#969 - Dr Michael Eisenberg - How To Protect & Improve Your Fertility As A Man

23:36You know, in the US probably a third of the time, a quarter of the time, men are never seen. So if there's a problem, you know, couples are treated immediately, you know, through maybe insemination, maybe IVF, but you know, the men are not seen to see if there's things that could be corrected or optimized. And I think it's just sort of that delay, right? If, you know, couples are trying for a year and then, you know, they figure out there's an issue, then they go in, it starts with the gynecologist and then, you know, sometimes the male's bypass. So hopefully through, you know, attention through more education, you know, through the platform that you're providing here today, we can sort of educate that, you know, when couples are having a problem about half the time it's a male factor.

24:14So the men should definitely always be evaluated. What is the, that I've read about varicosell being fixed sooner rather than later for outcomes in men? What's the mechanism? Well, I think, you know, it's there thought to be a progressive lesion. So the longer you have it, the more opportunity there is to do damage. So, you know, when like I talked about, you know, there's kids that have these as well. You know, I think if we identify that early, you know, hopefully we can just, you know, alter that trajectory because it's much easier to prevent a problem from occurring than to fix it once it does.

24:47You know, again, if we only see improvements 70 % of the time, if we can sort of freeze it and prevent further to climb, I think that's our goal. So I think if men have it, you know, again, it doesn't affect or negatively impact everybody. So, you know, we do evaluate it. We check semen data. We check, you know, hormone data. We see these men to figure out who, you know, really needs it or not. But everybody kind of chooses it differently. And rather than, you know, follow it for the rest of their lives, some men choose to have it fixed. And obviously a lot of people have an aversion to surgeries.

25:16So some will just say, I'll just a little bit that we'll figure it out later. What are the most common interventions that you offer when guys come in sperm quality isn't where it needs to be? What are the most common interventions that they get? So a varicoseal is a very common one, probably about a third of the time we identify those for the patients that we see and then you know a hormone optimization. I think that's also a common one that will do you know men will have lower levels than if we optimize it that can improve things. You know there's There's also other surgeries that we can do. Vasek to me reversal is a very common thing that men come to reproductive urologist for.

25:53So how do vasectomy maybe change relationship or maybe that couple of the size they want another child? That's something that we'll do. And then another group of patients that we see are men don't have any sperm in the ejaculate. It's called asuspermia, our nose sperm in the ejaculate. And so there's procedures that we can do to try to either improve that or to get sperm directly from the testicles that we could use for a beach of fertilization. So that's sort of the flavor of things. Getting spammed directly from the testicles songs like a rather serious intervention. Yes. Well, I think it sounds scary and you know, when I've showed videos of this, it sort of mixed medical conferences or others.

26:36I think some people do get a little queasy just to see what we do. But most men do great. You know, there's actually, you know, it's so, you know, you can imagine how devastating it is when you do a semen analysis, you know, because you haven't gotten pregnant and you're told that there's no sperm. So it can be, yeah, you know, I've seen men break down and you can imagine, I mean, you know, there's so much tied up. I mean, obviously, you know, goals of the relationship, I think there's a lot of, you know, concerns about masculinity as well. So one of the first things that we do is just try and be hopeful about it about half the time we can actually find sperm.

27:11Sometimes there's like a correctable blockage that we can actually bypass so they can, you know, then achieve without, you know, any other assistance besides the surgical correction. But essentially what we do is, you know, you can find within the testicle where sperm is being made. So there's like a minimum threshold of production that's necessary before it actually gets out. And if you're below that threshold and we can't sort of medically, you know, induce more production, we can go inside and try and find it. But it's an outpatient procedure usually takes a couple hours. You know, most men, I've had men, you know, go back to work the next day if you can believe it.

27:46Take a red eye out of town and back to work the next day. So, you know, it's not pleasant, but most men, most men do great. Okay. What should men do? What are the areas that most guys are overlooking when it comes to improving sperm quality? That they, you know, the first port of call that you should be doing in terms of changing lifestyle, making a self -assessment that? Yeah. Well, I think just having some awareness of what your seamen quality is. I mean, I think that, you know, looking at it when you're first kind of, I don't know, when you're watching this or when you first think about it, I think it's never too early to just get some initial information about it to find out where you are because it can change over time as well.

