Modern Wisdom - #969 - Dr Michael Eisenberg - How To Protect & Improve Your Fertility As A Man

Episode Date: July 19, 2025

Dr Michael Eisenberg is a professor of Urology at Stanford, a urologic surgeon, and a leading expert in male fertility and reproductive medicine. It's no secret that global population decline is accelerating, but what's driving it? Male fertility might be a major piece of the puzzle. So why are so many men struggling with infertility and low testosterone, and what can be done to reverse it? Expect to learn why global sperm counts have declined by over 50% in the last 40 years, what the biggest determining factors that influence a man’s sperm quality is, what men should do if they want to improve their sperm quality, what the relationship between age and fertility is for men and when fertility starts to drop off, if there is a relationship between sperm quality and there a relationship between alcohol, marijuana, smoking & vaping, what men can do to improve their testosterone, and much more… Sponsors: See me on tour in America: ⁠https://chriswilliamson.live⁠ See discounts for all the products I use and recommend: https://chriswillx.com/deals Get the brand new Whoop 5.0 at https://join.whoop.com/modernwisdom Sign up for a one-dollar-per-month trial period from Shopify at https://shopify.com/modernwisdom Get a Free Sample Pack of LMNT’s most popular Flavours with your first purchase at https://drinklmnt.com/modernwisdom Extra Stuff: Get my free reading list of 100 books to read before you die: https://chriswillx.com/books Try my productivity energy drink Neutonic: https://neutonic.com/modernwisdom Episodes You Might Enjoy: #577 - David Goggins - This Is How To Master Your Life: https://tinyurl.com/43hv6y59 #712 - Dr Jordan Peterson - How To Destroy Your Negative Beliefs: https://tinyurl.com/2rtz7avf #700 - Dr Andrew Huberman - The Secret Tools To Hack Your Brain: https://tinyurl.com/3ccn5vkp - Get In Touch: Instagram: https://www.instagram.com/chriswillx Twitter: https://www.twitter.com/chriswillx YouTube: https://www.youtube.com/modernwisdompodcast Email: https://chriswillx.com/contact - Learn more about your ad choices. Visit megaphone.fm/adchoices

Global sperm counts have declined by over 50 percent in the last 40 years. Is that true? It really is. I think in the last few years, there's been a lot of consensus around that. One of the most famous studies that looked at this was published in the 90s. When it was released, I've talked to some of the authors about it. There was a lot of fame for it around it.

They had it in a big media hall, there were television cameras, but since then there was a lot of controversy around it. 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 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 U.S. we see that, but around the world we see that too. And so there were some concerns about how all that was incorporated to some of these studies. You can imagine over 40 years, some of the methodology for testing sperm has probably improved a little bit. And even our statistical methodologies, 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's 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 10, 20 years, it's accelerated actually about 2% decline.

And so I think it's, you know, now that there's a little more, again, sort of consensus around it, I think it's really up to us to understand why, because, yeah, it's 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's happening?

Yeah. I mean, I think that's the million-dollar question or billion or trillion-dollar question, really. I think there could be a few reasons. The pace of change is probably too quick for evolution. I don't think it's a genetic factor. So I think people have really honed in on exposures, whether it's lifestyle factors. I mean, I think that we're probably a little less sedentary than we used to be.

Obesity was going up, although maybe with some of the new medications, we'll see a 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 may be the culprits, but I think, you know, we need to really do more work to try and understand it, 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, 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, obviously, 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 our goals are.

So I think lifestyle, health, I think all those things are going to come into play. I always tell men anything is good for your heart, it's good for fertility. So we talk about diet, exercise, maintaining good body weight. So I think things that you can do, 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, 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. Exactly right. Yeah. What are the, you mentioned exposures, microplastics being one 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 the likelihood that this is having an impact on fertility? Yeah. I mean, I think, you know think that was a really interesting study from New Mexico.

