The Truth About Male Infertility & Low Testosterone | World’s Leading Men’s Health Doctor - Live Well Be Well with Sarah Ann Macklin | Health, Lifestyle, Nutrition

Episode Transcript
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(00:00):
From a young age, women are always taught to know about
their fertility. Yeah, half of infertility in
general is also led by men. Why do we not talk about male
fertility as much as women's fertility?
Men generally don't want to talkabout it.
You're not gonna sit there down the pub and say to your friend
I'm having a bit of difficulty conceive my wife and my sperm
counts a bit low. You just don't talk about it.

(00:21):
In a sense it's a woman's job tohave a child.
Therefore, the natural blame is on the female side.
You are one of the world leadingexperts in men's health.
You have urologists like me, or andrologists, as we're termed,
who deal with men's health. What's your thoughts on where
the sperm count lies now do? We kind of just assume that men
are fertile, but the answer is they're not.

(00:42):
And fertility does decline. And it's not just about sperm
count, it's also about DNA damage and other factors.
There is enough evidence about endocrine disruption and
chemicals. Industrialisation may be a
factor for the decline in sperm counts.
Caffeine has been associated with DNA damage, or the sperm.
And sauna use, does that harm sperm production?

(01:02):
It's not. Going to do you any harm to
avoid these kind of situations were exposed to adverse
temperatures. Stress has a massive impact on
our Physiology. Do you talk a lot to patients
about how to manage their stresslevels?
Honestly, to a degree, but not really not as much as I should.
There's a lot of conversation around freezing sperm and Chris
Williamson has actually frozen his sperm at 36.
Sperm freezing is not something I would particularly encourage.

(01:25):
I don't think that one can say that you're going to freeze
sperm in your late 30s because if you have a child at 45, then
my sperm count might be much worse.
We don't know that. What's the risk versus the
benefits of TRT therapy? Testosterone in the form of TRT
acts like a male conceptive, so don't take it if you want to
have a child. Can men without treatment
medication naturally increase their testosterone levels?

(01:47):
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(02:30):
subscribe to the show. Thank you.
I am so excited for this conversation today.
This is probably in one of our most demanded episodes around
male fertility and male health in general.
Actually, I was trying to think about where I start this
conversation because there's been a huge discussion in the
press. I read a New York Times article
that was just released a couple of weeks ago all around male

(02:53):
infertility and sperm count and endocrine disruptors.
And I was trying to really thinkabout where to start this.
And I wanted to start it from a woman's perspective, which is
from a young age, women are always taught to know about
their fertility. We always have this ticking
clock that we're always very aware of, yet half of

(03:14):
infertility in general is also led by men.
So why do we not talk about malefertility as much as women's
fertility? So I think there are probably
culturally, socially, I think men are less inclined and we
know men are less inclined to talk about their health or even

(03:34):
go and see clinicians about their health.
I think that's really important to put across, which is often
why if you look at screening programs, for example,
colorectal screening programs orbowel cancer screening program,
men's uptake is far less. So I think men generally don't
want to talk about it. And then obviously not being a

(03:54):
woman, it's very difficult to say what women talk about.
But in the sense that you're notgoing to sit there down the pub
and say to your friend, you know, I'm having a bit of
difficulty conceiving my wife and my sperm count's a bit low.
I mean, you just don't talk about it and you tend to blot it
away and put it aside. So I think that that's one
aspect. I think also there's a political

(04:14):
part of this as well. I think politically men's or
male fertility is not something that is talked about very much.
It's not a high priority. It's not a cancer.
But as we'll see, hopefully as we talk, we will, we'll see the
importance of it in terms of longevity and health in general.
So I think that there is both the, the, the cultural issue

(04:34):
about men being men. I think there's also the issue
of politically, it's not seen asan important aspect of our
health, which it should be. And I think the third thing is,
is also for women as well as we were talking earlier that women
in a sense, it's a woman's job to have a child.
So therefore the natural blame is on the female side.
So people's perceptions are, well, it can't be me.

(04:57):
And this perhaps indication of perhaps our misogynistic society
that we live in. So I think that there are those
3 aspects to it that are very important.
So and also education, which is the 4th aspect.
There is a lack of education outthere because of resource,
resource allocation. And as we said, the the
political climate isn't geared towards talking about men's
health in general, aside from obviously from prostate cancer

(05:21):
as well. Yeah, I think it's really
interesting because I think for myself as a woman in her 30s,
we're not always talking about fertility at this age.
It's a very, very big conversation for people that I
know personally that have struggled to conceive, where
actually it's not been about thewoman, it's been more on the
man's side. It's become like a very big
shock in those conversations andit has interested me that we

(05:45):
aren't talking about it as much.Men aren't really aware of this
as much in their 20s, and maybe they only start to realise this
when they have that moment to conceive.
But you said something really interesting there, that it isn't
just linked to conceiving a child, that's also linked to
longevity. So can you talk about why this
is so important in a general health term for men to
understand? Yeah.
I mean, if we look at, you know,you mentioned early statistical,

(06:07):
up to 50% of men or, or male utilities due to a male factor.
The issue there is that, yes, itis.
And what we forget is that although if you look at society
in general, yeah, we're geared up to have a child.
So when you get married or you you join somebody in
partnership, one of your, one ofyour aims in life is to have a
child. So it's also comes as a shock

(06:28):
when you can't have a child. So naturally the end point to
all of this is having a child. But what we miss in between all
of this in terms of men's fertility is the concept of
health. So if you look at health in
general, we know that, for example, there are men with
infertility. We define infertility's
inability to conceive after one year of unprotected intercourse.

