Huberman Lab Podcast | Dr. Michael Eisenberg | Male Sexual Health | Podcast Summary | The Pod Slice

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November 3, 2023November 9, 2023

In this podcast, Dr. Andrew Huberman and Dr. Michael Eisenberg discuss a range of subjects about male sexual health. They touch on erectile dysfunction, prostate health, urinary health, fertility, sperm count, and even penile length. Interestingly, a very small percentage of erectile dysfunction originates from hormone dysfunction; the majority stems from vascular issues related to blood flow or neurological issues. This highlights the importance of a variety of treatments for erectile dysfunction.

Eisenberg, a urologist and male sexual function and fertility expert, demystifies several popular myths regarding male sexual health. Key among these is the debate about declining sperm quality. Although Eisenberg notes this topic’s controversy — and the fact that his opinions shift depending on whose research he has recently read — recent meta-analyses including tens of thousands of men worldwide support the decline. Yet the reasons behind this decline — whether due to environmental exposures, obesity, or other factors — remains unknown.

The duo also uncover the role of geography in sperm quality and the concerning fact that only about a quarter of men in a Denmark study had normal semen quality. Interestingly, they note that half the time, one contributing factor to infertility lies in male issues, despite females often bearing the bracer of blame.

Lastly, they delve into testosterone levels, framing evidence that these are indeed declining on average across the male population. The reasons behind this decline, similar to the sperm quality issue, remain uncertain.

This discussion reveals that there is a myriad of factors influencing male sexual health, from environmental exposures to obesity rates. As outlined by Dr. Eisenberg, testosterone levels have been observed to be declining over time in longitudinal studies conducted by the CDC, with potential explanations including chemical or environmental exposures, changes in life stages, and increased obesity rates due to sedentary lifestyles.

Obesity is particularly interesting as it has direct effects on testosterone. It carries the capability of converting testosterone into estrogen, leading to lowered circulating testosterone levels. Obesity can even affect testicular function, reducing the efficiency of production due to insulating heat effects.

Dr. Eisenberg also talks about the potential impact of smartphones on sperm health and testosterone levels. Although there is no concrete evidence to say that smartphones can harm testosterone levels, certain studies suggest that they could potentially affect sperm quality and increase DNA fragmentation. The impact of heat on the efficiency of testosterone and semen production is highlighted, with advice for men to be aware of heat exposure and to avoid scenarios like frequently using a laptop directly on their lap.

Dr. Eisenberg and Dr. Huberman also explore the topic of aging and testosterone levels. They note that while testosterone levels usually peak in the early 20s and then gradually decline about 1% per year, there are outliers. Some men, even in their 80s, show incredibly high levels of testosterone. Despite this, men with high testosterone levels can still experience dysfunction, showing that factors beyond hormonal levels play a role in male sexual health.

Another important point discussed is the difficulty in predicting testosterone levels based on outward appearance. Even individuals who appear healthy and fit can have low testosterone levels. As such, Dr. Eisenberg emphasizes the importance of clinical tests to accurately determine testosterone and semen levels as opposed to making educated guesses based on a person’s physical condition or lifestyle.

Lastly, they talk about how improving health parameters isn’t just about getting the highest possible testosterone or sperm quality. Instead, it’s about maintaining healthy levels and improving vitality. Dr. Eisenberg lists some risk factors that could be detrimental, such as excessive heat from hot tubs, saunas, and seat warmers. He suggests strategies to counteract these risks, like using a cooling pack to keep the testicles cool during sauna sessions to minimize their heat exposure. Dr. Eisenberg emphasizes the sensitivity of sperm production processes to heat, and the importance of mitigating excessive exposure to external heat sources for maintaining optimal sexual health.

Dr. Eisenberg delves into major lifestyle factors that can impact male fertility. Firstly, smoking is tackled, with data strongly associating it with lower quality of sperm and longer duration to achieve pregnancy. Alcohol use gets a more nuanced discussion. Studies suggest high levels of alcohol consumption (classified as over 20 drinks a week) can have an impact on sperm quality, but the association is less strong. The negative effects of high alcohol consumption could also be influenced by other accompanying unhealthy habits such as smoking and drug use.

Further, Dr. Eisenberg mentions that alcohol sensitivity could vary among different populations. For instance, East Asians have a mutation that leads to alcohol flush reaction (which most people take to mean, that they have difficulty metabolizing alcohol), while there are certain other populations with different kinds of mutation in the alcohol dehydrogenase gene that may make them less capable of metabolizing alcohol efficiently. This can potentially have a greater impact on these individuals’ sperm parameters when they consume alcohol.

