men need to understand the average age

of the father has gone up about three

and a half years and with that the

chance of problems with the child also

can increase then that pregnancy becomes

a lot riskier and this is why Dr Michael

Eisenberg is an expert in male sexual

function and fertility who's helping us

to learn the truth about optimal Sexual

Health if you just look at all the data

sperm counts are declining but low sperm

counts and low testosterone could have

devastating effects for example men with

lower semen quality have higher risk of

death wow and there's a lot of really

interesting questions that need to be

answered okay let's get into that is

there any evidence that the chemicals in

our environment are impacting our sperm

count now testosterone levels yes it's a

chemical that's in a lot of creams and

lotions that we use and then there's a

chemical that's used in the manufacturer

of plastic and that could have pretty

devastating effects and so don't drink

out of plastic water bottles what about

paros couldn't figure out if low

testosterone or high testosterone causes

a receding hairline most men are not

going to in like this but it turns out

that if I'm sat down all day is that

going to have an impact on my sperm C

there are studies that do support that I

would say take breaks stand up to try

and air out the area what can I do to

give myself the best possible chance of

increasing my fertility so there's a lot

that we can do and usually we start with

and then erectile dysfunction hundreds

of millions of men all over the world

have trouble with directions but as long

as you have a penis we can always make

it hard for example we can teach men to

give

themselves ooh I just got shiver down my

body but it probably works 80 to 90% of

the

time congratul ulations Dio gang we've

made some progress 63% of you that

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[Music]

