The Fertility Test Most Men Are Never Offered | Dr Michael Eisenberg and Dr Natalie Crawford

0:03For the listeners, I wanted to start with the backstory for bringing you two together to have this conversation today. Natalie, you and I had a conversation maybe half a year ago now and that was an incredible conversation about fertility but really specific or mostly specific, not exclusive to the female reproductive system. and in that episode though you mentioned a few things about sperm health and male fertility that certainly surprised me and surprised our community and i went away and was doing some more reading and the more i was reading about sperm health and learning that it's not just about conception and it influences the the development of the fetus and pregnancy outcomes and perhaps even influences or is associated with other outcomes for males, I became more and more interested in this topic and also have a personal stake.

1:01So, I'm at the stage of my life where next couple of years, I'm looking to plan with my partner to have children. So, I then went and looked for a podcast, a resource, just as anyone else might, that was really, really comprehensive covering male fertility with a urologist and an obgyn and i couldn't find it so i invited both of you and kindly you said yes and here we are so that's a background michael perhaps we start with you all right because you're new to the show thank you for for making your way down to la to do this can you just run people through your academic background qualifications in urology and the kind of world that you live in with regards to male fertility and the things that you're thinking about?

1:54Dr. Michael Eisenberg: So, you know, to become like sort of a male fertility specialist, the path is you go through medical school, then you do urology residency. So it's five or six years. And then for those of us interested, you do a special additional year to focus on male fertility. So I did that. And then I'm currently at Stanford. So I initiated the male fertility program there. I've been there for about 15 years. And essentially what I do is help men have babies. So I partner with our gynecology colleagues, our reproductive endocrinology colleagues for couples that do need assistance and work on the male to optimize sperm production for men where there's no sperm, help to find sperm or restart sperm production, trying to understand the etiology of any difficulties and work to fix it.

2:39Dr. Michael Eisenberg: And then at Stanford, you're involved in research as well. I also do research as well. Yeah. So, I try and understand sort of the origins of dermatogenesis. A lot of the things you talked about, this link between overall health and reproductive health, that's one of the main focuses of the lab. I think both things that we can do to optimize a man's health that can improve reproductive health, improve sperm production. But also, we've increasingly learned that reproductive health or sperm production may be a window into future health. So, men with impairments in sperm production have higher risks of, you know, later chronic diseases and trying to understand why that is and what men can do hopefully to mitigate some of that risk.

3:17And how do you think we're going as a society in terms of having this conversation?

3:23Dr. Michael Eisenberg: I think it's getting better and better. I mean, obviously, you're, you know, this podcast here, I think is an example. I think more people are understanding it a little bit more. I think as there's been more dialogue and research about sperm counts, you know, their changes over time, the declines over time, I think there's a lot more awareness of it. I think that, you know, from a political level, I think we're seeing a little more focus on it as well from a research standpoint, from surveillance standpoint. So hopefully it's getting better. I think it still lags far behind what's needed just because it is such an existential issue.

3:54Dr. Michael Eisenberg: But I think I'm optimistic about the direction. And Natalie, you've been on, but in case listeners didn't catch our last episode, which I really recommend people go back and listen to, So what are your qualifications and what does your clinical work look like with regards to fertility and how does male fertility kind of work into that?

4:17Dr. Natalie Crawford: Thanks for having me back, Simon. I'm thrilled to be here. I'm a reproductive endocrinologist. So I did four years of OBGYN residency and then three years of reproductive endocrinology fellowship for my training. And I was really fortunate that where I trained, there was a male fellowship trained urologist who was in our department of reproductive endocrinology. So I had a lot of insight really early on to male specific problems and understanding, especially in the timeframe when we weren't talking about it as much, that male fertility is a huge piece of the puzzle. We've luckily seen a cultural shift where now we are talking about male fertility being half of the causes of infertility.

4:58Dr. Natalie Crawford: and we see more male partners willing to step into this conversation. And I have to say this is a huge change. You know, when I started practicing over 10 years ago, men weren't even present in appointments. They were declining semen analysis. There was such a female-only burden. And even though women still carry a lot of the burden, we do see a new generation of men, you are a great example, who are curious about their health, who want to optimize their health, and who understand that their sperm is an essential component when it comes to reproduction. But there's been a lot of education that has had to happen and still does.

5:32Dr. Natalie Crawford: So I sit across from couples every single day. I own a private practice called For a Fertility in Austin. And people come when they are struggling to get pregnant. And we really have to expand and bring both partners into that conversation. What percentage of your clinical work do you think would be spent on educating the man and assessing his contribution to their fertility? 50 % for sure. And this is one place where I have to say COVID has changed this for me in such a positive way because we started doing telemedicine consults and now we still exclusively see all of our patients virtually. And the reason why is we have a greater uptake of male patients on that first consult.

6:10Dr. Natalie Crawford: So if we think about fertility specifically, usually for in a traditional model, we're billing insurance based on the female partner's insurance. The female has to be present for that consult. We're talking about everything that's happening. When it was in person, the uptake of having you present when I'm talking to your partner was so much lower. Navigating two people's schedule, travel to the office. And we really put the burden of care on one person more. Because let's imagine I'm giving a female really bad information, bad news. That's what a lot of infertility is, right? Rates of success, invasive procedures.

6:45Dr. Natalie Crawford: You're overwhelming them with what is to come. then they have to go tell that information to their partner who is rightfully going to have a lot of questions and now that female partner was centric having to interpret all of that relay it it really put them in the middle of their care instead of being able to make it be a team sport like we always talk about so now having male partners on consults from the up go we're talking about egg quality and sperm quality together and like you said sperm quality is a marker of future health, not just health right now. Unlike for female fertility, it's more easily modified in a lot of ways or faster than egg quality can be.

7:26Dr. Natalie Crawford: So that's an excellent opportunity for a male partner to come to the table doing what they can to improve odds of conceiving, health of the pregnancy, health of the baby, and then of course their own future health as well. And 50 % of cases of infertility are explained by some type of contribution from the male? Correct. There's one third that we would say are solely female causes, one third that would be just male causes, and then a third would have some contribution of both. And that's also really important because I have women sit across from me who say, oh, I have endometriosis, so the problem's all me.

8:01Dr. Natalie Crawford: We don't need to check him or worry about him. And we don't know that to be true. Both partners need to be evaluated and evaluated completely so that we know all the data about what is going on and can help manage them the best. Would it be common practice with that in mind that a woman may go and see her OBGYN and get some testing done and begin interventions before a man has even done sperm testing? Simon, this drives me nuts, but this is actually probably the experience of the majority of couples who have infertility. As the female partner brings it up to her OBGYN, they say, oh, we can do some preliminary testing on you.

8:39Dr. Natalie Crawford: They don't always even check a semen analysis, ask any questions about male health. They then offer low-cost treatment, whether it's ovulation induction medication, even IUI. I have seen couples doing intrauterine insemination without ever having a formal semen analysis done. And at some offices, they'll do this for up to a year. And you get a formal semen analysis, and you see the concentration is extremely low. Nobody was looking at the sperm under a microscope. They were just putting couples through treatment. It's really tragic when you think about the resources that a couple has when it comes to fertility.

9:16You have your physical and emotional effort, right?

9:20Dr. Natalie Crawford: You have to take on a lot, especially as a woman or a man. You have to go through things emotionally to go through things. You have money. I think everybody thinks about money, but your time is your most valuable commodity. and to be going through months and months or years of trying, spending money on treatments, going into offices, and then to realize, you know, he has azospermia, needs a completely different evaluation. I mean, it's tragic. And so we have to empower people to know what questions to ask at what stages of the journey so that they can advocate for themselves better. Is that a willingness from the male partner that's contributing to that?

9:59Or is it a a lack of education within the medical system and at the OBGYN level, or is it a lack of cross-communication between OBGYN and urologist?

10:09Dr. Michael Eisenberg: Yeah, I mean, I think it's a combination, but a lot of it has to do with education. I think that when we talk about fertility, as Natalie said, it used to be thought of as a female issue, right? And that was where the journey began for the couple. But now we know that about half the time is a male factor. But I think that hasn't really kind of permeated the whole ecosystem quite yet. And if you look at, you know, surveillance like data where you survey lots of infertile couples, probably a quarter of the time to a third of the time, the males never evaluated. Like Natalie said, they're totally ignored.

10:40Dr. Michael Eisenberg: And, you know, this is very early in the conversation, but to get on my soapbox, if you think about sort of the downstream effects of that, it's really devastating for men's health because couples wait longer and longer for the male to be seen. And a lot of times there are things that we can do. You know, there's an evaluation to look at health aspects, but there's things that you can measurably do to improve fertility sperm quality. But if a couple's already been struggling for a year or two years, a lot of times they don't want to put in any extra time. So, these couples then move along to IVF or other technologies.

11:11Dr. Michael Eisenberg: And so, that really, it's at the detriment of, you know, the evaluation we do for men. And it also really affects some of the research that we're able to do because couples are not interested in enrolling in trials and doing other things because they just want to move as efficiently as possible. If you've been trying to have a child for one year, two years, you don't want to take a pill that takes three months to help with sperm production. You just want a baby. And so, I think that's really one of the, I think, the kind of the devastating parts of some of this that we've seen. Yeah, I imagine that burden swings both ways because that would be a shock for the man to find out and then feel responsible for the last two years of emotional turmoil and time invested.

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13:01Dr. Natalie Crawford: Simon, I have this couple who I've taken care of and they came to see me and I'll always remember them. And Michael has been involved in couples like this and they'd been trying to get pregnant without tracking cycles and went to their doctor and said, hey, we haven't gotten pregnant. We've been trying about a year and they told her well you need to make sure you're really timing intercourse right so track and time for another six months so they spend a year and a half trying then they finally come into me for testing and we do testing and he's a cystic fibrosis carrier so he has a birth defect which means he doesn't have a vas deferens so he has zero sperm in his ejaculate so he makes sperm but it just doesn't get it doesn't get out right so he's making sperm but if anybody had looked at a semen analysis, they would know all of those months and those months they were being told to wait longer, there was a 0 % chance that they were going to get pregnant then.

13:54Dr. Natalie Crawford: And they had to go through IVF and have a sperm aspiration procedure and they were able to get pregnant and have a family. But I remember her sitting across from me and crying and saying, I just can't believe all this time. We just kept being told to try and try. And for a simple test, the treatment was never going to be simple this was going to be their treatment one way or another but starting that journey a year and a half earlier could have made a huge difference for them you know her age was older she had to do multiple cycles they may not have had to had she done this younger and it really speaks to the point that michael and i are both really passionate about is the current system fails patients right now we say hey i want to get pregnant what should i do majority of physicians will say just start trying they won't talk about preconception health.

14:39Dr. Natalie Crawford: They won't talk about male health. They won't talk about vitamins. They won't even talk about preconception testing. Is that what the guidelines also recommend? The guidelines, they do a semen analysis after you fail to get pregnant for a year. Okay. So it's pretty like low threshold. A year. So try for a year. Then we'll take you. Yeah. Instead of, I mean, I'm not a man, but it seems like a relatively easy test to do a semen analysis. There's easy options now, right? You can mail them in. There's great valid options where technology has helped. So it's not even as burdensome of going into a doctor's office.

15:09Dr. Natalie Crawford: But why are we making couples fail before they then get the diagnostics? And then, as Michael said, sometimes the diagnostics aren't even complete or accurate. There's so many pieces, especially for the male puzzle, where men, maybe they get a semen analysis, but not a sperm fragmentation, which we'll talk about, or they don't get hormone levels checked, or nobody's even getting a history on them. And you get a history, and you could learn a lot of tidbits about what they're telling you. And I'll sometimes sit across from somebody in a virtual consult. I have no labs, no physical exam. And I know, oh, there's a male component based on the things that he is telling us.

15:46Dr. Natalie Crawford: So we both feel passionately, and I know you do too, that this narrative doesn't serve anybody anymore. That's just relying on the fact that hopefully things will work out for us because it does for most people. But the reality is, as infertility rates are rising, sperm counts are dropping, we need to be more proactive on this end. What do you think it would take for the guidelines to change? Is that an economic thing? I can't imagine it being economic because the cost compared to some of these other investigations would be much less. But would it be some type of research showing that routine screening leads to a shorter time to conceive?

16:25Dr. Michael Eisenberg: I think just education. I think really, I mean, all those things I think would be great. But For women, for example, they know their fertility to some extent because they have regular cycles after puberty where we have no feedback. And so, I think that it would be great to be able to advocate for men to get a semen analysis when they're ready to conceive or potentially even before that. Maybe as like a parting gift after high school for your parents to pay for a test just so you see where you are. You don't necessarily have to do anything at that point. you know most you know 18 20 year olds are not thinking about conceiving but to have that information early on so that there's you know enough lead time if you need that evaluated and that treated or it could be again something underlying that you want you know taking care of a little bit a little bit sooner so on on that i think this is an important point for for people to understand it seems basic but i think it it might not be fully appreciated and it was in that example there with that guy who had cystic fibrosis just having semen like ejaculation doesn't tell you about the quality of that right so you were saying you get women get feedback and i was thinking yeah men might think they're getting feedback but just because you can ejaculate it's not telling you that you're you have a certain sperm concentration or that they're healthy there's not dna damage etc that's right yeah there's so many components i think that we hinted at that we look at in a semen analysis.

