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Improving Fertility in Men with Poor Sperm Count UCLA Urology UCLAMDChat Webinar

Hi there, welcome, I'm Dr. Jesse Mills, Director of the Men's Clinic at UCLA and Associated Clinical Professor of Urology at the David Geffen School of Medicine at UCLA. I'm really excited to be here today to this UCLA webinar series because I'm talking about something that I'm very passionate about that combines two of my greatest interests. One is men's health, and anything that can make a man healthier makes me happier, and it makes me realize that I'm doing my job well as a men's health specialist. But two is we're going to be talking about how to optimize a man's sperm counts to be able to initiate a pregnancy. There are few things in my career that are more gratifying than counseling couples and figuring out a way for a couple that is unable to achieve a pregnancy to get them all the way through that process so that they can have a baby. That is one of the greatest things that I do in my career and one of the things that I'm most passionate about, so to that end, we're gonna have a fun time here discussing a few different ways to do this. And this is going to be a little bit of what you can do at home, and then what I can do in the office when you see me for a visit because, as everything else that I do in my practice of medicine, this is a dialogue. This is a team effort, so what you're doing in my office for 30 minutes every couple of months is only a part of the picture about how you can really optimize your fertility. What you're doing outside of the office, that's really the key working with your partner. Doing everything that we set out as a plan for you is how to make this the best possible outcome for you. This talk is going to specifically address how a man that has a low fertility potential or low sperm counts can be treated, and again it's going to involve some lifestyle factors. It may involve me doing some blood work and analyzing the sperm test to figure out exactly where the problem is and then coming up with a treatment strategy, so to that end, let's get started. Like all the ground rules for our UCLA webinars, we're going to start with a introductory slide on what we're talking about today, and then we're also going to ask you to use Twitter and tweet questions to the hashtag #UCLAMDChat, or give us a comment on Facebook. We should have plenty of time at the end of this discussion for me to answer all questions that come through and give everybody out there listening a really good idea of what's going on. So, the first thing is that anything in medicine is "When do we know when a man needs help?" What are the parameters that I look at that can allow me to intervene and do something to help this couple achieve their pregnancy? So, let's go down through this list right now. So, important questions to ask yourself. First of all, as a couple, how long have you been trying? We typically, in the infertility world, both male and female infertility experts, think that over 6 months of trying and having no successful pregnancy is a reasonable time to get a workup. The old parameters, and you may read this in old textbooks, that it's a year of unprotected intercourse, monitoring ovulation, and knowing exactly when the most fertile periods are for the woman's ovulatory cycle, that after one year it's a good time to start, but what's really going to change in 6 months over a year, other than another frustrating 6 months of not being able to get pregnant? So I like 6 months. Obviously, that's never perfect. Whenever you have difficulty, or whenever you have any questions at all, is the right time to make an appointment and get checked out. In terms of how you do this, the female ovulatory cycle, you only have one chance every month, or a couple of days, and so, part of this is figuring out exactly when the most fertile times are, and that's a little beyond the scope of my practice as a male fertility specialist, but we are going to look at some ways that we can at least dial that in a little bit more and know when the most optimal times of fertility are going to be in that ovulatory cycle. And then, "What am I doing?" Myself and anybody that's seen me talk before knows the thing, that 3 keys to a successful men's health experience is what is a guy eating, how is he moving or exercising, and how is he sleeping, and guess what? All 3 of those things are critical for sperm development, production, and optimizing sperm parameters, so it's going to be the same thing over again, eat, move, sleep, and then lastly, "How stressed am I?" I can't tell you, I can't tell you how many men I see in my clinic that are not only stressed professionally, they're trying to make it in their career, they have done very well for themselves, they're in their mid 30s, maybe their mid 40s, and now is the time to try to make a baby, and you're adding that stress on top of an already stressed professional. Doesn't do anybody any good. And I wish I had the secret for how to reduce stress. Other than what we already talked about in in some of the other discussions we're having, exercise helps, but identifying that you have the problem is the most important thing first, because just that stress of