The Fertility Expert: Delaying Having Kids Is Impacting Your Future Children & Reducing Your Chances Of Parenthood By 90%! Masturbation Reduces Cancer Risk!

Michael Eisenberg
Men need to understand the average age of the father has gone up about three and a half years. And with that, the chance of problems with the child also can increase. Then that pregnancy becomes a lot riskier. And this is why doctor Michael Eisenberg. Is an expert in male sexual function.

And fertility, who's helping us to learn the truth about optimal sexual health. If you just look at all the data, sperm counts are declining. But low sperm counts and low testosterone could have devastating effects. For example, men with lower semen quality have higher risk of death. Wow.

There's a lot of really interesting questions that need to be answered. Okay, let's get into that. Is there any evidence that the chemicals in our environment are impacting our sperm count and our testosterone levels? Yes. It's a chemical that's in a lot of creams and lotions that we use, and then there's a chemical that's used in the manufacturer of plastic, and that could have pretty devastating effects.

And so don't drink out of plastic water bottles. What about hair loss? I couldn't figure out if low testosterone or high testosterone causes a receding hairline. Most men are not gonna like this, but it turns out that if I'm. Sat down all day, is that gonna have an impact on my sperm count?

There are studies that do support that. I would say take breaks, stand up to try and air out the area. What can I do to give myself the best possible chance of increasing my fertility? So there's a lot that we can do, and usually we start with and then erectile dysfunction. Hundreds of millions of men all over the world have trouble with erections.

But as long as you have a penis, we can always make it hard. For example, we can teach men to give themselves. Ooh, I just got shiver down my body. But it probably works 80% to 90% of the time. Congratulations, diary of a seogang.

Steven Bartlett
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And the bigger the channel gets, as you've seen, the bigger the guests get. Thank you and enjoy this episode.

Doctor Michael Eisenberg. Why do you do what you do and what you do? It's a pleasure to be here. Certainly an honor. I kind of see myself as a researcher and advocate for men's health, men's reproductive health, sexual health.

Michael Eisenberg
And so, you know, I think when I see patients in clinic, that's what I'm trying to do, to try and understand where, where they're coming from, any issues they have, and find out ways that we can work and improve them together. And certainly from my research perspective, I always want to try and define what the issues are and just improve our treatments that we have for men. I am the director of male reproductive and sexual health at Stanford, or men's health in the department of Urology. I have a joint appointment in the department of obstetrics and gynecology because fertility is a team sport. And so I also help couples and I refer women to the female side and just like I get lots of referrals from them when we're kind of worried about the male partner.

Steven Bartlett
When you say sort of reproductive health, what are all the sort of things that fall within that bucket or underneath that umbrella? So I think reproductive health really, I mean, I guess its sort of name implies would be trying to have a baby. But I think its so much more than that because I think what were really learning is that fertility is kind of a window into future health. Probably about 10% of the male genome is devoted to reproduction. And given there's only about 25,000 genes in the body, it makes sense that some genes that are operating in reproduction also operate in another organ system.

Michael Eisenberg
There was a study done where they took biopsies of men that had trouble making sperm and tried to replicate these cells, and they found that these cells had very high rates of mutations in their DNA. So you can imagine for checks and balances when we're making sperm, it makes sense. If you can't faithfully replicate your DNA, there's probably going to be some blocks where you can't make a sperm if there's going to be mutations. But also these men may be set up for other problems like cancers or something like that. If the body can't effectively replicate cells or DNA, there could also be hormonal links.

And that's another thing that we commonly look at when we're evaluating men with infertility. Infertile men actually have lower testosterone levels than fertile men.

Theres also been studies that show that men with lower testosterone levels have lower survival. So it may be that kind of hormonal links between fertility may kind of put men on a different trajectory. Another, I think, very important aspect of reproduction. Theres other kind of what I call social factors that are at play, things that necessarily go with reproduction. Having a partner, um, and having kids, hopefully.

And it turns out that those factors actually are very important for health and longevity. So, um, like, having a partner actually increases survival. So if you, like, compare sort of, if you have, like, uh, you know, a man with a partner and a child, if you then take away the partner, the chance of that man dying goes up 60%, and then if you take away just a child, the chance of him dying goes up 60%. But it turns out if both of those things are absent, that man has a threefold higher risk of death than somebody with a partner and a child. So there's really kind of this sort of important aspect, I think, to health and reproduction.

I think that men kind of need to understand, and then obviously there's also just a lot of kind of intrinsic things that we do, like lifestyle, behavior, obesity, smoking, those are all very important for health as well. So I think when I see these men for reproduction, I really try and broaden it a little bit to overall health, because I think there's certainly data that as we improve a man's health, we'll improve their reproduction and hopefully give them a baby, but also improve their overall survival, health, everything. So how many patients have you seen in your career, if you had to hazard a guess, roughly? Oh, I mean, I think it would probably be in tens of thousands. I would guess maybe 20, 30,000.

Steven Bartlett
And how many years have you been working on this subject of male health, fertility, reproductive health, all these kind of. About, probably ten to 15 years. It feels like the world has kind of turned towards your work more so in the last couple of years than ever before. It feels like you just so happen to be doing research and educating people on a space that quite suddenly, relatively suddenly, has become really important to people. And I was even looking at some of the data around sort of testosterone replacement therapies and how that's just absolutely skyrocketed in recent times.

And also the conversation around fertility. I was looking at the data around fertility, how many people are searching out for information on it, and it skyrocketed over the last five years. And even in my circle of friends, we weren't talking about fertility or testosterone or sperm count even two years ago, whereas this year and in the last twelve months, it's been a frequent topic of conversation. Why is this, and is my assessment there accurate, and can that be supported with what you're seeing? I mean, I think so.

Michael Eisenberg
Obviously, I guess I would say I'm biased and that I think this is very interesting and I think there is a lot of momentum towards this. There have been a lot of landmark studies suggesting, like you say, declines in testosterone over time, declines in sperm count over time, and we can certainly talk about that a little bit more. And I think with that, there's been really an explosion in assisted reproductive technologies. I'm familiar in the United States how that's happening. A few years ago, it was maybe about half percent of all bursts in the US were conceived with IVF.

Now it's about 2% and only increasing. It used to be that insurance never covered it. Now insurance commonly covers it. And so with that, there's just really been explosion in the offerings, the number of cycles that are done. In my particular area in northern California, it seems like every year a new IVF clinic is opening up, and you're always worried and wondering how could there be enough business to support it, but instantly, all the patients, all the slots are filled, they're booked out for six months.

And I think there's just a tremendous amount of demand. And I think to your point, the question really is why is fertility declining or more couples becoming reliant on IVF? And I think, again, our sperm counts declining. I think all those things are probably going together that's leading to this. And I think it's something that we're doing to ourselves, potentially.

Is there some environmental exposure? I think all these things are really interesting questions that need to be answered. Let's start with why then, if we stay zoomed out a little bit on some of the social factors that might be leading to infertility issues, but also just correlated issues like things like testosterone and all of these things, what are some of the broader social factors that are causing IVF clinics to become so in demand now? Yeah, I mean, I think one of the big ones would just be rising parental age. You know, there's been sort of less data, I think, on male age over time, at least here in the United States.

But, you know, a few years ago, there was a study done where it showed that over the last maybe 30, 40 years, the average age of the father has gone up about three and a half years. It used to be like in the seventies, an older father, and that would be considered over 40, was maybe about 4% of births. Now it's probably 910 percent of births. So I think there's just more delay. And with that, infertility gets higher.

There's usually a close correlation between mother's age and a father's age. And so I think a lot of people are sort of familiar as women get older fertility goes down, probably at a steeper rate. But for men, the same thing happens. Sperm counts get a little lower, testosterone gets a little lower, takes a little longer to conceive. The chance of problems with the child also can increase.

I mean, the oldest father ever is 96, so the biologic potential does persist, but it certainly gets a little bit more difficult and that pregnancy becomes a lot riskier. What is the rate of decline in men and women in terms of fertility? If you're looking from an evolutionary standpoint, peak fertility would probably be late teens, early twenties, something like that. For women, they're born with a set number of eggs. As soon as cycles start, they continue to lose them over time.

Usually we think about over 30, 35, 40. Those are pretty big points where fertility gets a little bit more challenging. For men, the sperm counts do decline. Why? This cutoff where we say older father is 40 is a constellation of different risks.

The sperm counts get a little bit lower. But the other thing that happens is every year we're born with sperm precursors, or sperm stem cells in our body, and they are constantly replicated. Every year, every time that happens, there's some chance of a mutation occurring. It turns out that every year we probably accumulate two mutations in our DNA. And so over time, that becomes a little riskier.

So for like, a 40 year old is going to have 20 more mutations than a 30 year old, for example. So we have billions of base pairs of DNA in our body. So the chance of 20 mutations making a difference is probably pretty low. But that's at an individual level, at a population level, that's something that you may start to see. And so for men, I think it is just sort of a slow, steady decline, you know, again, probably in the thirties, forties, do you have the data.

Steven Bartlett
On the oldest ever mother, that is the oldest ever woman to conceive a child? So with using like a donor egg, I think it's sixties, or even in the seventies, I think it's been described before, but I think with her own egg, I think it's late fifties, early sixties. Are you concerned about this as a macro trend? Because if we play this forward, it would lead us to assume that fertility is going to be an increasing problem for society. Yeah, I mean, I think very much so.

Michael Eisenberg
Right. It's existential. I mean, as a disclaimer, obviously, I'm in the fertility business, so I do certainly care about this trend and want to make sure that we reverse it. It's a risk factor that we know about. But I think the solution is not obvious, right?