(06:50):
You find that approximately 10% of those men can have no sperm
in ejaculum, which is very common, more common than we
think probably 1% of the generalpopulation.
But the more important thing about these patients and we call
them patients, is that ultimately they may have
hormonal problems. 30% of men may have low testosterone who
have abnormal semen analysis. You also find an increased risk

(07:13):
of testes, cancer, partly due toendocrine disrupting chemicals
and other aspects from childhood, but also there's a
higher risk of other diseases, in particular metabolic
syndrome. Metabolic syndrome is a cluster
of cardiovascular symptoms such as hypertension, heart attacks,
diabetes, and there's a higher risk of having these type of

(07:35):
disorders and we call it metabolic syndrome.
And in fact, some studies which are not great studies, but there
are studies suggesting that men with immutility have a higher
risk of mortality long term because of the link with
testosterone and because of the link with metabolic syndrome,
which I'm sure we'll talk about later.
But I think the main issue is there are other diseases that
clearly are important. So it's not just about

(07:59):
evaluating whether you can have a child, it's also evaluating
you for your general health because of all those factors.
And so I think it's important that the message gets across is
that it's fine and we understandthe end point here is to try and
get you to have a child and takeyou on that journey.
But within that journey, there has to be, you have to look at
your own health and a long term health of noting yourself.

(08:22):
Because then if you look at it and say, well, what about if I
do have a child? What about I want to keep myself
healthy so I can look after thatchild long term and because of
those other risk factors we talked about?
So I'm really going to delve into later around testosterone.
It's one of the things that you pointed out.
You are one of the world leadingexperts in men's health.
I want to know that what is one of the biggest misconceptions

(08:44):
that you see about men's health and men fertility today?
Like what is the one thing that you wish that you could just?
I I think that the biggest myth is you can't do something about
it. You can.
There are various things and even, and I think this is the,
the, the, the problem we have intwo parallel worlds.
Because you have on one hand, gynecologists looking after

(09:06):
women. You have urologists like me or
andrologists as we're termed, who deal with men's health
looking after men. And often those, both those
services and both those health aspects are not integrated.
So what they should be is they should be integrated.
So there's an overlap and peopletalking.
So one of the biggest problems you see is that when men go and

(09:27):
see a doctor, invariably if theycan't conceive, it will be a
gynecologist or an IVF centre. I think it's slowly changing,
but invariably they won't come and see a urologist like me
because often people say well you've got sperm there, we can
use this for IVF treatment. But ultimately there is a bigger

(09:47):
picture as we've already discussed, in terms of their
health and there may be other common causes that you need to
exclude as well. So that's probably one of the
most frustrating things I see inclinical practice.
Well, I know that you said on the NHS wait list you have a
year for people to come and see you, which is long especially
this feels like, you know, quitea prominent problem for some men

(10:08):
really wanting to conceive and happen to a year.
What's the most common problem that you see with males that
walk through your door? So in in the context of male
fertility, I mean the waiting times are like that throughout
the country. And I think that one of the
problems is that we mentioned talked about women and we talked
about the biological clock. We know that female fertility

(10:30):
declines after 3537 and definitely by 40.
So the problem is that most patients are referred probably
at that age because women havingchildren later in life.
Now, as we know, birth rates have declined as well due to
multiple factors. But my point being that one of
the the key problems we see is that there can be correctable

(10:52):
causes, but you almost reached apoint where the female partner
may be above 37. They might have, for example, a
varicose cell or varicose veins of a testicle, which you
normally might 710 years earliertreat that, but in a sense you
almost run out of time and you then send in those patients onto
IVF. So I think one of the biggest
frustrations is because of waiting times, because of the

(11:14):
lack of resource that we have isactually being able to probably
treat patients the way we want to treat the patients.
In a sense we have a, we have a kind of almost a time bomb.
It's not just about NHS wait time.
It's also about the fact that women do have children later now
and the fact that they don't come forward as quickly.
Part of that is as we talked about education and men as well,

(11:35):
and often it is people do kind of put it beneath the carpet and
you know, hide everything. And actually the key message is
what I want to see is people coming forwards earlier and
defining, although we say in utility is defined as a year of
I'm Titicans, which should be 6 months really in a, in a
partner, a female partner of 35.Because you know, we know how

(11:56):
important it is in terms of women's ovarian reserve at that
age and to try and get tests done, investigate and try and
impact upon treatments as well. So that's really the key I think
to to see in patients, but it's got to be streamlined really.
As you mentioned there about kind of women's ages, I think
there's always this kind of perception that men can have

(12:17):
children at any age and it's allgoing to be fine.
And women are way more aware of this kind of age 3537 and then
you're you're perimenopause. Is it true?
Because I've, I don't know if this is true, but men who have
children later have high risks of having a child with autism.
I don't know if that's true. It's something that I read.
Is it as easy for a man to have a child as he ages, or is

(12:39):
actually their very similar risks as women?
Yeah, I mean similar really. And I don't think we discussed
it enough, but after the age of 40, SIM parameters do decline.
But also the other thing that happens after the age of 40,
well, just doing a seam analysisdoesn't give you the whole
picture of fertilities. You can have a normal semen
analysis, but you can have difficulty conceiving.
And more and more where science is, it's changed.

(13:02):
I mean, we talk about more and more the concept of sperm DNA
damage, for example, which is very important, which we've done
some work on and others have done work on, where actually
your DNA damage increases as youget older.
Above the age of 40, definitely by 45 and certainly above 50,
which might have an impact on genetic problems.
We don't fully understand or know this.

(13:22):
And therefore, there are many, many causes sperm DNA damage.
So after the age of 40, yes, there are other factors.
You can have a normal seam analysis, but we talked less and
less about it, perhaps from Charlie Chaplin, for example, it
was what, 80 when he had a child.
So we kind of just assumed that men are fertile.
But the answer is, is that they're not.
And fertility does decline and it's not just about a sperm

(13:45):
count, it's also about about DNAdamage and other factors,
lifestyle, other illnesses whichcan impact upon fertility.
Because I think when people might go and get a fertility
test for a mile, for instance, they'll look at the morphology,
so the shape of the sperm and the mortality.
But you don't, we don't talk very much about this, the DNA

(14:06):
fragmentation, which you've donea lot of work on.
If somebody is going to get tested and it comes back, I
don't want to say normal, but inquotation marks that
everything's fine. Or maybe their morphology is is
a bit off and they're trying to do lifestyle interventions to
get it back. What at what phase should they
look at this DNA testing that that you talk a lot about?

