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

A study found that only around 25% of men had normal semen quality, raising concerns about reproductive health (Segment 1).
Obesity's link to lower testosterone and sperm quality doesn't fully explain the recent decline in these metrics (Segment 3).
Sperm quality and testosterone levels are negatively affected by excessive smoking and excessive alcohol consumption (Segment 5).
Regular cannabis use may lower sperm quality, and pain relievers (Ibuprofen and Acetaminophen) are safe for sperm health (Segment 6).
The pituitary gland produces hormones that regulate testosterone and sperm production, but exogenous testosterone reduces sperm production (Segment 7).
Prolonged cycling can reduce sperm production, but walking can improve testosterone levels, regardless of weight (Segment 8).
The increasing paternal age in the US raises concerns about the health of offspring (higher risk of neuro-psychiatric disorders) (Segment 14).
An enlarged prostate can cause urinary problems, but dietary changes, low-dose tadalafil, and can help manage them (Segment 15).
ED medications (sildenafil and tadalafil) are effective but can cause side effects; lifestyle changes are important (Segment 17).
Penis length has increased over 30 years, possibly due to earlier puberty onset, but using hormones for penis extension is risky (Segment 19).
Clomiphene can increase testosterone levels in men with low testosterone, but its effectiveness varies and it can affect estrogen signaling (Segment 21).

Summary

The episode features Dr. Michael Eisenberg, MD, an esteemed urologist and professor who specializes in the areas of male sexual function and fertility at Stanford University. Due to his extensive clinical practice and scholarly investigations, he is widely regarded as a preeminent global authority in the field of male sexual and reproductive health. This discussion pertains to the levels of testosterone and the factors that truly influence them, the use of testosterone therapy, the quality and quantity of sperm, the health and functionality of the penis and testicles, the well-being of the pelvic floor, prostate, and urinary tract, the capacity for erectile function and the presence of erectile dysfunction, as well as the diverse causes and treatments for prevalent male sexual, hormonal, and reproductive difficulties. In addition, we examine the phenomenon known as post-finasteride syndrome and analyze the prevailing patterns in penile length. This episode provides a substantial amount of practical information regarding the sexual and reproductive health of males. It covers essential tests and evaluations that may be conducted at home, as well as various behavioral, dietary, exercise, and prescription-based interventions that can promote male sexual and reproductive well-being.

(1). 00:04:20 Sperm Quality, Geographic & Environmental Factors

The importance of sperm quality in the context of reproduction was highlighted in a podcast. The process of semen analysis involves the assessment of many parameters such as semen volume, sperm count, motility, and morphology. In certain cases, further advanced tests like as DNA fragmentation and epigenetic profiling may be used to evaluate fertility. The establishment of normative and subfertile thresholds by the World Health Organization is informed by regular evaluations. The topic of declining sperm quality with time is a subject of ongoing dispute within academic circles. Various factors, such as environmental exposures, advancements in reproductive procedures, chemical exposure, obesity, and regional disparities, have been identified as potential contributors to this phenomenon. However, the exact impact and interplay of these factors on sperm quality remain unknown, leading to continued controversy in the field. There is a recognized importance in doing longitudinal data tracking of semen quality across different locations, akin to the monitoring of obesity rates, in order to enhance our comprehension of prevailing patterns and trends. A study conducted in Denmark discovered a rather consistent level of semen quality among participants. However, the findings indicated that only approximately 25% of men exhibited normal semen quality, hence raising concerns over reproductive health [1].

Environmental stressors impact on sperm quality. Different environmental stressors alter sperm motility, morphology, concentration, mitochondrial activity and induce DNA fragmentation, plasma membrane lipid peroxidation and ROS formation.

Figure 1. Environmental stressors impact on sperm quality [2].

References

Wang, N., et al., Study on Influencing Factors of Semen Quality in Fertile Men. 2022. 13.
Gallo, A., R. Boni, and E. Tosti, Gamete quality in a multistressor environment. Environment international, 2020. 138: p. 105627.