Next, the topic of drug use surfaces, with strong advice against recreational drug use for those concerned about their sperm quality. While it might seem obvious that minimal substance use would be better, Dr. Eisenberg underscores the benefit of drinking in moderation (as opposed to complete elimination of alcohol), due to potential social and emotional considerations. He cautions, however, against excessive use of alcohol.

Discussing testosterone therapy, Dr. Eisenberg reveals that about 5% of his infertile patients are on testosterone therapy, some even without realizing its impact on fertility. He also discusses the potential use of HCG (human chorionic gonadotropin), often prescribed to stimulate sperm production, as a treatment for maintaining fertility while people are on testosterone therapy.

Throughout the discussion, Dr. Eisenberg continues to emphasize the importance of maintaining overall health and moderating unhealthy habits to optimize reproductive health. He highlights that patient education and promotion of a healthy lifestyle are key in addressing issues related to male fertility and sexual health.

Dr. Eisenberg delves into the correlation between cannabis use and sperm quality. He states that continual exposure to cannabis can contribute negatively toward sperm count and morphology. A study of around 1,200 men concluded that daily users of cannabis showed lower sperm concentration, motility, and morphology compared to non-users. However, aside from these findings, other data report a null effect. It’s worth noting, Dr. Eisenberg highlights, that the frequency and method of intake can influence these results.

Continuing, he discusses how common over-the-counter medications can impact sperm quality. Although more data may be needed, so far, typical over-the-counter drugs like non-steroid anti-inflammatory drugs and paracetamol are believed to be safe.

The conversation then shifts toward the pituitary gland’s role. Dr. Eisenberg explains how the gland produces two hormones, LH (lutenizing) and FSH (follicle-stimulating), which stimulate the testicle. The LH stimulates the cells to create testosterone, whilst FSH stimulates sperm production. Both hormones are fundamental to producing testosterone and sperm.

Continuing, Dr. Eisenberg gets into the nitty-gritty regarding recreational activities like cycling and their correlation to male reproductive health. While promoting overall physical fitness, he discusses the arguments around cycling’s potential negative impacts on reproductive health. Notably, the excessive heat on men’s reproductive organs during prolonged cycling periods could serve as a mechanism for sperm production decline. He suggests riders take breaks to cool down as a strategy to combat this issue. In addition, studies hint that pressure from riding can result in sexual dysfunction. Hence, he advises that discomfort or numbness experienced during cycling should lead to a change in saddle or riding style.

In addition, increased daily activity, such as more steps counted, is linked with increased testosterone levels across diverse BMI ranges. This suggest physical exercise, like walking, not only contributes to men’s overall health but also to their reproductive health, irrespective of body weight.

Lastly, the discussion highlights the impact of taking testosterone therapy on the risk for prostate cancer. Contrary to fears that increased testosterone would heighten the risk of prostate cancer, studies suggest that the risk remains unchanged. The ‘saturation model’ further explains this by arguing that once there’s enough testosterone in the body, giving a man more testosterone doesn’t alter prostate cancer or growth risks. Thus, according to Dr. Eisenberg, it is safe considering prostate cancer as an outcome.

In this continuation of the podcast transcript, Dr. Eisenberg highlights the importance of overall penis health for men. He recommends maintaining the regular occurrence of erections, either spontaneous or sexually induced, as part of maintaining healthy neural innervation and blood flow. He also introduces the idea that the penis operates on a “use it or lose it” principle, which underscores the need to maintain a routine of regular sexual activity or self-stimulation to uphold the performance of this organ. If any issues are detected or suspected, Dr. Eisenberg advises seeing a physician.

Dr. Eisenberg then delves into the connection between sleep and men’s sexual health. He affirms a correlation between inadequate sleep and decreased sperm quality and testosterone levels. Research reveals that both excess and deficient sleep can negatively impact on the quality of semen, indicating an optimal sleep range of 7 to 9 hours for maintaining semen quality and general sexual health.

The conversation then takes an interesting turn when Dr. Eisenberg refers to semen quality as an excellent marker for overall health – effectively extending the importance of semen quality beyond the realm of fertility alone. He suggests that men with more health problems tend to have lower semen quality, while men with higher semen quality tend to live longer, visit the doctor less frequently, and face lower rates of cancer. This correlation between semen quality and men’s health is attributed to various theories, including the significant percentage of the male genome devoted to reproduction and the potential overlap of genes that play a role in reproduction and other systems such as the cardiovascular or neurological system.

