Delaying Having Kids Is Impacting Your Future Kids! Dr Michael Eisenberg

Men need to understand that the average age of the father has increased by approximately three and a half years and with that the possibility of problems with the child can also increase, so pregnancy becomes much riskier and that is why Dr. Michael Eisenberg is an expert in male sexual function and fertility who is helping us 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 effects Devastating, for example, men with lower semen quality have a higher risk of Death, wow, and there are a lot of really interesting questions that need to be answered.

Okay, let's get into it. Is there any evidence that chemicals in our environment are

impacting

our sperm count? Now, testosterone levels. Yes, it is a chemical found in many creams and lotions. that we use and then there is a chemical that is used in the manufacturing of plastic that could have quite devastating effects, so don't drink from plastic water bottles. What about Paros? I couldn't determine if low or high testosterone causes a setback. Most men aren't going to have a hairline like this, but it turns out that if I'm sitting all day, it's going to have an impact on my C for sperm.

There are studies to support that I would say take breaks, get up and try. and ventilate the area, what can I do to give myself the best possible chance of increasing my fertility? There are many things we can do and we usually start with erectile dysfunction. Hundreds of millions of men around the world have problems with instructions. but as long as you have a penis, we can always make it difficult for you, for example, we can teach men to surrender ooh, it just gave me a chill, but it probably works 80-90% of the time, congratulations, Dio, gang that we have formed. some progress 63% of you who listen to this podcast regularly do not subscribe, which is down from 69%.

Our goal is 50%, so if you ever liked any of the videos we post, if you like this channel, can you please? Do me a quick favor and hit that subscribe button. It helps this channel more than you think and the bigger the channel gets, as you've seen, the bigger the guests get. Thank you and enjoy this episode. Dr. Michael Eisenberg, why do you do what you do? what you do, it is a pleasure to be here, without a doubt, it is an honor. I see myself as a researcher and advocate for men's health, men's reproductive health, sexual health, and you know, I think when I see patients in the clinic, that's what I'm trying to do. do to try to understand where the problems that they have are coming from and figure out ways that we can work and improve them together and certainly from my research perspective, I always want you to know try to define what the problems are, um and just improve our treatments that we have for men.

I'm the director of Men's Sexual and Reproductive Health at Stanford or Men's Health in the Department of Urology. I have a joint appointment in the obstetrics and gynecology department because fertility is a team sport and so I also help you meet couples and I recommend women to the female side and, like me, I get a lot of referrals from them, you know , when we are a little worried about the male partner when you say type of reproductive health, what are they? all the kinds of things that fall into that bucket or under that umbrella, so I think you really know about reproductive health.

I guess, as the name implies, it would be trying to have a baby, but I think it's much more than that because I think what we're really learning is that you know fertility is kind of a window to

future

health, probably around the 10% of the male genome is dedicated to reproduction and since there are only about 25,000 genes in the body, you know what produces the feeling that some genes that operate in reproduction also operate in another organ system, a study was conducted in which biopsies were taken from men who were

having

trouble producing sperm and they tried to replicate these cells and they found that these cells had very high rates of mutations in their DNA so you can imagine you know there are checks and balances when we produce sperm.

It makes sense if you can't faithfully replicate

your

DNA. You know there probably won't be, there will probably be some blocks where you can't produce a correct sperm if there will be mutations, but also these men can be set up for other problems, like cancers or something, if you know the body, can't you? know how to 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 evaluate men with infertility, um infertile. Men actually have lower testosterone levels than fertile men, so you know there have also been studies that show that men with lower testosterone levels have. a lower survival species, so you might know some kind of hormonal link between fertility.

It can put men on a different trajectory, you know, you know another. I think it's a very important aspect of reproduction. There's another type of what I call something like that. social factors that are at play, you know, things that necessarily go with reproduction, like

having

a partner, and hopefully having children, and it turns out that those factors are actually very important for health and longevity, as well as having a couple. it actually increases survival, so if you like to compare if you have a man with a partner and a child, if you then take away the partner, the probability of that man dying increases by 60% and then if you take away just one child, the probability of him dying increases by 60%, but it turns out that if both things are absent, the man has a risk of death three times higher than someone with a partner and a child, so there really is this kind of important I think that men need to understand and then obviously there are also many of you who know intrinsic things that we like, lifestyle, behavior, obesity, smoking, all of that is also very important for health.

Well, so I think when I look at these men for reproduction, I really try to 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 his reproduction and, with Good luck, we'll give them a baby, but you also know how to improve their overall survival, you know, health, everything, so how many patients have you seen in

your

career? If you had to hazard a guess approximately oh, I mean, I think it would probably be tens of thousands, I guess maybe. 20 30,000 and how many years have you been working on this topic of men's health, fertility, reproductive health, all of this probably between 10 and 15 years, it seems like the world has turned more towards your work in the last two. years than ever, it sounds like you're researching and educating people in a space that has suddenly, relatively suddenly, become really important to people and I was even looking at some of the data on types of testosterone replacement therapies. . and how that has absolutely exploded in recent times and also the fertility conversation.

I was looking at the data on fertility, how many people are searching for information about it and it's skyrocketed in the last five years, and even in my circle of friends. We weren't talking about fertility, testosterone or sperm count even two years ago, whereas this year and then the last 12 months it has been a frequent topic of conversation. Why is this? Is my assessment accurate? Can you back it up with what you? I'm seeing, I mean, I think so. You know, obviously, I guess I would say I'm biased and I think this is, you know, very interesting and I think you know there's a lot of momentum towards us.

You know there have been a There are many landmark studies that suggest, as you say, decreases in testosterone over time, decreases in sperm count over time and we can certainly talk about that a little bit more and I think with that you know there has There really has been 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 a percent of all bursts in the i in the US were conceived with IVF, now it's around 2% and only going up.

I know that before insurance never covered it, now insurance commonly covers it, so there really has been an explosion in the offerings, the number of cycles that are done, and in my particular area in Northern California, it seems like everyone Every year a new IVF clinic opens and you're always worried and wondering how there could be enough business to support it, but you instantly know all the patients, you know that all the spaces are taken, they're booked for six months and I think there's a enormous amount of demand and I think you know, I think to your point, you know the question really is why do you know fertility is declining.

I think all of those things probably go together, that's leading to this and I think it's something we're doing to ourselves, potentially there's some environmental exposure. I think all of these things are really interesting questions that need to be answered, so let's start with the why, so if we step back a little bit from some of the social factors that could be leading to infertility problems, but also correlated problems like things like testosterone and all these things, what are some of the broader ones? social factors that are causing IVF clinics to be so in demand now, yeah, I mean, I think one of the biggest ones would just be the increasing age of parents, you know, I think there's been less data on age. masculine over time, at least here. in the United States, but a few years ago there was a study done that showed that in the last 30 or 40 years, the average father's age has increased by about three and a half years, it used to be like in the '70s, you know, a older father and that would be considered over 40 was maybe around 4% of bursts, now it's probably 9 to 10% of bursts so I think there's more lag and with that, you know, infertility increases , there is usually a closure. correlation between mother's age and father's age, so I think a lot of people are familiar with age as women age.

You know, fertility declines probably at a steeper rate, but the same thing happens to men, you know, sperm. counts go down a little testosterone goes down a little it takes a little longer to conceive you know, the possibility of problems with CH the child can also increase I mean, the oldest father is 96 years old, so the biological potential remains, but it certainly gets a little bit more difficult because pregnancy becomes much riskier, what is the rate of decline in men and women, in terms of fertility, so I think you know, if you're looking at your guest from a point of view evolutionary, you know that peak fertility probably occurs in late adolescence.