They looked at dog testicles that were taken at the time of neutering, and then they looked at testicles from men that were taken from autopsy. And it was interesting, all of them actually had microplastics within. So it's very ubiquitous exposure. Again, we get it from just the environment. Talk to experts in the field, probably in our food supply. So it is difficult to the extent possible to eliminate it. But, you know, I guess it's a question of, you know, what it's doing. And, you know, matte 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, you know, properties have some of them are carcinogens. So, you know, the, I think the of other chemicals that are usually at play that have endocrine-distracting properties, some of them are carcinogens. So I think the studies that we have that look at function of this I think are concerning. So they don't have semen quality on the dogs, unfortunately, or the people. But there's sort of a rough approximation. So in the dogs, they saw that larger testicles had lower levels than smaller testicles. And so we do see that most of the size of the testicles devoted to sperm production,

so larger testicles usually make more sperm. And so if we're seeing that those have less microplastics, maybe there is some functional consequence to that. And 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 concerning elements to the 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 exposures. So I think trying to limit like pesticide exposure. So, you know, again, I think data around organic 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 strawberries are notorious

for having very high pesticide levels just because, you know, we eat the whole thing. There's all these nooks and crannies, so it's hard to adequately wash them. Although I love strawberries, so does my family, but you know, you try and get organic when you can. And then sort of being more sort of aware of some of the other chemicals that we talk about, like phthalates, different phenols as well. So, looking at packaging,

I think for like skincare product, for sunscreen, I think there's organic types that do have some endocrine disrupting properties compared to mineral sunscreens are thought to be potentially safer. So 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 count, 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 facts when it comes to sperm health, male fertility. What are people talking about? Yeah, this is a great question, sort of fundamental. So, you know, what are we measuring?

What is the semen 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 concentrations, so how many million sperm per milliliter. We look at the motility, you know, how many are moving around, and then we look at the

shape as well, or call the morphology. You know, there's 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. We haven't looked at some of the other parameters, because those have been kind of a moving target to some extent. Morphology, the shape, I think we've advanced a little of what we think sperm are supposed

to look like, so that's sort of hard to measure. And then 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. You know, we talk, you know, sort of on average, you know, men have probably about 50 to 100 million moving sperm. 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 sperms, 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 sperms, some of them are able to get pregnant without difficulty. So, you know, 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. 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's sperm quality then? Well, I think genetics play a big role. I think you're kind of born with some potential as well. I think one thing that 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 this link between semen quality and health is just 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, diabetes, high cholesterol, all those are definitely correlated with semen quality. It goes down. Men that are more obese, overweight,

we do see also lower levels of semen quality with that too. And all men that are on different medications, obese, overweight, we do see also lower levels of semen quality with that too. Men that are on different medications, we see some of those can have an effect as well. And then what's also interesting is that semen quality is actually correlated with later health too. 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 testis cancer. 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 testis cancer, 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, higher risk of heart disease, surprisingly, higher risk of diabetes for men with lower semen quality. So these are men that are normal when they come to see us. And then if you follow them years later, 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 is a study published, I think a few months ago, actually in Denmark, where they have this sort of large cohort of over 50,000 men with semen data

and follow them for decades. And if these men had lower semen quality, you could predict their death up to 40 years later. So men with a little better semen quality tend to live, now this is not decades longer, but they live three to five years longer than men with poor semen quality. So it's really a biomarker.

One of the talks that I give on this topic is called the sixth vital sign, what our sperm is trying to tell us. Because I think it is really, it's a measure of how we're doing. I think 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 rearing their head through sperm quality. 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 something going on here. Yeah. I mean, that's a great question, right? Because a lot of guys come in and 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 really if they're bleeding or if 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. You know, they may have some underlying conditions.

Some of them have never seen a doctor before. So maybe they do have undiagnosed blood pressure problems or something. But others, again, we do an extensive evaluation. There's nothing that we can necessarily find. And so I think it's really, that may kind of tell us more about just sort of just overall how they're doing. Now, my sister always tells me, 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 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, 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 diets, 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 the reproductive history, make sure they're doing everything correctly. We take some things for granted, but we want to make sure they know all the machinery and the anatomy.

