Dr. Michael Eisenberg: Improving Male Sexual Health, Function & Fertility

Dr. Michael Eisenberg (00:00:00)

• Dr. Michael Eisenberg is a medical doctor specializing in urology and an expert in male sexual function and fertility.
• He has published over 300 peer-reviewed articles on male sexual function, urology, and fertility and is one of the world's foremost experts in male sexual health.
• Topics of discussion include erectile dysfunction and function, prostate health, urinary Health, fertility, and sperm count.
• Also discussed are considerations such as the increase in penile lengths over time while sperm counts seem to be decreasing.
• Eisenberg also talks about common myths related to male sexual health and function.
• The conversation aims to offer an understanding of male sexual health, how it relates to other aspects of health, and how to think about treating, maintaining, and improving all aspects of male sexual health, fertility, and function.

Sperm Quality, Geographic & Environmental Factors (00:04:20)

• The diminishing quality of sperm is a controversial topic. Sperm quality is defined by quantity, motility or movement, and morphology or shape of the sperm, with some advanced tests looking at DNA fragmentation and epigenetic profiles of sperm.
• The World Health Organization sets the standards for what's considered "normal" or "subfertile".
• There is uncertainty whether there has been a true decline in sperm quality over time, with some evidence suggesting a decline and others showing no change.
• Possible reasons for a decline include environmental changes, less physical activity, less exposure to sunlight, increased chemical exposure, and the obesity epidemic.
• The relationship between a man's reproductive function and body weight is well-established.
• Geographic variation in semen quality is another factor, possibly linked to different environmental exposures, diet, exercise, lifestyle, and population genetics.
• A study suggested higher semen quality in urban centers compared to more rural settings.
• In Denmark, a study found uniform semen quality over 20 years but only about a quarter of men had normal semen quality.

Fertility & Sperm Quality; Testosterone, Cell Phones & Heat (00:12:00)

• Some decline in sperm quality may be related to advancements in measuring tools; more sensitive instruments lead to more accurate and detailed evaluations.
• About half of the cases of infertility in couples can be attributed to the male factor, although it is often overlooked due to historical reasons, and common misconceptions that fertility is mainly a female issue.
• The trend towards using IVF treatments, which require only one sperm to fertilize the egg, may have led to less research and innovation in addressing male fertility issues.
• The average testosterone levels in men across the population are decreasing, possibly due to reasons like chemical exposure and obesity.
• Higher body fat can lower testosterone production as it tends to convert testosterone into estrogen.
• Obesity can also reduce efficiency of testosterone production by insulating the testes and causing heat effects.

Cell Phone use and Sperm Quality

• Sperm production is more sensitive to heat and radiation effects than testosterone production.
• Studies suggest that excessive use of cell phones or keeping cell phones in close proximity may lead to lower semen quality and increased DNA fragmentation in sperm, although the data is not entirely convincing.
• Heat from laptops on laps is suggested to be avoided to minimize heat exposure to the testes.

Testosterone, Age, Obesity (00:19:26)

• An episode touched on the topic of testosterone and estrogen production in the male and female body.

• A graph from a textbook on Behavioral Endocrinology illustrates testosterone levels in correlation with age in males. As expected, levels are higher in late teens to early 30s, with a gradual decline afterward.

• However, outliers exist with men in their 50s through 90s still exhibiting testosterone levels similar to those of men in their 30s.

• Clinically, a wide natural variation in testosterone levels is observed, regardless of age group, with men in their 80s sometimes recorded having significantly high testosterone levels.

• Factors contributing to these high testosterone levels may include androgen sensitivity and efficient production.

• Testosterone levels are usually checked in men presenting symptoms such as low energy, low libido, or sexual dysfunction.

• Men who have significantly high testosterone levels can also exhibit dysfunction, indicative that other issues may be present.

• Obesity is earlier noted as a risk factor for low testosterone and poor sperm quality, with fat aromatizing testosterone into estrogen being a possible mechanism.

• Clinically, not every obese person is expected to have subnormal testosterone levels, similarly, fit individuals can surprisingly also have low testosterone levels.

• Obesity doesn't solely explain the observed decline in semen quality, it corresponds to approximately a 10% decline while a 50% decrease in semen quality has been reported.

• The observation implies that something more than what can be identified visually contributes to semen quality. It is further stressed that everyone should screen for testosterone and semen quality as they serve as health barometers; men with lower testosterone levels are reportedly at a higher risk for heart disease, diabetes, and mortality.

