Michael Eisenberg: The Fertility Expert: Delaying Having Kids Is Impacting Your Future Children & Reducing Your Chances Of Parenthood By 90%! Masturbation Reduces Cancer Risk!
Guests: Michael Eisenberg
Full transcript · Read the full conversation in order, with its original context.
§01Transcript — part 1
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 and 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. There's a lot of really interesting questions that need to be answered. OK, let's get into that. Is there any evidence that the chemicals in our environment are impacting our sperm count and our 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 manufacture of plastic. And that could have pretty devastating effects.
And so don't drink out of plastic water bottles. What about hair loss? I couldn't figure out if low testosterone or high testosterone causes a receding hairline. Most men are not going to like this, but it turns out that... If I'm sat down all day, is that going to have an impact on my sperm count? 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 erections. But as long as you have a penis, we can always make it hard. For example, we can teach men to give themselves... Oh, I just got a shiver down my body. But it probably works 80% and 90% of the time. Dr. Michael Eisenberg, why do you do what you do and what you do? It's a pleasure to be here, certainly an honor.
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 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 in the department of urology. I have a joint appointment in the department of obstetrics 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 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, is it sort of name applies would be, you know, trying to have a baby. 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. 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 trouble 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 with infertility. Infertile men actually have lower testosterone levels than fertile men. So, you know... There's also been studies show that no 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 trajectory. You know, another, I think, very sort of important aspect of reproduction. And there's other kind of what I call sort of social factors that are sort of at play. You know, things that kind of necessarily go with reproduction. So like having a partner. And having kids, hopefully. And it turns out that those factors actually are very important for health and longevity.
So like having a partner actually increases survival. So if you like compare sort of if you have like 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 they're both of those things are absent, that man has a threefold 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 intrinsic things that we do like lifestyle behavior, obesity, smoking. Those are all very important for health as well. 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. Right. 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 in 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, 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 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 sort of 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 in the 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, you know, very interesting.
And I think, you know, there is a lot of momentum towards this. You know, there've been a lot of landmark studies suggesting, like you say, declines in testosterone over time, declines in sperm count over time. And we can certainly talk about that a little bit more. And I think with that, you know, 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 births in the in the US were conceived with IVF.
Now it's about two percent 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, in my particular area in Northern California, you know, it seems like every year a new IVF clinic is opening up and you're always worried and wondering how could there be enough businesses supported.
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 fertility declining or more couples becoming reliant on IVF? And I think, you know, again, our sperm counts declining. I think all those things are probably kind of going together that's leading to this.
And I think it's, you know, it's something that we're doing to ourselves potentially. Is there some environmental exposure? I think all these things are, you know, really interesting questions 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 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 rising parental age, you know, There's been sort of less data, I think, on male age over time, at least here in the United States. But, 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. It used to be like in the 70s, you know, the an older father and that would be considered over 40 was maybe about four percent of births now it's probably nine ten percent of births so i think there's just a more delay and with that um you know infertility gets higher there's usually a close correlation between you know mother's age and a father's age and so I think a lot of people are sort of familiar as women get older, fertility goes down, probably at a steeper rate.
But for men, the same thing happens. Sperm counts get a little lower. Testosterone gets a little lower. It takes a little longer to conceive. The chance of problems with the child also can increase. I mean, the oldest father ever is 96. So the biologic potential does persist. 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 in terms of fertility? So I think, you know, if you're, I guess you're looking from an evolutionary standpoint, you know, peak fertility would 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, the cycle 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 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, 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. 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, i.e. the oldest ever woman to conceive a child? So with using like a donor egg, I think it's 60s or 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 assume that fertility is going to be an increasing problem for society. Yeah. 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, 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 solution is not obvious, right? Because asking couples to delay careers, education, all that is very challenging. You know, I think some countries have tried 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.
