Why Is Male Fertility Crashing Globally? - Dr Michael Eisenberg

1. 0:00 – 7:11

   Why The Global Sperm Count Is Declining

   1. CWChris Williamson0:00

      Global sperm counts have declined by over 50% in the last 40 years. Is that true?

   2. MEDr Michael Eisenberg0:07

      (laughs) You know, it really is. I think, you know, in the last few years, there's been a lot of consensus around that. Uh, you know, one of the most famous studies that looked at this was published in the '90s, um, and, you know, when it was released, I've talked to some of the authors about it, there was a lot of fanfare around it. You know, they had it in a big, um, media hall. There were television cameras. Uh, but since then, there was a lot of controversy around it, um, you know, for a few reasons. You know, there is... You know, there are differences in semen quality around the world, like for example, there's a study in the United States that showed that, if you can believe it, sperm quality is higher in New York than in the Midwest. And I think reasons for that are not certain, you know, whether it's lifestyle, you know, activity levels. There may be differences in, you know, just sort of race/ethnicity composition. I think the reasons are not known, but, you know, in the US we see that, but around the world we see that too, and so there were some concerns about how all that was incorporated into some of these studies. Um, you can imagine over 40 years some of the methodology for testing sperm has probably improved a little bit. And even our, you know, statistical methodologies compu- computational abilities have improved. So, you know, initially in the '90s, I think it was somewhat controversial. Even some of my mentors questioned this. But I would say over the last, you know, few years, there's another study in 2017 and even 2023 most recently, and it's really kind of solidified, and now there's consensus in the field that we're seeing this decline. You know, over the last 50 years, maybe it's called about 1%, so maybe about one million less sperm per year on average every year. But over the last, you know, 10, 20 years, it's accelerated actually about 2%, uh, decline. And so, I think it's... You know, now that there's a little more, um, you know, again sort of consensus around it, I think it's really up to us to understand why, 'cause, um, yeah, it's not- not a good thing. Existential, I think, in a lot of ways.

   3. CWChris Williamson1:50

      Okay. Why do we think that this is happening, uh, beyond the ability to detect statistical improvements physically? What- what- what's happening?

   4. MEDr Michael Eisenberg1:59

      Yeah. I mean, I think that's the million-dollar question, or billion or trillion-dollar question really. Um, I think there could be a few reasons. You know, the pace of change is probably too quick for evolution. I don't think it's a genetic factor, you know, so I think people have really honed in on exposures, you know, whether it's, you know, lifestyle factors. I mean, I think that, you know, we're probably a little less sedentary than we used to be. You know, obesity was going up, although maybe with some of the new medications, we'll see a reversal of that trend. But I think there's a lot of concern about just some of our exposures, you know, some of the chemicals in the environment, microplastics, I think those sorts of things. You know, there're some endocrine-disrupting factors that are at play here that- that may be the culprits, but I think, you know, we need to really do more work to try and understand it, um, and I think that's kind of where we are.

   5. CWChris Williamson2:43

      So you at the forefront of this have a broad perspective that stuff's not great, numbers are going in the wrong direction. We kind of have an idea of what's going on, but actually finding an individual target or a couple of targets that we could intervene with, uh, it sounds like a pretty complex problem to try and solve.

   6. MEDr Michael Eisenberg3:00

      Yeah. I think that's fair to say. I mean, I think there's... You know, there's things that we talk to patients about, I think just sort of broadly when they come into the clinic. You know, obviously, you know, if patients come to see me for fertility, they wanna figure out how to get better sperm counts, right? And I think that's ultimately what- what our goals are. Um, so I think, you know, lifestyle, you know, health, I think all those things are gonna come at play. I always tell men, "Anything that's good for your heart is good for fertility." So we talk about diet, exercise, maintaining good body weight. So, you know, I think things that you can do, um, you know, like whole grains, fruits, vegetables, I think those are important. You know, try and spend more time, you know, walking around and, you know, less time on the couch. I think those are sort of easy, actionable things. I mean, I think to the extent possible, try and limit exposures. You know, I think we've gotten a lot more awareness of, you know, some of the harms of, like, plastics, so trying to minimize, like, plastic water bottle exposures. You know, but I don't want to be alarmist or scare people. I think, um, you know, it can very easily increase anxiety, which also isn't good for sperm production.

   7. CWChris Williamson3:55

      Uh, right. Yeah.

   8. MEDr Michael Eisenberg3:56

      Yeah.

   9. CWChris Williamson3:56

      A vicious- a vicious cycle where worrying about your sperm production reduces your sperm production.

   10. MEDr Michael Eisenberg4:00

       (laughs) That's exactly right. Yeah.

   11. CWChris Williamson4:02

       What are the... You mentioned exposures-

   12. MEDr Michael Eisenberg4:05

       Mm-hmm.

   13. CWChris Williamson4:06

       ... uh, mic- microplastics being one of them.

   14. MEDr Michael Eisenberg4:08

       Yeah.

   15. CWChris Williamson4:08

       I saw this study, microplastics found in dog testes and all donor testes from men.

   16. MEDr Michael Eisenberg4:16

       Yeah.

   17. CWChris Williamson4:18

       What's- what's the likelihood that this is having an impact on fertility?

   18. MEDr Michael Eisenberg4:22

       Yeah. I mean, I think, you know, that was a really interesting study from New Mexico. They looked at, you know, dog testicles, uh, that were taken at the time of neutering, and then they looked at testicles from men, you know, that were taken, like, from autopsy. Um, and it was interesting, all of them actually had, uh, microplastics within. So, you know, it's very ubiquitous exposure. Again, we get it from just the environment, and talked to experts in the field, probably in our food supply. So it is difficult, um, to the extent possible, to eliminate it. Um, but, you know, the... I guess it's a question of, you know, what it's doing. And, you know, ma-... Plastics are thought to be somewhat inert, so maybe it's doing nothing, but there also... You know, there's lots of other chemicals that are usually at play that have endocrine-disrupting, um, you know, properties, have... Some of them are carcinogens. So, you know, the... I think the studies that we have that look at function of this I think are- are concerning. So, you know, they don't have s- ... you know, semen quality on the dogs, unfortunately, or the people, but, you know, there's sort of a rough approximation. So in the dogs, they saw the larger testicles had m-... had higher levels than, uh... or sorry, had lower levels than smaller testicles. And so, we do see this sort of... Most of the size of the testicle is devoted to sperm production, so larger testicles usually, you know, make more sperm. And so, if we're seeing that, you know, those have less ex- ... you know, less microplastics, maybe there is some functional consequence to that. And, you know, there have been some add-on studies where they've looked at, you know, s- semen samples and actually did show correlations between higher levels of microplastics and lower semen quality, like counts, movement, shape. So I think, you know, again, all these are- are- are concerning elements, uh, to the story.

   19. CWChris Williamson5:58

       Right. What other exposures should people be worried about?

   20. MEDr Michael Eisenberg6:03

       Well, I think, you know, the things that you can, you know, sort of think about are some food exposures, so I think trying to limit, like, pesticide exposures. So, you know, again, the... I think data around organic, um, produce is not great, but I think there... you know, there is some, you know, pretty good evidence. So if... To the extent possible, trying to eat organic. I mean, there are some foods or fruits and vegetables that tend to have higher pesticide exposures than others, so... You know, like foods where you eat, like, the peel, like, um, strawberries are notorious for having very high pesticide levels just 'cause... You know, we eat the whole thing. There's all these nooks and crannies, so it's hid- hard to adequately wash them. Although I love, I love strawberries, um, so does my family, but, you know, you try and get organic when you can. Um, and then sort of being, you know, more sort of aware of some of the other chemicals that we talked about, like phthalates, you know, different, uh, phenols as well. Um, so, you know, looking at packaging. I think, you know, for, like, skincare product for, um, you know, sun- you know, sunscreen, I think, you know, there's organic types that do have some endocrine-disrupting properties compared to m- mineral sunscreens who are thought to be potentially safer, so I... You know, when possible try and switch to those as well. I think that also makes

2. 7:11 – 18:24

   How Is Sperm Count Measured?