28:27And then I think if there's an issue, you know, I think, you know, going to the doctor to try and figure out, I mean, I think, you know, getting basic health screening, again, because men don't always do that. I think women go to the doctor or they're used to annual pap smears or semi -annual pap smears, but men don't unless there's a problem. I think routine health screening is not done. So checking that out. But again, I think I just always go back to health. Again, I don't want to be alarmist about any of this, but just making sure that you're living life the right way, that you're good body weight, that you're eating, not just ultra -process foods or fast foods that you take some ownership of your health.

28:59I think those are good places to start and pretty actionable and easy. What about pharmaceutical interventions, stuff like HCG and clomathene? Yeah, so I think for the right patient, I think those can't help. You know, for patients that aren't making enough of those on their own, I think that can help. You know, testosterone is important for sperm production. So for men that have a lower than average levels, I think there's some reasonable data that if we give men, you know, those medications, we can't see improvements. Not just in testosterone, so sometimes they'll feel better, but also we can see improvements in sperm quality.

29:31But I think it's important for Menda, you know, go see a doctor and have that done under, you know, kind of medical supervisor rather than treating themselves. Yes. Yeah. That's that's generally a good rule. What about the relationship between age and fertility for men? What's the sort of curve look like that? Yeah. So the oldest father ever is 96 allegedly. So I think the biologic potential does persist forever. When we looked at the US over the last 50 years, the oldest father was 88. So again, men are doing it again. We always make sperm essentially. You know, the numbers do go down a little bit.

30:09Volume goes down, but we persist. Interesting. Over the last 50 years, the youngest was 11. So it can start sooner than we'd like. But, you know, I think it's important for men to know that, you know, even though, again, they think the runways unlimited, it's probably not. So there are, you know, risks of taking longer to get pregnant. So our fertility does decline because we do see lowering of sperm quality over time, but also risks of sort of rare, you know, a disorder has grew up a little bit. So I think classically, you know, hear about autism, which goes up, there's other rare, you know, genetic conditions, which can increase a little bit.

30:44Now again, these are rare conditions, but you know, we do see a measurable increase. And you know, as a country and as sort of a society, we are, the parental age is increasing, paternal age is increasing over time. So, you know, for an individual, I think most men want to be genetically related. So they would, you know, sort of not be as concerned about these risks because, you know, these risks are relatively small. But, you know, as a population, if more and more men are waiting longer and longer, we may see, you know, more of these conditions become a little more prevalent over time. So I think that's kind of the thing, just to understand that, you know, while you can't have a child, you know, laid into your 60, 70s, 80s, It's, you know, there are some advantages to doing it earlier.

31:28When does the drop -off begin from peak male fertility? You know, I think that the, um, are sort of a governing board. The American side of reproductive medicine defines an older father at a 40 -year -over. That's also what sperm -done or sperm -drenation, um, you know, companies do as well. But it probably doesn't just start there. I think it's sort of a slow decline, you know, probably, you know, from an evolutionary standpoint, our peak fertility is probably late teens early 20s. So it probably starts at that point. If you look at sperm DNA, we accumulate about two mutations a year. So if you look at somebody 30 compared to 20, the 30 year olds got about 20 more mutations in their DNA.

32:10Now, given the fact that we have billions of molecules of DNA, two mutations is not going to make a big difference over time for an individual. But again, we're talking about a population level. You may see chum changes. Okay. What's the increase in autism risk? Do you know that at 40 at 50 at 60? You know, I don't recall the specific, you know, increase like the actual percentage, but it does go up, you know, a little bit. Okay. I'd also heard that the sex ratio, the likelihood of the sex ratio changes with male age. Is this right? Yeah, that's also, yeah, it's a very interesting finding as well.

32:49You know, we talk about sort of declining reprenade reproductive health. So we talked about sperm counts. Testosterone levels have gone down over the decades as well. And there's some studies that show that the sex ratio has as well, sort of independent of age. But if you look specifically at age, as men get older, the chance of a male birth goes down a little bit. So over age 70, it does go down. It goes down sort of a few percentage points, but it's measurable. And anything that changes is a sex ratio, it's sort of a big deal to a population, just given how important that ratio is for the propagation of the species.

