The Fertility Expert: Delaying Having Kids Is Impacting Your Future Children & Reducing Your Chances Of Parenthood By 90%! Masturbation Reduces Cancer Risk!

23:12And or anything that you, it's kind of made you think differently about the choices you make in your own life with your kids, because you've got three kids. So you have an opportunity to kind of influence them at an earlier stage than most of us can influence ourselves. But yeah, so one thing that we do is I've thrown away all plastic water bottles. I would say I still use it because I find them very convenient. And I'm done with reproduction, but, but certainly for the kids, I make sure they don't drink out a plastic water bottle. So we have either glass or, or metal. I do think there's data that that's, you know, a very, you know, large exposure that kids get.

23:49And I think it's, you know, fairly easy now to remove that. What is the day to say about plastic bottles? You know, if you look at, you know, exposures from that, you know, they have, they just leach a tremendous amount, you know, with wash with water. It kind of sits there all day. So I think it's a, it's a very, you know, again, most plastic water bottles want the plastic bottle industry to come after us. But, that's a common way for, you know, individuals to get exposed to it. So I think if, again, if we're seeing that's one of the main touch points for plastics is usually through our kind of food and water supply, then, yeah, I think it's easy to get rid of it if you can.

24:28Is there anything else? I've read recently that heat has a role in our sort of sperm quality. So if we're, if we're going into soreners or something, or if we're spending a lot of time on a sunbathing, then there's science that suggests that will lower our sperm count. Yeah, so that is right. So, I mean, I think that, you know, again, you can kind of look at this sort of in a bigger sort of global warming kind of context. And people have, you know, theorized that maybe that could also play a role because, you know, the testicles are outside the body because they need to be a few degrees cooler for sperm production to occur.

25:01So anything that warms them up can definitely be a problem. So when I talk to patients in clinic, for example, we do talk about sauna use hot tub use some men bathe every day, like in a bath. And those all can impact sperm production. There have been studies to show that men that, you know, use, you know, sauna is on a regular basis, they have lower sperm counts. And then when you withdraw that exposure, sperm counts will go back to normal. One, you know, sort of interesting application of this was to try and use this data or use that knowledge to come up with a contraceptive. So there was this weird sort of like trust kind of belt that actually pushed the testicles up into the groin, which actually turned out did reduce sperm counts to zero, I think, and again, the few men that volunteered to do that.

25:46But you can imagine, I think most men are not going to be too excited about that. Because it's probably pretty uncomfortable. The other way that I've seen it is I've had patients that have gotten sick certainly around COVID that happened not infrequently men would come in, you know, telling me that, you know, they just got over a COVID infection that where they had high fivers for, you know, a few weeks. And then their sperm counts to be very low. And then, you know, we wait a few months, it takes about two to three months to make a sperm. So we let one of those cycles or two of those cycles go through and their sperm counts came back.

26:16I had a patient even before COVID, like 41 year old guy, he had normal sperm count. And then all of a sudden, he measured and the sperm count had gone to zero. And it turns out he had a flu with fivers about 102 degrees Fahrenheit. The week before. And again, we let kind of sort of nature take us course. He recovered. And then his firm counts came back to baseline. So we do see that as well. With that belt that you mentioned that it holds the sort of test testicles closer to the body. I'm guessing it's doing that to heat them up basically, which reduces the sperm count. Obviously, then one would think about their boxy shorts.

26:52We're all wearing very tight boxy shorts these days. That's like in vogue or whatever. So is there any studies to suggest that boxy shorts can reduce sperm count if they're tight. So that's like a very calm. That's one of the most common questions I get like boxers versus briefs. And that's been studied a lot because that is a very common exposure. I think I usually just tell men whatever's comfortable. I think it's unlikely that any single layer is going to make a big difference. Unless again, you have the specially designed underwear that pushes testicles up into the groin. But otherwise, as long as they're outside the body, it should be OK.

27:23What about mobile phones and technology? Is there any link between fertility and our use of technology specifically having these devices in our pockets close to our genitals? That's another common question that I get. And that is certainly something that's changed right now versus 20, 30 years ago. So there were some studies that initially showed kind of this signal that men that use cell phones more had lower sperm count. But some of these studies were, you know, they're older and you also worry about some of these kind of confounding things. It may be that people that use phones more do other things more.

27:58You know, they have may have more stress in their life and other things that could affect seem equality. So there was a clever study that was done where they actually took a jacket. So it took sperm, put it in a cup and put a cell phone next to it and tried to measure changes and, you know, the quality of the sperm. And they actually did find some they found higher rates of like DNA damage within the sperm that was exposed to the phone versus not. You know, kind of trying to control for temperature, which we, you know, said is important for the help in the sperm. Wait, so they controlled for temperature, they control for temperature and just having kind of the cell phone, you know, getting its signal seem to affect, you know, the DNA damage and sperm.

28:35It wasn't, you know, it was a statistically significant, you know, difference. It maybe would not be kind of a point where we would get as worried clinically. But it is a change. So I think it's something to think about. And I think that, you know, aside from that, cell phones, I think nowadays don't get too hot. So not as worried about heat, but whether this RF, you know, this radio frequency exposure may impact things as a, you know, maybe a theoretical risk. But again, there's not a lot of concrete data. So I think that, you know, again, I saw a lot of my patients do tell me that they keep their, try and keep their cell phone in their back pocket or front pocket to try and avoid that.

29:09I think that's, that's fine. I've been having this conversation with my partner a lot. She really believes that my cell phone should never be slid under my genitals, which I sometimes do. When I'm like, I don't know when I'm in the car or something or when I'm on the sofa, I don't know when I've got my hands full, I'll just grab it and I'll kind of slide it between my legs. Yeah. And she'll be reaching and pull it out and say, and I think she's concerned about those four kids that we want to have. I think she cares about you too. Yeah, to be fair, she's not someone that's going to read PubMed and read about the studies, but it's just a feeling she has.

29:43Yeah. And I always refuted it and thought, now there's no way there's no way because they would have tested it. And it's the test seems so easy. You get sperm, you put it in a little thing, you put the phone on top of it, send it some text messages, connect us to Wi -Fi, the Bluetooth and see how the sperm get on. Yeah. I didn't realize there was a study associated with it. Yeah. I think laptops also can do that too, but they also have a little more heat associated with it. So a similar study was done in laptops where they had sperm put it next to a laptop and they controlled for temperature and saw the same pattern.

30:14You know, again, sort of the Wi -Fi signal can also affect against sperm DNA damage and sperm quality. But also laptops can get warm too, right? Some of the batteries, some of the moving parts within can heat up too. And it also just serves as almost like an insulation if you put it over your lap. So I do talk to patients about that as well, you know, to maybe use like a pillow or something else just to try and shield yourself a little bit. But wouldn't we see a sort of big difference between hot countries and cold countries, or sort of warm countries and sperm counts then? So if I'm in sort of sub -Saharan Africa, I'm assuming my sperm count will be pretty low because I'm going to be sweating all day.

30:51So I think that the other sort of elements of that though is that there are differences in populations. And I think that that has not been well described, you know, but if you compare, you know, again, we talked about California, New York, the Midwest, and the United States. But people have also compared, you know, like Denmark, which they have a lot of sort of problems with reproduction. So they've really studied it very, very aggressively. And if you compare them to other countries nearby or other countries in Europe, it's much different. And so, you know, a one possibility could be exposures, you know, and what these men are doing, what they're exposed to.