Because asking couples to delay careers, education, all that is very challenging. I think some countries have tried to come up with ways to support parenthood through leave or other kind of programs like that. Childcare also becomes very important. But even with those, I think that there's just sort of a perception. It's not as easy as you'd think.

And it turns out, actually, that the return on investment for some of these things, having a child is so kind of important for the health of a society, right? There's this concept called replacement rate. That's the number of children that need to be born to a reproductive age woman to maintain a population's level. Sort of. This is kind of ignoring immigration.

So it turns out you need about 2.1 children per reproductive age woman for a population level to stay the same. So if in some societies it's lower, like in the US, it's a little lower than that. And some, like asian countries like Korea and Japan, it's lower than that. And that's really existential because if, you know, if your working population starts to decline, you know, tax base, everything will really collapse. And so from an economic standpoint, it makes sense if these are couples that want to have kids and they, you know, these are wanted children to try and invest in allowing them to do that really makes sense because, you know, it'll kind of pay it back at a societal level.

Steven Bartlett
I read about in Hungary that if you have four or more babies, then you'll pay no income tax for the rest of your life, according to the prime minister. It's an article that I'd seen, and I think this speaks to a broader trend of how there's going to be a top down approach towards getting us to get back to having babies to stop the population collapse and decline that you talked about. Hungary's prime minister has announced a raft of measures aimed at boosting the country's declining birth rate and reducing immigration. And one of them is that essentially you'll be given a check and you only have to pay that check back if you don't have four kids. So for every kid you have, 25% of the money that you're given is discounted.

And once you get to four kids, you never have to pay income tax again, which I thought was a really interesting idea, but it's a sign of things to come. Yeah, yeah, it's fascinating, right? I mean, I think that these economic ministers, prime ministers, are really thinking about things. I'm sure they've looked at the numbers and realize that society really relies on maintaining numbers. And when the population starts to slip, it could be a problem.

Michael Eisenberg
I think that's a very clever solution. Sperm quality. Sperm quality, I read, is declining. Yeah, it's interesting because that's such a controversial statement. I think there is a tremendous amount of data that supports that.

A number of years ago, I was actually involved in a study looking at data from a sperm bank here in the United States. It was a sperm bank that was in the northeastern us at a few locations. And it wasn't a lot of data. It was just a few years of data, about like a little over maybe 1015 years. But what we found is that, actually, if you looked at men that were coming in to try and be donors, because at these banks, they're very selective.

So you have to have excellent sperm that freezes well, that thaws well really high numbers, and they also look at your pedigree a little, make sure there aren't conditions that run your family. They like you to be fit. These are kind of things that are thought to make a better donor. And when we looked at the candidates that came in over this really short period of time, probably 1015 years, there was declines in sperm counts. The movement, shape, all these parameters that we look at when we're talking about a semen analysis.

And what was interesting is that when people have talked about declines in sperm count, people have sort of attributed to different things. For example, people have talked about the obesity epidemic and that maybe we're more sedentary now than we used to be, or environmental exposures or another thing, there's more chemicals now than there used to be, or cell phone prevalence and things like that. But over this short period of time where we did have a lot of information on these men, they filled out surveys, they filled out kind of rich family histories, they filled out information about whether they drank a lot, smoked a lot, things like that. Theres really no differences in these men from the beginning of the study to the end. The only difference was that their sperm counts were lower.

It was really surprising. Very interesting. Other investigators have used studies like that, pooled them all together using advanced statistical techniques, and found this decline over time, over the last, maybe 2030, 40, 50 years. So there is a preponderance of data that supports that. So the counterargument that others have made is that over that same period of time, some of our techniques have changed.

Right. We're better at counting sperm now than we used to be. Some of the different tools that we use to measure sperm count, some of the analyzers are better now than they used to be. So we're a little bit more precise than we used to be. The other thing that these studies have done is when they pull together data, they assume that everybody's the same.

Like, right. If we were both in this study, they would assume that I'm like you, you're like me. But it turns out that there's a lot of variation based on, like, region. So there was a study in the United States where they looked at fathers. So men that had kids at different regions of the country, you know, like, had some in California, New York, some in the Midwest.

And even though these were all fathers, similar ages, the sperm quality was much different. Turned out it was really high in New York. I think California was next, and the midwest was a lot lower. So, you know, again, why you'd think that New York would be kind of hustle bustle metropolis. Maybe they would have some poor risk factors, but turns out they had the best sperm.

And so why that is, is, you know, wasn't certain. But it just shows us that there's a lot of variation in semen quality from individuals. So when you put things together, sometimes it can be difficult to, you know, to identify trends. So, ideally, what we do is, you know, I, in my neighbor, would give sperm maybe every year, every five years, ten years over time, and you'd see what changed. Um, and those studies aren't available.

So that's sort of the criticism of these studies. But again, if. If you just look at all the data, if you compare studies from the, you know, seventies, eighties, nineties to today, sperm counts are lower. What is the current best guess as to why sperm counts are lower? Yeah, I think that's the million dollar question, because I, you know, we've talked about this is sort of an accidental existential threat, right?

We need a, you know, I think any species has sort of three main functions, right? Eat, survive, reproduce. You eat to survive. You survive, reproduce, spread your DNA. And so if you can't do that, it's definitely gonna be an issue.

So, you know, I think that we've talked about, you know, maybe obesity. I think we're certainly different now than we used to be. You know, in terms of walking around, you know, sedentary behavior. People have, you know, hypothesized different chemicals in the environment are kind of leaching into our food supply, our water supply. Is there any evidence for that?

Steven Bartlett
That the chemicals in our environment are impacting our sperm count and our testosterone levels and things like that? Yeah, there are studies that do support that. There are certainly preclinical studies where you can actually dose rats and mice. There's also human studies where you can compare sperm quality to different chemical traces in the blood and see these correlations as well. And then there's a study called NHANEs, which is a study by our Centers for Disease Control, where every year men and women are sort of surveyed, or they collect data on obesity, blood pressure, things like that.

Michael Eisenberg
They do collect data on chemical exposures for these select group of individuals that kind of represent the whole population. This has been done for the last many, many decades. When we talk about obesity kind of rising in prevalence in the United States, it's based on that data. This is kind of a rigorously sort of researched, you know, group of individuals that selected every year. And so those same studies collect data on testosterone or estrogen for women, and they collect it on these different environmental chemicals and do see these correlations.

I would say that not every study supports this, but there are certainly a good number that do show that there is this correlation, that if you have higher exposure to some of these chemicals, there's higher risk of lower hormone levels. What are those chemicals, and where do we find them? Because I spoke to someone who was a urologist recently, I think, from NYU, and they were telling me that things like the microplastics, and I'm not particularly aware of what a microplastic is, to be honest, but things like microplastics in our environment are some of the chemicals that are causing sperm quality to reduce. Is there evidence to support that? There's a lot of different chemicals to be sort of concerned about or think about.

I think microplastics, for one, phthalates. What is the phthalate? A phthalate is a chemical that's in a lot of different creams and lotions that we use. And so those also have been shown to affect androgen and endocrine function inside the body. Bisphenol A is a common chemical that's used in the manufacture of plastic, and that's also been found to have these endocrine disrupting properties.

Um, so that's also been correlated with semen quality. Endocrine disrupting, endocrine disrupting. What does that mean? So, you know, if you look at sort of pathways for men and women, there's, you know, hormones, right? I'm making testosterone and that axon my body as I was a child to help make me a man now it kind of helps, you know, keep me a man, you know, with grow a beard, all those sorts of things, giving me my, uh, my deeper voice.

Um, and so there's some of these chemicals that kind of mimic some of that action or block some of that action. And so if that happens, it can affect normal development of boys or girls, maybe can affect semen quality. If we think about the origins of changes in semen quality, some of it may be when we're adults, but some of it also could be during development, either when we're developing inside of our mothers or during puberty. If something affects the normal timing of that, it, again, could have pretty devastating effects. Theory for that is some of these chemicals that affect these sort of biologic pathways, these endocrine pathways involved in that.

Steven Bartlett
From the research you've seen on sort of these chemicals, is there any changes that you've made in your own life at all? Anything that's kind of made you think differently about the choices you make in your own life with your kids because you've got three kids, so you have an opportunity to kind of influence them at an earlier stage than most of us can influence ourselves. Yeah. So one thing that we do is I've thrown away all plastic water bottles. I would say I still use it because I find them very convenient and I'm done with reproduction.

Michael Eisenberg
But certainly for the kids, I make sure they don't drink out of plastic water bottle. So we have either glass or metal. I do think there's data that that's, you know, a very, you know, large exposure that kids get. And I think it's, you know, fairly easy now to remove that. What does the data say about plastic bottles?

You know, if you look at, you know, exposures from that, you know, they have, they just leech a tremendous amount. You know, with wash, with water, it kind of sits there all day. So I think it's a. It's a very, you know, again, most plastic water bottles want the, you know, plastic bottle industry to come after us, but that's a common way for, you know, individuals to get exposed to it. So I think if, again, if we're seeing that's one of the main touch points for plastics is usually through our kind of food and water supply, then, yeah, I think it's easy to get rid of it if you can.

Steven Bartlett
Is there anything else? I've read recently that heat has a role in our sperm quality. So if we're, I don't know if we're going into saunas or something or if we're spending a lot of time sunbathing, then there's science that suggests that will lower our sperm count. Yeah, that is right. So, I mean, I think that you can kind of look at this sort of in a bigger sort of global warming kind of context.

Michael Eisenberg
And people have theorized that maybe that could also play a role because the testicles are outside the body, because they need to be a few degrees cooler for sperm production to occur. So anything that warms them up can definitely be a problem. Um, so when I talk to patients in clinic, for example, we do talk about sauna use hot tub use. Some men bathe every day, like in a bath. Um, and those all can impact sperm production.

