister it's an article that I'd seen and I think this is speaks to a broader trend of how there's going to be a topown approach towards getting us to be get back to having babies to stop the population collapse and decline that you talked about um hungary's prime minister has announced a raft of measures aimed at boosting the country's declining birth rate and reducing immigration and one of them is that essentially you'll get be given a check and you only have to pay that check back if you don't have four kids so for every kid you have 25% of the money that you're given is discounted and once you get to full kids you never have to pay income tax again which I thought was a really interesting idea but it's a sign of things to come yeah yeah I mean it's fascinating right I mean I think that
these you know the economic ministers Prime Ministers are really thinking about things I'm sure they've looked at the numbers right and realize that um you Society really relies on you know maintaining numbers and when you know when the population starts to slip could be a problem I mean I think that's it's a very clever solution sperm quality sperm quality I read is declining yeah so that's a very it's interesting because that's such a controversial statement uh you know I think there is a tremendous amount of data that supports that a number of years ago I was actually involved in a study looking at data from a sperm bank here in the United States um it was a sperm bank that was in uh the northeastern us at a few locations and it wasn't a lot of data it was just sort of a few years of data um about like a little over maybe 10 15 years but what what we found is that actually if you looked at men that were coming in to try and be donors because you know these Banks they're very selective so you have to have you know excellent sperm that freezes well that thaws well really high numbers and you know they also look at your pedigree a little make sure there aren't conditions to run your family they like you to be fit you know these are kind of things that are thought to you know sort of make make a better donor um and when we looked at sort of the candidates that came in over this you know really short period of time probably 10 15 years there was declines in you know sperm counts um you know the movement shape all these sort of parameters that we look at when we're talking about a seman analysis and what was interesting is that you know when people have talked about declines in sperm count people have sort of attributed to different things for example people have talked about the Obesity epidemic right and that maybe we're more sedentary now than we used to be or you know environmental exposures or another thing there's more chemicals now than it used to be or cell phone prevalence and things like that but you know over this short period of time where we did have you know a lot of information on these men they filled out surveys um you know they filled out kind of Rich family histories they filled out
information about whether they drank a lot smoked a lot things like that there's really no differences in these men you know from the beginning of the study to the end the only difference was that their sperm counts were lower so it was really you know kind of surprising um very interesting and so you know other investigators have used studies like that kind of pulled them all together using kind of advanced statistical techniques and found this decline over time um you know over the last maybe 20 30 40 50 years um so there is a preponderance of data that supports that so the counterargument that others have made is that you know over that same period of time some of our techniques have changed right we're better at counting sperm now than we used to be you know some of the different um you know tools that we use to measure sperm count some of the analyzers are better now than they used to be so we're a little bit more precise than we used to be the other um you know thing that these Studies have done is when they pull together data they assume that you know everybody's the same like right if we were both in the study they would assume that I'm like you you're like me but it turns out that there's a lot of variation based on like region so there was a study in the United States where they looked at fathers so men that had kids at different regions of the country you know like had some in California New York some in the Midwest and even though these were all fathers similar ages the sperm quality was much different turned out it was really high and in New York I think California was next and the Midwest was a lot lower um so so you know again why you think that right New York would be kind of hustle bustle Metropolis maybe they would have some poor risk factors but turns out they had the best sperm and so why that is is you know wasn't certain but it just shows us that there's a lot of variation in seon quality from individuals so when you put things together sometimes it can be difficult to you know to identify Trends so ideally what we do is you know I and my neighbor would give sperm maybe every year every 5 years 10 years over time and you'd see what changed um and those studies aren't ail so that's sort of the criticism of these studies but again if
if you just look at all the data if you compare studies from the you 70s ' 80s 90s to today sperm counts are lower what is the current best guess as to why sperm counts are lower yeah I think that's the million-dollar question because I you know we've talked about this is sort of an existential existential threat right we need a you know I think any species has sort of three main functions right eat survive reproduce you eat to survive you survive to reproduce spread your DNA and so if you can't do that it's definitely going to be an issue so you know I think that we've talked about you know maybe obesity I think we're certainly different now than we used to be you in terms of walking around you know um sedentary Behavior people have you know hypothesized different chemicals in the environment are kind of leeching into our food supply our water supply is there any evidence for that that the chemicals in our environment are impacting our sperm count and our testosterone levels and things like that yeah there are there are studies uh that do support that um you know there are certainly like pre-clinical studies you know where you can actually you know dose like rats um and mice these there's also human studies where you can you know compare sperm quality to you know different sort of chemical traces in the blood and see these correlations as well and then there's um a study called enh Hanes which is a a study by our Centers for Disease Control where every year men and women are sort of surveyed or they collect data on Obesity blood pressure things like that um and they do collect data on sort of chemical exposures for these you know select group of individuals that kind of represent the whole population this has been done for the last you know many many decades and so when we talk about obesity kind of rising in prevalence in the United States it's been it's based on that data this is kind of a rigorously sort of researched you know group of individuals it's selected every year and so those same studies collect data on testosterone or estrogen for women and they collect it on these different environmental chemicals and do see these correlations I would say that not every study supports this but there are certainly a good number that do show
that um there is this correlation that if you have higher exposure to some of these chemicals uh there's higher risk of lower hormone levels what are those chemicals and where do we find them CU I I I spoke to someone who was a urologist recently um I think from NYU and they were telling me that things like the microplastics and I'm not particularly aware of what a microplastic is to be honest but things like microplastics in our environment are some of the chemicals that are causing sperm quality to reduce mhm is there evidence to support that there's a lot of different chemicals to be sort of concerned about or think about I think you know microplastics are one phalates what is aite aite is it's a chemical that's in a lot of like um you know different uh like creams and lotions that we use um and so those also have been shown to affect Androgen you know and kind of endocrine function inside the body uh bisphenol a is a you know a common chemical that's used in the manufacturer of plastic and that's also been found to have these endocrine disrupting properties um so that's also been correlated with Sean quality endocrine disrupting endocrine disrupting what does that mean so you know if you look at sort of Pathways for men and women there's you know hormones right I'm making testosterone and that acts on my body as I was a child to help make me a man now it kind of helps you know keep me a man you know with grow a beard all those sorts of things giving me my U my deeper voice um and so there's some of these chemicals that kind of mimic some of that action or block some of that action and so if that happens um it can affect you know normal development of you know boys or girls you know maybe you know again affect sort of semen quality if we think about sort of the origins of changes in semen quality some of it may be when we're adults but some of it also could be during development you know either when we're developing inside of our mothers or you know during puberty if something kind of affects the normal timing of that it could be you know again could have pretty devastating effects and so one theory for that is some of these chemicals that affect these sort of biologic Pathways these endocrine Pathways involved in that from the research you've seen on sort of
