Dr. Michael Eisenberg: Improving Male Sexual Health, Function & Fertility
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Welcome to the huberman lab podcast, where we discuss science and science space tools for everyday life. I'm ander huberman and am a professor of neurobiology and optimal gy at stanford school of medicine. My guess today is doctor Michael isenberg. Doctor Michael isenberg is a medical doctor specializing in neurology and an expert in male sexual function and fertility.

He is both a clinician who sees patients as well as a research scientist having published over three hundred peer reviewed articles on male sexual function, neurology and fertility, and he is considered one of the world's foremost experts in male sexual health. Today, we discuss a broad range of topics important to all men, including erectile disfunction and function. We also discuss prostate health and urinary health.

We discuss fertility and sperm count. We discuss even topics seemingly esoteric s such as why penile lanes are actually increasing over time while sperm seem to be decreasing. Today, you'll also learn some very interesting surprises, such as the fact that a very, very small percentage of erectile is function actually stems from hormone dis function.

Rather, the vast majority of rector dis function stems from issues that are either vascular that is related to blood flow or neural. And today you will learn about a large variety of treatment for erectile is function. dr. Izon berg also display lot of common myth that you hear out there on the internet and in popular culture that relate to male sexual health and function.

By the end of today's episode, I assure you that you will have a thro understanding of what male sexual health is, how IT relates to other aspects of health, and how to think about treating, maintaining and improving all aspects of male sexual health, fertility and function. Before we begin, i'd like to emphasize that this podcast is separate from my teaching and researchers at stanford. IT is, however, part of my desire and effort to bring zero cost to consumer information about science and science related tools to the general public.

In keeping with that theme, i'd like to thank the sponsors of today's podcast. Our first sponsor is element. Element is an electoral light drink with everything you need and nothing you don't.

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I started using the waking up up a few years ago because even though i've been doing regular meditation since my teens, and I started doing yoga eja about a decade ago, my dad mentioned to me that he had found an APP, turned out to be the waking up APP, which could teach you meditations of different durations, and that had a lot of different types of meditations to place the bringing body into different states, and that he liked IT very much. So I gave the waking up up a try, and I too found IT to be extremely useful, because sometimes I only have a few minutes to mediate, other times I have longer to meditate. And indeed, I love the fact that I can explore different types of meditation to bring about different levels of understanding about consciousness, but also to place my brain body into lots of different kinds of states, depending on which meditation I do.

I also love that the waking up up has lots of different types of yoga. Eda, recessions, those you don't know. Yogananda is a process of lying very still, but keeping an active mind. It's very different than most meditations.

And there is excEllent scientific data to show that yogananda, and something similar to IT called non sleep deep breath or n sdr, can greatly restore levels of cognitive physical energy even, which is to a short ten minute session, if you'd like to try the waking up up, you can go to waking up dot com slash huberman and access a free thirty day trial. Again, that's waking up dot com slash huberman to access a free thirty day trial. And now for my discussion with doctor Michael eisenberg. Doctor eisenberg, welcome.

Thank you. Going to be here have .

been looking for to talking to you for a long time, because these days we hear a lot about about the diminishing quality of sperm, which in some way he seems to be touch the conversation about diminishing quality of environment, people, intelligence, you. There's a lot woven into this statement that sperm quality is declining. And some of that, I think people assume is related to envionmental changes.

Some of IT think people assume that are related to changes in behaviors. So maybe less exercise, less sudden light. Who knows? Hopefully, i'll tell us what's really going on. But the first question I have is, is sperm quality actually declining and regardless, what is sperm quality?

Yeah, a great question. So I think it's very controversial. I think is you're a question elude to. So I think we will start by just talking about what sperm quality is and why it's important.

So for reproduction, as you ve covered on the podcast, for a man, make semon ah and that has permanent. And so when we're talking clinically about a Simon analysis, there are a few things we look at. We look at the amount of a acute cement that comes out.

We look at the sperm, how many there are. We look at their motility or movement. We look at their more followers, your shape. There's some more advances testing that's done in rare cases, looking at fragmentation of DNA. For example, there's some newer test looking at epigenetic profiles of firm, but essentially these are all markers or fertility so fertility itself as a team sport, right?

So it's hard to you make label a man is fruit or not further without knowing about his partner um but nevertheless, based on different these different parameters, we try and quantify how likely man is to be able to achieve a pregNancy. So the world held organization every decade or so looks over the existing literature and defines these different cut points of what's Normal or what's sub footle for those levels. So that's sort of the backdrop of what season is and how you these these test are done or you know what these test represent.

Now the question of whether they've declined over time um has been, you know a question for a number of years. There is a landmark paper in the early nineties, mike carlson, in a group and denmark, that showed this temporal decline in over the last fifty years from that time point. And so what the investigators had done has looked over the literature, four studies that reported semen quality around the world and noted that the quality in the earliest studies I can kind of mid two of the century were here and then over time, that sort of decline the more recent studies.

Um now that study was very controversial. There was questions about waiting from different studies putting because you can imagine there is not a lot of early studies, so putting a lot more importance on those rather than some of the later ones. And so since then, there's been many other studies that have that have come out in time.

And even today, IT remains very controversial. I think, you know I want to say that I believe there's I declined some of my colleagues and friends would be very upset with me, but I say I don't believe that some my colleagues and friends would be very upset with me. So I would say that, you know, my opinion really varies based on whose paper i've read.

And there is some very convincing studies on each side of IT know there are most recently just in last year. So there was an analysis of tens of thousands of men where they looked at, again, a host of these studies over the last number of decades, all around the globe. So prior studies really just focused on the western hemisphere, western countries, because there was more data from that.

But more recently, you ve gotten a lot of data from africa, from asian countries as well. And there is also support this decline. So you know one of the counter arguments to why we're seeing that is just sort of an evolution of techniques over time.

Um so that's one of the the two of the popular um questions about whether there is really a true decline. You I think it's looting to why there would cline is also you know unknown and but you've sort of label know perfectly that kind of most common hypothetic. So where there's an environmental exposure, right, a lot of things have change over the last fifty years.

And I think you know, chemical exposure are certainly one of those. And there have been some fairly convincing the preclinical studies, so you know, mostly done in animals. The showed like exposure to different chemicals, dalla's. Our B, P, A. Other things may actually harm in reproductive function for men and for women as well.

And so maybe that you know these chemicals you that are they were being exposed to as kids and adults or even problem more in australia when we're you know kind of developing in utero, that may be kind of the most harmful exposure. Um but there's also been a obesity epidemic this well and there is a strong link between a man man reproductive function um and body weight. And so that's also to play a role in some of this too.

Um so I think there are convincing studies. But the other I guess aspect to this is that there's variations and semen quality around the country and around the world. There's geographic variation.

And so that's also sort of an unknown uh, explanation uh you know there could be different for the genetic you know compositions of men and so there's different reproductive potential net source. There can be different environmental exposure, dial exercise, lifestyle. And there's a famous study done a number of years ago where they looked at semon quality among fathers.

So these are men that are achieved privacy. And at the first pinata is that they had um the fathers give a seam example. And so this is one four centers around the country.

I think you want to california. There was a one in the midwest. Uh, there is one in new york. So they basically found that steam on quality was the highest in the urban centers in new york, tend to be the highest numbers where IT was lower in the midwest.

And so the hypotheses was potentially because there was a more real setting, maybe there was pesticide posed to and that had been to these lower numbers. But you know another equally plausible explanation, maybe that you know different of a different population and maybe you know that that could explain these differences. So I think it's it's a very important um and I think you know one of the sort of lacking things and this is there's not really logical data.

One of the greatest things would be if we just started tracking cement quality around the country, just like we do obesity, like you know enhance cdc survey of health in in the us. If we added seamon quality onto that, that way you could really see you know how IT burries around the country and sort of a compare like to like to see over time if there's really this progression in one of the only studies to do up in denmark, they have ve started around around two thousand and track seon quality among volunteers that came in when they were conscripted for military service in denmark. They were offered the IT to participate in the study um and so some did.

And what they have found is actually that many quality was virtually uniform over about twenty years or they had data. But sort of another very interesting part of that study is that only about a quarter of those men had Normal steam on quality. Um so sort of very concerning you know I guess reassuring that IT wasn't further declining but very concerning. And only a quarter of danish men have been a Normal seam quality. And there one of the, I think, thought leaders in this field is because of a reproductive crisis there you .

mentioned that some of this apparent decline in seaming quality might be related to the fact that the tools to measure seaming quality are getting Better and Better. And that would make sense if, for instance, this one is just looking at total volume, mortal logy, which mean shape, I should have clarify that um how many forward motors firm there are and then also adding in you know a very sensitive measure such as DNA fragmentation, essentially as the instruments get finer and finer, you discover more and more details. And if you are rating quality along a number of different dimensions, then I would make sense that those would tear out into different levels. So if one were to simply ask four couples who want to get pregnant, and assuming that egg quality is not the issue, what percentage of failures to achieve successful pregNancy are the consequence of efficient sperm efficient in any way? And is that number increasing over time?

yeah. So I think that's really key. I think when couples think about fertility, usually it's thought of as a female problem. And I think there's a historic reasons for that.

You know, if you look at data in the us, when couples do see careful fatlings, the man is bypass probably a third of the time, even though when you look at the reasons for infertility, man contributes probably half of the time to infertility. So I think there is a half half yeah. So I think there is a huge need just to understand and to buy away the man and IT.

And one of the reasons for this, I think, is that, you know, one of the main treatments for infertility in the us. Is ibf, which is very powerful. I think one of the the greatest marvel of medicine, and probably the last a quarter century, is our ability to mix this permanent dish and create a life.

It's really remarkable. But because IT now takes just a single firm, you know, through something called interest side of psc experiment, and we can ject one agent once burned into an egg, you know the bar has gone down dramatically. If for couples just trying without know any assistance, probably need twenty to forty million moving sperm, but now if you these remarkable techne, you just need one sperm. Um and so because of that, you know I think a lot of our innovation and research on the opportunity ity is probably gone to the wayside just because clinically, we just need a few dozen sperm for most couples.

What about test astre one levels? Are those also declining? We hear this. Um and when I look at the literature I can find evidence for that but the question is also whether not the amount of decline into the storm levels are significant in a way that impacts, let's say, filler but also um vitality in other ways, energy, mood, sexual health, SATA. Um what's the story with to astern levels? Are they indeed declining on average across the male population in the us and elsewhere?

I think there is pretty convincing evidence that, that is happening. And I think the reason for that again is probably not certain. But there have been some pretty nicely designed cohorts studies where they have recruit you know, men and the two thousands, the nineties, the eighties.

And you can see that depending on when these manner recruit just, you know, matching age for age, these test option levels tend to be lower and then enhance, which is, again, this sort of logic. No study run by the cdc that is also shown he looking at test ocean levels over, you know, decades. The test ocean levels have declined over time.

So there, you know, chemical exposure. One possible explanation again, you either an adult or had a lesson life for an utero but ob c ethnic is also sort of a convincing explanation is more more secondary. Um you we get bigger that's one of the place of the test order and and I think there's different sort of explanations for that. Um you know test station to produced it's a romanized in preferable tissue and bad tissue fat has a lot of this eromanga converse test also into so necessarily you know there is the test astern level that circulating in our body also just installation the the tesco's are size get bigger, insulating the tests can also sometimes lower the efficiency of production a little .

bit too because of heat effects .

because of heat effects.

Yeah I was going to ask about this later, but I ask about IT now since we're taking my heat effects in a sperm to stop rone. Um the heat of course being a not good for spring health and testosterone, which is i've read a metal analysis, I don't know um how high quality IT is, but um that explained that there is some evidence for um either heat effects or possibly non heat related effects of cell phone and smart phone in the pocket in paring sperm health maybe in test stone levels now you hear this more often in kind of bio hacky um I don't know circles which you know i'm not a fan of the word biohacking IT does not clear what that means but IT sounds like IT means something about taking a shortcut using one thing for a purpose IT wasn't intended but you know IT also makes sense to me that H A smart phone could generate some heat, some radiation that might empire um testicular function and therefore impaired sperm quality and or testosterone levels. But is there any real solid data that caring your cell phone in your pocket let's assume on that the cl phone is on is bad for sperm health or just astronauts?

Vell, yeah. So um I think there's not convincing evidence that this can helps test stone level.

I think the heart not .

so I should make clear that I think that in terms of production and heat effects, no spam production is much more sensitive than test stone production. Um but there have been some studies looking in cell phone exposure because again, you're getting this whether it's keep, whether it's sort of the you radio frequency waves coming in, I think you could posit sort of different explanations of why that may be harmful.

So there have been some studies that you looked early on. Men that use cell phones more or less, they had lower seamon quality if they used IT more. But you can also imagine there's huge differences of men that do and do not use cell phone.

So it's it's a hard experiment to design. But there have been some studies are doing this in ventures. So in the laboratories are taking you know sperm in a cup basically and putting a cell phone next to IT or not next to to try and see if that played a role.

There have been studies done where they sort of Normalized the the heat they kind of put on sort of a special stage so that it's not heat necessarily, but maybe it's art of exposure. So those studies, I think, don't show what of A A clinically meaningful change. But there have been some studies to say that maybe DNA for raggett of sperm can go up a little bit if there is close proximity to a cell phone.

Um so I think you know I when patients asked me that, which is the common question I get, the clinic obviously patience are coming and they want to do know whatever they can um to try and improve their chances. Um so I think generally only the data is not convincing. Um but you if it's easy enough certainly to be aware of IT know I think putting a laptop on a death grab and in your lap, I think for heat exposure is probably the biggest thing that we want to minimize.

About a year and a half ago I did an episode about stores on an s rogen were manufactured in the male, female IT said and found a very interesting graph in a uh textbook on behavioral and chronology by guy name andy Nelson, who I happen to know through the field of behavioral and the chronic gy, as it's typically studied in animals. So most of that book centers on animal studies, but there's A A fraction of the studies that center on human data.

