Sex & Infertility Expert: You Need To Grow Your Sex Span! This Is Killing Your Fertility! This Daily Habit Transforms Your Sex Life!

22:35A guy named, a very famous physician named Dr. Kloen, or Publisher in Article recently, showing that those men who took daily CLS had a 13 % reduction in cardiac events and a 25 % reduction in mortality, which just came out because of the potential effects of protecting the endothelial lining of the blood vessels. How does this work to solve for this sort of psychogenic component that we talked about, that vicious cycle we'll get into with like, I'm guessing you're telling me that it increases your probability of having a good erection. But this still isn't really working on a libido, is it? Right, so let's say you started falling through the vicious cycle, and you started having ED, and it was two times three times.

23:16And now I put you on this medication, and every time you have sex, you have the most amazing erection of your life, and 30 times, 40 times, three, six months go by, and you're having these amazing erections, you're relaxed, and you're calm. Then I start going to every other day, you still get amazing erections, then I go to once a week, you still get amazing erections. Then I stop, you still get amazing erections. I just need to show you that everything is perfect again, and that has a huge value. What about for women? This is the unfortunate part. We don't have a lot of treatment options for women, and if you look about it, if I want to give you the example, in 2015, if you and I went into the drug store in the US, Walgreens, and said, give me all the drugs to treat women, treat men for sexual dysfunction.

23:57They would put 30 drugs on the counter. These are all the wonderful treatments for men. In 2015, there was not a single FDA approved drug to treat women for any sexual dysfunction, very sad. In 2015, the first drug to treat women for female sexual dysfunction came out, and it was called Adi or Flabansion. And Flabansion basically is a drug that a woman takes every day and increases her desire for sex. That's it, that's the FDA education, increases her desire for sex. Several years later, the second drug for women came out. This was called Valisi or Bremeliana Tide. Essentially, it's an injection that she takes, 45 minutes prior to intercourse, and it increases her desire for sex.

24:36But again, we have only two drugs. The reason being is because the research, the funding that we have for female sexual dysfunction is far less than we have for male sexual dysfunction. And it's unfortunate, because as I mentioned earlier, this is a couple's disease. And so many times, I have to use drugs that I use for men to help treat women. So I do use Viagra for women, but Viagra for women helps arousal. So let me explain. Female sexual dysfunction has four components. One is decreased libido. The second is decreased arousal, third is orgasmic dysfunction, and the fourth is pain with intercourse.

25:14These are the four. If a woman has any one of these four, and she's bothered by it, she suffers from female sexual dysfunction. In the US, roughly 43 to 48 % of women suffer from female sexual dysfunction, significant number. Only 19 % seek therapy. We'll get therapy. So it's a huge number of women that I say are suffering in silence. They suffer from the condition. They don't know where to get help. And unfortunately, there are not many treatment options available. So it's a big problem and a big unmet need. And on that hormonal component, you talked about how if dopamine is up, we're much more likely to be aroused.

25:55And if serotonin is up, then we're much less likely to be aroused. So this kind of ties into something I was thinking when you were talking about stress and tiredness. When I'm stressed and tired, is my dopamine down? It can be. Your cortisol goes up. So it makes it much more difficult. And there's more than just dopamine and serotonin. There's norepinephrine. There's melana -courtine. There's many other neuro -sterroids. And it's really just what we call a plus minus game. If I have more positives than negatives, I'm going to have desire. And I'm also going to have orgasm. That's important also.

26:36So if you give someone too much serotonin, and it goes this way, not only does the libido go down, but it's difficult to achieve climax on orgasm. So one of the ways I treat premature ejaculation is I give them an antidepressant because it delays the orgasm. So we have to be very careful on these neurotransmitters, how we use them. But if you talk about adi, the drug I mentioned, all it does is it increases dopamine and norepinephrine, which increases libido. So they increase neuro -sterroids. Many women, particularly with the history of breast cancer, like this, because they don't want to use testosterone or estrogen hormones.

27:11This is non -hormonal. Right? It's just neuro -sterroids, increasing the desire for sex. Can I think about dopamine and serotonin as like as scales? Yes. If I put weight on one end, the other one goes up. And if I put weight on the other end, the other one goes up. Yes. There is a very famous, Michael Proman came up with a tipping point. And it's basically a scale. You're looking at the pluses and the minuses. And if you have more pluses than minuses, libido goes up. Orgasmic function goes up. If you have more minuses, essentially your ability to orgasm and libido will go down. So if I want to be around us to have a desire for sex and have good sex, then I want my dopamine levels to be high.

27:47Dopamine high, oxytocin high, norepinephrine high, serotonin low. What are the types of activities that make my dopamine high? Well, exercise. Exercise? Okay. It can be a really high dopamine. Other things increase dopamine as well. Right? So the gambling, there's certain things that are high. It's like gambling. Anything that gives you a high, a certain foods will cause a dopamine rush, but they're temporary. Right? And so that's the problem, right? Because if it goes down, it crash. So you want your dopamine to go up in men and women. So we use medications like well but turn. Have you heard of well but turn?

28:24It's an antidepressant, but that antidepressant increases dopamine. So I use that to help men increase their libido or women increase their libido or sexual function. I use Adi in men and off label in men and women to increase dopamine. I don't want to do drugs then. Yes. I don't want to take any pills. So then I would say I need you to exercise and you do, but exercise is critical. I need you to sleep. I need you to reduce your stress. Right? Those things will significantly improve your libido. So what things then lower dopamine? Because I've spoken to a few like dopamine experts from the show before and they talk to me about this sort of...

28:58I mean, Andrew Hoover, mom's telling me that when you do an exercise like let's say gambling or go on TikTok, your dopamine is going to go up, but then it's going to crash below the base point. And some of us live in this kind of dopamine rollercoaster where we're doing these dopamine inducing activities as dopamine goes up. It then crashes below. Yes. And when it gets low, we have cravings for dopamine inducing activities. So we go out and want to gamble or go on TikTok again or eat something. And then it goes up again and then we kind of live in this kind of rollercoaster of dopamine. I mean, one of the things that I was told by a dopamine expert on the show recently, that does that as well, that links to some things I found in your work is pornography.

29:33Yes. And when we talk about this psychogenic component, we talk about dopamine levels. How much is pornography causing this libido crisis? Yeah. Pornography and ED and libido is somewhat controversial. There's some data that suggests that it does not cause an issue and there's some data that suggests that it does. The first question I ask a patient with, I ask a man, I say, is your ED present with pornography also? So if he says, look, I have a rectal dysfunction with my partner and I have a rectal dysfunction with pornography. That's very different than when he says I have a rectal dysfunction with my partner and I have amazing erections with pornography.

30:17Because then I know that there's a psychogenic component as well. This is what I believe. I believe that when a man watches excessive amounts of pornography, what his expectation is becomes hair and his reality becomes hair. And that delta causes them to have a rectal dysfunction and low libido. They're not getting what they're expecting to get. So many times, a question man, when they come in, when all men who come in free, do you ask how much pornography are you watching? In men who watch excessive pornography, if I ask them to stop watching pornography for a while, many will report improvements in the rectal function and libido.

30:55So again, I do think that pornography in excess can have a negative impact only because of your expectation and your reality. The delta can be an issue. Reading some stats here from JAMA Network that says the percentage of men between 18 and 24 reporting no such activity in the past year increased from roughly 18 % to roughly 30 % in the space of what looks like just a few years. And similarly, the average number of times American adults engaged in sexual activity per year has decreased from 60 between 1989 and 1994 to 50, roughly 50 between 2010 and 2024. These shifts suggest a notable shift in sexual behavior over recent decades.

31:42Why do you think this is happening? I think it's multifactorial. So I think one is I think that ED and sexual dysfunction is on the rise. And if you look at the causes for ED, it's very simple. You look at obesity diabetes metabolic syndrome. It's a pandemic. It's an epidemic throughout. If you look at just diabetes from 1990 to 2022, 100 % from 7 % to 14 % of the population, one out of eight people globally are obese, one out of eight people. So these can make it very difficult as obesity and diabetes are going on the rise. What happens? Testosterone levels go down. Right. So testosterone levels go down.