Dr Michael

Eisenberg why do you do what you do and

what you do it's a pleasure to be here

certainly an honor um I kind of see

myself as a researcher and advocate for

Men's Health men's reproductive Health

sexual health and so you know I think

when I see patients in clinic that's

what I'm trying to do to try and

understand where they're coming from any

issues they have and find out ways that

we can you know work and improve them

together and certainly from my research

perspective I always want to you know

try and Define what the issues are um

and just improve our treatments that we

have for men I am the director of male

reproductive and Sexual Health at

Stanford or Men's Health uh in the

Department of Urology um I have a joint

appointment in the department of obstetr

and Gynecology because fertility is a

team sport and so I also help you know

couples and I refer women to the female

side and just like I you know get lots

of referrals from them you know when

we're kind of worried about the male

partner when you say sort of

reproductive Health what what are all

the sort of things that fall within that

bucket or underneath that

umbrella so I think you know

reproductive Health really I mean I

guess as it sort of name implies would

be you know trying to have a baby um but

I think it's so much more than that

because I think what we're really

learning is that you know fertility is

kind of a window into future health

probably about 10% of the male genome is

devoted to reproduction um and given

there's only about 25,000 genes in the

body you know it makes sense that some

genes that are operating in reproduction

also operate in another organ system

there was a study done where they took

biopsies of men that had troubl making

sperm and tried to sort of replicate

these cells and they found that these

cells had very high rates of mutations

in their DNA so you can imagine you know

sort of for checks and balances when

we're making sperm it makes sense if you

can't sort of faithfully replicate your

DNA you know there's probably not

there's probably going to be some blocks

where you can't make a sperm right if

there's going to be mutations but also

these men may be set up for other

problems right like cancers or something

like that if you know the body can't you

know effectively replicate cells or DNA

there could also be sort of hormonal

links and that's another thing that we

commonly look at when we're evaluating

men uh with infertility um infertile Men

actually have lower testosterone levels

than fertile men so you know there's

also been studies show that men with

lower testosterone levels have you know

sort of lower survival so it may be that

you know kind of hormonal links between

fertility May kind of put men on a

different you know trajectory you know

another I think very sort of important

aspect of reproduction you there's other

kind of what I call sort of social

factors that are sort of at play um you

know things that kind of necessarily go

with reproduction so like having a

partner um and having kids hopefully and

it turns out that those factors actually

are very important for Health and

Longevity so um like having a partner

actually increases survival so if you

like compare sort of if you have like a

you know a man with a partner and a

child if you then take away the partner

the chance of that man dying goes up 60

% and then if you take away just a child

the chance of him dying goes up

60% but it turns out if there both of

those things are absent that man has a

three-fold higher risk of death than

somebody with a partner and a

child so there's really kind of this

sort of important aspect I think to

health and reproduction I think that men

kind of need to understand and then

obviously there's also just a lot of you

know kind of um intrinsic things that we

do like lifestyle Behavior obesity

smoking those are all very important um

for health as well um so I think you

know when I see these men for

reproduction I really try and broaden it

a little bit to overall health because I

think there's certainly data that you

know as we improve a man's health we'll

improve their reproduction um and

hopefully give them a baby but also you

know improve their overall you know

survival Health everything so how many

patients have you seen in your career if

you had to Hazard a guess roughly oh I

mean I think it would probably be

mean tens of thousands I would guess

maybe 20 30,000 and how many years have

you been working on this subject of sort

of male Health fertility uh reproductive

Health all these kind of about probably

10 to 15 years it feels like the world

has kind of turned towards your work

more so in the last couple of years than

ever before it feels like you you just

so happen to be doing research and

educating people on a space that quite

suddenly relatively suddenly has become

really important to people and I was

even looking at some of the data around

sort of testosterone replacement

therapies and how that's just absolutely

skyrocketed in recent times and also the

conversation around fertility I was

looking at the data around fertility how

many people are searching out for

information on it and it's skyrocketed

over the last what five years and even

in my circle of friends we weren't

talking about fertility or testosterone

or sperm count even two years ago

whereas this year and then last sort of

12 months it's been a frequent topic of

conversation why is this and is my

assessment there accurate and can that

be supported with what you're seeing I

mean I think so I you know obviously I

guess I would say I'm biased and that I

think this is um you know very

interesting and I think you know there

is a lot of momentum towards us you know

there have been a lot of landmark

studies suggesting like you say declines

in testosterone over time uh declines in

sperm count over time and we can

certainly talk about that um a little

bit more and I think with that you know

um there's been really an explosion in

assisted reproductive Technologies you

know I'm familiar you know in the United

States how that's happening you know a

few years ago it was you know maybe

about half percent of all bursts in the

i in the US were conceived with IVF now

it's about 2% and only increasing you

know it used to be that insurance never

covered it now Insurance commonly covers

it and so with that there's just really

been explosion in the offerings the

number of cycles that are done you know

and in my particular area in Northern

California you know it seems like every

year a new IVF Clinic um is opening up

and you're always worried and wondering

how could there be enough business to

support it but instantly you know all

the patients you know all the slots are

filled they're booked out for six months

and I think there's just tremendous

amount of demand and I think that you

know I think to your point you know the

question really is why you know is is

fertility declining are more couples

becoming riing on IVF um and I think you

know again our sperm counts declining I

think all those things are probably kind

of going together

um that's leading to this and I think

it's you know it's something that we're

doing to ourselves potentially there's

some environmental exposure I think all

these things are you know really

interesting questions that that need to

be answered so let's start with why then

if we stay zoomed out a little bit on

some of the social factors that might be

leading to um infertility issues but

also just correlated issues like things

like testosterone and all of these

things what are some of the broader

social factors that are causing IVF

clinics to become so in demand now yeah

I mean I think one of the big ones would

just be uh Rising parental age um you

know

uh there's been sort of less data I

think on male age over time at least

here in the United States but um you

know a few years ago there was a study

done where it showed that over the last

maybe 30 40 years the average age of the

father has gone up about three and a

half years um it used to be like in the

70s you know the an older father and

that would be considered over 40 was

maybe about 4 % of bursts now it's

probably 9 10% of bursts so I think

there's just more delay and with that um

you know infertility gets higher there's

usually a close correlation between you

know a mother's age and a father's age

and so you know I think a lot of people

are sort of familiar as women get older

um you know fertility goes down probably

at a steeper rate but for men the same

thing happens you know sperm counts get

a little lower testosterone gets a

little lower takes a little longer to

conceive you know the chance of problems

with the CH the child also can increase

I mean the oldest father ever is 96 so

the biologic potential does persist um

but it certainly gets a little bit more

difficult in that pregnancy becomes a

lot riskier what is the rate of decline

in men and women um in terms of

fertility so I think you know if your

guest you're looking from an

evolutionary standpoint you know Peak

fertility probably be late teens early

20s something like that and so for women

you know they're born with a set number

of eggs and so as soon as you know

Cycles start they continue to lose them

over time and so usually we think about

you know over 30 35 40 you know those

are pretty big points where fertility

gets a little bit more challenging for

men you know we the the sperm counts do

decline you know why this sort of cut

off where we say older father is 40 is

sort of a constellation of sort of

different risks you know the sperm

counts get a little bit lower but the

other thing that happens is every year

um you know we're born with sort of

sperm precursors or sperm stem cells in

our body and they are constantly

replicated every year and every time

that happens there's some chance of a

mutation occurring so it turns out that

you know every year we probably

accumulate sort of two mutations in our

DNA and so over time you know that

becomes a little riskier so for like a

40-year-old is going to have 20 more

mutations than a 30-year-old for example

so we have you know billions of base

pairs of DNA in our body so the chance

of you know 20 you know mutations making

a difference is probably pretty low um

but you know that's at an individual

level at a population level that's

something that you may start to see and