Childcare also becomes, you know, very important. But even with those, I think that 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, so kind of important for the health of a society, right? There's this concept called replacement rate. That's the number of children that need to be born to a reproductive age woman 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 woman for a population level to stay the same. So if in some societies it's lower, like in the U.S. it's a little lower than that. In some Asian countries like Korea and Japan, it's lower than that. And that's really existential because if your working population starts to decline, tax base, everything 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 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 top-down approach towards getting us to get back to having babies to stop the population collapse and decline that you talked about. 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 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 four kids, you never have to pay income tax again, which I thought was 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 realized that, you know, society really relies on, you know, maintaining numbers. And when, you know, when the population starts to slip, it could be a problem. I mean, I think that's a very clever solution. Sperm quality. Sperm quality. The sperm quality I read is declining. Yeah, so that's a very, it's interesting because that's such a controversial statement. 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. It was a sperm bank that was in the northeastern U.S. at a few locations. Yeah. And it wasn't a lot of data. It was just sort of a few years of data, about like a little over maybe 10, 15 years. But what we found is that actually if you looked at men that were coming in to try and be donors, because at these banks, they're very selective.
So you have to have excellent sperm that freezes well, that thaws well, really high numbers. And they also look at your pedigree a little, make sure there aren't conditions that 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 a better donor. 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, you know, the movement, shape, all these sort of parameters that we look at when we're talking about a semen 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 are 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, 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, very interesting. And so, you know, other investigators have used studies like that, kind of pooled them all together using kind of advanced statistical techniques and found this decline over time, you know, over the last maybe 20, 30, 40, 50 years.
Yeah. So there is a preponderance of data that supports that. So the counter argument that others have made is that, you know, over that same period of time, some of our techniques have changed, right? We're better counting sperm now than we used to be. You know, some of the different, 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 thing that these studies have done is when they pull together data, they assume that 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 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 in New York, I think California was next, and the Midwest was a lot lower. So, you know, again, why you think that right in 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 semen 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 five years, 10 years over time. And you'd see what changed, you know, And those studies aren't available. So that's sort of the criticism of these studies. But again, if you just look at all the data, if you compare studies from the 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, you know, we've talked about this is sort of an 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, 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 in terms of walking around, you know, sedentary behavior. People have, you know, hypothesized different chemicals in the environment are kind of leaching 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 studies that do support that. There are certainly preclinical studies where you can actually dose rats and mice these.
There's also human studies where you can compare sperm quality to different sort of chemical traces in the blood and see these correlations as well. And then there's a study called NHANES, which is a study by our Centers for Disease Control where Every year, men and women are sort of surveyed. They collect data on obesity, blood pressure, things like that. 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 based on that data. This is kind of a rigorously sort of researched, you know, group of individuals that'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 there is this correlation that if you have higher exposure to some of these chemicals, there's higher risk of lower hormone levels. What are those chemicals and where do we find them? Because I spoke to someone who was a urologist recently, I think from NYU. Yeah. 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.
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, phthalates. What is a phthalate? A phthalate is it's a chemical that's in a lot of like, you know, different like creams and lotions that we use. 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, uh, chemical that's used in the manufacture of plastic.
And that's also been found to have these endocrine disrupting properties. Um, so that's also been correlated with semen quality. Endocrine disrupting. Endocrine disrupting. What does that mean? Endocrine. 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 my deeper voice.
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, it can affect, you know, normal development of, you know, boys or girls, you know, maybe, you know, again, affects 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've got three kids. So you have an opportunity to kind of influence them at an earlier stage than most of us can influence ourselves.
But Yeah, so one thing that we do is I've thrown away all plastic water bottles. I'd say I still use it because I find them very convenient and I'm done with reproduction. But certainly for the kids, I make sure they don't drink out of plastic water bottles. So we have either glass or metal. I do think there's data that that's a very large exposure that kids get. And I think it's fairly easy now to remove that. What does the data say about plastic bottles?
You know, if you look at, you know, exposures from that, you know, they have, they just leach 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 plastic bottle industry to come after us. But that's a common way for individuals to get exposed to it. So I think if, again, if we're seeing that's one of the main touch points for plastics is usually through our kind of food and water supply, then I think it's easy to get rid of it if you can.
Is there anything else? I've read recently that heat has a role in our sperm quality. So if we're going into saunas or something, or if we're spending a lot of time 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, again, 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. So when I talk to patients in clinic, for example, we do talk about sauna use, hot tub use. Some men bathe every day, like in a bath. And those all can impact sperm production. There have been studies to show that men that use saunas on a regular basis, they have lower sperm counts. And then when you withdraw that exposure, sperm counts will go back to normal. One 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. which actually turned out did reduce sperm counts to zero, I think. And again, the few men that volunteered to do that. But you can imagine... I think most men are not going to be too excited about that because it's probably pretty uncomfortable. 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 telling me that they just got over a COVID infection where they had high fevers for a few weeks. And then their sperm counts would be very low. And then 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. It was like 41 year old guy. He had normal sperm count and then all of a sudden he measured and his sperm count had gone to zero and it turns out he had a flu.
