351 ‒ Male fertility: optimizing reproductive health, treating infertility, & navigating TRT

1. 0:00 – 1:12

   Intro

   1. PTPaul Turek0:00

      If you ask me, "What's the theme for today?" I'd say sperm matter a lot.

   2. PAPeter Attia0:05

      All right, so now let's talk about the guy who comes to see you. He's been on exogenous testosterone for three years. Presumably, there are no sperm.

   3. PTPaul Turek0:13

      I would bet ninety-five percent confidence that he would have no sperm in his semen.

   4. PAPeter Attia0:17

      So what are you telling him now? How are you gonna solve this problem? Oh, this is a very important point.

   5. PTPaul Turek0:22

      So eighty percent of conceptions naturally or at home occur when sex is front-loaded as opposed to reacting to ovulation.

   6. PAPeter Attia0:29

      Tell me about the impact of cold plunging and sauna and hot tubbing on fertility for men.

   7. PTPaul Turek0:36

      Twenty minutes, a hundred and four degrees, uh, three times a week would probably make you zero.

   8. PAPeter Attia0:40

      What paternal age do you worry about?

   9. PTPaul Turek0:43

      National guidelines for sperm donation, forty is considered older paternal age. Uh, fifty for sure, right?

   10. PAPeter Attia0:49

       Mm-hmm.

   11. PTPaul Turek0:50

       If you look at risks to offspring-

   12. PAPeter Attia0:53

       Tell me what your impression is of the effect of any or all of the above on fertility.

   13. PTPaul Turek0:59

       You double the stress in a man and his testosterone level will fall.

   14. PAPeter Attia1:03

       Yeah.

   15. PTPaul Turek1:03

       And then the sperm production falls for a whole different reason.

   16. PAPeter Attia1:05

       [upbeat music] Hey, everyone, welcome to "The Drive" podcast. I'm your host, Peter Attia.

2. 1:12 – 8:15

   The complex & hostile journey sperm must take to fertilize an egg

   1. PAPeter Attia1:15

      Hey, Paul. Thank you so much for coming out to Austin.

   2. PTPaul Turek1:17

      Peter Attia, the man, the myth, the legend. I am so excited to be here.

   3. PAPeter Attia1:21

      So, um, this is, in many ways, I guess, what's gonna be part one of a two-part series I hope to do on fertility.

   4. PTPaul Turek1:27

      Yeah.

   5. PAPeter Attia1:28

      And given the complexity of it, I think the most logical way to do it would be to break it down into male fertility, female fertility, and there's obviously gonna be things we talk about that'll overlap. But, um, I was trying to think about the best way to start this, and I-- the first thing that came to my mind was, can we just explain what's involved in conception? And, and maybe do it through the lens of the sperm, but, but, like, how much of a, how much of a challenge is this? I mean, obviously, there's an enormous evolutionary pressure for this to go as easily as possible. But what is actually involved? So, um, what, what, what happens for a sperm to fuse with an egg? What are all the things that are standing in its way, so to speak?

   6. PTPaul Turek2:09

      I mean, there are a lot. So reproduction is, uh, an incredibly highly evolved million-year process and remarkably conserved among mammalian species, even among land species and water species of animals, vaginas, cervixes, uteruses, and the question is, w-why, why is it so much work for a sperm to get into the vagina, especially in, say, water-

   7. PAPeter Attia2:32

      Yeah

   8. PTPaul Turek2:32

      ... and then have to go through a cervix, and then the immune system in the uterus is very active because there's a hole in the woman to the peritoneum, to the abdomen, so it has to be highly protected. And then you have to go through the uterus, so there's an, a ten-inch, twelve-inch swim, which is equivalent to about a twenty-mile swim for a human.

   9. PAPeter Attia2:54

      Based on the size of the sperm.

   10. PTPaul Turek2:55

       After ejaculation-

   11. PAPeter Attia2:56

       Yeah

   12. PTPaul Turek2:56

       ... and how much distance they have to go, and they do that in minutes, which is crazy. So it's an in-interesting challenge that nature has kept in place for a million years, and I really respect evolution. And it is why we're here for, you know, eat, sleep, reproduce. So, uh, it's, so basically, uh, with ejaculation, the penis is shaped to fit into the cervix. So everyone wonders, am I, is it getting to the right spot? It's also interesting that the semen is coagulated and then it liquefies, and that's because there's a lot of species of lower phyla that they have to leave as soon as they have sex, otherwise they'll get killed, like praying mantises and black widow spiders. So you gotta get out of there as a guy. So our ejaculates in humans st-st-are sticky.

   13. PAPeter Attia3:41

       By the way, do, do we, is there an e- is there an evolutionary explanation for that phenomenon?

   14. PTPaul Turek3:45

       I have no idea, Peter. [laughs] I have no idea-

   15. PAPeter Attia3:47

       Yeah

   16. PTPaul Turek3:47

       ... why he would do that. I don't know why one queen bee and, you know, the, the, the bees in the hive die after mating. I, I have no idea why that's an advantage, but I guess, uh, you know, females are prioritized in, in evolution, and that makes sense. So there's a, th-the anatomy is perfectly defined, so a lot of men think they're having trouble placement, placing things, but that I usually don't worry about it 'cause the cervix and the penis sh- uh, it expands, it, it forms a seal. Then there's a crypt, sperm have to go through a crypt, uh, a channel, which is, uh, only a few sperm make it, so a hundred million sperm may start out, maybe five million make it through the first barrier, which is the cervical barrier. The vaginal fluid is acidic. Sperm-

   17. PAPeter Attia4:31

       How is, how acidic?

   18. PTPaul Turek4:32

       Five.

   19. PAPeter Attia4:33

       Okay.

   20. PTPaul Turek4:33

       PH of five, and the semen is a PH of seven. It's all buffered, so as soon as that, so that's, that's a hostile environment, so it has to get out of there quickly. As soon as it liquefies, there's sugars in there, and then they go through the cervical path. So five million will make it, one out of twenty, one out of what, no.

   21. PAPeter Attia4:50

       Yeah.

   22. PTPaul Turek4:50

       Yeah, one out of twenty makes it through the cervix. Then a hundred make it to the fallopian tube, and then one will make it to the egg.

   23. PAPeter Attia4:56

       Literally only a hundred?

   24. PTPaul Turek4:58

       Right. And this Setlarge studies in the fifties where he had, had women have sex before hysterectomies, and then he swabbed different parts of the reproductive tract, these are young women for different reasons, not infertility, and found these numbers. And that's the basis for our move to technology from five million moving sperm is when we start doing inseminations versus sex, et cetera. So those are based on the kind of numbers of sperm that reach the uterus and reach the, the thing. What's really interesting is there's some fascinating research. Everyone thought the vanguard sperm wins.

   25. PAPeter Attia5:34

       Yeah.

   26. PTPaul Turek5:34

       Right? So it's the Phelps sperm that's gonna make it.

   27. PAPeter Attia5:36

       [laughs] Right.

   28. PTPaul Turek5:37

       And there's a company in, out of Boston called Eric's Biosciences, and I'm consulting with them, disclosure, um, but they've discovered that sperm work in phalanxes. So because the immune system is so vibrant in the uterus, the first round of sperm gets through the cervix and typically absorbs the immune system. It, and it secretes FcR receptor.

   29. PAPeter Attia5:58

       And by the way, we, we've referred to the immune system a couple of times now. What is it? Is it just a bunch of antibodies? Are they B cells? What, what is the barrier?

   30. PTPaul Turek6:07

       There's side, side, there's T cells, B cells, and antibodies
3. 8:15 – 14:53

   How sperm are made & the continuous renewal influenced by environmental factors

   1. PAPeter Attia8:15

      what makes up the ejaculate, because we've talked about the sperm, so how are sperm made? Because an important consideration for a sperm is it can only have half the genetic information contained within all the other cells in the man's body. So when does that take place?

   2. PTPaul Turek8:28

      So the testicle makes sperm. It takes about 60 to 70 days, and it's a process called meiosis. So in a, in a car assembly line, you want everything to be the Model T assembly, you know, mass-produced. You want it all be the same. In meiosis, which is unlike mitosis, you want things to be different and to be a little, little easy-peasy. So you get what's called recombination, and so that's the source of evolution. So the genes, the, the chromosomes blend in a different way and separate a different way, and, and through that process of a couple of those, you get half the number of chromosomes, which is required to join the other half, which is the female's.

   3. PAPeter Attia9:03

      But it's not always the same half.

   4. PTPaul Turek9:05

      Correct.

   5. PAPeter Attia9:06

      Yep.

   6. PTPaul Turek9:06

      And it's loosey-goosey. It's not the same as when it started.

   7. PAPeter Attia9:09

      Yeah. Uh, a funny story, which I think I've shared on the podcast before, but if, if not, I'm sure someone will be amused by my stupidity.

   8. PTPaul Turek9:16

      [laughs]

   9. PAPeter Attia9:17

      Um, I had to take the MCAT before doing any of the pre-med stuff, 'cause I had studied engineering and then-

   10. PTPaul Turek9:24

       Right

   11. PAPeter Attia9:24

       ... decided I wanted to do medicine, but didn't want to spend two years preparing, one year taking the post-bac and then the MCAT and then doing it. So I was like, "I'm gonna just wing it and take this MCAT," having never taken a biology class since high school. Uh, and I didn't even... I think I took one bi- I took freshman biology, right? So I am studying my heart out for this little MCAT test, and the physics and the chemistry are fine, but this biology thing is killing me.

   12. PTPaul Turek9:57

       [laughs]

   13. PAPeter Attia9:58

       I bought this cheap study guide. I didn't have the money, or I didn't wanna splurge for the official study guide. Like, there's an official MCAT study guide, but the thing was, like, 60 bucks, but there were these knockoff books for 10 bucks. I was like, "Eh, they're just as thick." So I buy one of those, and every time I encounter the word meiosis and mitosis, I assume it's a spelling mistake because I bought the knockoff book.

   14. PTPaul Turek10:21

       [laughs]

   15. PAPeter Attia10:21

       So I'm treating it as the same thing. Every time I see the word meiosis, I'm like, "These guys, you know, they just misspelled it. Idiots. It's mitosis, mitosis, mitosis." Finally, on the night before the exam, which I still remember, it was October, uh, sorry, August 17th was the day I took the test, I realized they were two totally different things.

   16. PTPaul Turek10:41

       [laughs] Big things. There's a big difference.

   17. PAPeter Attia10:42

       Oh, my God. That, that, that realization might have got me into med school because, you know, I think I barely, I think I barely got a 10 on the biology section, which was, you know, you, you, it's hard to get into a good med school if you get below that. Uh, so anyway, I, to this day, I get such a chuckle out of the confusion of the nomenclature. But, um, again, just to explain for people, mitosis is what happens when cells are dividing in our body constantly, where they're trying to create a perfect replica of the entire suite of DNA. So really, to my knowledge, the only time we're undergoing meiosis is in the creation of an egg or a sperm.

   18. PTPaul Turek11:18

       That's right.

   19. PAPeter Attia11:18

       Okay.

   20. PTPaul Turek11:19

       The only-

   21. PAPeter Attia11:19

       Now remind me, do, do, are women born with all of their eggs? I feel like that's something I vaguely remember.

