Dr. Michael Eisenberg: Improving Male Sexual Health, Function & Fertility

welcome to the huberman Lab podcast

where we discuss science and

science-based tools for everyday

[Music]

life I'm Andrew huberman and I'm a

professor of neurobiology and

Opthalmology at Stanford School of

Medicine my guest today is Dr Michael

Eisenberg Dr Michael Eisenberg is a

medical doctor specializing in urology

and an expert in male sexual function

and fertility he is both a clinician who

sees patients as well as a research

scientist have having published over 300

peer-reviewed articles on male sexual

function Urology and fertility and he is

considered one of the world's foremost

experts in male sexual health today we

discuss a broad range of topics

important to all men including erectile

dysfunction and function we also discuss

prostate health and urinary Health we

discuss fertility and sperm count we

discuss even topics seemingly esoteric

such as why penile lengths are actually

increasing over time while sperm count

seem to be decreasing today you'll also

learn some very interesting surprises

such as the fact that a very very small

percentage of erectile dysfunction

actually stems from hormone dysfunction

rather the vast majority of erectile

dysfunction stems from issues that are

either vascular that is related to blood

flow or neural and today you'll learn

about a large variety of treatments for

erectile dysfunction Dr Eisenberg also

dispels a lot of common myths that you

hear out there both on the internet and

in popular culture that relate to male

sexual health and function by the end of

today's episode I assure you that you

will have a thorough understanding of

what male sexual health is how it

relates to other aspects of health and

how to think about treating maintaining

and improving all aspects of male sexual

health fertility and function before we

begin I'd like to emphasize that this

podcast is separate from my teaching and

research roles at Stanford it is however

part of my desire and effort to bring

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huberman and now for my discussion with

