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

welcome to the huberman Lab podcast where we discuss science and science-based tools for everyday [Music] life I'm Andrew huberman and I'm a professor of neurobiology and Opthalmology at Stanford School of Medicine my guest today is Dr Michael Eisenberg Dr Michael Eisenberg is a medical doctor specializing in urology and an expert in male sexual function and fertility he is both a clinician who sees patients as well as a research scientist having published over 300 peer-reviewed articles on male sexual function Urology and fertility and he is considered one of the world's foremost experts in male sexual health today we discuss a broad range of topics important to all men including erectile dysfunction and function we also discuss prostate health and urinary Health we discuss fertility and sperm count we discuss even topics seemingly esoteric such as why penile lengths are actually increasing over time while sperm count seem to be decreasing today you'll also learn some very interesting surprises such as the fact that a very very small percentage of erectile dysfunction actually stems from hormone dysfunction rather the vast majority of erectile dysfunction stems from issues that are either vascular that is related to blood flow or neural and today you'll learn about a large variety of treatments for erectile dysfunction Dr Eisenberg also dispels a lot of common myths that you hear out there both on the internet and in popular culture that relate to male sexual health and function by the end of today's episode I assure you that you will have a thorough understanding of what male sexual health is how it relates to other aspects of health and how to think about treating maintaining and improving all aspects of male sexual health fertility and function before we begin I'd like to emphasize that this podcast is separate from my teaching and research roles at Stanford it is however part of my desire and effort to bring zero cost to Consumer information about science and science related tools TOS to the general public in keeping with that theme I'd like to thank the sponsors of today's podcast our first sponsor is Roa Roa makes eyeglasses and sunglasses that are of the absolute highest quality the company was founded by two All-American swimmers from Stanford and everything about Roa 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 Roa understands this and as design I glasses both for sport and for wearing in casual settings or to work or to dinner that always allow you to see with Crystal Clarity their eyeg glasses are extremely lightweight and they won't slip off your face even if you get sweaty I wear Roa sunglasses when I'm driving into direct sunlight or when it's particularly bright during the middle of the day if you'd like to try Roa eyeglasses or sunglasses go to Roa that's r.com and enter the code huberman to save 20% off your first order again that's Roa r.com and enter the code huberman at checkout today's episode is also brought To Us by eight sleep eight sleep makes Smart mattress covers with cooling Heating and sleep tracking capacity I've spoken many times before in this podcast about the fact that getting a great night's sleep really is the foundation of mental health physical health and performance one of the key things to getting a great night's sleep is to make sure that the temperature of your sleeping environment is correct and that's because in order to fall and stay deeply asleep your body temperature actually has to drop by about 1 to 3° and in order to wake up feeling refreshed and energized your body temperature actually has to increase by about 1 to 3° with eight sleep you can program the temperature of your sleeping environment in the beginning middle and end of your night it has a 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about diminishing quality of environment people intelligence you know there's a lot woven into this statement that sperm quality is declining and some of it I think people assume is related to environmental changes some of it I think people assume it are related to changes in Behavior so maybe less exercise less sunlight who knows hopefully you'll tell us what's really going on but the first question I have is is sperm quality actually declining and regardless what is sperm quality yeah great question so I think it's very controversial I think as your question alludes to so I think we'll start by just talking about what sperm quality is and why it's important so for reproduction as you've covered on the podcast before a man makes semen uh and that has sperm in it and so when we're talking clinically about a semen analysis there's a few things we look at we look at the amount of ejaculate semen that comes out we look at the sperm how many there are we look at their motility or Movement we look at their morphology or shape there's some more advanced testing that's done in rare cases looking at like fragmentation of DNA for example or there's some newer tests looking at epigenetic profiles of sperm uh but essentially these are all markers or fertility so fertility in itself is a team sport right so it's hard to you know make label a man as fertile or not fertile without knowing about his partner um but nevertheless based on different these different parameters we try and quantify How likely a man is to be able to achieve a pregnancy so the World Health Organization every decade or so looks over the existing literature and defines these different cut points of what's normal or what's subfertile uh for those levels so that's sort of the backdrop of what Seaman is and how you know these these tests are done or you know what these tests represent now the question of whether they've declined over time um has been you know a question for a number of years there was a landmark paper in the early 90s by Carlson and a group in Denmark that showed this temporal decline you know over the last 50 years from that time point and so what the investigators had done is looked over the literature for studies that reported semen quality around the world and noted that you know the quality in the earliest studies like in kind of the mid uh 20th century were here and then over time they had sort of declined the more recent studies um now that study was very controversial there was questions about waiting from different studies putting because you can imagine these there's not a lot of early studies so putting a lot more importance on those rather than some of the later ones um and so since then there's been many other studies that have that have come out in time and even today it remains very controversial I think you know if I were to say that I believe there's a decline some of my colleagues and friends would be very upset with me if I say I don't believe it some of my colleagues and friends would be very upset with me so I would say that you know my opinion really varies based on Whose paper I've read and I there's some very convincing you know studies uh on each side of it you know there most recently just in the last year or so there was a meta analysis of you know tens of thousands of men where they looked at again a host of these studies over the last uh number of decades all around the globe so prior studies to really just focused on the Western Hemisphere Western countries CU there was more data from that but more recently we've gotten a lot of data from Africa from Asian countries as well uh and those also support this decline um so you know one of the counterarguments to why we're seeing that is just sort of an evolution of techniques over time um so that's one of the the sort of the popular um questions about whether there's really a true decline um you know I think as you're alluding to why there would be a is also you know unknown and but you've sort of labeled you know perfectly the kind of most common hypotheses so whether there's some environmental exposures right 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 pre-clinical studies so you know mostly done in animals uh that show that like exposure to different chemicals phalates um or BPA other things may actually harm you know reproductive function for men and for women as well uh and so it may be that you know these chemicals you know that are that we're being exposed to as kids and adults or even probably um more sinisterly when we're um you know kind of developing in utero that may be kind of the most harmful exposure um but there's also been you know an obesity epidemic as well and there's a strong link between a men man's reproductive function um and body weight and so that's also um thought to play a role in some of this too um so I think there are convincing studies but the other I guess aspect to this is that there's variations in SE quality around the country and around the world there's Geographic variation and so that's also sort of an unknown um uh explanation uh you know there could be different sort of genetic you know compositions of men and so there's different reproductive potential in that Source there could be different environmental exposures diet exercise lifestyle and there's a famous study um done a number of years ago where they looked at se in equality among fathers so these are men that had achieved a pregnancy and at the first you know prenatal visit they had um the fathers give a seaman sample and so this was done four centers around the country I think it one in California there was um think one in the midwest uh there was one in New York so they basically found that steam in quality was sort of highest in the urban centers in New York tended to be the highest numbers where it was was you know lower in the Midwest and so the hypothesis was potentially because it was a more rural setting maybe there was pesticide exposure and that had led to these lower numbers but you know another equally plausible explanation may be that you know they different sort of a different population and maybe you know that that could explain these differences so I think it's it's you know very important um and I think you know one of the sort of lacking things in this is there's not really longitudinal data one of the greatest things would be if we just started tracking um seen quality around the country just like we do obesity like you know n Hayes cdc's uh survey of Health in in the us if we added semen quality onto that that way you could really see you know how it varries around the country and you know sort of compare like to like to see over time if there's really this progression you know one of the only studies to do that in Denmark um that started around you know around 2000 and tracked Sean quality among um you know volunteers that came in when they were conscripted for military service in Denmark they were offered the opportunity to participate in this study um and so some men did and what they found is actually that seam quality was fairly uniform over about 20 years where they had data but sort of another very interesting part of that study is that only about a quarter of those men had normal seam quality um so sort of very concerning you know it was I guess reassuring that it wasn't further declining but very concerning that only a quarter of Danish men had you know normal Seamon quality and they're one of the I think thought leaders in this field um just because sort of a reproductive crisis there you mentioned that some of this apparent decline in seaming quality might be related to the fact that the tools to measure seaming quality are getting better and better and that would make sense if for instance one is just looking at total volume morphology which means shape I should have clarified that um how many forwardly motile sperm there are and then also adding in you know a very sensitive measure such as um DNA fragmentation you know essentially as the instruments get finer and finer you discover more and more details and if you are um rating quality along a number of different dimensions then it would make sense that those would tear out into different levels so if one were to Simply ask for couples who want to get pregnant and assuming that egg quality is not the issue what percentage of failures to achieve successful pregnancy are the consequence of deficient sperm deficient in any way and is that number increasing over time yeah so I think that's really key I think when couples think about fertility usually it's thought of as a female problem um and I think there's just historic reasons for that you know if you look at data in the US when couples do seek care for fertility the man has bypassed probably a third of the time even though when you look at the reasons for infertility man contributes probably half of the time to infertility so I think there's a half half yeah so I think there's a huge need just to understand and evaluate the man and one of the reasons for this I think is that um you know one of the main treatments for infertility in the US is IVF which is very powerful I think one of the you know greatest marvels of medicine in probably the last you know quarter century is our ability to mix a sperm and egg in a dish and create a life it's really remarkable but because it now takes just a single sperm you know through something called inid plasmic sperm injection where you can inject one egg or one sperm into an egg you know the bar has gone down dramatically you know if a couple's just trying without you know any assistance probably need 20 to 40 million moving sperm but now with you know these remarkable techniques you just need one sperm um and so because of that you know I think a lot of our Innovation and research on male fertility has probably gone to the Wayside just because clinically you know we just need you know a few dozen sperm for most couples what about testosterone levels are those also declining we hear this um and when I look at the literature I can find evidence for that but the question is also whether or not the amount of decline in testosterone levels is significant in a way that impacts let's say fertility but also um Vitality in other ways energy mood um Sexual Health Etc U what's the story with testosterone levels are they indeed declining on average across the male population in the US and elsewhere I think there is pretty convincing evidence that that is happening and I think the reason for that again is probably not certain but you know there have been you know some pretty nicely designed cohort studies where theyve recruited you know men in the the 2000s the 90s the 80s and you can see that depending on when these men are recruited just you know matching age for age these testosterone levels tend to be lower um and then en haanes which is again this sort of longitudinal study run by the CDC um that has also sh looking at testosterone levels over you know decades the testosterone levels have declined over time um so there you know chemical exposure is one possible explanation again either in adult or adolescent life or in utero um but obesity I think is also sort of a convincing explanation is we're more sedentary um you know we get bigger that's one of the places that testosterone can decline I think there's different sort of explanations for that um you know as testosterone produced it's aromatized in U peripheral tissue you know in fat tissue fat has a lot of this aromatase so that converts testosterone to estrogen so it necessarily you know lowers the testosterone level that's circulating in our body um also just insulating the the testicles our thighs get bigger insulating the testes can also sometimes lower the efficiency of production a little bit too because of heat effects because of heat effects yeah I was going to ask about this later but I'll ask about it now since we're talking about heat effects and um sperm and testosterone um The Heat Of course being not good for um sperm health and testosterone which is I've read a metaanalysis I don't know um how high quality it is but um that explained that there is some evidence for um either heat effects or possibly non-heat related effects of cell phone you know smartphone in the pocket impairing sperm Health maybe even testosterone levels now you hear this more often kind of bioh hacky um I don't know uh circles um which you know I'm not a fan of the word biohacking um ites it's not clear what it means but it it it sounds like it means something about taking a shortcut using one thing for a purpose it wasn't intended but you know it also makes sense to me that a smartphone could generate some heat um some radiation that might impair um testicular function and therefore impair sperm quality and or testosterone levels but is there any real solid data that carrying your cell phone in your pocket let's assume on that the cell phone is on is bad for sperm health or testosterone levels yeah so um I think there's not convincing evidence that it's going to help um testosterone levels I think that you know it's Gonna Hurt testosterone it's not going to hurt yeah so I should you know make clear that I think that in terms of production and heat effects you know sperm production is much more sensitive than testosterone production um but there have been some studies looking at cell phone exposure because again you're getting this whether it's heat whether it's sort of the you know radio frequency you know waves coming in I think you could posit sort of different explanations of why that may be harmful so there have been some studies that you know looked early on you know men that used cell phones more or less they had lower semen quality if they used it more but you can also imagine there's huge differences in men that do and do not use cell phones so you know it's it's it's a hard experiment to design but there have been some studies uh doing this in vitro so in the laboratory so taking you know sperm in a cup basically and putting a cell phone next to it or not next to it to try and see if that played a role there have been studies done where they um sort of normalized the the heat you know they kind of put it on um sort of a special stage so that it's not heat necessarily but maybe it's RF exposure so those studies I think don't show sort of a a clinically meaningful change but there have been some studies that say that maybe DNA fragmentation of