   22. PTPaul Turek11:24

       You can have, you'll have a guessed, uh, yes, five million eggs at birth.

   23. PAPeter Attia11:27

       Okay.

   24. PTPaul Turek11:28

       One million, no, five million eggs at conception, one million eggs at birth, and you basically ovulate a thousand in your lifetime.

   25. PAPeter Attia11:36

       Okay.

   26. PTPaul Turek11:36

       So by the time you're 45, you're out of eggs. You actually ovulate, you ovulate one a month, but you actually produce 10 a month.

   27. PAPeter Attia11:44

       Got it.

   28. PTPaul Turek11:44

       So you lose 10 per month.

   29. PAPeter Attia11:46

       For every one.

   30. PTPaul Turek11:46

       Right. So, so there's a l- a lot of waste, but n- there's no, they're stuck in a stage of perpetual space-
4. 14:53 – 18:57

   The built-in filter that weeds out genetically abnormal sperm

   1. PAPeter Attia14:53

      focus on that for a second. I hadn't considered that. So when, when the, when the cell that is becoming a sperm undergoes meiosis and it divides, what's the fraction of times when this becomes an aneuploidic sperm? And, and explain maybe to people what aneuploidy is, and what's the process by which that thing gets discarded?

   2. PTPaul Turek15:14

      So if you look at, uh, healthy human sperm for chromosomal content and what's correct and what's incorrect, probably 2% of them are off. They're still being made, they're just off because it doesn't really, it doesn't really, uh, click the system to, to negate it. We don't know at what level of chromosomal abnormalities the system will say, "This is not, this is a bad product."

   3. PAPeter Attia15:38

      This is absolutely defective, yeah.

   4. PTPaul Turek15:39

      Right. But I would say if you look at making of sperm, it's very logarithmic. Um, you're probably looking at one out of four that are being made go through the epididymis, which is the next 10 days, which is a collecting duct after the testicle where it matures, gets epigenetically modified, and you'll see these, these s- sosomes, different epi- epididymosomes and things like that happening. And there's a lot of post-production modification, not of DNA essentially, but I think there's a filter going on where a lot of the bad aneuploidy comes out because if you look at the chromosomal abnormality rate in testicular sperm before it goes through the rest of the system and compared to ejaculate, it's higher. It's two to threefold higher.

   5. PAPeter Attia16:20

      So something is getting filtered.

   6. PTPaul Turek16:21

      So there's a filter.

   7. PAPeter Attia16:21

      Yeah, and just so folks know, when we say aneuploidy, we mean you don't have one copy of each chromosome. You either have none or you have two or any- anything that's not one is bad.

   8. PTPaul Turek16:31

      Right.

   9. PAPeter Attia16:31

      Yeah. And, um, when aneuploidy occurs in, um, in the, in the, in the fusion of the sperm and the egg, is it, do we know, I guess we can figure out pretty easily if it's maternal or paternal in origin?

   10. PTPaul Turek16:47

       Hmm. If you look at the embryo, it's h- it's kind of hard to tell.

   11. PAPeter Attia16:51

       Okay.

   12. PTPaul Turek16:51

       There are some markers of paternal and maternal origin. It depends on where you're going back in mitosis and meiosis. So they can sort of ascribe it in the embryo. In the sperm, you're really gonna have to look at the sperm, and if you see a translocation, some characteristic change in sperm, and you see it in the embryo, then you know it's, it's paternal.

   13. PAPeter Attia17:09

       Yep, okay.

   14. PTPaul Turek17:10

       But not usually, and, uh, you know, 98% of sperm are typically normal. In a guy with infertility, it might be 95%. Here's an example. If you have a patient with Klinefelter syndrome-

   15. PAPeter Attia17:24

       Yep

   16. PTPaul Turek17:24

       ... a male with an extra X chromosome in every cell in their body or an, a transgenic model with that, that feature, uh-

   17. PAPeter Attia17:32

       So this is a man who's XXY instead of XY.

   18. PTPaul Turek17:35

       Right, so 47 chromosomes, not 46.

   19. PAPeter Attia17:37

       Yep, and phenotypically-

   20. PTPaul Turek17:39

       Extra X

   21. PAPeter Attia17:40

       ... he kind of has a distinctive look, right?

   22. PTPaul Turek17:42

       10% of the time.

   23. PAPeter Attia17:43

       Oh, really?

   24. PTPaul Turek17:44

       Yeah.

   25. PAPeter Attia17:44

       90% of the time-

   26. PTPaul Turek17:45

       You would never know

   27. PAPeter Attia17:45

       ... a man with Klinefelter, you'd never know.

   28. PTPaul Turek17:47

       Yeah.

   29. PAPeter Attia17:47

       Okay.

   30. PTPaul Turek17:48

       So that's the board question.
5. 18:57 – 28:33

   How sperm are finalized in form & function

   1. PAPeter Attia18:57

      I interrupted you. You were in the process of explaining how we actually make the sperm, where the tail comes from and the, and the whole process.

   2. PTPaul Turek19:02

      Yeah, it's all done in the testicle.

   3. PAPeter Attia19:03

      Yep.

   4. PTPaul Turek19:04

      It's an amazing machine. Uh, the weird question we should maybe get to is why is it out in the breeze like that? How, how come it was-

   5. PAPeter Attia19:11

      I assume it was temperature related.

   6. PTPaul Turek19:12

      But why, why?

   7. PAPeter Attia19:13

      Why does it need to be a little cooler?

   8. PTPaul Turek19:15

      Yeah, yeah. Why? [laughs] We've been asking ourselves-

   9. PAPeter Attia19:18

      Probably it's so ener-

   10. PTPaul Turek19:18

       ... in the field for years

   11. PAPeter Attia19:19

       I mean, I, I, I would guess, because I like to make things up-

   12. PTPaul Turek19:22

       [laughs]

   13. PAPeter Attia19:22

       ... that it's so energetically demanding that it's giving off more heat in the process of creating something that is going to be so efficient to be able to swim 20 miles effectively, and that's very glycolytic, I'm assuming, right? Like the amount of ATP-

   14. PTPaul Turek19:35

       Yeah

   15. PAPeter Attia19:35

       ... that must be generated includes some-

   16. PTPaul Turek19:37

       75 mitochondria per sperm. That's like, you know, four, it's like an electric motor on each wheel.

   17. PAPeter Attia19:42

       Yeah. So that would be my guess is you just, that's, that's, it's-

   18. PTPaul Turek19:45

       Heat, oxidative stress probably

   19. PAPeter Attia19:46

       ... it's an over, it's an overheating problem if you tried to keep those guys inside.

   20. PTPaul Turek19:49

       And I think overheating could be translated to oxidative stress, which is a cause of a lot of infertility. Anyway, it's, it's-

   21. PAPeter Attia19:54

       We don't know is the answer.

   22. PTPaul Turek19:55

       Right.

   23. PAPeter Attia19:56

       Yeah.

   24. PTPaul Turek19:56

       And, and it's in- interesting that, you know, ovaries are inside, so men get in hot baths and they're cooked. Women can get in hot baths and they're okay. So it's-

   25. PAPeter Attia20:03

       It's funny, I had a buddy over who, who shall remain nameless-

   26. PTPaul Turek20:06

       [laughs]

   27. PAPeter Attia20:06

       ... and, um, he's, he, he does not have kids, but he would like to have kids, and we, we saunad the other day and, um, he went up to my freezer beforehand. I didn't really know what he was doing in there. I thought he was getting a drink or something, and he came down with ice packs and he, he, he-

   28. PTPaul Turek20:19

       There's two companies that do that, yeah

   29. PAPeter Attia20:20

       ... yeah, he, so he basically, we were sitting in the sauna, and he was in the sauna, but he's got ice packs all over his groin and, uh, I, I immediately understood why he was doing that.

   30. PTPaul Turek20:29

       What are you doing? [laughs]
6. 28:33 – 37:03

   How to optimize conception through the timing of sex, ejaculation frequency, & understanding the sperm lifecycle

   1. PAPeter Attia28:33

      that if, if a guy is, say, ejaculating every single day, is that insufficient to get a complete replenishment where if he's having infertility, you would say-

   2. PTPaul Turek28:42

      Yes

   3. PAPeter Attia28:42

      ... you gotta move it to every other day-

   4. PTPaul Turek28:43

      Yes

   5. PAPeter Attia28:43

      ... or whatever the number is.

   6. PTPaul Turek28:45

      So that's a, a great extrapolation of the pot, of the pot of soup idea. And so on that note, I would say typically we recommend every two days of a, two days of abstinence between or sex every other day for-

   7. PAPeter Attia28:58

      Is to optimize.

   8. PTPaul Turek28:59

      Right, but not for the semen analysis. That's for conception.

   9. PAPeter Attia29:02

      Okay.

   10. PTPaul Turek29:03

       Because, uh, depends how old you are and your biology, but most men need a day or two to refill, to, to recharge completely, a day or two. So that's, that's why we do it. That, that's why we recommend that, and that's sort of a generalization. Some men are fine every day.

   11. PAPeter Attia29:19

       Okay.

   12. PTPaul Turek29:20

       I had a guy, uh, once who had to bank sperm for hepatitis treatment, and he was, looked like Mickey Rourke, and had a wooden leg, and he was about fifty. And I said, "You're gonna need to abstain for a couple, couple, three days to do this semen analysis, so we get a good sample. I want it to be, you know, optimized one." He looked at his partner, and he goes... And she looked at me, and she goes, and he grabs, he, she grabs him and says, "He can't do that. He's every day. He can't do that. I don't know what he's gonna do." So he's like, he was panicking that he had to hold off for days. [laughs] Like, I was like... I said, "How often do you have sex?" He said, "Twice a day, every day." I'm like, "Okay." So that was, uh, that was great. Then I had one man, wonderful orthopedic surgeon at Stanford, and I asked him on my questionnaire, I said, "How often do you have sex?" And he wrote .00001356. I went [laughs] Which meant-

   13. PAPeter Attia30:08

       He divided once a year?

   14. PTPaul Turek30:09

       Well, .00... Weekly. 0.0015, like, you know, Avogadro's number, right? Uh, like, which meant he was so frustrated that [laughs] it was, it was a beautiful way to say that. It was the .001355.

   15. PAPeter Attia30:24

       Yeah.

   16. PTPaul Turek30:24

       [laughs] So anyway, the, um... Yeah, so that's, so there, for a semen analysis for diagnostics for infertility, when you, when you abstain longer, your sperm count will rise, but your motility will fall 'cause it's older. So there's a, you know, there's two different intersections

   17. PAPeter Attia30:44

       There's a min-max curve that you're optimizing for-

   18. PTPaul Turek30:46

       Right

   19. PAPeter Attia30:46

       ... which you would say is-

   20. PTPaul Turek30:48

       Three days would be about right, when you're not going to gain that much, you're not going to lose that much motility. After that, it starts to go. So there's sort of biological variability, which we try to minimize when we do the semen analysis, so two to four days of abstinence. That's a different period than what we're recommending for sex, which is every other day.

   21. PAPeter Attia31:07

       Mm-hmm.