Dr Michael Eisenberg Dr Eisenberg

welcome thank you good to be here I've

been looking forward to talking to you

for a long time because these days we

hear a lot about

the diminishing quality of sperm which

in some way seems to be tacked to the

conversation about diminishing quality

of environment

people intelligence you know there's a

lot woven into this statement that sperm

quality is declining and some of it I

think people assume is related to

environmental changes some of it I think

people assume it are related to changes

in Behavior years so maybe less exercise

less sunlight who knows hopefully you'll

tell us what's really going on but the

first question I have is is sperm

quality actually declining and

regardless what is sperm quality yeah

great question so I think it's very

controversial I think as your question

alludes to so I think we'll start by

just talking about what sperm quality is

and why it's important so for

reproduction as you've covered on the

podcast before a man makes semen um and

that has sperm in it and so when we're

talking clinically about a semen

analysis there's a few things we look at

we look at the amount of ejaculate semen

that comes out we look at the sperm how

many there are we look at their motility

or Movement we look at their morphology

or shape there's some more advanced

testing that's done in rare cases

looking at like fragmentation of DNA for

example or there's some newer tests

looking at epigenetic profiles of sperm

uh but essentially these are all markers

or fertility so fertility in itself is a

team sport right so it's hard to you

know M label a man as fertile or not

fertile without knowing about his

partner um but nevertheless based on

different these different parameters we

try and quantify How likely a man is to

be able to achieve a pregnancy so the

World Health Organization every decade

or so looks over the existing literature

and defines these different cut points

of what's normal or what's subfertile uh

for those levels so that's sort of the

backdrop of what Seaman is and how you

know these these tests are done or you

know what these tests represent now the

question of whether they've declined

over time um has been you know a

question for a number of years there was

a landmark paper in the early 90s by

Carlson and a group in Denmark that

showed this temporal decline you know

over the last 50 years from that time

point and so what the investigators had

done is looked over the literature for

studies that reported semen quality

around the world and noted that you know

the quality in the earliest studies like

in kind of the mid uh 20th century were

here and then over time they had sort of

declined the more recent studies um now

that study was very controversial there

was questions about waiting from

different studies putting because you

can imagine these there's not a lot of

early studies so putting a lot more

importance on those rather than some of

the later ones um and so since then

there's been many other studies that

have that have come out in time and even

today it remains very controversial I

think you know if I were to say that I

believe there's a decline some of my

colleagues and friends would be very

upset with me if I say I don't believe

it some of my colleagues and friends

would be very upset with me so I would

say that you know my opinion really

varies based on Whose paper I've read

and I there's some very convincing you

know studies uh on each side of it you

know there most recently just in the

last year or so there was a meta

analysis of you know tens of thousands

of men where they looked at again a host

of these studies over the last uh number

of decades all around the globe so prior

studies who really just focused on the

Western Hemisphere Western countries

because there was more data from that

but more recently we've gotten a lot of

data from Africa from Asian countries as

well uh and those also support this

decline um so you know one of the

counterarguments to why we're seeing

that is just sort of an evolution of

techniques over time um so that's one of

the the sort of the popular um questions

about whether there's really a true

decline um you know I think as you're

alluding to why there would be decline

is also you know unknown and but you've

sort of labeled you know perfectly the

kind of most common hypotheses so

whether there some environmental

exposures right a lot of things have

changed over the last 50 years and I

think you know chemical exposure is

certainly one of those and there have

been some fairly convincing you know

pre-clinical studies so you know mostly

done in animals uh that show that like

exposure to different chemicals thetes

um or BPA other things may actually harm

you know reproductive function for men

and for women as well uh and so it may

be that you know these chemicals you

know that are that we're being exposed

to as kids and adults or even probably

um more sinisterly when we're um you

know kind of developing in utero that

may be kind of the most harmful exposure

um but there's also been you know an

obesity epidemic as well and there's a

strong link between a men man's

reproductive function um and body weight

and so that's also um to play a role in

some of this too um so I think there are

convincing studies but the other I guess

aspect to this is that there's

variations in semen quality around the

country and around the world there's

Geographic variation and so that's also

sort of an unknown um uh explanation uh

you know there could be different sort

of genetic you know compositions of men

and so there's different reproductive

potential in that Source there could be

different environmental exposures diet

exercise lifestyle and there's a famous

stud study um done a number of years ago

where they looked at se quality among

fathers so these are men that had

achieved a pregnancy and at the first

you know prenatal visit they had um the

fathers give a seaman sample and so this

was done in four centers around the

country I think it one in California

there was um I think one in the midwest

uh there was one in New York so they

basically found that steam inequality

was sort of highest in the urban centers

in New York tended to be the highest

numbers where was you know lower in the

Midwest and so the hypothesis was

potentially because it was a more rural

setting maybe there was pesticide

exposure and that had led to these lower

numbers but you know another equally

plausible explanation may be that you

know different sort of a different

population and maybe you know that that

could explain these differences so I

think it's it's you know very important

um and I think you know one of the sort

of lacking things in this is there's not

really longitudinal data one of the

greatest things would be if we just

started tracking um seen quality around

the country just like we do obesity like

you know n Hayes cdc's uh survey of

Health in in the us if we added seen

quality onto that that way you could

really see you know how it varies around

the country and you know sort of compare

like to like to see over time if there's

really this progression you know one of

the only studies to do that in Denmark

um that started around you know around

2000 and track Seaman quality among um

you know volunteers that came in when

they were conscripted for military

service in Denmark they were offered the

opportunity to participate in this study

um and so some men did and what they

found is actually that se quality was

fairly uniform over about 20 years where

they had data but sort of another very

interesting part of that study is that

only about a quarter of those men had

normal Seamon quality um so it sort of

very concerning you know it was I guess

reassuring that it wasn't further

declining but very concerning that only

a quarter of Danish men had you know

normal semen quality and they're one of

the I think thought leaders in this

field um just because sort of a

reproductive of Crisis there you

mentioned that some of this apparent

decline in seaming quality might be

related to the fact that the tools to

measure seaming quality are getting

better and better and that would make

sense if for instance one is just

looking at total volume morphology which

means shape I should have clarified that

um how many forwardly motile sperm there

are and then also adding in you know a

very sensitive measure such as um DNA

fragmentation you know as the

instruments get finer and finer you

discover more and more details and if

you are um rating quality along a number

of different dimensions then it would

make sense that those would tear out

into different levels so if one were to

Simply ask for couples who want to get

pregnant and assuming that egg quality

is not the

issue what percentage of failures to

achieve successful pregnancy are the

consequence of

deficient sperm deficient in any way and

is that number increasing over time yeah

so I think that's really key I think

when couples think about fertility

usually it's thought of as a female

problem um and I think there's just

historic reasons for that you know if

you look at data in the US when couples

do seek care for fertility the man has

bypassed probably a third of the time

even though when you look at the reasons

for infertility man contributes probably

half of the time to infertility so I

think a half half yeah so I think

there's a huge need just to understand

and evaluate the man and one of the

reasons for this I think is that um you

know one of the main treatments for

infertility in the US is IVF which is

very powerful I think one of the you

know greatest marvels of medicine in

probably the last you know quarter

century is our ability to mix a sperm

and egg in a dish and create a life it's

really remarkable but because it now

takes just a single sperm you know

through something called iny plasmic

sperm injection where you can inject one

egg or one sperm into an egg you know

the bar has gone down dramatically you

know if a couple's just trying without

you know any assistance probably need 20

to 40 million moving sperm but now with

you know these remarkable techniques you

just need one sperm um and so because of

that you know I think a lot of our

Innovation and research on male

fertility has probably gone to the

Wayside just because clinically you know

we just need you know a few dozen sperm

for most

couples what about testosterone levels

are those also declining we hear this um

and when I look at the literature I can

find evidence for that but the question

is also whether or not the amount of

decline in testosterone levels is

significant in a way that impacts let's

say fertility but also um Vitality in

other ways energy mood um Sexual Health

Etc U what's the story with testosterone

levels are they indeed declining on

average across the male population

in the US and elsewhere I think there is

pretty convincing evidence that that is

happening and I think the reason for

that again is probably not certain but

you know there have been you know some

pretty nicely designed cohort studies

where they've recruited you know men in

the the 2000s the '90s the 80s and you

can see that depending on when these men

are recruited just you know matching age

for age these testosterone levels tend

to be lower um and then enh Hanes which

is again this sort of longitudinal study

run by the CDC um that is o shown

looking at testosterone levels over you

know decades the testosterone levels

have declined over time um so there you

know chemical exposure is one possible

explanation again either in adult or

adolescent life or in utero um but

obesity I think is also sort of a

convincing explanation is we're more

sedentary um you know we get bigger

that's one of the places that

testosterone can decline I think there's

different sort of explanations for that

um you know as testosterone's produced

it's aromatized in U peripheral tissue

you know fatty tissue fat has a lot of

this aromat taste so that converts

testosterone to estrogen so it

necessarily you know lowers the

testosterone level that's circulating in

our body um also just insulating the the

testicles our thighs get bigger

insulating the testes can also sometimes

lower the efficiency of production a

little bit too because of heat effects

because of heat effects yeah I was going

to ask about this later but I'll ask

about it now since we're talking about

heat effects and um sperm and

testosterone um The Heat Of course being

not good for um sperm health and

testosterone which is I've read a

metaanalysis I don't know um how high

quality it is but um that explained that

there is some evidence for um either

heat effects or possibly non-heat

related effects of cell phone you know

smartphone in the pocket impairing sperm

Health maybe even testosterone levels

now you hear this more often often in

kind of bioh hacky um I don't know uh

circles um which you know I'm not a fan

of the word biohacking um ites it's not

clear what it means but it it it sounds

like it means something about taking a

shortcut using one thing for a purpose

it wasn't intended but you know it also

makes sense to me that a smartphone

could generate some heat um some

radiation that might impair um

testicular function and therefore impair

sperm quality and or testosterone levels

but is there any real solid data that

carrying your cell phone in your pocket

let's assume on that the cell phone is

on is bad for sperm health or

testosterone levels yeah so um I think

there's not convincing evidence that

it's going to help um testosterone

levels I think that you know it's G to

hurt testosterone it's not going to hurt

yeah so I should you know make clear

that I think that in terms of production

and heat effects you know sperm

production is much more sensitive than

testosterone prodction production um but

there have been some studies looking at

cell phone exposure because again you're

getting this whether it's heat whether

it's sort of the you know radio

frequency you know waves coming in I

think you could posit sort of different

explanations of why that may be harmful

so there have been some studies that you

know looked early on you know men that

Ed cell phones more or less they had

lower semen quality if they used it more

but you can also imagine there's huge

differences in men that do and do not

use cell phones so you know it's it's

it's a hard experiment to design but

there been some studies uh doing this in

vitro so in the laboratory so taking you

know sperm in a cup basically and

putting a cell phone next to it or not

next to it to try and see if that played

a role there have been studies done

where they um sort of normalized the the

heat you know they kind of put on um

sort of a special stage so that it's not

heat necessarily but maybe it's RF

exposure so those studies I think don't

show sort of a me a clinically

meaningful change but there have been

some studies that say that maybe DNA

fragmentation of sperm can go up a

little bit if there's close proximity uh

to a cell phone um so I think you know

when patients ask me that which is a

common question I get in clinic

obviously patients are coming in they

want to do you know whatever they can um

to try and improve their chances um so I

think generally I think the data is not

convincing um but you know if it's easy

enough certainly to be aware of it you

know I think putting a laptop on a desk

rather than in your lap I think for heat

exposure is probably the biggest thing

that we want to

minimize about a year and a half ago I

did an episode about testosterone and

estrogen where it's manufactured in the

male and female body Etc and I found a

very interesting graph in a uh textbook

on U behavioral Endocrinology by a guy

named Randy Nelson who I happen to know

through the field of Behavioral

Endocrinology as it's typically studied

in animals so most of that book centers

on animal studies but there's a a

fraction of the studies that Center on

human uh data and there was a very

interesting graph that showed

testosterone levels as a function of age

in males um and as one might expect

testosterone levels were on average much

higher in late teens early 20s 30s and

there was a progressive decline but what

was remarkable to me about that graph is

that even when exploring the um the

Scatter Plots because they showed

individual points they didn't just show

the averages of testosterone levels in

men in their 50s 60s 7s 80s even 90s

there were these outliers these guys who

had testosterone levels that were on par

with uh testosterone levels of men in

their 30s but these guys were in their

50s 60s 7s 80s even 90s so do you

observe this clinically Do You observe

that um men are coming in you know a who

are older than 40 and have testosterone