sperm can go up a little bit if there's close proximity uh to a cell phone um so I think you know when patients ask me that which is a common question I get in clinic obviously patients are coming in they want to do you know whatever they can um to try and improve their chances um so I think generally I think the data is not convincing um but you know if it's easy enough certainly to be aware of it you know I think putting a laptop on a desk rather than in your lap I think for heat exposure is probably the biggest thing that we want to minimize about a year and a half ago I did an episode about about testosterone and estrogen where it's manufactured in the male and female body Etc and I found a very interesting graph in a uh textbook on U behavioral Endocrinology by a guy named Randy Nelson who I happen to know through the field of Behavioral Endocrinology as it's typically studied in animals so most of that book centers on animal studies but there's a a fraction of the studies that Center on human uh data and there was a very interesting graph that showed testosterone levels as a function of age in na s um and as one might expect testosterone levels were on average much higher in late teens early 20s 30s and there was a progressive decline but what was remarkable to me about that graph is that even when exploring the um Scatter Plots because they showed individual points they didn't just show the averages of testosterone levels in men in their 50s 60s 7s 80s even 90s there were these outliers these guys who had testost levels that were on par with uh testosterone levels of men in their 30s but these guys were in their 50s 60s 7s 80s even 90s so do you observe this clinically Do You observe that um men are coming in you know a who are older than 40 and have testosterone levels and presumably free testosterone levels as well um that are still very high you know and the reason I asked 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 of course we don't know whether or not those guys in their 90s who have the testosterone levels of that match the averages of men in their 30s didn't have even greater testosterone levels in their 30s but given that they were ceilinged out around 900 nanograms per deciliter you know toward the highend normal depending on the scale um in already at age 90 it's kind of hard to imagine that earlier they're walking around with you know 2,000 nanogram per deser testosterone so do you see this are there some is there just a lot of natural variation in testosterone levels of men walk into the clinic at any age and of course what is special about these individuals that are you know maintaining high normal testosterone levels into their uh later years yeah that's a great question I think this is such a common question anytime we talk about testosterone I think anytime we talk about most sort of uh clinical tests that we do you know what is average what is normal um so we do see great variation I mean I think just like you're saying I usually let everybody know that you know usually testosterone Peaks you know kind of early 20s and it tends to go down probably 1% a year forever uh but there are people that have very you know very very high levels I you know just mirroring you know that graph that you describe I certainly have patients you know we screen for testosterone levels you know when patients come in with complaints or we're worried about that low energy level you know low liido 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 test stost level I'll see you know for 6 months um you know why that is I think is not certain maybe it has to do with you know I think with everything there's probably sort of a bell-shaped curve and everybody's a little bit different um but Androgen sensitivity you know sensitivity of the receptor you know they make it more efficiently but I have not really noticed again because at least in clinical practice you know when patients come in they come in with a complaint and so even men you know with very high levels they may have some of the same dysfunction men with low levels so I think with low levels you can try and treat that and that may be the solution but for men with you know these what we would consider high levels um you know there may be other issues going on let me frame the question I was going to ask a little bit differently when someone comes into your clinic and you measure their testosterone levels as you mentioned they're likely coming in because they have some issue prostate issue sexual function issue Etc but you do get a read on their you know so crude morol of their body right so you could visibly determine whether or not they're likely to be obese or not um regardless of age so earlier you mentioned obesity as a risk factor for lowering testosterone and sperm quality you mentioned that fat aromatizes testosterone into estrogen so that's at least one mechanism by which that could happen but if you were to just step back and say okay if somebody who walks into my clinic tends to be um let's say healthier looking you know not obese let's just put the cut off at what you would presume is obese um is there a higher probability that their testosterone levels are going to be within normal range conversely when somebody walks in and their obese do you fully expect their testosterone levels to be subnormal um or are you sometimes seeing obese people walking in with you know high testosterone um and the reason I'm asking this is not to create confusion is that I think that everybody out there who's thinking about sperm quality and testosterone levels and this uh apparent decline trying to figure out you know okay what can we do in order to maintain the health metrics that are going to of course increase fertility but for those that don't want to have kids or already have kids are going to at least maintain or improve Vitality is obesity really the thing to avoid so is there a not one for one but is there a tight correlation between obesity and testosterone levels I would say that you cannot predict I think that sort of would be the take-home and so I think that you know more information is always better you know when I see patients in clinic um you know some patients are walking around you know with yeah everything is totally normal they're very healthy all the numbers come in at the normal range but sometimes when men you know look totally normal they talked about taking care of their life they exercise you know five seven days a week their testosterone levels can be very low so even despite you know having what we would consider should really give them you know symptoms um they're able to compensate you know maybe they've lived their whole life in that they don't know what normal is now we get them you know to sort of normal levels a lot of times they feel better again because they have no idea how they should feel um but I think that that's just sort of important that everybody you know should be screened I think that you know testosterone semen quality they have been shown to even be barometers of Health um so you know men with lower testosterone levels of higher risk of you know heart disease diabetes mortality the same studies exist for semen quality as well um and you know again they may have sort of a similar Rel relationship and explanation why that may be but I think it's hard to just predict you know based on appearance what you know testosterone will be what seam quality be what testicular function will be without actually getting some objective data and actually if you look at the trend of test of seman quality decline over time kind of getting back to some of those earlier points you're making if you were to Overlay that on the known association between obesity um its effects on SE quality that actually doesn't explain the whole decline because the you the purported decline in seam quality is about 50% but if you just if you were to say well what would we expect if you know we look at you know because we were able to track exactly how much fatter we are now than we used to be that actually only explains about a 10% decline so I think there is you know to your point something more um and it is not something that you can just identify by eye what are the dos and don'ts as it relates to I don't want to use the word optimizing it's gotten me into trouble before because word optimize or optimal suggest that there's an perfect number that one should all attain if possible but in reality um optimal is a day-to-day thing um at least but what should people avoid in order to get their sperm quality as high as possible their testosterone level again here I have to be careful I don't want to say as high as possible because some people might not want excessive Androgen um but at the high end of normal 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 uh chonic gatr human coron and genotropin things we can talk about a little bit later but what should every male be doing in order to optimize these Health parameters yeah so I think that there are some risk factors that we do like we'll start with steam and quality so we talked about heat I think that's a big one so like hot tub on us trying and avoid those some you know light data on seat warmers anytime you know we kind of get this external heat source to the scrotum you know the testicles are outside the body because they need to be a little cooler so anything that warms them up can certainly be a problem could I just briefly interrupt there um to ask we've done episodes on sauna and some of the health benefits of sauna um is it sufficient for somebody to bring in a cold pack to the sauna and put that in their groin I actually have suggested that that's actually what I do when I go into the sauna um and I have suggested this on podcasts um not just for people who are trying to conceive because it seems like heat as you 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 thwart the effects of external heat with a cooling pack I think it makes sense there are studies that have looked at different ways to cool the scrotum and have compared you know semen quality before and after and there's some data that may help um it just depends how long you're going to spend in the sauna and how cold you know that pack is going to remain so ice pack and in the sauna for 20 to 45 minutes and is the ice pack still cold afterwards yeah yeah they actually sell and by the way have no relationship to any of these companies but they actually sell cold packs that are designed to be worn in your short so if you go to a you know I'll go to a Russian Bia every once in a while now I guess I'm outing myself yes I have a yes I have a cold pack in my shorts when I go to the Russian B um but um but they have a a sort of an insulation so that you're the cold the very cold surface is cold enough but it's not right up in contact with the scrotal skin because that could get um I want to make a bad joke and say it could get sticky uh that situation you you don't want it get being so cold that it actually would stick to the skin and then it could potentially damage the skin when you try to remove the cold pack so it has a thin insulating layer um and uh yeah that's essentially what it is yeah I mean frostbite to the scrotum is not theoretical it could certainly happen so you do want to be careful so I mean in theory that should be that should be adequate to sort of you know to decrease the risk of that particular effect um you know I keep coming back to health how important that is to maintain um you know sperm production because I think these two are very linked you know there have been studies that show that men with more com morid conditions so obesity hypertension hyper lipidemia as these sort of Stack Up we see a decline in testicular function so lower testosterone levels and lower sperm quality so I think you know taking ownership of your your health I think is important as well um you know a lot of times um fertility tends to be one of the first touch points that some men have with Healthcare you know because generally what brings men to the doctor it's usually pain or you know kind of a problem um so you know if men are in their 20s and 30s getting ready to start a family or 40s in some cases sometimes they haven't you know seen a primary care doctor so some of these things some of this relationship has not been established yet so I think you know thinking about ways to start that I think would be important too um and then I know you don't want to talk about testosterone but testosterone is actually a fairly common problem that we see in fertility clinics um I would say that you estimates say maybe about one in 20 infertile men are that way because of testosterone so I I think when you know people get testosterone from different places and hopefully you know whatever prietor you're getting it from tells you that one of the side effects of this um is lower sperm production it's actually been tested as a contraceptive and you know with some other agents it can actually be fairly effective so we just want to make sure that you know if men are starting testosterone they're doing it for the right reasons and they're doing it safely I think you're talking about testosterone replacement therapy although as we were talking about before we started recording I I am really on a push now to rename what people call trt testosterone replacement therapy because indeed some people have low testosterone and need it replaced the r and trt but I think what you're referring to if I'm not mistaken is that there are probably Millions yeah of young men and older men taking exogenous testosterone injections creams pills pellets you know any number nasal sprays now you know any number of different routes of delivery of exogenous um testo tone and that um dramatically reduces one's endogenous testosterone production and dramatically reduces one's sperm count and maybe even quality we'll maybe talk about this a little bit later but maybe even can there there's I've been told that it can perhaps introduce a DNA fragmentation uh within the remaining viable sperm as well so do I have that Craig you're saying that that you see one in 120 men have issues with fertility because they are taking testosterone right so they testosterone levels presumably are going to be highend normal or more but they are doing presumably not testosterone replacement therapy but they're doing what I call testosterone augmentation therapy meaning they were somewhere in the 300 to 900 nanograms per deciliter range but decided to start taking testosterone anyway and then their their sperm count essentially diminishes to nil or close to it in some cases yeah so I mean I think there's various reasons you would take testosterone I think you know some people have been treated you know years ago and so they do need to replace testosterone you know um but some people do it for augmentation I just usually say testosterone therapy just so it you kill the R I like that that's better than the t a which doesn't S very good okay just testosterone therapy yeah okay but if you had you know for example we take 100 of my infertile patients that come in to see me in clinic at least five of those men will be infertile because they're on testosterone therapy and some of them do you know have that suspicion they say you know I'm 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 um because there can be some other you know ways that we kind of maintain sperm production I think sperm cry preservation is a good option for these men as well um or there may be other therapies they can think about just because of reproductive toxicity what about um HCG human chonic gonadotrope and I hear about a lot of people who go on testosterone therapy who take HCG every other day or so um typically the dosages that I hear about because people write to me about this stuff all the time really it's one of the most commonly asked questions um I get many questions about many topics but I would say a full 10 to 20% of them are about um penises or testosterone um those is perfect then right exactly um so a number of those um guys who are taking test testosterone will be prescribed HCG to um stimulate sperm production um endogenous sperm production to maintain um healthy sperm presumably because they either want to conceive or are intending to conceive in the future is that the best line of treatment for maintaining fertility while people are taking testosterone therapy yeah that's one of the therapies that we use and I think it can work well you know just a low dose um usually again for those that that know 500 to 1,000 units every other day is usually adequate as we all know quality nutrition influences of course our physical health but also our mental health and our cognitive functioning our memory our ability to learn new things and to focus and we know that one of the most important features of highquality nutrition is making sure that we get enough vitamins and minerals from high quality unprocessed or minimally processed sources as well as enough probiotics and prebiotics and fiber to support basically all the cellular functions in our body including the gut microbiome now I like most everybody try to get optimal nutrition from Whole Foods ideally mostly from minimally processed or nonprocessed Foods however one of the challenges that I and so many other people face is getting enough servings of high quality fruits and vegetables per day as well as fiber and probiotics that often accompany those fruits and vegetables that's why way back in 2012 long before I ever had a podcast I started drinking ag1 and so I'm delighted that ag1 is sponsoring the huberman Lab podcast the reason I started taking ag1 and the reason I still drink ag1 once or twice a day is that it provides all of my foundational nutritional needs that is it provides insurance that I get the proper amounts of those vitamins minerals probiotics and fiber to ensure optimal mental health physical health and performance if you'd like to try ag1 you can go to drink a1.com huberman to claim a special offer they're giving away five free travel packs plus a year supply of vitamin D3 K2 again that's drink a1.com huberman to claim that special offer so if somebody is not taking testosterone exogenously they gotten their um body fat level down to a point