And then we do a comprehensive look at 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 counts. 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 for an autoimmune condition. And he said that, 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 bright blue. And it was something I'd never heard of before. We looked it up on the internet and 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 there's a 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? Yeah. No, I mean, we try to look it up. I think there may be 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 only fans page and alien semen. Yeah. Yeah. Yeah. But, uh, no, I mean, but, you know, I think a lot of times, 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 straying phenotype then it's not really looked at when it goes into you know Actually, you know studies clinical human studies But you know just to say that you know kind of a tangent, but some of these medications can affect semen quality in some ways, again, color is maybe a secondary. Okay, so 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 drink how much, we look at tobacco use, other drug use to see if that's going on. I think those are things that we want to optimize. We do talk about the sort of lifestyle factors that they exercise. And then we'll do a physical examination as well to make sure everything is where it's supposed to be. There can be other conditions that we sometimes detect. Some men have larger veins in the scrotum called a varicoseal,

and that just sort of impairs normal temperature regulation in that area, impairs, you know, kind of toxin excretion, and so that's also can affect fertility. 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, that's kind of our baseline.

Also talk to the female partner's physician as well to get that information again, cause it's a team sport. And then come up with a plan to see what there is, what's correctable and how to get them, the path to having a child. This episode is brought to you by Whoop. Your body is constantly sending you signals, but without real data, it's easy

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So 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, 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, men can have them on both sides.

And again, they're just sort of larger veins, and so it's thought to warm up the testicles a little bit. So that's sort of the common thinking about how they lead to reproductive issues. So they're associated with lower sperm counts, sometimes linked to lower testosterone levels, but the reasons that we fix them, the reason we worry are a few. So obviously for fertility reasons is a common reason that we would do that.

Some men have discomfort from them. Like they describe an ache, you know, worse to the end of the day than the beginning, worse activity. Anytime blood can pool, it can stretch and some men feel that. Believe it or not, usually they don't have any sort of, that's sort of the extent of it. I actually have seen patients before where it actually popped, you can believe it, and led to, yeah, nothing devastating, but a lot of swelling and bruising. Sounds pretty devastating to me.

Yeah, well, yes, yeah. Ultimately he did great. Okay. But yeah. I've seen that as well. And then in kids, we worry about testicular growth. So it can actually, for kids before puberty, who develop them, it can actually affect trajectory of growth. So those 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 varicoseal given that this is something that I imagine a lot of the guys that come in, if they're thinking, I was struggling to get pregnant or I'm thinking about getting pregnant or did the sperm analysis, my numbers aren't where I want them to be. You say, Hey man, you've got a varicosele. Uh, what is the 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. And some other places, there's also a radiology procedure that can be done. Um, they can, they can help repair it. But essentially it's an outpatient procedure. It usually takes less than an hour. Go home the same day.

I usually have men kind of relax. I usually operate on Fridays, so relax over the weekend, back to work on Monday. It takes two to three months to make a sperm, so we don't expect it to improve immediately. But over the next few months, we'll expect to see improvements in semen quality. That probably happens about 70% of the time. And then they can, again, start to try. I think 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 about half of patients, a third to a half of patients are going to be able to just conceive without other assistance with that. But it also improves some of our outcomes for the insemination that I talked about earlier, even in vitro fertilization as well for men with these conditions. Does that mean then that most men who want to have kids and find out that they've got a varicoseal should probably get it fixed? Everybody has different feelings and desires.

I think there's lots of pathways to get pregnant. You know, I think one thing interestingly about varicoseal is that, 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 varicoseal and your sperm counts 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, 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 varicose aloe as a community

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 the reproductive evaluation, most couples didn't want to wait for their time. Just because of this time lag we talked about, 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 a 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 U.S., 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. 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 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,'s bypass. So hopefully through attention, just through more education, through a platform that you're providing here today, we can educate that.

