From podcast: https://BenGreenfieldFitness.com/podcast/dr-amin-herati-fertility-podcast/
[00:00:00] Coaching Challenge
[00:02:48] Sponsor Podcast
[00:06:53] Guest Introduction
[00:09:02] Is infertility a genetic issue to any degree?
[00:12:10] Why infertility is more an issue among men in recent history than generations prior
[00:21:23] Environmental causes of infertility
[00:31:07] Testosterone replacement therapy and its effects on fertility
[00:36:00] Podcast Sponsors
[00:39:08] Injectable peptides to regulate male fertility hormones
[00:46:01] Does a cool crotch affects one’s fertility levels?
[00:48:53] The effects of alcohol, tobacco, and drugs on fertility
[00:53:16] Monitoring diet and food allergies in relation to fertility
[00:56:05] Why plenteous semen doesn’t always equate to abundant sperm
[00:59:11] Strategies for enhancing fertility
[01:06:25] Why the experts are recommending you cum more frequently
[01:10:03] Diets or foods recommended for fertility
[01:17:19] Dadi’s Semen Analysis
[01:19:39] How to proactively take care of business, even if you’re not ready to have children
[01:27:49] Final Words on Fertility
[01:31:19] Legal Disclaimer
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On this episode of the Ben Greenfield Fitness podcast.
Amin: One of the things that I’m very passionate about is advanced paternal aging and the effects it has on the genetics. One of the strategies where you can avoid all of the negative effects of all the exposures is to bank sperm early. Kids these days are probably not as active as they used to be or getting hit by phones in their pocket. The risk with some of these antioxidant therapies is that sperm lose portion of the cell that is around the nucleus and it sloughs it off. And so–
Ben: Health, performance, nutrition, longevity, ancestral living, biohacking, and much more. My name is Ben Greenfield, welcome to the show.
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Alright, folks. Well, I get asked a lot of questions by honestly both males and females about fertility or perhaps more accurately that infertility increasingly these days. I don’t know, maybe my audience is aging as I age or people are just stuck at home during the COVID pandemic locked away trying to figure out how to make babies. I don’t know. But yeah, I get questions like how to increase sperm count? How to how to store and freeze sperm? The best diets and supplements for fertility, and a whole lot more. I’ve never done an episode just devoted to how to get your swimmers a little bit more dialed in or how to optimize fertility particularly when it comes to males and sperm.
I know there’s a whole bunch of topics related to fertility, there’s an entire other consideration for the egg component for females et cetera, et cetera, but for you couples who may be wanting to conceive or for you guys who may want to analyze your sperm, get your sperm stored, et cetera, I think that’s going to really be the topic of the day for today’s podcast with Dr. Amin Herati. He’s an MD. He’s an assistant professor at the James Buchanan Brady Urological Institute and works at the Johns Hopkins Hospital. He’s also the director of men’s health and director of male infertility there. And, he’s the advisor to Dadi, D-A-D-I, which is an at-home male fertility services company for sperm testing and for sperm storage. I actually just sent in my own kit to store my sperm and Dr. Herati will be able to debrief us on why that might be a good idea. He researches everything from spinal cord injuries to genetic basis of male infertility to hypogonadism, to pelvic pain syndrome, and a whole lot more. So, this guy knows his way around our nether regions, I suppose would be the best way to describe him.
So, Dr. Herati, welcome to the show, man.
Amin: Thank you so much, Ben. It’s a true honor to be with you.
Ben: Yeah. I hadn’t plan on asking you this question right off the bat, but as I was kind of filling folks in on your history, for some reason, when I said, “genetic basis of male infertility,” that kind of got me thinking just a second here, is this something in terms of male infertility which I do want to get into more with you regarding statistics and stuff on it, but are there actually genetic snips that would predispose you to being less fertile?
Amin: Yeah. There are gene mutations, there are epigenetic mutations that are passed on from generation to generation to generation to generation. And, that’s one of the things that we harp on whenever we talk to our male patients who are interested in fertility evaluation, preservation, or optimization that if there’s a lifestyle factor that they are consuming, or imbibing, or whatever exposure they’re getting, that impact on their sperm quality is marked on the DNA, the sperm and passed on multiple generations. So, our health is a factor of our great, great, great, great grandparents halting their–
Ben: Really? Interesting. Is that something that, because a lot of people will just get for example a 23andMe evaluation. Is that something that would show up on an evaluation like that or do you have to test specific snips if you wanted to see if genetically you were actually predisposed to have, I guess, a little bit more of an uphill climb in the fertility department?
Amin: Yeah. So, unfortunately those 23andMe tests wouldn’t be able to identify the mutations. The hard part is that there are thousands of genes between 3 to 4,000 genes involved in sperm production. And then, within those genes, there are areas, the genes that code for protein, areas that don’t code for protein, areas that sit on top of the DNA called epigenetic markers. So, it takes one inflection of one of those markers epigenetically or a ding in the DNA to cause a mutation. And unfortunately, we’ve only identified as less than 10 mutations in animal and confirmed it in humans that cause infertility. So, we still have a mountain of work left to do to identify the true genetic cause of infertility. We’ve only scratched the surface of it.
Ben: Wow. That’s crazy. And then, I know there’s probably a few research papers I can hunt down and put in the shownotes for people. The shownotes are going to be at BenGreenfieldFitness.com/D-A-D-I.
I know that for women, Dr. Herati, there are a variety of predisposing conditions are probably related to genetics like polycystic ovarian syndrome I know is one issue. I think there’s another gonadal gene issue. It’s the XX gonadal dysgenesis and a premature ovarian failure, and a lot of stuff that goes on with women. But before I interviewed you, I started to look into it and it appears that about 50% of infertility cases from the stats that I could find are not related to women but are indeed related to men. And, there’s mitochondrial DNA mutations, and endocrine disorders, and chromosomal abnormalities, and all sorts of things that you can look at to find out whether or not you’re kind of at a higher risk of being infertile.
But one of the main things that I seem to run into over and over again is that it seems that infertility is really on the rise. They say that guy’s testosterone is decreasing as, I guess, more little boys are probably sitting at home playing video games not out chopping wood and doing hard manual labor like, I don’t know, bailing hay with their dad out in the field, which kind of makes sense. But along with that general drop in fertility or journal dropping testosterone among men, infertility seems to be on the rise. Is there a good reason that you think that infertility kind of seems to be a bigger issue amongst guys?
Amin: I think part is the fact that we’re focusing a little bit more on it than we have in the past. If you look at the media portrayal of male infertility, there’s very little in pop culture media that talks about male infertility. And, one of the shows that comes to mind most recently was the show “Ballers” on HBO Season 3 where Dwayne Johnson’s character was dealing with infertility and he was going through the process of getting checked for his semen analysis and visiting with the urologist. And, he was given really bad information, was a very poor depiction of what the infertility process looked like. And, all too often we hear from patients that their wife went in for the evaluation first and then the husband grudgingly went in for his check. And then, when he was checked, they found out that there was a problem with his sperm counts and semen parameters. And then, they found their way to a urologist. So, rarely does it happen reverse where we see male partners seeking out fertility care first and then the female partner. That’s the way it should be.
The American Society for Reproductive Medicine actually recommends that after a year of not being able to conceive that the male and female partner should be studied and evaluated for their fertility. So, that’s something that I’m glad that we’re having this conversation. I’m glad that your readership, your audience is interested in tuning in for this because this is something that really we need to be talking more about.
Amin: Reason being fertility is a barometer of a man’s health.
Ben: Yeah. By the way, I heard I believe it was Tim Ferriss said that in his book “4-Hour Body” way back in the day. He’s like, “If you want to get a glimpse into how healthy you are, one of the first places to start is to check into your fertility because as the body becomes unhealthy,” I think this is the reasoning behind that, it’s like from an ancestor or an evolutionary standpoint, “nature doesn’t want a sick dude to go out and make babies.” That’s kind of the general overview. Is that basically accurate to a certain extent?