And there was a very interesting graph that showed testosterone levels as a function of age in males um and as one might expect, teasing levels were on average much higher in late teens, early twenty thirties and there was a progressive decline. But what was remarkable to me about that graph is that even when expLoring the scatter plots because they showed individual points, they didn't just show the averages of test astro on levels in men in their fifty, sixty, seventy, eighty, even nineties. There were these outliers, these guys who had testosterone levels that were on power with h.

Testosterone levels of men in their thirties, but disgust in their fifty, sixty, seventy, eighty seven, nine so do you observe this clinically? Do you observe that um men are coming in know f who are older than forty and have test astern levels and prisoners ably free test astern levels as well um that are still very high know the reason I asked that I think we evolved in told and we presume that just stop levels decline with age and one would expect some outliers and of course we don't know whether not those guys in their nineties who we have the teater n levels of. That match the averages of men in their thirties didn't have even greater testosterone levels in their thirties but given that they were ceiling out out around one hundred grams, producer told the high and Normal depending on the scale um in already at eight and ninety, kind of hard to imagine that earlier they are walking around with two thousand and agram protestor test.

Astro, so do you see this? Are there are some is there just a lot of natural variation into astern levels of men who walked into the clinic at any age? And of course, what is special about these individuals that are you maintaining high Normal testosterone n levels into their later years?

He has a great question. I think this is such a common question. And any time we talk about test stand, I think any time we talk about most sort of clinical test that we do, you know what is average, what is Normal? So we do see great variation. I mean, I think just like you're saying, I usually let everybody know that usually test all some peaks, you know kind of early twenty and attends to go down probably one percent a year forever. But there are people that have very, very, very eyes levels just hearing you know that grab that you describe by certainly have patients we screen for test astern levels.

You know when patients come in with complaints or we're worried about that low energy level, low lobel, some of the symptoms of low test sexual dis function and you to my surprise, sometimes these men, you know i've seen eighty robbs that certainly have the highest test option level all see you for six months um know why that is I think is not certain. Maybe he has to do with everything. With everything is probably sort of a bell shape curve and everybody's little bit different.

But he android, in sensitivity, sensitivity of the receptor, they make IT more efficiently. But I have not really noticed again because at least in clinical practice, you know, when patients come in, they come in with the complaint. And so even men with very high levels, they may have some of the same diffunce men with low levels. So I think with low levels, you can try and treat that and that may be the solution. But for men worth, you know these what we will consider high levels there, maybe other issues going on.

Me frame the question I was going to ask a little bit differently. When someone comes in to your clinic and you measure their testosterone levels, as you mentioned, they're likely coming in because they have some issue prostate issue as a social function issue at that.

but you do get .

a read on there so crude morphology of their body, right so you could visibly determine whether not they are likely to be obese or not um regardless of age. So earlier you mentioned obesity as a risk factor for lowering test stern and sperm quality. You mentioned a fat a romanized to stand intestate gen so that at least one mechanism by which that could happen. But if you were to just step back and say, okay, if somebody who walks into my clinic tends to be less than healthy, you're looking, you know not obese, just put the cut off what you would presume is obese.

Um is there a higher probably that their testosterone al levels are going to be with a Normal range? Conversely, when somebody walks in in their obese, do you fully expect their test after some levels to be subNormal? Um or are you sometimes seeing obese people walking in with, you know high test stone? And the reason i'm asking this is not to create confusion is that I think that everybody out there who is thinking about sperm quality into stores levels in this apparent decline, trying to figure out, you know, okay, what can we do in order to maintain the health metrics that are going to, of course, increase fertility.

But for those that don't want to have kids, already have kids are going to at least maintainer improve vitality. Is the obesity really tough thing to avoid? So is there are not one for one, but is there a tight correlation between obesity and test to astronaut levels?

I would say that you cannot predict. I think that sort of would be the take home. And so I think that you know more information is always Better.

You know when I see patients in clinic, some patients are walking around. You know we know everything is totally Normal. They're very healthy.

All the numbers come in at the Normal range. But sometimes when men look totally Normal, they talked about taking care of their life. They exercise you know, five, seven days a week.

Their teasing levels can be very low. So even despite you know, having what we would consider IT should really give them you know symptoms, um they're able to compensate. No maybe they have live their whole life and that they don't know what Normal is.

Now we get them you know to start to Normal levels. A lot of times they feel Better again, no idea how they should feel um but I think that that's just sort of important that everybody you know should be screen. I think that you know test stone cement quality there have been shown to even be bombers of health. Um so men with lower testoon level of higher risk of your heart disease, diabetes mortality, the same study is exists for semon quality as well. Um and you know again, they may have thought of a similar relationship and explanation why that may be, but I think it's hard to just predict you based on appearance what you know testoon be, what season quality to be, what testily are functional will be without actually getting some objective data.

And actually if you look at the trend of test of semon quality decline over time, kind of getting back to some of those earlier points are making, if you were to overlay that on the known association between obesity, it's effects on Steven quality that actually doesn't explain the whole decline because the you know, the proportion decline seen qualities is about fifty percent. But if you just if you were to say, well, well, would we expect if you know, we look at because we are able to track exactly how much Better we are now, then we used to be that actually explains about a ten percent to client. So I think there is, you know, to your point, something more and IT is not something that you .

can just identify my eye what are the dues and don't as IT relates to, I don't want to use the word optimizing. It's gotten me into trouble before because the word optimized or optimal suggest that there's an perfect number that one should all time if possible but in reality um optimal a day to day thing at least. But what should people avoid in order to get their sperm quality as high as possible? Their test test level.

Again, here I have to be careful. I don't want say as high as possible because some people might not want excessive androgen. But at the highland of Normal, perhaps, would be the ideal for many people.

What should people do? What should they avoid? And here i'm setting aside any prescription clinical treatments that, such as testosterone injections or things like a correo ic, canada human correo ic, cannot to rock things. We can talk about a little bit later, but what should every mal be doing in order to optimize these health parameters?

yes. So I think that there are some risk factors that we do like. We will start with semen quality. So we talked about heat. I think that's a big one.

So like hot to san is trying avoid those some, you know, light da on sea warmers anytime, you know, we can get the little heat source to the screw. M, the testicles are outside the body because they need to be a little cooler. Anything that warms them up can certainly be a problem.

Could I just briefly drop there to ask? We've done episodes on sona and some of the health benefits of sona um is IT sufficient for somebody to bring in a cold pack to the song and put that out? They're drawing. I actually suggested that that's actually what I do when I go into the sauna. And I have suggested is on podcast, not just for people are trying to conceive because IT seems like heat, as you mention, is bad for sperm, not quite as bad for testosterone levels. But is IT also true that heating the testicle too much is generally bad for grant function and males? And therefore, if one is going to go into hot sona for twenty minutes or more to essentially cool the the scroll al area here, I mean, I I think this .

permai genesis response production is certainly a lot more sensitive. You know, whether you can put through the effects of extra heat with a cool impact, I think that makes sense. There are studies that have looked at different ways to cool this gradum and have compared seen quality before, after. And there are some day that that may help um IT gets depends how I we're going to spend in the sona and how cold you know that pack .

is going to remain. So ice pack and in the sana r twenty to forty five .

minutes and the ice packs to cold afterward.

yes, yeah, they actually sell. And by the way, of no relationship in companies, but they actually sell cold packs that are designed to be born in your short. So if you go to a i'll go to a russian boney every once while now, and I guess i'm outing myself, yes I yes I have a cold pack in my shorts when I go to the russian boney.

Um but um but they have a sort of an installation so that you the the very cold surfaces cold enough but it's not right up in contact with the scrotton skin because they could get I want to make a bad to take you get sticky that situation. You don't want to get being so cold that I actually would stick to the skin and then I could potentially damage the skin when you trying to remove the cool packs. So IT has a thin insuing layer um and um yeah that essentially what this is yeah I mean, first spite to the screwed .

of is not theoretical. IT can certainly happen. So you do want to be careful. So I mean theory that should be, that should be adequate or to decrease the risk of that particular effect. You know, I keep coming back to health, how important that is to maintain you know, adequate sperm production because I think is too a very links.

And there have been studies to show that men with more cover and condition, so obesity, hypertension, hyper lip demy, is he sort of stack up? We see a decline and testicular functions of lower testosterone levels and lower firm quality. So I think no taking ownership of your your health I think is important as well.

Um you know a lot of times um fertility tends to be one of the first touch points that some have with health care. Because generally what brings men to the doctor reduce the pain or you know kind of a problem. Um so know men are in their twenties and thirties getting ready to start a family or four years.

In some cases, sometimes they have in you seen a primary her doctor to some of these things in some of this relationship has not been established yet. So I think thinking about ways to start that I think would be important to um and then I don't don't want to talk about test stop, but test astern is actually a fairly common problem that we see in fertility clinics. Um I would say that in estimates say maybe about one and two and four men are that way because of test astro.

So I think when you people get test also from different places and hopefully you whatever provider you're getting IT from tells you that one of the side effects of this um is lower spin production. It's actually been tested as a contraceptive and you know with the mother agents that can actually be fairly effective. So we just want to make sure that you, if men are starting to stop, they're doing for the right reasons, they're doing IT safely.

I think think about testosterone replacement therapy. Although as we were talking about before we started recording, I I am really on a push now to regain what people call T R T test stone replacement therapy because indeed some people have low testosterone need IT replaced the R N T R T. But I think what you're referring to, if i'm not mistaken, is that there are probably millions of Young men and older men taking exogenous st disastrous injection creams, pills, pills, any number nasal spray now, any number of different, a rouse of delivery of exogamous testosterone and dramatically reduces one's indulging ous testosterone production and dramatically reduces once sperm count and maybe even quality. What maybe talk about this little bit later, but maybe even can there's i've been told that I can perhaps introduce a DNA fragmentation, uh, within the remaining viable sperm as well.

So do I have that right? You're saying that that you see one twenty men have issues with fertility because they are taking test off, right? So their testosterone levels presumably are going to be high and Normal or more, but they are doing presumably not testosterone replacement therapy, but they're doing what I called testosterone augmentation therapy, meaning they were somewhere in the three hundred and nine hundred anagrams products later range, but decided to starting to ostern anyway. And then they're sperm count essentially diminishes to nail or close to IT in some cases.

yeah. So I mean, I think there's very reasons that you would take test. And I think some people have been treated you know years ago and so they do need to replace test after you know. Um but some people do IT for augmentation. I just used to say, test.

you kill the R I like that. That's Better than the T A T, which doesn't have very good. Okay just testosterone on therapy.

Yeah okay. But if you had you know for example, if we take hundred of my inferable patients that come to see me clinic, at least five of those men will be in feral because they're on test cost, on therapy. And some of them, do you have that suspicion? They say, you know, i'm to level with you.

This is why my levels are probably low. But a lot of men were not told that, you know, when they started therapy. So I think certainly for reproductive age men, that's in a very important conversation to have because there can be some other ways that we kind of maintains firm production. I think infirm crap reservation is a good option for these men as well. Or there maybe other therapies as they can think about just because of reproductive toxic.

What about hcg? Human coryon ic can have a trip. And I hear about a lot of people go on to stop therapy who would take hcg every other or so. Um typically the dosages that I hear about because people write IT to me about this stuff all the time, really want to most commonly ask questions. Um I get many questions about many topics, but I would say a four ten to twenty percent of them are about penises or just astra perfect that right exactly um so a number of those um guys who are taking test ask room will be prescribed cg to stimulate spring production in doggy ous sperm production to maintain a healthy y sperm presumedly because they either want to conceive or intending to conceive in the future is that the best line of treatment for maintaining futility while people are taking to astern therapy yeah that's one of the .

therapy years and think well know just a low dose. I'm usually gain for those that, but no, five hundred to a thousand units every other day is usually adequate.

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Supply of vitamin three k two. So if somebody is not taking to stop drone exogamous sly, they gotten their body fat level down to a point where they're not considered to be so hopefull doing some cardio accused exercise each week, maybe doing some sport, some resistance training to with the intention of maintaining all around a good health, stave off superb vascular cardiovascular issues. What are some of the other? Don't am I going to assume that smoking cigarettes or wapping cigarettes is bad? There are any studies that looks specifically at waking and sperm quality or to start rian levels um and is there any any evidence that smoking cigarettes is good for testoon levels? Spring productions? I'm guessing the answers no I feel like nowadays we just say don't smoke um but the data of the data, who knows maybe neck team can help spring. I have no idea.

right? Uh, it's possible. I don't think we have the data on that yet.

But yeah, I think I think like to your point, I think lifestyle factors are certainly a big one. And you know some of these potentially a heavy habits. So smoking is certainly something you should not do.

There have been a lots of studies to do. Link that too. A lower quality.

Again, all the different measures that we look at. Also looking at fertility, these men tend to have longer time to get pregnant. Alcohol, I think, is another very common question and get asked as well.

And I think for that, there's no, I think, less of a strong association that we've seen. So there you know there happened some studies that showed very high levels of the alcohol. I guess that's a subjective what some would consider higher or not. But you know when you get about maybe twenty drinks a week, they're having some effects.

but you have a lot of drinking.

I think yeah but some people don't 可以。

I didn't never say an alcohol。 I think anything more than two I know people we're going to you know balk at this point you know I think anymore and two drinks per week is where you start to see some negative effects on some health parameters but i'm not a little .

yeah um but when you get to this twenty drink, that's when we started to see some effects on semen quality but the other you know the thing about that is usually of these matter drinking twenty, they are doing other things to smoking. There can be other drug use as well so it's hard to tease that out. But in general that you know I think certainly anything in moderation is probably OK you know is probably Better.

And so that's how I counsel patients. I think again, very rare that I see men that are that level. But I certainly you know what I do.

Um there's some new data coming out of that. We've started to work on looking at if there are different sensitivities to alcohol. So you some east asians have a mutation that leads to flushing. And so that may put those men at higher risk when they mix alcohol. We may see some slide, lower spring fram meters.

