Welcome to the huberman Lab podcast where we
discuss science and science based tools
for everyday life. I'm Andrew huberman, and I'm a
professor of neurobiology and Ophthalmology 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
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 discussed prostate health and urinary Health, we discussed fertility and sperm count. We discuss even topics seemingly esoteric such as why penile lengths are actually increasing over time while sperm
don't 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 hormonal 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.
Sure, 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 zero cost to Consumer information about science and science related to
Rules to the general public in keeping with that theme. I'd like to thank the sponsors of today's podcast. Our first sponsor is rokka rokka makes eyeglasses and sunglasses that are the absolute highest quality. The company was founded by two all-americans swimmers from Stanford and everything about Roca eyeglasses and sunglasses were designed with performance in mind. I've spent a lifetime working on the biology of the visual system and I can tell you that your visual system has to contend with an enormous number of challenges in order for you to be able to see clearly Roka understands this and this design. I
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Prior to using an eight Sleep mattress cover if you'd like to try eight sleep you can go to eight sleep.com huberman to save $150 off their pod three cover eight sleep currently ships to the USA Canada UK select countries in the EU and Australia again. That's eight sleep.com hubermann, 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 ways 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 behaviors.
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 is 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 man makes semen and that
It's permanent. 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 ejaculated semen that comes out. We'll look at the sperm. How many there are we look at their motility or Movement? We would get their morphology or shape. There's some more advanced testing that's done in rare cases looking at make fragmentation of DNA for example, or there's some newer tests looking at Epi genetic profiles of sperm. But essentially these are all markers or fertility. So fertility in itself is a team sport, right? So it's hard to you know,
label a man as fertile or not fertile without knowing about his partner, 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 points of what's normal or what subfertile for those levels. So that's sort of the backdrop of what semen is and how you know, these these tests are done or you know, what these tests represent how the question of
They're they've declined over time has been you know question for a number of years. There was a landmark paper in the early 90s by Carlson in a group and Denmark that showed this temporal decline 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 20th century.
Or here and then over time they had sort of decline the more recent studies. Now, that study was very controversial. There was questions about waiting from different studies putting because there as 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 and so since then there's been many other studies that have that have come out and time and even today it remains very controversial. I think, you know, if I were to say that I believe there's a decline
And some of my colleagues and friends would be very upset with me. If I say, I don't believe it's on 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 think there's some very convincing, you know studies on each side of it, you know, their most recently just in the last year or so. There was a meta-analysis of tens of thousands of men where they looked at again a host of these studies over the last number of decades all around the globe. So prior studies to really just focus
Tan 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 and those also support this decline. So, you know, one of the counter-arguments to why we're seeing that as just sort of an evolution of techniques over time. So that's one of the sort of the popular questions about whether there's really a true decline. You know, I think is you're alluding to why there would be a client as
So, you know unknown and but you've sort of labeled, you know perfectly that kind of most common hypotheses. So whether its environmental exposures write a lot of things have changed over the last 50 years and I think you know chemical exposure certainly one of those and there have been some fairly convincing, you know, preclinical studies. So, you know, mostly done in animals that showed that like exposure to different chemicals phthalates and BPA other things may actually harm, you know reproductive function for men.
And for women as well, and so it may be that you know, these chemicals that are we're being exposed to as kids and adults or even probably more sinisterly when were you know, kind of developing in utero that maybe kind of the most harmful exposure but there's also been a you know, an obesity epidemic as well and there's a strong link between amend man's reproductive function and body weight. And so that's also thought to play a role.
And some of this too. 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 explanation, you know, there could be different for the genetic, you know compositions of men and so there's different reproductive potential not Source there can be different environmental exposures diet exercise lifestyle. There's a famous study.
Done a number of years ago where they looked at semen quality among father's so these are men that are achieved pregnancy and at the first, you know prenatal visit they had the father's give a semen sample. And so this was done for centers around the country. I think it went in California. There was one in the midwest. There is one in New York. So they basically found that the semen quality was real highest in the urban centers in New York tended to be the highest numbers where it was you
Lower in the Midwest and so the hypothesis was potentially because it was a more rural setting maybe there was pesticide exposure in 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 very important and I think you know, one of the sort of lacking things and this is there's not really longitudinal data. One of the greatest things would be if we just started tracking semen quality around the country.
Just like we do obesity like, you know nhanes cdc's survey of Health in the u.s. If we added semen quality on to 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 that have started around around 2000 and track semen quality among, you know volunteers that came in when they were conscripted for military service in Denmark. They were offered the opportunity to participate
In the study and so some men did and what they found is actually the semen quality was fairly uniform over about 20 years where they had data, but sort of another very interesting part of that study has that only about a quarter of those men had normal semen quality. So sort of very concerning, you know, it was I guess reassuring that it wasn't further declining but very concerning and only a quarter of Danish men had normal semen quality and they're one of the I think thought leaders in this field just because sort of a reproductive crisis.
Are you mentioned that some of this apparent decline in semen quality might be related to the fact that the tools to measure semen 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 should have clarified that how many forwardly motile sperm there are and then also adding in, you know, a very sensitive measure such as DNA fragmentation, you know, essentially as the
Instruments get finer and finer you discover more and more details. And if you are rating quality along a number of different dimensions than 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
Efficient 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 and I think there's this historic reasons for that. You know, if you look at data in the u.s. When couples do see care for fertility, the man is bypass 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 there's a half
Yeah, so I think there's a huge need just to understand and evaluate the man and and one of the reasons for this I think is that you know, one of the main treatments for infertility in the u.s. Is IVF, which is very powerful. I think one of the greatest marvels of medicine and probably the last you know quarter century is our ability to mix a sperm and egg and Dish and create a life. It's really remarkable. But because it now takes just a single sperm, you know through something called intracytoplasmic sperm injection, re-inject one egg.
One sperm into an egg, you know, the bar is gone down dramatically, you know for a couple just trying without any assistance probably need 20 to 40 million moving sperm. But now with you know, these remarkable techniques, you just need one sperm and so because of that, you know, I think a lot of our Innovation and research on male fertility is 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
Meaning we hear this 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 vitality and other ways energy mood Sexual Health cetera. What's the story with testosterone levels are they indeed declining on average across the male population in the u.s.
Yes
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 design cohort studies where they've recruited, you know men and 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 and then nhanes which is again this sort of longitudinal study run by the CDC. That is also shown here.
Looking at testosterone levels over, you know decades the testosterone levels have declined over time. So there you know chemical exposure is one possible explanation again, either adults or adolescent life or in utero, but obesity I think is also part of a convincing explanation is were more sedentary, 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, you know as testosterone produced its aromatized in peripheral tissue, you know fatty tissue fat.
It has a lot of this Aroma taste of that converts testosterone to estrogen so a necessarily, you know, lowers the testosterone level that's circulating in our body also just insulating the testicles or thighs gets 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 now since we're talking about heat effects and sperm and testosterone the heat of course being not good for sperm health
Testosterone which is I've read a meta-analysis. I don't know how high quality it is. But that explained that there is some evidence for either heat effects or possibly non heat related effects of cell phone, you know smart phone in the pocket in pairing sperm Health, maybe even testosterone levels that you hear this more often and kind of
Hackie, I don't know circles which you know, I'm not a fan of the word biohacking. It does it's not clear what it means but it sounds like it means something about taking a short cut 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 some radiation that might impair 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. Yes. So I think there's not
convincing evidence that it's going to help testosterone levels. I think that you know, it's going to hurt testosterone is not going to hurt you so I should make clear that I think that in terms of production and heat effects, you know sperm production is much more sensitive than testosterone production, but
R have been some studies looking at cell phone exposure because again, you're getting this whether its 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 use cell phones more or less. They had lower semen quality. 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 a hard experiment to design but there have been some studies.
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 sort of normalize the heat, you know, they kind of put it on sort of a special stage so that it's not heat necessarily. Maybe it's RF exposure. So those studies I think don't show sort of 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
Is close proximity to a cell phone? So I think you know I 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 to try and improve their chances. So I think generally I think the data is not convincing but you know, if it's easy enough certainly to be aware of it, you know, I think putting a laptop on a desk rub and 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
An estrogen where it's manufactured in the male and female body Etc and found a very interesting graph in a textbook on behavioral Endocrinology by 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 fraction of the studies that Center on human data and there was a very interesting graph that showed testosterone levels as a function of age in males.
And as one might expect to solve our own 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 Scatter Plots because he they showed individual points. They didn't just show the averages of testosterone levels in men in their 50s 60s 70s 80s even 90s. There were these outliers these guys who had testosterone levels that were
On par with testosterone levels of men in their thirties, but these guys were in their 50s 60s 70s 80s even 90s. So do you observe this? Clinically Do You observe that men are coming in, you know after who are older than 40 and have testosterone levels and presumably free testosterone levels as well that are still very high. You know, I know the reason I asked is that 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 90's 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 ceilinged out around 900 milligrams per deciliter, you know toward the high-end normal depending on the scale in already at age 90. It's kind of hard to imagine that earlier they're walking around with, you know, two thousand and a gram per deciliter testosterone. So do you see this are there some is there just a lot of natural variation in testosterone levels of men?
Come to 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 later years.
Yeah. It's a great question. I think this is such a common question anytime we talk about testosterone. I think right side we talked about most sort of clinical tests that we do, you know, what is average what is normal? So we do see great variation. I mean, I think just like you're saying I usually let everybody know that usually testosterone peaks.
Kind of early 20s and it tends to go down probably 1% a year forever. But there are people that have very, you know, very very high levels. I you know just mirroring, you know that graph that you described I certainly have patience we screen for testosterone levels, you know, when patients come in with complaints were 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
For six months, you know why that is I think is not certain. Maybe it has to do with everything with everything. There's probably sort of a bell-shaped curve and everybody's a little bit different but handwritten 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 in men with low levels. So I think with low levels you can try and treat that
that may be the solution but for men with you know, these what we would consider high levels, you know, there may be other issues going on.
Reframe 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 issues actual function issue Etc. But you do get a read on their, you know, sort of crude morphology of their body, right so you could visibly determine whether or not they're likely to be obese or not regardless of age. So earlier you mentioned obesity as a
Tractor for lowering testosterone and sperm quality you mentioned the fat aromatize his 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 less a healthier looking, you know, not obese. Let's just put the cutoff at what you would presume is obese. Is there a higher probability that their testosterone levels are going to be within normal range.
Conversely when somebody walks in and they're obese. Do you fully expect their testosterone levels to be subnormal or are you sometimes seeing obese people walking in with you know high testosterone 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 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 who are already have kids are going to at least maintain or improve Vitality is obesity really the thing to avoid. So is there a not 141 but is there a tight correlation between obesity and testosterone levels?
I would say that you cannot predict. I think that's 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, you know, some patients are walking around, you know with everything is totally normal in there.
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, 57 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 they're able to compensate me know maybe they've lived their whole life in that. They don't know what normal is now. We get them, you know, just sort of normal levels. A lot of times they feel better again because I had no idea how they should feel but I think that's just sort of important that everybody, you know should be screened. I think that you know, testosterone semen quality there have been shown to even be barometers of health. So, you know men with lower testosterone levels of higher risk of heart disease diabetes mortality the same studies exist for semen quality as
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 based on appearance what you know, testosterone will be what semen quality be what testicular function will be without actually getting some objective data. And actually if you look at the trend of test of semen 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 its effects on semen quality.