Amin: I couldn’t agree more. So, when the body’s under stress such as from a COVID infection, an illness like a malignancy in the body or a genetic condition to predispose them to cancers down the road, we start seeing those changes developing in the semen parameters. The machinery and the metabolism and the cell turnover associated with infertility is so robust that the timing of it, the feast or famine mentality that if this is a time to feast, then reproduction is on the table. If it’s a time of famine, then it’s not. So, that concept holds true.
And, we find a lot of problems in guys with infertility at a higher rate. So, how progressively worse off their semen parameters are, the more likely we are to find low testosterone. Guys with infertility are higher risk of having testicular cancer and blood tumors like leukemia, lymphoma, prostate cancer down the road. So, there are a lot of different conditions that can be picked up as part of the evaluation and a lot of conditions that bring guys in who didn’t realize that if they had COVID that their sperm counts could go to zero afterwards.
Ben: Yeah. Maybe a dumb question here, but a little bit of a logistical question I was curious about. So, when you say that you are infertile and that’s just basically a catch-all term as a disease or condition of the reproductive system characterized by an inability to achieve pregnancy. Is there a point at which you would actually diagnose someone as being infertile? What I mean by that is, let’s say a male and female having regular unprotected sexual intercourse for a certain period of time. And, since we’re kind of focusing on sperm and semen and males for this podcast, let’s say that the woman has been checked out. She doesn’t have polycystic ovarian syndrome or any of this gonadal, this genesis issues, or premature ovarian failure, and the woman appears to be all right from a fertility standpoint. And, maybe it’s the guys, I will say the guy’s fault so to speak. How many days or weeks or months of unprotected sex do a male and female have without producing a baby at which point you say, “Yeah, the male could be diagnosed with some type of infertility.” Or, is there a general consensus?
Amin: Our general consensus for couples is that they should try for about 12 months if the female partner is under the age of 35. And then, if she’s over the age of 35, then six months. So, if no success after that, then to have both partners checked out.
Ben: Wait. You say if you’re over 35 and you’ve been trying for six months or if you’re under 35, you’ve been trying for 12 months, that’s when you diagnose infertility?
Amin: Yeah, exactly. So, we would call that couple sub-fertile because we don’t know at this point if they’re truly infertile or if they’re reducing their fertility potential.
Ben: Okay. Okay, got it. Alright. So basically, we have infertility on the rise and you said when I asked you that question that part of it is because we’re just able to test for it more which of course makes sense, any disease or condition that you have better testing methods for when you’re testing more of. It’s going to obviously throw in a variable where more conditions are going to pop up just due to the increased testing. But would there be other reasons that you suppose infertility is on the rise?
Amin: Yeah. So, we know that there are environmental exposures that are occurring day-to-day. So, we have environmental endocrine disruptors that we’re getting exposed to. There are electromagnetic–
Ben: You mean personal care products, household cleaning chemicals, stuff like that?
Amin: Exactly, yeah. So, over time, we’re getting exposed to this and it’s a compounding effect on the sperm. So, the sperm is getting marked with changes over time. And, a lot of these changes, a lot of these mutations the body can fix. But over time, the more stress on it from these exposures and changes in hormones as a result of exposure to these endocrine disruptors, the less healthy the sperm is, the less able it is to repair itself for DNA damage.
So, we know that there are environmental exposures that are affecting our hormones and affecting sperm health. We know that there are electromagnetic fields around us ionizing non-ionizing radiation that is affecting us. And then, also, our health, as I mentioned before, is a factor of our parent’s health and our great-grandparents health, et cetera, et cetera. So, the longer they’re waiting to have kids, the more DNA mutations they’re accumulating, the more likely the kids are to have a problem down the road as well. So, it’s a snowball effect.
Ben: So, those DNA mutations, if you were born and your parents were older, those can actually get passed on to you. And so, you might have just drawn the short straw if you were, I don’t know, last in line in your family and your parents had you and maybe they’re 40 years old, you might actually have increased risk for infertility.
Amin: Yeah, absolutely and other conditions. So, even if their parents married and had kids at a young age, even if their grandparents were of advanced age, so specifically advanced paternal age that the grandchild’s risk of having a learning disorder or even having schizophrenias increased. So, it skips that generation and shows up in the great grandkids.
Amin: So, those things will show up. And, that’s the transmission of genetic information from generation to generation that we’re seeing. And, I think some of the changes are, as you mentioned, our kids these days are probably not as active as they used to be. There’s a lot more exposure to different chemicals. We’re getting hit by phones in our pocket, computers on our laps, electromagnetic fields from all over. That’s an area of our research as well here in Hopkins is looking at electromagnetic fields and non-ionizing radiation effects. So, that’s an area that we’re interested in.
Amin: We know these things are snowballing and the exposure is cumulative. So, over time, the more these stressors come on our system, the more DNA mutations occur and the less fertile we’ll be down the road.
Ben: Yeah, yeah. A couple of quick questions for you. Obviously, I mentioned like personal care products and household cleaning chemicals and everybody’s listening and they’re pretty smart. It’s not that hard to go to the environmental working groups website or I talk about this in my book “Boundless.” I have a whole chapter devoted to what to replace common household cleaning chemicals and common personal care products with to have fewer endocrine disruptors in them. Pesticides and herbicides would also be something to consider, yeah?
Amin: Absolutely. Yeah.
Amin: There’s chemicals within them. Cleansing agents that we commonly use at the grocery store, we’re constantly wiping down surfaces to protect ourselves from COVID, but there’s a component in a lot of these cleansing wipes called benzalkonium chloride. And, studies from Duke University have shown that when you expose benzalkonium chloride, which is an FDA-approved “safe drug,” you expose cells called Sertoli cells, which are the nerve cells that enable sperm production to proceed. Those cells will be wiped out, the Sertoli cells will be completely gone as a result of exposure to benzalkonium chloride.
Ben: Where do you find that form of chloride primarily?
Amin: It’s in eye drops and it’s also in cleansing wipes.
Ben: Wow. Okay. That’s crazy. Like the little cleansing wipes they hand you when you walk onto the airplane for example?
Amin: Yeah. So, I routinely check if I can see. Now, if it’s alcohol, that’s not as bad. But in a lot of these wipes that you see at the gym where there’s a larger sheet rather than these little, smaller hands wipe.
Ben: Yeah, that’s right. They’re all over gyms as well. That’s interesting. The impact of some of this stuff when it comes to male fertility seems kind of similar, in my mind, to looking at a book like “The End of Alzheimer’s.” When you look at Dr. Dale Bredesen’s multimodal approach to Alzheimer’s, there’s so many variables that he goes after: ketosis, high dose fish oil, infrared, light therapy, hyperbaric oxygen. With fertility, it seems to me as though as you become aware of some of the stuff that we’re talking about, that we’re going to talk about, ideally, if you wanted to be as fertile as possible, you’d stack a lot of this stuff. It’s not just about switching your shampoos or bringing your own natural wipes to the gym, I would say there’s probably a lot of variables that you want to check.
I did a podcast interview with one of my friends, Adam Wenguer sometime back, and I’ll link to that in the shownotes. But he was trying for a few months, he and his wife to get pregnant. And, towards the end of that podcast, we started talking and he laid out what he wound up doing. And, I mean, he did everything from HCG and follicle-stimulating hormone to optimizing his coenzyme Q10 levels. He was on a couple Chinese medicine-based herbs. He was using cannabidiol to decrease inflammation and did a lot of things, stacked a lot of things. But it seems increasingly when I talk to guys who have been struggling for a while and then found success, they’re actually doing a lot of things at once in order to boost fertility. So, it seems as though a lot of stuff adds up.
Now, speaking of the airplane and cleansing wipes that they hang on an airplane, what about radiation or X-ray exposure? Similar to EMF, do you need to be careful with X-rays?
Amin: Definitely. So, X-rays, definitely. Whenever we see a male partner of an infertile couple, one of the things we check for, we check for structural problems that could be causing DNA damage, we check for specifically varicose veins. And, varicose veins when present through dilated veins that allow the blood to yo-yo in the veins that would normally be taking the blood from the testicle back up towards the heart. When those veins are yo-yoing and not allowing efficient unidirectional flow, what can happen is that it brings body temperature blood back down to the testis. It heats up the testicle, it damages the DNA of the sperm, it makes the sperm less successful for natural conception and use with IVF. And, one of the treatments that we have for that is either a surgery to fix those veins to tie the big veins off or we can send them to radiologists and the radiologist can put a coil on the inside of the vessel in order to embolize it.