33:26And interestingly, if you look at stressful societal events, you can see that as well. The sex ratio goes down during economic downturns, for example, wars. We see changes in the sex ratio. It's a real phenomenon. The fact that it tracks with the father's age, I think, is very telling. What's the mechanism? Do you know why? You know, I think it's it's thought to be You know kind of selective fetal loss, you know at the uterine level and again Why it sort of selects the males more than females? I think is not not totally known, but it's yeah, it's it's measurable but it's as males age Female likelihood increases for children is that right or is it the other way around?

34:13Well, so I guess so yeah, I think there are kind of two things I was saying so So I was clear. So for a societal level, I think that we see that kind of, I guess, calling it the uterine level, but we think that for paternal age, it is kind of the sperm level, just that those sperm, for whatever reason, the wide -bearing sperm don't seem to be as efficient as making it all the way to live birth. This episode is brought to you by Shopify. Look, you're not going into business to learn how to code or build a website or do back -end inventory management, Shopify takes all of that off your hands and allows you to focus on the job that you came here to do, which is designing and selling an awesome product.

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35:28That's Shopify .com slash modern wisdom to upgrade your selling today. Oh, okay, that's interesting. How do you think? I mean, IVF is everywhere. I learned about Andrew Schultz's live show, which is kind of an interesting, and then there's I -S -C -I or I -S -S -S -I or something as well. There's an IVF revolution going on. How do you come to think about that new technology changing the landscape here? I think that XC, I -C -S -I, the Interest -Cyto -Posmics Perm Injection, where you can take a single sperm and inject into an egg. He's really been in my opinion one of the revolutions of medicine in the last you know quarter half century because it allows like these men that we talked about where there's no sperm in the ejaculate, very rare sperm in the testicle to be able to come biologic fathers.

36:21So it really allows it really lowers the bar significantly for who can become a father you know for men that have had you know some guy we talked about again some genetic conditions but other conditions too if they've retreated for cancer as a child and now they can't make sperm as efficiently, I mean, allowing these men to be able to come parents, I think, is terrific. But we are seeing increases in the number of couples that are requiring these technologies. And I think they are great. The US, it used to be that maybe 1 % of births were conceived by IVF. Most recently, it's about 2 % of all births in the US were conceived by IVF.

36:57And those numbers are only increasing. There's a variety of reasons. I mean, I think falling sperm counts are probably a contributor, but also couples from a social standpoint are just waiting a little bit longer. And as we age, both men and women fertility declines. And so I think more couples are becoming rely on needing these technologies. But I think there's, I guess from an evolutionary standpoint, it doesn't sound like it would be the best. But I think there are some potential advantages to IVF. It allows selection of specific embryos to try and avoid kind of heritable conditions. Some of these genetic conditions at Lower Spurne for example, you know, you'd be able to avoid those in the future.

37:37There's this emphasis that Stanford hang really that wrote this book called the End of Sex. And so he rationalized in the future that sex will just be for pleasure. And then in the future, we'll be able to take skin biopsies from men and women, make sperm and eggs, grow embryos and additions. That's the IVG, right? Yeah, in vitro gamete genesis exactly. But the advantage is to doing this and why sort of society will be incentivized to do this is you could eliminate genetic diseases. We talked about things we know about like cystic fibrosis or certain genetic conditions of lower sperm, but maybe you could even look at susceptibility to high blood pressure, diabetes, and things like that.

38:18So really trying to root out, again, it kind of gets a little bit brave new world and maybe it's not where we want to be at society. But it's a difficult one man. I've had a you know Jonathan anomaly is you familiar with him? No, there's a company that he is involved with that is doing Emberia selection for certain traits and He uses this example, which I thought was really smart. He was really interesting Around myopia like people that just have worse eyesight and you know, there's not really much moral weight that's put on that. I know that some people, you know, sort of the death community identifies that and that's kind of close to their sense of self.