so for men I think it is just sort of a

slow steady decline you know again

probably in the 30s 40s do you have the

data on the oldest ever mother are you

the oldest ever woman to conceive a

child so with uh using like a donor egg

I think it's 60s or even even in the 70s

I think it's been described before but I

think with her own egg I think it's late

50s early 60s are you concerned about

this as a macro Trend because if we play

this forward it would lead us to a

assume that fertility is going to be an

increasing problem for

society yeah I mean I think very much so

right it's existential I mean you know

as a disclaimer obviously I'm in the

fertility business so um you know I do

certainly care about this trend and want

to make sure that we reverse it it's a

risk factor that we know about but I

think you know the the solution is not

obvious right because asking couples to

delay careers education all that is very

challenging you know I think some

countries have try to come up with you

know ways to support you know Parenthood

you know through leave or you know other

kind of programs like that child care

also becomes uh you know very important

um but even with those I think that um

there's just sort of a perception it's

just it's not as easy as you'd think and

it turns out actually that you know the

return on investment for some of these

things you know having a child is so

kind of important for the health of a

society right there's some there's this

concept called replacement rate that's

the number of children that need to be

born to a reprodu age women to maintain

a population's level sort of this is

kind of ignoring immigration so it turns

out you need about 2.1 children per

reproductive age women for a population

level to stay the same so if you in some

societies it's lower like in the US it's

a little lower than that and some um

like Asian countries like Korea JP Japan

it's lower than that and that's really

existential because if you know if your

working population starts to decline um

you know tax Spas everything you know

will really collapse and so from an

economic standpoint it makes sense if

these are couples that want to have kids

and they you know these are wanted

children you know to try and invest in

you know allowing them to do that really

makes sense because you

know it'll it'll kind of pay it back it

is at a societal level I read about in

Hungary that if you have four or more

babies then you'll pay no income tax for

the rest of your life according to the

Prime Minister it's an article that I'd

seen and I think this is speaks to a

broader trend of how there's going to be

a topown approach towards getting us to

be get back to having babies to stop the

population collapse and decline that you

talked about um hungary's prime minister

has announced a raft of measures aimed

at boosting the country's declining

birth rate and reducing immigration and

one of them is that essentially you'll

get be given a check and you only have

to pay that check back if you don't have

four kids so for every kid you have 25%

of the money that you're given is

discounted and once you get to full kids

you never have to pay income tax again

which I thought was a

really interesting idea but it's a sign

of things to come yeah yeah I mean it's

fascinating right I mean I think that

these you know the economic ministers

Prime Ministers are really thinking

about things I'm sure they've looked at

the numbers right and realize that um

you Society really relies on you know

maintaining numbers and when you know

when the population starts to slip could

be a problem I mean I think that's it's

a very clever solution

sperm

quality sperm quality I read is

declining yeah so that's a very it's

interesting because that's such a

controversial statement uh you know I

think there is a tremendous amount of

data that supports that a number of

years ago I was actually involved in a

study looking at data from a sperm bank

here in the United States um it was a

sperm bank that was in uh the

northeastern us at a few locations and

it wasn't a lot of data it was just sort

of a few years of data um about like a

little over maybe 10 15 years but what

what we found is that actually if you

looked at men that were coming in to try

and be donors because you know these

Banks they're very selective so you have

to have you know excellent sperm that

freezes well that thaws well really high

numbers and you know they also look at

your pedigree a little make sure there

aren't conditions to run your family

they like you to be fit you know these

are kind of things that are thought to

you know sort of make make a better

donor um and when we looked at sort of

the candidates that came in over this

you know really short period of time

probably 10 15 years there was declines

in you know sperm counts um you know the

movement shape all these sort of

parameters that we look at when we're

talking about a seman analysis and what

was interesting is that you know when

people have talked about declines in

sperm count people have sort of

attributed to different things for

example people have talked about the

Obesity epidemic right and that maybe

we're more sedentary now than we used to

be or you know environmental exposures

or another thing there's more chemicals

now than it used to be or cell phone

prevalence and things like that but you

know over this short period of time

where we did have you know a lot of

information on these men they filled out

surveys um you know they filled out kind

of Rich family histories they filled out

information about whether they drank a

lot smoked a lot things like that

there's really no differences in these

men you know from the beginning of the

study to the end the only difference was

that their sperm counts were lower so it

was really you know kind of surprising

um very interesting and so you know

other investigators have used studies

like that kind of pulled them all

together using kind of advanced

statistical techniques and found this

decline over time um you know over the

last maybe 20 30 40 50 years um so there

is a preponderance of data that supports

that so the counterargument that others

have made is that you know over that

same period of time some of our

techniques have changed right we're

better at counting sperm now than we

used to be you know some of the

different um you know tools that we use

to measure sperm count some of the

analyzers are better now than they used

to be so we're a little bit more precise

than we used to be the other um you know

thing that these Studies have done is

when they pull together data they assume

that you know everybody's the same like

right if we were both in the study they

would assume that I'm like you you're

like me but it turns out that there's a

lot of variation based on like region so

there was a study in the United States

where they looked at fathers so men that

had kids at different regions of the

country you know like had some in

California New York some in the Midwest

and even though these were all fathers

similar ages the sperm quality was much

different turned out it was really high

and in New York I think California was

next and the Midwest was a lot lower um

so so you know again why you think that

right New York would be kind of hustle

bustle Metropolis maybe they would have

some poor risk factors but turns out

they had the best sperm and so why that

is is you know wasn't certain but it

just shows us that there's a lot of

variation in seon quality from

individuals so when you put things

together sometimes it can be difficult

to you know to identify Trends so

ideally what we do is you know I and my

neighbor would give sperm maybe every

year every 5 years 10 years over time

and you'd see what changed um and those

studies aren't ail so that's sort of the

criticism of these studies but again if

if you just look at all the data if you

compare studies from the you 70s ' 80s

90s to today sperm counts are lower what

is the current best guess as to why

sperm counts are lower yeah I think

that's the million-dollar question

because I you know we've talked about

this is sort of an existential

existential threat right we need a you

know I think any species has sort of

three main functions right eat survive

reproduce you eat to survive you survive

to reproduce spread your DNA and so if

you can't do that it's definitely going

to be an issue so you know I think that

we've talked about you know maybe

obesity I think we're certainly

different now than we used to be you in

terms of walking around you know um

sedentary Behavior people have you know

hypothesized different chemicals in the

environment are kind of leeching into

our food supply our water supply is

there any evidence for that that the

chemicals in our environment are

impacting our sperm count and our

testosterone levels and things like that

yeah there are there are studies uh that

do support that um you know there are

certainly like pre-clinical studies you

know where you can actually you know

dose like rats um and mice these there's

also human studies where you can you

know compare sperm quality to you know

different sort of chemical traces in the

blood and see these correlations as well

and then there's um a study called enh

Hanes which is a a study by our Centers

for Disease Control where every year men

and women are sort of surveyed or they

collect data on Obesity blood pressure

things like that um and they do collect

data on sort of chemical exposures for

these you know select group of

individuals that kind of represent the

whole population this has been done for

the last you know many many decades and

so when we talk about obesity kind of

rising in prevalence in the United

States it's been it's based on that data

this is kind of a rigorously sort of

researched you know group of individuals

it's selected every year and so those

same studies collect data on

testosterone or estrogen for women and

they collect it on these different

environmental chemicals and do see these

correlations I would say that not every

study supports this but there are

certainly a good number that do show

that um there is this correlation that

if you have higher exposure to some of

these chemicals uh there's higher risk

of lower hormone levels what are those

chemicals and where do we find them CU I

I I spoke to someone who was a urologist

recently um I think from NYU and they

were telling me that things like the