31:24But the other could be, you know, again, there could be some genetic components. But one interesting thing about sort of on that same line is that sperm quality does vary based on a time of year. So during the hotter months, it does go down a little bit, you know, not meaningfully. And then during the cooler months, it goes up a little bit. But the other thing is that, you know, we don't spend some of us do, I guess, or some of us don't. But no, spend all your time outdoors, right? And sometimes during the cooler months, you're kind of bundled up inside. And during the warm months, you're maybe in cool air conditioning.

31:59Did you say that was Denmark has had a problem with sperm count? Yes, yeah. So, you know, in the United States, I said that about 2 % of births can see with IVF. And Denmark, it's about 10%. Wow. And it's actually, they again, they have really a crisis of reproduction here. So they've really done some really good research on semen quality. And it estimated only about 25 % of Danish men have normal semen quality. Have they figured out why? That's what they're looking into. They have lots of theories. And again, I think, you know, again, it goes to many of these same topics that we talked about, whether it's environmental exposures on, you know, mothers, or, you know, again, pubertal boys or, you know, adults as well.

32:40So they are trying to figure it out. But it is, you know, it's also one of the countries where the fertility rate is below replacement. So it's definitely an issue. One would assume that it's some kind of environmental factor. I guess it could be some other social factor, but one would assume that it's some kind of environmental factor. Yeah, some people have postulated during World War II, they're very isolated. And so potentially there were some chemical exposures that are just, you know, kind of persisted and remained in the population. And it's kind of tough to work through that, but it's not known.

33:13If I'm sat down all day, is that going to have an impact on my sperm count as well? Because of the heat generated from me just sitting here. And or if I'm a cyclist, or someone that's doing, you know, sat down on my testicles, doing something warm. People have looked at sort of different occupations where you sit a lot. And there are associations like drivers, you know, taxi drivers, truck drivers. They certainly can have changes in sperm count, you know, probably due to heat. You know, again, I think it could be a combination of sort of sitting all day is also, you know, from probably other health standpoints is not great.

33:47And cycling too, you know, people have looked at sort of peak athlete cyclists. And there are differences in seam inequality. But, you know, peak cyclists, you know, they do a lot to their body. And so, you know, it's possible that there could be other effects too. But, you know, looking at men that sort of recreationally cycle too. I think that the number that I use, there's a study that showed if you cycle over five hours a week, there can be lower sperm counts. So, you know, I talked to men about that when they do cycle, you know, more than that. You know, potentially taking breaks, trying to stand up if we think the mechanism is heat to try and sort of circulate air out the area to spend some time out of the saddle if possible.

34:25What about men with big thighs? Yeah. Well, I think, you know, obesity is an issue. There's certainly a strong correlation between body mass index and seam inequality. So, as men get bigger, sperm counts go down. And so, heat is certainly one of the possible mechanisms for that. Just kind of insulating that area, warming things up can kind of do it. You know, obesity also affects, you know, the, kind of hormonal axis as well. So, that also may be it, it play too, because, you know, there's kind of a normal simulation that's given by your pituitary and your brain. And that tells your testicles to make sperm, make testosterone.

35:00And some of that's also affected by obesity as well. So, it's probably a combination, but that is something I do think about when I see, you know, my patients. And we do talk about sort of heat exposure as well and see if there's a different sort of strategies they can use to try and allow more circulation in the area. Is there a link between sperm counts and alcohol consumption? I think it depends, is what I would say. So, in general, for most kind of moderate use, I would say kind of a drink a day. And some people think that no amount of alcohol, you know, is safe. But probably if you look at these studies, looking at maybe a drink or two a day, probably doesn't correlate too strongly with seam inequality.

35:39But it seems like there are some studies that say that one men get to three a day. So, maybe 20 a week, there can be lower quality in seamen. And there is also another study that we did looking at, you know, to see if some men are more susceptible to alcohol intake. So, there are some East Asian men and women that have a mutation in one of the enzymes that's used to metabolize alcohol. And so, they accumulate what's called acid aldehyde, which is toxin, actually. And so, when they drink, they flush. I don't know if you have any friends that have this. But we have hypothesized that, you know, when you have this large load of this chemical in your body that leads to flushing headache, dizziness, maybe it also affects seamen quality.

36:22And it turns out that it does. So, for these men that have this mutation, when they drink, their sperm movement goes down a little bit. So, it turns out that there's actually a reasonable number of men on earth that have this. You know, it's probably in some populations up to 50 % like in Taiwan. You know, it's very common in Japan, men with Chinese, Vietnamese ancestry. So, I think it's something to be aware of. And I think usually, you know, men do know if they flush when they drink. It's probably because they have this mutation and aldehyde dehydrogenase too. So, you know, for those men, I think that it's probably better to, you know, avoid alcohol or just sort of be aware because it can affect seamen quality.

37:03If I came into your clinic and I said, Dr. Michael, I'm trying to have a kid with my partner. And I want to make sure that everything I'm doing is giving me the best chance of having a kid. What's the list of things? Because this is basically where I am in my life now. I'm 31 years old. I want to have a kid. I'm ideally, I want to have four of them. And I'm thinking about the time, my partner's the same age as me. We're almost identical in age. And she's 31. So, we've got, you know, we want to have these kids before 40, ideally. So, I kind of need to get going. Get going. You know what I mean?

37:38So, what can I do to give myself the best possible chance of increasing my fertility, my sperm count? So, that we have those four kids that I want over the next nine years. Was the four number, it was something you came up with before that tax incentive or?

37:56You know, we are planning to move to Hungary. So, there you go. It was really about tax avoidance. It's not that I want kids. I come from a family of four. So, I've always had four in my head. I think she's fine with it as well. I think we've chatted and she's happy with four to six. That's a good number. I've had six signed off, but four for sure. What would you say to me then? So, I think, you know, we look at, you know, your overall health. You know, it's you and if risk factors you had, obviously we're talking about sauna, hot tubs, buying out, you know, how you exercise, if there's things that you do that are not, you know, good.

38:30Look at, you know, if any medical conditions that you have, surveys that you've had, some of those can put men at risk for that. If there's any medications you're on, there can be medications that affect it. And then we'll do an exam. So, we don't have to do that here for the cameras. I'm down. I do, yeah, I do have a California let medical license. So, you know, we want to make sure we look at the sides of the testicles, make sure all the other structures are where they're supposed to be. You know, one of the basic evaluations will be a cement analysis. So, we'll measure how much comes out, how many sperm there are, look at how many are moving, look at their shape as well.

39:04And then usually we also check hormones as well. So, we'll check testosterone. Again, this sort of is very male hormone. The testicle does two things. It makes sperm, makes testosterone. So, we check that. And then usually we check some other hormones involved in the kind of hormonal axis that controls reproduction. And that's usually what we start. Again, fertility is a team sport. So, I would encourage your partner to also get evaluated as well. And we'd see, you know, depending on kind of sperm counts, usually then we're able to sort of counsel about, you know, how likely you are to be able to achieve, you know, those four kids.

39:32But, you know, again, if you're kind of thinking about four, I would agree that you should get started. Fertility issues, we tend to think of it, I think there's a stereotype that it's typically the woman who has the fertility issue and the man is okay. And I think if you, when I looked at the data, that's kind of supported. This idea that couples assume it's the woman that has the fertility issue. Is that a misconception? It's a huge misconception. Yeah, so absolutely. I think that, you know, in the United States and other countries too, I think usually, you know, women are kind of a gatekeeper of fertility.