17:52Dr. Michael Eisenberg: So you look at how much comes out, that's important. You look at how many sperm there are. So there could be zero. And just to the naked eye, it would look the same. So there could be very low levels. We look at their movement as well. We look at their shape. We look at the DNA damage. I mean, all these things are very important and predictive of fertility, but they're not anything that you can just tell based on being able to produce an ejaculate.

18:13Dr. Natalie Crawford: I think it's important for people to understand too, that so many different components go into having normal sperm, right? You have to have normal hormone levels to drive the body to make sperm. There's structural pieces of the puzzle that need to be in place. Like we talked about the vas deferens. There's how the testicle is actually going to function and going to respond, the environmental influence from chronic inflammation or toxins. Because sometimes men have this idea, oh, my testosterone is fine, so my sperm is fine, right? Maybe they did get their testosterone checked or they say they don't have any issue with erection, so they know that they're good.

18:46Dr. Natalie Crawford: but that's not the full puzzle. So to Michael's point, there's no one single symptom that's going to help you know, oh, I can do this. So everything is good. Really a semen analysis is pretty comprehensive, but it's telling us about different pieces of the puzzle that we really do need to look at. And to your earlier question, it would take a major overhaul of how we approach women's health and fertility in this country to do proactive testing for fertility. We talked about this last time too, we talked about AMH testing for your egg count for women and how the medical recommendation is clearly not to do it if you do not have infertility because it can cause undue stress and for a variety of quite paternalistic reasons.

19:27Dr. Natalie Crawford: Some of this is rooted in the fact that infertility has a very timeline definition, right? You've tried to get pregnant for a year and you have failed and now you qualify, quote, for testing. And if we are playing in the standard insurance model, insurance doesn't cover testing for patients who do have coverage until they've met that timeline-based definition. So if we're sitting here saying we want to be proactive about it, which is my entire platform, right? You can't make decisions on data you don't know. Why do you not know your own health data? A lot of times we're asking couples to reach into their own pocket to get this testing because it's not going to be covered by insurance.

20:02What's the actual incidence of true infertility by that definition in this country? About 15%. So about one in seven couples are unable to conceive after a year of trying. And then 50 % of that is contributed by the male. Yeah.

20:17Dr. Natalie Crawford: I'll say if we isolate it down to the United States for people who are trying to get pregnant for the first time, so we take secondary infertility out of it, the rate of infertility is one out of five. So there's some subset of people who are coming into it. If we look at all comers who are trying to get pregnant, and if you've had a pregnancy see in the past. You have a stronger predictive factor that you have more likelihood to get pregnant again. There was sperm, right? You did have vas deferens. There's a lot of working parts that were in order. But for somebody sitting across from us who says, hey, we're going to try for the first time, what are our odds of having a problem?

20:52Dr. Natalie Crawford: Up to 20%. And then providing you don't have erectile dysfunction, so you can ejaculate, is male fertility synonymous with sperm health?

21:05Dr. Michael Eisenberg: I think semen, that's sort of a fun question because the semen health is not a perfect measure of fertility. So there have been lots of studies where you look at men with, you know, sort of the range of semen quality or sperm counts, for example. And there's men that have 100 million sperm that can't get their wife pregnant or partner pregnant. And then there's men with 5 million sperm, which is very low and they're able to easily conceive. So it's not a perfect measure, but it does give you some idea of risk. So in general, I think it's the best test that we have now. A semen analysis can be very useful for that.

21:36Dr. Michael Eisenberg: But I think there are, and we'll probably get into this later, there's a bunch of adjunctive tests that are being done now to look more at sperm function more than, you know, sort of these kind of general anatomic views. Is some of that also an interaction between the sperm and the specific egg as well? Yeah, it's a team sport. So I think that's, you know, a big part of fertility is not just the sperm, but the partner as well. I read something, and maybe you guys can tell me if this is true or not, that a woman is better able to resolve defects in a sperm from a younger man compared to sperm from an older man.

22:12Is that true?

22:14Dr. Natalie Crawford: A lot of that, though, is egg functionality, because typically women who are with younger men tend to be younger also. Watching sperm in an IVF lab, right? I have an IVF lab. It gives you so much more perspective on what Michael is saying, right? You can have a sperm count. We can think the problem. We can identify some problems from low concentration or abnormal motility. But even in some men who have perfectly normal, quote, sperm on standard testing, we see that their sperm won't fertilize eggs or that development stops when the male genome comes in. And we do advanced diagnostics and figure out there actually is a functional component here to what the male is contributing.

22:54Dr. Natalie Crawford: But I think it's interesting and important for people to understand too that especially if we're doing IVF and a lot of times we're doing something called ICSI, which we can go into, which is intracytoplasmic sperm injection, picking up a sperm and putting it in an egg. So we're really trying to say like, let's put the best sperm in the egg. You know, the egg has to accept the sperm. So there's some of this idea that like, oh, we're not fertilizing and it's all the sperm's fault. But often when we see fertilization failure, that's an egg quality component because the egg has to accept it. And then the eggs, mitochondria and DNA really control those first few days of development.

23:31Dr. Natalie Crawford: The sperm genome kicks in a little bit later. So it does take two, but seeing where problems arise in the lab sometimes bring to light, hey, looked okay, but sperm's not really functioning well. We go sit down with patients and often we uncover things. I told you this last time and everybody hates it, right? Cannabis use is one of the top ones where sperm might still look fine. Sometimes it doesn't and then it's really obvious, but sometimes it looks fine, but we're not getting the outcome we want. And you go down and say something's happening with the sperm. And then somebody comes to the table and says, oh, well, you know, a nightly cannabis use to help me relax, you think that's causing a problem?

24:09Say, yes.

24:11Dr. Natalie Crawford: And we stop it, wait three months, cycle again, and have a very different outcome. But we shouldn't have to spend$20 ,000 or$30 ,000 and have a failed cycle to get to that point. We know that, that cannabis is negatively affecting sperm. I actually had a community question about this specifically. A woman wrote in seemingly frustrated saying, why did our doctor not tell my partner to stop smoking cannabis? Cannabis use negatively impacts sperm. That doesn't mean, right, like with all, quote, bad things, that if somebody uses, they can't get pregnant, right? Certainly there's some people who do all kinds of negative health habits who get pregnant just fine.

24:50Dr. Natalie Crawford: But when we look at the impact that cannabis is having, it's multiple. It's, you know, on the brain, it's on sperm production, it's on sperm quality, sperm motility, it's on the pregnancy outcome. You know, women whose partners use cannabis, even if they themselves do not, have a higher rate of miscarriage. we just think about that right because because sperm is half of the equation here and from an ivf standpoint right stakes are really high there we're putting a lot of dollars a lot of time a lot of physical energy we see lower embryo development rates and male partners who are

25:20Dr. Michael Eisenberg: using cannabis i think yeah to natalie's point i think there are you know i guess sort of gradations and some people are a little bit different than others so i think if you look at the literature too, it's somewhat mixed. I think the overall kind of consensus is it is a negative. And, you know, I think there is a dose response curve as well so that the, you know, the more men use, the worse it is. So, we think probably daily is bad. But, you know, when I counsel patients, I think that I certainly bring up all these points. I try and also just understand why they're using it. And if they're using it, you know, every day, I think that is probably too much.

25:54Dr. Michael Eisenberg: But once in a while for, if relaxation or pain i think that you know again i'm very honest about where the literature is and i think it's somewhat heterogeneous somewhat mixed so i just try and i relay that as well but i think everything in moderation you know alcohol cannabis all that stuff i think can can impact things when you take it to extremes you both alluded to this and i i think both of you talk about the sixth vital sign if someone's listening and they're thinking this doesn't really apply to me because I'm not planning to have children. What other science establishes a relationship between semen parameters and things outside of fertility that might be of interest to a male listener right now that may promote them or inspire them, motivate them to go and get a sperm test?

26:47Dr. Michael Eisenberg: I think this is such a fascinating line of research. I mean, obviously I'm biased given what I do, but You know, there's good data that as semen quality really lets you know where you are currently. So, there's strong links between semen quality and current health, but also, again, future health as well. And it's just sort of this amazing marker of fitness, right? It's like a check engine light, right? I mean, you're driving and a check engine light comes on doesn't mean your car is going to stop immediately, but there's some issue with, you know, a sensor or a valve or something. So, in a similar fashion, I think a semen analysis gives us that kind of window into many different things.

27:26Dr. Michael Eisenberg: Metabolic health, immune health, you know, men with lower semen quality have higher risks, psoriasis, rheumatoid arthritis. I mean, these are conditions that most would probably not think to be associated with spermatogenesis. But yet, if you look at it, there is strong data that links that. And this is, you know, both men that have these conditions but also men that don't have these conditions and develop them 5, 10, you know, years later. So, there's just something about sperm production that really gives us sort of this insight into just overall fitness, genetic fitness. You know, there's conditions, you know, cystic fibrosis is one, but there's certainly many others.

28:00Dr. Michael Eisenberg: You know, some genes that we understand, some we don't understand as well. But it's just sort of this subtlety. You know, it's estimated that 10 % of the male genome is devoted to reproduction. So, there's about 25 ,000 genes in the body. So there's thousands of genes that can get us that that we get, you know, a little bit of information on just with a semen analysis. So even if you're not interested in fertility, I think it does tell you just overall how you're doing. You know, Brian Johnson, I think, does a lot with, you know, obviously longevity, overall health. And, you know, he's been very upfront about his semen quality, which is excellent.

28:32Dr. Michael Eisenberg: But he really invests a lot in it. And I think it is that kind of window into overall health, but also, again, gives us, you know, insight into how he's going to do, you know, next year, the year following and onward. I saw he posted something about using sauna and other interventions, at least according to his before and after test and the things that he shared to reduce microplastics. Yeah. In sperm. Yeah. I think, well, heat is not great for somatogenesis. You know, the testicles are outside the body because they need to be a little cooler. And so, protecting them when if you're going to expose yourself to heat, I think is very important.

29:06Dr. Michael Eisenberg: And microplastics are certainly another sort of emerging area. I think when people look at why sperm counts are going down, you know, we've seen enormous increases in plastic production, microplastic accumulation in our bodies. And so, that's been, you know, thought to be a potential culprit. You know, their study that was done just a few years ago in New Mexico, one of the real leaders in microplastic research found microplastics in every cadaver testicle that was tested, every dog testicle that was tested. I mean, it's really pervasive. It's in our blood supply, it's in our clothes, it's really everywhere.

29:38Dr. Michael Eisenberg: And I think it's really, you know, kind of important to understand exactly what that's doing. So certainly it's good instinct to try and get rid of it. But I think that, you know, we're sort of early days in terms of understanding what microplastics can do. Is a certain sperm parameters associated with longevity? The one that's been looked at the most is count or concentration, just how many sperm we're able to make because that's sort of been most consistent and most consistently studied over time. The, you know, really the evaluation methods have not really progressed that much. But there is also data on motility as well, morphology or shape.

30:15Dr. Michael Eisenberg: I think those also have some interesting observations as well. There is a study just published last year out of Denmark where they had, they followed men from a semen analysis 30, 40, even 50 years in some cases later. and every single parameter was associated with the age of death. So, if you had a lower volume, you died on average, let's say two or three years before a man that had an average volume. Same with concentration, same with total sperm count, really every parameter had that same. So, it's really amazing to think you could do a semen analysis now and you have some insight into when you're going to die decades and decades later.

30:53To be clear, that's not necessarily like a causal thing, but it's symbolic of the person's underlying metabolic overall physiological health at the moment right we

31:05Dr. Natalie Crawford: see all the same data in women right if you have infertility if you have a higher risk of cardiac disease metabolic syndrome cancer stroke earlier death you know the earlier you go into menopause the same you know risks all increase the ovaries and the testicles are the same embryologic origin right we have the same two components working at them because i know a lot of your audience is women listening to this on behalf of their partners and then going to push it over. We want to think about the brain, the same hormones, FSH and LH, which stimulate ovulation, estrogen, progesterone production, are stimulating both sperm production and testosterone production.

31:41Dr. Natalie Crawford: So there's this hormonal component. So if something's interfering with this hormone system, which could be some medical condition, you could have thyroid disease or hyperlactin, but it also can be chronic inflammation other metabolic state you being really sick that can interfere with that brain ovary brain testicle communication but then the sperm are developing in the body like eggs are stored in the body so they are susceptible to the world around them and unique to the sperm right as they're growing and changing in your body so the ability for them to move their motility the shape of the sperm the morphology these have an influence based on lifestyle or total body health at the moment.

32:21Dr. Natalie Crawford: And one of the strongest underlying factors that ties the whole piece together is these diseases or states that are associated with higher levels of chronic inflammation and insulin resistance. You're going to have worse sperm quality, worse egg quality. You tend to see lower chance of ovulation, maybe lower sperm production. So it becomes a double hit. And if we start viewing your fertility, whether you are a man or a woman, not just as a means to get pregnant, but as a state of your health, right? Having been able to conceive if you wanted to is reflecting a state of current good health. That is why it is predictive of future health.

