Before IVF, Before Panic: The Truth Behind Low Sperm Count

18:27Dr. Jesse Mills:Wow.

18:27Dr. Jim Smith:Such a big deal. I mean, I see that all the time in my clinic. It's a life changing event. Is, is my, are my family plans or my life dreams, or are they going to change?

18:38Dr. Jesse Mills:Yeah.

18:38Dr. Jim Smith:Very, very difficult for people.

18:40Dr. Jesse Mills:Yeah. Not to, not to go off the script, which of course, you know, one of the great things about this show is that we don't actually have a script, but one of the things that I wasn't going to necessarily talk about, but now I'm going to bring up is what you said though, may not be mutually exclusive in that there is also this concern, this, this trend towards, you know, worsening fertility counts, right? That's kind of one of the hot topics these days. And so is it that in the 80s, if you had semen analyses that, you know, if you had a male and kitten in the 80s, would it be 5 % then? Or was it 1 % then?

19:15Dr. Jesse Mills:And now we're just even worse because the azoospermic rates are going up, the Y chromosome is getting smaller. So kind of chicken little me a little bit, James. And actually, I'll run right back into, we also have the segment where I always say, am I going to be okay? You're probably going to be okay. Is the Y chromosome going to be okay? That's going to be our hook for this section. Is this really true? You're just so much better at capturing that that 5 % number has always been there and we're no worse off than they were in the 80s. And I don't mean to put you on the spot like this.

19:52Dr. Jim Smith:So a couple of things. I mean, it's very interesting to me now in the hat that I wear as Chief Medical Officer or Fellow because the lab has gone from just an idea that came out of my UCSF clinic to now a lab that is doing 500 to 800 semen analyses every single day. So it's a lab that is really experienced and does a very high quality job at semen analyses from all over the country. I was having a conversation not too long ago, Jesse, with John Amory of the University of Washington. We're talking a little bit about this. And John's a contraception researcher. And he's been having a hard time finding normal men to enroll in his contraceptive stuff.

20:30Dr. Jim Smith:Wow. And what he found up in Seattle area was that about 10 % of men were azospermic. And it's surprising. He also thought, though, that when he had looked at semen analysis data at the University of Washington, that there had actually not been a trend in decline over time. In another epidemiologic project that I'm working on right now, I'm looking at regional variation in semen quality. And interestingly enough, the Pacific actually has kind of the strongest overall semen quality. So up and down the coast, but there are many parts of the country relative to the West Coast that have much worse total modal count overall.

21:12Dr. Jim Smith:And that's something that it would be great to dive in because I think that's probably related to health in many ways in our environment overall. As far as going back to the 80s, I really wish we had a robust system to be able to track and follow that. And that's part of how I see fellow now is that it's nationwide, it is at scale, and it's a high quality single lab. So it's kind of the thing that's been missing really up till now.

21:56Dr. Jim Smith:Cardiometabolic is one of the biggest health challenges in the US and evaluating patient risk across multiple conditions requires careful attention. With so many testing options and guidelines, getting a clear picture of patient health can still be a challenge. LabCorp brings clarity. Our cardiometabolic testing solutions support early risk assessment and empower more informed decision-making so you can focus on what matters most, your patients. Visit labcorp.com to partner with LabCorp and simplify complex patient profiles. Support for the show comes from Public, the investing platform for those who take it seriously.

22:31Dr. Jim Smith:On Public, you can build a multi-asset portfolio of stocks, bonds, options, crypto, and now generated assets, which allow you to turn any idea into an investable index with AI. It all starts with your prompt. From renewable energy companies with high free cash flow to semiconductor suppliers growing revenue over 20 % year over year, you can literally type any prompt and put the AI to work. It screens thousands of stocks, builds a one-of-a-kind index, and lets you backtest it against the S &P 500. Then you can invest in a few clicks. generated assets are like etfs with infinite possibilities completely customizable and based on your thesis not someone else's go to public.com slash podcast and earn an uncapped one percent bonus when you transfer your portfolio that's public.com slash podcast paid for by public investing brokerage services by open to the public investing inc member finra and sipc advisory services by public advisors llc sec registered advisor generated assets is an interactive analysis tool output is for informational purposes only and is not an investment recommendation or advice complete disclosures available at public.com slash disclosures less support through telehealth but it feels overwhelming and rushed?

23:31Dr. Jim Smith:Check out orderlymeds.com now. Orderlymeds.com was built to be different. Here, you connect with real doctors who take the time to understand your goals, review your eligibility, and guide you through a plan that's right for you. Orderlymeds provides access to proven GLP-1 medications like semaglutide and terzepatide, including both name brand options and personalized compound versions when appropriate. So you have choices backed by clinical oversight, not guesswork. It's a simpler, more supportive telehealth experience designed around people who want clarity, care, and confidence in their weight loss journey.