And, a lot of patients are interested in that embolization approach where they can get a coil on the inside not have to go through a four-day period where they’re out of work and the two-week of no heavy lifting restriction. But the downside is when they go for that embolization, the average time of X-ray exposure is 24 minutes as part of that treatment to get their fertility improved. They’re correcting one problem and getting exposed to another. So, to the extent possible, I try to steer patients away from radiation from medical sources to the extent possible, X-rays and CT scans, things of that nature will expose patients to a significant amount of radiation. But walking through the airport and going through the scanners, and that’s going to be a low-level amount of radiation.
We know that non-ionizing radiation, the radiation that doesn’t change the DNA material can also affect the way that the cells function. So, radiation, even from our computer, from our phones, can flip the polarity of our cells. And, their studies have shown that when the testosterone-producing cells called Leydig cells have exposure to electromagnetic field that the testosterone production will be lower.
Ben: Interesting. Yeah, yeah. The non-ionizing and ionizing radiation, I think, is sometimes a little bit confusing to people in terms of the difference between them. But from what I understand, the non-ionizing radiation is any type of electromagnetic radiation. There’s an ionized, the atoms or the molecules totally remove an electron from an atom or a molecule but still has sufficient energy to kind of excite the electron to a higher energy states. Whereas, ionizing radiation, from what I understand, would be something that would be a little bit more intense like higher power, higher frequency, I suppose. Would ionizing radiation be something closer to say some type of nuclear exposure or how would you differentiate for the average person between non-ionizing and ionizing?
Amin: So, UV light, there’s different types of UV, light there’s ABC. I believe UVB or I can’t remember UVB or C that flips between non-ionizing and ionizing. Like you said, when you have ionizing, you’re flipping the electrons, and that’s when you start getting the DNA damage is when you start knocking out the electrons, the DNA and the DNA breaks in it. And, that’s when mutations occur.
When you have non-ionizing, so when you think about the electromagnetic waves and the less frequent the waves are, the more spread out they are, you start going down the path towards infrared lights, the light spectrum power lines that were around on a day-to-day basis. The electric cables in our walls, the computer, microwave, things of that nature. So, ionizing would be X-rays, gamma waves, CT scans, things of that nature and non-ionizing would be more of our day-to-day exposure.
Ben: Okay. Alright, got it. But we should be aware of both when it comes to fertility.
Amin: Exactly. Yeah. So, ionizing affects the DNA of the sperm, non-ionizing can affect the functionality of the cells that produce testosterone, which is an area of our research is potentially also the development of the sperm cells in the architecture of the tissue.
Ben: Okay, got it. Now, this might be confusing to some people because obviously, we hear we shouldn’t overheat the testicles because elevated temperatures can impair sperm production and function. And so, frequent use of hot tubs and saunas, sitting for long periods of time wearing very tight clothing, using your laptop, computer, even if it’s not a radiation issue, it’s just the heat issue. Anything that’s going to increase the temperature in the scrotum, I think that’s pretty common knowledge amongst guys is not that great of an idea when it comes to sperm production. But there are a lot of guys now using the red-light therapy in terms of infrared saunas or even using red-light therapy devices.
One very popular one I’ve even talked about my podcast before, it’s like this Joovv light that supposedly increases the mitochondrial activity, the Leydig cells and the testes. It may increase fertility to a certain extent. Do you think that’s true or do you think that that type of even like infrared sauna, infrared light exposure is something that could impair fertility? Because to me, it’s a little bit confusing. It seems you’re stimulating the Leydig cells but at the same time could that radiation be causing some type of DNA damage that would impair fertility?
Amin: Yeah. So, the main thing there would be the depth penetration of that light. And, if the depth isn’t to the level of where the Leydig cells and the sperm cells are, so it’s multiple tissue layers deep, then it likely isn’t improving the situation by much or hurting it much. I would be on the fence about it as far as it is hurting, and I think if somebody’s interested in trying that, I wouldn’t discourage them.
Ben: Okay. Alright, got it.
And, I know we’re kind of, right now, just staying focused on the things that might decrease fertility. And then, I want to throw a few things that I know a lot of guys are doing, the herbs, supplements, et cetera, to increase fertility. But I know there’s a few other things that a lot of people are or have been asking me questions about guys on testosterone replacement therapy less. That’s more common obviously than long-term anabolic steroid use, which I know can decrease fertility. But when it comes to all the different pharmaceuticals and drugs out there, obviously some can impair sperm production and decrease male fertility. But testosterone placement therapy, it’s kind of a catch-22 for a lot of guys because they do it to increase drive, increase virility, increase attraction to the opposite sex, et cetera, et cetera. But at the same time, it’s something that seems to, from most of what I’ve seen, impair fertility. Is it true that testosterone replacement therapy can do that? And, if so, are there certain things that guys can do along with testosterone replacement therapy that would cause infertility to be less of an issue?
Amin: Yeah. So, great point. We see this too often with guys that are going to these men’s health clinics and wellness clinics where they’re getting testosterone therapy to improve their drive and their virility. And then, they’re coming in saying, “I’ve been trying to have a child for the last two years, no success. And now, I have a semen analysis that shows no sperm.” And, the reason for it is that whenever there’s exogenous testosterone given specifically through pellets or intramuscular injection or cream-based where you have testosterone sticking around in the system for longer durations, it can negatively feedback on the areas of the brain called the hypothalamus and the pituitary. And, it basically suppresses the signals that would come from the hypothalamus and the pituitary that would go to the testicle to stimulate testosterone production endogenously in sperm production. So, it specifically drops down LH and FSH, luteinizing hormone, follicle-stimulating hormone, which are the two signals the gonadotropins from the brain.
And so, when guys take HCG to boost up their testosterone, that is analogous to luteinizing hormone. So, if they were to take testosterone with HCG, that could have a sperm-preserving effect. But I would recommend if they’re doing this, they do it in a consultation with a urologist and track their numbers beforehand and during treatment to make sure that they haven’t dropped their sperm counts. But there are papers from Baylor where I trained at where sperm counts were analyzed at baseline. And, at one year after, when men were given testosterone therapy even intramuscular with HCG that their semen parameters at one year were no different, not statistically significantly different from their baseline.
Ben: Okay, got it. So, if you’re on testosterone replacement therapy, you think that simultaneously being on HCG would be a good strategy.
Amin: Because HCG is LH and you’re replacing the gonadotropin from the pituitary that would have been suppressed if it wasn’t for HCG.
Amin: There are other types of testosterone therapy that can be taken that don’t have as detrimental of an effect on sperm production. So, nasal testosterone is one type of testosterone that has been studied as a method of giving testosterone exogenously but it has such a short half-life that it doesn’t disrupt the functionality of the hypothalamus and the pituitary. And, potentially one of the newer testosterone modalities called Jatenzo, which is an oral-based testosterone, may also have that same quality although that is in an area of our research.
Ben: That’s called Jatenzo?
Ben: Okay, cool. I’ll take notes for you guys who are driving 60 miles an hour down the highway want to have babies and don’t have time to take notes. I’ll put them all at BenGreenfieldFitness.com/Dadi, BenGreenfieldFitness.com/D-A-D-I.
The other one that in addition to HCG that I had talked with that podcast guest, Adam Wenguer that I mentioned to you, Dr. Herati, was it was FSH, follicle-stimulating hormone. Do you think that that’s also something that would be prudent to include along with HCG?
Amin: So, the data is mixed on it. There was recent research presented in one of our national meetings that said that adding FSH for guys who are taking testosterone with HCG would have a beneficial effect. And, one would say if it’s a naturally occurring gonadotropin and it’s necessary for sperm production, why wouldn’t it be necessary? We’re not sure that what we’re finding is that once guys pass through puberty that LH seems to be the main driver of testosterone. And then, once testosterone is present, then sperm production seems to continue on from that point forward. And, FSH becomes less important.