Leti that actually doesn't explain the whole decline because the you know, the purported decline in semen 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 explains about a 10% decline. So I think there is you know to your point something more and it is not something that you can just identify my hi.
What are the do's and don'ts as it relates to I don't want to use the word optimizing it's gotten me into trouble before because weird optimized or optimal suggests that there's a perfect number that one should all attained if possible, but in reality optimal is a day-to-day thing 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 say it's high as possible because some people might not want excessive Androgen but at the high end of normal, perhaps 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 chorionic gonadotropin human chorionic gonadotropin things. We can talk about a little bit later, but what should every male be doing in order to
Demise these Health parameters. Yes. I think that there are some risk
factors that we do like we'll start with semen quality. So we talked about heat. I think that's a big one. So I hot tub sauna is try and avoid those some you know, light data on see 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 draw up there to ask we've done episodes on sauna and some of the health benefits of sauna
It's efficient for somebody to bring in a cold pack to the sauna and put that out in their groin. I actually suggested that that's actually what I do when I go into the sauna and I have suggested this on podcasts not just for people who are trying to conceive because it seems like heat as you mentioned 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 forth 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 if compared semen quality before and after and there's some data that may help it gets depends how long you're going to spend in the sauna and how cold you know that pack is
Remain, so ice pack and in the sauna for 20 to 45 minutes
and as 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 a I'll go to a Russian Banya every once in a while now, I guess I'm outing myself. Yes. Yes. I have a cold pack in my shorts when I go to the Russian Banya, but but they have a sort of an insulation so that your the cold
very cold surface is cold enough, but it's not right up in contact with the scrotal skin because that could get want to make a bad joke and say you could get sticky that situation. You don't want it get it being so cold that it actually would stick to the skin and then it could potentially damage the skin when you try and remove the cold pack so it has a thin insulating layer. And 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.
Sort of you know to decrease the risk of that particular effect, you know, I keep coming back to health how important that is to maintain, you know adequate sperm production because I think is to are very linked there have been studies that show that men with more comorbid conditions obesity hypertension hyperlipidemia, is 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, you know.
A lot of times 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 and it's usually pain or you know, kind of a problem. 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 seen a primary care doctor. So some of these things and 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 to and then I know you don't want to talk about testosterone but testosterone is actually a fairly common problem.
On that we see in fertility clinics, I would say that estimates say maybe about 1 in 20 and fertile 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 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
Get safely I think about testosterone replacement therapy. Although as we were talking about before we started recording. 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 are 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 exogenously.
On injections creams pills pellets, you know any number nasal sprays now, you know any number of different routes of delivery of exogenous testosterone and that dramatically reduces ones endogenous testosterone production and dramatically reduces ones sperm count and maybe even quality maybe talk about this a little bit later, but maybe even can there's I've been told that it can perhaps introduce DNA fragmentation within the remaining.
Viable sperm as well. So do I have that correct? You're saying that you see 120 men have issues with fertility because they are taking testosterone. Right? So their testosterone levels presumably are going to be high in 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 there's their sperm count essentially diminishes to nil or close to it and some cases. Yeah. So I mean, I think there's
various reasons you would take testosterone. I think you know, some people have been treated, you know years ago and so they do need to replace testosterone, you know, but some people do it for augmentation. I just use this a testosterone therapy to so encoding kill
the are I like that that's better than the t-80 which doesn't ever get. Okay. Just testosterone therapy. Yeah, okay,
but if you had you know,
Example we take 100 of my infertile patients that come in to see me and clinic at least five of those men will be infertile because they're on testosterone therapy and some of them do have, 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 in a very important conversation to have because there can be some other ways that we kind of maintain sperm production. I think sperm cryopreservation is a good option for these men as well.
Or there may be other therapies. They can think about just because of reproductive
toxicity. What about HCG human chorionic gonadotropin, I hear about a lot of people go on testosterone therapy who take HCG every other day or so typically the dosages that I hear about because people write to me about the stuff all the time really. It's one the most commonly asked questions. I get many questions about many topics, but I would say a full ten to twenty percent of them are
Out penises or testosterone those perfect then right? Exactly. So a number of those guys who are taking testosterone will be prescribed HCG to stimulate sperm production endogenous burn production to maintain healthy sperm presumably because they either want to conceive or intending to conceive in the future. Is that the best line of treatment for maintaining fertility while people are taking testosterone
therapy? Yeah.
It's one of the therapies that we use and I think can work. Well, you know just a low dose usually again for those that know 500 to 1000 units. Every other day is usually
on equipment.
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So if somebody is not taking testosterone exotic, honestly, they gotten their body fat level down to a point where they're not considered obese. So there hopefully doing some cardiovascular exercise each week maybe doing some sport or some resistance training to with the intention of maintaining all around good health.
Stave off cerebrovascular cardiovascular issues, what are some of the other don'ts I'm going to assume that smoking cigarettes or vaping cigarettes is bad there any Studies have looked specifically at vaping and sperm quality or testosterone levels? And is there any evidence that smoking cigarettes is good for testosterone levels or sperm production because I'm guessing the answer's. No, I feel like nowadays. We just say don't smoke but the data or the data who knows maybe nicotine can help sperm. I have no idea,
right?
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, you know, kind of unhealthy habits. So smoking is certainly something you should not do there have been lots of studies to do link that to you know, lower quality again, all the different measures that we look at also looking at fertility these men tend to have a longer time to get pregnant alcohol. I think is another very common question we get asked as well and I think for that there's you know, I think less of
Of a strong Association that we've seen so there 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 got didn't episode on alcohol. I think anything more than to I know people are going to you know balk at this but you know, I think any more than two drinks per week, it's where you start to see some
It affects on some health parameters, but you know, I'm I'm not a teetotaler so yeah. Yeah,
but when you get to this 20 drink, that's when we started to see some effects on semen quality, but the other you know, the thing about that is that usually if these men are drinking 20, they're doing other things to 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, it's probably better and so that's how I counseled patience. I think again, it's very rare that I see men that are that
Well, but I certainly let him know when I do. There's some new data coming out of the the 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. And so that may put those men at higher risk when they mix alcohol. We may see some, you know slightly lower sperm parameters. You mean skin flushing because they
don't make alcohol dehydrogenase is a good idea. Yeah. And is it I've heard about that in Asian cultures is there
Um Nation population scuse me, but is there any evidence that other populations might have slight variance on alcohol dehydrogenase that perhaps maybe they don't lack it all together, but they have I don't know there are hyper morphs 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? And I
think that you're exactly right. I mean, I think the one that we think about is East Asian culture.
Is where it can be depending on you know, the reason like Chinese Taiwanese probably about forty to fifty percent of the population has, you know mutation aldh2 Gene, but other populations in people of African ancestry, there's a rate of mutation. I think I'm not gonna remember the exact percentage but I think a few percentage points to some individual Hispanic ancestry Ashkenazi 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 where we see sort of negative effects would persist and the hypothesis that you know, Millennia ago pretend potentially, you know, gave some sort of benefit for maybe an infectious disease or something similar to cystic fibrosis. Why again, this mutation would persist in our population if there's not, you know, or you know some sort of advantage to those carrying it, but we do see another, you know other men as well. So I think if it's simple question, do you flush if you
Rush then maybe alcohol may have more of a harm than someone else and then you know, I could probably getting along the lines I think drug use is also something that we should try and we do counsel patients about because that can also negatively affects semen 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
Dance that not smoking at all is better than smoking a little bit. Actually when I was a postdoc at Stanford from 2005. Yes, 2005 to end of 2010. You could still smoke on the Stanford campus. I'm not a smoker but there was this collection of have to be careful. What I say here. There was a particular group on campus of postdocs and graduate students that would you know that would call an Eis this little area outside the hospital and smoke because that's where you could smoke that was eventually eliminated as a possibility.
You can't smoke on Stanford campus as far as I know they would smoke right outside the hospital actually allow the hospital workers would take a cigarette on their break. This is very concerning. Yeah, exactly. Yeah, and this was common all over the country, right? This isn't unique to Stanford. But nowadays you just don't see that because it's not allowed and we here don't smoke. It's terrible for XYZ and everything every other letter the Alp, but with alcohol we tend to hear that if you're going to drink drink in moderation.
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, but how could I think we don't have that data for yet? And so I think it's hard and it's harder for me to make that recommendation to patients, especially because you know people do it for different reasons and if it's not necessarily going to help them.
You know harm them in social situations or other things. Yeah. I usually just I usually give them moderation one unless again for the very high drinkers. I definitely talk about that.
You mentioned other drug use. I'm going to assume that unless prescribed for sort of post-surgical pain or something like that that benzodiazepines heroin opiates of any kind are just bad for sperm and testosterone. I think that we could probably make that a short discussion, right? Yeah.
I can't imagine any of that would be good for Reproductive Health.
Yeah, that's true. I mean there's again you'd imagine or maybe not but there's not a lot of data on it would be difficult to enroll or maybe easy to enroll but a lot of those Studies have not been done but there's limited ones of you know people in rehab where they have shown, you know, these associations with you know addicts or users and lower quality. So 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 May predispose, especially young males to later psychotic episodes that are more and more data coming out about that all the time. I got a lot of flak for saying that but that's my take on the data. And I know a lot of people use cannabis recreationally and in a kind of pseudo therapeutic way. I say pseudo therapeutic because I think a lot of
People use cannabis to manage their anxiety and as an alternative to alcohol for a number of reasons, what is the relationship between cannabis use and just tossed her own and sperm production or I should say sperm quality. Excuse me.
Yeah. So this is also a very common question again with wave of legalization across the country. I think more and more men and women are exposed to it. So again, there's data that
the more men are exposed to it and can lead to some harm in terms of sperm morphology and sperm numbers as well. 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. 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
Men are taking it the frequency because a lot of that data is not well teased out in a lot of these studies. So, you know, I think I sometimes struggle with is with patients because some of them are taking it for, you know, some what they consider legitimate reasons anxiety sleep pain and if there's not sort of very convincing evidence that it's going to help and they're taking it may be lower than the threshold where I know that there's good data that will cause harm, you know, I guess I'm trying to be sort of on
Just about where we are, but I think with a lot of things related to sperm I think our level of evidence is not
great. Are there any common over-the-counter medications that can negatively impact sperm quality and or testosterone things like non-steroidal anti-inflammatory drugs Tylenol Advil type stuff, you know, ibuprofen acetaminophen 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 know that
Um, you know, a lot of over the counter drugs have effects that were 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 listeners of this podcasts or I know is a gland that receives signals from the brain the gland sits near the roof of the mouth. I think that's fair 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. I know a number of people and 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
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 they wonder whether or not there's any traumatic head injury or maybe pituitary injury related impairment to the reproductive access that includes
when pituitary and the testes, do you see that 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 or if they have a TBI or had a TBI that the reproductive Health can be impaired.
That's fascinating.
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 luteinizing hormone and FSH follicle stimulating hormone, which then stimulates the testicle. So the luteinizing hormone hormone stimulates the latex 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 exoticness testosterone is used, you know, it shuts down that axis as you know, so we get less of these gonadotropins is LH F sh to stimulate the testicle and the other sort of reason that sperm production is lost with exoticness testosterone uses. It is actually the interesting color testosterone is much higher than serum levels. So, you know, our serum levels are you know between 300 and 900
and in a deciliter on average but in the testicle or probably tenfold higher at least so when men are given exoticness testosterone and not producing their own the levels of testosterone in the Tesco, which are necessary for sperm production are much much lower.