   1. MEDr Michael Eisenberg7:11

      sense.

   2. CWChris Williamson7:12

      Right. Okay, getting back to the question at hand, the problem of sperm count, what do people mean when they're talking about sperm count? The total volume of sperm are we talking about? I know that there's a lot of different contributing constituting facts when it comes to sperm health, male fertility, uh... What, what are people talking about?

   3. MEDr Michael Eisenberg7:31

      Yeah. This is a great question, sort of fundamental. So, you know, what are we measuring? What's... What is a semen analysis? So there's a few things that we do, you know. Just logistically, we ask men to collect and then we let it liquefy, so it comes out, you know, somewhat viscous and then after a few minutes, it'll liquefy and then we can measure it. So we measure how much there is, the volume, you know, that's an important measure. We also measure the concentration, so how many million sperm per milliliter. Um, we look at the motility, you know, how many are moving around, and then we look at the shape as well or call the morphology. You know, there are some other tests as well. You can look at sort of evidence of oxidative damage in the sperm. You could look at something called DNA fragmentation, which looks at, as the name implies, damage within DNA. So, you know, we look at all that. Now, when we're talking about declining sperm counts, it really is the count, so they look at, you know, the concentration, how many million sperm are in each drop of sperm, and then also just look at the total sort of number of sperm, kind of the payload and how that's changed over time. You know, we haven't looked at some of the other parameters because those, uh, you know, have been, you know, kind of a moving target to some extent, you know, morphology, the shape. I think we've, you know, advanced a little of what we think sperm are supposed to look like, so that's sort of hard to measure and then, you know, the way that we measure sperm movement has also changed over time, so that's also been a little bit more challenging to measure over time. So when we talk about declining, you know, fertility, really, we're talking about the counts.

   4. CWChris Williamson8:50

      Right. What... Is there a triage list of priority here in terms of all of the different contributing factors? Wh- what's most important when it comes to assessing male fertility and sperm quality?

   5. MEDr Michael Eisenberg9:03

      Well, you know, usually I think the count is probably the most important. That's usually how we talk to patients about it, or at least, you know, the number of moving sperm. Um, you know, we talk... You know, sort of on: on average, you know, men have probably about 50 to 100 million moving sperm, um, and, you know, for couples trying on their own, you probably want at least 20 to 40 million moving sperm. Now, when you get lower, then you need to su- start thinking about some assistance, you know, to get pregnant. So, you know, if you have like, you know, less than... again, less than kind of the 20 million, five to 20 million, there's something called intrauterine insemination where you can take sperm, put it inside female partner's uterus when she's ovulating or with just a few dozen sperm, you can do in vitro fertilization where you mix sperm and eggs together in a dish. So, you know, ultimately for men I always say it is somewhat of a numbers game. Although it's interesting when you look at it, it's not a perfect measure of fertility. So, you know, if you look at men with, you know, hu- hundreds of millions of sperm, some of them won't get pregnant, and then when you look at men with just a few sperm, you know, like a million sperm or two million sperm, some of them are able to get pregnant without difficulty. So, you know, it's- it's a complex problem. I think also, you know, fertility is ultimately a team sport, so I think, you know, what the female partner brings to the table is also going to be very important to some of this, um, but it does give us just sort of an overall assessment of, you know, likelihood of having issues or not.

   6. CWChris Williamson10:17

      Right. Okay. W- what are the biggest determining factors that influence a man- a man's sperm quality then?

   7. MEDr Michael Eisenberg10:25

      Well, I think genetics play a big role. I think, you know, you're kind of born with, you know, some potential as well. You know, I think one thing that, um, is really interesting that we've come to understand over the last maybe 10, 15 years is how important health is with fertility. I think, you know, this link between, uh, semen quality and health is just so, um, so tight. It's really interesting. If you look at men that are less healthy, their sperm quality is lower too. So men with like hypertension, high blood pressure, you know, diabetes, high cholesterol, all those are definitely correlated with semen quality and it goes down. Men that are more obese, you know, overweight, we do see also lower levels of semen quality with that too. Um, and al-... You know, men that are on different medications, we see some of those can have an effect as well. Um, and then what's also interesting is that semen quality is actually correlated with later health too. Um, so men with lower semen quality have higher risk of problems later in life. So for example, if you have lower semen quality, slightly higher risk of testis cancer. Um, and maybe that makes sense, you know, because the testicles make sperm and if they're not doing that well, maybe there's other problems too and it leads to a higher chance of cancer. But it's not just testis cancer. Um, you know, another male cancer like prostate cancer, we do see those correlations as well with lower semen quality, higher risk of prostate cancer later in life. Uh, higher risk of heart disease surprisingly, higher risk of diabetes for men with lower semen quality. So these are men that have... you know, that are normal when they come to see us and then if you follow them years later, you know, the ones with lower semen quality have a higher risk of developing diabetes. And it's actually sort of a dose response, so the lower the semen quality, the higher that risk is.

   8. CWChris Williamson12:02

      Mm.

   9. MEDr Michael Eisenberg12:02

      You know what's fascinating is even...... mortality, even death is correlated with it. So there is a study published, uh, I think a few months ago actually, uh, in Denmark where they have this sort of large cohort of over 50,000 men with semen data and followed them for decades. And, you know, if these men had lower semen quality, you could me- you could predict their death 40, up to 40 years later. You know, so men with a little better semen quality tended to live... Now this is not decades longer, but they lived, you know, three to five years longer than men with poorer semen quality. So it's really a biomarker. One of the talks that I give, you know, on this topic is called The Sixth Vital Sign: What Our Sperm Is Trying to Tell Us, uh, because I think it is really... You know, it's-it's a measure of how we're doing. I think, you know, it talks about genetic fitness, but also just, you know, overall health, where we are at that point in time.

   10. CWChris Williamson12:49

       Is it strange to have patients come in who seem to have their health in order and have low sperm quality and then that be predictive of mortality? It sounds like there's something outside of... Well, I guess this could maybe be the genetic factors, uh, rearing their head through sperm quality. Uh, but other than that, if outwardly all of their health markers are in line, but sperm quality isn't, but it's predictive of mortality, you think, "Well, there's- there's something going on here."

   11. MEDr Michael Eisenberg13:19

       Yeah. I mean, that- I- that's a great- it's a great question, right? 'Cause a lot of guys come in and they look, you know, they look perfect, right? I mean, I think, you know, it takes a lot to get a man into the doctor, and so usually they only come in if, you know, really if they're bleeding or if there's some other crisis. So, you know, when they come in, there's a problem with fertility, right? And otherwise they look, you know, the picture of health. And I think that's really the question of what this is telling us. Um, you know, they may have some underlying, you know, conditions. Some of them have never seen a doctor before, so maybe they do have undiagnosed blood pressure problems or something. Um, but others, you know, again they're- we do an extensive evaluation, there's nothing that we can necessarily find. And so I think it's really, um... Th- and that may kind of tell us more about just sort of just overall how they're doing. Now, you know, my- (clears throat) my sister always tells me, you know, "You're kind of being alarmist about some of this. You don't want to kick a man while he's down."

   12. CWChris Williamson14:07

       Hm.