with fevers about 102 degrees Fahrenheit the week before. And again, we let kind of sort of nature take its course. He recovered, and then his sperm counts came back to baseline. So we do see that as well. With that belt that you mentioned that holds the sort of testicles closer to the body, I'm guessing it's doing that to heat them up, basically, which reduces the sperm count. Mm-hmm. obviously then one would think about their boxer shorts. We're all wearing very tight boxer shorts these days.
That's like in vogue or whatever. So is there any studies to suggest that boxer shorts can reduce sperm count if they're tight? So that's like a very common, 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's comfortable. I think it's unlikely that any single layer is gonna 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 link between fertility and our use of technology, specifically having these devices in our pockets close to our genitals? That's another common question that I get. And that is certainly something that's changed right now versus, you know, 20, 30 years ago. So there were some studies that 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 may have more stress in their life and other things that could affect semen quality. So there was a clever study that was done where they actually took ejaculate. So it took sperm, put it in a cup and put a cell phone next to it. and tried to measure changes in the quality of the sperm.
And they actually did find some. They found higher rates of DNA damage within the sperm that was exposed to the phone versus not. Kind of trying to control for temperature, which we 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 seemed to affect, you know, the DNA damage in sperm. It wasn't, you know, it was a statistically significant, you know, difference.
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. And I think that... And, 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 as a, you know, maybe a theoretical risk. But again, there's not a lot of concrete data. So I think that, you know, again, 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.
§02Transcript — part 2
I think that's, 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. To be fair, I... She's not someone that's going to read PubMed and read about the studies, but it's just a feeling she has. 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, connect it to the Wi-Fi, the Bluetooth, and see how the sperm get on.
I didn't realize there was a study associated 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. where they had sperm put it next to a laptop. And they controlled for temperature 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. But also, you know, laptops can get warm too, right?
Some of the batteries, some of the moving parts within 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, 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'm in sort of sub-Saharan Africa, I'm assuming my sperm count will be pretty low because I'm going to be sweating all day.
So I think that 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. But if you compare, again, we talked about California, New York, the Midwest, and the United States. But people have also compared 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, 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 sperm quality does vary based on 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 goes up a little bit, but the other thing is that, you know, we don't spend, uh, 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 cooler months you're, you know, kind of bundled up inside and during the warmer months you're maybe in, you know, cool air conditioning. Did you say that Denmark has had a problem with sperm count? Yes. Yeah. So, um, yeah. You know, in the United States, I said that about 2% of births are conceived with IVF. In Denmark, it's about 10%. Wow. And it's actually, again, they have really a crisis of reproduction there.
So they've really done some really good research on semen quality. And it's estimated that only about 25% of Danish men have normal semen quality. Have they figured out why? That's what they're looking into. 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 or, again, pubertal boys or, you know, adults as well. So they are trying to figure it out.
But it is, you know, it's also one of the countries where the fertility rate 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 one would assume that it's some kind of environmental 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 kind of persisted 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? And or 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. And there are associations like drivers, taxi drivers, truck drivers. They certainly can have changes in sperm count, probably due to heat.
Again, I think it could be a combination of sort of sitting all day is also, from probably other health standpoints is not great. And cycling too. People have looked at sort of peak athlete cyclists and there are differences in semen quality. 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 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. Yeah. What about men with big thighs? Yeah. Well, I think 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.
And so heat is certainly one of 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 testosterone. And some of that's also affected by obesity as well.
So it's probably a combination, but that is something 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 know, there's different sort of strategies they can use to try and allow more circulation in the area. Is there a link between 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.
And some people think that no amount of alcohol is safe. But if you look at these studies, looking at maybe a drink or two a day, it probably doesn't correlate too strongly with semen quality. But it seems like there are some studies that say that when men get to three a day, so maybe 20 a week, there can be lower quality in semen. And there was also another study that we did looking at, you know, to see if some men are more susceptible to alcohol intake.
So there are some East Asian men and women that have a mutation in one of the enzymes that's used to metabolize alcohol. And so they accumulate what's called acetaldehyde, 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... We hypothesize that when you have this large load of this chemical in your body that leads to flushing, headache, dizziness, maybe it also affects semen quality.