Early 20s, something like that, and for women, you know they're born with a certain number of eggs and as soon as you know, cycles start, they continue to lose them over time, so we usually think about, you know, over 30 35 40. You know those are pretty big points where fertility gets a little bit more difficult for men. You know that sperm count decreases. You know why this kind of limit where we say the oldest parent is 40 is kind of a constellation of different risks. You know, the sperm count goes down a little bit, but the other thing that happens is that every year, you know, we're born with some sort of sperm precursors or sperm stem cells in our body and they're constantly replicating every year and every time. that that happens. there is some chance of a mutation occurring so it turns out that every year we probably accumulate sort of two mutations in our DNA and over time you know that becomes a little bit riskier so a 40 year old will have 20 more mutations than a 30-year-old, for example, so we have billions of base pairs of DNA in our body, so the probability of 20 mutations making a difference is probably pretty low, but you know, that it's on an individual level at a population level that's something that you can start to see and so for men, I think it's just kind of a slow and steady decline, you know, probably in your 30s and 40s. , do you have the data on the oldest mother?

The oldest woman to conceive a child, so using a donor egg, I think it's the 60's or even the 70's. I think she's been described before, but I think with her own egg. I think she is in her late 50's early 60's. Does this worry you? as a macro trend because if we move forward this would lead us to assume that fertility will be a growing problem for society, yes, I mean, I think it's veryTrue, it is existential. I mean, as a disclaimer, obviously, I'm in the fertility business, so, you know, I certainly care about this trend and I want to make sure that we reverse it, it's a risk factor that we know about, but I think you know that the solution is not obvious because asking couples to delay their careers education, all of that is a big challenge, you know, I think some countries have tried to find ways to support, you know, parenthood, you know, through leave or you know, other types of programs like that, child care also becomes, you know, very important, but even with that, I think there's kind of a perception that it's not as easy as it seems and it turns out that you actually know the return on investment for some Of these things, you know that having a child is something like that.

Important to the health of a society, there is a concept called the replacement rate which is the number of children that need to be born to a woman of reproductive age to maintain the population level. This is like ignoring immigration, so it turns out that it takes about 2.1 children per woman of reproductive age for the population level to stay the same, so if in some societies it is lower, such as in the US .U.S., it's a little bit lower than that and in some, like Asian countries, like Korea, Japan, Japan, it's lower than that and that's really existential because if you know if your workforce starts to decline, you know, tax Spas, everything you know will really increase. collapse and therefore, from an economic point of view, it makes sense if these are couples who want to have children and they know that they are desired children, they know that they should try to invest in them, they know that allowing them to do so really makes sense because they know that in a way it will bring it back it's at a social level I read about in Hungary that if you have four or more babies then you won't pay income tax for the rest of your life according to the Prime Minister it's an article I had seen it and I think this speaks to a broader trend of how there will be a local approach to getting us back to having babies to stop the population collapse and decline that you talked about, as announced by the Prime Minister of Hungary. a series of measures aimed at boosting the country's declining birth rate and reducing immigration and one of them is that they will essentially give you a check and you only have to pay it back if you don't have four children, so for each child, you have the 25% of the money they give you is deducted and once you become full children you will never have to pay income taxes 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, isn't it, I mean, I think these, you know, the chancellors, the prime ministers are really thinking about things. I'm sure you've taken a good look at the numbers and realized that society really depends on keeping the numbers and when you know. when the population starts to decrease it could be a problem. I mean, I think it's a very smart solution. Sperm quality. Sperm quality I read is decreasing, yes, so that's very interesting because it's a very controversial statement. You know, I think there's a tremendous. amount of data to support that several years ago I was involved in a study that analyzed data from a sperm bank here in the United States.

It was a sperm bank that was in the northeastern United States in some places and it was There's not a lot of data, it was just a few years of data, about a little over 10 or 15 years, but what we found is that actually , if you look at the men that come in to try to be donors because you know these banks, they are very selective, so you have to have excellent sperm that freezes well and thaws well. Really high numbers and you know they also look at your pedigree a little bit to make sure there are no conditions to manage your family. to be in shape, you know these are things that are thought about, you know, that make you a better donor, um and when we look at the candidates that came in during this really short period of time, probably 10 to 15 years.

There were decreases in sperm count, you know, movement shapes all these kinds of parameters that we look at when we talk about a semen analysis and the interesting thing is you know when people have talked about decreases in sperm count. have been attributed to different things, for example, people have talked well about the obesity epidemic and that maybe we are more sedentary now than we used to be or, you know, environmental exposures or something else, there are more chemicals now that before or cells. telephone prevalence and things like that, but you know, during this short period of time where we had a lot of information on these men, they filled out surveys, you know, they filled out rich family histories, they filled out information about whether he 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, something surprising, very interesting and So, you know, others Researchers have used studies like that to put them all together using advanced statistical techniques and found this decline over time, you know, over the last 20, 30, 40, 50 years, so there's a preponderance of data to support that.

So the counterargument that others have made is that you know that during that same period of time some of our techniques have changed. We are now better than before at counting sperm. You know some of the different tools we use. Some of the analyzers used to measure sperm count are better now than they used to be, so we are a little more accurate than we used to be. What these studies have done is when they gather the data they assume. that you know we're all the same, right, if we were both in the study, they would assume I'm like you, you're like me, but it turns out there's a lot of variation depending on the similar region, so there was a study in the United States, where They looked at fathers, so men who had children in different regions of the country, you know, they had some in California, New York, some in the Midwest, and even though they were all fathers of similar ages, the quality of the sperm was very different, it turned out to be very high and in New York I think California was next and the Midwest was much lower, so you know why you think New York would be some kind of bustling metropolis, maybe they would have some risk factors poor, but it turns out he had the best sperm and that's why I wasn't sure, but that just shows us that there is a lot of variation in the seon quality of individuals, so when you put things together it can sometimes be difficult to identify trends, so Ideally, what we do is my neighbor and I would give sperm maybe every year, every 5 years, 10 years over time, and you would see what changed, and those studies are not all, so that's kind of of criticism of these studies, but again.

If you just look at all the data and compare the studies from the '70s, '80s, and '90s to today, sperm counts are lower, what's the current best guess as to why sperm counts are lower? Yeah, I think that's the million dollar question because you know, we've talked about this is kind of an existential threat right, we need a you know, I think any species has kind of three main functions, it eats, it survives, it reproduces, you eat to survive, you survive to reproduce, you spread your DNA and so if you can't do that, it's definitely going to be a problem, so you know, I think we've talked about, you know, maybe obesity.

I think we're certainly different now than you used to be in terms of walking, you know, sedentary. Behavioral people, do you know that they have hypothesized that different chemicals in the environment are leaching into our food supply, our water supply, is there any evidence that chemicals in our environment are affecting our sperm count and our testosterone levels and things like that, yes, there are? There are studies that support that, you know, there are certainly preclinical studies, you know, where you can, actually, you know, doses like rats and mice, these are also human studies where you can compare sperm quality with others. kind of chemical traces in the blood and look at these correlations as well and then there's a study called enh Hanes which is a study done by our Centers for Disease Control where every year men and women are surveyed or blood pressure data is collected of obesity.