Tool: Optimize Sperm Quality, Exogenous Testosterone, hCG (00:26:49)

• Optimal sperm quality and testosterone level can vary from day to day.
• Avoiding factors such as excessive heat, like hot tubs and saunas, can improve sperm quality.
• An external heat source to the scrotum can be problematic as the testicles need to be cooler than body temperature for optimal sperm production.
• Using a cool pack in the scrotum area while in a sauna can help reduce the effects of the heat.
• General health, including avoiding obesity, hypertension, and hyperlipidemia, plays a significant role in maintaining adequate sperm production and testosterone levels.
• Testosterone therapy can lower sperm production and is a common issue in fertility clinics.
• Around 5% of infertile men can attribute their infertility to testosterone therapy.
• For those wishing to conceive while on testosterone therapy, therapies such as sperm cryopreservation and use of HCG (Human Chorionic Gonadotropin) are options.
• A low dose of HCG (500-1000 units every other day) can stimulate endogenous sperm production.

Tool: Lifestyle Factors & Sperm Quality, Alcohol (00:36:57)

• Non-obese individuals who maintain regular cardiovascular exercise improve their overall health and lower the risk of cardiovascular and cerebrovascular issues.
• Smoking cigarettes and vaping have been linked to lower sperm quality, leading to longer time to conceive.
• High levels of alcohol consumption may lead to decreased sperm quality, especially for those consuming more than 20 drinks per week.
• Moderation in alcohol consumption is generally recommended, with notable impacts on sperm quality occurring at higher consumption levels.
• Certain genetic factors, like the ALH2 gene mutation prevalent in the East Asian population, may influence responses to alcohol consumption. This mutation may also exist in African, Hispanic, and Ashkanazi Jewish populations, indicating that these individuals are more susceptible to the ill effects of alcohol consumption.
• Recreational drug use, including cannabis, can negatively affect sperm quality.

Sperm Quality, Recreational & Over-The-Counter Drugs, Cannabis (00:43:27)

• The use of opioids, heroin, and benzodiazepines can negatively affect reproductive health, however, specific studies focusing on these substances are limited.
• Regular cannabis users have shown significantly lower sperm concentration, motility, and morphology when compared with non-users. However, there are also studies showing no effects, possibly due to variations in consumption frequency and method.
• Over-the-counter medications, such as non-steroid anti-inflammatory drugs (NSAIDs), are generally believed to be safe for sperm quality and testosterone levels.

High-Impact Sports, Traumatic Brain Injury (TBI), Pituitary & Testosterone (00:46:56)

• The pituitary gland produces key hormones for testosterone production and sperm health, being damaged by traumatic brain injuries could potentially affect reproductive health.
• Exogenous testosterone use can lower in-testicular testosterone levels, which are necessary for sperm production.
• While traumatic injuries and their effects on the pituitary gland have not been directly linked to diminished reproductive health, the impact of such injuries on the hormonal production necessary for reproductive functions suggests a potential connection.

Bicycling, Numbness & Sexual Dysfunction; Walking & Testosterone (00:49:55)

• Bicycling's effect on male sexual and reproductive health could be potentially negative due to prolonged periods in the saddle leading to heat exposure, potentially impairing sperm production. Weekly cycle durations longer than five hours could decrease sperm count.
• Pressure caused by a bicycle's saddle configuration can interfere with blood flow to the penis and the nerves supplying it, leading to sexual dysfunction, such as numbness and erection issues.
• Using specifically designed saddles or adjusting bicycling style may help to avoid these issues, which may affect around 20-30% of cyclists.
• Increased walking or standing activity, separate from obesity levels, has been associated with increased testosterone levels, which could help to improve testicular function.

Exogenous Testosterone Therapy & Cancer (00:55:39)

• There's no evidence linking exogenous testosterone therapy with an increased risk of prostate cancer or other types of cancer, dispelling a myth arising from prostate cancer being androgen mediated.
• The saturation model suggests that an increased testosterone level would not affect prostate cancer risk as testosterone receptors in the body are already filled to adequate levels.

Sexual & Urinary Health, Nighttime Urination (00:59:57)

• To maintain prostate and penis health, regular penile activity, including spontaneous erections during sleep, is advised due to the "use it or lose it" nature of the organ.
• Decreased normal sexual function or troubling urinary symptoms, such as frequent night urination or weak urine stream, should prompt a visit to a doctor.
• Waking to urinate once or twice a night is considered normal for most men.