microplastics and I'm not particularly

aware of what a microplastic is to be

honest but things like microplastics in

our environment are some of the

chemicals that are causing sperm quality

to reduce mhm is there evidence to

support that there's a lot of different

chemicals to be sort of concerned about

or think about I think you know

microplastics are one phalates what is

aite aite is it's a chemical that's in a

lot of like um you know different uh

like creams and lotions that we use um

and so those also have been shown to

affect Androgen you know and kind of

endocrine function inside the body uh

bisphenol a is a you know a common

chemical that's used in the manufacturer

of plastic and that's also been found to

have these endocrine disrupting

properties um so that's also been

correlated with Sean quality endocrine

disrupting endocrine disrupting what

does that mean so you know if you look

at sort of Pathways for men and women

there's you know hormones right I'm

making testosterone and that acts on my

body as I was a child to help make me a

man now it kind of helps you know keep

me a man you know with grow a beard all

those sorts of things giving me my U my

deeper voice um and so there's some of

these chemicals that kind of mimic some

of that action or block some of that

action and so if that happens um it can

affect you know normal development of

you know boys or girls you know maybe

you know again affect sort of semen

quality if we think about sort of the

origins of changes in semen quality some

of it may be when we're adults but some

of it also could be during development

you know either when we're developing

inside of our mothers or you know during

puberty if something kind of affects the

normal timing of that it could be you

know again could have pretty devastating

effects and so one theory for that is

some of these chemicals that affect

these sort of biologic Pathways these

endocrine Pathways involved in that from

the research you've seen on sort of

these chemicals is there any changes

that you've made in your own life at all

anything that you it's kind of made you

think differently about the choices you

make in your own life with your kids

because you got three kids so you have

an opportunity to kind of influence them

at a at a earlier stage than most of us

can influence ourselves but yeah so one

thing that we do um is I've thrown away

all plastic water bottles I I'd say I

still use it because I find them very

convenient um and I'm done with

reproduction but um but certainly for

the kids um I make sure they don't drink

out of plastic water bottle so we have

either glass or um or metal I do think

there is data that that's um you know a

very you know large exposure that kids

get and I think it's you know fairly

easy now to remove that what does the

data say about plastic bottles you know

if you look at um you know exposures

from that you know they have they just

leech a tremendous amount you know with

wash with water it kind of sits there

all day so I think it's a it's a very

you know again most plastic water

bottles want the you know plastic bottle

industry to come after us but um that's

a common way for you know individuals to

get exposed to it so I think if again if

we're saying that's one of the main

touch points for Plastics um is is

usually through our kind of food and

water supply then yeah I think it's easy

to to get rid of it if you

can is there anything else I I I've read

recently that heat has a a role in our

sort of sperm quality so if we're don't

know if we're going into saers or

something or if we're spending a lot of

time I don't know sunbathing then

there's science that suggests that will

lower our sperm count yeah so that is

right so I mean I think that you know gu

you can kind of look at this sort of in

a bigger sort of global warming kind of

context and people have you know

theorized that maybe that could also

play a role because you know the

testicles are outside the body because

they need to be a few degrees cooler for

sperm production to occur so anything

that warms them up can definitely be a

problem um so when I talk to patients in

clinic for example we do talk about Saun

use hot tub use some men bathe every day

like in a bath um and those all can

impact sperm production there there have

been studies to show that men that you

know use you know saunas on a regular

basis they have lower sperm counts and

then when you withdraw that exposure um

sperm counts will go back to normal one

you know sort of interesting application

of this was to try and use this data or

use that knowledge to come up with a

contraceptive so there was this weird

sort of like truss kind of belt that

actually pushed the testicles up into

the groin um which actually turned out

did reduce sperm counts uh to zero I

think and again the the few men that

that volunteered to do that um but you

can imagine I think most men are not

going to be too excited about that um

because it's probably pretty

uncomfortable uh the other way that I've

seen it is I've had patients that have

gotten sick certainly around covid that

happened not infrequently men would come

in you know telling me that you know

they just got over a covid infection

that where they had high fevers for you

know a few weeks um and then their sperm

csed be very low and then you know we

wait a few months it takes about two to

three months to make a sperm so we let

one of those Cycles or two of those

Cycles go through and their sperm counts

came back I had a patient even before

covid uh like 41y old guy he had normal

sperm count and then all of a sudden he

measured and the sperm count had gone to

zero and it turns out he had a a flu

with fevers about 102 degrees Fahrenheit

um the week before and again we let kind

of sort of nature take his course he

recovered and then his sperm counts came

back to Baseline so we do see that um as

well with that belt that you mentioned

that it holds the sort of test testicles

closer to the body I'm guessing it's

doing that to heat them up basically

which reduces the sperm count MH

obviously then one would think about

their boxer shorts we're all wearing

very tight boxer shorts these days

that's like invogue or whatever so is

there any studies to suggest that boxy

shorts can reduce sperm count if they're

tight so that's like a very Comm that's

one of the most common questions I get

like boxers versus briefs and that's

been studied a lot because that is a

very common exposure I think I usually

just tell men whatever is comfortable I

think it's unlikely that any single

layer is going to make a big difference

unless again you have the specially

designed underwear that pushes testicles

up into the groin but otherwise as long

as they're outside the body it should be

okay what about mobile

phones and technology is there any um

link between fertility and are use of

Technology specifically having these

devices in our pockets close to our

genitals that's you know another common

question that I get um and that is

certainly something that's changed right

now versus you know 20 30 years ago uh

so there were some studies that you know

initially showed kind of this signal

that men that use cell phones more had

lower sperm count but some of these

studies were you know they're older and

you also worry about some of these kind

of confounding things it may be that

people that use phones more do other

things more you know they have may have

more stress in their life and other

things that could affect SE quality so

there was a clever study that was done

where they actually took ejaculate so

took sperm put it in a cup and put a

cell phone next to it and tried to

measure changes in you know the quality

of the sperm and they actually did find

some they found higher rates of like DNA

damage within the sperm that was exposed

to the the phone versus not you know

kind of trying to control for

temperature which we you know said is

important for the health of the sperm

wait so they controlled for temperature

they controlled for temperature and just

having kind of the cell phone you know

getting its signal um seemed to affect

you know the DNA damage in sperm it

wasn't you know it was a statistically

significant you know difference um it

maybe would not be kind of a point where

we would get as worried clinically but

it is a change so I think it's something

to think about I think that um you know

aside from that cell phones I think

nowadays don't get too hot so not as

worried about heat but whether this RF

you know this radio frequency exposure

may impact things is a you know maybe a

theoretical risk but I gu there's not a

lot of concrete data so I think that you

know again if so a lot of my patients do

tell me that they keep their try and

keep their cell phone in their back

pocket or front pocket to try and avoid

that I think that's I think that's fine

I've been having this conversation with

my partner a lot she really believes

that my cell phone should never be slid

under my genitals which I sometimes do

when I'm like I don't know when I'm in

the car or something or when I'm on the

sofa I don't know when I've got my hands

full I'll just grab it and I'll kind of

like slide it between my legs yeah and

she'll

reach in and pull it out and say and I

think because she's concerned about

those four kids that we want to have and

you I think she cares about you too yeah

I to be fair she's not someone that's

going to read PubMed and read about the

studies but it's just a feeling she has

yeah and I always refuted it and thought

now there's no way there's no way

because they would have tested it and

the test seems so easy you get sperm you

put it in a little thing you put the

phone on top of it send it some text

messages connected to the Wi-Fi the

Bluetooth and see how the sperm get on

yeah I didn't realize there was a study

asso with it yeah I think laptops also

can do that too but they also have a

little more heat associated with it so a

similar study was done in laptops um

where they had sperm put it next to a

laptop and they controlled for

temperature uh and saw the same pattern

you know again sort of the Wi-Fi signal

can also affect again sperm you know DNA

damage and sperm quality um but also you

know laptops can get warm too right some

of the batteries some of the moving

Parts within uh can heat up too and it

also just serves as almost like