But it's interesting because I think I am not aware of sort of how traumatic injuries would would do that. Okay,
that's good to know. I'm curious about the non endocrine non-chemical so effects on sperm quality and testosterone levels. So here I'm thinking about a bunch of news stories or heard a few years ago about how Bicycle Seat pressure.
Or on the prostate or maybe it was other other portions of the it was the nervous running to the penis itself where surrounding areas maybe those pelvic floor related and somehow you'll tell us I'm sure was impairing sexual function was it impairing sexual function in any way by comparing testosterone levels cutting off blood flow to the testes and here perhaps the most important thing to ask straight off is 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 cycling is very very popular. So these are questions that I get a lot. So I think you know
In general like we talked about before anything. It's good for your heart. It's going to be good for fertility. So good diet and exercise maintaining 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 activities may put men in more risk. So I think cycling could be one of them if bit of a 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 for these prolonged, you know.
Adds that men take you know on weekends, you know how H 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 maybe too much. So if you're above that level is from Council 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 stand up in the saddle to try and again sort of are things out to try and dissipate heat if that's the mechanism we're going to think
regarding sexual dysfunction 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 ischial tuberosities are 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 ischial 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
Get this for lack of blood flow or ischemia 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 or a day for I don't get erections for that sort of a same amount of time or sometimes, you know, men just sort of you know ride through it and you know, hopefully things come back in a day or two. So that's that could be the mechanism. There are some Saddles that you
Hopefully I'll be a little safer. And you know, I think that this sort of first was noted probably around 2,000 or so, and there is a big redesign in terms of saddles and try and make them a little bit more anatomically correct to try and minimize some of this and there's you know cycle fit that can be done or saddle fit rather. They 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, you know not this doesn't happen to everybody. I would say maybe if
Were to serve a cyclist maybe twenty to thirty percent of men and women tend to be susceptible to this. So I think if you are having discomfort and when you cycle whether it be pain numbness or you notice dysfunction think certainly you should you know, think about changing saddles or think about changing writing style. There's other strategies are sometimes used but you know, absolutely something that everybody should be aware of
I meant to ask this earlier, but I seem to recall a study that Drew a
correlation between amount of walking and maybe it was sperm quality, but I think it was testosterone levels may be some other metrics of male sexual health and forgive me. I'm not recalling the details now, is there any evidence that walking more standing more maybe even using a standing desk is beneficial for you know, pelvic floor Health blood flow prostate health 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 watch that tells me bad something that I look at every day and kind of strive for and and it turns out that the more active you are. It's been shown for the 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 vertical, irr 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 obesity. In other words can we incentivize people to walk more simply on the on the promise of improved Sexual Health?
Well, I don't know your sexual health will be a different one. But we can I think there is an association between testosterone levels and
Step count 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 you earlier and then we can close the hatch on on exogenous testosterone therapy. At least for the time being. Maybe we'll come back to it is assuming that somebody can maintain adequate sperm production through the use of HCG or some other 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 banked sperm in any of had assuming that somebody takes testosterone therapy because they were prescribed that 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 increased risk of say prostate?
Sir, or other forms of cancer and here I'm going to assume that this person is keeping their their lipid levels in check like this. We hear about some hyperlipidemia with testosterone therapy is let's assume that they're taking a Statin or they're not taking a Statin 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 and they don't have to worry about sperm production because it's they're either maintaining it or it's been banked or they don't
Don't care about that. 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 check and 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 myths 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
Prizes again decades ago was awarded because it was found that when we lowered man's testosterone the prostate cancer would regress dramatically so that put that association between testosterone and prostate cancer. So then the concerned we can if we were to either replace testosterone or augment testosterone give a man testosterone. Is that going to alter his risk or increases risk? So I think we have pretty convincing data that that's not the case, you know, there's lots of longitudinal data spanning decades where if man is
And testosterone it doesn't change its risk. The reason for that in sort of seeming contradiction, you know this contradiction with being prostate cancer therapy where we lower testosterone where if you give a man testosterone doesn't change his prostate cancer risk 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 that tends to be a fairly low level that all this sort of the prostate testosterone receptors. You know, you kind of think
His have been filled. So if you were to give men 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 cancers is an
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Berman getting back to prostate health and neural innervation 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 innervation of the penis for obvious reasons, and we'll get into the specifics of those reasons in our later discussion.
Yeah, I mean, I think that you know, I always kind of think of the penis as a user to 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 if there's any reason to sort of suspect that may not be going on 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 them.
He's talking about spontaneous erections during sleep there. So and short of assigning one's partner.
R22 check frequency and tumescence. What is the way that men would know that that's happening. Are you talking about waking up with an erection? Is that requisite for knowing that nocturnal erections are occurring?
Well, I yeah, thank 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 a normal response, you know when either by yourself with a partner, I think that generally means that you are going to get normal erection. So I think I
yes, when I say use it or lose it, it doesn't mean that's really the man has to stimulate himself or kind of make sure that he does have you know adequate function because usually most of that normal function just occurs, you know with these nocturnal penile tumescence, 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 and 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 in
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 amount 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 you have to go to the bathroom often after stream is getting weaker. Those are all sort of complaints that we hear
about what is often. My understanding is that it's normal to wake up perhaps once during the night to urinate and this is of course, assuming and again forgive.
Me for all the caveats, but I've done this long enough that you know, why don't get really granular about some of this than she was a 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 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 100.
That number might be in the one to two times per night. Is that about right? Yeah. I mean, I think once the night yeah is normal for most men and then I
think if things start to bother you I think you can certainly see somebody but it's hard to get better than once or twice a night for most men.
My understanding is that there's a pretty good relationship between the nocturnal erection and the amount of REM sleep rapid eye movement sleep that one is getting to this tends to be more frequent toward morning as the proportion of rapid eye movement sleep.
Reese's I don't know if that's true or not, but I found a couple of studies that least point in that direction no pun intended. So that raises a bigger issue that we haven't talked about yet, which is getting adequate amounts of quality sleep each night. And I think for most people that 7 to 9 hours ideally 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 not working excessive hours are
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 Sexual Health.
Yeah. I mean, I think certainly there's reasonable data for semen quality and there tends to be a we call like in science sort of a u-shape relationship so that it's not sort of linear. So as you get more sleep things are better, there's sort of there's this concept of too much sleep and not enough sleep.
So the ideal I think as you pointed out as 7 to 9 hours and for men that are not getting that semen quality tends to be lower and then for men getting too much. We also see a decline and you know why that is is 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 so I think kind of getting in that ideal sleep amount is best for semen quality and probably for broad testicular function as
well. You keep bringing up semen quality in
Way that makes me wonder whether or not is semen quality of proxy for overall vitality and health or testosterone level a proxy for overall vitality and health. It sounds like semen quality is the metric that you keep coming back to in a way that after assume reflects your, you know, your clinical experience and the many papers that you've authored in this area.
I think for people that hear semen quality and who are not interested in conceiving children now or who are which of course could include people who have already had children or who don't want children semen quality sounds like something that relates to fertility but is semen 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 Mill my tell
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 measure of how healthy you are. You know, if you look at men with more health problems, they can have lower semen 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. 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
even quality may be a good barometer of Health, 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 ten percent of the male genome is devoted to reproduction. And so it makes sense given the one I have about, you know, 24,000 genes of the body that there's a lot of 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
No, sort of sign that reproduction is not perfect. There may be some other health consequences down the line 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 you know just station is sort of very critical to our you know, existence right in a perturbations to that system have prolonged, you know effects. So the so-called sort of Developmental origin of adult disease or the Barker hypothesis.
And so we know that you know premature children have higher risk of cardiovascular disease Urban studies to show that but we also know that you know, these just a tional effects can also play out on reproductive function to so that also may be kind of a link sort of early seating of reproductive function and then that's maybe the first marker that we're going to have four other health effects later on they're all so it's just sort of sort of inherent sort of similarities between reproduction and some others
Social effects so, you 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 semen quality is that you know, there's sort of factors that necessarily involve reproduction so children and having a partner and having a partner prolongs life 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 so, you know, that's another possible explanation.
Nation but I think you know really sort of this health, 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 a 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 sort of lower levels that may tell us about something else going on, you know, when when men come in from fertility evaluation is a lot of time we do diagnose, you know these new medical problems. Sometimes we diagnose cancer.
Sort of alluding to some of the questions you've asked 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 and other things so it is something I think that it's sort of it's very important I think for people to realize and it would be great. I think another I think advantage to like the Centers for Disease Control for example the to start
tracking it would it be a good idea for males?
In their 20s and 30s to get a sperm analysis to have a baseline. I confess. I'm 47. Now one thing. I wish I had done in my 20s was to get my blood hormone profiles and lipid profiles done when I was in my teens and twenties because I'd have something to compare to I started doing that in my mid-30s and I'm so glad I did because I can now compare to my mid-30s levels. I started including sperm analysis about eight years ago with the intention of freezing sperm and did that.
Because I was also reading at that time about the increased risk of autism in offspring of males older than 40 something that I really would like your take on but it seems like it's inexpensive enough to do a sperm analysis. I think now they people can get it done at home. They have male-male kits. Although I don't understand how the motility could be maintained if you're mailing your sperm back at room temperature or you know, it's heading through the post office now everyone's imagine all these sperm
Babbling through the Postal Service. It's out there out there folks. Yeah, what are your thoughts should should people invest the I think it was a couple hundred dollars to get a sperm analysis more costly to get the DNA fragmentation. Then you get up into the low thousands. 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, you know, I think sort of one of the same reasons that
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 maybe 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 they'll maybe rip reproductive difficulties, but I think just as sort of a marker
ER for Reproductive potential I think it's useful and I like you said, I think it's become a lot easier one of the Innovations in the space and the you know, somebody that you know is in the reproductive world. I think it's just really great to see sort of this influx and capital and new companies coming in the trying to just decrease the barrier to getting a seaman test used to be up to go to a lab schedule an appointment. Sometimes they would send you to a bathroom which can be uncomfortable people are doing you know, you know people do in a bathroom just next to you while you're trying to
collect so they would send them into a
Common space manometer basemap, they would even give them the quiet room with the with the red light which is 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 think that okay. Yes. I've done this. I'll just say I mean, I'm trying to normalize things related to all aspects of mental health physical health. So yeah, I just had to freeze sperm and basically they sent me to a room and I went to a university based Clinic it actually wasn't Stanford but different University and
Yeah, they put the cup through the window. They give you the cup. They they closed 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 Assumption now is that you figure it out one way or another how to provide the sample and then put the sample back through the thing and then one thing is clinics really need to work out is that any time you're walking out? You see the people processing your sample as you walk out. So there's all this this fainting.
Of you know anonymity but really it isn't there, you know because they're like see you later and you think it's great you don't you do you know that they rarely ask you questions on the way out but it's a pretty simple process overall and and I must say that the data are informative you get the you know, you get the volume number motile forward and the motile. I did opt for the DNA fragmentation data, and I just love data. So I think it's really interesting. But again, maybe this is a good time.
I'm to flag. This this set of findings. I believe that there seems to be a small but statistically significant increase in the number of autistic births do two pregnancies where the male was over 40 at the time of conception. 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
Maternal age has increased from about twenty seven and a half to about 31 and I should say this is all fathers. So birth certificate data 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 asked characteristics of the father, you know age education obviously region in the country. The child was born so we don't know, you know, what number child that was for the father we do for the mother.