You mean skin flushing because they don't make alcohol? Hydro g same idea. yeah. And is IT i've i've heard about that in asian cultures.

Is there um asian population? Excuse me, but is there any evidence that other populations might have slight variations on alcoa hydrological? Is that perhaps maybe they don't lack IT alter together, but they have no, there are hyper works for whatever gene makes alcohol d hydro genes, and therefore they don't metabolite IT as well and therefore the toxic form of alcohol is active in their system longer. Any evidence for that?

No, I think you're exactly right. I think I think the one that we think about his eating cultures, where can be know, depending on know the region like chinese, taiwan is probably about forty to fifty percent of the population has mita al each two gene but other populations um and people have candian cestre there's a rate of mutation I think and not to remember the exact percent but I think a few percent tage points has some individual of spanning cestre anti jewish ancestry.

So in this particular gene, there is a mutation, not the same one that e stations have. But you know, again, I think IT gets to why a mutation where we see sort of negative facts would persist and the hypotheses that you know will any ago, potentially IT gave some sort of benefit for maybe an infective disease or something. So some more artistic biros is why you, again, this mutation would persist in our population.

If there's not, it's some sort of advantage to those Carrying IT, but we do see another other men as well. So I think if it's a simple question, do you flush? If you flush, then maybe alcohol may have you know more of A A harm than than someone else. And then, you know, I getting along the lines, I think drug use is also something that we should try. We do council patients about because I can also nature affect the equality.

Do you think it's fair to say that? Okay, moderation is best. But if somebody had the option to either not drink or drink in moderation that they should not drink with, that be even Better than any evidence for that.

I mean, IT seems like nowaday we take the stance that um not smoking at all is Better than smoking a little bit. Actually, when I was a postdoc at stanford from two thousand five, yes, two thousand five to end of two thousand and ten, you could still smoke on the stand for campus. I'm not a smoker, but there was this collection of, I have to be careful what I say here.

There was a particular group on campus of post dogs and graduate students that would, that were colonized this little area outside the hospital and smoke, because that's where you could smoke. That was eventually eliminated as a possibility. You can't smoke on temper campus, as far as I know, but they would smoke right outside the hospital, actually allow the hospital workers would take a cigaret on their break.

This is a very y yeah exactly yeah. And this was common all over the country, right? This isn't unique to stand for, but nowadays you just don't see that um because it's not allowed um and we here don't smoke.

It's terrible for X, Y, Z and everything every other letter of the elf. But with alcohol um we tend to hear that if you're going to drink drink moderation, not clear exactly what number that is. But is IT possible that zero alcohol is Better for sperm underground health than any alcohol? Or is that not not a fair .

assumption? I mean, I think it's a good question. I think you know that your point about tobacco is an excEllent one because I think any smoking is bad um but alcohol, I think we don't have that data for yet. And so I think it's harder, harder for me to make that recommendation of patients, especially because no people do IT for different reasons and if it's not necessarily going to help them, you know all harm them in social situations or other things. Yeah I usually I usually give them the moderation one unless again for the the very hydro kers I definite talk about that.

Um you mention other drug use. Um i'm going to assume that um unless prescribed for post surgical pain or something like that that bends a day as of peans, heroin, opiates of any kind are just bad for sperm test. Astro, I think that we probably make that a short discussion right. Yeah you know I can't imagine any of that would be good for reproductive health.

Yeah, that's I mean, there's again, you imagine or maybe not, but there's not a lot of data on IT um to be difficult to enroll or maybe easy to enroll, but a lot of those studies have not been done. But there is limited ones of you know people in rehab where they have shown you these associations with you know add s or users and lower quality. So that's how we talk to patients. What about cannabis?

I didn't episodes podcast about cannabis is, and I did highlight some of the medical applications of cannabis. I also highlight that very high T H C cannabis um may predispose especially Young males to later psychotic episodes. There are more and more data coming out about that all the time. I um got a lot of flag for for saying that, but that might take on the data um and I know a lot of people use cannabis um recreationally um and in a kind of soda therapeutic c way I say sudarat pute because I think a lot of people use cannabis to manage their anxiety and as an alternative to alcohol um for a number of reasons. What is the relationship between cannabis use and to stop one and sperm production or I should say sperm quality, excuse me.

yeah. So this is also a very common question we gain with wave of legalization across the contract, more and more men and women are exposed to IT. Um so again, there's data that either more mental exposed to IT can lead to some harm in terms of sperm orthologic sperm numbers as well.

You know one of the three of landmark studies was about twelve hundred men, and I found that men that use canvas daily had significant lower concentration motility morpho gy compared to those who didn't use IT. Um so I think that's generally how mental councillor, but there is also you know other data that shows really a no effect. And I think that is that goes into probably the composition, how men are taking IT the frequency because a lot of that data is not well tea out and a lot of these studies.

Um so you know I think I sometimes strugling with this with patients because some of them are taking IT for you know some what they consider legitimate reasons, anxiety, sleep pain um and if there's not sort of very convincing evidence that it's going to help and they're taking IT maybe lower than the threshold where I know that there's a good day, a little cause harm. I guess I I trying to sort of honest about where we are. But I think with a lot of things related to firm, I think our level of evidence is not great.

Are there any common over the counter medications that can negatively impact sperm quality? And or retest astro, things like non sterile, entire flaming ory drugs, tallin all add val type stuff proper to see the manifest things of that sort that I and others might not be aware of. I'm not pRobing fraying in particular here. I just I know that you a lot of over the counter drugs have effects that we're just simply not aware of.

Yeah, I mean, I think we probably need more data, but I think currently, we think all .

those are safe. I'm curious about the patra ua tory gland, as many of the listeners of the podcast, or I know, is a glad that receive signals from the brain. The glass sits near the room of the mouth. I think that's fair and releases critical hormones into the bloodstream that control the output of disastrous from the test use as well as output of hormones from other gLance. Um I know a number of people and playing sports like football or rugby, we're even cross or even soccer of read or date on this.

You they're heading the soccer ball quite a lot or marsh arts or they get a head injury at some point and I certainly hear a lot from people who played these high context and then to their surprise later, they have diminished australian levels also work with the number of military groups that talk about this. You know that they leave and maybe it's from combat related stress that but they wonder whether or not there's any traumatic head injury or maybe patuit tory injury related impairment to the reproductive access that includes brain prejudice and the testis. Do you see that? And if somebody played a contact port, in particular contacts port, where the head was hit or they were hitting things with their head, often where they have a tbi I or had A T, B, I, that the reproductive .

health can be impaired. I I not, I mean, I think you know, interesting. I guess you know what the patrica does. You ve, I ve been covered this before, but IT does go to a lot of authorities.

I mean, so you know, for your listeners, you know that, but tate producers, two hormones, L A look mazing F H follow stimulating ing hormones, which then stimulates the testicle. So the luizi horn hormone stimulates the lady cells to make test room. And then the final stimulating form epithetic stimulate spring production. So both of those are very key.

And in terms of production, and interestingly, when exogenous test stone is used, you know that shuts down, that accesses, you know so we get less of these going out of troops as lh passage um to stimulate the testicle um and the other sort of reason that spring production is lost with exotic of neues IT is actually the interesting secreted to stores. One is much higher than syrian levels. So you know our system levels are between three hundred and nine hundred, nine years years later on average.

But in the text are pride tenfold higher, at least so when men are given exogenous test for and not promising their own, the levels of tea. And in the text o, which are necessary reform production are much, much lower. But it's interesting because I think I am not aware of how traumatic entries would do that OK.

That's good to know. I'm curious about the non decline, non chemical so affects on sperm quality and to level. So here i'm thinking about a bone of news stories heard a few years ago about how bicycle seat pressure on the prostate or maybe with other other portions of the um IT was the uh nervous running to the penis itself.

Um we're surrounding areas. Maybe this was perfect flor related. And somehow you'll tell us some sure was impairing sexual function. Was IT impairing sexual function in any way by impairing to stop n levels, cutting off blood flow to the tests um and here perhaps the most important thing to ask straight off is um is riding a bicycle bad for male reproductive health and sexual health?

Yeah these are great questions. These again, living in the area, working in the barrier cycling is very, very popular. So these are things that I get a lot.

So I think, no, I in general, like we talked about before, anything is good for your heart. It's going to be good for tilly. So good diet and exercise maintained a good body weight.

And so I always trying to encourage physical fitness. I think that's important, but may be possible that some particular activities may put men more risk. So I think cycling could be one of them if, but that would sort of depend on exactly why we think that maybe a problem.

So I guess the theory is heat if you're in the settle for a long time, you know for these prolong you know drives that men take you know on weekends, you know hours um that maybe if there's too much heat exposure, that maybe the mechanism or spring production would decline. So there have been some studies say maybe five hours a week would be that maybe too much so far above that level is from accounts to be lower less than that, that maybe okay. So when I talk to patients about, I try and to encourage and and stand up in the sample to try and again sort of air things out to try and discipline heat.

If that's the mechanical ism we're going to think regarding sexual diffunce um that is thought to be pressure as you're alluding to. So you know the way that seattle is configured, ideally, all the pressures put on our rescue tuberose ties are our sit bones. That's what i'm sitting on now.

But on the that all you know, there's obviously kind of the rigid nose. And if there's too much product on that, that actually squeeze between the is guilty, boris. Where, you know, the main blood flow to the piano goes and the main nerve supply is too. And so if there's compression on this, you get this for a lack of blood flow schema, and you get a nerve practice.

Well, do you crush these nerves and so that over time can lead the problems? So in the some patients say that, you know, after I cycle, you know, things are none down there for thirty minutes or a day or I don't get directions for that sort of same matter time. Or sometimes, you know men just to ride through and and you hopeful ly things come back in a day or two so that that could be the activities.

There are some settles that you know hopefully will be a little safer. And you know, I think that this sort of first was noted probably around the two thousand or so. And there is a big redesign in terms of settles to try to make them a little bit more, you know, anatomically correct to try to minimize some of this.

And there's no cycle fit that can be done or sample fit. Rather, they can be done at some of the cycling shops to try you look at your body position, look at your size and try and find a settled is safer um no not this doesn't happen to everybody. I would say maybe if you were to um survey cyclist, maybe twenty or thirty percent of men and women tend to be excepted to this. So I think if you are having discomfort and when you're cycle, whether be pain nonetheless or you notice this function paying, certainly you should you know think about changing settles or think about changing writing style um other strategy are sometimes used but you is absolutely something that that everybody should be aware.

I'm going to asked this earlier, but I seem to recall a study that drew at a correlation between amount of walking and maybe I was sperm quality, but I think was testosterone levels, maybe some other metrics of male sexual health. Forgive me, i'm not recalling the details now um is there any evidence that walking more, standing more, maybe even using a standing desk is beneficial for you? Poc, for health, blood flow, prostate health, who knows, could be any and all of those things in some way that is beneficial for spring quality to stop on level and or overall male sexual health.

Yeah, I think you know one of the ways that we can characterize activity as step count, right? I think I know have a watch that tells me bad, that something that I look at every day and kind of strife and and IT turns out that the more active you are, it's been shown for of looking at large national data polls across different age ranges that IT is associated with test levels. So being more active, I think, is very important. And that's another thing that, you know, everybody can do IT to try and improve for the testicular function badly, but testore specifically.

And do you know whether not that can be separated out from the relationship between being more active and less obese is something that's independent of a obesity? In other words, can we incentivize people to walk more um simply on on the promise of um improved sexual health?

Well, I know your sexual health will be a different one, but we can. I think there is association to test stop levels and step account a across different B M I stra. So I think you know whether you have the ideal body away, whether you have a few pounds to lose, perhaps if you walk more you will see higher levels of test stream .

o and another question um to ask earlier and then we can close the hatch on on exhAusting to austral therapy, least for the time being. Maybe we will come back to IT is um assuming that somebody can maintain adequate spam production through the use of hcg or some other h therapy or perhaps they don't care if they're still making sperm because they've already had children or they don't care to have children.

Maybe they banks in any event, assuming that somebody takes testosterone therapy because they were prescribed that, let's in your clinic, just use you in your k clinic as an example. And they are happy with the psychological and physical consequences of that and they're comfortable with the tradeoffs. Is there any increased risk of a prostate cancer or other forms of cancer? And here i'm going to assume that this person is keeping their their lipid levels in check.

Like this week you hear about some hyper lip dema with testosterone therapies to assume that they're are taking a stand or they're not taking a stand. They're getting enough cardiff acute exercise that things are in check in terms of L D L, H D L, apple b and all and their testa stern levels are now high Normal and they're feeling Better. Um and they don't have to worry about spam production because they either maintaining IT or it's been bank to or they don't care about that.

Um is there an increased risk of prostate cancer? My understanding is the answer is no. But what's the real deal? Does taking test astern therapy, assuming all other things are being held in, in checking a healthy check, does IT increase the risk of any kind of cancer? Yeah I mean, this is another .

great question because I think there's a lot of missed around his door and that's one of them. You know this the origin is that prostate cancer is thought to be or is sort of android beated. One of the nobel prize again decades ago was awarded because I was found that when we lowered man's testosterone, the prostate cancer would regress dramatically.

So that put that the association between tests and prostate cancer. So then the concern we can, if we were to you, either replace test option or augment test off, and to give a man test off, and as I can alter his risk or increase his risk. Um so I think we have pretty convincing data that that's not the case.

There's lots of water to no data spending decades where if man is given test also um IT doesn't change this risk. The reason for that in sort of seeming this contradiction with them, you know, plastic cancer therapy, where we lowered testosterone, where if you give a man has one, doesn't change this Price of cancer risk, is not certain. But there is a popular model called the saturation model so that once there's enough test astern in the body and it's tends to be a fairly low level that all this sort of the prostate test and receptors, know you, I think i've has had been filled. So if you ready, give me more tests and doesn't change anything regarding the prostate cancer, prostate growth, any of that. So IT is IT is safe for we're looking at prostate cancer is an outcome.

getting back to prostate health and um neural innovation of the penis and and blood flow to the penis. If you mentioned the bike seat related issues, are there are other things that men should do in order to maintain prostate health, state of prostate diseases and to maintain healthy blood flow and neural innovation of the piano for obvious reasons. They will get into the physics of those reasons in our later discussion.