40:05Everybody assumes that that's where the issue lies. But if you actually look at, you know, the data, probably about half a time, there's a male factor contributing. And you know, this sort of stereotype is so prevalent that probably at least a quarter of the time in the United States, the man is never evaluated. And he could be, you know, one of the issues. So some couples may go to IVF, you know, for the loan reason of, you know, again, low sperm count. And the man would never evaluate it. And maybe there is a condition that we can improve. Maybe he's on a medicine. Maybe, you know, he's going to jacuzzi every day, you know, something like that that we be able to reverse.

40:37You mentioned testosterone would be one of the things that you would measure if you were trying to make sure that my fertility was good. Mel testosterone decline. This is another hot topic. He talked about it at the start of this conversation. Is it true that Mel testosterone is declining? And how much has it declined to buy? Yeah, so again, study from this endhains, this CDC, you know, measuring men every year for the last several decades. If, you know, there's data that shows that testosterone levels have gone down over time. You know, people have also looked at, you know, other cohorts of men, you know, from the 2000s and 90s, 80s.

41:13And there's just a progressive decline in average testosterone levels over that amount of time. So, you know, the amounts, you know, kind of very 50 to 100 points. But, you know, generally, these are, you know, meaningful, measurable amounts. In addition to sort of these kind of cohort changes, where if you kind of, you know, look at the average four -year -old now versus, you know, 10 years ago, our testosterone levels change too. So, I would say that I usually tell them that after the age of 20, your testosterone is going to go down maybe about a percentage point every year. So, as we get older, testosterone does go down.

41:42And there's things, again, that can affect that trajectory. You know, men that get more obese, that also affects testosterone level. A portion of all of our testosterone is converted to estrogen. A lot of that conversion happens in, you know, adipose tissue or fatty tissue. So, the more kind of extra tissue there is in the body, the more that conversion will happen. And so, your, you know, effective testosterone levels will be lower. What about movement and exercise? Does that have an impact on our testosterone levels in a significant way? Yeah. I mean, I think that, you know, the more walking you do, the more active you are, we've looked at that as well.

42:14You know, step count is directly correlated to testosterone. And you don't have to take 20 ,000 steps today, you know, 4 ,000, 8 ,000 steps today, you know, just kind of walking around, you know, sort of reasonable amounts. It can make a big difference. And I think that, you know, activity is important. It probably also helps stave off obesity a little bit as well as another mechanism. Okay. So, I'm a men just United fan right now. We're losing a lot. I thought you guys had turned it around. Yeah, I thought so too, until last week. Okay. So, if you're supporting a team that is losing your testosterone levels are likely going to be lower.

42:46Well, I think this is sort of a cute thing. And maybe we could do that experiment, right? What is that research come from that if your team wins your testosterone increases? I don't remember. I've, that study's pretty old. I think that even predated my training. But I do remember reading that. I think that was one of the articles that get picked up by the newspaper. Okay, of course. Why does testosterone matter? Well, I think testosterone is very important for, you know, a lot of things. I think it's important for our quality of life. So, energy level, sex drive, mood, sleep, concentration, all those things are very important.

43:20When testosterone gets very low, it also has a lot of health implications. So, muscle health, bone health, heart health. So, we do want to keep our levels in a normal range. Because I think it, yeah, kind of helps us with our function and our life and happiness. How does it impact our sort of muscles and bows? I don't really understand what testosterone is doing. I kind of think of it as the chemical that kind of makes you a man. I know women have testosterone too, but I just think of it as the chemical that makes my beard grow in my voice deep. Yeah, well, that's what it's doing. But it's anabolic.

43:51It does help kind of grow. It helps with bone turnover and kind of keeps sort of, you know, the strength of the bones. So, men that have very low testosterone levels have, you know, frailer bones, higher risk of osteophenia, osteoporosis. So, you know, I think it helps with muscle growth, bone turnover, bone strength. So, I think all those things are important. Usually, don't get into those problems unless men are very, very low. I would say that, you know, I don't know you, but you know, the average testosterone levels are probably 300 to 900. I would guess probably I'm a higher, higher end of that.

44:27But, you know, when men are low, probably less than 200, 100. That's where we start to worry more about, you know, bone health, muscle health. And so, I think that there is some wiggle. But when you get kind of lower than sort of the normal ranges, kind of the 300 ranges, that's when some men do develop, you know, some of the symptoms of lower energy level sex drive problems, things like that. So, low testosterone typically means lower sex drive? It can. It's one of the common symptoms that we see with that. Does that mean that if I just take loads of testosterone in my sex drive, it's going to go back up?

44:57You know, the last probably 10 to 20 years, the number of prescriptions of testosterone written in the US have kind of gone up almost at an exponential rate. And because people did think of it sort of as a kind of an anti -aging kind of rejuvenation therapy. And so, there was hope that it would help people. But if you look at some of the randomized trials, if a man has a normal testosterone level and you give him testosterone, it may not help him that much. Even men that have kind of a low -ish testosterone, like we talked about sort of this 300 cut point. So, I've had plenty of patients test testosterone of 250, let's say.

45:28So, we talk about risk and benefits of being on testosterone. We'll try them on it. And, you know, a lot of men do feel better, but not everybody. Some men say, I don't feel any, you know, do I can't feel any different, even though we get his levels, you know, from 250 to 500. And so, then it's probably not worth, you know, to be on a medicine every day if it's not helping you. I'm not worried about his bone health, you know, we'll check some other measures to make sure that's okay. So, then it's not, you know, again, when you look at risk and benefits, it's probably not worth it. But there are certainly some men who do, who do you see improvement?

45:55So, is testosterone hurting some people, their testosterone treatments? Does it actually have an adverse effect if you take it basically when you don't need to? I mean, even when you do need to, I think it could sometimes cause issues. Yeah, there are certainly side effects to testosterone. You know, one of the big things that I see in my practice is how testosterone impacts sperm production. It actually was tested as a contraceptive by the World Health Organization because it does lose lower sperm counts in most men. I would say 90 % of men. Now, it doesn't do 100 % so it's not that great of the contraceptive yet.

46:28They're kind of working on some other ways to tweak it. But I have plenty of patients that come in, you know, some of them suspect that testosterone is the issue. Some don't know. I remember one couple in particular, they came in as a couple together. You know, we measured his sperm count. It was zero. We started talking about risk factors and he was on testosterone. I said, well, the best thing to do would be to stop testosterone. And for his work, I'm going to tell you what he did, but for his work, he really couldn't stop it. So there's some other medicines we were able to add while he continued to the testosterone.

46:58And then they ended up with triplets shortly thereafter. So I think that, you know, men need to be aware of it because that's, you know, certainly one of the big risk factors, at least of reproductive age men, is this risk to fertility. So it can impact my sperm count negatively. Sort of quote from you that said, if we take a hundred of my infertile patients that I see in the clinic, at least five of those men will be infertile because they're on testosterone therapy. One in 20 infertile men are that way because of testosterone as relates to infertility. One of the things that I've always worried about is if I take testosterone, then my hair would fall out.

47:39Yeah, so that can definitely happen. So, you know, hair loss, breast growth, acne, those can all occur. I would say those are things that we can monitor. So, you know, one thing I always tell men is that we're not trying to get them to superhuman. Right? We're just trying to get you to normal. So I think if we monitor it closely, most men, you know, will do okay. Again, there are some other therapies that we can do for men that have side effects, you know, from those things. It can also affect the thickness of the blood, something called the hematocrit, or we count the number of red blood cells in the body.