levels and presumably free testosterone

levels as well um that are still very

high you know and the reason I asked

this is I think we've all been told and

we presume that testosterone levels

decline with age and one would expect

some outliers and of course we don't

know whether or not those guys in their

90s who have the testosterone levels of

that match the averages of men in their

30s didn't have even greater

testosterone levels in their 30s but

given that they were sealing out around

900 nanograms per deciliter you know

toward the high-end normal depending on

the scale um in already at age 90 it's

kind of hard to imagine that earlier

they're walking around with you know

2,000 nanogram per deiler testosterone

so do you see this are there some is

there just a lot of natural variation in

testosterone levels of men who walk into

the clinic at any age and of course what

is special about these individuals that

are you know maintaining high normal

testosterone levels into their uh later

years yeah that's a great question I

think this is such a common question

anytime we talk about testosterone I

think anytime we talk about most sort of

uh clinical tests that we do you know

what is average what is normal um so we

do see great variation I mean I think

just like you're saying I usually let

everybody know that you know usually

testosterone peaks you know kind of

early 20s and it tends to go down

probably 1% a year forever uh but there

are people that have very you know very

very high levels I you know just

mirroring you know that graph that you

describe I certainly have patients you

know we screen for testosterone levels

you know when patients come in with

complaints or we're worried about that

low energy level you know low libido

some of the symptoms of low testosterone

sexual dysfunction and you know to my

surprise sometimes these men you know

I've seen 80-year-olds that certainly

have the highest testosterone level I'll

see you know for 6 months um you know

why that is I think is not certain maybe

it has to do with you know I think with

everything there's probably sort of a

bell-shaped curve and everybody's a

little bit different um but Androgen

sensitivity you know sensitivity of the

receptor you know they make it more

efficiently but I have not really

noticed again because at least in

clinical practice you know when patients

come in they come in with a complaint

and so even men you know with very high

levels they may have some of the same

dysfunction men with low levels so I

think with low levels you can try and

treat that and that may be the solution

but for men with you know these what we

would consider high levels um you know

there may be other issues going

on let me frame the question I was going

to ask a little bit differently when

someone comes into your clinic and you

measure their testosterone levels as you

mentioned they're likely coming in

because they have some issue prostate

issue sexual function issue

Etc but you do get a read on their you

know s morphology of their body right so

you could visibly determine whether or

not they're likely to be obese or not um

regardless of age so earlier you

mentioned obesity as a risk factor for

lowering testosterone and sperm quality

you mentioned that fat aromatizes

testosterone into estrogen so that's at

least one mechanism by which that could

happen but if you were to just step back

and say okay if somebody who walks into

my clinic tends to be um let's say

healthier looking you know not obese

let's just put the cut off at what you

would presume is obese um is there a

higher probability that their

testosterone levels are going to be

within normal range conversely when

somebody walks in and their

obese do you fully expect their

testosterone levels to be

subnormal um or are you sometimes seeing

obese people walking in with you know

high testosterone um and the reason I'm

asking this is not to create confusion

is that I think that everybody out there

who's thinking about sperm quality and

testosterone levels and this uh apparent

decline trying to figure out you know

okay what can we do in order to maintain

the health metrics that are going to of

course increase fertility but for those

that don't want to have kids or already

have kids are going to at least maintain

or improve Vitality is obesity really

the thing to avoid so is there a not one

for one but is there a tight correlation

between obesity and testosterone levels

I would say that you cannot predict I

think that sort of would be the

take-home and so I think that you know

more information is always better you

know when I see patients in clinic um

you know some patients are walking

around you know with everything is

totally normal they're very healthy all

the numbers come in at the normal range

but sometimes when men you know look

totally normal they talked about taking

care of their life they exercise you

know five seven days a week their

testosterone levels can be very low so

even despite you know having what we

would consider should really give them

you

know symptoms um they're able to

compensate you know maybe they've lived

their whole life in that they don't know

what normal is now we get them you know

to sort of normal levels a lot of times

they feel better again because they have

no idea how they should feel um but I

think that that's just sort of important

that everybody you know should be

screened I think that you know

testosterone seman quality they've been

shown to even be barometers of Health um

so you know men with lower testosterone

levels of higher risk of you know heart

disease diabetes mortality the same

studies exist for semen quality as well

um and you know again they may have sort

of a similar relationship and

explanation why that may be but I think

it's hard to just predict you know based

on appearance what you know Testo will

be what seam equality be what testicular

function will be without actually

getting some objective data and actually

if you look at the trend of test of seam

in quality decline over time kind of

getting back to some of those earlier

points you're making if you were to

Overlay that on the known association

between

obesity um its effects on SE quality

that actually doesn't explain the whole

decline because the you know the

purported decline in seam quality is

about 50% but if you just if you were to

say well what would we expect if you

know we look at you know because we were

able to track exactly how much fatter we

are now than we used to be that actually

only explains about a 10% decline so I

think there is you know to your point

something more um and it is not

something that you can just identify by

eye what are the dos and don'ts as it

relates to I don't want to use the word

optimizing it's gotten me into trouble

before because the word optimize or

optimal suggests that there's an perfect

number that one should all attain if

possible but in reality um optimal is a

day-to-day thing um at least but what

should people avoid in order to get

their sperm quality as high as possible

their testosterone level again here I

have to be careful I don't want to say

as high as possible because some people

might not want excessive Androgen um but

at the high end of normal perh would be

the ideal for many

people what should people do what should

they avoid and here I'm setting aside

any prescription clinical treatments

that such as testosterone injections or

things like uh chonic gatr human coron

and gatot Trope and things we can talk

about a little bit later but what should

every male be doing in order to optimize

these Health parameters yeah so I think

that there are some risk factors that we

do like we'll start with steam in

quality so we talked about heat I think

that's a big one so like hot tub saunas

try and avoid those some you know light

data on seat warmers anytime you know we

kind of get this external heat source to

the scrotum you know the testicles are

outside the body because they need to be

a little cooler so anything that warms

them up can certainly be a problem could

I just briefly interrupt there um to ask

we've done episodes on sauna and some of

the health benefits of sauna um is it

sufficient for somebody to bring in a

cold pack to the sauna and put that in

their groin I actually have suggested

that that's actually what I do when I go

into the sauna um and I have suggested

this on podcasts um not just for people

who are trying to conceive because it

seems like heat as you mention is bad

for sperm not quite as bad for

testosterone levels but is it also true

that heating the testicle too much is

generally bad for endocrine function in

males and therefore would if one is

going to go into a hot sauna for 20

minutes or more to essentially cool the

the scrotal area yeah I mean I think the

spermatogenesis or sperm production is

certainly a lot more sensitive you know

whether you can sort of thwart the

effects of external heat with a cooling

pack I think it makes sense there are

studies that have looked at different

ways to cool the scrotum and have

compared you know semen quality before

and after and there's some data that may

help um it just depends how long you're

going to spend in the sauna and how cold

you know that pack is going to remain so

ice pack and in the sauna for 20 to 45

minutes and is the ice pack still cold

afterwards yeah yeah they actually sell

and by the way I have no relationship to

any of these companies but they actually

sell cold packs that are designed to be

worn in your short so if you go to a you

know I'll go to a Russian B every once

in a while now I guess I'm outing myself

yes I have a yes I have a cold pack in

my shorts when I go to the Russian B um

but um but they have a a sort of an

insulation so that you're the cold the

very cold surface is cold enough but

it's not right up in contact with the

scrotal skin because that could get um I

want to make a bad joke and say it could

get sticky uh that situation you you

don't want it get being so cold that it

actually would stick to the skin and

then it could potentially damage the

skin when you try to remove the cold

pack so it has a thin insulating layer

um and uh yeah that's essentially what

it is yeah I mean frostbite to the

scrotum is not theoretical it could

certainly happen so you do want to be

careful so I mean in theory that should

be that should be adequate to sort of

you know to decrease the risk of that

particular effect um you know I keep

coming back to health how important that

is to maintain um you know know adequate

sperm production because I think these

two are very linked you know there have

been studies that show that men with

more com morid conditions so obesity

hypertension hyper lipidemia as these

sort of Stack Up we see a decline in

testicular function so lower

testosterone levels and lower sperm

quality so I think you know taking

ownership of your your health I think is

important as well um you know a lot of

times um fertility tends to be one of

the first touch points that some men

have with Healthcare you know because

generally what brings men to the doctor

it's usually pain or you know kind of a

problem um so you know if men are in

their 20s and 30s getting ready to start

a family or 40s in some cases sometimes

they haven't you know seen a primary

care doctor so some of these things some

of this relationship has not been

established yet so I think you know

thinking about ways to start that I

think would be important too um and then

I know you don't want to talk about

testosterone but testosterone is

actually a fairly common problem that we

see in fertility clinics um I would say

that you estimat say maybe about one in

20 infertile men are that way because of

testosterone

so I think when you know people get

testosterone different places and

hopefully you know whatever provider

you're getting it from tells you that

one of the side effects of this um is

lower sperm production it's actually

been tested as a contraceptive and you

know with some other agents it can

actually be fairly effective so we just

want to make sure that you know if men

are starting testosterone they're doing

it for the right reasons and they're

doing it safely I think talking about

testosterone replacement therapy

although as we were talking about before

we started recording I I am really on a

push now to rename what people call trt

testosterone replacement therapy because

indeed some people have low testosterone

and need it replaced the r in trt but I

think what you're referring to if I'm

not mistaken is that there are probably

Millions yeah of young men and older men

taking exogenous testosterone injections

creams pills pellets you know any number

nasal sprays now you know any number of

different routes of delivery of

exogenous um testosterone and that um

dramatically reduces one's endogenous

testosterone production and dramatically

reduces one's sperm count and maybe even

quality we'll maybe talk about this a

little bit later but maybe even can

there there's I've been told that it can

perhaps introduce a DNA

fragmentation uh within the remaining

viable sperm as well so do I have that

correct you're saying that that you see

one 120 men have issues with fertility

because they are taking testosterone

right so their testosterone levels

presumably are going to be highend

normal or more but they are doing

presumably not testosterone replacement

therapy but they're doing what I call

testosterone augmentation therapy

meaning they were somewhere in the 300

to 900 nanograms per deciliter

range but decided to start taking

testosterone

anyway and then their their sperm count

essentially diminishes to nil or close

to it in some cases yeah so I mean I

think there's various reasons you would

take test I think you know some people

have been treated you know years ago and

so they do need to replace testosterone

you know um but some people do it for

augmentation I just usually say

testosterone therapy just so it you kill

the R I like that that's better than the

t a which doesn't S very good okay just

testosterone therapy yeah okay but if

you had you know for example we take 100

of my infertile patients that come in to

seei in clinic at least five of those

men will be infertile because they're on

testosterone therapy and some of them do

you know have that suspicion they say

you know I'm going to level with you

this is why my levels are probably low

but a lot of men were not told that you

know when they started therapy so I

think certainly for Reproductive age men

that's a very important conversation to

have um because there can be some other

you know ways that we kind of maintain

sperm production I think sperm cry

preservation is a good option for these

men as well um or there may be other

therapies they can think about just

because of reproductive toxicity what

about um HCG human chonic gatot Trope

and I hear about a lot of people who go

on testosterone therapy who take HCG

every other day or so um typically the

dosages that I hear about because people

write to me about this stuff all the

time really it's one of the most

commonly asked questions um I get many

questions about many topics but I would

say a full 10 to 20% of them are about

um penises or

testosterone um those is perfect then

right exactly um

so a number of those um guys who are

taking

testosterone will be prescribed HCG to

um stimulate sperm production um

endogenous sperm production to maintain

um healthy sperm presumably because they

either want to conceive or are intending

to conceive in the future is that the

best line of treatment for maintaining

fertility while people are taking

testosterone therapy yeah that's one of

the therapies that we use and I think it

can work well you know just a low dose

um usually again for those that that

know 500 to 1,000 units every other day

is usually

adequate as we all know quality

nutrition influences of course our

physical health but also our mental

health and our cognitive functioning our

memory our ability to learn new things

and to focus and we know that one of the

most important features of highquality

nutrition is making sure that we get

enough vitamins and minerals from

highquality unprocessed or minimally

processed sources as well as enough

probiotics and prebiotics and fiber to

support basically all the cellular

functions in our body including the gut

microbiome now I like most everybody try

to get optimal nutrition from Whole

Foods ideally mostly from minimally

processed or non-processed Foods however

one of the challenges that I and so many

other people face is getting enough

servings of high quality fruits and

vegetables per day as well as fiber and

probiotics that often accompany those

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so if somebody is not taking