   13. MEDr Michael Eisenberg14:07

       So I think just to say that this is sort of a relative risk versus absolute risk kind of thing, I think the risk goes up, you know, a little, but overall most of these men are gonna do fine, so it's like buying two lottery tickets instead of one. If you buy two, your chance of winning doubles, but still an unlikely event. So again, most of these guys are great, but I think there's a- sort of an opportunity here, you know, if we can sort of tell them about some of this, or just help them sort of recapture and get more ownership of their health, hopefully they can do better, um, you know, kind of moving forward. Hopefully they'll be able to, you know, change some things. I think we all can do a little better with exercise, with diets, just with lifestyle, you know, if they're smoking, stop, you know, moderate drinking, things like that. I think hopefully that can just change trajectory a little bit and put them on the path to better reproductive health, which is why they came to see me, but then hopefully overall health as well.

   14. CWChris Williamson14:54

       What are the first places that you look at when a man comes in, low sperm quality? What- what are the things that you assess?

   15. MEDr Michael Eisenberg15:02

       So it's pretty comprehensive. You know, we wanna talk about, you know, the reproductive history, make sure they're doing everything correctly, think about every... We take some things for granted, but wanna make sure they know, you know, all the machinery and the anatomy. Um, and then we do a comprehensive look at, you know, prior exposures, their health history to see if they're on anything, if they ever took anything. I think one of the things that we find not infrequently is testosterone. Um, you know, that's actually been tested as a contraceptive. It's actually fairly effective as such, and some men are on it, you know, to boost health and boost, you know, vitality, maybe sports performance, but it actually lowers sperm count, so we wanna, you know, evaluate for that as well, look at the other medications, um, that can affect things. Um, it actually reminds me of a... This is not related to fertility directly, but this is interesting. I saw a patient yesterday in clinic that's on a medication, um, for- um, for an autoimmune condition, and he said that, you know, he was coming in because he had talked to his autoimmune doctor, they didn't know what was going on, but he said all of a sudden his semen turned, um, bright blue. And it was something I'd never heard of before. We looked it up on the internet and n- nobody in the clinic had heard of that before either, but there were some Reddit threads about it, which is sort of the, you know, kind of the advantages of- of that.

   16. CWChris Williamson16:14

       (laughs)

   17. MEDr Michael Eisenberg16:15

       And they, and they did, they sort of correlated it. They said that it was... I think they liken it to Gatorade, uh, Glacier Freeze.

   18. CWChris Williamson16:21

       Okay...

   19. MEDr Michael Eisenberg16:21

       So this bright blue color, so it's sort of, sort of wild. So-

   20. CWChris Williamson16:24

       Do you know what it is that causes that? What's the, what's the drug?

   21. MEDr Michael Eisenberg16:26

       No. No, I mean, we tried to look it up. I think there'd maybe been one publication about it, but just a really wild thing, right? And I think people are... It- it was... You know, Reddit is hilarious, right? They talked about him getting an OnlyFans page and-

   22. CWChris Williamson16:39

       Ah, alien semen. Yeah, yeah, yeah.

   23. MEDr Michael Eisenberg16:42

       But, uh, no. I mean, but, you know, I think a lot of times, um, you know, reproductive effects of medications or semen effects certainly are not really studied. I think there's some pre-clinical work that's done in animal models and if there's not a strong phenotype, then it's not really looked at when it goes into, um, you know, actually, you know, studies, clinical human studies. Um, but, you know, just to say that, you know, kind of a tangent, but some of these medicin- medications can affect semen quality in some ways, you know, again, color is more maybe a...

   24. CWChris Williamson17:10

       (laughs) Secondary.

   25. MEDr Michael Eisenberg17:12

       Yeah.

   26. CWChris Williamson17:12

       Uh, okay. So, um-

   27. MEDr Michael Eisenberg17:13

       Other things.

   28. CWChris Williamson17:13

       ... medications, testosterone, past testosterone use I'm gonna guess as well.

   29. MEDr Michael Eisenberg17:17

       Yep, exactly right, and we look at exposures as well, right? If they, you know, if they drink, how much. We look at, you know, tobacco use, other drug use to see, you know, if that's going on. I think those are things we wanna optimize. We do talk about the sort of lifestyle factors, if they exercise, um, and then we'll do a physical examination as well to make sure everything is where it's supposed to be. Um, there can be other, you know, conditions that we sometimes detect. You know, some men have, uh, larger veins in the- the- the scrotum called a varicocele, um, and that just sort of impairs normal temperature regulation in that area, impo- impairs, um, you know, kind of toxin, um, uh, excretion, and so that's- also can affect fertility. Um, and then, you know, we do a very comprehensive hormone assessment as well. The testicle does two things: it makes sperm but it makes testosterone as well.So we'll check testosterone, some of the other hormones involved in that axis, and then, you know, that's kind of our baseline. Um, I also talk to, you know, the female partner's physician as well to get that information, again, 'cause it's a team sport, and then come up with a plan, uh, to see, you know, what there is, what's correctable, and how to get them, you know, the path to having a child.

3. 18:24 – 27:01

   The Impact Of Varicoceles On Fertility

   1. MEDr Michael Eisenberg18:24

   2. CWChris Williamson18:24

      Give me a primer on varicocele.

   3. MEDr Michael Eisenberg18:27

      So, er, um, you know, again, the speech that I tell is that, you know, they're very common. Probably 15% of all men have them, you know, about so one in seven. They, um, they usually arise around puberty or so. You know, most men that have these don't have any problems, but maybe about 20, 25% of the times, they cause problems. So again, it's dilated veins in the scrotum, more common on the left side than the right side, although some men can have them on both sides, um, and, you know, again, they're just sort of larger veins, and so it's thought to warm up the testicles a little bit. So that's the- sort of the, the common thinking about how they lead to reproductive issues. So they're associated with lower sperm counts. Uh, they're sometimes l- linked to lower testosterone levels, but the reasons that we fix them, the reason we worry are a few. So obviously for fertility reasons is a common reason that we would do that. Some men have discomfort from them, um, like they describe an ache, you know, worse at the end of the day than at the beginning, worse with activity. Anytime blood can pool, it can stretch, and some men feel that. Um, believe it or... Usually, they don't have any sort of... That's sort of the extent of it. I actually have seen, you know, patients before where it actually popped, if you can believe it, and led to, yeah, nothing devastating, but, you know, a lot of swelling and bruising.

   4. CWChris Williamson19:39

      Sounds pretty devastating to me.

   5. MEDr Michael Eisenberg19:40

      Yeah. Well, yes, yeah. Ultimately, he did great.

   6. CWChris Williamson19:44

      Okay.

   7. MEDr Michael Eisenberg19:44

      But yeah, um, I've seen that as well. And then in kids, we worry about testicular growth. So it can actually, you know, for kids before puberty who, who develop them, it can actually affect trajectory of growth. So those are the reasons that we kind of think and worry about those.

   8. CWChris Williamson19:57

      Right. What is the impact of fixing a varicocele given that this is something that I'm- imagine a lot of the guys that come in if they're thinking, "I was struggling to get pregnant," or, "I'm thinking about getting pregnant," or, "I did a sperm analysis, and my numbers aren't where I want them to be," and you say, "Hey man, you've got a varicocele." Uh, what is the, uh, process of fixing it like? What are the outcomes like, um, all of that?

   9. MEDr Michael Eisenberg20:21

      Yeah. So, you know, in the United States, usually it's fixed surgically. In some other places, there's also a radiology procedure that can be done, um, that can, that can help repair it. But essentially, it's an outpatient procedure. It usually takes, you know, less than an hour, go home the same day. I usually have men kind of relax. I usually operate on Fridays, so relax over the weekend, back to work on Monday. You know, it takes two to three months to make a sperm, so we don't expect it to improve immediately. Um, but, you know, over the next few months, we'll expect to see improvements in semen quality. That probably happens about 70% of the time. Um, and then, you know, they can, again, start to try. I think, you know, not every... Again, 'cause there's a lot that goes into fertility, so not everybody is just gonna be able to conceive instantly on their own, but, you know, about half of patients, a third to a half of patients are gonna be able to just conceive without other assistance, uh, with that. But it also improves, you know, some of our outcomes for, you know, the insemination that I talked about earlier, even in vitro fertilization as well for men with these conditions.