insulation if you put it over your lap

so I do talk to patients about that as

well um you know to maybe use like a

pillow or something else just to try and

shield yourself a little bit wouldn't we

see a sort of big difference between hot

countries and cold countries or sort of

warm countries and sperm counts then so

if I in sort of subsaharan Africa I'm

assuming my sperm count will be pretty

low because I'm going to be sweating all

day so I think that um the other sort of

element to that though is that there are

differences in populations and I think

that that has not been well described

you know but if you compare you know

again we talked about California New

York the Midwest and the United States

but people have also compared you know

like Denmark which they have a lot of

sort of problems with reproduction so

they've really studied it very very

aggressively and if you compare them to

other countries nearby or other

countries in Europe it's much different

and so you know one possibility could be

exposures you know and what these men

are doing what they're exposed to but

the other could be you know again there

could be some genetic components but one

interesting thing about sort of on that

same line is that uh sperm quality does

vary based on uh time of year so during

the hotter months it does go down a

little bit you know not meaningfully um

and then during the cooler months it it

goes up a little bit but the other thing

is that you know we don't spend well

some of us do I guess or some of us

don't but no spend all your time

Outdoors right and sometimes in the um

you know during the the cooler months

you're you know kind of bundled up

inside and during the warmer months

you're may be in you know cool air

conditioning did you say that this

Denmark has had a problem with sperm

count yes yeah so um you know in the

United States I said that about 2% of

bursts are conceived with IVF in Denmark

it's about 10% wow um and it's actually

they they've again they have really a

crisis of reproduction there so they've

really um done some really good research

on seam quality and it estimated that

only about 25% of Danish men have normal

Sean

quality have they figured out why that's

what they're looking into and they have

lots of theories and again I think you

know again it goes to many of these same

topics that we talked about whether it's

environmental exposures on you know

mothers um or you again pubertal boys or

you know adults as well so they are

trying to figure it out but it is you

know that's also one of the countries

where the fertility rate is is below

replacement so it's definitely an issue

one would assume that it's some kind of

environmental factor I guess it could be

some other social Factor but but one

would assume that it's some kind of

environmental yeah Factor yeah some

people have postulated during World War

II they were very isolated and so

potentially there were some chemical

exposures that have just you know kind

of persisted uh and remained in the

population and it's kind of tough to

work through that but it's not

known if I'm sat down all day is that

going to have an impact on my sperm

count as well because of the heat

generated from me just sitting here um

and or if I'm a if I'm a cyclist or

someone that's doing you know sat down

on my testicles doing something warm

people have looked at sort of different

occupations where you sit a lot um and

there are associations like drivers you

know taxi drivers truck drivers they

certainly can have changes in sperm

count you know probably due to heat you

know again I think it could be a

combination of sort of sitting all day

is also you know from probably other

health standpoints is not great and

cycling too you know people have looked

at sort of peak athlete cyclist and

there are differences in Seaman quality

um but you know Peak cyclists you know

they do a lot to their body and so you

know it's possible that there could be

other effects too but you know looking

at men that sort of recreationally cycle

too I think that the number that I use

there's a study that showed um if you

cycle over five hours a week there can

be lower sperm counts so you know I

talked to men about that when they do

cycle you know more than that you know

potentially taking breaks trying to

stand up if we think the mechanism is

heat to try and sort of circulate air

out the area to spend some time out of

the saddle if possible what about men

with big thighs

yeah well I think you know obesity is an

issue there's certainly a strong

correlation between body mass index and

semen quality so as men get bigger sperm

counts go down um and so heat is

certainly one of the the possible

mechanisms for that just kind of

insulating that area warming things up

can kind of do it you know obesity also

affects you know the kind of hormonal

axis as well so that also may be at play

too because you know there's kind of a

normal stimulation that's given by your

pituitary in your brain that tells your

testicles to make sperm make testost

tone and some of that's also affected by

obesity as well so it's probably a

combination but that is something I I do

think about when I see you know my

patients and we do talk about sort of

heat exposures as well and see if

there's you different sort of strategies

they can use to try and allow more

circulation in the area is there a link

between um sperm counts and alcohol

consumption I think it depends is what I

would say so in general for most kind of

moderate use I would say kind of a drink

a day um and some people think that no

amount of alcohol you know is safe but

probably if you look at these studies

looking at maybe a drink or two a day it

probably doesn't correlate too strongly

with Sean quality but it seems like

there there are some studies say that

when men get to three a day so maybe 20

a week there can be lower quality uh in

semen and there was also another study

that we did looking at you know to see

if some men are more susceptible to to

alcohol intake so there are some um East

Asian men and women that have a mutation

and one of the enzymes that's used to

metabolize alcohol and so they

accumulate what's called acid alahh

which is a toxin actually and so when

they drink they flush I don't know if

you have any friends that have this but

um we hypothesize that you know when you

have this you know this large load of

this chemical in your body that leads to

Flushing headache dizziness um maybe it

also affects semen quality and it turns

out that it does so for these men that

have this mutation um when they drink

their sperm movement goes down a little

bit

so it turns out that there's actually a

reasonable number of men on Earth that

have this you know it's probably in some

populations up to 50% like in Taiwan um

you know it's very common in Japan you

with chinese vietnamese ancestry so I

think it's something to be aware of and

I think usually you know men do know if

they flush when they drink it's probably

because they have this mutation and Al

alahh dehydrogenase too so you know for

those men I think that it's probably

better to you know avoid alcohol or uh

just to sort of be aware because um it

can affect SE quality if I if I came

into your clinic and I said Dr Michael I

I'm trying to have a kid with my partner

and I want to make sure that everything

I'm doing is giving me the best chance

of having a kid what is what's the list

of things because this is basically

where I am at my in my life now I'm 31

years old I want to have a kid I'm

ideally want to have four of them and

I'm thinking about the time my partner's

the same age as me we're almost

identical in age

and she's 31 so we're we've got you know

we want to have these kids before 40

ideally so I kind of need to get get

going get going you know what I mean so

so what can I do to give myself the best

possible chance of increasing my

fertility my sperm count so that we have

those four kids that I want over the

next nine years was the four number it

was something you came up with before

that the tax incentive

or yeah we are planning to move to

Hungary so there you go was really it's

really about tax avoidance it's not that

I I want kids um no I come from a family

of four so for some reason I've always

had four in my head I I think she's fine

with it as well I think we've we've

we've chatted and she's she's happy with

four to six no it's a good number not

had six signed off but four for sure

what would you say to me then so I think

you know we look at you know your

overall health um you know we' see any

risk factors you had obviously we're

talking about saunas hot tubs find out

you know how you exercise if there's

things that you do that are not you know

good

um look at you know if any medical

conditions that you have surgeries that

you've had some of those can put men at

risk for for that if there's any

medications you're on there can be

medications that affect it and then

we'll do an exam um so we don't have to

do that here in front of the

cameras I'm

down U I do have yeah I do have a

California medical license but um so you

know we want to make sure we look at the

sides of the testicles make sure all the

other structures are where they're

supposed to be um you know one of the

basic evaluations will be a seman

analysis so we'll measure how much comes

out look at how many sperm there are

look at how many are moving look at

their shape as well and then usually we

also check hormones as well so we'll

check testosterone again sort of this

very male hormone the testicle does two

things it makes sperm makes testosterone

so we check that and then usually we

check some other hormones involved in

the kind of hormonal axis that controls

reproduction and that's usually what we

start again fertility is a team sport so

I would encourage your partner to also

get evaluated as well um and we'd see

you know depending on kind of sperm

counts usually then we're able to sort

of counsel about you know how likely you

are to be able to achieve um you know

those four kids but you know again it if

you're kind of thinking about four I I

would agree that you should get

started fertility issues we tend to

think of it I think there's a stereotype

that it's typically the woman who has

the fertility issue and and the man is

okay and I think if you when I looked at

the data that it that's kind of

supported this idea that couples assume