32:58Dr. Natalie Crawford: It is a health marker for the future. And if instead of making you fail, getting diagnosed, and then feeling rushed to try to get pregnant, we say, hey, let's proactively not just make changes to get you pregnant, but to what you were saying, well, we don't want to be pregnant yet, so why do I care? Two biggest reasons. One is what is causing this problem and can we change it now for your longevity, for your future health, for your health span? And two, unique to men, the spermatogenesis cycle, sperm develop in the body. And so unlike eggs, which are constantly stored there, kind of build up this wear and tear where age starts to become a bigger and bigger issue that's harder to overcome, men can make a change right now and see different sperm counts in as little as three months.

33:43It's a new opportunity.

33:44Dr. Natalie Crawford: It's one of the most powerful opportunities for a couple, but that time does start to feel too much when you get diagnosed late in the game. And so being proactive about it is not going to just make you feel better now, lower your disease risk later, but it is also going to optimize your chances when you are trying. So that's why a lot of the lifestyle behaviors, the things that you can do to improve your sperm health overlap with the things that you can do to improve your metabolic health or reduce your risk of heart disease or dementia. Michael and I don't have like a completely different list for what you do for eggs and sperm.

34:19And if, you know, Dr.

34:21Dr. Natalie Crawford: B was here talking about gut health, the things he's recommending are very similar too because they're all trying to get to a common root cause potentially that is something in your body is contributing to higher levels of chronic inflammation. And there's always exceptions, right? Like a pituitary problem. Yeah, there's these medical conditions. Someone taking exogenous testosterone. Yes, but a lot of times a guy will get a, even if he is getting testing, he'll get this normal semen analysis. And sometimes he considers that like a free card to do whatever else he wants, right? It is just a reflection of the right now, even though it does carry significance for the future.

34:56Dr. Natalie Crawford: But also, we need to start understanding that this is, you know, a bigger piece of the puzzle. You need a medical evaluation, too, if things are abnormal. But you'll get a normal semen analysis and be like, oh, everything's totally fine. Michael said it, too. That's not the full puzzle. So we really want to think about what it's saying about your overall health. And, I mean, men aren't great at going to the doctor. Men aren't great at getting evaluated until there's a problem.

35:21Dr. Michael Eisenberg: One of my favorite sort of statistics about, I guess, the value of a semen analysis compared to other things, I would imagine that everybody that's interested in health knows their weight, right, and probably knows their body mass index. But super interesting, if you think about what each of those is telling you, if you have sort of like a 4x4 grid and you have somebody with a high sperm count and a low sperm count, obese, not obese, all right? So, if you're going to say who's at risk, right? Conventionally, I would say obese, right? Obesity carries the most risk. So, if you're obese, whether you have a high sperm count, low sperm count, whatever health metric we're looking at, that's going to be a problem.

35:56Dr. Michael Eisenberg: but interestingly the main discriminator for that little grid is actually sperm count so if you have a high sperm count it doesn't matter if you're obese or not obese you're in a better risk category than somebody with a low sperm count and that actually also applies to smoking amazingly so you know we talk about sort of this healthy obesity but even smoking i mean if you if you smoke but you have a good sperm count you're in a much better trajectory than someone that doesn't smoke and has a low sperm count. Better trajectory for our long-term health outcomes. Yeah. So, you're saying sperm health is a very strong indicator it survives those things.

36:33Dr. Michael Eisenberg: So, just well, I guess yes, but also if we're just trying to have sort of a carrot for why someone would do a semen analysis, they have no plan to ever have a child in their life. They probably know how much they weigh, right? They probably have some sense of that. So, this really tells them, I think, a tremendous amount about how they're doing. But just to be clear, you're not telling people to optimize their sperm health and smoke a pack of cigarettes? No, no, no. Well, I mean, I think, again, there's sort of this concept.

36:57Dr. Natalie Crawford: The answer is no, Michael.

36:58Dr. Michael Eisenberg: Yes, but there's this concept of healthy obesity, right? I mean, there are some men that are obese that do fine, and we don't really know why. We can't tell the difference, but maybe a semen analysis would help us discriminate. No one should ever smoke, obviously, but I just think it's really interesting to think about this as just this really, really powerful health metric that I think a lot of people probably ignore. How do you explain spermatogenesis to a patient? Well, I say that, you know, we start off with these sperm precursors and they go through several rounds of division and maturation and they become a sperm.

37:32Dr. Michael Eisenberg: And there's a lot of things that you do that influence that. This whole process takes about three months. And so, that's sort of the window where you can really make a positive impact, you know, through optimization of all the factors that we've talked about, health, diet, avoiding toxic exposures, avoiding heat. And so some of them, some patients really want to get much more into the weeds. So I'm happy to do that. But that's usually the top level discussion that I have. Here's something that gets lost in the protein conversation. Protein synthesis, the building of new proteins, doesn't just happen because you ate enough leucine.

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40:19Interesting longevity science to follow, though still early days. Get 20 % off at peaklife.com forward slash Simon. That's P-I-Q-U-E life.com forward slash Simon. And I think a lot of people will have heard, and I think you maybe even mentioned it, that sperm counts seem to have gone down or that's what's reported. So what is it that's affecting spermatogenesis such that populations of men today have lower sperm count? And is that accurate?

40:54Dr. Michael Eisenberg: So it's still somewhat controversial. I think if you look at the world's literature, one of the first studies that ever report that was in the early 90s. And it reported this 50 % decline over the last half century or so. There was a lot of controversy about it, about sort of the distribution of the studies, some of the statistical modeling. And so that was updated more recently in like the late 2000 teens. It showed the same thing. And then most recently, it's just updated a few years ago. And, you know, that study expanded beyond just sort of Western countries to really all over the globe. And it shows this decline.

41:26Dr. Michael Eisenberg: So, I think generally the consensus is that, yes, sperm counts are declining. If anything, the rate of decline appears to be accelerating over the last probably quarter century. But there are still some that don't believe that. I think there is still some controversy in it. But even if you put sort of that aside, if you look at other sort of male reproductive health or overall health measures, testosterone levels are going down. I don't think that's really in dispute. I've been lots of studies that have supported that. Higher rates of male genital birth defects like undescended testicles, for example.

42:00Dr. Michael Eisenberg: Pediatric penile length is getting smaller over time. Pubertal timing in boys is changing. So, we're seeing all of these sort of different male reproductive health metrics that seem to be going in the wrong direction. And I think, yeah, to your point, the real question is why. You know, it's too quick for genetic changes to occur. So, it seems like it's likely exposure. And people have looked at different ones, whether it be chemical exposure, microplastics, which we talked about, you know, just sort of our overall lifestyle, sedentary life, obesity. Type 2 diabetes. Technology. Yeah, I think that it's not certain, I think, but it is existential.

42:37Dr. Michael Eisenberg: Right. It's likely multifactorial.

42:39Dr. Natalie Crawford: Clinically, right, Michael sees patients when they have a problem, right? I see patient two of a kind of a bigger problem, fertility, and then we're trying to figure out what the components of it are. And I will say, like, we definitely see more abnormal semen analyses now than we did a decade ago. Like, there's no doubt about it. And I, you know, the data is more compelling that more recently this decline in sperm parameters is worsening. And it correlates with what we see, a decline in female parameters, you know, increased rate of miscarriage, decrease in, ovarian reserve markers, increase in autoimmune disease diagnosis.

43:15Dr. Natalie Crawford: Everything's trending in the same way, back to the fact that the world we live in is more inflammatory, more toxic, and we've normalized certain things. A big bitey thing from this episode will be something about cannabis, for sure, because it is so normalized and then people are surprised that it can impact their sperm production or their overall health. Just because something is legal or normalized doesn't mean that it's good for you. Is it smoking cannabis? Is it like the active component or a gummy's okay? It depends on the outcome that you're looking at. You know, if we're looking at, you know, miscarriage or pregnancy outcomes, then any form and like THC and gummy specifically, you know, is higher than you're getting sometimes in other modalities of it.

44:01Dr. Natalie Crawford: If you're looking at semen quality, it's probably smoking more specifically. That's the one that's been study the best. Yeah. So miscarriage can be traced back to sperm parameters? It can be traced back to sperm parameters, especially when it comes to the point now where ASRM, which is the American Society for Reproductive Medicine, finally released new guidelines on recurrent pregnancy loss, saying if you've had two or more pregnancy losses, here are the tests that you should do. And they've now included a DNA sperm fragmentation, which is the first time that they've included that, which people should know is not standard in most semen analysis.

44:37Dr. Natalie Crawford: When we talk about a semen analysis, we're looking at the volume of the sample, so the whole ejaculate, the concentration, how many sperm are in the sample, how they move, the motility, and the morphology or the shape. Those are the top parameters. And you get extraneous information like different types of cells and the pH. But DNA sperm fragmentation actually destroys the sperm, for lack of a better word to look at the head and say how much oxidative stress is there, how much DNA damage is there. And that is potentially a better reflection of what we loosely call sperm quality, which is like the sum of how the sperm is going to function.

45:13Dr. Natalie Crawford: And function doesn't mean just swim and fertilize an egg, but we want to have a normal baby grow and develop. So that is one way where we start to say, hey, this fragmented sperm is definitely associated with chronic inflammation and lifestyle parameters, dietary choices, obesity, smoking, alcohol, cannabis, endocrine disrupting chemicals. And a lot of the data is observational. That makes it all non-conclusive, right? Because it's telling us an association. It's not saying this causes this. But when you put the full piece of the puzzle together, especially when you are sitting across from somebody who says, what can I do?

45:52Dr. Natalie Crawford: Or I want to do everything I can to avoid this outcome. Or how do I have the highest chance of having the best sperm? Then we say, hey, all these things are associated with higher sperm frag, higher miscarriage rates, lower fertility rates. Those are these kind of healthy lifestyle practices that we both talk about looking to try to decrease inflammation or toxic exposure.

46:14Dr. Michael Eisenberg: I mean, in addition to the parameters, I think, you know as natalie alluded to it's the quality and if you look at sort of the health of the man going into a pregnancy if he has more components of the metabolic syndrome like obesity hypertension all these inflammatory states or really any health condition the risk of miscarriage goes up the risk of stillbirth goes up ectopic pregnancies all these things that type 1 diabetics like they're yeah that's exactly right so i think that you know again we too talk about sort of this preconception period, which usually has been focused exclusively on the women, but bring it to the man too.

46:48Dr. Michael Eisenberg: I think there's a real opportunity to optimize both his health, but then, you know, again, pregnancy trajectory and hopefully his child. Yeah.

46:55Dr. Natalie Crawford: You asked Michael's description of spermatogenesis, which is really nice and scientific. And, you know, I like really simple analogies for my patients to try to understand when it comes to sperm, why there's almost like a piece of it you control and a piece of it that you don't. If we imagine like all those, you know, germ cells where sperm come from are like, I like birds. They're, you know, eggs that are sitting in a nest. You have to, they have to hatch. So it has to be some capacity of functionality inside the testes, but then the brain has, you have to have a worm. So if FSH and LH, these hormones from the brain, they're coming in, they're your worms, right?

47:27Dr. Natalie Crawford: So you need worms coming in for the birds to eat, to grow, but also the environment matters, right? If the nest is in a hailstorm or heavy wind, or if they're not getting the right type of food, whatever the other birds are bringing in or how they're treating each other like that environment matters too so you need proper brain signaling to get sperm to grow but you also need an environment that can sustain that growth as well so it's not just one it's not over at the fertilization because what i'm hearing is that the quality of the sperm can affect the outcomes later like miscarriage and i think i think people generally appreciate the importance of the placenta yeah is it is it true that the quality the physiology of the placenta is also in some way shaped, affected by sperm?

48:15Dr. Natalie Crawford: Yeah, some of the sperm genes control placentation, the ability of the placenta to grow into the uterus, but then also the functionality of it, and then therefore risk to mom during the pregnancy, whether it's risk of hyperemesis or risk for preterm birth, how long will the placenta function, and preeclampsia. A lot of conditions of pregnancy we now know are actually related to placenta health. It's a fascinating organ, but some of those genes are coming from the sperm directly. So if you're a guy and you do want your partner to get pregnant, this is how you can also bring to the table better quality sperm for better pregnancy outcomes.

48:53Yeah.

48:54Dr. Michael Eisenberg: And you can trace all those just right back to the father in a lot of cases. yeah wow the abnormal results that you mentioned you're seeing more and more of let's let's click on that a little bit where are the results coming from that you see clinically are these people that are doing tests at home the ones that you can do at home and get the results on an app are they ones that you do at home and send into a lab are people going into a clinic is all that testing equivalent yeah i think that it's it's sort of a combination i think that At Tenali's point, a lot of people that see me know there's an issue.

49:27Dr. Michael Eisenberg: And so, they come in and they've had, you know, more and more we're seeing the home testing because I think it does, you know, bring it to, it just makes it a lot more accessible to more people. So, I think it's becoming easier for men to get tested even early in the journey, even sometimes before they've begun. Sometimes they suspect they may have a problem based on, you know, past history of some injury or surgery or things like that. but even in the lab i think we're seeing more and more just abnormal numbers just less sperm sperm not moving is effectively abnormal shape we're seeing all of that i noticed because i did this and michael actually reviewed my results no good which i was happy but i noticed that the at home one that gives you the results on the app it had far less parameters so i think it was total count and maybe morphology, maybe, but it didn't have DNA fragmentation or motility, some of these other kind of, I guess, more.