these chemicals is there any changes that you've made in your own life at all anything that you it's kind of made you think differently about the choices you make in your own life with your kids because you got three kids so you have an opportunity to kind of influence them at a at a earlier stage than most of us can influence ourselves but yeah so one thing that we do um is I've thrown away all plastic water bottles I I'd say I still use it because I find them very convenient um and I'm done with reproduction but um but certainly for the kids um I make sure they don't drink out of plastic water bottle so we have either glass or um or metal I do think there is data that that's um you know a very you know large exposure that kids get and I think it's you know fairly easy now to remove that what does the data say about plastic bottles you know if you look at um you know exposures from that you know they have they just leech a tremendous amount you know with wash with water it kind of sits there all day so I think it's a it's a very you know again most plastic water bottles want the you know plastic bottle industry to come after us but um that's a common way for you know individuals to get exposed to it so I think if again if we're saying that's one of the main touch points for Plastics um is is usually through our kind of food and water supply then yeah I think it's easy to to get rid of it if you can is there anything else I I I've read recently that heat has a a role in our sort of sperm quality so if we're don't know if we're going into saers or something or if we're spending a lot of time I don't know sunbathing then there's science that suggests that will lower our sperm count yeah so that is right so I mean I think that you know gu you can kind of look at this sort of in a bigger sort of global warming kind of context and people have you know theorized that maybe that could also play a role because you know the testicles are outside the body because they need to be a few degrees cooler for sperm production to occur so anything that warms them up can definitely be a problem um so when I talk to patients in clinic for example we do talk about Saun use hot tub use some men bathe every day like in a bath um and those all can impact sperm production there there have
been studies to show that men that you know use you know saunas on a regular basis they have lower sperm counts and then when you withdraw that exposure um sperm counts will go back to normal one you know sort of interesting application of this was to try and use this data or use that knowledge to come up with a contraceptive so there was this weird sort of like truss kind of belt that actually pushed the testicles up into the groin um which actually turned out did reduce sperm counts uh to zero I think and again the the few men that that volunteered to do that um but you can imagine I think most men are not going to be too excited about that um because it's probably pretty uncomfortable uh the other way that I've seen it is I've had patients that have gotten sick certainly around covid that happened not infrequently men would come in you know telling me that you know they just got over a covid infection that where they had high fevers for you know a few weeks um and then their sperm csed be very low and then you know we wait a few months it takes about two to three months to make a sperm so we let one of those Cycles or two of those Cycles go through and their sperm counts came back I had a patient even before covid uh like 41y old guy he had normal sperm count and then all of a sudden he measured and the sperm count had gone to zero and it turns out he had a a flu with fevers about 102 degrees Fahrenheit um the week before and again we let kind of sort of nature take his course he recovered and then his sperm counts came back to Baseline so we do see that um as well with that belt that you mentioned that it holds the sort of test testicles closer to the body I'm guessing it's doing that to heat them up basically which reduces the sperm count MH obviously then one would think about their boxer shorts we're all wearing very tight boxer shorts these days that's like invogue or whatever so is there any studies to suggest that boxy shorts can reduce sperm count if they're tight so that's like a very Comm that's one of the most common questions I get like boxers versus briefs and that's been studied a lot because that is a very common exposure I think I usually just tell men whatever is comfortable I think it's unlikely that any single layer is going to make a big difference
unless again you have the specially designed underwear that pushes testicles up into the groin but otherwise as long as they're outside the body it should be okay what about mobile phones and technology is there any um link between fertility and are use of Technology specifically having these devices in our pockets close to our genitals that's you know another common question that I get um and that is certainly something that's changed right now versus you know 20 30 years ago uh so there were some studies that you know initially showed kind of this signal that men that use cell phones more had lower sperm count but some of these studies were you know they're older and you also worry about some of these kind of confounding things it may be that people that use phones more do other things more you know they have may have more stress in their life and other things that could affect SE quality so there was a clever study that was done where they actually took ejaculate so took sperm put it in a cup and put a cell phone next to it and tried to measure changes in you know the quality of the sperm and they actually did find some they found higher rates of like DNA damage within the sperm that was exposed to the the phone versus not you know kind of trying to control for temperature which we you know said is important for the health of the sperm wait so they controlled for temperature they controlled for temperature and just having kind of the cell phone you know getting its signal um seemed to affect you know the DNA damage in sperm it wasn't you know it was a statistically significant you know difference um it maybe would not be kind of a point where we would get as worried clinically but it is a change so I think it's something to think about I think that um you know aside from that cell phones I think nowadays don't get too hot so not as worried about heat but whether this RF you know this radio frequency exposure may impact things is a you know maybe a theoretical risk but I gu there's not a lot of concrete data so I think that you know again if so a lot of my patients do tell me that they keep their try and keep their cell phone in their back pocket or front pocket to try and avoid that I think that's I think that's fine I've been having this conversation with
my partner a lot she really believes that my cell phone should never be slid under my genitals which I sometimes do when I'm like I don't know when I'm in the car or something or when I'm on the sofa I don't know when I've got my hands full I'll just grab it and I'll kind of like slide it between my legs yeah and she'll reach in and pull it out and say and I think because she's concerned about those four kids that we want to have and you I think she cares about you too yeah I to be fair she's not someone that's going to read PubMed and read about the studies but it's just a feeling she has yeah and I always refuted it and thought now there's no way there's no way because they would have tested it and the test seems so easy you get sperm you put it in a little thing you put the phone on top of it send it some text messages connected to the Wi-Fi the Bluetooth and see how the sperm get on yeah I didn't realize there was a study asso with it yeah I think laptops also can do that too but they also have a little more heat associated with it so a similar study was done in laptops um where they had sperm put it next to a laptop and they controlled for temperature uh and saw the same pattern you know again sort of the Wi-Fi signal can also affect again sperm you know DNA damage and sperm quality um but also you know laptops can get warm too right some of the batteries some of the moving Parts within uh can heat up too and it also just serves as almost like insulation if you put it over your lap so I do talk to patients about that as well um you know to maybe use like a pillow or something else just to try and shield yourself a little bit wouldn't we see a sort of big difference between hot countries and cold countries or sort of warm countries and sperm counts then so if I in sort of subsaharan Africa I'm assuming my sperm count will be pretty low because I'm going to be sweating all day so I think that um the other sort of element to that though is that there are differences in populations and I think that that has not been well described you know but if you compare you know again we talked about California New York the Midwest and the United States but people have also compared you know like Denmark which they have a lot of sort of problems with reproduction so
they've really studied it very very aggressively and if you compare them to other countries nearby or other countries in Europe it's much different and so you know one possibility could be exposures you know and what these men are doing what they're exposed to but the other could be you know again there could be some genetic components but one interesting thing about sort of on that same line is that uh sperm quality does vary based on uh time of year so during the hotter months it does go down a little bit you know not meaningfully um and then during the cooler months it it goes up a little bit but the other thing is that you know we don't spend well some of us do I guess or some of us don't but no spend all your time Outdoors right and sometimes in the um you know during the the cooler months you're you know kind of bundled up inside and during the warmer months you're may be in you know cool air conditioning did you say that this Denmark has had a problem with sperm count yes yeah so um you know in the United States I said that about 2% of bursts are conceived with IVF in Denmark it's about 10% wow um and it's actually they they've again they have really a crisis of reproduction there so they've really um done some really good research on seam quality and it estimated that only about 25% of Danish men have normal Sean quality have they figured out why that's what they're looking into and they have lots of theories and again I think you know again it goes to many of these same topics that we talked about whether it's environmental exposures on you know mothers um or you again pubertal boys or you know adults as well so they are trying to figure it out but it is you know that's also one of the countries where the fertility rate is is below replacement so it's definitely an issue one would assume that it's some kind of environmental factor I guess it could be some other social Factor but but one would assume that it's some kind of environmental yeah Factor yeah some people have postulated during World War II they were very isolated and so potentially there were some chemical exposures that have just you know kind of persisted uh and remained in the population and it's kind of tough to work through that but it's not