Things like that, um, and they collect data on types of chemical exposures for these, you know, a select group of individuals that represent the entire population. This has been done for the last many, many decades, so when we talk about obesity, the increasing prevalence in the United States is based on that data. These are a rigorously researched group of people, you know, selected every year, so those same studies collect data on testosterone or estrogen for women and compile it. these different environmental chemicals and I see these correlations. I would say that not all studies support this, but there are certainly a good number that show that there is this correlation that if you have greater exposure to some of these chemicals, there is a greater risk of lower hormone levels.

What are those chemicals and where do we find them? CU I I I talked to someone who was a urologist recently, I think from New York University, and they were telling me things like 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 cause sperm quality to reduce mhm, is there evidence to support that there are a lot of different chemicals to worry about or think about? I think you know that microplastics are one of the phalates, what is aite aite, it's a chemical that's found in a lot of things, like um, you know, different, like creams and lotions that we use, and it's also been proven to affect androgens, you know, and the kind of endocrine function within the body.

Bisphenol A is a common chemical used in plastic manufacturing that has also been found to have these endocrine disrupting properties, so it has also been correlated with Sean's quality endocrine disrupting. Endocrine disruption, what does that mean? So you know if you look at In kind of Paths for Men and Women there are hormones, right? I am producing testosterone and that acts on my body as a child to help me become a man. Now it helps me stay like a man you know. a beard, all those kinds of things that give my U my deeper voice, um, and there are some of these chemicals that mimic part of that action or block part of that action and if that happens, it can affect normal development. from you know, boys or girls, maybe you know, again they affect semen quality if we think about the origins of changes in semen quality, some of them can occur when we are adults, but others could also occur during development, you know. whether it's when we're developing inside our mothers or during puberty, if something affects the normal timing of that, it could be that, again, it could have pretty devastating effects, so one theory is that some of these chemicals affect these. sort of biological pathways, these endocrine pathways involved in that, based on the research that you've seen on these types of chemicals, are there any changes that you've made in your own life?

Anything that made you think differently about options. What do you do in your own life with your children because you have three children, so you have the opportunity to influence them at an earlier stage than most of us can influence ourselves, but yes, one thing we do is: I threw all plastic water bottles. I would say I still use them because I find them very convenient. And I'm done with streaming, but certainly for the

kids

. I make sure they don't drink from plastic water bottles. So, we have glass, or metal. I think there's data that, you know, there's a lot of exposure that children get and I think it's pretty easy to eliminate it now.

What does the data say about plastic bottles? you know, if you look at, you know, the exposures of that, you know they have, they just absorb a tremendous amount, you know, with washing with water, it stays there all day, so I think it's very, you know, most of plastic water bottles want. You know, the plastic bottle industry will come after us, but that's a common way for people to be exposed to them, so I think if we say that's one of the main touch points for plastics, it's usually through our kind of food and water supply, so yeah, I think it's easy to get rid of it if you can, is there anything else?

I read recently that heat plays a role in the quality of our sperm, so if we don't know if we're going to get into saers or somethinglike this or if we spend a lot of time. I don't know sunbathing. So there is science to suggest that that will reduce our sperm count. Yes, so that's right. I mean, I think you already know. Gu, you can see this in a broader context of global warming and people have 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. colder degrees for sperm production to occur, so anything that warms them up can definitely be a problem.

So when I talk to patients in the clinic, for example, we talk about Saun, jacuzzi use, some men bathe every day like in a bath, um and those. everything can affect sperm production. There have been studies that show that men you know use saunas regularly, have lower sperm counts, and then when you remove that exposure, the sperm count will return to normal. An interesting application of this was trying to use this data or use that knowledge to create a contraceptive, so there was some kind of strange belt that actually pushed the testicles into the groin, which actually turned out to reduce sperm. counts down to zero, I think, and again the few men who volunteered to do that, but you can imagine, I think most men are not going to be too enthusiastic about that, because it's probably pretty uncomfortable, the other way around. that I've seen that I've had patients that have gotten sick, certainly around Covid, which happened not infrequently, men would come in, you know, telling me you know they just got over a Covid infection where they had a high fever. for, you know, a few weeks, um and then his sperm was very low and then, you know, we waited a few months, it takes about two to three months to produce a sperm, so we let one of those cycles or two of those cycles pass and his sperm counts came back.

I had a patient even before covid, like a 41 year old guy who had a normal sperm count and all of a sudden he measured and the sperm count had gone to zero and it turns out he had a flu with a fever of around 102 degrees Fahrenheit the week previous and again we let nature take its course, he recovered and then his sperm count went back to baseline, so we see that too with that belt you mentioned. Holds the test type testicles closer to the body. I guess he does it to basically warm them up, which lowers their sperm count.

MH, obviously, then one would think of his underpants. We all wear very tight underpants these days. invogue or whatever, are there any studies that suggest that boxy briefs can reduce sperm count if they're tight, so that's like a very common communication? That's one of the most common questions I get about boxers versus briefs and that's been studied a lot because it's a very common exposure. I think I generally just tell men what's comfortable. I think a single layer is unlikely to make much of a difference unless you have specially designed underwear that pushes the testicles into the groin, but otherwise, as long as we're out of body, it should be fine.

What about cell phones and technology? Is there any link between fertility and technology use, specifically having these devices in our pockets near our genitals? Know? Another common question that I get that is certainly something that has changed right now compared to 20 or 30 years ago, so there were some studies that initially showed kind of a sign that men who used more cell phones had a lower cell count. of sperm, but some of these studies were, you know, If you're older and you're also worried about some of these kinds of confusing things, it may be that people who use phones more do other things that you know they have, they may have more stress in their lives and other things that could affect the quality of the SE, so there was a smart study done where they took ejaculate, then they took sperm, put it in a cup and put a cell phone next to it and tried to measure changes in sperm quality and they actually found some, they found higher rates of like DNA damage within sperm that was exposed to the phone versus not, you know, trying to control the temperature, which we know he said that it's important for sperm health, wait, so they controlled the temperature, controlled the temperature and just having kind of cell phone, you know, receiving its signal, um, it seemed to affect, you know, the DNA damage in the sperm, it wasn't. , you know, it was a statistically significant difference, you know, um, maybe it wouldn't be a point where we would get so I'm worried clinically, but it's a change, so I think it's something to think about.

I think, you know, other than that, cell phones I think nowadays don't get too hot, so I'm not that worried about the heat, but if this RF, you know this radio frequency. exposure can affect things, you know, maybe it's a theoretical risk, but I guess there's not a lot of hard data, so I think you know again. If so, many of my patients tell me that they keep trying and keep their cell phone in their back pocket or front pocket to try to avoid that. I think it's okay. I've been having a lot of conversations with my partner.

She really believes that my cell phone should never slide under my genitals, which I do sometimes when it's like I don't know when I'm in the car or something or when I'm on the couch. I don't know when my hands are full. I just grab it and kind of slide it between my legs, yeah, and she reaches in and pulls it out and says, and I think because she's worried about these four

kids

that we want to have and you, I think she cares about you too, yeah , to be fair, it is not. Someone who's going to read PubMed and read about the studies, but it's just a feeling that 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 that you get sperm.

In a small thing, you put your phone on it, send it some text messages connected to Wi-Fi, Bluetooth and see how the sperm is transmitted. Yeah, I didn't realize there was a study about it. Yes, I think laptops. They can do that too, but they also have a little bit more heat associated with them, so a similar study was done on laptops, where they put sperm next to a laptop and monitored the temperature, and they saw the same pattern, you know, again. of the Wi-Fi signal can also affect the sperm again, you know, damage to the DNA and the quality of the sperm, but you also know that laptops can also get hot, some of the batteries, some of the moving parts inside uh they can also get warm and they also serve as almost insulation if you put it on your lap, so I also talk to patients about that, you know, maybe using it as a pillow or something else just to try to protect yourself a little bit, wouldn't we see a kind of great isolation?

