About this video

• Video Title: 351 ‒ Male fertility: optimizing reproductive health, treating infertility, & navigating TRT
• Channel: Peter Attia MD
• Speakers: Peter Attia, Paul Turban
• Duration: 02:37:18

Overview

This video features a discussion between Peter Attia and Dr. Paul Turban on male fertility. They cover the complex journey of sperm, how sperm are made and the factors influencing their quality, and the process of conception. The conversation also delves into the causes and diagnosis of male infertility, the impact of various lifestyle factors (including medications, microplastics, stress, exercise, alcohol, marijuana, nicotine), and the effects of heat and cold exposure. They discuss TRT and its implications for fertility, as well as methods for restoring fertility after exogenous testosterone use. Additionally, they touch upon genetic factors, the role of stem cell and PRP therapies, sperm banking, paternal age, and the significance of semen quality as a health biomarker.

Key takeaways

• Sperm Production and Journey: Sperm are continuously renewed and influenced by environmental factors. The journey from production to fertilization is challenging, with only a fraction of sperm successfully reaching the egg.
• Male Infertility Causes: Infertility can stem from viral infections, medication effects, microplastics, stress, exercise (especially extreme or cycling), alcohol, marijuana, nicotine, type 2 diabetes, varicoceles, and genetic factors.
• TRT and Fertility: Testosterone replacement therapy (TRT) can suppress natural sperm production. While some formulations may have less impact, prolonged use often leads to infertility, which can be difficult to restore.
• Lifestyle and Environmental Impact: Factors like heat exposure (hot tubs, saunas), certain types of exercise, alcohol, marijuana, nicotine, stress, and environmental toxins (like microplastics) can negatively affect male fertility.
• Semen Analysis and Hormones: A comprehensive semen analysis (count, motility, morphology) and hormonal evaluation are crucial for diagnosing male infertility. These metrics can also serve as biomarkers for overall health and longevity.
• Paternal Age: Advancing paternal age (especially after 40) is associated with increased risks to offspring, including miscarriages, birth defects, and neurodevelopmental disorders like autism.
• Sperm Banking: For men undergoing treatments that may affect fertility (e.g., cancer therapies) or at advanced paternal age, sperm banking is a recommended option.

The video suggests that for conception, it's generally recommended to have sex every other day. This strategy is based on a study that found optimal pregnancy rates when couples engaged in intercourse on days 9, 11, and 13 of the menstrual cycle, with every other day being the most effective interval. The key point is to "front-load" the sex, meaning to have intercourse in the days leading up to ovulation rather than waiting until ovulation occurs, as sperm can survive for a period within the female reproductive tract.

Lifestyle choices can significantly impact sperm quality and male fertility:

• Hot Tubs and Hot Baths: Prolonged exposure to high temperatures (e.g., 104°F or 43°C) in hot tubs or baths can be detrimental. Studies suggest that 20-minute sessions three times a week at 104°F could lead to zero sperm count. Submerging in hot water is considered particularly harmful as the testicles can quickly assume the water's temperature.
• Alcohol Consumption: Alcohol is a direct toxin to sperm and can affect quality and quantity. Excessive alcohol use can lead to hormonal imbalances, increasing estrogen levels and subsequently lowering testosterone, which impacts sperm production.
• Marijuana Use: Marijuana (THC) is considered a significant negative factor for fertility. It can negatively affect sperm count, motility, and morphology. There's also concern about potential epigenetic effects and a possible link between chronic marijuana use and an increased risk of testicular cancer. The depot effect of THC, where it lingers in fat tissue for weeks, can lead to chronic low-level toxicity.
• Nicotine: Nicotine, whether from smoking or other sources, is also considered a negative factor for fertility, likely due to its oxidative properties. It can affect sperm count and motility.

The typical diagnostic approach for a man experiencing infertility involves several steps:

1. Thorough History: This is considered the most important step. It involves a detailed questionnaire (potentially up to 200 questions) covering medical history, lifestyle (including hot tub use, exposures), sexual history, and any past fertility issues.
2. Physical Exam: A physical examination is crucial to identify any physical abnormalities, such as varicoceles, infections, or signs of major medical issues like diabetes or testicular cancer. It can also help detect congenital conditions like the absence of the vas deferens.
3. Semen Analysis: This is a key diagnostic tool. The analysis evaluates several parameters, often described metaphorically as a "poker hand":
   • Volume: The amount of ejaculate. Low volume can indicate issues like collection errors, low testosterone, or absent vas deferens/seminal vesicles.
   • Count/Concentration: The number of sperm per milliliter of semen.
   • Motility: The percentage of sperm that are moving.
   • Progressive Motility: The quality of sperm movement, specifically how well they move forward.
   • Morphology: The shape of the sperm. While historically 4% normal morphology was considered the benchmark, there's discussion about the variability and interpretation of this metric. Abnormal forms can indicate issues with sperm maturation.
   • Liquefaction, Agglutination, Viscosity: These are properties of the seminal fluid.
   • Round Cells: These can be pus cells (indicating infection) or immature germ cells. High numbers are generally undesirable.
4. Hormonal Evaluation: Blood tests are done to check hormone levels like FSH, LH, testosterone, and estradiol. These hormones play critical roles in sperm production and overall reproductive function.

It's important to note that semen analysis results can vary significantly, so at least two analyses, spaced a few weeks apart, are typically recommended for a reliable assessment.