Why Is Male Fertility Crashing Globally? - Dr Michael Eisenberg

global sperm counts have declined by over 50% in the last 40 years. Is that true? >> You know, it really is. I think, you know, in the last few years, there's been a lot of consensus around that. You know, one of the most famous studies that looked at this was published in the '9s. Um, and you know, when it was released, I've talked to some of the authors about it. There was a lot of fanfare around it. You know, they had it in a big um media hall. There were television cameras. uh but since then there was a lot of controversy around it um you know for a few reasons you know there is you know there are differences in semen quality around the world like for example there's a study in the United States that showed if you can believe it sperm quality is higher in New York than in the Midwest and I think reasons for that are not certain you know whether it's lifestyle you know activity levels there may be differences and you know just sort of race ethnicity composition I think the reasons are not known but you know in the US we see that but around the world we see that too and so there were some concerns about how all that incorporated to some of these studies. Um you can imagine over 40 years some of the methodology for testing sperm has probably improved a little bit and even our you know statistical methodologies comput computational abilities have improved. So you know initially in the '90s I think it was somewhat controversial. Even some of my mentors questioned this but I would say over the last you know few years there was another study in 2017 then even 2023 most recently and it's really kind of solidified and now there's consensus in the field that we're seeing this decline. You know over the last 50 years maybe it's called about 1% so maybe about 1 million less sperm per year on average every year but over the last you know 10 20 years it's accelerated actually about 2% uh decline. And so I think it's you know now that there's a little more um you know again sort of consensus around it I think it's really up to us to understand why because um yeah it's not not a good thing existential I think in a lot of ways >> okay why do we think that this is happening beyond the ability to detect statistical improvements physically what what what's happening >> yeah I mean I think that's the million-dollar question or billion or trillion dollar question really um I think there could be a few reasons you know the pace of change is probably too quick for evolution I don't think it's a genetic factor, you know, so I think people have really honed in on exposures, you know, whether it's, you know, lifestyle factors. I mean, I think that, you know, we're probably a little less sedentary than we used to be. You know, obesity was going up, although maybe with some of the new medications, we'll see reversal of that trend. But I think there's a lot of concern about just some of our exposures. You know, some of the chemicals in the environment, microplastics, I think those sorts of things. you know, there's some endocrine disrupting factors that are at play here that that may be the culprits, but I think, you know, we need to really do more work to try and understand it. Um, and I think that's kind of where we are. >> So, you at the forefront of this have a broad perspective that stuff's not great. Numbers are going in the wrong direction. We kind of have an idea of what's going on, but actually finding an individual target or a couple of targets that we could intervene with, uh, it sounds like a pretty complex problem to try and solve. >> Yeah, I think that's fair to say. I mean, I think there's, you know, there's things that we talk to patients about. I think just sort of broadly when they come into the clinic, you know, obviously, you know, patients come to see me for fertility, they want to figure out how to get better sperm counts, right? And I think that's ultimately what what our goals are. Um, so I think, you know, lifestyle, you know, health, I think all those things are going to come at play. I always tell men, anything is good for your heart, it's good fertility. So, we talk about diet, exercise, maintaining good body weight. So, you know, I think things that you can do, um, you know, like whole grains, fruits, vegetables, I think those are important. you know, try and spend more time, you know, walking around and, you know, less time on the couch. I think those are sort of easy, actionable things. I mean, I think to the extent possible, try and limit exposures, you know, I think we've gotten a lot more awareness of, you know, some of the harms of like plastic. So, trying to minimize like plastic water bottle exposures, you know, but I don't want to be alarmist or scare people. I think um, you know, can very easily increase anxiety, which also isn't good for sperm production, >> right? Yeah. a vicious a vicious cycle where worrying about your sperm production reduces your sperm production. >> That's exactly right. Yeah. >> What are the you mentioned exposures microplastics being one of them. >> Yeah. >> I saw this study microplastics found in dog testes and all donor testes from men. What's what's the likelihood that this is having an impact on fertility? >> Yeah. I mean I think you know that was a really interesting study from New Mexico. They looked at, you know, dog testicles uh that were taken at the time of neutering. And then they looked at testicles from men, you know, that were taken like from autopsy. Um, and it was interesting all of them actually had uh microplastics within. So, you know, it's very ubiquitous exposure. Again, we get it from just the environment and talk to experts in the field probably in our food supply. So, it is difficult um to the extent possible to eliminate it. Um but you know I guess it's question of you know what it's doing and you know plastics are thought to be somewhat inert so maybe it's doing nothing but they're also you know there's lots of other chemicals that are usually at play that have endocrine destructing um you know properties have some of them are carcinogens so you know the I think the studies that we have that look at function of this I think are are concerning so you know they don't have you know semen quality on the dogs unfortunately or the people but you know there's sort of a rough approximation So in the dogs they saw that larger testicles had had higher levels than uh or sorry had lower levels than smaller testicles. And so we do see this sort of most of the size of testicles devoted to sperm production. So larger testicles usually you know make more sperm. And so if we're seeing that you know those have less you know less microplastics maybe there is some functional consequence to that. And you know, there have been some add-on studies where they've looked at, you know, semen samples and actually did show correlations between higher levels of microplastics and lower semen quality like counts, movement, shape. So I think, you know, again, all these are are are concerning elements uh to this story, >> right? What other exposures should people be worried about? >> Well, I think you know the things that you can you know sort of think about are some food exposure. So I think trying to limit like pesticide exposure. So you know again I think data around organic um produce is not great but I think there you know there is some you know pretty good evidence. So to the extent possible trying to eat organic I mean there's some foods or fruits and vegetables that tend to have higher pesticide exposures than others. So you know like foods where you eat like the peel like um strawberries are notorious for having very high pesticide levels just cuz you know we eat the whole thing. There's all these nooks and crannies so it's hard hard to adequately wash them. Although I love I love strawberries. um so does my family but you know you try and get organic when you can um and then sort of being you know more sort of aware of some of the other chemicals that we talk about like phalates you know different uh phenols as well um so you know looking at packaging I think you know for like skinincare product for um you know sun you know sunscreen I think you know there's organic types that do have some endocrine disrupting properties compared to mineral sunscreens are thought to be potentially safer so you know when possible, try and switch to those as well. I think that also makes sense, >> right? Okay. Getting back to the question at hand, the problem of sperm counts. What do people mean when they're talking about sperm count? The total volume of sperm are we talking about? I know that there's a lot of different contributing constituting factor when it comes to sperm health, male fertility. Uh