There have been studies that show that men that, you know, use, you know, saunas on a regular basis, they have lower sperm counts. And then when you withdraw that exposure, um, sperm counts will go back to normal. One sort of interesting application of this was to try and use this data or use that knowledge to come up with a contraceptive. So there was this weird sort of, like, truss kind of belt that actually pushed the testicles up into the groin, which actually turned out did reduce sperm counts to zero, I think. And again, the few men that volunteered to do that.

But you can imagine, I think most men are not going to be too excited about that. Um. Cause it's probably pretty uncomfortable. Uh, the other way that I've seen it is I've had patients that have gotten sick, certainly around COVID, that happened not infrequently. Men would come in, you know, telling me that, you know, they just got over a COVID infection that.

Where they had high fevers for, you know, a few weeks, um, and then their sperm counts would be very low. And then, you know, we wait a few months. It takes about two to three months to make a sperm. So we let one of those cycles or two of those cycles go through, and their sperm counts came back. I had a patient even before COVID like, 41 year old guy.

He had normal sperm count, and then all of a sudden he measured and his sperm count had gone to zero. And it turns out he had a flu with fevers about 102 degrees fahrenheit the week before. And again, we let kind of, sort of nature take its course. He recovered, and then his sperm counts came back to baseline. So we do see that as well.

Steven Bartlett
With that belt that you mentioned that holds the sort of testicles closer to the body. I'm guessing it's doing that to heat them up, basically, which reduces the sperm count. Obviously. Then one would think about their boxer shorts. We're all wearing very tight boxer shorts these days.

That's like in vogue or whatever. So is there any studies to suggest that boxer shorts can reduce sperm count if they're tight? So that's like a very common, that's one of the most common questions I get, like boxers versus briefs, and that's been studied a lot because that is a very common exposure. I think I usually just tell men whatever's comfortable. I think it's unlikely that any single layer is going to make a big difference.

Michael Eisenberg
Unless again, you have the specially designed underwear that pushes testicles up into the groin, but otherwise, as long as they're outside the body, it should be okay. What about mobile phones and technology? Is there any link between fertility and our use of technology, specifically having these devices in our pockets close to our genitals? That's another common question that I get, and that is certainly something thats changed right now versus 2030 years ago. So there were some studies that initially showed kind of this signal that men that use cell phones more had lower sperm count, but some of these studies were older.

And you also worry about some of these kind of confounding things. It may be that people that use phones more do other things more, they may have more stress in their life and other things that could affect semen quality. There was a clever study that was done where they actually took ejaculate, so took sperm, put it in a cup and put a cell phone next to it, and tried to measure changes in the quality of the sperm. And they actually did find some. They found higher rates of DNA damage within the sperm that was exposed to the phone, versus not trying to control for temperature, which we said is important for the help of the sperm.

Steven Bartlett
Wait, so they controlled for temperature? They controlled for temperature. And just having kind of, the cell phone getting its signal seemed to affect the DNA damage and sperm, it wasn't, it was a statistically significant, you know, difference. Um, it maybe would not be kind of a point where we would get as worried clinically, but it is a change. So I think it's something to think about.

Michael Eisenberg
I think that, um, you know, aside from that, cell phones, I think nowadays don't get too hot. So not as worried about heat, but whether this rf, you know, this radio frequency exposure may impact things is a, you know, maybe a theoretical risk. But again, there's not a lot of concrete data. So I think that, you know, again, if a lot of my patients do tell me that they keep their, try and keep their cell phone in their back pocket or front pocket to try and avoid that, I think that's and that's fine. I've been having this conversation with my partner a lot.

Steven Bartlett
She really believes that my cell phone should never be slid under my genitals, which I sometimes do when I'm like, I don't know, when I'm in the car or something, or when I'm on the sofa. I don't know. When I've got my hands full, I'll just grab it and I'll kind of, like, slide it between my legs. Yeah. And she'll reach in and pull it out and say, and I think.

Cause she's concerned about those four kids that we want to have and you. I think she cares about you, too. Yeah. To be fair, she's not someone that's going to read pubmed and read about the studies, but it's just a feeling she has. And I always refuted it and thought, now there's no way.

There's no way. Because they would have tested it. And the test seems so easy. You get sperm, you put it in a little thing, you put the phone on top of it, send it some text messages, connect it to the wifi, the bluetooth, and see how the sperm get on. Yeah.

I didn't realize there was a study associated with it. Yeah, I think laptops also can do that, too, but they also have a little more heat associated with it. So a similar study was done in laptops where they had sperm, put it next to a laptop, and they controlled for temperature and saw the same pattern again. The wifi signal can also affect against sperm DNA damage and sperm quality. But also laptops can get warm, too.

Michael Eisenberg
Some of the batteries, some of the moving parts within can heat up, too. It also just serves as almost like insulation if you put it over your lap. So I do talk to patients about that as well, to maybe use a pillow or something else, just to try and shield yourself a little bit. Wouldn't we see a sort of big difference between hot countries and cold countries or sort of warm countries and sperm counts, then? So if I'm in sort of sub saharan Africa, I'm assuming my sperm count will be pretty low because I'm going to be sweating all day.

So I think that the other sort of element to that, though, is that there are differences in populations. And I think that that has not been well described. But if you compare again, we talked about California, New York, the Midwest and the United States. But people have also compared Denmark, which they have a lot of problems with reproduction. So they've really studied it very, very aggressively.

And if you compare them to other countries nearby or other countries in Europe, it's much different. And so one possibility could be exposures and what these men are doing, what they're exposed to, but the other could be, again, there could be some genetic components. But one interesting thing about on that same line is that sperm quality does vary based on time of year. So during the hotter months, it does go down a little bit, you know, not meaningfully. Um, and then during the cooler months, it goes up a little bit.

But the other thing is that, you know, we don't spend. Some of us do, I guess, or some of us don't, but no, spend all your time outdoors. Right. And sometimes in the, um, you know, during the cooler months, you're, you know, kind of bundled up inside, and during the warmer months, you're maybe in, you know, cool air conditioning. Did you say that Denmark has had a problem with sperm count?

Yes. Yeah. So in the United States, I said that about 2% of births are conceived with IVF. In Denmark, it's about 10%. Wow.

And it's actually, again, they have really a crisis of reproduction there. So they've really done some really good research on semen quality, and it estimated that only about 25% of danish men have normal semen quality. Have they figured out why? That's what they're looking into. They have lots of theories.

And again, I think, again, it goes to many of these same topics that we talked about, whether it's environmental exposures on mothers or, again, pubertal boys or adults as well. So they are trying to figure it out. But that's also one of the countries where the fertility rate is below replacement. So it's definitely an issue. One would assume that it's some kind of environmental factor.

Steven Bartlett
I guess it could be some other social factor, but one would assume that it's some kind of environmental factor. Yeah. Some people have postulated during World War Two. They were very isolated, and so potentially there were some chemical exposures that have just kind of persisted and remained in the population. And it's kind of tough to work through that.

Michael Eisenberg
But it's not known. If I'm sat down all day, is that going to have an impact on my sperm count as well because of the heat generated from me just sitting here and or if I'm a cyclist or someone that's doing, you know, sat down on my testicles doing something warm? People have looked at sort of different occupations where you sit a lot, and there are associations like drivers, you know, taxi drivers, truck drivers. They certainly can have changes in sperm count probably due to heat. You know, again, I think it could be a combination of sort of sitting all day is also from probably other health standpoints is not great.

And cycling, too. People have looked at sort of peak athlete cyclists, and there are differences in semen quality, but, you know, peak cyclists, you know, they do a lot to their body. And so, you know, it's possible that there could be other effects, too. But, you know, looking at men that sort of recreationally Cycle, too, I think that the number that I use, there's a study that showed if you cycle over 5 hours a week, there can be lower sperm counts. So, you know, I talked to men about that when they do cycle, you know, more than that, you know, potentially taking breaks, trying to stand up.

If we think the mechanism is heat, to try and sort of circulate air out the area, to spend some time out of the saddle, if possible. What about men with big thighs? Yeah, well, I think, you know, obesity is an issue. There's certainly a strong correlation between body mass index and semen quality. So as men get bigger, sperm counts go down.

Um, and so heat is certainly one of the. The possible mechanisms for that. Just kind of insulating that area, warming things up, can kind of do it. You know, obesity also affects, you know, the kind of hormonal axis as well. So that also may be at play, too, because, you know, there's kind of a normal stimulation that's given by your pituitary and your brain that tells your testicles to make sperm make testosterone.

And some of that's also affected by obesity as well. So it's. It's probably a combination. But that is something I do think about when I see, you know, my patients, and we do talk about sort of heat exposures as well, and see if there's different sort of strategies they can use to try and allow more circulation in the area. Is there a link between sperm counts and alcohol consumption?

I think it depends, is what I would say. So, in general, for most kind of moderate use, I would say kind of a drink a day. And some people think that no amount of alcohol is safe. But if you look at these studies, looking at maybe a drink or two a day, it probably doesn't correlate too strongly with semen quality. But it seems like there are some studies that say that when men get to three a day, so maybe 20 a week, there can be lower quality in semen.

And there was also another study that we did looking at, you know, to see if some men are more susceptible to alcohol intake. So there are some east asian men and women that have a mutation in one of the enzymes that's used to metabolize alcohol. And so they accumulate what's called acetaldehyde, which is a toxin, actually. And so when they drink, they flush. I don't know if you have any friends that have this, but, um, we hypothesize that, you know, when you have this, you know, this large load of this chemical in your body that leads to flushing, headache, dizziness, um, maybe it also affects semen quality, and it turns out that it does.