39:00I don't know anybody who has short -sightedness that identifies with their short -sightedness. You know, it's a thing that requires them to have glasses or wear contact or, you know, squint a little bit when the lighting's too dark. Right. And yeah, the opportunity to select, hey, you have the choice between your kid having really great eyesight or your kid needing glasses from age 11, but then you're right. This technology and this approach has not exactly had an illustrious, fair and humane history. So it gets perilous with this, but I think it is a, probably I was going to say like a slow, but it's going to be a pretty quick transition, I think, to a world where embryo selection, especially for particular traits is going to become even more common given how likely it is for older parents or whatever they're called.

39:55What's the elder pregnancy called? I get advanced paternal age or geriatric. Geriatric pregnancy, that's it. Yeah, the most unfaith of all of them. But yeah, I think I think this is going to be pretty common. Okay, so we've got on one side, sperm quality, but the other side that most guys care about as well, testosterone levels. Yes. What's happening with testosterone levels? What's the relationship between that and male fertility? What's the sort of current state of play that? Yeah, so I think just like we talked about, we are seeing declines and testosterone over time as well. And I think when people look at it, I think they sort of attribute it to similar things.

40:41I think that, you know, exposures, sedentary lifestyle, more obesity. So testosterone, again, made in the testicles, and then it's converted to different things, you know, in the body like it's aromatized, peripherally, to estradiol. And a lot of that happens in fatty tissues. So you can imagine if there's more fatty tissue, more of that aromatization will occur. And so the levels will decline a little bit. And so, you know, these levels go down, I think it does, you know, it can affect, you know, sperm production to an extent. So I think there is a relationship to that as well. And, you know, again, when men sort of seek out treatment for this, when they start on testosterone, we can also see, you know, direct correlation with sperm counts just because testosterone supplementation or testosterone therapy can directly, you know, decrease sperm production.

41:29Well, you've got this weird inverse relationship sometimes as well between higher testosterone lower sperm quality, but also very few guys say that they want the testosterone level to be lower. Yeah. So, yeah. Yeah. Interesting. I've had patients come in that say their penis is too big, but it's a rare complaint. I imagine so as well. Yeah. All right. right. Well, actually, the penis is getting bigger thing. Was that not a study about that? Yes. Is it not statistics that is it testicles getting smaller, a no genital distance getting small about penis is getting bigger? Yeah. Yeah. It's a good segue.

42:14So, um, we did, uh, it's so we did a study on that. So interestingly, there are lots of, um, you know, just like, The sperm count study was done is that over time people have measured semen quality in different populations and published it And then you can look at all these you know studies together and just see if there's changes over time. So Similarly penis length has been measured over time in a variety of populations So we looked at it you know over the last several decades and found you know We expected it to decline you know for all these reasons right we're seeing you know the lower sort of development, male general development, lower sperm counts, lower testosterone levels, more obesity, all those things should necessarily lower sperm or sorry, lower penis length, right?

42:57Because the way that penis length is measured is you kind of pull the penis on stretch and measure from the tip to the pubic ball. But much to our surprise, it actually got a little longer over time. And so, you know, why it is is not certain, you know, we saw it pretty consistently. you know, we had one hypothesis we had is that puberty is changing over time. The timing of puberty is changing and it's actually gotten a little bit earlier and when it gets earlier puberty leads to kind of board time for general development, longer general development. So that's sort of our hypothesis, why that may explain it, but yeah, that was a finding.

43:36Yeah, I imagine that that caused some rations. Okay, erections, sorry about erections. Okay. How often is erectile dysfunction due to physiological or psychological factors? Yeah. So, we used to think it was all psychological, but now we know that it's probably only 10 % psychogenic and most of it's actually due to organic causes. So, blood flow issues are the main culprit. And I think that's anything that affects blood flow in the heart can also affect it in the penis. Diabetes, high blood pressure, all those vascular conditions are very common. Different medications, medications that lower blood pressure anywhere in the body, lower the blood pressure ahead of the penises and can also cause those issues.