known if I'm sat down all day is that going to have an impact on my sperm count as well because of the heat generated from me just sitting here um and or if I'm a if I'm a cyclist or someone that's doing you know sat down on my testicles doing something warm people have looked at sort of different occupations where you sit a lot um and there are associations like drivers you know taxi drivers truck drivers they certainly can have changes in sperm count you know probably due to heat you know again I think it could be a combination of sort of sitting all day is also you know from probably other health standpoints is not great and cycling too you know people have looked at sort of peak athlete cyclist and there are differences in Seaman quality um but you know Peak cyclists you know they do a lot to their body and so you know it's possible that there could be other effects too but you know looking at men that sort of recreationally cycle too I think that the number that I use there's a study that showed um if you cycle over five hours a week there can be lower sperm counts so you know I talked to men about that when they do cycle you know more than that you know potentially taking breaks trying to stand up if we think the mechanism is heat to try and sort of circulate air out the area to spend some time out of the saddle if possible what about men with big thighs yeah well I think you know obesity is an issue there's certainly a strong correlation between body mass index and semen quality so as men get bigger sperm counts go down um and so heat is certainly one of the the possible mechanisms for that just kind of insulating that area warming things up can kind of do it you know obesity also affects you know the kind of hormonal axis as well so that also may be at play too because you know there's kind of a normal stimulation that's given by your pituitary in your brain that tells your testicles to make sperm make testost tone and some of that's also affected by obesity as well so it's probably a combination but that is something I I do think about when I see you know my patients and we do talk about sort of heat exposures as well and see if there's you different sort of strategies they can use to try and allow more
circulation in the area is there a link between um sperm counts and alcohol consumption I think it depends is what I would say so in general for most kind of moderate use I would say kind of a drink a day um and some people think that no amount of alcohol you know is safe but probably if you look at these studies looking at maybe a drink or two a day it probably doesn't correlate too strongly with Sean quality but it seems like there there are some studies say that when men get to three a day so maybe 20 a week there can be lower quality uh in semen and there was also another study that we did looking at you know to see if some men are more susceptible to to alcohol intake so there are some um East Asian men and women that have a mutation and one of the enzymes that's used to metabolize alcohol and so they accumulate what's called acid alahh which is a toxin actually and so when they drink they flush I don't know if you have any friends that have this but um we hypothesize that you know when you have this you know this large load of this chemical in your body that leads to Flushing headache dizziness um maybe it also affects semen quality and it turns out that it does so for these men that have this mutation um when they drink their sperm movement goes down a little bit so it turns out that there's actually a reasonable number of men on Earth that have this you know it's probably in some populations up to 50% like in Taiwan um you know it's very common in Japan you with chinese vietnamese ancestry so I think it's something to be aware of and I think usually you know men do know if they flush when they drink it's probably because they have this mutation and Al alahh dehydrogenase too so you know for those men I think that it's probably better to you know avoid alcohol or uh just to sort of be aware because um it can affect SE quality if I if I came into your clinic and I said Dr Michael I I'm trying to have a kid with my partner and I want to make sure that everything I'm doing is giving me the best chance of having a kid what is what's the list of things because this is basically where I am at my in my life now I'm 31 years old I want to have a kid I'm ideally want to have four of them and I'm thinking about the time my partner's the same age as me we're almost
identical in age and she's 31 so we're we've got you know we want to have these kids before 40 ideally so I kind of need to get get going get going you know what I mean so so what can I do to give myself the best possible chance of increasing my fertility my sperm count so that we have those four kids that I want over the next nine years was the four number it was something you came up with before that the tax incentive or yeah we are planning to move to Hungary so there you go was really it's really about tax avoidance it's not that I I want kids um no I come from a family of four so for some reason I've always had four in my head I I think she's fine with it as well I think we've we've we've chatted and she's she's happy with four to six no it's a good number not had six signed off but four for sure what would you say to me then so I think you know we look at you know your overall health um you know we' see any risk factors you had obviously we're talking about saunas hot tubs find out you know how you exercise if there's things that you do that are not you know good um look at you know if any medical conditions that you have surgeries that you've had some of those can put men at risk for for that if there's any medications you're on there can be medications that affect it and then we'll do an exam um so we don't have to do that here in front of the cameras I'm down U I do have yeah I do have a California medical license but um so you know we want to make sure we look at the sides of the testicles make sure all the other structures are where they're supposed to be um you know one of the basic evaluations will be a seman analysis so we'll measure how much comes out look at how many sperm there are look at how many are moving look at their shape as well and then usually we also check hormones as well so we'll check testosterone again sort of this very male hormone the testicle does two things it makes sperm makes testosterone so we check that and then usually we check some other hormones involved in the kind of hormonal axis that controls reproduction and that's usually what we start again fertility is a team sport so I would encourage your partner to also
get evaluated as well um and we'd see you know depending on kind of sperm counts usually then we're able to sort of counsel about you know how likely you are to be able to achieve um you know those four kids but you know again it if you're kind of thinking about four I I would agree that you should get started fertility issues we tend to think of it I think there's a stereotype that it's typically the woman who has the fertility issue and and the man is okay and I think if you when I looked at the data that it that's kind of supported this idea that couples assume it's the woman that has the fertility issue is that a misconception it's a huge misconception yeah so absolutely I think that you know in United States and other countries too I think usually you know women are kind of the gatekeeper of fertility everybody assumes that that's where the issue lies but if you actually look at you know the data probably about half the time there's a male Factor contributing and you know this sort of stereotype is so prevalent that probably at least a quarter of the time in the United States the man's never evaluated and he could be you know one of the issues so some couples may go to IVF you know for the lone reason of you know again low sperm count and the man would never evaluate it and maybe there is a condition that we can improve maybe he's on a medicine maybe you know he's going to the jacuzzi every day you know something like that that we be able to reverse you mentioned testosterone would be one of the things that you would measure if you were trying to make sure that my fertility was good male testosterone decline this is another Hot Topic you talked about it at the start of this conversation is it true that male testosterone is declining and how much has it declined by yeah so um again study from this enhan this CDC you know measuring men every year for the last several decades if um you know there's data that shows that testosterone levels have have gone down over time you know people have also looked at um you know other cohorts of men you know from the 2000s the '90s 80s and there's just a progressive decline in average testosterone levels over that amount of time so you know the amounts you know kind of vary 50 to 100 points but you know generally these are you know
meaningful measurable amounts in addition to sort of these kind of cohort changes where if you kind of you know look at the average 40-year-old Now versus you know 10 years ago our our testosterone levels change too so I would say that I usually tell men after the age of 20 your testosterone is going to go down maybe about a percentage point every year so as we get older testosterone does go down and there's things again that can affect that trajectory you know men that get more obese that also affects testosterone level a portion of all of our testosterone is converted to estrogen a lot of that conversion happens in you know adapost tissue or fatty tissue so the more kind of extra tissue there is in the body the more that conversion will happen and so your you know effective testosterone levels will be lower what about movement and exercise does that have an impact on our testosterone levels in a significant way yeah I mean I think that you know the more walking you do the more active you are we've looked at that as well you know step count is directly correlated to testosterone and you don't have to take 20,000 steps a day you know 4,000 8,000 steps a day you know just kind of walking around you know sort of reasonable amounts it can make a big difference and I think that um you know activity is important it probably also helps Dave off obesity a little bit as well as another mechanism okay so I'm a Manchester United fan right now we're losing a lot I thought you guys have turned it around yeah I thought so too until last week okay so if you're if you're supporting a team that is losing your testosterone levels likely going to be lower well I think this is sort of an acute thing maybe we could do that experiment right where does that that research come from that if your team wins your testosterone increases I don't remember I I that stud is pretty old I think that even dated my um training but I do remember reading that I think that was one of the articles that get picked up by the newspaper okay of course why why does testosterone matter well I think testosterone is very important for you know a lot of things I think it's it's important for our quality of life so energy level sex drive mood sleep concentration all those