making a baby is enough to send couples fighting and and not being able to accomplish their fertility goals, so that's the other critical thing. So, now, what are you going to do before you come to my office? So I want you guys, and the wives, for that matter, you can make it a game. Check your shorts. So, what does that mean? So, a testicle should be firm, and it should be about the size of a reasonable apricot, so something about like this is a good sized testicle, and it should be firm. If it's soft and squishy, that usually means there's a problem with sperm production because about 80% of a man's testicular volume, the mass, of his testicle is devoted to sperm production, so if he has a big testicle, he's probably making more sperm than a guy that has a smaller testicle, and those are things that I might be able to change with either medication or procedures that we'll get into here towards the end of our discussion. So, 80% of the testes size is sperm production. If it's small and squishy, not a good thing. So, let's get into the hopeful dad's guide to pregnancy. You're trying all you can do, you've been with your partner, you're diligently monitoring her ovulation, and you're still having problems. So, first of all, how do you do that? So, knowing when to do it, it's easier and easier every day because, of course, like everything else in the world of technology, we have an app for this. In fact, there's multiple apps, and I don't endorse any one of these but these apps are very nice in that they allow women to track their ovulatory cycle, figure out--and they're smart, they're intelligent in terms of you plugging in data on a day to day, at a month to month basis, to be able to narrow down exactly when that ovulatory window is, when a woman is at her peak fertility, which varies, anywhere from day 9 to day 14, and the length of that ovulatory window, 48 hours, 72 hours, may vary as well, so it's a really nice way to track that, and of course, there's over-the-counter kits you can buy that actually looks for a hormone that peaks during ovulation, the old pee stick test, and those are important, and they're very inexpensive to get so that you can get an idea of when you're dialed in, and then, of course, the last, oldest, and truest is the basal body temperature measuring, which some of these apps also take into account, so as a single tool, I don't recommend that in 2018, with so many great ancillary tools available for you, and more important, if you're a real guy watching this video, then when your partner says it's go time, it's go time. I mean, that's just all there is to it. She's gonna be more in tuned to her biological clock than you are, and she's gonna have a much better idea of when is her peak ovulatory time is, so you always got to be ready to play, and we'll get into some strategies for that as well because, again, it gets back to the stress issue that we talked about earlier, so you get to the point where you know exactly when ovulation is occurring, and you know that that's the best time to have sex. Well. Well, how do you do that? Well, I'll leave the imagination up to you about how you have sex, but one of the important things is that once a man ejaculates, it's important for the woman to have her pelvis tilted up so that the sperm are not swimming upstream like our salmon, but actually swimming downstream. The sperm has to swim from the tip of the penis all the way through the cervix and up into the uterus and fallopian tubes. The distance that sperm swims is about, to him, the same distance as it would take for you or I to run from here in Los Angeles to San Francisco. So that's a long distance for such a tiny little micro speck of a sperm to do, so if it's an all downhill run, gravity becomes that sperm's best friend, so that tilted pelvis is helpful, go get her a cup of water, and give her an iPad, something to do since you're incapacitating her for 20 minutes. At least be the gentleman there. What if you can't get to that point, what are the barriers to conception purely from a mechanical standpoint? So, erectile dysfunction. It's something that is becoming more and more common in younger men, men in fertility age, and some of this is probably awareness, some of this is that we have effective treatments, and so there's a market for it, and, again, there are many different reasons for why that's an issue, and it's a big part of what I'm gonna do if you come to my office, is figure out how to optimize directions too, but the bottom line is you need a stiff enough erection to be able to penetrate the vagina to be able to deposit sperm when you need to go, and if you don't, then it's going to make spontaneous conception very difficult. It goes without saying, but it's the simple things that sometimes help get the best outcomes. Secondly, what if the guy's not able to ejaculate or not able to ejaculate enough volume? Normal ejaculate volume should be about a half a teaspoon to a teaspoon, so it's a good amount of fluid that comes out during an ejaculation. If it's less than that, then there may be a blockage or something that we need to work up as well, that we'll get into as we get into how to make things better, so how to ejaculate, it should not be painful. So, there are men that have