Dr. Eisenberg proposes the idea of including regular semen analysis as a part of men’s health monitoring routines, just like blood pressure checks or lipid level tests. Like these health indicators, semen quality might offer early detection of medical problems, sometimes even unknown health issues or undiagnosed cancers. Lastly, Dr. Huberman adds his personal experience of sperm analysis and how it helped him monitor his health over the years, thus advocating for more men to consider this.

In the continuation of the conversation, Dr. Eisenberg provides insights into the complexities of male reproduction factors including age, physical health and environmental conditions. He focuses on how these factors result in significant change in semen production, sharing surprising facts about the youngest and oldest fathers recorded by scientific studies. He notes the former as young as 11 and the latter a staggering 88 years old, offering insights into the fundamental determinants of human fertility.

He then moves onto the critical topic of male puberty and the onset of sperm production discussing its importance in understanding the timing of reproductive capability in men. There is mention of semen production possibly starting as early as 11-13 years old, peaking intensity around 14-16 years old. The conversation emphasizes that the timing is individual-based and can differ greatly.

Addressing recent research, he drives the conversation further into the changing patterns of puberty onset. He confirms that males, like females, appear to be entering puberty earlier than in the past indicate a complex interplay between biology and environmental influences.

Dr. Eisenberg also points out that an older father might have more financial resources and wisdom which could be advantageous for the child. However, he also shares there is compelling evidence to suggest that these potential benefits are outweighed by risks, such as lower attainment in school and higher susceptibility to several medical conditions, indicating a strong correlation between paternal age and certain risks.

The podcast discussion then explores how the prostate gland, an organ of pivotal importance to male fertility and urinary function, operates. The prostate, a walnut-sized organ located behind the bladder, is crucial for the production of certain proteins and enzymes vital to the health and function of sperm cells. The prostate also plays a crucial role in urination as the urethra (carrying urine from the bladder to the penis) runs right through it. As men age, the prostate gets larger, increasing resistance in the urethra and making the bladder work harder. This effect is what leads to common symptoms in aging men such as the increased need to urinate and weakened urine flow.

To maintain prostate health, Dr. Eisenberg suggests being aware of certain triggers like specific drinks and foods that may irritate the bladder. He also recommends small lifestyle adjustments, such as reducing liquid intake before bed to prevent nighttime urination.

As the conversation continues, Dr. Eisenberg discusses the increased prevalence of Low-dose Tadalafil, a medication typically employed to treat Erectile Dysfunction (ED), for maintaining prostate health. He affirms that it can help mitigate urinary symptoms and improve blood flow to the prostate. However, he suggests these daily doses primarily for men who are dealing with these issues, not as a preventive measure.

In a more candid exchange, Dr. Eisenberg notes a divergence in the receptiveness to medication between two groups of men. One group prefers a more natural approach, potentially eschewing any form of pharmacological intervention. The other group, largely from the younger demographic, is more open to medication in attempts to improve or maintain their sexual health. This latter group often seeks advice on what they could take to help, including early testosterone therapy.

Transmitting caution, Dr. Eisenberg asserts that whilst testosterone can be beneficial, it’s vital to comprehend the associated risks. He proposes initially exploring healthier lifestyle choices, such as getting enough sleep, limiting alcohol intake, not smoking, and incorporating regular exercise, before resorting to testosterone therapy.

Discussing urinary tract infections (UTIs) in men, Dr. Eisenberg clarifies that they are relatively rare due to their longer urethra, which makes the trek for bacteria to the bladder more difficult. Persistent UTIs should be evaluated for possible anatomical causes, such as bladder or kidney stones, scar tissue, or incomplete bladder emptying.

Turning their attention to erectile dysfunction (ED), Dr. Eisenberg reveals that this condition is more common than most realize. Highlighting the causal factors, he asserts that less than 10% of ED cases are hormonal. The majority are organically linked to blood flow issues, similar to the ones causing vascular problems like high blood pressure or diabetes. Eisenberg also mentions other triggers like obesity and pelvic cancer treatments, and stresses that lifestyle adjustments combined with medication can vastly improve erections in most cases.