things are very important um when testosterone gets very low it also has a lot of Health implications so muscle Health bone health heart health so we do want to keep our levels in a normal range um because I think it yeah kind of helps us with our function and our life uh and happiness how how does the impact our sort of muscles and Bones I don't really understand what testosterone is doing I I kind of think of it as the chemical that kind of makes you a man I know women have testosterone too but I I just think of it's the chemical that makes my beard grow in my voice deep yeah well that's what it's doing but it's anabolic it does help kind of grow it helps with bone turnover um and kind of keeps sort of uh you know the strength of the bone so men that have very low testosterone levels have you know frailer bones higher risks of osteopenia osteoporosis so um you know I think it helps with muscle growth bone turnover bone strength so I think all those things are um are important they usually don't get into those problems unless men are very very low I would say that you know I don't know you but you know the average testosterone levels are probably 300 to 900 I would guess probably on the higher higher end of that um but you know when are low probably less than 200 100 that's where we start to worry more about you know bone health muscle health and so I think that there is some wiggle but when you get kind of lower than sort of the normal ranges kind of the 300 range that's when some men do develop you know some of the symptoms of lower energy level sex drive problems things like that so low testosterone typically means lower sex drive uh it can it's one of the it's one of the common symptoms that we see with that does that mean that if I just take loads of testosterone my sex drive is going to go back up you know over the last probably 10 to 20 years the number of prescriptions of testosterone written in the US have kind of gone up almost at an exponential rate and because people did think of it sort of as a um kind of an anti-aging kind of Rejuvenation therapy and so there was hope that it would help people but if you look at some of the randomized trials if a man has a normal testosterone level and you give him testosterone uh it may not help him that
much even men that have kind of a lowish testosterone like we talked about sort of this 300 cut points so I've had plenty of patients testosterone of 250 let's say so we talk about risks and benefits of being on testosterone uh we'll try them on it and you know a lot of men do feel better but not everybody some men I don't feel any you know doc I don't feel any different even though he get his levels you know from 250 to 500 um and so then it's probably not worth you know to be on a medicine every day if it's not helping you I'm not worried about his bone health you know we'll check some other measures to make sure that's okay um so then it's not you know again when you look at risk and benefits it's probably not worth it but there's certainly some men who do who do see Improvement so is testosterone hurting some people their testosterone treatment does it actually have an adverse effect if you take it basically when you don't need to I mean even when you do need to I think it could C sometimes cause issues yeah there's certainly side effects to testosterone um you know one of the big things that I see in my practice is how testosterone impacts sperm production um it actually was tested as a contraceptive by the World Health Organization because it does low lower sperm counts in most men I would say 90% of men now it doesn't do 100% so it's not that great of the contraceptive yet they're kind of working on some other ways to tweak it um but I have plenty of patients that come in you know some of them suspect that testosterone is the issue some don't know um I remember one couple in particular they came in as a couple together you know we measured his sperm count it was Zero we started talking about risk factors and he was on testosterone I said well the best thing to do would be to stop testosterone um and for his work I'm going tell you what he did but for his work he really couldn't stop it um so there's some other medicines we were able to add while he continued the testosterone um and then and then they ended up with triplets um shortly thereafter so I think that you know men need to be aware of it um because that's you know certainly one of the big risk factors at least of reproductive age men is this risk to fertility so it can impact my sperm
count negatively um I I I saw a quote from you that said if we take a hundred of my infertile patients that I see in the clinic at least five of those men will be infertile because they're on testosterone therapy one in 20 infertile men are that way because of testosterone as it relates to infertility one of the things that I've always worried about is if I take testosterone then my hair would fall out yeah so that can do definitely happen so you know hair loss breast growth acne those can all occur I would say those are things that we can monitor so you know one thing I always tell men is that we're not trying to get them to superum right we're just trying to get you to normal so I think if we monitor it closely most men you know will do okay again there are some other therapies that we can do for men that have side effects uh you know from those things it can also affect the thickness of the blood something called the hematocrit or we count the number of red blood cells in the body it can increase that number so if it gets too high that can be an issue so that's another number that we follow there used to be a concern about um higher rates of heart attack and stroke with testosterone so there were some studies done um you know about maybe 10 year five 10 years ago that suggested that but a really large trial just came out uh with about 5 200 men half of them randomized to testosterone half not and there was actually no difference in the risk of cardiovascular disease so I think that's something that we can probably put to bed the other thing that men worried about is increase of risk of prostate problems prostate cancer prostate growth and you know that same trial also showed that um from a prostate standpoint probably not a lot of risk as well do you have many men coming to you to talk to you about hair loss and Bolding uh some men do I think one of the ways that men talk to me about it is one of the common medication for that is finasteride right or you know sold on the trade name propa um and so they want to understand some of the risks of that and so you know when that medicine was approved for a hair loss they you know again because people that are going to take it are usually in the reproductive age they did randomized Placebo control
trials to look at semen quality and it turns out that it didn't meaningfully impact things maybe it went down a little but not a lot um but in sort of post um you know analyses of some of this and now seeing lots of patients coming in we do see men that are on finasterid some of them are more susceptible and so one of the interesting thing about trials is there's you know kind of inclusion and exclusion criteria right not not everybody can be in it and so if men had sperm counts that were too low they weren't invited to be in these trials so for men that you know don't have as much Reserve as others I think they may be more susceptible so that's one of the risk factors finasteride you know the other thing in aash in addition to reproductive health is sexual health that I deal with a lot and there's also a concern that finasteride impacts sexual function function in men too so you know we have these discussions I've had some men that come in after having been on finasterid and have you know different issues with sexual desire low liido or rectile dysfunction and so then we you know work through an algorithm to try and improve that as well this is one of the things I think about a lot because I don't want to I don't want to have a receding hairline and I also don't want to have a air operation or anything like that but when I hear about some of these testosterone replacement therapies and and such my big concern is that if I take testosterone maybe not now cuz I'm you know probably don't need it right now but maybe when I'm a little bit older which is when I assume one would start taking it maybe when I'm about 50ish on average but there are younger men that are on it as well for what reason just because they're low on what's the sort of symptoms that that have caused them to take it well I think there's you know with all things there's a bell-shaped curve so some men are a little bit lower some have genetic conditions you know there are um some more nefarious testosterone prescribers so even though men have a normal level they're offered testosterone to kind of get in these kind of testosterone clinics and some men you know if kind of look at data maybe 10 to 20% of you know high school athletes have experimented with testosterone and if you stay on
that too long it can really shut down your own axis so um if you take exogenous testosterone so like testosterone injections or gels your body stops making it and the longer you're on it the less likely your body is able to sort of restart and so for some of these men you know poor choices or or whatever they've been on testosterone for a while and they can't ever stop I don't know if you've ever had any experience in it because I know you focus predominantly on male Health but um I've had a long conversation about contraceptive pills with my partner because she was on she said this publicly before that she was on a contraceptive pill for a long time and then and everyone's relationship with contraception is different but after taking it for seven or eight years she she came off it and her period didn't happen didn't occur so she really struggled with that for a while previously and it made me really you know it illuminated the fact that when we start messing with the chemical balances of our body using pills and injections and other things we could do pretty long-term Andor permanent damage to ourselves and there's no real such thing as a free lunch is there in biology and chemistry yeah I think that's what it comes down to I think a lot of people have said that if they tried to get the uh the pill approv now it would be a much different process and unlikely to succeed for those kind of reasons if I have low testosterone um and I come to see you what is the typical way of getting a testosterone replacement therapy is it a pill is it an injection that I have to take um I know that it's quadrupled according to the data in the US since two since the 2000s which is staggering but how are people taking testosterone so there's lots of different ways it can be taken I think one thing you know again we talk about all the risks so fertility is certainly be you know a big one so if you come in in your 30s you know I'd ask you about your reproductive intent so if you have a low testosterone and you're interested in having four kids I wouldn't start you on testosterone directly there's some off label things um you know so medicines that we kind of repurpose to help increase your body's own testosterone um