So if I'm in kind of sub-Saharan Africa, I guess my sperm count is going to be pretty low because I'm going to be sweating all day, so I think that's a big difference between hot countries and cold countries or hot countries and sperm counts. sperm. However, the other kind of element is that there are differences in populations and I think that has not been described well, but if you compare, you know again that we talk about California, New York, the Midwest and the United States, but people also In comparison, you know, like Denmark, they have many kinds of problems with reproduction, so they have really studied it very, very aggressively and if you compare them to other countries nearby or other countries in Europe, it is very different, so you know one possibility could be exposures, you know, and what are these men doing, what are they exposed to, but the other could be, you know, there could be some genetic components, but one interesting thing along those same lines. is that sperm quality varies depending on uh, time of year, so during the warmer months it goes down a little bit, not significantly, and then during the colder months it goes up a little bit, but the other thing is you know it doesn't I guess we do, or some of us don't, but we don't spend all our time outdoors and sometimes in the colder months, you know, you're warm inside and during the warmer months, you can Be in, you know, air conditioning, did you say that Denmark has had a problem with sperm count?

Yeah, yeah, so, you know, in the United States I said about 2% of bursts are conceived with IVF in Denmark, it's about 10%. Wow, um. and it's actually that again they really have a breeding crisis there so they actually did a very good research on seam quality and it was estimated that only about 25% of Danish men have normal Sean quality. Have you discovered why? that's what they're researching and they have a lot of theories and again, I think you know, it's a lot of the same issues that we talked about, whether it's environmental exposures in, you know, mothers, or again, pubescent children. or, you know, adults.

They're trying to figure it out too, but it's also one of the countries where the fertility rate is below replacement, so it's definitely an issue that one would assume is some kind of environmental factor. I guess it could be some other social factor but one would assume it's some kind of environmental factor, yes some people have postulated that during World War II they were very isolated and therefore potentially there were some chemical exposures that as you know , they persisted and stayed in the population and it's a little bit difficult to overcome that, but there's no telling if I'm sitting all day, that's also going to have an impact on my sperm count because of the heat generated by sitting here, um, or if I'm a cyclist or someone who's doing, you know, I sat on my balls doing something warm.

People have looked at different occupations where you sit a lot and there are associations like drivers, you know, taxi drivers, truck drivers. There certainly can be changes in sperm count. Probably due to the heat. You know it again. I think it might be a combination of sitting all day. You also know that from other health points of view it is probably not good and so is cycling. You know people have noticed it. kind of a high level cycling athlete and there are differences in the quality of Seaman, um, but you know, peak cyclists, you know they do a lot for their body, so you know it's possible that there could be other effects as well, but you know, looking at men recreationally.

I cycle too I think the number I use there is a study that showed that if you cycle more than five hours a week there can be lower sperm counts so you know I talked to men about that when they cycle you know more than that . potentially taking breaks trying to stand up if we think the mechanism is heat to try to circulate air out of the area to spend some time out of the chair if possible, what about men with big thighs? Yeah, well, I think you know that obesity is a problem. There is certainly a strong correlation between body mass index and semen quality, so as men get larger, sperm count decreases, so heat is certainly one of the possible mechanisms for simply isolating that area, warming things up can do it.

You know that obesity also affects, you know the type of hormonal axis, so that may also be at play because you know that there is a kind of normal stimulation provided by your pituitary in your brain that tells your testicles to produce sperm and that produce testicular tone. This is also affected by obesity, so it's probably a combination, but that's something I think about when I see you meet my patients and we also talk about the type of heat exposure and see if there are different types of strategies that They can use it to try to allow more circulation in the area.

Is there a link between sperm count and alcohol consumption? I think it depends is what I would say, so generally for most types of moderate use I would say one drink a day, um and Some people think that no amount of alcohol that they know of is safe, but probably yes. look at these studies that look at maybe a drink or two a day, it probably doesn't correlate too much with Sean's quality, but there seem to be some studies that say that when men get to three a day, maybe 20 a week, it can There may be lower quality in semen and there was also another study that we did to see if some men are more susceptible to alcohol intake, so there are some um East Asian men and women who have a mutation and one of the enzymes that are used to metabolize alcohol and that is why they accumulate what is called alahh acid, which is actually a toxin and whenthey drink they blush.

I don't know if you have friends. that they have this, but we assume that you know that when you have this, you know that this large load of this chemical in your body leads to redness, headache, dizziness, maybe it also affects the quality of semen and it turns out that it does too in these men who have this mutation um, when they drink, their sperm movement slows down a little bit, so it turns out that there are actually a reasonable number of men on Earth who have this, you know, probably in some populations up to 50 % like in Taiwan um you know it's It's very common in Japan you're of Chinese Vietnamese descent so I think that's something to keep in mind and I think normally you know men know that if they blush when they drink it's probably because they have this mutation and also Al alahh dehydrogenase, so you know. men, I think it's probably best that you avoid alcohol or just be aware because it can affect the quality of the SE if I walked into your clinic and said, Dr.

Michael, I'm trying to have a child with My partner and I want to make sure that everything I'm doing gives me the best chance of having a child. What is the list of things? Because this is basically where I am in my life now that I'm 31 years old. I want to have one child, ideally I want to have four and I'm thinking about the time when my partner is the same age as me, we are almost identical in age and she is 31, so we have you. I know we want to have these kids before we're 40, ideally, so I need to get going, you know what I mean, so what can I do to give myself the best possible chance of increasing my fertility, my sperm count so that let's have? those four children that I want for the next nine years was number four, was it something you thought of before, the tax incentive or yes, we are planning to move to Hungary, so there you have it, it really is about tax evasion, it's not that.

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 think she's fine with it too. I think we've chatted and she's happy with it. Four to six no, she is a good number, there were not six approved, but four for sure, what would you tell me then? So I think you know we look at your overall health, you know we look at any risk factors that you've had, obviously We're talking about saunas, hot tubs, figure out, you know how you exercise, if there are things that you do that aren't good, um, look, You know if you have any medical conditions, you have surgeries, some of those can make men. at risk of that, if there are any medications that you're taking, there may be medications that affect you and then we'll do an exam, um, so we don't have to do that here in front of the cameras.

I feel depressed. Yes, I have a California medical license, but, um, just 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, you know, one of the basic evaluations will be a seminal analysis, so we'll measure how much is coming out, look at how many sperm are there , look at how many are moving, look at their shape as well and then usually we also check hormones, so we'll check testosterone again, a very male kind of hormone, the testicle does two things, it produces the sperm, it produces testosterone, so we check that and then we usually check some other hormones involved in the kind of hormonal axis that controls reproduction and that's usually what we start over.

Fertility is a team sport, so I would recommend your partner also get an evaluation and we'll see. You know, depending on the type of sperm count, we can usually give you advice on how likely you are to achieve it. You already know those four children, but you know again if you are thinking of four. I agree that you should start with fertility issues, we tend to think about that. I think there's a stereotype that it's usually the woman who has the fertility problem and the man is fine and I think if you look at the data, that kind of supports this idea that couples assume it's the woman who has it. the fertility problem, it's a misconception, it's a big misconception, yes, absolutely, I think you know that in the United States and other countries as well.