And it turns out that it does. So for these men that have this mutation, 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. It's probably in some populations up to 50%, like in Taiwan. It's very common in Japan. men with Chinese and 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 aldehyde dehydrogenase too.
So, you know, for those men, I think that it's probably better to, you know, avoid alcohol or just to sort of be aware because it can affect semen quality. If I came into your clinic and I said, Dr. Michael, 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's the list of things? Because this is basically where I am in my life now. I'm 31 years old. I want to have a kid.
I 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. Yeah. And she's 31. So we've got, you know, we want to have these kids before 40, ideally. So I kind of 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 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 tax incentive? Or? Yeah, we are planning to move to Hungary. So it's really about tax avoidance. It's not that I want kids. 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 as well. I think we've chatted and 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, you know, to 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. 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 that. If there's any medications you're on, there can be medications that affect it.
And then we'll do an exam. So we don't have to do that here in front of the cameras. I'm down. I do. Yeah, I do have a California medical license. So, you know, we want to make sure we look at the size 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 semen 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. 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, you know, those four kids.
But, you know, again, if you're kind of thinking about four, 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 the man is okay. And I think if you, when I looked at the data, 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 the 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'd 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 Yeah, so again, study from this NHANES, this CDC, you know, measuring men every year for the last several decades. If, you know, there's data that shows that testosterone levels have gone down over time. You know, people have also looked at, you know, other cohorts of men, you know, from the 2000s and 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 four-year-old now versus, you know, 10 years ago, 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, adipose 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, you know, activity is important. It probably also helps stave 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 had turned it around. Yeah, I thought so too, until last week. Okay, so if you're supporting a team that is losing, your testosterone levels are 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 research come from, that if your team wins, your testosterone increases? I don't remember. That study is pretty old. I think that even predated my 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 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. 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 because I think it kind of helps us with our function and our life and happiness. How does it impact our sort of muscles and bones? I don't really understand what testosterone is doing.
I kind of think of it as the chemical that kind of makes you a man. I know women have testosterone too, but I just think of it as the chemical that makes my beard grow and 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 and kind of keeps sort of, 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, you know, I think it helps with muscle growth, bone turnover, bone strength. So I think all those things are important. They usually don't get into those problems unless men are very, very low. I don't know you, but, you know, the average testosterone levels are probably 300 to 900. I would guess probably on the higher end of that. But, you know, when men are low, probably less than 200, 100, that's where you 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 levels, sex drive problems, things like that. So low testosterone typically means lower sex drive? It can. 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 in the U.S. have kind of gone up almost at an exponential rate. And because people did think of it sort of as a... 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, 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 point. So I've had plenty of patients testosterone of 250, let's say. So we talk about risks and benefits of being on testosterone. We'll try them on it. And, you know, a lot of men do feel better, but not everybody. Some men say, I don't feel any, you know, doc, I don't feel any different, even though we get his levels, you know, from 250 to 500. 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. So then it's not, you know, again, when you look at risks and benefits, it's probably not worth it. But there are certainly some men who do see improvement. So is testosterone hurting some people, their testosterone treatments? 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 sometimes cause issues.
Yeah, there's certainly side effects to testosterone. You know, one of the big things that I see in my practice is how testosterone impacts sperm production. It actually was tested as a contraceptive by the World Health Organization because it does lower sperm counts significantly. 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. But I have plenty of patients that come in, some of them suspect that testosterone is the issue, some don't know.
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. And I said, well, the best thing to do would be to stop testosterone. And for his work, I mean, we'll tell you what he did, but for his work, he really couldn't stop it. So there are some other medicines we were able to add while he continued the testosterone.
And then they ended up with triplets shortly thereafter. So I think that, you know, men need to be aware of it. Um, yeah. Because that's 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. I saw a quote from you that said, if we take 100 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 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 superhuman, right?