that we would start with but assuming that let's say you're in your 60s you're not interested in fertility then you know there's gels or patches that you put on every day testosterone gel or patch um because that can work well probably 10 to 20% of men don't absorb testosterone that well through the skin the other thing to be aware of is that there's a risk of um like transference like to your partner to anybody that kind of touches your skin so if you have young kids just to sort of be aware of but as long as you know you put it on let it dry put clothes on over it it's not a big risk um you know again and also have to be I guess mindful of laundry as well uh so you know gel's patches are one there's injections uh that you can do every usually one to three weeks on average there's testost pellets um so these are pellets that have testosterone they're kind of slow release so um they're just injected uh we kind of implant them under the skin usually in the hip area and those last probably 3 to six months there's longer acting injections so those are very common in Europe um they're kind of gaining steam in the US but those are injections that last probably 10 weeks or so and then there's a new oral therapy so there's an oral form of testosterone um that's available as well I was quite confused on this subjec of hair loss in testosterone because I couldn't figure out if low testosterone causes me to bold and have a receding hairline or if it's high testosterone that causes me to bold and have a receding hairline or if it's both I mean it could be both I think usually we think about it as um as higher levels okay it's funny because I've I've wondered before whether me doing a lot of exercise which is I guess increasing my testosterone levels is going to accelerate my Bolding in receding Airline anything that's good for your heart should be good for your hairline so I would exercise I think that's good but what if I'm doing like Iron Mans and Thousand Mile runs and all that kind of thing which you see in in certain groups so I don't know that it I I do think it's possible to OV exercise I don't know if it'll affect your hairline but um you know I testosterone levels it can affect testosterone levels I do think that it's you know when you kind of
exercise to the point of exhaustion you know we do see declines in sperm counts as well so hormone levels can certainly be affective did um CU my cortisol goes up so my testosterone I'm I guess goes down can go down sometimes interesting what about penis size I heard you did some pretty Landmark research which suggests that the length of a man's penis is increasing decade over a decade in terms of um men that are being born and boys that are going through puberty yeah so um this this study also got a lot of attention so um you know similar to how we've tracked testosterone levels over time or sperm counts over time you know for different reasons investigators have measured penal length you know to kind of give normative data across different populations to understand how different surgeries or conditions may affect um penal length so you know we looked at you know all the studies and there were there were dozens and so we kind of pulled all that together this was tens of thousands of men and just looked at sort of average pile length over time and so you know again based on some of the data on Seamon quality we would have expected things to get shorter over time and also because we're more obese now you know the way that penises are measured is you kind of pull the penis on stretch and use a tape measure some sort of ruler measuring device so if the there's kind of more gut you know more fat in theory length should be a little bit shorter now than it used to be um but it turns out at least when you measure a Rec penile length uh that penises are longer now than they used to be uh and so over the you know past 30 years or so they've probably gone up about 25% why I mean it's it's a good question I think one hypothesis we had kind of looking at sort of different endocrine you know abnormalities um and changes in puberty is that if men go through puberty or boys go through puberty earlier that tends to correlate with longer penis length and so if we are shifting puberty again through these different environmental exposures maybe that is leading to you know changes in general development and this may be one of the consequences of it does this have any Upstream like implications for for sex I think that well the numbers we're talking about shouldn't be um you
know kind of enough to make a big big difference um you know people as this study came out we talked about you know very enterprising patients kind of reaching out sending emails some people hypothesize that this was kind of natural selection so it's it's hard to know um but again it's it's a very short period of time so it's hard to believe that there's you know that's kind of at play do you have many people that come into your practice that are with erectile dysfunction yeah so that's another very common condition we see you if you look at men over the age of 40 over half have some trouble with erection so very very common hundreds of millions of men all over the world are afflicted we don't talk about this much um what what is the cause of this and are you seeing it increase over time the the prevalence of erectile dysfunction I mean I think the rates are going up and I think you know the risk factors you know are the same risk largely the same risk factors that affect heart disease so you know diabetes obesity high blood pressure high cholesterol you know minority of these um conditions can be caused by low testosterone sometimes the outcomes of you know surgical treatment for pelvic cancers as well um but by and by and large it's vascular just it's a blood flow issue because I used to think it was more of like a like a hormonal thing or a psych psychology thing like you know sexual anxiety or some kind of you know change to our testosterone levels is causing us to struggle with getting erections now you're saying it's about so I think you know psychogenic used to be thought of like you're saying used to be thought of as the kind of the primary ideology um and maybe for some you know populations it could be a little bit more common but generally for most men sort of all crummers it's going to be a blood flow issue a vascular organic cause and how would you get about treating um erectile dysfunction um so there's a lot we can do we do want to you know kind of reverse anything that we can kind of understand where the man's coming from find out if there's you know new relationship or other kind of factors you know for men like you know suggesting that we do s like kind of suspect a psychogenic component work with sex therapists as well um but for
other men you know I always like to be very positive it's like to say you know as long as you have a penis we can always make it hard so there's a lot that we can do so usually we start with pills um like bagra sealas does that work for people it works probably 60 to 70% of the time so that does work well um even for men with a psychogenic cause sometimes it can kind of help reset the system a little bit you know convince them and their body that everything is working well like a placebo effect well it's I think to some extent but even more than that because it does work it does help and then I think once they kind of regain that confidence if there was some sort of traumatic event traumatic relationship it can help um improve things pills aren't enough or they don't like those or they have side effects from those um there's other therapies so there's medicines you can actually put in the tip of the penis like a gel or a repository we can teach men to give themselves injections in the penis oh I just got shiver my bu there's certainly a uh a kind of a a psychological um sort of fear of that but it does work well probably works 80 to 90% of the time um there is something called a vacuum erection device so it's like a plastic cylinder you put over the penis that sucks blood into the penis kind of treats it like a balloon and then you put a band at the base to trap blood inside um and there's even surgers we can do to put a device inside the penis so whenever want whenever a man wants to be hard he can be hard I didn't know there was surgery you could do it a surgery mhm what does that do it puts a so there there's two main flavors of it there's um or forms maybe that's a better term uh there's one called a malleable so it's bendable so it kind of puts this sort of bendable um metal it's a metal core with sort of a plastic um kind of covering so when they don't want to have sex you bend it down when you're ready for sex you bend it up um or there's inflatable versions so when you're whenever you're ready for sex there's uh basically a pump that goes in the scrotum and you just Pump It Up and moves fluid into the cylinders and you'll get a rigid erection is that increasing in popularity I think you know there it's made by a few manufacturers in in the US
or in the world um and I so I think the data is not as freely available I mean in my practice I've seen more and more of it um we're seeing more patients come in I also say that you know my practice is getting a little bit more mature with time as I get older and so you know naturally you know more patients kind of hear about these different things but it does work well I always say it's a self- selected population right we don't hold men down and force them to get it but generally they're very happy probably 90% of men are very happy they'd recommend it to their friends Partners very happy recommend it to other couples and you just you press a button and you get like a you can it's a pump right now they are working actually on um either a fob or like a phone app that'll kind of automatically inflate it to make it easier for Pati I had no idea it sounds like sci-fi or something it sounds like it's um sounds like something you might see on like a YouTube video that people are working on in like 20 30 years time but to to know that men have that installed now is amazing yeah yeah the I mean it's uh yeah it's very common um the youngest patient I put it in is about 20 the oldest is in his 80s what was the is it seen as like a last option in the that menu of options that you presented there where like the first option probably Viagra and in terms of popularity is it a last port of core I think for a lot of men it's the most aggressive but some men don't want to do like you had a reaction to the injection I think that's a very common reaction there are certainly some advantages to it compared to others you know for Viagra for example even though it's obviously the easiest it's a pill you know there's some side effects with it and there's also you know a lag time right you have to take the pill wait an hour wait 30 minutes something like that whereas this you know the penal prosthesis you know if you just pump it up it's ready to go in seconds so it can be very spontaneous so patients like that um you know some patients don't you know they have other medications so they can't take pills they don't like some of the other kind of intermediate options that we have shock wve therapy for erections does that work and what is it so the idea is that um as kind of the name implies