48:08It can increase that number. So if it gets too high, that can be an issue. So that's another number that we follow. There used to be a concern about higher rates of heart attack and stroke with testosterone. So there were some studies done, you know, about maybe 10 -year, five, 10 years ago that suggested that. But a really large trial just came out with about 5 ,200 men, having them randomized to testosterone and half -not. And there was actually no difference in the risk of cardiovascular disease. So I think that's something that we can probably put to bed. The other thing that I'm then worried about is increase of risk of prostate problems.

48:41Prostate cancer, prostate growth, and you know, that same trial also showed that from a prostate standpoint, probably not a lot of risk as well. Do you have many men coming to you to talk to you about halos? And balding. Some men do. I think one of the ways that men talk to me about it is one of the common medications for that is finasteride. Or, you know, solvent -and -trade name propisha. And so they want to understand some of the risks of that. And so, you know, when that medicine was approved for a hair loss, they, you know, again, because people are going to take it or usually in their reproductive age, they did randomized placebo -controlled trials to look at semen quality.

49:19And it turns out that it didn't meaningfully impact things. Maybe it went down a little, but not a lot. But in sort of post, you know, analyses of some of this and now seeing lots of patients coming in, we do see men that are on finasteride. Some of them are more susceptible. And so, one of the interesting thing about trials is there's, you know, kind of inclusion and exclusion criteria, right? Not everybody can be in it. And so, if men had sperm counts that were too low, they weren't invited to be in these trials. So, for men that, you know, don't have as much reserve as others, I think they may be more susceptible.

49:49So, that's one of the risk factors of finasteride. You know, the other thing, in addition to reproductive health, the sexual health would be a lot. And there's also a concern that finasteride impacts sexual function in men, too. So, you know, we have these discussions. I've had some men that come in after having been on finasteride and have, you know, different issues with sexual desire, low libido, or rectal dysfunction. And so, then we, you know, work through an algorithm to try and improve that as well. This is one of the things I think about a lot, because I don't want to, I don't want to have a receding headline.

50:17And I also don't want to have an air operation or anything like that. But when I hear about some of these testosterone replacement therapies and such, my big concern is that if I take testosterone, maybe not now, because I'm, you know, probably don't need it right now. But maybe when I'm a little bit older, which is when I assume one would start taking it, maybe when I'm about 50 -ish. On average, but there are a met younger men that are on it as well. For what reason? Just because they're low on what's the sort of symptoms that have caused them to take it? Well, I think there's, you know, with all things, there's a bell shaped curve, so some men are a little bit lower, some have genetic conditions.

50:51You know, there are some more nefarious testosterone prescribers. So even though men have a normal level, they're offered testosterone to kind of get in these kind of testosterone clinics. And some men, you know, if, kind of look at data, maybe 10 to 20 % of, you know, high school athletes have experimental with testosterone. And if you stay on that too long, you can really shut down your own axis. So if you take exogenous testosterone, so like testosterone injections or gels, your body stops making it. And the longer you're on it, the less likely your body is able to sort of restart. And so for some of these men, you know, poor choices or, you know, whatever, they've been on testosterone for a while and they can't ever stop.

51:32I don't know if you've ever had any experience in it because I know you focus predominantly on male health, but I've had a long conversation about contraceptive pills with my partner because she was on, she said this publicly before that she was on a contraceptive pill for a long time. And then and everyone's relationship with contraception is different, but after taking it for seven or eight years, she, she came off it in her period, didn't happen, didn't occur. So she really struggled with that for a while previously, and it made me really, you know, it eliminated the fact that when we start messing with the chemical balances of our body using pills and injections and other things, we could do pretty long time and or permanent damage to ourselves.

52:12And there's no real such thing as a free lunch is there in biology and chemistry. Yeah, I think that's what it comes down to. I think a lot of people have said that if they tried to get the pill approved now, it would be a much different process and unlikely to succeed for those kind of reasons. If I have low testosterone, and I come to see you, what is the typical way of getting a testosterone replacement therapy? Is it a pill? Is it an injection that I have to take? I know that it's quadrupled according to the data in the US since the 2000s, which is staggering. How are people taking testosterone?

52:52So there's lots of different ways it can be taken. I think one thing, you know, again, we talk about all the risks. So fertility, it's certainly be a, you know, a big one. So if you come in in your 30s, you know, I ask you about your reproductive intent. So if you have a low testosterone, you're interested in having four kids. I wouldn't start you in testosterone directly. There's some off label things, you know, so medicines that we kind of repurpose to help increase your body's own testosterone that we would start with. But assuming that let's say you're in your 60s, you're not interested in fertility, then, you know, there's gels or patches that you put on every day at testosterone, gel or patch.

53:26Because that can work well, probably 10 to 20 % of men don't absorb testosterone that well through the skin. The other thing to be aware of is that there's a risk of like transference, like to your partner or to anybody, they kind of touches your skin. So if you have young kids, just to sort of be aware of. But as long as you know, you put it on, let it dry, put clothes on over it. It's not a big risk. You know, again, and also have to be, I guess mindful of laundry as well. So, you know, gels patches are one. There's injections that you can do every usually one to three weeks on average. There's testosterone pellets.

53:59So these are pellets that have testosterone that are kind of slow release. So they're just injected. We kind of implant them under the skin usually in the hip area and those last probably three to six months. There's longer acting injections. So there's a very common in Europe. They're kind of gaining steam in the US. But those are injections that last probably 10 weeks or so. And then there's a new oral therapy. So there's an oral form of testosterone that's available as well. I was quite confused on this subjective hair loss and testosterone because I couldn't figure out if low testosterone causes meter, bold and have a receiving hairline or if it's high testosterone that causes meter, bold and have a receiving hairline or if it's both.

54:42I mean, it could be both. I think usually we think about it as as higher levels. It's funny because I've wondered before whether me doing a lot of exercise, which is I guess increasing my testosterone levels is going to accelerate my bolding and receiving hairline. Anything that's good for your heart should be good for your hairline. So I would exercise. I think that's good. But what if I'm doing like iron man's and thousand malgrans and all that kind of thing, which you see in certain groups? So I don't know that I do think it's possible to overexercise. I don't know if it'll affect your hairline, but you know, I think my testosterone levels.

55:17It can affect testosterone levels. I do think that it's, you know, when you kind of exercise at the point of exhaustion, you know, we do see declines and sperm counts as well. So hormone levels can certainly be affected. Is my cortisol guys up? So my testosterone I'm I guess goes down can go down sometimes. Interesting. What about penis size? I heard you did some pretty landmark research, which suggests that the length of a man's penis is increasing decade of a decade in terms of men that are being born and boys that are going through puberty. Yeah. So this study also got a lot of attention. So, you know, similar to how we have tracked testosterone levels over time or sperm counts over time, you know, for different reasons investigators have measured penile length, you know, to kind of give normative data across different populations to understand how different surgeries or conditions may affect penile length.

56:11So, you know, we looked at, you know, all the studies and there were there were dozens. And so we kind of pulled all that together. This was tens of thousands of men and just looked at sort of average penile length over time. And so, you know, again, based on some of the data on semen quality, we would have expected things to get shorter over time. And also because we're more obese now, you know, the way that penises are measured is you kind of pull the penis on stretch and use the tape measure some sort of ruler measuring device. So if there's kind of more gut, you know, more fat and theory length should be a little bit shorter now than it used to be.

56:44But it turns out, at least when you measure a wreck penile length, that penises are longer now than they used to be. And so over the past 30 years or so, they've probably gone up about 25%. Why? I mean, it's a good question. I think one hypothesis we had kind of looking at sort of different endocrine, you know, abnormalities and changes in puberty is that if men go through puberty or boys go through puberty earlier, that tends to correlate with longer penis length. And so if we are shifting puberty again through these different environmental exposures, maybe that has leading to, you know, changes in general development.