We're just trying to get you to normal. So I think if we monitor it closely, most men, you know, do okay. Again, there's some other therapies that we can do for men that have side effects, you know, from those things. It can also affect the thickness of the blood, something called the hematocrit, where 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 higher rates of heart attack and stroke with testosterone. So there were some studies done about maybe 10 years, 5, 10 years ago that suggested that. But a really large trial just came out. 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 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 balding? Some men do. I think one of the ways that men talk to me about it is one of the common medications for that is finasteride or sold on the trade name Propecia. And so they want to understand some of the risks of that. And so when that medicine was approved for a hair loss, again, because people that are going to take it are usually in their reproductive age, they did randomized placebo-controlled 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. But in sort of post, you know, analyses of some of this and now seeing lots of patients coming in, we do see men that are on finasteride. 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 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 don't have as much reserve as others, I think they may be more susceptible. So that's one of the risk factors of finasteride. The other thing 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 in men too. So we have these discussions. I've had some men that come in after having been on finasteride, and have different issues with sexual desire, low libido or erectile dysfunction.
And so then we 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 have a receding hairline and I also don't want to have a hair operation or anything like that. But when I hear about some of these testosterone replacement therapies and such, my big concern is that if I take testosterone, maybe not now because I 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 50-ish.
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 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 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, if you kind of look at data, maybe 10% to 20% of high school athletes have experimented with testosterone. And if you stay on that too long, it can really shut down your own axis. So 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's able to sort of restart. And so for some of these men, you know, poor choices or, you know, 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 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 everyone's relationship with contraception is different. But after taking it for seven or eight years, 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 and or permanent damage to ourselves. And there's no real such thing as a free lunch, is there? Right. 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 much different process and unlikely to succeed for those kind of reasons.
If I have low testosterone 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? I know that it's quadrupled, according to the data in the US, since the 2000s, which is staggering. But how are people taking testosterone? Yeah. So there's lots of different ways that it can be taken. I think one thing, you know, again, we talk about all the risks. So fertility, it's certainly be a, 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, you know, so medicines that we kind of repurpose to help increase your body's own testosterone that we would start with. But assuming that, let's say you're in your 60s, you're not interested in fertility, then there's gels or patches that you put on every day, testosterone gel or patch, 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 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 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, gels, patches are one there's injections, uh, that you can do every usually one to three weeks on average.
There's testosterone pellets. Um, so these are pellets that have testosterone that are 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 three to six months. There's longer acting injections. So those are very common in Europe. 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 that's available as well. I was quite confused on the subject of hair loss and testosterone because I couldn't figure out if low testosterone causes me to bald and have a receding hairline or if it's high testosterone that causes me to bald and have a receding hairline or if it's both. I mean, it could be both. I think usually we think about it as higher levels. Okay. It's funny because I've wondered before whether me doing a lot of exercise, which is, I guess, increasing my testosterone levels, is going to accelerate my balding and receding hairline.
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 Ironmans and thousand mile runs and all that kind of thing, which you see in certain groups? So I don't know that it, I do think it's possible to overexercise. I don't know if it'll affect your hairline, but, um, you know, I think. My 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 affected. As my cortisol goes up, so my testosterone, 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 decade in terms of men that are being born and boys that are going through puberty. Yeah. Yeah, so this study also got a lot of attention. So similar to how we have tracked testosterone levels over time or sperm counts over time, for different reasons, investigators have measured penile length to kind of give normative data across different populations to understand how different surgeries or conditions may affect penile length.
§03Transcript — part 3
So we looked at all the studies, and there were dozens. And so we kind of pooled all that together, and this was tens of thousands of men and just looked at sort of average penile length over time. And so, you know, again, based on some of the data on semen quality, we would have expected things to get shorter over time. And also because we're more obese now, the way that penises are measured is you kind of pull the penis on stretch and use a tape measure or some sort of ruler or measuring device.
So if there's kind of more gut, more fat, in theory, length should be a little bit shorter now than it used to be. But it turns out, at least when you measure erect penile length, that penises are longer now than they used to be. And so over the past 30 years or so, they've probably gone up about 25%. Why? Why? I mean, it's a good question. I think one hypothesis we had kind of looking at sort of different endocrine, you know, abnormalities 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 implications for sex? I think that, well, the numbers we're talking about shouldn't be, you know, kind of, enough to make a big, big difference. You know, people has 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 hard to know. But again, 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 struggling with erectile dysfunction? Yeah, so that's another very common condition we see. And if you look at men over the Very, very common. Hundreds of millions of men all over the world are afflicted.
We don't talk about this much. What is the cause of this? And are you seeing it increase over time, 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 conditions can be caused by low testosterone.
Sometimes the outcomes of, you know, surgical treatment for pelvic cancers as well. 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 hormonal thing or a 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 etiology.