And, when you look at studies where researchers have given guys medications completely suppress the activity of their hypothalamus in their pituitary and then replace HCG and then in another group replace HCG and FSH, that group with the FSH did no better than the HCG alone.
Amin: So, once you go through puberty, the FSH becomes less important. It may still have a role, but not as critical of the role as LH.
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The other one I think that he had mentioned. Actually, there are a few. Kisspeptin. That’s interesting because I know kisspeptin plays a pretty strong role in female fertility and infertility and can be downregulated. I see this a lot in lean active females who do a lot of fasting. Apparently, it significantly suppresses their kisspeptin levels. And, of course, women who want to be fertile, one of the best things you can do is eat a whole bunch of healthy fats and super nutrient-dense and calorie-dense foods like a Weston A. price type of diet is one that I find myself recommending quite a bit, ghee, and butter, and full-fat fermented dairy and organ meats, and all these wonderful compounds. I’ve worked with a few women who are either trying to have a baby who are pregnant or breastfeeding and I always recommend to them that diet because it seems to work out pretty well.
And, in addition to that, avoidance of long fast, not doing fast that are longer than 10, 12 hours for intermittent fasting and things like that, which makes sense again based on what you were explaining earlier about how the body if it has the impression that it’s starving or that food is not plentiful. Why bring babies into a famine type of situation? But I think that Adam had mentioned that a kisspeptin is an injectable peptide might also be something that could regulate some of these fertility-related hormones in males as well. Have you ever looked into something like kisspeptin as a therapy?
Amin: Yeah. HCG is an easier way of doing what kisspeptin would do. So, kisspeptin would allow better functionality the hypothalamus and the pituitary to bump up the LH. But we can give HCG to do that. And so, I don’t see a strong role for kisspeptin in the male infertility population.
Ben: Okay. Alright, got it. So, that’d be kind of redundant if you were already using something like HCG, for example.
Amin: Exactly. Well, one more side is that the body likes to live in equilibrium and it has its patterns that it likes to see. So, one of the things that I see in male infertility treatments is that we try to ramp up LH as high as we can and FSH as high as we can hoping that the more LH, the better, the FSH the better. That may not be true. What we’re finding is that whenever we have guys at their physiologic levels of LH that things function better, the body wants to see LH in a cyclical low dose fashion. If you give it a flood of LH signal, that may not be a great thing. In fact, it can actually make the cells that normally responds with LH less responsive.
Ben: Okay. So, the other one is the estrogen levels in terms of a healthy metabolism of estrogen in males. I don’t know how much a high amount of estrogen in males would be an issue. Obviously, we talked about phytoestrogens in the environment, plastics, household cleaning chemicals, personal care products, et cetera. Those would be prudent to avoid as potential endocrine disruptors, but what about things that would traditionally be used to promote healthy metabolism of estrogen or even act as estrogen receptor antagonists like diindolylmethane. I think it’s diindolylmethane. DIM is one that a lot of people talk about. Indole-3-carbinol. A lot of these things that guys and girls will use for estrogen metabolism. Are you a fan of anything like that?
Amin: I would recommend that if somebody had a really low level of estradiol and they were having sexual dysfunction, from a fertility standpoint, we look at the ratio between the total testosterone and the estradiol. And, if you ignore the units on the side of it, it should be a ratio of 10 to one. So, if somebody’s testosterone is, for example, 350, then their estradiol should be no more than 3.5, for example. Sorry, 35. That is the ratio that we use. And, as long as that ratio is kept, then patients are kept in the sweet spot. If their estradiol creeps above 50, then we start talking about estrogen blockers to suppress the production of their estrogen level.
Ben: Okay, got it. When it comes to testing for things like that, a lot of times I find myself recommending a urine test versus a blood or saliva test as a really good test for checking out hormone balances, everything from testosterone metabolites and testosterone free, testosterone, estrogen, estrogen metabolites cortisol, even melatonin, things like that.
There’s one test that I like called the DUTCH test, the dried urine test. Do you have a certain form of testing that you really like when it comes to looking at actual hormones?
Amin: Yeah. So, testosterone is one that I’m really critical about. There’s a type of test that it should be run on called a Liquid Chromatography Mass Spec.
Another common type of test that’s run to determine the testosterone level something called an immunoassay where they’ve got antibodies that attach to the testosterone and you measure the amount of testosterone based on the signal that you get from the amount of antibodies and beads attached to it. The downside is that when you go on the outer ranges, so the patients that are low on testosterone are really high on testosterone, amino acid becomes unreliable. And so, when you’re wanting to have a test with good accuracy, you want to go with the most precise testing tool. And, that would be Liquid Chromatography Mass Spec where they have a very narrow range of variability between test results.
Ben: Do if a test like a dried urine test is using that form of analysis?
Amin: I’m not aware of it being tested on anything except for peripheral blood at this point. If there is, I’m not aware of it.
Ben: Okay, got it. Alright, so back to a few of the things that could impact fertility. I’ve heard that being obese or overweight, and I’m guessing, maybe has something to do with over-aromatization and increased estrogen to people with a higher number of fat cells is an issue. Is that true? If you’re overweight or obese, is it a good idea to try and lose weight if you’re trying to get fertile?
Amin: Absolutely. So, there was a poster presented at one of our national meetings that stated that for each 5 centimeters of waistline reduced, fertility potential improved by 9%.
Amin: And so, I quote that statistic to my patients when I see them to encourage them to lose weight. And, we’re not sure exactly why, I mean, aromatization of testosterone when testosterone is converted to estradiol. Then, the balance can go off-kilter. But also the heat between the legs can also probably damage the sperm. And, as we’re talking about before, you really want a cooler environment, and that’s why we recommend not taking baths and using hot tubs. But the heat between the thighs is detrimental, likely the foods that they’re consuming probably has a lot of environmental, the toxicants within it. But absolutely, the estrogen balance is also going to be off.
Ben: Okay. Related to that heating component, there’s the old Russian lore of the powerlifters who will ice their balls to increase testosterone before they go and compete. And, there’s even some companies now. I think it’s funny. There’s these ball icing companies and literally they are marketing ice packs at six times the cost you’d normally pay for an ice pack, but it’s kind of sort of shaped like your crotch so you’re able to ice your balls. I suppose somebody’s kind of raking in the cash on something like that because I don’t imagine it’s that expensive to buy and reshape an ice pack in something that can then be marketed as the ultimate ball icing strategy. But have you seen anything when it comes to actually not just keeping the gonads away from excess heat or ionizing and non-ionizing radiation but actually making a concerted effort to cool the balls on a regular basis? Have you seen that there’s any efficacy to something like that?
Amin: Yeah. So, there’s a cooling patch called FertilMate. And, I believe it’s available on Amazon. And, I’m not sure the mechanism how it cools but I think it’s menthol-based but you place it on scrotum and it cools. And, their studies have shown improvement in the sperm concentration and motility. But for those who have used it, they’ve been uncomfortable with, I think, the alcohol component within them. And, there’s a little bit of a burn if there’s alcohol exposure to the scrotum.
And, one of the things that I was really interested in, I was going on a bike ride with an engineer and he said, well, if varicose veins are heating the testicles, why not have a cooling mechanism with cables that wrap around the scrotum and a heat sink just like a computer has a microprocessor? And, digging through, and sure enough, somebody holds a patent on such a device but never came to fruition. So, the patent exists for this device for a scrotal cooling device just like you’d have for your computer but never came to market. But if something like that came, I think it would definitely help fertility potential.
Ben: Yeah. Speaking of the bike seat, when I used to race in Ironman triathlon, I always use the ISM Saddles, which is it’s at least one brand of bike saddles. And, if you look at it, it’s essentially more of a competition-style bike seat. So, it’s still aerodynamic, but it’s shaped in such a way to where it kind of leaves a ton of pressure off of your balls. I think it’s ISM is the main company that makes these. Do you think that that’s a good idea in terms of a strategy for cyclists who want to stay fertile?