what what are people talking about? >> Yeah, this is a great question. Sort of fundamental. So, you know, what are we measuring? What's what is a seam analysis? So there's a few things that we do you know just logistically we ask men to collect and then we let it liquefy so it comes at you know somewhat viscous and then after a few minutes it'll liquefy and then we can measure it. So we measure how much there is the volume you know that's an important measure we also measure the concentration so how many million sperm per milliliter um we look at the motility you know how many are moving around and then we look at the shape as well or called the morphology you know there are some other tests as well you can look at sort of evidence of oxidative damage in the sperm you can look at something called DNA fragmentation which looks at as the name implies damage within DNA so you know we look at all that now when we're talking about declining sperm counts it really is the counts So they look at, you know, the concentration, how many million sperm are in each drop of sperm, and then also just look at the total sort of number of sperm, kind of the payload and how that's changed over time. You know, we haven't looked at some of the other parameters because those, you know, have been, you know, kind of a moving target to some extent. You know, morphology, the shape, I think we've, you know, advanced a little of what we think sperm are supposed to look like. So that's sort of hard to measure. And then, you know, the way that we measure sperm movement has also changed over time. So that's also been a little bit more challenging to measure over time. So when we talk about declining, you know, fertility, really we're talking about the counts, >> right? What is there a triage list of priority here in terms of all of the different contributing factors? What's most important when it comes to assessing male fertility and sperm quality? >> Well, you know, usually I think the count is probably the most important. That's usually how we talk to patients about it or at least, you know, the number of moving sperm. Um, you know, we t you know, sort of on on average, you know, men have probably about 50 to 100 million moving sperm. Um, and you know, for couples trying on their own, you probably want at least 20 to 40 million moving sperm. Now, when you get lower, then you need to start thinking about some assistance, you know, to get pregnant. So you know if you have like you know less than again less than kind of the 20 million 5 to 20 million there's something called intrauterine insemination where you can take sperm put it inside female partner's uterus when she's ovulating or with just a few dozen sperm you can do in vitro fertilization where you mix sperm and eggs together in a dish. So you know ultimately for men I always say it is somewhat of a numbers game although it's interesting when you look at it it's not a perfect measure of fertility. So you know if you look at men with you know hundreds of millions of sperm some of them won't get pregnant and then when you look at men with just a few sperm you know like a million sperm or two million sperm some of them are able to get pregnant without difficulty. So you know it's it's a complex problem. I think also you know fertility is ultimately a team sport. So I think you know what the female partner brings to the table is also going to be very important to some of this. Um but it does give us just sort of an overall assessment of you know likelihood of having issues or not. >> Right. Okay. What are the biggest determining factors that influence a man a man's sperm quality then? >> Well, I think genetics play a big role. I think, you know, you're kind of born with, you know, some potential as well. You know, I think one thing that um is really interesting that we've come to understand over the last maybe 10, 15 years is how important health is with fertility. I think, you know, this link between uh semen quality and health is just so um so tight. It's really interesting. If you look at men that are less healthy, their sperm quality is lower too. So men with like hypertension, high blood pressure, you know, diabetes, high cholesterol, all those are definitely correlated with semen quality. It goes down. Men that are more obese, you know, overweight, we do see also lower levels of semen quality with that too. Um, and all, you know, men that are on different medications, we see some of those can have an effect as well. Um, and then what's also interesting is that semen quality is actually correlated with later health too. Um, so men with lower semen quality have higher risk of problems later in life. So for example, if you have lower semen quality, slightly higher risk of Tesus cancer. Um, and maybe that makes sense, you know, because the testicles make sperm and if they're not doing that well, maybe there's other problems too and it leads to a higher chance of cancer. But it's not just Tesus cancer. um you know another male cancer like prostate cancer we do see those correlations as well with lower semen quality higher risk of prostate cancer later in life uh higher risk of heart disease surprisingly higher risk of diabetes for men with lower semen quality so these are men that have you know that are normal when they come to see us and then if you follow them years later you know the ones with lower semen quality have a higher risk of developing diabetes and it's actually sort of a dose response so the lower the semen quality the higher that risk is >> and what's fascinating is even mortality, even death is correlated with it. So there was a study published uh I think a few months ago actually uh in Denmark where they had this sort of large cohort of over 50,000 men with semen data and follow them for decades and you know if these men had lower semen quality you could me you could predict their death 40 up to 40 years later you know so men with a little better semen quality tended to live now this is not decades longer but they lived you know three to five years longer than men with poor semen quality so it's really a biioarker one of the talks that I give you know on this topic is called the six vital sign what our sperm is trying to tell us. Uh because I think it is really you know it's it it's a measure of how we're doing. I think you know it talks about genetic fitness but also just you know overall health where we are at that point in time. >> Is it strange to have patients come in who seem to have the health in order and have low sperm quality and then that be predictive of mortality. It sounds like there's something outside of Well, I guess this could maybe be the genetic factors uh rearing their head through sperm quality. Uh but other than that, if outwardly all of their health markers are in line, but sperm quality isn't, but it's predictive of mortality, you think, well, there's there's something going on here. >> Yeah. I mean, that that's a great it's a great question, right? Because a lot of guys come in and they look, you know, they look perfect, right? I mean, I think, you know, it takes a lot to get a man into the doctor and so usually they only come in if you know, really if they're bleeding or there's some other crisis. So, you know, when they come in, there's a problem with fertility, right? And otherwise, they look, you know, the picture of health and I think that's really the question of what this is telling us. Um, you know, they may have some underlying, you know, conditions. Some of them have never seen a doctor before, so maybe they do have undiagnosed blood pressure problems or something. Um, but others, you know, again, there we do an extensive evaluation. there's nothing that we can necessarily find. And so I think it's really um and that may kind of tell us more about just sort of just overall how they're doing. Now, you know, my my sister always tells me, you know, you're kind of being alarmist about some of this. You don't want to kick a man while he's down. So I think >> just to say that this is sort of a relative risk versus absolute risk kind of thing. I think the risk goes up, you know, a little, but overall most of these men are going to do fine. So it's like buying two lottery tickets instead of one. If you buy two, your chance of winning doubles, but still an unlikely event. So again, most of these guys are great, but I think there's a sort of an opportunity here. You know, if we can sort of tell them about some of this or just help them sort of recapture and get more ownership of their health, hopefully they can do better. Um, you know, kind of moving forward, hopefully they'll be able to, you know, change some things. I think we all can do a little better with exercise, with diet, just with lifestyle. You know, if they're