(2). 00:12:00 Fertility & Sperm Quality; Testosterone, Cell Phones & Heat

The subjects of male fertility and testosterone levels are frequently disregarded, despite the substantial role that males play in leading to infertility problems within couples. In the context of assisted reproductive technologies such as in vitro fertilization (IVF), the facilitation of conception by the utilization of a single sperm has become more accessible. However, it is imperative to acknowledge and prioritize the examination of male reproductive health. The available research suggests that there is a decline in testosterone levels among males, and this phenomenon may be influenced by various variables such as exposure to chemicals and the prevalence of obesity. The investigation into the potential effects of heat exposure, such as the practice of carrying a cell phone in close proximity to the reproductive organs, on sperm quality and testosterone levels has garnered considerable attention. However, it is important to note that the existing body of evidence has not yet yielded definitive conclusions on this matter. Although there are some concerns, the available data does not provide conclusive evidence, hence it is recommended to reduce potential heat exposure from computers and other sources wherever feasible [3].

Possible effects of cell-phone radiation on testes, spermatogenesis and the ejaculated spermatozoa.

Figure 2. Possible effects of cell-phone radiation on testes, spermatogenesis and the ejaculated spermatozoa [4].

References

3. Kumar, N. and A.K. Singh, Trends of male factor infertility, an important cause of infertility: A review of literature. J Hum Reprod Sci, 2015. 8(4): p. 191-6.

4. https://www.renalandurologynews.com/on-the-forefront/cleveland-clinic/cell-phone-use-by-men-may-decrease-fertility/.

(3). 00:19:26 Testosterone, Age, and Obesity

Although there is evidence suggesting a relationship between obesity and alterations in testosterone levels and sperm quality, it is important to note that this association is not a definitive indicator of these health indicators. It is not uncommon for persons who present as physically healthy and in good shape to demonstrate low amounts of testosterone, while on the other hand, certain obese individuals may display elevated levels of testosterone. Hence, the task of accurately forecasting hormone levels based purely on physical attributes is a considerable challenge, underscoring the significance of conducting thorough assessments encompassing testosterone levels and semen quality. Both testosterone levels and sperm quality serve as important markers of fertility and overall health. Low levels of testosterone and poor sperm quality are connected with an elevated risk of several health issues, including heart disease, diabetes, and mortality. Moreover, although obesity does contribute to the deterioration of semen quality, it is insufficient to explain the notable decline observed in recent years, surpassing the anticipated impact only attributed to the rise in obesity prevalence [5].

Figure 3. Testosterone Concerns in Obese Men [6]

References

5. Wittert, G. and M. Grossmann, Obesity, type 2 diabetes, and testosterone in ageing men. Rev Endocr Metab Disord, 2022. 23(6): p. 1233-1242.

6. https://www.drlamcoaching.com/nem-therapy/hormonal/testosterone-concerns-in-obese-men/

(4). 00:26:49 Tool: Optimize Sperm Quality, Exogenous Testosterone, hCG

Various risk factors have the potential to influence the quality of sperm and levels of testosterone. The utilization of external heat sources, including hot tubs, saunas, and seat warmers, has been found to have an adverse impact on testicular function. Consequently, it is advisable to refrain from their use. However, in some circumstances, the implementation of cooling packs may serve as a viable remedy. Although there is a correlation between obesity and reduced testosterone levels as well as sperm quality, it should be noted that this relationship is not absolute, underscoring the significance of doing thorough health screenings. It is of utmost importance to prioritize the maintenance of one's health, as the presence of comorbidities such as obesity, hypertension, and hyperlipidemia has been associated with reduced testosterone levels and impaired sperm quality. Regarding testosterone therapy, it has the potential to exert adverse effects on sperm production, hence influencing fertility. Hence, individuals contemplating testosterone therapy should be cognizant of its potential impacts and deliberate the option of sperm cryopreservation or alternate therapeutic approaches to uphold fertility. The administration of human chorionic gonadotropin (HCG) in conjunction with testosterone therapy has been observed to promote the creation of sperm within the body and enhance fertility. In numerous instances, the utilization of small quantities of HCG has demonstrated notable efficacy [7].

References

7. An, Q., et al., The impact of exogenous testosterone supplementation on spermatogenesis in a rat model of oligoasthenospermia. Int J Clin Exp Pathol, 2020. 13(6): p. 1287-1299.