Amin: Great idea, yeah.
Amin: I think the less pressure on the prostate, the less heat the better the flow to reproductive organs.
Ben: Far less exhausting than trying to stand the whole time that you’re cycling. You could get massive bicycling triceps but you get pretty tired. So, yeah, choose your bike saddle wisely, fellas.
Tobacco, alcohol, and drug use is obviously something that’s frequently recommended to moderate pretty intensively. I know men who spoke have been shown in some studies to have a lower sperm count. Even second-hand smoke from tobacco might impact male fertility. I know that drinking, particularly excess drinking, not the typical healthy Mediterranean style glass of organic wine at the end of the day, but excess drinking, I know, can cause both erectile dysfunction and decrease sperm production. And, the effects on the liver can also affect estrogen metabolism which is an issue.
And then, of course, there’s a huge variety of drugs. I found one research paper that just goes into a ton of the different drugs that I’ll link to in the shownotes. If you go to BenGreenfieldFitness.com/Dadi, I’ll link to this wonderful study. It’s called “The impact of drugs on male fertility: a review.” It came out in 2017 and it just goes over, gosh, every last drug on the face of the planet. And, you may want to look at any pharmaceuticals that you’re taking and compare them to that list to make sure there’s nothing on there that might be interacting with fertility. I mean, we’re talking antidepressants, diuretics. There’s a lot of stuff on there that seems to have an impact that I think a lot of guys might be unaware of. But of course, amongst the healthy population, even the alternative hippie health folks who maybe aren’t using a lot of pharmaceuticals, marijuana seems to be something that’s very frequently used these days.
Now, like I mentioned earlier, when I spoke with that guest, Adam, about what he was doing for fertility, he was really into CBD. And, he actually found some interesting studies on endocannabinoid receptors found in sperm and in the female reproductive tract, and that CBD might be a way to improve a sperm’s ability to fertilize an egg, maybe decrease some inflammation and oxidation that could be having an impact on fertility. However, on the flip side, I’ve seen some chat out there that not isolated CBD but marijuana, in general, may impact not just testosterone, which I think is well-established but may also impact fertility. Do you think that marijuana particularly the THC component elements of marijuana would impact fertility?
Amin: Yeah, absolutely. Yeah. So, at our most recent reproductive meeting, there was a poster presented and a paper presented that showed a 50 to 60 reduction in the testicular size for guys that are using marijuana and THC.
Ben: Wow. I’ve seen some studies like that and then you look at the dosing and they’re taking 100-milligram edibles or some crazy bomb like that. Do you do if this was just regular use, like vape pens and things like that?
Amin: This was a randomized trial, I believe. And, I don’t remember the dosage that they had used in their subjects, but this was a controlled experiment where they had guys who used it and guys who didn’t. And then, when they compared the two, there was a significant reduction. Now, interestingly, the sperm counts were not different, the sperm concentration was not different between subjects which one would assume if the bulk volume of sperm production accounts for the volume of the testis. And, if the two are proportional that if you have a significant reduction in the size of the testicle, then you should see reduced concentration of sperm as well. But for whatever reason, they didn’t see that. So, I think that there may be a buffer zone potentially between the two where the body can compensate and will keep sperm counts going.
One thing that a lot of people don’t know is that there’s a very high number of sperm cells that are taken out of circulation before they ever leave the testes. So, it’s estimated that two-thirds of sperm that produce on a daily basis never make their way out. And, they’re pulled out due to quality control mechanisms from that Sertoli cell that I was talking about earlier. And, if that Sertoli cell is not working properly, then we can see a lot of sperm exiting that are not of good quality.
Ben: Interesting. Okay. So, probably a good idea if you’re trying to conceive to avoid maybe not CBD, which might actually be helpful but avoidance of marijuana would probably be a good idea.
Amin: I agree.
Ben: Okay, got it.
Now, when it comes to other things to avoid, I know that in terms of triggering of autoimmune conditions which it seems can have an impact on fertility, if you’re sensitive to certain things like dairy wheat, soy, et cetera, it might be prudent to avoid those compounds. But for you, somebody who works with people on fertility, do you actually do that? Do you run food allergy tests or any type of genetic evaluations for predisposition to celiac disease or the implementation of more of it like a paleo diet or an autoimmune-based diet or anything like that in your practice?
Amin: If I could, I would. And, it’s, I think, the limitation of our current medical system is that it doesn’t give me the time to be able to go that deep into their care to be able to talk about diet and test them for autoimmune conditions. And, I’ve seen patients even recently who dealt with autoimmune disorders that are [00:54:13]____ and their sperm counts went down. And, everything was going really well and humming along, we fixed this guy’s varicose veins. And, unfortunately, inflammatory bowel set in and his numbers changed. So, this is definitely something that we see and we recognize any inflammatory condition stress on the body can cause the detriment to the counts.
Ben: Yeah, yeah. I mean, speaking to testosterone, not fertility per se but for testosterone, I’ve noted that in guys who kind of take the dietary component too far like excess carbohydrate restriction, excess calorie restriction, particularly when paired with high calorie burning sports especially chronic repetitive motion sports like marathoning, swimming, triathlon, et cetera. There seems to be a pretty big impact on testosterone levels. And, I think that one thing I want to mention is that I’ve noticed that when people start to adopt a healthy diet, sometimes they synonymize the healthy diet with just restricting calories and restricting carbohydrates. And, I don’t think that that’s necessarily a good idea, but what I do think is a good idea is to do some type of Cyrex Food Allergy Test or looking at genetic components related to celiac disease, I’m just making sure that from a dietary standpoint, particularly an autoimmune-related dietary standpoint, you’re not consuming food products that would cause — even if they might be healthy for one person but not healthy for you. If you’re sensitive to oxalates and that your neighbors do much almonds and spinach in their smoothie, that’s something that for you could be an issue and trigger some type of inflammation or oxidation or trigger an autoimmune response. I think it’s important to test that as well. And, it sounds like, from what you’re saying, sadly if you could, you would, but it’s one of those things where you just don’t necessarily had the time in your practice.
Ben: Okay. Alright, got it.
Okay, I want to get into a couple other things related to popular strategies that folks are championing out there to increase your sperm count. But one quick aside because we’ve thrown this term around a couple of times, and that would be semen versus sperm. And, the reason I want to ask you this question is obviously semen is a little bit different than sperm. And, maybe you can explain the differences, but if a guy is ejaculating and noticing that there’s a certain healthy-looking volume of the ejaculate that they must be fertile because there’s a lot of stuff coming out the penis. So, therefore, the stuff must be working okay because you got a bunch of white milky fluid coming out. But correct me if I’m wrong, just because you can make a bunch of semen does not necessarily mean that your sperm are healthy, correct?
Amin: You’re absolutely right.
Ben: Is there a standard for the amount that most guys produce or does it widely vary as far as the volume of the ejaculate itself?
Amin: So, I’m quoting the World Health Organization the 5th Edition of their guidelines on what their reproductive counts should be. These studies that they perform were around 2,000 guys from different countries, different continents were able to see within 12 months of trying. When they looked at the bell curve for those guys and they looked specifically at their ejaculate volume, 1.5 mL was at the 5th percentile for them. So, as long as patients are above 1.5 mL, then it tells us that they’re in that 95% of guys at least in that range where they could be successful. But if they’re less than that, then it doesn’t mean that they’re infertile, it just means that their numbers are less and 5% of guys in that WHO study were less than 1.5.
We start asking questions when the volume is less than 1 mL. So, if the volume is less than 1 mL consistently, then we start looking at the ejaculate, go backwards into the bladder, or is it obstructed at a certain point. And, it leads us down a whole slew of tests that we start considering and talking about in order to delve a little bit deeper about why the ejaculate volume is not what it should be.
Ben: 1.5 mL for ejaculate volume. That’s somewhere right around the range of the size of a quarter or something like that, isn’t it? I think that’s about the approximation I’ve seen for guys who can’t picture 1.5 mL and instead need currency. What’s the other one you see thrown around? The size of a very, very small cube of cheese. But is that about what you’d be looking at like the size of a quarter or so?