32:19So the ability to engage in sexual activity, the desire to engage in sexual activity will be impaired by these conditions. I've got some some grass here, which show global obesity trends, global diabetes trends. I'll put them on the screen for anyone that's watching on video. Also, there's been an increase in pornography consumption from what I was able to tell from doing some research. 2020 study by the University of Antwerp found that 40 % of people age 35 to 45 who watched 300 minutes of porn a week had erectile dysfunction in a 2021 study by German public health and surveillance and 3400 men between 18 and 35 years old, 20 % of the participants suffered from erectile dysfunction and research has found that the greater the viewing frequency of pornography, the greater the development of this dysfunction.

33:08And that's 300 minutes quite a bit of time a week. It's five hours. It's five hours. Five hours a week, right? So that's quite a bit. Yeah, that's quite a bit. How important do you think that is as a component to this sort of fracturing relationships? We think about people having sex with each other less. Yeah, we're heading towards a world of like virtual reality in AI. Yes. What role do you think that's genuinely playing? And you must have private conversations with men that are really suffering with these things. So I definitely think it's a rule and it definitely plays a factor, but not as much as the epidemic of diabetes, obesity, mailbox syndrome.

33:41We are as a population becoming more and more unhealthy, right, as time goes on. And I look at again, as a pie, it's multifactorial, right? Most of us now are not, our socialization is virtual. And so we are not engaging and going into seeing everything is un -virtually. And so I think that's an issue. And so I really believe that pornography is a component, but the decline in overall health is a major component. The decline in testosterone levels, decade by decade, is also another component as well. It's pretty terrifying that young kids at the age of like 12, 13, 14, when they open their phones these days, will be exposed to sexually graphic images, whether they chose to seek them out or not.

34:23Yes. And I've always wondered what that's doing to a developing brain. You know, how it's adjusting your expectations, how it's creating some of those psychogenic factors that are making you less aroused. And it's difficult, right? It's difficult to go out and find a partner. You have to like put on the aftershave shave to carry yourself. You have to like risk rejection, spend some money, be interesting. Right. So it seems like if from an evolutionary perspective, if I was just trying to like get my nut off or like, I don't know, ejaculate. I've got this really easy way now. Like it's so easy.

34:56Yes. Three clicks on a computer, we're off to the races. Yes. Versus like all the effort and rejection and pain of trying to find an actual human being to have sex with. Right. And then when I do do approach number one, when I log on to some website and click a couple of times, I'm getting no headache. I'm getting whatever I want. I can order from an endless list of many. And I'm sure in the near future, I'll even be able to make my own. Yes. I'm not so distant future. I'll have it in my house. You know, talk to me. Yes. Yeah. So it's interesting. And you think about the, it's making it more difficult for people to socialize.

35:31So in other words, now when patients or people engage in sex activity, and they're usually having sex on the internet or with pornography, when you actually have, actually engage in sexual activity with another person, it can be causing anxiety, right? You get anxious. It's not something that you're doing regularly. And so I think that it can become an issue. I am, I saw an article this week from an only fans creator who posted that one, one customer of hers had given her $4 million this year. Oh my god. And you think about like, think about what it would take for you to spend $4 million on a parasocial relationship with an only fans creator sending you explicit pictures.

36:13And I don't, I don't quite believe we fully understand what's around the corner. I agree. These stats, I think, are nothing compared to what's, what's around the corner. And I don't know, I think about it a lot because when I read these stats about a rectal dysfunction being on the rise, and I read that we're having sex less and less. And then I see this rise in these parasocial relationships. I think we're just at the start of an exponential curve. Let's talk about obesity then. Yeah. Because these stats here are pretty shocking. This one shows the global obesity trends, which just shows them going straight up.

36:49Yes. Which is horrific. This one shows global diabetes trends, which is pretty much straight up as well. Yes. Has there been any studies done that show the link between being overweight? And your probability of having low libido and some kind of sexual dysfunction issues? Yes. Numerous. And so let's start with this. So obesity, it's not surprising that diabetes is going up because as obesity goes up, it causes insulin resistance. So obesity and diabetes typically go hand in hand. The problem with obesity is the following. Obesity significantly drops testosterone levels. So fat cells contain something called aromatase.

37:27Aromatase eats up the testosterone and converts it into estrogen. So the more fat you have, the less testosterone you'll have because you'll convert it into estrogen. Fat cells also secrete something called cortisol and leptin, which shut down your own natural testosterone production. So as it's not surprising that decade by decade, as you see an increase in obesity, you see a decline in testosterone levels in men. Because the testosterone levels will come down as people become more obese. And the lower testosterone equals low libido. Low testosterone increases low libido. The number one driver, the number one hormone for libido in men and women is testosterone.

38:01It's a strong driver. Men and women. Men and women. And don't forget that testosterone also significant, really important in erectile function. Men need testosterone for sexual functions. So do women. Right? It's extremely important. So now I have a hormone that's going down that's going to make it more difficult to get an erection. I have a hormone that's going down that's going to decrease my libido. And it's mainly due to this obesity that's occurring one of the biggest factors. So obesity. Obesity also, if you look at the risk factors for ED, obesity, diabetes, cardiovascular disease, these are all risk factors.

38:34And so as obesity goes up, erectile dysfunction goes up. And the number one condition is diabetes. Diabetics are four times more likely to have ED than any other population. Four times. So I get worried when we see this obesity, diabetes pandemic going up because it's increasing only the erectile dysfunction. Steven, if you look at the obesity, the group that's having the greatest rise in obesity is adolescents obesity, not adult obesity. The kids, younger and younger ages, are having that great age group has the greatest rise of obesity. So what does that turn into? The younger population are starting at at lower T levels and has an implication of fertility because you need testosterone to produce sperm.

39:17That's very important. So if I just lose a little bit of weight, that'll have a big impact on my testosterone levels. Let's talk about that. It's not a little bit. So the best study was at the European male aging study, Fred Wu. And what he showed was this. It's a bi -directional relationship. If you lose 10 % of your body weight, you can actually gain 85 nm per desolate and serum testosterone. If you lose 15 % of your body weight, you can actually gain 250 nm per desolate and serum testosterone. So it's actually significant if you can lose, but it also goes the other way. You gain weight, you drop the T proportionately as well.

39:54The only issue is I can get the patients to lose the weight, but I can't get them to sustain it. Many times they gain it back, right? But if they can keep the weight off, it's significantly increase the testosterone levels. The best data we've seen is in the bariatric surgery data. If I do bariatric surgery on a patient, it's to help them lose weight. You can shrink the stomach. We do surgery to help them lose weight. They lose a quite a bit of weight. Their T levels go quite up, right? And so again, there is a strong correlation between weight and testosterone. Have you got examples of patients where you've given them testosterone treatment in some form?

40:31You've done something to increase their testosterone. And you've seen a remarkable report to difference in their sex life. All the time. Yeah, so first let's backtrack. There's two ways to give a person testosterone. If I give a young man testosterone, remember it causes infertility. So you would never give someone testosterone if they're planning to have children. That's very important, right? So I have two ways to raise their testosterone. I can give you medications to raise your natural testosterone. There's several. There's a pill called clomophine citrate. There's HCG. I can use medications to raise your own natural testosterone.

41:07And they preserve your fertility. The second option is I can give you medications like testosterone. There's seven of them. They will shut your natural production down. Not only will they shut your natural testosterone production down, but they will shut down your sperm production. Now, if you've already had your kids, you're 60 years old, your testosterone levels already low in the first place, what are you preserving? Okay, it makes a lot of sense. And there's seven ways to do it. My favorite way are the injectables and the oral testosterone. They are fantastic. The oral testosterone was quite interesting.