(5). 00:36:57 Tool: Lifestyle Factors & Sperm Quality, Alcohol

The act of smoking cigarettes or engaging in vaping has been found to have adverse effects on both sperm quality and testosterone levels. Furthermore, no empirical evidence exists to support the notion that smoking may have any positive impact on these particular physiological parameters. The available research indicates a correlation between excessive alcohol consumption and a decline in sperm quality. However, the effects of moderate alcohol use on both sperm and endocrine health are still not fully understood. In contrast to the definitive position regarding tobacco, the available data is insufficient to advocate for total abstinence from alcohol, hence leading to the frequent suggestion of moderation as the most advisable course of action. There are genetic variations in the metabolism of alcohol, leading to differential responses among groups. For instance, East Asians have heightened sensitivity to alcohol, which can be attributed to specific mutations in the aldehyde dehydrogenase gene. Hence, there exists a considerable degree of variability in individual responses to alcohol, thereby necessitating the prudent consideration of personal sensitivity while making decisions pertaining to alcohol use [8].

Figure 4. Effect of Lifestyle practices on male fertility [9]

References

8. Gilis-Januszewska, A., Ł. Kluczyński, and A. Hubalewska-Dydejczyk, Traumatic brain injuries induced pituitary dysfunction: a call for algorithms. Endocr Connect, 2020. 9(5): p. R112-r123.

9. Leisegang, K., & Dutta, S. (2021). Do lifestyle practices impede male fertility?. Andrologia, 53(1), e13595.

(6). 00:43:27 Sperm Quality, Recreational & Over-the-Counter Drugs, Cannabis

The use of cannabis, particularly when consumed on a daily basis, has been linked to diminished levels of sperm concentration, motility, and morphology in certain investigations. However, it is important to note that the nature of this association might fluctuate based on variables such as the frequency and method of consumption. Nevertheless, the available research lacks consistency, so introduces potential uncertainty in the context of advising patients who employ cannabis for diverse purposes such as anxiety alleviation, sleep enhancement, and pain mitigation. In relation to non-prescription pharmaceuticals, there exists a lack of substantial evidence indicating any detrimental impact on sperm quality or testosterone levels from the use of widely available non-steroidal anti-inflammatory drugs like ibuprofen and acetaminophen. Further investigation is necessary to comprehensively examine the potential ramifications; however, these pharmaceuticals are generally regarded as being safe for utilization [10].

References

10. Nudell, D. M., Monoski, M. M., & Lipshultz, L. I. (2002). Common medications and drugs: how they affect male fertility. Urologic Clinics, 29(4), 965-973.

(7). 00:46:56 High-impact sports, Traumatic Brain Injury (TBI), Pituitary and testosterone

The pituitary gland assumes a vital function in the context of fertility by secreting luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Luteinizing hormone (LH) is known to induce the activation of Leydig cells located in the testes, hence facilitating the synthesis and secretion of testosterone. Conversely, follicle-stimulating hormone (FSH) plays a crucial role in the promotion and regulation of spermatogenesis, the process of sperm creation. The administration of exogenous testosterone has the potential to disturb the hormonal axis by diminishing the synthesis of luteinizing hormone (LH) and follicle-stimulating hormone (FSH), thus leading to decreased levels of testosterone in the bloodstream and adversely affecting the production of sperm. The concentrations of testosterone in the testes are notably greater than those seen in the bloodstream, and this disparity is crucial for the process of sperm generation. Nevertheless, the language fails to acknowledge the potential impact of traumatic injuries on this particular process [11].

Figure 5. Vascularization of the hypothalamus and pituitary gland [11].

References

11. Gasco, V., Cambria, V., Bioletto, F., Ghigo, E., & Grottoli, S. (2021). Traumatic brain injury as frequent cause of hypopituitarism and growth hormone deficiency: epidemiology, diagnosis, and treatment. Frontiers in endocrinology, 12, 634415.

(8). 00:49:55 Bicycling, Numbness & Sexual Dysfunction; Walking & Testosterone

Cycling is a widely practiced recreational pursuit in the Bay Area; yet, concerns have been raised regarding its potential implications for male fertility and sexual well-being. Engaging in extended periods of cycling, particularly above five hours per week, has the potential to subject males to elevated temperatures, which may result in diminished sperm counts. In relation to sexual dysfunction, the application of pressure exerted by the saddle might give rise to many complications, including but not limited to numbness or erectile difficulties. Certain individuals may exhibit a greater susceptibility to these effects, hence necessitating the selection of an appropriate saddle and the implementation of changes to body position. Various efforts have been made to address these issues through the development of redesigned seats, accompanied by the availability of specialized bicycle fitting services. While it is not universally applicable to all cyclists, it is estimated that approximately 20-30% of riders may have these challenges, indicating the need to prioritize considerations related to comfort and safety. The augmentation of physical activity, specifically walking, has been linked to enhanced testosterone levels, regardless of an individual's body weight, hence highlighting the prospective advantages for the functionality of the testes [12].