Sleep & Semen Quality; Overall Health (01:03:12)

• There is a strong correlation between quality of sleep and semen quality, as well as overall male sexual health and fertility.
• Adequate amounts of high-quality sleep, ideally between seven to nine hours, contributes to sufficient slow wave deep sleep and rapid eye movement sleep, which seems to improve semen quality and overall sexual health.
• A U-shaped relationship is seen where insufficient or excess amount of sleep can both contribute to lower semen quality.
• Semen quality is an important measure of overall male health and vitality. Studies suggest that men with higher semen quality tend to live longer, require fewer doctor visits and have lower rates of cancer.
• Reproduction is interconnected with other body systems like cardiovascular and neurological, therefore anomalies seen in reproductive health first can signal other underlying health issues.
• Fertility should be considered as the 'sixth vital sign' as it can be indicative of other health issues; reproductive failure is often the first symptom of significant health problems like diabetes, cancer, and other genetic conditions.

Tool: Sperm Analysis & Overall Health; Sperm Banking (01:09:19)

• It is beneficial for males in their 20s and 30s to get a sperm analysis as a baseline for their reproductive health.
• Including sperm analysis along with regular health checks like blood hormone and lipid profiles, can provide comprehensive data about one's health and its progression.
• Semen quality can act as an early health indicator, hinting at any potential reproductive difficulties.
• With the advent of new methods and technology, getting a semen test has become easier and more comfortable.
• Freezing sperm is an option that some men choose to explore; the process involves collecting a semen sample at a clinic, which is then processed and stored.
• It's important for men to normalize all aspects of their health, including reproductive health, and consider routine check-ups as an integral part of health management.

Paternal Age & Puberty Trends; Older Fathers & Child Health Risk (01:13:21)

• The average paternal age in the U.S. has increased from about 27.5 to around 31 in the last 40 years.
• Generally, puberty in males happens between the ages of 12 to 15.
• There's been a small but significant increase in autistic births where the male partner was over 40 at the time of conception.
• Risk factors such as autism, bipolar disorder, schizophrenia, less achievement in school, and failing grades have been linked with older fathers.
• There's evidence of epigenetic and mutational changes that occur with age which could contribute to these risks.
• Some studies indicate that children of older fathers tend to have slightly smaller brains just after birth.
• Older paternal age has also been associated with higher cancer risk in offspring.
• Though DNA fragmentation can be measured in sperm, this doesn't allow for selection of the best sperm on the basis of DNA composition.
• As a man ages, a percentage of his sperm may contain fragmented DNA which could affect the health of the offspring if it fertilises the egg.
• At present, there are no technologies that can improve the DNA of sperm.

Tool: Prostate Health, Urination; Tadalafil (Cialis) (01:26:42)

• The prostate gland supports reproduction by producing proteins and enzymes necessary for sperm health.
• The prostate gland enlarges with age, causing resistance in the urethra, often leading to symptoms like waking up at night, weak urine stream, need to urinate urgently and the feeling of not fully emptying the bladder.
• Certain triggers that can exacerbate these symptoms include drinking a lot before bed, spicy and acidic foods, and caffeine, all of which can irritate the bladder lining.
• Low doses of tadalfil (2.5 to 5 milligrams per day) can help with these urinary symptoms by maintaining or improving blood flow to the prostate. It can also help with erectile function at this dosage.
• Testosterone therapy should only be the fallback measure when lifestyle changes (adequate sleep, limiting alcohol intake, not smoking, exercising) proved inefficacious.

Urinary Tract Infections (UTIs); Erectile Dysfunction Causes (01:33:02)

• UTIs in men are relatively rare due to the long nature of the male urethra.
• If a man has recurrent UTIs, it should be investigated because this could indicate an anatomical issue such as scar tissue in the urethra, bladder stones, or incomplete bladder emptying.
• Most causes of erectile dysfunction are associated with blood flow rather than hormonal imbalances.
• High blood pressure, diabetes, atherosclerosis, and obesity are common causes of erectile dysfunction as they impede blood flow.
• Difficulty in achieving an erection may actually predate other serious vascular conditions as it can be an early marker for such diseases.
• Pelvic cancer treatment and post-operative hernia are also potential causes of erectile dysfunction.
• Less than 10% of erectile dysfunction is due to hormonal issues, contradicting the common belief linking testosterone levels with erectile function.