testosterone exogenously they gotten

their um body fat level down to a point

where they're not considered obese so

they're hopefully doing some

cardiovascular exercise each week maybe

doing some sport or some resistance

training too um uh with the intention of

maintaining all around good

health Stave off you know

cerebrovascular cardiovascular issues

what are some of the other don'ts um I'm

going to assume that smoking cigarettes

or vaping cigarettes is bad there any

studies that have looked specifically at

vaping and sperm quality or testosterone

levels um and is there any evidence that

uh smoking cigarettes is good for

testosterone levels or sperm production

because I'm guessing the answer is no I

feel like nowadays we just say don't

smoke um but the data or the data who

knows maybe nicotine can help sperm I

have no idea right uh it's possible I

don't think we have the data on that yet

but yeah I mean I think like to your

point I think lifestyle factors are

certainly a big one and you know some of

these you know potentially um you know

kind of unhealthy habits so smoking is

certainly something you should not do

there have been you know lots of studies

that do link that to you know lower

quality again all the different measures

that we look at um also looking at

fertility these men tend to have longer

time to get pregnant um alcohol I think

is another very common question get

asked as well and I think for that

there's you know I think less of a

strong Association that we've seen so

there um you know there have been some

studies that show that very high levels

of alcohol and I guess that's sort of

subjective what some would consider

higher or not but you know when you get

above maybe 20 drinks a week there have

been some effects but usually a lot of

drinking I would think that's a lot yeah

but some people don't but yeah I did an

episode on alcohol I think anything more

than two I know people are gonna um you

know bulk at this but you know I think

any more than two drinks per week it's

where you start to see some negative

effects on some health parameters but

you know I'm I'm not a tea toddler so

you know yeah um but when you get to

this 20 drink that's when we started to

see some effects on Cen quality but the

you know the thing about that is that

usually if these men are drinking 20

they're doing other things too smoking

there can be other drug use as well so

it's hard to tease that out but in

general that's you know I think

certainly anything in moderation is

probably you know is probably better and

so that's how I counsel patients I think

again it's very rare that I see men that

are at that level but I certainly let

them know when I do um there's some new

data coming out of that we've started to

work on looking at if there are

different sensitivities to alcohol so

you know some East Asians have a

mutation that leads to Flushing um and

so that may put those men at higher risk

when they mix alcohol we may see some

you know slightly lower uh sperm

parameters you mean skin flushing

because they don't make alcohol

dehydrogenates is idea yeah um and is it

I've heard about that in Asian cultures

is there um an Asian population excuse

me but is there any evidence that other

populations might have slight variance

on alcohol dehydr enas that perhaps

maybe they don't lack it Al together but

they have I don't know um they're

hypomorphs for whatever Gene makes

alcohol dehydrogenase and therefore they

don't metabolize it as well and

therefore the toxic form of alcohol is

active in their system longer is there

any evidence for that no I think you're

exactly right I mean I think the one

that we think about is East Asian

cultures where it can be you know

depending on you know the region like um

Chinese Taiwanese probably about 40 to

50% of population has you know mutation

in the alh2 gene U but other populations

um in people of African ancestry there's

a rate of mutation I think not going to

remember the exact percentage but I

think a few percentage points is some um

individual with Hispanic ancestry

ashkanazi Jewish ancestry so in this

particular Gene there's a mutation not

the same one that East Asians have but

you know again I think it gets to why

mutation you know where we see sort of

negative effects would persist and the

hypothesis that you know Millennia ago

po potentially it you know gave some

sort of benefit for maybe an infectious

disease or something similar to cystic

fibrosis why you know again this

mutation would persist in our population

if there's not you know you know some

sort of Advantage uh to those carrying

it um but we do see in other you know

other men as well so I think if you know

it's a simple question do you flush if

you flush then maybe alcohol may have

you know more of a a harm than than

someone else and then you know get S of

getting along the lines I think drug use

is something that we should try and you

know we do counsel patients about

because that can also negatively affect

SE quality do you think it's fair to say

that okay moderation is best but if

somebody had the option to either not

drink or drink in moderation that they

should not drink would that be even

better is there any evidence for that I

mean it seems like nowadays we take the

stance that um not smoking at all is

better than smoking a little bit

actually when I was a postto at Stanford

from 200 five yes 2005 to uh end of 2010

um you could still smoke on the Stanford

campus I'm not a smoker but there was

this collection of I have to be careful

what I say here there was a particular

group on campus of postdocs and graduate

students that would um you know that

would colonize this little area outside

the hospital and smoke because that's

where you could smoke that was

eventually um eliminated as a

possibility you can't smoke on Sanford

campus as far as I know but they would

smoke right outside the hospital

actually a lot of the hospital workers

would you know take a cigarette on their

break this is very common yeah and and

this was common all over the country

right this isn't unique to Stanford but

nowadays you just don't see that um

because it's not allowed um and we hear

don't smoke it's terrible for XYZ and

everything every other letter of the

alphabet with alcohol um we tend to hear

that if you're going to drink drink in

moderation um it's not clear exactly

what number that is but is it possible

that zero alcohol is better for sperm

and endocrine Health than any alcohol or

is that not not a fair assumption I mean

I think it's a good question I think you

know the your point about tobacco is an

excellent one because I think any

smoking is bad um but alcohol I think we

don't have that data for yet and so I

think it's it's harder to it's harder

for me to make that recommendation to

patients especially because you know

people do it for different reasons um

and if it's not necessarily going to

help them you know it'll harm them in

social situations or other things um

yeah I usually just I usually give the

the moderation one unless again for the

the very high drinkers definitely talk

about that um you mentioned other drug

use um I'm going to assume that uh

unless prescribed for sort of

postsurgical pain or something like that

that benzodiazapines

heroin opioids of any kind um are just

bad for sperm and testosterone I think

we could probably make that a short

discussion right yeah you know I can't

imagine any of that would be good um for

Reproductive Health yeah that's true I

mean there's again you'd imagine or may

maybe not but there's not a lot of data

on it um it'd be difficult to enroll or

maybe easy to enroll but a lot of those

Studies have not been done um but

there's limited ones of you know people

in rehab uh where they have shown you

know these associations with you know

addicts or users and lower quality so um

yeah that's how we talk to patients what

about cannabis I did an episode of this

podcast about cannabis and I did

highlight some of the medical

applications of cannabis I also

highlighted that very high THC cannabis

um May pred dispose especially young

males to later psychotic episodes there

are more and more data coming out about

that all the time I um got a lot of flak

for for saying that but that's my take

on the data um and um I know a lot of

people use cannabis uh

recreationally um and in a kind of

pseudo therapeutic way I say pseudo

what is the relationship between

cannabis use and testosterone and sperm

production or I should say sperm quality

excuse me yeah so this is also a very

common question um again with this wave

of legalization across the country I

think more and more men and women are

exposed to it um so again there's data

that the more men are exposed to it it

can lead to some harm in terms of sperm

morphology and sperm numbers as well um

you know one of the sort of landmark

studies was about 1,200 men and it found

that men that use cannabis daily had

significantly lower concentration

motility morphology compared to those

that didn't use it um so I think that's

generally how men are counseled but

there's also you know other data that

shows really a null effect and I think

that it's it goes into probably the

composition how men are taking it the

frequency because a lot of that data is

not well teased out in a lot of these

studies um so you know I think I I

sometimes struggle with is with patients

because some of them are taking it for

you know you know some what they

consider legitimate reasons anxiety

sleep pain um and if there's not sort of

very convincing evidence that it's going

to help and they're taking it maybe

lower than the threshold where I know

that there's good data that'll cause

harm you know I guess I'm try to be sort

of honest about where we are but I think

with a lot of things related to sperm I

think our our level of evidence is not

great are there any common

over-the-counter medications that can

negatively impact sperm quality Andor

testosterone things like um non-steroid

anti-inflammatory drugs Tylenol Advil

type stuff um you know ibuprofen

acetamin um things of that sort that I

and others might not be aware of I'm not

I'm not probing for anything in

particular here I just I I know that um

you know a lot of over-the-counter drugs

have effects that we're just simply not

aware of yeah I mean I think we probably

need more data but I think currently we

think all those are safe I'm curious

about the pituitary pituitary gland as

many the listeners of this podcast

already know is a gland that receives

signals from the brain um the gland sits

near the roof of the

mouth um I think that's fair um and

releases critical hormones into the

bloodstream that control the output of

testosterone from the testes as well as

output of hormones from other glands um

I know a number of people will end up

playing sports like football

or rugby or even LaCrosse or even soccer

I've read or data on this you know

they're heading the soccer ball quite a

lot or martial arts or they get a head

injury at some point and

um I certainly hear a lot from people

who played these high contact Sports and

then to their

surprise later they have diminished

testosterone levels I also work with a

number of military groups that talk