And maybe for some, you know, populations, it could be a little bit more common. But generally, for most men, sort of all comers, it's going to be a blood flow issue, a vascular organic cause. And how would you go about treating erectile dysfunction? 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 a new relationship or other kind of factors.
You know, for men, like you're suggesting that we do kind of suspect a psychogenic component, work with sex therapists as well. But for other men, I always like to be very positive. It's like to say, 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 like Viagra, Cialis. Does that work for people? It works probably 60% to 70% of the time. So that does work well. Even for men with a psychogenic cause, sometimes it can kind of help reset the system a little bit, convince them and their body that everything is working well.
Like a placebo effect. Yeah. Well, 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 improve things. Pills aren't enough or they don't like those or they have side effects from those. There's other therapies. So there's medicines you can actually put in the tip of the penis, like a gel or a suppository.
We can teach men to give themselves injections in the penis. Ooh, I just got shivered in my body. There's certainly a kind of a psychological sort of fear of that, but it does work well. It probably works 80% and 90% of the time. There is something called a vacuum erection device. So it's like a plastic cylinder. You put it over the penis. It 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.
And there's even surgeries we can do to put a device inside the penis. So whenever a man wants to be hard, he can be hard. I didn't know there was surgery you could do. There was a surgery. What does that do? It puts a- So there's two main flavors of it. There's, or forms, maybe that's a better term. There's one called a malleable, so it's bendable. So it kind of puts this sort of bendable metal. It's a metal core with sort of a plastic 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. Or there's inflatable versions. So whenever you're ready for sex, there's basically a pump that goes in the scrotum and you just pump it up. It moves fluid into the cylinders and you'll get a rigid erection. Is that increasing in popularity? I think it's made by a few manufacturers in the US or in the world. And 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 percent 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 you can It's a pump right now.
They are working actually on either a fob or like a phone app that'll kind of automatically inflate it to make it a little easier for patients. I had no idea. It sounds like sci-fi or something. It sounds like something you might see on like a YouTube video that people are working on in like 20, 30 years time. But to know that men have that installed now is... Amazing. Yeah. I mean, it's very common. 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 that menu of options that you presented there where like the first option is probably Viagra. And in terms of popularity, is it a last port of call? 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 are 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 penile 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, 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. Shockwave therapy for erections. Does that work and what is it? So the idea is that, as kind of the name implies, you're sending shockwaves into the penis. And the energy induces kind of some micro trauma, which induces new blood vessel growth, is the hypothesis. And so the hope is that with 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 because I think the data is not yet conclusive. But I think for men with milder forms of erectile dysfunction, it can help. Maybe the men that are on Viagra or sometimes on Viagra, maybe we can get them off those pills. But I think we need more data to understand really the best target population for it. You talk about pelvic floors as well. When we typically think about pelvic floors, we tend to think of women, things like these Kegel 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. But it can be a trigger for some men. So that can be an etiology of some different problems with urination. You see men with very tight pelvic floors, and they have a lot of urgency to urinate. They urinate frequently.
It can also lead to scrotal pain sometimes as well, because there's a lot of muscles, as you're kind of pointing out in the area, and sometimes if they're under tension, they're if they're not properly kind of trained and they can kind of trigger some other areas. And so for some of these different conditions, we do kind of work with pelvic floor physical therapists to train patients, you know, how to, you know, again, relax the area, strengthen 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 sayings is the enemy of good is better so if things are good you know to try and get better you know they're 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 some 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 I think with... With pelvic floor kind of strength, I think I usually kind of think about that as separate from cancer risk. But for testis cancer, you know, one of the risk factors for that is some men are born without testicles in their scrotum. So that's a risk factor in so-called undescended testicle, low sperm cancer associated with testicular cancer. There is one study I know of years ago that looked at, you know, comparing sort of sexual health to prostate cancer risk, found that men that ejaculated more frequently had a 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 a lot. 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, what are the common symptoms of testicular cancer?
Yeah, so usually it tends to be relatively asymptomatic. I think that the classic symptom would be a firm, painless mass that men find in the scrotum. So there are screening guidelines, even though our Preventative Services Task Force thinks that the utility of doing it for reproductive age men to their scrotums may lead to more anxiety than actually finding testes cancer because it's such a rare cancer. So it's more likely a man's going to just worry themselves and actually diagnose an early cancer.