(14:27):
It's a good. Question.
So if you I mean you can imagineI mean so-called unexplained
infertility accounts for about 30% of cases of infertility.
So if you look at unexplained infertility, probably somebody
who has a normal signal parameters partner has what we
term as a good over and reserve.And in those kind of cases, you
probably should be looking at DNA.
And these are the type of patients that historically would

(14:48):
just send for IVF treatment, butthey may fail IVF treatments
repeatedly. And actually then we go back and
they come back and see us. And this is one of the problems
about working in an integrated fashion, in a collaborative
fashion with gynecologists, withIVF units, because then you can,
of course, assess patients comprehensively.
So the DNA is raised. And that's one instance that you

(15:08):
look at DNA fragmentation. So if you've got normal semen
parameters and everything is normal in terms of the female
partner, and you might want to say, well, OK, is there an
underlying problem here? Other cases of DNA damage you
might want to be looking at in terms of DNA damage in those
patients who repeatedly fail IVFtreatment or have miscarriages
as well, because we also know DNA fragmentation can cause that

(15:31):
as well. So it can also be a marker in
terms of risk stratification foroutcomes from IVF.
Now, the data is difficult to delve into because the data is
surrounding all of this. There's very few perspective or
randomized studies, but most of the studies we have are
retrospective and patients are their own controls.

(15:52):
And in many ways a lot of peopledon't believe in the concept of
DNA fragmentation. So DNA can also be due to
nutritional factors as well. So alcohol, smoking, caffeine as
well, patients who are overweight as well.
Studies have shown reducing weight reduces DNA fragmentation
as well. And so there are many other

(16:12):
environmental factors and also DNA fragmentation could be due
to our own body bacteria, something called microbiome.
So rather than the concept of actual bacteria, which of course
can cause DNA damage because they create chemicals called
reactive oxygen species, which is thought to then damage sperm
DNA, it's also the concept now is called dysbiosis.
Dysbiosis where you get an imbalance of bacteria and

(16:35):
bacteria that we harbour. So normally may not be
pathogenical causing problems, but an imbalance has been
associated with infertility. So there are many studies out
there. We did a study recently at
Imperial shown that there was animbalance of certain types of
bacteria. So we're not saying that
somebody's got an SDI or somebody's got, but actually
these bacteria that we harbour can cause changes, inflammatory

(16:58):
changes, which can affect the sperm and all can affect the DNA
damage. As someone who has spent a long
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(17:20):
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(17:43):
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(18:05):
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(18:26):
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(18:48):
connected to DNA fragmentation, which you were talking about.
But also this is, I guess, connected to fertility in
general. Things that are also really
important to be aware of before I go and dial down too much in
the nutritional side, which I find very fascinating.
One thing that's very much come to mind in conversation in the
last year that I wanted to ask you personally is saunas and

(19:10):
sauna use, does that harm sperm production or sperm quality?
And does that impact fertility at all for men's health?
It's difficult to say because ifyou think about it, how do you
measure heat? How do you measure how often
people are exposed to heat? It's quite a difficult problem
to to define. The answer is yes.

(19:31):
So you want to try and avoid heat.
I suppose the more pertinent question would be, you know, I
mean hot baths, showers, saunas,yeah, it's not going to do any
harm to avoid those because obviously the temperature or
smatogenesis is very temperaturesensitive with with the the
testicular temperature being about a degree below the body

(19:52):
temperature and should be kept to that.
But I suppose the interesting question is what about a lot of
you see out there, you know, socially about douches, cold
douches, etcetera. Do they work?
I mean, again, it's very difficult to say.
And I think that ultimately it'sabout patients being happy.
I've always tried to avoid answering the question, but I'm
not. What I'm trying to say is that I

(20:14):
think the data about measuring temperature and measuring these
lifestyles, which is quite difficult because it's quite
variable and that's really the difficulty.
But it's not going to do you anyharm to avoid these kind of
situations were exposed to adverse temperatures.
Yeah, because I'm just thinking there's a lot of people that are
very, you know, into the side oflongevity and health and
especially in the kind of the tech culture.

(20:37):
And a lot of people will be going to saunas maybe every
single day or every other day and doing the sauna for 10 to 20
minutes, maybe thinking that's having a very beneficial impact
on the health and cardiovascular.
Yes, it is. And that's what research shows.
But then on the flip side, is italso impacting their fertility?
Yeah. So I think it's a balance isn't
there? That's what you've got to

(20:57):
achieve. And I think that's that's the
difficulty. I don't think I can answer the
question in many ways. The patient's got to make their
decision as an individual. But ultimately it's something to
avoid historically and traditionally if you want to
conceive. So we mentioned something very
early on, which is around the 50% decline in sperm cases since

(21:19):
the 1970s. And that meta analysis came out
by Doctor Sharna Swan. And then the World Health
Organization kind of hit back atit and said, well, they
disagreed actually, that it wasn't conclusive.
What's your thoughts on where the sperm count lies now with
Men's Health? And the question I actually want
to connect that to is does it impact fertility directly?

(21:41):
As you know, the this kind of data and historically the paper
before showed a 50% decline in sperm quality.
We should call it more sperm quality rather than sperm
counts, but we call it sperm quality.
Metro analysis is a good scientific way of collating data
over time, looking at data, but it has its flaws and it's very

(22:01):
much dependent upon the quality of studies, which do vary.
If you look at I think sperm counts overall, we've seen birth
rates to kind, but there are multiple factors.
So I think one of the things about meta analytical data, that
all sounds very posh, but what Imean by evidence based that
you're using is it doesn't take into account some of these other
factors. You mentioned social, cultural

(22:22):
reasons, female age, for example, what is the true
outcome? Pregnancy rates.
It's not just about sperm counts, is it?
It's also about the female partner, ovarian reserve, ETC,
other pathological diseases thatmight be present.
And so you've got so many other variables called heterogeneity
within these studies that it's very difficult to say.

(22:43):
But you should treat a metro analysis for face value.
And metro analysis ultimately has gone through rigorous peer
review and therefore there is a reduction in sperm quality.
But it would seem to fit with what's going on in terms of
global birth rates as we know now.
I mean, and if you look at China, for example, people now
being paid to have more childrenor receiving financially,

(23:05):
whereas historically if it's theother way around because of the
the growth in, in terms of the population.
So clearly something has changedover time and there is enough
evidence as we talked earlier about endocrine disruption and
chemicals industrialization, exposure to endocrine disrupting
chemicals, which may be a factorfor the decline in sperm counts.