pain with ejaculation. That not only is a sexual concern and a men's health concern, but certainly also a fertility concern, because that also may indicate either an infection, or it may indicate a blockage. I'm sure we've all heard of kidney stones, but one of the things that I see in my practice quite frequently are ejaculatory duct stones. It's the same process, a calcification builds up somewhere along the reproductive tract, and it blocks sperm from getting out. There's a procedure that we can do to relieve that and not only improve his pain, but also improve this fertility potential, so painful ejaculation, good reason to come in and get checked out. And then lastly, ejaculation color should be nice and pearly white. If it's too clear, there may be a problem, and if it's too thick, and especially if it has a yellow or greenish tinge, those might be signs of infection or inflammation that needs evaluation. So now, let's get to the sperm test. Now, we talked already about the sperm analysis as being the entryway to figure out how to make things better for men and their partners to achieve pregnancy. Let's break it down into its components because these components will allow me not only to diagnose the problem, but they'll also allow me to figure out exactly where we need to go to target our therapy to optimize your chances of pregnancy. So we'll start at the top. This is how we read semen analysis. As reproductive specialists, we start with the volume of ejaculate, and that just simply means how much is coming out. We alluded to that just a couple seconds ago, that if a man has very low ejaculate volume, he may not be getting enough fluid into the vagina in order to start that reproductive cascade, so if that's a problem, we need to work that up. The second thing we do is we look at the concentration of sperm, and what that means is not how much they're thinking, but it actually means how much sperm per milliliter a man makes. So, in a man that has a two milliliter ejaculate, which is about a half a teaspoon--that's sort of in that normal range-- we will look at how many million sperm per ejaculate he makes, and a normal number should be somewhere around 20 million or higher. I've seen men that have normal sperm counts and are initiating pregnancies with counts under that, say, 15 million. I've also seen men that come in and have 200 million sperm per milliliter that have that much difference in concentration. The point here, the key, is that this is just a rough estimate of what a man's fertility potential is. In other words, if you're having difficulty initiating a pregnancy, and your reproductive specialist says, or your your primary physician is saying, "I'm looking at your semen analysis, and it says you have 20 million sperm, so you're probably normal." That may be doing you a disservice. There may still be things we can do to optimize sperm parameters, so we don't go just by an absolute number, but we go by an entire clinical picture, because ultimately, as I tell my couples, I don't really care what your semen analysis is, I want you to be pregnant. So if you have a low sperm count and you're pregnant, I'm much happier than if you have a high sperm count and you're not pregnant. So, again, we have to treat the number in the context of treating the couple. That's the key to this entire endeavor, is not excluding men that may still need therapy even if they have that 20 million number. The next thing we look at is the motility, or how well the guys are swimming. You could make millions and millions and millions of sperm, but if none of them is swimming, if all of them are in a dead standstill, then those sperm are not going to be viable to be able to initiate a pregnancy, certainly not through spontaneous conception, and that triggers an entirely new workup for me and the reproductive endocrinologist colleagues on the female side to figure out how to either improve those sperm counts or use that sperm for some kind of assisted reproduction. So, motility is, very simply, the number of sperm that are swimming, and we use that in a percentage. So if you're looking at a semen analysis, you look at the percent modal, and that should be about 50% or more, so in other words, it's normal for a guy's sperm counts to have only about 50% of them moving because we're so constantly turning over sperm. We're making millions and millions of sperm every day, and millions and millions of sperm every day are turning over, so 50%, greater--normal. We also then look at how fast the fast guys are moving. That's what we call the progressive motility because, again, that changes how we approach things. If you have a man that has no motile sperm, zero swimmers, that's a problem. If you have a man that has all of the sperm are swimming, but they're swimming in place, they're treading water, those are what we call twitchers. Again, they're motile, but they're actually not going to be effectively swimming to find an egg, so motility is key. If we know how fast they're moving forward, and that's something we either call rapid progressive motility, or sometimes on a sperm test it's called forward progression, either way it means we want them swimming in a nice straight line looking for that egg. The last parameter we look at in a