But the recommendation used to be that you would once a month in the shower kind of feel yourself. And if you feel something new or something abnormal, bring it to your doctor's attention. 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, we'll kind of dive a little deeper. What is the demographic that's 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 is usually 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 reproductive age cancer, so that's the prime reproductive years. So it's possible that it kind of correlates with sperm counts declining with older age. There is another slight increase for men in their 50s and 60s. But again, it is a very rare cancer.
So I usually kind of quote probably 1 in 100,000 men are going to be diagnosed with it. So one in 100,000? It's fairly uncommon. But prostate cancer is more common. Prostate cancer is more common, yeah. So that, you know, in the United States, probably at least 200,000 men every year. 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. 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. It's just underneath the bladder. So the way that we're shaped is we have our bladder, which fills with urine from our kidneys, and then we urinate out the urethra, out the penis.
And so the prostate's just at that kind of intersection between the urethra. 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 and protect the sperm in the female reproductive tract. So after reproduction, it doesn't really have a lot of benefit. Mostly it just causes issues because it gets bigger with age.
So it leads to urinary symptoms. And then obviously 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 that might be regulating hormones long after we're using it for reproduction reasons. 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 side effects just given where it is anatomically. It's right by a lot of the structures that 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 have radiotherapy to sort of kill all the prostate cells. And there's other kind of energy therapies that are delivered, like high-frequency 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, look at biopsy patterns to try and figure out where the cancer is. 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. 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. So 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 blood tests called a PSA, prostate specific antigen.
And, you know, there's different screening guidance that's made. Usually you start, you know, men in their 50s or so and screen every year or two until 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 in 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 nocturium 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 6 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, 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? Spicy. So I think in a similar way, that can also affect some of the symptoms. It shouldn't affect your prostate cancer risk. That's just a symptom thing.
Okay. 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 Asian orange, the defoliant that was used during the Vietnam War, that was found to be a risk factor for prostate cancer.
So I don't know why you would, but try and avoid Asian orange. 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. What are the most important things that we haven't talked about that patients come into your clinic and 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 Peyronie's disease, which is a curvature of the penis. So, you know, the way erections 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 for different reasons. It's thought maybe microtrauma. 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... you know, kind of expand in a uniform fashion. So you can get a curvature or deviation. So some of these men have, you know, 90 degree curves to their penis. And so, you know, whether it goes up or down, it makes, can make sex pretty challenging. 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 five 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, if men are suffering from this, again, talk to your doctor because there are treatments that we can offer. Okay, so let's conclude then. If I want to make sure that my sperm count remains very, very high 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 400, 500 mg milligrams, is it?
Yeah, nanograms per deciliter. Okay, nanograms per deciliter. I want to keep it in that sort of healthy range. And I want to have rock art erections. Okay. So that I can have the four kids that I mentioned. What is the advice that you would give that is broadly applicable to everybody without you having to run 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 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. Sugar? Sugar is okay. Okay. Unless, again, for high-calorie foods or things to try and avoid. 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.
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 out of Japan that I always quote about this. So this was a study that looked at all patients that came in with male infertility 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 consultation and who was not.
Yeah. And so they looked at baseline sperm count. That wasn't predictive of who was gonna benefit. Baseline testosterone level wasn't, age wasn't. Some men had this condition called a varicocele, which has dilated veins in the scrotum. So about 15% of all men have them. In fertile men, maybe about 40% have them. So the testicles are outside the body, like we talked about, and having larger veins impairs normal temperature regulation. And so if you fix those, it turns out most of those men are gonna improve their sperm count.
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 is 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.
So sometimes, my patients, the first time I've ever seen anybody is seeing me to try and have a baby. And so it's an opportunity to make them take a little bit more ownership of their health. If they've never had a blood pressure check, check that. Blood sugar, cholesterol, all those things are ways to improve their health or opportunities to improve reproductive health, but 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, our 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%, you know, may have some form of depression. 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 know, 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. There's some studies that say that some of these may affect semen 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. 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. 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 we talked about, very optimistic about options that are available.
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, you know, men through, you know, some of these issues so they can have, you know, a fulfilling sex life. Anything else that I need to do to improve these things? Top line things, so lifestyle, you know, we've talked about food, exercise we've talked about as well, as a way to improve at least our testosterone levels.