(23:27):
Let's talk about the endocrine disruptors.
So people might be wondering what actually what that is like,
what we're talking about. That seems to be, for me,
looking at a lot of the studies where most of the research
really sits, linking it to the sperm quality.
Can you talk and let people understand what an endocrine
disruptor is and what sits within that and how people can

(23:48):
actively try and make maybe changes in their lifestyle to
reduce this? I mean, there's, there's a
massive long list and forgive megetting old, I can't remember
the full list, although I wrote about this, but the plasticized
pesticides, you know, essentially plastics which have
easternizing effects within the environment and these
easternizing effects 'cause thisdysgenetic testicle and

(24:11):
therefore you then get these developmental changes within the
testicle. How can you avoid it with
difficulty that requires, you know, that requires a social
change in terms of industrialisation exposure and,
and occupational exposures as well.
So that's a difficult one because it's almost in a sense

(24:33):
about the environment and how weavoid that.
So I think that's quite difficult.
That requires political change more than anything else, right?
As opposed to individual change,because we're all exposed to
these. Yeah.
Do you think it's also? About being aware of what we're
putting on our bodies as well. Like is it about using less
chemicals in our homes, airing our homes more choosing?

(24:55):
I mean, I know that's a kind of quite a hard one to say, like
choosing organic because that's a very kind of elitist term that
a lot of people can't afford that.
But is with any of those differences have any impact?
I don't think we know. I don't think there's enough
data to show that. I think, you know, there's
definitely data showing the association with these
chemicals, without a doubt endocrine disruptors, but I

(25:17):
don't think there's enough day to say in terms of preventative
measures, you know, how we can prevent this process basically
or pathophysiological process occurring.
Right. And do you think that's one of
the main reasons of the sperm quality that's lowering?
I think more and more it is because it was originally
described testicular disgenesis by a Scandinavian doctor called

(25:38):
Scakabak who originally described it as a theory.
And more and more there are studies ongoing confirming that.
So I think that that probably isone of at least one of the, the,
the, the issues in terms of maleinfertility.
I think the, there are of course, you know, multitude of
other factors as well, you know,you know, weight increase in

(25:59):
obesity throughout the world, which again, we've got to
remember that obesity itself canalso cause not only problems in
terms of cardiovascular health, but also fertility as well.
So there are, I think there are many, many factors, types of
food we eat. We don't fully understand or
know any of this in terms of theexact impact of certain types of

(26:21):
food. But if we work from the
assumption that obesity is not good for your health and also
fertility. And we assumed that a lot of the
the chemicals that we we use in all the foodstuffs that increase
weight are have a negative impact on your fertility.
The other way of looking at it is it's not going to do any harm

(26:42):
to lose weight or try and lose weight.
But studies again, you know, areinterested, aren't they, about
weight because if you look at weight in itself, but on the
other hand, if you look at, it'sreally fascinating, if you look
at, for example, operations to lose weight, so gastric stapling
operations, the impact on fertility is quite limited.

(27:03):
You would have thought that losing weight and doing these
type of operations you would improve fertility.
But studies are very controversial about that.
What's more interesting, losing weight naturally.
We did a study looking at an NHSdiet which interestingly
improved semen parameters, potentially improving or
reducing oxidative stress which causes DNA.

(27:26):
And it would be really interesting to see for example,
the drugs that are using the weight loss drugs, injections at
the moment and jar and their potential reproductive potential
as well and effects on testosterone.
So I think that's a really interesting area that we'll
begin to see evolve for the future of the next one to two
years. And there will be studies
looking at that and the potential effects of these

(27:47):
weight losing drugs on reproductive health, which would
be fascinating. Really interesting.
Well, you mentioned a term that people might not well might not
be too familiar with oxidative stress.
And I immediately think of antioxidants being a
nutritionist here, which is basically why we get people to
eat lots of fruits and vegetables.
Looking at the nutrient profile to help fertility for men,

(28:08):
women, I think we're pretty aware of what's important for
our fertility. We'll look at understanding,
taking folate when we want to conceive and Coq 10 can be
really helpful for us. But I don't think men, and I'm
only seeking out a term here because I'm not a man, but are
as aware of their nutritional status when looking at their
fertility. I know that you've done a lot of
research here. What would you recommend for

(28:30):
somebody who wants to improve their fertility or their sperm
quality or in general not testosteroniac?
So we'll get to that. I think that's a separate
conversation. How would you get them to look
at their nutrient profile and dosupplements help?
Yeah, it's a really good question.
Do supplements help? I think the, I mean, if you look
at data, yes, is the answer of individual studies, but you've

(28:52):
got to then look at the quality of those studies.
Going back to what we were talking about, quality of
science, meta analytical data. So often we use meta analysis to
look at all of this. So if you look at meta
analytical data, you can drill down on certain, we talked about
Q10, carnitine, for example, vitamin EC, selenium, zinc.
But what's interesting is one ofthe best studies probably was

(29:14):
called the Moxie study, which isa Scandinavian study which
looked at which is a prospectivestudy and one very few
prospective studies are looking at sperm DNA damage and semen
parameters, which actually showed no major benefit.
But if you then take the whole data in meta analysis, which is
what it does, it looks to pulse data.
When you look at a meta analysis, there is a benefit for

(29:35):
some of these, but a data again is what we would term as weak
because there's not that many randomized controlled studies
looking at outcome. And in particular, you can look
at data and it can say we've gotan improvement in semen
parameters, but a lot of data isn't controlled.
So you don't have a control group because semen parameters
do fluctuate. So this is 1 inherent problem or

(29:57):
variability in studies and also at the end of the day should you
be looking at pregnancy rates orpregnancy outcomes and there are
analysis which are much more rigid, Cochrane analysis which
have shown some benefit of antioxidants in that setting.
DNA is another issue. There is some evidence equally

(30:17):
there is as we mentioned that study contradictory evidence
suggesting the effects of antioxidants on DNA damage as
well. But I think the problem
underlying all of this is a lackof focus in terms of research
and driving research in these directions basically because
that's what you need is you moreneed need more robust data to
support practice. And I think that's where we lack

(30:39):
that evidence base or science inthe context of male infertility.
I'm interrupting for one moment to ask one small favour.
Please subscribe to the show. This helps it grow more than you
know. And I'm so bad at asking this
from you. I'm so bad at thinking about
this. But you know, my goal was