44:20Sometimes pelvic surgeries in that area, like prostate surgeries, notorious for that. Colin surgery as well, bladder surgery, those things can also affect the ability of the penis to get those signals, get the blood flow where it needs to be. And then, you know, the thing that I think is commonly thought of as, you know, hormonal causes are probably less than 5%, but sometimes low test austro can also do that, but it's really the minority of all patients coming in. Okay, so what the main reasons for rectile dysfunction, if you were to rank or to them for the patients that come in to see what are they?

44:55I think mostly it's just due to these vascular comorbidities, you know, so kind of the classic metabolic syndrome. So high blood pressure, cholesterol, diabetes, obesity, you know, again, other things like smoking. I think those are probably the most common causes for right, honest, but it's also very common. I think, you know, when men come to see me, they feel like they're all alone. But if you look at it over the age of 40, over half of men have some trouble with the right. So it is very, very common. I was like to tell men, as long as you have a penis, we can always make it hard. So there's a lot of...

45:27Trying to be optimistic. Okay. What should men do to improve blood flow? Normal guys, like, I'm not smoking that much, I'm not drinking that much, I should improve my blood flow. What does that mean? Yeah. So, I mean, I think you can do better, right? So, I mean, you should try and stop smoking or cut down if you can. You know, alcohol, I think, you know, there is an expression like whiskey dick, right? So, if you drink to excess, it can definitely lower that. But, you know, I think in moderation, it probably doesn't have as much of an effect. but you know, I get up there's room for improvement and then I think just anything that's good for your heart So I think more exercise.

46:00I think it'd be beneficial You know, I think that will definitely improve things. Okay. What's the role of hormones here? I think a lot of the time guys would just assume a rectile dysfunction some hormonal imbalance then the accelerator gets pressed and We're off to the races. That's right Yeah, so you know when you get evaluated I think that's one of the screening tests that we always do just because we do see that some of the time So we will check the testosterone level. And if it's low, those are the men we do discuss, putting on testosterone therapy to try and improve things. Now for men that have a borderline low or maybe low normal level, it's unlikely that's going to be the whole story.

46:40But for some men that are very low, that can be the difference between no erections and erections. Men that are familiar with the ranges, probably 300 to 900 is the average level of testosterone and anagrams for best leader. And so for men in the 200 range, you know, testosterone level may help a little bit, but I think those men also benefit from like Syldena filler by Agra, you know, those kind of medications, those therapies. But when they're in the 100 range, I think those men will see, you know, significant improvements in erectile function and sex drive as well with testosterone therapy.

47:11Yeah, that's a great point. What's the, is erectile function the same thing as libido in the body? How does this, what's similar? What's different? Yeah, I think there is, there tends to be a lot of overlap because I think there is kind of like just negative feedback if you're not getting erections, you just become less interested, but they are distinct entities. So I have patients that come in just with, you know, isolated, you know, sex drive, libido concerns, and then other men coming in, no problem with sex drive, it just doesn't work, it doesn't get us a little bit different. You soon, so.

47:43And we approach those a little bit differently. What contributes to libido? I mean, it seems to be one of those sort of, it's behavioral, right? to the huge psychological component, I have to imagine, but not exclusively. So, yeah, what's going on? Yeah. So, I mean, we are going to do a hormone evaluation. I think, you know, testosterone is something that we look at. Sometimes we expand that a little bit to looking at other things like estradiol is important in that prolactin as well. The other thing I think that's very valuable is, you know, we're talking, you mentioned sort of the psychogenic components to some of this, is it involves sex therapy.

48:16I think there's a bunch of excellent ones, you know, all over the world. There's excellent ones in our area that we collaborate with a lot. For some of these disorders, we do it as a multi -pronged approach. We want to optimize the organic causes and optimize some of the psychogenic causes. Just know that it's not going to get better overnight. It's unlikely a pill is going to solve some of these issues and it may take some time. We try and look at relationship and other aspects to it as well because I think all those are contributing. When you're talking about psychogenic causes there, what is the mechanism that's occurring, that your brain is somehow able to intervene with your penis?

48:56What's happening there? I mean, look, every guy that's listening to this has at some point just gone, I, not today, apparently, but you, it's not your choice. you didn't have any idea what the mechanism that was going on. So liberate us. Show us behind the cut. So the extent we can. Yeah. Well, I think one of the best ways to get rid of erections is to think about it. So I think if there's any. Yeah. So like, you know, anytime you're kind of worried about it, and I think it's not unusual like in a new relationship or other situations. If it was a stressful day at work, you know, you may have some problems.