   22. PTPaul Turek31:08

       And that's based on a New England Journal paper where you looked at, they looked at, um, I think 700 couples, and they had them keep diaries, it was a Boston-based paper, keep diaries of how they, uh, had sex, when they ovulated, and when they got pregnant. And then they said, "Do what you'd normally do, and then give us the diaries." And then they evaluated them, and they found that having sex, say, ovulation is day 15 of the cycle, um, when they started having sex on nine, 11, 13, there were significant pregnancy rates, and every other day was the optimal interval. But even five days before and three days before, there were substantial pregnancy rates before ovulation. But if you waited to ovulation and then had sex, that's about 20% of conception. So when you get the kit, don't react to it, predict in front of it. So front load the sex. Very important point.

   23. PAPeter Attia31:58

       And why is that? Is that because-

   24. PTPaul Turek32:01

       There's a reservoir effect in this uterus. It's managed. Sperm will survive for a day or two. So when men are under stress-

   25. PAPeter Attia32:07

       But how, if ovulation is day 15, how could a day 11 sperm survive four days?

   26. PTPaul Turek32:14

       Because it's nurtured once it's past the vagina.

   27. PAPeter Attia32:18

       But how many of them are surviving?

   28. PTPaul Turek32:20

       I don't know.

   29. PAPeter Attia32:20

       Is it literally the lone wolf-

   30. PTPaul Turek32:22

       Probably
7. 37:03 – 44:43

   Male infertility & Paul’s diagnostic approach: detailed history, a physical exam, & identifying red flags

   1. PTPaul Turek37:03

      Doesn't have to be timed intercourse, just has to be whatever the couple does when they think they're trying to conceive.

   2. PAPeter Attia37:07

      Okay. Um, when someone shows up in your office, is it usually after they've gone down the rabbit hole of troubleshooting the female partner or are people doing this in parallel?

   3. PTPaul Turek37:24

      There's a large bias in Western worlds about how infertility is evaluated, and it's a complex... The, the reasons are complex. But I would say my practice is not typical, so most of my patients have been through a lot before they come to me. And typically, I think Keith Jarvi's data was good, and about 23% of men get a formal evaluation for infertility before couples go through IVF in North America.

   4. PAPeter Attia37:52

      And how does that differ from the rest of the world, like, say, from Europe?

   5. PTPaul Turek37:55

      I don't think it's been studied in the rest of the world. But there are countries like Germany and Spain with, and, you know, with single insurers and government pays, and it, it's also recommended by society guidelines like American Society of Reproductive Medicine, WHO, et cetera, that both partners get evaluated simultaneously. Uh, but the bias is female gets very evaluated for lots of money, and the men typically may get a semen analysis but may not, and there's, it's very complex reasoning there. It's a different beast. You know, they're not part of the problem. They refuse to do it. There's a lot of denial. It does get at your masculinity a little bit to get checked out and, and things, so it does go deep.

   6. PAPeter Attia38:37

      Hmm.

   7. PTPaul Turek38:37

      For men, it can be a little bit of a, a problem. Uh, so I would say that lately with large insurers coming in, Progyny, Maven, and things like that, you're seeing a lot more men up front, which is fabulous, and we can have long discussions about the biomarker concept, why that's good for a field and good for men's health and good for longevity.

   8. PAPeter Attia39:00

      Okay. So let's, let's talk about, um, your, your workup. What do you do when a guy comes in and, um, what are the things you want to know about him?

   9. PTPaul Turek39:11

      So getting a guy in is great. Uh, usually they're dragged in by their partners. Uh, usually the partners come along to make sure they show up. For me, it's one visit. So we do one visit and I do everything else where they are where they are. I don't ask them to come in a million times anymore, so it's a very different kind of practice. But I try to get everything done in one visit 'cause when you get them there, it's rare to get them there. And the physical exam, so you do a history, a very thorough history, which is usually preceded by a questionnaire. I give like 200 questions and that has all the hot bath stuff and all the exposures they have and they have to do that before they see me 'cause [chuckles] that's a really important part of it. If you could pick one in a multiple choice question what matters the most, it's probably the history.

   10. PAPeter Attia39:52

       Hmm.

   11. PTPaul Turek39:53

       History of paternity matters, a history of exposures matters, et cetera. Physical exam, very important. One to five percent of male infertility can be due to a medi- major medical issue, testes cancer, diabetes, things like that. So physical exam, varicoceles is very important. You could be missing a vas deferens. Uh, one in 500 men have perfectly normal testicles but no, they have a natural vasectomy. It's congenital absence of the vas. It's, they're gonna be sterile or infertile.

   12. PAPeter Attia40:21

       Can you explain what that... We haven't talked about how a vasectomy works and why a guy still ejaculates but is infertile. Explain what the vas deferens, how, how the whole thing works in the plumbing.

   13. PTPaul Turek40:30

       Right. So we asked, we didn't answer that question-

   14. PAPeter Attia40:32

       Yeah

   15. PTPaul Turek40:32

       ... which was the, what the semen consist of.

   16. PAPeter Attia40:34

       Yeah.

   17. PTPaul Turek40:34

       So it's about 10% vasal fluid with sperm. It's about 80% seminal vesicle fluid which is an accessory sex, sex gland in the back of the prostate and about 10% prostate. So typically during ejaculation, prostatic fluid which is clear and sticky will grease the barrel of the urethra, sort of pre-cum. Then during the ejaculation process, the pellet of sperm gets pumped from the vas deferens into a chamber called the ejaculatory duct and this happens quickly and then the seminal vesicle, which is like a bladder, contracts, sends it into the prostatic urethra between the bladder and the, the outside world. There's two valves. One is the bladder neck, it closes, and one is the urethral sphincter that we pee through and that opens and it gets forced out with muscular contractions. So that happens in seconds.

   18. PAPeter Attia41:23

       Yeah. So therefore if the vas deferens is clipped, you're getting essentially 90% of the volume. You're just missing the 10% of the volume that contains the payload.

   19. PTPaul Turek41:32

       So in three thousand men I've done vasectomies on in 30 years, two men have said, "My volume went down." And I said, "Really?" One of them banked sperm and he had a semen analysis before and after and he did go down by 15% and he noticed it and I said, "Good for you. What do you want to do now?" [laughs] But so it can be noticeable.

   20. PAPeter Attia41:50

       Yeah.

   21. PTPaul Turek41:51

       But not usually and so the color's the same, the opacity's the same, the, the whole process of, uh, liquefaction's the same, viscosity, et cetera.

   22. PAPeter Attia41:59

       Got it. So physical exam, um, do you need an ultrasound?

   23. PTPaul Turek42:04

       No.

   24. PAPeter Attia42:04

       How are you able to detect if a person is congenitally missing a vas deferens?

   25. PTPaul Turek42:08

       Just pure physical exam.

   26. PAPeter Attia42:09

       What, what, you feel it?

   27. PTPaul Turek42:10

       Mm-hmm.

   28. PAPeter Attia42:11

       Interesting.

   29. PTPaul Turek42:11

       So my fingers can feel two and a half millimeters and the vas deferens is like a piano wire. I mean it is different than anything else in the cord. So I did a study, a third of my men with absent vas were, were m- were only found out having procedures un- until I saw them. I usually just do the exam, but it is an expertise thing.

   30. PAPeter Attia42:32

       Yeah, yeah. It's not like the PCP can figure this out. You have to be doing this all day every day obviously.
8. 44:43 – 50:50

   Viral infections that can affect the testes & potentially lead to sterility

   1. PTPaul Turek44:43

      cancers, infections, epididymitis.

   2. PAPeter Attia44:48

      Yeah, tell me about epididymitis. Obviously, anything that interferes with that section of the journey is gonna be critical.

   3. PTPaul Turek44:53

      Yeah, so-

   4. PAPeter Attia44:53

      And, and remind me, is it EBV that we typically, or measles, mumps? What's the, what's the infection?

   5. PTPaul Turek44:59

      Mumps.

   6. PAPeter Attia44:59

      Mumps, okay.

   7. PTPaul Turek45:00

      But that's typically... Yeah, so among viruses in the world, there aren't many that get into the testicle like other things. Very little gets into the testicle, similar to the brain. But the mumps virus does it about a third of the time it, when you're a child with mumps, you know, the parotid gland infection. It's a glandular disease.

   8. PAPeter Attia45:18

      Yep.

   9. PTPaul Turek45:19

      So it really only matters when you're pubertal and you get mumps. And then it goes to lots of glands. It go to your pancreas and cause diabetes. It can go to the salivary glands. It can go to the testicles. It's a, it's some kind of, there's an open time, open, open r- you know.

   10. PAPeter Attia45:36

       So just one more reason why everyone should really get the MMR vaccine when they're a child is like we, you know, not, notwithstanding the tragedy of-

   11. PTPaul Turek45:44

       This is a big deal, yeah

   12. PAPeter Attia45:44

       Yeah, yeah, yeah, of, of children dying from preventable diseases. But this is, this is another non-lethal but significant complication of the mumps.

   13. PTPaul Turek45:52

       Absolutely.

   14. PAPeter Attia45:52

       Yep.

   15. PTPaul Turek45:52

       And it will cause v- um, viral necrosis and edema of the testis. And it, similar to a brain, it's in a calvarium, right? The brain is in a fixed space, so when it swells, you gotta do something because it can, it, it can die-

   16. PAPeter Attia46:07

       Mm-hmm

   17. PTPaul Turek46:07

       ... if it swells too much. Testicle's a fixed cavity with the tunica albuginea. And so if it swells too much, it necrosis, and then you get fibrosis-

   18. PAPeter Attia46:14

       Hmm

   19. PTPaul Turek46:14

       ... and then you get sterility. And it's, you know, I've got techniques where I can find sperm in lots of these men, very little pockets, but most of it, you're ablating the testis. It's gonna scar and die from ischemic necrosis. So Zika, Ebola, these are... I mean, the CDC called me when these were coming around. Zika, you know, Zika's been transmitted through semen. It causes the anencephaly issues with, uh, child, and when these, when these pandemics recurring, Ebola too. Um, I got a call that there was an Ebola patient who survived, went to the institute, survived the hemorrhagic fever, and then, uh, a year later, transmitted Ebola to a partner who transmitted it to s- six other men, and it was another outbreak in South Africa.

   20. PAPeter Attia47:00

       Meaning the-

   21. PTPaul Turek47:02

       So a year after

   22. PAPeter Attia47:02

       ... patient that survived Ebola, the virus managed to survive in the testes?

   23. PTPaul Turek47:08

       Somewhere.

   24. PAPeter Attia47:09

       Okay.

   25. PTPaul Turek47:10

       But it was transmitted sexually a year later when he was well.

   26. PAPeter Attia47:13

       When he was asymptomatic. He had already developed immunity.

   27. PTPaul Turek47:15

       Right. So there are, we don't know about testes, but we know that mumps will do that to the testes, but there are, Zika is also persistent in the semen.

   28. PAPeter Attia47:23

       But in that case, you have to think they would h- wherever the virus hung out, it had to be very, very immune privileged.

   29. PTPaul Turek47:30

       Yep.