smoking, stop, you know, moderate drinking, things like that. I think hopefully that can just change trajectory a little bit and put them on the path to better reproductive health, which is why they came to see me, but then hopefully overall health as well. >> What are the first places that you look at when a man comes in, low sperm quality, what what are the things that you assess? >> So, it's pretty comprehensive. You know, we want to talk about, you know, the reproductive history, make sure they're doing everything correctly. I think not every we take some things for granted, but want to make sure they know, you know, all the machinery and the anatomy. Um, and then we do a comprehensive look at, you know, prior exposures, their health history to see if they're on anything, if they ever took anything. I think one of the things that we find, not infrequently, is testosterone. Um, you know, that's actually been tested as a contraceptive. It's actually fairly effective as such. And some men are on it, you know, to boost health and boost, you know, vitality, maybe sports performance, but it actually lowers sperm count. So, we want to, you know, evaluate for that as well. Look at the other medications um that can affect things. Um it's actually reminds me of a this is not related to fertility directly, but this is interesting. I saw a patient yesterday in clinic that's on a medication um for um for an autoimmune condition. And he said that, you know, he was coming in because he talked to his autoimmune doctor. They didn't know what was going on, but he said all of a sudden his semen turned um bright blue. And it was something I'd never heard of before. We looked it up on the internet. Nobody in the clinic had heard that before either. But there were some Reddit threads about it, which is sort of the, you know, kind of the advantages of that. And they and they did. They sort of correlated it. They said it was I think they likened it to Gatorade uh glacier freeze. >> So this bright blue color. So it's sort of sort of wild. So >> you know what it is that causes that? What's the what's the drug? >> No. No. I mean, we try to look it up. I think there maybe been one publication about it, but just a really wild thing, right? And I think people are It was You know, Reddit is hilarious, right? They talked about him getting an Oolie fans page and >> alien semen. Yeah. Yeah. Yeah. >> But uh no, I mean, but you know, I think a lot of times um you know, reproductive effects of medications or semen effects certainly are not really studied. I think there's some preclinical work that's done in animal models and if there's not a strong phenotype, then it's not really looked at when it goes into um you know, actually, you know, studies, clinical human studies. Um but you know just to say that you know kind of a tangent but some of these medic medications can affect semen quality in some ways you know again colors or maybe a >> secondary uh okay so um medications testosterone past testosterone use I'm going to guess as well >> yeah exactly right and we look at exposures as well right if they you know if they drink how much we look at you know tobacco use other drug use to see you know if that's going on I think those are things we want to optimize we do talk about the sort of lifestyle factors if exercise. Um, and then we'll do an a physical examination as well to make sure everything is where it's supposed to be. Um, there can be other, you know, conditions that we sometimes detect. You know, some men have uh larger veins in the the the scrotum called a varicile um and that just sort of impairs normal temperature regulation in that area impairs um you know kind of toxin um uh excretion and so that's also can affect fertility. Um and then you know we do a very comprehensive hormone assessment as well. The testicle does two things. It makes sperm but it makes testosterone as well. So we'll check testosterone some of the other hormones involved in that axis and then you that's kind of our baseline. Um also talk to you know the the female partner's physician as well to get that information again because it's a team sport and then come up with a plan uh to see you know what there is what's correctable uh and how to get them you know the path to having a child. >> Give me a primer on varicus seals. So um you know kind of the speech that I tell is that you know they're very common probably 15% of all men have them you know about so one in seven they um they usually arise around puberty or so you know most men that have these don't have any problems but maybe about 20 25% of the times they cause problems. So again it's dilated veins in the scrotum more common on the left side than the right side although some men can have them on both sides. Um, and you know, again, they're just sort of larger veins, and so it's thought to warm up the testicles a little bit. So that's the sort of the the common thinking about how they lead to reproductive issues. So they're associated with lower sperm counts. Uh, they're sometimes linked to lower testosterone levels, but the reasons that we fix them, the reasons we worry are a few. So obviously for fertility reasons is a common reason that we would do that. Some have discomfort from them. um like they describe an ache you know worse at the end of the day than at the beginning worse the activity anytime blood can pull it can stretch and some men feel that um believe it or usually they don't have any sort of that's sort of the extent of it I actually have seen you know patients before where it actually popped you can believe it and led to yeah nothing devastating but you know a lot of swelling and bruising >> sounds pretty sounds pretty devastating to me >> yeah well yes yeah ultimately he did great >> but yeah um I've seen that as well and then in kids we worry about testicular growth. So it can actually you know for kids before puberty who develop them it can actually affect trajectory of growth. So those are the reasons that we kind of think and worry about those >> right? What is the impact of fixing a varicusal given that this is something that I imagine a lot of the guys that come in if they're thinking was struggling to get pregnant or I'm thinking about getting pregnant or I did sperm analysis and my numbers aren't where I want them to be. you say, "Hey man, you've got a varicasil." Uh what is the uh process of fixing it like? What are the outcomes like? Um all of that. >> Yeah. So, you know, in the United States, usually it's fixed surgically. In some other places, there's also a radiology procedure that can be done um that can that can help repair it. But essentially, it's an outpatient procedure. It usually takes, you know, less than an hour. Go home the same day. I usually have men kind of relax. I usually operate on Friday, so relax over the weekend. Back to work on Monday. You know, it takes two to three months to make a sperm, so we don't expect it to improve immediately. Um, but you know, over the next few months, we'll expect to see improvements in semen quality. That probably happens about 70% of the time. Um, and then, you know, they can again start to try. I think, you know, not every again because there's a lot that goes into fertility. So not everybody is just going to be able to conceive instantly on their own but you know about half of patients a third to half of patients are going to be able to just conceive without other assistance uh with that but it also improves you know some of our outcomes for you know the insemination that I talked about earlier even in vitro fertilization as well for men with these conditions. M does that mean then that most men who want to have kids and find out that they've got a varicusil should probably get it fixed. >> You know I guess there's everybody has sort of different um I guess feelings and sort of desires. I think there's lots of pathways to get pregnant. Um you know I think one thing interestingly about varicusil is that um you know there is this sort of time lag for benefit and I think that does affect some couples. So if you come to this crossroads, you find you have a varicus seal uh and your sperm count's a little low. So you can either get it fixed, you know, and get that improvement or you can move right to IVF, for example. I think couples, you know, kind of weigh that differently. You know, it's interesting. We tried to do a study on varicus as a community um about I think 20 years ago. And you know, after 18 months, you know, to try and recruit couples from all over the country, only three couples enrolled. And one of the reasons for that delay was sort of interesting is that because men are seen so late in the process of you know the reproductive evaluation um you know they just most couples didn't want to wait for