57:22And this may be one of the consequences of it. Does this have any upstream in like implications for sex? I think that while the numbers we're talking about shouldn't be, you know, kind of enough to make a big, big difference. You know, people as this study came out, we talked about, you know, very enterprising patients kind of reaching out sending emails. Some people hypothesize that this was kind of natural selection. So it's hard to know, but it's a very short period of time. So it's hard to believe that there's, you know, that's kind of a play. Do you have many people that come into practice that are struggling with erectile dysfunction?

58:00Yeah, so that's another very common condition we see. If you look at men over the age of 40, over half have some trouble with erection. So very, very common hundreds of millions of men all over the world are afflicted. We don't talk about this much. What is the cause of this? And are you seeing an increase over time? The prevalence of erectile dysfunction? I mean, I think the rates are going up. And I think, you know, the risk factors, you know, are the same risk largely, the same risk factors that affect heart disease. So, you know, diabetes, obesity, high blood pressure, high cholesterol, you know, minority of these conditions can be caused by low testosterone.

58:39Sometimes the outcomes of, you know, surgical treatment for pelvic cancers as well. But by and by and large, it's vascular. Just, it's a blood flow issue. Because I used to think it was more of a, like a, like a hormonal thing or a psych, psychology thing. Like, you know, sexual anxiety or some kind of, you know, change to our testosterone levels is causing us to struggle with getting erections now. You're saying it's about. So, I think, you know, psychogenic used to be thought of, like you're saying, used to be thought of as the kind of the primary ideology. And maybe for some, you know, populations, it could be a little bit more common.

59:15But generally, for most men, sort of all crimmers, it's going to be a blood flow issue of vascular organic cause. And how would you do about treating erectile dysfunction? So there's a lot we can do. We do want to, you know, kind of reverse anything that we can kind of understand where the man's coming from, find out if there's, you know, new relationship or other kind of factors, you know, for men like, you're suggesting that we do see, like, kind of suspect a psychogenic component work with sex therapists as well. But for other men, you know, I always like to be very positive. It's like to say, you know, as long as you have a penis, we can always make it hard.

59:47So there's a lot that we can do. So usually we start with pills, like biagra, siallas, is that what for people? It works probably 60 to 70 % of the time. So that does work well. Even for men with a psychogenic cause, sometimes it can kind of help reset the system a little bit, you know, convinced them and their body that everything is working well. I could see by effect. Well, it's, I think to some extent, but even more than that, because it does work, it does help. And then I think once they kind of regain that confidence, if there was some sort of traumatic event, traumatic relationship, it could help improve things.

1:00:19Pills aren't enough or they don't like those or they have side effects from those. There's other therapies. So there's medicines you can actually put in the tip of the penis, like a gel or a suppository. We can teach men to give themselves injections in the penis. Oh, I've got to shoot very, very funny. There's certainly a, like kind of a psychological sort of fear of that, but it does work well. Probably works 80 % of the time. There is something called a vacuum erection device. So it's like a plastic cylinder, put over the penis. It sucks blood into the penis. Kind of treats it like a balloon.

1:00:51And then you put a band at the base to travel blood inside. And there's even surgeries we can do to put a device inside the penis. So whenever a man wants to be hard, he can be hard. I didn't know that was a surgery you could do. A surgery. What does that do? It puts a, so there's, there's two main flavors of it. There's a, or forms. Maybe that's a better term. There's one called a malleable. So it's bendable. So it kind of puts this sort of bendable metal. It's a metal core with sort of a plastic kind of covering. So when they don't want to have sex, you bend it down when you're ready for sex, you bend it up.

1:01:23Or there's inflatable versions. So when you're, whenever you're ready for sex, there's basically a pump that goes in the scrotum and you just pump it up and moves fluid into the cylinders and you get a rigid erection. Is that increasing in popularity? I think, you know, that it's made by a few manufacturers in, in the US or in the world. And so I think the data is not as freely available. I mean, in my practice, I've seen more and more of it. We're seeing more patients come in. I also say that, you know, my practice is getting a little bit more mature with time as I get older. And so, you know, naturally, you know, more patients, and I hear about these different things.

1:02:02But it does work well. I always say it's a self -selected population, right? We don't hold men down and force them to get it. But generally, they're very happy, probably 90 % of men are very happy. They'd recommend it to their friends, partners very happy, recommend it to other couples. And you just press a button and you get like a, you can. It's a pump right now. They are working actually on either a phab or like a phone app that'll kind of automatically inflate it to make it a little easier for patients. I had no idea. It sounds like sci -fi or something. It sounds like it's, um, it sounds like something you might see on a YouTube video that people are working on in like 20, 30 years time.

1:02:38But to know that men have that installed now is amazing. Yeah. I mean, it's, uh, yeah, it's very common. Um, the youngest patient I've put in is about 20, the oldest is in his 80s. What was the, is it seen as like a last option in that menu of options that you presented there where like the first option is probably Viagra and in terms of popularity is a last. Of course. I think for a lot of men, it's the most aggressive. But some men don't want to do like you had a reaction to the injection. I think that's a very common reaction. There are certainly some advantages to it compared to others. You know, for Viagra, for example, even though it's obviously the easiest it's a pill.

1:03:16You know, there's some side effects with it. And there's also, you know, a lag time, right? You have to take the pill wait an hour or wait 30 minutes, something like that. Whereas this, you know, the PNL prosthesis, you know, if you just pump it up, it's ready to go in seconds. So it can be very spontaneous. So it's patients like that. You know, some patients don't, you know, they have other medications so they can't take pills. They don't like some of the other kind of intermediate options that we have. Shockwave therapy for erections. Does that work and what is it? So the idea is that is kind of the name implies you're sending shockwaves into the penis.

1:03:52And the energy is induces kind of some micro trauma, which induces new blood vessel growth is the hypothesis. And so, you know, the hope is that with, you know, getting better blood vessel, better blood flow into the penis can improve the quality of erections. So there have been some studies that do show benefit is still considered experimental because I think the data is not yet conclusive. But I think for men with milder forms of erectile dysfunction, it can help, you know, maybe the men that are on Viagra or sometimes on Viagra, maybe we can get them off those pills. But I think we need more data to kind of understand really the kind of the best target population for it.

1:04:29You talk about pelvic floors as well. When we typically think about pelvic floors, we tend to think of women. You know, things like these kegilexercises that people talk about. But is it important for us to think about that as a man as well, ask what a pelvic floor strength and our pelvic floor muscles? I think in some conditions, I think if you're not thinking about it, it's probably okay. You're not having a lot of problems. But it can be a trigger for some men. So that can be an ideology of some different problems with urination. You'd see men with very tight, you know, pelvic floors and they have a lot of urgency to urinate.

1:05:03Urinate frequently can also lead to scrottle pain sometimes as well. Because there's a lot of muscles as you're kind of pointing out in the area and sometimes if they're under tension, if they're not properly kind of trained. And they can kind of trigger some other areas. And so for some of these different conditions, we do kind of work with pelvic floor physical therapists to train patients. You know, how to, you know, again, relax the area, strengthen the area, increase flexibility of some of those muscles, which can help. Is it plausible that doing pelvic floor exercises will improve one's sex life?