(30:59):
100,000 to get to on YouTube andI really want to bring you more
content and better guests and bigger episodes, and we can only
do that with your help together.So please do hit subscribe.
Thank you. I'm thinking about people that
want to try and actively do something for their health.
As I'm hearing this. Do you think people because it
doesn't feel like it's harmful with certain, I want to say

(31:23):
multivitamins, but you know, vitamin E assets that can on
high levels be actually more detrimental, correct?
But thinking about risk versus benefits, if people wanted to
dial down on looking at certain supplements to take or how they
should be approaching their nutrient profile, what advice
would you give? I think the the benefits out
outweigh the risks. Yeah, as we know unless you

(31:43):
mentioned importantly about vitamin E, Yeah, OK.
So I think that they do. So it's, you know, you can say,
and probably a nutritional pharmacologist would shoot me
down, but I would say that the risks do outweigh the benefits.
It's not going to cause you major harm.
But I think the question of course is that is it going to do
any good Possibly is all you cansay based upon the data that we

(32:06):
have. So if there's not really any
harm, then it's reasonable to dothat.
I think nutritionally it's important because I'm talking to
a nutritionist anyway, but I think it's important, you know,
the Mediterranean diet, I think it's important to lose weight,
to exercise, and to do all thesethings are important.
Stopping smoking, not drinking as much caffeine.
Caffeine very important as well,interestingly.

(32:29):
And caffeine important for DNA, interestingly, which is a rather
unusual thing to kind of pick out because you kind of look at
it and say, but again, caffeine,you know, reduction or caffeine
has been associated with DNA damage of the sperm.
So, but again, you look at it and there must be some other
biological factors or genetic factors as well which might

(32:50):
predispose, which is nobody's ever looked at.
Is all different patients more susceptible in their
reproductive health to oxidativestress.
That's one area which would be fascinating to look at.
Is there an abnormality there? Because if you look at other
people's lifestyle, because you always hear, don't you, that he
was taking drugs, he was overweight, smoking like a
chimney, drank lots of booze andhe managed to have 10 kids.

(33:15):
And there I am with a waist of 32 inches and I don't smoke, I
don't drink, I don't know anything about it and I I can't
conceive. So there's got to be other
factors involved, not just environmental.
There has to be genetic factors as well.
Yeah. I also can imagine within that
stress must be quite a big factor.
And before I go on to the stress, I just want you to

(33:36):
repeat those nutrients that you studied.
It was Co Q. Ten yeah, Q10 carnitine, vitamin
EC, selenium, zinc, these are these are ones.
These are the ones to be really aware of and I'm just thinking
people are going to go and have a blood test.
There are certain levels that they may be like, Is Vitamin DA
big player in this? Again, there's some evidence of

(33:58):
vitamin D, isn't it? But it's a lot of these are
animal space studies as well, which is a problem.
And therefore translating, we'vegot to remember that's one of
the problems we have. Actually, it's good you
mentioned it because if you lookat animal studies, animals are
more sensitive to toxins. Animals are more sensitive to
drugs compared to humans. So it's that's where it's
difficult in terms of the translational science, in terms

(34:18):
of extrapolating that to, to, to, to human beings basically.
So I think that those would be reasonable again.
One thing that does deplete nutrients that I know, speaking
as nutritionists, is stress. Stress has a massive impact on
our Physiology and I don't thinkthat we look at it as acutely as
we should when it comes to fertility.
Do you see a lot of people walking into your clinic that

(34:40):
suffer with high stress and thatcould be linked to fertility
problems? Yes, hugely.
We live in a society that is, it's a busy world and it's a
busy society and it's a society that doesn't take any prisoners
really. And I think that often people
can't switch off and often people can't stress.
I mean, the nearest thing you can do, because you can't
objectively measure stress in terms of fertility directly,

(35:05):
that would be difficult. But take for example, as part of
the reproductive potential is erections or male erections.
I mean, stress is a major factorfor psychological stress, for
erectile dysfunction, for example.
So in the same way, we've got tothink physiologically about the
effects. We don't know enough about
stress and male empty, but I'm sure it does have a role without

(35:26):
a doubt. But there are two aspects of
stress. One is obviously you're trying
for a child, you're not conceiving, it's stressful, it's
difficult. You see and you look around you,
people of the same age of you, if you're in your 30s, for
example, and you're going to Christians, you're going to
weddings and you see all these kids around your patients often
talk to me about that and say it's one of the biggest stress
and they begin to slowly marginalized themselves from

(35:49):
socially from people because they don't want to have contact
with children. That's really sad to see as
well. And that's also what does
happen. Then you look at the the stress
of a job. A lot of the time, you know,
people have very stressful lives, stressful jobs,
financially, many, many factors,relationship issues.
And the third thing, of course, is that relationship issue,
isn't it ultimately the way thatfertility can impact upon the

(36:12):
relationship with your partner as well and how relationships
can break down? And you do see that sadly in
relationships. And so do I think there are
multiple components or facets tothe stress.
It's not just stress within the environment or the world you
live in socially, but it's also about the process of infertility
and what it causes because it can have profound effects on

(36:33):
relationships and people's well-being.
Do you talk a lot to patients about this aspect when they come
through the door on how to manage their stress levels?
Honestly, to a degree, but not really not as much as I should
because again, it's that kind ofpressurize, isn't it?
I mean, what we would want to offer is holistic care.
But the trouble is, is that within confines of restricted

(36:55):
times resource, it's very difficult and also we don't have
that infrastructure. There are fertility specialists
out there who deal with the psychological counselor and
aspects of that. But more often of course is, you
know, we IVF units for example, have a counsellor who's really
more talking about donor sperm, for example, and not talking
about more holistically about the psychological well-being of

(37:17):
the patient and how that's impacted and how that's
affected. Because and you do see it, you
do when you're in clinic and youdetect that stress between a
couple. And it's not their fault, it's
just they also need guidance as well.
And I think we don't really, we deal with stress very well as as
a medical fraternity. And I think we should be, and we