it's the woman that has the fertility

issue is that a misconception it's a

huge misconception yeah so absolutely I

think that you know in United States and

other countries too I think usually you

know women are kind of the gatekeeper of

fertility everybody assumes that that's

where the issue lies but if you actually

look at you know the data probably about

half the time there's a male Factor

contributing and you know this sort of

stereotype is so prevalent that probably

at least a quarter of the time in the

United States the man's never evaluated

and he could be you know one of the

issues so some couples may go to IVF you

know for the lone reason of you know

again low sperm count and the man would

never evaluate it and maybe there is a

condition that we can improve maybe he's

on a medicine maybe you know he's going

to the jacuzzi every day you know

something like that that we be able to

reverse you mentioned testosterone would

be one of the things that you would

measure if you were trying to make sure

that my fertility was good male

testosterone decline this is another Hot

Topic you talked about it at the start

of this conversation is it true that

male testosterone is declining and how

much has it declined by yeah so um again

study from this enhan this CDC you know

measuring men every year for the last

several decades if um you know there's

data that shows that testosterone levels

have have gone down over time you know

people have also looked at um you know

other cohorts of men you know from the

2000s the '90s 80s and there's just a

progressive decline in average

testosterone levels over that amount of

time so you know the amounts you know

kind of vary 50 to 100 points but you

know generally these are you know

meaningful measurable amounts in

addition to sort of these kind of cohort

changes where if you kind of you know

look at the average 40-year-old Now

versus you know 10 years ago our our

testosterone levels change too so I

would say that I usually tell men after

the age of 20 your testosterone is going

to go down maybe about a percentage

point every year so as we get older

testosterone does go down and there's

things again that can affect that

trajectory you know men that get more

obese that also affects testosterone

level a portion of all of our

testosterone is converted to estrogen a

lot of that conversion happens in you

know adapost tissue or fatty tissue so

the more kind of extra tissue there is

in the body the more that conversion

will happen and so your you know

effective testosterone levels will be

lower what about movement and exercise

does that have an impact on our

testosterone levels in a significant way

yeah I mean I think that you know the

more walking you do the more active you

are we've looked at that as well you

know step count is directly correlated

to testosterone and you don't have to

take 20,000 steps a day you know 4,000

8,000 steps a day you know just kind of

walking around you know sort of

reasonable amounts it can make a big

difference and I think that um you know

activity is important it probably also

helps Dave off obesity a little bit as

well as another mechanism okay so I'm a

Manchester United fan right now we're

losing a lot I thought you guys have

turned it around yeah I thought so too

until last week okay so if you're if

you're supporting a team that is losing

your testosterone levels likely going to

be lower well I think this is sort of an

acute thing maybe we could do that

experiment right where does that that

research come from that if your team

wins your testosterone increases I don't

remember I I that stud is pretty old I

think that even dated my um training but

I do remember reading that I think that

was one of the articles that get picked

up by the newspaper okay of course why

why does testosterone

matter well I think testosterone is very

important for you know a lot of things I

think it's it's important for our

quality of life so energy level sex

drive mood sleep concentration all those

things are very important um when

testosterone gets very low it also has a

lot of Health implications so muscle

Health bone health heart health so we do

want to keep our levels in a normal

range um because I think it yeah kind of

helps us with our function and our life

uh and happiness how how does the impact

our sort of muscles and Bones I don't

really understand what testosterone is

doing I I kind of think of it as the

chemical that kind of makes you a man I

know women have testosterone too but I I

just think of it's the chemical that

makes my beard grow in my voice deep

yeah well that's what it's doing but

it's anabolic it does help kind of grow

it helps with bone turnover um and kind

of keeps sort of uh you know the

strength of the bone so men that have

very low testosterone levels have you

know frailer bones higher risks of

osteopenia

osteoporosis so um you know I think it

helps with muscle growth bone turnover

bone strength so I think all those

things are um are important they usually

don't get into those problems unless men

are very very low I would say that you

know I don't know you but you know the

average testosterone levels are probably

300 to 900 I would guess probably on the

higher higher end of that um but you

know when are low probably less than 200

100 that's where we start to worry more

about you know bone health muscle health

and so I think that there is some wiggle

but when you get kind of lower than sort

of the normal ranges kind of the 300

range that's when some men do develop

you know some of the symptoms of lower

energy level sex drive problems things

like that so low testosterone typically

means lower sex drive uh it can it's one

of the it's one of the common symptoms

that we see with that does that mean

that if I just take loads of

testosterone my sex drive is going to go

back up you know over the last probably

10 to 20 years the number of

prescriptions of testosterone written in

the US have kind of gone up almost at an

exponential rate and because people did

think of it sort of as a um kind of an

anti-aging kind of Rejuvenation therapy

and so there was hope that it would help

people but if you look at some of the

randomized trials if a man has a normal

testosterone level and you give him

testosterone uh it may not help him that

much even men that have kind of a lowish

testosterone like we talked about sort

of this 300 cut points so I've had

plenty of patients testosterone of 250

let's say so we talk about risks and

benefits of being on testosterone uh

we'll try them on it and you know a lot

of men do feel better but not everybody

some men I don't feel any you know doc I

don't feel any different even though he

get his levels you know from 250 to 500

um and so then it's probably not worth

you know to be on a medicine every day

if it's not helping you I'm not worried

about his bone health you know we'll

check some other measures to make sure

that's okay um so then it's not you know

again when you look at risk and benefits

it's probably not worth it but there's

certainly some men who do who do see

Improvement so is testosterone hurting

some people their testosterone treatment

does it actually have an adverse effect

if you take it basically when you don't

need to I mean even when you do need to

I think it could C sometimes cause

issues yeah there's certainly side

effects to testosterone um you know one

of the big things that I see in my

practice is how testosterone impacts

sperm production um it actually was

tested as a contraceptive by the World

Health Organization because it does low

lower sperm counts in most men I would

say 90% of men now it doesn't do 100% so

it's not that great of the contraceptive

yet they're kind of working on some

other ways to tweak it um but I have

plenty of patients that come in you know

some of them suspect that testosterone

is the issue some don't know um I

remember one couple in particular they

came in as a couple together you know we

measured his sperm count it was Zero we

started talking about risk factors and

he was on testosterone I said well the

best thing to do would be to stop

testosterone um and for his work I'm

going tell you what he did but for his

work he really couldn't stop it um so

there's some other medicines we were

able to add while he continued the

testosterone um and then and then they

ended up with triplets um shortly

thereafter so I think that you know men

need to be aware of it um because that's

you know certainly one of the big risk

factors at least of reproductive age men

is this risk to

fertility so it can impact my sperm

count negatively um I I I saw a quote

from you that said if we take a hundred

of my infertile patients that I see in

the clinic at least five of those men

will be infertile because they're on

testosterone therapy one in 20 infertile

men are that way because of testosterone

as it relates to infertility one of the

things that I've always worried about is

if I take

testosterone then my hair would fall out

yeah so that can do definitely happen so

you know hair loss breast growth acne

those can all occur I would say those

are things that we can monitor so you

know one thing I always tell men is that

we're not trying to get them to superum

right we're just trying to get you to

normal so I think if we monitor it

closely most men you know will do okay

again there are some other therapies

that we can do for men that have side

effects uh you know from those things it

can also affect the thickness of the

blood something called the hematocrit or

we count the number of red blood cells

in the body it can increase that number

so if it gets too high that can be an

issue so that's another number that we

follow there used to be a concern about

um higher rates of heart attack and

stroke with testosterone so there were

some studies done um you know about

maybe 10 year five 10 years ago that

suggested that but a really large trial

just came out uh with about 5 200 men

half of them randomized to testosterone

half not and there was actually no

difference in the risk of cardiovascular

disease so I think that's something that

we can probably put to bed the other

thing that men worried about is increase

of risk of prostate problems prostate

cancer prostate growth and you know that

same trial also showed that um from a

prostate standpoint probably not a lot

of risk as

well do you have many men coming to you

to talk to you about hair loss and