   10. CWChris Williamson21:18

       Mm. Does that mean then that most men who want to have kids and find out that they've got a varicocele should probably get it fixed?

   11. MEDr Michael Eisenberg21:26

       You know, I guess there's... Everybody has sort of different, um, I guess, feelings and sort of desires. I think there's lots of pathways to get pregnant. Um, you know, I think one thing interestingly about varicocele is that, um, you know, there is this sort of time lag for benefit, and I think that does affect some couples. So if you come to this crossroads, you find you have a varicocele, uh, and your sperm count's a little low, so you can either get it fixed, you know, and, and get that improvement, or you can move right to IVF, for example, I think couples, you know, kind of weigh that differently. You know, it's interesting. We tried to do a study on varicocele, we as a community, um, about, I think 20 years ago, and, you know, after 18 months, you know, to try and recruit couples from all over the country, only three couples enrolled. And one of the reasons for that delay, it was sort of interesting, is that because men are seen so late in the process of, you know, the reproductive evaluation, um, you know, they just... Most couples didn't wanna wait for their time. Just because of this time lag we talked about, you know, for this particular study, they didn't want to be randomized to do nothing. So there was just a lot of reticence to do that. They just wanted to move forward. It's interesting, if you look at couples, you know, there's sort of this perception for a variety of reasons, I think sort of, you know, cultural and, you know, sort of gender norms and biases, that men are not always evaluated. You know, in the US, probably a third of the time, a quarter of the time, men are never seen. So if there's a problem, you know, couples are treated immediately, you know, through maybe insemination, maybe IVF, um, but, you know, the men are not seen to see if there's things that could be corrected or optimized. And I think it's just sort of that delay, right? If, you know, couples are trying for a year, and then, you know, they figure out there's an issue, then they go in. It starts with the gynecologist, and then s- you know, sometimes the male's bypass. So, you know, hopefully through, you know, attention, just through more education, you know, through the platform that y- you're providing here today, we can sort of educate that, you know, when couples are having a problem, about half the time it's a male factor. So the men should definitely always be evaluated.

   12. CWChris Williamson23:24

       What is the- that I've read about varicoceles being fixed sooner rather than later for outcomes in men? What, uh, what's the mechanism there?

   13. MEDr Michael Eisenberg23:35

       Well, I think, you know, it's, it's- they're thought to be a progressive lesion. So the longer you have it, the more opportunity there is to do damage. So, you know, when, like I talked about, you know, there's kids that have these as well, you know, I think if we identify that early, you know, hopefully we can just, you know, alter that trajectory 'cause it's much easier to prevent a problem from occurring than to fix it once it does. You know, again, if we only see improvement 70% of the time, if we can sort of freeze it and prevent further decline, I think that's our goal. So I think if men have it, you know, again, it doesn't af- it doesn't affect or negatively impact everybody. So...You know, we do evaluate it. We check semen data, we check, you know, hormone data when we see these men to figure out who, you know, really needs it or not. But, you know, everybody kinda chooses it differently and rather than, you know, follow it for the rest of their lives, some men choose to have it fixed. And obviously a lot of people have an aversion to surgery so some will just say, "I'll just live with it and we'll, we'll, we'll figure it out later."

   14. CWChris Williamson24:27

       What are the most common interventions that you offer when guys come in, sperm quality isn't where it needs to be. What are the most common interventions that they get?

   15. MEDr Michael Eisenberg24:38

       So, um, a varicocele is a very common one. Probably about a third of the time we identify those for the patients that we see. Um, and then, you know, hormone optimization. I think that's also a common one that we'll do. You know, men will have low levels and if we optimize it, that can improve things. Um, you know, there's also other surgeries that we can do. You know, vasectomy reversal is a very common, you know, thing that men come to reproductive urologists for. So had a vasectomy, maybe changed relationship or maybe that couple decides they want another child, so that's something that we'll do. Um, and then another, um, you know, group of patients that we see are men that don't have any sperm in the ejaculate, so it's called azoospermia or no sperm in the ejaculate. And so there's procedures that we can do to try either improve that or to get sperm directly from the testicles that we could use for in vitro fertilization. So that's sort of the flavor of things.

   16. CWChris Williamson25:27

       Getting sperm directly from the testicles sounds-

   17. MEDr Michael Eisenberg25:29

       Mm-hmm.

   18. CWChris Williamson25:30

       ... like a-

   19. MEDr Michael Eisenberg25:31

       (laughs)

   20. CWChris Williamson25:31

       ... rather serious intervention.

   21. MEDr Michael Eisenberg25:34

       Yes. Well, (laughs) I think it sounds scary and, you know, when I've showed videos of this at sort of mixed co- mixed medical conferences or others, I think some people do get a little queasy just to see what we do, but most men do great. Um, you know, there's actually ... Mm. You know, it's so, um, you know, you can imagine how devastating it is when you do a semen analysis, you know, 'cause you haven't gotten pregnant and you're told that there's no sperm. So it can be, um, yeah, you know, I've seen men break down and you can imagine. I mean, you know, there's, there's so much tied up. I mean, obviously, you know, goals of the relationship. I think there's a lot of, you know, concerns about masculinity as well. So, (clears throat) one of the first things that we do is just try and be hopeful about it. About half the time we can actually find sperm. Sometimes there's, like, a correctable blockage that we can actually bypass, um, so they can, you know, then achieve without, you know, um, you know, any other assistance besides the surgical correction. Um, but essentially what we do is, you know, you can find within the testicle where sperm is being made. So there's, like, a minimum threshold of production that's necessary before it actually gets out, um, and if you're below that threshold a- and we can't sort of medically, you know, induce more production, we can go inside and try and find it. But it's an outpatient procedure. It usually takes a couple hours. You know, most men, I've had men, you know, go back to work the next day, if you can believe it, take a red eye outta town (laughs) then back to work the next day. So, you know, it's not pleasant, but most men, most men do

4. 27:01 – 33:47

   How Can Men Optimise The Quality Of Their Sperm?

   1. MEDr Michael Eisenberg27:01

      great.

   2. CWChris Williamson27:01

      Okay. What should men do or wha- what are the areas that most guys are overlooking when it comes to improving sperm quality that, uh, they, uh, you know, the first port of call that you should be doing in terms of changing lifestyle, making a, a self-assessment there?

   3. MEDr Michael Eisenberg27:17

      Yeah. Well, I think just having some awareness of what your semen quality is. I mean, I think that, you know, looking at it when you're first kind of, I don't know, when you're watching this or when you first think about it, I think it's never too early to just get some initial, um, in- information about it to find out where you are 'cause it can change over time as well. Um, and then I think if there's an issue, you know, I think, you know, going to the doctor to try and figure out. I mean, I think, you know, getting basic health screening, again, 'cause men don't always do that. I think, you know, women go to the doctor. They're used to annual Pap smears or semiannual Pap smears, but men don't unless there's a problem. I think routine health screening is not done, so checking that out. But, you know, again, I think I just always go back to health. Again, I don't wanna be alarmist about any of this, but just making sure that you're living life the right way, you know, that you're a good body weight, that you're eating, you know, not just ultra-processed foods or fast foods, that you, you take some ownership of your health. I think those are good places to start and pretty actionable and easy.

   4. CWChris Williamson28:10

      What about pharmaceutical interventions, stuff like hCG and clomiphene?