They do ask you know, this is your first second third Etc child. So the father unfortunately just have data that sort of all lumped together. 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
8811 quite a span. Yeah 88 M goodness unrelated. I want an ice cream. I assume goodness. It's anonymized data, but I Levin I have to ask this. Sorry to take us on a slight tangent.
What is the average age of puberty in males in the United States
now? Yeah, so asking about I guess sort of spur Marquis Wen like sperm production begins.
So there are a lot of markers of puberty secondary sexual characteristics beard growth deepening of voices. Are they happen at different rates in different people? But yeah, thank you at what point are ya males undergoing puberty at the level of that we're talking about here.
Yes, so it's
Yeah, there has been data that we're going through puberty a little bit earlier now that we used to but it really varies. So, you know, I think it's not, you know, just like testosterone ranges between like 309 heard. That's a wide range for anybody. I think for most individuals, you know puberty is, you know, probably 12 to kind of 1516 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 when sperm production begins in boys, and it's actually
Not that simple to be able to figure that out because you know, we don't generally talk to young boys about how to masturbate 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 their sperm in there. And so generally it probably starts around 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
Of it a little bit later. Probably 14 to 16 is when probably about 70 80 percent 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 to I
think but again for your listeners, I don't want to you know have this onslaught of you know, pediatrician seeing kids that haven't, you know, when boys haven't gone through puberty by a certain age, so I think it's still
Fairly
wide let's get back to the age of the father and issues like autism. What are the data there? And this to me is a practical issue because I think if there's one obvious takeaway from our discussion today, it's that male should probably not wait until they're trying to conceive in order to assess their reproductive Health at the level of sperm quality, too.
Stas, tirone levels perhaps but at least sperm quality, but 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 1 in 50 male births, but I think it's probably more like 1 in 60 to 80 is that right? And that the age of the father is a risk factor. Yeah. I think that this gets
in sort of the larger.
You have you know how men's were received fertility. So, you know, we know that as women age fertility declines, but the oldest father a 96 so the biologic potential certainly persists. We
don't want to know how long he lived to see how long his child grow up to be. He conceived at 96 supposedly supposedly. Yeah. Well, I'm assuming he did not meet his grandchildren at least not that your grandchild of that child. So wow. How long did he live? You know, I well so
This is a man in India. It's a sort of a famous story. But supposedly he had a child. He would have that child with him on like they're waiting at a bus stop. He fell asleep a child was kidnapped that led to divorce. Oh, yeah Dreadful sort of a horrible and but the wife was also old not not that old but in her 50s, I guess so yeah,
wow tragic and and incredible story for separate reasons. Okay. I'll get my head around this.
Six-year-old conceiving a child. Okay, please continue. Yeah,
so people I think are men think that the sort of the you know, they're you know for fertile road is sort of infinite but I think that's very much not the case. So those are alluding to people have looked into risks for older father's so, you know about 100 years ago was first noticed that dwarfism or achondroplasia was more common and last born children So eventually that link was made.
And since then other conditions to so there's like these Neuropsychiatric conditions are talking about like autism is certainly one bipolar schizophrenia people have looked at and also link that with older age, you know less attainment and 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 either can be sort of different explanations, you know, one explanation for the autism Association. I'll talk about
You know some of this more genetic or computational reasons about one thing that some people say is that, you know could be sort of a hereditary trait. And so it may be that you know, men that displays some sort of autistic characteristics, you know, maybe they take a little longer to meet a partner and so it's 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
Mutational changes that occur with age I think I read a statistic and you would no more being a neuroscientist at 84 percent of the genes in our body Express somewhere on the central nervous system. That
sounds about right. Yeah. Yeah. I don't want to stamp my name to that but that sounds about right. So
it's estimated that every year we generate about to mutations in our sperm DNA so you can imagine that you know of
A 40 year old is going to have you know, 20 or 30 40 more mutations that a 20 year old. So that rate does go up and if you're just randomly sprinkling mutations, you know in you know genome that they're more likely to sort of manifest and maybe Neuropsychiatric conditions. 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 he's random mutations likely most of them will not result in any
But there can be some meaningful and so for example achondroplasia, it's due to a mutation and fibroblast growth factor receptor. 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 1 in 100 million, but it turns out this these conditions occur in about 1 and I think 30 to 50,000 or so. So they're 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 spermatogonium selection. So what this suggests is that some of these mutations that occur randomly occurring proliferation Pathways. And so it gives the sperm that contain these sort of advantages over there, 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 through screen for some of these mutations and
Here's some of these Pathways again. The longer that were exposed to wife. There's more likely to be, you know, different chemical exposures other exposures. And so people have looked at epigenetic signatures sort of these signatures that the dictate which genes are going to be expressed and which aren't and they're 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 some of these risks that we see, you know, it used to be that people thought that you know, if you're an older
Or maybe there's a lot of advantages, you know for the kids, right? Because if you're more resource, 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 they pointed out that salary often goes up with age and wisdom goes up with age. So you could imagine if you're more resource. 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. There's even there's one study that I saw that showed that if you
You look at MRIs of brains of children, just after birth. They're actually a little smaller for older father's compared to younger father's so I think there are some, you know, sort of talking about kind of neurocognitive development some of those effects and there's also been studies looking at cancer risk to so higher risk of breast cancer prostate cancer and adult children higher risk of you know, leukemia or CNS cancers in children as well. So I think the more we look the
We find out if these associations with paternal age. So I think it's something certainly be aware of I think he talking about mitigation strategies. I think sort of Education to be important for couples to try earlier individuals to try her earlier to conceive. You know, if we think it's a mutational reason I think, you know, certainly freezing sperm I think is that is a good option as well.
My understanding is that analysis of DNA fragmentation and sperm didn't does not allow for selection of the best sperm on the basis of DNA composition translated to English. What I mean is in order to tell whether or not this the DNA are mutated a sperm you have to kill the sperm basically so and since in a given pool of sperm, so to speak there will be forward motile non-motile twitchers.
twitching in place dead sperm some percentage of dead sperm motile sperm is presumably normal some small percentage, hopefully and that some might have some DNA fragmentation some might not so is the way to address this averages it what I'm hearing here is that if you haven't already had kids or if you want more kids that you might want to know about your sperm quality, I would say you do and that if you can afford it you might want to take
take a look at DNA fragmentation data, but having done this 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 if one of those is the one that successfully
Um wins the egg, so to speak 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 select or four or improve the DNA of their sperm? Not just the motility. I mean, yeah, I wish right that's sort of the Holy
Grail because I think you pointed out sort of a variant of right 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 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 and I think every all those are pretty good at telling which firm they think are better. But again, we don't have any real objective data to try and understand, you know, which were harboring something or other but I think if we understood more about this link with age or again other conditions, hopefully we would be able to stop some of this pass.
Let's get back to the prostate this incredible gland tell us about the prostate. I think we hear about the prostate we hear about prostate cancer 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 give us a you know, a catalog of things that the prostate does I'm 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
You know, how do we keep it healthy 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 and produces some of the proteins enzymes that are necessary for you know sperm to be supported in the ejaculate to kind of keep the the sperm healthy in the female reproductive
tract. So, you know, it
functions in reproduction and then basically after reproduction is done. It doesn't really serve.
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, two exits the body 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 water after 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 we stream this need to urinate urgently sometimes feeling like you're not him.
Thing all the way, so it's sort of a consequence of the prostate for being there in terms of ways that you can keep the prostate healthy. I think that there's really nothing that you necessarily you 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, 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 don't even want to go into bed drove a little dehydrated just so you can try and last the night there are some particular drinks or food.
And to be more irritating so like spicy foods acidic Foods those can sometimes irritate the lining of the bladder make you have to pee a little bit more caffeine is a diuretic. So it makes us urinate more and it also 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 Stave 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 dalla Phil Cialis low dose meaning in the neighborhood of two point five two five milligrams per day not necessarily for erectile dysfunction, but for prostate health and was somewhat surprised to learn that those drugs were actually developed first for treatment of prostate health to increase blood flow to the prostate. Is that true? And is there a good reason to
Think about taking two point five two five milligrams of tadalafil 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-controlled trial sort of a high level of evidence does show that you know, low dose of tadalafil these two and a half to five milligrams daily dosing can help with these urinary symptoms. So I think that not necessarily as a preventive measure
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 as it can help with erectile function as well.
Even at the 2.5 25 milligram dosage has interesting. Yeah my experience is that there a lot of people who would love to take pills every day. Then there seems to be a kind of binary distribution where
and here I'm just thinking about the mail stay here from because I hear from course males and females but I get a lot of questions about what can I take? What can I take? What can I take and but as you point out there's also a category of men who seem to not want to take anything not want to measure anything. I want to take anything but especially not take anything and then there's the other group and the other group somewhat surprisingly seems to be the lone the younger scuse me population, maybe grew up in the YouTube era or
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 at my high school and I went to a very good high school were it only takes one sperm which as you point out is true for IVF, but more is better. If you're trying to conceive naturally and there were discussions about communication and consent obviously super important and then they just kind of turned us loose to learn from our friends and other sources. I mean that and
Family, sometimes had the discussion sometimes didn't different families different discussions. Obviously. So very very little information nowadays. I think there's a lot more discussion about these things. And so the 20 to 40 year 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 I think
I understand correctly. You're seeing a lot of testosterone therapy that perhaps people don't need. Is that right? Well, I think it's a mixed. 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 kind of highlighted some testosterone any medication right? It's going to have some rest 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 intake not smoking getting exercise Etc.
Seems that testosterone therapy would not be the primary entry point. Like first workout 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 that they could do to promote their health. Anyway, this is observation will on my part. You're the one who's Clinic they're showing up to of question about UTIs. We hear about UTIs urinary tract infections in
I'm pretty often do men get UTIs if they're getting more than one UTI per year is that abnormal should men be examined for this bladder urethra prostate penile architecture. I know their ways that people can come in. I was reading about this prior to this episode that can ingest a die and then they can die image the whole apparatus. Is that right? That's true without having to cut anything, right?
How is that worse people doing or is that only under conditions where people are experiencing some some 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 that it should be evaluated. So women have very short urethras, but men have a very long read the right. It has to go through the entire penile urethra the prosthetic urethra up into the bladder. And so the way I urinary tract infection what happened, you know one way would be that a bacteria actually gets all the way, you know.
Can that's just a much longer track? And so if something where like that does happen, we look for an atomic causes for that. So there can be different scar tissue in the urethra. For example, there can be stones in the bladder. There can be stones in the kidney. Sometimes men are emptying their bladders all the way. So those those men should be evaluated because there can be some pathology that we could hopefully identify and correct.
Let's talk about erectile dysfunction. I put out the call for questions in anticipation of this episode and no sir.