   30. PAPeter Attia47:32

       Huh.
9. 50:50 – 1:03:53

   Semen analysis: morphology, motility, & hormonal clues to male fertility

   1. PAPeter Attia50:50

      can we go back to s- semen analysis? Um, you're looking for obviously the count and the motility. What else do you look for?

   2. PTPaul Turek50:57

      So in the semen analysis, there's several features. I consider it sort of a poker hand. Uh, there's a volume, how much of the semen volume. There's a count, concentration of sperm. That's numbers per mil. And then there's motility, which is percent motion. You do a forward progression, so how good is the quality of motion? And typically, some measure of shape called morphology. There's three liquid issues, liquefaction, agglutination, uh, and viscosity. And then you look for other cells that aren't sperm. They're called round cells, and either they're gonna be pus cells or immature germ cells that are early, ejaculated early.

   3. PAPeter Attia51:33

      And presumably, you want to see fewer of those.

   4. PTPaul Turek51:36

      Right. There's a number, like less than a million is normal.

   5. PAPeter Attia51:39

      Okay.

   6. PTPaul Turek51:41

      So if you ask me, "Well, how do I look at a semen analysis?" That's a little different. I look at that as a poker hand with each card has a meaning, but they have a look. So if you said, "What do you mean by that?" So if the volume is low, it's one of five things. You're always gonna find something. It's either collection error, I call it first sample syndrome, guy's not good at it, right?

   7. PAPeter Attia52:00

      Yeah.

   8. PTPaul Turek52:00

      You know, it's like, "Okay, I got to put it in the cup, and I got to stop doing what I'm doing and okay," you know. So, so you do a second sample, and then there's low testosterone can cause it. There's an absent vas deferens, which means you have an absent seminal vesicle. There's ejaculatory duct obstruction.

   9. PAPeter Attia52:13

      And by the way, do you ever have that on one side and not the other?

   10. PTPaul Turek52:15

       Mm-hmm.

   11. PAPeter Attia52:15

       Or is that always... Okay.

   12. PTPaul Turek52:16

       Mm-hmm. Yeah, no, it's very variable. It's segmental.

   13. PAPeter Attia52:18

       Yeah.

   14. PTPaul Turek52:19

       And so there's five real issues. So when I see a low volume semen, as a surgeon and as a doc- I mean, I'm gonna find something. So that's really good. Other than that, the semen analysis, uh, I, I, I think I've been published as saying it's a blunt instrument for fertility. Unless it's zero, you can't really say much about their fertility, 'cause people conceive at all levels, and people-

   15. PAPeter Attia52:40

       Are there scenar- are there, you know, obviously you rattled off a whole bunch of parameters that you can access there, but are there certain null states that don't exist, where everything is amazing, but this one thing is horrible? Like, do you see scenarios where-

   16. PTPaul Turek52:52

       Sure

   17. PAPeter Attia52:52

       ... everything is remarkable, perfect motility, but bad morphology, or-

   18. PTPaul Turek52:56

       Yes

   19. PAPeter Attia52:57

       ... perfect morphology and-

   20. PTPaul Turek52:58

       Isolated, isolated examples.

   21. PAPeter Attia52:59

       You do see isolated things.

   22. PTPaul Turek53:00

       Right. So one of them is called, I call it syndromic sperm shape problem. So you can have a perfectly normal semen analysis, count, motility, volume, progression, and the sperm look terrible. And so there are rare conditions, one in 5,000, where you might have globospermia or two-tailed sperm or pinhead sperm. So if you look at shape, 4% should look normal, which is terrible. We can have a whole discussion about why 4% of human sperm being normal is normal when 99% of animal species in the wild have normal looking sperm. But it's all a construct, right? It's, it's all a construct of who someone decided what normal is. But in men who have large abnormal forms, like 4%'s normal, if they're 1% normal and you look at the abnormalities-

   23. PAPeter Attia53:45

       I'm sorry, I'm still confused on that point. Are you saying that in a... You would consider it perfectly normal if only 4% of the sperm are morphologically perfect-

   24. PTPaul Turek53:54

       Mm-hmm

   25. PAPeter Attia53:54

       ... and 96% are not? And that means the 96% that are not could be pinhead, could be double tail.

   26. PTPaul Turek54:03

       Amorphous or tapering at a-

   27. PAPeter Attia54:04

       Going back to the original-

   28. PTPaul Turek54:06

       That's a, that's a, as a mathematician, that's not a great number, is it? [laughs]

   29. PAPeter Attia54:08

       No. And if you-

   30. PTPaul Turek54:09

       If you look at marine species, 99.9 look perfect if in, in the wild.
10. 1:03:53 – 1:13:54

    Effects of medication, microplastics, stress, & exercise on fertility

    1. PAPeter Attia1:03:53

       So those are four big pillars. Anything else besides the history-

    2. PTPaul Turek1:03:56

       Yeah, so-

    3. PAPeter Attia1:03:56

       ... the exam, the analysis, and the hormones?

    4. PTPaul Turek1:03:58

       And then, so you usually do two semen analyses three weeks apart or more to get a sense of things because it varies quite a bit. So on, a lot of, a lot... A very important point is that the semen analysis, any feature of that semen analysis vary by 50 to 100%.

    5. PAPeter Attia1:04:14

       So never make a decision on one semen analysis.

    6. PTPaul Turek1:04:16

       It's really hard.

    7. PAPeter Attia1:04:16

       Yeah.

    8. PTPaul Turek1:04:17

       It's really hard.

    9. PAPeter Attia1:04:17

       Especially if it's the first one, as you said, for all the-

    10. PTPaul Turek1:04:19

        Right

    11. PAPeter Attia1:04:19

        ... potential.

    12. PTPaul Turek1:04:20

        So I, I do a lot of consulting for the FDA, and they do, you know, they do, they do medications in reproductive-aged men, and they're trying to show the semen analysis. They're going to the FDA and they're saying, "Can you help us interpret this data for the FDA?" And I said, "Garbage in, garbage out." I mean, there's so much variability, you really can't say anything. It's really hard to get... So you have to do at least two samples, and it still varies quite a bit. There's, there's interobserver variability.

    13. PAPeter Attia1:04:43

        Yeah.

    14. PTPaul Turek1:04:43

        Who does the semen analysis? There's biological variability on what your system's like. So that's the big problem with studies, is that there's a lot of variation.

    15. PAPeter Attia1:04:50

        So what percentage of drugs that are going through an FDA approval process are having a, a semen analysis as part of the evaluation?

    16. PTPaul Turek1:04:59

        I don't think many.

    17. PAPeter Attia1:05:00

        Why is that?

    18. PTPaul Turek1:05:01

        Uh, because usually the indications aren't reproductive age, reproductive age men or women for some of them. If they do, they'll do animal models. They won't do human studies, do animal models. They'll do beagles, so mice and beagles, and if there's no fertility effects, they don't really look at semen analyses in those. They'll look at fertility effects in the animals. If there's nothing there, then they'll probably not require human studies. If there's any suggestion of a problem in the animal, in animal models, which is a million dollars of work. So if you ask me why I patented the spermatogonial stem cell, I want an in vitro test for human infertility that we could use instead of animal models, save the animals, save a million dollars, do an in vitro spermatogenesis model and see where the, if there's an effect at all.

    19. PAPeter Attia1:05:47

        It just seems to me that in this day and age with people reproducing at older and older ages, we, we shouldn't just assume that because we've developed a drug for blood pressure or diabetes, that it's not going to be used by people with fertility. I'll give you a silly example. Have GLP-1 agonists been tested for fertility? Okay, well think of it-

    20. PTPaul Turek1:06:08

        No, because it's sort of an off-label use of a diabetic medication.

    21. PAPeter Attia1:06:11

        But it's no longer off label.

    22. PTPaul Turek1:06:12

        I know.

    23. PAPeter Attia1:06:12

        It's an on-label use today.

    24. PTPaul Turek1:06:14

        No, no. But it looks like it might be helping with fertility.

    25. PAPeter Attia1:06:16

        But even if it, but even if it was on label, I mean, I'm just using that as one example of a drug that was initially-

    26. PTPaul Turek1:06:21

        Yeah

    27. PAPeter Attia1:06:21

        ... approved when we thought, "Ah, this is going to be for people who are not having kids." But the truth of it is you're going to have lots of people that are trying to reproduce on many of these drugs.

    28. PTPaul Turek1:06:29

        Absolutely, and you know, there are 80,000 chemicals out there that have, are not been studied reproductively that are commonly in use in industry. European commissions are a little better off. They, they've screened them and they've warned about them, but America, mm-mm.

    29. PAPeter Attia1:06:43

        Why is that?

    30. PTPaul Turek1:06:45

        I don't know. It's attention to detail. It's one of those things that just doesn't... I don't know.
11. 1:13:54 – 1:35:50

    Testosterone replacement therapy (TRT) & male fertility

    1. PAPeter Attia1:13:54

       let's talk about the use of anabolic steroids. So, um, or let's, let's talk about it more broadly with sort of the three most commonly used approaches to testosterone replacement. So the, the way I see it is the three most common approaches are using either clomiphene or enclomiphene, using HCG, or using exogenous testosterone in one of its derivatives. Would you agree that those are kind of the big three?

    2. PTPaul Turek1:14:22

       Yeah.

    3. PAPeter Attia1:14:23

       Okay. Uh, we'll just r- briefly highlight for everybody why each is a little bit different. Exogenous testosterone, you're just giving testosterone. The body senses it and immediately shuts down the hypothalamus.

    4. PTPaul Turek1:14:34

       All natural production.

    5. PAPeter Attia1:14:35

       Yep. So LH and FSH will go to zero. Testosterone will be as high as you want it to be. It's... There's no limit to how high it goes. I've had a couple of people on this podcast who have blown my mind with how much testosterone they've talked about taking. Um, not clear how that's possible, but nevertheless-

    6. PTPaul Turek1:14:53

       [laughs]

    7. PAPeter Attia1:14:53

       ... they're, they're doing it. Okay. Uh, HCG is synthetic luteinizing hormone.

    8. PTPaul Turek1:14:59

       LH, right.

    9. PAPeter Attia1:14:59

       So you give a person HCG, they will make testosterone, so it's endogenously produced, but they're making so much of it that they'll also suppress LH and FSH. So LH and FSH will come down, testosterone will go up. And then clomiphene or enclomiphene block the signal of estrogen at the level of the hypothalamus.

    10. PTPaul Turek1:15:23

        Right.

    11. PAPeter Attia1:15:23

        So the hypothalamus thinks-

    12. PTPaul Turek1:15:24

        Doesn't see any

    13. PAPeter Attia1:15:24

        ... oh my gosh, we need more testosterone.

    14. PTPaul Turek1:15:27

        Right.

    15. PAPeter Attia1:15:27

        It ramps up FSH and LH production, which has the same effect as making more testosterone, but you'll now see high normal FSH and LH.

    16. PTPaul Turek1:15:36

        Yeah, and the two, the two different classes are the LH and Clomid versus testosterone. So unlike testosterone shutting off the natural production, the LH, the HCG, and the clomiphene, enclomiphene will stimulate natural production.

    17. PAPeter Attia1:15:49

        Yep.