   5. MEDr Michael Eisenberg28:14

      Mm-hmm. Yeah. So I think for the right patient, I think those can help. Um, you know, for patients that aren't making enough of those on their own, I think that can help. You know, testosterone is important for sperm production-

   6. CWChris Williamson28:25

      Mm-hmm.

   7. MEDr Michael Eisenberg28:25

      ... so for men that have lower than average levels, I think there's some reasonable data that if we give men, you know, those medications, we can see improvements, not just in testosterone, so sometimes they'll feel better, uh, but also we can see improvements in sperm quality. But I think it's important for men to, you know, go see a doctor, uh, and have that done under, you know, kinda medical supervisor ra- rather than treating themselves.

   8. CWChris Williamson28:46

      Yes. Yeah. That's, that's, uh, generally a good rule.

   9. MEDr Michael Eisenberg28:49

      Yeah.

   10. CWChris Williamson28:49

       What about the relationship between age and fertility for men? Um, wha- what's the sort of curve look like there?

   11. MEDr Michael Eisenberg28:56

       Yeah. So the oldest father ever is 96, allegedly. (laughs) So I think the biologic potential does persist forever. When we looked at the US over the last 50 years, the oldest father was 88. Um, so again, men are doing it. Again, e- we always make sperm essentially. You know, the numbers do go down a little bit, volume goes down, but we persist. Interesting, over the last 50 years, the youngest was 11. Um-

   12. CWChris Williamson29:21

       Mm-hmm.

   13. MEDr Michael Eisenberg29:21

       ... so it can s- start sooner than we'd like. Um, but, you know, I think it's important for men to know that, you know, even though, again, they think the runway's unlimited, it's probably not. So there are, you know, risks of taking longer to get pregnant. So our fertility does decline 'cause we do see lowering of sperm quality over time. Um, but also risks of sort of rare, you know, uh, disorders go up a little bit. So I think classically, you know, hear about autism, which goes up. There's other rare, um, you know, genetic conditions which can increase a little bit. Now again, these are rare conditions, um, but, you know, we do see a measurable increase and, you know, as a country and as sort of a society we are, the pa- uh, parental age is increasing, paternal age is increasing over time. So, you know, for an individual, I think most men wanna be genetically related. So they would, you know, sort of not-... be as concerned about these risks 'cause, you know, these risks are, are relatively small, but, you know, as a population, if more and more men are waiting longer and longer, we may see, you know, more of these conditions become a little more prevalent over time. So, I think that's kinda the, the thing, just to understand that, you know, while you can have a child, you know, late into your 60s, 70s, 80s, it's, you know, there are some advantages to doing it earlier.

   14. CWChris Williamson30:35

       When does the drop-off begin from peak male fertility?

   15. MEDr Michael Eisenberg30:40

       You know, uh, I think it- it- the- the, um, our sort of governing board, the American Society of Reproductive Medicine, defines an older father at 40 or over. That's also what sperm donor and sperm donation, um, you know, companies do as well. But it probably doesn't just start there. I think it's sort of a slow decline, you know, probably. You know, from an evolutionary standpoint, our peak fertility is probably late teens, early 20s, um, so it probably starts at that point. You know, if you look at s- you know, sperm DNA, we accumulate about two mutations a year. So, you know, if you look at somebody 30 compared to 20, he's gonna have- the 30-year-old's gonna have about 20 more mutations in their DNA. Now, given the fact that we have billions of, you know, molecules of DNA, you know, two mutations is not gonna make a, a big difference over time for an individual. But again, when we're talking about a population level, you may see some changes.

   16. CWChris Williamson31:29

       Okay. W- what's the increase in autism risk? Do you know that? At, at 40, at 50, at 60?

   17. MEDr Michael Eisenberg31:37

       You know, I don't recall the specific, you know, increase, like the actual percentage, but it does go up, you know, a a little bit.

   18. CWChris Williamson31:44

       Okay. Uh, I'd also heard that the sex ratio, li- the likelihood of the sex ratio changes with male age. Is this right?

   19. MEDr Michael Eisenberg31:53

       Yeah. That's also, yeah. It's a very interesting finding as well. You know, we talk about sort of declining rep- men reproductive health, so we talked about sperm counts. Testosterone levels go- have gone down, you know, over the decades as well, and there's some studies that show that, um, the sex ratio has as well, sort of independent of age. Um, but if you look specifically at age, as men get older, you know, the chance of a male birth goes down a little bit. So, you know, over age 70, it, it does go down. You know, it's- hmm, it goes down sort of a, a few percentage points, but it's measurable, and anything that changes the sex ratio is sort of a big deal to a population, just given how important, you know, that ratio is for the propagation of the species. And interestingly there's- if you look at sort of, like, stressful, you know, like s- sort of societal events, uh, you can see that as well. Like, you know, the sex ratio goes down during, like, economic downturns, for example, wars, we see changes i- in the sex ratio. So it's a real- it's a real phenomenon, and the fact that it, you know, tracks with the father's age, I think is, you know, very telling.

   20. CWChris Williamson32:55

       What's the mechanism? Do you know why?

   21. MEDr Michael Eisenberg32:57

       You know, I think it's- uh, it's thought to be, um, you know, kind of selective fetal loss, you know, at the uterine level, and again, why it sorta selects the males more than females I think is not, not totally known, but it's- yeah, it's, it's measurable.

   22. CWChris Williamson33:12

       It's- as males age, female likelihood increases for children? Is that right? Or is it the other way around?

   23. MEDr Michael Eisenberg33:20

       Well, so I guess where- uh, yeah, I think there are kinda two things I was saying. So, um, I, I wasn't clear. So, you know, for a societal level, I think that we see that kinda, I guess, culling at the uterine level-

   24. CWChris Williamson33:31

       Mm-hmm.

   25. MEDr Michael Eisenberg33:31

       ... but we think that for, for paternal age, it is kind of the, the f- it- it is sort of the sperm level, just that-

   26. CWChris Williamson33:38

       Mm-hmm.

   27. MEDr Michael Eisenberg33:38

       ... those sperm, for whatever reason, the Y-bearing sperm don't seem to be as efficient as making it all the way to live birth.

   28. CWChris Williamson33:45

       Oh.

   29. MEDr Michael Eisenberg33:46

       Yeah.

   30. CWChris Williamson33:46

       Okay. That's interesting.

5. 33:47 – 38:26

   New Technology Changing Fertility Rates

   1. CWChris Williamson33:47

      How do you think- I mean, i- IVF is everywhere. Uh, IUI I learned about at Andrew Schutzer's, uh, live show which-

   2. MEDr Michael Eisenberg33:56

      Yeah.

   3. CWChris Williamson33:57

      ... uh, kind of an interes- and then there's I- ISCI or ISSI or something as well. There's a whole- there's an IVF revolution going on.

   4. MEDr Michael Eisenberg34:04

      Mm-hmm.

   5. CWChris Williamson34:04

      How do you come to think about that new technology, uh, changing the landscape here?

   6. MEDr Michael Eisenberg34:13

      Yeah, I mean, I think, you know, that ICSI, the intracytoplasmic sperm injection where you can take a single sperm and inject it into an egg has really been, in my opinion, one of the revolutions of medicine in the last, you know, quarter, half century, um, because it allows like these men that we talked about where there's no sperm in the ejaculate, very rare sperm in the testicle to be able to become biologic fathers. Um, so it really, you know, allows- it really lowers the bar significantly for who can become a father, you know, for men that have had, you know- you know some guy who we talked about again, some genetic conditions, but other conditions too. If they were treated for cancer as a child and now they can't make sperm as efficiently, I mean, allowing these men to be able to become, uh, parents I think i- is terrific. But we are seeing increases in the number of couples that are, you know, requiring these technologies, and I think they are great. You know, in the US, um, it used to be that maybe 1% of births were conceived by IVF. Most recently, it's about 2% of all births in the US are conceived by IVF, and those numbers are only increasing.