I think you generally know that women are kind of the gatekeepers of fertility, everyone assumes that's where the problem lies, but if you really look, you'll know that the data probably half the time there's a male factor contributing and you know this type of stereotype is so prevalent, probably at least a quarter of the time. in the United States, the man is never tested and it could be one of the problems, so some couples may turn to IVF, you know, for the sole reason that you know again that the sperm count is low and the man I would never test him and maybe there's a condition we can improve maybe he's on medication maybe you know he goes to the hot tub every day you know something so we can reverse you mentioned that testosterone would be one of the things you would measure if you were trying to do I'm sure my fertility was good.

Decreased male testosterone. This is another hot topic. You talked about it at the beginning of this conversation. Is it true that male testosterone is decreasing and by how much has it decreased? you know measuring men every year for the last few decades if you know there is data showing that testosterone levels have decreased over time you know that people have also looked at other groups of men that you know from the 2000s, 90s and 80s and there's just a progressive decline in average testosterone levels over that period of time, so you know the amounts you know vary between 50 and 100 points, but you know that generally these are significant, measurable amounts, other than this type of cohort changes. where, if you know, look at the average 40-year-old man now, compared to 10 years ago, our testosterone levels also change, so I would say that I normally tell men after the age of 20 that their testosterone is going to go down. . maybe about a percentage point each year, so as we age, testosterone declines and there are things again that can affect that trajectory.

You know, men become more obese, which also affects the testosterone level. A portion of all our testosterone is converted to estrogen. Part of that conversion occurs in the adapted tissue or fatty tissue, so the more additional tissue there is in the body, the more that conversion will occur and therefore the lower effective testosterone levels will be. What about movement and exercise? impact on our testosterone levels in a significant way, yeah, I mean, I think you know that the more you walk, the more active you are, we've looked at that as well, you know that 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 walking, you know, in reasonable amounts, can make a big difference and I think that, you know, activity is important, it probably helps Dave get over it too. the obesity. a little bit, as well as another mechanism, okay, I'm a Manchester United fan at the moment, we're losing a lot.

I thought you guys had changed things, yeah, I thought that too until last week, okay, so, yes you are, yes you are. supporting a team that is losing your testosterone levels will probably be lower, well I think this is something serious, maybe we could do that experiment, where does that research come from? If your team wins, your testosterone increases. Don't know. I remember that stallion is quite old. I think it even dates back to my training, but I remember reading that. I think it was one of the articles that the newspaper picked up. Okay, of course, why does testosterone matter?

I think testosterone is very important. important for you, you know many things, I think it is important for our quality of life, so energy level, sexual desire, mood, sleep, concentration, all those things are very important, when testosterone lowers a lot, it also has many implications for health, so muscle and bone health. health, heart health, so we want to keep our levels in a normal range, um, because I think so, it kind of helps us with our function and our life, uh, and happiness, how does this affect our type of muscles? and bones? I really do not know.

I understand what testosterone does. I think of it as the chemical that makes you a man. I know women have testosterone too, but I think it's the chemical that makes my beard grow. In my deep voice, yeah, well, that's what he's doing. but it's anabolic, it helps growth, it helps with bone turnover and it kind of maintains bone strength, so men who have very low levels of testosterone know that more fragile bones have higher risks of osteopenia, osteoporosis, so , I know, I think it helps with muscle growth, bone turnover, bone strength, so I think all of those things are important, you usually don't get into those problems unless men are very, very short.

I would say you know, I don't know you, but you know, average testosterone levels are probably 300 to 900. I guess probably on the higher end of that range, but you know, when they're low, probably less than 200 to 100. , that's where we start to worry more about, you know, bone health, muscle health, etc. I think there is some movement, but when you get to a level lower than the normal range, like the 300 range, that's when some men develop, you know some of the symptoms of sex drive problems with a lower energy level, things like that, low testosterone levels. it usually means lower sex drive, uh, it can be one of the common symptoms that we see, that means if I just take a lot of testosterone, my sex drive will go back up, you know, over the last 10 years.

Over the past 20 years, the number of testosterone prescriptions written in the US has increased at almost an exponential rate and because people thought of it as a sort of anti-aging rejuvenation therapy, then there was hope. 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, it may not help him much, even men who have a low testosterone level. as we have spoken. Of these 300 cutoffs, I've had many testosterone patients, let's say 250, so we talked about the risks and benefits of taking testosterone.

We will try them and you know that many men feel better, but not all. with some men I don't feel anything, you know, doctor, I don't feel any different even though he gets his levels, you know, 250 to 500 um, so it's probably not worth taking a medication every day if you don't It's like that. helping you, I'm not worried about his bone health, you know, we'll check some other measures to make sure he's okay, so it's not what you know again when you look at the risks and benefits, it's probably not worth it, but there are certainly some men.

Who sees an improvement? Does testosterone harm some people? Your testosterone treatment actually has an adverse effect if you take it basically when it is not necessary. I mean, even when you need to. I think it could cause problems sometimes. Yes, testosterone certainly has side effects. You know, one of the biggest things I see in my practice is how testosterone affects sperm production. The World Health Organization actually tested it as a contraceptive because it reduces sperm count in most men. I would say now for 90% of men it doesn't work 100%, so it's not as good a contraceptive, but they are working on other ways to modify it, but I have a lot of patients that come in, you know?

Some of them suspect that testosterone is the problem. Some don't know it. I remember one couple in particular, they came together as a couple. You know, we measured his sperm count. It was zero. We started talking about risk factors and he was taking testosterone. Well, the best thing he could do would be to stop the testosterone and because of his work I'm going to tell you what he did, but because of his work he couldn't really stop it, so there are some other medications that we were able to add while he continued. . the testosterone um and then they ended up with triplets um shortly after, so I think you know men need to be aware of that um because that's what you know, certainly one of the big risk factors, at least in men in reproductive age, is this fertility risk, so it may negatively affect my sperm count.

I saw a quote from you that said that if we take a hundred of my infertile patients that I see in clinic, at least five of those men will be infertile because they are on testosterone therapy. Every 20 infertile men are that way because of testosterone when it comes to infertility. One of the things that has always worried me is that if I take testosterone my hair will fall out. If thatit can definitely happen. You know, breast hair loss. Acne growth, all of them can occur. I would say that they are things that we can control. One thing I always tell men is that we're not trying to get them to the next level, we're just trying to get them back to normal.

I think if we monitor it closely, most men will do well again. There are other therapies we can do for men who have side effects. You know, because of those things it can also affect the thickness of the blood, something called hematocrit. Counting the number of red blood cells in the body can increase that number, so if it increases too much it can be a problem, so that's another number we follow. There used to be a concern about higher rates of heart attacks and strokes with testosterone. So, there were some studies done, you know, 10 years ago, five or 10 years ago, that suggested that, but a really large trial just came out, with about 5,200 men, half of them randomly assigned to testosterone, the other half didn't and there was actually no difference in cardiovascular disease risk, so I think that's something we can probably leave out.

The other thing that worries men is the increased risk of prostate problems. Prostate cancer. Prostate growth. And you know, that same trial also showed that, from a prostate point of view, probably not. There is also a lot of risk. Are there many men who come to you to talk to you about hair loss and bolding? Some men do it. I think one of the ways men talk to me about this is one of the most common medications for it, finasteride. right or you know it's sold under the brand name propa um and so they want to understand some of the risks of that and to know when that drug was approved for hair loss, they know again because the people who are going to take it usually are of reproductive age they did randomized placebo control trials to look at semen quality and it turns out it didn't have a significant impact on things, maybe it went down a little bit, but not a lot, but in sort of a later analysis, you know , from some of This and now, seeing that many patients come in, we see men who take finasteride, some of them are more susceptible, so one of the interesting things about the trials is that there are inclusion and exclusion criteria, not all can participate.