you're sending shock waves into the penis um and the energy is induces kind of some microt trauma which induces new blood vessel growth is the hypothesis and so you know the hope is that with you know getting better blood vessel better blood flow into the penis can improve the quality of erections so there have been some studies that do show benefit it's still considered experimental um because I think the data is not yet conclusive but I think for men with milder forms of erectile dysfunction it can help you know maybe the men that are on Viagra or sometimes on Viagra may we can get them off those pills um but I think we need more data uh to kind of understand really the kind of best Target population for it you talk about pelvic flaws as well um when we typically think about pelvic flaws we tend to think of women you know things like these keegle exercises that people talk about but is it important for us to think about that as a man as well our sort of pelvic floor strength and our pelvic floor muscles I think in some conditions I think if you're not thinking about it it's probably okay you're not having a lot of problems um but it can be a trigger for some men so that can be an ideology of some different um like problems with urination you see men with very tight you know pelvic floors and they have a lot a lot of urgency to urinate they urinate frequently can also lead to scrotal pain sometimes as well um because there's a lot of muscles as you're kind of pointing out in the area and sometimes if they're under tension um if they're not um you know properly kind of trained and they're they can kind of trigger some other areas and so um for some of these different conditions um we do kind of work with pelvic floor physical therapists to train patients you know how to you know again relax the area strength in the area increase flexibility of some of those muscles which can help is it plausible that doing pelvic floor exercises will improve one's sex life I mean I think that unless we're treating a problem I would be very hesitant you know one of my favorite saying is the enemy of good is better so if things are good you know to try and get better you know there always there's always going to be like you said there's
no free lunch there's always some trade-offs so I think if you work on kind of over strengthening the pelvic floor it could lead to of these other dysfunctions so you don't want to end up with a floor that's too tight or too tense is there any correlation between these things like your pelvic floor strength your testosterone your sperm count and a variety of the different cancers that we see in men things like testicular cancer and prostate cancer so um I think with with uh pelvic floor kind of strength I think I usually kind of think about that as separate from uh cancer risk but for test cancer you know one of the risk factors for that is some men are born without testicles in their scrotum uh so that's a risk factor an un so-called undescended testicle low sperm counc associated with testicular cancer there was one study I know of years ago that looked at um you know comparing sort of sexual health to prostate cancer risk found that men that ejaculated more frequently had lower risk of prostate cancer the thought was that you know there was inflammation that you're kind of clearing out by frequent ejaculations I think this study had men ejaculating 30 times a month and showed a lower risk so that's that's a lot um but that was one study that said at least it's not dangerous to ejaculate more frequently but it's not something that I generally recommend to men to lower their risk if we talk about testicular cancer then um what are the the common symptoms of testicular cancer yeah so usually it tends to be relatively asymptomatic I think that you know the classic symptom would be a firm painless mass that men find in the scrotum so if you know um there used to be there are screening guidelines um even though our preventative Services Task Force thinks that you know the utility of doing it for you know reproductive ageement to their scrotums may lead to more anxiety than actually you know Finding test this cancer because it's such a rare cancer so it's more likely a man's going to just worry themselves than actually you know diagnose in early cancer but the recommendations used to be that you would you know once a month in the shower kind of feel yourself and if you feel something new or something abnormal you know bring it to your doctor's
attention you I certainly see a lot of men with this concern do an exam say you know that's normal or if there's something that we're worried about um we'll kind of dive a little deeper what is the demographic that are most likely to get testicular cancer is it something that affects young people as well as older people it's usually mostly a cancer of young men so I would say probably 20s to 40 uh is usually the the kind of the Prime demographic why is it a cancer of young men is there any sort of physiological reason for that well I mean it's a you know reproductive age cancer so that's the prime reproductive years um so it's possible that it kind of correlates with you know sperm C declining with older age there is another slight increase for men in their 50s and 60s um but again it's such a it is a very rare cancer so I usually kind of quote probably one in 100 thousand men um are going to be diagnosed with it so one in 100 thousand it's pretty it's fairly uncommon but prostate cancer is more more common prostate cancer is more common yeah so that we you know in the United States probably at least 200,000 men every year um some studies say that you know if you live long enough everybody will be diagnosed with prostate cancer but again most men with prostate cancer die of heart disease just like every other man in this country so most men you know with prostate cancer die with it not of it um so usually it's a slower growing disease although there's some that are more aggressive and that's why we screen for it and treat it I read a stat that it affects one out of every seven men prostate cancer yes okay so what is a prostate so a prostate is it's a walnut shaped organ yeah um it's just underneath the bladder so the way that we're shaped is we have our bladder which FS with urine from our kidneys and then we urinate out the urethra you know out the penis um and so the prostates just at that kind of intersection between the urethra um and the bladder and it really has a function in reproduction so it produces about 20% of the fluid of our ejaculate and it produces a lot of the different chemicals and sugars that support um and protect the sperm in the female reproductive tract so after reproduction it doesn't really have a lot of you know
benefit mostly it just causes issues because it gets bigger with age so it leads to urinary symptoms and then obviously it it's a cancer risk as well as we get older okay so we typically get prostate cancer once we've stopped using the prostate for reproduction yes so does it have a role outside of reproduction I guess because it's a gland it might be regulating hormones long long after we're using it for reproduction reasons uh it doesn't really have any useful benefit if we could find a way to remove the prostate without causing any complications that'd probably be a reasonable thing to do but unfortunately every treatment we have does have some uh some side effects just given where it is anatomically it's right by a lot of the structures are important for erections and for reproduction so when people have prostate treatment because they've got a prostate cancer are they getting their prostate removed some men get it removed some men um have radio therapy um to sort of kill all the prostate cells and there's other kind of energy therapies that are delivered like um highfrequency ultrasound can sometimes be delivered there's also something called cryotherapy where you can freeze the prostate you know usually these are done in kind of targeted Fashions where you can look at the prostate look at MRI imaging of the prostate um look at biopsy patterns to try and figure out where the cancer is so usually the whole gland is treated but sometimes you know I think newer modalities are trying to just treat you know a particular portion how often do you think we should get our prostate checked and what are the symptoms that we should be looking for from a sort of a urinary standpoint I think that if urination bothers you you should talk to your primary care doctor or your urologist about it you know if you're waking up at night if you feel like you have to pee too frequently if it burns to pee things like that um so and that sometimes is due to prostate enlargement prostate issues it could also be due to a tight pelvic floor as well from a cancer standpoint usually we check uh blood tests called a PSA prostate specific antigen and you know there's different screening uh screening guidance that's made usually start you know in men in their 50s or so um and