general screening semen analysis is something called the morphology, and this is one of the things that can be the most confusing not only for patients to interpret, but also for fertility specialists, because there are lots of papers out there on the effect of poor morphology on reproductive success, either during spontaneous pregnancy or during cycles of in vitro fertilization. So, for me, morphology is a general assessment over overall sperm health, for the most part. So in other words, if a man has lots of abnormal sperm--in fact, if all of them are abnormal, there may be more of a process going on at which those sperm are not either being shaped well, or they're degrading too fast, and they're not keeping their shape, and it's an overall surrogate for an impaired sperm parameter, but there are studies that show that men with 0% normal morphology are still able to initiate pregnancies, so it becomes a very interpretive test, and not only is it interpretive in what we do with the numbers, but it's also somewhat interpretive in who's doing the reading of it, because essentially, what we do is we break that morphology down into 3 or 4 parts. So, if you look at our little sperm here in the corner, we look at the the head defects, which is right here. So, the sperm head should be nice and pointy like this little electron micrograph because this point in the sperm is where it penetrates into the egg, so if he has a flatter, a round head, it's not gonna work. The next thing we look at is the neck, and this is really the motor. This is where the mitochondria and this is what keeps the sperm moving, and so if there's a neck defect, it's probably a defective motility in overall sperm function. And then lastly, we want a nice, healthy tail. Some people call this the body and this the tail. Essentially, it's what's whipping around to make sure the sperm is doing what it needs to do. So we'll break down morphology into head defects, neck defects, and body and tail defects, and that gives us an idea of fertility potential as well. The best example of this is that there are men that have a genetic defect called globospermia, where all of their sperm had abnormal globe-like or round heads. Those men essentially have a very low to zero chance of initiating a pregnancy spontaneously because they lack the genetic enzyme needed to burrow into that egg, and so those men, already, we are looking at for in vitro fertilization. And that's key because I wouldn't want a couple to keep going through, "we'll get the morphology a little bit better, we'll do this, we'll do that," if, in fact, they're gonna benefit from moving on to in vitro fertilization at an earlier stage. Because the nice thing about that technique is that they can select a sperm, and they can burrow into the egg for you so that the DNA from the sperm easily gets deposited into the egg to make an embryo from that perspective, so that that we get rid of that step that is missing in that man's sperm. So, that's globospermia, or low morphology and head defects. All right, so here's now, we'll get to the treatment segment of the talk. What can we do? And so, again, we break it down into lifestyle changes, and this is what you do, so when you're not in my office, when I'm telling you, "I want you to exercise more. I want you to eat better. I want you to sleep. I want you to de-stress." That's what you do. The second thing is what I do. I write prescriptions. I'll recommend some supplements, potentially some other traditional medicine techniques. There's rule for acupuncture and fertility, there's some interesting clinical trials out on that, so there's a host of things that I can lead you to that can help optimize your fertility. So, that's what I do, and then lastly, surgery or procedures. There are so many different ways that I can surgically improve a man's fertility that we'll get into that at the end of this talk, and this is a very broad subject, so if you're looking and watching this now, and you're thinking, "Well, do I benefit from a surgery?" The answer is, very possibly, you do, but we have to figure out which one we do because I do everything from endoscopic procedures to microsurgical reconstructive procedures to vascular surgery. There's so many different things I can do to improve sperm counts in a man if we figure out exactly where the defect is. So, 3 things that that's what we do, what you do, and what I do together. That's how we improve your fertility and your low sperm counts, so let's break it down a little bit more. What can you eat? So, anything that's good for a man is probably good for his sperm, so dark, leafy vegetables have lots of antioxidants. We know that sperm tend to be pretty fragile. One of the arguments of why men make so many millions and millions of sperm when all it takes is one egg is because we're not very good at it. We have a lot of translational difficulties when we make sperm, meaning that we're cranking about such numbers that we're just hoping one or two will be good enough to initiate a pregnancy. But what if you were able to take that number, 1 or 2 or 3 or 4, and multiply how many of those guys are good? The way to do that is to decrease their oxidative stress, and the way to do that is to improve the amount of good, raw