References

12. Sgrò, P., & Di Luigi, L. (2017). Sport and male sexuality. Journal of endocrinological investigation, 40, 911-923.

(9). 00:55:39 Exogenous Testosterone Therapy & Cancer

The potential relationship between testosterone therapy and prostate cancer risk has raised worries among researchers. However, a comprehensive analysis of longitudinal data collected over several decades indicates that there is no evidence to support the notion that testosterone replacement therapy contributes to an increased risk of prostate cancer [13]. The early association between prostate cancer and androgen activity led to the discovery that reducing testosterone levels can lead to the regression of the cancer. Nonetheless, according to the saturation model, it is postulated that the testosterone receptors in the prostate reach a state of saturation at a comparatively low quantity of testosterone. As a result, the administration of supplementary testosterone does not have an impact on the risk or growth of prostate cancer. Therefore, it may be concluded that the maintenance and monitoring of other health indicators are crucial in ensuring the safety of prostate cancer outcomes [14].

References

13. Lopez, D. S., Advani, S., Tsilidis, K. K., Wang, R., & Canfield, S. (2017). Endogenous and exogenous testosterone and prostate cancer: decreased-, increased-or null-risk?. Translational Andrology and Urology, 6(3), 566.

14. Pastuszak, A. W., Rodriguez, K. M., Nguyen, T. M., & Khera, M. (2016). Testosterone therapy and prostate cancer. Translational andrology and urology, 5(6), 909.

(10). 00:59:57 Sexual & Urinary Health, Nighttime Urination

The preservation of erectile function is of utmost importance, and regular occurrences of nocturnal erections can serve as a valuable signal in assessing this aspect. These involuntary penile erections manifest during the sleep cycle, although they often pass unnoticed due to the fact that individuals typically remain asleep during this physiological event. Although self-monitoring or self-stimulation is not obligatory, the presence of normal erectile function during sexual activity, whether with a partner or alone, typically suggests a state of sound penile functionality. If individuals have any issues related to erectile function or changes in urination patterns, such as more overnight awakenings or reduced urine flow, it is advisable to seek a consultation with a healthcare professional [15].

References

15. Rosen, R. C., Link, C. L., O’Leary, M. P., Giuliano, F., Aiyer, L. P., & Mollon, P. (2009). Lower urinary tract symptoms and sexual health: the role of gender, lifestyle and medical comorbidities. BJU international, 103, 42-47.

(11). 01:03:12 Sleep & Semen Quality; Overall Health

The assessment of semen quality, particularly the well-being of sperm, serves as a significant indicator of men's general vitality and health. Existing research indicates that individuals of the male sex who exhibit enhanced semen quality are associated with improved overall health, decreased mortality rates, and diminished susceptibility to a range of health complications. The correlation between reproductive health and general well-being can be ascribed to common genetic variables, the developmental origins of adult disorders, and other intrinsic commonalities. The assessment of semen quality holds considerable importance as a health indicator, warranting recognition as a noteworthy metric akin to the "sixth vital sign." Consequently, it is imperative to allocate greater attention to semen quality during healthcare evaluations to facilitate the timely identification of any underlying health concerns. The monitoring of semen quality has the potential to serve as a valuable indicator for evaluating male health, as it can aid in the identification of reproductive issues as well as a range of other diseases [16].

Figure 6. Sleep disorders affect the quality of sperm [16]

References

16. Zhong, O., Liao, B., Wang, J., Liu, K., Lei, X., & Hu, L. (2022). Effects of sleep disorders and circadian rhythm changes on male reproductive health: a systematic review and meta-analysis. Frontiers in physiology, 13, 913369.