   7. CWChris Williamson35:12

      Mm-hmm.

   8. MEDr Michael Eisenberg35:12

      I think there's a variety of reasons. I mean, I think, you know, falling sperm counts are probably a contributor, but, you know, also couples, you know, from a social standpoint are just waiting a little bit longer, and as we age, both men and women, fertility declines, and so I think more couples are becoming reliant, um, on needing these technologies. But, you know, I think there's- you know, it just- I guess from an evolutionary standpoint, it doesn't sound like it would be the best, but I think, you know, there are some potential advantages to IVF that allows, you know, sort of selection of specific embryos to try and, you know, avoid, you know, kinda heritable conditions. You know, some of these genetic conditions that lower sperm counts, for example-

   9. CWChris Williamson35:48

      Mm-hmm.

   10. MEDr Michael Eisenberg35:48

       ... you know, we could be able to avoid those in the future. There's this, um, ethicist at Stanford, uh, Hank Greely, that wrote this book called the, uh, The End of Sex, and so he rationalized in the future that sex will just be for pleasure, and then in the future we'll be able to take, you know, skin biopsies from men and women, make sperm and eggs, you know, grow embryos in a dish and call it-

   11. CWChris Williamson36:08

       So that's, uh, IVG, right?

   12. MEDr Michael Eisenberg36:10

       Yeah. Yeah, in vitro- in vitro gametogenesis. Exactly. But the advantage to doing this and why sort of society will be, um-... you know, incentivized to do this is you could eliminate sort of genetic diseases. You know, we talked about things we know about, like cystic fibrosis or certain genetic conditions that lower sperm, but, you know, maybe you could even look at, you know, susceptibility to high blood pressure, diabetes, and things like that, so really try and root out, um, you know... Again, it kind of gets a little bit Brave New World, and maybe it's not where we want to be as a society, but-

   13. CWChris Williamson36:39

       It's a difficult one, man. I- I've had a... Do you know who Jonathan Anomaly is? Are you familiar with him?

   14. MEDr Michael Eisenberg36:44

       No.

   15. CWChris Williamson36:45

       He, uh, th- there's a, uh, a company that he is involved with, uh, that is doing, um, embryo selection for, uh, certain traits. And he, he uses this example, which I thought was really smart, it was really interesting, uh, around, uh, myopia, like people that just have worse eyesight.

   16. MEDr Michael Eisenberg37:01

       Yeah.

   17. CWChris Williamson37:01

       And, you know, there's not really much moral weight that's put on that. I know that some people, you know, sort of the deaf community identify as that, and that's kind of close to their sense of self.

   18. MEDr Michael Eisenberg37:13

       Mm-hmm.

   19. CWChris Williamson37:13

       I don't know anybody who has shortsightedness that identifies with their shortsightedness. You know, it's just, it's a thing that requires them to have glasses or wear contact or, you know, squint a little bit when the lighting's too dark.

   20. MEDr Michael Eisenberg37:25

       Right.

   21. CWChris Williamson37:26

       And, um, yeah, the opportunity to select, hey, w- we, you have the choice between your kid having really great eyesight or your kid needing glasses from age 11. Um, it, uh, but then, you're right, this technology and this approach has not exactly had an illustrious fair and humane history. Um, so it gets perilous with, with this. But I, you know, I think it is a, probably, actually I was gonna say like a, a slow, but it's gonna be a pretty quick transition, I think, to a world where embryo selection, especially for, for particular traits, is gonna become, um, even more common given how likely it is for older parents, uh, whatever they're called, um, uh, uh, what's the elder pregnancy called? Uh, when a woman-

   22. MEDr Michael Eisenberg38:14

       Oh, like advanced maternal age or geriatric?

   23. CWChris Williamson38:16

       Geriatric pregnancy, that's it. Yeah, the m- the most unfair term-

   24. MEDr Michael Eisenberg38:20

       Yeah.

   25. CWChris Williamson38:20

       ... of, of all of them.

   26. MEDr Michael Eisenberg38:21

       Yes.

   27. CWChris Williamson38:21

       But, uh, yeah, I think, I think this is gonna be, this is gonna be pretty,

6. 38:26 – 41:52

   Is Testosterone Lowering Sperm Counts?

   1. CWChris Williamson38:26

      pretty common. Okay, so we've got on one side sperm quality.

   2. MEDr Michael Eisenberg38:30

      Mm-hmm.

   3. CWChris Williamson38:30

      But the other side that most guys care about as well, testosterone levels.

   4. MEDr Michael Eisenberg38:33

      Yes.

   5. CWChris Williamson38:35

      What's happening with testosterone levels? What's the relationship between that and male fertility? Um, what, what's the sort of current state of play there?

   6. MEDr Michael Eisenberg38:44

      Yeah, so I think, uh, just like we talked about, I think we are seeing declines in testosterone over time as well. And I think when people look at it, I think they, um, they sort of attribute it to similar things. I think that, you know, exposures, sedentary lifestyle, more obesity. So testosterone, again, made in the testicles, um, and then it's converted to different things, you know, in the body, like it's aromatized peripherally to estradiol. And a lot of that happens in fatty tissue, so you can imagine if there's more fatty tissue, more of that, uh, aromatization will occur, and so the levels will decline a little bit. Um, and so, you know, as these levels go down, I think it does, you know, it can affect, you know, sperm production, uh, t- to an extent. So I think there is a relationship to that as well. And, you know, again, when men sort of seek out treatment for this, when they start on testosterone, we can also see, you know, direct correlation with sperm counts just 'cause testosterone supplementation or testosterone therapy can directly, you know, decli- uh, decrease sperm production.

   7. CWChris Williamson39:42

      Mm. Well, you've got this weird inverse relationship sometimes as well between higher testosterone, lower sperm quality.

   8. MEDr Michael Eisenberg39:49

      Mm-hmm. Yeah.

   9. CWChris Williamson39:50

      But also m- very few guys say that they want their testosterone level to be lower, um-

   10. MEDr Michael Eisenberg39:55

       Yeah. I have-

   11. CWChris Williamson39:56

       ... so yeah.

   12. MEDr Michael Eisenberg39:56

       (laughs) Yeah. Interesting, I've had patients that come in that say their penis is, is too big. But, uh, it's a rare complaint.

   13. CWChris Williamson40:04

       I imagine so as well. Yeah. Uh, all right. Th- well, actually the penis is getting bigger thing, was there not a study about that?

   14. MEDr Michael Eisenberg40:14

       Yes, yes.

   15. CWChris Williamson40:14

       Was there not (laughs) , is it not statistic- statistics that... Is it testicles getting smaller, uh, anogenital distance getting smaller, but penises getting bigger?

   16. MEDr Michael Eisenberg40:24

       Yeah. Yeah, it's a, it's a good segue. So, um-

   17. CWChris Williamson40:27

       (laughs)

   18. MEDr Michael Eisenberg40:30

       ... that's a... We did a, yeah, so we did a study on this. So interestingly, there are lots of, um, you know, just like in a way the sperm count study was done is that over time people have measured semen quality in different populations and published it, and then you can look at all these, you know, studies together and just see if there's changes over time. So similarly, penis length has been measured over time in a variety of populations. So we looked at it, you know, over the last several decades and found, you know, we s- expected it to decline, you know, for all these reasons, right? We're seeing, you know, the lower sort of development, male genital development, lower sperm counts, lower testosterone levels, more obesity. All those things should necessarily lower sperm per- or sorry, lower, uh, penis length, right? 'Cause the way that penis length is measured is you kind of pull the penis on stretch and measure from the tip to the pubic bone. Um, but much to our surprise, it'd actually gotten a little longer over time. Um, (clears throat) and so, you know, why that is is not certain. You know, we saw it pretty consistently. Um, you know, we had... One hypothesis we had is that puberty is changing over time, the timing of puberty is changing, and it's actually gotten a little bit earlier. And when it gets earlier puberty, um, leads to kind of more time for genital development, longer genital development. So that's sort of our hypothesis why that may explain it. But, um, yeah, that was, uh, a finding. (laughs)

   19. CWChris Williamson41:50

       Yeah, I imagine that that caused

7. 41:52 – 55:30

   Is Porn Affecting Erections?