their time just because of this time lag we talked about you know for this particular study they didn't want to be randomized to do nothing so there was just a lot of reticence to do that they just wanted to move forward it's interesting if you look at couples you know there's sort of this perception for variety of reasons I think sort of you know cultural and you know sort of gender norms and biases that men are not always evaluated. You know, in the US, probably a third of the time, a quarter of the time, men are never seen. So, if there's a problem, you know, couples are treated immediately, you know, through maybe insemination, maybe IVF. Um, but, you know, the men are not seen to see if there's things that could be corrected or optimized. And I think it's just sort of that delay, right? If you know couples are trying for a year and then you know they figure out there's an issue then they go in it starts with the gynecologist and then you know sometimes the males bypass. So you know hopefully through you know attention through more education you know through the platform that you're providing here today we can sort of educate that you know when couples are having a problem about half the time it's a male factor. So the men should definitely always be evaluated. What is the that I've read about varicusils being fixed sooner rather than later for outcomes in men? What what's the mechanism there? >> Well, I think, you know, it's it's they're thought to be a progressive lesion. So, the longer you have it, the more opportunity there is to do damage. So, you know, when like I talked about, you know, there's kids that have these as well. Well, you know, I think if we identify that early, you know, hopefully we can just, you know, alter that trajectory because it's much easier to prevent a problem from occurring than to fix it once it does. You know, again, if we only see improvement 70% of the time, if we can sort of freeze it and prevent further decline, I think that's our goal. So, I think if men have it, you know, again, it doesn't it doesn't affect or negatively impact everybody. So, you know, we do evaluate it. We check semen data. We check, you know, hormone data when we see these men to figure out who, you know, really needs it or not. But, you know, everybody kind of chooses it differently and rather than, you know, follow it for the rest of their lives, some men choose to have it fixed. And obviously, a lot of people have an aversion to surgery. So, some will just say, "I'll just live with it. We'll we'll we'll figure it out later." >> What are the most common interventions that you offer when guys come in, sperm quality isn't where it needs to be. What are the most common interventions that they get? >> So, um, a varicile is a very common one. probably about a third of the time we identify those for the patients that we see. Um and then you know hormone optimization I think that's also a common one that we'll do. You know men will have low levels and if we optimize it that can improve things. Um you know there's also other surgeries that we can do. You know vasectomy reversal is a very common you know thing that men come to reproductive urologist for. So had a vasectomy maybe changed relationship or maybe that couple decides they want another child. So that's something that we'll do. Um and then another um you know group of patients that we see are men don't have any sperm in the ejaculate. So it's called aospermia or no sperm in the ejaculate. And so there's procedures that we can do to try to either improve that or to get sperm directly from the testicles that we could use for beach of fertilization. So that's sort of the flavor of things. >> Getting sperm directly from the testicles sounds like a rather serious intervention. >> Yes. Well, I I think it sounds scary and you know, when I've showed videos of this at sort of mixed co mixed medical conferences or others, I think some people do get a little queasy just to see what we do. But most men do great. Um, you know, there's actually, you know, it's so um, you know, you can imagine how devastating it is when you do a semen analysis, you know, because you haven't gotten pregnant and you're told that there's no sperm. So it can be um yeah you know I've seen men break down and you can imagine I mean you know there's there's so much tied up I mean obviously you know goals of the relationship I think there's a lot of you know concerns about masculinity as well so one of the first things that we do is just try and be hopeful about it about half the time we can actually find sperm sometimes there's like a correctable blockage that we can actually bypass um so they can you know then achieve without you know um you know any other assistance besides the surgical correction Um, but essentially what we do is, you know, you can find within the testicle where sperm is being made. So there's like a minimum threshold of production that's necessary before it actually gets out. Um, and if you're below that threshold and we can't sort of medically, you know, induce more production, we can go inside and try and find it. But it's an outpatient procedure. Usually takes a couple hours. You know, most men, I've had men, you know, go back to work the next day, if you can believe it. Take a red eye out of town, then back to work the next day. So, you know, it's not pleasant, but most men most men do great. >> Okay. What should men do or what are the areas that most guys are overlooking when it comes to improving sperm quality that uh they you know, the first port of call that you should be doing in terms of changing lifestyle, making a a self assessment that? >> Yeah. Well, I think just having some awareness of what your semen quality is. I mean, I think that, you know, looking at it when you first kind of, I don't know, when you're watching this or when you first think about it, I think it's never too early to just get some initial um information about it to find out where you are because it can change over time as well. Um, and then I think if there's an issue, you know, I think, you know, going to the doctor to try and figure out. I mean, I think, you know, getting basic health screening again because men don't always do that. I think, you know, women go to the doctor, they're used to annual papsmears or semiannual papsmears, but men don't unless there's a problem. I think routine health screening is not done. So checking that out, but you know, again, I think I just always go back to health. Again, I don't want to be alarmist about any of this, but just making sure that you're living life the right way, you know, that you're good body weight, that you're eating, you know, not just ultrarocessed foods or fast foods, that you you take some ownership of your health. I think those are good places to start and pretty actionable and easy. >> What about pharmaceutical interventions? Stuff like hcg and clomophene. >> Yeah. Yeah. So, I think for the right patient, I think those can help. Um, you know, for patients that aren't making enough of those on their own, I think that can help. You know, testosterone is important for sperm production. So, for men that have lower than average levels, I think there's some reasonable data that if we give men, you know, those medications, we can see improvements not just in testosterone. So, sometimes they'll feel better, uh, but also we can see improvements in sperm quality. But I think it's important for men to you know go see a doctor uh and have that done under you know kind of medical supervision rather than treating themselves. >> Yes. Yeah. That's that's generally a good rule. What about the relationship between age and fertility for men? Uh what what's the sort of curve look like there? >> Yeah. So the oldest father ever is 96 allegedly. So I think the biologic potential does persist forever. When we looked at the US over the last 50 years, the oldest father was 88. Um, so again, men are doing it. Again, we always make sperm essentially. You know, the numbers do go down a little bit. Volume goes down, but we persist. Interesting. Over the last 50 years, the youngest was 11. Um, so it can start sooner than we'd like. Um, but you know, I think it's important for men to know that, you know, even though again, they think the runway is unlimited, it's probably not. So there are you know risks of taking longer to get pregnant. So our fertility does decline because we do see lowering of sperm quality over time. Um but also risks of sort of rare you know disorders go up a little bit. So I think classically you know hear about autism which goes up. There's other rare um you know genetic conditions which can increase a little bit. Now again these are rare conditions. Um but you know we do see a measurable increase and you