    18. PTPaul Turek1:15:49

        So you keep your testicular size, you maintain your fertility, whereas the others, you're gonna shrivel up your testicles and not maintain your fertility, and you can't generate levels that you can with the exogenous testosterone g- with these. You, you'll never get to 3,000. You can't do that because it's, it's tightly regulated.

    19. PAPeter Attia1:16:07

        So question one, if a guy is taking exogenous testosterone, and let's just say he's been on it now for a few months, is he able to create sperm?

    20. PTPaul Turek1:16:20

        Not... 95% chance he's not.

    21. PAPeter Attia1:16:23

        Wow.

    22. PTPaul Turek1:16:24

        While he's on it.

    23. PAPeter Attia1:16:25

        Yep. Understood.

    24. PTPaul Turek1:16:25

        But can he create it once he stops?

    25. PAPeter Attia1:16:27

        And we'll-

    26. PTPaul Turek1:16:27

        Yeah

    27. PAPeter Attia1:16:27

        ... and we'll definitely address that. But just to be clear, even a couple of months on exogenous testosterone in any form, injection, topical, oral, whatever, you basically have shut off the ability to make sperm because your testes themselves have shut down.

    28. PTPaul Turek1:16:46

        Right. No signals.

    29. PAPeter Attia1:16:47

        Yep. Okay.

    30. PTPaul Turek1:16:48

        No gas to the engine. Now, there are s- some ex- it's nuanced.
12. 1:35:50 – 1:48:24

    Restoring fertility after prolonged use of exogenous testosterone

    1. PAPeter Attia1:35:50

       All right, so now let's talk about the guy who comes to see you. He's been on exogenous testosterone for three years. So he was given poor advice three years ago. He went to some shady-

    2. PTPaul Turek1:36:01

       Sure

    3. PAPeter Attia1:36:01

       ... you know, back alley website, and they just... You know, he was 27 years old at the time. He just wanted to... I mean, this is tragically a very common story, by the way, right?

    4. PTPaul Turek1:36:10

       Yeah, it is.

    5. PAPeter Attia1:36:11

       So this guy's been on 200 milligrams of testosterone a week for the past three years. He's now 30 years old. He's met the love of his life, and lo and behold, they can't seem to get pregnant. So he's in your office. During the history, you find out pretty quickly he's been on 200 milligrams of testosterone for three years. Tell me what his, uh, sperm analysis looks like. Do you see... There are no sp- there presumably there are no sperm.

    6. PTPaul Turek1:36:35

       I would bet 95% confidence that he would be n- have no sperm in his semen.

    7. PAPeter Attia1:36:40

       Okay. So you-

    8. PTPaul Turek1:36:40

       At 200 milligrams a week.

    9. PAPeter Attia1:36:41

       So what are you telling him now? How are you gonna solve this problem?

    10. PTPaul Turek1:36:44

        So it's funny, 'cause a lot of guys come in, um, they're, they look good, and, uh, and I'll, when I examine, I'll say, "Are you taking anything? Are you taking..." 'Cause they never put it on their medications, right? [laughs] They never write it out on the history. You always have to get it out of them. And if they look-

    11. PAPeter Attia1:36:59

        If they're super jacked, but then they have shriveled testes.

    12. PTPaul Turek1:37:02

        Yeah, and they're zero.

    13. PAPeter Attia1:37:03

        Yeah.

    14. PTPaul Turek1:37:03

        And they're, and they're wondering, like, "Eh, what, what?" You know, right? [laughs] So I will look them in the eye and say, "Are you taking testosterone?" And I'll look them in the eye until they answer. And if they look down and, and they don't say anything, I know they're on it. If they look me in the eye and say no, then I know they're not. But they'll always look away, 'cause it's, it's this verboten thing. So-

    15. PAPeter Attia1:37:24

        This is the same, by the way, as I'm sure you experienced as a resident in the ER. The people that come in with foreign rectal bodies and abdominal pain, that's the one thing they omit from their history, right? It's like they tell you, you know, "This is the last time I ate. This is this. This is this." But then you get the X-ray back, and there's like a candlestick in their colon. And then you say, "What about this-"

    16. PTPaul Turek1:37:45

        [laughs] This is your Hopkins training. This is Baltimore.

    17. PAPeter Attia1:37:46

        "What about this can-" Yeah, yeah. "What about this candlestick?" And they're like, "Oh, I totally forgot to mention that. Yes, yes, that."

    18. PTPaul Turek1:37:52

        It was lit when it went in, yeah.

    19. PAPeter Attia1:37:53

        Yeah, yeah, yeah.

    20. PTPaul Turek1:37:54

        So, um, typically I'll say So my theories about this is if he's... Why is he taking it? So if he's taking it for anabolics-

    21. PAPeter Attia1:38:03

        Yep

    22. PTPaul Turek1:38:03

        ... then, you know, he probably has a pretty good idea, and I, I want to send you, uh, give you a little research we're doing on the lifespan of anabolic steroid users. So remind me to, at the end of the story, to give you a little brief about what, what I know about that. But, um, so I... So when you take... So how he takes it matters.

    23. PAPeter Attia1:38:23

        Yep.

    24. PTPaul Turek1:38:23

        So if he's been in constant use injectables-

    25. PAPeter Attia1:38:26

        Yep

    26. PTPaul Turek1:38:26

        ... that's the most suppressive of fertility, and if you turn a gland, like a testicle, off long enough, it's off. So I gave a lecture to the Endocrine Society on recovering men from hypogonadism in young men, and I asked them a question at the end because I, just, I, my whole p- procedure comes from steroid users. I, I, I take notes when the anabolic guys come see me because they're really smart and they know a lot about reactions, biology.

    27. PAPeter Attia1:38:53

        It's incredible.

    28. PTPaul Turek1:38:54

        Not everything.

    29. PAPeter Attia1:38:54

        Yeah, yeah.

    30. PTPaul Turek1:38:55

        But there's a science. Some of them are PhDs. I took notes for years, and it came up my approach, uh, along with what I know, right? So it's very much in concert with, concert with them, so everything I say is sort of built on ex- a large experience, uh, and it's called Getting Off the Juice, the blog. And I have people read that blog, do it, and say get about 80% of the way and then call me and say, "You know, I need help here. Now I'm here."
13. 1:48:24 – 1:55:05

    Effects of heat & cold exposure on fertility

    1. PAPeter Attia1:48:24

       All right. So let's shift gears and talk about other modifiable factors. Um, let's talk about heat. We've talked about it a little bit.

    2. PTPaul Turek1:48:30

       So for fertility.

    3. PAPeter Attia1:48:31

       Yes, for fertility. So tell me about the impact of cold plunging and sauna and hot tubbing, um, on, uh, on, on fertility for men.

    4. PTPaul Turek1:48:43

       Okay. So the testis is outside the body.

    5. PAPeter Attia1:48:45

       Yep.

    6. PTPaul Turek1:48:45

       It's three degrees cooler than the rest of the body, so ninety-five versus ninety-eight degrees Fahrenheit, and then there's a reason for that, unknown. We had that conversation. Don't really know why, but, uh, it may be that it's an immunologic sanctuary, and that's the only way to do it, and that God or Darwin could figure out. But, um, if you heat up the testicle, it's also close to the skin, so it's a radiator. So when the heat comes down the arterial blood, it has to cool, so it raises and lowers, and there was a journal in the jour... There was an article in the Journal of Irreproducible Results about twenty years ago. A man went to Big Sur and wore nothing, and he measured ambient temperature, and then he marked on his leg with a marker where his, his scrotum hung, how low it hung, and he could tell the ambient temperature by how high or low his scrotum hung. He became a thermometer. So, [laughs] so it does go up and down. [laughs] Is that Peter Attia laughing? [laughs] Journal of Irreproducible Results.

    7. PAPeter Attia1:49:41

       Oh, God.

    8. PTPaul Turek1:49:41

       Really cool, but it showed that it's very s- temperature sensitive, right? And it goes up and down to regulate it closer to the body when you want it warmer, et cetera, right? You go into a cold shower or plunge, where are your testicles? They're way up there, right?

    9. PAPeter Attia1:49:52

       They're in my abdomen, yeah.

    10. PTPaul Turek1:49:54

        And that's all the cremasteric muscle, and it's all s- temperature driven. So it spends all of its time regulating its temperature to stay at ninety-five. Now, saunas, baths, hot tubs, jacuzzis, steam rooms change that, right? The worst one of those is anything underwater, submerging underwater, because you're one centimeter away, you're a liquid, it's a liquid, you're going to turn that temperature, maybe not the ins- in part, inner part of your body, but little kids going into hot tubs, right? They overheat. So testicles will certainly overheat.

    11. PAPeter Attia1:50:24

        So you get into a one oh five degree hot tub, which is a very typical temperature for a hot tub, is a hundred and five to a hundred and ten. You're saying within a relatively short period of time, your testes will assume that temperature.

    12. PTPaul Turek1:50:35

        Absolutely.

    13. PAPeter Attia1:50:36

        Yeah.

    14. PTPaul Turek1:50:36

        You're seventy percent liquid.

    15. PAPeter Attia1:50:37

        Yeah.

    16. PTPaul Turek1:50:37

        And this is right at the surface. So I did a study, published it in the Brazilian Journal of Urology. Very-- I published two hundred studies. This was the hardest one to get in. Everyone said, "We know that it affects, it affects fertility, so I don't-- we're not going to publish it." So American-- So I went to the Brazilian Journal of Urology. It then went to The New York Times as a press release. That's how popular it was. It's probably my most cited paper ever, and it's certainly not my best. It's very interesting. I took infertile men with low sperm counts and stopped the tubs. They were in hot baths, jacuzzi. I used the word jacuzzi. Jacuzzi called me up and said, "Stop. Don't use that word." So I don't use that word. So hot baths or tubs, and I told them out, and they went up three hundred percent. Their semen anal- semen quality went up three hundred percent, total mole count in three months or four months, and six hundred percent at six months. So, you know, you have to give it some time, and that's that curve, right? The recovery curve. And we didn't look at fertility, we just looked at that recovery. And some of them were zero and went up to close to normal.

    17. PAPeter Attia1:51:39

        What was the age range of these men?

    18. PTPaul Turek1:51:40

        Think thirty-five.

    19. PAPeter Attia1:51:41

        So fertile men.

    20. PTPaul Turek1:51:42

        Yep.

    21. PAPeter Attia1:51:43

        And-

    22. PTPaul Turek1:51:43

        Trying to conceive

    23. PAPeter Attia1:51:44

        ... yeah, these are men who are not able to conceive. You're making the diagnosis, "I think it's your hot tub. Let's get you out of there," and they have a sixfold increase in sperm count.

    24. PTPaul Turek1:51:53

        Total modal sperm count, meaning count, motility, mainly driven by motility.

    25. PAPeter Attia1:51:57

        Interesting.

    26. PTPaul Turek1:51:58

        Mainly dri- but-

    27. PAPeter Attia1:51:58

        So it's the motility that the price-

    28. PTPaul Turek1:51:59

        The biggest one, but also count might have doubled, motility may have gone up threefold kind of thing, so sixfold increase overall. Then I calculated, after that, I calculated a lethal dose of tubbing.

    29. PAPeter Attia1:52:10

        Hmm.