   1. CWChris Williamson41:52

      some ructions. Okay, erections. Let's talk about-

   2. MEDr Michael Eisenberg41:54

      Yeah.

   3. CWChris Williamson41:54

      ... erections.

   4. MEDr Michael Eisenberg41:55

      Okay.

   5. CWChris Williamson41:56

      How often is erectile dysfunction due to physiological or psychological factors?

   6. MEDr Michael Eisenberg42:05

      Yeah. So we used to think it was all psychologic, uh, but now we know that it probably only 10%, uh, is psychogenic, and most of it's actually due to organic causes. So, you know, blood flow issues are the main culprit, and I think this... Anything that affects blood flow in the heart can also affect it in the penis. So, you know, diabetes, high blood pressure, all those vascular conditions are very common.... different medications. You know, medications that lower blood pressure anywhere in the body lower the blood pressure head to penises and can also cause those issues. Sometimes pelvic surgeries, you know, in that area, like prostate surgery is notorious for that. Um, you know, colon surgery as well, bladder surgery, those things can also affect, you know, the ability of the penis to get erect, to, you know, get those signals, get the blood flow where it needs to be. Um, and then, you know, the thing that I think is commonly thought of is, you know, hormonal causes are probably less than 5%, but sometimes low testosterone can also do that. But it's really the minority of all patients coming in.

   7. CWChris Williamson43:00

      Mm. Okay. So what ... The main reasons for erectile dysfunction, if you were to rank order them, for the patients that come in to see you, what are they?

   8. MEDr Michael Eisenberg43:09

      I think mostly it's just du- due to these vascular comorbidities, you know, so kind of the classic metabolic syndrome, so high blood pressure, cholesterol, diabetes, obesity, you know, again, other things like smoking. I think those are probably the most common causes for erectile dysfunction.

   9. CWChris Williamson43:23

      Mm.

   10. MEDr Michael Eisenberg43:23

       But it's also very common, I think, you know, when men come to see me, uh, they feel like they're all alone, but if you look at it, over the age of 40, over half of men have some trouble with erection. So it is very, very common. Um, I always like to tell men, "As long as you have a penis, we can always make it hard."

   11. CWChris Williamson43:37

       (laughs)

   12. MEDr Michael Eisenberg43:37

       So there's a lot (00:02:00) you can do. Try and be optimistic.

   13. CWChris Williamson43:42

       Okay. What should men do to improve blood flow? Normal guy, he's like, "Uh, I'm not smoking that much, I'm not drinking that much, I should improve my blood flow." What- what- what does that mean?

   14. MEDr Michael Eisenberg43:52

       Yeah. So, I mean, I think you can do better, right? So, I mean, you should try and stop smoking or cut down if you can. You know, alcohol, I think, you know, there is an expression like whiskey dick, right? So if you drink to excess, it can definitely lower that. But, you know, I think in moderation, it probably doesn't have as much of an effect. But, you know, again, if there's room for improvement. And then I think just anything that's good for your heart, so I think more exercise, I think, would be beneficial, you know? I think that will definitely improve things.

   15. CWChris Williamson44:17

       Okay. What- what's the role of hormones here? I think a lot of the time guys would just assume erectile dysfunction, some hormonal imbalance, then the accelerator gets pressed and we're off to the races.

   16. MEDr Michael Eisenberg44:31

       That's right. So, you know, when you get evaluated, I think that's one of the screening tests that we always do, just because we do see that some of the time, so we will check testosterone level. You know, and if it's low, you know, those are the men we do discuss, you know, putting on testosterone therapy to try and improve things. Now, for men that have, you know, kind of a borderline low or maybe low-normal level, it's unlikely that's gonna be the whole story. Um, but for some men that are very low, you know, that can be, you know, the difference between no erections and erections, you know, men that are ... You know, if you're familiar with sort of the ranges, probably 300 to 900 is sort of the average levels of testosterone, nanograms per deciliter. And so for men in the 200 range, you know, testosterone level may help a little bit, but I think those men will also benefit from like sildenafil or Viagra, you know, those kind of medications, those therapies. But when they're in the 100 range, I think those men will see, you know, significant improvements in erectile function and sex drive as well, um, with testosterone therapy.

   17. CWChris Williamson45:24

       Yeah, that's a great point. What's the ... Is- is erectile function the same thing as libido in the body? What- w- how does this ... Uh, w- what's similar, what's different?

   18. MEDr Michael Eisenberg45:36

       Yeah, I think there is a- there tends to be a lot of overlap because I think there is kind of like just negative feedback. If you're not getting erections, you just become less interested. But they are distinct entities. So I have patients that come in just with, you know, isolated, you know, sex drive, libido concerns, and then other men coming in, no problem with sex drive, they just- just doesn't work, doesn't get Mm- mm-hmm. ... as erect as they used to. And so, you know, we- we approach those a little bit differently.

   19. CWChris Williamson45:58

       What contributes to libido? I mean, it- it- it seems to be one of those sort of ... It's behavioral, right?

   20. MEDr Michael Eisenberg46:03

       Mm-hmm.

   21. CWChris Williamson46:03

       It's the huge psychological component, I have to imagine-

   22. MEDr Michael Eisenberg46:06

       Yep. Yes.

   23. CWChris Williamson46:06

       ... but not exclusively. So, yeah, what's going on?

   24. MEDr Michael Eisenberg46:10

       Yeah. So, I mean, we are gonna look- do a hormone evaluation. I think, you know, testosterone is something that we look at. Sometimes we expand that a little bit to looking at other things, like estradiol is important in that, prolactin as well. The other thing I think that's very valuable is, you know, when we were talking, you mentioned sort of the psychogenic components to some of this, is to involve sex therapy. I think there's a bunch of excellent ones, you know, all over the world. There's excellent ones in our area that we, you know, collaborate with a lot. So for some of these disorders, we, you know, kind of do it as sort of a multi-pronged approach. So, you know, we wanna optimize the organic causes and optimize some of the psychogenic causes. And just know that it's not gonna get better overnight. It's unlikely a pill is gonna solve some of these issues and it-

   25. CWChris Williamson46:49

       Mm.

   26. MEDr Michael Eisenberg46:49

       ... you know, may take some time. But, you know, we try and, you know, look at relationship and other aspects to it as well because I think all those are contributing.

   27. CWChris Williamson46:58

       When you're talking about psychogenic causes there-

   28. MEDr Michael Eisenberg47:01

       Mm-hmm.

   29. CWChris Williamson47:01

       ... what is the- what's the mechanism that's occurring that your brain is somehow able to intervene with your penis? What i- what's happening there? I mean, look, ev- every guy that's listening to this has at some point just gone, "I- I ... Uh, not today apparently." And, uh, but you k- it's not your choice. You didn't have any idea what the mechanism that was going on. So liberate us, show us behind the curtain.

   30. MEDr Michael Eisenberg47:29

       (laughs) To the extent we can, yeah.
8. 55:30 – 1:01:16

   The Peak Fertility Checklist

   1. MEDr Michael Eisenberg55:31

   2. CWChris Williamson55:31

      It's... Okay, from the tactical side, um, if you had to build a, a checklist for men to maintain reproductive and sexual health, sort of what, what would be the non-negotiables that you would put on there?