Sleep, I guess, might be important. Sleep's important too. Sleep's interesting because it's what's called a U-shaped association. So it's possible to get too much sleep. So you probably want sort of an ideal amount, probably seven to nine hours is usually that's been associated with better semen quality. For men that get less, semen quality tends to be a little lower. For men that get too much sleep, again, for men that 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 I think sleep, I think, is certainly important. There's also been studies looking at weight loss as well. I think it's obviously easy to say lose weight, but it's not always as straightforward to do. But there is a nice study that came out a few years ago where men were randomized to a weight loss program, a very low calorie diet, 800 calories a day for a few weeks.
And then they lost weight. And then they follow them for the rest of the year. 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. One of these arms actually also had one of these hot GLP-1 analogs as well. And so even men that were on those that kind of helped them keep their weight loss were also able to maintain sperm count.
So patients do ask about that a lot. I was just going to ask about, obviously, as Zempex exploded and there's many other forms of this sort of GLP-1 sort of fat loss injections. I was wondering if that had any consequences on fertility. So again, there's only one study that did study it and 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, 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, sorry, bariatric surgery, like gastric bypass. I don't know if this is popular in Europe or the United Kingdom, but for some obese individuals, there are surgeries that can be done to help sort of reroute intestinal absorption. So you can lose weight with that. There's also something. I think the gastric band thing. There's gastric bands, too. Yeah. So there's different ways that's been done. And so with all those, actually, it 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 of a surgery potentially. You know, there are, you know, some vitamins, minerals are important too. So yeah. 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're wondering if that same thing would happen with, you know, these newer medications. But it doesn't seem like it. So, again, the GLP-1 analogs seem like they're 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 and minerals that are typically deficient in people that have infertility issues?
So I think there is some data that antioxidants can improve fertility. So it's sort of a very broad group. of things that have been tested. Berries and stuff, is that? Yeah, dark berries, yeah. Those certainly can have a lot. But I usually tell 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 looked at the data and try and pick out specific supplements that are thought to be more beneficial.
§04Transcript — part 4
Coenzyme Q 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 can help. Protein, does that play a role in fertility or testosterone? I think, you know, again, sort of part of a balanced meal and 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, as it I guess, what are you going to do?
Is it more of the same or are you going to, are you interested in changing 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. 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 am passionate about this, 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 can, you know, hopefully mitigate some of these risks.
Yeah. I also like to hopefully through information channels and platforms like this, hopefully engage more of the community to try and come up with some therapies for male fertility. I think we talked about some of the things that can be done, but there's no, in the United States there's the Food and Drug Administration that sort of oversees all therapeutics and there's no FDA 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 to try and get more engagement from the scientific community, from the pharmaceutical community, to try and, you know, see that opportunity, because I think that'll be very important 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 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 when we're talking about sperm counts declining, I do worry that that is a barometer of health. And so it may be that in addition to men's reproductive health, just our overall health is declining. When we look at sort of the health of fathers over time, we've seen fathers are getting a little older. We talked about that. But with that comes more comorbidities, higher rates of hypertension, hyperlipidemia, 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.
But I think there's a lot of opportunities. 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? with any of the things we've discussed, what is 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 it takes a lot of bravery to go in and see doctors about some of this thing and some of these different issues, but it's what we're used to dealing with. And I think there's plenty of options that are available. So I would just encourage them to talk to friends, but 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 couples struggling, they've only seen gynecologists, I would encourage them to maybe see, you know, male reproductive specialists 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 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, certainly apropos of our conversation, was that I would make, 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. And hopefully that would, again, solve some of the issues that we talked about from a demographic standpoint. What would that do for humanity? Would it be having more kids, I guess? Would it be happier 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, decreases cardiovascular risk. 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 in the workforce. It's very difficult in politics now, certainly in the United States.
Um, there's a lot of, you know, issues 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 helping to ultimately to create families and to also alleviate a lot of the stress and anxiety and worry and concern 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. as it relates to some of these big issues like, you know, testosterone and fertility. But it's really important for people like you that have the information, that are doing the research, to not just keep it in the lab and not just keep it on PubMed where it's very hard for people like me to access it because we can't bloody read PubMed.
So thank you for making the decision, which you absolutely don't have to do, to come out and speak on these subjects in a way that's really accessible and inspiring and empowering for people because I think that's going to do a tremendous world of good. Thank you. Thank you. My pleasure.