50:22Dr. Natalie Crawford: A lot of the at-home ones do, and this is actually some of the ones in a lab too, right? There's a big lab called CPL. And a lot of times the semen analysis there are giving you concentration and motility, but they're not even giving you a morphology because it's an extra type of evaluation. You have to freeze the sperm, stain them, look at them, or have advanced technology to do so. To do morphology. To do morphology. So it's subjective? Like someone has to look at that? I mean, that's how, yeah, I mean, now we use AI-based methods to do it, but it's subjective on the computer where, you know, they're looking at how many sperm per grid have normal shape or not.

50:52So many of these, and I don't want to lump all at-home tests together.

50:56Dr. Natalie Crawford: I do want to say there's some you can get that are like a pregnancy test. Yes, no, sperm are present or not. They're telling you nothing about how much. It's just a dichotomous outcome. And then there are some that are giving you some parameters. So it sounds like you did, where maybe it's looking kind of precursory, which is great, better than nothing. Because if it's abnormal, come on in. But if it's normal, that doesn't mean everything's checked. So understanding it still has a value. There's also at-home tests, though, that you can mail in to what we call a CLIA-certified lab. It's doing the full semen parameters.

51:28Dr. Natalie Crawford: I did that too. Yeah, I don't want to say all at-home tests. The DNA fragmentation, that's the one we reviewed. Yeah, and that is easy sometimes because you get to collect at home and mail it in. You don't have to come into a clinic. And they'll freeze it if you have a good sample and you want to freeze it. Right, and so it can help save your sperm for later in case your health changes or if you want to conceive at an older age because advanced paternal age is a piece of the discussion as well. But even in a fertility clinic, you know, our men are collecting at home and bringing a sample in. And like you don't have to necessarily always collect an office.

52:00Dr. Natalie Crawford: And I think that is important for men to know because that could be an uncomfortable situation. Again, I would assume. No, I just had this conversation and I won't say his name because people on the show will know him. And I'll just say he's the previous guest of the show. But we had this exact conversation and he was talking about how uncomfortable it was and the room and the magazines. The whole thing. I was just happy that I did it at home. Yeah, but technology has gotten better so that we can have men collect at home and mail in a sample so that you can still get good data from it. So we don't want to say all at-home tests are the same or that they're all bad.

52:42Dr. Natalie Crawford: But it's really important to that degree to know what is this test looking at and is it as comprehensive as I need for what I'm looking for? What are the must-haves? So there's essentially, to my knowledge, six parameters. So concentration, volume, motility, morphology, pH, and DNA fragmentation. I would say for the standard semen analysis, we'll have all of those, but not DNA sperm fragmentation. Yeah.

53:09Dr. Michael Eisenberg: I think there's sort of special cases. I think miscarriage is one where we do that, sometimes recurrent IVF failure. So there's other indications where that's something that we would check, but as a routine sort of screening test, it's not typically done. How do you review the results? Is it normal for results to come back and let's say one or two of the different parameters to be below the kind of World Health Organization reference range?

53:34Dr. Natalie Crawford: Hold on. Before you answer this, you can answer this part of the question too, though. The difference in the low end of the reference range for normal and optimal are different when it comes to sperm.

53:43Dr. Michael Eisenberg: Where do the reference ranges come from? Yeah. So that's actually how I counsel patients. So when we look at any parameter, let's say concentration. So the World Health Organization took, you know, every 10 years, they kind of redefined things that look at current data. So the reference range has changed over time. But they look at, you know, all the data that they can assemble on fertile couples. So they have, you know, let's say 10 ,000 fertile men. They'll look at all their different semen parameters, and then they define subfertile as the fifth percentile. So 95, 100 men have higher numbers in this bottom five.

54:17Dr. Michael Eisenberg: And they just say this fifth percentile is where we're going to say if you're lower than that, you're subfertile. So when I counsel men like about concentration, for example, I say the average is probably 50 to 100 million. So if a man comes in and he's 30, for example, he's certainly below average, but that the range that the World Health Organization gives us where we would be concerned would be below probably 15 or 16. so I always let them know that we think that you have enough reserve but you're certainly below average and so we go through all the different parameters using that sort of overall framework and has anyone sort of with machine learning created some type of overall score so you take the concentration the morphology the motility because I'm assuming that they all kind of intersect and and affect that overall chance of conception yeah so I think like the total number of moving sperm is a number that we all try and look at.

55:11Dr. Michael Eisenberg: And if you look at there's, there aren't that many studies, but there have been some where they look at hundreds of couples trying to get pregnant and then just look at the time to pregnancy based on semen quality. And you can see that there is a plateau. So, you don't need billions of sperm. You know, the numbers, you know, you don't, your fertility doesn't keep going up and up and up, but it sort of plateaus around a certain level. And interesting, that level is a little bit above where we put those kind of World Health Organization cut points. So I think there is a lot of benefit in terms of time to pregnancy as we get further and further up.

55:41Dr. Michael Eisenberg: So again, I also counsel men discuss that with patients as well.

55:44Dr. Natalie Crawford: So total modal sperm count is a calculated value from your individual parameters. So you take the volume times concentration times motility, and you're saying in this one ejaculated sample, how many of the sperm are moving? I like to think about, you know, if it just takes one, yes, even if there's very low sperm counts, you could still get pregnant. You know, I have some couples whose sperm counts have total modal sperm is very low, and I might say your odds are 1%, but that's not zero, right? If there are sperm, it can happen. But for most men, I like to say, I want you to imagine though that it takes an army, that the egg has this outer shell called the zona pellucida, it's hard to break through, and you need millions of sperm to get to where the egg is, to exert enough force to let the guy who's going to win in.

56:26So even from it takes a

56:28Dr. Natalie Crawford: team sport, it takes the whole sports team to help one person get into the end zone. And that's why we need a higher number of total motile sperm. We like to see at least 40 million total motile sperm when you put the numbers together to say that you have the best odds of conceding per your age group. Now, if we calculate out what that number should be based on the WHO recommendations, it's closer to 20 million moving sperm. So I'm saying I want it higher to have optimal fertility. Ultimately, though, we're trying to counsel people so you can make decisions that are best for you. On the other hand, when that number is really low, we start to say some fertility treatments are now going to be less successful or not any different than having intercourse.

57:08Dr. Natalie Crawford: And I always use my sports team analogy. If I move the players further down the field, but like none of them can move because your motility sucks, they're still not going to win the game. Or if everybody has a broken leg, there's no normal sperm in the example, it's still going to be very hard to play. So I love the idea you said, is there like a sperm score, right? We as humans right now love like your biological age or your score for this. But the problem there is that sometimes just one parameter being off could lose the game for you. Sometime every parameter can be above normal numbers, but when we calculate it out, it is contributing to sub-fertility, meaning it can take you longer to get pregnant.

57:47Dr. Natalie Crawford: You have a lower chance of conceiving per month, even though that number's not zero. It would just be great if there was a large enough data set where you could do your sperm test. It looked at all of your different parameters and said, people that typically have this set of parameters. Michael, it sounds like a new business adventure. Yeah, there we go. I like the football analogy too. Really catering to the dudes. It landed for me. It does help them understand a little bit when you start talking about eggs and ovulation and what the difference is IUI. in. And I always say, if I move you further down the field, that's an IUI, right?

58:23Dr. Natalie Crawford: An IUI or intrauterine insemination is taking an ejaculated sperm sample and we concentrate it and we put it into the uterus. So we're just, we're getting closer to where we need to be, but I'm not making a goal. In IVF, I'm very often putting a sperm inside the egg. So I've scored, but that doesn't mean you're going to win the game, right? You're getting closer. You have to score to win the game, but that doesn't mean you're going to get there. So just when you're trying to make treatment-based decisions, thinking about the different markers, right? A lot of what Michael does sometimes, how we work together, would be sometimes I don't have any players or there's not enough players on the team.

58:57Dr. Natalie Crawford: So we're not even playing the game yet. I'm sending a guy to say like, hey, his sperm counts are so low. Like I need you to help work with them, whether that's, you know, met hormones to help drive spermatogenesis, whether it's procedures, like I need some players to play the game because that is one of those pieces of the puzzle. You asked earlier, you know, what is driving this increase in abnormal sperm tests i would go as far to say normalization of unhealthy lifestyle practices cannabis being one of them but that's honestly more recently it's accessibility to testosterone so many men are using testosterone not under medical supervision right you can use it you know with medical supervision and it can be a great huge tool That doesn't mean that a man having low testosterone is not something that deserves treatment because it does.

59:48Dr. Natalie Crawford: But using testosterone without doing so in a way to preserve sperm function can sometimes lead to irreversible changes where you might not be able to get sperm to be produced again later. And right now men can walk into a men's health clinic. They can get testosterone on an app. Nobody's checking their semen analysis. Nobody's checking why their T is low. And it's a very unregulated usage that is highly accessible and really damaging. I mean, I will also have patients who say, we went to a doctor for infertility or for his low libido or his issues with erection. And they gave him testosterone injections.

1:00:26Dr. Natalie Crawford: And we've been trying two years.

1:00:28Dr. Michael Eisenberg: yeah and they don't tell them that this is tested as a contraceptive by the world health organization it's going to lower your sperm count yeah it's always very difficult this is super like rife right now in the the 20 year old kind of sphere where dudes are trying to do everything they can to be more masculine And I imagine that if we had a 20-year-old here now, they may say, okay, hear what you're saying. But if I go and speak to a urologist or an endocrinologist, they're not going to support me. They're just going to say, don't do it. So that's why they end up going on the forum or, you know, wherever online and ordering it out of a gray lab and then just doing it without any supervision.

1:01:09Yeah.

1:01:09Dr. Michael Eisenberg: I mean, I think all medicines, there's risks and benefits. And I think that if you look at good studies, usually inappropriate use doesn't support that, right? It's there's going to be a lot more harms than there are benefits. You know, when we look at studies of sexual function, libido, things like that, for men that have normal levels, they're not going to see a benefit over placebo. And so that always really concerns me about putting men on this. And especially reproductive age, right? The harms are really very profound, like Natalie talked about. I mean, a lot of these men are not counseled about it.

1:01:38Dr. Michael Eisenberg: you know hopefully it's reversible but it's not always reversible if they're on it for years and years we think that they're not going to potentially reach where they were before and if they have not had the chance to either cryopreserve sperm or do some you know other like adjuvant medications that can kind of preserve some metagenesis it can really be devastating and you know again when you're 20 you may not be interested in conceiving but you know it's likely at some point in your life that is going to be very interesting interesting to you or your partner. And to really shut that down very early, I think, is pretty devastating.

1:02:09When you say shut that down, can you explain what happens when you use exogenous? So, from outside of the body, you inject testosterone and you elevate the testosterone levels in your blood. What is that doing to spermatogenesis?

1:02:25Dr. Michael Eisenberg: Yeah. So, there's an intricate feedback loop within our body. So, our brain sends signal to the testicle to make sperm and testosterone. And then the testosterone feeds back and says, you know, we have kind of a normal amount so you can, you know, downregulate that hormone. So, when you're taking exogenous, what happens is it basically stops that loop because you're getting exogenous testosterone. So, your body thinks there's enough. So, it stops signaling the testicles to make that. So, it stops making testosterone, also stops making sperm. The testicles will shrink because most of the size of the testicles devoted to sperm production.

1:02:55Dr. Michael Eisenberg: So, most men would not be excited about that side effect. And so, that sometimes can come back, but sometimes not. And it's interesting, you know, some men ask, well, if I'm getting testosterone, it shouldn't matter then, right? Because my testicles still have a lot of testosterone around them. But the testosterone levels in the testicle are probably tenfold higher at least than the rest of the body. And so, if you're taking testosterone and you're getting, let's say, 500 nanograms per deciliter, in the testicle, it should be thousands. So, that's not going to be enough to support spermatogenesis.

1:03:24Dr. Michael Eisenberg: In addition, you're not getting the other signals that you need to support spermatogenesis. So that's why it shuts down. And then when you withdraw it, it can take a while for that whole system to restart if it will. And so there's also sort of a difficulty with men doing that because then their levels really bottom out if we withdraw the exogenous testosterone. So there's a protocol that we can go through that can often restore them. But, you know, it can be very unpleasant.

1:03:49Dr. Natalie Crawford: Expensive and takes time too. Yeah, and very prolonged. That's like involving HCG and different drugs. Exactly, exactly. Do you ever see men come in that you just can't get them that system working again? That does happen sometimes.

1:04:03Dr. Michael Eisenberg: There's also some men that come in, interestingly, even with their partner, and they're unwilling to stop testosterone. It's done so much for them. They need it as part of their job. How long do they need to stop it for? Well, a cycle traumatogenesis takes about three months, so ideally that. But to restart can take six months, nine months, a year in some cases.

1:04:19Dr. Natalie Crawford: And then they can start trying to get pregnant. So however long it then takes, depending on if they're willing or interested in doing IVF, sometimes they do because it's faster or we don't need as many sperm. Because even when they start spermatogenesis back, it is going to take sometimes a while to get to the sperm levels that they need. But because the testicles have atrophied, they've shrunk, some of the cells haven't worked, died, that is why sometimes you can't get it back. And I think even if something is not a common side effect, It is something that men need to know about because the outcomes are so profound, right?

1:04:55Do you think the TIT clinics are doing enough education?