1:05:36I mean, I think that unless we're treating a problem, I would be very hesitant. You know, one of my favorite things is the enemy of good is better. So if things are good, you know, to try and get better, you know, there's always, there's always going to be like you said, there's no free lunch. There's always some trade -offs. So I think if you work on kind of over strengthening the pelvic floor, it could lead to some of these other dysfunction. So you don't want to end up with a floor that's too tight or too tense. Is there any correlation between these things like your pelvic floor strength, your testosterone, your sperm count?

1:06:08And a variety of the different cancers that we see in men, things like testicular cancer and prostate cancer? So I think with pelvic floor kind of strength, I think I usually kind of think about that as separate from cancer risk. But for testous cancer, you know, one of the risk factors for that is some men are born without testicles in their scrotum. So that's a risk factor under so -called undistended testicle, low sperm cancer associated with a testicular cancer. There is one study I know of years ago that looked at, you know, comparing sort of sexual health to prostate cancer risk, found that men that ejaculated more frequently had lower risk of prostate cancer.

1:06:48The thought was that, you know, there was inflammation that you're kind of clearing out by frequent ejaculations. I think this study had men ejaculating 30 times a month and showed a lower risk. So that's, that's a lot. But that was one study that said, at least it's not dangerous to ejaculate more frequently. But I've shot something that I generally recommend to men to lower their risk. If we talk about testicular cancer then, what are the common symptoms of testicular cancer? Yes, so usually it tends to be relatively asymptomatic. I think that, you know, the classic symptom will be a firm painless mass that men find in the scrotum.

1:07:21So, you know, there used to be, there are screening guidelines, even though our preventative services task force thinks that, you know, the utility of doing it for, you know, reproductive age of men to their scrotum, may lead to more anxiety than actually, you know, finding testicular cancer because it's such a rare cancer. So it's more likely a man is going to just worry themselves and actually, you know, diagnose an early cancer. But the recommendations used to be that you would, you know, once a month in the shower, kind of feel yourself and you feel something new or something abnormal, you know, bring it to your doctor's attention.

1:07:53I certainly see a lot of men with this concern and do an exam say, you know, that's normal or if there's something that we're worried about, we'll kind of dive a little deeper. What is the demographic that's most likely to get to stick your cancer? Is it something that affects young people as well as older people? It's usually mostly a cancer of young men. So I would say probably 20s to 40 is usually that the kind of the prime demographic. Why is it a cancer of young men? Is there any sort of physiological reason for that? Well, I mean, it's a, you know, reproductive age cancer. So that's the prime reproductive years.

1:08:23So it's possible that it kind of correlates with, you know, sperm counts declining with older age. There is another slight increase for men in their 50s and 60s. But again, it's such a, it is a very rare cancer. So I usually kind of quote probably one in a hundred thousand men are going to be diagnosed with it. So one in a hundred thousand. Pretty, it's fairly uncommon. But prostate cancer is more common. Yeah. So that we die, you know, in the United States probably at least 200 ,000 men every year. Some studies say that, you know, if you live long enough, everybody will be diagnosed with prostate cancer.

1:08:57But again, most men with prostate cancer die of heart disease, just like every other man in this country. So most men, you know, with prostate cancer die with it, not of it. So usually it's a slower growing disease, although there's some that are more aggressive and that's why we screened for it and treated. I read a stat that it affects one out of every seven men prostate cancer. Yes. Okay. So what is a prostate? So prostate is it's a walnut shaped organ. Yeah. It's just underneath the bladder. So the way that we're shaped is we have a bladder which fills with urine from our kidneys. And then we urinate out the urethra, you know, out the penis.

1:09:32And so the prostate's just at that kind of intersection between the urethra and the bladder. And it really has a function in reproduction. So it produces about 20 % of the fluid of our ejaculate. And it produces a lot of the different chemicals and sugars that support and protect the sperm in the female reproductive tract. So after reproduction, it doesn't really have a lot of, you know, benefit. Mostly it just causes issues because it gets bigger with age. So it leads to urinary symptoms. And then obviously it gets a cancer risk as well as we get older. Okay. So we typically get prostate cancer once we've stopped using the prostate.

1:10:09Reproduction. Yes. So does it have a role outside of reproduction? I guess because it's a gland that might be regulating hormones long, long after we're using it for reproduction reasons. It doesn't really have any useful benefit. If we could find a way to remove the prostate without causing any complications, that'd probably be a reasonable thing to do. But unfortunately every treatment we have does have some, some side effects just given where it is anatomically. It's right by a lot of the structures are important for erections and for reproduction. So when people have prostate treatment because they've got a prostate cancer, they're getting the prostate removed.

1:10:41Some men get it removed. Some men have radiotherapy to sort of kill all the prostate cells. And there's other kind of energy therapies that are delivered like high frequency ultrasound can sometimes be delivered. There's also something called cryotherapy where you can freeze the prostate. Usually these are done in kind of targeted fashions where you can look at the prostate, look at MRI imaging of the prostate, look at biopsy patterns to try and figure out where the cancer is. So usually the whole gland is treated but sometimes I think newer modalities are trying to just treat a particular portion.

1:11:12How often do you think we should get our prostate checked? And what are the symptoms that we should be looking for? From a sort of a urinary standpoint, I think that if you're a nation bothers you, you should talk to your primary care doctor or your neurologist about it. If you're waking up at night, if you feel like you have to pee too frequently, if it burns to pee, things like that. So that sometimes is due to prostate enlargement, prostate issues. It could also be due to a tight pelvic floor as well. From a cancer standpoint, usually we check blood tests called the PSA prostate specific antigen.

1:11:43And there's different screening guidance that's made. Usually start men in their 50s or so and screen every year or two to a man turned 70. Some of the guidance or some of the screening patterns will vary based on family history, which is a very strong predictor of cancer risk. Is there anything I can do or is there any research that gives me advice on how to treat my body in such a way where I reduce my risk of prostate cancer? We talked about some of these risks for erectile dysfunction, obesity, diabetes. I think those same things can also play a risk in a lot of these prostate conditions too.

1:12:20So good diet, exercise, maintaining good body weight. I think all those are important. Avoiding drinking water before bed? Well, that'll help with sometimes waking up at night. So for some men that are most bothered by so -called nocturary or waking up at night to urinate, I think trying to dehydrate yourself, saying I'm not going to drink any fluid after 7 o 'clock at night or 6 o 'clock at night. So that you're more likely to get a full night's sleep. Waking up once at night is not that unusual, but if it becomes a little bit more frequent, that's one strategy that some men use. Okay, so reducing my water consumption at night time isn't going to reduce my chance of having prostate cancer.

1:12:56Right. Okay, fine. What about spicy foods? So I think in a similar way that can also affect some of the symptoms. It shouldn't affect your prostate cancer. Is there any studies that show ways that we can reduce our prostate risk that aren't just the sort of health and what sort of lifestyle related things? Is there anything linked to other parts of our lifestyle, like our use of technology or alcohol consumption or anything at all? Not to my knowledge. I think that Asian Orange, the defolient that was used during the Vietnam War, that was found to be a risk factor for prostate cancer. So I don't know why you would, but try and avoid Asian Orange.

1:13:38But otherwise, there are not a lot of modifiable risk factors. Other than the ones that we talked about, I think that cancer risk goes up with obesity, I mean I thought to do the different things, but maybe inflammation and things like that. So I think kind of living a healthy life, I think hopefully we'll keep you on a healthy trajectory. Q1 is often when businesses start implementing new systems and processes in hopes of creating efficiencies for the year ahead. And over the course of my career, I've learnt just how crucial having the right systems in places, one which has helped me across many of my investments is net suite.