Screen every year or two till a man turns 70 you know some of the guidance or some of the screening patterns will vary based on family history which is a very strong predictor of cancer risk is there anything I can do or is there any research that gives me advice on how to treat my body in such a way where I reduce my risk of prostate cancer you know we talked about some of these you know risks for erectile dysfunction right like obesity diabetes I think those same things can also play a risk um in so a lot of these prostate conditions too so good diet exercise maintaining good body weight I think all those are important avoiding drinking water before bed well that'll help with you know sometimes waking up at night so for some men that are most bothered by you know so-called noctua or waking up at night to urinate I think you know trying to dehydrate yourself you know saying I'm not going to drink any fluid after 7 o'clock at night or six o'clock at night so that you're more likely to get you know a full night's sleep you know waking up once at night is not that unusual um but if it becomes a little bit more frequent you know that's one strategy that some men use okay so reducing my water consumption at night time isn't going to reduce my chance of having prostate cancer right okay fine what about spicy foods so I think in a a similar way that can also affect um some of the symptoms it shouldn't affect your prostate symptom thing M ah okay is there any is there any studies that show ways that we can reduce our prostate risk that aren't just the sort of health and what sort of Lifestyle related things is there anything linked to I don't know other parts of our lifestyle like our use of technology or alcohol consumption or anything at all not to my knowledge I think that you know Asian ore uh the defoliant that was used during Vietnam war that was found to be a risk factor for prostate cancer so um I don't know why you would but try and try and avoid Ancient Orange um but otherwise there are not a lot of modifiable risk factors other than the ones that we talked about I think that you know cancer risk goes up with obesity you know thought to be due to different things but maybe inflammation and things
like that so I think kind of living a healthy life I think hopefully will keep you on a healthy trajectory I'm the first person to lean into new tools to support my productivity but also to save me time and one that that's been a real gain for both me and my team as nordvpn who I'm pleased to say are a sponsor of this podcast I don't think many people know just how useful having nordvpn can be for you for both business but also for personal needs personally I use nordvpn for online privacy and for security because I'm often traveling and working on the go connecting to public Wi-Fi networks which can often be quite risky nordvpn has been helpful for me but also the whole executive team here including Jack who's the producer of our podcast and The Wider production team who use it for fast file downloads and accessing local networks especially when we're shooting the podcast in different parts of the world like New York where I am now and La nordvpn is incredibly simple to use and it's officially the fastest VPN available nord's 30day moneyback guarantee makes it totally risk-free too and it only equals roughly the cost of buying a coffee try it out for yourself by going to nordvpn.com doac what is the what are the most important things that we haven't talked about that patients come into your Clinic can speak to you about as it relates to reproductive Health you know hormones everything in between well another condition that I see men for a lot is something called ponis disease which is a curvature of the penis so um you know the way erections worth work is everything swells you know there's sort of these kind of tough tissue layers in the penis that trap blood inside and sometimes Scar Tissue can form on those layers um for different reasons it's thought maybe microt trauma some men do remember sort of a traumatic sexual episode that leads to an injury and scar formation and you can imagine if there's scar tissue in there everything will not um you know kind of expand in a uniform fashion so you can get a curvature deviation so some of these men have you know 90 degree curves to their penis um and so you know whether it goes up or down it makes can make sex pretty challenging um and so that's another condition we see I think it's important for men to know I think again like it's
just similar to erectile dysfunction I think you know men are sometimes you know a little bit reticent to talk about some of these conditions but it's fairly common probably 5 to 10% of men are affected and there are effective treatments for this as well so I think just as sort of a public service announcement um if men are suffering from this again talk to your doctor because there are treatments that we can we can offer okay so let's conclude then if I want to make sure that my sperm count remains very very high um so I can have those four kids and I want to make sure my testosterone levels remain at a healthy sort of balance let's say is it sort of 4 500 is G milligrams is it yeah nanograms per deciliter okay nanograms per deciliter want to keep it in that sort of healthy range and I want to have Rock our directions okay so that I can have the four kids that I mentioned mhm what is the the advice that you would give that is broadly applicable to everybody without you having to run my my blood tests and all those things and this is really a conclusive point the first one that I've heard is about sort of lifestyle and dietary choices is there anything that I definitely shouldn't be eating if I'm trying to to become optimal in these three areas again people have looked at sort of different diets which can affect health and reproductive Health you know more specifically so I think generally healthy foods are a good idea you know whole grains fruits vegetables you know usually the control group for all these is like a western diet you know like you know processed foods fast food things like that foods that have a lot of fat high calorie those you and you know some of them also the packaging has you know some of these same kind of chemicals that we talked about earlier so I think trying to avoid some of those I think is a good idea yeah sugar um Sugar's okay okay um unless again sort of high calorie foods or things to to try and avoid um if you have any medical conditions you know I think that trying to get those treated you know sometimes men do worry that you know if you're taking a pill for something it may affect your fertility um but you know I think just generally being healthy anything that's good for your heart is going to be good for fertility so I
think it's a good idea to get that you know treated there is a study um out of Japan that I always quote about this so this was study that looked at all patients that came in with male infertility um and tried to figure out who they helped right and so they wanted to see if they could predict who was likely to benefit from a Urologic concultation and who was not and so they looked at you know Baseline sperm count that wasn't predictive of who was going to benefit Baseline testosterone level wasn't age wasn't some men had this condition called a verical which has dilated veins in the scrotum so about 15% of all men have them um infertile men maybe about 40% have them so you know the testicles are outside the body like we talked about and having larger veins impairs normal temperature regulation um and so if you fix those it turns out most of those men are going to improve their sperm count um but the other really interesting finding is that they also found that men that had a comorbidity treated had improvements so the data they provided as men that had high blood pressure if they got that under control their sperm counts went up about 25% so you know a lot of times you know the first time men see the doctor men don't go to the doctor a lot right unless there's a problem right unless they're in pain or some other you know condition um so sometimes my patients the first time I've ever seen anybody is they seeing me to try and have a baby um and so it's an opportunity to you know make them take a little bit more ownership of their health you know if they've never had a blood pressure check check that blood sugar cholesterol all those things are you know ways to improve their health or opportunities to improve reproductive Health but you know overall health as well so I think that's another thing to be kind of mindful of what about depression then our mental health and the role that that will have on our fertility are erectile performance and all of those things is there correlation there there's strong correlation yeah so I think we do see a strong correlation between erectile dysfunction and depression you know if you look at men with erectile dysfunction I think up to 20% it you know may have some form of depression um
and we sometimes worry that some of the treatments can also you know exacerbate sexual dysfunction but I think trying to get men on a better path is important I think it's also important to work you again with a therapist as well you know so that you kind of attacking these things from multiple you know multiple angles you know generally most of these medicines you know probably have not been tested you know in terms of reproductive Health um there's some studies that say that some of these may affect seman quality but I think those studies are limited so I think you know generally if men are on these medicines we're not sure and I think it's helping them um you know we try and sort of you know carry on and persevere because I do want them to get the benefit of some of these therapies what about childhood trauma and the role that plays you must see that show up in your practice this yeah I mean I think it certainly can affect Sexual Health you know pretty profoundly I think you know when you do suspect you know kind of this sort of psychogenic component I think you know we do try and be again like talked about very optimistic about options that are available um but working with the therapist working with a sex therapist to come up with sort of a good sort of strategy and plan to kind of get um you know men through you know some of these issues um so they can have you know a fulfilling sex life anything else that I need to do to improve these things Topline things so lifestyle TR you know we've talked about food exercise we've talked about as well as a way to improve at least our testosterone levels yeah sleep I guess might be a important sleep's important too sleep's interesting because it's um it's what's called a U-shaped Association so it's it's possible to get too much sleep so you know you probably want sort of an ideal amount probably seven to nine hours is usually that's been associated with better seamen quality for men that get less seamen quality tends to be a little lower for men that get too much sleep uh you know again men that have you know are able to sleep 12 13 14 hours a day there may be other things going on there maybe there's some underlying depression or something those men tend to have lower semen quality but you know I think sleep I think is