where they're not considered obese so they're hopefully doing some cardiovascular exercise each week maybe doing some sport or some resistance training too um uh with the intention of maintaining all around good health Stave off you know cerebrovascular cardiovascular issues what are some of the other don'ts um I'm going to assume that smoking cigarettes or vaping cigarettes is Bad are there any studies that have looked specifically at vaping and sperm quality or testosterone levels um and is there any evidence that uh smoking cigarettes is good for testosterone levels or sperm production because I'm guessing the answer is no I feel like nowadays we just say don't smoke um but the data are the data who knows maybe nicotine can help sperm I have no idea right uh it's possible I don't think we have the data on that yet but yeah I mean I think like to your point I think lifestyle factors are certainly a big one and you know some of these you know potentially um you know kind of unhealthy habits so smoking is certainly something you should not do there have been you know lots of studies that do link that to you know lower quality again all the different measures that we look at um also looking at fertility these men tend to have a longer time to get pregnant um alcohol I think is another very common question get asked as well and I think for that there's you know I think less of a strong Association that we've seen so there um you know there have been some studies that show that very high levels of alcohol and I guess that's sort of subjective what some would consider are higher or not but you know when you get above maybe 20 drinks a week there have been some effects but usually that's a lot of drinking I would think that's a lot yeah but some people don't but yeah I did an episode on alcohol I think anything more than two I know people are gonna um you know bulk at this but you know I think any more than two drinks per week is where you start to see some negative effects on some health parameters but you know I'm I'm not a tea Toler so yeah yeah um but when you get to this 20 drink that's when we started to see some effects on cement quality but the you know the thing about that is that usually if these men are drinking 20 they're doing other things too smoking there can be other drug use as well so it's hard to tease that out but in general that's you know I think certainly anything in moderation is probably you know is probably better and so that's how I counsel patients I think again it's very rare that I see men that are at that level but I certainly let them know when I do um there's some new data coming out of that we've started to work on looking at if there are different sensitivities to alcohol so you know some East Asians have a mutation that leads to Flushing um and so that may put those men at higher risk when they mix alcohol we may see some you know slightly lower uh sperm parameters you mean skin flushing because they don't make alcohol dehydrogen is idea yeah yeah um and is it I've heard about that in Asian cultures is there um in Asian population excuse me but is there any evidence that other populations might have slight variance on alcohol dehydrogenase that perhaps maybe they don't lack it Al together but they have I don't know um they're hypomorphs for whatever Gene makes alcohol dehydrogenase and therefore they don't metabolize it as well and therefore the toxic form of alcohol is active in their system longer is there any evidence for that no I think you're exactly right I mean I think the one that we think about is East Asian cultures where it can be you know depending on you know the region like um Chinese Taiwanese probably about 40 to 50% of the population has you know mutation in the alh2 gene but other populations um in people of African ancestry there's a rate of mutation I think not going to remember the exact percentage but I think a few percentage points is some um individual with Hispanic ancestry ashkanazi Jewish ancestry so in this particular Gene there's a mutation not the same one that East Asians have but you know again I think it gets to why mutation you know where we see sort of negative effects would persist and the hypothesis that you know Millennia ago po potentially it you know gave some sort of benefit for maybe an infectious disease or something similar to cystic fibrosis why you know again this mutation would persist in our population if there's not you know you know some sort of Advantage uh to those carrying it um but we do see another you know other men as well so I think if you know it's a simple question do you flush if you flush then maybe alcohol may have you know more of a a harm than than someone else and then you know get S of getting along the lines I think drug use is also something that we should you know we do counsel patients about because that can also negatively affect SE quality do you think it's fair to say that okay moderation is best but if somebody had the option to either not drink or drink in moderation that they should not drink would that be even better is there any evidence for that I mean it seems like nowadays we take the stance that um not smoking at all is better than smoking a little bit actually when I was a postto at Stanford from 2005 yes 2005 to uh end of 2010 um you could still smoke on the Stanford campus I'm not a smoker but there was this collection of I have to be careful what I say here there was a particular group on campus of postdocs and graduate students that would um you know that would colonize this little area outside the hospital and smoke because that's where you could smoke that was eventually um eliminated as a possibility you can't smoke on Sanford campus as far as I know but they would smoke right outside the hospital actually a lot of the hospital workers would you know take a cigarette on their break this is very common exactly yeah and and this common all over the country right this isn't unique to Stanford but nowadays you just don't see that um because it's not allowed um and we here don't smoke it's terrible for XYZ and everything every other letter of the alphabet with alcohol um we tend to hear that if you're going to drink drink in moderation um it's not clear exactly what number that is but is it possible that zero alcohol is better for sperm and endocrine Health than any alcohol or is that not not a fair assumption I mean I think that's a good question I think you know the your point about tobacco is an excellent one because I think any smoking is bad um but alcohol I think we don't have that data for yet and so I think it's it's harder to it's harder for me to make that recommendation to patients especially because you know people do it for different reasons um and if it's not necessarily going to help them you know it'll harm them in social situations or other things um yeah I usually just I usually give the the moderation one unless again for the the very high drinkers I definitely talk about that um you mentioned other drug use um I'm going to assume that uh unless prescribed for sort of postsurgical pain or something like that that benzodiazapines heroin opioids of any kind um are just bad for sperm and testosterone I think we could probably make that a short discussion right yeah you know I can't imagine any of that would be good um for Reproductive Health yeah that's true I mean there's again you'd imagine or may maybe not but there's not a lot of data on it um it'd be difficult to enroll or maybe easy to enroll but a lot of those Studies have not been done um but there's limited ones of you know people in rehab uh where they have shown you know these associations with you know addicts or users and lower quality so um yeah that's how we talk to patients what about cannabis I did an episode of this podcast about cannabis and I did highlight some of the medical applications of cannabis I also highlighted that very high THC cannabis um May predispose especially young men s to later psychotic episodes there are more and more data coming out about that all the time I um got a lot of flak for for saying that but that's my take on the data um and um I know a lot of people use cannabis uh recreationally um and in a kind of pseudo therapeutic way I say pseudo is the relationship between cannabis use and testosterone and sperm production or I should say sperm quality excuse me yeah so this is also a very common question um again with this wave of legalization across the country I think more and more men and women are exposed to it um so again there's data that the more men are exposed to it it can lead to some harm in terms of sperm morphology and sperm numbers as well um you know one of the sort of landmarks that IES was about 1,200 men and it found that men that use cannabis daily had significantly lower concentration motility morphology compared to those that didn't use it um so I think that's generally how men are counseled but there's also you know other data that shows really a null effect and I think that it's it goes into probably the composition how men are taking it the frequency because a lot of that data is not well teased out in a lot of these studies um so you know I think I I sometimes struggle with this with patients because some of them are taking it for you know you know some what they consider legitimate reasons anxiety sleep pain um and if there's not sort of very convincing evidence that it's going to help and they're taking it maybe lower than the threshold where I know that there's good data that'll cause harm you know I guess I'm trying to be sort of honest about where we are but I think with a lot of things related to sperm I think our our level of evidence is not great are there any common over-the-counter medications that can negatively impact sperm quality Endor testosterone things like um non-steroid anti-inflammatory drugs Tylenol Advil type stuff um you know ibuprofen aceta menen um things of that sort that I and others might not be aware of I'm not I'm not probing for anything in particular here I just I I know that um you know a lot of over-the-counter drugs have effects that we're just simply not aware of yeah I mean I think we probably need more data but I think currently we think all those are safe I'm curious about the pituitary pituitary gland as many listeners of this podcast already know is a gland that receives signals from the brain um the gland sits near the roof of the mouth um I think that's fair um and releases critical hormones into the bloodstream that control the output of testosterone from the testes as well as output of hormones from other glands um I know a number of people end up playing sports like football or rug or even LaCrosse or even soccer I've read our data on this you know they're heading the soccer ball quite a lot or martial arts or they get a head injury at some point and um I certainly hear a lot from people who played these high contact Sports and then to their surprise later they have diminished testosterone levels I also work with a number of military groups that talk about this you know that they leave and maybe it's from combat related stress Etc but um they wonder whether or not there's any traumatic head injury or maybe pituitary injury related um impairment to the reproductive axis that includes brain pituitary and the testes do you see that um and if somebody played a contact sport in particular a contact sport where the head was hit or they were hitting things with their head often um or if they have a TBI or had a TBI that um their reproductive Health can be impaired that's F fascinating um I have I have not I mean I think you know it's interesting I guess you know what the pituitary does you've obviously covered this before but it does go to a lot of our therapies I mean so you know for your listeners you know that pituitary produces two hormones LH lutenizing hormone and FSH follicle stimulating hormone which then stimulates the testicle so the lutenizing hormone hormone stimulates the leig cells to make testosterone and then the follicle stimulating hormone or FSH stimul sperm production so both of those are very key you know in terms of production and interestingly when exogenous testosterone is used you know it shuts down that axis as you know so we get less of these gatot tropins this LH FSH um to stimulate the testicle um and the other sort of reason that sperm production is lost with exogenous testosterone uses is actually the in testicular testosterone is much higher than serum levels so you know our serum levels are you know between 300 and 900 uh NRS per deciliter on average but in the testicle are probably 10 fold higher at least so when men are given exogenous testosterone they not producing their own the levels of testosterone in the testicle which are necessary for sperm production are much much lower um but it's interesting because I think um I am not aware of sort of how tra traumatic injuries would would do that okay um that's good to know I'm curious about the nonendocrine nonchemical so effects on sperm quality and testosterone levels so here I'm thinking about uh bunch of news stories we heard a few years ago about how Bicycle Seat pressure on the prostate or maybe it was other other portions of the um maybe was the uh nerves running to the penis itself um or surrounding areas maybe it was pelvic floor related and somehow you'll tell us I'm sure uh was impairing sexual function was it impairing sexual function in any way by impairing testosterone levels cutting off blood flow to the testes um and here perhaps the most important thing to ask straight off is um is riding a bicycle bad for male reproductive health and Sexual Health yeah these are great questions these again living in the Bay Area working in the Bay Area uh cycling is very very popular so these are questions that I get a lot so I think you know I in general like we talked about before anything that's good for your heart it's going to be good for fertility so good diet and exercise 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 um activities may put men at more risk so I think cycling could be one of them if but it would sort of depend on exactly why we think that may be a problem so I guess the theory is heat if you're in the saddle for a long time you know for these prolonged you know rides that men take you know on weekends you know hours um that maybe if there's too much heat exposure that may be the mechanism where sperm production would decline so there have been some studies say maybe five hours a week would be you know that may be too much so if you're above that level the sperm counts shown to be lower if you're less than that that may be okay so when I talk to patients about it I try and just encourage them to you know stand up in the saddle to try and again sort of air things out to try and dissipate heat if if that's the mechanism we're going to think regarding sexual dysfunction um that is thought to be pressure as you're alluding to so you know the way that the saddle is configured ideally all the pressure is put on our iscal tuberosities or our sit bones that's what I'm sitting on now but on the saddle you know there's obviously kind of the rigid nose and if there's too much pressure on that that actually squeezes between the iscal tuberosities where you know the main blood flow to the penis goes and the main nerve Supply is too and so if there's compression on this you get this sort of lack of blood flow or esema and you can get a neuropraxia as well if you crush these nerves and so that over time can lead to problems so you know some patients will say that you know after I cycle you know things are numb down there for 30 minutes um or a day or I don't get erections for that sort of same amount of time or sometimes you know men just sort of you know ride through it um and you know hopefully things come back in a day or two so that's that could be the mechanism there are some saddles you know hopefully it'll be a little safer and you know I think that this sort of first was noted probably around the 2000 or so and there is a big redesign in terms of saddles to try and make them a little bit more you know anatomically correct to try and minimize some of this and there's you know cycle fit that can be done or saddle fit rather that can be done at some of the cycling shops to try and you know look at your body position look at your size and try and find a saddle that's safer um you know not this doesn't happen to everybody I would say maybe you if you were to um serve a cyclist maybe 20 to 30% of men and women tend to be susceptible to this so I think if you are having discomfort in when you cycle whether it be pain numbness or you notice dysfunction I think certainly you should you know think about changing saddles or think about changing writing style um there's other strategies are sometimes used but you know it's absolutely something that that everybody should be aware of I me to asked this earlier but I seem to recall a study that Drew a a correlation between um amount of walking and maybe it was sperm quality but I think it was testosterone levels maybe some other metrics of um male sexual health forgive me I'm not recalling the details now um is there any evidence that walking more standing more maybe even using a standing desk uh is beneficial for um you know pelvic floor Health blood flow um prostate health it who knows could be any and all of those things in some way that is beneficial for sperm quality testosterone level and or overall male sexual health yeah I think you know one of the ways that we can characterize activity is Step count right I think I know I have a a watch that tells me that something that I look at every day and kind of strive for it and it turns out that the more active you are uh it's been shown sort of looking at you know large National Data pools across different age ranges that it is associated with testosterone levels so being more active I think is very important and that's another thing that you know everybody can do to try and improve sort of testicular function broadly but testosterone specifically and do you know whether or not that can be separated out from the relationship between being more active and less obese I mean is this something that's independent of of obesity in other words can