41:39First of all, testosterone was invented in 1935. This is not a new drug. 1935. And oral testosterone initially was feared because it would actually cause liver toxicity and liver cancer. And it wasn't until the 1970s when they were able to make oral testosterone undecan await. And what's nice about undecan await, it bypasses the liver, no cancer. But it had to be taken three to four times a day. It was available in the UK as a drug called Andrial, all over the world, but not the US. The US, we did not get our first oral testosterone till 2019. And then in 2022, we received two more. And now we have Tulando, Jitenzo, and Kaiser Trex is our oral.

42:22They're taken twice a day with a meal. What's nice about Kaiser Trex, it's actually available in the UK. So in the UK now, they can actually get Kaiser Trex as well. But oral testosterone, most patients don't mind taking a pill and it seems very easy to do. So should someone like me be taking testosterone? If your levels are low, yeah, and you're symptomatic. And I think that's very important. If a man comes in with low levels of testosterone and says, I feel great. I have no symptoms. I said, I'm not giving it to you. These are the symptoms, low energy, low libido, erectile dysfunction, decreased muscle mass, increased fat deposition, poor sleep, and depression.

42:57These are some of the common symptoms you'll see. Most sensitive symptoms are the sexual symptoms, erectile dysfunction and low libido. So if he says, I have these symptoms and my levels are low and I recheck it and confirm that it's low. That man is a candidate for testosterone therapy. But if he's young, haven't had as much children yet, I'm going to say, look, let's hold off on giving you testosterone and use medications to make you make testosterone. And if you don't want to take medications, actually there are many things you can do on lifestyle modification to raise your testosterone that we talked about weight loss as well.

43:31So let's live in this area here. You are too young to take testosterone now. But conversely, let's say a patient comes in and has every single sign and symptom of low testosterone. But his testosterone levels are normal. I'm not giving him testosterone because it could be something else. Maybe he's depressed. Maybe he has a low thyroid. Something else is going on. So you must have signs and symptoms and a low T level to be a candidate. And if you fit that, then you may benefit. What about women? So this is important. In 1935, when testosterone was invented, it wasn't many years later until they actually started using testosterone in women.

44:05And early reports of testosterone women were actually quite remarkable. The earlier manuscripts describe improved quality of life, improved libido. And if you and I walked into the drugstore today and said, give me the testosterone for women, it does not exist. There's not a single FDA -proof testosterone for women in the United States. But we have well over a dozen for men. Can you explain this to me just because I want to make sure I'm clear. Why would a woman take testosterone? Because when I think of testosterone, I think of men. Yes. So women make more testosterone than any other hormone in their body.

44:39Make more testosterone than any other hormone in their body. Right? And when women have higher levels of testosterone, they tend to see a greater improvement in libido, muscle mass, bone mineral density, sense of well -being, some of reported improvements in cognition. As the testosterone level goes down, we start seeing these symptoms particularly low libido. If you give a woman back her testosterone, she would, many of these women see a significant improvement in their libido. But the issue is that we don't have an FDA -approved product for testosterone in the United States. I think in the UK you call it off -license.

45:16We call it off -label. Now in the UK, they did have one. They had a wonderful patch called Intrinsa. And in the women in the UK could get the patch for testosterone, go into the drugstore, NHS covered it. And it was fine. Then they had Androfem. And Androfem was actually approved and now no longer is approved. So now in the UK, you also don't have an on -license medication. You can still get Androfem from Australia. But unfortunately, it's very difficult to get. So what do we do? We use the drugs for men and we give it to the women in one -tenth the dose. That's all we do. So if we have a packet that's a man puts on a day, we say use one -tenth of the packet every day for the women.

45:55And they can see significant improvements. It is not illegal to give a woman testosterone. It's just considered off -label or off -license. But they see significant improvements. Sexual function by far the most. Libero goes up. No question. Many women report that. Muscle mass. If you think about testosterone, bodybuilders take testosterone for a reason why it's significantly improves muscle mass. It can decrease fat deposition. Many patients will import improvements in cognition. It can help with bone mineral density as well in men and women. And I also believe in depression. So I think testosterone does help with depression.

46:30I just want to just make a very important point. Testosterone is not just about sex. There are five other things that you need to think about in men and women. And I want to talk about those. Men with low testosterone levels are much more likely to have a heart attack. Non -negotiable. Men with low testosterone levels are much more likely to have diabetes, obesity. Men with low testosterone levels are much more likely to suffer from depression. Men with low testosterone levels are much more likely to have a bone fracture. So it's not just about sex. It's about their overall health. And if you were to check one blood test to assess a man's overall health, it's his testosterone level.

47:06One blood test to check his overall health. It would be because it affects heart, diabetes, obesity, bone mineral density, energy, muscle mass, erections, libido, one blood test. I can't think of another blood test that is a better barometer of overall health. I want to get clear on something because I've heard people talking on my podcast before about HRT. Yeah. And women taking HRT because of menopause and things like that. Should they be, does HRT have testosterone in it? No. So typically when we say HRT, we're talking about estrogen and progesterone, typically. Yeah. And typically when we talk about TRT testosterone placement therapy, it's a little bit different.

47:44In a woman, there's something I call the triangle. And it's just basically estrogen, progesterone and testosterone. Just simple. And if you have a woman who's deplete in estrogen, testosterone and progesterone, testosterone and replace it, many of those women feel better, right? So many of them do. There are other hormones that are also important. I call it the outside circle, cortisol, thyroid, growth hormone. We look at those as well. And so I think those are also very important. And I tell them we're going to optimize your hormones. But what you're going to, and we're going to optimize your medical condition.

48:17But that is only 50 % of the story. The other 50 % again is diet, exercise, sleep and stress reduction. And if you do your part, I do my part, we're on fire. We're absolutely on fire. But you have to do your part. Same with men. I put you on the testosterone. I will optimize your medical conditions. And but you kind of exercise. You got to eat right? Why aren't women being prescribed testosterone then? Right. Because it's considered, well, in many countries, it's in Australia. It's available in the UK. It was available. And many women are being prescribed testosterone. It's just off label. It is the first time that I've seen someone on my show anyway, really emphasized the point that testosterone isn't just for men.

48:57It's for women as well. And it can significantly improve their quality of life. Talking about testosterone. One of the big conversations that's rattling on the internet is about this decline in male testosterone over the last couple of years. What exactly is that decline? If you had to sort of quantify it. If you look at the original studies that we call the Framingham Heart Study back in the 70s, testosterone levels were roughly around the 700s, average men between the ages of 18 and 40 were around the 700s. In every decade, we're starting to see a decline almost by 15 -anagram per desolate. And so the latest, in 2015 numbers were roughly in the mid 400s.

49:34So we've seen almost a 300 -anagram per desolate decline in serum testosterone, which is significant, because it has two implications. It's not just about the way you feel and energy, muscle mass, rectile function. But that low testosterone kind of invocations on fertility. That's really important. So we didn't talk about that. But fertility, sperm need testosterone. Low testosterone decreases your sperm count. Sperm counts have also been on the decline as well. So, you know, I think it's really a testament to the fact that decade by decade we're becoming a more unhealthy population. Do you think that's really the heart of it?

50:10Is that is this sort of our diets and the way we live and becoming more set in tree less exercise, more processed food, et cetera? Do you think that's the heart of it? I think that's the key. That's absolutely the key. The types of foods we eat, the processed foods that we eat, high fructose, high carbohydrate diets. And the way we know that is just look at the obesity. Look at the diabetes. There has to be a reason why it's on the rise, right? And on that point of fertility, I'm in a season of life where I'm going to be trying to have kids pretty soon. What's the most important things I should be thinking about from a lifestyle perspective in your view?

50:45Yeah. So, I tell patients Darwinism, in other words, survival of the fetus. Healthier people are more fertile, right? You're passing on the genes. So, essentially, we tell patients, the number one cause of infertility in the world for men is a varicoseal. A varicoseal is the swelling of the veins around the testicle. You know how women sometimes can get swelling of the veins in their legs? You see those veins are kind of obvious. Well, men can get those veins dilated around the testicle. And those varicoseals can impair sperm production. Now, 15 % of men in the world walk around with varicoseals, but up to 40 % of men with infertility will have varicoseal.