49:35You know, if you didn't get a good night's sleep, I think it's not unusual, you know, every once in a while for there to be problems. And then it can also be a vicious cycle. So if you worry about it, you know, the next time, then it becomes a problem and then you kind of, you know, go down that spiral. And, you know, certainly by the time patients have come to see me, you know, they're worried about it, right? And so it's been going on for months. And so I think those are the guys we need to sort of reset to some extent. So I think, you know, we do an evaluation, you know, oftentimes there's not a clear organic cause.

50:03You know, we can try and reset them, I think like, you know, so denifled biagros, to dothylsialis, I think those work well. Then we gradually wean them off. Also work with sex therapists as well for different exercise and techniques to minimize some of those anxiety responses. If you think about it like 10 ,000 years ago when we lived in caves in a tire comes around, you don't want erection, right? There's all those grouts respond. It might scare it off. Yeah, I hope so. I guess it depends how you think about tigers. But yeah, so you know, you want to run away, right? And so, you know, the body is designed to shift that to the rest of your body so you can escape.

50:42And so that same thing happens now, you know, when you're worried about it, it's just, you know, erections are just not functional. And so we did take some time, but usually, you know, these are guys that, you know, we can't come up with an effective regimen for. Are we seeing an increase in erectile dysfunction in the modern world in young men? Are there any trends occurring at the moment? There are some studies. I think those studies are still ongoing. I think there is certainly some concern about some of that with some of the isolation and social media, just kind of how we're living dating practices now.

51:17But I think that in general, I think overall the rates of state pretty consistent. and I think again a lot of the causes, psychogenic does contribute to some extent, but I think a lot of it has to do with just vascular health. So hopefully, as technology has made us to the extent it can, you know, a little healthier. I mean, I think that exercise has gotten more fun over time, right? Instead of just like running in front of nothing, you know, now you can listen to an interesting podcast, for example, or, you know, you can, you know, exercise, you know, with, you know, a community, you know, on the screen.

51:48So I think those things I think I find more engaging, so I think there's certainly some good that comes with a lot of that as well. This episode is brought to you by element. Summer hits different when you're actually hydrated. That tired, foggy, muscle crampy feeling, most people chalk up to heat or exhaustion. It might be electrolytes and plain water alone won't fix it, which is why element is such a game changer. It's a zero sugar electrolyte drink mix with sodium potassium and magnesium in the exact ratio your body needs. no sugar, no food dies, no artificial junk, and this summer they've dropped something new, lemonade salt.

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52:46That's drinklmnt .com slash modern wisdom. You've sort of hinted there at potentially new technology and lifestyles having an impact. How much evidence is there for a mechanism between porn use and erectile dysfunction? Is that does that actually appear in the literature? I know it kind of appears a lot on the internet. Sorry, what was the between what? Paul. Oh, yes, yes. So I think, yeah, we do see that. I think that, you know, basically, it's a lot more accessible now, and you know, you can find lots of it. And it's, you know, the, obviously, there's varying kinds, but, you know, the issues that there's just, you know, it's nonstop.

53:29It can be, and very intense. And so, you know, if men kind of are attuned to that, it's difficult to sort of retrain after that because it can give you, it can give men more than they can get with a partner on a routine basis. Without that level of intensity, sometimes they have trouble maintaining erections, kind of in a normal partner setting. That also is going to take just some retraining. Again, I think it's the same regimen we use for other forms of psychogenic ED, but collaborate with sex therapists. But you know, I think it's in the literature, I think there are some associations. I think, you know, some men are probably more susceptible than others.

54:09So it's certainly not going to affect everybody. But it is something to be aware of. And I think a lot of patients that I've come in or that have come into clinic to see me, I think they have some sense that it may play a role. And I think those are the ones that are going to be a lot more willing to, you know, kind of go through the measures to get it better. If something like Tadala Phil fixes things, does that suggest other quality of osculinous issues? If the primary issue when you maintain an interaction is fixed by something that improves blood flow, that suggests that other issues with regards to blood flow may be elsewhere in your body.