(12). 01:09:19 Tool: Sperm Analysis & Overall Health; Sperm Banking

The assessment of semen quality functions as a crucial first health indicator, analogous to the monitoring of cholesterol levels or the measurement of blood pressure. Although the exact relationship between semen quality and overall health is not fully understood, it provides valuable information regarding an individual's reproductive capacity and general well-being. In recent years, advancements in technology have facilitated greater accessibility to semen testing, hence obviating the necessity for laborious and inconvenient visits to the laboratory. Startups and companies are actively engaged in efforts to mitigate obstacles associated with semen testing, aiming to enhance privacy and convenience. These initiatives include the provision of at-home testing options that incorporate sophisticated features like soundproof rooms and red light technology, thereby facilitating a more comfortable process for sample collection. Consequently, these endeavors contribute to the facilitation of individuals' ability to effectively monitor their reproductive well-being [17].

References:

17. Cabrita, E., Martínez-Páramo, S., Gavaia, P. J., Riesco, M. F., Valcarce, D. G., Sarasquete, C., ... & Robles, V. (2014). Factors enhancing fish sperm quality and emerging tools for sperm analysis. Aquaculture, 432, 389-401.

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

The assessment of semen quality plays a crucial role as an early indicator of health, akin to the monitoring of cholesterol levels or blood pressure. Although the exact relationship between semen quality and overall health is not fully understood, it provides valuable information regarding an individual's reproductive capacity and general well-being. In recent years, advancements in technology have significantly enhanced the accessibility of semen testing, hence obviating the necessity for laborious and inconvenient visits to the laboratory. Startups and companies are currently engaged in efforts to decrease obstacles associated with semen testing. These initiatives aim to enhance privacy and convenience by introducing at-home testing options that incorporate advanced features, such as quiet rooms and red-light technology. These innovations are intended to improve the overall collection experience, thereby facilitating the monitoring of individuals' reproductive health [18].

Figure 7. Effects of increased paternal age on male fertility status, reproductive/fertility outcome [19]

References

18. Sartorius, G. A., & Nieschlag, E. (2010). Paternal age and reproduction. Human reproduction update, 16(1), 65-79.

19. Kaltsas, A., Moustakli, E., Zikopoulos, A., Georgiou, I., Dimitriadis, F., Symeonidis, E. N., ... & Zachariou, A. (2023). Impact of advanced paternal age on fertility and risks of genetic disorders in offspring. Genes, 14(2), 486.

(14). 01:26:42 Tool: Prostate Health, Urination; Tadalafil (Cialis)

In the United States, there has been a noticeable upward trend in the average paternal age over the course of the last forty years, resulting in a higher age of fathers at the moment of their offspring's birth. The paternal age can exert a substantial influence on the well-being and maturation of their progeny. There exists a correlation between advanced paternal age and heightened susceptibility to a range of health ailments, encompassing neuro-psychiatric disorders such as autism, bipolar disorder, and schizophrenia. The advanced paternal age is associated with an increased likelihood of accumulating spontaneous mutations in the DNA of sperm, perhaps leading to the development of these disorders. The association between age-related hazards epigenetic alterations and mutational events has been established. Although being an older father may have certain benefits in terms of financial resources, it is crucial to acknowledge the potential health consequences for offspring. Mitigation measures encompass several approaches, such as implementing family planning at an earlier stage and considering sperm freezing as a possible solution for individuals who express concerns over the impact of aging on their sperm, thereby enabling them to safeguard their reproductive capacity [20].

References

20. Urios, A., Ordoño, F., García-García, R., Mangas-Losada, A., Leone, P., José Gallego, J., ... & Montoliu, C. (2019).

(15). 01:33:02 Urinary Tract Infections (UTIs); Erectile Dysfunction Causes

The prostate gland, situated posterior to the bladder and resembling the size of a walnut, contributes to the process of reproduction through the synthesis of proteins and enzymes that facilitate the maintenance of sperm viability within the female reproductive system. Nevertheless, with advancing age, there is a tendency for the prostate to undergo enlargement, resulting in heightened resistance within the urethra, which is the conduit responsible for the process of urination. These manifestations can lead to prevalent urinary symptoms, including nocturia, diminished urine flow, urgency, and inadequate voiding of the bladder. Although there is no definitive method for preventing prostate enlargement, it is beneficial to be aware of potential triggers that may exacerbate symptoms. These triggers include the consumption of irritating foods and beverages, such as those that are spicy, acidic, caffeinated, or alcoholic, which can aid in the management of these symptoms. Furthermore, it has been observed that the administration of low-dose tadalafil, ranging from 2.5 to 5 milligrams, can effectively mitigate urinary symptoms and enhance erectile function. Consequently, this therapeutic approach is a feasible alternative for individuals encountering pain in both domains. Nevertheless, the choice to utilize such medication ought to be grounded in an assessment of personal symptoms and individual preferences [21].