know as a country and as sort of a society we are the a parental age is increasing paternal age is increasing over time. So you know for an individual I think most men want to be genetically related. So they would you know sort of not be as concerned about these risks because you know these risks are relatively small but you know as a population if more and more men are waiting longer and longer we may see you know more of these conditions become a little more prevalent over time. So I think that's kind of the the thing just to understand that you know while you can have a child you know late into your 60s7s 80s it's you know there are some advantages to doing it earlier. >> When does the drop off begin from peak male fertility >> you know I think it the the um our sort of governing board the American Society of Reproductive Medicine defines an older father at 40 or over. That's also what sperm donor sperm donation um you know companies do as well. But it probably doesn't just start there. I think it's sort of a slow decline. You know probably you know from an evolutionary standpoint our peak fertility is probably late teens early 20s. Um so it probably starts at that point. You know if you look at you know sperm DNA we accumulate about two mutations a year. So you know if you look at somebody 30 compared to 20 who's going to have the 30-year-old is going to have about 20 more mutations in their DNA. Now given the fact that we have billions of you know molecules of DNA you know two mutations is not going to make a big difference over time for an individual but again when we're talking about a population level may see some changes >> okay what's the increase in autism risk do you know that at at 40 at 50 at 60 >> you know I don't recall the specific you know increase like the actual percentage but it does go up you know a little bit >> okay uh I'd also heard that the sex ratio the likelihood of the sex ratio changes with male age. Is this right? >> Yeah, that's also yeah it's a very interesting finding as well. You know we talk about sort of declining re men reproductive health. So we talked about sperm counts testosterone levels go have gone down you know over the decades as well and there's some studies that show that um the sex ratio has as well sort of independent of age. Um, but if you look specifically at age, as men get older, you know, the chance of a male birth goes down a little bit. So, you know, over age 70, it it does go down. You know, it's it goes down sort of a few percentage points, but it's measurable. And anything that changes a sex ratio is sort of a big deal to a population just given how important, you know, that ratio is for the propagation of the species. And interestingly there's if you look at sort of like stressful you know like sort of societal events uh you can see that as well like you know the sex ratio goes down during like economic downturns for example wars we see changes in the sex ratio so it's a real it's a real phenomenon and the fact that it you know tracks with the father's age I think is you know very telling >> what's the mechanism do you know why >> you know I think it's it's thought to be um you know kind of selective fetal loss you know, at the uterine level. And again, why it sort of selects the males more than females, I think, is not not totally known, but it's yeah, it's it's measurable, >> but it's as males age, female likelihood increases for children. Is that right? Or is it the other way around? >> Well, so I guess yeah, I think there are kind of two things I was saying. So, um I I wasn't clear. So you know for a societal level I think that we see that kind of I guess calling it the uterine level but we think that for for paternal age it is kind of the the it is sort of the sperm level just that those sperm for whatever reason the wbearing sperm don't seem to be as efficient as making it all the way to live birth. >> Oh okay that's interesting. How do you think I mean IVF is everywhere. uh IUI I learned about at Andrew Schultz's uh live show which is >> uh kind of an interest and then there's ISCI or ISSI or something as well. There's a whole there's an IVF revolution going on. How do you come to think about that new technology uh changing the landscape here? Yeah, I mean I think you know that ixxie ICSI the intracytolasmic sperm injection where you can take a single sperm and inject into an egg is really been in my opinion one of the revolutions of medicine in the last you know quarter half century. Um because it allows like these men that we talked about where there's no sperm in the ejaculate very rare sperm in the testicle to be able to come biologic fathers. Um so it really you know allows it really lowers the bar significantly for who can become a father you know for men that have had you know you know some guy we talked about again some genetic conditions but other conditions too if they were treated for cancer as a child and now they can't make sperm as efficiently I mean allowing these men to be able to become uh parents I think is is terrific but we are seeing increases in the number of couples that are you know requiring these technologies and I think they are great you know in the US um it used to be that maybe 1% of bursts were conceived by IVF. Most recently, it's about 2% of all bursts in the US are conceived by IVF and those numbers are only increasing. >> I think there's a variety of reasons. I mean, I think, you know, falling sperm counts are probably a contributor. But, you know, also couples, you know, from a social standpoint are just waiting a little bit longer and as we age, both men and women fertility declines. And so, I think more couples are becoming reliant um on needing these technologies. But, you know, I think there's, you know, it just I guess from an evolutionary standpoint, it doesn't sound like it would be the best. But I think, you know, there are some potential advantages to IVF. It allows, you know, sort of selection of specific embryos to try and, you know, avoid, you know, kind of heritable conditions. You know, some of these genetic conditions that lower sperm counts, for example. You know, we could be able to avoid those in the future. There's this um ethicist at Stanford, Hank Greley, that wrote this book called the uh the end of sex. And so he rationalized in the future that sex will just be for pleasure and that in the future we'll be able to take you know skin biopsies for men and women make sperm and eggs you know grow embryos in a dish. >> That's IVG right? >> Yeah. Yeah. In in vitro gamitoenesis. Exactly. But the advantage to doing this and why sort of society will be um you know incentivized to do this is you could eliminate sort of genetic diseases. You know, we talked about things we know about like cystic fibrosis or certain genetic conditions of lower sperm, but you know, maybe you could even look at, you know, susceptibility to high blood pressure, diabetes, and things like that. So, really try and root out um, you know, again, it kind of gets a little bit brave new world and maybe it's not where we want to be as society, but >> it's a difficult one, man. I've had a Do you know who Jonathan Anomaly is? You familiar with him? the there's a a company that he is involved with uh that is doing um embryo selection for uh certain traits and he he uses this example which I thought was really smart. It was really interesting uh around uh myopia like people that just have worse eyesight and you know there's not really much moral weight that's put on that. I know that some people you know sort of the deaf community identify as that and that's kind of close to their sense of self. I don't know anybody who has short-sightedness that identifies with their short-sightedness. You know, it's just it's a thing that requires them to have glasses or wear contacts or, you know, squint a little bit when the lighting is too dark. >> And um yeah, the opportunity to select, hey, you have the choice between your kid having really great eyesight or your kid needing glasses from age 11. it. But then you're right, this technology and this approach has not exactly had an illustrious, fair and humane history. Um, so it gets perilous with with this. But, you know, I think it is a probably actually I was going to say like a a slow but it's going to be a pretty quick transition I think to a world where embryo selection especially for for particular traits is going to become um even more common given how likely it is for older parents whatever they're called. Um uh uh what's the elder pregnancy called? uh a woman >> like advanced maternal age or geriatric >> geriatric pregnancy. That's it. Yeah. The the most unfair term of of all of them. But uh yeah, I think I think this is going to be this is going to be pretty pretty