(37:38):
should have that resource as well because it does affect
people's mental health, you know, and it will impact upon
relationships and at worse, willresult in people ending the
relationships. Yeah, absolutely.
Well, I think it was really interesting going back to
earlier when you were saying about women's kind of big
markers of 3537 and 40. And egg freezing now has become

(38:01):
very common among women, especially in their 30s.
But now there's a lot of conversation around freezing
sperm. And Chris Williamson, who's a
big podcaster as well, has spoken openly about this, that
he's actually frozen his sperm at 36.
And I wanted to talk to you about fertility preservation.
Should we encourage it for men as as similarly as we do to

(38:22):
women? And you know, what's kind of the
outcomes is I'm quite aware of if a woman freezes their egg
solely on their own, there's less of a likelihood to get
pregnant than freezing with an embryo because of the throwing
process. And then we have to see if they
obviously the embryo connects properly.
Is there, what's the risks versus benefits?
Like is it quite a high likelihood that if you freeze

(38:43):
your sperm, you could then go into IVF?
Like what's your thoughts aroundthis?
I mean, sperm freezing for let'ssay for lifestyle reasons is not
something I would particularly encourage.
I mean it's individual choice, isn't it really?
If you want to do that and you feel more comfortable that I'm

(39:04):
in the context of that. We tend to freeze sperm in, for
example, is patients preoperatively, you having
certain types of cancer chemotherapy treatments where
it's mandatory to freeze sperm in terms of the effects or the
negative impact of these varioustreatments like chemotherapy,
radiotherapy, removal of testes for testes cancer on sperm
production. So that's one group of patients.

(39:26):
The other group of patients may be that you're faced in clinic
with a patient who may have a very low sperm count because
sperm counts can appear and disappear that you might want to
freeze. The concept of freezing for a
man who gets older, I'm not surethat I would particularly
advocate or believe that it's something that I would say to

(39:47):
patients to do outside of those indications that we talked
about. I think it's about individual
choice. If you feel happier doing that,
fine. We know there is a decline, but
we also talked about DNA as a sperm preserving sperm at a
younger age, fine. You might get better sperm
quality in terms of DNA at a younger age and you would if
you're older. But then we go back to what we

(40:07):
were talking about earlier and even pre interview about the
concept of societal pressure. We tend to have children at a
later age now and you know, and society is moving towards them.
And is this just, is this just aresult of that rather than a
necessary indication to do that?I mean, it's, I think there's,

(40:30):
there's, there's different arguments about this, but I, I,
I don't think that one can say that you're going to freeze
sperm in your late 30s because if you have a child at 45, then
my sperm count might be much worse.
We don't know that. But if it's something you want
to do, you feel comfortable withthat, then fine.
But it's not something that I would be particularly going out
there advocating. Really.

(40:50):
OK, that's interesting. Well, that's going to Tesla
string because I think that's a really important topic,
especially for men right now. Can men naturally without
treatment, medication, naturallyincrease their testosterone
levels? And how should men be looking at
this themselves? Well, testosterone is important
for cognitive health, mental health argument about

(41:12):
depression. It's also important as we talked
about weight, we talked about cardiovascular disease and its
association with metabolic syndrome, erectile function,
libido, and there are many studies showing its association
and importance for general well-being to try and improve it
naturally. There are things you can do.
I'm not a great proponent of so-called natural testosterone

(41:34):
products. The evidence based on them is
very limited. Data is very weak supporting
them. But if you look at the concept
of central adiposicity, men who are overweight or obese have a
lower testosterone because of this concept of testosterone
conversion into estrogens, whichmight then impact upon the brain
axis, which then reduces testosterone or other chemicals

(41:56):
called leptins produced as well which interact with that axis
and causing something called secondary hypogonadism.
But reducing weight, for example, natural weight
reduction might improve your testosterone levels by one to
two points or nanomoles per litre.
But we've also got to analyze what do we mean by low
testosterone? What is, what is, what is low

(42:16):
testosterone? Because ultimately you're,
you're not going to treat somebody who is asymptomatic,
who doesn't have symptoms, but you might nowadays because of
the associated metabolic syndrome.
But men are normally what we term as hypogonadol.
They have symptoms of hypogonadism, low testosterone
in in and also biochemical evidence of low testosterone.
You should be treating both handin hand.

(42:39):
But if you look at guidelines, guidelines vary about what
levels you should treat. And that's really where it gets
very difficult. So, and there are lots of kind
of myths at it, but we formulated some guidelines for
guidelines group that I work forand we said that if your
testosterone is less than 8 you and you have symptoms you
definitely hypogonadal, you could consider testosterone
placement. 8 to 12 is borderlineand above 12, which is the total

(43:02):
testosterone, then you're OK. Basically the problem is, is
we've got this very grey group between 8:00 to 12:00 where
people talk about measuring freetestosterone as well.
But I think if I got a patient who, for example, has 8 to 12,
I'd probably be initially sayingto them, look, we can try
lifestyle modification in terms of losing weight, exercising to

(43:25):
try and increase testosterone levels, Sleep as well.
It's important because sleep canalso improve testosterone levels
in studies as well. So, but then what comes first,
chicken or the egg? Because testosterone can cause,
as we know, problems in terms ofsleeping as well.
So you've got to weigh that up. So I think that there there are
some natural ways to do it to answer the question in a long

(43:47):
winded way. Well, I want to talk about a
supplement that's going off I think a lot online right now,
all the things that I've been looking at which is Tonga Alley.
Now you just mentioned there total testosterone and free
testosterone, which people mightnot know the difference between
those two, but it's very interesting.
There's a lot of people talking about Tonga Alley helping boost

(44:09):
free testosterone by significantly quite a lot.
Is it worth taking this? Is it harmful?
What's the risk versus the benefits?
And what's the difference between free testosterone and
total testosterone that you werejust mentioning?
So the first difference is totaltestosterone is a total amount
of testosterone in your body that is bound to proteins,
including something called albumin and SHPG or sex woman

(44:32):
binding globulin. Free testosterone is that the
body uses it's free, it's withinthe the plasma.
So again, there's this whole issue about what's important is
your total testosterone, your free testosterone, your total
testosterone, your free can vary.
It's also very difficult to measure free testosterone
bioassays as well. So I think if I was going to

(44:54):
comment and I, I don't know enough in all honesty about
tongue and even nor have I nor would I want to comment too much
if I'm honest, honest with you about it, Sarah.
But I think that you have to be careful about data analysis and
be careful about hype and careful about data that people,
because that's what we've got torely on.
Evidence based scientifically, if it's not harmful, fine, I

(45:18):
don't see a problem in it. But on the other hand, I think
we want to see more studies, more evidence based controlled
studies. You want to see more science.
That's really what you want to and what I'd be saying to people
about it. So before we speak about TRT,
which I really want to talk about because you mentioned
there that actually it can be detrimental to fertility, this
is a really interesting picture that I've kind of collated from

(45:43):
speaking to a few people before this episode, and it's kind of
in relation to testosterone. So men's roles are changing.
Generally men are being told to be maybe more in their feminine,
more connected to their emotions.
Women are becoming more educated, are taking on more CEO
roles. So, you know, traditional roles
are naturally shaping and shifting a bit, which is great.