Figure 8. Urinary Tract Infection [21].

References

21. https://asui.org/what-we-treat/urinary-tract-infections/.

(16). 01:38:21 Blood Flow & Erectile Dysfunction, Medication; Cardiovascular Health

Erectile dysfunction (ED) is a prevalent condition that mostly affects men, particularly in the context of advancing age. It is characterized by the persistent inability to attain and sustain an erection. Although psychogenic causes contribute to ED, it is frequently associated with organic variables, particularly those related to blood flow impairments. Hypertension, diabetes mellitus, atherosclerosis, obesity, and vascular disorders are influential factors in the development of this condition. Endocrine disorders make a relatively minor contribution to the overall prevalence of cases. In addition, ED can arise because of pelvic cancer therapies, including those employed in the treatment of prostate and bladder cancer. While hernias generally do not directly result in ED, they can potentially contribute to the development of pain symptoms. ED can potentially function as an early indicator of vascular disorders. The selection of treatment modalities is contingent upon the etiology, encompassing risk factor management, lifestyle adjustments, pharmacotherapy, and perhaps surgical procedures [22].

Figure 9. Interactions between erectile dysfunction, cardiovascular disease, and cardiovascular drugs [23].

References

22. Jackson, G., Erectile dysfunction and cardiovascular disease. Arab J Urol, 2013. 11(3): p. 212-6.

23. Terentes-Printzios, D., Ioakeimidis, N., Rokkas, K., & Vlachopoulos, C. (2022). Interactions between erectile dysfunction, cardiovascular disease and cardiovascular drugs. Nature Reviews Cardiology, 19(1), 59-74.

(17). 01:44:30 Mechanical Erectile Dysfunction Treatments; Peptides; Delayed Ejaculation

ED is a prevalent medical disorder that frequently responds well to treatment with phosphodiesterase inhibitor drugs, including sildenafil (commonly known as Viagra) and tadalafil (marketed as Cialis). The selection of a dosing regimen, such as daily low dose versus on-demand, is contingent upon an individual's frequency of sexual activity. It is observed that a significant proportion of males prefer on-demand dosing. The primary focus of these treatments is to target vascular issues, which are a prevalent underlying factor contributing to ED. These vascular issues are frequently associated with medical illnesses such as hypertension, diabetes, atherosclerosis, obesity, and vascular disorders. Although these medications efficiently treat ED, they primarily function as vasodilators, which can lead to various adverse effects such as headaches, facial flushing, back discomfort, leg cramps, indigestion, and nasal congestion. It is advisable for individuals who are having ED to also contemplate undergoing screening for their general vascular health. This screening can help detect potential risk factors for cardiovascular and cerebrovascular illnesses. It is worth noting that ED can serve as an early indicator for such disorders. The utilization of drugs to raise blood flow has prompted their application in sports for augmenting performance through the amplification of blood flow to both muscles and the brain [24].

Figure 10. Summary of the repairing of erectile dysfunction [25].

References

24. Porst, H., et al., SOP conservative (medical and mechanical) treatment of erectile dysfunction. J Sex Med, 2013. 10(1): p. 130-71.

25. Ren, Y., Yuan, J., Xue, Y., Zhang, Y., Li, S., Liu, C., & Liu, Y. (2023). Advanced hydrogels: New expectation for the repair of organic erectile dysfunction. Materials Today Bio, 100588.

(18). 01:52:36 Pelvic Floor Health, Urology & Physical Therapy; Split-Stream Urination

The podcast examines a range of urological concerns and associated symptoms, such as the occurrence of split urine streams and the likely underlying factors contributing to this phenomenon. The occurrence of split pee streams, characterized by the separation of urine into two distinct streams upon evacuation, can be attributed to a range of reasons, encompassing conditions such as prostate abnormalities and urethral complications. The podcast refutes the notion that hypospadias, a condition characterized by the presence of two urethral openings, is a prevalent contributing factor. This statement underscores the significance of addressing these concerns by medical assessment, as the presence of erratic urine flow may suggest an underlying condition that has the potential to be ameliorated or addressed. Additionally, the podcast briefly alludes to the evolutionary viewpoint of the efficacy of urine deposition and the advantages of minimizing detectability by predators in order to avoid potential risks [26].