   3. MEDr Michael Eisenberg55:44

      Yeah, so, I mean, I think, you know, exercise, you know, being very conscious of diet. I think those are gonna be really crucial. You know, avoiding smoking, I think is also crucial. And then, you know, again, moderation with, you know, other exposures, you know, moderate alcohol. You know, you wanna be kind of mindful of that. Prioritizing... You know, these are all things I think that overlap with health as well. Um, but, you know, trying to moderate, you know, like, make sure you get a good amount of sleep, you know, try and minimize stress to the extent possible. I think... The other thing that I think would be great is if men had, you know, sort of a, a good handle on baseline, you know, like trying to get a testosterone level at baseline even before problems arise. Again, 'cause when we talked about testosterone, it's such a wide range of normal, right, 300 to 900. Um, and when men come to see me and they're 400, you know, they say, "Well, I'm a little below average," but it depends where you are, right? I mean, the range is so wide, and statistically, if we get you from 400 to 500, you know, maybe you can hit a baseball further, but it's unlikely-

   4. CWChris Williamson56:40

      (laughs)

   5. MEDr Michael Eisenberg56:40

      ... that some of these other conditions that you, that you came to see me for are gonna get better. So we just wanna know where you live. I think that would be helpful. And then I've also, again, advocated for doing a semen analysis early. I think-

   6. CWChris Williamson56:52

      Hm.

   7. MEDr Michael Eisenberg56:52

      ... that would be very helpful. I talked to, actually, the Centers for Disease Control about 10 years ago, adding it to this sort of, um, this national health survey that they conduct. Just, again, for all these reasons that we've talked about, right? Declining sperm counts, to be able to understand maybe why it is. Because with this health survey, they track so much. They get blood samples, urine samples from individuals, from men and women, old and young, and they can see, you know, again, what sort of toxic exposures there are and things like that. And so if we could see, you know, who these sperm counts are changing in, I think it'd be really valuable. But, you know, there is some concern that this could affect recruitment into this, um, in the survey, uh, 'cause there's sort of an ick factor.

   8. CWChris Williamson57:31

      Yeah.

   9. MEDr Michael Eisenberg57:31

      You know, even though, right, I mean, it's... I'd be a lot more pleasant to give a, I think, a semen sample than a blood sample. I guess it depends what you think about (laughs) about needle sticks.

   10. CWChris Williamson57:38

       (laughs)

   11. MEDr Michael Eisenberg57:39

       But, but again-

   12. CWChris Williamson57:41

       Yeah.

   13. MEDr Michael Eisenberg57:42

       ... you know, I think those are... I think it'd just be... I think that'd be a valuable, a valuable piece of information.

   14. CWChris Williamson57:46

       Are there underrated signs of urological dysfunction that most men miss? Is there something that they probably should be aware of that they're not?

   15. MEDr Michael Eisenberg57:56

       Well, I think, you know, um, one of the great things, you know, that's like, again, a big discovery was Viagra. I think that got men a lot more comfortable talking about erectile dysfunction because there used to be a perception that we couldn't do much about it, and I think now men are a lot more comfortable talking to their partners about it, their doctors about it. So I think, you know, any sort of concern that men have, I think they should bring to the forefront. I mean, I think, you know, urinary issues, I think there's a lot that we can do. We talked about erectile issues. There's a lot we can do. Some men have curvature of their penis, and they're very embarrassed about it, even though it affects probably 5 to 10% of men. There's tr- effective treatments we have for that as well. So I think anything that you think is different... No one knows your genitals better than you, so if you detect any issues, you know, bring it to your doctor's attention 'cause, you know, at least to alleviate anxiety, but also, again, if it's a problem, maybe we can fix it.

   16. CWChris Williamson58:46

       It's so... I, I didn't... It feels like such a revolution at the moment, uh, to finally have reproductive technologies that can help both sides. And, uh, you know, for a long time, this is Schultz's entire standup, uh, which is, you know, he, he... The night before him and his wife maybe got the results or went in to do the tests or something, he sort of prayed to God and was like, "Just please let it be me." Because he was so sure-

   17. MEDr Michael Eisenberg59:14

       Yeah.

   18. CWChris Williamson59:14

       ... that if there was a fertility issue, that it was on the female side of the equation. And then he turns up and (laughs) sure enough, his, his prayers-

   19. MEDr Michael Eisenberg59:21

       Yeah.

   20. CWChris Williamson59:21

       ... were a- his prayers were answered. And, uh, yeah, I think, you know, the more conversations that are on this... I've, you know, waved my flag in the air since watching Schultz's special last year. I then went and got a sperm count done. I then went and found that I had varicocele, so I'm gonna get varicocele surgery at some point later this summer.

   21. MEDr Michael Eisenberg59:41

       Great.

   22. CWChris Williamson59:41

       And, you know, all of this is only occurring because there's this increasing territory of guys that are prepared to talk about it.

   23. MEDr Michael Eisenberg59:49

       Yeah.

   24. CWChris Williamson59:50

       Uh, and, yeah, uh, I guess our parents' generation would have been a lot more in the dark. You... This is... You're right. It is an ick factor. It's very private. There's a lot of shame associated with it. It's attached to your sense of self and masculinity and, and, and, you know, um, uh, aptness as a partner, uh, potential future, all that sort of stuff. And, uh, yeah, long live comedians talking about their low sperm counts 'cause I think it's a, it's a, a good impact.

   25. MEDr Michael Eisenberg1:00:18

       Oh, it's been so great, right? I mean, I think... What was his like... That he used to be worried he'd get pregnant from, like, a toilet seat, and now it takes, like, a bunch of doctors-

   26. CWChris Williamson1:00:27

       (laughs)

   27. MEDr Michael Eisenberg1:00:28

       ... care. But I think that's hilarious. You know, Hasan Minhaj had a, uh, so... A funny, a very funny routine on it. Ronny Chieng talked about it. So I think it's this great growing awareness and comfort and, you know, again, you lending your platform to talking about this. I think all that is gonna, you know, do a great thing. And I think, you know, like we talked about Viagra, I think, you know, there hasn't really been a blockbuster treatment or drug for, you know, the increased sperm counts, right? I think one of the most effective treatments we have for low sperm counts is IBF, which, which, you know, puts all the burden on the female partner, you know, given-

   28. CWChris Williamson1:00:58

       Mm-hmm.

   29. MEDr Michael Eisenberg1:00:58

       ... all the procedures and medicines that she's gonna require. So if we had, you know, again, pharmaceutical investment in some technology that could improve male, you know, sperm across the board, I think that would be amazing. And again, I think it just goes to, you know, more education and research about why counts are falling, what we can do to reverse that trend.

9. 1:01:16 – 1:01:48

   Find Out More About Michael

   1. MEDr Michael Eisenberg1:01:16

   2. CWChris Williamson1:01:16

      Heck yeah. Dr. Michael Eisenberg, ladies and gentlemen. I, I love this. It's a, uh, a topic that I'm, uh, very passionate about, so thank you for all the stuff that you do. Where should people go if they're gonna wanna keep up to date with everything that you've got online?

   3. MEDr Michael Eisenberg1:01:27

      Well, we have a lab website, so they can go to that. They can support, you know, the cause and then learn more about men's reproductive health.

   4. CWChris Williamson1:01:34

      Heck yeah. Mike, I appreciate you.

   5. MEDr Michael Eisenberg1:01:36

      Thank you. Appreciate it.

   6. CWChris Williamson1:01:37

      Congratulations. You made it to the end of the episode. And if you want more, well, why don't you press right here? Come on.

Episode duration: 1:01:48