51:21So, it's really important to assess for the varicoseals. But lifestyle modification, each one again, diet, exercise, sleep, have been shown to help improve fertility in men as well. So, I say healthier people are more fertile. I need you to start getting healthier. That's very important. We raise the testosterone level in many of these men naturally. We don't give it to them to help improve their fertility as well. But check, it's even check your semen analysis. That's the simplest thing you do. Check it. Yeah, it's a great predictor. It's not just, you know, there was so many amazing studies showing that a semen analysis is a phenomenal predictor of overall health.

51:57Many studies showing that if your semen analysis today is impaired, it's a predictor of you having comorbid conditions today like diabetes, obesity, metabolic syndrome. It's also a predictor of prostate cancer. So, we know that if you have infertility, you're at a higher risk of having testicular cancer than those that don't have infertility. And it's also a predictor of who will have problems in the future. Mike Eisenberg, one showed a very nice study. Men who have low sperm counts can have a 30 % increased risk in diabetes, 50 % increased risk in the schema -card disease in the future. Tom Walsh showed those men can have 2 .5 times higher risk of high grade prostate cancer in the future.

52:34So again, to me, it's just a marker of overall health. Check the semen analysis. I did that and it was quite, I was actually, to be honest, I was really quite nervous about it because as someone who's, you know, in my early 30s and wants to have kids, I was really scared that it would come back and say that like my sperm is dysfunctional. And I have got a huge amount of empathy and, you know, feelings for people that do those analysis and get bad results back. 15 % of all couples in the world, 15 % suffer from infertility. That's a lot. And if you think about it, 30 % of the time, it's a male factor, 30%.

53:1120 % of the time, it's a male and a female factor combined. So indirectly, a male is involved 50 % of the time when you have infertile couple. And it can be devastating for that couple. I mean, psychologically devastating. And what's also interesting is that most couples, most couples, 50 % of couples don't seek therapy. And of those couples that do seek therapy, this is globally, only 25 % of those couples actually go forward. And so I call this a group of individuals that also suffer in silence. They should know that there are excellent treatment options available. This, this graph that I had printed out is just shocking to me.

53:51It's going back to the point about testosterone. But the really shocking thing is how quickly this has happened. Because this is the year 2000. And this is the year 2015, 16 year. And the decline there is from roughly 600 nanograms. Yes, nanogram per deciliter. Nanogram per deciliter to roughly, for some age groups here, 400 nanograms per deciliter. And that's only in 16 years. So if you play that for another 16 years, there's going to be a bit of an infertility crisis. There is. Fortunately on that graph, it's plateauing a little bit, which makes me feel a little comfortable. Okay. It is actually.

54:28It's plateauing just a little bit. But you're right, it could be a significant crisis. And again, as I mentioned, it's the adolescence, the younger folks who are having the greatest rise of obesity. And that's where fertility comes in. Because fertility, obesity in someone in 60s is not concerned about fertility. But a young patient who has infertility, obesity will have a higher risk of infertility. If you're an entrepreneur, you're probably going to want to listen to this. It's a message from one of our sponsors on this podcast, which is LinkedIn. If you've listened to me on this podcast for a while now, you'll know that I've been on a bit of an evolution as a business owner and entrepreneur.

55:03And one of those evolutions that has become clearer and clearer as I've matured is that the single most important thing in building a business, in building a company is hiring. The definition of the word company is actually group of people. And that is the first responsibility in job that any entrepreneur has and should focus on. But surprisingly, most don't. About 80 % of my team have been hired from LinkedIn. And I think there's very few platforms, if any, in the world that could give you that diversity of candidate with that much information and data on their profiles. It usually costs money.

55:36But for the entrepreneurs that are listening to me, I've got you a free job ad post for your company on LinkedIn. Just go to LinkedIn .com slash D O A C to post your free job ad today. That's LinkedIn .com slash D O A C. Hands in Conditions apply. If me and my partner came to you and we said, listen, we've got sexual problems in the bedroom. What are the steps that you would, the things you'd look at that we haven't focused on so much today? Is there anything particularly you'd circuit? And I'm trying to stay away from being prescribed a pill. So I want to do anything natural I can. Before I get to that, and then we'll talk about some of the other more drastic measures.

56:11Let's talk about natural things because everyone wants to know about what's the natural things I can do. So when we talk about diet, there's certain diets that have been helpful to improve sexual function. For me, it's the Mediterranean diet. The Mediterranean diet is rich in whole grains, legumes, fruits, vegetables. And if you look at red meat and sweets, it's once a month. If you look at poultry, it's maybe once a week, but mainly fish. Those diets have typically been anti -inflammatory diets. Many studies have shown that that diet can significantly improve erectile function. And one study, the Medita trial actually showed that it improves sexual function in men and women.

56:44So I'm a big believer in using the Mediterranean diet. When Esposito did her first trial, it was a prospective trial 110 obese men. 55 men get a Mediterranean diet. 55 men don't get any intervention at all. She falls in prospectively for two years. What does she find? Not only a significant improvement in endothelial function, remember that line of the blood vessel, but a significant improvement in her rectile function in these men. No Viagra, no pills, nothing. Simply changing the diet, improved the erectile function, and the same with sexual function in women. So that's an important one. The second is sleep.

57:20Let's talk about sleep. So studies show that if you're getting less than six hours of sleep a night, a significant increase is your risk for sexual dysfunction in men and women. Right? Ideal amount of sleep should be seven to eight hours. Now let's say you say, well, that makes sense. Maybe I'm going to get sleep for nine to ten hours, because I'm more sleep I get, the better my sexual function. But that's not true. If platos. So if above nine hours, it does not increase your ability or sexual function. So seven to eight hours of sleep a night, I need you to get third is I really need you to focus on exercise.

57:55So I published a very nice study looking at it was a meta analysis on how much exercise one needs and what type of exercise to actually improve rectile function in this study. Typically, you need 160 minutes a week. So 40 minutes, four times a week for a course of six months of moderate or to severe exercise, vigorous exercise. And so most people can get 160 minutes in a week of exercise, but that's getting your heart rate up and doing the exercise significantly improved the rectile function in men. If you did that, and the more severe your ED was, the greater improvement you saw in rectile function strictly by exercise alone, no other interventions even just exercise.

58:34So here you have a patient that now starts doing some exercise, starts sleeping better, starts changing the diet. It's all additive. You are now significantly improving a rectile function just by less of modification alone. Pretty profound exercise can have such big impact, isn't it? Is that the same for women? It is true because many of the things so unfortunately once again, the research we have in women is not close to what we have in men, but the meditative trial was also in women, the sleep studies were also in women. And so these studies also show that sexual function can be improved with sleep and with diet.

59:10I think that men and women are not that different. I mean, if you see a significant improvement in a male sexual function with diet exercise sleep, you can also see it in women as well. Actually, there was a great study. This looked at 110 women and they had coronary artery stenosis that is angiograms on 110 women. And they showed that the greater her stenosis she had, the worse her sexual function. So the greater the blockage in her heart, the worse her sexual function. They put those women on a cardiac rehab program to actually improve their cardiac function. So a diet and exercise program. And those women that actually put through the program were through the program for full increase almost in their sexual function.

59:49For 100%. For full. Yes, sorry, because we use a questionnaire called the FSFI, which is a questionnaire. So a significant improvement in sexual function, just on improving cardiac function. So remember, cardiac function and sexual function are related and it's bidirectional. You improve one, you improve the other. That's very important. We talked about this earlier. 40 % of men in the in the world at 40 will suffer from rectal dysfunction. 40 % 50 % at 50. 60 % at 60, 70, 70, 80, 80. You do the math. It essentially is a very prevalent condition. This condition is associated with increased cardiovascular events.

1:00:28It's the first sign of a heart attack. We talked about that. This condition is associated with two and a half times more likely to be anxious, three and a half times more likely to suffer from depression. And this condition is also associated with diabetes. In other words, men with ED, two times more likely to have undiagnosed diabetes. And yet, only 50 % of men even talk about it because they're so embarrassed. So you show me another condition in the world that affects more men's lives. That's associated with adverse conditions. And they're too embarrassed to speak about it. They suffer in silence.