24:05Dr. Jim Smith:And your medication is delivered directly to your home in discreet packaging. So your experience stays private from start to finish. Do your research. Ask the right questions. Then visit orderlymeds.com slash podcast for an exclusive offer. Again, that's orderlymeds.com slash podcast. Individual results may vary. Not medical advice. Eligibility required. See site for details. Let's talk about modern home shopping. It's sort of become a fun side hobby, right? Scrolling listings at night, dreaming about kitchens you've never seen, or backyards you haven't even stepped foot in. All from the comfort of pretty much anywhere.

24:42Dr. Jim Smith:Redfin knows a lot of people like you want to own, but are stuck in this browsing mode loop. That's where Redfin flips the script. With listings that update within minutes and tours you can book right from the Redfin app, you can see your dream home the moment it appears. Now, liking a listing is easy, but actually landing it, that's where Redfin comes in. Redfin has over 2 ,200 agents with local expertise. And Redfin agents close twice as many deals as other agents. That means they want to help you win, not just window shop. Redfin is built to help you go from just looking to wait. This could actually be home.

25:21Dr. Jim Smith:So become the newest neighbor on the block. Visit redfin.com to start finding and start owning. That's redfin.com.

25:38Dr. Jesse Mills:Is the semen analysis, should it be a vital site? Is it a window into men's health? And I will say my bias is yes, because one of the things we did a couple of years ago with a bunch of our societies is we redeveloped the men's health checklist for the American Urologic Association. And I advocated strongly for and got at least a reasonable evidence-based assessment that we could offer semen analysis to guys in their 20s, screening semen analysis. And what the AUA men's health checklist is, is basically by decade, what should we be doing to make sure men are optimized from cholesterol checks to blood pressure to making sure, you know, asking about seatbelt wearing and helmet wearing on bicycles, you know, for teenagers, all the way through colonoscopy in your 40s and prostate cancer in your 50s.

26:27Dr. Jesse Mills:And so semen analysis finally got on that list that at least offer it, you know, have a conversation to say, hey, would it be good to not only know your fertility status, but as Jim, you just mentioned, maybe as, you know, a very small canary in a very large coal mine.

26:45Dr. Jim Smith:I think that's really, really important. You know, I think back to the beginning of your and my career, we used to think of erectile dysfunction as the canary in the coal mine. Now that's just accepted that if you have ED as a younger person, that can predate significant cardiovascular disease by a decade or more. And when I think about our male patients, when do guys go to the doctor? They go to the doctor when the penis doesn't work and their testicles don't work. That sounds about right. And if it's not that, if their penis is working fine, their testicles are working fine, then they're good.

27:16Dr. Jim Smith:Then everything, of course, is just fine.

27:18Dr. Jesse Mills:Right.

27:19Dr. Jim Smith:But the more that I look at semen quality from around the United States, the more concerned that I am that it's something that we should look at and start to peel back the onion of why semen quality is not so good. I see over nationally about 50 % of the time, one or more semen analysis parameters are abnormal. That's in low concentration, low motility, low morphology. When in the studies we've done and with you and some of your fellows too, looking at things like marijuana use and testosterone use, that it's high prevalence. And in fact, in a group of men within Fellow who said they were just curious about, that was the reason that they gave for checking, about 7 % of those men were using testosterone.

28:00Dr. Jim Smith:And the follow-up study to that, I found that the median sperm count in men on testosterone was zero. Right.

28:07Dr. Jesse Mills:Yeah. And we talk about that different podcast on treatments for testosterone therapy. and it's an amazing male birth control that a lot of guys don't even know. I saw two men in my clinic this afternoon, both on testosterone shock that they had zero sperm counts. And so, right. And I know the other thing about that is that you were giving a talk where some of the work that you've done at Fellow in this epidemiology, and maybe I'll misquote you, so I'll let you jump in, but I think you said something like across the board, about 20 % of guys have significant oligospermia or low sperm count, low motility.

28:45Dr. Jesse Mills:And it actually made sense to me because we had that publication out of UCLA in 2019, the Gold Journal, one of our reasonably high-quality journals, that it did the same thing, that we saw guys under 40 with erectile dysfunction. We offered them a semen analysis, and 18 % of those guys who came in without any interest infertility, all under 40 had significantly impaired sperm parameters. And no idea, you know, it was the first time they'd ever done an essay. And so I think, I think our numbers, our data from totally different data sets actually jibed pretty well.

29:21Dr. Jim Smith:That's really, you know, when I first saw these data, so three, four years ago, when I started to see early versions of these data come in, I didn't want to say anything about it. It's like, could this really be real? But it just, keep seeing this at greater and greater scale. So if you look at total modal count, so for your audience, clinically we'll think about the total number of moving sperm as a clinical way of looking at the semen analysis. And generally speaking, we'll put men into categories. And so zero or azospermia, anywhere above zero up to about 5 million moving sperm. We generally think of like an in vitro fertilization range.