about this you know that they leave and

maybe it's from combat related stress

Etc but um they wonder whether or not

there's any traumatic head injury or

maybe pituitary injury related um

impairment to the reproductive axis that

includes brain pituitary and the testes

do you see that um and if somebody

played a contact sport in particular

contact sport where the head was hit or

they were hitting things with their head

often um or if they have a TBI or had a

TBI that um reproductive Health can be

impaired that's F fascinating um I have

I have not I mean I think you know it's

interesting I guess you know what the

pituitary does you've obviously covered

this before but it does go to a lot of

our therapies I mean so you know for

your listeners you know that pituitary

produces two hormones LH lutenizing

hormone and FSH follicle stimulating

hormone which then stimulates the

testicle so the lutenizing hormone

hormone stimulates the Ling cells to

make testosterone and then the follicle

stimulating hormone or FSH stimulates

sperm production so both of those are

very key you know in terms of production

and interestingly when exogenous

testostrone is used you know it shuts

down that axis as you know so we get

less of these gatot tropins this LH FSH

um to stimulate the testicle um and the

other sort of reason that sperm

production is lost with exogenous

testosterone uses is actually the in

testicular testosterone is much higher

than serum levels so you know our serum

levels are you know between 300 and 900

uh nanograms per deciliter on average

but in the testicle are probably tfold

higher at least so when men are given

exogenous testosterone and they're not

producing their own the levels of

testosterone in the testicle which are

necessary for sperm production are much

much lower

um but it's interesting because I think

um I am not aware of sort of how tra

traumatic injuries would would do that

okay um that's good to know I'm curious

about the

nonendocrine

nonchemical so effects on sperm quality

and testosterone levels so here I'm

thinking about uh bunch of news stories

we heard a few years ago about how

Bicycle Seat pressure on the prostate or

maybe it was other other portions of the

um maybe was the uh nerves running to

the penis itself um or surrounding areas

maybe it was pelvic floor related and

somehow you'll tell us I'm sure uh was

impairing sexual function was it

impairing sexual function in any way by

impairing testosterone levels cutting

off blood flow to the testes um and here

perhaps the most important thing to ask

straight off is um is riding a bicycle

bad for male reproductive health and

Sexual Health yeah these are great

questions these again living in the Bay

Area working in the Bay Area uh cycling

is very very popular so these are

questions that I get a lot so I think

you

know I in general like we talked about

before anything that's good for your

heart it's going to be good for

fertility so good diet and exercise

maintain a good body weight and so I

always try and encourage physical

fitness I think that's important but you

know it may be possible that some

particular um activities may put men at

more risk so I think cycling could be

one of them if but it would sort of

depend on exactly why we think that may

be a problem so I guess the theory is

heat if you're in the saddle for a long

time you know these prolonged you know

rides that men take you know on weekends

you know hours um that maybe if there's

too much heat exposure that may be the

mechanism where sperm production would

decline so there have been some studies

say maybe five hours a week would be you

know that may be too much so if you're

above that level the sperm counts shown

to be lower if you're less than that

that may be okay so when I talk to

patients about it I try and just

encourage them to you know stand up in

the saddle to try and again sort of air

things out to try and dissipate heat if

if that's the mechan ISM we're going to

think regarding sexual

dysfunction um that is thought to be

pressure as you're alluding to so you

know the way that the saddle is

configured ideally all the pressure is

put on our iscal tuberosities or our sit

bones that's what I'm sitting on now but

on the saddle you know there's obviously

kind of the rigid nose and if there's

too much pressure on that that actually

squeezes between the iscal tuberosities

where you know the main blood flow to

the penis goes and the main nerve Supply

is too and so if there's compression on

this you get this sort of lack of blood

flow or esea and you can get a

neuropraxia as well if you crush these

nerves and so that over time can lead to

problems so you know some patients will

say that you know after I cycle you know

things are numb down there for 30

minutes um or a day or I don't get

erections for that sort of same amount

of time or sometimes you know men just

sort of you know ride through it um and

you know hopefully things come back in a

day or two so that's that could be the

mechanism and there are some Saddles

that you know hopefully will be a little

safer and you know I think that this

sort of first was noted probably around

the 2000 or so and there is a big

redesign in terms of saddles to try and

make them a little bit more you know

anatomically correct to try and minimize

some of this and there's you know cycle

fit that can be done or saddle fit

rather that can be done at some of the

cycling shops to try and you know look

at your body position look at your size

and try and find a saddle that's safer

um you know not this doesn't happen to

everybody I would say maybe if if you

were to um serve a cyclist maybe 20 to

30% of men and women tend to be

susceptible to this so I think if you

are having discomfort in when you cycle

whether it be pain numbness or you

notice dysfunction I think certainly you

should you know think about changing

saddles or think about changing writing

style um there's other strategies are

sometimes used but you know it's

absolutely something that that everybody

should be aware of I me to ask this

earlier but I seem to recall a study

that Drew a a correlation between um

amount of walking and maybe it was sperm

quality but I think it was testosterone

levels maybe some other metrics of um

male sexual health forgive me I'm not

recalling the details now um is there

any evidence that walking more standing

more maybe even using a standing desk uh

is beneficial for um you know pelvic

floor Health blood flow um prostate

health it who knows could be any and all

of those things in some way that is

beneficial for sperm quality

testosterone level and or overall male

sexual health yeah I think you know one

of the ways that we can characterize

activity is Step count right I think I

know I have a a watch that tells me that

it's something that I look at every day

and kind of strive for it and it turns

out that the more active you are uh it's

been shown sort of looking at you know

large National Data pools across

different age ranges that it is

associated with testosterone levels so

being more active I think is very

important and that's another thing that

you know everybody can do to try and

improve sort of testicular function

broadly but testosterone specifically

and do you know whether or not that can

be separated out from the relationship

between being more active and less obese

I mean is this something that's

independent of of obesity in other words

can we incentivize people to walk more

um simply on the on the promise of um

improved Sexual Health well I don't know

Sexual Health would be a different one

but we can I think there is a

association between testosterone levels

and step count uh across different BMI

straight up so I think you know whether

you're have the ideal body weight

whether you have a few pounds to lose

perhaps if you walk more you will see

higher levels of testosterone okay and

another question I meant to ask earlier

and then we can um close the hatch on on

exogenous testosterone therapy at least

for the time being maybe we'll come back

to it is um assuming that somebody can

maintain adequate sperm production

through the use of HCG or some other uh

therapy

or perhaps they don't care if they're

still making sperm because they've

already had children or they don't care

to have children maybe they've Bank

sperm in any event assuming that

somebody takes testosterone therapy

because they were prescribed that um

let's say in your clinic let's just use

you and your clinic as an example and

they are happy with the psychological

and physical consequences of that and

they are comfortable with the

trade-offs is there any increase risk of

say prostate cancer or other forms of

cancer and here I'm going to assume that

this person is keeping their um their

lipid levels in check right because you

hear about some hyper lipidemia with

testosterone therapies let's assume that

they're either taking a stattin or

they're not taking a stat and they're

getting enough cardiovascular exercise

that things are in check in terms of LDL

HDL apob and all of that and their

testosterone levels are now high normal

and they're feeling better um and they

don't have to worry about sperm

production because it's they're either

maintaining aing it or it's been banked

or they don't care about that um is

there an increased risk of prostate

cancer my understanding is the answer is

no but what's the real deal does taking

testosterone therapy assuming all other

things are being held in a in check in a

healthy check does it increase the risk

of any kind of cancer yeah I mean this

is a another great question because I

think there's a lot of Miss around

testosterone and that's one of them you

know this the origin is that prostate

cancer is thought to be or is sort of

Androgen mediated you know one of the

Nobel prizes U you know again decades

ago was awarded because it was found

that when we lowered a man's

testosterone the prostate cancer would

regress dramatically so that put that

association between testosterone and

prostate cancer so then the concern

became if we were to you know either

replace testosterone or augment

testosterone give a man testosterone is

that going to alter his risk or increase

his risk um so I think we have pretty

convincing data that that's not the case

you know there's lots of logitudinal

data spanning decades where if man is

given testosterone um it doesn't change

its risk the reason for that in sort of

seeming Contra you know this

contradiction between you know prostate

cancer a therapy where we lower

testosterone where if you give a man

testosterone doesn't change his prostate

cancer risk uh is not certain but

there's this popular model called the

saturation model so that once there's

enough testosterone in the body and it's

tends to be a fairly low level um that

all the sort of the prostate test

testosterone receptors you know you can

kind of think of as have been filled so

if you were to give man more

testosterone doesn't change anything

regarding the prostate cancer prostate

growth any of that so it is it is safe

when we're looking at prostate cancer as

an outcome I'd like to just take a brief

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huberman getting back to prostate health