So for these men that have this mutation, um, when they drink, their sperm movement goes down a little bit. So it turns out that there's actually a reasonable number of men on earth that have this. You know, it's probably in some populations up to 50%, like in Taiwan, you know, it's very common in Japan, you know, chinese and vietnamese ancestry. So I think it's something to be aware of. And I think usually, you know, men do know if they flush when they drink, it's probably because they have this mutation and aldehyde dehydrogenase, too.

So, you know, for those men, I think that it's probably better to, you know, avoid alcohol or just to sort of be aware, because it can affect semen quality. If I, if I came into your clinic and I said, doctor Michael, I'm trying to have a kid with my partner, and I want to make sure that everything I'm doing is giving me the best chance of having a kid. What's the list of things? Because this is basically where I am in my life now. I'm 31 years old.

Steven Bartlett
I want to have a kid. I ideally want to have four of them. And I'm thinking about the time. My partner's the same age as me, we're almost identical in age, and she's 31. So we're, we've got, you know, we want to have these kids before 40, ideally.

So I kind of need to get going. Get going, you know what I mean? So what can I do to give myself the best possible chance of increasing my fertility, my sperm count, so that we have those four kids that I want over the next nine years? Was the four number it was something you came up with before that tax incentive or.

Yeah, we are planning to move to Hungary, so there you go. It's really about tax avoidance. It's not that I want kids. No. I come from a family of four, so for some reason, I've always had four in my head.

I think she's fine. With it as well. I think we've chatted and she's happy with four to six. No, it's a good number. Not had six signed off, but four for sure.

What would you say to me then? So I think we look at your overall health. We'd see any risk factors that you had. Obviously, we're talking about saunas, hot tubs. Find out how you exercise, if there's things that you do that are not, you know, good.

Michael Eisenberg
Look at, you know, if any medical conditions that you have, surgeries that you've had, some of those can put men at risk for. For that. If there's any medications you're on, there can be medications that affect it. And then we'll do an exam so we don't have to do that here in front of the cameras. I'm down.

Yeah, I do have a California medical license. So, you know, we wanna make sure we look at the sides of the testicles, make sure all the other structures are where they're supposed to be. You know, one of the basic evaluations will be a semen analysis. So we'll measure how much comes out, look at how many sperm there are, look at how many are moving, look at their shape as well. And then usually we also check hormones as well.

So we'll check testosterone again, sort of this very male hormone. The testicle does two things. That makes sperm makes testosterone. So we check that, and then usually we check some other hormones involved in the kind of hormonal axis that controls reproduction. And that's usually what we start.

Again, fertility is a team sport, so I would encourage your partner to also get evaluated as well. And we'd see, depending on sperm counts, usually, then we're able to counsel about how likely you are to be able to achieve those four kids. But again, if you're thinking about four, I would agree that you should get started. Fertility issues, we tend to think of it. I think there's a stereotype that it's typically the woman who has the fertility issue and the man is okay.

Steven Bartlett
When I looked at the data that's supported this idea that couples assume it's the woman that has the fertility issue, is that a misconception? That's a huge misconception, yeah. So, absolutely. I think that in the United States and other countries, too, I think usually women are kind of the gatekeeper of fertility. Everybody assumes that that's where the issue lies.

Michael Eisenberg
But if you actually look at the data, probably about half the time there's a male factor contributing. And this sort of stereotype is so prevalent that probably at least a quarter of the time in the United States, demand is never evaluated. And he could be one of the issues. So some couples may go to IVF for the lone reason of, again, low sperm count, and the man would never evaluate it. And maybe there is a condition that we can improve.

Maybe he's on a medicine, maybe he's going to the jacuzzi every day, something like that that we be able to reverse. You mentioned testosterone would be one of the things that you would measure if you were trying to make sure that my fertility was good. Male testosterone decline. This is another hot topic. You talked about it at the start of this conversation.

Steven Bartlett
Is it true that male testosterone is declining and how much has it declined by? Yeah. So again, study from this NHANEs, this CDC, measuring men every year for the last several decades, there's data that shows that testosterone levels have gone down over time. People have also looked at other cohorts of men from the two thousands, the nineties, eighties, and there's just a progressive decline in average testosterone levels over that amount of time. So the amounts kind of vary 50 to 100 points.

Michael Eisenberg
But generally, these are meaningful, measurable amounts in addition to these kind of cohort changes, where if you look at the average 40 year old now versus ten years ago, our testosterone levels change, too. So I would say that I usually tell men, after the age of 20, your testosterone is going to go down maybe about a percentage point every year. So as we get older, testosterone does go down, and there's things again that can affect that trajectory. You know, men that get more obese, that also affects testosterone level. A portion of all of our testosterone is converted to estrogen.

A lot of that conversion happens in adipose tissue or fatty tissue. So the more kind of extra tissue there is in the body, the more that conversion will happen. And so your effective testosterone levels will be lower. What about movement and exercise? Does that have an impact on our testosterone levels in a significant way?

Yeah, I mean, I think that the more walking you do, the more active you are. We've looked at that as well. You know, step count is directly correlated to testosterone. And you don't have to take 20,000 steps a day, you know, 4000, 8000 steps a day. You know, just kind of walking around, you know, sort of reasonable amounts can make a big difference.

And I think that, you know, activity is important. It probably also helps stave off obesity a little bit, as well as another mechanism. Okay, so I'm a Manchester United fan. Right now, we're losing a lot I. Thought you guys had turned it around.

Steven Bartlett
Yeah, I thought so, too, until last week. Okay, so if you're supporting a team that is losing, your testosterone levels are likely going to be lower. Well, I think this is sort of an acute thing. Maybe we could do that experiment. Right.

Where does that research come from that if your team wins, your testosterone increases? I don't remember. That study is pretty old. I think that even predated my training. But I do remember reading that.

Michael Eisenberg
I think that was one of the articles that get picked up by the newspaper. Okay. Of course. Why does testosterone matter, doctor? Well, I think testosterone is very important for a lot of things.

I think it's important for our quality of life. So energy level, sex drive, mood, sleep, concentration, all those things are very important. When testosterone gets very low, it also has a lot of health implications. Muscle health, bone health, heart health. We do want to keep our levels in a normal range because I think it kind of helps us with our function and our life and happiness.

Steven Bartlett
How does it impact our sort of muscles and bones? I don't really understand what testosterone is doing. I kind of think of it as the chemical that kind of makes you a man. I know women have testosterone, too, but I just think of it as the chemical that makes my beard grow in my voice. Deep.

Michael Eisenberg
Yeah, well, that's what it's doing. But it's anabolic. It does help kind of grow. It helps with bone turnover and kind of keeps sort of, you know, the strength of the bone. So men that have very low testosterone levels have, you know, frailer bones, higher risks of osteopenia, osteoporosis.

So, um, you know, I think it helps with muscle growth, bone turnover, bone strength. So I think all those things are, um, are important. They usually don't get into those problems unless men are very, very low. I would say that, you know, I don't know you, but, you know, the average testosterone levels are probably 300 to 900, I would guess probably on the higher, higher end of that. Um, but, you know, when men are low, probably less than 200, 100, that's where you start to worry more about, you know, bone health, muscle health.

And so I think that there is some wiggle. But when you get kind of lower than sort of the normal ranges, kind of the 300 range, that's when some men do develop, you know, some of the symptoms of lower energy levels, sex drive problems, things like that. So low testosterone typically means lower sex drive. It can. It's one of the.

It's one of the common symptoms that we see with that does that mean. That if I just take loads of testosterone, my sex drive is going to go back up? Over the last probably ten to 20 years, the number of prescriptions of testosterone written in the US have gone up almost at an exponential rate because people did think of it as an anti aging rejuvenation therapy. There was hope that it would help people. If you look at some of the randomized trials, if a man has a normal testosterone level and you give him testosterone, uh, it may not help them that much.

Even men that have kind of a lowish testosterone, like we talked about, sort of this 300 cut point. So I've had plenty of patients testosterone of 250, let's say. So we talk about risks and benefits of being on testosterone. Uh, we'll try them on it. And, you know, a lot of men do feel better, but not everybody.

Some men say, I don't feel any, you know, Doc, I don't feel any different, even though we get his levels, you know, from 250 to 500. And so then it's probably not worth, you know, to be on a medicine every day if it's not helping you. I'm not worried about his bone health. You know, we'll check some other measures to make sure that's okay. So then it's not, you know, again, when you look at risks and benefits, it's probably not worth it.

But there are certainly some men who do see improvement. So is testosterone hurting some people, their testosterone treatments, does it actually have an adverse effect if you take it basically when you don't need to? I mean, even when you do need to, I think it could sometimes cause issues. Yeah, there's certainly side effects to testosterone. You know, one of the big things that I see in my practice is how testosterone impacts sperm production.

It actually was tested as a contraceptive by the World Health Organization because it does lower sperm counts in most men. I would say 90% of men now, it doesn't do 100%. So it's not that great of the contraceptive yet. They're kind of working on some other ways to tweak it. But I have plenty of patients that come in.

Some of them suspect that testosterone is the issue. Some don't know. I remember one couple in particular. They came in as a couple together. We measured his sperm count.

It was zero. We started talking about risk factors, and he was on testosterone. And I said, well, the best thing to do would be to stop testosterone. And for his work, and I will tell you what he did, but for his work, he really couldn't stop it. So there are some other medicines we were able to add while he continued the testosterone, and then they ended up with triplets shortly thereafter.