29:56Dr. Jim Smith:For about 5 million up to maybe 20 to 40 million, something like that will think about, well, maybe that's an intrauterine insemination range. And more than around 40 or so, we'd say it's roughly kind of normal number of moving sperm. And we're trying to do anything we can to try to improve the sperm quality, anything about their health or their medications or surgically things that we can fix to try to move men in these groups. And overall, Jesse, what I see in the fellow data set, and this is looking at about 30 ,000 men getting their first semen analysis across a range of fertility journeys.

30:29Dr. Jim Smith:So they're curious, they've just started, they're a year or more into their journey. The average total modal count, about 20 % of those guys were under 5 million total modal count. So it really, really, one in five guys have IVF range sperm.

30:46Dr. Jesse Mills:Well, that leads perfectly into another question I was going going to ask, you may as well ask it now, is talk to me if there's a couple listening right now, and they are thinking about starting the fertility journey, or just walk me through how the average couple interested in fertility, and this would be a male-female couple that doesn't know they necessarily are going to need to use IVF, so not our same-sex couples that know that they're going to end up with surrogacy or anything like that. So just kind of the run-of-the-mill people trying to have a baby, how do they engage the system? Do they go to a urologist?

31:25Dr. Jesse Mills:Do they go somewhere else? And then how should they engage the system if you were devising the ultimate world for optimizing fertility outcomes, as well as minimizing the amount of time it takes to actually go from thought to baby?

31:41Dr. Jim Smith:Well, so it's such a great question, you know, because when you think of guys, this idea that they're just not going to the doctor, they're really not doing the sorts of typical things that would engage the healthcare system. So usually what happens for that heterosexual couple is the woman is plugged into a gynecologist and they're thinking about having a baby. They go to the gynecologist. Gynecologist knows that they need to get a semen analysis to assess the male partner, but they don't really know how to order a semen analysis. They don't know how to interpret it. It's not really their patient.

32:10Dr. Jim Smith:It's their patient's partner. So they don't quite know what to do in that situation. So oftentimes, they'll send that patient to a woman's fertility doctor and REI, and then they know how to order semen analysis, but they're typically also not focusing on the men's health and what the man needs. What they want to do is the things that they know how to do, which are intrauterine insemination and IVF. And we know that those can work very well. In an ideal world, a man would get a semen analysis, which is really the starting point for all of this. He gets that early and he could talk to his primary care doctor if he's very early on and he could say, look, my semen quality is not so good.

32:51Dr. Jim Smith:He could go to his primary care doctor and he could say, hey, what can I do? And that primary care doctor can assess his history, any medications, is he overweight? Is he smoking weed? Is he on peptides? Anything that might affect his fertility in that family practice doc could potentially make a difference. If he's a little farther on in his journey, he should go see a reproductive urologist. And that's something that you and I and our colleagues do all the time.

33:19Dr. Jesse Mills:Yes. And I will tell you maybe a cautionary tale that will really hit this home. Because of what you were saying at the beginning of this is that sometimes abnormal semen analysis isn't just about the baby. And if you go to a reproductive endocrinologist, they love to say, all I need is one sperm. And they're right. We are so good at creating babies from very, very little sperm material. I mean, sometimes we do sperm retrievals, what we call microsurgical sperm extractions or microtestes, where it's a good day if I find three sperm, right? I mean, that's, wow, we could actually make a baby if I spend three and a half hours looking under a microscope to find three sperm.

34:03But there are couples that never get to that level, and they never may get

34:07Dr. Jesse Mills:the evaluation. And so I can think of early in my career is working with a couple who thankfully their gynecologist, the reproductive endocrinologist, sent them to me because his numbers were about 300 ,000 sperm. And he said, hey, Jess, I just want you to optimize this guy. They definitely need IVF. Sperm counts are terrible, but I'm sure I can make a baby. Don't even know why he did that because he didn't necessarily do that with every guy, but I think the numbers were low enough. He came in, not only did he have a varicocele so large on the left side that I couldn't feel his testicle, it was one of the rare times when I did an ultrasound of the scrotum because I couldn't feel the testicle.

34:45Dr. Jesse Mills:And part of it is because his entire testicle was replaced by a massive testicular tumor. And so there was no actual normal testicular tissue. And so I had a very difficult, but ultimately optimistic conversation with him and said, look, I'm so glad that your wife's doctor sent you over because, you know, you have a much bigger problem right now than fertility. And the crazy thing about this story, because we all love happy endings, is that I booked him for surgery the next day. I removed his testicle with cancer in it. And believe it or not, just, and I'm surprised I still got referrals from this reproductive endocrinologist, but that guy, just by removing the tumor and getting rid of his test his cancer, his right testicle woke up and his counts went from 5 million to normal and they're able to conceive spontaneously.