1:04:59Dr. Natalie Crawford: No, they're not doing any education, Simon. They are, they're not probably, the person who a patient is seeing is likely unqualified or uneducated themselves, even if somebody maybe who is overseeing the clinic maybe has the knowledge. But I see the patients, and I know Michael does too, who had zero idea, zero, that being on testosterone would hurt their sperm count. They actually thought it was going to be supportive of their fertility to be on testosterone, not understanding that you slid this in there. It's a birth control, essentially. Taking, you know, injectable testosterone prevents at the brain FSH and LH, which cause you to make sperm, just like taking the birth control pill binds at the brain and you don't send out FSH and LH to grow an egg.

1:05:45Dr. Natalie Crawford: It's the same process, but sometimes it is irreversible. And that is lifelong testosterone use then you're going to have to be on. You're not going to be able to have children. If we can't get any sperm, you can't have kids. And then in some of these guys, they feel terrible trying to get sperm back. It takes a long time. It's very expensive. You probably still half the time are going and doing a sperm aspiration procedure because they're not getting very many sperm. We're doing IVF. This is taking a long time, very expensive. And often the sperm quality is not great after they've restored some of that if it was really profound.

1:06:20Dr. Natalie Crawford: So men at least need to be making educated decisions and the baseline knowledge that testosterone really should only be given, you know, in my opinion, by a urologist who's trained, a reproductive urologist who understands, or with a doctor who's monitoring your semen analysis, talking to you about adjunct medications to maintain sperm, but that's not the experience of most people who are on it. Do you see it? Do you have people coming to you as a kind of first line of call before they start testosterone replacement?

1:06:54Dr. Michael Eisenberg: I think it's becoming more common, but still not enough. I think I see more men that are on it. They know it's a problem or more men that are on it. They didn't know that it was a problem. I think, you know, when you're talking about your sort of theoretical person, you know, 20-year-old, I think what you want to do is make sure that your healthcare provider and you are aligned, right? And I think a lot of these clinics, I think their incentive is to get you on testosterone. It's not to optimize health. It's not to make you better. And so, you know, to now he's point like having a urologist sort of supervising it, making sure it's done safely, making sure it's done appropriately.

1:07:26Dr. Michael Eisenberg: I think that is a much different thing than, you know, just trying to get you on this medicine. Right. There's more to consider than how much muscle am I going to put on in the next year, right? When you're a 20 year old, there's, you want someone who is looking after you that's also thinking about what are the types of things you're going to want to do in 10 years, 20 years? What health do you want when you're 50? And thinking back to when I was 20, sometimes it's hard to think that far ahead.

1:07:55Dr. Natalie Crawford: But I would go as far as to say another really big problem is that these clinics aren't set up to figure out why you might have low testosterone. And I saw a guy once in his mid-30s who'd been on T for a really long time, And he did have documented proof that his testosterone was really low. But on further evaluation, it was because he actually had a brain tumor called a prolactinoma making prolactin. And because prolactin was so high, it was preventing the brain to sending out these signals to drive sperm and testosterone. He needed a completely different treatment to then naturally restore being able to make testosterone and sperm.

1:08:29Dr. Natalie Crawford: So he had a real medical problem contributing to why his T was low. He went to get help for a real reason, but they didn't evaluate it. So for years, he's taking testosterone to feel better, was totally unwilling to get off of it. But he had a real medical problem that a lot of places are not doing that next step. Well, hey, why does a 30-year-old have low T? To Michael's point, their goal is to put you on medication and sell medication. So it's not that, oh, everybody who's looking for T is just trying to look smacks. I mean, there's a group of people. But I see a lot of people who unknowingly didn't know it would hurt their fertility and truly didn't feel good or had low or borderline testosterone as a young guy noticing my libido feels low.

1:09:14Dr. Natalie Crawford: I don't feel like I have the energy and I was looking for help. That is just being managed wrong. We've got a new piece of tech at home that's been really helpful. Before Skylight, our household ran on scattered notes. Some on my desk, more on my phone, others in my email. and Tawny split between her diary, her notes, and audio messages. Half the time, we didn't know who was traveling where, what events we had or hadn't RSVP'd to, when we were seeing family next, and so on. Nothing lived in one centralized, organized place, which is a great recipe for forgetting things. The Skylight Calendar fixes all of that.

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1:10:41It's not just the things that we can see, taste, smell, or feel that shape our health. Some things slip by completely undetected. BPA from plastics and receipts. PIFAs from clothing. yes your favorite activewear mercury from fish these are just a few of the everyday items that contain compounds linked to hormone disruption cognitive decline and illness yet very few of us measure and therefore understand our cumulative exposure over time tawny and i are planning to have kids sometime in the next few years something that we're both very excited about so recently we've been looking under the hood a bit more closely, doing what we can to optimize fertility, pregnancy, and most importantly, give our future children the healthiest possible start.

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1:12:22Dr. Natalie Crawford: Now, yeah. Right. That's exactly right. Okay. Back to the sperm test results, because I know a bunch of people will, as you said before, there's probably a lot of women listening who will now encourage their partners, hey, do you want to do a sperm test? Great news. You can do it at home. Send it in. That seems like a pretty good starting point. And let's say you get the results back. I appreciate that it doesn't perfectly associate with fertility. And there's a number of different parameters. Did I hear correctly that total motility, if you were going to say one is the most important, is that the most important parameter?

1:12:58Dr. Natalie Crawford: I mean, probably everyone's going to say concentration because if you have zero sperm, they can't move at all. Okay. But providing you have, let's say providing you have decent concentration out of the next, the other five is total motility most important.

1:13:10Dr. Michael Eisenberg: Yeah. And that's, I think to Natalie's point, the reason is because it incorporates so many things, volume, concentration, and motility to give you sort of a summary number.

1:13:18Dr. Natalie Crawford: But that's not listed for most people on their semen analysis report. It's a calculated value. So you have to actually, a few companies are different, but most of the time you have to look and you say, what is the volume times concentration times the percentage for motility to get your total modal sperm count? Or find a company that says this is going to be provided in the results. Yeah. I mean, that's one thing all companies and all clinics do it really different, right? So if somebody comes to my clinic and we do a semen analysis, yes, you get your numbers and a beautiful picture of your sperm.

1:13:47Dr. Natalie Crawford: But then we're telling you, hey, your total motile sperm count is this. That means this. If you're trying to get pregnant, these are the recommendations. And some of these online companies do an excellent job of that. But not all tests are created equal. Let's say the test come back and it looks pretty good across the board. But you've been trying with your partner for a couple of years. Is that a one and done test for the male or would it be something that they're testing more than once?

1:14:13Dr. Michael Eisenberg: Yeah, I think that it's good to do more than one. That's what the guidelines say. There's a famous study by the World Health Organization published about 25 years ago where they had one man give a semen analysis every week for two years. I've heard he was either a student or a prisoner, some sort of captured individual. But there are wild fluctuations. Sometimes he was 100 million, sometimes he's around zero. There weren't clear reasons why there is that variability. I think a lot of it is health and exposures and things that we just don't really fully understand. But it is good to get more than one because there can be fluctuations.

1:14:43Dr. Michael Eisenberg: I think it's important. But also for that same couple, if they're trying for a long time, even if the man's analysis was normal, I think he still warrants an evaluation because we can do more advanced testing like DNA fragmentation and see if there's some underlying conditions that we can identify. Because a lot of times when couples are struggling, whether it be on their own, whether it be with IVF, you know, sometimes it's difficult to figure out as a male problem, female problem, sperm problem, egg problem, because I think our testing is not perfect. And so I think it is important to kind of go as deep as we can to try and figure that out.

1:15:12Dr. Natalie Crawford: I'll go back to my football analogy. A semen analysis is telling you about your team. That's it. It's not telling you about how they play, how they work together as a team. It just tells you how many players do you have? Are they injured? Right. It's giving you some basic facts about who's sitting on the sidelines. Are they moving well on the field? Are they tall? Right. So we don't know about their functionality. That's one of the limitations with a semen analysis is we can presume some functionality when we put these parameters together, but we truly don't know how sperm is going to react with an egg inside a body, which there's so many other factors.

1:15:45Dr. Natalie Crawford: The environment of the woman, what's the environment of the fallopian tube where fertilization has to happen, the egg quality as well. There's a lot of moving parts that really need to be in play for the sperm to function appropriately. So it is really important and helpful data. It's not the end-all, be-all. We don't have all the tests that we would love to have created to truly evaluate both sperm quality, sperm function, egg quality, egg function. Those are actually really, they're single cells. They're actually really hard to study, right? And to try to understand how they interact together.

1:16:15Dr. Natalie Crawford: We have more data on sperm because you can ejaculate it and we can study it. Egg data takes a long time because we have to get it out of the body in egg retrievals. And so trying to see how they interact together in an IVF lab is also where a lot of our data comes from. when we start looking at sperm and egg functionality together. With regards to that variability in that example that you mentioned, I remember the instructions said to have like two to six days abstinence before giving the sample. Why is that? And does that also affect planning intercourse when you are trying to conceive?

1:16:52Dr. Michael Eisenberg: Yeah, I think it takes us a little while to sort of replenish stores. So sex every day can be challenging for some couples, but also you do want time to make more sperm to get more deposits. So, it's just a more efficient process. So, you know, we usually do the two to five days, two to six days just to give, you know, to try and take some of the pressure off to give you some, you know, some leeway. But, you know, when I counsel couples about, you know, trying to conceive on their own around ovulation, I usually say sex every other day. You know, the sperm can last about two days in the female reproductive tract.

1:17:22Dr. Michael Eisenberg: I think it is challenging for some couples to have sex every day. If they want to, they certainly can. But that's usually sort of the most efficient payload delivery that we can do.

1:17:30Dr. Natalie Crawford: I want to refine that. Two to three days abstinence, at least, before you do a semen analysis, because we have set parameters for what the volume and what the findings should be. And we know that if you just ejaculated yesterday, you might not have enough volume. And so everything can be skewed off. So that is why we want an abstinence interval before we collect sperm for an evaluation where we're looking for standard parameters to be. When you're trying to get pregnant, it really depends on your sexual practices. By no means should anybody ever have less sex. If you and your partner have sex every day, good for you don't stop.

1:18:00Dr. Natalie Crawford: You do not need to save and store up sperm to try to get a higher load there just at the time of ovulation. Like Michael said, sperm can live in the female reproductive tract. The same sperm are being generated. And in fact, putting more out at different times has a higher likelihood of capturing ovulation for when it's happening because the egg only lives for 24 hours. Okay. So even though you're not replenishing, you don't have as much every time you're having sex as an accumulated volume. Yeah. And you're putting more out because you don't usually know the exact moment when ovulation is happening.

1:18:32Dr. Natalie Crawford: Stress can be stressful to have it every day if you're not an everyday couple. So some of the original data showed that couples would burn out on sex. They start having sex every day around cycle day eight. By the time they get closer to ovulation, they are over each other if this is not their standard behavior. And then they wouldn't be having intercourse when it was the most important. So understanding your relationship and your sexual practices are really important. But because the egg lives for 24 hours only, sperm can live for up to five days, but we'll say most of the sperm will be there for about two days.

1:19:05Dr. Natalie Crawford: The two highest days for you to have intercourse to have the highest odds of getting pregnant are the day before ovulation and the day of ovulation. If you are in a fight with your partner but want to have a baby, I would have sex at least one or both of those days. Almost every other day has a significantly lower chance. So you don't have to go to this every other day mentality, but certainly sometimes that's easy. You don't know when you're ovulating, you have sex every other day, that feels doable for you and your partner. But I do sometimes see the other where couples who have a really robust sex life are now having less sex to store up sperm.

1:19:40Dr. Natalie Crawford: And there's no need for that.

1:19:42Dr. Michael Eisenberg: The other time we change like our recommendations is it's becoming more and more common in IVF practices to have men have shorter abstinence periods because it's fresher sperm and actually can benefit like DNA fragmentation, which we alluded to. So sometimes some of your listeners may get that recommendation.

1:19:58Dr. Natalie Crawford: So that's a good point for IVF. We don't need as many sperm, right? Because we are able to, we don't have as many, we don't need the whole millions of the army because we're helping egg and sperm come together. So if you are clearing the pipes every day, you're going to have less backup, less debris, less dead cells. So the sperm are not sitting in the waiting line of the ejaculatory system as long. So we will often recommend daily ejaculation, especially if you've had unexplained infertility, poor outcomes in the past. We think there's a male problem, even if the semen analysis looks okay, kind of Clearing the pipes every day may give you less sperm, but potentially higher quality.

1:20:36Is there enough data that exists such that when you do look at someone's results and you look at all the different parameters and whether it's morphology or it's motility or it's DNA fragmentation, does that specific result and where they might be struggling a little bit, does that affect your interventions? do we have that level of precision such that okay if someone's morphology is not great this intervention i'm going to speak to them about this this and this whereas if it's concentration i'm

1:21:07Dr. Natalie Crawford: going to focus more on this yeah treatment is going to vary based on which parameter you're seeing we'll use concentration as a great example you know if we said you know we really love we really love the concentration to be you know you're trying to have intercourse to get pregnant at least 20 million sperm per ml. It's like kind of that level when we're looking at one parameter alone. We know that once it gets to a certain point, we lose about half the sperm in the wash for an IUI. So even if we're talking about putting the sperm in the uterus, when that concentration starts to get lower, closer to 10 to 15 million range, I'm not going to have as many sperm as I need to get you pregnant even with an IUI.