So I think that men need to be aware of it because that's certainly one of the big risk factors, at least of reproductive H men is this risk to fertility, so it can impact. My sperm count negatively. I saw a quote from you that said, if we take 100 of my infertile patients that I see in the clinic, at least five of those men will be infertile because they're on testosterone therapy. One in 20 infertile men are that way because of testosterone as it relates to infertility. One of the things that I've always worried about is if I take testosterone, then my hair would fall out.

Yeah. So that can definitely happen. So, you know, hair loss, breast growth, acne, those can all occur. I would say those are things that we can monitor. So, you know, one thing I always tell men is that were not trying to get them to superhuman, right?

Were just trying to get you to normal. So I think if we monitor it closely, most men will do okay. Again, theres some other therapies that we can do for men that have side effects from those things. It can also affect the thickness of the blood, something called the hematocrit, where we count the number of red blood cells in the body, it can increase that number. So if it gets too high, that can be an issue.

So that's another number that we follow. There used to be a concern about higher rates of heart attack and stroke with testosterone. So there were some studies done about maybe ten year, 510 years ago that suggested that. But a really large trial just came out with about 5200 men, half of them randomized to testosterone, half not. And there was actually no difference in the risk of cardiovascular disease.

So I think that's something that we can probably put to bed. The other thing that men worried about is increase the risk of prostate problems, prostate cancer, prostate growth. And, you know, that same trial also showed that from a prostate standpoint, probably not a lot of risk as well. Do you have many men coming to you to talk to you about hair loss and balding? Some men do.

I think one of the ways that men talk to me about it is one of the common medications for that is finasteride or sold on the trade name propecia. And so they want to understand some of the risks of that. And so when that medicine was approved for hair loss, because people are going to take it, are usually in the reproductive age, they did randomized placebo controlled trials to look at semen quality. And it turns out that it didn't meaningfully impact things. Maybe it went down a little, but not a lot.

But in sort of post analyses of some of this and now seeing lots of patients coming in, we do see men that are on finasteride. Some of them are more susceptible. And so one of the interesting thing about trials is there's kind of inclusion and exclusion criteria, right? Not everybody can be in it. And so if men had sperm counts that were too low, they weren't invited to be in these trials.

So for men that don't have as much reserve as others, I think they may be more susceptible. So that's one of the risk factors, finasteride. The other thing, in addition to reproductive health, is sexual health that I deal with a lot. And there's also a concern that finasteride impacts sex, sexual function in men, too. So we have these discussions.

I've had some men that come in after having been on finasteride and have different issues with sexual desire, low libido or erectile dysfunction. And so then we work through an algorithm to try and improve that as well. This is one of the things I think about a lot, because I don't want to have a receding hairline, and I also don't want to have a hair operation or anything like that. But when I hear about some of these testosterone replacement therapies and such, my big concern is that if I take testosterone, maybe not now, cause I'm, you know, probably don't need it right now, but maybe when I'm a little bit older, which is when I assume one would start taking it, maybe when I'm about 50 ish on average. But there are younger men that are on it as well.

Steven Bartlett
For what reason? Just because they're low on. What's the sort of symptoms that have caused them to take it? Well, I think there's, you know, with all things, there's a bell shaped curve. So some men are a little bit lower, some have genetic conditions, there are some more nefarious testosterone prescribers.

Michael Eisenberg
So even though men have a normal level, theyre offered testosterone to kind of get in these testosterone clinics. And some men, if look at data, maybe ten to 20% of high school athletes have experimented with testosterone. And if you stay on that too long, it can really shut down your own axis. So if you take exogenous testosterone, so, like testosterone injections or gels, your body stops making it. And the longer you're on it, the less likely your body's able to sort of restart.

And so for some of these men, you know, poor choices or, you know, whatever, they've been on testosterone for a while and they can't ever stop. I don't know if you've ever had any experience in it, because I know you focus predominantly on male health, but I've had a long conversation about contraceptive pills with my partner, because she was on. She said this publicly before, that she was on a contraceptive pill for a long time, and then. And everyone's relationship with contraception is different, but after taking it for seven or eight years, she came off it and her period didn't happen. Didn't occur.

Steven Bartlett
So she really struggled with that for a while previously, and it made me really, you know, it eliminated the fact that when we start messing with the chemical balances of our body, using pills and injections and other things, we could do pretty long term and or permanent damage to ourselves. And there's no real such thing as a free lunch, is there? Biology and chemistry, yeah, I think that's. What it comes down to. I think a lot of people have said that if they tried to get the pill approved now, it would be a much different process and unlikely to succeed for those kind of reasons.

If I have low testosterone and I come to see you, what is the typical way of getting a testosterone replacement therapy? Is it a pill, is it an injection that I have to take? I know that it's quadrupled, according to the data in the US, since the two thousands, which is staggering. But how are people taking testosterone? So there's lots of different ways that it can be taken.

Michael Eisenberg
I think one thing, again, we talk about all the risks, so fertility would certainly be a big one. So if you come in, in your thirties, I'd ask you about your reproductive intent. So if you have a low testosterone and you're interested in having four kids, I wouldn't start you in testosterone directly. There are some off label things, so medicines that we kind of repurpose to help increase your body's own testosterone that we would start with. But assuming that, let's say you're in your sixties, you're not interested in fertility, then there's gels or patches that you put on every day, testosterone gel or patch, because that can work well.

Probably ten to 20% of men don't absorb testosterone that well through the skin. The other thing to be aware of is that there's a risk of, like, transference, like to your partner, to anybody that kind of touches your skin. So if you have young kids just to sort of be aware of. But as long as, you know, you put it on, let it dry, put clothes on over it, it's not a big risk. Um, you know, again, and also have to be, I guess, mindful of laundry as well.

Uh, so, you know, gels, patches are one. There's injections, uh, that you can do every. Usually one to three weeks on average. There's testosterone pellets. Um, so these are pellets that have testosterone that are kind of slow release.

So they're just injected. We kind of implant them under the skin, usually in the hip area. And those last probably three to six months. There's longer acting injections. So those are very common in Europe.

They're kind of gaining steam in the US. But those are injections that last probably ten weeks or so. And then there's new oral therapy. So there's an oral form of testosterone that's available as well. I was quite confused on this subject of hair loss and testosterone because I couldn't figure out if low testosterone causes me to bald and have a receding hairline, or if it's high testosterone that causes me to bald and have a receding hairline, or if it's both.

I mean, it could be both. I think usually we think about it as higher levels. Okay. It's funny because I've wondered before whether me doing a lot of exercise, which is, I guess increasing my testosterone levels, is going to accelerate my balding in receding airline. Anything that's good for your heart should be good for your hairline.

So I would exercise. I think that's good. But what if I'm doing like ironmans and thousand mile runs and all that kind of thing, which you see in certain groups. So I don't know that it. I do think it's possible to over exercise.

I don't know if it'll affect your hairline, but, you know, my testosterone levels, it can affect testosterone levels. I do think that it's, you know, when you kind of exercise to the point of exhaustion, we do see declines in sperm counts as well. So hormone levels can certainly be affected. Because my cortisol goes up. So my testosterone, I guess, goes down.

Can go down sometimes. Interesting. What about penis size? I heard you did some pretty landmark research which suggests that the length of a man's penis is increasing decade over decade in terms of men that are being born and boys that are going through puberty. Yeah.

So this study also got a lot of attention. So similar to how we have tracked testosterone levels over time or sperm counts over time for different reasons. Investigators have measured penile length to give normative data across different populations to understand how different surgeries or conditions may affect penile length. So we looked at all the studies and there were dozens, and so we kind of pooled all that together. This was tens of thousands of men and just looked at average penile length over time.

And so, again, based on some of the data on semen quality, we would have expected things to get shorter over time, and also because we're more obese now, the way that penises are measured is you kind of pull the penis on stretch and use a tape measure or some sort of ruler or measuring device. So if there's kind of more gut, more fat, in theory, length should be a little bit shorter now than it used to be. But it turns out, at least when you measure a rec penile length, that penises are longer now than they used to be. And so over the past 30 years or so, it probably gone up about 25%. Why?

I mean, it's a good question. I think one hypothesis we had kind of looking at sort of different endocrine abnormalities and changes in puberty is that if men go through puberty or boys go through puberty earlier, that tends to correlate with longer penis length. And so if we are shifting puberty again through these different environmental exposures, maybe that is leading to changes in genital development, and this may be one of the consequences of it. Does this have any upstream implications for sex? I think that.

Well, the numbers we're talking about shouldn't be enough to make a big, big difference. Um, you know, people, as this study came out, we talked about, you know, very enterprising patients kind of reaching out, sending emails. Some people hypothesized that this was kind of natural selection, so it's hard to know. Um, but it, again, it's. It's a very short period of time, so it's hard to believe that there's, you know, that's kind of at play.

Steven Bartlett
Do you have many people that come into your practice that are struggling with erectile dysfunction? Yeah. So that's another very common condition we see. And if you look at men over the age of 40, over half have some trouble with erection. So, very, very common.

Michael Eisenberg
Hundreds of millions of men all over the world are afflicted. We don't talk about this much.

Steven Bartlett
What is the cause of this? And are you seeing it increase over time, the prevalence of erectile dysfunction? I mean, I think the rates are going up and I think the risk factors are largely the same risk factors that affect heart disease. So diabetes, obesity, high blood pressure, high cholesterol, you know, minority of these conditions can be caused by low testosterone. Sometimes the outcomes of surgical treatment for pelvic cancers as well.

Michael Eisenberg
But by and large, it's vascular, it's a blood flow issue. Cause. I used to think it was more of like a hormonal thing or a psychology thing, like sexual anxiety or some kind of change to our testosterone levels is causing us to struggle with getting erections. Now you're saying it's about. So I think psychogenic used to be thought of, like you're saying used to be thought of as the kind of the primary etiology.