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1:14:45That's netsweep .com slash Bartlett. This episode is brought to you by me undies. While me undies can't totally help your love life this Valentine's Day, they can offer you insanely comfy undies and loungewear to buy or gift. Me undies has so many awesome Valentine's Day prints and styles. Plus you can match with your partner, friends, or even your pets. This Valentine's Day, give the gift that'll keep them thinking of you and score huge site white savings at me undies .com slash Spotify. That's me undies .com slash Spotify me undies comfort from the outside in. What is the most important things that we haven't talked about that patients come into your clinic and speak to you about as it relates to reproductive health, you know, hormones, everything in between.

1:15:30Well, another condition that I see men for a lot is something called peironies disease, which is a curvature of the penis. So, you know, the way erections work is everything swells. You know, there's sort of these kind of tough tissue layers in the penis that trap blood inside. And sometimes scar tissue can form on those layers. For different reasons, it's thought maybe micro trauma. Some men do remember a sort of a traumatic sexual episode that leads to an injury and scar formation. And you can imagine if there's scar tissue in there, everything will not, you know, kind of expand in the uniform fashion.

1:16:02So you can get a curvature or deviation. So some of these men have, you know, 90 degree curves to their penis. And so, you know, whether it goes up or down, it makes, can make sex pretty challenging. And so that's another condition we see. I think it's important for men to know. I think, again, like, it's just similar to a rectal dysfunction. I think, you know, men are sometimes, you know, a little bit rediscent to talk about some of these conditions, but it's fairly common probably five to 10 % of men are affected. And there are effective treatments for this as well. So I think just as sort of a public service announcement, if men are suffering from this, again, talk to your doctor because there are treatments that we can offer.

1:16:38Okay, so let's conclude then. If I want to make sure that my sperm count remains very, very high. So I can have those four kids. And I want to make sure my testosterone levels remain at a healthy sort of balance. Let's say is it sort of four 500 mg milligrams is it? Yeah. Yeah. I need a grams for a desolator. Okay. Nantograms per desolita. We'll know, keep it in that sort of healthy range. And I want to have rock our directions. Okay. So that I can have the four kids that I mentioned. What is the advice that you would give that is broadly applicable to everybody without you having to run my blood tests and all those things.

1:17:14And this is really a conclusive point. The first one that I've heard is about sort of lifestyle and dietary choices. Is there anything that I definitely shouldn't be eating if I'm trying to become optimal in these three areas? Again, people have looked at sort of different diets, which can affect health and reproductive health, you know, more specifically. So I think generally healthy foods are a good idea. You know, whole grains, food, vegetables, you know, usually the control group for all these is like a Western diet, you know, like, you know, process foods, fast food, things like that. Foods that have a lot of fat, high calorie.

1:17:46Those you, and you know, some of them also the packaging has seen some of these same kind of chemicals that we talked about earlier. So I think trying to avoid some of those, I think is a good idea. Sugar? Sugar is okay. Okay. Unless again, for high calorie foods are things to try and avoid. If you have any medical conditions, you know, I think that trying to get those treated, you know, sometimes men do worry that, you know, if you're taking a pill for something, it may affect your fertility. But, you know, I think just generally being healthy, anything that's good for your heart is going to be good fertility.

1:18:16So I think it's a good idea to get that, you know, treated. There is a study out of Japan that I always quote about this. So this was a study that looked at all patients that came in with male infertility and tried to figure out who they helped. Right. And so they wanted to see if they could predict who was likely to benefit from a urologic concentration and who was not. And so they looked at, you know, baseline sperm count. That wasn't predictive of who was going to benefit baseline testosterone level wasn't age wasn't some men had this condition called a barricose seal, which has dilated veins in the scrotum.

1:18:44So about 15 % of all men have them infertile men, maybe about 40 % have them. So, you know, the testicles are outside the body like we talked about and having larger veins, impairs normal temperature regulation. And so if you fix those, it turns out most of those men are going to improve their sperm count. But the other really interesting finding is that they also found that men that had a comorbidity treated had improvements. So the data they provided is men that had a high blood pressure. If they got that under control, their sperm counts went up about 25%. So, you know, a lot of times, you know, the first time men see the doctor, men don't go to the doctor a lot, right?

1:19:21Unless there's a problem, right? Unless there's a pain or some other, you know, condition. So sometimes my patients, the first time I've ever seen anybody is missing me to try and have a baby. And so it's an opportunity to, you know, make them take a little bit more ownership of their health. You know, if they never had a blood pressure check, check that blood sugar cholesterol, all those things are, you know, ways to improve their health or opportunities to improve reproductive health. But, you know, overall health as well. So I think that's another thing to be kind of mindful of. What about depression and mental health and the role that that will have on our fertility or erectile performance in one of those things?

1:19:56Is that correlation? There's strong correlation. Yeah. So I think we do see a strong correlation between erectile dysfunction and depression. You know, if you look at men with erectile dysfunction, I think up to 20 % it, you know, may have some form of depression. And we sometimes worry that some of the treatments can also exacerbate sexual dysfunction. But I think trying to get men on a better path is important. I think it's also important to work, you know, again with a therapist as well, you know, so that you kind of attacking these things from multiple, you know, multiple angles. You know, generally most of these medicines, you know, probably have not been tested, you know, in terms of reproductive health.

1:20:31There's some studies that say that some of these may affect seeming quality, but I think those studies are limited. So I think, you know, generally if men are on these medicines, we're not sure and I think it's helping them. You know, we try and sort of, you know, carry on in person here because I do want them to get the benefit of some of these therapies. What about childhood trauma and the role that plays? You must see that show up in your practice. Yeah. I mean, I think it certainly can affect sexual health, you know, pretty profoundly. I think, you know, when you do suspect, you know, kind of this sort of psychogenic component, I think, you know, we do, I try and be again, like talked about very optimistic about options that are available.

1:21:08But working with the therapist, working with the sex therapist to come up with sort of a good sort of strategy and plan to kind of get, you know, men through, you know, some of these issues. So they can have, you know, a fulfilling sex life. Anything else that I need to do to improve these things, top line things, so lifestyle, true, you know, we've talked about food, exercise, you've talked about as well as a way to improve at least our testosterone levels. Yeah. Sleep, I guess might be a important sleep. It's important to sleep. It's interesting because it's what's called a U -shaped association.

1:21:40So it's possible to get too much sleep. So, you know, you probably want sort of an ideal amount, probably seven to nine hours is usually that's been associated with better sleep and quality for men that get less sleep and quality tends to be a little lower for men that get too much sleep. You know, again, for men that have, you know, are able to sleep 12, 13, 14 hours a day, there may be other things going on there. Maybe there's some underlying depression or something. Those men tend to have lower sleep and quality, but you know, I think sleep, I think is certainly important. There's also been studies looking at weight loss as well.

1:22:10You know, I think it's obviously easy to stay lose weight. But it's not always a straightforward to do. But there is, you know, a nice study that came out a few years ago where men are randomized to, you know, weight loss program, a very low calorie diet, 800 calories a day. For a few weeks, and then they lost, you know, weight, and then they follow them for the rest of the year. And so this is important because men that were able to keep weight off were able to maintain the benefits of their sperm count versus men that were, you know, kind of fell off the exercise routine. They ended up gaining back, you know, their weight and then their sperm counts declined again.

1:22:47One of these arms actually also had one of these, you know, hot GLP one analogs as well. And so you've meant that we're on those that kind of help them keep their weight loss were also able to maintain sperm count. So patients do ask about that a lot. I'm just going to ask about obviously, his impacts exploded and there's many other forms of this sort of GLP one. Sort of fat loss injections. I was wondering if I had any consequences on fatality. So again, there's only one study that did study it and it did seem to show benefit. So it doesn't cause any harm as long as you maintain weight loss with it.