So if men had sperm counts that were too low, they were not invited to participate in these trials. So for men who 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 on aash besides reproductive health is sexual health which I deal with a lot and there is also concern that finasteride also affects sexual function in men so you know we have these discussions. I've had some men who come in after they've been on finasterid and you know different issues related to sex drive, low libido, or rectal dysfunction, and then we work through an algorithm to try to improve that as well.

This is one of the things that I think about a lot because I don't want to, I don't want to have a receding hairline and I don't want to have air surgery or anything like that, but when I hear about some of these testosterone replacement therapies and things like that, my big concern is that if I take testosterone maybe not now because I probably don't need it now, but maybe when I'm a little older, which is when I guess you would start taking it, maybe when you're in your 50s. average, but there are younger men who also take it, for what reason, simply because they have few symptoms.

That has made them take it well. I think, you know, with all things there is a bell-shaped curve, so some Men are a little shorter, some have genetic conditions, you know, there are some more nefarious testosterone prescribers, so even though men have a normal level, they are offered testosterone to enter these types of testosterone clinics and some men you know, if you look at the data, maybe 10 to 20% of the high school athletes you know have experimented with testosterone and if you stay on it too long it can really shut down your own axis, so, if you take exogenous testosterone , like testosterone injections or gels, your body stops producing it and the longer you take it, the less likely it is that your body can restart and so on for the rest.

Some of these men, you know bad decisions or whatever, they've been taking testosterone for a while and they can never stop. I don't know if you've ever had any experience with that because I know you focus predominantly on men. Cheers, but I've had a long conversation about birth control pills with my partner because she was taking, she said this publicly before she was on a birth control pill for a long time and then, everyone's relationship with contraception is different, but after After taking it for seven or eight years she stopped and her period didn't come, so she really struggled with that for a while before and that made me really know that it illuminated the fact that when we start to alter the chemical balances of our body using pills and injections and other things that we could cause quite long term or permanent damage to ourselves and there's no real thing like a free lunch 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 pill approved now, it would be a very different process and it's unlikely to be successful for those types of reasons if I have low testosterone and I come to see what the typical way is. of getting testosterone replacement therapy it's a pill it's an injection that I have to take um I know it's quadrupled based on data in the US from two since the 2000s which is amazing but how do they take Testosterone people so there are so many different ways it can be taken.

I think one thing you know again is we talked about all the risks so fertility is certainly important so if you get to 30 you know I would ask you about your reproductive intent so if you have low testosterone and you are interested in having four children. I wouldn't start you on testosterone directly. There are some off-label things, you know, medications that we repurpose to help increase your body's testosterone, um, that we would start with. but assuming let's say you're 60 years old and you're not interested in fertility, then you know there are gels or patches that you put on every day, testosterone gel or patch, because that can work well, probably 10 to 20%. of men do not.

It doesn't absorb testosterone as well through the skin, the other thing to keep in mind is that there is a risk of transfer, such as from your partner, to anyone who touches your skin, so if you have small children, be aware but as long as you know you put it on, you let it dry, you put clothes on it, it's not a big risk, you know again, and you have to be careful with your clothes too, so you know, gel patches are one , there are injections, uh. what you can do generally every one to three weeks on average there are testost granules um so these are granules that have testosterone and they are slow release so they are simply injected uh we implant them under the skin usually in the hip and those last probably 3 to six months, there are longer-acting injections, which is why they are very common in Europe.

They are gaining traction in the US, but they are injections that last probably 10 weeks or so and then there is a new oral therapy. There is an oral form of testosterone that is also available. I was quite confused with this topic of hair loss on testosterone because I couldn't determine if low testosterone is causing me to bold and have a receding hairline or if it is high testosterone that is causing it. bold and having a receding hairline or if it's both, I mean, it could be both. I think we generally think of it as higher levels, okay, it's funny because I've asked myself before if I'm exercising too much.

I suppose increasing my testosterone levels will accelerate my receding boldness. Airline, anything that's good for your heart should be good for your hair, so I'd exercise. I think that's good, but what if I'm doing like Iron Mans and the Thousand Mile races? all that kind of stuff you see in certain groups, so I don't know. I think it is possible to do OV exercise. I don't know if it will affect the hairline, but you know, testosterone levels can affect it. Testosterone levels. I think it's when you exercise to the point of exhaustion. You know, we also see decreases in sperm count, so hormone levels can certainly be affective.

What? My cortisol goes up, so does my testosterone. I guess it can go down, sometimes it's interesting what happens to penis size? I heard you did some pretty landmark research suggesting that the length of a man's penis is increasing decade after decade in terms of men being born and boys being born. through puberty, yeah, this study also got a lot of attention, so, you know, it's similar to how we've tracked testosterone levels over time or sperm counts over time, you know, For different reasons, researchers have measured the length of the sentence, you know what should be given. normative data in different populations to understand how different surgeries or conditions can affect penal duration, so you know, we looked at all the studies and there were dozens, so we put all of that together, it was tens of thousands of men. and we just look at sort of an average stack length over time and 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 penises are measured is to stretch the penis and use a tape measure, some kind of ruler measuring device, so if there's more intestine, you know there's more fat, in theory the length should be a little bit shorter now than it used to be um but it turns out that at least when you measure rec penis length, penises are now longer than they used to be, and over the last 30 years they've probably grown by about 25% , so I want to say that it is a good question.

I think one hypothesis we had looking at different types of endocrine abnormalities, you know, 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. long, so if they are changing puberty again through these different environmental exposures perhaps that is leading to changes in overall development and this may be one of the consequences of that. Does this have any Upstream-like implications for sex? I think, well, the numbers we're talking about. about shouldn't be um you know enough to make a big difference um you know the people when this study came out what we talked about you know very enterprising patients who reach out sending emails some people hypothesize that this was kind of natural selection So, it's hard to know, but again, it's a very short period of time, so it's hard to believe that you know that's at play.

You have a lot of people who come to your practice with erectile dysfunction, yeah, so that's another one. A very common condition, we see it if you look at men over 40 years old, more than half have problems with erections, so it is very common that hundreds of millions of men around the world are affected, we don't talk about this much . What is it? What is causing this and are you seeing it increase over time? The prevalence of erectile dysfunction. I mean, I think the rates are increasing and I think you know the risk factors that 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, a minority of these conditions can be caused by low testosterone, sometimes, the results of you know, surgical treatment for pelvic cancer as well , but in general it is vascular, it is just a blood flow. problem because I used to think it was more of a hormonal or psychological issue, like sexual anxiety or some kind of change in our testosterone levels that is causing us difficulty getting erections, now you're saying it's about that, I think you know that before it was thought that the psychogenic, as you say, used to be considered the type of primary ideology, um and maybe for some populations that you know it might be a little more common, but generally for the majority. men, kind of like crummers, it's going to be a blood flow problem, a vascular organic cause and how would erectile dysfunction be treated, um, so there's a lot of things we can do, we want you to know, reverse anything we can.

Understand where theLet's have our prostate checked and what symptoms we should look for from a urinary point of view. I think if urinating bothers you you should talk to your primary care doctor or your urologist, you know if you're waking up. at night, if you feel like you have to urinate too often, if it hurts to urinate, things like that, um, such and such, sometimes it's due to an enlarged prostate, prostate problems, it could also be due to a tight pelvic floor and, from a cancer standpoint, we generally do. check blood tests called prostate specific antigen PSA and you know there are different screening guidelines that usually start, you know, in men in their 50s or so, and testing is done every year or two until a man turns 70, you know some of the guidelines. o Some of the screening patterns will vary depending on family history, which is a very strong predictor of cancer risk.