Blood Flow & Erectile Dysfunction, Medication; Cardiovascular Health (01:38:21)

• The first line of treatment is usually oral therapy, example PDE-5 inhibitors like sildenafil (Viagra) and tadalafil (Cialis).
• The amount of medication prescribed depends on the level of sexual activity, with daily doses beneficial for those with a high frequency of sexual activity.
• Around 60-70% of men find these medications effective and the choice can depend on factors such as how quickly the drug reaches peak levels and how quickly it's cleared from the body.
• Tadalafil (Cialis) is marketed as a "weekend pill" due to its 20-hour half-life.
• Men who find these drugs effective are encouraged to consult a healthcare provider for checks related to vascular health, such as blood pressure, lipid levels and blood glucose.
• Side effects of these treatments include headaches, facial flushing, back aches, leg cramps, indigestion and nasal congestion.
• These drugs were initially designed as blood pressure treatments and have been used by athletes and in cycling to increase blood flow and slightly reduce blood pressure.

Mechanical Erectile Dysfunction Treatments; Peptides; Delayed Ejaculation (01:44:30)

• Erectile dysfunction is often resolved with drugs like Viagra and Cialis that influence blood flow.
• Other treatments include medication in a form of urethal suppository that is absorbed by the entire penis, acting similar to the blood flow influencing drugs. This is preferable for some men due to its efficacy.
• Penile injections that stimulate blood vessels, resulting in easier erections, are another common therapy, with an efficiency rate of approximately 80-90%.
• These injections are to be done on-demand by the patients themselves and are intended to last for 20-30 minutes.
• Penile implants, surgical procedures that place a device inside the penis to aid erections could be either non-inflatable or inflatable.
• Non-inflatable implants consist of a bendable metal core, whereas inflatable implants come with a pump in the scrotum for controlling the state of erection.
• Some treatments approach blood flow to the penis in an autonomous manner, however, typical erection involves different stimulations leading to neurotransmitters' release in the penis.
• Various external substances, including vasopressin and melanocyte-stimulating hormone, have been considered for impacting sexual desire and erections, but their usage in clinic is not prevalent yet.
• Delayed ejaculation, a condition where men take considerably longer than average to ejaculate, is another area needing medical attention. Various experimental solutions, including devices and substances, are considered for its treatment.

Pelvic Floor Health, Urology & Physical Therapy; Split-Stream Urination (01:52:36)

• The issue of pelvic floor health is usually associated with female reproductive health in urology, with Keel Kagel having named the pelvic floor strengthening exercise after himself.
• Some people may experience urinary or sexual dysfunction due to a weak (overly relaxed) pelvic floor, while others may face similar problems because of an overly tense (hypercontracted) pelvic floor.
• Pelvic floor health should be of concern to men as well, and different men may require different therapies - some needing to relax their pelvic floors and others needing to strengthen them.
• Pelvic floor Physical Therapy can benefit men with pelvic floor tension, with feedback exercises proving useful for relaxation.
• Keel exercises can be useful for certain men, particularly for prostate cancer rehabilitation, for rebuilding strength and improving continence.
• Pelvic floor therapists usually treat regardless of gender, are able to address different needs, and can help people achieve a more relaxed pelvic floor if needed.
• The pelvic floor muscles are located in the perineum, between the scrotum and the anus, supporting structures such as the penis, prostate, bladder, and rectum.
• Dysfunction in these muscles can sometimes lead to scrotal pain, urinary symptoms, and other discomfort.
• Split urine stream, which a couple dozen people asked about, could signal an issue such as prostatic issue or a urethral issue and therefore warrants a consultation with a physician. Split stream could be due to turbulent flow which could be improved via addressing underlying issues.

Penile Length & Trends; Dihydrotestosterone (DHT), Puberty (01:59:03)

• A study was conducted to determine average penile length for a different project, analyzing data on 55,000 men worldwide.
• The study aimed to see if there was a time pattern in penile length, hypothesizing there would be a decline due to factors such as chemical and environmental exposure, and increasing obesity rates.
• To their surprise, the study found that penile lengths were getting longer over time.
• The study’s methodology included measuring both the stretched length (flaccid state) and erect length in a clinical setting.
• Around 10-15,000 men participated in measuring erect lengths. Methods for achieving erection included self-stimulation or injection of medication.
• The major finding was that the average erect penis length varied around the world, generally between 5 to 6 inches.
• The study also found a change in penile length over a short interval of approximately 30 years, suggesting a possible environmental impact on male hormones.
• Possible causes for the increase in length might include exposure to endocrine-disrupting chemicals in utero, and shifting patterns in puberty onset, with earlier pubertal onset potentially leading to longer exposure to dihydrotestosterone and consequently, longer penises.
• It was noted that an online subculture of men reportedly take dihydrotestosterone and low levels of growth hormone post-puberty to try and increase penile length, however the physiological justification for this is unclear and not recommended.