Yeah I mean, I think that no, I always kind of think of the penis as a user to lose its organs. So that doesn't mean that you have to have sex. But you Normally we get directions every night so that should be maintained that there's any reasons to sort of suspect that, that may not be going on. Um usually in my practice that would be from you know some public surgical intervention or something like that. Sometimes we can intervene to try and maintain them.

You're talking about spontini erections during sleep. So and short of assigning ones partner to to check um frequency and to message, what is the uh way that men would know that that happening? Are you talking about waking up with interaction? Is that a required for knowing that not terminal actions are returning?

Well, yeah, I think you yes, you can to call me. I think that's a good question. So I think a lot of times you won't know, but I think if you have sort of Normal response, you know when either by yourself with a partner, I think that generally means that you are going to get Normal action.

So I think I guess when I say use IT or lose IT doesn't mean that said, that the man has to stimulate himself or kind of make sure that he does have no adequate function. Because usually most of that Normal function just occurs, you know, with this not nal p out two mesons, which we all get. I think sometimes men do notice when they wake up at night.

Sometimes in the morning you wake up with the direction. Men notice that. But the absence of that doesn't me, is not happening. And likely is just, you know, most people sleep through IT, which is Normal, otherwise then would never get any sleep because that happens many, many times at night.

So I think you know again, if you're not have a Normal function, I think that something you should probably see, you know a physician about and then same for like you in any function. I think if IT bothers you, if there's if you're waking up at night, you have to go to the bathroom often the stream is getting week. Those are all sort of complaints.

Do we hear about what is often? Um my understanding is that it's Normal to wake up perhaps once during the night to year and eight and this is a course assuming and again, forgive me for all the caveats but i've done this long enough that you know if if I don't get really granular about some of them what I drank you know thirty two hounds es of fluid right before sleep and you're in ating three times for night. Well, we're assuming that people are tapering their liquid intake as they approach bad time and that waking up once may be twice but once in the mild n ninety and eight is Normal for somebody, let's say age I know eighteen to forty and maybe fro m 4 to a one hundred um that number might be in the a one to two times per night。 Is that about right?

Yeah I think I think once a night yeah is Normal for most men. And then I think you have things start to bother you. I think you could certainly see somebody, but it's hard to get Better than once or twice a um my .

understanding is that there is a pretty good relationship between the um nocturnal action and the amount of rem sleep rapid I move and sleep that one is getting that this tends to be more frequent toward morning as the a proportion of rabbit I movement sleep increases. I don't know if that's true or not, but I found a couple of studies that at least point in that direction no one intended.

Uh, so that raises A A bigger issue that we haven't talked about yet, which is getting adequate amounts of quality sleep night. And I think for most people, that seven to nine hours, ideally, which means getting sufficient slow way of deep sleep as well as well. But I move and sleep. But now that is a lot of people, including Young people, who are not working excessive hours, are getting know four, five, six hours of sleep per night is their direct relationship between getting lessons sufficient amounts of sleep and sperm quality to astral levels and sexual health.

You I mean I think certainly there's reasonable data for Simon quality and there tends to be um we call like in science sort of A U shape relationship so that it's not sort of linear. So yet more sleep things are Better. There's sort of there's this concept of too much sleep but not enough sleep. So the idea I think is you pointed out of seven to nine hours and for men that are not getting that seen on quality and civil lower and then for men and getting too much, um we also see a decline and know why that is you get not certain again, if you're able to get that much sleep, maybe there's other things as well that we should look at. But so I think kind of getting in that ideal sleep now is best for seen on quality and probably for broad to take out function as well.

You keep bringing up seamon quality um in a way that makes me wonder whether not is seeing equality a proxy for overall vitality and health or is testosterone level a proxy for overall vitality and health? IT sounds like seem equality is the the metric that you keep coming back to in a way that um have to assume reflects your you know your clinical experience and the many papers that you have authored in the area. Um I think for people that hear semon quality and who are not interested in conceiving children now or who are which you of course go to include people had children or who don't want children um seeming quality sounds like something that relates to face late but is seeming quality something that is a good goal for those who are interested in overall male vitaly and health is that is that one of the Better metrics of overall mital ity and health?

Well, I think you know, I think it's an excEllent marker for overall health. I think there are studies that support IT can be a measure of how healthy you are if you look at the man with more health problems, that can enable our season quality.

But also if you look at semon quality despite itself and then you look into the future how these men tend to deal if they have higher seamon quality, they tend to live longer, need to go to the doctor, less lower rates of cancer. So I think there is a lot of different ways that steam on quality may be a good barometer. Health know why that link exists, I think is not is not known, but there's lots of dearies.

So one is that why about ten percent of the male genome is devoted reproduction and so makes sense given the world have about you know twenty four thousand genes in the body that there's a lot of um no overlap. So one gene that plays a role and reproduction may play a role and the cardio aster system or interrogation ical system. And so if we get the first, no sort of sign that reproduction is not perfect, there maybe some other health consequences down the line.

Um another sort of hypotheses that again sort of going along this line that reproduction is one of the first things that we see is that um know just station is sort of very critical to our know existence right in a perturbations to that system have prolonged um you know effects so the so called sort of development of origin of adult disease of the barter home offices um and so we know that you know premature children of higher risk of cardio asked disease have been studies to show that, but we also know that you know these gestational effects can also play out on reproductive function too. So that also may be kind of a link sort of early seating of reproductive function and then that maybe the first marker that we're going to have for other health effects later on. Um there are also sort of sort of inherent um sort of similarities between um reproduction in some other sort of social effects.

So you know kind of one sort of confounding factor when we're looking at some of these studies, I talked about looking in mortality, for example, and semen quality is that there are sort of factors that necessarily involve reproduction. So your children and having a partner and having a partner prolonged life um having kids prolonged even though that feels like kids are killing you. If you look at studies, men with kids tend to live longer.

Um so you know that's another possible explanation, but I think we know really sort of this health um you know link between fertility. I think I sort of a powerful one. So I do think IT should be a brother.

I think that you know that should be a of a given lectures on, as I call the six pital sign. I think of something that we should probably check because if there is no sort of lower levels that may tell us about something else going on. You know when when men come in from futility visitations.

A lot of time we do diagnose, you know, these new medical problems. Sometimes we diagnose cancer polluting to some of the questions you've asked, diabetes and some other, you know, very significant genetic conditions as well. And you know the first way that we would identify as reproductive failure because there are sperm council low and other thing.

So IT is something I think it's part of. Its very important, I think for people to realize um and IT would be great. I think you know another I think advantage to like the centers for disease control, for example, that just start tracking .

IT would IT be a good idea for males in their twenty and thirties to get a superman alysa to tab a baseline, I confess. And forty seven now um one thing I wish i'd done in my twenty years was to get my a blood form profiles and lipid profiles done when I was in my teens in twenty years because i'd have something to compare to. I started doing that in my mid thirties and i'm so glad I did because I can now compare to my mid thirty levels.

I started including spr manali sis about eight years ago um with the intention of freezing sperm。 But did that because I was also reading at that time about the increased risk of autism um in offspring of males older than forty, something I really would like you're take on. But um IT seems like it's inexpensive enough to do as per analysis. Um I think now that people can get IT done at home, they have male male kits. Although I don't understand how the motility could be maintained if you're mAiling your sperm back at room temperature or settle through the post office.

Now even imagine all these sperm traveling through the post service, is there are out there books ah, what you thought should should people invest, I think is a couple hundred dollars to get a sperm analysis more costly to get the DNA fragmentation than you get up into the low thousands? But if people have the disposable income, is that a good idea for them to do? I mean.

I think it's a worthwhile test. I think more information is always good. I think one of one of the same reasons that um you know you were talking about checking like a lipid levels or we talk men and women, they get blood first checked. I think getting that sort of early health indicator, I think you can be important. I think you know going back to not known actually why steam on quality is telling us about health, what the exactly may be you know means that if somebody is coming in with a low sperm counter, including absent sperm count, it's hard to know exactly how to cancel that. That person other than that may be reproductive difficulties um but I think just is sort of a marker for reproductive potential.

I think it's useful and I said I think it's become a lot easier one of for innovations in the space and you know somebody that you know is in the republic, the world, I think it's just really great to see sort of this influx of capital and new companies coming in that trying to just decrease the barrier to, you know, getting a cement used to be able to go to a lab, schedule an appointment. Sometimes I would send you you to a bathroom, which can be uncomfortable. People doing, you know what?

People doing a bathroom just next day, or you trying to collect, send them to in common place, they even give them the quiet room, red light, what I AR they do now. yeah.

So to have video so there are some higher level.

So I didn't even mean videos. S I just I think that um okay yes i've done that. So just I mean i've trying to Normalize things related to all aspects of mental health of health um so um yeah I I decided to free sperm basically they sent me to a room and I went to a university basic IT actually wasn't stamper a different university and yeah they put the cup through the window.

They give you the cup, they they closed the door and they tell you that as long as that red light is on over the door, knowing e's gona walk in, and then they leave. And I think the assumption now is that you figure IT out one way another how to provide the sample and then put the sample back through the the thing. And then one thing these clinics really need to work out is that any time you're walking out yet, you see the people processing your sample as you walk out.

So there's all this this a fain of of, you know, anonymity, but really isn't there? Does they like you later? And you great ounce, they rarely ask you questions on the way out, but it's a pretty simple process overall.

And and I must say that the data are informative. You get you get the volume number motile forwardthe motel. I did opt for the DNA fragmentation um data um and I just love data. So I think it's really interesting. But again um and maybe this is a good time to flag this this set of findings. I believe that there seems to be a small, but it's a specially significant increase in the number of artistic birth due to pregnancies where the mail was over forty at the time of um uh conception. So I figured, you know why not free some spare man, it's relatively inexpensive.

Yeah so I think eternal age is also you know something that's increasing in this country. So over the last forty years or so we've seen that the average eternal age is increased from about twenty seven and a half, about thirty one um and I should say this is all fathers. So um birth certificate data, birth data is collected a maternal.

So you know, when a child is born, somebody comes in to collect data on the birth. So they asked, you know, all the characteristics of the mother, and they also asked characteristics of the father, you know, age education, obviously region in the country, the child is born, so we don't know, you know what number child that was for the father know for the mother. They do ask, know the first, second, third, exact her child.

So the father unfortunately just have data that sort of all lumped gether. But over the last again forty years, you've seen that increase. interesting. Over the last forty years, the Youngest father was eleven and the older was A D, A eleven, quite a and yeah A D A. 嗯。

goodness.

unrelated goodness. It's an ized data.

But I I have to ask that sorry to take us on a slight change, but what is the average of puberty in males in the united states now? Yeah, so asking by .

a sort of supermarket when my experiment production began. So yeah.

there are a lot of markers of a purely secondary sexual characters of the growth, depending voices there are. They happen at different rates in different people. But yeah, thank you. At what point um are yeah males undergoing puberty there at at the level of of that we're talking about here?

Yeah so their husband data, they were going through puberty a little bit earlier now though we used to but IT really varies. So you know I think it's not um you know just like test astern ranges between like three hundred and nine and heard that's a wide range for anybody. I think for most individuals, property is know probably twelve to kind of fifteen, sixteen in general.

So I just give sort of a very wide range when we're going to say that's okay. You know some of the data be seen on is when sperm production begins and boys and it's actually you know not that simple to be able to figure that out because, you know we don't generally talk to the you know Young boys about how to master, had to collect and then check on that. But there's something called first morning boy ded euro or we can actually look at that and there having some studies and and they see if there are sort of nocturnal emissions, whether there's sperm in there. And so generally a probably starts around um the earliest to be kind of eleven, twelve, thirteen, but usually most is probably little later. So maybe i'll refine that purity and move IT a little bit later by fourteen to sixteen um is when probably about seventy eighty percent of boys are going to have produced started producing firm.

My understanding is that in females puberty is also shifting earlier perhaps that a more dramatic rate than appears to be the case for males.

Well, I think there is some data for males too, I think. But I get through the listeners. I don't want to you have this on slot of pediatricians seeing kids, haven't you know when I haven't gone through purity bia certaine? So I think it's still fairly wide.

Let's get back to each of the father and issues like autism um what are the data there um and this to me is a practical issue because I think if there's one obvious take away from our discussion today is that males should probably not wait until they're trying to conceive in order to assess their reproductive health at the level of sperm quality.

Testosterone levels perhaps, but at least in quality but but perhaps men should also be freezing their firm if in fact, conceiving children after forty places their children at far greater for autism minor standing is that the rates of autism are somewhere between one and eighty. You'll hear as high as one in fifty melbourn. I think it's probably more like one in sixty to eighty is that right? Um and that the age of the father is a river actor yeah I think .

that this gets in sort of the larger issue. You know how men are to perceived fertility so you know we know that as women age fertility clients, but the oldest father ever, ninety six. So the biologic potential certainly persist.

I want to know how long he lived to see how long his child grow up. He conceived that ninety six opposed to Powell.

I was.

he did not mean his grandchildren, at least not the the grandchild of that child. So wow, how long did he live?

You know? Well, so this is a man in india. It's a sort of a famous story, but supposedly he had a child.

He had that child with him on, like they're waiting at the bus stop. He fell a sleep. The child was the legit or so h yeah dreadful sort of A A horrible end. But the wife was also not not battled, but in her fifties. So yes.

well, tragic and incredible story for a separate reasons. Okay, I get my head around this nine, six year old conceiving a child. Okay, please continue. Yeah so people.

I think our men thinks that the sort of the um you know there feral road is sort of infinite, but I think that's very much application. So they are looting to people have looked into risks for older father.