And maybe for some populations, it could be a little bit more common. But generally, for most men, sort of all comers, it's going to be a blood flow issue, a vascular organic cause. And how would you go about treating erectile dysfunction? So there's a lot we can do. We do want to kind of reverse anything that we can kind of understand where the man's coming from, find out if there's new relationship or other kind of factors for men.

Like, you're suggesting that we do kind of suspect a psychogenic component. Work with sex therapists as well. But for other men, I always like to be very positive. It's like to say, as long as you have a penis, we can always make it hard. So there's a lot that we can do.

So usually we start with pills like Viagra, cialis. Does that work for people? It works probably 60% to 70% of the time. So that does work well, even for men with a psychogenic cause. Sometimes it can kind of help reset the system a little bit, you know, convince them and their body that everything is working well.

Steven Bartlett
Like a placebo effect. Well, I think to some extent, but even more than that, because it does work, it does help. And then I think once they kind of regain that confidence, if there was some sort of traumatic event, traumatic relationship, it can help improve things. Pills aren't enough, or they don't like those, or they have side effects from those. There's other therapies.

Michael Eisenberg
So there's medicines you can actually put in the tip of the penis, like a gel or a suppository. We can teach men to give themselves injections in the penis. Ooh, I just got shivering on my body. There's certainly a kind of a psychological sort of fear of that, but it does work well. Probably works 80% to 90% of the time.

There is something called a vacuum erection device. So it's like a plastic cylinder you put over the penis. It sucks blood into the penis, kind of treats it like a balloon, and then you put a band at the base to trap blood inside. Um, and there's even surgeries we can do to put a device inside the penis. So whenever a wa, whenever a man wants to be hard, he can be hard.

Steven Bartlett
I didn't know there was a surgery you could do. There's a surgery? Mm hmm. What does that do? It puts a.

Michael Eisenberg
So there's, there's two main flavors of it. There's um. Or forms. Maybe that's a better term. Uh, there's one called a malleable.

So it's bendable. So it kind of puts this sort of bendable, um, metal. It's a metal core with sort of a plastic, um, kind of covering. So when they don't want to have sex, you bend it down. When you're ready for sex, you bend it up.

Or there's inflatable versions. So whenever you're ready for sex, there's basically a pump that goes in the scrotum and you just pump it up, it moves fluid into the cylinders and you'll get a rigid erection. Is that increasing in popularity? I think it's made by a few manufacturers in the US or in the world. And so I think the data is not as freely available.

I mean, in my practice, I've seen more and more of it. Were seeing more patients come in. I also say that my practice is getting a little bit more mature with time as I get older. And so naturally more patients hear about these different things. But it does work well.

I always say its a self selected population. We dont hold men down and force them to get it, but generally theyre very happy. Probably 90% of men are very happy. Theyd recommend it to their friends, partners. Very happy, recommend it to other couples.

Steven Bartlett
And you just, you press a button and you get like a, you can, it's a pump. Right now they are working actually on either a fob or like a phone app that'll kind of automatically inflate it to make it a little easier for patients. I had no idea. It sounds like Sci-Fi or something. It sounds like, it's, sounds like something you might see on like a YouTube video that people are working on in like 2030 years time.

But to know that men have that installed now is amazing. Yeah, I mean, it's very common. The youngest patient I put it in is about 20. The oldest is in his eighties. Is it seen as a last option in that menu of options that you presented there, where the first option is probably Viagra, in terms of popularity, is it a last port of call?

Michael Eisenberg
I think for a lot of men it's the most aggressive, but some men don't want to do you had a reaction to the injection. I think that's a very common reaction. There are certainly some advantages to it compared to others. For Viagra, for example, even though it's obviously the easiest, it's a pill, there's some side effects with it, and there's also a lag time. You have to take the pill, wait an hour, wait 30 minutes, something like that.

Whereas the penile prosthesis, if you just pump it up, it's ready to go in seconds. It can be very spontaneous. Patients like that. Some patients have other medications, so they can't take pills they don't like. Some of the other kind of intermediate options that we have, shockwave therapy for erections.

Steven Bartlett
Does that work and what is it? So the idea is that, as kind of the name implies, you're sending shockwaves into the penis and the energy induces kind of some micro trauma, which induces new blood vessel growth, is the hypothesis. And so the hope is that with getting better blood vessel, better blood flow into the penis can improve the quality of erections. So there have been some studies that do show benefit. It's still considered experimental because I think the data is not yet conclusive, but I think for men with milder forms of erectile dysfunction, it can help.

Michael Eisenberg
Maybe the men that are on viagra or sometimes on viagra, maybe we can get them off those pills. But I think we need more data to kind of understand really the kind of the best target population for it. You talk about pelvic floors as well. When we typically think about pelvic floors, we tend to think of women. Things like these Kegel exercises that people talk about.

Steven Bartlett
But is it important for us to think about that as a man as well? Our pelvic floor strength and our pelvic floor muscles? I think in some conditions, I think if you're not thinking about it, it's probably okay, you're not having a lot of problems, but it can be a trigger for some men. So that can be an etiology of some different, like problems with urination. You'd see men with very tight pelvic floors and they have a lot of urgency to urinate.

Michael Eisenberg
They urinate frequently, can also lead to scrotal pain sometimes as well, cause there's a lot of muscles as you're kind of pointing out in the area, and sometimes if they're under tension, if they're not properly trained, and they can trigger some other areas. And so for some of these different conditions, we do kind of work with pelvic floor physical therapists to train patients, you know, how to, again, relax the area, strengthen the area, increase flexibility of some of those muscles, which can help. Is it plausible that doing pelvic floor exercises will improve one's sex life? I mean, I think that unless we're treating a problem, I would be very hesitant. One of my favorite sayings is the enemy of good is better.

So if things are good to try and get better, there's always going to be, like you said, there's no free lunch. There's always some trade offs. So I think if you work on kind of over strengthening the pelvic floor, it could lead to some of these other dysfunctions. So you don't want to end up with a floor that's too tight or too tense. Is there any correlation between these things like your pelvic floor strength, your testosterone, your sperm count, and a variety of the different cancers that we see in men, things like testicular cancer and prostate cancer?

So I think with, with pelvic floor kind of strength, I think I usually kind of think about that as separate from cancer risk. But for testis cancer, you know, one of the risk factors for that is some men are born without testicles in their scrotum, so that's a risk factor. And so called undescended testicle low sperm counts are associated with testicular cancer. There is one study I know of years ago that looked at, you know, comparing sort of sexual health to prostate cancer risk, found that men that ejaculated more frequently had a lower risk of prostate cancer. The thought was that there was inflammation that you're clearing out by frequent ejaculations.

I think the study had men ejaculating 30 times a month and showed a lower risk. So that's a lot. But that was one study that said, at least it's not dangerous to ejaculate more frequently, but it's not something that I generally recommend to men to lower their risk. If we talk about testicular cancer, then what are the common symptoms of testicular cancer? Yeah.

So usually it tends to be relatively asymptomatic. I think that the classic symptom would be a firm, painless mass that men find in the scrotum. So if, you know, there used to be, there are screening guidelines, even though our preventative services task force thinks that the utility of doing it for reproductive age, mention their scrotums, may lead to more anxiety than actually finding testis cancer because it's such a rare cancer. So it's more likely a man's going to just worry themselves and actually diagnose an early cancer. But the recommendations used to be that you would, once a month in the shower, kind of feel yourself, and if you feel something new or something abnormal, bring it to your doctor's attention.

I certainly see a lot of men with this concern do an exam, say that's normal, or if there's something that we're worried about, we'll kind of dive a little deeper. What is the demographic that's most likely to get testicular cancer? Is it something that affects young people as well as older people? It's usually mostly a cancer of young men. So I would say probably twenties to 40 is usually the prime demographic.

Steven Bartlett
Why is it a cancer of young men? Is there any sort of physiological reason for that? Well, I mean, it's reproductive age cancer, so that's the prime reproductive years. So it's possible that it kind of correlates with sperm counts declining with older age. There is another slight increase for men in their fifties and sixties, but again, it's such a.

Michael Eisenberg
It is a very rare cancer. So I usually kind of quote, probably one in 100,000 men are gonna be diagnosed with it. One in 100,000. It's fairly uncommon, but prostate cancer is more common. Prostate cancer is more common?

Yeah. So that we die in the United States, probably at least 200,000 men every year. Some studies say that if you live long enough, everybody will be diagnosed with prostate cancer. But again, most men with prostate cancer die of heart disease, just like every other man in this country. So most men with prostate cancer die with it, not of it.

So usually it's a slower growing disease, although there's some that are more aggressive, and that's why we screen for it and treat it. I read a stat that it affects one out of every seven men. Prostate cancer. Yes. Okay, so what is a prostate?

So a prostate is, it's a walnut shaped organ. It's just underneath the bladder. So the way that we're shaped is we have our bladder, which fills with urine from our kidneys, and then we urinate out the urethra, out the penis. And so the prostate's just at that kind of intersection between the urethra and the bladder. And it really has a function in reproduction, so it produces about 20% of the fluid of our ejaculate, and it produces a lot of the different chemicals and sugars that support and protect the sperm in the female reproductive tract.

So after reproduction, it doesn't really have a lot of, you know, benefit. Mostly it just causes issues because it gets bigger with age, so it leads to urinary symptoms, and then obviously it's a cancer risk as well as we get older. Okay, so we typically get prostate cancer once we've stopped using the prostate for reproduction. Yes. So does it have a role outside of reproduction?