fresh fruits and vegetables that you can eat. So, that's important. The sperm membrane, that little head that we talked about that penetrates into the egg, it turns out that's full of polyunsaturated fatty acids. So, there's always this thought if you eat more of something, well, some of that end up in the sperm, and the answer is we don't know. There's not a really good molecular tagging way of saying this. There are some interesting environmental studies and longitudinal or prospective studies where you put guys on diets that are rich in polyunsaturated fatty acids and their sperm production goes up, but is that enough of a reason to do that? The answer is, from a fertility perspective, maybe not. From an overall men's health perspective, of course, because we know that tree nuts, walnuts, almonds, those are all heart healthy, and if it's heart healthy, it's men's health healthy. If it's men's health healthy, it's probably sperm healthy, so from that perspective alone, just being more cognizant of what you're eating, what you're taking into your body, is going to translate probably to better sperm production and a higher quality sperm, so that's the key part to eating. One of the other things we know that is very important, I don't think--get rid of my Windows update here that's hitting the middle of the screen-- or if I can maybe I can do that--excuse me for one second out there-- we'll postpone it. Perfect, great. The next thing we're going to do is we're going to talk about moving. So if you are exercising once or twice a week, that's not enough. It's not enough for you, It's not enough for your sperm, and it's amazing to me, and I give credit to the women out there because typically when I see the couples in my office, it's amazing how much more often the women are in great shape, and they're doing everything right to optimize their fertility, but guys are often a little bit slow to do that, and I'm not throwing shade, I promise, because this is what I do to try to get you guys up and running, but listen to your wives because most of the time they already are on a very good exercise regimen, anything from yoga to stretching to Pilates to more intensive cardiovascular exercise, I don't care. Anything that improves blood flow, improves your heart rate, and improves your metabolism, it's probably going to translate to better sperm production. One of the other things that we know is that guys that tend to carry more weight, especially around their trunk and their inner thighs, have a higher incidence of fertility issues. So, obesity--not good for sperm. And why is that? We think a couple of different things. One is we know that testicles and sperm like to be cooler, and if you have big thighs and your testicles are always sandwiched in between those big thighs, and you're sitting all the time, there's no way that the sperm can be as cool as they want to be. So if you're able to get up, stand around, move around a lot and try to get that inner thigh off of your scrotum as often as you can. That's going to help improve your sperm motility and sperm quality. Losing weight is a big part of that. Of course, to see what you can do to decrease that truncal fat pad. So, obesity--bad, you don't need me to say that any more than you've already heard it. And then lastly, sleep-- so, sleep is really important. Not only for distressing, because we know that the more stressed you are, the less sleep you get, and you have a vicious cycle, but we know that when men sleep, they recharge their pituitary gland, and their pituitary gland right here controls sperm production by the testicle, so if you're always under 6 hours of sleep, there's a very good chance that your pituitary hormones that control sperm production are sagging, and they're not doing the job that they need to do to stimulate more sperm production. So without a doubt, if you're sleeping fewer than 6 hours a night, you need to crank up, you need to get at least 7-8 hours of sleep, especially during this fertility period. You will relax more, you'll de-stress more, cortisol levels will change, which will help you lose weight and also de-stress. So the problem always comes back to when one organ system is not operating properly, it has an impact on multiple organ systems. So, just doing the simple things that you know you have to do are going to help improve your parameters and ultimately allow me to be more successful in treating you. To get into the really difficult and complex nature of male fertility, which we'll get to here in a second-- and now we might be frozen--there we go, perfect-- so there's a slide here for folks that are way down the pathway that are out there watching today. You've had a semen analysis, and everything is is normal, or maybe there's some, a pair of parameters, and you're still not getting pregnant, there are a couple of advanced sperm diagnostics that we may want to look at, and the two that we'll talk about today, these are kind of, some of the most common ones and the ones that we potentially have data to show that it can improve outcomes, especially if we have to go down the in vitro fertilization pathway. The first one I alluded to a little bit earlier, which is something called reactive oxygen species, and it's a way of looking