common. Okay. So, we've got on one side sperm quality. >> Mhm. >> But the other side that most guys care about as well testosterone levels. >> Yes. >> What's happening with testosterone levels? What's the relationship between that and male fertility? um what what's the sort of current state of play there? >> Yeah, so I think just like we talked about we are seeing declines in testosterone over time as well. And I think when people look at it, I think they um they sort of attribute it to similar things. I think that you know exposures, sedentary lifestyle, more obesity. So testosterone again made in the testicles um and then it's converted to different things you know in the body like it's aromatized peripherally to estradile and a lot of that happens in fatty tissue. So you can imagine if there's more fatty tissue more of that aromatization will occur and so the levels will decline a little bit. Um and so you know as these levels go down I think it does you know it can affect you know sperm production uh to an extent. So I think there is a relationship to that as well. And you know again when men sort of seek out treatment for this when they start on testosterone we can also see you know direct correlation with sperm counts just because testosterone supplementation or testosterone therapy can directly you know decline decrease sperm production. >> Well you've got this weird inverse relationship sometimes as well between higher testosterone lower sperm quality but also very few guys say that they want their testosterone level to be lower. >> Yeah. So, yeah. >> Yeah. Interesting. I've had patients that come in that say their penis is is too big, but uh it's a rare complaint. >> I imagine so as well. Yeah. Uh all right. Well, actually, the penis is getting bigger thing. Was there not a study about that? >> Yes. >> Was there not is it not statistic statistics that is it testicles getting smaller? Uh ano genenital distance getting smaller but penises getting bigger? Yeah. Yeah. It's a good segue. So, um we did a Yes. So, we did a study on this. So, interestingly, there are lots of um you know, just like, you know, the way the sperm count study was done is that over time, people have measured semen quality in different populations and published it and then you can look at all these, you know, studies together and just see if there's changes over time. So, similarly, penis length has been measured over time in a variety of populations. So we looked at it, you know, over the last several decades and found, you know, we expected it to decline, you know, for all these reasons, right? We're seeing, you know, the lower sort of development, the male genital development, lower sperm counts, lower testosterone levels, more obesity, all those things should necessarily lower sperm or sorry, a lower uh penis length, right? Because the way that penis length is measured is you kind of pull the penis on stretch and measure from the tip to the pubic bone. Um but much to our surprise, it had actually gotten a little longer over time. Um and so, you know, why that is is not certain. You know, we saw it pretty consistently. Um you know, we had one hypothesis we had is that puberty is changing over time. The timing of puberty is changing and it's actually gotten a little bit earlier and when it gets earlier, puberty um leads to kind of more time for genital development, longer genital development. So that's sort of our hypothesis why that may explain it but um yeah that was a finding. >> Yeah I imagine that that caused some ruptions. Okay erections. Let's talk about erections. >> Okay. >> How often is erectile dysfunction due to physiological or psychological factors? >> Yeah. So we used to think it was all psychologic uh but now we know that it probably only 10% uh psychoggenic and most of it's actually due to organic causes. So you know blood flow issues are the main culprit and I think this anything that affects blood flow in the heart can also affect it in the penis. So you know diabetes high blood pressure all those vascular conditions are very common different medications you know medications that lower blood pressure anywhere in the body lower the blood pressure head the penis sees and can also cause those issues. Sometimes pelvic surgeries, you know, in that area like prostate surgery is notorious for that. Um, you know, colon surgery as well, bladder surgery, those things can also affect, you know, the ability of the penis to get erect to, you know, get those signals, get the blood flow where it needs to be. Um, and then, you know, the thing that I think is commonly thought of is, you know, hormonal causes are probably less than 5%, but sometimes low testosterone can also do that, but it's really the minority of all patients coming in. >> Okay. So what the main reasons for erectile dysfunction if you were to rank order them for the patients that come in to see you what are they? I think mostly it's just due due to these vascular coorbidities you know so kind of the classic metabolic syndrome so high blood pressure cholesterol diabetes obesity you know again other things like smoking I think those are probably the most common causes for erectile dysfunction but it's also very common I think you know when men come to see me they feel like they're all alone but if you look at it over the age of 40 over half of men have some trouble with erection so it is very very common um I always like to tell men as long as you have a penis we can always make it hard so there's a lot Try and be optimistic. >> Okay. What should men do to improve blood flow? Normal guy, he's like, "Ah, I'm not smoking that much. I'm not drinking that much. I should improve my blood flow." What What does that mean? >> Yeah. So, I mean, I think you can do better, right? So, I mean, you should try and stop smoking or cut down if you can. You know, alcohol, I think, you know, there is an expression like whiskey dick, right? So, if you drink to excess, it can definitely lower that. But, you know, I think in moderation it probably doesn't have as much of an effect. But, you know, again, if there's room for improvement and then I think just anything that's good for your heart. So, I think more exercise I think could be beneficial. You know, I think that will definitely improve things. >> Okay. What what's the role of hormones here? I think a lot of the time guys would just assume erectile dysfunction, some hormonal imbalance, then the accelerator gets pressed and we're off to the races. >> That's right. So you know when you get evaluated I think that's one of the screening tests that we always do just because we do see that some of the time. So we will check testosterone level you know and if it's low you know those are the men we do discuss you know putting on testosterone therapy to try and improve things. Now for men that have you know kind of a borderline low or maybe low normal level. It's unlikely that's going to be the whole story. Um but for some men that are very low you know that can be you know the difference between no erections and erections. you know, men that are, you know, if you're familiar with sort of the ranges, probably 300 to 900 is sort of the average levels of testosterone nanogs per deciliter. And so for men in the 200 range, you know, testosterone level may help a little bit, but I think those men will also benefit from like selenophil or Viagra, you know, those kind of medications, those therapies. But when they're in the 100 range, I think those men will see, you know, significant improvements in erectile function and sex drive as well um with testosterone therapy. >> Yeah, that's a great point. What's the is is erectile function the same thing as libido in the body? What how does this what's similar? What's different? >> Yeah, I think there is there tends to be a lot of overlap because I think there is kind of like just negative feedback. If you're not getting erections, you just become less interested. But they are distinct entities. So I have patients that come in just with, you know, isolated, you know, sex drive, libido concerns, and then other men coming in, no problems with sex drive. They just just doesn't work. doesn't get as used to. So >> yeah, we we approach those a little bit differently. >> What contributes to libido? I mean, it it seems to be one of those sort of it's behavioral, right? The huge psychological component, I have to imagine, >> but not exclusively. So yeah, what's going on? >> Yeah. So I mean we are going to look do a hormone evaluation. I think you know testosterone is something that we look at. Sometimes we expand that a little bit to looking at other things like estradiol is important in that prolactin as well. The other thing I think that's very valuable is, you know, we're talking, you