we incentivize people to walk more um simply on the on the promise of um improved Sexual Health well I don't know sexual health will be a different one but we can I think there is association between testosterone level and step count uh across different BMI straight up so I think you know whether you're have the ideal body weight whether you have a few pounds to lose perhaps if you walk more you will see higher levels of testosterone okay and another question I meant to ask earlier and then we can um close the hatch on on exogenous testosterone therapy at least for the time being maybe we'll come back to it is um assuming that somebody can maintain adequate sperm production through the use of HCG or some other uh therapy or perhaps they don't care if they're still making sperm because they've already had children or they don't care to have children maybe they've banked sperm in any event assuming that somebody takes testosterone therapy because they were prescribed that um let's say in your clinic let's just use you in your clinic as an example and they are happy with the psychological and physical consequences of that and they are comfortable with the tradeoffs is there any increased risk of say Pro State cancer or other forms of cancer and here I'm going to assume that this person is keeping their um their lipid levels in check right because you hear about some hyper lipidemia with testosterone therapies let's assume that they're either taking a 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 um and they don't have to worry about sperm production because they're either maintaining it or it's been banged or they don't care about that um is there an increased risk of prostate cancer my understanding is the answer is no but what's the real deal does taking testosterone therapy assuming all other things are being held in a in check in a healthy check does it increase the risk of any kind of cancer yeah I mean this is a another great question because I think there's a lot of 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 Nobel Prize um you know 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 concern became if we were to you know either replace testosterone or augment testosterone give a man testosterone is that going to alter his risk or increase his risk um so I think we have pretty convincing data that that's not the case you know there's lots of longitudinal data spanning decades where if man it's given testosterone um it doesn't change its risk the reason for that in sort of seeming cont you know this contradiction between you know prostate cancer therapy where we lower testosterone where if you give a man testosterone doesn't change his prostate cancer risk uh is not certain but there's this popular model called the saturation model so that once there's enough testosterone in the body and it's tends to be a fairly low level um that all the sort of the prostate testosterone receptors you know you kind of think of as have been filled so if you were to give man more testosterone doesn't change anything regarding the prostate cancer prostate growth any of that so it is it is safe when we're looking at prostate cancer as as an outcome I'd like to just take a brief break and thank one of our sponsors which is element element is an electrolyte drink that has everything you need and nothing you don't that means plenty of salt sodium magnesium and pottassium the so-called electrolytes and no sugar now salt magnesium and potassium are critical to the function of all the cells in your body in particular to the function of your nerve cells also called neurons now people of course have varying levels of requirements for sodium so people with hypertension or prehypertension probably shouldn't increase their sodium however many people are surprised to find that by increasing their sodium intake they are able to function better cognitively and physically and that's because a lot of people especially people who are following low carbohydrate or even moderate carbohydrate and really clean diets often times they're excreting a lot of water and electrolytes along with it and simply by increasing their electrolyte intake using element they just feel better and function better I typically drink element first thing in the morning when I wake up in order to hydrate my body and make sure I have enough electrolytes and while I do any kind of physical training and certainly I drink element in my water when I'm in the sauna and after going in the sauna because that causes quite a lot of sweating if you'd like to try element you can go to drink element that's lm.com huberman to claim a free element sample pack with your purchase again that's drink element lnt.com SL huberman getting back to prostate health and um 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 inovation of the penis for obvious reasons and we'll get um 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 a loser organ so that doesn't mean necessarily you have to have sex but you know normally we get erections every night so that should be maintained and if there's any reason to sort of suspect that that may not be going on um usually in my practice that would be from you know some pelvic surgical intervention or something like that sometimes we can intervene to try and maintain that you're talking about spontaneous erections during sleep right so um and short of assigning one's partner to uh to check um frequency and T Essence what is the uh way that men would know that that's happening are you talking about waking up with an erection is that a requisite for knowing that nocturnal erections are occurring well yeah that think you yeah you kind of caught me I think that's a good question so I think a lot of times you won't know but I think if you have sort of normal response you know when either by yourself with a partner I think that generally means um that you are going to get normal erection so I think I guess when I say use it or lose it it doesn't mean necessarily the man has to stimulate himself or kind of um make sure that he does have you know adequate function because usually most of that normal function just occurs you know with his nocturnal penal 2 mein which we all get you know I think sometimes men do notice when they wake up at night sometimes in the morning you wake up with an erection men notice that but the absence of that doesn't mean it's not happening it likely is just you know most people sleep through it which is normal otherwise men would never get any sleep because of many many times a night um so I think you know again if you're not having normal function I think that's something you should probably see you know a physician about and then same for like urinary function I think if it bothers you if there's you know if you're waking up at night if you have to go to the bathroom often if your stream is getting weaker those are all sort of complaints that we hear about what is often um my understanding is that it's uh normal to wake up perhaps once during the night to urinate um and this is of course assuming and again forgive me for all the caveats but I've done this long enough that you know if I don't get really granular about some of this then say well what if I drank you know 32 ounces of fluid right before sleep and I'm urinating three times per night well we're assuming that people are tapering their liquid intake as they approach bedtime um and that waking up once maybe twice but once in the middle of the night to urinate is normal for somebody let's say age I don't know 18 to 40 and maybe from 40 to uh 100 um that number might be in the uh one to two times per night is that about right yeah I mean I think once a night yeah is normal for most men and then I think you know if things start to bother you I think you could certainly see somebody but it's hard to get better than once or twice a night for most men um my understanding is that there's a pretty good relationship between the um nocturnal erection and the amount of REM sleep rapid eye movement sleep that one is getting that this tends to be more frequent toward morning as the proportion of rapid ey movement sleep increases I don't know if that's true or not but I found a couple of studies that at least point in that direction no pun intended uh so that raises a a bigger issue that we haven't talked about yet which is getting adequate amounts of quality sleep each night and um I think for most people that's 7 to n hours ideally um which means getting sufficient slow wave deep sleep as well as WRA and ey movement sleep but nowadays A lot of people including young people who are not working excessive hours are um getting you know four five six hours of sleep per night is there a direct relationship between getting less than sufficient amounts of sleep and sperm quality testosterone levels and um Sexual Health yeah I mean I think certainly there's reasonable data for seman quality and there tends to be um you know what we call like in science sort of a U-shaped relationship so that it's not sort of lineer so as you get more sleep things are better it 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 is 7 to 9 hours and for men that are not getting that se quality tends to be lower and then for men getting too much um we also see a decline and you know why that is is not certain these again if you're able to get that much sleep maybe there's other things as well that we should look at but um so I think kind of getting in that ideal sleep amount is best for semen quality and probably for broad ttic function as well you keep bringing up semen quality um in a way that makes me wonder whether or not is seamen quality a proxy for overall vitality and health or is testosterone level appr proxy for overall vitality and health um it sounds like semen quality is the the metric that you keep coming back to in a way that um I have to assume reflects your you know your clinical experience and the the the many um papers that you've authored in this area um I think for people that hear seamen quality and who are not interested in conceiving children now or who are which of course could include people who've already had children or who don't want children um seam in quality sounds like something that relates to fertility but is seam inquality something that is a good goal for those who are interested in overall male vitality and health is it is it one of the better metrics of overall male vitality and health well I think you know it's I think it's an excellent marker for overall health I think there are studies that support it can be a measure of how healthy you are you know if you look at men with more health problems they tend 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 um they tend to live longer need to go to the doctor less lower rates of cancer so I think there's a lot of different ways that Seamon quality may be a good barometer of Health um you know it's you know why that link exists I think is not is not known but there's lots of theories so one is that you know probably about 10% of the male genome is devoted to reproduction um and so it makes sense given that we only have about you know 24,000 genes in the body that there's a lot of um you know overlap so one gene that plays a role in reproduction may play a role in you the cardiovascular system or the neurological system and so if we get the first you know sort of sign that reproduction is not perfect there may be some other consequences down the line um another sort of hypothesis is that again sort of going along this line that reproduction is one of the first things that we see is that um you know gestation is sort of very critical to our you know existence right and if perturbations to that system have prolonged um you know effects so the so-called sort of Developmental origin of adult disease or the Barker hypothesis um and so we know that you know premature children have higher risk of cardiovascular disease or been studies to show that but we also know that you know these gestational effects can also uh play out on reproductive function too so that also may be kind of a link you know sort of early seating of reproductive function and then that's maybe the first marker that we're going to have for other health effects later on um there also just sort of sort of inherent um sort of similarities between um reproduction and some other sort of social effects so you know 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 semon quality is that you know there's sort of factors that necessarily involve reproduction so your children and having a partner and having a partner prolongs life um having kids prolong life even though it feels like kids are killing you if you look at studies men with kids tend to live longer um so you know that's another possible explanation but I think you know really sort of this health um you know link between fertility I think is sort of a powerful one so I do think it should be a barometer I think that you know it should be 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 you know sort of lower levels that may tell us about something else going on you know when when men come in for infertility evaluations a lot of time we do diagnose you know these new medical problems sometimes we diagnose cancer you know sort of alluding to some of the questions you've 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 um and other things so it is something I think that it's sort of it's very important I think for people to realize um and it would be great I think you know another um I think advantage to like the Centers for Disease Control for example to start tracking it would it be a good idea for um males in their 20s and 30s to get a sperm analysis just have a Baseline I confess I'm 47 now um one thing I wish I had done in my 20s was to get my uh blood hormone profiles and lipid profiles done when I was in my teens and 20s because I'd have something to compare to um I started doing that in my mid-30s and I'm so glad I did because I can now compar to my mid-30 levels I started including um sperm analysis about eight years ago um with the intention of freezing sperm and did that um because I was also reading at that time about the increased risk of autism um in offspring of males older than 40 something that I really would like your take on but um it seems like it's inexpensive enough to do a sperm analysis um I think now they people can get it done at home they have male mail kits although I don't understand how the motility could be maintained if you're mailing your sperm back um at room temperature or you know it's heading through the post office now everyone's imagining all these sperm traveling through the the Postal Service it's out they're out there folks um yeah what what are your thoughts should um should people invest the I think it was a couple hundred dollars to get a sperm analysis more um costly to get the DNA fragmentation than you get up into the low thousands um but if people have the disposable income is it a good idea for them to do I mean I think it's a worthwhile test I think more information is always good um you know I think sort of one of the same reasons that um you know you're talking about checking like lipid levels or tell you know men and women to get blood pressure checked I think you know getting that sort of early Health indicator I think can be important I think you know going back to not knowing exactly why semen quality is telling us about health what the exact link may be you know means that if somebody is coming in with a low sperm count or completely absent sperm count it's hard to know exactly how to counsel that that person other than there maybe reproductive difficulties um but I think just as sort of a marker for Reproductive potential I think it's useful and like you said I think become a lot easier one of the sort of Innovations in the space um and you know as somebody that you know is in the reproductive world I think it's just really great to see sort of this influx in capital and new companies coming in they're trying to just decrease the barrier to you know getting a cement test used to be have to go to a lab schedule an appointment sometimes they would send you to a bathroom which can be uncomfortable you know because people are doing you know you know what people do in a bathroom just next to you trying to collect oh they would send them into a in a common space bathro they wouldn't even give them the quiet room with the with the red light which is uh right what I hear they do now yeah some of them do have videos so there are some higher level oh I didn't even mean videos I just I I think that um okay yes I've done this I'll just I mean I'm trying to normalize things related to all aspects of mental health physical health um so um yeah I I decided to freeze sperm and basically they sent me to a room I went to a university based CL it actually wasn't Stanford but different University and um uh yeah they put the cup through the window they give you the cup they um they close the door and they tell you that as long as that red light is on over the door no one's going to walk in and then they leave and I think the the Assumption now is that uh you figure it out one way or another um how to provide the sample and then you put the sample back through the the thing and then one thing these clinics really need to work out is that anytime you're walking out you see the people processing your sample as you walk out so there's all this um this figing of of uh you know anonymity but really it isn't there you know because they're like see you later and you're like great you you know they they rarely ask you questions on the way out but it's a pretty simple process overall and um and I must say that the the data are informative you get the you know you get the volume number motile forwardly motile I did opt for the DNA fragmentation um data um and I I just love data so I think it's really interesting but again um and maybe this is a good time to flag this what this set of findings I believe believe that there seems to be a small but statistically significant increase in the number of autistic births due to pregnancies where the male was over 40 at the time of um of conception um so I figured you know why not freeze some sperm and it's relatively