35:37So I love the community where this really well-intentioned

35:41Dr. Jesse Mills:physician essentially took an IVF cycle out of his month because he did the right thing. And I think that speaks to the health and how important it is to have somebody that is a sperm and men's health expert that is at least helping call the shots on the guy's side. And I'm sure, tell me, what's your craziest story of where you saw somebody in your clinic that was only like an afterthought of, oh, it's your privacy, Dr. Smith, make sure you're good for IVF. And what did you find?

36:12Dr. Jim Smith:Boy, there's so many stories. I mean, as you were telling me your story, I mean, actually, this is not answering your question exactly, but I remember a 19-year-old patient who had testis cancer and no ejaculated sperm at all. But I took him to the operand room and I did an oncotessi. So essentially in the operating room, removed the testicle, bivalved the testis, and you could see this tumor just invading into the central part of the testis and there just wasn't any sperm that was able to get out. And so I was able to extract those, some of the tubules around that tumor and find sperm. And he had many modal sperm that were able to freeze and allow him later on down to conceive.

36:52Dr. Jim Smith:So that's at least, that was the first story that came to my mind as I was hearing your amazing story.

36:57Dr. Jesse Mills:But that's a beautiful story, Jim, because, well, A, it's perfect to talk about what we're going to talk about next, which is sperm cryopreservation, but also B, that what you just said actually was a pretty heroic thing. And just to kind of fill in the audience is that essentially what Jim did with his oncology colleagues managing the cancer part of this is that sometimes the testis cancer, it grows focally, and there's lots of normal testicular tissue. In the old days, we would actually remove the entire testicle and send it to pathology, essentially making the diagnosis of cancer and, for lack of a better term, throwing away that tissue.

37:38Dr. Jesse Mills:But that could have been his only chance at fertility. So you took a 19-year-old guy and potentially could have completely lost his chance to have a biologic pregnancy when he wanted to in the future, but you were able to not only cure him of cancer, but also freeze sperm so that he can make those decisions later in life and still have that. So that's a great story. It definitely shows the value of having a comprehensive approach to non-alue oncology, but to male reproductive medicine, which is going to basically, next question I'm going to ask you is, what is sperm cryopreservation? Who should do it?

38:16Dr. Jesse Mills:Tell me how that works. And then walk into some of your advocacy work that you've done along those lines. Because again, the field of sperm cryopreservation goes back 40 plus years, but it's really exploded just because of how good we are with using frozen sperm on the reproductive endocrinology side. Because in the old days, somebody froze sperm, we could only freeze ejaculated sperm and use that. We couldn't use testicular sperm. We couldn't use, in your case, oncofertility sperm necessarily because nobody's doing that. That's a pioneering effort to go down that pathway. So, yeah, walk me through what this means and how long is it good for?

38:54Dr. Jesse Mills:And just give me a 101 on sperm cryopreservation, Dr. Smith.

38:58Dr. Jim Smith:Yeah, sure. So, you know, at its most fundamental level, it's essentially a guy's producing a semen sample. The sample comes to the lab, whether it's mailed into the lab or whether it comes to your local lab. The sample is processed. Typically, it's centrifuged. You add a solution to it to protect the sperm cells. And then the sample is put into very, very cold liquid nitrogen. And the sample can be preserved essentially indefinitely. Typically, the sample, you lose about half of the sample in the freezing and thawing process. when men try to use the sample down the road, they can either use the sample for intrauterine insemination or in vitro fertilization.

39:37Dr. Jim Smith:And this part, people don't really quite get. They try to protect their fertility, but they don't realize, what are you going to do down the road? And it comes to really, really important practical things. For example, if that patient doesn't get his blood tests and there are certain FDA infectious disease tests, if he doesn't get those done, then his sample may not be able to be used down the road. Fertility clinics won't necessarily accept a sample that hasn't been tested and been shown to be negative for these infectious disease labs. But the sample itself could be used from a timing standpoint, really indefinitely down the road.

40:11Dr. Jesse Mills:Yeah, that's amazing. And I think that is super, super key is that the blood testing is not only to make sure that you can freeze that in a tank with other samples, but also that the the timing of when you do that sperm cryopreservation, it has to be really within a very tight window to do the blood test to make sure that it's not like you can freeze in 2025, go into your sperm bank, make a withdrawal in 2030 and get your blood test at that time because they want to know what was happening five years ago. And I think that's a critical point for people that you have to do both. You have to freeze and do the serologies, as we call them, but all of the infectious disease testing, HIV, cytomegalovirus, hepatitis, et cetera, et cetera.

40:55Dr. Jim Smith:Well, you know, your question about, you know, who should bank, I mean, it's really is an important question. And for men who are facing fertility-threatening events, that's the time really to think about it. a clear-cut case is for our cancer patients or for patients who have benign conditions where they're going to be receiving high doses of chemotherapy, or you're going to have both testicles removed for testes cancer, radiation therapy, many medical events that can happen that lead you to think this patient's going to have really big fertility problems. They should bank a semen sample if they can.