1:00:58There's not another condition. There's not another condition. But yet we're embarrassed to discuss it. I used to give these lectures. Now, look out to the audience and say, please raise your hand if you suffer from hypertension. And many people raise your hand. They have high blood pressure. And say, okay, please raise your hand if you suffer from sexual dysfunction. No hands go up. But statistically, you know that over 50 % of those people had sexual dysfunction. So why is it okay to raise your hand if you have hypertension, but that okay to raise your hand if you have sexual dysfunction? It's got to stop.

1:01:29We have to destigmatize. It's okay to have sexual dysfunction. It's a common condition. It's curable. Why don't men raise their hands from a psychological standpoint? Why is that? I think they're embarrassed. I think that historically, sexual dysfunction looks as a weakness. I'm not a man, less of a man. You know, you have hypertension. It doesn't mean you're less of a man. Right. But they have this assumption that it's a weakness, less of a man. And I think that it's okay. You have to be comfortable saying that you have sexual dysfunction. There are amazing treatment options for sexual dysfunction.

1:02:01Amazing. That work very, very well. You just have to raise your hand and let me know that you have it. I just want to make one of the comment about diabetes. There was a study that came out of St. Louis looking at young men 18 to 40 years old. And they were screening them for a rectal dysfunction. And what they found was within those men came in for rectal dysfunction. 30 % of those men had pre -divities or diabetes on that day. On the day they were being diagnosed 30%. And I thought to myself, young men do not go get screened. I remember when I was 30 years old, I didn't go in for my annual blood pressure check.

1:02:38In my answer, sugar check, there's no way I'd get my glucose checked. But if a young man gets a rectal dysfunction, he is at my front door first thing tomorrow morning. They show up. It's the first thing I'm going to do because it's a very big condition to them and they want to get treated. And that is the opportunity to treat these young men and treat the condition. If you see a young man or someone who comes for ED and you screen them for diabetes and I catch the diabetes at 30 as opposed to 40. That is 10 years of damage on the vessels that you're saving because you catch the disease early.

1:03:11So ED is the gateway to men's health and to treating men early before it's too late. So I really use sexual health as a tool of vehicle to improve overall health because men take sexual health much more seriously, particularly young men. Have you ever had sexual dysfunction? I have not. Never in your life. I have not. I have. But it doesn't mean that it's not, but it's okay if I did. It's not, there's nothing wrong with it. There's nothing. It's normal. It's okay. And it's transient. It can be temporary and come back. It's nothing wrong with having sexual dysfunction. We must destigmatize it. It's completely okay.

1:03:49The reason I'm showing this is because if anyone has been in the situations, the situations I've been in are generally my sex life has been good my whole life. But there's been certain times with certain partners or you know, you might be drunk a little bit or in the day when I was single. There was like the old person who. For some reason, it just wasn't working for me. And all there was other instances in a previous relationship where near the end of the relationship, I'd like to lose my erection during sex. And that became a little bit bothersome for me because I was like, oh my God, it's like.

1:04:25It almost made me not want to have this person or it convinced me that maybe I don't like them anymore or something else was going on. And for me, it has always been what's the word use psychogenic? Yes. It's always been in my head that the problems have arose. And the other part of the thing that I've experienced a lot is in terms of libido, I have like no libido when actually it's like different. When I'm when work is very, very busy and I'm very, very tired and I come home very, very late.

1:04:58It's not that I'm not horny, but I just the act of sex is just really an appealing. But you're just like everyone else. You're not unique when it comes to that. Yeah, but that much of my life is like that. I come home late all a lot. So I'm I'm like tired and stressed quite a lot. Right, but what if I took you and your partner and put you on a beautiful island and Hawaii for two weeks? Oh, we have great sex. Okay. Yeah. So that's what we're going to be like.

1:05:35We're going to have to go to our hotel room. It's actually a bit of a game changer that you could just like go to a hotel room in the same city. Like a book of stacation. Yes. And that seems to have a big impact because it just removes you from the context. Right. And then like get going away for the weekends holidays and stuff. A lot of my friends say to me they go when they're struggling with their sex life, they just like book a book a local, a local sort of stacation. Yeah. And I wonder what I also I don't have kids. So I've not experienced the impact that kids can have. Which can have a significant impact.

1:06:09Really? Right. Because it increases your stress. Right. Particularly for many times for the partner as well. So if you both are stressed because of the children, sex goes lower and lower on the totem pole. And under slaps as well. Right. If you're not sleeping, if you're going to wake up in the dark, I'll go. Is there stats that say like when someone has a kid a sex life like vanishes for 18 months or something? I don't know. I'm not from that. But I believe it. I believe it. I believe it. I read something about post -caring a kid libido, but also sexual function. It makes sense. I see it in couples.

1:06:39And particularly, you know, many times it can take years for them to start engaging sexually because the stress is so high, particularly when they originally have the child. There was a British study done that found over 80 % of women experienced sexual problems three months postpartum with nearly two thirds still affected it six months. Yes. Which is, which is a lot of. It's a lot of women. A lot of women. Yeah. Significant amount of time. So what about premature ejaculation? Let's talk about it. Very important. So sexual dysfunction. We've been talking about ED today, right? But there are many different types of sexual dysfunction.

1:07:10There's premature ejaculation. There's peronies disease. There's gelatage. We're just focusing on one aspect. Premature ejaculation affects 30 % of men globally, 30 % of men. How did you define that? There's two ways to think about it. When they come in, you have to figure out, is this lifelong going their whole life? Or is this acquired? It's very important because it takes me down two different roads. If you say, look, I've never had premature ejaculation. And yesterday it started. That's very different than if you come to me and say, my whole life, I had premature ejaculation. And we now define premature ejaculation as having an ejaculation less than two minutes.

1:07:43You should be one minute less than two minutes. You have to have a loss of control. Like, I couldn't control it. And you have to be bothered by it. So if you tell me, Stephen, look, I ejaculate in 30 seconds and I'm happy. That's great. Then we're done. You know, you are content. You have to be bothered by the condition. The average ejaculatory time in the United States is 5 .4 minutes on average. The average time for a woman to achieve orgasm is simply 13 .4 minutes. So there's a big discrepancy here, as you can see. So 30 % of men suffer. But we know that only a small percentage, these men, 9 % of these men will ever seek therapy.

1:08:18And it can be a significant problem in a relationship that needs to be addressed. Okay, so there's not like a time limit. It's not like, okay, if you're coming within two minutes, then you've got a problem. Let's say you're not bothered by it. Let's say you and your partner are completely satisfied with it. What's the problem? Okay. What's the problem? And sometimes, if you think about acquired means that typically we define it as 50 % less than your normal time. So if you say, look, I typically use ejaculate in eight minutes. And now it's four minutes. And it's bothering me. I'd say, okay, that's an issue.

1:08:51So we talk, it's relative. What's comfortable for you? And some men will say, you know, so I think that's very important to look at the definition. The treatment options are actually quite simple. One of the best treatment options is sex therapy. Because we can train your mind. We can train you to delay that ejaculation. There's techniques, the start stop technique, the squeeze technique, how we can delay it. No, but there is. But most men say, just give me a pill. I don't know, I don't have the time for this. Just give me a pill. But there are ways to do it with sex therapy, which I think are fantastic.

1:09:20Sex therapy is a cure. The pill is just a band -aid, right? Sex therapy is a cure. But the pills that we use, the most commonly used pills, are antidepressants. Because they increase serotonin and make it harder to ejaculate. Well, that's what we want in this situation. We want to delay the ejaculation. So we can use antidepressants. They sometimes have be taken daily, which work better. Or you may have to take it on demand. But if you take it on demand, six to eight hours ahead of time. So you need some notice. But there's going to be significant side effects of taking antidepressants. Yeah, there are side effects of antidepressants.