and um neural inovation of the penis and

and blood flow to the penis you

mentioned the bike seat related issues

are there other things that men should

do in order to maintain prostate health

Stave off prostate diseases and to

maintain healthy blood flow and neural

inovation of the penis for obvious

reasons and we'll get um into the

specifics of those reasons in in our

later discussion yeah I mean I think

that you know I always kind of think of

the penis as a use it or lose it organ

so that doesn't mean necessarily you

have to have sex but you know normally

we get erections every night so that

should be maintained and if there's any

reason to sort of suspect that that may

not be going on um usually in my

practice that would be from you know

some pelvic surgical intervention or

something like that sometimes we can

intervene to try and maintain that

you're talking about spontaneous

erections during sleep right so um and

uh short of assigning uh one's partner

to uh to check um frequency and tence

what is the uh way that men would know

that that's happening are you talking

about waking up with an erection is that

a requisite for knowing that nocturnal

erections are occurring well yeah I

think you yeah you kind of caught me I

think that's a good question so I think

a lot of times you won't know but I

think if you have sort of normal

response you know when either by

yourself with a partner I think that

generally means um that you are going to

get normal erection so I think I guess

when I say use it or lose it it doesn't

mean necessarily the man has to

stimulate himself or kind of um make

sure that he does have you know adequate

function because usually most of that

normal function just occurs you know

with his nocturnal penal tessin which we

all get you know I think sometimes men

do notice when they wake up at night

sometimes in the morning you wake up

with an erection men notice that but the

absence of that doesn't mean it's not

happening it likely is just you know

most people sleep through it which is

normal otherwise men would never get any

sleep because it happens many many times

a night um so I think you know again if

you're not having normal function I

think that's something you should

probably see you know a physician about

and then same for like urinary function

I think if it bothers you if there's you

know if you're waking up at night if you

have to go to the bathroom often if your

stream is getting weaker those are all

sort of complaints that we hear about

what is often um my understanding is

that it's normal to wake up perhaps once

during the night to urinate um and this

is of course assuming and again forgive

me for all the caveats but I've done

this long enough that you know if I

don't get really granular about some of

this then well what if I drank you know

32 ounces of fluid right before sleep

and I'm urinating three times per night

well we're assuming that people are

tapering their liquid intake as they

approach bedtime um and that waking up

once maybe twice but once in the middle

of the night to urinate is normal for

somebody let's say age I don't know 18

to 40 and maybe from 40 to uh 100 um

that number might be in the uh one to

two times per night is that about right

yeah I mean I think once a night yeah is

normal for most men and then I think you

know if things start to bother you I

think you could certainly see somebody

but it's hard to get better than once or

twice a night yeah for most men um my

understanding is that there's a pretty

good relationship between the um

nocturnal erection and the amount of REM

sleep rapid eye movement sleep that one

is getting that this tends to be more

frequent toward morning as the

proportion of rapid eye movement sleep

increases I don't know if that's true or

not but I found a couple of studies that

at least point in that direction no pun

intended uh so that raises a a bigger

issue that we haven't talked about yet

which is getting adequate amounts of

quality sleep each night and um I think

for most people that's s to n hours

ideally um which means getting

sufficient slow wave deep sleep as well

as rapid eye movement sleep but nowadays

A lot of people including young people

who are are not working excessive hours

are um getting you know four five six

hours of sleep per night is there a

direct relationship between getting less

than sufficient amounts of sleep and

sperm quality testosterone levels and um

Sexual Health yeah I mean I think

certainly there's reasonable data for

seman quality and there tends to be um

you know what we call like in science

sort of a u-shape relationship so that

it's not sort of linear so you get more

sleep things are better it there's sort

of there this concept of too much sleep

and not enough sleep so the ideal I

think as you pointed out is 7 to n hours

and for men that are not getting that

seam in quality tends to be lower and

then for men getting too much um we also

see a decline and you know why that is

is again not certain these again if

you're able to get that much sleep maybe

there's other things as well that we

should look at but um so I think kind of

getting in that ideal sleep amount is

best for seam in quality and probably

for broad ttic function as well you keep

bringing up seam and quality um in a way

that makes me wonder whether or not is

seamen quality a proxy for overall

vitality and health or is testosterone

level appr proxy for overall vitality

and health um it sounds like seamen

quality is the the metric that you keep

coming back to in a way that um I have

to assume reflects your you know your

clinical experience and the the the many

um papers that you've authored in this

area um I think for people that hear

Seaman quity and who are not interested

in conceiving children now or who are

which of course could include people

who've already had children or who don't

want children um seaming Quality sounds

like something that relates to fertility

but is seam in quality something that is

a good goal for those who are interested

in overall male vitality and health is

it is it one of the better metrics of

overall male vitality and health well I

think you know

it's I think it's an excellent marker

for overall health I think there are

studies that support it can be a measure

of how healthy you are you know if you

look at men with more health problems

they can have lower seen quality but

also if you look at semen quality just

by itself and then you look into the

future how these men tend to do if they

have higher semen quality um they tend

to live longer need to go to the doctor

less lower rates of cancer so I think

there's a lot of different ways that

seon quality may be a good barometer of

Health um you know it's you know why

that link exists I think is not is not

known but there's lots of theories so

one is that you know probably about 10%

of the male genome is devoted to

reproduction um and so it makes sense

given that we only have about you know

24,000 genes in the body that there's a

lot of um you know overlap so one gene

that plays a role in reproduction may

play a role in the cardiovascular system

or the neurological system and so if we

get the first you know sort of sign that

reproduction is not perfect there may be

some other health consequences down the

line um another sort of hypothesis is

that again sort of going along this line

that reproduction is one of the first

things that we see is that um you know

gestation is sort of very critical to

our you know existence right and

perturbations to that system have

prolonged um you know effects soort of

the so-called sort of Developmental

origin of adult disease or the Barker

hypothesis um and so we know that you

know pretty much sure children have

higher risk of cardiovascular disease or

been studies to show that but we also

know that you know these gestational

effects can also uh play out on

reproductive function too so that also

may be kind of a link you know sort of

early seating of reproductive function

and then that's maybe the first marker

that we're going to have for other

health effects later on um there also

just sort of sort of inherent um sort of

similarities between um reproduction and

some other sort of social effects so you

know know kind of one sort of

confounding Factor when we're looking at

some of these studies I talked about

looking at mortality for example and sem

quality is that you know there's sort of

factors that necessarily involve

reproduction so your children and having

a partner and having a partner prolongs

life um having kids prolong life even

though it feels like kids are killing

you if you look at studies men with kids

tend to live longer um so you know

that's another possible explanation but

I think you know really sort of this

health

um you know link between fertility I

think is sort of a powerful one so I do

think it should be a barometer I think

that you know it should be sort of when

I've given lectures on this I call it

the six Vital sign I think it's

something that we should probably check

because if there is you know sort of

lower levels that may tell us about

something else going on you know when

when men come in for infertility

evaluations a lot of times we do

diagnose you know these new medical

problems sometimes we diagnose cancer

you know sort of alluding to some of the

questions you've as F diabetes and some

other you know very significant genetic

conditions as well and you know the

first way that we would identify it is

reproductive failure because their sperm

counts are low um and other things so it

is something I think that it's sort of

it's very important I think for people

to realize um and it would be great I

think you know another um I think

advantage to like the Centers for

Disease Control for example to to start

tracking it would it be a good idea for

um males in their 20s and 30s to get

sperm analysis to have a baseline I

confess I'm 47 now um one thing I wish I

had done in my 20s was to get my uh

blood hormone profiles and lipid

profiles done when I was in my teens and

20s because I'd have something to

compare to um I started doing that in my

mid-30s and I'm so glad I did because I

can now compare to my mid-30 levels I

started including um sperm analysis

about eight years ago um with the

intention of freezing sperm and did that

um because I was also reading at that

time time about the increased risk of

autism um in offspring of males older

than 40 something that I really would

like your take on but um it seems like

it's inexpensive enough to do a sperm

analysis um I think now they people can

get it done at home they have mail mail

kits although I don't understand how the

motility could be maintained if you're

mailing your sperm back um at room

temperature or you know it's heading

through the post office now everyone's

imagining all these sperm traveling

through the the Postal Service out

they're out there folks um yeah what

what are your thoughts should um should

people invest the I think it was a

couple hundred dollars to get a a sperm

analysis more um costly to get the DNA

fragmentation than you get up into the

low thousands um but if people have the

disposable income is it a good idea for

them to do I mean I think it's a

worthwhile test I think more information

is always good um you know I think sort

of one of the same reasons that um you

know you're talking about checking like

lipid levels or we tell you know men and

women to get blood pressure checked I

think you know getting that sort of

early Health indicator I think can be

important I think you know going back to

not knowing exactly why semen quality is

telling us about health what the exact

link may be you know means that if

somebody is coming in with a low sperm

count or completely absent sperm count

it's hard to know exactly how to counsel

that that person other than the maybe RI

reproductive difficulties um but I think

just as sort of a marker for

Reproductive potential I I think it's

useful and like you said I think it's

become a lot easier one of the sort of

Innovations in the space um and you know

somebody that you know is in the

reproductive world I think it's just

really great to see sort of this influx

in capital and new companies coming in

they're trying to just decrease the

barrier to you know getting a cement

test it used to be you have to go to a

lab schedule an appointment sometimes

they would send you to a bathroom which

can be uncomfortable you know because

people are doing you know you know what

people do in a bathroom just next to

your way trying to collect oh they would