inexpensive yeah yeah so I think paternal age is also you know something that's increasing in this country so over the last 40 years or so we've seen that the average paternal age has increased from about 27 and a half to about 31 um and I should say that this is all fathers so um birth certificate data or birth data is collected a maternal level so you know when a child is born somebody comes in to collect data on the birth so they ask you know all the characteristics of the mother and they also ask characteristics of the father you know age education obviously region of the country the child was born um so we don't know you know what number child that was for the father we know it for the mother they do ask you know is this your first second third Etc child um so the father unfortunately we just have data that sort of all lumped together um but over the last again 40 years we've seen that increase interesting over the last 40 years the youngest father was 11 and the oldest was 88 11 quite a span yeah 88 mhm goodness unrelated I I don't know I assume I assume goodness it's anonymized data but I 11 uh I have to ask this sorry to uh take us on a slight tangent but what is the average age of puberty in males in the United States um now yeah so asking about I guess sort of Sparky when like sperm production begins so um yeah there are a lot of markers of of puberty secondary sexual characters of beard growth deepening of voice Etc they happen at different rates in different people but yeah thank you um at what point um are um yeah males undergoing puberty yeah uh at at the level of of that we're talking about here yeah so it's yeah there has been data that we're going through puberty a little bit early now than we used to um but it really varies so you know I think it's not um you know just like testosterone ranges between like 300 to 900 that's a wide range for anybody I think for most individuals you know puberty is you know probably 12 to kind of 15 16 in general so I just give sort of a very wide range when we're going to say that's okay and you know some of the data I'm basing it on is um when sperm production begins in boys and it's actually you know not that simple to be able to figure that out because you know we don't generally talk to you know young boys about how to masterb 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 were sort of you know nocturnal emissions whether there's sperm in there and so generally it probably starts around um the earliest would be kind of 11 12 13 but usually most it's probably a little later so maybe I'll refine that puberty and move it a little bit later probably 14 to 16 um is when probably about 70 80% of boys are going to have produced started producing sperm my understanding is that in females puberty is also shifting earlier perhaps at a more dramatic rate than appears to be the case for males well I think there is some data for males too I think um but again for your listeners I don't want to you know have this onslaught of you know pediatricians seeing kids that haven't you know when boys haven't gone through puberty by a certain age so I think it's still fairly wide let's get back to age of the father and issues like autism um what are the data there um and this to me is a practical issue because I think if there's one obvious takeaway from our discussion today it's that um males should probably not wait until they're trying to conceive in order to assess their reproductive Health at the level of sperm quality um testosterone levels perhaps but at least sperm quality but um but perhaps men should also be freezing their sperm if in fact conceiving children after 40 places their children at far greater risk for autism I mean my understanding is that the rates of autism are somewhere between 1 and 80 you'll hear as high as 1 and 50 male birth but I think it's probably more like one in 60 to 80 is that about right um and that the age of the father is a risk factor yeah I think that this gets into sort of the larger issue of you know how men sort of perceive fertility so so you know we know that as women age fertility declines uh but the oldest father ever is 96 so the biologic potential certainly persists wait I want to know how long he lived to see how long his child grow up we he conceived at 96 amaz supposedly supposedly yeah well I'm assuming he did not meet his grandchildren at least not the grandchild of that child so wow how long did he live um you know I well so this this is a man in India it's sort of a famous story but supposedly um he had a child he had that child with him on uh like they're waiting at a bus stop he fell asleep the child was kidnapped that led to divorce so yeah Dreadful sort of a a horrible end but the wife was also old not not that old but in her 50s goodness so yeah wow um tragic and and incredible story for separate reasons um okay I'll get my head around this 96-year-old uh conceiving a child okay please continue yeah uh so people I think or men think that the sort of the um you know their you know fertile road is sort of infinite um but I think that's very much not the case so as you're alluding to people have looked into risks for older fathers so you know about a hundred years ago was first noticed that dwarfism or condop plasia was more common in last born children So eventually that link was made um and since then other conditions too so there's like these neuros psychiatric conditions you're talking talking about like autism is certainly one bipolar schizophrenia people have looked at and also linked that with older age you know Less attainment in school you know failing grades all that has been shown to be a little bit more common with older fathers so you know why I think all these exist there can be sort of different explanations um you know one explanation for the autism Association I'll talk about um you know some of this more genetic or um of mutation reasons but one thing that some people say is that you know it could be sort of a hereditary trait and so it may be that you know men that display some sort of autistic characteristics you know maybe they take a little longer to meet a partner and so it sort of delayed childbearing so maybe that's that's one possible explanation but I think you know there's been a lot of convincing evidence that there could be you know real epigenetic changes that occur with age and mutational changes that occur with age um I think I read a statistic and you would know more being a neuroscientist that 84% of the the genes in our body are expressed somewhere in the central nervous system is that sounds about right yeah I don't want to stamp my name to that uh um but that sounds about right so um it's it's estimated that every year we generate about two mutations in our um you know sperm DNA so you can imagine that you know a 40-year-old is going to have you know 20 or 40 more mutations um than a 20-year-old so that rate does go up and if you're just randomly sprinkling mutations you know in you know a genome that they're more likely to sort of manifest in you know maybe neuros pych atric conditions um so there are you know data convincing data that shows that that does occur now again there's billions of Bas pairs in the body so these random mutations likely most of them will will not result in anything but there can be some meaningful ones so for example a condr plasia it's due to a a mutation in fiberblast growth factor receptor um and what's interesting is that this condition is not that rare right based on sort of these rare mutations you'd expect this would you know occur maybe about one in 100 million but it turns out this these conditions occur in about one in I think 30 to 50,000 or so so there's sort of the discrepancy based on sort of mutational rate that we expect based on age and the rate that we actually see so the explanation for this is something called Selfish spermatogonial selection so what this suggests is that some of these mutations that occur randomly occur in proliferation Pathways and so it gives the sperm that contain these sort of advantages over their you know brothers and sisters that don't have them for example and so then they out compete the other sperm and so they're more likely to lead to a child rather than sort of a random smattering you can actually see that some of these mutations are more common in older men than younger men if you look you screen for some of these mutations and you know some of these Pathways um again the longer that we're exposed to life there's just more likely to be you know different chemical exposures other exposures and so people have looked at epigenetic signatures sort of these signatures that um you know that dictate which genes are going to be expressed and which aren't and there are different patterns between older and younger fathers and you know why what triggering those is not known but there are differences so those could also potentially explain you know some of these risks that we see um you know it used to be that people thought that you know if you're an older father maybe there's a lot of advantages you know for the kids right because if you're you're more resourced right I always tell patients that you know when they come to see me for like erection problems or anything I always say nothing gets better with age right and that's mostly true although they've pointed out that um salary often goes up with age and wisdom goes up with age so you would imagine if you're more resourced maybe the kids are going to also have an advantage to that but you know again there's a lot of convincing data that that's that's probably not the case um there's even there's one study that I saw that showed that if you look at MRIs uh of brains of children just after birth they're actually a little smaller for older fathers compared to younger fathers so um I think there are some you know sort of talking about kind of neurocognitive development um some of those effects and there's also been um studies looking at cancer risk too so higher risk of breast cancer prostate cancer and adult children higher risk of you know leukemia or CNS cancers in children as well so I think the more we look the more we find out of these associations with paternal age um so I think it's something you certainly to be aware of I think you talking about mitigation strategies I think sort of Education would be important for you know couples to try earlier you know individuals to try earlier to conceive you know if we think it's a mutational reason I think um you know certainly freezing sperm I think is a is a good option as well my understanding is that um analysis of DNA fragmentation in sperm does not allow for selection of the best sperm on the basis of uh DNA composition um translated to English what I mean is in order to tell whether or not this the DNA are mutated in a sperm you have to kill the sperm basically so um and since um in a given pool of sperm so to speak um there will be forward motile non-motile twitchers twitching in place dead sperm um some percentage of dead sperm or immotile sperm is presumably normal some small percentage hopefully um and that some might have some DNA fragmentation some might not so um is the way to address this um averages what I'm hearing here is that if you haven't already had kids or if you want more kids um that you might want to know about your sperm quality I would say you do um and that if you can afford it you might want to take a look at DNA fragmentation data um but having done this um what one receives is a chart that goes from Red bad to Green good and then they put the arrow hopefully in the green zone and then you say oh good you know I'm in the green zone I don't have fragmented DNA in my sperm but really that's an averaging of all the sperm right it could be that as you age that some percentage of those sperm have fragmented DNA and um if one of those is the one that successfully um wins the egg so to speak um fertilizes the egg then that fragmented DNA containing sperm is going to propagate that into your Offspring so are there any technologies that allow men to um select or for or improve the DNA of their sperm not just the motility I me yeah I wish right that's sort of the Holy Grail because I think he pointed out sort of a variant of right the Heisenberg uncertainty principle is that we can't if we identify which sperm is bad we're necessarily going to destroy it so to tell you know which one is harboring these mutations um would be great but I think we're not there yet I mean one thing that we do do is wash sperm so we do sort of select the most modal sperm we clear out the dead ones um and I think embas are pretty good at telling which sperm they think are better but you again we don't have any real objective data to try and understand you know which are harboring something or other but I think if we understood more about this link with age or again other conditions um hopefully we would be able to stop some of this pass through let's get back to the prostate um this incredible gland tell tell us about the prostate I I think we hear about the prostate we hear about prostate cancer um people might have heard that it's involved in the ejaculatory response it's involved in erections it's involved in a number of things if you could give us a you know a catalog of things that the prostate does um I you spent a lot of time thinking about this gland what are some of the cooler things that it that it does that we don't know about um you know how do we keep it healthy uh and what are the consequences of not keeping it healthy yeah so the prostate is a gland about the size of a walnut it sits behind the bladder and it's involved in reproduction it produces some of the proteins enzymes that are necessary for you know sperm to be supported and you know the ejacate to kind of keep the the sperm healthy um in the female reproductive tract so you know it functions in reproduction and then basically after reproduction is done it doesn't really serve any useful function so then it just becomes a problem essentially so the urethra which is where we pee through so it connects the bladder you know to exits the body um runs right through the prostate and as we age the prostate does get bigger that's sort of a known thing and as the prostate gets bigger it creates sort of more resistance in this pipe and so it makes the bladder have to work harder and that leads to a lot of the symptoms you know that we've been talking about already you know waking up at night weak stream this need to uh urinate urgently um sometimes feeling like you're not emptying all the way so it's sort of a consequence of the prostate um sort of being there uh in terms of ways that you can keep the prostate healthy I think that there's really nothing that you know necessarily you can do I think that you know one thing I talked to patients about when these sort of symptoms start is to know some of the triggers so um you know like you mentioned drinking a lot before you go to bed so if you don't want to wake up at night that's not a good practice you know may even want to go into bed sort of a little dehydrated just so you can try and last the night um there are some you know particular drinks or foods that tend to be more irritating so like spicy foods acidic Foods those can sometimes irritate the lining of the bladder and make you have to pee a little bit more you know caffeine is a diuretic uh so it makes us urinate more and also um uh can also irritate the bladder and give you that sensation alcohol will do the same thing so I think you know kind of knowing some of those triggers May kind of saave off some of the symptoms a little bit but you know again if you enjoy those vices and you're willing to tolerate it that's okay too I'm hearing more and more about a practice of people taking low dose to dofil seis um low dose meaning in the neighborhood of 2.5 to 5 milligrams per day um not necessarily for erectile dysfunction but for prostate health and was um somewhat surprised to learn that those drugs were actually developed first for treatment of prostate health to increase blood flow to the prostate um is that true and um is there good reason to um think about taking 2.5 to 5 milligrams of tadalfil per day simply for maintaining blood flow to the prostate and thereby maintaining or improving prostate health I mean certainly it can do that that it can definitely help with some of these urinary symptoms that we've been talking about you know looking at Placebo control trial sort of our highest level of evidence does show that you know low dose of tadalfil these two and a half to 5 milligram these daily dosing um can help with these urinary symptoms so I think that not necessarily it's a preventative measure but for men that are bothered you know otherwise I think most men probably wouldn't want to take a pill every day but certainly if you have some of these symptoms it can definitely help with urinary bother and then the added benefit as you also alluded to is it can help with erectile function as well even at the 2.5 to 5 milligram dosage that does interesting um yeah my experience is that there are a lot of people who would love to take pills every day um there seems to be a kind of binary distribution where um and here I'm just thinking about the malale that I hear from because I hear from of course males and females but um I get a lot of questions about what can I take what can I take what can I take um and uh but as you point out there's also a category of of men who seem to um not take anything not want to measure anything not want to take anything but especially not take anything and then there's the other group um and the other group somewhat surprisingly seem to be the L the younger excuse me population um who maybe grew up in the YouTube era or maybe in the era where Sexual Health was discussed more openly than it was certainly when I was in college I mean the extent of sexual health discussions in my high school and I went to a very good high school were um it only takes one sperm which as he pointed out is true for IVF but more is better if you're trying to conceive natur naturally um and um there were discussions about communication and consent obviously super important um and then um they just kind of turned us loose uh to learn from our friends