for not what's wrong with the sperm necessarily, but it's actually looking at what's wrong with the semen. So the semen is the vehicle, or the liquid, that transports the sperm, and if there's a high level of reactive oxygen species, which basically means molecules that are attacking the sperm membrane and causing it not to behave appropriately, that can be an impairment of fertility. So even though you have a perfectly normal sperm count, if they're constantly getting onslaughted with reactive oxygen species, then they may have a difficulty doing the job that they're supposed to do, and so when I see a guy that has perfectly normal sperm counts and and the wife's evaluation is also very very normal, and we still don't have a reason for why they're not getting pregnant, that's when I will look at at some of these advanced diagnostics. And the second one is something that's a little more controversial, and we're getting more and more information on this in terms of what we do with the data once we get it, but it's called DNA fragmentation index, or DFI, and it's quite simply how, what kind of integrity the DNA within the sperm has, and so the assay is pretty simple, we do it off of a sperm test and we essentially throw some chemicals at that sperm, and we see how resistant that sperm is to degrading, and if you have a high level of sperm that degrades faster or worse than the rest of the sperm counts--and the number we use is somewhere around 25-30%--if it's that high, that means that those sperm, even if they get in and penetrate the egg, their DNA just turns to mush. It falls apart and is not able to do what it needs to do to line up with the chromosome complement in the egg, so a DFI can be important in couples that have unexplained infertility. It can also be important in couples where the wife has suffered from early terminations or miscarriages. So if a couple has had 2 or 3 miscarriages that have also been unexplained, then we tend to look at the DFI because there may be a male factor involved. And then the more recent thing that we're doing with DFIs is we are finding that there is a difference between the sperm the man ejaculates and the sperm that's within the man's testicle, and the sperm in the man's testicle tends to have a lower DNA fragmentation index, which, essentially, you can roughly think of that as it's more healthy, the sperm is a little bit fresher, it's a little bit newer, and it may be a better sperm if that couple has to go on to in vitro fertilization. So let me give you an example which would seem extreme but actually can be quite successful. If a couple is down the pathway where they need to have in vitro fertilization, and we check a DNA fragmentation index on that man, and his DFI is elevated in his ejaculated sperm, he may be a candidate for doing a sperm extraction, where I actually go in through a very minor procedure and remove sperm directly from the testicle. where it's as fresh as it possibly can be, and we use those sperm to initiate the pregnancy through IVF. It's something that is growing in popularity for couples that have had multiple cycles of IVF that have not gone well and have not ended in live pregnancies. So, something to consider as you're going through all of the different tests and all of the different work ups that you've had, if you're far enough along this pathway, and things are not been working out for you, is to consider a DFI as well as what we do with those data when we get there. Okay. What about male prenatal vitamins? If women take prenatal vitamins, why shouldn't men? And the answer is they probably should. At worst, they're harmless. At best, there are some randomized trials out there that show that they can improve a lot of the parameters that we just talked about, from sperm counts to sperm motility to even sperm morphology, and there are a lot of prepackaged fertility supplements out there on the web. I don't endorse any one specifically, but do your research, see which ones of those actually have good, randomized, placebo-controlled data to show that they're effective. The alternative is you can look at the list that I have up here, and all those agents in various combinations can also improve sperm parameters, and you just buy the supplements individually, and I would recommend that as well. It tends to be a little bit less expensive but more cumbersome. But either way, there are some pretty good data that sperm vitamins or prenatal vitamins work, so I do typically recommend my couples. They're trying everything. To do something that's not only harmless, but probably has a small advantage as well, so why not male prenatal vitamins? Secondarily, what about prescriptions? So this becomes a very complex topic that we'll simplify today, and then of course everything I do in my practice is individually tailored, so I don't treat one man's infertility the way I would treat another man's because everyone has nuances, and the nuances are either in their history, how they're having trouble in their physical exam or in their blood work, and so every man that sees me for an infertility workup is either going to have these blood tests drawn or already has them for me to interpret, so I can figure out exactly what I can do to optimize the hormonal environment