In the recommencing discussion, Dr. Eisenberg explains various factors influencing the choice and dosage of ED medications and their side effects. The decision hinges on factors such as frequency of sex, insurance considerations, and individual preferences. The conversation reveals the importance of attentiveness to overall vascular health, with Dr. Eisenberg advocating for men to monitor their blood pressure, lipid levels and blood glucose, an early marker of vascular disease. Rather than causing alarm, the aim is to encourage men to take ownership of their health.

Dr. Eisenberg delves deeper into diverse treatments available for erectile dysfunction, ranging from urethral suppositories to penile injections and implants. The choice for each method depends on its efficiency for a given patient and their personal comfort. Urethral suppositories, which are inserted in the tip of the penis, and penile injections, which work by dilating blood vessels, can sometimes help where oral medications cannot. However, these methods aren’t the first choice for many, given the discomfort they may cause.

For more extreme cases, Dr. Eisenberg brings up penile implants. These surgically implanted devices, either non-inflatable ones with a metal core that are manually adjusted or inflatable ones controlled by a pump in the scrotum, offer a mechanical tool for producing erections. While these solutions are devoid of any intuitive sexual desire, they provide an effective workaround, especially for those individuals who have an inadequate blood flow.

In the latter part of the discussion, Dr. Eisenberg discusses the topic of pelvic floor health. Just like its crucial role in female reproductive health, maintaining a healthy pelvic floor, which supports various organs such as the bladder, prostate, and the rectum, is also important for men. Exercises, called Kegels, which serve to strengthen or relax these muscles, help improve continence and even help in the recovery process post-prostate cancer surgery. However, the appropriateness of these exercises is contingent upon an individual’s needs; for some, relaxation rather than strengthening may be required.

Dr. Eisenberg also addresses the question of split urine stream. Often assumed to be a symptom of prostate overgrowth or a urethral issue, it actually has a rather common occurrence associated with a condition called hypospadias which affects 1% of births. Usually recognized at birth, this condition involves the misplacement of the urethral opening away from the penis tip and is typically corrected through surgical intervention at an early stage.

In this part of the conversation, Dr. Michael Eisenberg and Dr. Andrew Huberman discuss a wide range of intriguing subjects related to male reproductive health. They start with details describing a comprehensive study conducted to determine the average penile lengths around the world. The research involved data from more than 50,000 men globally. Beyond simply providing normative data, some fascinating findings emerged. The average erect penis length was found to range between about 5 to 6 inches with slight variations based on different regions. Interestingly, it was discovered that penile length is gradually increasing over time.

Further in the conversation, they move into discussion of hair loss medications like finasteride and dutasteride. These drugs work by blocking dihydrotestosterone, which can cause hair loss when levels are too high. However, sometimes users experience sexual dysfunction issues, a side effect that tends to appear most frequently in men in their 20s, 30s, and 40s. These side effects can affect both sperm count and sexual function, leading to conditions such as low libido and erectile dysfunction. A distressing condition known as post finasteride syndrome was also mentioned. Here, even after discontinuing the medication, some men continue to suffer from sexual dysfunction issues on a seemingly permanent basis. This distressing complication leads many to seek professional aid from specialists like urologists. The clear mechanism behind these persistent effects still remains elusive, and more understanding of the exact pathophysiology is necessary.

Newly highlighted in the discussion, Drs. Michael Eisenberg and Andrew Huberman broach even more relevant topics centered around male reproductive health, including certain medical conditions and the use of selective hormones.

They talk about Postfinasterid Syndrome, a condition where sexual dysfunction persist even after the discontinuation of hair loss medications like finasteride and dutasteride. This can result in various discomforts such as erectile dysfunction and low libido, affecting both a man’s overall sexual functionality and sperm count. The challenge lies in the fact that potential victims of Postfinasterid Syndrome cannot be preemptively identified and the specifics on how the condition operates still remain unknown. This calls for serious consideration before deciding to use these types of medications.

A little further into the discussion, they speak about Clomiphene, an estrogen receptor modulator used to block estrogen. This blockage stimulates the pituitary gland, encouraging a higher production of testosterone and improving sperm, thus beneficial to men with low testosterone. However, while it effectively increases testosterone levels, it may also inhibit necessary estrogen signaling, consequently affecting libido among other aspects of sexual health.

While discussing hormones related to sexual health, they also mention the use of FSH (Follicle Stimulating Hormone) and HCG (Human Chorionic Gonadotropin). FSH is known to encourage sperm production and is beneficial, however, it is not as commonly used due to its cost. HCG on the other hand, is a less expensive but equally effective alternative.