and other sources I mean that and family sometimes had the discussion sometimes didn't um uh different families different discussions obviously um so very very little information nowadays I think there's a lot more discussion about these things and so the 20 to 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 um I I think uh if I understand correctly um you're seeing a lot of testosterone therapy that perhaps people don't need is that right well I think it's a mix some people probably do need it but I think that you know before starting it everybody should be aware of all the risks and you've kind of highlighted some but testosterone any any medication right is going to have some risks and so everybody needs to be aware of what those are and for testosterone reproduction is certainly one of them and if they're not already doing all the other things getting adequate sleep limiting their alcohol intakes not smoking getting exercise Etc seems that testosterone therapy would not be the primary entry point like first work out all the right all the basics I think that's the big difference I think nowadays the what should I take question comes up early when people aren't necessarily doing all the other things um that they could do to promote their health anyway this is observational on my part um you're the one whose Clinic they're showing up uh to um I have a question about UTI um we hear about UTI urinary tract infections um in women pretty often um do men get UTI if they're getting more than one UTI per year is that abnormal um should uh men be uh examined for um this bladder arthra prostate penile architecture I know there are ways that people can come in I was reading about this prior to this episode that um you can ingest a die and then they can die image the whole apparatus is that right that's true without having to cut anything is right is that worth people doing or is that only under conditions where people are experiencing some some um some vexing issue yeah I think that some of those tests should only be done if there's a problem but I think a male urinary tract infection is rare enough that it should be evaluated so women have very short urethras but men have a very long urethra right it has to go through the entire penile urethra the prostatic urethra up into the bladder and so the way a urinary tract infection would happen you know one way would be that a bacteria actually gets all the way you know back and that's just a much longer Trek um and so if something rare like that does happen we look for anatomic causes for that so there can be different scar tissue in the uretha for example there can be stones in the bladder there can be stones in the kidney sometimes men AR empty their bladders all the way so those those men should be evaluated because there can be some pathology that we could hopefully identify in correct let's talk about erectile disfunction um I put out the call for questions in anticipation of this episode and um no surprise um at least 30% of the questions from males were about erectile dysfunction um or uh questions about what's normal in terms of libido level kind of interesting right you know and we'll deal with the first question first but um what are the most common causes of rectile dysfunction are they hormonal in nature I think that's a a common belief that if people are experiencing erectile dysfunction that it's because their testosterone levels are too low hence all the interest in um testosterone therapy um or are there other say blood flow related pelvic flow related neural um brain to um to body neural connections that are responsible I'm guessing it's all of these things how do we parse this um and yeah what tell us about erectile dysfunction what you most commonly see what you most commonly do in order to treat it yeah so you know erectile dysfunction as you know it's sort of the inability to consistently achieve and maintain an erection and it's fairly common um you know of all the conditions I see that's definitely the number one so you know if you look at men over the age of 40 over half will have some trouble trouble with erections under age of 40 is probably about 15 to 20% so this is a very common condition that we see in terms of the ideology it can vary a little bit you know we used to think that they were primarily psychogenic um but that was you know years that was 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 sort of nationally would be the same things that cause blood flow problems anywhere in the body so high blood pressure diabetes you know atherosclerosis anything that sort of can impair blood getting you know to the end organ um 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 penal arteries are about 1 millimeter you know and the heart and the Brain they're much larger so you know it's much easier to olude a small vessel than a large vessel so that's why there have been some studies to support that it's sort of an early marker for vascular disease um so I think looking at those risk factors you you know sort of Lifestyle obesity again is another is a common one um endocrine disorders is actually fairly small it's probably less than 10% probably around 5% or so um pelvic cancer treatment is another very common one after you know treatment for prostate cancer whether it be radio therapy or surgical therapy bladder cancer um sometimes rectal colar rectal cancer that treatment also anytime it we you know um involving some of the nerves and the the vasculature and the pelvis that can also imp impact uh erectile function as well what about hernia hernia that should be separate so sometimes if there you know I always say that in medicine you can never say never um but you know generally if that was going to manifest as a rectile function it would probably be due to maybe some pain syndroms can rarely happen during just the early postoperative period but the blood supply the nervous Supply is separate so you said something very important for people to hear so I'm going to highlight it um you said that less than 10% of erectile dysfunction is due to a hormonal issue um I don't know how much time you're spending on YouTube and the internet but um 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 um it's key for people to hear that it's also key for them to know about this other 90% um when you say blood flow issue then what is the common first pass for treatment and again I and forgive me for listing this off over and over but we are assuming here that people have gotten their body weight down they're sleeping enough they're not in ingesting excessive alcohol they're not smoking or vaping they're not smoking cannabis um or doing the Edibles although maybe we should talk about Edibles and cannabis and endocrine effects we'll do that later um 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 that correctly their testosterone levels are somewhere in that 300 to 900 nanogram per deciliter range that's typical for the the so-called reference range uh in at least in the US I think it goes up to 1,200 or maybe 1400 in other countries but um as other countries like to point out um but it starts at two no I'm just kidding um but assuming they're doing everything correctly and it's not a testosterone issue then if it's a blood flow issue um meaning they haven't had treatment for some pelvic cancer what is the first line of treatment yeah so 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 you're the most um popular doctor in your field do that yeah that usually does kind of ease everybody um so usually we start with oral therapy so phosph phosphodiester inhibitor therapy so that would be like selenop or viag talil seis ail Stendra venil litra and would you be willing to talk about some of the specifics there are you um is the typical thing to put people on this 2.5 to 5 milligrams per day low dose or to um give the higher doses that are more commonly used uh for rectile dysfunction per se I think it depends you know why we're putting them on and how much sex they have too you know on average people probably have sex you know partnered sex maybe once a week on average you know when we're looking looking at men in their 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 or very often then sometimes a daily dose can be useful but generally most men are on just on demand U because they're going to fall into that you know maybe about you know a few times a month category so that's usually where we start and you know there is 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 um and you know we talk about some of the side effects they may have but those probably help 60 to 70% of men um and they work well 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 um 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 tadalfil is somewhat different and then it lasts longer the halflife 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 Friday still having some left on Saturday um but for others you know we start with with one of the other ones the fact that these drugs like toal Phil uh also called Calis right is seal the brand name right okay and um Viagra is that a brand name right stands for um what is the generic name oh selenop s okay um so because they are effective in such a large percentage cases what does that say about the vascular system of all these males that are um 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 um 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 email say everything's great um but do you need to have a discussion with that person about their over overall vascular health because if few minutes ago you told us that the fact that they weren't getting erections due to what now appears to be a vascular issue um can be resolved for the panol tissue but um 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 and may be 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 um 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 U blood glucose all those things again sort of for early markers of some of these sometimes they're 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 a 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 of the health because that sometimes can improve um you know some of these conditions but again we have terrific medications for for men in whom we cannot what are the common side effects of these drugs so they're baso dilator so they open up blood vessels so we get some of Target effects so headache facial flushing back aches leg 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 at low dosages before the game presumably to increase blood flow to their muscles and brain is that is that what the rational was I think so yeah you know another we talked about sort of how cycling may lead to erectile problems or sexual problems there has been some data looking at taking like biago or one of these medications the AL to alil 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 just increasing blood flow and lowering blood pressure slightly is just a good thing all around yeah I think there's certainly a benefit yeah because these medications were originally I think as you're alluding to were developed as a blood pressure treatment and this was sort of an amazing of 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% can be resolved with um with these blood flow enhancers I know it's a terribly non uh non-clinical non-scientific way describe the Viagra Calis toil um Etc um what about the remaining percentage and are there other treatments that um you you prescribed or or given um in which cases do you need to uh resort to um I guess more invasive approaches yeah so another therapy we have is urethal suppository so you can actually put a medication in the tip of the penis it's then absorbed by the rest of the penis also inject it's suppository suppository or a gel or a jelly yeah um so it's also a basa dilator sort of the concept is very similar um some times that you know is is okay for men and they tolerate it it's uh safe for partners as well um it can tingle a little bit so we definitely let men know because um one of the main medications does cause like a little bit of a 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 um and so this this this can sometimes help where others cannot so that's one uh penile injections are another common therapy so the efficacy of penile injections are probably 80 to 90% uh again we're injecting basa dilators into the penis so the idea just opens up blood vessels easier to get and to keep erections you can imagine there's a huge psychological barrier to putting an needle in your penis is this 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 we teach them how to do it the first time I do it with us in clinic I ideally we try and get an erection that lasts probably 20 to 30 minutes so we usually start at a low dose and then they just increase at home until they get you know an erection that last for that amount of time is it injected subcutaneous or actually into the um goodness the meteor tissue of of the penis that's right into the erecti bodies directly yeah and they you only have to inject one side they do communicate with each other most men say it's fine it's a small it's a very small gauge needle about as big as you know a few strains of hair like I have an appointment over in Opthalmology 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 skilled opthalmologist it's just striking you know you hear you think about needle in the eye you know what's worse it's like the childhood rhyme right stick a needle in my eyes like can't think of anything worse but um maybe you know an injection in the penis sounds almost as bad but you're telling me that if patients are prescribed this that they can do this with with limited if any discomfort well it does have a high dropout rate surprise surprise um yeah I think no one's excited about it you know it's I guess the mood can sometimes be affected but a lot of couples are very comfortable with it again it's very efficacious the part the man can do it his partner can do it um so it does work well and I I guess here we're sort of ascending the the list of um invasiveness right um what what is at the the sort of top tier of invasiveness for for etile dysfunction so then we go into penal 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 the non-inflatable is sort of a bendable um 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 it's really just they are on demand yes H yeah interesting yeah so it's very simple to use um sort of the more I gu kind of um sort of natural form would 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 it' 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 you which usually is also it's also surgically implanted into the penis to get a rigid erection what is the relationship between psychological arousal and erection as it relates to these Technologies I mean the way you're describing it sounds purely mechanical right um we're talking about nocturnal erections which I suppose people could be having erotic dreams but I don't think that's a prerequisite for nocturnal erections at all right so um is the idea that if adequate blood flow is achieved 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 um sounds like blood flow is almost um autonomous right well I think a lot of these um yeah 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 um that sort of starts that Cascade that releases neurotransmitters in the penis that leads to this phase of dilation you know naturally and men get erections a few years I was reading about um vasopress inhalence you know there was a bunch of stuff hitting the market um by the way I don't suggest that people um get experimental with this stuff you know as a neuroscientist who also um knows the thing about neuropeptides and neuro hormones that can impact the hypothalamus you know I just I I just cover my eyes and kind of um cringe when I think about people inhaling vas oppress and thinking oh yeah you know there's a study that is oppress and increases sexual desire or something like that um but nowadays I'm reading a lot more about a really interesting peptide um treatment which I think is a FDA approved prescription drug which is um relates to uh a um melanocyte stimulating hormone that comes out of the medial pituitary um that is used to increase sexual desire it's prescribed for women um but men are starting to take it um and it seems to have at least from what you read on the internet um a pretty profound impact on libido and on erectile frequency and persistence um is this something that you know it's you're using in your clinic um uh yeah what about these peptides that people are inhaling and injecting and some of them are taken in oral form but most often I think it's nasal inhalent or um uh or it's uh a subcutaneous injection yeah so um those are not ones that 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 um and one of the things sort of that I 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 men ejaculate too quickly um but on the other end of the spectrum there's men that takes you know a long time to ejaculate and you know what that is is sort of defined differently but generally most people would say like sort of two standard deviations above average on average probably around 5 minutes or so two standard deviations would be kind of 20 to 25 minutes so for men that take that long to ejaculate that would be considered delayed or sometimes they don't ejaculate every time that they you know have relations so for those I think there is a need for treatment because there's no FDA proof therapy for that um and so that's why I think you know providers are trying some of these other you know more experimental things um there's some that we use just not that one in particular um there's also some devices that have been trial as well but it's it's a challenge because you know I certainly you really feel for these men um it's one of the pleasures in life um 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 um the topic of pelvic floor health is something that comes up more often around female reproductive health and Urology um you hear about Keel Kagel kull I don't know I guess we'll have to ask him because it turns out keigle Kel was a person um who named the exercise after himself um whether or not he