So you know about one hundred years ago was first noticed that dwarfism or a counterpoint to, was more common and last borne children so eventually that link was made um and since then other conditions too so there's like these neuropsychiatric distance you're talking about autism certainly one bipolar schizophrenia. A people have looked at how to linked that with older age less certainty in school know fAiling grades all that has been shown to be a little bit more common with older fathers. So you know why I think all these exist? There can be sort of different explanations.

One explanation for the autism association i'll talk about you know some of this more genetic or um kind of mutational reasons about one thing that some people say is that you know could be sort of a hedi ory trade and so IT may be that you member that displays some sort of to characteristic. Maybe they take a little longer to meet a partner. And so it's sort of delayed chAllenging. So maybe that's that's one possible explanation, but I think there has been a lot of convincing evidence that there could be real epigenetic changes that occur with age and mutational changes that occur with age. Um I think I read a statistic and you would know more being in a science as that eighty four percent of the the genes and our body expressed somewhere in the central nervous .

system that be about right yeah yeah I don't want to stamp my name to that, but that sounds about right.

So it's estimated that every year we generate about two mutations in our um firm DNA. So you can imagine that forty years old is going to have twenty years thirty forty more mutations um than a twenty one. So that rate does go up.

And if you're just randomly sprinkling mutations genome, that they are more likely that sort of manifest and maybe in a psychiatric conditions. So there are, you know data, convent data that shows that does occur. Now again, there's billions of base pairs in the body, so these rain limitations, likely most of them will not result in anything, but there can be some minimum.

So for example, a contractions due to a amita and fiberglass growth factor receptor. And what's interesting is that this condition is not that rare, right? Based on sort of these rare mutations, you'd expect this occur maybe about one, one hundred million.

But IT turns out these east conditions occur about one, and I think thirty to fifty thousand or so. There are sort of the discrepancy based on a mutational rate that we expect, based on age and the rate that we actually see. So the explanation for this is something called self dramatical nial selection.

So what this suggest is that some of these mutations, s that OK renomme occur. R in proliferation athons. And so IT gives the sperm that contain is sort of advantages over there, you know, brothers and sisters that don't have them, for example.

And so then they outcompete. The other are sperm. And so they're more likely to lead to a child rather sort of a random battering. And you can actually see that some of these mutations are more common in older man and Younger men. If you look, we screen for some of these mutations and in some of these pathways, ids, um again, the longer they were exposed to wife, there's a more likely to be different chemical exposure, other exposures.

And so people have looked at epigenetic natures are these signatures that um you know the dictate which genes are going to be expressed in which aren't and there are different patterns between older and Younger fathers and you know why what trigger ing those is not known, but there are differences that those could also potentially explain. Some of these is rest that we see um you know used to be that people thought that you're an older father. Maybe there's a lot of advantages you know for the kids, right? Because if you you're more resource, I always tell patients that you know when they come to see me for direction problems or anything, I always say nothing gets Better with each right.

And that's mostly true that they pointed out that um salary often goes up with age and wisdom goes up with age. So you would imagine if you're more resource and maybe the kids are gonna also have an advantage to that. But again, there's a lot of convincing data that's that's probably not the case.

There's even there's one study that I saw that showed that if you look at mrs of brains of children just after birth, they're actually a little smaller for holder fathers compared to Younger fathers. So I think there are some of talking about kind of neural kind of development um some of those backs. And there's also been um studies looking at cancer risk too.

So higher risk of breast cancer, prostate cancer and adult children, higher risk of you know luke mia or cn s cancers and children as well. So I think the more we look, the more we find out of these associations with maternal age. Um so I think that somebody certainly be aware of, I thinking talking about mitigation strategies. I think out of education be important for know couples to try earlier, individuals to try earlier to conceive. You know, if we think it's a mutational reason, I think you certainly freezing sphere, I think is that is a good option as well.

My understanding is that analysis of DNA fragmentation in sperm does not allow for selection of the best firm on the basis of DNA composition. Um translated to english, what I mean is in order to tell what they're not this the DNA mutation perm, you have to kill the spam basically. So um and since um in a given pool of sperm, so to speak, um there will be ford motor, non motor twitchers twitching in place, dead sperm, some percentile dead sperm and motl burma's presumable Normal some small presents hopefully um and that some might have some DNA rag mentation, some might not so um is the way to address this. averages.

What i'm hearing here is that if you haven't already had kids are if you want more kids um that you might want to know about your sperm quality, I would say you do um and that if you can afford that you might want to take a look at DNA fragmentation data um but having done this um what one receives as a chart that goes from red, bad, Green, good and then they put the arrow hopefully in the Green zone and then you say good you know i'm in the Green zone. I don't have fragmented DNA in my sperm but really that's an averaging of all this spam right right? IT could be that as you age that some percent of those perm have fragmented DNA and if one of those is the one that successfully wins the egg, so to speak, um fertilizes the egg, then that fragmented DNA containing sport is gna propagate that into your offspring. So are there any technologies that can allow men to um select for or improve the DNA of the sperm, not just the motility?

Yeah I wish right that sort of the holy grail because I think he pointed out sort of a bar of right hydrogen certainty principle is that we can if we identify which sport is bad, we're not going to destroy. And so to tell you know which one is harboring these mutations would be great. But I think you're not there yet.

I mean, one thing that we do do is wash sperm. So we do sort of select the most models firm. We clear out the dead ones.

And I think every one is were pretty good at telling which very think or Better or Better. Again, we don't have any really objective data to try and understand, you know, which are harboring something or other. But I think if we understood more about this link with age or again, other conditions, hopefully we'll be able to stop some of this bathroom.

Let's go back to the protest. Incredible gen tell us about the prostate. I think we hear about the prostate.

We hear about prostate cancer. Um people might have heard that is involved in the ejaculatory response, is involved in directions. It's involved in a number of things. You give us a you know catalog of things that the prostate does. You spent a lot time thinking about this plane. What are some of the cooler things that is that IT does that we don't know about um you know how do we keep IT healthy um and what are the consequences of not keeping healthy? yes.

So the prostate is a glass of the size of awan a it's it's behind the blade and it's involved in reproduction. IT produces some of the proteins, enzymes that are necessary for you know sperm to be supported and exactly to kind of keep the the sperm healthy um in the female reproductive tract.

So you know IT functions and reproduction and then basically after reproduction is done, IT doesn't really serve any useful functions so then IT just becomes the problem essentially. So the a retha which is very peared so IT connects the batter to exits the body, runs right through the prostate. And as we ages, the prostate does get bigger, that sort of a known thing.

And as the prostate gets bigger, IT create sort of more resistance in this pipe. And so that makes the water after work harder. And that leads to a lot of the symptoms that we have been talking about already, know waking up at night.

We extreme this needed urinate urgently, sometimes feeling like you're not empty all the way. So it's sort of a consequence of the prostate um being there are in terms of ways you can keep the Price healthy. I think that there's really nothing that not necessarily you can do.

I think that you know one thing I talked to patient about when these sort of symptom started is to know some of the triggers. So you know you mentioned drinking a lot before you go to bed. So if you don't want to wake up at night, that's not a good practice and even want to going to bed to have a little dehydrate just so you can try and last the night.

There are some you know particular drinks or foods intend to be more herriton, so like spicy foods as citic foods, so can sometimes irritate the lining of the bladder makeup to pee a little bit more. You caffeine is a diabetic so that makes us year and nate more and also um can also irritate the batter and give you that sensation alcohol will do the same thing. So I think you know kind of knowing some of those triggers may to stave off some of the symptoms a little bit. But you know again, if you enjoy those vices and you're willing to tolerate IT, that's okay too.

I'm hearing more and more about the practice of people taking low dose to dolphin sea as low dose, meaning in the neighborhood of two point five to five milligrams per day um not necessarily for direct all this function but for prostate health and was um somewhat surprised to learn that those drugs that are actually developed first for treatment of prostate health to increase blood flow to the prostate. Is that true and um is there good reason to um think about taking two point five to five milligrams of to delle fill per day simply for maintaining blood flow to the prostate and thereby maintaining or improving prostate health?

I mean, certainly I can do that. I can definitely help with some of these ordinary systems that we've been talking about. You looking at civil control trial, sort of a higher level of evidence does show that no los of to David is two and half the five milgram.

These daily dosing can help with these ordinary symptoms. So I think that not that is a preventive measures, but for men that are bothered, you know, otherwise I think most then probably wouldn't want to take a pill every day, but certainly to have some of these symptoms that can definitely help with urinary bother. And then the added benefit is you also load to, as I can help with the rect out function as well.

even at the two point five to five milligram. Because interesting, yeah, my experiences that there are lot of people who would love to take pills everyday, there seems to be a kind binary distribution where, and here I am just thinking about the male die here from, because I hear from course males and females.

But I get a lot of questions about what can I take, what can I take, what can I take? And but as you point out, there is also a category of of men who seem to not want to take anything, not want to measure anything. I want to take anything, but especially not take anything.

And then there's the other group and the other group, somewhat surprisingly, seem to be the Younger excuse me, population um may be grew up in the youtube era or maybe in the era where sexual health was discuss more openly than IT was certainly when I was in college. I mean the extended sexual health discussions in my high school. I want to very good high or um IT only takes one sperm, which is the point I was true for I vf, but more is Better if you're trying to consume naturally.

And um there were discussions about communication and consent, obviously super important um and then um they just can't turn to lose um to learn from our friends and other sources. I mean that and family sometimes had the discussion, sometimes didn't. Different families different discussions obviously.

Um so very, very little information nowadays, think there's a lot more discussion about these things and so the twenty to forty year old male crowd seems to be the crowd that are asking, yeah, what can I take? These are also the people are getting on to therapy early, perhaps without the need. I just want to flag that because I think uh by understand quickly um you're seeing a lot of testosterone therapy that perhaps people don't need. Is that right? Well.

I think it's a mix. Some people probably do need IT, but I think that you know before starting and everybody should be aware of all the risks. And you've got to highlight IT, testoon any medication, right? It's gna have some rest. And so everybody is to be aware what those are. And for testoon production, certain ly.

and if they're not already doing all the other things, getting adequate sleep, limiting their alcohol and takes, not smoking, getting exert a, seems that toast astern therapy would not be the primary entry point. Like first, work out all the right, all the basics. I think that's the big difference.

I think now that is that what should I take? Question comes up early when people aren't necessarily doing all the other things that they could do to promote their health. Anyway, this is observation, my part.

Um you're the one who's clinic they are showing up um to. I have a question about U T S. Um we hear about U T S your ordinary tracked infections.

Um in women pretty often do men get uti if they're getting more than one uti per year that abNormal. Um should a men be a examined for um this battle? You retha prostate piano architecture in other ways that people can come in.

I was reading about this prior to the episode, can then just a die and then they can die. Image the whole APP aratus. Is that right? That's without having to cut anything. Is is that worth people doing? Or that only other conditions where people are experiencing some some um some vexing issue.

Yeah I think that some of those test should only be done if there's a problem. But I think a male international tract infection is rare enough that IT should be evaluated. So women have very short to redress but men have a very long riad to read us, to go through the entire pani, right through the prosthetic, to read that IT up into the blender.

And so the way you're not track infection, what happened, you know, one way would be that of bacteria actually gets all the way back, and that's just a much longer track. And so if something rare like that does happen, we look for anatomic causes for that. So there can be different, scarce.

Sue in the reader, for example, there can be stones in the batter. There can be stones in the kidney. Sometimes men empty their batters all the way so those those men should be evaluated because there can be some biology that we can hopeful ly identify and correct.

Let's talk about direct out this function.

Um I put out the call for questions and anticipation of this episode and um no surprise uh at least thirty percent of the questions from males were about direct all this function um or uh questions about what's Normal in terms of libido level of interesting right you and we'll deal with the first question first but um what are the most common causes direct tile this function? Are they for mono in nature? I think that's A A common belief that if people are experiencing erect out this function, that is because there are just astral levels are too low, hence. All the interest in testosterone therapy or are there others say blood flow related, pelvic floor related neural um bring to um to body neural connections that are responsible hum guessing its all of these things how do we pass this um and yeah what tell us about rect all this function, what you most commonly see, what you most commonly do in order to treat yeah so .

you know direct out this function, as you know, is sort of the inability to consistently achieve and maintain an direction and it's barely common you know all the conditions I see, that's definitely the number one. So you know, you look at me, over the age of forty, over half will have some trouble with directions. Under asia, forty is probably about fifty to twenty percent.

So this is a very common condition that we see in terms of the ideology. IT can vary a little bit, even think they were primarily psychogenic. But that was no years.

That was decades ago. Now we know that most of more organic, so it's actually a blood flow issue. So the most common conditions, just sort of nationally would be the same things that cause blood flow problems anywhere in the body.

So high blood pressured diabetes and address growth. Anything that can impair love getting you know to the end organ um and sometimes you know there has been data that you know trouble with directions can actually predate others more serious you know basic lar condition. So the blood muscles in the penis, the pearter ies are about one millimeter know in the heart and the brain they're much larger.

So it's much easier to have a small vessel than a large vessel. So that's why there have been some studies support that is sort of an early marker for vascular disease. Um so I think looking at those rise factors, you know a lot of lifestyle ob city again is another is a common one, underground disorders actually fairly small. It's probably less than ten percent, probably one five percent or so. Um pale cancer treatment is another very common one after in a treatment for prostate cancer, whether be radio there surgical Better people had our cancer, sometimes the rectal color red cancer that treatment also any time where you know involving some of the nerves and the vast future in the palace that can also impact uh erect or function as well.

What about her .

nier cornea? That should be separate. So sometimes if there, you know always say that medicine, you can never say never. But generally if that was going to matter us, the direct of function that would probably due to maybe some pain systems can really happen during this. The early leaf is Operate period, but the blood supply and nervous supplies .

is departing. So you says something very important for people to hear so i'm going to highlight IT um he said that less than ten percent of direct al this function is due to a hormonal issue. Um I don't know how much time you're spending on youtube in the internet, but that is going to be a shocker for a lot of males out there because so much of the discussion around testoon is around libido and sexual function.