References

26. Aoki, Y., et al., Urinary incontinence in women. Nat Rev Dis Primers, 2017. 3: p. 17042.

(19). 01:59:03 Penile Length & Trends; Dihydrotestosterone (DHT), Puberty

This section of the podcast explores a study focused on penis length and its surprising conclusions. The project attempted to acquire normative data on penis length, measuring it in both flaccid and erect states in 55,000 men worldwide. Contrary to expectations of falling penile length, the results showed an increase in penis size over a relatively short period of 30 years, raising curiosity regarding potential mechanisms responsible for this development. The discussion digs into dihydrotestosterone's involvement during puberty in organ development, proposing probable linkages between the earlier onset of puberty and longer penis length. However, the work also discusses subcultures aiming to employ dihydrotestosterone and growth hormone for penis extension post-puberty, emphasizing the significance of good physiological rationale and the potential hazards involved with such practices [27].

References

27. Sasaki, G., et al., Effects of pre- and post-pubertal dihydrotestosterone treatment on penile length in 5α-reductase type 2 deficiency. Endocr J, 2019. 66(9): p. 837-842.

(20). 02:09:01 Hair Loss, Dutasteride, Finasteride & Sexual Health; Post-Finasteride Syndrome

In his podcast, Dr. Michael Eisenberg delves into an examination of the plausible adverse effects associated with the utilization of finasteride and dutasteride, which are frequently prescribed for the treatment of alopecia. Specifically, he focuses on the impact of these medications on the sexual and reproductive well-being of males, with specific emphasis on the younger demographic encompassing individuals in their twenties, thirties, and forties. Certain drugs, which have previously received approval from the Food and Drug Administration (FDA) for different purposes, have the potential to cause alterations in both semen quality and sexual function among certain individuals. The precise methods and underlying causes of these adverse effects remain unknown, rendering it a complex matter to tackle. Although a significant number of males observe a restoration of sperm counts and sexual functionality upon cessation of the prescription, there exist instances of enduring post-finasteride syndrome, prompting certain individuals to seek assistance from urologists and specialists in reproductive health. The variability in the severity and long-term nature of these adverse effects highlights the significance of exercising caution prior to initiating the use of these medications, considering their possible implications for sexual well-being 28.

Figure 11. A hypothetical model of finasteride acting as an endocrine disrupter [29].

References

28. Trüeb, R.M., et al., Post-Finasteride Syndrome: An Induced Delusional Disorder with the Potential of a Mass Psychogenic Illness? Skin Appendage Disord, 2019. 5(5): p. 320-326.

29. Traish, A. M. (2018). The post-finasteride syndrome: clinical manifestation of drug-induced epigenetics due to endocrine disruption. Current Sexual Health Reports, 10, 88-103.

(21). 02:16:11 Clomiphene, Testosterone & Estrogen Signaling

The utilization of clomiphene, a pharmacological agent classified as a selective estrogen receptor modulator, has been examined as a potential therapeutic intervention for those experiencing low levels of testosterone in the male population. The mechanism of action involves the inhibition of estrogen receptors located at the hypothalamus and pituitary levels. This inhibition subsequently triggers an upregulation in the secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH), so promoting enhanced testosterone synthesis in the testes. Although this method has the potential to increase testosterone levels, its effectiveness is subject to individual variation, and its advantages may be constrained due to the essential involvement of estrogen signaling in sexual health, bone health, and libido. Clomiphene possesses the notable benefit of not exerting detrimental effects on sperm production, rendering it a viable therapeutic choice for males afflicted with low testosterone levels. This therapy option is particularly applicable to those manifesting symptoms such as diminished energy levels, reduced libido, mood disturbances, or sleep disorders. However, it is important to note that the efficacy of clomiphene may not be universally consistent [30].

References

30. Shabsigh, A., et al., Clomiphene citrate effects on testosterone/estrogen ratio in male hypogonadism. J Sex Med, 2005. 2(5): p. 716-21.