41:28Dr. Jim Smith:I was part of one of the ASRM committees a few years ago, looking at whether or not we should recommend that age should also be one of those reasons, that younger men should bank just in case. We've seen that as men get older, their sperm quality seems to decline. We see that things like DNA fragmentation seems to increase. But is that such a significant thing that we should recommend that all young men bank their sperm samples and have the cost of doing that year after year? And we came down as as ASRM that we should not do that. There can certainly be specific reasons why an individual would want to bank their sperm at various ages, but as a routine that we came down advising against doing that.

42:09So I think that's really critical because there is one of the things I want to do

42:13Dr. Jesse Mills:with this podcast is try to separate what people are getting clickbaited on versus what is good medical evidence-based advice. And I think that's one of them because this is another one of these, am I probably going to be okay moments where if I see a 40-year-old guy come into me and say, oh, Mills, if I had known you 20 years ago or 15 years ago, I would have banked sperm because now my DNA fragmentation is high. I'll probably never be a dad and I'm probably not going to be okay. And what you're saying with the advocacy of the American Society of Pre-referred Act of Medicine, which is kind of the premier world group, it's not only American society, but actually really most of the world looks at these guidelines is that, no, you're probably going to be okay.

42:58Dr. Jesse Mills:Like you can also improve DNA fragmentation. You can improve sperm quality almost at any time in your lifespan. One of the things that's different about sperm versus egg quality is that when women are developing, they make all the eggs they're ever going to make when they're still in utero. So when they're still part of their mom, they already have all the eggs that they're going to have, whereas sperm recycle every 56 to 72 days. And so if you had an insult, like for example, we had Dr. Bash, former fellow as well as researcher in marijuana and sperm environmental pathogens. And if you smoked a lot of weed in your 20s, and you're trying to have a kid in your 30s, you're probably going to be okay.

43:41Dr. Jesse Mills:In other words, there's a little bit of a washout period because we recycle our sperm so much. So I think that's a critical point you bring up, guys, is that you don't necessarily have to click on that bank sperm tomorrow because your sperm is going to get old and you're going to have terrible kids and you're going to have all kinds of birth defects and other things that you don't want. And it doesn't, the evidence doesn't really support that.

44:05Dr. Jim Smith:I agree with that completely. That's absolutely is clickbait, you know, for young guys don't need to bank sperm unless there's something else significant that's, that's going on. And if there's a significant health issue for sure, you know, bank banking sperm, but as a matter of course, because you're 25 and you don't know if you're going to have kids, so you're 35 or 40, that's not a reason why you need to spend your money on freezing sperm.

44:28Dr. Jesse Mills:Right. Well, now, now we get to the doctor's orders fun part of this in that one of the most impressive ways that you can improve your sperm quality, correct me if I'm wrong, is frequent ejaculation. Is that, is that right? Is Is that your understanding too, that the more often you clean your pipes, the better your DNA fragmentation will be? Or is that another good reason to tell guys to get out of the office and go do your thing?

44:51Dr. Jim Smith:I think that there's every excuse to have to write a prescription for a guy to get out of the office and do his thing, the better.

44:57Dr. Jesse Mills:There you go. Keep the pipes flowing is the message, is the take-home message. With all of the science evidence-based, that's one thing that holds up.

45:05Dr. Jim Smith:And if you need a prescription for that, Dr. Mills or Dr. Smith are happy to help.

45:12Thank you.

45:40Dr. Jim Smith:Anabolic testing solutions support early risk assessment and empower more informed decision making so you can focus on what matters most, your patients. Visit LabCorp.com to partner with LabCorp and simplify complex patient profiles. Support for the show comes from Public, the investing platform for those who take it seriously. On Public, you can build a multi-asset portfolio of stocks, bonds, options, crypto, and now generated assets, which allow you to turn any idea into an investable index with AI. It all starts with your prompt from renewable energy companies with high free cash flow to semiconductor suppliers growing revenue over 20 % year over year.

46:16Dr. Jim Smith:You can literally type any prompt and put the AI to work. It screens thousands of stocks, builds a one of a kind index and lets you backtest it against the S &P 500. Then you can invest in a few clicks. Generated assets are like ETFs with infinite possibilities, completely customizable and based on your thesis, not someone else's. Go to public.com slash podcast and earn an uncapped 1 % bonus when you transfer your portfolio. That's public.com slash podcast. Paid for by Public Investing. Brokered services by Open to the Public Investing, Inc., member FINRA, and SIPC. Advisory services by Public Advisors, LLC, SEC Registered Advisor.

46:47Dr. Jim Smith:Generated assets is an interactive analysis tool. Output is for informational purposes only and is not an investment recommendation or advice. Complete disclosures available at public.com slash disclosures. Less support through telehealth, but it feels overwhelming and rushed. Check out orderlymeds.com now. Orderlymeds.com was built to be different. Here, you connect with real doctors who take the time to understand your goals, review your eligibility and guide you through a plan that's right for you. Orderly meds provides access to proven GLP-1 medications like semaglutide and terzepatide, including both name brand options and personalized compound versions when appropriate.