So um it's key for people to hear that. It's also key for them to know about the other ninety percent. Um when you say blood flow issue, then a what is the common first pass for treatment? And again, forgive me for a listening off over and over, but we are assuming here that people have got ten their body wait down their enough.

They are not testing excessive alcohol. They're not smoking or raping. You're not smoking cannabis um or doing the edibles the wenglish talk about edibles and cannabis and any facts will that later? Doing all the things right, avoiding doing the wrong things too often or at least completely.

So we're assuming they are doing all that correctly. Their testosterone levels are somewhere in that three hundred to nine hundred and gram predecessors or range that typical for the the so called reference range in at least in the U S. I think he goes up to two thousand hundred or maybe fourteen hundred and other countries but um as other countries like to point out, but IT starts too.

No, i'm just kidding. But assuming they are doing everything correctly and it's not a just a stern issue, then if it's a blood flow issue, meaning they haven't had treatment for some private cancer, what is the first line of treatment? yes. So assuming .

that lifestyle, you know and all that has been optimized, medical treat has been optimized, there's a lot that we can always tell men as long as have a penis, we can always make IT hard.

So there is a tremendous amount.

i'm sure you the most popular doctor in your field, that everybody um so usually we start with oral therapy. So fast, fast, fast inhibited therapy. So that would be like soda or biagio to deliver seals, a benefico standard of a dennie's betray. Would you be going .

to talk about something the specific s there are you um is the typical al thing to put people on this two point five to five milligrams per day low doses or to um give the higher doses that are more commonly used for rect all this function pursue.

I think that depends we know why we're putting them on and end to how much sex they have to. You know on average, people probably have sex, you know harder sex, maybe once a week on average. You know when we're looking at men, there are kind of thirties and beyond.

You know sometimes there can be a few more times a week than that. But you if they're having sex everyday, you're very often that sometimes a daily those can be useful, but generally most matter on just on demand because they are going to fall into that maybe about you a few times a month category. So that's using what we started.

And you know there are sort of a tighter tion that can be done. You can go sliding, you know high doses or lower doses. So you should we started in the middle of the higher doses um and you know we talk about some of the side effects they may have, but those probably help success to seventy percent of men um and they work well.

You know in terms of another common question is how do we decide which one we're onna start sometimes insurance we will tell us which we're going to do. That's a common one. You know all these medications tend to be somewhat similar.

One difference tends to be the time of answer. You know, how could be the repeal levels in the body and then also how quickly they're cleared from the body? So to dolphs somewhat different and last longer, the half life is about twenty hours or so.

So it's sort of market IT is a weekend pill. So some people like the idea of that you're taking a pill on friday, so having some left on saturday. But for others, we start with with one of the other ones.

the fact that these drugs like to deal full uh also called see right see is the brand name right? Okay and um viagras at a brand name right stands for um what is the genre name okay? So because they are effective in such a large percentage cases, what does that say about vascular system of all these males that um having correct all this function but then it's being resolved by these drug treatments, is that in other words, somebody comes in to your clinic, they're having this issue. You prescribed um one of these drugs, they come back and say everything is working great or may they don't come back, they just know send an email say everything is great um but do you need to have a discuss with that person about their overall asking or health? Because a few minutes ago you told us that the fact that they weren't getting reactions to do what now appears to be a accused issue um can be resolved for the panel tissue but um is he going to solve the other accused issues or should those people beyond look out for sugar accused cardio accused disease that can potentially cause things at least as bad as erect function and maybe worse?

Yeah absolutely. I think they should be screen. So you know sometimes i'm diagnosing in the first doctor that they're saying at a long, long time but otherwise I do encourage to see a primary care doctor to be screen for blood pressure, lipid levels, fasting blood lucus.

All those things, again, sort of for early markers of some things, sometimes are identified, sometimes not. But I think it's you know, I think we can talk about sort of the ideal patient that's perfect body with nothing else going on, but no very rare entity. So user is something that can be done to be optimize. And I don't I try not to be alarming about this, but I do want to know current that sort of take ownership of the health because that sometimes can improve um some of these conditions. But again, we have traffic medications for for men and who we cannot.

What are the common side effects of these drugs?

So there are based a dialect or they open up blood vessel so we get some off target effects. So headache, facial flushing, backers like crimes, interjection, nasal condition, that would be the most common before .

the last supermom. There was so impressed about the fact that a lot of the players were taking these drugs, that low dosages before the game person will lead to increase blood flow to the muscles and brain. Is that, is that what the rational .

I was I think so yeah you know another is we talked about rd of how cycling may lead to erect out problems or sexual problems. There has been some data looking at taking like biaggi or one of these medications. See listed, although before a ride again to trying crease circulation that decreased a chance of they either negative effects of prolonged battle pressure so that sounds .

like just increasing blood flow and lowering blood pressure slightly is just a good thing all around.

Yeah I think there are still yeah because these medications were originally, I think these are allowing to or developed as a blood pressure treatment. And this was sort of an amazing off target effects that has turned into a billion dollar industry. So you .

mentioned about ten percent or less of recitals function is due to underground sues as sixty to seventy percent can be resolved with with these blood flow inherences. I know it's a terribly non non clinical, non scientific way. Describe the viagra, cialis to all for set up. What about the remaining percentage? And are the other treatments that you you prescribe or given um in what cases do you need to uh resort to um I guess more invasive approaches yeah so another theri we have is .

you need also the positive is so you can actually put a medication in the tip of the penis, absorb by the rest of .

the also inject in poor.

poor or a jell a jelly yeah um so it's also a basic die later of the concept is very simple sometimes that is OK for men and they tolerated it's safer partners as well. IT can tingle little bit. So we definitely let men know one of the main medications does cause like a little bit of a burn as well.

Why would somebody do this? Is supposed to taking the pills form of the drugs we were just talking about.

Mostly advocacy would be a big one um and so this this can sometimes help where others can not. So that's one uh, piano injections or another common therapy. So the F I can see of penile injections are probably eighty and ninety percent.

Again, we're injecting basic dialect or into the peos. So the ID just opens up blood vessels. He's here to get in the keeper directions. You can imagine the huge psychological burried to putting a leedle entrepreneurs.

but is something that the patients are doing for themselves at home or that you're doing is IT long lasting. Is that something you do with the clinic and then they come back every few weeks or so?

No, yeah, this is an on demand treatment. So we we need them how to do at the first time. I do with us in clinic. Ideally, we try and get direction at last, probably twenty thirty minutes. So we usually started the low dose and then they just increase at home until they get direction that last .

for that amount time is this injected subcutaneous are actually into the do this the media tissue of of the penis that's right .

into the erect dw bodies directly yeah and they only have to inject one side. They do communicate with each other. Most one is fine. It's a small it's a very small gauge. And you know that is because, you know.

a few trains of there have an appointment. Over an optimist, i've seen injections into the human eyeball. And IT is incredible how fast and how painless that procedure is when it's done by the right person.

Nobody should try that at home on their own. But when done by scaled up theologist, it's just striking. You know hear you think about needle in the eye.

You know what's worse? Like the childhood, right? right? Stick in my think of anything worse. But um maybe you know an injection of the piano sounds almost as bad. But you're telling me that if patients are prescribes that they can do this with with limited, if any, discomfort.

well, IT does have a high drop out, right?

Surprised, surprised.

Yeah, I think no one is excited about IT know guess the mood can sometimes we be affected, but a lot of couples are very comfortable with that. Again, it's very applications. The part the man can do IT as partner can do IT. Um so that does work well.

And I I guess here we're sort of a sending the list of um invasiveness right um what is the sort of top tier of invasiveness for function?

So then we go into peano implants. So there is actually a critical procedure we can do to put a device inside the penis that can help men be hard when they want to. And that comes in sort of two main forms.

There's either nor in fatal uh or inflatable um so the non afflatus ble sort of abendanon you know has sort of a metal core. And so when men don't want to have sex, they bend IT down. When they ready for sex, they can kind of bend IT up.

It's really just there on demand. yes. Yeah interesting.

Yeah, so it's very simple to use sort of the more, I guess, of natural form be inflatable. So when you're not using IT, it's deflated. And then when you're ready to use that, it's inflated and you inflated with basically a pump that in this grown.

So all this is out of surgically implanted inside a man all under the skin, unless you know you're looking for you. Very difficult to tell if a man hazard IT doesn't happen, but when he's ready, he pumped IT up. And that moves fluid from a reservoir, which usually is also also surgically planned into the penis to get a rigid direction.

What is the relationship between psychological arousal and interaction as IT relates to these technologies? I mean, the way you're describing IT sounds purely mechanical, right, which i'm not not actions which I suppose people could be having erotic dreams, but I don't think that's prerecorded for not internal directions at all, right? So is the idea that if adequate blood flow is achieved, then any signal from the brain can initiate a cascade of blood flow that creates the direction? Or is IT the case with some of these treatments that um sound like blood flow is almost autonomists.

right? I think a lot of these um yeah the blood of is not adequate and that's why we're having to know to go beyond. But generally, as you point out, there is different stimulation, whether the visual taxi or factory um where to start to that cats cane that releases neurotransmitters ors in the penis that leads to this violation naturally and then get directions.

Few years ago I was reading about VISA present in halloes. There is a bunch of stuff hitting the market. Um by the way, I don't suggest that people um get experimental with the stuff as a neuroscientist who also knows a thing about neuropathic and ur hormones that can impact the hypothenuse you know I I discovered my eyes and kind of chrge when I think about people in healing these oppressing thinking, oh yeah you know there's a is a present increases sexual desire or something like that um but nowaday i'm reading a lot more about a really interesting peptide treatment which I think is A F D A P prescription drug which is um relates to a milanesi stimulating hormone that comes out of the media patuit ory um that is used to increase the sexual desire it's prescribe bed for women um but men are starting to take IT and IT seems to have, at least from what you read on the internet, a pretty profound impact on label and on erect al frequency and persistence um is is something that you know is you're using in your clinic um yeah what what about these peptides that people are in hAiling and injecting and some of them are taken in neural form but most often and I think it's nasal and Helen or um or it's a subcutaneous jacket yeah .

so those are not ones that we use in clinic. But I think you know looking at sort of to sexual disfunction broadly, there are a lot of things that you know we do try and help um and one of things sort of that I kind of related to that, that is been a proposed treatment for IT is this concept of delayed orgasm or delayed ejaculation. So I think everybody is familiar with creature adjure lation and right where mean ejaculate too quickly.

But on the other of the spectrum, there's a men that takes you a long time to ejaculate. And you know what that is, is sort of defined differently. But generally, most people would say like sort of two standard deviations about the average.

On average, probably around five minutes or so, two standard deviations were become twenty to twenty five minutes for men. They take that long to ejaculation that would be considered delayed or sometimes they don't adjacent every time that they have relations. So for those, I think there is a need for treatment because there is no fd approved therapy for that.

And so that's why I think, you know providers are trying some of these other you know more experimental things. Um there are some that we use, just not that one particular. There's also some devices that have been drowned as well.

But it's it's a chAllenge because you know, I certainly really feel for these men, it's one of the pleasure in life. And some of them are never able to have sex or only, or starting to able to. Horgan m, and some are only able to do IT very rely, so we do not offer them benefit.

What about pelvic floor health? More generally, the topic of pelvic floor health is something that comes up more often around female reproductive health and neurology. Um hear about key goles carles key goles. Oh, no, I guess we will have to ask him. So he turns out ego k go was a person um who named the exercise after himself.

Um he did them or not I do not know, but my understanding that cargoes are a pell VC floor strengthening exercise um and my understanding is that some people experience urinary or sexual this function because of a overly relaxed A K weak PVC floor but that some people have the exacting problems because of a hyper contracted A K A very tense, tight, strong peeling floor meaning don't run out and start doing carles just because you heard about them. They're not good for everybody. They might be bad for certain people, but what about perfec floor health? I mean, should men be paying attention to perfec flor health? Should men be doing perfec flor exercises?

I mean, I think it's truly key that you say that because, you know, not everything you hear about is good and I think it's not good for the right person. So there are certainly men that I see that have very no, just a lot of attention and a lot of anxiety. Sometimes these men, you know, urinate every hour.

I mean, there's other things that you can just tell there is out of very wound up. And I think for that man, you know one of the issues so you kind of value to as you probably need to relax more. So you know public for physical therapy can still benefit because there are some just different feedback exercise that could be done to help with relaxation.

So you know any urologist offer, there's usually list a lot of different providers around the region that can help with some of these key exercise though can be useful. You know for example, for um my prostate cancer rehabilitation, some of these what we're trying to can we build some of the strengths or maintained or improve content in his men? We do want to strengthen some of these muscles so that they can recreated, replace what was lost when the prostate was removed. So I think for the right man, they can be useful, but yet IT could be a dangerous tool and wrong hands.

And you mention that if people want to learn more about tovit floor therapy um they can contact their local error gist and find a good perfect floor good male pElvis floor specialist. Do they tend to specialized male, female?

They're usually pretty much gender technology s so they usually able to help. And forgive .

me for a asking for an a bridge anatomy lesson here, but um could you describe the pelvic four muscles and how they relate to the batter, prostate, uri thur penis and anemia you talked about before because I have the picture of the glad you read across the penis in my brain um I know um by a life experience where the test and screw them more relatives all of that but and now i'm trying to figure out um how like to the perfect floor a bunch of muscles that that are attached the pElvis but how do they interact with those? Uh with those organs .

yeah good questions. So they sit beneath, you know the sort of in the parameters of the area between the screw m in the inner and back beyond two. So they basically support all the structures there.

They support you know the base of the penis, the process dates, the batter, the reactor and you know, there they kind of keep me adequate tension to keep all those structures up. They relax when the different functions are necessary. They're very important for jaculation.

Some people think that they kind of trigger some of the orgasmic response as well. Um you sometimes men will have pain in that area, in the paranoid area, can transmit to other parts of the body like this scrotum. You know, one of the one cause of scrotal pain, and there can be many, can sometimes be politic ford, is function.