    30. PTPaul Turek1:52:11

        So what's the lethal dose?
14. 1:55:05 – 2:00:00

    How different levels of exercise—especially cycling—affect male fertility

    1. PAPeter Attia1:55:05

       Let's talk about exercise. You mentioned one example of exercise that can be problematic, which was, I believe you said in a study where men were ramped up-

    2. PTPaul Turek1:55:15

       Extreme

    3. PAPeter Attia1:55:15

       ... to two hours a day of exercise-

    4. PTPaul Turek1:55:18

       Five days a week

    5. PAPeter Attia1:55:18

       ... that was above eighty percent of VO2 max-

    6. PTPaul Turek1:55:21

       Right

    7. PAPeter Attia1:55:21

       ... which is pretty strenuous.

    8. PTPaul Turek1:55:22

       That's right.

    9. PAPeter Attia1:55:22

       Um, that, that was enough to put a dent in their fertility. Um, tell me about riding a bicycle.

    10. PTPaul Turek1:55:28

        I'm a biker. Uh, I have old vintage bikes that I used to race in Connecticut, and I had them rehabbed, and they're all Italian, and they're all steel, and they weigh a ton, and the seats are from Brit- Britain, and they've got ten thousand miles on them, and they weigh four pounds, as much as like-

    11. PAPeter Attia1:55:44

        Just like a Brooks saddle, these Brooks leather saddles?

    12. PTPaul Turek1:55:45

        Yeah, Brooks leather saddles.

    13. PAPeter Attia1:55:46

        Yep.

    14. PTPaul Turek1:55:46

        And, you know, all, all worked out, and it's like that saddle nowadays is about half the weight of a, of a, of carbon bike, right?

    15. PAPeter Attia1:55:54

        Yeah.

    16. PTPaul Turek1:55:54

        So, but I love it, and I'm, I was thinking of maybe going senior league and doing these gorgeous steel frames and, and, and trying to keep up with those guys, 'cause it's not about the bike, really. It's like when you get golf clubs And I got a $150 set of golf clubs. I'm going to be as bad a golfer with thousand dollar clubs as a hundred. So it's really about the biker. But there are some differences in terms of the momentum and the wheel force and all that. But I love my old steel bikes. So, um, and they see this. It's like hanging in my office when I come to work in the morning and I bike in San Francisco, and I have the seat, and it's like, you, you... That's a bad saddle. And so the issue really is that it got started that biking was bad for reproductive health with a Spanish competitive cycling study. So competitive Spanish cyclists, Tour de France caliber cyclists, their sperm counts were examined.

    17. PAPeter Attia1:56:43

        But what was the control group? Did they have a control group of runners?

    18. PTPaul Turek1:56:46

        I don't remember. I don't think so.

    19. PAPeter Attia1:56:47

        So in other words, it could have been the exercise that was the... It could have been the intensity of their exercise.

    20. PTPaul Turek1:56:51

        Not a good group to study.

    21. PAPeter Attia1:56:52

        Yeah.

    22. PTPaul Turek1:56:55

        So their sperm counts were low, their morphologies were off, and they're extreme athletes, so we know that, and we know maybe they were on drugs, maybe they were, you know. [laughs]

    23. PAPeter Attia1:57:03

        Yeah.

    24. PTPaul Turek1:57:03

        It's a big industry. They're super fit. They're certainly exercising two hours, right? And so they said, you know, "Look at these guys who are really healthy and look at their sperm counts," but this other data didn't come out. So I did a blog called Cycling into Childlessness, and I looked at a more comparable study, which was British commuting cyclists, so everyday people bicycling to work in Britain on different saddles and, you know. And I looked at their fertility, and their fertility was far better than the average Brit.

    25. PAPeter Attia1:57:32

        So even if they were taking some hit off the bike, it was probably more than compensated for by their healthy lifestyle, which included probably riding the bike. But obviously, there's a healthy user bias because anybody who's riding their bike to work is probably consuming less Guinness, fewer fish and chips, smoking less. In other words, riding a bike is a proxy for being healthy. But in spite of that, it didn't offset that health risk, at least unless we found people who were equally healthy who didn't ride a bike.

    26. PTPaul Turek1:58:03

        Yeah, I don't remember what they controlled for-

    27. PAPeter Attia1:58:04

        Yeah

    28. PTPaul Turek1:58:04

        ... but I think they did a lot of the socioeconomics.

    29. PAPeter Attia1:58:07

        Okay.

    30. PTPaul Turek1:58:07

        And it was just, it may have just been activity, but the bicycle didn't appear to-
15. 2:00:00 – 2:04:31

    How alcohol, marijuana, & nicotine affect male fertility

    1. PAPeter Attia2:00:00

       talk about alcohol specifically, and, uh, and let's talk about any other, uh, recreational drugs.

    2. PTPaul Turek2:00:09

       Recreational toxins. Yeah.

    3. PAPeter Attia2:00:10

       Yeah.

    4. PTPaul Turek2:00:10

       So fertility wise, I'd say, you know, the government wants men, I'm going to talk about men, to, you know, less than two glasses of alcohol a day is okay. They consider four binging. Now, alcohol is, um, a small molecule, goes right into the brain, goes right into the testicle. It's definitely a poison, right? It, it goes everywhere. It, the testicle doesn't limit it. So I worry about it a lot. The effects I see are direct when it's abused. So I would say I, you see morphology, motility, and count issues, though that's a direct effect as a direct toxin because it gets in. It's one of the few things that gets into the testicle. Second would be a hormonal effect.

    5. PAPeter Attia2:00:51

       Yeah.

    6. PTPaul Turek2:00:52

       So alcohol use, uh, tends to cause the liver to rev up, tends to cause more estrogenization, so you tend to get low testosterone from that. So it's a hormonal effect and a direct effect.

    7. PAPeter Attia2:01:03

       Any evidence that it's having an epigenetic effect?

    8. PTPaul Turek2:01:06

       God, probably. No, I don't know about evidence, but I'm sure it does.

    9. PAPeter Attia2:01:11

       Um, let's talk about common recreational drugs. Let's start with marijuana.

    10. PTPaul Turek2:01:15

        That's the worst player for me. Um, so THC, same thing, count motility, morphology, so it, it, and it probably has an effect, we know it has an effect on, um, fragmentation, which is a quality measure of sperm, not only the way it looks descriptively, but quality, and also probably an epigenetic effect. Some of the early studies on sperm epigenetics showed alterations with, with nicotine and with pot. What I don't like about pot is, um, depending, depending how you ingest it, and however you ingest it, you get a peak, you feel it, it goes away, you feel it's out of your system like nicotine.

    11. PAPeter Attia2:01:47

        But it's two weeks, right?

    12. PTPaul Turek2:01:47

        But it sits in your fat for a month or three weeks-

    13. PAPeter Attia2:01:50

        Yeah

    14. PTPaul Turek2:01:50

        ... and it's a depot effect, and it keeps coming back. So you get a low level toxicity, which I don't like at all. So I am not a fan of pot. The other thing that really concerns me about pot in reproductive age men is, I wrote a couple blogs on this, I called The Weed Worries, and it, there's some compelling evidence from epidemiology in two studies, ten years apart, validating each other. That, uh, chronic pot use is associated with testis cancer

    15. PAPeter Attia2:02:19

        And we think that that's causal?

    16. PTPaul Turek2:02:21

        I don't know. I'm, it just worries me. Weed worries me.

    17. PAPeter Attia2:02:25

        Interesting, given that it otherwise seems, you know, kinda benign. Uh, I personally can't stand the stuff, but, um, you know, I know so many people that use it so frequently that seem to have relatively few effects.

    18. PTPaul Turek2:02:39

        I mean, it's an interesting phenomenon. It's medical marijuana, right?

    19. PAPeter Attia2:02:41

        Yeah.

    20. PTPaul Turek2:02:41

        So medical means safe. But I asked someone, you know, I have a lot of pot growers in the Emerald City up in Northern California, and they have the artisanal stuff that wins awards and stuff, and it's like, "Which is worse for driving, being stoned or being drunk?"

    21. PAPeter Attia2:02:55

        Undoubtedly being drunk.

    22. PTPaul Turek2:02:57

        Yeah, so it looks like reflexes, but, you know, [laughs] like he said to me, "Well, we tend to stop at stoplights and wait for them to turn-

    23. PAPeter Attia2:03:04

        Yeah, exactly

    24. PTPaul Turek2:03:04

        ... when we're stoned." It's like, okay. [laughs]

    25. PAPeter Attia2:03:06

        Yeah, I'm not saying, I'm not saying that one is, I'm not saying that they're both, that, that, you know, driving stoned is good, but, but there are probably far fewer people that die at the hands of, uh, of a stoned driver than a drunk driver.

    26. PTPaul Turek2:03:17

        Probably, and I think the signs, you know, the, the, uh, LA Story signs in, in LA, you know, like if they have like, you know, they have the lit-up signs about open season traffic. Remember the movie LA Story? The, they do say now, "Stoned," you know, "Drunk or stoned, watch out."

    27. PAPeter Attia2:03:32

        Yeah.

    28. PTPaul Turek2:03:32

        "We're gonna get you."

    29. PAPeter Attia2:03:33

        What, what do you think is the mechanism of action by which THC is having these negative fertility impacts?

    30. PTPaul Turek2:03:38

        Not sure. Um, I don't think it's the mechanism. I don't think it's the root, so I don't think it's toking or, or, you know, or edibles, but it might just be the chronic exposure, and I don't see... There's some evidence that THC acts like LH and binds the receptor and neutralize and, and, and not, blocks it.
16. 2:04:31 – 2:05:54

    Why type 2 diabetes is a risk factor for male infertility

    1. PAPeter Attia2:04:31

       mentioned diabetes earlier as part of your history and physical. Um, what is it about diabetes? Uh, is it the high levels of glucose? Is it the microvascular damage? Is it the inflammation that typically, uh, travels in parallel with it? Why, why is, uh, type 2 diabetes a risk factor for infertility?

    2. PTPaul Turek2:04:48

       Um, probably all of them. I don't think we know exactly, but I'd say that, um, I diagnose diabetes a lo- in a lot of infertile men. I, I make the diagnosis.

    3. PAPeter Attia2:04:59

       What's the physical finding you're seeing in the testes that tells you? Like, you know how an ophthalmologist will often make-

    4. PTPaul Turek2:05:04

       Sure

    5. PAPeter Attia2:05:04

       ... the diagnosis because they're looking-

    6. PTPaul Turek2:05:05

       Right

    7. PAPeter Attia2:05:05

       ... into the eye?

    8. PTPaul Turek2:05:06

       So for me, it's usually their weight, and their count motility are low, so s- I'm looking for a chronic exposure, and then they have polyuria or polydipsia or something, symptom like that, where they're drinking a lot and they're peeing a lot 'cause the sugar is dragging it out, and you check their UA and it's full of sugar, and you said, you know, you've... And then some of them have an A1c that's a little pre-diabetic. But I think a lot of it is nerve, neurogenic too.

    9. PAPeter Attia2:05:34

       Mm-hmm.