Is there anything I can do or is there any research that will give me advice on how to treat my body in such a way that I can reduce my risk? prostate cancer risk, you know, we talked about some of these, you know, erectile dysfunction risks, like obesity, diabetes, I think those same things can also pose a risk, um, in a lot of these prostate cancer conditions. prostate too, so a good diet, exercise, maintaining a good body weight. I think all of that is important, avoid drinking water before going to bed, that will help you sometimes wake up at night, so for some men who are more bothered by it, you know what is 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 fluids after 7 p.m. or six p.m., so that you're more likely to be able to sleep through the night, you know, wake up once. at night it's not that unusual, but if it becomes a little more frequent, you know, that's a strategy that some men use, so reducing my water consumption at night won't reduce my chances of getting prostate cancer. about spicy foods, so I think similarly it may also affect some of the symptoms, it shouldn't affect the prostate symptoms.

Oh okay, are there any studies that show ways we can reduce prostate risk? Not just the kind of health and what kind of lifestyle related things, is there anything related? I don't know other parts of our lifestyle, like our use of technology or alcohol consumption or anything else that I don't know about. I think you already know. Asian mineral, uh, the defoliant that was used during the Vietnam War and was found to be a risk factor for prostate cancer, so I don't know why you would try and try to avoid Ancient Orange, but otherwise There are not many modifiable ones. risk factors other than those we talked about.

I think you know that the risk of cancer increases with obesity. It's thought to be due to different things, but maybe inflammation and things like that, so I think living a healthy life I hope that's the case. keep you on a healthy trajectory. I'm the first person to lean on new tools to support my productivity but also to save me time and that's been a real win for both me and my team at nordvpn, who I'm happy to say I'm a sponsor of this podcast. I don't think many people know how useful having nordvpn can be for you, both for your business and your personal needs.

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Try it yourself by visiting nordvpn.com doac. What are the most important things we haven't talked about that patients who come to your clinic can talk to you about? It's related to reproductive health, you know, hormones, everything else, well, another condition that I see a lot in men is something called pony disease, which is a curvature of the penis, so you know, the way worth working for erections is that everything swells, you know there's kind of This kind of layers of tough tissue in the penis that trap blood inside and sometimes scar tissue can form in those layers.

For different reasons, it is believed that perhaps a microtrauma, some men remember a type of traumatic sexual episode that leads to injury and scar formation. You can imagine that if there is scar tissue there, everything is not going to expand evenly so that you can get a deviation in curvature, so some of these men have 90 degree curves in their penis and so you know if it goes up or down, it can make sex quite challenging, um, and that's another condition that we see. I think it's important for men to know that. I think again it is similar to erectile dysfunction.

I think you know, men are a little reticent sometimes. I don't want to talk about some of these conditions, but it's pretty common, probably 5-10% of men are affected and there are effective treatments for this as well, so I think just as kind of a public service announcement, yeah men suffer from this again talk to your doctor because there are treatments that we can offer okay so let's conclude so if I want to make sure that my sperm count stays very very high then I can have those four children and I want making sure my testosterone levels stay at a healthy balance, let's say, it's 4,500, it's G milligrams, yeah, nanograms per deciliter, okay, nanograms per deciliter.

I want to keep it that way. healthy range and I want Rock our instructions to be good so I can have the four kids I mentioned mhm, what's one piece of advice you would give that is broadly applicable to everyone without you having to do my blood work and everything? those things and this is really a conclusive point. The first one I heard is about lifestyle and dietary choices. Is there anything I definitely shouldn't eat if I'm trying to get back to being optimal in these three areas? People have looked at different types of diets that can affect health and reproductive health.

You know more specifically, so I think in general, healthy foods are a good idea. I know like you know processed foods, fast food, things like that, foods that are high in fat and high in calories, those and you know some of them, and the packaging also contains some of these same types of chemicals that we talked about. before, so I think I'll try it. to avoid some of those, I think it's a good idea, yeah, sugar, um, sugar is okay, okay, um, unless you go back to eating high-calorie foods or things that you can try to avoid, um, yeah you have a medical condition, you know, I think trying to get treated I know sometimes men worry because you know if you're taking a pill for something it can affect your fertility, but you know, I think generally being healthy, anything. if it's good for your heart it's going to be good for your fertility so I think it's a good idea to get treatment you know there's a study out of Japan that I always cite about this so this was a study that looked at all the patients They came in with male infertility and tried to find out who they helped correctly and so they wanted to see if they could predict who was likely to benefit from a urological consultation and who was not, so they looked at the initial sperm count which did not predict who would benefit.

The initial testosterone level was not the age. Some men had this condition called verical which has dilated veins in the scrotum, so about 15% of all men have them. Infertile men maybe around 40% have them, so you know the testicles are outside the body like we mentioned and they are bigger. Veins disrupt normal temperature regulation, so if you fix them, it turns out that most of those men will improve their sperm count, but the other really interesting finding is that they also found that men who had a treated comorbidity had improvements, so the data provided that men had high blood pressure, if they got it under control their sperm counts increased by about 25%, so a lot of times the first time men visit the doctor, men don't go much to the doctor, right?

Unless there's a problem, unless they have pain or some other condition that you know of, then sometimes my patients, the first time I see someone, they see me to try to have a baby, so it's an opportunity for you. make them take a little more ownership of their health, you know if they've never had their blood pressure checked, check their blood sugar, cholesterol, all those things, you know ways to improve their health u opportunities to improve reproductive health, but know about health in general. Also, I think that's another thing to consider about depression, then our mental health and the role that that will play in our fertility is erectile performance and all those things, is there a correlation?

There is a strong correlation, yes, so I think. We see a strong correlation between erectile dysfunction and depression. If you look at men with erectile dysfunction, I think up to 20% may have some type of depression. And sometimes we worry that some of the treatments might work too. exacerbate sexual dysfunction, but I think trying to get men on a better path is important. I think it's also important to work with yourself again with a therapist, you know, so that you can attack these things from multiple, you know, multiple angles, you know, in general. You know that some of these medications probably haven't been tested in terms of reproductive health.

There are some studies that say some of these can affect semen quality, but I think those studies are limited, so I think generally you know if men are taking these medications. We're not sure and I think it's helping them. You know, we try and you kind of keep going and persevere because I want them to get the benefit of some of these therapies. What about childhood trauma and the role you should play? I see it showing up in your practice, yeah, I mean, I think it can certainly affect sexual health. You know it quite deeply. I think you know when you suspect that you know this kind of psychogenic component.

I think you know we try and do it again. He's very optimistic about the options that are available, but work with the therapist, work with a sex therapist to come up with a good strategy and plan to get you to meet men through some of these issues. so they can let you know a full sexual life. Anything else I need to do to improve these things. Highlights about the TR lifestyle. You know, we've talked about diet, exercise and also a way to at least improve our testosterone levels, yeah, sleep, I guess that could be important, sleep is also important, sleep is interesting because it's what's called an association.