So I think, you know, again, has therapy can be useful for a sort of a conStellation of symptoms against the urinary symptoms as well. So I think for some patients, that can be helpful. But you again there, if you get things to tense back in something, be harmful.

So presumable, these public floor therapies also help people achieve a more relaxed public floor, if that's what they need. exactly. Got IT going to some of the questions that um came back to me when I solicit for questions and anticipation episode um several not a few let's say a couple dozen people asked about split urine stream.

Is that a signature of prostate overgrowth? Is that a your ritual issue is IT perfectly Normal? Um i'm assuming here they mean a split stream of urine that doesn't unify at any point. They're trying about a consistently split your dream. And for those who they don't know I am talking about, we're talking about a year in stream that's actually two year and streams.

And we're assuming one you rethrocide ens, because I hit the literature on this, there is a case of a failure to fully refused to that you retha ducked during development, where people, some assuming small of action of males, have you been thrown, opening on the base of the penis and at the tip of the penis? Let's rule that out, as I was possibility for now. But now there is on the table what percentage males have that two year through the openings.

So well, hype a bit is for sure describing where the the actual meatus is, not at the tip, but it's kind of along the proxy retha know even further down sometimes in the score on right about one percent of birth and usually it's recognized at birth and often times it's surgically correct because it's Better to repair early rather .

than later OK so ruling that out um what is the cause of split your dream and is IT a signature of a larger know one of .

the reasons that we know you and I sort of um from an evolutionary time point right, is to basically deposit sort of a convenient time, our wait. And we don't want to get IT everywhere because we don't want to sort of label ourselves with smell of yarn because I will be easier for predators to be able identify. So just similar to today, we'd like everything to get in the toilet without creating a mess.

So any time there, turbulent flow um turbine can sign in issue. So IT could be like retha issues are pointing out of cross theme issue, an adequate speed you know of getting year and altimeters. So definitely see you know a position to get up and because there's likely some issue that could be improved.

the the most popular question I received from males, however, was about perhaps no surprise, penis life. You're an expert in this actually not just because you're a ologies mail reproduction health expert, but um you publish a study recently on the changing trends in po live um tell us about that study. I have so many questions about um the methodology because um I have to assume the stint involve self .

report right those .

were excluded yes yeah so lying was excluded um being for serious here but um yeah how was this study done? I mean pretty incredible study um and the results are I don't know if they're surprising or not first I thought of this is surprising, but the results are only surprising in light of what you were tell you my earlier about sperm testoon of us, I think um i'll let you describe the study now rather than than giving people the punch line here.

Yeah so I mean the origin was that we were looking at, we wanted no average length for another project that we were doing and going down the rabbit hole. This has been reported for decades. There's different reasons that people have reported in.

Like you sometimes they do IT just on volunteers against sort of give the average length of different populations. Sometimes it's done creating program icons to try and understand what change is what occur. Um so we just want to call the literature found data on fifty five thousand men all over the world um and wanted to see if there is no sort of a time pattern with that.

And so where do your hypotheses we assumed based on all the other data that we would likely see decline, you know whether the chemical environmental exposure, but if nothing else before are getting bigger, you know the functional pipino length should decline because, you know, the super previous fat pad will get a little bit bigger. And so we kind of lose peano length with that. And so much to our surprise.

the super preview, excuse me, being pad a fat directly over the peanut.

right? And so know if that is bigger, that will necessarily compromise panel link. But you looked to, he found, is actually the opposite, that the penis order getting getting longer with time.

So how is measured? Measured differently. So one of our inclusion criteria was that all the studies had have measured sort of in an office, sort of in a clinical setting. So whether be a you know, a clinic or whether be a researcher that actually did that. So there's different ways you can measure penis.

You can just do a stretch line so you kind of stretch IT up as much as you can, and then use sort of A A ruler to measure how long IT is, again, from deep as you can get. You know, the two big bone ID up to the tip of the the company. okay.

I here's what he's describing. He's talking about measuring from the top, the bottle. Believe not that you will ask questions about this measures from the top, not from the bottom. No cheating. You stretching the penis wallet flash presumably. And then measure from essentially contact with the location that contact with the pupil bone to the the tip right? Okay, so that that length was recorded in fifty thousand men.

wow. yeah. So that was one. And then we also looked at direct line. And so there's different ways that in direction can be achieved sort of an a clinical setting. So one, as you can ask the man to stimulate himself and then measure, so that was some of the studies. And then the other method, so we have looked too earlier, as you can inject the man with the medicine to give an interaction and then measure IT.

And did fifty thousand men participate in that aspect of the study?

That was less? No, that was think that was about probably ten to fifteen thousand men.

I have to wonder whether not is easier, difficult for people to recruit subjects for these studies? I don't know. I could see you going both ways.

Yeah, some of the studies actually had a tremendous number had about um like fifteen thousand men. Some individual studies contributed to that. And actually interesting in after we published there were some men that volunteered for the next study to be Better.

I'm sure you'll hear from some of them after this episode what was the major finding? So the major finding .

we wanted to do is just give enormous data. We found that IT varied around the world based on different regions. Average length, you know very a little bit, but generally on average. Um erectness is private oe about five, six inches somewhere in that neighborhood that was grounded .

to take home me was the .

average the average for right?

Did you publish the full distribution?

Uh, we did nothing where our plane was actually to make a follow on study so we could show everybody, you know, I guess probably they were interested where they kind of fell on the graph but IT was barely .

was Normally distributed yeah we think that despite the know the wide capability of pornography that that the distributions like the scatter plots of all the data would be interesting to men um for the same reason that the test stone by function of age data publishes a scatter plot in the textbook refered too earlier we're interesting because um the scatter plot distributions, if you like, point to other other take away that one can be in their seventies and have testosterone levels equivalent to mall healthy male authorities.

That one can be in their thirties and have just a different levels that are twice as much as half as much as as age matched cohort, this kind of thing. Think there there is value in that. So um what what other takeaway I arrived with the data from the the the life study that perhaps we didn't we didn't hear about like what what did you find most interesting about about the data?

Well, that there was any change over time is the study was right about thirty years or so, but we did find that the line has been increasing over time. So um you know that was a sort of fascine that we would see sort of in such a short and ervy of time that there would be a change number one, but that would see a lengthening number two.

So again, similar to the concerns that arose for these products will be short period of time where you see changes in cement quality. You know it's just something sensor, right? It's unlikely to be a genetic change because that would take no centuries, probably a certainly several generations of the fact that this happened so quickly was .

just surprising um this brings mind some of work that I was involved in years ago um when I was a master student I studied early organizing effects of cormon's on the brain and body and i'm sure this has been updated um since then but my recollection is that during embry onic development males are exposed to a certain amount of die hydro testosterone on not testoon but die ida testoon, which organizes the brain mae, as they used to say.

Now the verbs round that would probably be a little bit different, but the ideas that males are born without issue, of course, but then it's during puberty that the same hormone dyne drot stone then exerts an activating effects on the genitals. And the genitals grow during puberty. Venus lamp increases. So assuming that the study that you did was on males post puberty, assume IT was then I would imply that sometimes is changing about the levels or the signaling. Related to dhada test astra.

How could that happen? Um do we have any ideas about what might be happening? I mean is the opposite of environmental underground disrupters preventing sperm from being is know high quality and numerous as they could be or environmental factors either in utero or post um suppressing testosterone levels who were turning about the opposite effect. We were turning by die hydro testosterone level presumedly being higher in males over the last thirty years and thereby longer penises, right? So I mean.

I think there's different conductors that you can make about why this could and I mean, could be you maybe understand disrupting chemicals, you know, in utero some early exposure, you know that some of the mothers had to kind of androgens effects during the male programing window that may have had to some longer length.

Another hypotheses we had is that if if males are going through puberty earlier, the earlier one goes through puberty, the longer length tends to be. So maybe that provides sort of this link. So earlier .

puberty tends to be longer, potentially means longer duration exposure to the hda dist, astro, longer penises, right? Yeah, you may be surprised to know, you might not be surprised to know that there is a, uh, subculture online. I know because they contacted me in anticipation of this episode of post puerto males who take a combination of die harder to and low levels of growth hormones in efforts to trying to increase the piano life and the um once taking die hirer to offer and they are not taking pure day see there taking things like oxana alone um which very closely moment the structure of dh um they report um some success um fortunately they did not send me pictures otherwise what is just forded them to you for your next study but this stuff is happening imposed pipal mail. So IT all rests on this diagraph nostro hypothesis just a point of interest yeah I don't know what is busy logically doesn't .

make sense why that would work as you're pointing up close to vertu. And then unless they are doing other things, you some sort of stretching exercises are joking. But yeah, I would not recommend that.

Thank you. That was the response I was looking for. So um that community will be listening with open ears. Don't do IT as long we're talking about dht that had had to stop um it's only fair to discuss the drugs that many people take to suppress the harder testosterone in hopes to keep or grow their hair things like fan aste ode due to asteroid.

Um some maybe many not all people who take these drugs, particularly in oral form experience, sexual dis function issues and other issues relate to suppressing the ht. That said, my understanding is that these drugs are also quite useful, maybe in lifesaving in some cases for staving off certain forms of prostate cancer. What are your thoughts about fancy taste? I do you see people coming into your clinic who are having sexual diffunce or other types of issues because of their hair, or attempt to maintain or grow their hair issues? And equally important is that we talk about so called post panax rode syndrome. I got a lot of questions about post for us at sym um because i'll described in a couple of minutes um IT sounds predefined stating for these people's lives and i'll explain in wide so devastating for them um in a moment but yeah what about phanatic stride you task ride in these drugs that are effectively dht blockers um D H T levels if they get to hide, indeed can mense the hair follow, cause people lose their hair typically up front in the back so called crown or whatever you know windows peak uh uh or everywhere in some cases but also uses her growth on the back beard growth as we understand but then people go and take these drugs to try and maintain to grow their hair and often times they have direct all this function or other issues is that surprising to you?

You know I think the men that we see these um these side effects are tend to be you know Younger men and there are twenty thirties and forties and theyd take that as your pointing out for hair loss. So before was fd approved for that indication, at least financial? I was you know they did retire ze control trials to look um and one of the other things that we will talk about two is just reproductive effects.

So they did know lots of studies to see if there were changes in semon quality for men on panax ride versus the playbill, and there were some very subbed changes. But you know what of in push marketing. Now we see these patients in clinic, um you know everybody to enroll.

These studies had Normal functioning. So I think that have important to understand. And obviously, that's not life, right? The people come in with sort of different baseline ines and different amounts of reserve.

And so we now know that there's probably people there are a lot more sensitive to these medications and others. And so there are some men that droppers from counts dramatically. And usually if we we stop these medications from test recovery and usually for mateo ic cycles product about two to three months.

So usually in may be three to six months, we usually see recovery for most men um but similarly for sexual function, I certainly you have a number of patients you know that do the plane of low label rect out function, this postman asteria syndrome um know in the mechanisms I think they are less certain because you know measuring test auction levels, which we do. You know sometimes if handrosan are low, or even if hander's seem to be in maybe Normal range or low Normal range, will try and increase testosterone through a variety of means. Testosterone combine, sometimes will give, that helps some men, but not all. So I think the exact mechanism of what is going on here, what is changing, I think you know we need more you more understanding about the exact for the path of physiology. No, are newer chemically IT seems like .

a prety serious trade off, either maintain a grow hair or loose sexual function. I mean, talk about dht and some of these side effects of financial tax ride on previous episodes. And i'm not a clinician, but my encouragement is always for people to approaches these drugs with the with a real level of seriousness, if not caution.

The postpone asteroid syndrome was described in these online questions as seemingly permanent even though um people had ceased to take fanatic o or do tax. So in other words, they were taking the stuff they I don't know how they felt while they were on IT, but they stop taking IT and the sexual this function issues um don't seem to be resolving. Does that mean they should go see uh you or another uh male urologist, reproductive health specialist you I mean opening .

times they do for you know these complaints um you know they started to notice that they're on the medication then when they usually throw online research, kind of learn about this potential. Hannity, sometimes they discontinue.

Now some men, do you have resolution when they stop? But there is this permanent in some handful of men know they've done MRI imaging to try and understand sort of morning atomically are functionally what exactly is going on. I think there's so a lot of them unknowns about this, but IT can be permanent persume. So they come in, you know, when they see me in clinic, erect about this function, low the video, and then we go down hobo. The host of treatments that we talked about, violations we talked about, again, we have resolution in some, but there are some that seem treatment .

of factory ex. That's my only response. I mean, permanent effects on sexual health in the as a consequence of an attempt to maintain ones hair.

I mean, this is where you in all serious and IT just sounds like something that people need to think very seriously about because I understand there's nothing that can predict whether not someone will have postpone astro's syndrome, right? And I did a bit of reading on this um within the scientific journals as well. There isn't to a lot of information, as you point out, because it's a fairly recent phenomenon that highlights different.

This may be the first time in history where Young males are taking fan stride and do tax ride and that might be the cause of the postpone astaroth syndrome right? I think you looted to this earlier, right? These drugs have proven to be very beneficial for older men treating prostate issues, right? So this is a postmaster syndrome um I think falls under the category of medical conditions that um you know few years ago we would hear the same about chronic fatigue and syndrome even fibre mielgo a not long ago was considered one of these always at all psychosis tic issue now we we now clearly know that's not the case for fiber.

My ulch by the way um but I can recall a time not that long go when people um in the medical profession I like yeah I don't know this is a real thing, but post by synergy, certainly real for the people they are suffering from IT okay. Well, the reason i'm spending so much time on this is that I get a lot of questions about IT and there are clearly a lot of Young males who take for strider do task rider or thinking of doing that um for cosmetic reasons and I think they should be aware of the potentially serious consequences. But you did say earlier that if someone has a penis, you can get IT hard.