send them into a in a common space

bathroom Comm space bathroom they would

even give them the quiet room with the

with the red light which is uh right

what I hear they do now yeah some of

them do have videos so there are some

higher level oh I didn't even mean

videos I just I I think that um okay yes

I've done this I'll just I mean I'm

trying to normalize things related to

all aspects of mental health physical

health um so um yeah I I decided to

freeze sperm and basically they sent me

to a room I went to a university based

Clinic it actually wasn't Stanford but

different University and um uh yeah they

put the cup through the window they give

you the cup they um they close the door

and they tell you that as long as that

red light is on over the door no one's

going to walk in and then they leave and

I think the the Assumption now is that

uh you figure it out one way or another

um how to provide the sample and then

you put the sample back through the the

thing and then one thing these clinics

really need to work out is that anytime

you're walking out you see the people

processing your sample as you walk out

so there's all this um this figing of of

uh you know anonymity but really it

isn't there you know because they're

like see you later and you're like great

you you know they they rarely ask you

questions on the way out but it's a

pretty simple process overall and um and

I must say that the the data are

informative you get the you know you get

the volume number motile forwardly

motile I did opt for the DNA

fragmentation um data um and I I just

love data so I think it's really

interesting but again um and maybe this

is a good time to flag this what this

set of findings I believe that there

seems to be a small but statistically

significant increase in the number of

autistic births due to pregnancies where

the male was over 40 at the time of um

of conception um so I figured you know

why not freeze some sperm and it's

relatively inexpensive yeah yeah so I

think paternal age is also you know

something that's increasing in this

country so over the last 40 years or so

we've seen that the average paternal age

has increased from about 27 and a half

to about 31 um and I should say that

this is all fathers so um birth

certificate data or birth data is

collected a maternal level so you know

when a child is born somebody comes in

to collect data on the birth so they ask

you know all the characteristics of the

mother and they also ask characteristics

of the father you know age education

obviously region of the country the

child was born um so we don't know you

know what number child that was for the

father we know it for the mother they do

ask you know is your first second their

Etc child um so the father unfortunately

we just have data that sort of all

lumped together um but over the last

again 40 years we've seen that increase

interesting over the last 40 years the

youngest father was 11 and the oldest

was 88 11 quite a span yeah

88 goodness unrelated I I don't know I

assume I assume goodness it's anonymized

data but ium 11 uh I have to ask this

sorry to uh take us on a slight tangent

but what is the average age of of

puberty in males in the United States um

now yeah so asking about I guess sort of

Sparky when like sperm production begins

so um yeah there are a lot of markers of

of puberty secondary sexual characters

of beard growth deepening of voice ET

they happen at different rates and

different people but yeah thank you um

at what point um are um yeah males

undergoing puberty yeah uh at at the

level of of that we're talking about

here yeah so it's yeah there has been

data we're going through puberty a

little bit earlier now than we used to

um but it really varies so you know I

think it's not um you know just like

testosterone ranges between like 300 and

900 that's a wide range for anybody I

think for most individuals you know

puberty is you know probably 12 to kind

of 15 16 in general so I just give sort

of a very wide range when we're going to

say that's okay and you know some of the

data I'm basing it on is um when sperm

production begins in boys and it's

actually you know not that simple to be

be able to figure that out because you

know we don't generally talk to you know

young boys about how to masterbate how

to collect and then check on that but

there's something called first morning

voided urine where we can actually look

at that and there have been some studies

done and they see if there are sort of

you know nocturnal emissions whether

there're sperm in there and so generally

it probably starts around um the

earliest would be kind of 11 12 13 but

usually most is probably a little later

so maybe I'll refine that puberty and

move it a little bit later probably 14

to 16 um is when probably about 70 80%

of boys are going to have produced

started producing sperm my understanding

is that in females puberty is also

shifting earlier perhaps at a more

dramatic rate than appears to be the

case for males well I think there is

some data for males too I think um but

again for your listeners I don't want to

you know have this onslaught of you know

pediatricians seeing kids that haven't

you know and boys haven't gone through

puberty by a certain age so I think it's

still fairly wide

let's get back to age of the father and

issues like

autism um what are the data there um and

this to me is a practical issue because

I think if there's one obvious takeaway

from our discussion today it's that um

males should probably not wait until

they're trying to conceive in order to

assess their reproductive Health at the

level of sperm quality um testosterone

levels perhaps perhaps but at least

sperm quality but um but perhaps men

should also be freezing their sperm if

in fact conceiving children after 40

places their children at far greater

risk for autism I mean my understanding

is that the rates of autism are

somewhere between 1 and 80 you'll hear

as high as one in 50 male birth but I

think it's probably more like one in 60

to 80 is that about right um and that

the age of the father is a risk factor

yeah I think that this gets into sort of

the larger issue of you know how men

sort of perceive fertility so you know

we know that as women age fertility

declines uh but the oldest father ever

is 96 so the biologic potential

certainly persists wait I want to know

how long he lived to see how his child

grow up we he conceived at 96 amaz

supposedly supposedly yeah well I'm

assuming he did not meet his

grandchildren at least not the

grandchild of that child so wow how long

did he live um you know I well so this

this is a man in India it's just right

up famous story but supposedly um he had

a child he was had that child with him

on uh like they're waiting at a bus stop

he fell asleep the child was kidnapped

that led to divorce so yeah Dreadful

sort of a a horrible end but the wife

was also old not not that old but in her

50s so yeah wow um tragic and and

incredible story for separate reasons um

okay I'll get my head around this 996

year-old uh conceiving a child okay

please continue yeah uh so people I

think or men think that the sort of the

um you know their you know F fertile

road is sort of infinite um but I think

that's very much not the case so as

you're alluding to people have looked

into risks for older fathers so you know

about a hundred years ago was first

noticed that dwarfism or condr plasia

was more common in last born children So

eventually that link was made um and

since then other conditions too so

there's like these neuros psychiatric

conditions you're talking about like

autism is certainly one bipolar

schizophrenia people have looked at and

also linked that with older age you know

Less attainment in school you know

failing grades all that has been shown

to be a little bit more common with

older fathers so you know why I think

all these exist there can be sort of

different

explanations um you know one explanation

for the autism Association I'll talk

about um you know some of this more gen

gentic or um of mutational reasons but

one thing that some people say is that

you know it could be sort of a

hereditary trait and so it maybe that

you know men that display some sort of

autistic characteristics you know maybe

they take a little longer to meet a

partner and so it sort of delayed

childbearing so maybe that's that's one

possible explanation but I think you

know there's been a lot of convincing

evidence that there could be you know

real epigenetic changes that occur with

age and mutational changes that occur

with age um I think I read a statistic

and you would know more being a

neuroscientist that 84% of the the genes

in our body are expressed somewhere in

the central nervous system is that

sounds about right yeah I don't want to

stamp my name to that uh um but that

sounds about right so um it's it's

estimated that every year we generate

about two mutations in our um you know

sperm DNA so you can imagine that you

know a 40-year-old is going to have you

know 20 or TR 40 more mutations um than

a 20-year-old so that rate does go up

and if you're just randomly sprinkling

mutations you know in you know a genome

that they're more likely to sort of

manifest in you know maybe neuros

psychiatric conditions um so there are

you know data convincing data that shows

that that does occur now again there's

billions of base pairs in the body so

these random mutations likely most of

them will will not result in anything

but there can be some meaningful ones so

for example Le a condr plasia it's due

to a mutation in fiberblast growth

factor receptor um and what's

interesting is that this condition is

not that rare right based on sort of

these rare mutations you'd expect this

would you know occur maybe about one in

100 million but it turns out these these

conditions occur in about one in I think

30 to 50,000 or so so there's sort of

the discrepancy based on sort of

mutational rate that we expect based on

age and the rate that we actually see so

the explanation for this is something

called selfish spermatogonial selection

so what this suggests is that some of

these mutations that occur randomly

occur in proliferation Pathways and so

it gives the sperm that contain these

sort of advantages over their you know

brothers and sisters that don't have

them for example and so then they out

compete the other sperm and so they're

more likely to lead to a child rather

than sort of a random smattering you can

actually see that some of these

mutations are more common in older men

than younger men if you look you screen

for some of these mutations in you know

some of these Pathways um

again the longer that we're exposed to

life there's just more likely to be you

know different chemical exposures other

exposures and so people have looked at

epigenetic signatures sort of these

signatures that um you know that dictate

which genes are going to be expressed

and which aren't and there are different

patterns between older and younger

fathers and you know why what triggering

those is not known but there are

differences so those could also

potentially explain you know some of

these risks that we see um you know it

used to be that people thought that you

know if you're an older father maybe

there's a lot of advantages you you know

for the kids right because if you're

you're more resourced right I always

tell patients that you know when they

come to see me for like erection

problems or anything I always say

nothing gets better with age right and

that's mostly true although theyve

pointed out that um salary often goes up

with age and wisdom goes up with age so

you would imagine if you're more

resourced maybe the kids are going to

also have an advantage to that but you

know again there's a lot of convincing

data that that's that's probably not the

case um there's even there's one study

that I saw that showed that if you look

at MRIs uh of brains of children just

after birth they're actually a little

smaller for older fathers compared to

younger fathers so um I think there are

some you know sort of talking about kind

of neurocognitive development um some of

those effects and there's also been um

studies looking at cancer risk too so

higher risk of breast cancer prostate

cancer and adult children higher risk of

you know leukemia or CNS Cancers and

children as well so I think the more we

look the more we find out of these

associations with paternal age um so I

think it's some you certainly be aware

of I think you talking about mitigation

strategies I think sort of Education