(22). 02:19:31 Follicle-stimulating hormone (FSH) Therapy; Prolactin, Estrogen

Hyperprolactinemia, characterized by abnormally high levels of prolactin, is a rather infrequent diagnosis in the realm of sexual health issues, affecting less than 1% of individuals seeking medical attention from urologists. Typical symptoms and indicators encompass diminished levels of testosterone, particularly in instances of significantly decreased sperm production. Elevated levels of prolactin can arise due to the presence of prolactin-secreting tumors, and this condition is frequently diagnosed when patients display signs of reduced fertility or sexual dysfunction. Furthermore, it is essential to monitor estrogen levels due to the potential complications associated with excessive aromatization, which can result in the development of disorders such as gynecomastia. Although the presence of some male breast tissue is considered normal, it is crucial to prevent uncontrolled growth. Therefore, the evaluation and management of sexual health issues should take into account the significance of these hormones [31].

Figure 12, Regulatory mechanism involved in follicle stimulating hormone (32).

References

31. Lavaee, F., et al., Follicular-Stimulating Hormone, Luteinizing Hormone, and Prolactin Serum Level in Patients with Oral Lichen Planus in Comparison to Healthy Population. Biomed Res Int, 2021. 2021: p. 8679505.

32. Mostafapour, S., Zare, S., Sadrkhanlou, R. A., Ahmadi, A., & Razi, M. (2014). Sulpiride-induced hyperprolactinemia in mature female rats: evidence for alterations in the reproductive system, pituitary and ovarian hormones. International Journal of Fertility & Sterility, 8(2), 193.

(23). 02:24:15 Varicocele; Peyronie’s Disease

Dr. Michael Eisenberg delves into the examination of two prevalent ailments pertaining to male reproductive health, namely varicoceles and Peyronie's disease. Varicoceles are distinguished by the presence of enlarged veins in the scrotum, which have the potential to impact the regulation of temperature and the clearance of metabolites in the testicles. The prevalence of this condition is widespread, affecting approximately 15% of males. Consequently, it can result in complications related to fertility and physical pain, with a notable proportion of instances, ranging from 20% to 25%, leading to such issues. Conversely, Peyronie's disease, which impacts around 5-10% of the male population, is characterized by fibrous tissue formation inside the penile region, resulting in the manifestation of curvature or deformity during the erect state. This illness may arise as a result of injuries, such as penile fractures, or complications following surgical procedures. In the discourse, Dr. Eisenberg elucidates the array of therapeutic options accessible for the management of Peyronie's disease. These include the use of an FDA-approved pharmacological agent known as collagenase (Xiaflex), mechanical stretching devices, and surgical therapies. The author underscores the significance of actively seeking medical counsel and engaging in discussions regarding these matters in order to identify suitable strategies for managing them [33].

Figure 13. Pathophysiology of varicocele.

References

33. Usta, M.F., et al., Relationship between the severity of penile curvature and the presence of comorbidities in men with Peyronie's disease. J Urol, 2004. 171(2 Pt 1): p. 775-9.

34. Panner Selvam, M. K., & Agarwal, A. (2020). Sperm and seminal plasma proteomics: molecular changes associated with varicocele-mediated male infertility. The World Journal of Men's Health, 38(4), 472-483.

(24). 02:27:26 Testis & Cancer Risk; Insurance, Blood Profiles & Semen Analysis

In his podcast, Dr. Michael Eisenberg delves into the criticality of male reproductive health, with particular emphasis on the value of hormone profiles, lipid profiles, and sperm analysis as valuable tools for obtaining insights into both sexual and general well-being. The author advocates for individuals to take an active approach to evaluating their reproductive health, even in cases when insurance coverage may not be comprehensive. In his analysis, Dr. Eisenberg emphasizes the frequency of many disorders impacting the male reproductive system, including varicoceles and Peyronie's disease, as well as the imperative of timely identification and intervention. In addition, the author addresses and corrects misunderstandings around cancer self-examinations while advocating for the practice of testicular self-examinations, irrespective of national rules. This approach aims to empower individuals of the male gender to proactively detect any health concerns at an early stage. In general, the discourse highlights the significance of male reproductive health and promotes understanding of the various dimensions of sexual health and overall well-being, recognizing their impact on both physical and mental health [35].

References

35. Jacobsen, R., et al., Risk of testicular cancer in men with abnormal semen characteristics: cohort study. Bmj, 2000. 321(7264): p. 789-92.

Preprint

Preprint

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