So, so all is not last even for these post. Very good. Okay, so you mentioned clamored ine. Could you explain what lamh in is and what is used for? Because, again, we want this discussion to be centered around the real science, the real medicine but there is a growing kind of sub community of people out there who are saying, okay, stone therapy can cause us this firm suppressive issues and perhaps some other issues um but doing nothing might not be an option for somebody who wants to increase their whatever libido, other aspects of energy gen function um and so there are a growing number of people out there who are taking colum hine only in order to presumed ly increase to stop.

But minor sharing is that I would impact the estrogen pathway as well yeah what's coffin? What do you thought about people using commodity sof off label simply to freece androgen? Yes, sketchy to me for reasons related to changes in neural circuits um but you'll tell us how IT works. yes. Well thank you .

for including the off law disclose or anytime I talk about this, I have to say, say that. But if so, clumsy is a slack to exchange receptor modulator, so basically blocks estrogen. And so from our earlier discussions of how the two eti works, you know, there's sort of an elaborate feedback loop between the petite I and the gown ads and man the tests.

And so what happens is, F, H L, these going out of troops stimulate tesco to make experiment, test, astro test, aston's perfectly converted to extradition, and that feeds back on the hypothenuse to stop that. So again, you don't get an overproduction. So by blocking the S R general sector, the level, the two atrio of the hypothalamus, it'll stop that.

And so the idea behind blocking that is that you'll get more production of F S H L lakes, more of these drivers. So you get more testosterone, you get the highest stimulation of the tesla. You know, the hope is that for fertility that sometimes that can improve firm production too, and there's some limited data that can help.

But I think is you're alluding to its sort of a way to just August, your body's own production of test astros. So IT certainly does that. I think there is no question that test option levels do rise.

I think that the reason that doesn't always help us because not every problem is solved by test astro. We can talk about someone in this discussion, but also that you do need some estrogens signals as well. And so by blocking that, even partially because there also partial high against effects of column as well, IT may limit IT.

Um and you IT turns out that extra cy is important for a lot of things, is important for bone health. But sexual health too is important for libido. So that may be partially blunting some of the hope for benefits of testoon.

I found that meant tend to be happier on test astra and some of these other forms and that could be a possible explanation. But one of the advantage of columbus y, if we are thinking about this, is a treatment for a low test, astern and harrigan addison m, is that IT doesn't have the same toxic effects on spin production. So by maintaining the body's own production of testosterone, by maintaining production of F S H L, will continue against m production. So for of the reproductive aged man that has low test stone and symptomatic low testosterone, low energy levels, sextra mood, sleep problems, IT can be a worthwhile treatment. And IT IT does help a lot of men um but not everybody.

I've always been curious why if the goal is to increase firm production that the most common treatment is hcg human corean ic and out of open because as you mentioned earlier, luti zing hormones and fa a focal stimulation ormond are deployed from the petitionary in trial to the testis, where they stimulate to stop strom production and spring production. But is the F S H specifically that encourages spring production? So why wouldn't a man who's taking maybe astern therapy, or who perhaps just wants increased sperm counting quality take F S H instead of human korean ic attrition, which is more or less of proxy for luti zing hormones?

That's a really good question. And so what F S H does, like he said, is similar spin production. So that seems like to be a much more logical treatment and actually, and realize we will see you more control trials.

IT doesn't do that. So one of the ways not IT does do that IT does help OK. So it's beneficial and we we should give IT more.

But one of the reasons that we don't is cost. So it's rarely covered by insurance and H C. G. A month of that is in one hundred of dollars. So let's say like three to five hundred dollars, but a month of sort of therapeutic c eastry is probably two to three thousand dollars. So that costs is really limiting.

IT takes two to three months to make a sperm so um you know men often have to be would have to be honor for several months, but there is reasonable data that would help and IT does make you know a lot more sense that that should be given as a edge of an therapy with test doesn rather than A G G um but hd does work. You know, if everyone's surprise, that does actually help. But yeah, I agree there is sort of a contradiction there. So if the Price came down, IT doesn't know this is another hot label medication um for that indication um IT would be IT could be worthwhile.

One hormone that we haven't discussed is proactive. I'm familiar with proactive from a variety of perspective, but I always think of a dopamine and proactive is kind of A C saw relationship. Dopamine production is down, you know me elevated with sexual desire, actual activity, project lation proactive goes up, that perhaps the refractory period on erection, ejaculation, for some period time, the document in comes back up, but not this kind of thing. And I realized that far too simplistic, that production, doing many things in the brain body besides that but how often do you see hyper pro acting umea I don't plural pretty me as is clinically correct but elevated levels of production that are causing problems um for men um what total signs of that um and this i'd like to use as a safe way to talking about some of the sexual this function that is commonly discussed around the use of sr s and other other drugs to treat depression in and mental health issues that sometimes create an end or sexual health issues.

Yeah so collecting um is sometimes it's a diagnosis I flexing is a diagnosis making up that many times, I would say you know less than one percent of the patients that we see we're into having that. But usually it's a handful at times a year because we see a lot of patients. Typically the the tail tales word of symptoms would be ones of low test ostrom.

That's a common one. But in my product, as I see, IT a lot with no very low sperm production. So I have died with several producing screen tumors.

And the main of the station of hours, they weren't getting pregnant. We check the firm count is very low, you know, that Mandates to check of test osment, which is also very low. And then that leads to a pact and which is very high.

And then that, that was diagnosed. So it's something I think to be aware of, but I don't know that there's not usually a lot of systems and really going into a clinical when you're having sexual disfunction symptoms, low testosterone or fertility problems will usually you be able to diagnose. Ce, if it's present.

are there any other hormones in the in the galaxy of sexual health related hormones that fall into you? Common clinical practice for you? I check X, R.

gen as well. So I think that's another one. Again, because of the relationship with obesity, I think that can be important.

Sometimes there's too much roommate's ation, and so sometimes that can be a problem. I think just like we talked about, Normal as and d is important. I think too much can be bad.

So there are some men who will you see? Manifestations that can manifest is gannan communicate some cases. Mail best issue. Mail best issue.

as I was um told um what was that that the male breast issue is sort of like um the appendix is there, but it's not very interesting.

Yeah everybody has some and we just don't want the growth to get a control.

Could you tell us about one of the world's most difficult to pronounce words, which is very cascio? Yes.

so very casual. It's a very common condition, right? About fifteen percent of all men habit.

And it's a very common cause of infertility. You look at all the ideologies that can be thirty to forty percent. So basically, winter is the dillaway veins on the scrotum.

So obviously we need veins to get blood out of testicles les, but sometimes there can be a little larger than average. And there is sort of a Normal part of feral regulations of the veins get too big and thought to warm up the test. The other thought is that IT doesn't edicated clear some of the metabolites. Um so exactly the pathy sio logic, you know somewhat debated, but I think those probably contribute and it's something that everybody should be evaluated for after your concern of our fertility. So again, we see IT very commonly, you know, given the fact a lot of inhabit about one in seven habit doesn't always cause a problem, but maybe about twenty to twenty five percent of the time that does.

So men or man of us with low sperm counts, we see sometimes is discomfort, you know he know worth the end of the day than the beginning worth of the activity anytime blood can pool and that stretches and some feel that and then in kids sometimes they can lead to um either stunted testis growth through shrinkage of the testicle. It's also thought to be a progressive reasons that the longer man has IT, the more damage you can do. You usually man of us around puberty in general. So it's not a concern for everybody, but I think certainly of couples are having difficult to conceiving. You're having discomfort in the area and you have wanted the discussion .

you should have about payoneer disease. Yes.

the payroll is a scaring of the piano, which leads to curvature or deformity. So the way actions work is everything swells. And you can imagine that there's a scar tissue e IT doesn't swell symmetrically.

So get like a creature deviation. Sometimes you can get our gas sort of banding. You look IT up on the internet.

You can see, you know, a host of different information that men yet IT. I present about five, ten percent of men. So it's very common. Sometimes you could be from hinders y you from, you know, like a pean fracture, other sort of less severe form of injury to the pean's times men have described hit IT on different things potentially that could lead to IT.

And sometimes they can manifest after a prostate cancer surgery or other kind of surgery, which can know has done the penis or interest some of the nerves of the penis. So that's another condition we see commonly. You obviously, I can lead to bother, you know, and directions are not straight.

I can just, you know, because a psychologic bothered and men, you can also physically make IT difficult for a man to have sex. Sometimes you can limit certain positions. That's another common complaint. We see, I think, that something that men should be aware of. There's now awareness campaigns.

Now there's an have approved medicine for IT collagen or side flex, which is a medicine dissolved scar tissue um so that's one of the treatments we have for is also you know different devices or are stretching devices. Are we trying to mechanically remodel the piano to allow IT to be a little bit stricter? And then there's also surgical options, too.

So there's a lot we can do. I always tell me again something to us. We can make IT. We can make IT hard, but we can also make .

a straight i'm wondering why in the study about penis life, a testicular size in volume wasn't also measured and and that's something that we haven't discussed. Um what is the relationship between testicular size and volume um and some of the other parameters we've been talking about. And maybe this is also a good time to highlight um any kind of morphine gc signals that would warrant people coming to the clinic. So a simec and testicle size, for instance, changes and testicular size um obviously A P size lump they taught us in high schools. A warning sign of potential testicular tumor cancer um yeah we didn't really talk about testicles yeah .

so I think that kind of being aware you know the average size of um a testicle for a man is about what about a one a it's about sixteen to twenty cc. You use if you're going to measure IT to be about four four and a half centimeters. And longest access to give you know your listeners or viewers at some idea if that changes is certainly let people know if you feel anything, let people know.

Although our national guidelines on screening practices recommends against regular testicular self examined dingily, because I think the concern is that IT leads to more anxiety than cancers that I would diagnose. But I think you always tell me that no one knows just grown Better than news. If you identify problem, you should bring IT to attention. So you know, the classic appearance, or the way that test as cancer manifests a firm paintless mass that you kind of feel coming from the tesco find an that.

at least as I understand, women are encouraged to do regular self exams of their best for lums. So but you're telling me that man are actually discourage from doing regular exams of their testicles. S for lums like coffee cancer and feels like a unfair a symmetry. Does I mean cancer? I mean both both seem very important.

Oh yeah, think there's .

no question .

yeah want to get .

caner. I mean I so um I don't want a dog to get cancer. Um so i'm surprised that they discourage self exam. Um but is that because men are getting IT wrong, they're coming into the clinic thinking they have testicular cancer and then most of the time they don't.

I think that's the concern that you know the number of cancers that are diagnosed versus the false you um the false you know lumps to be identified just lead to more anxiety and I have not actually causing more harm than good I think is the concern. But yeah, there was a surprising recommendation when I came down using your patients ask about that. I certainly don't discourage them from doing these exams and I have we've certainly identify cancer through that means.

Before I saw the episode E R, where the guy was having trouble breathing when he was an elite runner, and IT turned out he had testicular cancer and he had overlooked a lump on his test. So I mean, continued to self screen very up.

Numerous times today.

we've talked about the potential benefit of getting a blood test for hormonal profiles, lipid profiles and other things as well as a super analysis. My understanding is that one can only do that if they have the disposable income to elect to do that through some commercial online service. Um but is there any way that um patients who have insurance can approach their physician in a way that this would be covered by insurance? Um I don't want to get to you in danny trouble here, but you know it's it's always such a shame IT is such a shame when we're talking about something that is really pervasively related to health as a sexual health, reproductive health.

And people are not aware of a potential problem in the presenter in the future that could have been mitigated simply because they didn't get a blood test or do something as simple as a spr analysis um so we can be presumed ous and saying, oh you know two hundred dollars or a thousand dollars no big deal. I me for that a huge deal. It's prohibitive um for many people.

So how can people get this stuff assessed? Um should they talk to their primary care physician? Should they call urologist? What's the best approach?

I think both are good strategies. I think you know insurance is becoming a lot more open to covering some, in particular at least testing sometimes treatment IT as well. So I think a lot of insurance does covered that.

Now yes, sometimes we cheat season analysis for other jacket tory issues. But I think that again, as more of this data gets out, I think there's more recognition how important the mail is. I think we'll get sort of more buying.

And covert jc women have know the automatic feedback of arbiters cycle, so they kind of know there is a problem. They can bring that to the attention. But men don't have that feedback without some of these testing.

We probably should have mention this earlier. So forgive me, this was on me to mention that when we talk about sperm quality and we sort of shifting back and forth to semon quality is possible to have Normal seamon volume and have very low sperm count, right? We're not talking about the total amount of ejaculate pursue.

We're talking about the density of ford motor. Healthy non DNA fragment is firm in that seam, right? So in other words, it's not sufficient to just um assume because you can eacus late that your sparing healthy.

That's exactly right. yeah. I mean, I think you know about fifteen percent of men have low season quality where there be concentration, movement, shape, one percent of them have no space in the adjacent and that something sometimes they have no idea about. So the only way that no would you'd actually do a formal test.

But i'm encouraging people to get these parameters assessed and making that statement because it's very clear based on everything that you've told us today, that sperm quality and hormonal levels are just also important not just for sexual health, but for urinary health and for reflecting prostate health and other aspects of whole body health. And and sexy health relates directly to mental health, right? We didn't talk so much about the psychogenic issues but um the two real hand in hand exam I wanted. Thank you so much for coming here today and sharing so much knowledge with us.

I mean these really are the issues that um males think about and wonder about and um have questions about um and they do so to varying degrees depending on whether at in life um but I think especially for Younger men who are hearing this who are not at the point where they want to conceive um it's really important to start thinking about these issues for all the all the reasons you mentioned. I think these issues are really important um for women to know about as well just as it's important for men understand female reproductive health and to not just to improve communication but this after all is at the heart of the present and proliferation of our species so thanks we're taking care of the male half and um and thanks for doing the work you do. It's incredible. Um the large scale studies the the more detail the studies the on smaller populations the you asked the questions that IT seems um uh many people are just afraid to ask and and you get ready in there and and come out with the the really rigorous data and the answer. So thank you so much for what you do.

I'm please sure. Thank you. Thank you for highlighting .

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