54:43It could be. I mean, I think it depends. I think these medications are very powerful. Some people use them recreationally because it does help you physiologically what it does is it keeps the chemical that basically opens up the blood vessels and the penis. It just keeps that there for longer. So regardless of whether you have a problem or not, it should make erections better. But erectile dysfunction can precede other vascular conditions just because the blood vessels and the penis are smaller than they are on the rest of the body like in the carotids or in our heart. So there have been some studies that say that men with erectile dysfunction are higher risk for a heart attack in the next five to ten years.

55:22So I think potentially it could be a warning sign and again another reason to get evaluated by your doctor to see if there's underlying blood pressure issues or you know blood sugar issues for example. I'm interested in how sleep impacts testosterone and fertility what the relationship is there. Yeah so it's also important I mean not surprising. I think that you know when we talk to patients about things they can do sleep is certainly one of them that we'll focus on but you know tends not to be the whole story but it can definitely be a contributor. It's interestingly it's for sperm. It's sort of a ushap relationship.

55:59So it's possible to get too much sleep and then not enough sleep, right? There's sort of a sweet spot, probably like six to nine hours is good. You know, if you sleep 12 hours a day, I mean, I think some professional athletes do that, but for other people, there may just be other things going on. And so we do see the clients in sperm counts at those levels and then for men that don't get enough sleep, you know, less than six hours, we see lower sperm count as well. So I think there's, you know, again, it's easy to say more sleep less stress. It's probably a little harder for some to, you know, to actually, you know, put that into action, but it certainly can, can play a role.

56:32And for testosterone, it's the same thing. I think that we do see stress negatively impact testosterone levels, because cortisol, you know, you know, is it play with stress and sleep and it sort of antagonizes testosterone to some extent? So I think if men can optimize those things, it'll only be beneficial. So there's a relationship here with mental health, stress, lifestyle, stress, as well as sleep too. Yes, yeah, that's exactly right. That's elevated cortisol is not good for anything at all, and the body just down prioritizes making sperm if it feels like you're at war all the time. Yeah, that's, yeah, that's sort of thought to be the mechanism.

57:12I think, yeah, you know, the body knows, right? It's, It wants to survive. That's, you know, eat survive, reproduce. So survive is slightly ahead of reproduction, although reproduction is certainly, you know, very, very important. But, you know, if you're in that situation, it'll deprioritize reproduction. I imagine that makes for a very vicious loop if you become stressed about the potential of having kids because the stress itself is going to further decline fertility, which is the precise thing that you're trying to have a positive impact on. Yeah, that's exactly right. Yeah. And so that's really key.

57:42I mean, that's when we talk about these things, you know, try and be optimistic, you know, try and give people some actionable things, but you don't want to be overwhelming at the same time. Again, there's so much potential, you know, if you read studies, you know, in people I sort of make fun of epidemiologists because it's exposure, you know, X leads to outcome Y and there's so many things that are related. So I just want to, you know, again, make it very approachable and possible. And I think that, you know, a lot of these things that we talked about already, you know, So hopefully it will benefit reproductive health, certainly benefit overall health and I think they're under our control.

58:15Okay, from the tactical side, if you had to build a checklist for men to maintain reproductive and sexual health, what would be the non -negotiables that you would put on there? Yeah, so I mean, I think exercise being very conscious of diet, I think those are going to be really crucial, avoiding smoking, I think is also crucial. And then, again, moderation with other exposures, moderate alcohol. You want to be mindful of that prioritizing. These are all things I think that overlap with health as well. But trying to moderate, make sure you get a good amount of sleep, trying to minimize stress to the extent possible.

58:57I think the other thing that I think would be great is if men had a good handle on baseline. You know, like trying to get a testosterone level up baseline even before problems arise Again, because when we talked about testosterone it's such a wide range of normal right 300 and 900 And when men come to see me and they're 400, you know, they say well, I'm a little below average But it depends where you are right? I mean the range is so wide and statistically if we get you from 400 to 500 You know, maybe you can hit a baseball further, but it's unlikely that some of these other conditions that you that you came to see me for Again, I get better so we just want to know where you live I think that would be helpful.