1:09:53So I try to stay away from them. And the other ones I try to use are topical, lidocaine sprays. Because if I decrease the sensitivity of the penis, you're more likely to be able to engage in sexuality for a longer period of time. So those are commonly used. So sex therapy and sprays are very easy to use. You don't need a prescription for sprays, and they're commonly used. One thing that we have to talk about that's really important is the traverse trial. It's really big. Everyone historically has always said that testosterone is dangerous. It causes prostate cancer, and it causes a heart attack and a stroke.

1:10:27And in 2015, there were some studies that suggested testosterone may cause a heart attack. Before 2015, all the studies suggested that there was no increased risk. So in the United States, they mandated that there be a large trial, 5 ,200 patients, 6 years long, strictly to decide, does testosterone increase the risk of a heart attack? So myself and 8 others designed the study, ran the study for 6 years, and we published it last year. It finally came out. And it showed that there was no significant increase in cardiovascular events. Finally, but until that time, until that came out, many people said, I still believe that testosterone causes a heart attack.

1:11:05But when the traverse trial came out, the largest randomized placebo control trial ever published, we finally showed that giving testosterone did not increase the risk of a heart attack. In fact, the study also showed it did not increase the risk of prostate cancer. Many people are worried that testosterone causes prostate cancer and no negative effect on urinary symptoms. So many people have thought that if I give testosterone the urinary symptoms become worse, the study showed no worsening of urinary symptoms. So very important study, the traverse trial finally came out. It's the largest trial in men ever published on testosterone.

1:11:37Will it reduce my lifespan? Well, low testosterone, I believe will reduce your lifespan. I mean, taking testosterone injections and stuff. Sometimes I think about like, again, I don't really know what I'm talking about here, but I think about athletes taking steroids. Different. Okay. Those athletes are taking super physiologic steroids. So the normal range is typically 300 to 1000 is a normal range. And they will take testosterone levels to much higher, 2 ,000, 2 ,500. Okay. There's a reason for that. There's something called a plateau effect. So if you take testosterone and you have better libido, you intuitively would think, if I take more testosterone, I'll feel even better in libido, but that's not true.

1:12:20It's a certain point at which it plateaus. So the more you take, you've already hit an on -off button, you've hit it, you're done. The exception is muscle. The more testosterone your body sees, the more upregulates and receptors in the muscle, and you put on more muscle. So body builders are addicted to higher levels of testosterone, but they're also taking other off -label medications, Anivare, Deca, Winstraw. They're taking other medications, and those testosterone formulations have a lower endogenic ratio. Endogenic means facial hair, acne, they're more anabolic. So it's very different than what you're taking.

1:12:56You're simply what you would be taking. All you're trying to do is take a medication that you had before and put yourself back into the normal range, nothing fancy. So the more I've learned about testosterone, the more I've started to think that maybe when I've had my kids, and I've done having kids, and maybe I am 45, I should consider it, providing that my levels are low. And you're symptomatic. If you're 45 and you say, I feel great, I'm a cyst, even you're not getting it. I feel great. So if you say, look, I'm 45, my levels are low, and I'm starting to have symptoms. I said, okay, now's the time to consider taking the medication.

1:13:36Those symptoms you said were like tiredness, energy levels. Well, the most specific are my libido has gone down. My regimen is a worse. My energy has gone down. Increase fat deposition, decrease muscle mass, poor sleep, end depression, and we have to talk about depression. So early on in my career, I conducted a very large trial looking at depression and testosterone. And we had almost 850 patients. And we showed that men with low testosterone levels were much more likely to suffer from depression. Almost 92 % of those men with low testosterone had some degree of depression. And when we treated 17 % of those men actually had severe depression, we treated these men for one year with testosterone supplementation.

1:14:16And that 17 % dropped down to 2%. Now, I'm not advocating to treat major depressive disorder with testosterone. But what I am advocating for is to at least check a testosterone level in men who are depressed, because it can help them. In fact, in our study, even the men who are on an antidepressant, like say, Prozac, we put them on testosterone. Those men also saw significant improvements in depression. So there may be some synergy between testosterone and what we call SSRIs. So again, it's very important to check a testosterone level in men who suffer from depression. You wrote a book called Re -Coupling.

1:14:49Yes. A couple's four -step guide to greater intimacy and better sex. Yes. What are the four steps in this book? And you wrote this alongside of... Over 10 years ago, yes. So I wrote it with the sex therapist. She's an amazing sex therapist. Her name is Mary Joerpini. And we decided to write a book together to really help couples get through. So the four steps really are number one for almost communication. You got to communicate. You got to at least be able to tell each other. Did you know that four, only 44 % of men who start developing ED even tell their partners? Now think about that. You said, what do you mean they don't tell their partner?

1:15:22You know what they do? They just start avoiding sex. They just start avoiding sex. So they got to communicate. Number one. I'm making excuses, right? Yeah, I mean... If I lost my erection, I'd probably say, oh, sorry, I'm just tired of words. You know, because I want to just, on this point, much of the reason why it's hard to communicate is because it can sound a lot like blame. And it also can make someone feel like you're not into them. Right. So if I said, and maybe you're not that into them. And also maybe you're not that attracted to them. So that could be the only thing. That's an issue.

1:15:57And that's why the sex therapist is amazing. Right. That's what they do. Right. That's what they do. They work through these issues with couples and they're fantastic. But the number one step we put in the book was communication. You have to communicate. The second chapter was my main chapter, what I wrote about. What can we do to improve sexual dysfunction in men and women? testosterone replacement therapy using Viagra, vaginal lubrications, local vaginal estrogen therapy. We didn't talk about that. It's critical for post -menopausal women. Local vaginal estrogen therapy is very important. Decreases is risk of UTIs.

1:16:32Decreases pain within, of course. So very important. The third chapter really... Sir, what is that, vaginal? So younger women have estrogen in the vagina. That estrogen is so important. It keeps all the bad bacteria away and keeps the good bacteria within the vagina. It keeps the lining of the wall thick. It allows for the vagina wall to function with arousal properly. And as she gets older and she goes through menopause, the estrogen goes away. The bad bacteria come in. The risk of urinary tract infections go up. The wall starts to atrophy, means it gets thinner. It's more susceptible to injury and tear.

1:17:13It hurts. Right? So you can't ask a woman to enjoy sex if it hurts every time she has sex. A lot of women, I've had a lot of women talking about that, about this idea that the reason they don't like to have sex is because it hurts. It hurts. Because when they lose the estrogen, the wall gets very thin. And it can tear. It hurts. Good even young women. Young women, but it's usually typically a different reason. They could suffer from vaginismus. There's other things that could cause. The stabilitis, but in older women, the most common cause is atrophy of the vaginal wall because of the lack of estrogen.

1:17:47So what do you do? You give back local estrogen therapy. It can be in the form of a suppository, form of a cream. It doesn't happen overnight. I tell my patients it can take up to three months. But after three months, they notice a difference. And the urinary tract infections go away. The pain goes down. So these are simple things that women can do to help. Because again, if someone's having pain within a course, man or woman, they will tend to avoid it. It's an important concept. So the second chapter is really important on what are the many different things that you can do to improve your sexual function.

1:18:18The third chapter is really about intimacy. They're really the intimacy. And the fourth chapter really is ways to improve your sexual experience. It was written by my sex therapist. She talks about vibrators, masturbation. So there's a four step guide that I think is very helpful. And I think what's unique about this book is that really it's really two perspectives. It's one who is the medical care that I provide and the psychological care that she provides. Now, she's obviously handling the psychological side of things and she's not here. But just on this point of improving communication, what is the best advice you give to people that are currently in a situation where they're both kind of suffering in silence because they're just not communicating with each other.

1:18:59Number one, most important is time. We don't spend enough time. It's basically the shadows in the night. You coming in, I'm going out and it's you have to make time. That's extremely important. And the second one is open dialogue. You have to be able to express to your partner what you're suffering from. Otherwise, you can't get treated. You just have to be able to express it. But time, I think, is important in open communication and dialogue. There's nothing embarrassing about this. It really is something that needs to be distinctly stigmatized. And the consequences of addressing it. So couples who engage in regular sex activity have a significant improvement in their quality of their relationship.