did them or not I do not know but um my understanding is that Kagel are a pelvic floor strengthening exercise um and my understanding is that some people experience urinary or sexual dysfunction because of a overly relaxed AKA weak pelvic floor but that some people have the exact same problems because of a hypercontracted AKA overly tense tight strong pelvic floor meaning don't run out and start doing Kagel just because you heard about them they're not good for everybody they might be bad for certain people but what about pelvic floor health I mean should men be paying attention to pelvic 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 you know 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 allude to is he probably needs to relax more so you know pelvic floor Physical Therapy can still benefit you because there are some just different feedback exercises that could be done to help with relaxation so you know any urologist office there's usually a list a lot of different providers around the region that can help with some of these um keegle exercises though can be useful you know for example for um like prostate cancer Rehabilitation some of these men where we're trying to kind of rebuild some of the strength or maintain or improve continence in these men we do want to strengthen some of these muscles 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 um 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 uh pretty much gender or sex agnostic so they usually are able to help all and um forgive me for uh asking for an Abridged Anatomy lesson here but um could you describe the pelvic floor muscles and how they relate to the bladder prostate urethras anatomy that you talked about before because I have the picture of the bladder urethro prostate penis in my brain um I know um my uh life experience where the testes and scrotom are relative to all of that but now I'm trying to figure out um how like so the pelvic floor a bunch of muscles that that are attached to the pelvis but how do they interact with those uh 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 Beyond too so they basically support all the structures there they support you know the base of the penis the prostates the bladder the rectum uh and you know they're they kind of keep M you know adequate tension to keep all those structures up they relax when you know different functions are necessary they're very important for ejaculation um you know some people think that they kind of trigger some of the orgasmic response as well um you know sometimes men will have you know pain in that area in the perinal area can transmit to other parts of the body like the scrotum you know one of the one cause of scrotal pain and there can be many can we pelvic flooor dysfunction so I think you know again pelvic floor therapy can be useful for sort of a constellation of symptoms against some urinary symptoms as well so I think for some patients it can be helpful but um you know again there if if you get things too tense um that can sometimes be harmful so presumably these pelvic floor therapists 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 um came back to me when I I solicited for questions and anticipation of this episode um several not a few um let's say a couple dozen people asked about split urine stream is that a signature of prostate overgrowth is that a a urethal issue is it perfectly normal um I'm assuming here they mean a split stream of urine that doesn't unify at any point they're talking about a consistently split urine stream and for those of you that don't know what I'm talking about we're talking about a urine stream that's actually two urine streams and we're assuming one urethal opening because I hit the literature on this and um there is a case of of failure to fully fuse the urethral duct during development where people some I'm assuming small fraction of males have a ureal opening on the base of the penis and at the tip of the penis let's rule that out as a as a possibility for now um but now that it's on the table what percentage of males have that uh twoyear rethal openings so well hypospadius which you're describing where the the actual meatus is not at the tip but it's kind of along the proximal urethra or you know even further down sometimes in the scrotum probably about 1% of births um and usually it's recognized at Birth and oftentimes it's surgically corrected because it's better to repair it early rather than later okay so ruling that out um what is the cause of split urine dream and is it um a signature of a larger issue you know one of the reasons that we you know urinate sort of um from an evolutionary standpoint right is to you know basically deposit in sort of a convenient time our waste and we don't want to get it everywhere because we don't want to sort of label ourselves um with smell of urine because that'll be easier for predators to to be able to identify so just similar to today we'd like everything to get in the toilet without creating a mess so anytime there's turbulent flow um it it certainly could signal an issue so it could be like a urethal issue as you're pointing out a prostatic issue inadequate speed you know of getting the urine out the meatus so you definitely should see you know a physician to get evaluated because there's likely some issue that could 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 um not just because you're a urologist male reproductive health expert but um you published a study recently on the changing Trends in penile length um tell us about that study I have so many questions about um the methodology because um I have to assume this didn't involve self report right those were excluded yeah yeah so um lying was excluded um being fous here but um yeah how was this study done I mean pretty incredible study um and the results are I don't know if they're surprising or not I 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 um I'll let you describe the study now rather than 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 P length you know sometimes they do it uh just on volunteers again to sort of get the average lengths of different populations sometimes it's done pre and pro- surgically to try and understand what changes would occur um so we just sort of called the literature found data on 55,000 men all over the world um and wanted to see if there was a you know sort of a Time pattern with that and similar to your hypothesis we assumed based on all the other data that we would likely see a decline you know whether it be you know chemical environmental exposure but if nothing else if we're getting bigger you know the functional penile length should decline because you know the super pubic fat pad will get a little bit bigger and so we'll kind of lose penile length with that and so much to our surprise the super pric F pad excuse me um being the pad of fat directly over the penis right right and so you know if that gets bigger that'll necessarily compromise penal length but you know as you alluded to what we found is actually the opposite that um that penises were getting getting longer with time so how it's measured measured differently so one of our inclusion criteria was that all the study 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 a penis you can just do a stretch length so you kind of stretch it up as much as you can and then use sort of a ruler to measure how long it is again from as 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 from the bottom believe or not people ask questions about this um my daughter made that joke actually oh yeah yeah yeah uh measuring from the top not from the bottom no cheating um you're talking about stretching the penis while it's flaccid presumably and then measuring from essentially contact with the 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 mhm wow yeah so that was one and then we also looked at ere length and so there's different ways that an erection can be achieved 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've alluded to earlier is you could inject a man with a medicine to give him an erection and then measure it and did 50,000 men participate in that aspect of the study it was less no that was I think that was about probably 10 to 15, men I have to wonder whether or not it's easy or 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 tremend mendous number had about um like 15,000 men some individual studies contributed that and actually interesting after we published it there were some men that volunteered uh for the next study to be measured I'm sure you'll hear from some of them after this episode um 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 um the average lengths you know varied a little bit but generally on average um erect penis is probably between about 5 to six in somewhere in that neighborhood so that was kind of the take-home we want that was the average the average for rec length did you publish the full distribution uh we didn't I think we were we're we're 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 I would think that um despite the um you know the wide availability of pornography that um that the distributions like the plots of all the data uh would be interesting to men um for the same reason that the testosterone by function of age data published as a scatter plot in that textbook I referred to earlier right were interesting because um the scatter plot distributions I feel like um point to um other takeaways that one can be in their 70s and have testosterone levels equivalent to a male in 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 as AG match cohort this kind of thing um I think there there's value in that so um what what other takeaways um uh arrived with the data from the the penis length study that perhaps we didn't we didn't hear about like what what did you find most interesting about about the data well that there was any change over time you know this was a fairly short uh study was probably about you know 30 years or so um but we did find that penile length has been increasing over time so um 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 wouldd see a lengthening number two so you know again similar to the concerns that arose for these you know relatively short period of time where you would see changes in seman quality um you know it suggests something sinister right it's unlikely to be a genetic change because that would take you know centuries probably uh certainly several Generations so the fact that this happened so quickly um was just surprising um this brings to mind some of work that I was involved in years ago um when I was a master student I studied um early organizing effects of hormones on uh the brain and body and um I'm sure this has been updated um since then but um my recollection is that uh during embryonic development males um are exposed to a certain amount of dihydrotestosterone not testosterone but dihydrotestosterone which organizes the brain male as they used to say now the the verbiage around that would probably be a little bit different but the idea is that um males are born um 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 um post puberty right I'm assuming it was um then it would imply that something's changing about the levels or the signaling related to dihydro testosterone um how could that happen um 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 from you know or environmental factors either in utero or post utero um suppressing testosterone levels here we're talking about the opposite effect we're talking about dihydro testosterone 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 could make about why this could happen I mean it could be you know 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 um another hypo 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 link so earlier puberty tends to be longer 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 uh subculture online I know because they contacted me in anticipation of this episode um of um post puberal males who take a combination of dihydrotestosterone and low levels of growth hormone in efforts to try and increase their penile length and the the um ones taking dihydrotestosterone they're not taking pure dhg they're taking things like oxandrolone um which very closely mimics the structure of DHT um they report um some success um fortunately they did not send me pictures um otherwise I would have just forwarded them to you for your next study um but this stuff is happening um in post puberal males so um it it all rests on this dihydrotestosterone hypothesis um I don't know just a point of Interest yeah I don't know it just physiologically it doesn't make sense why that would work as you're pointing out post pubertally and then unless they're doing other things you know some sort of stretching exercises or call joking but yeah it I would not recommend that thank you that was the response I was looking for so um that Community will be listening with um uh open ears don't do it as long as we're talking about DHT dihydrotestosterone um it's only fair to discuss the drugs that many people take to suppress dihydro testosterone in hopes to keep or grow their hair things like finasteride dutasteride um some maybe many not all people who take these drugs particularly in oral form experience um sexual dysfunction issues um 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 um staving off certain forms of prostate cancer what are your thoughts about fide toride do you see people coming into your clinic who are having sexual dysfunction or types of issues because of their hair or attempt to maintain or grow their hair issues and um equally important is that we talk about so-called postfastr syndrome I got a lot of questions about post finasteride syndrome um because I'll describe it in a couple of minutes um it sounds pretty devastating for these people's lives um and I'll explain why it's so devastating for them um in a moment but yeah what about finasteride dutasteride and these drugs that are effectively DHT block ERS um DHT levels if they get too high indeed can miniaturize the hair follicle cause people to lose their hair typically up front or in the back so-called crown or whatever you know widows PE uh uh uh or everywhere some cases um 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 often times they have erectile dysfunction or other issues is that surprising to you you know I think the men that see these um these side effects are are tend to be you know younger men in their 20s 30s and 40s uh 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 you know they did randomized control trials to look um and one of the other things that we'll talk about too is just reproductive effects so they did you know lots of studies to see if there were changes in cement 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 um you know everybody to enroll in these studies had normal function so I think that's sort of important to understand and obviously that's not life right that people come in with sort of different baselines and different amounts of reserve and so we now know that there's probably people that are a lot more sensitive to these medications and others and so there are some men that drop their sperm counts dramatically and usually if we're we stop these medications their sperm couns can recover you know usually a spermatogenic cycle is probably about 2 to three months so usually in maybe 3 to six months we usually see recovery for most men um but similarly for you know sexual function I certainly you know have a number of patients you know that do complain of low libido erectile function this post finasteride syndrome um you know and the mechanisms I think are less certain because you know measuring testosterone levels which we do you know sometimes if androgens are low or even if androgens seem to be in the maybe normal range or low normal range we'll try and increase testosterone through a variety of means testosterone chopine sometimes will give you know it helps some but not all so I think the exact mechanism of what is going on here what is changing I think um you know we need more you know more understanding about the exact sort of path of physiology um neur you know or neurochemically it seems like a pretty serious trade-off to either maintain to grow hair or lose sexual function I mean I talked about DHT and some of these um side effects of faside dutasteride on um previous episodes and you know I'm not a clinician but my encouragement is always for people to approach these drugs with a with a real level of seriousness if not caution um the post finasteride syndrome was described in these online questions as seemingly permanent even though um people had ceased to take finasteride or dutasteride so in other words they were taking this stuff they I don't know how they felt while they were on it but they stopped taking it and the sexual dysfunction issues um don't seem to be resolving um does that mean they should go see uh you or another uh male urologist reproductive health specialist yeah I mean oftentimes they do for you know these complaints um you know they start to notice it when they're on the medication then when they you know usually through online research kind of learn about this potential entity sometimes they discontinue now some men do have resolution when they stop but there is this permanence in some handful of men um you know they've done you know MRI imaging to try and understand sort of you know more anatomically or fun what exactly is going on I think there's still a lot of unknowns about it but it can be you know permanent for some so they come in you know and they see me in clinic erectile dysfunction low libido and then we go down all the the host of treatments that we talked about and evaluations that we talked about again we have resolution in some but there are some that seem treatment refractory yikes that's my only response I mean permanent effects uh on Sexual Health in it as a consequence of an attempt to maintain one's hair I mean this is where you know um in all seriousness it it it just sounds like something that um people need to think very seriously about because it as I understand there's nothing that can predict whether or not someone will have post finasteride