Prize at least 30 percent of the questions from males were about erectile dysfunction or questions about what's normal in terms of libido level of interesting, right, you know and we'll deal with the first question first, but what are the most common causes of erectile dysfunction? Are they hormonal in nature? I think that's a common belief that if people are experiencing erectile dysfunction that it's because they're
Our own levels are too low hence all the interest in testosterone therapy, or are there other say blood flow related pelvic floor related neural brain to to body neural connections that are responsible. I'm guessing it's all of these things. How do we parse this and you know, 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 is sort of the inability to consistently achieve and
maintain an erection and it's fairly common, 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 fifteen to twenty percent. So this is a very common condition that we see in terms of the etiology. It can vary a little bit, you know, we used to think that they were primarily psychogenic but that was you know years
Decades ago now we know that most of them are organic. So it's actually a blood flow issue. So the most common conditions just part of nationally would be the same things that cause blood flow problems anywhere in the body so high blood pressure diabetes, you have through sclerosis anything that sort of can impair blood getting to the end organ and sometimes you know, there has been data that, you know trouble with erections can actually predate other more, you know, serious, you know vascular conditions. So the blood vessels in the penis, the penile arteries are about 1 mm, you know, and
And the heart and the brain that are much larger, so it's much easier to include a small vessel than a large vessel. So that's why there have been some studies support that is sort of an early marker for vascular disease. So I think looking at those risk factors, you know, sort of Lifestyle obesity again is another is a common one endocrine disorder is actually fairly small. It's probably less than 10 percent probably around five percent or so pelvic cancer treatment has another very common one after.
For prostate cancer whether it be radiotherapy or surgical therapy bladder cancer sometimes rectal colorectal cancer that treatment also anytime it were you know, involving some of the nerves in the vasculature and the pelvis that can also impact erectile function as well. What about
hernia? Hernia? That should be
separate so sometimes if they're you know, I always say that medicine you can never say never but you know, generally if that was going to manifest erectile function would probably be due to
To maybe some pain syndromes can rarely happen during this the early post-operative period but the blood supply the nervous supplies is
separate. So you said something very important for people to hear. So I'm going to highlight it you said that less than 10% of erectile dysfunction is due to a hormonal issue. I don't know how much time you're spending on YouTube and the internet but that is going to be a shocker for a lot of males out there because so much.
Of the discussion around testosterone is around libido and sexual function. So it's key for people to hear that. It's also key for them to know about this other 90% when you say blood flow issue then what is the common first pass for treatment? And again, forgive me for listening this off over and over but we are assuming here that people have gotten their body weight down their sleeping enough. They're not ingesting excessive alcohol. They're not smoking or vaping and not smoke.
In cannabis, we're doing the Edibles. Although maybe we should talk about Edibles and cannabis and endocrine effects will do that later doing all the things right avoiding doing the wrong things too often or at least completely. So we're assuming they're doing all that correctly. Their testosterone levels are somewhere in that 300 to 900 nanograms per deciliter range. That's typical for the so-called reference range in at least in the u.s. I think it goes up to 1200 or maybe 1400 in other countries, but
As other countries like to point out but it starts at two. No, I'm just kidding but assuming they're doing everything correctly and it's not a testosterone issue then if it's a blood flow issue meaning they haven't had treatment for some pelvic cancer.
What is the first line of treatment? Yes, assuming that
lifestyle, you know and all that has been optimized medical treatment has been optimized. There's a lot that we can do. I always tell men as long as you have a penis we can always make it hard.
So there's there's a tremendous amount. I'm sure he was the most popular doctor in your field as
long to do that. Yeah, that usually does kind of he's everybody so usually we start with oral therapy. So phosphide it phosphodiesterase inhibitor therapy, so that would be like, so then I fill our Viagra tadalafil Cialis eventful Stendra over Dennis philby.
From and would you be willing to talk about some of the specifics there? Are you is the typical thing to put people on this 2.5 25 milligrams per day low dose or to give the higher doses that are more commonly used for erectile dysfunction per se.
I think it depends we know why we're putting them on it and how much sex they have to you know on average people probably have sex, you know Carter and sex maybe once a week on average, you know, when we're looking at men and they're kind of 30s and Beyond, you know, sometimes it can be a few more.
Times a week than that, but you know if they're having sex every day are very often that sometimes a daily dose can be useful but generally most men are on just on demand because they're going to fall into that, you know, maybe about, you know, a few times a month category. So that's usually what we start and you know, there are sort of a titration that can be done. You can go slightly, you know higher doses or lower doses. So usually we start in the middle to the higher Doses and you know, we talked about some of the side effects they may have but those probably help sixty to seventy percent of men and they work
All you know in terms of another common question is how do we decide which one we're going to start sometimes insurance will tell us which one we're going to do. That's a common one, you know, all these medications tend to be somewhat similar one difference tends to be the time of onset. You know how quickly they reach Peak levels in the body. And then also how quickly they're cleared from the body. So to dowel is somewhat different and then it lasts longer the half life is about 20 hours or so, so it's sort of marketed as a weekend pill. So some people like the idea of that, you know taking a pill on
On Friday, so having some left on Saturday, but for others, you know, we start with one of the other ones
the fact that these drugs like to Del Phil also called Cialis right the office to see how it's the brand name, right? Okay and Viagra, is that a brand name? Right stands for what is the generic name? Oh, so then I feel so down my okay. So because they are effective in such a large percentage of cases. What does that say about the vascular system of all these males?
Are having erectile dysfunction, but then it's getting resolved by these drug treatments is that in other words, somebody comes into your clinic. They're having this issue. You prescribe one of these drugs they come back and say everything's working great. Or maybe they don't come back. They just, you know, send an e-mail say everything's great. But do you need to have a discussion with that person about their oval overall vascular health because a few minutes ago, you told us that the fact that they weren't getting erections due to what now appears to be
Be a vascular issue can be resolved for the penile tissue, but is it going to solve their other vascular issues or should those people be on the lookout for cerebrovascular cardiovascular disease that can potentially cause things at least as bad as erectile dysfunction or maybe worse?
Yeah. Absolutely. Well, I think they should be screened. So, you know, sometimes I'm diagnosing in the first doctor that they're seeing in a long long time. But otherwise, I do encourage them to see a primary care doctor to be screened for you know blood pressure lipid levels.
You know fasting blood glucose all those things again sort of early markers of some of these sometimes are identified sometimes not but I think it's you know, I think we kind of talked about sort of the ideal patient. That's perfect body weight. Nothing else is going on, but that's as you know, very rare entity. So usually there's something that can be done to be optimized and I don't I try not to be alarmist about this, but I do want to you know, encourage men to sort of take ownership in the health because that sometimes can improve, you know, some of these conditions. But again, we have terrific medications for four men in whom we
cannot
What are the common side effects of these drugs?
So they're basil dilators? They open up blood vessels. So we get some off-target effect. So headache facial flushing back aches like cramps indigestion nasal congestion. Those would be the most common
before the last Super Bowl. There was some press about the fact that a lot of the players were taking these drugs that low dosages before the game person will lead to increased blood flow to the muscles and brain is that aside what the rationale was I think so. Yeah, you know another we talked about sort
of how cycling met
Lead to erectile parameter sexual problems. There has been some data looking at taking like Viagra or one of these medications Cialis tadalafil before a ride again to try and increase circulation to decrease the chance of any of the negative effects of prolonged saddle
pressure. So it sounds like you just increasing blood flow and lowering blood pressure slightly is just a good thing all around. Yeah. I think they're silly about it. But yeah because
these medications were originally I think is you're alluding to or developed as a blood pressure treatment and this was sort of an amazing off-target effect that
has turned into a billion-dollar
industry. So you mentioned about 10% or less of erectile dysfunction is due to endocrine issues. Was it 60 to 70 percent can be resolved with with these blood flow enhancers. I know it's a terribly non non clinical non-scientific way to describe the Viagra Cialis to doleful Etc. What about the remaining percentage and are there other treatments that
You prescribed or given in which cases do you need to resort to I guess more invasive approaches. Yeah. So
another therapy we have is urethral suppository. So you can actually put a medication in the tip of the penis is then absorbed by the rest of the
penis also injected suppository
suppository or gel or a jelly. Yeah. So it's also a basil dilator sort of the concept is very similar. Sometimes that you know is okay for men and they tolerated it's
it's safe for partners as well. It can tingle a little bit so he definitely let men know because one of the main medications does cause like a little bit of a burn as well.
Why would somebody do this as opposed to taking the pill form of the drugs? We were just talking about
mostly efficacy would be a big one. And so this this this can sometimes help where others cannot so that's one penile injections are another common therapy. So the efficacy of penile injections are probably 80 to 90% again.
Ejecting beza dilators into the penis. So the idea is just opens up blood vessels easier to get and to keep erections. You can imagine there's a huge psychological barrier to putting a needle in your penis.
But this is something that the patients are doing for themselves at home or that you're doing. Is it long-lasting? Is that something you do at the clinic and then they come back every few weeks or so. No. Yeah. This is an on-demand treatment. So
we teach them how to do it. The first time I do it with us in clinic. Ideally, we'd try and get a reaction to last probably 20 or 30 minutes. So easily started a low dose.
And then they just increase it home until they get you know, an erection that lasts for that amount of time.
Is it injected subcutaneous or actually into the goodness the meteor tissue of the
penis that's right into the erectile bodies directly. Yeah, and they only have to inject one side. They do communicate with each other.
Most men say it's fine. It's a small it's very small gauge needle about as big as you know, a few strands of hair.
Like I haven't been appointment over in Ophthalmology and I've seen injections into the human eyeball and it is incredible how fast and how painless that procedure is when it's done by the right person. Nobody should try that at home on their own but when it's done by a sealed-off them ologist, it's just striking and here you think about needle in the eye, you know, what's worse? It's like the childhood rhyme right stick a needle in my eye so you can't think of anything worse, but maybe you know an injection of the
It sounds almost as bad but you're telling me that if patients are prescribed is that they can do this with with limited if any discomfort. Well, it does have a high dropout rate surprise their
breaths. Yeah, I think no one's excited about it. You know, it's guess the mood can sometimes be affected but a lot of couples are very comfortable with it. Again. It's very efficacious. The part of the man can do it is partner can do it. So it does work. Well
and I guess here we're sort of a sending the the list of invasiveness, right?
What what is that the sort of top tier of invasiveness for McDowell
dysfunction? So then we go on to a penile implants. So there's actually a surgical procedure we can do to put a device inside the penis that can help men be hard when they want to and that comes in sort of two main forms. There's either non inflatable or inflatable. So they're not inflatable sort of a bendable. It's you know has sort of a metal core. And so when men don't want to have sex, they bend it down when they're ready for sex. They can kind of bend it up
is really
Are on demand. Yes. Hmm. Yeah interesting.
Yeah, so it's very simple to use sort of the more. I guess kind of natural form of be the inflatable. So when you're not using it, it's deflated and then when you're ready to use it, it's inflated and you inflate it with basically a pump that's in the scrotum. So all this is sort of surgically implanted inside a man all under the skin, you know, unless you know what you're looking for and be very difficult to tell if a man has it or doesn't have it but when he's ready, he pumps it up and it moves fluid from a reservoir.
Wash from which usually is also it's also surgically implanted into the penis to get original rection.
What is the relationship between psychological arousal and direction as it relates to these Technologies? I mean the way you're describing it sounds purely mechanical right which I'm out nocturnal reactions, which I suppose people could be having an erotic dreams, but I don't think that's a prerequisite for nocturnal erections at all. Right. So is the idea that if adequate blood flow is it?
Peeved then any signal from the brain can initiate a Cascade of blood flow that creates the erection or is it the case with some of these treatments that sounds like blood flow is almost autonomous,
right? I think a lot of these you have the blood flow is not adequate and that's why we're having to you know, sort of go beyond but generally as you point out, there's different stimulation, whether it be, you know, visual tactile or factory that sort of starts that Cascade.