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 varicoseals being fixed sooner rather than later for outcomes in men. What's the mechanism there? Well, I think, you know, 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. 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. 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, again,

it doesn't affect or negatively impact everybody. So we do evaluate it, we check semen data, we check hormone data when we see these men to figure out who 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 and 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 a varicoseal is a very common one, probably about a third of the time we identify those for the patients that we see. And then, you know, hormone optimization, I think that's also a common one that we'll do, you know, men will have lower levels and if we optimize it, that can improve things. You know, there's also common one that we'll do. You know, men will have low levels, and if we optimize it, that can improve things. 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 urologists 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. And then another, you know, group of patients that we see are men that don't have any sperm in the ejaculate. So it's called asa-spermia 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 in 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 think it sounds scary. And, you know, when I've showed videos of this, it's sort of mixed, 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, yeah, you know, I've seen men break down and you can imagine, I mean, you know, 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 so they can, you know, then achieve without, you know, any other assistance besides the surgical correction. 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. And if you're below that threshold, and we can't sort of medically induce more production, we can go inside and try and find it.

But it's an outpatient procedure, usually takes a couple hours. Most men, I've had men go back to work the next day, if you can believe it, take a red eye out of town and then back to work the next day. So, you know, it's not pleasant, but 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 they, you know, the first port of call that you should be doing in terms of changing lifestyle,

making 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 information about it,

to find out where you are, because it can change over time as well. 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 pap smears or semi-annual pap smears, 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, that you're a good body weight, that you're eating, not just ultra-processed foods or fast foods, that 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 Clomiphene? Yeah, so I think for the right patient, I think those can help. For patients that aren't making enough of those on their own, I think that can help. 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 those medications, we can see improvements, not just in testosterone, so sometimes they'll feel better, but also we can see improvements in sperm quality. But I think it's important for men to go see a doctor and have that done under, you know, kind of medical supervisor rather than treating themselves. Yes.

Yeah. That's generally a good rule. What about the relationship between age and fertility for men? 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 U S over the last 50 years, the oldest father was 88.

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 risks of taking longer to get pregnant,

so our fertility does decline because we do see lowering of sperm quality over time. But also risks of sort of rare disorders go up a little bit. So I think classically, hear about autism, which goes up. There's other rare genetic conditions which can increase a little bit. Now again, these are rare conditions, but we do see a measurable increase. And as a country and as a society, a parental age is increasing, paternal age is increasing

over time. So for an individual, I think most men want to be genetically related, so they would 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 a thing just to understand that you know while You can't have a child. You know late into your 60s, 70s, 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 that the, 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, you know donation 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. 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, he's gonna have the 30 year old's gonna 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 gonna make a big difference over time for an individual. But again, we're talking about a population level, may see some changes. Okay. What's the increase in autism risk?

Do you know that 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. 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.

We talk about sort of declining men reproductive health. So we talked about sperm counts, testosterone levels have gone down over the decades as well. And there's some studies that show that the sex ratio has as well, sort of independent of age. But if you look specifically at age, as men get older, the chance of a male birth goes down a little bit.

So over age 70, it does go down. It goes down sort of a few percentage points, but it's measurable. And anything that changes the sex ratio is sort of a big deal to a population, just given how important that ratio is for the propagation of the species.

Interestingly, if you look at sort of like stressful, you know, like sort of societal events, 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 phenomenon. And the fact that it tracks with the father's age, I think, is very telling. What's the mechanism?

Do you know why? I think it's thought to be selective fetal loss at the uterine level. And again, why it sort of selects the males more than females, I think, is not totally known, but 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 I wasn't clear. So, you know, for a societal level, I think that we see that kind of, I guess, culling at the uterine level, but we think that for, for paternal age, it is kind of the, it is sort of the sperm level, just that those sperm, for whatever reason, the Y-bearing sperm don't seem to

be as efficient as making it all the way to live birth. This episode is brought to you by Shopify. Look, you're not going into business to learn how to code or build a website or do back-end inventory management. Shopify takes all of that off your hands and allows you to focus on the job that you came here to do, which is designing and selling an awesome product.