syndrome right right um and I did um a bit of reading on this uh within the scientific journals as well there isn't a lot of information as you point out because it's a fairly recent phenomenon and that highlights a different issue this may be the first time in history where young males are taking finasteride and dutasteride and that might be the cause of the post finasteride syndrome right I think you 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 finasterid syndrome um I think falls under the category of medical conditions that um you know a few years ago we we would hear the same about um chronic fatigue syndrome even fibromyalgia not long was considered one of these oh is it all a psychosomatic issue now we we now clearly know that's not the case for fibromyalgia by the way um but I can recall a time not that long ago when people um in the medical profession kind of like well yeah this I don't know if this is a real thing but post finasterid syndrome sounds certainly real for the people that are suffering from it exactly yeah yeah okay well the reason I'm spending so much time on this is that um I get a lot of questions about it and there clearly a lot of young males who take finast rid or do tast Rider are thinking of doing that um for cosmetic reasons and I think they should be aware of the potentially serious consequences yeah agree yeah but you did say earlier that if someone has a penis you can get it hard so um so all is not lost even for these post finasterid syndrome individual good okay we'll hold you that um you mentioned chopine um could you explain what chopine is and what it's used for um because again uh we want this discussion to be centered around the real science the real medicine um but there is a growing kind of subcommunity of people out there who are saying okay testosterone therapy can cause us these sperm um suppressive issues and perhaps some other issues um but doing nothing might not be an option for somebody who wants to increase their whatever libido other aspects of of um Androgen function um and so there are a growing number of people out there who are taking chopine only in order to presumably increase testosterone but my understanding is that it would impact the estrogen pathway as well yeah what's chopine uh what are your thoughts about people using chopine um sort of off label um simply to increase androgens seems sketchy to me for reasons related to changes in neural circuits um but you'll tell us how it works well thank you for including the off Lael disclosure anytime I talk about this I always have to say say that but F so chopine 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 and the man the testes and so what happens is you know FSH LH these genotropin stimulate the testicle to make sperm and testosterone testosterone's peripherally converted to estrogen and that feeds back on the hypothalamus to stop that so again you don't get an over production so by blocking the estrogen receptor the level the pituitary or the hypothalamus you'll stop that and so the idea behind blocking that is that you'll get more production of FSH LH more of these drivers so you get more testosterone you get a higher stimulation of the testicle you know the hope is that for fertility that sometimes it can improve sperm production too and there's some limited data that can help um but I think as 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 we kind of talked about somewhat in this uh this discussion but also that you know you do need some estrogenic signaling as well and so by blocking that you know even partially because there's also some partial Agonist effects of chopine as well it may limit it um and you know it turns out that estrogen signal is important for a lot of things is important for you know bone health but sexual health too 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 um but one of the advantage of chopine if we are thinking about this as a treatment for low testosterone hyperism 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 we'll continue to get sperm production so for this reproductive age man that has low testosterone and symptomatic low testosterone you know low to you know low energy level sex drive mood sleep problems uh it can be a worthwhile treatment and it it does help a lot of men um 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 chonic gonadotropin because as you mentioned earlier luteinizing hormone and FSH follicle stimulating hormone um are deployed from the pit and travel to the testes where they stimulate um testosterone production and sperm production but it's the FSH specifically that encourages sperm production so why wouldn't um a man who's taking maybe testosterone therapy or who perhaps just wants increased sperm caltin quality take FSH instead of human chonic G atropin which is more or less a proxy for luteinizing hormone that's a really good question and so what FSH does like said is it simulates sperm production so it seems like it'd be a much more logical treatment and actually in randomized Placebo control trials it does do that so one of the Reas it does do that it does 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 $300 to $500 but a month of sort of therapeutic FSH is probably $2 to $3,000 so that cost is really limiting it takes two to three months to make a sperm so um you know men often have to be would 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 as Aden therapy with testosterone rather than HCG um but HCG does work you know sort of everyone's surprised it does actually help um but yeah I agree there is sort of a contradiction there so if the price came down it doesn't you know this is another off Lael medication for that indication um it would be it could be worthwhile one hormone that we haven't discussed is Pro prolactin um I'm familiar with prolactin from a variety of perspectives but um I always think of uh dopamine and prolactin is kind of a seesaw relationship dopamine's up prolactin is down you know dopamine is elevated with sexual desire sexual activity post ejaculation prolactin goes up sets perhaps the refractory period on erection ejaculation for some period of time and then dopamine comes back up but you know this kind of thing and I realize 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 um I don't know if plural Pras is uh is clinically correct but um elevated levels of prolactin that are causing problems um for men um what are some of the telltale signs of that um and this I'd like to use as a segue to talking about um some of the sexual dysfunction that is commonly discussed around the use of ssris and other other drugs to treat depression and and mental health issues that sometimes create um endocrine and or sexual health issues yeah so prolactin um is sometimes it's a diagnosis hyperprolactinemia it's a diagnosis make not that many times I would say you know less than 1% 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 we see a lot of patients um typically the The Telltale sort of symptoms would be you know ones of low testosterone that's a common one but you know in my practice I see it a lot with men with very low sperm production so I've diagnosed several prolactin secreting tumors and the manifestation of that was you know they weren't getting pregnant we checked a sperm count it was 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 testost or fertility problems will usually you know be able to diagnose it if it's present are there any other hormones in the um in the galaxy of sexual health related hormones that uh fall into uh you know Common clinical practice uh for you um I check estrogen as well so I think that's another one it's again because of the relationship with obesity I think that can be important sometimes there's too much aromatization and so sometimes uh that can be a problem I think you just like we talked about normal estrogen signaling is important I think too 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 male breast tissue yeah as I was um told um what was it that the uh male breast tissue is sort of like um the appendix it's there but it's not very interesting that's 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 veric yes so verical it's a very common condition probably about 15% of all men have it and it's a very common cause of infertility if you look at all the ideologies it can be 30 to 40% so basically what it is is dilated veins in the scrotum um so obviously we need veins to get blood out of the testicles uh but sometimes they can be a little larger than average and there's sort of a normal sort of thermal regulation so if the veins get too big it's thought to warm up the testicle the other thought is that it doesn't adequately clear some of the metabolites um so exact the pathophysiology is you know somewhat debated but I think those probably contribute um and it's something that everybody should be evaluated for if you're concerned about fertility um so again we see it very commonly you know given the fact that a lot of men have it about one in seven men have it it doesn't always cause a problem but maybe about 20 to 25% of the time it does so men will manifest with low sperm counts we see sometimes discomfort you know ache you know worse at the end of the day then at the beginning orse of the activity anytime blood can pull sometimes it stretches and some men feel that and then kids sometimes it can lead to um either stunted testicular growth or shrinkage of the testicle um it's also thought to be a progressive lesion so the longer a man has it the more damage it can do it usually manifests around puberty in general um so it's not a concern for everybody but I think certainly if couples are having difficulty conceiving you're having discomfort in the area and you have one it's a discussion you should have what about Pon disease yes so ponis 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'll get like a curvature deviation sometimes you can get an hourglass or sort of a banding um if you look it up on the internet you can see you know a host of different deformities that men get it probably present about 5 to 10% of men so it's very common um sometimes it could be from injury you know from you know a like a penal fracture other you know sort of less severe form of injury to the penis sometimes men have described hitting it on different things potentially that could could lead to it sometimes it can manifest after um prostate cancer surgery or other kind of surgeries which can you know sort of stun the penis or you know injure some of the nerves of the penis um so that's another condition we see commonly um you know obviously it can lead to bother you know and erections are not straight that can just you know cause um you know psychologic bothered a men it can also physically make it difficult for a man to have sex you know um sometimes it can limit certain positions so that's another common complaint we see um I think it's something that men should be aware of there's now awareness campaigns now that there's an FDA approved medicine for it collagenase or zlex which is a medicine that disolves scar tissue um so that's one of the treatments we have for it 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 um and then there's also surgical options too so there's a lot we can do I always tell men again as long as we have a 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 uh testicular size and volume wasn't also measured and and that's something that we haven't discussed um what is the relationship between testicular size and volume um and some of the other parameters we've been talking about and maybe this is also a good time to highlight um any kind of um morphological signals that uh would warrant people coming to the clinic so asymmetry in testical size for instance um changes in testicular size um obviously a psize lump uh they taught us in uh High School is um a warning sign of potential testicular tumor or cancer um yeah we didn't really talk about testicles yeah so I think that yeah kind of being aware you know the average size of um a testicle for a man is about you know sort of about a walnut so it's about 16 to 20 CC's um you usually if you're going to measure it it'd be about four to four and a half centimeters and longest axis to give you know your listeners or viewers some idea um if it changes certainly let people know if you feel anything let people know although um our uh you know 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 diagnosed but I think you know I always tell men no one knows your scrotum better than you so if you identify you know a problem you should bring it to attention so you know the classic appearance or the way that a test cancer would manifest is a firm painless mass that you kind of feel coming from the testicle um I find it interesting that um at least as I understand women are encouraged to do regular self- exams of their breasts for for lumps so but you're telling me that men are actually discouraged from doing regular exams of their testicles for lumps could be cancer that feels like a um unfair asymmetry it does I mean Cancer I mean both both seem very important um oh yeah well I think there's no question obviously I'm very biased yeah I was trying to say it so you didn't have to right oh yeah I don't want to get in trouble with the US I don't want anyone to get cancer I mean I so um I don't even want a dog to get cancer um so I'm surprised that they discourage self- exam um 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 um the false you know lumps that they identify just lead to more anxiety and end up not actually you know causing more harm than good I think is the concern but um yeah it was a surprising recommendation when it came down usually patients ask 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 the 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 um 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 um but is there any way that um patients who have insurance can uh approach their physician in a way that this would be covered by Insurance um I don't want to get you into any trouble here but I you know it's it's always such a shame it is such a shame when we're talking about something that is really um per pervasively related to health as is sexual health reproductive health and people are not aware of a potential 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 um a sperm analysis um so we can't be presumptuous and saying oh well you know two $200 or $1,000 is no big deal I mean for a lot of people that's a huge deal right um it's prohibitive um for many people so how can people get this stuff assessed um should they talk to their primary care physician should they um 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 you know sometimes we check Sean analyses for other Jacory issues um but I think that you know again as more of this data gets out I think as more recognition how important the mail is I think we'll get um sort of more buying and coverage obviously women have you know the automatic feedback of obory Cycles so they kind of know and 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 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 um normal seamen volume and have very low sperm count right we're not talking about the total amount of ejaculate per se we're talking about the density of forwardly motile healthy non-dna fragmented sperm in that at seen right so in other words it's not sufficient to just um assume because uh 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 1% of men have no sperm in the ejaculate and that's something sometimes they have no idea about so the only way to know would be to actually do a formal test well I'm encouraging people um to get these parameters assessed and I'm making that statement um because it's very clear based on everything that you've told us today that sperm quality and hormone levels are just oh so important um not just for sexual health um but for urinary health and for reflecting prostate health and other aspects of whole body health and and um Sexual Health relates um directly to mental health right we we didn't talk so much about the psychogenic issues but um the two go hand inand exam I wanted thank you so much for coming here today and sharing so much knowledge with us I mean these really are the issues that um males think about and wonder about and um have questions about um and they do so to varying degrees depending on where they're at in life um but I think especially for younger men who are hearing this um who are not at the point where they want to conceive um it's really important to start thinking about these issues for all all the reasons you mentioned I think these issues are really important um for women to know about as well just as it's important for men to understand uh female reproductive health and and uh to not just improve communication but this after all um is at the heart of the uh the presence and proliferation of our species so thanks for taking care of the male half and um uh and thanks for doing the work you do it's incredible um the large scale studies the the more detailed the studies the uh on smaller populations the you ask the questions that it seems um uh many people are just uh afraid to ask and and you get right in there and 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 thank you for joining me for today's discussion with Dr Michael Eisenberg to learn more about his research and his clinical practice please check out the links in the show note captions if you're learning from Andor enjoying this podcast please subscribe to our YouTube channel that's a terrific zeroc cost way to support us in addition please subscribe to the podcast on both Spotify and apple and on both Spotify and apple you can leave us up to a five-star review please also check out the sponsors mentioned at the beginning and throughout today's episode that's the best way to support this podcast if you have questions for me or comments about the podcast or guests that you'd like me to consider hosting on the hubman Lab podcast please put those in the comment section on YouTube I do read all the comments not during today's episode but on many previous episodes of The hubman Lab 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