1:19:38They tend to be happier and suffer from less depression. They are physical and emotional benefits from regular sexual activity. In the opener of the book where you start talking about communication, there's a sentence that says, when sex isn't going well, it can become 90 % of the relationship. And couples seldom know how to communicate about any of these problems. And that is true. We've done a couple of conversations now on the Diuracy about sex and intimacy in these subjects. And the amount of messages that I get from couples saying that everything else in their relationship is great. Everything is great.

1:20:11Love this person so much. But there's this massive elephant in the room. Right. No pun intended, which is the lack of sexual intimacy. Now, when we talk about sexual intimacy, does it mean penetration? Yeah, it doesn't. Because the definition of sex span is the ability and the desire to engage in satisfying sexual activity. I have patients that come to me and say, we do not have penetrative sex, but we have a wonderful sex life. I say, great, if this is working for you because satisfying sexual activity, you're set. It's if you want penetrative sex and you cannot have it, then we will address it and we can fix it.

1:20:50But you get to define, Steven, you define what is satisfying sexual activity. On chapter four, where you talk about things like vibrators and stuff like that, I know that was the the chucked handle by your sex therapist, according to what you said. Is there any risk that using vibrators or other toys and tools will impact normal intimacy without vibrators? Like, is there any studies that say, okay, you get desensitized to the real thing if you start using a vibrator? Yeah, I've seen the opposite. I've seen that the study is showing that vibrators and these kinds of toys can actually enhance the ability of the relationship so that you can because you're communicating as you're doing it.

1:21:27So you're communicating with your partner, what is giving me pleasure, what is not giving me pleasure? You're learning about each other. It's a great tool to use to learn about each other. So when you're engaging in sex activity, you're more aware. I think it was a game changer for me. I'm going to be honest. I think like just having other things. You know why? It's a game changer. And I'm not just talking about vibrators, I'm talking about all toys in the bedroom, whether it's like dice or handcuffs or whether it's something else or blindfold, is just because novelty, doing new things for me is so critical, as it relates to being excited sexually.

1:22:02And there's only so many things you can do. There's kind of, there's a relatively limited list of things you could do. If you're not bringing in other tools and toys and stuff, you know. So I think that for me, it actually has helped me to prolong the novelty of my sexual relationship. In a way that nobody told me about before. Because I think, I think as a guy, especially, I think you kind of think that toys are something you're partner buys for herself, maybe. Yeah. Something she uses for herself. And now I think if anything, I'm the instigator of using other things. Yeah, chapter four. I mean, and we, and we prescribe vibrators for men.

1:22:40We sometimes call vibrrect. It helps with men with delayed orgasm. These toys can be very helpful in a relationship. I think she prefers the toys to me, personally. That's another conversation for you all the time. In terms of energy, there are so many reasons why I'm a big match up fan if you don't already know by now. And so much so that I actually invested in the UK's leading match a company called Perfect Ted. And one of my favorite Perfect Ted products is these delicious matcha pouches that come in every flavor from salted caramel to peach flavor, to mint flavor, to berry flavor. One of my favorites is this vanilla flavor, which I'm going to make in just two seconds.

1:23:17You just take this mixer here, get a little bit of a powder, pop it on top of the shaker like that's lit on. Shake, shake, shake.

1:23:32Delicious. If you haven't tried this yet, you can find Perfect Ted at Tesco and Holland Barrett stores or online where you can get 40 % off with my code, diary 40. Head to Perfect Ted .com and put in code diary 40 to try this delicious multi -flavored matcha now. Highly recommended. If you do it, please tag me some e -message online. What's the most important thing we haven't talked about that we should have? Well, there's a couple of things I want to talk about. One is we didn't talk about Peroni's disease. It's an important disease. 9 % of men in the world suffer from Peroni's. 9 % of men in the world.

1:24:04Peroni's disease is an abnormal curvature of the penis when it's erect. So once you think about this, the way I can describe it is I have a balloon. I put a piece of tape on the balloon. I blow the balloon up. What's going to happen? It's going to curve in the direction of the tape. So if a penis curves greater than 60 degrees, it's prohibitive for intercourse. Many of these men suffer from severe depression. It's this figurement. It's this figurement of the penis. So think about it. 9 % of men in the world suffer from this condition. Most men have never heard what Peroni's disease is. And essentially in the US, we have now one FDA approved treatment for this.

1:24:40It's an injection called collagenase where we can put an injection into the rock, the plaque, and break it up. There are surgeries that we can do to make the penis straight again. But again, it's very important to realize that patients who have Peroni's disease are also suffering in silence. They don't know where to get the treatment. And there are many good treatment options whether it be surgical or medical to solve this condition. So my whole take away from this is this. I know that millions of people right now men and women are suffering from sexual dysfunction. I know they're silent and they're not saying a word because they don't know where to go.

1:25:11They know what to do. But they have to realize that there are excellent treatment options available and they should seek therapy. They're not suffering alone. What else? I want you to think about sexual dysfunction as no longer a band aid. We are not looking for a viagra. We are looking for a cure. We want a cure for ED. And a cure for ED could be based on many things. As I mentioned earlier, diet, exercise, sleep, stress. We've also moved into a new generation of regenerative therapies in my field. Stem cells, PRP, shockwave therapy. Now we're starting to look at radio frequency in our laboratory.

1:25:48We're looking at hyperberegoxygen. Men are looking for ways to cure this condition. They no longer want to take a pill to solve the problem. And so I think that's very important. And many of these new therapies are promising. I think shockwave therapy is very promising. Well, we have a device that delivers shocks to the penaltissue. We've been doing this. It's like... It's fucking amazing. Yeah, it's fucking amazing. But I'll tell you, we've been doing it after five years. And it was invented in 2010. It's actually quite brilliant. If I take your finger and I take a hammer and I hit your finger multiple times, what do you think your finger is going to do?

1:26:22Your fingers are going to start bringing in new blood vessels and new ways to heal your finger. So before urology, the cardiologists have been doing it for the heart for many years. And they would shock the heart many times. And you would see new blood vessels forms called neo -anogenesis. Orthopedic surgeons have been doing it for a long period of time. In terms of injury, it's sort of healing injury that use shockwave therapy. We are new to the game. But what we see is when you give these shocks, it can potentially improve the blood flow and sexual function in men. And I think the new era could potentially be hyperberegoxygen therapy.

1:26:52And also radio frequency. Radio frequency is a way to increase heat within the tissue and improve sexual function as well. So again, I think what you're going to see five to ten years as we move forward is new ways to cure erectile dysfunction stem cells. I potentially have some promise as well. But patients don't want a pill anymore. One thing we haven't talked directly about, but we've talked about indirectly, is the role that trauma plays in sexual dysfunction. And trauma in all of its forms. I think I had a partner who was very public again about the fact that the reason why they had sexual dysfunction was because in their view, because they had been through a sort of traumatic experience, how often do you see that in your office?

1:27:33How often do you see a patient come to a man or woman with some kind of trauma? We query all men and women if they've had any kind of trauma, sexual or just physical trauma. It doesn't have to be sexual trauma. It's going to be any kind of physical trauma. I will tell you that most patients don't disclose or not very commonly described to have having it. But there will many times disclose it to the sex therapist, and I'll find out on the back end to be honest with you. But I think when someone discloses sexual trauma or trauma, it takes more of a relationship in time. And on the first visit, sometimes they're not forthcoming.

1:28:09What's that that you have in front of you on the desk? It's, I've been hesitating talking about this. This is a PNL implant. Oh gosh. And this, yes, that's exactly what it is. And this is a device that was invented in 1973 by a very famous urologist named Dr. Brantley Scott. Brantley Scott, I will have to brag a little bit, was from my institution, a Baylor College of Medicine, and it's been around for 51 years. And the penis actually has two bodies sitting on top, and they have the urethra sitting on the bottom. And those two bodies have muscle inside them, or casing. And what this device is, the surgery that I won't quite often, where we put these balloons or cylinders into those two bodies and fill them up.