certainly important there's also been studies looking at weight loss as well you know I think it's obviously easy to say lose weight um but it's not always a straightforward to do um but there is you know a nice study that came out a few years ago where men were randomized to you know weight loss program on a very low calorie diet 800 calories a day um for a few weeks and then they lost you know weight and then they follow them for the rest of the year um and so this is important because men that were able to keep weight off were able to maintain the benefits of their sperm count versus men that were you know kind of fell off the exercise routine they ended up gaining back you know their weight and then their sperm counts declined again uh one of these arms actually also had one of these you know hot glp1 analoges as well and so even men that were on those that kind of help them keep their weight loss were also able to maintain sperm count so patients do ask about that a lot you know I was just going to ask about obviously as zexs exploded and there's many other forms of this sort of glp1 um sort of fat loss injections I was wondering if that had any consequences on fertility so again there's only one study that that did study it and it did seem to show benefit so it doesn't cause any harm as long as you maintain weight loss with it you know you do seem to see Improvement you know in contrast um you know some men also ask about like bariatric surgery which you know again may be declining a little now with these you know very effective medications but interestingly for bariatric surger like by like gastric bypass I don't know if this is popular in Europe or the United Kingdom but for some obese individuals um there are surgeries that can be done to help sort of reroute intestinal absorption um so you can lose weight with that there's also something I thought you meant the gastric band thing there's gastric bands too yeah so there different ways that it's been done and so with all those um actually uh tends to decrease sperm sort of right paradoxically so you would think that if you lost weight your sperm counts would improve but it turns out with these surgeries sperm counts actually declined some of them some actually men went from a reasonable
sperm count to zero so the thought was that you know it's the trauma trauma of a surgery potentially you know um there are you know some vitamins minerals are important too so um you know without that normal absorption that occurs in the intestines that could also lead to infertility you know that was sort of a concern and we were wondering if that same thing would happen with you know these newer medications um but it doesn't seem like it so again the glp1 analog seem like they safe safe form of weight loss at least when we're looking at semen quality as an outcome what about supplementation is there any supplements one might recommend I guess it's difficult for you to recommend supplements but are there any sort of vitamins or minerals that are typically deficient in people that have have infertility issues so I think there is some data that antioxidants can improve fertility so it's sort of a very broad group um of things that have been tested berries and stuff is that like yeah dark berries yeah those certainly can have a lot um but you know I usually tell you know patients to take a multivitamin they do make special male fertility Blends like if you were to look it up on the internet or Amazon or other platforms there are special fertility Blends that have kind of some of them have you know looked at the data and try and pick out you know specific supplements that are thought to be more beneficial coenzyme Q um is a powerful antioxidant that has shown some benefit for fertility so I think that's something else that you try and Empower patients and they can do that too and that that can help protein does that play a role in fertility or testosterone I think you know again sort of part of a balanced meal part of a balanced sort of diet I think it's important what's your mission from here on what are you going to do for the next 10 years if you had to ha it a guess what's are you going to do is it more of the same or are you going to are you interested in changing um focus at all slightly or are you going to just continue to do research on these subjects what's your big sort of decade Mission yeah I mean this really gets me up in the morning and this is the stuff that I like to do like late at night as well I mean I really passionate about this trying to understand you know
why we see this link between fertility and health why sperm couns are declining because I think the more we understand about it we can you know hopefully mitigate some of these risks um also like to hopefully you know through you know information channels and platforms like this you know hopefully engage more of the community to try and come up with some therapies you know for male fertility I think you know we talked about some of the things that can be done but there's no you know in in the United States there's the Food and Drug Administration that sort of oversees all you know Therapeutics and there's no FD approved therapy for male fertility which is really a shame especially because you know again we have this data that it's becoming more prevalent existential right as a species so it'd be nice if there was some so try and get more engagement from the scientific Community from the pharmaceutical Community um to try and you know see that opportunity um because I think that'll be very important for for you know for our Fields but again you know I think like you said sort of more of the same in some ways but I think trying to understand some of these questions in a lot more detail so that we can you know really help these men is there of all the subjects we've discussed today is there a particular part of it that concerns you the most well I think you know when we're talking about sperm counts declining I do worry that that is a barometer of health and so it may be that you know in addition to men's reproductive Health just our overall health is declining you know when we look at sort of the health of fathers over time we've seen you know fathers are getting a little older you know we talked about that but you know with that comes more comorbidities right higher rates of hypertension hyper lipidemia you know other things and that sometimes can have sort of transgenerational impacts so like a father that has high blood pressure or you know is obese that child is you know a slightly higher risk of having some other issues later on so trying to understand that again if there's maybe opportunities to try and figure out what in that sperm is a little different maybe we can turn that switch off to try and you know prevent that I think those
are all things I don't want to be alarmist about this these risks are all very very low um but I think there's a lot of opportunities um you know I think one of the reasons I got into it I think is because male reproductive Health was really wide open so I think there's still a lot of opportunities to try and improve it what would you say to a man that's listening to this that's struggling with any of the things we've discussed what is what is your your closing message for them well I think I would just try and be optimistic and hopeful I think there's a lot that we can do I think that you know it takes a lot of Bravery you know to go in and see doctors about some of this thing and some of these you know different these different issues but you know it's what we're used to dealing with and I think there's uh you know plenty of options that are available so I would just encourage them to you know talk to friends but you know men talk to their primary care doctor talk to their urologist come see urologist you have a very broad platform so I think if there's couple struggling they've only seen gynecologists I would encourage them to maybe see you a male reproductive specialist as well to try and get some other perspectives we have a closing tradition on this podcast where the last guest leaves a question for the next not knowing who they're leaving it for the question that's been left for you is a tricky one it is what's one thing you would do to change the world I guess one thing that I would do to change the world I guess is certainly um appropo of our conversation was that I would make um try and make policy that all governments would pay for infertility services so that this is a universal benefit for all of humanity I think that would certainly help open up the doors for a lot of people that don't have resources for it kind of hesitant to use it um and hopefully that would again solves some of the issues that we talked about from a demographic standpoint what would that do for Humanity we' be having more kids I guess we'd be happier in in our relationships potentially I mean yeah I think it could do all that I think that you know I guess from from a father standpoint having a child again increases longevity
um decreases cardiovascular risk um increasing from a sort of societal perspective having you know um getting getting to that replacement level sort of maintain population I think that's again existential for a society um increase the tax base and all the other things that are associated with that and the workforce it's very difficult in politics now certainly in United States um there's a lot of you know ISS isues that are going on but you know making policy that really affects everyone I think would be you know very profound and I think there's be a lot of um benefit to that Dr Michael Eisenberg thank you so much for your time and thank you for the work that you're doing because you know you're uh you're helping to ultimately to create families and to also alleviate a lot of the stress and anxiety and worry and concern um people have about their reproductive health and I think it's an incredible service to humanity to be doing that and especially at the time when we're in where it feels like it's more needed than ever before and frankly the direction of travel isn't fantastic um as it relates to some of these big issues like you know testosterone and fertility and um but it's it's really important for you people like you that have the information that are doing the re research to not just keep it in the lab and not just keep it on Pub Med where it's very hard for people like me to access it because we can't bloody read PubMed um so thank you for for for making the decision which you don't have to do to come out and speak on these subjects in a way that's really accessible um and inspiring and empowering for people because I think that's going to do a tremendous world of good so thank you thank you my pleasure how many of you started thinking about your long-term Health when you hit 30 for me this was a wakeup moment of me thinking to myself okay I probably need to start paying a little bit more attention now I already felt a change in myself when I hit 30 with things like my metabolism my energy levels so this year is no different Zoe which is a company I've invested in but also a company that are a sponsor of this podcast helps me to make smarter food choices all based on their world
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