Hair Loss, Dutasteride, Finasteride & Sexual Health; Post-Finasteride Syndrome (02:09:01)

• Finasteride and dutasteride are drugs people take to suppress dihydrotestosterone with the aim of keeping or regrowing hair.
• These drugs, when taken orally, may result in sexual dysfunction issues in some users. They can also be useful in warding off some forms of prostate cancer.
• Regular users of these drugs reported experiencing sexual dysfunction issues and other issues related to suppressing DHT - a matter referred to as post-finasteride syndrome.
• The usage of these drugs can lead to some level of hair upkeep and growth, but also to erectile dysfunction. Individuals in their 20s, 30s, and 40s are more likely to experience these side effects.
• During initial testing, there were minimal changes observed, but post-marketing experiences highlighted more serious sexual function side effects.
• The mechanism causing these side effects isn't completely understood. It's sometimes treated with testosterone, but its efficacy varies among patients.
• Some individuals continue to suffer from sexual dysfunction issues even after stopping the drug usage. Their state of dysfunction can sometimes be permanent.
• The post-finasteride syndrome relates to medical conditions that were not recognized by the medical community in the past.
• Young men are especially at risk as they are the first generation taking these drugs in high quantities.

Clomiphene, Testosterone & Estrogen Signaling (02:16:11)

• Clomiphene is a selective estrogen receptor modulator, used to block estrogen, stimulating increased production of testosterone. It's often used to boost one's own testosterone production.
• Blocking the estrogen receptor can lead to increased pituitary production of the hormones FSH and LH, which stimulate the production of sperm and testosterone.
• Increased testosterone production can sometimes improve sperm production, but not all issues are resolved by testosterone. It's also important to note that estrogenic signaling is important for various aspects of health.
• Clomiphene doesn't have the toxic effects on sperm production that are observed with other substances. It's sometimes used for treating symptomatic low testosterone.

Follicle-Stimulating Hormone (FSH) Therapy; Prolactin, Estrogen (02:19:31)

• The most common treatment to increase sperm production is HCG human chonic gadat tropin, despite FSH being specifically responsible for encouraging sperm production.
• FSH proves beneficial in increasing sperm production as per randomized placebo-controlled trials.
• FSH treatment is limited due to its high cost and is rarely covered by insurance: a month of therapeutic FSH typically costs between $2,000 - $3,000.
• Hyperprolactinemia is not commonly diagnosed, usually less than 1% of patients.
• High Prolactin is often associated with low testosterone and very low sperm production.
• Checking estrogen levels can be important because of its relationship with obesity.
• High levels of aromatization can also indicate too much estrogen, which can sometimes manifest as gynecomastia, a condition of male breast tissue growth.

Varicocele; Peyronie’s Disease (02:24:15)

• Varicocele is a common condition in around 15% of all men and a regular cause of infertility, accounting for 30 to 40% of all infertility cases.
• Varicocele is attributed to dilated veins in the scrotum that warm up the testicle or don't adequately clear metabolites. It's a progressive condition typically emerging around puberty.
• Not all cases of varicocele cause issues, but they may lead to low sperm counts, discomfort, testicular shrinkage, or stunted testicular growth.
• Peyronie’s disease, a scar baring of the penis leading to curvature or deformity, affects about 5 to 10% of men.
• The condition can arise from injury, surgery, or stunning of the penis. It can result in bothersome or limiting erections or difficulty in sexual activities.
• Treatments for Peyronie’s include FDA-approved, collagenase or zlex, a medicine that dissolves scar tissue, devices to mechanically remodel the penis, and surgical options.

Testis & Cancer Risk

• Testicular size and volume typically measure around 16 to 20 CC's, similar to the size of a walnut.
• Changes in testicular size or the presence of lumps are indications that medical attention is necessary.
• Testicular cancer typically presents as a firm, painless mass.
• Despite the importance of early detection for testicular cancer, national guidelines currently recommend against regular self-exams due to concerns about causing anxiety.

Blood Profiles & Semen Analysis

• Blood tests to check hormone levels and sperm analyses are useful to monitor male sexual health, but are perceived as inaccessible due to costs.
• Some insurance companies are becoming more open to covering infertility tests and treatments, allowing these types of analyses to be more accessible.
• Semen quality does not necessarily correlate with sperm count; a normal semen volume may still contain low sperm count or poor quality sperm.
• It is important to get regular check-ups for prostate health and sexual health, as these directly impact overall health, including mental health.

Importance of Sexual Health Awareness

• It's critical for men, regardless of their age or reproductive aspirations, to understand and consider their sexual health.
• Sexual health doesn't only pertain to the ability to conceive, but it's also associated with urinary health, prostate health, and overall well-being.