1:28:50There's a small pump that goes into the scrotum, and there's a small reservoir that just holds water, normal saline, that goes behind the pubic bone, typically. When a man squeezes this, he starts filling up these cylinders with water, and it gives him a very rigid, very good erection. When he finishes engaging in sexual activity, he'll press this button here, and it will actually release, and all the fluid will come out of the peanut bodies, and go back into that reservoir. So theoretically, anyone who's willing to have this surgery, we can cure ED, but it's a surgery. And what's the consequence and cost of that in terms of sexual experience?

1:29:30So monetary costs, I would say that in the US Medicare covers this product, so that's actually quite good. In terms of pleasure, and men report no significant decline in pleasure. If you look at overall satisfaction, it's greater than 92 % for patient and partner with the peanut prosthesis. So it is a very, it's a game changer. It really is a game changer. Most patients have never heard of it, or most people have never heard of this peanut prosthesis. But let's be honest, if you had a bad shoulder, you'd get a prosthetic. If you had a bad hip, you'd get a prosthetic. It's a prosthetic that fixes an organ.

1:30:09And it's even, the satisfaction rate is extremely high. But I'll tell you something, you owe me something, because when I brought this on the plane, and I went through security, they may be pulled us out and explained what this was, and nobody had heard of it. No one had seen this. Well, I had to explain it, and I had to pump it up and show them, but I had a little bit of an audience. But yes, but I'll tell you this, this is something that really has revolutionized as early treatment for rectile dysfunction. But this is surely like a last ditch attempt. It is because it is a last ditch attempt.

1:30:41Because if I take it out, no other treatments will ever work again. Oh, really? It's the end, right? So if I take it out, no other treatments will work again. So I want you to try every single option before we come to this. Well, situation does someone have to be in for you to insert this into their penis. So remember when I told you that 40 % a minute, 40%, 50 % of the idiot, and most patients will take Viagra, but I told you Viagra is not a cure. It's a bandaid. So what's going to happen? That Viagra is just like that pain pill. And that pain pill, eventually, what's going to happen is you can't walk.

1:31:14Or the same thing happens with ED. Eventually, the meds stop working. Right. So once the meds stop working, and then the second level, we use something called penonjections. Some men will use penonjections. Once you've tried everything, and nothing works, what are you going to do? Okay. So this is like a last ditch attempt. If you still want to get, but if I look at satisfaction rates, if I give men questionnaires for the pill, for the injections, vacuum reaction device, for the implant, highest satisfaction with the implant. At what point? What would you mean? How satisfied? From the starting point to.

1:31:49Right. Because from starting at a point where I'm completely unable to get an erection. Right. If anyone helps me get that thing up, my satisfaction is going to be really high. Right. But let's say you have an erection with a pill, you get an erection with an injection, you get an erection with a vacuum, and you get an erection with this. All four, you know, over time, gave you an erection. Which gave you the best erection, and which one were you most satisfied with? This will win. It's crazy. And can you still ejaculate with this? Yes. No issues.

1:32:18Gosh. No. I mean, again, I have to, I have tremendous sympathy because it's, it ruins people's lives, right? Yes. If you, if you can't perform in that way and it just rows your relationships and relationships are like the essence of life. So. But essentially taking someone who can't have sex, we can now have sex again. And someone argue that they can have sex whenever they want, as long as they want, with this device. Right. It only goes down when you tell it to go down. Dr. Mo, we have a closing tradition on this podcast where the last guest leaves a question for the next guest, not knowing who they're going to be leaving it for.

1:32:49Yeah. And the question that has been left for you. No. Is, have you ever experienced anything that you cannot explain from a position of rational materialism? I mean, I think so many things in science that we can't explain. So many things that are idiopathic that I have no explanation for. That, for example, for fertility, which is something we talked about, 40 % of men who come to me, our explanation is no explanation. We don't know why you're infertile. Right. So obviously that's very uncomfortable for many patients to hear that. But many things in science, I have no explanation for. And many things that I do have an explanation for, we find out 10 years later, we're wrong.

1:33:31So I think that's what comes to mind. What about any personal experiences at all in your life? Spiritual, religious? Yeah. I'm very spiritual. I'm very religious. Sometimes death. It's hard to explain, hard to understand. Why? It's real. I see it every day. You know, we see it. We do work. I see it personally in my own life, my father passed away at an early age from idiopathic pulmonary fibrosis. It's a condition where your lungs start to scar. It's probably the worst condition you could ask for. And he had to have a lung transplant at 70. So it was pretty young. And he retired at 69. And said, you know, when it worked very hard, he was a general surgeon single, you know, solo practice.

1:34:23And he said, one day I'll enjoy, one day I'll enjoy. And then it's 69. He retires. He's ready to enjoy. It's 70 gets idiopathic pulmonary fibrosis. It's 70 gets a lung transplant and lives for five years with someone else's lungs, which is pretty tough. And his one message was, you know, don't wait to the end. Enjoy the ride. I wish I'd enjoyed the ride. He was waiting to the end. Sometimes there may be no end. And by that, I interpreted that to me and that he had worked his whole life very, very hard. Extremely hard. And he sort of delayed the gratification to a point that it didn't really come necessarily.

1:35:03He thought it would come at 70. And he had to enjoy the last 15 years and enjoy. But at 69, he got idiopathic pulmonary fibrosis at 70. We got a lung transplant and it's 75 years passed away. And I think that if anything I learned was, don't wait to the end. Enjoy the ride. Are you doing that? I am. Every second. I can. And how do you do that sort of practically when you're so busy? So I make time. I meditate every morning. I work out every morning. I have my own time to myself. I pray very religious. I think those were very important things that keep me going. I spend it. It's God family work patience.

1:35:44I mean, it's order my family is extremely important to me. And I make time for them as well. And I think that keeps me grounded. Dr. Moe, thank you. Thank you for the work you're doing. Because as you say in your work, there's a huge proportion of people, couples, men, women, that are suffering in silence. And there are in search of answers. And there's not a lot of people in your friendship group that are necessarily going to know this stuff or even talk about their own experiences with this. So I think it's important to have these kinds of conversations that anyone in the private or comfort of their own home or with their air pods on can tune into to get a better understanding.

1:36:15If there was a closing message for those people that are suffering in silence in some way, whether they're couples, individuals, what is that closing message to them? It's okay to suffer from sexual dysfunction. It's normal as we age. And there are many treatment options, good treatment options that can help you today. And I ask you to seek therapy. Raise your hand. Tell your doctor you suffer from sexual dysfunction because they're excellent treatment options. And if people want to learn more about you and your work, where's the best place for them to find you? Well, it's my website, drmoeukera .com and sexbandhealth .com.

1:36:53I have sexbandhealth .com where you can learn all the different ways to improve lifestyle modification. I started a nonprofit. I just want you to know, call the Testosterone Project just so you know that. It's really geared at education, advocacy for Testosterone. We're trying to get Testosterone approved for women in the United States. I think that's important. We're trying to get testing done as well. We want everyone to be tested for Testosterone. It should be norm as well. And we're trying to get it deregulated. So the TestosteroneProject .com is a great way to get information as well. I'll put all of those links below.

1:37:24Dr. Moeukera, thank you so much for the work that you're doing. Please do keep doing it because it's so incredibly important. Pleasure to talk to you. Thank you. Do you know that 80 % of New Year's resolutions fail by February? It's because we focus too much on the end goal. And we forget the small daily actions that actually move us forward. Those actions that are easy to do are also easy not to do in life. It's easy to save a dollar, so it's also easy not to. Making one small improvement each day, one tiny step in the right direction has a big difference over time. And that is the 1 % mindset, which is why we created the 1 % diary.

1:37:55A 90 -day journal designed to help you stay consistent and focus on the small wins and make real progress over time. It also gives you access to the 1 % community, a space where you can stay accountable, motivated, inspired, along with many others on the same journey. We launched the 1 % diary in November and it sold out. So now we're doing a second drop. Join the wait list at the diary .com and you'll be the first to know as soon as it's back in stock. I'll put the link below.

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