mentioned sort of the psychoggenic components of some of this is to involve sex therapy. I think there's a bunch of excellent ones, you know, all over the world. There's excellent ones in our area that we, you know, collaborate with a lot. So, for some of these disorders, we, you know, kind of do it as sort of a multi-pronged approach. So, you know, we want to optimize the organic causes and optimize some of the psychoggenic causes. And just know that it's not going to get better overnight. It's unlikely a pill is going to solve some of these issues. And it you know may take some time but you know we try and you know look at relationship and other aspects to it as well because I think all those are contributing. >> When you're talking about psychoggenic causes there >> what is the what's the mechanism that's occurring that your brain is somehow able to intervene with your penis? What is what's happening there? I mean, look, every guy that's listening to this has at some point just gone, I I not today apparently. And uh but you it's not your choice. You didn't have any idea what the mechanism that was going on. So liberate us. Show us behind the curtain >> to the extent we can. Yeah. >> Well, I think one of the best ways to get rid of erections is to think about it. So I think if there's any >> Yeah. So, like, you know, anytime you're kind of worried about it, and I think it's not unusual, like in a new relationship or other situations, if it was a stressful day at work, you know, you may have some problems. You know, if you didn't get a good night's sleep, I think it's not unusual, you know, every once in a while for there to be problems. And then it can also be a vicious cycle. So, if you worry about it, you know, the next time then it becomes a problem and then you kind of, you know, go down that spiral. And, you know, certainly by the time patients have come to see me, you know, they're worried about it, right? And so, it's been going on for months. And so I think those are the guys we need to sort of reset to some extent. So I think you know we do an evaluation you know oftent times there's not a clear organic cause you know we can try and reset them I think like you know selden Viagra teddall seialis I think those work well you know and then we kind of gradually wean them off and then also you know work with sex therapists as well for you know different exercises and techniques to sort of minimize you know some of those sort of anxiety responses. I mean, you know, if you think about it, like 10,000 years ago when we lived in caves and a tire comes around, you don't want erection, right? I mean, there's a stress response. >> It might scare it off. >> Yeah. Yeah. Hopeful. I mean, yeah, I guess depends how you think about tigers, but yeah. Um, so, you know, you want to run away, right? And so, you know, the body is designed to shift that to the rest of your body so you can escape. And so, that same thing happens now, you know, when you're worried about it. It's just it, you know, erections are just not not functional. And so we did take some time but usually you know these are guys that you know we can come up with an effective regimen for. >> Are we seeing an increase in erectile dysfunction in the modern world in younger men? Are there any trends occurring at the moment? >> There are some studies I think those studies are still ongoing. I think there is certainly some concern about some of that with some of the isolation from social media um just kind of how we're living dating practices now. Um but I think that in general I think the overall the rates have stayed you know pretty consistent and I think again a lot of the causes psychoggenic does contribute to some extent but I think a lot of it has to do with just vascular health. So hopefully you know as technology has made us you know to the extent it can you know a little healthier. I mean, I think that exercise has gotten more fun over time, right? Instead of just like running in front of nothing, you know, now you can listen to an interesting podcast, for example, or, you know, you can, you know, exercise, you know, with, you know, a community, um, you know, on a screen. So, I think those things I think I find more engaging. So, I think there's certainly some good that comes with a lot of that as well. >> You've sort of hinted there at potentially new technology and lifestyles having an impact. How much evidence is there for a mechanism between porn use and erectile dysfunction? Is that does that actually appear in the literature? I know it kind of appears a lot on the internet >> about sorry what was the between what >> porn dysfunction? Yes. Yes. So I think yeah we do see that. I think that you know basically it's a lot more accessible now and you know you can you can find lots of it and it's you know the obviously there's varying kinds but you know the issue is that there's just you know it's non-stop it can be and very intense and so you know if men kind of are attuned to that it's difficult to sort of retrain after that because you know it can give you it can give men sort of more than they can get with a sort of a you know a partner on a routine basis and So, you know, without that level of intensity, sometimes they have trouble, you know, maintaining erections, you know, kind of in a normal pardoned setting. And so, that also is going to take um, you know, just some retraining. Again, I think sort of the same regimen we use for other forms of psychoggenic ED, but you know, collaborate with sex therapists. But, you know, I think it's in the literature. I think there are some associations. I think, you know, some men are probably more susceptible than others, so it's certainly not going to affect everybody. Um, but it is something to be aware of. And I think a lot of patients that I've come in or that have come into clinic to see me, I think they have some sense that it may play a role. And I think those are the ones that are going to be a lot more um willing to, you know, kind of go through the the measures to get it better. >> If uh something like Tadalapil fixes things, >> does that suggest other cardiovascular issues? If the primary issue in you maintaining an erection is fixed by something that improves improves blood flow that suggests that other issues with regards to blood flow may be elsewhere in your body. It could be I mean I think it depends you know I think these medications are very powerful. Some people use them recreationally you know because it does help you you know physiologically what it does is it you know keeps the chemical that basically opens up the blood vessels in the penis. It just keeps that there for longer. So regardless of whether you have a problem or not, it should make erections better. Um but you know erectile dysfunction can preede other vascular conditions just because the pen the blood vessels in the penis are smaller than they are in the rest of the body like in their karate or in our heart. So there have been some studies that say that men with erectile dysfunction you know are at higher risk for a heart attack in the next you know 5 to 10 years. So I think potentially could be a warning sign and again another reason to get evaluated by your doctor to see if there's underlying blood pressure issues or >> you know blood sugar issues for example. >> I'm interested in how sleep impacts testosterone infertility what the relationship is there. >> Yeah. So it's also important. I mean not surprising. I think that you know when we talk to patients about things they can do sleep is certainly one of them that we'll we'll focus on but you know it tends not to be the whole story but it can be definitely be a contributor. It's interestingly it's um for uh for sperm it's a sort of a U-shaped relationship. So it's possible to get too much sleep and then not enough sleep. Right? There's sort of a sweet spot probably like 6 to9 hours is good. you know, if you sleep 12 hours a day, I mean, I think some professional athletes do that, but for other people, there may just be other things going on. And so, we do see declines in sperm counts at those levels. And then for men that don't get enough sleep, you know, less than six hours, we see lower sperm count as well. So, I think there's, you know, again, it's easy to say more sleep, less stress. It's probably a little harder for some to, you know, to actually um, you know, put that into action, but it certainly can um can play a role. And for testosterone, it's the same thing. I think that we do see stress negatively impact testosterone levels because cortisol you know you know is at play with stress and sleep and it sort of antagonizes testosterone to some extent. So I think if men can optimize those things that'll it'll only be beneficial. >> So there's