Amin: Yeah. I think that’s a great analogy. I’ve never actually compared the two. But if I had to think back to the last time I saw somebody with approximately, I would say that’s fairly accurate.
Ben: Yeah. Guys, just a little tip for the relationship department. After you’ve made love, don’t take out the quarter right away to compare volume or anything like that, it ruins the moment. But maybe keep a quarter in your back pocket for later just to check.
Okay. So, let’s get into a few other strategies here. We talked about HCG, FSH, kisspeptin. We talked about CBD a little bit. When it comes to the mitochondria, obviously sperm have cells that contain mitochondria. I mentioned that one of the reasons people like this red-light therapy is based on the idea that it might increase the mitochondrial health of the Leydig cells in the testes. But another one that I’ve seen thrown out there quite a bit, and perhaps this is related to the mitochondrial health component as far as studies that have been done on fertility is coenzyme Q10. You looked into coenzyme Q10 at all?
Amin: Yeah. So, I do recommend it for guys with idiopathic. Meaning. we don’t identify a cause of their fertility. So, I will recommend it for that population, but I am more likely to recommend it if I know that there is another component of their infertility that is off. So, if they have a structural problem with varicose veins, if they have obesity, or if they have a known deficiency of CoQ10, then definitely recommend replacement.
Ben: Okay, got it. In women, inositol. Inositol is something that that several studies show can significantly increase ovulation and fertility rates. Have you seen any data on inositol supplementation in men as being something that would be effective at all?
Amin: Yeah. So, just a few studies, I think, on the topic of myo-inositol. They had guys over 45 years of age and they looked at their hormone levels and their gonadotropins, the LH, FSH, and it seemed as though when they were taking the Myo-inositol that their testosterone levels improved and also helped improve the semen parameters. So, it helped the morphology of the sperm and improve their concentration of sperm as well.
Ben: Okay. Got it. So, thumbs up on coenzyme Q10, thumbs up on inositol. What about astaxanthin? Astaxanthin is another one that I noticed a few decent studies out there for increasing pregnancy rate of couples and when the man was taking astaxanthin.
Amin: Yeah. So, the studies seem to be mixed on that one. There’s some that show no benefit and some that show improved motility and dropping the amount of free oxygen radical species that are around which would be very beneficial. And, the one study I think that I may have seen the same study as you that showed an improved pregnancy rate compared to those who weren’t taking it. But with small studies, everything has to be taken with a grain of caution.
Ben: Yeah, yeah. I mean, the nice thing about astaxanthin, I interviewed doctor–actually, she’s not a doctor, she’s just an author. Sandra Kaufmann who wrote a book about longevity and she kind of ranked prioritized based on studies all the different compounds that might be smart to take for the anti-aging and longevity compartment or component. NAD was pretty high on there. Curcumin was pretty high on there. I think spermidine oddly enough related to sperm is increasingly a popular supplement for men and women for just overall health and the anti-aging effect was up there. But astaxanthin was another one that kind of seemed to cover a lot of bases from an overall health standpoint. And, I mean in terms of that pregnancy rate study that I think both you and I saw, I think they’re only using 10 to 20 milligrams which is pretty standard for an astaxanthin dosage. So, that just might be prudent as something to throw into the mix and many supplements are including that now as well.
Zinc is one that pops up a lot as something that could potentially increase both fertility as well as possibly address low circulating testosterone. What do you think about zinc?
Amin: Zinc has been shown to have benefit but only when taken with folic acid. So, zinc alone, no benefit but with the folic acid, there’s been an increase in the amount of ejaculate volume. So, for guys who want to try to improve their ejaculate volume, they could try zinc supplementation with folate.
Ben: Okay. Why do you think the folate acid is a necessary component?
Amin: I’m not sure. Yeah, I’m not sure what it is about the folic acid that makes it be more functional perhaps in the turnover of cells. And, I think it is important in the turnover of DNA.
Amin: And so, that improves the DNA replication and efficiency of replication.
Ben: Okay, got it. Yeah, that’s interesting. A lot of times, zinc, in combination with the zinc ionophore is something that I know improved outcomes in hospitalized, the COVID patients. And, it seems that a lot of times zinc when combined with something seems to work a little bit better. So, zinc with folic acid. I suppose you could also just consume zinc and have a dietary source of bioavailable folic acid, I don’t know, like organ meats for something like that or liver extract. So, that’s another one.
And, by the way, guys, I’m a bigger fan personally just because I’ve seen some increases in homocysteine and inflammatory markers and guys who do a synthetic folic acid, more of that natural bioavailable folate such as you would find, something like organ meats or it’s typically listed as methyl tetrahydrofolate on a multivitamin instead of synthetic folic acid. That seems to be a better idea.
One other I was going to ask you about, doctor. And, that’s d-aspartic acid, d-aspartic acid, also a lot of times called DAA in the supplement realm. Is that one that you’ve seen much data on for increasing fertility?
Amin: I believe it’s just one study that I’ve seen in the past and it did improve the count and the motility, but just one study.
Ben: Okay. Alright, got it. So, theoretically, if you guys go to the shownotes, I’ll link to a lot of stuff, but you could probably, as you’re listening in, visualize some kind of a stack that you could try that might include CoQ10, inositol, maybe some astaxanthin, some zinc, some d-aspartic acid. Actually, there was one other study I just saw it come through last week because I subscribed to a lot of these digests that send you research papers related to a wide variety of topics. I think this one came through from the website Examine which is wonderful, and that was vitamin E combined with selenium. That increased a number of sperm parameters related to fertility in men who had low sperm motility or abnormal sperm morphology. Did you see that paper on vitamin E combined with selenium? Or, have you used much vitamin E or selenium?
Amin: Selenium, yes. Vitamin E, I think from what I’ve seen, the data has been mixed but perhaps there’s a newer study that I just haven’t come across. But selenium has some antioxidant properties to it that would be helpful to improve sperm concentration motility morphology and potentially even semen volume.
Ben: Yeah, okay. Yeah, I interviewed Dr. Barrie Tan from Designs for Health a couple of years ago about vitamin E, and there were so many benefits from muscle protein synthesis to testosterone to the antioxidant capability of a well-formulated vitamin E compound. He talked about the importance of having both your alpha tocopherols and tocotrienols. There’s four different tocopherols, and four different tocotrienols, and vitamin E, and a well-formulated vitamin E supplement. I think, it kind of covers a lot of bases similar to astaxanthin anyways. So, that’s probably not going to hurt you to at least look into something like that.
And then, and then there’s a couple of other things that I think are less common, Dr. Herati that might fall into the same category as cold packs on the balls. One is more of, I suppose, an ayurvedic or eastern strategy. And, that’s this idea of reduced ejaculation frequency, just basically either having sexual intercourse but not ejaculating or reducing the amount of sexual intercourse you have. I think the reasoning here on how scientific it is is that if you’re just basically wasting less sperm and less semen when you do ejaculate, it might be a higher quality, or by holding stuff back, you might increase your testosterone a little bit. Have you seen anything at all in terms of like reduced ejaculation frequency?
Amin: Yeah. So, we’re actually going the opposite way right now in our field. We’re recommending more frequent ejaculation and quicker turnover. And, really the main thing is that sperm concentration when it’s in a normal range or even sub-normal, it really doesn’t fluctuate that much with more frequent ejaculation and abstinence of longer periods doesn’t add much more to the concentration because there’s constant cell death and cell turnover, even in the reproductive organs that have sperm parked and waiting to go. The more rapid the ejaculation, the less the DNA fragmentation and the better the DNA health. And so, what we’re seeing is that when you study DNA fragmentation levels between guys who have less than a day abstinence or a day abstinence versus two days versus seven days that the DNA fragmentation is less in the more frequent. And so, one strategy that we sometimes use for guys with really high amounts of DNA damage on their sperm is to try around natural conception cycles to have intercourse as often as they can.