47:22Dr. Jim Smith:So you have choices backed by clinical oversight, not guesswork. It's a simpler, more supportive telehealth experience designed around people who want clarity, care, and confidence in their weight loss journey. And your medication is delivered directly to your home in discreet packaging. So your experience stays private from start to finish. Do your research. Ask the right questions. Then visit orderlymeds.com slash podcast for an exclusive offer. Again, that's orderlymeds.com slash podcast. Individual results may vary. Not medical advice. Eligibility required. See site for details. Let's talk about modern home shopping.

47:58Dr. Jim Smith:It's sort of become a fun side hobby, right? Scrolling listings at night, dreaming about kitchens you've never seen, or backyards you haven't even stepped foot in. All from the comforts of pretty much anywhere. Redfin knows a lot of people like you want to own, but are stuck in this browsing mode loop. That's where Redfin flips the script. With listings that update within minutes, and tours you can book right from the Redfin app, you can see your dream home the moment it appears. Now, liking a listing is easy, but actually landing it, that's where Redfin comes in. Redfin has over 2 ,200 agents with local expertise.

48:35Dr. Jim Smith:And Redfin agents close twice as many deals as other agents. That means they want to help you win, not just window shop. Redfin is built to help you go from just looking to wait. This could actually be home. So become the newest neighbor on the block. Visit redfin.com to start finding and start owning. That's redfin.com.

49:08Dr. Jesse Mills:yeah jim so you bring up something else in that that there's this thing that i've been reading about and i i try so hard and i think i've resisted to click on this idea of there's some celebrities doing it but mostly it's in the social media zeitgeist called no nut november where you are not supposed to ejaculate. There's some sort of improved, I don't know, testosterone levels. I don't even know the impetus for saying that somehow it's that kind of that old boxing myth about, you know, not ejaculating for a few days before a fight because you lose your essence. But what you're saying is that's probably not good medical advice to hold on to sperm because they're just going to get older and have more brittle DNA and certainly not from a fertility standpoint.

49:52Dr. Jesse Mills:So do I have you on record that no nut November is a fraud?

49:57Dr. Jim Smith:I think that's probably something I wouldn't be advocating for.

50:01Dr. Jesse Mills:Yeah, good. All right. That's good. I just got to get you to take a stance on something. Well, I think what I want to do now, I mean, I would love for you to just tell me a little bit about your advocacy work in sperm cryopreservation, because one of the things that I think is so impressive about you is that you are in a startup that is very patient focused. And one of the rules that I always teach my fellows and really one of the ways that I practice medicine and practice everything I do is whatever I'm going to do, whether it's a surgery or whether it's a prescription or whether it's a talk or whether it's even a podcast, I always say, is it good for the patient?

50:44Is it good for the practice?

50:45Dr. Jesse Mills:And then lastly, is it good for the physician? And I mean that in all categories. whether it's good for the physician's wallet, if it's good for the physician's mental health, if it's good for their reputation. But it's the same thing as if you lead with the patient, then you really can't go wrong. And I think for somebody that holds an amazingly strong foot in the world of academia, at really the pinnacle of academic medical practice, and in a startup, which by nature is going to be driven by sales, I think you've managed to toe this line very well. And I would love for you to just share your thoughts about what you can do to create advocacy and create a space for men that have barriers to access to care, whether it's geography or financial.

51:33Dr. Jesse Mills:So kind of walk me through a day and how your mind works to do what's right.

51:40Dr. Jim Smith:Wow, that's a whole lot of interesting stuff to reflect on. So I basically wanted to do two things. I wanted to develop from a scientific and a quality standpoint, a semen analysis that we could trust as physicians, something that had the same quality as a high quality in-person lab, my UCSF or your UCLA lab. So that was my first goal. The second goal was to make information accessible to patients. What I found when we were beginning this journey about eight years ago was that my secretary would spend three to five hours a day scheduling semen analysis. Guys are coming from hours away, phone tag to schedule people.

52:16Dr. Jim Smith:Then once they actually got the semen analysis done, the resorts would come back and they'd be faxed to the nursing team. And the nursing team didn't know what to make of just the standard kind of normal ranges that they would see. Patients had no idea what this meant. So we wanted to rethink what the report would look like. And so we put front and center total modal count. These are the kinds of things that can affect your sperm concentration. Here's a list of doctors around your area who you could go contact for a consultation. So I wanted to make information more accessible. I wanted doctors to be able to trust this result.

52:50Dr. Jim Smith:Now, Fellow is used so widely around the United States that nearly 300 ,000 men have now used Fellow around the U.S., and it's allowed people from a cancer standpoint much greater access to this. This past cycle, I served on the ASCO fertility preservation guidelines. It's the American Society of Clinical Oncology. And so they review every couple of years what our medical organization's guidelines should be about freezing sperm. And so what we strengthened even more for patients with cancer, that they should be banking sperm ahead of time. What's interesting, Jesse, as you look at this though, is how often do guys actually follow through with that?