(46:07):
And if three people said to me for the show, is it because
men's roles are changing in society that it's impacting
their testosterone levels? And could that be impacting
fertility, which I just thought was a really interesting
observation that I wanted to I. Don't know the answer to that
one possibly, but I think that, you know, there are, I mean,

(46:30):
biologically, physiologically there is, there is testosterone
is the the kind of male hormone,isn't it really?
I don't personally think there'senough data surrounding that
concept, but open to any conceptreally nowadays to kind of
explore it. So I don't think there's, I
don't think there's enough data to support that.
But equally we wouldn't have thought, you know, years ago

(46:52):
about certain diseases, conditions that would be caused
by certain things. So I think there's a lot to to
learn, isn't there? Yeah.
I mean, it was just a very interesting thought that if
you're thinking about the drop in sperm quality since the 70s
and how much men's roles are changing since then, it's an
interesting thought to think, well, we're putting men more in
their feminine as their testosterone.

(47:12):
Possibly, but then how does it affect testosterone?
But yeah, sure, sure. So let's talk about TRT because
I think this is something that'sbeen spoken about a lot online.
When should people look at this as a treatment and when should
they not look at this as a treatment?
What's the risk versus the benefits of TRT therapy?
Sure. I think one of the one of the
problems is about TRT is the concept.

(47:36):
It is used more and more recreationally now historically
and I think probably one of the negative factors about science
is that we now know that testosterone has less harmful
effects than what it used to in terms of exogenous or
testosterone. It's given either injections or
in the form of gels. I mean, we used to talk about

(47:58):
the risk of prostate cancer, forexample, where we now believe
that it doesn't cause prostate cancer per SE.
OK. So given it doesn't 'cause
prostate cancer if you don't have prostate cancer, The other
thing about it is that there used to be this issue of
cardiovascular disease, a higherrisk of cardiovascular disease.
Oddly, with testosterone taking exogenous testosterone, we now

(48:20):
believe from studies done that it doesn't.
So it's become more and more acceptable that it's a safe
treatment, especially now with more data emerging.
We talked about metabolic syndrome and low testosterone
association with longevity as well.
So if we look at testosterone replacement therapy itself,
there are various forms, but in which patients are indicated.

(48:43):
Well, I think that's if patientsare symptomatic that we talked
about earlier and have truly biochemical evidence of low
testosterone. The group of patients we talked
about, if your, if your total testosterone is normal above 12,
you don't need testosterone replacement therapy.
Because there's also this concept, isn't it, that people
sell and say my testosterone could have been 20 odd when I

(49:06):
was, when I was in my 20s, it's now 12.
That's hard. So therefore I need it.
That's not correct. I mean, ultimately it's about
these thresholds and these values have been studies that
have done that show what these thresholds mean in terms of
symptoms. So testosterone, there are two
different types. You've got to go back to basics.
Two different types of hypogonadism or low

(49:27):
testosterone. 1 is secondary which can include late onset
which is late onset is the commonest 1 so-called male
menopause if we talk about that.So if when once you fall below
the age of 50, certainly testosterone levels fall and can
fall significantly. The, the other group is the
primary hypogonalism. So men who have an intrinsic

(49:50):
problem with their testicles that might have had
chemotherapy, radiotherapy, surgery, twists of the testicle,
cancers of the testicle where there's primarily a problem with
the function of the testicle. So there's two different times
you got to differentiate that. So it's important to see a a
clinician and differentiate thatrather than just starting
testosterone placement therapy. You want to know why is my
testosterone low? And also screen you for other

(50:12):
types of problems like we talkedabout dyslipidemias, we talked
about pre diabetes or type 2 diabetes that can occur as well.
So it's also important to to look at all of that as well as
lifestyle. So the type of patient that you
would treat or treat patients genuinely biochemically with low
testosterone who after you've gone through a comprehensive

(50:35):
testing and tried to differentiate the two different
types. So those patients who have
generally low testosterone with symptoms and those are usually
in clinical practice, the late onset group of patients, in
other words, the so-called male andropause or menopause as well.
TRT generally is is safe. There are some

(50:57):
contraindications, for example, active prostate cancer, for
example, patients who have breast cancer, which is very
rare, patients who may have too much thickened blood, so-called
polycythemia as well and patients who may have heart
failure as well. But generally speaking, it's a
safe drug, which therefore meansthat one of the problems, of
course, is is often used as a recreational type of drug, that

(51:18):
kind of image, social perceptionand concept of men, you know,
who are muscular and strong. And that's the image that people
want. That's more of a societal
perception and more of a problemin terms of the media in
portraying what is a male, an ideal male.
And I think that's kind of one of the problems that we face
because we've got to remember, as you just said, that
testosterone itself can have a negative impact on your sperm

(51:42):
exogenous, although we need testosterone, paradoxically
intratesticular testosterone foryour sperm production.
Testosterone itself exogenous inhibits the brain hormones
called FSH, which drives sperm production.
So it suppresses it. So therefore it acts like a male
contraceptive. So this concept of taking it now
and that's kind of emerged and over many years, but we still

(52:06):
don't fully, you know, understand the full cycle of
that. And there are also various other
types of treatment people have tried, of course, which we can
talk about. So I think anyone who is hasn't
had a child yet or is looking for facility, it's really not a
good idea to be doing TRT. No.
And although it's reversible in the vast majority, but in some