1:21:46Dr. Natalie Crawford: So you can get under the threshold where even an insemination could be an option. And then you start migrating into IVF only territory. And then even at very low levels, I sometimes say, I don't even know that I'm going to have enough ejaculated sperm here for IVF. I mean, so when some guys have less than a million or less than a half a million sperm in the sample, I'm really concerned I'm not going to find any alive sperm at the time of egg retrieval. And this is where we then start talking about adding on sperm aspiration procedures or, you know, hormone treatments to see if we can generate more sperm.

1:22:15Dr. Natalie Crawford: So certainly when we're looking at these different parameters, you know, from my end, And of course, we have to take the couple together as well. You know, for example, using HCG, that's not going to help you from a motility standpoint, right? It helps you drive more sperm production. So concentration would be a value that you're on saying, no, this could be a potential treatment for us. I see a lot of men who say, oh, my motility is really low. So can I, you know, go take some hormone treatments to get it better? But they may have a great concentration and a really low motility and a really low morphology.

1:22:49Dr. Natalie Crawford: So hormone treatments, in quotes, may not be the option for them based on what the sperm parameter is.

1:22:54Dr. Michael Eisenberg: And I think certainly when it comes to the different ART treatments that we're going to do, IVF, IUI, there are, you know, certain parameters that every, you know, every lab is going to have. I think when we talk to patients about, you know, concentration, motility, morphology, DNA fragmentation, I think a lot of it is somewhat individualized based on them. And we, you know, do comprehensive evaluations to look at their hormone parameters, look at anatomically. there's a condition called varicocele, which is these dilated veins in the scrotum, which turns out about 40 % of our infertile men have.

1:23:24Dr. Michael Eisenberg: And it's thought that that warms up the testicle, can basically impair metabolite excretion in the area. So, it can impact things. And we do see that it affects the numbers of sperm, the motility, the morphology. So, it sort of depends where the man is. But the other thing that I always talk to men about is that there's many paths to fertility. And we kind of alluded to it a little bit earlier that some of these couples have been through a lot and they want the most efficient path forward. And in some of those cases, that is going to be IVF, for example. But some of the couples are averse to that or they're very early in the journey.

1:23:55Dr. Michael Eisenberg: They want to explore other options. And so, if there's some time to try and optimize male fertility, you know, we talk about many things. We talk about lifestyle interventions. We talk about different, you know, supplements, nutraceuticals, which also have good data behind them. if they have a correctable factor like hormone abnormality that we can fix with HGG with some of the other medications that we use or anatomically, there are surgeries that we can do. I think those are also potential. And sometimes we do these in parallel. We sometimes say baby one may be with IVF and then we're going to get you all tuned up.

1:24:25Dr. Michael Eisenberg: So baby two, you don't maybe need that technology. How malleable are those results? And is that malleability, the ability to kind of see your results improve is that affected by a man's age you mentioned earlier that and i think there is a lot of pressure on women about the the clocks ticking yeah it does that exist for men in a same or similar or a way that is kind of less communicated or known it's it's similar for a man i think that it doesn't have kind of the as steep a decline i The oldest father ever is 96, supposedly. So, the biologic potential does persist, but it can take longer because I think the quality goes down, the numbers of sperm go down.

1:25:09Dr. Michael Eisenberg: And also, you know, we continuously generate sperm every year, every day, every second, right? About 1 ,000 sperm are made every second. And there's sort of a self-renewal process as well for these sperm precursor cells. And it's pretty perfect, but it's not 100%. And so, mutations can be introduced. So, we do know that as men aged, there's more mutations and that can lead to the higher risk of rare conditions, higher risk of different neurodevelopmental disorders like autism, schizophrenia, for example. So, I think all those also have to be weighed in as we're kind of thinking about age as well.

1:25:40Dr. Michael Eisenberg: But again, usually there's a lot of resilience in the system. And for the most part, I think we do well. But as you look at sort of nationally or in the developed countries, you know, paternal age is going up, maternal age is going up. And I think on a societal level, we are seeing some of these implications. What age does a man have the best sperm usually? I guess from an evolutionary standpoint, it'd probably be like late teens, early 20s. You know, the American side of reproductive medicine, the American Neurologic Association defined an older father as over 40. So I think if we're kind of less than that, I think in general, when you look at some of the risks, they tend to be a little bit lower.

1:26:16Dr. Michael Eisenberg: So that'd be a good time to freeze your sperm.

1:26:18Dr. Natalie Crawford: Yeah. We would love for somebody to freeze it before they're in their 40s or in their early 40s if you're starting to conceive a little bit later. Functionality, you know, once you're over 45, approaching 50, we do start to see, you know, kind of less good quality sperm. When that male genome kicks in, as Michael mentioned, we see more issues and mutations, higher rate of genetic abnormalities, less embryo development through the lab. And the age that's usually quoted is over age 50 for advanced paternal age. So when a man's over age 50, having a statistical significance of higher rate of some of those conditions, autism in a child, schizophrenia, other mental health issues, new onset autosomal dominant diseases like dwarfism.

1:26:58Dr. Natalie Crawford: And then there's something called imprinting disorders where some of your genetic code gets imprinted wrong. And some of these are really significant for the child. It's not that everybody's going to have them, but you ask, like, do people know about it? And I don't think they do because freezing sperm is relatively simple compared to freezing eggs. If you said, hey, I want to have kids one day, but not yet. And I know I'm getting older. Should I put some sperm in the freezer? Yes, there's no downsides to that. I did it. Yes. I mean, it comes at a cost, but it's not that crazy. And it was done by the company that, so I did the at-home testing.

1:27:33Yeah, mailed it in. And it says, yes, you have a good sample. Do you want to freeze it? We can freeze it. Would you like to freeze it?

1:27:38Dr. Michael Eisenberg: You click it. I think the other thing to think about, and I've actually, interestingly, over the last, I think five years, I've had patients come in that are over 50, over 60, that just want to talk about it. Not that they need help necessarily, but what does it mean that I'm older? What are the risks that we're going to deal with? And I think all these things we certainly talk about. But the other sort of aspect of it, and it's, I think, a little heavier, is just, you know, the idea of being 60 or 70 and having a child. You know, I think there's some life years ahead, but are you going to see that kid have kids of his own, right?

1:28:09Dr. Michael Eisenberg: Are you going to become a grandparent? I think some of those things and I always tell patients, everybody now, I tell friends too, if you want grandkids, you need to get going. Don't wait because it does all these things sort of take time. And so, if you look at sort of healthy life years remaining, I think that's another way of thinking about this as well because, you know, if you are 50, 60, 70 having a child, you know, when your kid is 10, 20, I mean, you're going to start also having health problems. Even if you're healthy now, you know, kind of looking in the future, I think, again, it's a very difficult conversation to have with individuals, with men, but it's something that's sort of the other thing, I guess, to think about because some of these conditions, dwarfism or, you know, A.P.A.R.

1:28:49Dr. Michael Eisenberg: syndrome, there's a lot of these paternal age effect disorders. These are, you know, 1 in 50 ,000, 1 in 30 ,000. But when you're talking about autism, maybe 1 or 2 % or up, you know, 10 % in some studies. But having, you know, if you're a 70-year-old or an 80-year-old, right, we're seeing some celebrities that have, you know, kids, you know, very early. The chance of that kid not having a father at age 20, which is super impactful, you know, sort of this loss of innocence in some ways, is very, very likely.

1:29:15Dr. Natalie Crawford: You know, many fertility clinics, and obviously not everybody who's of this age is undergoing IVF or using fertility treatment, but this is an ethical issue that gets brought up that there's no easy answer to it. But I will say most clinics do have a combined paternal age limit where, you know, the difference if, you know, the partner is really young and, you know, maybe you'll lose one parent versus if both partners are older and you have to look at a child losing both. So clinics have individual limits, right, when it comes to whether it's each individual parental age or whether there's a combined parental age limit.

1:29:49Dr. Natalie Crawford: But typically there are thresholds, and that's not meant to be mean or discriminating, but it's really trying to draw a line. It's unethical. I mean, a lot of what we do is, you know, technology advances before we know everything about it. And sometimes you have to make decisions on how you're going to apply this technology to everybody. I have to imagine, and I haven't looked at this space, but I have to imagine, you know, I'm familiar with what's happening in the type 1 diabetes world where they're engineering islet cells and then they use genetic editing to kind of edit the gene in a way so that when you implant them in the body, they're not seen as foreign.

1:30:28Right. the body doesn't attack them they don't have to take immunosuppression they can produce insulin again and this is you know fairly early but they're starting to prove that as a model and it looks like type 1 diabetes would will be cured before type 2 diabetes which is way more complex but i have to imagine someone out there is looking at how can we take sperm that is damaged or not doing well and like engineer it genetically engineer it to do better there are companies

1:30:57Dr. Michael Eisenberg: looking at this. I think for men that don't make sperm, you know, these azo-spermic men where there's not a clear reason or maybe they had a history of like a childhood exposure to chemotherapy. So, these are men if we could somehow grow like a skin cell into a sperm cell, it'd be tremendous. But I think you're even getting there have been like ethicists, there was an ethicist at Stanford named Hank Greeley that wrote this book, The End of Sex, which sort of talked about this. The other reasons that you could potentially do this is you could end genetic disease or potentially end almost all disease.

1:31:24Dr. Michael Eisenberg: If you could take a sperm, figure out what the drivers are for that, whether they be genetic, epigenetic, and really modify the gametes, sperm and eggs, to create sort of the healthiest child possible. So, I think we're a long way off. It's a huge ethical conversation. Yeah. Because you could, I mean, your genes, your DNA could be passed on in a thousand years from now, if your sample was kept now and engineered. Yeah.

1:31:50Dr. Natalie Crawford: These are really intriguing questions that aren't going to be solved in this country. I mean, countries are light years ahead of us when it comes to studying eggs, sperm, and embryos. Like we, you know, especially when it comes to embryo genetics and modifying embryo genetics, risk of disease before you implant an embryo is another potential source of that too, right? And for some people, you know, certain diseases are passed on all the time, right? We look at mitochondrial diseases, mitochondrial transfers, all of the research on these are not happening here in the states so it's interesting it's ethically questioning i'd love to step back and say in this country our bigger issue right now is that you know we have a lot of places i mean i live in texas where the gop has said they'd like to ban ivf because they view ivf itself as unethical they want to ban gestational carriers which is where if you you know i have a patient who lost her uterus due to cancer still had her ovaries she and her husband wanted kids right go through IVF and we had a gestational carrier who carried their genetic child.

1:32:52Dr. Natalie Crawford: I mean, we are losing reproductive rights in this country. So the conversation about genetic optimization or, you know, advancing technology is so interesting and fascinating and to spare people, you know, chronic or severe genetic illness could be really incredible. But we have to step back and say, you know, as people who have spent our lives trying to help more people have families, we need more access to care and not less and that needs to be an important part of the discussion we start talking about what is available to people is that reproductive rights include access to IVF they include access to be able to freeze sperm freeze eggs utilize some of this technology and restricting it will mean less people can get pregnant yeah i don't want to make this overly political but but i mean that seems like it's an overreach right i think if you have consenting adults, they should be able to make that decision.

1:33:46Dr. Natalie Crawford: Yeah, but it's an important point because I think a lot of people in this country don't like where politics are right now and they don't think it applies to them, right? So they want to stay out of this discussion. But you know somebody who's had infertility, you might have infertility, you might need IVF. There are people and family members of yours who've gone through it. And so it's worth knowing that standing up for access to healthcare technology is pro-family. All right. So let's go through the best things that a man can do for his sperm health and the worst things. Let's start with the best.

1:34:21So we've established that every about 90 days, new sperm is being produced. So there's a great opportunity. If your results come back and they're not exactly where you want them, right you can make some changes and you might see those changes in the next 90 day period so where would where would a man kind of start from a a lifestyle point of view and if you were to prioritize them what is is most important to least important well i just try and give sort of

1:34:55Dr. Michael Eisenberg: overall health guidance i think i always say anything that's good for your heart it's good fertility. So, good diet, you know, cutting out processed foods, whole grains, fruits, vegetables, I think are important. Exercise, I think is important. And it's interesting when you look at exercise, it is possible to do too much. Certainly, it's possible to do too little. So, like studies of marathoners or professional cyclists, for example, those men actually have lower sperm counts just because they exercise so much to exhaustion. So, you do want to kind of be in the sweet spot. Is there anything about sitting on the bike for too long?

1:35:24Dr. Michael Eisenberg: So, there have been some studies say if you like cycle, for example, more than five hours a week, those men tend to have lower sperm counts. Interestingly, saddle also plays a role. Like big, thick, soft saddles seem to bunch and probably heat things up. They make noseless saddles now as well that also allow more breathability. So, I think there is something that I tell men if they're really, you know, firm and fixed in their saddle, just at least try and air the area out. So, maybe every 30 minutes kind of set up and let things circulate. I think that's also something that one can do. Someone needs to invent, and this is another invention, the eight sleep for the saddle.

1:35:59Cooling it off while you're biking. So it's just cool the whole time. Interesting. Yeah. Yeah.