53:31Dr. Jim Smith:So ASCO guidelines. You should talk about fertility if you're a cancer doctor, but how often do guys follow through? So interestingly, in the literature, there are very, very few reports of this. And so on average, just like two reports, the chance that guys will follow through is like at most 30%. So they have cancer, follow through. Only one out of three is actually following through for a variety of reasons. Their hospital doesn't have a lab. It's too expensive. It's too far away. They're about to start their chemotherapy, all sorts of reasons. So it's a really, it's a huge barrier to an important care.

54:07Dr. Jim Smith:You know, as we talked about this young 19 year old guy, if the guy doesn't have any sperm, that whole part of his life journey could be not open to him. Wow. So I looked in our fellow data and we now, this is published in fertility and sterility, but I looked at the probability of actually sending in a kit if the doctor orders the test and it's over 90%. And it holds true whether a person is wealthy, whether they're poor, or whether they, you know, anywhere in the country, this held true.

54:35Dr. Jesse Mills:That's amazing. So advocacy, I think information is probably one of the things that is most gratifying as a consumer is that you have that network available to them. You have that ability to say, not only here are your results, but here's where you go for more information if you need that support. And I think that's one of the great partnerships you've done by partnering with so many different academic medical centers, as well as the Veterans Administration, as well as Kaiser, as these big healthcare systems. You know, as we led off with that, your ability to break down those barriers between payers and between healthcare systems, ultimately by keeping the patient first and keeping them in control of their information is really, you know, that's kind of the roadmap to what medicine should look like, what startups should look like of taking an age-old problem, looking at it with a different lens and making it better.

55:28Dr. Jesse Mills:So I congratulate you on that. And then I fully expect that of you knowing that you have person of character that you are, that you're doing this. So it's great to be a partner in this as we go through our careers. And I think one of the other things that we always do in these podcasts is that we have a premier expert in men's health. You are in great shape. I want to know what your must-haves. What do you do on a daily basis, on a weekly basis? What do you do so that you can continue to provide the level of care you do for your patients, your clients? Are you a runner? Are you a snorkeler? Talk to me about what makes Jim grounded so that he can continue to be the superstar he is.

56:12Dr. Jim Smith:Jesse, I don't know if you knew this about me, but I asked my dad, who's big into genealogy, I asked my dad, I said, what did our family do? And so my dad came from Illinois, kind of northern Illinois. And I said, Dad, what did our family do? Well, he's traced our family back for hundreds of years in the United States and basically all farmers. We had one barrel maker, but mostly farmers. So that has come through. And if I weren't a reproductive urologist, I'd probably be a farmer.

56:40Dr. Jesse Mills:Nice.

56:40Dr. Jim Smith:So in my backyard, I have lots of things I'm growing from fruit trees to lots of vegetables. I have chickens. I have a feral cat that I adopted because the chickens and the produce brings in rats, but my feral cat eats the rats. I really love thinking about things in systems. And I love that. Right now, I'm very excited because in my backyard, I'm building a shed office. And so this shed office, I needed to move an irrigation system. So I've used all my available evenings and weekends, digging trenches and moving irrigation line. And so that's what keeps me happy and sane.

57:19Dr. Jesse Mills:And also physically fit. I did the same thing when I moved back to California over 10 years ago. I said one of the main things that I missed being all over the world from Iowa to Colorado to the East Coast is I missed citrus trees. And I said, can I have my own orange tree? And I did something very similar. I dug out my own irrigation, set up five citrus trees that each have their own drip system, dug it into this decomposed granite, which is amazing, right? Because it's good for, it's drought tolerant and holds water okay, but it's also really less messy. But I started off with a 3 ,600 pound pallet of DG and bucket by bucket, five gallons, I carried it to the back and built that system.

58:06And yeah, I love it.

58:07Dr. Jesse Mills:And same thing, the mills is Iowa, so close to Illinois, dating back to the 1840s. We're farmers. So somehow we all return to the ground, some metaphorically and some actually. And I think so far, thank goodness for us in the world. In your case, it's an actual return to the ground. So, Jim, this has been a delight. I can't wait to the next time we get to hang out in a meeting together. The next time you're in Los Angeles. And I got to come up and see your urban farm at some point as well.

58:35Dr. Jim Smith:Yeah, you know, I love to make pizzas. We built a pizza oven up here, too. So next time you're up, we'll have to have a little pizza party as well.

58:42Dr. Jesse Mills:Total renaissance, man. I mean, I think, you know, if the grid shuts down and tech goes away, you'll have one beacon of hope in San Francisco area.

58:52Dr. Jim Smith:Farming and the feral cat and I are all good.