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Nutonic with Shopify by going to the link in the description below and signing up for a $1 per month trial period, or by heading to Shopify.com slash modern wisdom or lowercase that's Shopify.com slash modern wisdom to upgrade just selling today. Oh, okay. That's interesting. How do you think, I mean, IVF is everywhere. Uh, IUI I learned about at Andrew Schultz's live show, which is kind of an interest and then there's I S C I or I S S I or something as well. I learned about at Andrew Schultz's live show, which is 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 changing the landscape here? Yeah, I mean, I think, you know, that ICSI, the inter-cytoplasmic sperm injection, where you can take a single sperm and inject into an egg, has really been, in my opinion, one of the

revolutions of medicine in the last quarter, half century, 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. So it really, you know, allows it really lowers the bar significantly for who can become a father, you know, for men that 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, 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 come parents, I think, is terrific. But we are seeing increases in the number of couples that are requiring these technologies. And I think they are great. In the US, it used to be that maybe 1% of births were conceived by IVF. Most recently, it's about 2% of all births in the US were conceived by IVF, and those numbers are only increasing.

I think there's a variety of reasons. I mean, I think falling sperm counts are probably a contributor, but also couples 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 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 that allows, you know, sort of selection of specific embryos to try and avoid kind of heritable conditions, some of these genetic conditions at lower sperm counts, for example. We could be able to avoid those in the future. There's this ethicist at Stanford, Hank Greeley, that wrote this book called 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 skin biopsies for men and women, make sperm and eggs,

grow embryos in a dish. That's IVG, right? Yeah, in vitro gametogenesis, exactly. But the advantage to doing this and why society will be incentivized to do this is you could eliminate sort of genetic diseases. We talked about things we know about like cystic fibrosis or certain genetic conditions of lower sperm, but maybe you could even look at susceptibility to high blood pressure,

diabetes and things like that. So really try and root out, again, it kind of gets a little bit brave new world and maybe it's not where we want to be as a society, but. It's a difficult one, man. I've had a, do you know who Jonathan Anomaly is? You familiar with him? No.

There's a company that he is involved with, uh, that is doing, um, embryo selection for, uh, certain traits. And 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. Right. And 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. But then you're right.

This technology and this approach has not exactly had an illustrious, fair and humane history. So it gets perilous with this, but I think it is a probably, actually I was going to say like 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, uh, whatever they're called. Um, uh, uh, what's the elder pregnancy called?

Uh, I would have one. I get advanced paternal age or geriatric. Geriatric pregnancy. That's it. Yeah. The most unfair term of all of them, but 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, 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? 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 sort of attribute it to similar things. I think that exposures, sedentary lifestyle, more obesity, so testosterone again made in the testicles and then it's converted to different things in the body like it's aromatized peripherally to estradiol. 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 and so, you know as these levels go down I think it does you know, it can affect, you know sperm production 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 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 too big, but it's a rare complaint. I imagine so as well. Yeah. All right. Actually, the penis is getting bigger thing. Was there not a study about that?

Is it not statistics that is it testicles getting smaller, uh, anal genital distance getting smaller, but penises getting bigger? Yeah. Yeah. That's a good segue. So, um, we did a, yeah, 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 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 over the last several decades and found, we expected it to decline for all these reasons. We're seeing 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, lower 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. But much to our surprise, it had actually gotten a little longer over time. And so, while it is not certain, we saw it pretty consistently. 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, 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 yeah, that was a finding. Yeah. I imagine that that caused some ructions. Okay.

Erections. Let's talk about erections. Okay. 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 psychological, but now we know that it's probably only 10% psychogenic

and most of it's actually due to organic causes. So, you know, blood flow issues are the main culprit. And I think that anything that affects blood flow in the heart can also affect it in the penis. So, you know, blood flow issues are the main culprit. And I think that 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 ahead the penis sees and can also cause those issues. Sometimes pelvic surgeries, you know, in that area, like prostate surgery is notorious for that. You know, colon surgery as well, you know, in that area, like prostate surgery is notorious for that. 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. And then, you know, the thing that I think is commonly thought of as, 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 are the main reasons for erectile dysfunction if you were to rank order them for the patients that come in to see? What are they? I think mostly it's just due to these vascular comorbidities, 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 rectal 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. I always like to tell men, as long as you have a penis, we can always make it hard. So there's a lot. I try and be optimistic. Okay, what should men do to improve blood flow?