would be important for you know couples

to try earlier you individuals to try

earlier to conceive you know if we think

it's a mutational reason I think um you

know certainly freezing sperm I think is

a is a good option as

well my understanding is that um

analysis of DNA fragmentation in sperm

didn't does not allow for selection of

the best sperm on the basis of uh DNA

composition um translated to English

what I mean is in order to tell whether

or not this the DNA are mutated in a

sperm you have to kill the sperm

basically so um and since um in a given

pool of sperm so to speak um there will

be forward motile non-motile twitchers

twitching in place dead sperm um some

percentage of dead sperm or immotile

sperm is presumably normal some small

percentage hopefully um and that some

might have some DNA fragmentation some

might not so um is the way to address

this um averages what I'm hearing here

is that if you haven't already had kids

or if you want more kids um that you

might want to know about your sperm

quality I would say you do um and that

if you can afford it you might want to

take a look at DNA fragmentation data um

but having done this um what one

receives is a chart that goes from Red

bad to Green good and then they put the

arrow hopefully in the green zone and

then you say oh good you know I'm in the

green zone I don't have fragmented DNA

in my sperm but really that's an

averaging of all the sperm right it

could be that as you age that some

percentage of those sperm have

fragmented DNA and um if one of those is

the one that successfully um wins the

egg so to speak um fertilizes the egg

then that fragmented DNA containing

sperm is going to propagate that into

your offspring so are there any

technologies that can allow men to um

select or for or improve the DNA of

their sperm not just the motility I me

yeah I wish right that's sort of the

Holy Grail because I think he pointed

out sort of a variant of right the

Heisenberg uncertainty principle is that

we can't if we identify which sperm is

bad we're necessarily going to destroy

it so to tell you know which one is

harboring these mutations um would be

great but I think we're not there yet I

mean one thing that we do do is wash

sperm so we do sort of Select the most

modal sperm we clear out the dead ones

um and I think embas are pretty good at

telling which sperm they think are

better but you again we don't have any

real objective data to try and

understand you know which are harboring

something or other but I think if we

understood more about this link with age

or again other conditions um hopefully

we'll be able to stop some of this pass

through let's get back to the prostate

um this incredible gland tell tell us

about the prostate I I think we hear

about the prostate we hear about

prostate cancer um

people might have heard that it's

involved in the ejaculatory response

it's involved in erections it's involved

in a number of things if you could give

us a you know catalog of things that the

prostate does um I you spent a lot of

time thinking about this gland what are

some of the cooler things that it that

it does that we don't know about um you

know how do we keep it healthy uh and

what are the consequences of not keeping

it healthy yeah so the prostate is a

gland about the size of a walnut it sits

behind the bladder and it's involved in

reproduction it produces some of the

proteins enzymes that are necessary for

you know sperm to be supported and you

know the ejacalate to kind of keep the

the sperm healthy um in the female

reproductive tract so you know it

functions in reproduction and then

basically after reproduction is done it

doesn't really serve any useful function

so then it just becomes a problem

essentially so the urethra which is

where we pee through so it connects the

bladder you know to exits the body um

runs right through the prostate and as

we age the prostate does get bigger

that's sort of a known thing and as the

prostate gets bigger it creates sort of

more resistance in this pipe and so it

makes the bladder have to work harder

and that leads to a lot of the symptoms

you know that we've been talking about

already you know waking up at night weak

stream this need to uh urinate urgently

um sometimes feeling like you're not

emptying all the way so it's sort of a

consequence of the prostate um sort of

being there uh in terms of ways that you

can keep the prostate healthy I think

that there's really nothing that you

know necessarily can do I think that you

know one thing I talk to patients about

when these sort of symptoms start is to

know some of the triggers so um you know

like you mentioned drinking a lot before

you go to bed so if you don't want to

wake up at night that's not a good

practice you know may even want to go

into bed sort of a little dehydrated

just so you can try and last the night

um there are some you know particular

drinks or foods that tend to be more

irritating so like spicy foods acidic

Foods those can sometimes irritate the

lining of the bladder and make you have

to pee a little bit more you know

caffeine is a diuretic uh so it makes us

urinate more and it also um uh can also

irritate the bladder and give you that

sensation alcohol will do the same thing

so I think you know kind of knowing some

of those triggers May kind of saave off

some of the symptoms a little bit but

you know again if you enjoy those vices

and you're willing to tolerate it that's

okay too I'm hearing more and more about

a practice of people taking low dose to

dofil seis um low dose meaning in the

neighborhood of 2.5 to 5 milligrams per

day um not necessarily for erectile

dysfunction but for prostate health and

was um somewhat surprised to learn that

those drugs were actually developed

first for treatment of prostate health

to increase blood flow to the prostate

um is that true and um is there good

reason to um think about taking 2.5 to 5

milligrams of tadalfil per day simply

for maintaining blood flow to the

prostate and thereby maintaining or

improving prostate health I mean

certainly it can do that it can

definitely help with some of these

urinary symptoms that we've been talking

about you know looking at Placebo

control trial sort of our highest level

of evidence does show that you know low

dose of tadalfil these two and a half to

5 milligram these daily dosing um can

help with these urinary symptoms so I

think that not necessarily it's a

preventative measure but for men that

are bothered you know otherwise I think

most men probably wouldn't want to take

a pill every day but certainly if you

have some of these symptoms it can

definitely help with urinary bother and

then the added benefit is you also

alluded to is it can help with the

rectile function as well even at the 2.5

to 5 milligram dosage interesting um

yeah my experience is that there are a

lot of people who would love to take

pills every day um there seems to be a

kind of binary distribution where um and

here I'm just thinking about the malale

that I hear from because I hear from of

course males and females but um I get a

lot of questions about what can I take

what can I take what can I take um and

uh but as you point out there's also a

category of of of men who seem to um not

want to take anything not want to

measure anything not want to take

anything but especially not take

anything and then there's the other

group um and the other group somewhat

surprisingly seemed to be the L the

younger excuse me population um who

maybe grew up in the YouTube era or

maybe in the era where Sexual Health was

discussed more openly than it was

certainly when I was in college I mean

the extent of sexual health discussions

in my high school and I went to a very

good high school where um it only takes

one sperm which as you pointed out is

true for IV F but more is better if

you're trying to conceive naturally um

and um there were discussions about

communication and consent obviously

super important um and then um they just

kind of turned us loose uh to learn from

our friends and other sources I mean

that and family sometimes had the

discussion sometimes didn't um uh

different families different discussions

obviously um so very very little

information nowadays I think there's a

lot more discussion about these things

and so the 20 to 40y old male crowd

seems to be the crowd that are asking

yeah what can I take these are also the

people who are getting on testosterone

therapy early perhaps without the need I

just want to flag that because um I I

think uh if I understand correctly um

you're seeing a lot of testosterone

therapy that perhaps people don't need

is that right well I think it's a mix

some people probably do need it but I

think that you know before starting it

everybody should be aware of all the

risks and you've kind of highlighted

some but testosterone any any medication

right is going to have some risks and so

everybody needs to be aware of what

those are and for testosterone

reproduction is certainly one of them

and if they're not already doing all the

other things getting adequate sleep

limiting their alcohol intakes not

smoking getting exercise Etc seems that

testosterone therapy would not be the

primary entry point like first work out

all the right all the basics I think

that's the big difference I think

nowadays the what should I take question

comes up early when people aren't

necessarily doing all the other things

um that they could do to promote their

health anyway this is observational on

my part um you're the one whose's Clinic

they're showing up uh too um have a

question about

UTI um we hear about UTI urinary tract

infections um in women pretty often um

do men get UTI if they're getting more

than one UTI per year is that abnormal

um should uh men be uh examined for for

um this bladder urethra prostate penile

architecture I know there are ways that

people can come in I was reading about

this prior to this episode that um you

can ingest a Dy and then they can die

image the whole apparatus is that right

that's true without having to cut

anything is right is that worth people

doing or is that only under conditions

where people are experiencing some some

um some vexing issue yeah I think that

some of those tests should only be done

if there's a problem but I think a male

urinary tract infection is rare enough

enough that it should be evaluated so

women have very short urethras but men

have a very long urethra right it has to

go through the entire penile urethra the

prostatic urethra up into the bladder

and so the way a urinary tract infection

would happen you know one way would be

that a bacteria actually gets all the

way you know back and that's just a much

longer Trek um and so if something rare

like that does happen we look for

anatomic causes for that so there can be

different scar tissue in the uretha for

example there can be stones in the

bladder there can be stones in the

kidney sometimes men AR emptying their

bladders all the way so those those men

should be evaluated because there can be

some pathology that we could hopefully

identify

incorrect let's talk about erectile

dysfunction um I put out the call for

questions in anticipation of this

episode and um no surprise um at least

30% of the questions from males were

about erectile dysfunction um or uh

questions about what's normal in terms

of libido level kind of interesting

right you know and we'll deal with the

first question first but um what are the

most common causes erectile dysfunction

are they hormonal in nature I think

that's a a common belief that if people

are experiencing erectile dysfunction

that it's because their testosterone

levels are too low hence all the

interest in um testosterone therapy um

or are there other say blood flow

related pelvic flow related neural um

brain to um

to body neural connections that are

responsible I'm guessing it's all of

these things how do we parse this um and

yeah what tell us about erectile

dysfunction what you most commonly see

what you most commonly do in order to

treat it yeah so you know erectile

dysfunction is you know sort of the

inability to consistently achieve and

maintain an erection and it's fairly

common um you know of all the conditions

I see that's definitely the number one

so you know if you look at men over the

age of 40 over half will have some

trouble with erections under age of 40

is probably about 15 to 20% so this is a

very common condition that we see in

terms of the ideology it can vary a

little bit you know we used to think

that they were primarily psychogenic um

but that was you know years that was