It releases neurotransmitters in the penis that leads to this vasodilation, you know naturally and men get erections
few years ago. I was reading about vasopressin inhalants, you know, there was a bunch of stuff hitting the market by the way. I don't suggest that people get experimental with the stuff, you know, as a neuroscientist who also knows a thing about neuro peptides and her hormones that can impact the hypothalamus. You know, I just I just cover my eyes and kind of cringe when I think about people inhaling these oppressive
You know, yeah, you know, there's a study that is a pressing increases sexual desire or something like that. But nowadays I'm reading a lot more about a really interesting peptide treatment, which I think is a FDA-approved prescription drug, which is relates to a melanocytes stimulating hormone that comes out of the medial pituitary that is used to increase sexual desire. It's prescribed for women, but men are starting to take it and it
seems to have at least from what you read on the internet a pretty profound impact on libido and on erectile frequency and persistence. Is this something that you know, you're using in your clinic. Yeah, what about these peptides that people are inhaling and injecting and some of them are taking an oral form, but most often. I think it's nasal inhalant or or it's a subcutaneous injection.
Yeah, so those are not ones that we use
in clinic but I think you know looking
at sort of just
sexual dysfunction broadly. There are a lot of things that you know, we do try and help and one of the things sort of the kind of relates to that. That is it's been a proposed treatment for it is this concept of delayed orgasm or delayed ejaculation. So I think everybody's familiar with premature ejaculation right where managed actually too quickly but on the other end of the spectrum, there's men that takes you know a long time to ejaculate and you know
know what that is is sort of defined differently, but generally most people would say like sort of two standard deviations above the average on average probably around five minutes or so two standard deviations would be kind of 20 to 25 minutes over men to take that long to ejaculate that would be considered delayed or sometimes they don't ejaculate every time that they have relations. So for those I think there is a need for treatment because there's no FDA approved therapy for that. And so that's why I think you know providers are trying some of these other, you know, more experimental things.
There's some that we use just not that one in particular. There's also some devices that have been trialed as well. But it's it's a challenge because you know certainly really feel for these men. It's one of the pleasures in life and some of them are never able to have sex or only or sorry never able to orgasm and some are only able to do it very rarely. So we do want to offer them
benefit.
What about pelvic floor Health more? Generally the topic of pelvic floor health is something that comes up more often around female reproductive health and Urology your about key goals cables cables. I don't know. I guess we'll have to ask him because it turns out he go Kegel was a person who named the exercise after himself with an eye. He did them or not. I do not know but my understanding is that kegels are a pelvic floor.
Strengthening exercise and my understanding is that some people experience urinary or sexual dysfunction because of a overly relaxed AK weak pelvic floor, but that some people have the exact same problems because of a hyper contracted AKA overly tense tight strong pelvic floor meaning don't run out and start doing kegels just because you heard about them. They're not good for everybody. They might be
Be bad for certain people but what about pelvic floor health? I mean should men be paying attention to public floor Health should men be doing pelvic floor exercises.
I mean, I think it's really key that you say that because you know, not everything you hear about is good. And I think it's not good for the right person. So there are certainly men that I see that have very just a lot of tension a lot of anxiety. Sometimes these men, you know, urinate every hour. I mean there's other things and you can just tell they're just sort of very wound up and I think for that man, you know, one of the issues you kind of alluded to as he probably needs to relax more so
Pelvic floor Physical Therapy can still benefit you because there are some just different feedback exercises that can be done to help with relaxation. So, you know any urologists office, there's usually a list a lot of different providers around the region that can help with some of these Kegel exercises though can be useful, you know, for example for like prostate cancer Rehabilitation some of these men or we're trying to kind of rebuild some of the strength or maintain or improve continents in these men. We do want to strengthen some of these muscles to so that they can sort of recreate or replace. What was lost
When the prostate was removed, so I think for the right man, they can be useful. But yeah, it could be a dangerous tool in the wrong hands
and you mentioned that if people want to learn more about pelvic floor therapy, they can contact their local urologist and find a good pelvic floor good male pelvic floor specialist. Do they tend to specialize male-female?
They're usually pretty much gender sex agnostic so they usually are able to help all
and forgive me for asking.
For an Abridged Anatomy lesson here, but could you describe the pelvic floor muscles and how they relate to the bladder prostate urethra penis Anatomy that you talked about before because I have the picture of the bladder urethra the prostate penis in my brain. No my life experience where the testes and scrotum our relatives all of that. But now I'm trying to figure out out like so the pelvic floor bunch of muscles that are attached to the
Elvis but how do they interact with those with those organs? Yeah good question. So they
sit beneath, you know the sort of in the perineum. So the area between the scrotum and the anus and back Beyond to so they basically support all the structures there. They support the base of the penis the prostates the bladder the rectum and you know there they kind of keep maintaining adequate attention to keep all those structures up. They relax when you know different functions are necessary. They're very important for ejaculation.
You know, some people think that they kind of trigger some of the orgasmic response as well, you know, sometimes men will have you no pain in that area and the perineal area can transmit to other parts of the body like the scrotum, you know, one of the 1 cause of scrotal pain and there can be many can sometimes you pelvic floor dysfunction. So I think you know again has pelvic floor therapy can be useful for sort of a constellation of symptoms again some urinary symptoms as well. So I think for some patients it can be helpful, but you know again,
There if you get things too tense that can sometimes be harmful.
So presumably these pelvic floor therapist also help people achieve a more relaxed pelvic floor if that's what they need. Exactly. Got it going to some of the questions that came back to me. When I solicited for questions and anticipation this episode several not a few let's say a couple dozen people asked about split urine stream. Is that its signature of prostate.
Growth, is that a urethral issue? Is it perfectly normal? I'm assuming here. They mean a split stream of urine that doesn't unify at any point. They're trying about a consistently split urine stream. And for those of you who don't know I'm talking about we're talking about a urine stream that's actually two urine streams and we're assuming one urethral opening because I hit the literature on this and there is a case of failure to fully fuse the urethral docked during development where people some
I'm assuming small fraction of males have a urethral opening on the base of the penis and at the tip of the penis, lets rule that out as a possibility for now, but now that it's on the table what percentage of males have that to urethral openings.
So well hypospadias mature describing where the the actual meatus is not at the tip, but it's kind of a long the proximal urethra or you know, even further down sometimes in the scrotum probably about one percent of births and usually it's recognize it.
Earth and often times it surgically corrected because better to prepare it earlier rather than later.
Okay. So ruling that out. What is the cause of split urine stream and is it a signature of a larger issue? You know, one of the reasons that we you know,
you're in a sort of from an evolutionary standpoint right is to you know, basically deposit sort of a convenient time our ways and we don't want to get it everywhere. Can we don't want to sort of label ourselves with
With smell of urine because that'll be easier for predators to be able to identify. So just similar to today. We'd like to everything to get in the toilet without creating a mess. So anytime there's turbulent flow it certainly could signal an issue. So it could be like a urethral shoes are pointing out a prosthetic issue and adequate speed, you know, getting the urine out the - so you definitely should see you know, physician to get evaluated because there's likely some issue that can be
improved.
The most popular question I received from males. However was about perhaps no surprise penis length. You're an expert in this actually not just because you're a urologist male reproductive health expert but you publish a study recently on the changing Trends in penile length. Tell us about that study. I have so many questions.
Out the methodology because I have to assume this didn't involve self-report, right that was were excluded. Yeah. Yeah. So lying was excluded specious here. But yeah, how was this study done? I mean pretty incredible study and the results are I don't know if they're surprising or not. I first I thought oh, this is surprising but the results were only surprising in light of what you were talking about earlier about sperm and testosterone levels.
I think I'll let you describe the study now rather than giving people the punchline here. Yeah. So I mean the origin was that we were
looking at we wanted to know average lengths for another project that we were doing and you know going down the rabbit hole. This has been reported for decades, you know, there's different reasons that people have reported penile length. You know, that sometimes they do it just on volunteers again to sort of get the average length of a different populations. Sometimes it's done pre and post surgically to try and understand what changes would occur. So we
Just sort of cold the literature found data on 55,000 men all over the world and wanted to see if there is a you know sort of a Time pattern with that and similar to your hypothesis. We assume based on all the other data that we would likely see a decline, you know, whether it be chemical environmental exposure. But if nothing else if we're getting bigger, you know,
the functional penile length should
decline because you know, the suprapubic fat pad will get a little bit bigger and so we'll kind of lose peanut length with that and so much to our
surprise the suprapubic fat pad scuse
me being the pad of fat directly over the penis.
Right? Right. And so, you know, if that gets bigger that will necessarily compromise penile length, but you know, as you alluded to we found is actually the opposite that the penises were getting getting longer with time. So how its measured measured differently. So one of our inclusion criteria was that all the studies had have measured sort of in an office sort of in a clinical setting. So whether it be a you know, a clinician or whether it be a researcher that actually did it. So there's different ways. You can measure penis you can just do a straight.
Length, so you kind of stretch it up as much as you can and then you sort of a ruler to measure how long it is again from deep as you can get, you know, the pubic bone ideally up to the tip of the the
glands or the okay guys. So here's what he's describing. He's talking about measuring from the top not on the bottom believe not people ask questions about this my daughter made that joke, actually. Oh, yeah measuring from the top not from the bottom. No cheating talk about stretching. The penis wallets flaccid presumably and then measuring
I'm from essentially contact with a location that's contact with the pubic bone to the the tip, right? Okay, so that that length was recorded in 50,000 men. Hmm. Wow.
Yeah, so that was one and then we also looked at a wrecked length. And so there's different ways that interaction can be achieved sort of in a clinical setting. So one is you could ask a man to stimulate himself and then measure so that was some of the studies and then the other method as we alluded to earlier as you could inject the man with the medicine to give them an erection and then
And did 50,000 men participate in that aspect of the
study was less. That was that think that was about probably 10 to 15,000 men.
I have to wonder whether or not it's easier difficult for people to recruit subjects for these studies. I don't know I could see it going both ways.
Yeah, some of the studies actually had a tremendous number had about 15,000 men some individual studies contribute to that and actually interesting after we published that there were some men that volunteered for the next setting to be measured.
I'm sure you'll hear from some of them after this episode. What was the major finding?
So the major finding we wanted to do is just give normative data. We found that it varied around the world So based on different regions the average lengths, you know varied a little bit but generally on average erect penis is probably in about five to six inches somewhere in that neighborhood. So that was kind of the take-home. We want the average the average for
rec length. Did you publish the full distributions?
We did not think we were weird.
Our plan was actually to make a follow-on study. So we could show everybody, you know, I guess probably they were interested where they kind of fell on the graph but it was fairly, you know, it was normally
distributed. Yeah, we think that despite the, you know, the wide availability of pornography that that the distributions like the Scatter Plots of them. All the data would be interesting to men for the same reason that the testosterone by function of age data.