    10. PTPaul Turek2:05:34

        Um, they can develop ED. They can develop... A third of type 2 diabetics have low testosterone, so that's a clue, and that's secondary, so you can Clomid, you can put them right back, but th- that's, that's probably the common one is the look, the sugars, and then the low T and the low sperm count. It's a kind of a picture. It's a syndrome.

    11. PAPeter Attia2:05:53

        And then we've kinda talked

17. 2:05:54 – 2:09:10

    How varicoceles—a common cause of male infertility—are diagnosed & treated

    1. PAPeter Attia2:05:54

       about sleep and stress, obviously metabolic health in general. What are, what are some of the other modifiable things that you see that people-

    2. PTPaul Turek2:06:02

       The most common is a varicocele.

    3. PAPeter Attia2:06:04

       Okay. Tell people what a varicocele is.

    4. PTPaul Turek2:06:05

       So you could develop varicose veins in your leg-

    5. PAPeter Attia2:06:08

       Yep

    6. PTPaul Turek2:06:08

       ... which can be, uh, need treatment, and this is the same thing in the scrotum, but it's not related. And it happens in, typically at puberty you'll develop this. You won't know it sometimes unless it hurts. And it's a, it's a, it's a reflux of blood in the wrong direction, so the testicle drains to the kidney, which is uphill, and it wants to drain back down. The reason why it drains back down is because as a species we stood up a half a million years ago, maybe three-quarters of a million years ago, and when you're an animal, your, your kidney and your testicle drains this way. There's no gravity. But when you stand up, you're now draining uphill. The system was never made for valves, and if you said to me, "What's the reason our sperm counts are falling?" I would say, "We stood up as a species. Probably not a good idea for male fertility because that blood that's supposed to be staying up there comes back down to the testicle, pools around it like a hot bath is warmer and, and it affect it." And usually the first sign is a testicle on that side, which is the left, usually is smaller than the right. So the physical exam will be a testicular discrepancy in size. That's the first thing you see. And then you feel above it, and you feel a bag of worms.

    7. PAPeter Attia2:07:11

       But sorry, there are no valves in that vein?

    8. PTPaul Turek2:07:13

       Correct.

    9. PAPeter Attia2:07:14

       So what's the head it has to climb? That's gotta be this, this-

    10. PTPaul Turek2:07:16

        30 centimeters.

    11. PAPeter Attia2:07:18

        So how is it doing that without a valve?

    12. PTPaul Turek2:07:22

        I don't know.

    13. PAPeter Attia2:07:22

        That's a big, that's a pretty big distance to travel without a valve.

    14. PTPaul Turek2:07:25

        Maybe it only does it at night. I don't know. [laughs]

    15. PAPeter Attia2:07:26

        Yeah, interesting. Okay.

    16. PTPaul Turek2:07:27

        But there might be a few, but during puberty with the growth spurt, those blow, and the, the angle of the renal vein and the, and, and the, is, is there's a right angle.

    17. PAPeter Attia2:07:35

        Yeah.

    18. PTPaul Turek2:07:35

        The right side has a natural valve off the vena cava, so it's kinda has to go around 270 degrees, so you don't reflux on the right. Left-sided lesion in most men, you can be perfectly fertile with it. If you look at statistically, you know, 85% of men conceive naturally with, without varicoceles, 80% will conceive naturally about a year. So, so the curves are very similar, clinically maybe insignificant, but there's a d- there is a difference, and it's statistical. But if you multiply that by millions of people, it becomes important.

    19. PAPeter Attia2:08:04

        And you'll figure that out easily on a physical exam?

    20. PTPaul Turek2:08:06

        The best way is easy phys- I don't order ultrasounds. I, if it's, if I can palpate it, then it's clinical.

    21. PAPeter Attia2:08:13

        And you will... That's an office repair?

    22. PTPaul Turek2:08:16

        It's an outpatient surgery. It takes an hour. We do microsurgery.

    23. PAPeter Attia2:08:18

        Oh, it is? Okay.

    24. PTPaul Turek2:08:18

        Yeah.

    25. PAPeter Attia2:08:19

        So it's more involved than a vasectomy.

    26. PTPaul Turek2:08:21

        Yes, it is. And because if you, you're doing it at microsurgery at the level where you don't cut muscle, you want them to cover- recover quicker. It, it's pretty... It's, it's a, it's a, uh, it's an involved area with lots of veins.

    27. PAPeter Attia2:08:33

        But he's not under general.

    28. PTPaul Turek2:08:34

        I use, uh, I use twilight-

    29. PAPeter Attia2:08:36

        Sedation?

    30. PTPaul Turek2:08:36

        ... twilight sedation.
18. 2:09:10 – 2:12:08

    Genetic factors that affect fertility

    1. PAPeter Attia2:09:10

       other ones in, on the genetic side?

    2. PTPaul Turek2:09:11

       For genetics?

    3. PAPeter Attia2:09:11

       Yep.

    4. PTPaul Turek2:09:12

       The most common one is for zero sperm is Klinefelter.

    5. PAPeter Attia2:09:15

       Yep.

    6. PTPaul Turek2:09:15

       Is extra X chromosome. The most common one for low sperm count is Y chromosome deletions. This is an interesting area. Right.

    7. PAPeter Attia2:09:21

       What, what does that phenotype look like?

    8. PTPaul Turek2:09:24

       No phenotype. You mean on a, in general?

    9. PAPeter Attia2:09:27

       Yeah.

    10. PTPaul Turek2:09:27

        No phenotype. Normal looking.

    11. PAPeter Attia2:09:30

        A Y chromosome deletion male?

    12. PTPaul Turek2:09:32

        Yeah. 'Cause it's only the long arm.

    13. PAPeter Attia2:09:34

        Yeah.

    14. PTPaul Turek2:09:35

        And it's only a couple of floors on the building.

    15. PAPeter Attia2:09:37

        Got it.

    16. PTPaul Turek2:09:37

        So there's regions that are missing.

    17. PAPeter Attia2:09:39

        I see. Okay.

    18. PTPaul Turek2:09:40

        So very interesting.

    19. PAPeter Attia2:09:41

        Oh, I'm sorry. I thought you meant a complete deletion of the Y chromosome.

    20. PTPaul Turek2:09:44

        Right. No.

    21. PAPeter Attia2:09:44

        Yeah, yeah, yeah. Got it.

    22. PTPaul Turek2:09:45

        Partial.

    23. PAPeter Attia2:09:45

        Yeah.

    24. PTPaul Turek2:09:45

        So it's the long arm and-

    25. PAPeter Attia2:09:46

        Yep

    26. PTPaul Turek2:09:46

        ... deletions, regions delete.

    27. PAPeter Attia2:09:47

        Yep, yep.

    28. PTPaul Turek2:09:48

        Not... Yeah. [laughs] Y chromosome deletion. Yeah, you're, you're right. So, um, Rene Reijo Pera found that in, at MIT 20, 30 years ago now that the Y chromosome is a, is a hall of mirrors. And in meiosis, every chromosome has a partner, except the Y and the X in a man. And so the X, the Y plays with itself. It combines with itself. Instead of finding a partner, it has to do the dance, too. And so it changes a lot, so it's very ad- adaptable. It actually comes from the X-

    29. PAPeter Attia2:10:17

        Hmm

    30. PTPaul Turek2:10:17

        ... through the million, through, through evolution. So there's a lot of X genes that are on the Y, and the Y doesn't... We thought it was sort of a wasteland, maybe hairy ears and tooth decay and things like that, but now it's probably more important. So there are regions on the long arm of the Y. The short arm of the Y is very important. Has a gene called SRY, which makes you male. The SRY is the male sex determining gene. If you have that gene, your phenotype will be male. If you don't have that gene, you're probably gonna be female. There, it's complicated now, but that's sort of what it is. But the, the long arm has these genes that control fertility, and some of them... So typically, we order it in men with a low sperm count of below five million. So that would be a pretty common cause of a sperm count lower than five million. And I published a study that if you have a Y chromosome deletion and you have a varicocele, and they both cause low sperm counts, and you fix the varicocele, you're not gonna improve, 'cause, 'cause the, the mon... It's non-modifiable in all ways. Right? It's who you are.
19. 2:12:08 – 2:16:44

    The impact of lifestyle & environmental exposures on fertility

    1. PTPaul Turek2:12:08

       there's, I would say there's environmental lifestyle things. So I think obesity's a big one.

    2. PAPeter Attia2:12:13

       Yep. And do you think that that's mostly propagated through the endocrine system, then?

    3. PTPaul Turek2:12:16

       Yeah.

    4. PAPeter Attia2:12:16

       Yep.

    5. PTPaul Turek2:12:17

       And I think, you know, that's probably, that's a big one in America.

    6. PAPeter Attia2:12:20

       Oxidation. Yep.

    7. PTPaul Turek2:12:21

       Uh, in terms of the percent of sperm with the lifestyle issues, and then lousy diet is probably something that, and, and so o- so obesity and diet, lifestyle, recreational drugs. What else do I review with them? Um, toxic exposures at work. So any smelly solvents, I don't, I'm really wary of some. Uh, airport fuels, you know, airline stuff, uh, g- machine shop oils, anything, anything benzene derivatives. Used to be pesticides and stuff like that, but they're pretty well controlled. So environmental exposures are, are, you know, kind of an unknown. I, I think viruses have a role.

    8. PAPeter Attia2:12:59

       Yep.

    9. PTPaul Turek2:12:59

       Uh, I saw you recently wrote about HPV, and I've been thinking about that for years, 'cause there are men... It used to be half the men who came in when I entered the field 30 years ago, we didn't know what was going on with them, but now it's probably like 10 or 20%.

    10. PAPeter Attia2:13:13

        Hmm.