58:56Dr. Jesse Mills:Jim, this has been amazing. The time went by too fast. I really appreciate the time away from your practice, your responsibilities at Fellow, as well as your family. And Jordan, what did I miss? Anything from the everyday guy that you got the world's expert before we sign off that Jim can answer for you? Did we hit it all?

59:15Dr. Jim Smith:I mean, I guess my one question, and I know it was sort of touched on at points, but just as sort of the voice of the everyman here, you know, you hear so many alarmist headlines about XYZ lower sperm count. Don't you know that? Don't you know that? Don't put your laptop on your lap because that lowers sperm count. Don't drink that because that lowers sperm count. What is the biggest myth about things that lower sperm count that you've encountered? I'm sure there must be many. That's kind of a long list. I often spend a fair part of my clinic visit with young men, you know, kind of talking about things that probably don't matter too much.

59:45Dr. Jim Smith:Probably boxers and briefs probably don't matter too much. Hot tubs, not good at all. Lots of illnesses, COVID and flu. The febrile illnesses can absolutely hurt your sperm. You often can see a rebound. Cell phones, probably not a big deal. We haven't really studied it too well, but probably not a big deal. laptops not studied too well, but it can make your boys kind of toasty. You can say balls on here.

1:00:11Dr. Jesse Mills:It's okay. We got the E rating, so it's okay. You can say balls.

1:00:15Dr. Jim Smith:So, you know, laptops, there's a study of medical students where the medical students probably, I don't know that they even got paid for this, but they put temperature sensors on their sack. And they found that within about an hour, their sack went up by several degrees, more than what we would see in our enlarged veins like that case that Dr. Mills was talking about. We don't really know about laptops though.

1:00:37Dr. Jesse Mills:Yeah. One of my favorite old studies that came out of Brazil, Brazilian medical students, I think this made it into my book as well, because it's a great story that we would never be able to do in the United States, but they looked at sort of common bad things that young people do to themselves. And it involved binge drinking, cocaine, which, you know, I mean, I guess it was the nineties, whatever, Brazil and marijuana, but it was low marijuana exposure, You're not sort of at the level that we might be seeing these days. And essentially, cocaine, and by the way, this is no advocacy to anybody out there that said, oh, yeah, Mil says it's okay to go out and do a couple bumps tonight.

1:01:13Dr. Jesse Mills:I didn't say that. But the effect of cocaine was almost negligible on sperm. The binge drinking, so greater than five alcoholic beverages at one sitting, was catastrophic for sperm. And it lasts a long time. So, you know, the number of guys that I see that come off of a bachelor party in Vegas, and they come back hung over barely out of the plane from LAX and do a sperm test that's terrible. You know, they didn't sleep for a couple of days. They drank themselves silly, and their sperm counts are terrible. But again, thankfully, those things can bounce back.

1:01:47Dr. Jim Smith:Yeah, you know, keep an eye on it. I mean, I think that basically fertility is a window into your health, both short-term and long-term. I mean, there are now long-term studies that show that if you've got abnormalities on the semen analysis, you may be more likely to die earlier. And these are big studies that came out of the Scandinavian country. So I'm looking right now at the relationship between metabolic health, so this is diabetes and obesity and hypertension, how that's related to semen quality. And there appears to be quite a strong relationship there as well, looking at a nationwide sample.

1:02:16Dr. Jim Smith:So Jordan, it's an important question. You know, get your semen analysis done. use that as a springboard to look into your overall health.

1:02:24Dr. Jesse Mills:There you go. And I think that's a great teaser to have you back sometime in a few months to talk to us about using semen analysis as a window into metabolic health, diabetes, cardiovascular disease, because I think we could keep going on forever. And we didn't even get into 1960s rock and country music. And so that'll be a whole nother lifestyle show spinoff. But Jim, thanks so much for giving up your time for us and our audiences at the Mailroom with Dr. Jesse Mills. Jordan, thanks again for putting this all together and iHeartRadio for bringing this on the Air Force. I appreciate everybody's contributions.

1:03:00Dr. Jesse Mills:Have a great rest of your day wherever you are.

1:03:03Dr. Jim Smith:Thanks for having me on. It was a pleasure to be here.

1:03:16Dr. Jesse Mills:Let's talk about it in the mailroom. Let's talk about it. Let's talk about it in the mailroom. Let's talk about it. Let's talk about it in the mailroom.

1:03:36Dr. Jim Smith:The Mailroom with Dr. Jesse Mills was a production of iHeartRadio. It was executive produced by Jordan Runtog. It was edited, mixed, and mastered by Bahid Frazier, and the theme was provided by Long Transit. If you liked what you heard, please subscribe and leave a review. For more podcasts from iHeartRadio, check out the iHeartRadio app, Apple Podcasts, or wherever you listen to your favorite shows. This program is intended for educational and informational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Consult your health care provider for any medical or other related questions or concerns.

1:04:16Dr. Jim Smith:The views and discussions aired on this podcast are those of Dr. Mills and do not represent the official positions of UCLA or UCLA Health.

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