Bolding uh some men do I think one of

the ways that men talk to me about it is

one of the common medication for that is

finasteride right or you know sold on

the trade name propa um and so they want

to understand some of the risks of that

and so you know when that medicine was

approved for a hair loss they you know

again because people that are going to

take it are usually in the reproductive

age they did randomized Placebo control

trials to look at semen quality and it

turns out that it didn't meaningfully

impact things maybe it went down a

little but not a lot um but in sort of

post um you know analyses of some of

this and now seeing lots of patients

coming in we do see men that are on

finasterid some of them are more

susceptible and so one of the

interesting thing about trials is

there's you know kind of inclusion and

exclusion criteria right not not

everybody can be in it and so if men had

sperm counts that were too low they

weren't invited to be in these trials so

for men that you know don't have as much

Reserve as others I think they may be

more susceptible so that's one of the

risk factors finasteride you know the

other thing in aash in addition to

reproductive health is sexual health

that I deal with a lot and there's also

a concern that finasteride impacts

sexual function function in men too so

you know we have these discussions I've

had some men that come in after having

been on finasterid and have you know

different issues with sexual desire low

liido or rectile dysfunction and so then

we you know work through an algorithm to

try and improve that as well this is one

of the things I think about a lot

because I don't want to I don't want to

have a receding hairline and I also

don't want to have a air operation or

anything like that but when I hear about

some of these testosterone replacement

therapies and and such my big concern is

that if I take testosterone maybe not

now cuz I'm you know probably don't need

it right now but maybe when I'm a little

bit older which is when I assume one

would start taking it maybe when I'm

about 50ish on average but there are

younger men that are on it as well for

what reason just because they're low

on what's the sort of symptoms that that

have caused them to take it well I think

there's you know with all things there's

a bell-shaped curve so some men are a

little bit lower some have genetic

conditions you know there are um some

more nefarious testosterone prescribers

so even though men have a normal level

they're offered testosterone to kind of

get in these kind of testosterone

clinics and some men you know if kind of

look at data maybe 10 to 20% of you know

high school athletes have experimented

with testosterone and if you stay on

that too long it can really shut down

your own axis so um if you take

exogenous testosterone so like

testosterone injections or gels your

body stops making it and the longer

you're on it the less likely your body

is able to sort of restart and so for

some of these men you know poor choices

or or whatever they've been on

testosterone for a while and they can't

ever stop I don't know if you've ever

had any experience in it because I know

you focus predominantly on male Health

but um I've had a long conversation

about contraceptive pills with my

partner because she was on she said this

publicly before that she was on a

contraceptive pill for a long time and

then and everyone's relationship with

contraception is different but after

taking it for seven or eight years she

she came off it and her period didn't

happen didn't occur so she really

struggled with that for a while

previously and it made me really you

know it illuminated the fact that when

we start messing with the chemical

balances of our body using pills and

injections and other things we could do

pretty long-term Andor permanent damage

to ourselves and there's no real such

thing as a free lunch is there in

biology and chemistry yeah I think

that's what it comes down to I think a

lot of people have said that if they

tried to get the uh the pill approv now

it would be a much different process and

unlikely to succeed for those kind of

reasons if I have low

testosterone um and I come to see you

what is the typical way of getting a

testosterone replacement therapy is it a

pill is it an injection that I have to

take um I know that it's quadrupled

according to the data in the US since

two since the 2000s which is staggering

but how are people taking testosterone

so there's lots of different ways it can

be taken I think one thing you know

again we talk about all the risks so

fertility is certainly be you know a big

one so if you come in in your 30s you

know I'd ask you about your reproductive

intent so if you have a low testosterone

and you're interested in having four

kids I wouldn't start you on

testosterone directly there's some off

label things um you know so medicines

that we kind of repurpose to help

increase your body's own testosterone um

that we would start with but assuming

that let's say you're in your 60s you're

not interested in fertility then you

know there's gels or patches that you

put on every day testosterone gel or

patch um because that can work well

probably 10 to 20% of men don't absorb

testosterone that well through the skin

the other thing to be aware of is that

there's a risk of um like transference

like to your partner to anybody that

kind of touches your skin so if you have

young kids just to sort of be aware of

but as long as you know you put it on

let it dry put clothes on over it it's

not a big risk um you know again and

also have to be I guess mindful of

laundry as well uh so you know gel's

patches are one there's injections uh

that you can do every usually one to

three weeks on average there's testost

pellets um so these are pellets that

have testosterone they're kind of slow

release so um they're just injected uh

we kind of implant them under the skin

usually in the hip area and those last

probably 3 to six months there's longer

acting injections so those are very

common in Europe um they're kind of

gaining steam in the US but those are

injections that last probably 10 weeks

or so and then there's a new oral

therapy so there's an oral form of

testosterone um that's available as well

I was quite confused on this subjec of

hair loss in testosterone because I

couldn't figure out if low testosterone

causes me to bold and have a receding

hairline or if it's high testosterone

that causes me to bold and have a

receding hairline or if it's both I mean

it could be both I think usually we

think about it as um as higher levels

okay it's funny because I've I've

wondered before whether me doing a lot

of exercise which is I guess increasing

my testosterone levels is going to

accelerate my Bolding in receding

Airline anything that's good for your

heart should be good for your hairline

so I would exercise I think that's good

but what if I'm doing like Iron Mans and

Thousand Mile runs and all that kind of

thing which you see in in certain groups

so I don't know that it I I do think

it's possible to OV exercise I don't

know if it'll affect your hairline but

um you know I testosterone levels it can

affect testosterone levels I do think

that it's you know when you kind of

exercise to the point of exhaustion you

know we do see declines in sperm counts

as well so hormone levels can certainly

be affective did um CU my cortisol goes

up so my testosterone I'm I guess goes

down can go down sometimes interesting

what about penis size I heard you did

some pretty Landmark research which

suggests that the length of a man's

penis is increasing decade over a decade

in terms of um men that are being born

and boys that are going through puberty

yeah so um this this study also got a

lot of attention so um you know similar

to how we've tracked testosterone levels

over time or sperm counts over time you

know for different reasons investigators

have measured penal length you know to

kind of give normative data across

different populations to understand how

different surgeries or conditions may

affect um penal length so you know we

looked at you know all the studies and

there were there were dozens and so we

kind of pulled all that together this

was tens of thousands of men and just

looked at sort of average pile length

over time and so you know again based on

some of the data on Seamon quality we

would have expected things to get

shorter over time and also because we're

more obese now you know the way that

penises are measured is you kind of pull

the penis on stretch and use a tape

measure some sort of ruler measuring

device so if the there's kind of more

gut you know more fat in theory length

should be a little bit shorter now than

it used to be um but it turns out at

least when you measure a Rec penile

length uh that penises are longer now

than they used to be uh and so over the

you know past 30 years or so they've

probably gone up about

25% why I mean it's it's a good question

I think one hypothesis we had kind of

looking at sort of different endocrine

you know abnormalities um and changes in

puberty is that if men go through

puberty or boys go through puberty

earlier that tends to correlate with

longer penis length and so if we are

shifting puberty again through these

different environmental exposures maybe

that is leading to you know changes in

general development and this may be one

of the consequences of it does this have

any Upstream like implications for

for sex I think that well the numbers

we're talking about shouldn't be um you

know kind

of enough to make a big big difference

um you know people as this study came

out we talked about you know very

enterprising patients kind of reaching

out sending emails some people

hypothesize that this was kind of

natural selection so it's it's hard to

know um but again it's it's a very short

period of time so it's hard to believe

that there's you know that's kind of at

play do you have many people that come

into your practice that are with

erectile dysfunction yeah so that's

another very common condition we see you

if you look at men over the age of 40

over half have some trouble with

erection so very very common hundreds of

millions of men all over the world are

afflicted we don't talk about this much

um what what is the cause of this and

are you seeing it increase over time the

the prevalence of erectile dysfunction I