Steven Bartlett
I guess because it's a gland that might be regulating hormones long after we're using it for reproduction reasons. It doesn't really have any useful benefit. If we could find a way to remove the prostate without causing any complications, that'd probably be a reasonable thing to do. But unfortunately, every treatment we have does have some side effects. Just given where it is anatomically, it's right by a lot of the structures that are important for erections and for reproduction.

So when people have prostate treatment because they've got a prostate cancer, are they getting their prostate removed? Some men get it removed. Some men have radiotherapy to sort of kill all the prostate cells. And there's other kind of energy therapies that are delivered, like high frequency ultrasound, can sometimes be delivered. There's also something called cryotherapy, where you can freeze the prostate.

Michael Eisenberg
Usually these are done in targeted fashions where you can look at the prostate, look at MRI imaging of the prostate, look at biopsy patterns to try and figure out where the cancer is. So usually the whole gland is treated, but sometimes I think newer modalities are trying to just treat a particular portion. How often do you think we should get our prostate checked, and what are the symptoms that we should be looking. For from sort of a urinary standpoint? I think that if urination bothers you, you should talk to your primary care doctor or your urologist about it.

You know, if you're waking up at night, if you feel like you have to pee too frequently, if it burns to pee, things like that. So that sometimes is due to prostate enlargement, prostate issues. It could also be due to a tight pelvic floor as well. From a cancer standpoint, usually we check blood tests called a psa, prostate specific antigen, and there's different screening guidance that's made. Usually start men in their fifties or so and screen every year or two until a man turns 70.

Some of the guidance or some of the screening patterns will vary based on family history, which is a very strong predictor of cancer risk. Is there anything I can do, or is there any research that gives me advice on how to treat my body in such a way where I reduce my risk of prostate cancer? We talked about some of these risks for erectile dysfunction, right? Like obesity, diabetes. I think those same things can also play a risk in a lot of these prostate conditions, too.

So good diet, exercise, maintaining good body weight, I think all those are important. Avoiding drinking water before bed. Well, that'll help with sometimes waking up at night. So for some men that are most bothered by so called nocturia or waking up at night to urinate, I think trying to dehydrate yourself, you know, saying, I'm not going to drink any fluid after 07:00 at night or 06:00 at night, so that you're more likely to get a full night's sleep. You know, waking up once at night is not that unusual, but if it becomes a little bit more frequent, you know, that's one strategy that some men use.

Steven Bartlett
Okay, so reducing my water consumption at nighttime isn't going to reduce my chance of having prostate cancer, right? Okay, fine. What about spicy foods? So, I think, in a similar way, that can also affect some of the symptoms, it shouldn't affect your prostate cancer risk. Okay.

Is there any studies that show ways that we can reduce our prostate risk that aren't just the sort of health and what sort of lifestyle related things is there anything linked to? I don't know, other parts of our lifestyle, like our use of technology or alcohol consumption or anything at all? Not to my knowledge. I think that, you know, asian orange, the defoliant that was used during the Vietnam war, that was found to be a risk factor for prostate cancer. So, um, I don't know why you would, but try and try and avoid Agent Orange.

Michael Eisenberg
Um, but otherwise, there are not a lot of modifiable risk factors other than the ones that we talked about. I think that, you know, cancer risk goes up with obesity, you know, thought to be due to different things, but maybe inflammation and things like that. So I think, kind of living a healthy life, I think, hopefully will keep you on a healthy trajectory. I'm the first person to lean into. New tools to support my productivity, but also to save me time.

Steven Bartlett
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And a decision that's helped me to transform my business is moving over to Netsuite, who I'm excited to say are a sponsor of this podcast. If you don't know already, Netsuite is the number one cloud financial system, bringing accounting, financial management, inventory, hr into one platform and one source of truth. It's reduced it costs because it lives in the cloud, so you can access it from anywhere. And the cost of managing and running multiple systems because it's in one unified business management suite. My team and I don't have to worry about tasks being manual and clunky, and it means that I can be more efficient and to focus on more important things like bringing you the best episodes and guests on this show.

So I become one of the 37,000 companies that have already made the move over to Netsuite. Netsuite has extended its one of a kind, flexible financing program for a few more weeks. So head to netweek.com Bartlett for a free product tour. Back to the episode DoAC, what are. The most important things that we haven't talked about that patients come into your clinic and speak to you about as it relates to reproductive health, hormones, everything in between?

Michael Eisenberg
Well, another condition that I see men for a lot is something called Peyronie's disease, which is a curvature of the penis. So the way erections work is everything swells. There's sort of these kind of tough tissue layers in the penis that trap blood inside, and sometimes scar tissue can form on those layers for different reasons. It's thought maybe micro trauma. Some men do remember sort of a traumatic sexual episode that leads to an injury and scar formation.

And you can imagine if there's scar tissue in there. Everything will not expand in a uniform fashion, so you can get a curvature deviation. So some of these men have 90 degree curves to their penis. And so whether it goes up or down, it can make sex pretty challenging. And so that's another condition we see.

I think it's important for men to know. I think, again, it's just similar to erectile dysfunction. I think, you know, men are sometimes, you know, a little bit reticent to talk about some of these conditions, but it's fairly common. Probably five to 10% of men are affected. And there are effective treatments for this as well.

So I think just as sort of a public service announcement, um, if men are suffering from this, again, talk to your doctor, because there are treatments that we can. We can offer. Okay, so let's conclude, then, if I want to make sure that my sperm count remains very, very high, um, so I can have those four kids, and I want to make sure my testosterone levels remain at a healthy sort of balance, let's say. Is it sort of 4500 mg milligrams? Is it?

Yeah. Nanograms per deciliter. Okay. Nanograms per deciliter. I want to keep it in that sort of healthy range, and I want to have rock hard erections.

Steven Bartlett
Okay. So that I can have the four kids that I mentioned. What is the advice that you would give that is broadly applicable to everybody without you having to run my blood tests and all those things? And this is really a conclusive point. The first one that I've heard is about sort of lifestyle and dietary choices.

Is there anything that I definitely shouldn't be eating if I'm trying to become optimal in these three areas? Again, people have looked at sort of different diets which can affect health and reproductive health more specifically. So I think generally, healthy foods are a good idea. Whole grains, fruits, vegetables. Usually the control group for all these is like a western diet, like processed foods, fast food, things like that.

Michael Eisenberg
Foods that have a lot of fat, high calorie those, and, you know, some of them. Also, the packaging has, you know, some of these same kind of chemicals that we talked about earlier. So I think trying to avoid some of those, I think, is a good idea. Sugar. Sugar is okay.

Steven Bartlett
Okay. Unless, again, for a high calorie, foods are things to try and avoid. Um, if you have any medical conditions, you know, I think that trying to get those treated, you know, sometimes men do worry that, you know, if you're taking a pill for something, it may affect your fertility. But I think just generally being healthy anything that's good for your heart is going to be good for fertility. So I think it's a good idea to get that treated.

Michael Eisenberg
There is a study out of Japan that I always quote about this. This was a study that looked at all patients that came in with male infertility and tried to figure out who they helped. They wanted to see if they could predict who was likely to benefit from a urologic concentration and who was not. They looked at baseline sperm count that wasn't predictive of who was going to benefit. Baseline testosterone level wasn't, age wasn't.

Some men have this condition called a varicocele, which has dilated veins in the scrotum. So about 15% of all men have them. Infertile men, maybe about 40% have them. So the testicles are outside the body, like we talked about, and having larger veins impairs normal temperature regulation. And so if you fix those, it turns out most of those men are going to improve their sperm count.

But the other really interesting finding is that they also found that men that had a comorbidity treated had improvements. So the data they provided is men that had high blood pressure. If they got that under control, their sperm counts went up about 25%. So, you know, a lot of times, you know, the first time men see the doctor. Men don't go to the doctor a lot.

Right, unless there's a problem. Right. Unless they're in pain or some other, you know, condition. So sometimes my patients, the first time I've ever seen anybody is seeing me to try and have a baby. And so it's an opportunity to, you know, make them take a little bit more ownership of their health.

You know, if they've never had a blood pressure check, check that blood sugar, cholesterol, all those things are, you know, ways to improve their health or opportunities to improve reproductive health, but, you know, overall health as well. So I think that's another thing to be kind of mindful of. What about depression, then? Our mental health and the role that that will have on our fertility, our erectile performance and all of those things? Is there a correlation there?

There's strong correlation, yeah. So I think we do see a strong correlation between erectile dysfunction and depression. If you look at men with erectile dysfunction, I think up to 20% may have some form of depression. And we sometimes worry that some of the treatments can also exacerbate sexual dysfunction. But I think trying to get men on a better path is important.

I think it's also important to work again with a therapist as well, so that you're attacking these things from multiple angles. Generally, most of these medicines probably have not been tested in terms of reproductive health. There's some studies that say that some of these may affect semen quality, but I think those studies are limited. So I think generally, if men are on these medicines, we're not sure, and I think it's helping them. We try and sort of carry on and persevere.

Cause I do want them to get the benefit of some of these therapies. What about childhood trauma and the role that plays? You must see that show up in your practice. Yeah, I mean, I think it certainly can affect sexual health pretty profoundly. I think.

When you do suspect kind of this sort of psychogenic component, I think, you know, we do. I try and be, again, like we talked about, very optimistic about options that are available. Um, but working with the therapist, working with a sex therapist to come up with sort of a good sort of strategy and plan to kind of get, um, you know, men through, you know, some of these issues, um, so they can have, you know, a fulfilling sex life. Anything else that I need to do to improve these things, top line things. So lifestyle, you know, we've talked about food, exercise, we've talked about.