Normal guys like, I'm not smoking that much, I'm not drinking that much, I should improve my blood flow. 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 you can do better, right? So I mean, you should try and stop smoking or cut down if you can. Alcohol, I think there is an expression like whiskey dick, right, so if you drink to excess,

it can definitely lower that. But I think in moderation, it probably doesn't have as much of an effect. But 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 it'd be beneficial. I think that will definitely improve things. Okay, 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. 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. We will check the 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 gonna be the whole story

But for some men that are very low, you know, that can be you know be the difference between no erections and erections. Men that are, if you're familiar with the ranges, probably 300 to 900 is the average levels of testosterone nanograms per deciliter. So for men in the 200 range, testosterone level may help a little bit, but I think those men also benefit from like sildenafil or Viagra, those medications, those therapies. But when they're in the 100 range,

I think those men will see significant improvements in erectile function and sex drive as well with testosterone therapy. Yeah, that's a great point. What's the, is erectile function the same thing as libido in the body? How does this, what's similar, what's different? Yeah, I think 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 problem with sex drive. It just, just doesn't work. It doesn't get us around these students. Yeah. We, we approached those a little bit differently. What contributes to libido?

I mean, it seems to be one of those sort of, it's behavioral, right? It's 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, when we're talking,

you mentioned sort of the psychogenic components to some of this, is to involve sex therapy. I think there's a bunch of excellent ones all over the world. There's excellent ones in our area that we collaborate with a lot. So for some of these disorders, we do it as a multi-pronged approach. So we want to optimize the organic causes and optimize some of the psychogenic causes. 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 may take some time. But we try and look at relationship and other aspects to it as well, because I think all those are contributing.

When you're talking about psychogenic causes there, relationship and other aspects to it as well, because I think all those are contributing. When you're talking about psychogenic causes there, what's the mechanism that's occurring that your brain is somehow able to intervene with your penis? What's happening there? I mean, look, every guy that's listening to this has at some point just gone, 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 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, oftentimes there's not a clear organic cause, you know, we can try and reset them. I think like, you know, sildenafil Viagra, Tadalafil Cialis, 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 all the spreads respond. It might scare it off.

Yeah, yeah, hopefully. I mean, yeah, I guess it depends how you think about tigers, but yeah. So, you wanna run away, right? And so, the body is designed to shift that to the rest of your body so you can escape. And so that same thing happens now, when you're worried about it,

it's just, you know, erections are just not functional. And so we did take some time, but usually, you know, these are guys that, you know, we can't 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's 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, social media, just kind of how we're living, dating practices now. But I think that in general, I think overall the rates have stayed pretty consistent. And I think again, a lot of the causes, psychogenic does contribute to some extent, but I think a lot of it has to do with just vascular health. So hopefully, this technology has made us, to the extent it can, 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, now you can listen to an interesting podcast, for example, or you can exercise with a community on the screen. So I think those things I find more engaging. So I think there's certainly some good that comes with a lot of that as well. This episode is brought to you by Element.

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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. Oh, 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 find lots of it. And it's, you know,'s, obviously there's varying kinds, but the issue is that there's just, it's nonstop, it can be, and very intense. And so, if men kind of are attuned to that, it's difficult to sort of retrain after that

because it can give you, it can give men sort of more than they can get with just sort of a partner on a routine basis. And so, without that level of intensity, sometimes they have trouble, you know, maintaining erections, you know, kind of in a normal part and setting. And so that also is going to take, you know, just some retraining. Again, I think sort of the same regimen we use for other forms of psychogenic 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 gonna affect everybody. 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 gonna be

a lot more willing to, you know, kind of go through the measures to get it better. If something like Tadalafil fixes things, does that suggest other cardiovascular issues? If the primary issue in you maintaining an erection is fixed by something that 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. But, you know, erectile dysfunction can precede other vascular conditions just because the penis, the blood vessels in the penis are smaller than they are on the rest of the body, like in our carotids or in our heart.