Ben: I could get behind that strategy. I like that better than reduce ejaculation frequency, which I tried for an article that I was writing just kind of looking at from an immersive journalistic standpoint, these objective effects. And, I found that it made me a little bit too amped up, a little bit grumpy, and I definitely didn’t enjoy sex as much obviously. That should go without saying. But I love it when you tell me that the increase ejaculation frequency could be helpful. That sounds like a far more pleasant way to increase fertility.
When I was working on that at that article, that was actually an article for men’s health magazine on male sexual health. One of the things that I did as part of that article, I actually call it a flak for this and still haven’t lived it down is I got a stem cell injection. Well, I did a stem cell injection into my penis and I also did a PRP injection as part of that. And, this idea of injection for erectile dysfunction or Peyronie’s disease or something like that. There’s obviously some literature that supports that approach. You’ve seen anything when it comes to actual injections though Dr. Herati for increasing fertility like the fringe number of guys who might actually go out and get a stem cell injection, or a PRP injection, or something like that?
Amin: So, I’ve had patients come from international locations who have come to see me and they brought paper showing PRP injection, which there is, I think, a rationale to it. I don’t recommend it because anytime you inject the testicles, you can introduce foreign objects that can lead to an infection, inflammation. And, that can lead to its own set of issues. But with some of these medications or agents, there can be growth factors inside that could be helpful. So, I think the jury is still out on this one and the total studies are done. It’d be hard to say yay or nay to it. But the growth factors could be helpful to them.
Ben: Okay, got you.
There’s a book out there. I think it’s called “It Starts With the Egg, The Fertility Cookbook.” I checked it out because whenever I’m going to interview somebody, I like to just see what’s floating around out there because obviously what’s floating around out there is what people are being told. And, sometimes podcasts like this can clear things up. That particular cookbook just basically appeared to be a bunch of Mediterranean diet type of recipes, which I think overall the Mediterranean diet seems to be a pretty healthy diet as long as it’s not the olive garden version with unlimited breadsticks and iceberg lettuce drenched in ranch.
But when it comes to dietary guidelines, I also mentioned I’m a huge fan of the Weston A. Price diet possibly due to the fact that that one just does a pretty good job not sending the body a message that it’s in starvation syndrome because it’s a bunch of full-fat milk products and wild fish, and fish eggs, and organ meats, and fermented vegetables and all sorts of pretty calorie-dense and nutrient-dense foods. But when it comes to diets or just foods that you might find yourself recommending frequently even though you’ve already established you don’t do a lot of that as a doctor is due to time limitations. Are there any particular foods, food groups, or diets that you see over and over again? You’re like, “Well, it’d be pretty prudent to include this stuff in your diet if you’re trying to have a baby.”
Amin: Yeah. So, I actually generally recommend the guys if they don’t have an identifiable structural problem affecting their fertility such as varicose veins, then if they’re thinking about the antioxidants and the vitamins to try the diet-based approach first. And, a diet rich in omega-3 fatty acid-rich foods like tuna, mackerel, salmon. Having walnuts, flaxseed, things like that replete in the diet, the body will take from it what it needs.
Amin: And then, if there is a structural problem, that’s when these vitamins typically come in. The risk with some of these antioxidant therapies is that sperm lose their cytoplasm, the portion of the cell that is around the nucleus and it sloughs it off. And so, it keeps a very small amount of oxidative species around and you need some amount of that oxidative species for sperm function. So, if you take the pendulum, you swing it the other way or you go from oxidative stress to reductive stress. You can actually hurt sperm function to some capacity. So, if the balance is really important and keeping that balance well-maintained is probably a better approach for a lot of guys. Now, there are some guys who definitely benefit from it and obviously, the studies are supportive of it. But as far as sperm functionality such as allowing the sperm tails to start whipping faster to be able to penetrate to the egg, that process sperm, and egg fusion, that is dependent on the reactive oxygen species. So, keeping that balance is really important and the cells that are the sperm cells don’t have the ability to counteract or produce any more of those ROS species.
Ben: Okay. So, basically what you’re saying is it sounds to me avoiding excess use of antioxidants so that you’re not completely suppressing your reactive oxygen species. Signaling pathways is something that you should think about. This reminds me of the studies that have shown that excess use of synthetic vitamin C or vitamin E in a post-workout scenario or extremely long cryotherapy or ice bath sessions after an exercise session, which would decrease the oxidative species to the extent to where you don’t get as much post-exercise, mitochondrial proliferation, or satellite cell generation, or muscle growth or anything like that. That would dictate that excess use of antioxidants related to exercise would suppress your reactive oxygen species signaling pathways too much. What you’re saying is that that would also be something that you may want to think about when it comes to fertility just because vitamin E and selenium is good, it doesn’t mean more or excess use is best.
Amin: Exactly, yeah. And, that’s why seeing a reproductive urologist is always a great idea. If there is something that can be identified, fine-tuned structurally, hormonally, and then to supplement it with the vitamin approach is oftentimes a really good strategy to try to do it all with dietary can perpetuate the problem and maybe even compound the problem.
Ben: Yeah, yeah. I found one interesting article that went into different foods that actually have been studied and/or looked at or different dietary approaches. And, the main thing that I saw over and over again was making sure you get adequate protein, which I just did a big podcast on protein. That one’s pretty straightforward and probably related to that idea that we’ve already, a horse we’ve kicked to death related to not sending the body a message that it’s in a protein-restricted or calorie-restricted scenario, folic acid, really good sources of folic acid. Beans and legumes are pretty high up there. And, you already mentioned that folic acid and zinc would be good. Some of these foods that are higher in zinc like sunflower seeds and pumpkin seeds. Avocados come up. There’s this idea based on the doctrine of signatures that things in nature that look like something might actually be good for that particular body part. So, people say, well, avocados look like the gonads. And, it turns out avocados have a lot of folic acid. They get a lot of monounsaturated healthy fats. They got vitamin K, they got potassium, they have a lot of things that might influence fertility.
Have you ever come across that idea that there are certain things in nature that look like the testicles or that might look like a pair of ovaries and therefore they might be good for fertility?
Amin: That’s very interesting. Aphrodisiacs sometimes have phthalic shape or the shape or consistency of a testicle or the structure of, I guess, the female reproductive tract. And, that’s always considered as an aphrodisiac and something that would stimulate drive. But as far as the correlation between the shape and the benefit, I haven’t seen that before.
Ben: Yeah. Well, one other I’ll throw in there for you guys, a wild-caught salmon. Wild-caught salmon is chock full of selenium. It’s got natural levels of astaxanthin in it. It’s got fat-soluble vitamins like vitamin D and vitamin E. So, that’d probably be a pretty good protein staple in your diet as well. So, there you have it, folks. have Some wild-caught salmon, have some guacamole, maybe throw in some beans and lentils, pumpkin seeds, sunflower seeds, a limited amount of antioxidants like small berries or walnuts or things like that. And, I don’t think that it’s necessarily rocket science to eat healthy for fertility. I think that really for a lot of guys who I talk to, it comes down more to avoiding a lot of those environmental variables that we talked about. So many guys just won’t stop putting their cellphone with the Wi-Fi turned on in their pockets hitting the sauna and not changing out their personal care products or household cleaning chemicals. And, I just think that it seems to me it’s more of an issue of more things needing to be omitted for a lot of guys rather than yet another pill to pop or supplement to take.
We talked about this company Dadi that you work with Dr. Herati, which from what I understand because I sent my kid in, you ejaculate into this little box that gets sent to your house and then I send it off to you guys. Now, you guys analyze sperm, first of all, or that this company Dadi analyzes sperm, what are they looking at when they analyze sperm? What does a semen analysis report actually tell somebody?
Amin: Yeah. So, the company will issue a semen analysis and send that back to whoever is submitting a sample to them. And then, you can go through that analysis and find a lot of good information. A typical standard semen analysis report would tell you the ejaculate volume, the concentration of sperm, seeing the motility of the sperm, how well they’re moving, whether are they moving, are they moving forward or not. The shape of them, the morphology of them, and then tell you if there are other types of cells that may be present such as white blood cells or neutrophils that would be suggestive of an infection or prostatitis.