1:36:04Dr. Natalie Crawford: I mean, we do see sperm counts in men who are cyclers or marathon runners lower in general. Like that's one of those red flags when you're getting history for somebody for cycling specifically because I'm in Austin. So we have a lot of guys who are really active in this. I usually say I don't want you going on rides that are more than about an hour total. because if you tell sometimes like five hours a week they'll still do some like really long rides and kind of break it up if we're actively trying to get pregnant and we're concerned about our sperm we're trying to optimize it and if they said okay so i can i can run instead of usually running is fine i mean it's all of these lifestyle factors for the vast majority of them not for everyone it is the culmination of them together that is really what is influencing the state of your body, right?

1:36:51Dr. Natalie Crawford: So marathon running specifically, not like usually it's competitive marathon runners and who I see this in versus just, I like to go for long runs. They tend to be fine, but truly competitive marathon runners have a really hard time, you know, with how much energy they're getting into their body. Their overall body needs are often not prioritizing making sperm, let's say, because they're generating so much energy in those runs over and over. That's not going to be most people. So yeah, saying, hey, you can get off the saddle a couple days a week if you're cycling. You can run in those times or lift weights.

1:37:27Dr. Natalie Crawford: It doesn't mean you can't exercise, but the variety of what you're doing versus just compression of the testicles in the saddle while you're riding so much.

1:37:35Dr. Michael Eisenberg: Exercise is generally good. Again, with very rare exceptions, we always want to encourage exercise. Okay. So anything else on that list you were moving through a diet, exercise? Well, maintaining good body weight. I think that kind of goes hand in hand with that. I think that's also important. You know, you want to be kind of in the ideal way because if you're, you know, too thin, maybe marathon runner, or if you're, you know, overweight, obese, we do see associations. And that can be from different things. I think that, you know, if you accumulate extra adiposity, extra fat tissue, it can sometimes insulate the scrotum and warm it up.

1:38:04Dr. Michael Eisenberg: So, that's one potential mechanism. It blunts some of the hypothalamic pituitary axis, this hormonal axis that we talked about that's important for sperm production as well. So those are some of the ways. And then testosterone is made in the body. It's converted peripherally primarily to estrogen. And a lot of that happens in fatty tissue. So the more fatty tissue you have, the less testosterone you're going to have. And again, that's not great for sperm production. So I think for all those reasons, an ideal body weight is going to be important.

1:38:31Dr. Natalie Crawford: You know, I'll add sleep to the list. And this is what I usually tell my couples first, right? There's good data when it comes to trying to get pregnant that for every hour less a man gets of sleep. He has worse sperm parameters and it takes the couple longer to get pregnant. And I think sleep is nuanced because it gets prioritized last. We're focused on the foods we're eating or the exercise we're doing or the supplements we're taking. And I like to simplify it and say, sleep is when your body's cleaning up shop, getting rid of inflammation, helping improve your insulin sensitivity. It's when a lot of your gonadotropins, the hormones from the brain, are really active at nighttime.

1:39:06Dr. Natalie Crawford: So we want to make sure you're getting enough sleep so you can have good hormone production. And you've heard me say this too, if you're sleeping with a person, you guys have to be on the same sleep schedule or it can be really disruptive. So having honest conversations about going to bed, a cooler temperature, a sleep mask, a sound machine, putting phones away, what is the environment that you need with your partner to get at least seven hours of sleep a night? I think sleep is like my number one on the list and i'm speaking anecdotally here but my exercise and my nutrition fall into place much better when you get sleep yeah right it's everything and even even i mean more important than those two things my relationship with my partner is way better i always like to think of that inside your body having you know this metric that's your inflammatory burden right how much inflammation or chronic inflammation you have on a day and sometimes there's medical conditions You have endometriosis, so it's higher.

1:40:06Dr. Natalie Crawford: Or maybe you're overweight, so your baseline value is higher. But all of these things can add to it, right? You don't get enough sleep, it gets higher. You eat a lot of processed food, it gets higher. You're exposed to endocrine-disrupting chemicals. You're just upping the ante. Sleep is one of the strongest markers to pull that down, right? It's where you get that reset every day. So when you're not getting enough sleep, you are not starting as low as you need to on that inflammatory burden scale. And it's going to make every other decision harder. Plus, we all know when you don't sleep as good, you don't feel as good, you're not mentally as sharp, you're less likely to work out.

1:40:39Dr. Natalie Crawford: You're less likely to eat the healthy foods. You make poor health decisions when you don't have enough sleep as well. I've been using WHOOP for over six years, and I can confidently say it keeps me on track when it comes to my sleep and exercise routines. The next generation of WHOOP isn't just tracking your workouts. It's monitoring your sleep quality, your recovery state, and even giving you insights into your biological age. No screen, no distractions, just continuous data on what your body actually needs. And here's what matters. Daily WHOOP wear is linked to increased physical activity, to better sleep, and improved heart rate variability.

1:41:23I have no doubt that my WHOOP is helping me train smarter, recover faster, and make decisions that support my long-term health. Head to join.whoop.com forward slash Simon. That's join.whoop.com forward slash Simon to get one month off your first subscription. How do both of you feel about the emergence of GLP-1s? Given the association between obesity and sperm parameters, I assume, and I haven't looked at this data, but I assume that losing a significant amount of weight will improve sleep quality as well. Are we seeing any signal yet where men that are using GLP-1s, there's an improvement in sperm parameters or fertility?

1:42:12Dr. Natalie Crawford: Yes, we do see that. And it's not just, yes, if you're overweight and you lose weight, as Michael described from a variety of mechanisms, fat cells are inflammatory, it causes more estrogen, it blunts your natural response to testosterone. But even in patients who maybe didn't have a profound amount of weight to lose, a lot of the benefit on treating insulin resistant and decreasing inflammation also has been shown to improve sperm parameters. We don't have like long-term fertility live birth data yet. At least I don't know of any if you do. But we see similar things in, you know, female fertility as well, where yes, if you had weight to lose.

1:42:48Dr. Natalie Crawford: There's an obvious benefit, but even in PCOS, endometriosis, unexplained infertility, it can be a tool. It's actually easier to leverage for men because for women right now, we're recommending you come off of GLP-1s one to two months before you conceive because of course we want to keep the baby safe. But for men, I will sometimes have men go on a GLP-1 for a variety of reasons and they can continue it through their trying to conceive journey and have seen sperm parameters improve dramatically for some men?

1:43:15Dr. Michael Eisenberg: I think we need more data, as with many things. There's one study where they randomized men to GLP-1 or exercise or other forms of weight loss, and I think this benefits and semen quality was equivalent. So I think that's very encouraging. It doesn't seem harmful because, you know, in our world, there was sort of a paradoxical result for men that underwent like obesity surgery, bariatric surgery. So those men actually had their sperm counts declined, sometimes to zero after they had bariatric surgery.

1:43:42Dr. Natalie Crawford: Because they're malnourished?

1:43:44Dr. Michael Eisenberg: Well, it's not known. I think that was one thing, but it persisted. It could also just be the stress of the surgery, but it persisted one year, two years in some cases, even when they were getting back supplementation, which again is also very important. So, I think we were always a little worried what GLP-1s would do. And I think the early data seems to suggest that it's safe. Hopefully, some of the big pharma companies are going to do some studies that directly look at this because it is very important. And I think, you know, for the same concerns that we have in women where we stop GLP-1s, I think we just need that data in men.

1:44:14Dr. Michael Eisenberg: I think there's just really a lack of evidence about the harm that GLP-1s can do to sperm. Certainly parameters are one thing, but there can also be other effects too. We did a study looking at metformin, for example, a very common medication for diabetes. And did show actually higher rates of birth defects in children conceived with fathers on metformin compared to other diabetic medications. And that's something that we don't know, right? These are not commonly tested endpoints for these medicines. Is there a mechanism for that? Like that metformin does affect a specific parameter? Is it poor diabetes control?

1:44:47Dr. Natalie Crawford: I mean, Simon and I are now curious. Yeah, well, it's not known.

1:44:50Dr. Michael Eisenberg: But it was really interesting because if you look at it, it was just the three months before. If men took metformin like six months before, a year before, it didn't have the effect. It was just six months before, even after. So, it seemed like it was more than just control. And again, we looked at other medicines as well. you know we hypothesize maybe epigenetic changes or other things I think it's not known exactly why this happens and again this is an association study so I don't want to tell anybody to discontinue metformin you know consult your doctor but I think these are just questions that need to be asked and need to be answered because we're seeing now about a third of all men about or a third of all fathers are taking a medication when they're conceiving in that kind of three-month window so it's very very prevalent.

1:45:28So no one's done a study yet looking at GLP-1 use and sperm parameters or egg quality.

1:45:35Dr. Natalie Crawford: There's been one study looking at sperm parameters and it did show some improvement, but they couldn't say, is it due to losing weight or is it due to other factors? And then that didn't follow through to safety of pregnancy to what Michael is saying, right? If the sperm DNA, how the sperm is functioning is controlling embryo growth, implantation, fetal outcomes, we don't have that long-term data yet. We can extrapolate from women, right? Even though I sat here and said, we want you to be off medications one to two months before you get pregnant, that many women now have conceived while on GLP-1s, right?

1:46:07Dr. Natalie Crawford: This ozempic baby trend that we saw because women who were previously deemed infertile, maybe they lost weight or decreased inflammation or improved insulin resistance, started ovulating again, have gotten pregnant while on these medications. And we've not seen poor fetal outcomes, which is reassuring, right? That if when the mom is carrying the baby or the environment of the egg or the environment of the uterus, but that doesn't mean that we have all the data we need. So this is where popular culture and scientific nuance have to come together in a really, really careful way. And this is individualized care because for the person sitting across from you, it might make a lot of sense.

1:46:43Dr. Natalie Crawford: And you might say, hey, we don't know it's safe. We don't have proof that it's harmful. But in you, this could be a tool that we have in the toolbox because it's really tough when you start getting couples, we'll say fertility specifically. You start to fall into this kind of unexplained infertility outcome, especially when you're doing IVF and you're getting unexplained IVF failure, poor embryo growth or development or implantation failure. We don't have all the testing we need to know what is going on. So that's a scenario where we're often more willing to leverage treatments that don't have long-term data because we've got to change the environment of egg or sperm somehow.

1:47:21Dr. Natalie Crawford: But that doesn't mean that that's how we should treat the entire population of people.

1:47:25Dr. Michael Eisenberg: Yeah. I mean, we have so much data that GLP-1s help many outcomes. So we would assume if there's metabolic benefits that we would also see benefits in just overall fertility. But we just need the data because when patients ask you, you know, that's what we say. We don't know. for now it's it's one of those gray areas in medicine but i'm sure there'll be more data coming through in the next few years i would imagine yeah you mentioned supplements and i know that you so you were involved in the formulation of the swim club supplement for for improving sperm health i a lot of my listeners are going to hear what you said about diet and you know more fruits and vegetables and whatnot and they're going to want to know tell me what specific nutrients are known through whatever level of science it may be, whether it's clinical trials or animal studies or other, that will improve the sperm parameters.

1:48:17Dr. Michael Eisenberg: Yeah, well, that was one of the reasons that I got involved with SwinClub. I think because really they started at first principles. They were just very interested. They thought there was a huge need. And that, you know, when you look and when you do your own research, like if you put it into one of the large language models and ask, you know, show me the data, whereas there's so many different supplements that have been studied. So, we were able to go back to the primary literature, decide which evidence was best, you know, which studies could probably be excluded, and then come up with, you know, both the dosing.

1:48:46Dr. Michael Eisenberg: And then also, one thing that I learned from this group is that, you know, the quality really matters and sourcing really matters. And so, able to come up with a product that's easy for patients to take that has really just an accumulation of really good data that shows improvements in concentration, motility, morphology it's 11 ingredients and again it takes you know two to three months to make a sperm so the idea is that they would take it you know at least three months before but a lot of these you know these nutrients these vitamins also just benefit overall health too so it's also something that you could take longer what was that this is this is more of a personal question as a as a urologist and a professor at sanford was it difficult for you to enter the supplement an industry which has a fair bit of stigma and there's obviously a lot of cowboys and kind of nefarious play out there?

1:49:34Dr. Michael Eisenberg: Yeah, I mean, it's a good question. I mean, initially I was somewhat skeptical when they met, you know, and I talked about all those reservations. But I think the way it was approached was a lot different. And, you know, this was not, yeah, just sort of a product to sell. It wanted to make something that legitimately worked. And so, I think looking at the data, if you really go back and look at it, you know, there are some that are beneficial, You know, and there are some that are not some, you know, some of the studies that have done years ago have been, you know, retracted because of questionable methodology.

1:50:03What would you say are the powerhouse nutrients that are best supported?

1:50:08Dr. Michael Eisenberg: Well, I think that coenzyme Q, I think that's a lot, you know, that probably, you know, around the country, a lot of people probably recommend that just in isolation. So I think there's good data that that helps. I think omega-3 fatty acids, I think there's a lot of good data behind that. I think sort of just this rich antioxidant blend can be helpful like N-acetylcysteine, vitamin E. I think, you know, together I think we're seeing benefits from each of these individually and I think then coming together should only be, you know, going to be additive. Have you seen any kind of remarkable results, this is for both of you, where people have put these things into practice, what we're talking about, the sleep and the exercise, the diet, supplementation, and being able to significantly improve their sperm results?