To published as a scatter plot in that textbook. I referred to earlier right? We're interesting because the scatterplot distributions. I feel like point to other takeaways that one can be in their 70s and have testosterone levels equivalent to a male and healthy male in his 30s. That one can be in their 30s and have testosterone levels that are twice as much or half as much as age matched cohort this kind of thing. I think there's value in that. So what
What other takeaways arrived with the data from the penis length study that perhaps we didn't we didn't hear about like what did you find most interesting about about the
data? Well that there was any change over time, you know, this is a fairly short study was probably about 30 years or so, but we did find that penile length has been increasing over time. So, you know that was just sort of fascinating that we would see sort of in such a short interval of time that there would be a change number one, but that we'd see a lengthening number two, so, you know again,
In similar to the concerns arose for these relatively short period of time where you would see changes in semen quality, you know, it suggests something sinister, right? It's unlikely to be genetic change because that would take you know centuries probably certainly several generations of the fact that this happened so quickly was just surprising
this brings to mind some of work that I was involved in years ago when I was a master student, I studied early organizing effects of hormones on
add the brain and body and I'm sure this has been updated since then, but my recollection is that during embryonic development males are exposed to a certain amount of dihydrotestosterone not testosterone to dihydrotestosterone which organizes the brain male as they used to say now the the the verbage around that would probably be a little bit different but the idea is that
males are born with penile tissue, of course, but then it's during puberty that the same hormone dihydrotestosterone then exerts an activating effects on the genitals and the genitals grow during puberty penis length increases. So assuming that the study that you did was on males post puberty, right assuming it was then it would imply that something is changing about the levels or the signaling related to dihydrotestosterone.
Strong how could that happen? Do we have any ideas about what might be happening? I mean this is the opposite of environmental endocrine disruptors preventing sperm from being as you know, high quality and numerous as they could be or for, you know, or environmental factors, either in utero or post utero suppressing testosterone levels here. We're talking about the opposite effect. We're talking about dihydrotestosterone levels presumably being higher in males over the last 30 years and thereby longer.
Penises,
right? So I mean I think there's different conjectures that you can make about why this could happen. I mean, it could be maybe endocrine disrupting chemicals, you know in utero some early exposure, you know that some of the mothers had to kind of androgenic effects during the male programming window that may have led to some longer lengths another hypothesis. We had is that if if males are going through puberty earlier, the earlier one goes through puberty, the longer length tends to be so maybe that provides sort of this Lincoln.
So earlier puberty,
Tends to be longer but potentially means longer duration exposure to dihydrotestosterone longer penises, right? Yeah, you may be surprised to know to know you might not be surprised to know that there is a subculture online. I know because they contacted me and anticipation of this episode post pubertal males who take a combination of dihydrotestosterone and low levels of
growth hormone in efforts to try and increase their penile length and the ones taking dihydrotestosterone. They're not taking pure DHT. They're taking things like oxandrolone which very closely mimics the structure of DHT they report some success fortunately. They did not send me pictures. Otherwise, I would have just forwarded them to you for your next study, but this stuff is happening in post pubertal male, so
It all rests on this dihydrotestosterone hypothesis. Just a point of Interest. Yeah, I don't
know it just physiologically. It doesn't make sense by that would work as you're cleaning up close pubertal and them unless they're doing other things, you know, some sort of stretching exercises or called joking. But yeah, I would not recommend that
thank you. That was the response I was looking for so that Community will be listening with open ears. Don't do it.
As long as we're talking about DHT dihydrotestosterone, it's only fair to discuss the drugs that many people take to suppress dihydrotestosterone in hopes to keep or grow their hair things like finasteride due to asteroid. Some may be many not all people who take these drugs particularly in oral form experience sexual dysfunction issues.
And other issues related to suppressing DHT that said my understanding is that these drugs are also quite useful maybe even life-saving in some cases for staving off certain forms of prostate cancer. What are your thoughts about finasteride to test ride? Do you see people coming into your clinic who are having sexual dysfunction or other types of issues because of their hair or attempt to maintain or grow their hair issues and equally
That we talked about so called post finasteride syndrome. I got a lot of questions about post finasteride syndrome because I'll describe it in a couple of minutes. It sounds pretty devastating for these people's lives and I'll explain why it's so devastating for them in a moment. But what about finasteride you task dried in these drugs that are effectively DHT blockers DHT levels if they get too high indeed can miniaturize the hair follicle cause people to lose their
her hair typically up front or in the back so called crown or whatever, you know, widow's peak or everywhere in some cases. It also induces hair growth on the back beard growth as we understand but then people go and take these drugs to try and maintain or grow their hair and oftentimes they have erectile dysfunction or other issues. Is that surprising to you, you know, I think the men that we see views on these
side effects are tend to be you know, younger men in their 20s 30s and 40s and they take it as you're pointing out for hair loss.
So before it was FDA approved for that indication at least finasteride was they did randomized controlled trials to look and one of the other things that we will talk about too is just reproductive effects. So they did, you know, lots of studies to see if there were changes in semen quality, you know for men on finasteride versus the placebo and there were some very subtle changes but you know sort of in post-marketing now, we see these patients in clinic, you know, everybody to enroll in these studies had normal functions. I think that's sort of important to understand and obviously that's not
life right there people come in with sort of different baselines and different amounts of reserved. And so we now know that there's probably people that are a lot more sensitive to these medications than others. And so there are some men that drop their sperm counts dramatically and usually if we are we stop these medications their sperm counts can recover and use this format agentic cycle is probably about two to three months. So usually in maybe three to six months, we usually see recovery for most men but similarly for you know sexual function. I certainly, you know have a number of patients. You know that
Complain of low libido erectile function this post finasteride syndrome, you know in the mechanisms, I think are less certain because you know measuring testosterone levels, which we do, you know, some kinds of androgens are low or even if anderton seem to be in the maybe normal range or low normal range will try and increase testosterone through a variety of means testosterone clomiphene. Sometimes will give it helps some men but not also I think the exact mechanism of what is going on here. What is changing? I think we need more, you know.
No, more understanding about the exact sort of path of physiology, you know for neurochemically.
It seems like a pretty serious trade-off to either maintain grow hair or lose sexual function. I mean, I talked about DHT and some of these side effects have finasteride you test ride on previous episodes and you know, I'm not a clinician but my encouragement is always for people to approach these drugs with a real level of seriousness if not caution.
The post finasteride syndrome was described in these online questions as seemingly permanent, even though people had ceased to take finasteride and or do test drive. So in other words, they were taking the stuff. They don't know how they felt while they were on it, but they stopped taking it and the sexual dysfunction issues don't seem to be resolving does that mean they should go see you or another male urologist reproductive Health bone specialist. Yeah, I mean oftentimes
They do for you know these complaints,
you know, they start to notice it when they're on the medication then when they usually through online research kind of learn about this potential entity. Sometimes they discontinued now some men do have resolution when they stopped but there is this permanent since some handful of men, you know, they've done MRI imaging to try and understand sort of more anatomically or functionally what exactly is going on. I think there's still a lot of unknowns about it, but it can be permanent for some so they come in, you know, and they see me in clinic.
This function low libido and then we go down all the host of treatments that we talked about in the evaluations that we talked about again, we have resolution and sound but there are some that seem treatment
refractory yikes. That's my only response. I mean permanent effects on Sexual Health in it as a consequence of an attempt to maintain one's hair. I mean this is where you know in all seriousness. It just sounds like something that people need to think very seriously about because as I understand,
There's nothing that can predict whether or not someone will have.
Post finasteride syndrome, right and I did a bit of reading on this within the scientific journals as well. There isn't a lot of information as you point out because it's a fairly recent phenomenon that highlights a different issue. This may be the first time in history where young males are taking finasteride and do test ride and that might be the cause of the place finasteride syndrome, right? I think you alluded to this earlier right? These drugs have proven to be very beneficial for
Older men treating prostate issues exactly. Yeah, right. So this is a post finasteride syndrome. I think falls under the category of medical conditions that you know a few years ago. We would hear the same about chronic fatigue syndrome. Even fibromyalgia. Not long ago was considered one of these. Oh, is it all psychosomatic issue now, we now clearly know that's not the case for fibromyalgia, by the way, but I can recall a time not that long ago when people in the medical profession
Session kind of like oh, yeah this I don't know if this is a real thing but post finasteride syndrome sounds certainly real for the people that are suffering from it. Exactly. Yeah. Okay. Well, the reason I'm spending so much time on this is that I get a lot of questions about it and they're clearly a lot of young males who take finasteride or do test rider or thinking of doing that for cosmetic reasons, and I think they should be aware of the potentially serious consequences. Yeah Green. Yeah, but you did say earlier that if someone has a penis you can get it hard.
So so all is not lost even for these posts finasteride syndromes individual good. Okay. Well hold you that you mentioned clomiphene. Could you explain what clomiphene is and what it's used for because again, we want this discussion to be centered around the real science the real medicine, but there is a growing kind of sub community of people out there who are saying okay testosterone therapy can cause this these sperm
suppressive issues and perhaps some other issues but doing nothing might not be an option for somebody who wants to increase their whatever libido other aspects of Androgen function. And so there are a growing number of people out there who are taking clomiphene only in order to presumably increase testosterone, but my understanding is that it would impact the estrogen pathway as well. Yeah, what's clomiphene? What are your thoughts about people using clomiphene?
Sort of off-label Simply to increase androgens seems sketchy to me for reasons related to changes in neural circuits, but you'll tell us how it works. Yeah. Well, thank you for including
the off-label disclosure any time I talk about this. I always have to say say that but if so clomiphene is a selective estrogen receptor modulator. So basically it blocks estrogen and so from our earlier discussions of how the pituitary works, you know, there's sort of an elaborate feedback loop between the pituitary and the gonads
as in the man the testes and so what happens is, you know, FSH LH C is going to add a troponin stimulate the testicle to make sperm and testosterone testosterones peripherally converted to estrogen and that feeds back on the hypothalamus to stop that. So again, you don't get an overproduction. So by blocking the estrogen receptor the level of to a terrier the hypothalamus it'll stop that and so the idea behind blocking that as a you'll get more production of FSH LH more of these drivers, so you get more testosterone you get higher
Another testicle,
you know the hope is that for fertility that sometimes it can improve sperm production to and there's some limited data that can help but I think is you're alluding to it's sort of a way to just augment your body's own production of testosterone. So it certainly does that. I think there's no question that testosterone levels do rise. I think that the reason that doesn't always help is because not every problem is solved by testosterone kind of talked about someone in this discussion, but also that, you know, you do need some estrogenic signaling as well and so by blocking
That even partially because there's also some partial Agonist effects of clomiphene as well. It may limit it and you know, it turns out that estrogen certainly is important for a lot of things is important for you know bone health but sexual health to it's important for libido, so that may be partially blunting some of the hope for benefits of testosterone. I found that men tend to be happier on testosterone than some of these other forms and that could be a possible explanation but one of the advantage of clomiphene if we are thinking about this as a treatment for low testosterone,
Going out of them is that it doesn't have the same toxic effects on sperm production. So by maintaining the body's own production of testosterone by maintaining production of FSH LH will continue to get sperm production. So for this reproductive age, man that has low testosterone and symptomatic low testosterone, you know load tells, you know, low energy levels sex drive mood sleep problems. It can be a worthwhile treatment and it does help a lot of men but not everybody.
I've always been curious why if the goal is to increase sperm production that the most common treatment is HCG human chorionic gonadotropin because as you mentioned earlier luteinizing hormone and FSH follicle stimulating hormone are deployed from the pituitary and travel to the testes where they stimulate testosterone production and sperm production, but it's the FSH specifically that encourages sperm production.
So why wouldn't a man who's taking maybe testosterone therapy or who perhaps just wants increased sperm count and quality take FSH instead of human chorionic gonadotropin, which is more or less a proxy for luteinizing hormone.