    11. PTPaul Turek2:13:13

        With lifestyle issues and stuff like that. You can pretty much sort it out. It's not that unknown. But there are men who are like, "What is going on here?" He's a perfectly healthy guy. Practicing in California is incredible because everyone's so healthy, you have to look elsewhere, and you have to ask other questions. And, you know, when there's obesity, it's always the elephant in the room, but everyone is so healthy and eating... So I get to poke around places where no one else goes because I have to explain it and I, there's nowhere to go. But, um, I did a study. Uh, so HPV is the most common. You, you wrote about that. Is that, what's the link? It's hard to know. There's herpes, very common. The STDs that we know about, like the, like the 11 common beasts, you know, like, you know, chlamydia and gonorrhea and syphilis, those we know a little more about, and they're pretty obvious. But some of these, like trichomonas and stuff, are pretty subtle. And I had, uh... I was really concerned about this, 'cause one guy 20 years ago, now he's a professor at UCSF, he s- he sent me a picture of micro- mi- electron photograph of a sperm with a hexagonal herpes virus in it, and I don't even know if it was Photoshopped, but like there's this virus in a sperm. Like, yeah, it looks like there's a virus in the sperm. [laughs] Said that, "You think that's what's causing it?" I said, "I, I don't know. I don't know." But normally, when you see infections as a cause, viral or bacterial, as a cause of semen analysis, you'll see pus cells. So you'll see what's called pyospermia, leucocytospermia, the round cells we talked about-

    12. PAPeter Attia2:14:38

        Yeah

    13. PTPaul Turek2:14:38

        ... in the semen analysis will show up in higher numbers. They tend to be destructive, and they tend to lower motility, so you tend to see a certain look to the semen analysis, volume normal, count normal, motility's really low, a lot of the sperm are dead 'cause they've been wiped out by these cytokines and all the white cells. And then maybe you'll find the pathogen somewhere, maybe not. But culturing my- mycoplasma, CMV, all these viruses. So, so Joe DeRisi, really bright guy at UCSF, won a MacArthur award, he took my patients' semen, and he had a mi- this is back when microwaves were popular in the, in late and 2000s, and he had, like, 2,000, all mammalian viruses-

    14. PAPeter Attia2:15:16

        Hmm

    15. PTPaul Turek2:15:16

        ... on his chip, everything. And we ran fertile guys, and we ran infertile guys and, and looked at semen, not sperm, and 99% of the infertiles were positive for something, and 98% of the normals were positive for something. So ubiquitous was the word, and so it left us high and dry 'cause you can't really do much with that. So it's out there. But I do agree with your assessment that the, the pathologic phenotypes, the worst ones, are probably doing something. The question is how do we measure it? What do we look for? And with semen analysis, as I said earlier on, it's a blunt instrument. It doesn't really... It varies a lot. It's tough to, to do it, but I love whether we do genotyping on s- is it in sperm? Probably not. You know, I don't, I don't know. And when you look at HPV, it's probably one of those things that might be in the ejaculate after ejaculation. It might be coming from another fluid source-

    16. PAPeter Attia2:16:07

        Yeah

    17. PTPaul Turek2:16:07

        ... and not in the sperm itself, so its effect would be post-ejaculation, which could still have a fertility effect, but it won't be probably as deep, right?

    18. PAPeter Attia2:16:18

        And what if, for example, a guy has prostatitis and the prostatic fluid has-

    19. PTPaul Turek2:16:22

        Pus in it

    20. PAPeter Attia2:16:23

        ... pus in it, then that could sabotage the whole thing and...

    21. PTPaul Turek2:16:26

        Right, and I mean, the problem with the male system is it's all through the same tube, right?

    22. PAPeter Attia2:16:29

        Yeah.

    23. PTPaul Turek2:16:29

        And so urine comes through that tube, and semen comes through that tube, so you have to look for infections in the urinary tract and anything like that when you're doing fertility because pus cells kill whatever they see.

    24. PAPeter Attia2:16:39

        Yeah.

    25. PTPaul Turek2:16:40

        So if your urine's infected, you know, so that's a big deal.

20. 2:16:44 – 2:22:14

    The evidence (or lack thereof) behind stem cell & PRP therapies for male infertility, & how lifestyle & non-invasive interventions often lead to successful conception

    1. PAPeter Attia2:16:44

       Now, uh, have you done work with, um, interested intratesticular PRP and stem cells?

    2. PTPaul Turek2:16:50

       N- just stem cells, but not PRP.

    3. PAPeter Attia2:16:52

       Okay.

    4. PTPaul Turek2:16:52

       Um, not a big fan-

    5. PAPeter Attia2:16:54

       Okay

    6. PTPaul Turek2:16:54

       ... as a trained stem cell biologist and someone trying to make sperm from skin, uh, and working with some of the best stem cell scientists in the world. I, um, I have a lot of respect for them, but it's not that simple. So we've had, you know, people have injected bone marrow into... There's, there's 560 offshore, offshore stem cell companies in the world that will take your money and do things like stick PRP in there. They'll stick, uh, bone marrow aspirates, fat in your testicle, and I'd say my experience has been s- um, has not been favorable. I, uh, you know, these are some of the toughest cases in the world, and they come to me after that, and I do my techniques, and I don't find anything, and the t- the trials aren't really real.

    7. PAPeter Attia2:17:38

       Yeah.

    8. PTPaul Turek2:17:38

       They're kind of, "Here, come here. We're gonna do this, and then we're gonna do a microdissection on your testicle." Um, but they didn't have one beforehand, so the chance of it finding it even without that is X, and they're finding X. So, you know, it's just not well done. And I, I have my patients investigate all that, and I say, "You do the work. You tell me who you found. Let me call them."

    9. PAPeter Attia2:17:59

       Yeah.

    10. PTPaul Turek2:18:00

        So I'll let, I'll let them be my, the workers, and then I'll call them and I'll say, "Hi, um, I was just wondering about, do you have any papers or h- what's the science behind it?" And they usually hang up or, you know. It's really interesting, but so far, I'd say it's unfounded.

    11. PAPeter Attia2:18:14

        Yeah, I've had a very similar experience with, uh, a few of my friends [clears throat] and patients who have wanted me to talk with some of their, their stem cell docs, and, uh-

    12. PTPaul Turek2:18:26

        You're pretty evidence-based, Peter

    13. PAPeter Attia2:18:27

        ... w- well, yeah, and so I accept the fact that they're not gonna have remarkable peer-reviewed data, but-

    14. PTPaul Turek2:18:34

        Yeah, I agree

    15. PAPeter Attia2:18:34

        ... um, it is amazing at how few individuals can provide even one cell layer of scientific reasoning.

    16. PTPaul Turek2:18:43

        [laughs]

    17. PAPeter Attia2:18:44

        Um, and it's a topic I'd like to explore more deeply on the podcast. It's, um, you know. My guess is there are some indications for where it makes sense.

    18. PTPaul Turek2:18:53

        I think I agree with that.

    19. PAPeter Attia2:18:54

        Um, but boy, I'd like to figure it out without people wasting-

    20. PTPaul Turek2:18:58

        I think there's a there there

    21. PAPeter Attia2:18:58

        ... so much money.

    22. PTPaul Turek2:19:00

        There's a there there, but it's just not, not that easy.

    23. PAPeter Attia2:19:02

        Yeah. Um, so what is the... Uh, l- let's just say for every hundred guys that walk in your office who are struggling with infertility, what percentage of them will be able to conceive, assuming they are able to fully comply with the prescriptions you p- you, you provide, be it lifestyle or pharmaceutical, for example, hormone modulation, et cetera, without requiring, um... And let's exclude the 40% varicoceles 'cause you're gonna fix those guys, and they're fine. So hundred people who don't have a varicocele, um, who don't have a genetic condition. I'm gonna really simplify this.

    24. PTPaul Turek2:19:46

        Okay.

    25. PAPeter Attia2:19:46

        Okay, so these are a hundred guys that presumably have showed up with some iatrogenic reason for infertility. Um, how many of those guys are going to be able to conceive without resorting to IVF?

    26. PTPaul Turek2:20:00

        I would say that's the goal of my practice, and I would say the answer is most.

    27. PAPeter Attia2:20:05

        Wow.

    28. PTPaul Turek2:20:06

        But the caveat is w- you gotta tell me about the woman because-

    29. PAPeter Attia2:20:11

        Yes. Yeah, so-

    30. PTPaul Turek2:20:11

        ... because I will defer if there's any.
21. 2:22:14 – 2:33:35

    Considerations for sperm banking, & how paternal age impacts fertility & offspring health

    1. PAPeter Attia2:22:14

       What advice do you give a guy who comes into your practice? Maybe you don't see a lot of these guys, but let's, let's say you get a guy, um, who comes in and says, "Hey, look, I, I wanna, I wanna bank my sperm. I wanna freeze my sperm." Now presumably you'll get a lot of that if a guy's undergoing therapy for-

    2. PTPaul Turek2:22:29

       Sure

    3. PAPeter Attia2:22:29

       ... cancer or something like that. Um, is there anything a guy needs to know? And would you recommend a guy do that if he's 40, doesn't have a partner, but says, "Look, I wanna have kids, and is, isn't there something to the idea that my sperm are better today than they will be in a decade?"

    4. PTPaul Turek2:22:45

       It's a huge issue, paternal age.

    5. PAPeter Attia2:22:47

       Yep.

    6. PTPaul Turek2:22:47

       Paternal age and fertility, paternal age. So we can, we can go there.

    7. PAPeter Attia2:22:51

       Yeah.

    8. PTPaul Turek2:22:52

       But I don't place value judgments. I say good idea. Uh, I am... A disclosure, I'm on a, you know, a board of Legacy. Uh, I was -- I love their mission-driven, the way they're mission-driven. And so I, I like the fact they're going for military and exposed patients and this and that and VA. So but I'm, I'm, I'm for that. I think it's the lowest hanging fruit in the field, especially c- obviously for chemo, for cancer survivors and things. Like, I don't care what you think might have happened with your cancer, I would still bank it. I started a nonprofit called Banking on the Future. 16-year-olds to 21-year-olds with cancer, we'll do it for you. We'll pay for it for five years, just give us a sample. [laughs]

    9. PAPeter Attia2:23:33

       Yep.

    10. PTPaul Turek2:23:33

        Because it's so much harder afterwards or not, right? So-

    11. PAPeter Attia2:23:37

        So you would advise any male that's, that hasn't reproduced and who might want to, who's undergoing any chemotherapy for any cancer, just play it safe, bank?

    12. PTPaul Turek2:23:47

        For cancer, yes.

    13. PAPeter Attia2:23:48

        Yeah.

    14. PTPaul Turek2:23:48

        Now, should anyone do it for any reason? Probably not. But again, I don't pass the judgment.

    15. PAPeter Attia2:23:53

        Yep.

    16. PTPaul Turek2:23:53

        If they're worried about something, then I'm worried, then, then they should.

    17. PAPeter Attia2:23:57

        Yeah.

    18. PTPaul Turek2:23:57

        Now it's not-

    19. PAPeter Attia2:23:57

        What paternal age do you worry about?

    20. PTPaul Turek2:23:59

        So good question. Uh, and you look at like national guidelines for sperm donation, 40 is considered older paternal age, uh, 50 for sure, right?

    21. PAPeter Attia2:24:10

        Mm-hmm.

    22. PTPaul Turek2:24:10

        If you look at risks to offspring, miscarriages, stillborns, um-

    23. PAPeter Attia2:24:18

        Autism

    24. PTPaul Turek2:24:18

        ... birth defects, things immediately related to conception, prematurity, those go up with paternal age. Then you look at birth defects when they're born, those go up, you know, one to twofold. And then the worrisome ones are the single gene defects and the epigenetics like psychiatric morbidity, so the autism, schizophrenia, dyslexia, bipolar disorder, potentially Alzheimer's in offspring.

    25. PAPeter Attia2:24:43

        Yep.

    26. PTPaul Turek2:24:44

        And they're not detectable with young, so big issues. So I've written a lot about that, published on it. I was actually having my second child at 50 when I was writing this thing. Should I be doing this? [laughs] You know? Writing a paper on all these risks called Repro- and with Alan Dzbenko from University of Pittsburgh. But I think it's a hockey stick curve for risk to offspring.

    27. PAPeter Attia2:25:06

        And you think the, the, the inflection is 40 or 50?

    28. PTPaul Turek2:25:10

        I think it's more like 60.

    29. PAPeter Attia2:25:11

        Okay.

    30. PTPaul Turek2:25:11

        I think there's a slow linear increase in risk to offspring from 25 to 50 or 60, and then there's an inflection, and then there's the blade of the stick, and I think that's logarithmic. Same curve as women with chromosomal-

Episode duration: 2:37:17