Steven Bartlett
As well as a way to improve at least our testosterone levels. Yeah, sleep, I guess, might be an important. Sleep's important, too. Sleep's interesting because it's what's called a u shaped association. So it's possible to get too much sleep.

Michael Eisenberg
So, you know, you probably want sort of an ideal amount. Probably seven to 9 hours is usually. That's been associated with better semen quality. For men that get less semen quality tends to be a little lower for men that get too much sleep, you know, again, men that have, you know, are able to sleep 1213, 14 hours a day. There may be other things going on there.

Maybe there's some underlying depression or something. Those men tend to have lower semen quality. But, you know, I think sleep, I think, is certainly important. There's also been studies looking at weight loss as well. You know, I think it's obviously easy to say lose weight, but it's not always as straightforward to do.

But there was, you know, a nice study that came out a few years ago where men were randomized to, you know, weight loss program, a very low calorie diet, 800 calories a day, um, for a few weeks, and then they lost, you know, weight, and then they followed them for the rest of the year. Um, and so this is important because men that were able to keep weight off, were able to maintain the benefits of their sperm count, versus men that were, you know, kind of fell off the exercise routine. They ended up gaining back, you know, their weight, and then their sperm counts declined again. Uh, one of these arms actually also had one of these, you know, hot GLP one analogs as well. And so even men that were on those, that kind of help them keep their weight loss were also able to maintain sperm count.

So patients do ask about that a lot. I was just going to ask about. Obviously the Zenpex exploded, and there's many other forms of this sort of GLP one, sort of fat loss injections. I was wondering if that had any consequences on fertility. So again, there's only one study that did study it, and it did seem to show benefit.

So it doesn't cause any harm. As long as you maintain weight loss with it, you do seem to see improvement. In contrast, some men also ask about bariatric surgery, which again, may be declining a little now with these very effective medications. But interestingly, bariatric surgery, bariatric surgery, gastric bypass. I don't know if this is popular in Europe or the United Kingdom, but for some obese individuals, there are surgeries that can be done to help reroute intestinal absorption.

So you can lose weight with that. There's also something. I thought you meant the gastric band thing. There's gastric bands too, yeah. So there's different ways that it's been done.

And so with all those, actually, it tends to decrease sperm, sort of. Right. Paradoxically. So you would think that if you lost weight, your sperm counts would improve. But it turns out with these surgeries, sperm counts actually declined.

Some of them, some actually men went from a reasonable sperm count to zero. So the thought was that its the trauma of a surgery, potentially. There are some vitamins, minerals are important too. So without that normal absorption that occurs in the intestines, that could also lead to infertility. That was sort of a concern and were wondering if that same thing would happen with these newer medications, but it doesnt seem like it.

Again, the GLP one, analogs seem like theyre safe, safe form of weight loss, at least when we're looking at semen quality as an outcome. What about supplementation? Is there any supplements one might recommend? I guess it's difficult for you to recommend supplements, but are there any sort of vitamins or minerals that are typically deficient in people that have infertility issues? So I think there is some data that antioxidants can improve fertility.

So it's sort of a very broad group of things that have been tested. Berries and stuff. Is that. Yeah, dark berries. Yeah, those certainly can have a lot.

Um, but, you know, I usually tell, you know, patients to take a multivitamin. They do make special male fertility blends. Like if you were to look it up on the Internet or Amazon or other platforms, there are special fertility blends that have kind of, some of them have, you know, looked at the data and try and pick out, you know, specific supplements that are thought to be more beneficial. Coenzyme Q is a powerful antioxidant that has shown some benefit for fertility. So I think that's something else that try and empower patients and they can do that too, and that can help.

Steven Bartlett
Protein, does that play a role in fertility or testosterone? I think, again, part of a balanced meal and part of a balanced diet. I think it's important. What's your mission from here on? What are you going to do for the next ten years, if you had to, as it, I guess, are you going to do, is it more of the same, or are you interested in changing focus at all slightly, or are you going to just continue to do research on these subjects?

What's your big sort of decade mission? Yeah, I mean, this really gets me up in the morning and this is the stuff that I like to do, like late at night as well. I mean, I really am passionate about this, trying to understand why we see this link between fertility and health, why sperm counts are declining, because I think the more we understand about it, we can hopefully mitigate some of these risks. I also like to hopefully, through information channels and platforms like this, hopefully engage more of the community to try and come up with some therapies for male fertility. I think we talked about some of the things that can be done, but there's no, in the United States, there's the Food and Drug Administration that sort of oversees all therapeutics, and there's no FDA approved therapy for male fertility, which is really a shame, especially because, again, we have this data that it's becoming more prevalent, existential as a species.

Michael Eisenberg
So it'd be nice if there was some. So try and get more engagement from the scientific community, from the pharmaceutical community to try and see that opportunity, because I think that'll be very important for our field. But again, I think, like you said, sort of more of the same in some ways, but I think trying to understand some of these questions in a lot more detail so that we can really help these men. Is there, of all the subjects we've discussed today, is there a particular part of it that concerns you the most? Well, I think when we're talking about sperm counts declining, I do worry that that is a barometer of health.

And so it may be that in addition to men's reproductive health, just our overall health is declining. When we look at the health of fathers over time, we've seen fathers are getting a little older. We talked about that. But with that comes more comorbidities, higher rates of hypertension, hyperlipidemia, other things, and that sometimes can have transgenerational impacts. So, like a father that has high blood pressure or is obese, that child is slightly higher risk of having some other issues later on.

So trying to understand that again, if there's maybe opportunities to try and figure out what in that sperm is a little different, maybe we can turn that switch off to try and, you know, prevent that. I think those are all things. I don't want to be alarmist about this. These risks are all very, very low. But I think there's a lot of opportunities.

You know, I think one of the reasons I got into it, I think, is because male reproductive health was really wide open. So I think there's still a lot of opportunities to try and improve it. What would you say to a man that's listening to this, that's struggling with any of the things we've discussed? What is your closing message for them? Well, I think I would just try and be optimistic and hopeful.

I think there's a lot that we can do. I think that it takes a lot of bravery to go in and see doctors about some of this thing and some of these different issues. You know, it's what we're used to dealing with, and I think there's plenty of options that are available. So I would just encourage them to talk to friends, but, you know, men talk to their primary care doctor, talk to their urologist, come see a urologist. You have a very broad platform.

So I think if there's couples struggling, they've only seen gynecologists. I would encourage them to maybe see male reproductive specialists as well to try and get some other perspectives. We have a closing tradition on this podcast where the last guest leaves a question for the next not knowing who they're leaving it for. The question that's been left for you is a tricky one. It is.

Steven Bartlett
What's one thing you would do to change the world, I guess one thing. That I would do to change the world, I guess, certainly apropos of our conversation, was that I would try and make policy that all governments would pay for infertility services so that this is a universal benefit for all of humanity. I think that would certainly help open up the doors for a lot of people that don't have resources for it. Kind of hesitant to use it. And hopefully that would again solve some of the issues that we talked about.

From a demographic standpoint, what would that do for humanity? We'd be having more kids. I guess. We'd be happier in our relationships potentially. Yeah, I think it could do all that.

Michael Eisenberg
I think that. I guess from. From a father standpoint, having a child again increases longevity, decreases cardiovascular risk, increasing. From a sort of societal perspective, having, getting to that replacement level, sort of maintain population. I think that's, again, existential for a society to increase the tax base and all the other things that are associated with that in the workforce.

It's very difficult in politics now, certainly in the United States, there's a lot of issues that are going on, but making policy that really affects everyone, I think would be very profound, and I think there's be a lot of benefit to that.

Steven Bartlett
Doctor Michael Eisenberg, thank you so much for your time, and thank you for the work that you're doing, because you're helping ultimately to create families and to also alleviate a lot of the stress and anxiety and worry and concern people have about their reproductive health. And I think it's an incredible service to humanity to be doing that. And especially at the time when we're in where it feels like it's more needed than ever before. And frankly, the direction of travel isn't fantastic as it relates to some of these big issues like testosterone and fertility. But it's really important for people like you that have the information that are doing the research to not just keep it in the lab and not just keep it on pubmed, where it's very hard for people like me to access it because we can't bloody read PubMed.

So thank you for making the decision, which you absolutely don't have to do, to come out and speak on these subjects in a way that's really accessible and inspiring and empowering for people, because I think that's going to do a tremendous world of good. So thank you. Thank you. My pleasure. How many of you started thinking about your long term health when you hit 30?

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You are always one decision away from taking your business to the next level, and a decision that's helped me to transform my business is moving over to Netsuite, who I'm excited to say are a sponsor of this podcast. If you don't know already, Netsuite is the number one cloud financial system, bringing accounting, financial management, inventory, HR into one platform and one source of truth. It's reduced it costs because it lives in the cloud, so you can access it from anywhere, and the cost of managing and running multiple systems because it's in one unified business management suite. My team and I don't have to worry about tasks being manual and clunky, and it means that I can be more efficient and to focus on more important things like bringing you the best episodes and guests on this show. So I become one of the 37,000 companies that have already made the move over to Netsuite.

Netsuite has extended its one of a kind, flexible financing program for a few more weeks, so head to netsweek.com Bartlett for a free product tour. Back to the episode.

Steven Bartlett
Back to the episode.

The Fertility Expert: Delaying Having Kids Is Impacting Your Future Children & Reducing Your Chances Of Parenthood By 90%! Masturbation Reduces Cancer Risk!

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Episode Summary

Main Takeaways

Episode Chapters

1: Introduction to the Fertility Crisis

2: Environmental Impacts on Fertility

3: Lifestyle and Reproductive Health

4: Advancements in Fertility Treatments

Actionable Advice

About This Episode

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Transcript