59:33And then I've also again advocated for doing a semen analysis early. I think that would be very helpful. I talked to actually the Centers for Disease Control about 10 years ago, adding it to this national health survey that they conduct. Just again for all these reasons that we've talked about, right, declining sperm counts, to be able to understand maybe why it is because with this health survey, they track so much. They get blood samples, urine samples from individuals, from men and women, old and young. and they can see, you know, again, what sort of toxic exposures there are and things like that.

1:00:03And so if we could see, you know, who these sperm counts are changing in, I think it'd be really valuable. But, you know, there's some concern that this could affect recruitment into this, in this survey. Because there's sort of an Ick factor, you know, even though, right, I mean, it's, I'd be a lot more pleasant to give a, I think, a semen sample than a blood sample. I guess it depends what you think about. I don't need a step. But again, I think it just be, I think that would be a valuable piece of information. Are there underrated signs of urological dysfunction that most men miss? Is there something that they probably should be aware of that they're not?

1:00:40Well, I think one of the great things that, again, a big discovery was Viagra. I think that got men a lot more comfortable talking about erectile dysfunction. Because there used to be a perception that we couldn't do much about it. And I think now men are a lot more comfortable talking to their partners about it, their doctors about it. So I think, you know, any sort of concern that men have, I think they should bring to the forefront. I mean, I think, you know, urinary issues, I think there's a lot that we can do. We talked about erectile issues. There's a lot we can do. Some men have curvature of their penis and their very embarrassed about it, even though it affects probably five to 10 % of men, there's true affective treatments we have for that as well.

1:01:16So I think anything that you think is different, no one knows your genitals better than you. So if you detect any issues, you know, bring up to your doctor's attention because, yeah, at least to alleviate anxiety, but also, again, if it's a problem, maybe we can fix it. It's so, I didn't, it feels like such a revolution at the moment to finally have reproductive technologies that can help both sides. And, you know, for a long time, this is Schultz's entire the standard, which is, you know, the night before him and his wife maybe got the results or went into the tests or something, he sort of prayed to God and was like, just please let it be me, because he was so sure that if there was a fertility issue that it was on the female side of the equation, and then he turns up and sure enough, his prayers were answered.

1:02:08And yeah, I think, you know, the more conversations that are on this, I've, you know, waved my flag in the air since watching Schultz's special last year, I then went and got a sperm count done. I then went and found that I had varicoseal. So I'm going to get varicoseal surgery at some point later this summer. And you know, all of this is only occurring because there's this increasing territory of guys that are prepared to talk about it. And yeah, I guess our parents generation would have been a lot more in the dark. This is, you're right, there's an an ache factor, free private, as well as shame associated with it, to attach to your sense of self and masculinity and you know, aptness as a partner, potential future, all that sort of stuff.

1:02:56And yeah, long live comedians talking about that low sperm counts because I think it's a good impact. Oh, it's been so great, right? I mean, I think what was his like, that he used to be worried to get pregnant from like a toilet seat? And now it takes like bunch of doctors There's no air in boring. I think that's hilarious. Hassan Menage had a very funny routine on it. Ronnie Chang talked about it. So I think it's this great growing awareness and comfort. And again, you lending your platform to talking about this, I think all that is gonna do a great thing. And I think like we talked about Viagra, I think there hasn't really been a blockbuster treatment or drug for the increased sperm counts, right?

1:03:35I think one of the most effective treatments we have for low sperm counts is IBF, which puts all the burden on the female partner, given all the procedures and medicines that she's gonna require. So if we had, again, pharmaceutical investment and some technology that could improve male sperm across the board, that'd be amazing. And again, I think it just goes to more education research about why counts are falling what we can do to reverse that trend. Thank you. Dr. Michael Eisenberg, Lightning Judgment. I love this. It's a topic that I'm very passionate about. So thank you for all the stuff that you do.

1:04:08So where should people go? They're going to want to keep up to date with everything that you've got online. But we have a lab website so they can go to that, they can support the cause and then learn more about men's reproductive health. I can. Mike, I appreciate you. Thank you. Appreciate it.