1:50:51Dr. Natalie Crawford: Yes. And I do want to say, and this underlies everything Michael says, but just to double down on it, you can't out-supplement a bad diet. You know, these supplements are additive to everything else that you're doing. Sometimes people want the easy way out. They don't want to do the harder things about getting more sleep and managing stress and limiting toxins. Eating anti-inflammatory foods, lots of fruits, vegetables, your whole foods, avoiding the sugar and the ultra processed foods probably moves the needle one of the biggest, probably one of the biggest things you can do. Add that with getting sleep and proper avoidance of toxins.

1:51:26Dr. Natalie Crawford: When I put the supplements in the food category, you know, like they're supplemental and advantageous. But I have had, this is where the whole conversation needs to switch because I wish people could do this or be motivated to make these changes before they get pregnant. The time period where they're most motivated often in my clinic is when they've not had success. So we think there's a male problem. We see the sperm's not functioning well. We've gone through a failed IVF cycle. And I tell them we're taking three months off and these are the things that you're doing. And I've titled it Natalie's Very Strict Sperm Quality Protocol and give them a list of things.

1:51:59Dr. Natalie Crawford: I said, these aren't fun, but we're gonna take the nuance out. We're gonna be very black and white. We're not gonna drink alcohol. We're not gonna use cannabis. We're going to eat this many fruits and vegetables and really be in the position where when we spend this$25 ,000 again, we know we're controlling every variable we can because we can't control everything, but we should control everything we can. And I've had patients who couldn't make a single embryo make multiple normal embryos after going through three months of lifestyle changes, had them go on and get pregnant where they previously couldn't.

1:52:30Dr. Natalie Crawford: That's extremely powerful when the stakes are so high, right? Having a child, for some couples, one of their life goals, you start to run up against female age and time And so somebody who's listening to this saying like, oh, yeah, I should be healthy. What's good for my heart's good for my body. It really has such a bigger impact on your sperm in such a short time than it does your cardiac health. This is such a movable needle that more men should be empowered to say before we want to get pregnant I'm going to prepare myself for the pregnancy just like you know My partner's going to prepare herself and then she has to gestate the pregnancy This is my opportunity to come to the table And i'll add that your generation of men is doing this more than ever, right where men used to not be in the clinic I have guys asking all the questions like can I use the sauna?

1:53:19Dr. Natalie Crawford: Can I do this? What should I be doing? What do I need to cut out? Really willing to come to the table and be active participants, which is truly refreshing and something I haven't seen over the past couple of decades. So that's a great start to a change that conversations like this really can move the needle. but that's what I want people to take home is yes we give a lot of suggestions and they don't seem that different but together they are quite powerful especially when it comes to your ability to get pregnant to stay pregnant and we'll like double down asterisk asterisk if you're going through IVF why would you not try to do these things and set yourself up for success so start stacking these things as early as possible yeah you don't it's not all or nothing you don't have perfect every day and in fact the days when you're less perfect rely on the other factors more right you didn't get good sleep because you traveled here traveled across the country so really then make sure that you're managing some of the other things that you can be when it comes to toxins that gets very overwhelming right that you mentioned microplastics how do you avoid all plastics microplastics are in everything how do you avoid endocrine disrupting chemicals that are in the water, in the air, in every good that you are exposed to.

1:54:34Dr. Natalie Crawford: Well, make note where you spend most of your time to control them in your house. Get an air filter, get a water filter, get rid of the plastics, pay attention to the pots in your kitchen, get rid of the fragrance. Those are tangible steps that you can do where you spend most of your time so that you can say, I'm controlling this environment. And then I don't have to worry about as much that when I'm on the airplane or I'm staying in a hotel or I'm at my friend's house, I don't control their environment.

1:55:00Dr. Michael Eisenberg: Yeah, actionable. I mean, I think we're trying not to be overwhelming, right? This is, we're alarmist either. I think that, you know, couples are very vulnerable and you don't want to give them so much and make it sound just impossible. So I think, yeah, I mean, all those same things that I talk to patients about. There has to be a point where over-optimization and sort of stressing too much about this is counterintuitive to the very thing you're trying to achieve.

1:55:27Dr. Natalie Crawford: I would actually argue for the fertility population specifically, right? When you're going through infertility and you are questioning if one of your life goals is going to be achievable and you're watching all the people around you move on with their lives at a stage that you want to be at, knowing that you are controlling everything that you can actually brings peace of mind versus questioning every decision, right? So we talk about over-optimization. Is it causing more stress or people focusing, you know, on the wrong things? And maybe at a population-based level, there's some truth to that.

1:56:00Dr. Natalie Crawford: But in what comes to people who are going through infertility, who for the most part do not have access to the information they need to feel like they can make these choices, what they want most is to be able to make a choice and not think about it again. Say, okay, I know that I'm doing the best that I can with this, move on to the next thing. that having this more strict list or this protocol or this kind of guideline of these are things that in general I should be trying to do to have the best egg and sperm quality actually helps decrease stress because they feel like they are now controlling a piece of the puzzle because infertility at its heart feels so uncontrollable.

1:56:37That's good insight. I can appreciate that. Yeah. A sense of agency. On the list of things not to do, you mentioned the environmental kind of exposures. We spoke about cannabis, sauna. Is sauna strictly, that's a no-go, that's a once a week, you can do it twice a week, don't do it back to back. What does that look like?

1:57:00Dr. Michael Eisenberg: I try and tell patients, again, about spermatogenesis, why the testicles are outside the body, and try and avoid external heat. So, sauna, jacuzzi, hot tub, seat warmers, heating blankets, all of those things. I think we're just impacting the ability of the testicle to sort of dissipate heat. And so, while you're trying, it's best, if you can, just to cut it out. Baths, some of my patients take baths instead of showers. That's also not ideal. What about cold therapy? I think we don't have data. I don't think there's any data that it's harmful. So I think if that's part of their routine, I think that should be okay.

1:57:33Dr. Michael Eisenberg: And anything else we would add like cigarettes, vaping, these sorts of things?

1:57:38Dr. Natalie Crawford: Yes, vaping, cigarettes. We already talked about cannabis. I mean, alcohol use does look dose dependent. And I know Michael is a little more lenient on that. But I think the recommendations have to vary based on where you are too in your goals. If you know your sperm count's abnormal, if you know you're having infertility, you should draw a harder line because you're trying to move the needle back to normal. versus if you are just somebody who's trying to have the best sperm, but you don't want to get pregnant yet. So we have to think about where your goals are and what your current status is.

1:58:10Dr. Natalie Crawford: Anything that's causing inflammation inside your body is not going to help your sperm. That doesn't mean it universally harms it the same. But also, there's a huge individualized response to all of these different exposures, and that has to be accounted for. How you and I would respond to the same thing is going to be different.

1:58:28Dr. Michael Eisenberg: And I think there's also some medication. So, you know, certainly talk to your doctor if you're on some because there's medications we give, for example, for prostate health that can affect ejaculation, can affect sperm production. Finasteride, Propecia is certainly a common medication that reproductive age men take. And before that was approved, there were studies that show that it really had minimal to no impact on semen quality. But, you know, post approval, we now know that there are some men that have probably less reserve than those that were in those trials. and you know we do see strong decreases and when we withdraw the medications about two-thirds of those men actually improve so i think just sort of taking it for granted that if you're taking a medicine it's not going to affect sperm count is not true and there's also other medications i've had men come in that have inflammatory conditions autoimmune conditions that are on medications that turns their ejaculate different colors like supposedly gatorade blue was what wanted you know It's not listed in any of the package insert, but if you go to Reddit, other people report this too.

1:59:26Dr. Michael Eisenberg: So I think that just sort of being aware of some of these possibilities and talking to your doctor about some of the medicines.

1:59:30Dr. Natalie Crawford: I would add, and we mentioned this earlier when it came to testing, but we should say that prolonged abstinence interval should also be avoided. So studies showing that if you're abstaining longer than five days, you're having more degree or fragmentation. So even if you're not having frequent intercourse, but you want to try to get pregnant, ejaculating you know kind of before your partner gets into that fertile window can help as well so just something to be aware of because i still do see a lot of people with the i'm going to save up the sperm for the right moment there's a whole no fapping kind of movement online what is it called which is like around abstinence to increase testosterone oh no what really is that true no no you can we can debunk that now okay there we go that was easy there's not even like a physiologic reason why that would work yeah don't do that yeah okay so before we we kind of close this out let's imagine that there is a couple listening right now and they're sort of eight months into to trying to conceive and they're not having any any luck so far what what would be the next step for them kind of this week is there anything actionable, what would you leave them with?

2:00:43Dr. Natalie Crawford: Number one, fertility testing. If you've not had any testing, you've been trying to get pregnant for eight months, it's time. So that includes a semen analysis for the man. That includes ovarian reserve and anatomy testing for the female, and then some lab testing for both partners. And that's the minimum, in addition to history and other things that are going on. Number two, start to pay attention to all of these lifestyle factors to start taking agency and controlling what you can. So getting enough sleep, trying to decrease external stressors, building muscle exercising, anti-inflammatory eating with supplementation, and avoiding of toxins, right?

2:01:23Dr. Natalie Crawford: Start to control the factors that you can for both men and women. If you're a woman, you're not tracking your cycle, your ovulation, start tracking your cycle, your ovulation, and schedule that visit and really understand that this is a team sport. It doesn't mean you can't get pregnant. I always say, I love it. If you schedule that visit now and you get pregnant next month before your consult, we cancel it. Yay. There's too much noise online that if you schedule a fertility visit, you're going to be pushed into treatment. And that scares people from getting data about their bodies. And I really want to say that's not what we're doing.

2:01:57Dr. Natalie Crawford: The first consult is an hour long, getting a history, going through the tests that we're going to do. You're going to get the data about your body and then sit back down and go over it all and be presented with options choices sometimes couples say everything's great we're going to try a little bit longer fabulous sometimes we're talking about optimization of lifestyle factors or paramedical conditions sometimes i'm sending a couple to a reproductive urologist to help optimize sperm before we go further down the pathway and sometimes we're jumping to more advanced treatment options it's not one size fits all but you can't make any of those decisions without data.

2:02:32Dr. Natalie Crawford: So now that you know how important it is to know these facts about your body, you know, get that data now. And I still, even though generally the whole generation of men right now are different, I still have men in my clinic who say, I don't need to get a semen analysis. It's fine. Sperm do change every three months. You are half the piece of the puzzle. The low end of the bar of what you need to do is get a semen analysis so that we can know what is going on, both partners must be evaluated. What do you think is the underlying psychology behind that resistance? Is it shame potentially that maybe they are contributing or they are the problem?

2:03:09Dr. Michael Eisenberg: I think some of it. Yeah, some people are concerned about that. I think that people have seen that with genetic testing as well. You don't want to find out if you have a problem, right? Like Roediger's cat to some extent. So, I think that's part of it. I think there's also kind of an ick factor associated with it when we've tried to get a semen analysis added to use national health surveys. There's been some resistance because people just kind of consider that, you know, unpleasant, even though I would say that giving a semen sample is more pleasant than giving a blood sample. I feel like we need to get over that.

2:03:36Dr. Natalie Crawford: Yeah. And we could say that there are valid online or not at home semen analysis tests that I'm not going to repeat in my clinic. Right. So maybe you're afraid that, oh, if I do this test, you're just gonna make me do it again. You know, if you're doing a valid test that you will say like CLIA certified lab on it, Like we're not repeating those. So you can do it at home, mail it in, get the data in a place that feels comfortable. You don't always have to go into an awkward office. But data just is the baseline knowledge that you need, right? And we want to control what we can. So we want to optimize all these factors.

2:04:09Dr. Natalie Crawford: We want to advocate for our health. If somebody in front of us says, just try longer, you don't need data. You need data. Go see somebody else, right? And then you need to be in a position of power. because yes, for men, your sperm count, your health is a marker for your future health. And that's ultimately important for health, wellness, longevity. But if we're talking about fertility, we're talking about a life goal, fertility is finite. It will be a moment where a female partner no longer can conceive anymore. And if you are the male partner or you're gonna share this episode with your male partner, he contributes to this.

2:04:43Dr. Natalie Crawford: There's no reason why we're not in a position where we can at least say we do everything we can. I always tell people I don't control the outcome. I wish I did. Like I try my hardest to. But what we control is the journey. And the low end of the bar is that you had the data you needed to make the decisions that were right for you so that however this journey ends up, you don't look back and say, I wish I had made different decisions. You say, hey, we made the best decisions we could and this is the hand that we're dealt and how we're going to move forward. Beautiful. I think we did it, guys. Great.

2:05:17Michael, you got a plane to go hop on. You do. You do. What time is it? It's 2.05. So we'll let you get out of here. But thank you so much. Thank you for coming back. Thanks for doing this.

2:05:27Dr. Natalie Crawford: Michael, this was awesome. I learned a lot. And I think this is a great resource. It's more than I could have hoped for. So really appreciate your time.

2:05:35Dr. Michael Eisenberg: Yeah. Thanks for having me. You're the best. There you have it, friends. I hope you enjoyed this episode. If you did and want to stay up to date with future episodes, be sure to hit that subscribe button on YouTube and follow on Apple or Spotify. Finally, thank you for showing up and the effort that you're making to take control of your health. I look forward to hanging out with you again in the next episode.