mean I think the rates are going up and

I think you know the risk factors you

know are the same risk largely the same

risk factors that affect heart disease

so you know diabetes obesity high blood

pressure high cholesterol you know

minority of these um conditions can be

caused by low testosterone sometimes the

outcomes of you know surgical treatment

for pelvic cancers as well um but by and

by and large it's vascular just it's a

blood flow issue because I used to think

it was more of like a like a hormonal

thing or a psych psychology thing like

you know sexual anxiety or some kind of

you know change to our testosterone

levels is causing us to struggle with

getting erections now you're saying it's

about so I think you know psychogenic

used to be thought of like you're saying

used to be thought of as the kind of the

primary ideology um and maybe for some

you know populations it could be a

little bit more common but generally for

most men sort of all crummers it's going

to be a blood flow issue a vascular

organic cause and how would you get

about treating um erectile dysfunction

um so there's a lot we can do we do want

to you know kind of reverse anything

that we can kind of understand where the

man's coming from find out if there's

you know new relationship or other kind

of factors you know for men like you

know suggesting that we do s like kind

of suspect a psychogenic component work

with sex therapists as well um but for

other men you know I always like to be

very positive it's like to say you know

as long as you have a penis we can

always make it hard so there's a lot

that we can do so usually we start with

pills um like bagra sealas does that

work for people it works probably 60 to

70% of the time so that does work well

um even for men with a psychogenic cause

sometimes it can kind of help reset the

system a little bit you know convince

them and their body that everything is

working well like a placebo effect well

it's I think to some extent but even

more than that because it does work it

does help and then I think once they

kind of regain that confidence if there

was some sort of traumatic event

traumatic relationship it can help um

improve things pills aren't enough or

they don't like those or they have side

effects from those um there's other

therapies so there's medicines you can

actually put in the tip of the penis

like a gel or a repository we can teach

men to give themselves injections in the

penis oh I just got shiver my bu there's

certainly a uh a kind of a a

psychological um sort of fear of that

but it does work well probably works 80

to 90% of the time um there is something

called a vacuum erection device so it's

like a plastic cylinder you put over the

penis that sucks blood into the penis

kind of treats it like a balloon and

then you put a band at the base to trap

blood inside um and there's even surgers

we can do to put a device inside the

penis so whenever want whenever a man

wants to be hard he can be hard I didn't

know there was surgery you could do it a

surgery mhm what does that do it puts a

so there there's two main flavors of it

there's um or forms maybe that's a

better term uh there's one called a

malleable so it's bendable so it kind of

puts this sort of bendable um metal it's

a metal core with sort of a plastic um

kind of covering so when they don't want

to have sex you bend it down when you're

ready for sex you bend it up um or

there's inflatable versions so when

you're whenever you're ready for sex

there's uh basically a pump that goes in

the scrotum and you just Pump It Up and

moves fluid into the cylinders and

you'll get a rigid

erection is that increasing in

popularity I think you know there it's

made by a few manufacturers in in the US

or in the world um and I so I think the

data is not as freely available I mean

in my practice I've seen more and more

of it um we're seeing more patients come

in I also say that you know my practice

is getting a little bit more mature with

time as I get older and so you know

naturally you know more patients kind of

hear about these different things but it

does work well I always say it's a self-

selected population right we don't hold

men down and force them to get it but

generally they're very happy probably

90% of men are very happy they'd

recommend it to their friends Partners

very happy recommend it to other couples

and you just you press a button and you

get like a you can it's a pump right now

they are working actually on um either a

fob or like a phone app that'll kind of

automatically inflate it to make it

easier for Pati I had no idea it sounds

like sci-fi or something it sounds like

it's

um sounds like something you might see

on like a YouTube video that people are

working on in like 20 30 years time but

to to know that men have that installed

now is amazing yeah yeah the I mean it's

uh yeah it's very common um the youngest

patient I put it in is about 20 the

oldest is in his 80s what was the is it

seen as like a last option in the that

menu of options that you presented there

where like the first option probably

Viagra and in terms of popularity is it

a last port of core I think for a lot of

men it's the most aggressive but some

men don't want to do like you had a

reaction to the injection I think that's

a very common reaction there are

certainly some advantages to it compared

to others you know for Viagra for

example even though it's obviously the

easiest it's a pill you know there's

some side effects with it and there's

also you know a lag time right you have

to take the pill wait an hour wait 30

minutes something like that whereas this

you know the penal prosthesis you know

if you just pump it up it's ready to go

in seconds so it can be very spontaneous

so patients like that um you know some

patients don't you know they have other

medications so they can't take pills

they don't like some of the other kind

of intermediate options that we have

shock wve therapy for erections does

that work and what is it so the idea is

that um as kind of the name implies

you're sending shock waves into the

penis um and the energy is induces kind

of some microt trauma which induces new

blood vessel growth is the

hypothesis and so you know the hope is

that with you know getting better blood

vessel better blood flow into the penis

can improve the quality of erections so

there have been some studies that do

show benefit it's still considered

experimental um because I think the data

is not yet conclusive but I think for

men with milder forms of erectile

dysfunction it can help you know maybe

the men that are on Viagra or sometimes

on Viagra may we can get them off those

pills um but I think we need more data

uh to kind of understand really the kind

of best Target population for it you

talk about pelvic flaws as well um when

we typically think about pelvic flaws we

tend to think of women you know things

like these keegle exercises that people

talk about but is it important for us to

think about that as a man as well our

sort of pelvic floor strength and our

pelvic floor muscles I think in some

conditions I think if you're not

thinking about it it's probably okay

you're not having a lot of problems um

but it can be a trigger for some men so

that can be an ideology of some

different um like problems with

urination you see men with very tight

you know pelvic floors and they have a

lot a lot of urgency to urinate they

urinate frequently can also lead to

scrotal pain sometimes as well um

because there's a lot of muscles as

you're kind of pointing out in the area

and sometimes if they're under tension

um if they're not um you know properly

kind of trained and they're they can

kind of trigger some other areas and so

um for some of these different

conditions um we do kind of work with

pelvic floor physical therapists to

train patients you know how to you know

again relax the area strength in the

area increase flexibility of some of

those muscles which can help is it

plausible that doing pelvic floor

exercises will improve one's sex

life I mean I think that unless we're

treating a problem I would be very

hesitant you know one of my favorite

saying is the enemy of good is better so

if things are good you know to try and

get better you know there always there's

always going to be like you said there's

no free lunch there's always some

trade-offs so I think if you work on

kind of over strengthening the pelvic

floor it could lead to of these other

dysfunctions so you don't want to end up

with a floor that's too tight or too

tense is there any correlation between

these things like your pelvic floor

strength your testosterone your sperm

count and a variety of the different

cancers that we see in men things like

testicular cancer and prostate cancer so

um I think with with uh pelvic floor

kind of strength I think I usually kind

of think about that as separate from uh

cancer risk but for test cancer you know

one of the risk factors for that is some

men are born without testicles in their

scrotum uh so that's a risk factor an un

so-called undescended testicle low sperm

counc associated with testicular cancer

there was one study I know of years ago

that looked at um you know comparing

sort of sexual health to prostate cancer

risk found that men that ejaculated more

frequently had lower risk of prostate

cancer the thought was that you know

there was inflammation that you're kind

of clearing out by frequent ejaculations

I think this study had men ejaculating

30 times a month and showed a lower risk

so that's

that's a lot um but that was one study

that said at least it's not dangerous to

ejaculate more frequently but it's not

something that I generally recommend to

men to lower their risk if we talk about

testicular cancer then um what are the

the common symptoms of testicular cancer

yeah so usually it tends to be

relatively asymptomatic I think that you

know the classic symptom would be a firm

painless mass that men find in the

scrotum so if you know um there used to

be there are screening guidelines um

even though our preventative Services

Task Force thinks that you know the

utility of doing it for you know

reproductive ageement to their scrotums

may lead to more anxiety than actually

you know Finding test this cancer

because it's such a rare cancer so it's

more likely a man's going to just worry

themselves than actually you know

diagnose in early cancer but the

recommendations used to be that you