1:23:18You know, you do seem to see improvement. You know, in contrast, you know, some men also ask about like bariatric surgery, which, you know, again, maybe declining a little now with these, you know, very effective medications. But interestingly, very interesting, very interesting, like gastric bypass. I don't know if this is a popular in Europe or the United Kingdom. But for some obese individuals, there are surgeries that can be done to help sort of reroute intestinal absorption. So can lose weight with that. There's also something. I think we've been the gastric band thing. Gage gastric bands too.

1:23:49Yeah, so there's different ways that's been done. And so with all those, actually it tends to decrease sperm sort of right paradoxically. So you would think that if you lost weight, your sperm counts would improve. But it turns out with these surgeries sperm counts actually declined. Some of them, some actually men went from a reasonable sperm count to zero. So the thought was that, you know, it's the trauma trauma of a surgery potentially. You know, there are, you know, some vitamins, minerals are important to. So, you know, without that normal absorption that occurs in the intestines, that could also lead to infertility.

1:24:25You know, that was sort of a concern and we were wondering if that same thing would happen with, you know, these newer medications. But it doesn't seem like it. So again, the GLP1 analog seem like they're safe, safe form of weight loss, at least when we're looking at semen quality as an outcome. What about supplementation? Is there any supplements? One might recommend, I guess it's difficult for you to recommend supplements. But are there any sort of vitamins or minerals that are typically deficient in people that have infertility issues? So I think there is some data that antioxidants can improve fertility.

1:24:56So it's sort of a very broad group of things that have been tested. My reason stuff is that? Yeah, dark berries. Yeah, those certainly can have a lot. But, you know, usually tell patients to take a multivitamin, they do make special male fertility blends. Like if you were to look it up on the internet or Amazon or other platforms, there are special fertility blends that have kind of. Some of them have, you know, looked at the data and try and pick out, you know, specific supplements that are thought to be more beneficial. Coensile Q is a powerful antioxidant that has shown some benefit for fertility.

1:25:27So I think that's something else that you try and empower patients and they can do that too. And that can help. Right. See, does that play role in fertility or testosterone? I think, you know, again, sort of part of a balanced meal, part of a balanced sort of diet. I think it's important. What's your mission from here on? What are you going to do for the next 10 years if you had to ask it, I guess, what's are you going to do? Is it more of the same or are you going to? Are you interested in changing focus at all slightly or are you going to just continue to do research on these subjects? What's your big sort of decade mission?

1:25:56Yeah, I mean, this really gets me up in the morning. And this is the stuff that I like to do like late at night as well. I mean, I really am passionate about this trying to understand. And, you know, why we see this link between fertility and health, why sperm cancer declining? Because I think the more we understand about it, we can, you know, hopefully mitigate some of these risks. I also like to hopefully, you know, through, you know, information channels and platforms like this, you know, hopefully engage more of the community to try and come up with some therapies, you know, for male fertility.

1:26:24I think, you know, we talked about some of the things that can be done, but there's no, you know, in the United States, there's the Food and Drug Administration that sort of oversees all, you know, therapeutics. And there's no FDA proof therapy for male fertility, which is really a shame, especially because, you know, again, we have this data that it's becoming more prevalent, existential, right as a species. So it'd be nice if there was some to try and get more engagement from the scientific community, from the pharmaceutical community, to try and, you know, see that opportunity. Because I think that'll be very important for, you know, for our fields.

1:26:54But again, you know, I think, like you said, sort of more of the same in some ways, but I think trying to understand some of these questions in a lot more detail so that we can really help these men. Is that of all the subjects we've discussed today, is there a particular part of it that concerns you the most? Well, I think, you know, when we're talking about sperm counts declining, I do worry that that is a barometer of health. And so it may be that, you know, in addition to men's reproductive health, this our overall health is declining. You know, when we look at sort of the health of fathers over time, we've seen, you know, fathers are getting a little older, you know, we talked about that.

1:27:27But, you know, with that comes more comorbidities, right, higher rates of hypertension, hyperlipidemia, you know, other things. And that sometimes can't have sort of transgenerational impacts. So like a father that has high blood pressure or, you know, his obese, that child is, you know, a slightly higher risk of having some other issues later on. So trying to understand that again, if there's maybe opportunities to try and figure out what in that sperm is a little different, maybe we can turn that switch off to try and, you know, prevent that. I think those are all things. I don't want to be alarmed about this.

1:27:59These risks are all very, very low. But I think there's a lot of opportunities, you know, I think one of the reasons I got into it, I think it's because male reproductive health was really wide open. So I think there's still a lot of opportunities to try and improve it. What would you say to a man that's listening to this, that's struggling with any of the things we've discussed. What is your, your closing message for them? Well, I think I would just try and be optimistic and hopeful. I think there's a lot that we can do. I think that, you know, it takes a lot of bravery, you know, to go in and see doctors about some of this thing, some of these, you know, different, these different issues.

1:28:33But, you know, it's what we're used to dealing with. And I think there's, you know, plenty of options are available. So I would just encourage them to, you know, talk to friends, but, you know, men talk to their primary care doctor, talk to their neurologist, come see the neurologist. You have a very broad platform. So I think if there's couple struggling, they've only seen gynecologists, I would encourage them to maybe see, you know, male reproductive specialists as well to try and get some other perspectives. We have a closing traditional, this podcast with the Laskets leaves a question for the next, not knowing who they're leaving it for.

1:29:02The question that's been left for you is a tricky one. It is, what's one thing you would do to change the world? I guess one thing that I would do to change the world. I guess, certainly, I reprove our conversation was that I would make, try and make policy that all governments would pay for infertility services. So that this is a universal benefit for all of humanity. I think that would certainly help open up the doors for a lot of people that don't have resources for it, kind of hesitant to use it. And hopefully that would again solve some of the issues that we talked about from a demographic standpoint.

1:29:42What would that do for humanity? Would it be having more kids, I guess, would be happier in our relationships potentially? I mean, yeah, I think it could do all that. I think that, you know, I guess from a father standpoint, having a child again increases longevity, decreases cardiovascular risk, increasing from a sort of societal perspective, having, you know, getting into that replacement level sort of maintained population. I think that's again, existential for a society, increase the tax base and all the other things that are associated with that and the workforce. It's very difficult in politics now, certainly in the United States.

1:30:21There's a lot of, you know, issues that are going on, but, you know, making policy that really affects everyone, I think, would be, you know, very profound. And I think there's be a lot of benefit to that. Dr. Michael Eisenberg, thank you so much for your time and thank you for the work that you're doing because, you know, you're helping to ultimately to create families and to also alleviate a lot of the stress and anxiety and worry. And concern, people have about their reproductive health. And I think it's an incredible service to humanity to be doing that, and especially at the time when we're in where it feels like it's more needed to ever before.

1:30:58And frankly, the direction of travel isn't fantastic. As it relates to some of these big issues like, you know, testosterone and fertility and, but it's really important for people like you that have the information that are doing the research research to not just keep it in the lab. And not just keep it on PubMed where it's very hard for people like me to access it because we can't let you read PubMed. So thank you for making the decision, which you actually don't have to do to come out and speak on these subjects in a way that's really accessible and inspiring and empowering for people because I think that's going to do a tremendous world of good.

1:31:31Thank you. Thank you. My pleasure.

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