for those sperm to improve their chances of pregnancy. So there are a lot of medications out there. The 3 that you'll hear about a lot is something called clomiphene, it's also used in female fertility, but it works relatively similarly in men. It stimulates the testicle to not only make higher levels of testosterone, but also higher levels of sperm--if it's the appropriate guy. Not every man is gonna benefit from clomid, and so, in other words, we have to be the right guy, has to be the right guy with the right sperm parameters to do that. Same thing with these others, it all depends on what your hormone profile is for me to be able to figure out how to treat. ED pills. So, this is not uncommon. As we talked about earlier stress from trying to initiate a pregnancy and knowing when your partner says it's go time, and then you have to get an erection and perform, as much as you love her, as much would you care for her, and as sexually attracted as you are to her, if you have that extra level of stress, some guys do need a little help, so we have to talk about that a little bit as well in the clinic. All right, so a couple words on procedures. And again, this is where we're gonna sit down and talk when you come to my office because there are so many different surgical strategies that I can do to help you improve your sperm counts, everything from--if a man has a vein problem, what we call varicocele, where I have to go in and actually fix those veins, that can have a high impact on a fertility potential, sperm extractions--if a couple has to have a surgery for me to extract sperm, there's a lot of different ways to do that, and there are very complex ways for certain men that need that, and there are relatively simple ways, so, again, it all comes down to tailoring this to the individual. The vasectomy reversal is kind of obvious. If a man has had a vasectomy, then I can put him back together and initiate a pregnancy through spontaneous conception, and then lastly, if a man has a blockage anywhere along that spermatic tract, but usually higher up, closer to the prostate or the ejaculatory duct, then there's a role for me to go in and fix him surgically, and that can be very satisfying, a rewarding procedure if that couple would benefit from it. All right, so a couple of questions that come up all the time in my clinic, and then we're gonna open it up to the web, to Facebook and Twitter, for questions as well, and I'll answer anything there. "How long does it take to make a sperm?" And the reason that's important is because whatever I do in my office, if I give you a prescription to take something to help modulate your hormones, if I'm operating on you in hopes of improving your sperm production, all of those things take time to work. So it takes about 2.5-3 months to make a brand-new sperm, from the beginning material to the actual whipping tail and pointy-head that we're hoping for. So, 2.5-3 months. "Can I have my husband ride a bike?" I get this all the time, "Biking is bad, Dr. Mills, it causes penile numbness, it causes the testicles to be too hot," and all of that is relatively true, if a man is riding 100 miles a day. So if a guy's riding his bike to work 3-5 miles, or he's getting a little bit of exercise, perfect, he can continue to do that. It's everything in moderation. I have no problem with bike riding. What about drinking? "Should I quit drinking?" If you have to ask the question and you think that you have a problem with alcohol, then the answer is probably yes. From a sperm production standpoint, limiting alcohol consumption to fewer than 2 drinks at one setting is very important for sperm production. One of the biggest barriers in all of the drugs out there, from cocaine to heroin to marijuana, probably one of the worst things for sperm production is binge drinking, so 5-6 drinks at a time can impair sperm production for months. So, moderation. And if you're even more diligent, certainly cutting back less than than even the recommended 2 drinks a day, not a bad idea. And then lastly, "How do we decide on IUI (which is insemination) versus in vitro versus IVF and ICSI (which is the more complex, where we're actually taking one sperm and putting it in the egg)?" And the answer is a lot of that you don't decide on, that's decided on by your partner's egg reserve, her age, and also your sperm parameters. And that becomes a dialogue that your physicians will have because fertility is a two-part approach. We have female reproductive endocrinologists, who are trained in gynecology and obstetrics, that help the women achieve their pregnancy goals, and then we have guys like me that are male reproductive specialists on the urology side, and together we have a dialogue and come up with the best way to make that plan. But this is not a decision that you have to make, you just have to realize that all options we consider, from spontaneous pregnancy all the way to the most advanced diagnostics and therapeutics we can do for fertility, because the ultimate goal is for you to achieve your pregnancy goals, and however we do that, that's the right way to do it, okay? So, this is the Men's Clinic at UCLA Health. We have 2 locations, one in Westwood, one in Santa Monica. That's your appointment number, if you