U-shaped, so it's possible to oversleep, so you know you probably want an ideal amount, probably seven to nine. Hours are generally associated with better quality of sailors for men who have fewer sailors. The quality tends to be a little lower for men who sleep too much. You know, men who know they can 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 is certainly important. There have also been studies looking at weight loss. You know, I think it's obviously easy. say lose weight um but it's not always easy to do um but there's a good study that came out a few years ago where men were randomly assigned to a weight loss program on a very low calorie diet 800 calories a day um for a few weeks and then lost weight and then followed them for the rest of the year, and this is important because the men who were able to maintain the weight were able to maintain the benefits of their sperm count compared to the men who did you know who gave up the exercise routine ?

They ended up gaining weight and then their sperm counts decreased again. One of these arms actually also had one of these glp1 analogues, so even the men who in those that help them maintain their weight loss, were also able to maintain their sperm count, which is why patients ask a lot about that. . You know, I was just going to ask about, obviously, how the zexs exploded and there's a lot of other ways tothis type of LPG1 um. type of injections to lose fat. I was wondering if that would have any consequences on fertility, so again, there's only one study that looked at it and it seemed to show benefits, so it doesn't cause any harm as long as you maintain weight loss with it. you know, you seem to see an improvement, you know, in contrast, you know, some men also ask about bariatric surgery, which you know again may be going down a little bit now with these, you know, very effective medications, but interestingly enough for the bariatric surgeon like gastric bypass.

I don't know if this is popular in Europe or the UK, but for some obese people, there are surgeries that can be done to help redirect intestinal absorption, so they can lose weight. There's also something I thought you wanted to say. The gastric band thing, there are also gastric bands, yes, so there are different ways that it has been done and therefore, with all of those, um, it actually tends to decrease the sperm, paradoxically, so one would think that if he lost weight, his sperm count would improve, but it turns out. After these surgeries, the sperm counts actually went down in some of them, some men went from a reasonable sperm count to zero, so the idea was you know what?

It's the trauma of surgery, potentially, you know, um, you know some vitamins and minerals are important too. So, you know, without that normal absorption that happens in the intestines, which could also lead to infertility, you know, that was kind of a concern and we were wondering if the same thing would happen with these newer medications, but it doesn't seem like it. Like, again the glp1 analog seems to be a safe way to lose weight, at least when we look at semen quality as a result. What about supplementation? Are there any supplements one can recommend? I guess it's hard for you to recommend supplements, but is it possible?

There are some types of vitamins or minerals that are typically deficient in people who have infertility issues, so I think there is some data that antioxidants can improve fertility, so it's a very broad group of things that have been tested, berries and stuff. like, yeah, dark berries, yeah, those certainly can have a lot of them, but you know, I usually tell patients to take a multivitamin, they make special blends for male fertility, like if you look for them on the Internet or on Amazon or others platforms. Special fertility mixes that some of them have. Knows? He looked at the data and tried to choose specific supplements that are believed to be most beneficial.

Coenzyme Q um is a powerful antioxidant that has shown some benefit to fertility, so I think. that's something else that you try and empower patients and they can do that too and that can help protein play a role in fertility or testosterone. I think you already know, it's part of a balanced meal, part of a kind of balanced diet. I think it's important what your mission is from here on out, what are you going to do for the next 10 years, if you had to guess what you're going to do, is it going to be more of the same or are you going to be interested in change? um, focus a little or are you just going to continue researching these topics, what is your big mission of the decade?

Yeah, I mean, this really gets me up in the morning and these are the things I like to do late at night. I also want to say that I'm really passionate about trying to understand, you know, why we see this link between fertility and health, why sperm counts are declining, because I think the more we understand about it, we'll be able to know, hopefully, mitigate some of these risks. I hope you find out through information channels and platforms like this. Hopefully you'll get more community members involved in trying to find some therapies you know for male fertility.

I think you know we talked about some of the things that can be done, but in the United States there is the Food and Drug Administration that oversees everything that you know about therapies and there is no FD approved therapy for male fertility, which is really a shame, especially because, again, we have this data that it's becoming more common. existential right prevalent as a species, so it would be nice if there were any, so trying to get more participation from the scientific community of the pharmaceutical community, trying to see that opportunity, because I think it will be very important for because you know, for our fields, but again you know, I think you said more of the same in some respects, but I think trying to understand some of these questions in a lot more detail so that we can really know how to help these men is Of all the topics that we've discussed today, is there a particular part that concerns you the most?

I think you know that when we talk about declining sperm count, I'm concerned that it's a barometer of health and therefore it may be that I mean, in addition to men's reproductive health, our overall health is declining. When we look at parents' health over time, we've seen that parents are getting a little older. You know we talked about that, but. You know with that comes more comorbidities, higher rates of hypertension, hyperlipidemia, you know other things and that can sometimes have a kind of transgenerational impact, like a parent who has high blood pressure or you know is obese, that child is at risk. slightly older than I have other problems later on, so I'm trying to understand that again, if maybe there are opportunities to try to figure out what's in that sperm that's a little bit different, maybe we can turn that switch off to try and you know, avoid that .

I think those are all the things I have. I don't want to be alarmist about this, all of these risks are very, very low, but I think there's a lot of opportunity, you know, I think one of the reasons I got into this I think is because male reproductive health was so open. , so I think there are still many opportunities to try to improve it. What would you say to a man who is listening to this and who is struggling with any of the things we have discussed? What is your final message to them? Well, I think he would.

Just try to be optimistic and have hope. I think there is a lot we can do. I think you know it takes a lot of bravery to go see the doctors about some of these things and some of them you know different problems, but you know it's what we're used to dealing with and I think there are a lot of options available. , so I would encourage you to talk to friends, but you know men talk to their primary care doctor. your urologist come see the urologist. You have a very broad platform, so I think if there is a couple with difficulties, they have only seen gynecologists.

I would encourage them to maybe look at you as a male reproduction specialist as well to try to get other perspectives. We have a closed tradition. in this podcast where the last guest leaves a question for the next one without knowing who they leave it to because the question they left you is complicated is what would you do to change the world I guess one thing that What I would do to change the world . I guess certainly what was appropriate about our conversation was that it would make it try to formulate policies to have all governments pay for infertility services so that this would be a universal benefit for all of humanity.

I think that will certainly help open the doors to a lot of people who don't have the resources for it and who are a little hesitant to use it and hopefully that will solve again some of the problems that we talked about from a demographic standpoint, what Would you do that for humanity? 'Having more children, I guess we would potentially be happier in our relationships, I mean, yeah, I think I could do all that, I think you know, I guess from the father's point of view, having a child again increases longevity, um, it decreases cardiovascular risk, um. increasing from a sort of social perspective, you know, getting to that replacement level, maintaining the population, I think that's again existential for a society, increasing the tax base and all the other things associated with that and the workforce, it's very difficult. in politics now certainly in the United States, there are many of you who know ISS issues that are happening, but you know that making policies that really affect everyone, I think that would be very profound and I think there will be a lot of benefits to that, Dr.

Michael Eisenberg, thank you very much for your time and thank you for the work that you are doing because you know that ultimately you are helping to create families and also to alleviate a lot of the stress, anxiety, worries and concerns that people have about your reproductive health and I think it's an incredible service to humanity to do that and especially at a time when we feel like it's more necessary than ever and, frankly, the direction of travel is not the same. Great, because it relates to some of these big topics, like testosterone and fertility, but it's very important for you, people like you, who have the information that are doing the new research, to not just keep it in the lab and Not only. keep it in Pub Med, where it's very difficult for people like me to access it because we can't read PubMed, so thank you for making the decision that you don't have to make to come out and talk about these topics. in a way that's really accessible and inspiring and empowering for people because I think that's going to do a lot of good so thank you thank you it's my pleasure how many of you started thinking about your long term health when you got to 30 for me.

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