a relationship here with mental health stress lifestyle stress as well as sleep too. >> Yes. Yeah. I think that's exactly right. M and that's elevated cortisol is not good for anything at all and the body just downprioritizes making sperm if it feels like you're at war all the time. Yeah, that yeah that's sort of thought to be the mechanism I think. Yeah, you know, the body knows, right? It's, you know, it wants to survive. That's, you know, eat, survive, reproduce. So, survive is slightly ahead of reproduction. Although reproduction is certainly, you know, very, very important, but, you know, if you're in that situation, it'll dep prioritize reproduction. >> I imagine that makes for a very vicious loop if you become stressed about the potential of having kids because the stress itself is going to further decline fertility, which is the precise thing that you're trying to have a positive impact on. >> Yeah, that's exactly right. Yeah. And so that's really key. I mean, that's when we talk about these things, you know, try and be optimistic, you know, try and give people some actionable things, but you don't want to be overwhelming at the same time. Again, there's so much potential. You know, if you read studies, you know, people I sort of make fun of epidemiologists because it's exposure, you know, X leads to outcome Y and there's so many things that are related. So, we just want to, you know, again, make it very approachable and possible. And I think that, you know, a lot of these things that we talked about already, you know, hopefully will benefit reproductive health, but certainly benefit overall health. And I think they're all under our control. >> If Okay, from the tactical side, um, if you had to build a a checklist for men to maintain reproductive and sexual health, sort of what what would be the non-negotiables that you would put on there? >> Yeah. So, I mean, I think, you know, exercise, you know, being very conscious of diet. I think those are going to be really crucial. You know, avoiding smoking I think is also crucial. And then, you know, again, moderation with, you know, other exposures. You know, moderate alcohol. You know, you want to be kind of mindful of that. Prioritizing, you know, these are all things I think that overlap with health as well. Um, but, you know, trying to moderate, you know, like make sure you get a good amount of sleep, you know, try and minimize stress to the extent possible. I think the other thing that I think would be great is if men had, you know, sort of a a good handle on baseline, you know, like trying to get a testosterone level at baseline even before problems arise again because when we talked about testosterone, it's such a wide range of normal, right? 300 to 900. Um, and when men come to see me and they're 400, you know, they say, "Well, I'm a little below average." But it depends where you are, right? I mean, the range is so wide and statistically if we get you from 400 to 500, you know, maybe you can hit a baseball further, but it's unlikely that some of these other conditions that you that you came to see me for are going to get better. So, we just want to know where you live. I think that would be helpful. >> And then I've also again advocated for doing a semen analysis early. I think that would be very helpful. I talked to actually the Centers for Disease Control about 10 years ago adding it to the sort of um this national health survey that they conduct just again for all these reasons that we've talked about right declining sperm counts to be able to understand maybe why it is because with this health survey they track so much they get blood samples urine samples from individuals from men and women old and young and they can see you know again what sort of toxic exposures there are and things like that and so if we could see you know who these sperm counts are changing in I could be really valuable. But, you know, there is some concern that this could affect recruitment into this um in this survey. Uh because there's sort of an ick factor, >> you know, even though right, I mean, it's I'd be a lot more pleasant to give a I think a semen sample than a blood sample. I guess it depends what you think about about needles, >> but but again, I think those are I think it' just be I think that'd be a valuable a valuable piece of information. >> Are there underrated signs of urological dysfunction that most men miss? Is there something that they probably should be aware of that they're not? >> Well, I think you know um one of the great things, you know, that like again a big discovery was Viagra. I think that got men a lot more comfortable talking about erectile dysfunction because there used to be a perception that we couldn't do much about it and I think now men are a lot more comfortable talking to their partners about it, their doctors about it. So I think you know any sort of concern that men have I think they should bring to the forefront. I mean I think you know urinary issues I think there's a lot that we can do. We talked about erectile issues. There's a lot we can do. Some men have curvature of their penis and they're very embarrassed about it. Even though it affects probably 5 to 10% of men, there's effective treatments we have for that as well. So, I think anything that you think is different, no one knows your genitals better than you. So, if you detect any issues, you know, bring it to your doctor's attention because, you know, at least to alleviate anxiety, but also again, if it's a problem, maybe we can fix it. >> It's so I I didn't It feels like such a revolution at the moment. uh to finally have reproductive technologies that can help both sides and uh you know for a long time this is Schultz's entire standup um which is you know the night before him and his wife maybe got the results or went in to do the tests or something he sort of prayed to God and was like just please let it be me because he was so sure that if there was a fertility issue that it was on the female side of the equation and then he turns up And sure enough, his his prayers were his prayers were answered. And uh yeah, I think, you know, the more conversations there are around this, I've you know, waved my flag in the air. Since watching Schultz's special last year, I then went and got a sperm count done. I then went and found that I had varicus seal. So, I'm going to get varicile surgery at some point later this summer. And you know, all of this is only occurring because there's this >> increasing territory of guys that are prepared to talk about it. >> Uh, and yeah, I guess our parents' generation would have been a lot more in the dark. This is, you're right, there's an ick factor. It's very private. There's a lot of shame associated with it. detached to your sense of self and masculinity and and and you know um aptness as a partner uh potential future all that sort of stuff and uh yeah long live comedians talking about their love sperm counts because I think it's a it's a a good impact. Oh, it's been so great, right? I mean, I think what was his like that he used to be worried to get pregnant from like a toilet seat and now it takes like bunch of doctors. I think that's hilarious. You know, Hassan Minaj had a funny very funny routine on it. Ronnie Chang talked about it. So, I think it's this great growing awareness and comfort and you know, again, you lending your platform to talking about this. I think all that is going to, you know, do a great thing. And I think, you know, like we talked about Viagra, I think, you know, there hasn't really been a blockbuster treatment or drug for, you know, the increased sperm counts, right? I think one of the most effective treatments we have for low sperm counts is IVF, which which, you know, puts all the burden on the female partner, you know, given all the procedures and medicines that she's going to require. So, if we had, you know, again, pharmaceutical investment and some technology that could improve male, you know, sperm across the board, I think that would be amazing. And again, I think it just goes to, you know, more education, research about why counts are falling, what we can do to reverse that trend. >> Heck yeah. Dr. Michael Eisenberg, ladies and gentlemen, I I love this. It's a a topic that I'm uh very passionate about. So, thank you for all the stuff that you do. Where should people go? They're going to want to keep up to date with everything that you've got online. >> Well, we have a lab website, so they can go to that. They can support, you know, the cause and then learn more about men's reproductive health. >> Heck yeah, Mike. I appreciate you. >> Thank you. Appreciate it. >> Congratulations. You made it to the end of the episode. And if you want more, well, why don't you press right here? Come on.