(52:26):
patients it's not reversible. Androgen abuse as we call it.
And certain patients don't recover their their axis.
There are other drugs that people can use generally
patients who have hypogonism or low testosterone, you can give
things such off label treatmentswhich should be prescribed by a
specialist I add as well. But often on actually, and this
is kind of the gym environment, drugs such as Clomid or HCG,

(52:49):
which act differently, they boost your endogenous or your
own body's testosterone rather than relying on exogenous form.
But exactly what you just said is that if you're thinking of
having children, you shouldn't really be starting TRT or
considering TRT. So I think I found really
interesting when I was looking at testosterone levels in men,

(53:10):
is that testosterone levels seemto drop after men have children.
And I saw a study that said, remember, the highest levels of
testosterone were more likely tobecome committed partners and
fathers, at which point they showed steeper drops in their
testosterone than did their single childless counterparts.
I found that quite interesting. I haven't seen that study, but

(53:33):
my comment would be that if you're in a relationship and
it's good relationship, invariably it's probably going
to be a long term relationship. And where I'm coming to is that
if you've had kids, invariably you've been in that relationship
for a while. So therefore you're going to be
older. So therefore, is it just an age
dependent factor that testosterone drops as we know as

(53:53):
you get older. So if you think you're going to
have kids, if you, if we're having kids in our 30s, you
might have a 10 year old, an 8 year old, you can be in your 40s
and testosterone might be dropping.
That's the way I would look at. It that's really interesting.
So I was thinking, is that the body saying no more children?
It could be biologically, you know, it could be we don't know
enough, do we, about it. Why do women, you know, in terms

(54:14):
of their ovarian reserve by 40 become it's very difficult,
isn't it? Why is that what you know, is it
a why? Why should it switch off?
I mean, that's, that's really kind of an evolutionary
discussion, isn't it? Yeah.
I mean, that's one question thatI.
It's an interesting concept because we don't look at it in
men, do we? So.
We don't look at it in men. I think everything around
children and fertility is alwaysanchored towards women and men

(54:38):
just seem to, I think not. It's just not conceptually
spoken about at all. But I do think it is becoming
now. I think men are becoming so much
more aware of their health, are becoming much more conscious of
their health. And as you said, I think, you
know, looking back at the 1970s,people weren't having children
later. And so now we are, we're wanting
to try and become more acutely aware of things that we can

(54:59):
actively do that are. But as you said, also living in
an environment that is has so many more endocrine disruptors
around us all the time. I mean, especially even living
in London, you know, in built upcities, I'd also find that quite
interesting. I haven't listened to data for
this podcast but I'd love to know if there is reduce
fertility rates in in cities in more than rural areas.

(55:21):
Do you know if that's a thing? I can't tell you offhand, but
there are studies, yeah, which potentially showdown.
What about America versus Europe?
Because I also know there's hard, like more tighter
regulations of what can get passed in Europe.
Yeah. And you talked to me about
political and regulatory capacity.
I can't tell you offhand about that either, but that's this
kind of work we need doing, you know, in terms of rural areas,

(55:43):
in terms of is it a first world problem or is it a third world
problem as well? And we need comparative studies
to look at that. Yeah, because I know the
regulations here in the EU are much, much tighter than
regulations in America. And I know there's a lot of
conversation right now, especially with everything
that's happening over there withpeople wanting to change that

(56:04):
policy to make it harder to makeit similar to Europe, which will
also have an impact on fertility.
And that's the kind of wider issue that is out of the
individual's hands when it comesto this.
I think. So thinking overall from a male
who's listening to this, whetherthey're experiencing
infertility, whether they're just curious about fertility for

(56:26):
longevity or for children. What would you say is one of the
most important concepts for thatperson, this individual right
now, to be taking away from today's conversation on how they
can support their health in thisway?
I think the basics of good health basically eat well, live
well, be happy, try and take outstress, exercise.

(56:50):
We talked about Mediterranean diet.
It's not to overindulge in alcohol, stop smoking,
recreational drugs, don't take TRT as a recreational use.
All those things are important. I think if you want to get
checked, you should get checked.Don't be scared of checking.
I mean there are on, there are companies now that do home

(57:11):
delivery kits for same analysis.It's a bit difficult, you know,
if you say to somebody, look, you've got to go to a lab for a
test, it's kind kind of embarrassing, isn't it?
It's very embarrassing to to go and have to do that.
And so therefore I think there are people, specialists who can
help you as well. I think that's really important
to be aware of and there are things you need to think about

(57:31):
in terms of your general health.It's not just about your sperm
count as well. So I'd be saying to get yourself
checked out. You can do a sperm test very
easily. Either you can get it online or
you can go to a lab. There are many, many out there.
But I think it's also putting itinto context as well of your
partner's age as well. And make sure that you don't

(57:51):
leave it too late. And, you know, if you're
thinking about kids, you know, start early and ultimately, you
know, it depends on your own lifestyle, but ultimately do get
tested if, if if need be. But it's it's not AI.
Don't think we should be scaringpeople into all of this.
I think it's also about choice and People's Choice.
And really, you know, and ultimately we do live in a

(58:12):
society that we are older and having children at an older age
as well. But get if you need testing and
then go and see a specialist. Yeah.
And that there are things that you can actively do.
Absolutely, you know, and there are things that you can change
and you empower yourself, take control.
And I think it is quite simple to do a sperm test.
Remember we said it's not just asperm test, it's not the whole

(58:35):
picture, but it gives you an idea of your fertility
potential. So thank you so much for coming
on to live what we were today. Always leave with a final
question, which I'm looking forward to your answer with,
which is what does live well be well mean to you?
Mine is a bit different, I think.
I think to live well is to try and live healthily as you can.

(58:59):
We will like a glass of champagne and we all like to do
things that are bad for us and Ithink it's basically getting a
balance. I think it's a balance of your
own health and psychological well-being.
You can't always be strict in terms of your diet.
You've got to have some vice in life and you've got to enjoy

(59:20):
yourself as well, but get the balance right.
As long as you have insight intothat and you can change that and
modify that, then that's fine. Yeah, joy is such an important
word, I think in in house today.So I'm really glad that you said
that. Great.
Thank you. Thank you so much.
Pleasure.

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