That's a really good question. And so what FSH does like you said is it stimulates sperm production? So it seems like it'd be a much more logical treatment and actually in randomized placebo-controlled Trials. It does do that. So one of the reasons not it does do that. Let's help okay.
So it's beneficial and we should we should give it more but one of the reasons that we don't is cost. So it's rarely covered by insurance and HCG a month of that is in the hundreds of dollars. So let's say like three to five hundred dollars but a month of sort of therapeutic FSH is probably two to three thousand dollars. So that cost is really limiting. It takes two to three months to make a sperm. So, you know men often have to be what have to be on it for several months, but there is reasonable data that would help and it does make you know, a lot more sense that that should be given is adjuvant.
Testosterone rather than HCG but HUD doesn't work. You know sort of everyone's surprised. It does actually help. But yeah, I agree there is sort of a contradiction there. So if the price came down and doesn't, you know, this is another off-label medication for that indication. It would be it could be worthwhile
one hormone that we haven't discussed is Prolactin. I'm familiar with prolactin from a variety of perspectives, but I always think of dopamine and prolactin is kind of a seesaw relationship do
open means up prolactin is down, you know don't mean he's elevated with sexual desire sexual activity post ejaculation prolactin goes up SATs, perhaps the refractory period on erection and ejaculation for some period of time and then dopamine comes back out but you know this kind of thing and I realized that's far too simplistic that prolactin is doing many things in the brain and body besides that but how often do you see hyperprolactinemia has I don't know if plural pearly Mia's is as clinically correct, but
Elevated levels of prolactin that are causing problems for men what are some of the Tell-Tale signs of that and this I'd like to use as a segue to talking about some of the sexual dysfunction that is commonly discussed around the use of ssris and other other drugs to treat depression and mental health issues that sometimes create endocrine and or sexual health issues. Yeah. So prolactin
is sometimes
as we it's a diagnosis hyperprolactinemia. It's a diagnosis make it not that many times. I would say, you know less than one percent of the patients that we see will end up having that but usually it's a handful of times a year because you know, we see a lot of patients. Typically the telltale's word of symptoms would be ones of low testosterone. That's a common one. But you know in my practice I see it a lot with me with very low sperm production. So I've diagnosed several prolactin secreting tumors and the manifestation of that was they weren't getting pregnant. We checked the
How is very low you know that mandates a check of testosterone, which is also very low and then that leads to a prolactin which is very high. And then that that was diagnosed. So it's something I think to be aware of but I don't know that there's not usually a lot of symptoms and sort of going to a clinician when you're having sexual dysfunction symptoms low testosterone or fertility problems will usually be able to diagnose it if its present
are there any other hormones in the in the galaxy of sexual health related hormones?
That fall into you know Common clinical practice for you. I check estrogen as well. So I think that's another one is
again because of the relationship with obesity. I think that can be important. Sometimes there's too much aromatization. And so sometimes that can be a problem. I think you just like we talked about normal as yours and certainly is important I think to much can be bad. So there are some men where we do see manifestations that it can manifest as gynecomastia in some cases male breast tissue no breast tissue
Young.
As I was told what was it that the male breast tissue is sort of like the appendix it's there but it's not very interesting.
Right? Yeah, everybody has some and we just don't want the growth to get out of
control. Could you tell us about one of the world's most difficult to pronounce words, which is varicocele. Yes so varicocele, it's a very
common condition probably about 15 percent of all men have it and it's a very common cause of infertility if you look at all the ideologies of can be 30 to 40.
Percent so basically what it is is dilated veins in the scrotum. So obviously we need veins to get blood out of the testicles, but sometimes it can be a little larger than average and there's sort of a normal for the thermal regulation. So if the veins get too big and start to warm up the test School the other thought is that it doesn't adequately clear some of the metabolites. So exactly the path of physiology is, you know, somewhat debated but I think those probably contribute and it's something that everybody should be evaluated for if you're concerned about fertility. So again, we see it very commonly.
You know given the fact that a lot of men have about one in seven men have it doesn't always cause a problem but maybe about 20 to 25 percent of the time. It does so mental manifest with low sperm counts. We see sometimes discomfort, you know ache worse the end of the day then the beginning or is it activity anytime blood can pool. Sometimes it stretches and some men feel that and then in kids, sometimes it can lead to either stunted testicular growth or shrinkage of the testicle. It's also thought to be a progressive Legion. So the longer man, has it the more damage it can do.
Do it usually manifests around puberty in general. So it's not a concern for everybody. But I think certainly of couples are having difficulty conceiving your having discomfort in the area and you have one it's a discussion you should
have
About Peyronie's disease. Yes. The pepperoni is a scarring of the penis which leads to curvature or deformity.
So the way erections work is everything swells and you can imagine if there's a scar tissue. It doesn't swell symmetrically. So you get like a curvature deviation. Sometimes you can get an hourglass or sort of them banding. If you look it up on the internet, you can see, you know, a host of different deformities that men get it probably president about 5 to 10% of men. So it's very common. Sometimes it could be from injury, you know from
You know, like a penile fracture other, you know sort of less severe form of injury to the penis. Sometimes men are described hitting it on different things. Potentially that could lead to it. Sometimes it can manifest after prostate cancer surgery or other kind of surgery which can you know, sort of stun the penis or injure some of the nerves to the penis. So that's another condition. We see commonly, you know, obviously it can lead to bother you know, and directions are not straight I can.
Just you know, cause you know psychologic bothered amend it can also physically make it difficult for a man to have sex. You know, sometimes it can limit certain positions. That's another common complaint. We see I think it's something that men should be aware of there's now awareness campaigns. Now, there's an FDA-approved medicine for it collagenase cause I flex which is a medicine that is all Scar Tissue. So that's one of the treatments we have for there's also, you know different devices sort of stretching devices where we try and just mechanically
Remodel the penis to allow it to be a little bit straighter and then there's also surgical options to so there's a lot we can do. I always tell men again plenty of penis we can make it we can make it hard but we can also make it
straight. I'm wondering why in the study about penis length testicular size and volume wasn't also measured and and that's something that we haven't discussed. What is the relationship between testicular size and volume and some of the other parameters?
As we've been talking about and maybe this is also a good time to highlight any kind of morphological signals that would warrant people coming to the clinic so asymmetry and testicle size for instance changes in testicular size. Obviously a pea sized lump. They taught us in high schools a warning sign of potential testicular tumor cancer. Yeah. We didn't really talk about testicles.
Yeah, so I think that yeah kind of being aware, you know, the average size of a testicle for a man has about you know, sort of about a walnut. So it's about 16 to 20 CCS. Usually if you're going to measure it would be about four to four and a half centimeters and longest axis to give you know, your listeners or viewers at some idea if it changes certainly let people know if you feel anything let people know Although our national guidelines on screening practices recommends against
regular testicular self exams interestingly because I think the concern is that it leads to more anxiety than cancers that it would diagnose but I think you know, I always tell men no one knows your scrotum better than you. So if you identify, you know problem you should bring it to attention. So, you know, the classic appearance or the way that a test is cancer and manifest is a firm painless mass that you kind of feel coming from the testicle
find it interesting that at least as I understand women are encouraged to do regular self.
Sam's of their breasts for for lumps of but you're telling me that men are actually discouraged from doing regular exams of their testicles for lumps. They could be cancer that feels like a unfair asymmetry it does. I mean Cancer I mean both both seem very important. Oh, yeah. Well, I think there's no question. Obviously. I'm very biased. Yeah, and I was trying to say it so you didn't have to write. Oh, yeah. I don't want to get in trouble with the US preventive service task for anyone.
So I'm surprised that they discourage self-exam but is it because men are getting it wrong? They're coming into the clinic thinking they have testicular cancer and then most of the time they don't
I think that's the concern that you know, the number of cancers that are diagnosed versus the false, you know, the false, you know lumps that they identify just lead to more anxiety and of not actually causing more harm than good. I think is the concern but yeah, it was a surprising recommendation.
Came down usually patients asked about it. I certainly don't discourage them from doing these exams and I have we've certainly identified cancers through that means
before well. I saw the episode of er where the guy was having trouble breathing when he was an elite Runner and it turned out he had testicular cancer and he had overlooked a lump on his testicle. So I'm going to continue to self screen. Okay fair enough numerous times today. We've talked about the potential benefit of getting a blood test for hormone profiles lipid profiles and other things as well as a sperm analysis.
My understanding is that one can only do that. If they have the disposable income to elect to do that through some commercial online service. But is there any way that patients who have insurance can approach their physician in a way that this would be covered by insurance? I don't want to get you into any trouble here. But you know, it's always such a shame. It is such a shame when we're talking about something. That is really
Pervasively related to health as a sexual health reproductive health and people are not aware of a protential problem in the present or in the future that could have been mitigated simply because they didn't get a blood test or do something as simple as a sperm analysis. So we can't be presumptuous in saying oh, you know to two hundred dollars or a thousand dollars. No big deal. I mean for a lot of people that's a huge deal. It's prohibitive for many people.
Well, so how can people get the stuff assess should they talk to their primary care physician? Should they call a urologist? What's the best approach? Yeah, I think both are good strategies. I
think you know insurance is becoming a lot more open to covering some infertility at least testing sometimes treatment as well. So I think a lot of insurance does cover that now yes, sometimes we check semen analysis for other jacket or a issues but I think that you know again is more of this data gets out. I think is more recognition how important the mail.
As I think we'll get sort of more buying coverage. Obviously women have you know, the automatic feedback of auditory Cycles? So they kind of know if there's a problem they can bring that to the attention but men don't have that feedback without some of these testing.
Yeah, and we probably should have mentioned this earlier. So forgive me I this was on me to mention that when we talk about sperm quality and we sort of shifted back and forth to semen quality. It's possible to have normal semen volume and have very low sperm count right? We're not
about the total amount of ejaculate per say we're talking about the density of forwardly motile healthy, non-dna fragmented sperm in that semen, right? So in other words, it's not sufficient to just assume because you can ejaculate that your sperm are healthy.
That's exactly right. Yeah. I mean, I think you know about 15% of men have low semen quality whether it be concentration movement shape about one percent of men have no sperm in the ejaculate and that's something sometimes they have new idea about so the only way to know what
Actually do a
formal test. Well, I'm encouraging people to get these parameters assessed and I'm making that statement because it's very clear based on everything that you've told us today that sperm quality and hormone levels are just so so important not just for sexual health, but for urinary health and for reflecting prostate health and other aspects of whole body health and and Sexual Health relates directly to Mental Health
I know we didn't talk so much about the psychogenic issues. But the two go hand-in-hand exam. I want to thank you so much for coming here today and sharing so much knowledge with us. I mean, these really are the issues that males think about and wonder about and have questions about and they do so to varying degrees depending on where they're at in life, but I think especially for younger men who are hearing this
We're not at the point where they want to conceive. It's really important to start thinking about these issues for all the reasons you mentioned. I think these issues are really important for women to know about as well. Just as it's important for men to understand female reproductive health and and to not just improve communication, but this after all is at the heart of the presence in proliferation of our species, so thanks for taking care of the male half and and thanks for doing the work you do. It's incredible.
A large-scale studies, the more detailed studies the on smaller populations the you ask the questions that it seems many people are just afraid to ask and Annie get right in there and come out with the the really rigorous data and answer. So, thank you so much for what you do. My
pleasure. Thank you. Thank you for highlighting men's reproductive
health.
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