want to see me about anything related to male fertility or home run dysfunction or sexual dysfunction, I'm happy to happy to see you in my office. And so now, I think it's time to open up the Twitterverse and have me take some questions online. Thank you very much for your attention so far. I really, really enjoyed my time with you over the last half hour, and boy, the first question we just answered. "Should I quit drinking, and how much is normal?" Yeah, again, if it is fewer than 2 drinks at a sitting, it's probably fine, but if you've done everything else and you're not getting pregnant, there are a couple articles out there in the literature that maybe ceasing drinking just for that pregnancy period is not a bad idea to fully optimize, but again, fewer than 2 drinks is fine. And then the same thing, the next question, "How do we decide IUI versus IVF/ICSI?" I will give you a parameter that most reproductive endocrinologists use, which is that if a man, from just from a male perspective, so regardless of what's going on in the female side, but if this is a male factor, and you're deciding between IUI and IVF, the answer is that a man should have about 3 million progressively moving sperm. So out of that semen analysis, you have 20 million sperm. It goes back to if none of them is moving, then IUI is not going to help. If 10% of them-- you have a 10% motility, and you have 20 million sperm, you're still pretty far below where we would want that that number to be for you to be successful with IUI. And if there's nothing else I can do to improve those parameters, that's when we're gonna look at IVF. So next question, "Does chemical radiation exposure such as iPhones or laptop use affects sperm count?" And the answer is probably, with laptop exposure, maybe not as much with iPhone use. There's been a lot of studies in the literature to look at this, and the old saying was that absolutely there's something about the laptop itself, probably the heat that it generates. When a man has a laptop, especially the ones that have an internal hard drive and the cooling fan, even with that cooling fan the scrotal temperature of a man with a laptop for greater than 20 minutes on his lap can be over a hundred degrees, which, again, we want our sperm to be about 96 degrees, so that 4 degrees is enough to cook those sperm, so laptops--bad from that perspective. But again, it's also if you're sitting down and the laptop is in your lap, then you're sitting down, so your testicles are between your thighs, your thighs are hot, you've got a laptop that's on top of that, and maybe you're more sedentary than you should be, then there's some confounding variables to say, get a standing desk, get the laptop off your lap, get up and exercise, don't sit in one place for so many hours at a time that you are going to impair sperm production, from that perspective as well. The iPhone radiation use, again, it's just not quite all the way there yet, but what we did find about ten years ago, there was a study that showed that men that were on their iPhones for greater than 4 hours a day had impaired sperm production, and again, that may be a lifestyle thing as well, but we don't know, so I don't typically tell my patients to not carry an iPhone, which is practically impossible in 2018, or any kind of mobile device, but I do encourage them to spend as much time off it as possible and spend as much time being active and exercising appropriately. But the intrinsic radiation exposure is probably not that dramatic. Okay, "Do certain foods like oysters improve fertility?" I love that question. Whoever's marketing oysters is doing a very good job because I think everybody has this theory that oysters are good for not only sperm production, but also as an aphrodisiac, or as some kind of sexual enhancer, and the only thing about oysters that is interesting is that they do have high levels of zinc in them, and we know that semen has high levels of zinc as well, so that's one of these supplement correlations, where if you ingest enough of something, then maybe a little bit of that will get deposited in the semen and help sperm counts. But it goes back to what I said about polyunsaturated fatty acids. There's not ever going to be a study where you tag an unsaturated fatty acid with a molecular marker that you can see exploited, or you can see in the sperm once it gets developed, so the answer is I don't know at all, and oysters in general, you know, seafood has some inherent good things about it as well, but in general, the foods that you want to keep on is just any healthy diet that allows you to eat lean and keep your body weight down and increase the amount of raw fruits and raw vegetables you take. That's the best way to improve your diet, from a fertility perspective as well as a men's health perspective, which is what we're really here for. Alright, so I think I have no more--is that correct? We have no more additional questions. I really, really appreciate your time and delighted to see you in my office if you're having trouble. I can help you meet those fertility goals. Then let me know, and we'll get you in. Thanks very much for tuning in to UCLA Health today, and have a great rest of your day.

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