Another condition they discuss is varicocele, a common condition in men characterized by dilation of veins in the scrotum, with symptoms such as discomfort and fertility issues. Peyronie’s disease, a scar-bearing condition that results in curvatures or deformities of the penis, is also examined. This condition, which is common in about 5-10% of men, can be caused by injury, penal fracture, or certain surgeries.

Certainly, these are significant issues in male reproductive health that require careful scrutiny, however, with the growing body of research and burgeoning treatment options, these conditions can be effectively managed.

Dr. Michael Eisenberg and Dr. Andrew Huberman continue their discussion, touching on various aspects of male reproductive health and preventative measures. They recommend men be more aware of their bodies, especially the scrotum, and bring to attention any abnormalities. They reference the classic manifestation of testicular cancer as a firm, painless mass felt on the testicle. The view is surprising to Dr. Huberman, who says women are encouraged to examine their breasts regularly for lumps, but men are discouraged from doing the same to detect testicular cancer. Eisenberg explains this paradigm arises due to the potential for false lumps to cause more anxiety and harm than good.

They also discuss the practicality of getting a blood test for hormone profiles, lipid profiles, and sperm analysis. Understanding that the cost can be prohibitive for many, Eisenberg suggests approaching a primary care physician or a urologist, as insurance is becoming increasingly open to covering some infertility testing. He insists that despite their cost, these tests are vital since male reproductive health directly links to mental health.

It’s crucial, according to the doctors, for men to understand the difference between semen volume and sperm count. They note that a man can have a normal semen volume but a low sperm count, leading to challenges in fertility. The only way to confirm the health of a man’s sperm is through a formal test.

The dialogue shines a light on the importance of regular tests both for cancer screening, hormone level checks, and sperm analysis, as these aspects play a significant role in overall health and specifically male reproductive health.

Wrapping up the discussion, Eisenberg extends his gratitude to Dr. Huberman for highlighting men’s reproductive health, drawing attention to its widespread implications, not just for the individual man but for the whole species. This conversation is a compelling call to action for men of all ages to prioritize preventative care in their reproductive health.

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Review Questions

Elementary Level Questions:

1. What part of the body does Dr. Michael Eisenberg specialize in?
   • Answer: Dr. Michael Eisenberg specializes in urology, which is the part of the body that deals with the urinary system and male reproductive organs.
2. What is one of the major causes of erectile dysfunction mentioned in the podcast?
   • Answer: One of the major causes of erectile dysfunction mentioned is vascular issues related to blood flow.
3. Can only women be responsible for infertility in a couple according to the podcast?
   • Answer: No, the podcast mentions that about half the time, infertility issues can lie with the male partner.

High School Level Questions:

1. What has been noted to decline in men worldwide according to recent studies discussed in the podcast?
   • Answer: Recent studies have noted a decline in both sperm quality and testosterone levels in men worldwide.
2. How does obesity affect testosterone levels?
   • Answer: Obesity can convert testosterone into estrogen, leading to lowered levels of circulating testosterone, and it can also reduce the efficiency of testosterone production due to insulating heat effects.
3. What is the correlation between alcohol consumption and sperm quality mentioned by Dr. Eisenberg?
   • Answer: Dr. Eisenberg mentions that high levels of alcohol consumption, classified as over 20 drinks a week, can impact sperm quality, but the association is less strong compared to other factors like smoking and drug use.

College Level Questions:

1. Discuss the concept of the ‘saturation model’ as it pertains to testosterone therapy and prostate cancer risk mentioned in the podcast.
   • Answer: The ‘saturation model’ suggests that there is a threshold of testosterone above which there is no increased risk of prostate cancer growth. Once the body has enough testosterone, adding more doesn’t alter the risks related to prostate cancer according to this model.
2. What does Dr. Eisenberg suggest as part of maintaining overall penis health?
   • Answer: Dr. Eisenberg suggests maintaining the regular occurrence of erections, which could be spontaneous or sexually induced, as part of maintaining healthy neural innervation and blood flow for overall penis health.
3. What is the proposed correlation between semen quality and overall health according to Dr. Eisenberg?
   • Answer: Dr. Eisenberg suggests that semen quality is an excellent marker for overall health. He mentions that men with higher semen quality tend to live longer, visit the doctor less frequently, and have lower rates of diseases like cancer. There is a proposed link between the genes involved in reproduction and those that play a role in other systems like the cardiovascular or neurological system.