So there have been some studies that say that men with erectile dysfunction, you know, are higher risk for a heart attack in the next, you know, five to 10 years. So I think potentially it 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 blood sugar issues, for example. I'm interested in how sleep impacts testosterone and infertility or what the relationship is there. Yeah.

So it's also important. I mean, not surprising. I think that when we talk to patients about things they can do sleep is certainly one of them that will 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 For sperm it's a sort of a u-shape 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 six to nine 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, 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, you know, put that

into action, but it certainly 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 a play with stress and sleep and it sort of antagonizes testosterone to some extent. So I think if men can optimize those things, it'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. Hmm. That's elevated cortisol is not good for anything at all. And the body just down prioritizes making sperm if it feels like you're at war all the time? Yeah, that's sort of thought to be the mechanism. I think the body knows, right? It wants to survive.

That's, you know, eat, survive, reproduce. Survive is slightly ahead of reproduction, although reproduction is certainly very, very important. But if you're in that situation, it'll deprioritize 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, when we talk about these things, try, 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, in 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. 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, if you had to build a checklist for men to maintain reproductive and sexual health, sort of 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 want to be mindful of that prioritizing.

These are all things I think that overlap with health as well. But trying to moderate, make sure you get a good amount of sleep, try and minimize stress to the extent possible. I think the other thing that I think would be great is if men had a good handle on baseline, trying to get a testosterone level of baseline even before problems arise.

Again, because when we talked about testosterone, it's such a wide range of normal, right? 300 and 900. And when men come to see me and they're 400, 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,

maybe you can hit a baseball further, but it's unlikely that some of these other conditions that you came to see me for are gonna get better. So we just wanna 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 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 who these sperm counts are changing in, I think it'd be really valuable. But there is some concern that this could affect recruitment into this, in this survey. Cause there's sort of an ick factor. Even though, right, I mean, it'd be a lot more pleasant

to give, I think, a semen sample than a blood sample. I guess it depends what you think about needles. But again, I think those are, I think it'd 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's 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 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 five 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, bring it to your doctor's attention because at least to alleviate anxiety, but also again, if it's a problem, maybe we can fix it.

It's so, I didn't, it feels like such a revolution at the moment to finally have reproductive technologies that can help both sides. And, you know, for a long time, And, uh, you know, for a long time, this is Schultz's entire standup, uh, 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 that are on this, I've, you know, waved my flag in the air since watching Schultz his special last year. I then went and got a sperm count done. I then went and found that I had varicoseal. So I'm going to get varicoseal 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, it's attached to your sense of self and masculinity and, you know, aptness as a partner, potential future,

all that sort of stuff. And yeah, long live comedians talking about that, a lot of sperm counts, because I think it's a good impact. Oh, it's been so great, right? I mean, I think what was his like that he used to, we were to get pregnant from like a toilet seat, and now it takes like a bunch of doctors. Yeah.

I think that's hilarious. Hassan Minaj had a funny, a very funny routine on it. Ronnie Chang talked about it. So I think it's this great growing awareness and comfort. And again, you lending your platform to talking about this. I think all that is gonna do a great thing. And I think, like we talked about Viagra, I think there hasn't really been a blockbuster treatment

or drug for the increased sperm counts, right? I think one of the most effective treatments we have for low sperm counts is IBF, which puts all the burden on the female partner, given all the procedures and medicines that she's going to require. So if we had, again, pharmaceutical investment and some technology that could improve male sperm across the board,

that would be amazing. Again, I think it just goes to more education and research about why counts are falling, what we can do to reverse that trend. Thank you. Dr. Michael Eisenberg, ladies and gentlemen. I love this. It's a topic that I'm very passionate about, so thank you for all the stuff that you do. Where should people go? They're gonna 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. Okay. Mike, I appreciate you. Thank you. Appreciate it.