The hard part with the semen analysis is that we sometimes get couples that come in and they say the semen analysis looked normal, husband never got checked, your male partner never got checked. He wasn’t deemed to have a problem, but then when you look a little bit deeper, he did have some structural things or had something in his lifestyle that was impacting the DNA, the sperm, which isn’t always as visible on semen analysis report. And, the semen analysis report is the 60,000-foot view of the forest and then the individual trees are obviously more important. And, the DNA quality within the sperm isn’t always indicated by the semen or sperm but it gives you very good information. The more semen parameter abnormalities that are identified, the more likely there is a problem. And, this is something that Dadi will issue with their sample whenever it’s sent in that they’ll analyze the semen parameters and then that can be turned back around to the male partner so that he can see what his numbers look like and be able to take that back to their physician, reproductive urologist and say, “How do I make heads and tails of this? Do I need to check for anything? What does all this mean?”
Ben: Okay, got it. Do you just get a PDF mail to you or something with that analysis of your semen?
Ben: Okay. Alright, got it.
So, what would be other reasons that a guy would actually send in? I mean, obviously, the storage component makes sense like you just store it so that when you want to use your sperm at a later dates, you could actually use it. But are there other reasons that a guy would actually deposit and store and freeze his sperm with a company like Dadi?
Amin: Yeah. So, that brings me to how I found Dadi myself. One of the things that I’m very passionate about is advanced paternal aging and the effects it has on the genetics of sperm. And, one of the strategies where you can avoid all of the negative effects, of all the exposures, environmental exposures through all the endocrine structures, and EMF, and et cetera, et cetera is to bank sperm early. If you have a campaign where you have 18 to 22-year-olds who bank sperm, put it away, you can potentially avoid a condition called secondary infertility or even primary infertility where primary infertility being couples have never had a child and secondary being couples who have had a child but are having trouble with the [01:20:43]____ child because male/female age has advanced or a new condition has set in. So, you can do away with a large portion of fertility if guys are more proactive in freezing their sperm.
And so, I had reached out to the leadership at Dadi and I said, hey, I’m really interested in this and I’m interested in getting the message out there. And, I think what you guys are doing is fantastic because you’re giving guys who don’t want to go to a lab and go through the formal process of going to a lab in an exam room, it’s very awkward. To be able to do this at home would open up the opportunity for young guys to put away some sperm and keep it as an insurance policy. So, if God forbid something changed down the road, they were involved in a car accident, they developed a malignancy, they had to go through X, Y, Z medication, they don’t have to think about it because they have healthy young sperm that hasn’t gone through all the genetic stress that somebody who is 45, 50 years of age has had inflicted on their sperm.
So, that’s my segue into the company and that’s how I reached out. And, that’s why I reached out and that’s how the union formed for my advisorship was that passion. So, this is actually a great platform. I appreciate you inviting me on to speak about this because I really am hoping to get the message out there that more people should consider this at a young age.
Ben: Yeah, yeah. I’m one of those guys who believes that children are a blessing from God and that when you decide you’re going to have kids, you’re never quite feel fully ready. If you wait until you’re ready to have kids, kind of similar if you wait until you feel you’re fully ready to get married, you’re probably going to be waiting a while. Sometimes you just got to do it. But at the same time, if you’re 20 years old incredibly healthy, virile, fertile and maybe you just got married and you want to just go globetrot for a couple of years with your wife and enjoy some time with just your wife until maybe you’re on 25 or 30 or whatever, it seems banking your sperm and storing would be a good idea from that standpoint. And, also just for generally having that peace of mind that you got something kind of just waiting for you and ready should you need it.
And, I would imagine if I have my sperm, because I’m going to store my sperm with you guys, and if I store it and I want access to it, how’s that actually work? Because I’ve stored my stem cells down in Florida before and I literally can just call them up and have them. It cost me 200 bucks. They can ship with a doctor and that doctor can then inject those stem cells into joints or do an intravenous infusion for anti-aging or what have you. Is it similar with the sperm? Would I just call or email Dadi and say, “Hey, I’m ready”? And, they send my sperm up, is that kind of how it works?
Amin: Yeah. So, there’s a partner lab that has the cryogenically stored sperm. And, the team of Dadi can help ship that sample out to wherever you like it to be sent to.
Ben: And, at that point, I mean logistically, if you get it shipped to your house, you’re just using a horse baster with your partner. How’s that actually work logistically?
Amin: And so, I wouldn’t recommend that because usually the sperm and oftentimes in a precious commodity and not something that you’d want to not give it the optimal opportunity for it to have the best effect. But typically, with these cryogenically stored, they have to go through a thaw cycle. So, they have to come out of the liquid nitrogen, be thawed to room temperature. And, there’s a protocol that labs use to do that. And then, that either can be sectioned out into really small amounts to do IBF or can be used for a process called intrauterine insemination which is that turkey baster that you’re referring to. It’s a little casual.
Ben: Yeah, I think said horse baster. I meant to say turkey baster, folks, turkey baster.
Amin: And, that can be advanced up into the uterus and then the ejaculate can be passed into the uterus.
Ben: Do folks do at home or I assume they go into a clinic to have something like that done?
Amin: In a clinic, yeah.
Amin: You wouldn’t want to really handle liquid nitrogen.
Ben: Yeah, yeah, I wouldn’t imagine, especially not in the bedroom with romantic jazz music playing in the background as you take out your box with your cryogenically stored sperm and your turkey baster. I feel that might eliminate a little bit of the romanticism from that scenario.
What about storing? Should you store more than one sample? Is that prudent?
Amin: I’m with the mindset that it’s a good idea to have a couple samples frozen. And, most labs will divide the sample out into different vials held in different tanks. So, God forbid, if the tank goes down for whatever reason, there’s a backup but more vials, more opportunities for more IUI cycles is the way I see it. If you have only one vial and God forbid something happens to a male partner, gets chemotherapy, he loses the ability to produce his own, then that amount saved is what he has. And, there is unfortunately with each freeze and thought cycle decay of sperm.
Amin: So, we see some cases have two or two-thirds don’t make that life cycle of being able to go through freeze and thaw. But still, the more you have, the better the outcome is.
Ben: Yeah, yeah. And, I think with Dadi, I believe it’s around 200 bucks. You get your year of free storage, you get your semen analysis report. And then, I think there you guys have a slightly more expensive version where you can do like additional storage, additional kits, et cetera, et cetera. So, it’s not that expensive but I agree that storing more than one sample. I did the same thing with stem cells. I have all my fat stem cells harvested and stored with the U.S. stem cell clinic. I have all my bone stem cells stored with Forever Labs in Berkeley. So, I’ve got a couple of backups should I need it.
I’ll put a link to all this stuff. You guys can also go to BenGreenfieldFitness.com/Dadikit. That’s BenGreenfieldFitness.com/D-A-D-I-kit. It’s kind of cool. This little blue box comes to your house, it’s got all the instructions. You do your deposit and then you ship it off same day or it’s actually got to bring it to a FedEx ship center or do a FedEx ship center. And then, I have a code that’s $20 off. They gave me a code. It’s BEN20 get you $20 off at BenGreenfieldFitness.com/Dadikit. That’s D-A-D-I-kit. And then, the shownotes for this particular interview, you’re going to find at BenGreenfieldFitness.com/D-A-D-I.
Now, the Dadi Kit, folks, they actually have a really great blog where they have a whole bunch of fascinating articles that delve into other aspects of fertility like one recent one that I read was that sperm concentrations are highest in the winter. There’s actual seasonal variations in sperm count in men which was super interesting. Another one found that watching TV more than 20 hours of TV weekly resulted in a 44% lower of sperm count compared to guys who didn’t watch that much TV. They’ve got the ultimate guide to semen, the ultimate guide to sperm. So, useful website anyways. But related to all this information, just while I have you on the call, Dr. Herati, is there anything else that you would love just while you’re on this platform talking to a whole bunch of people to share about fertility that you haven’t had a chance to share yet in our discussion?
Amin: Yeah. For me, the main thing was to encourage people to make the lifestyle changes that they need to take their health seriously to get checked out. A lot of times fertility, as we talked about before, is the barometer of a man’s health. And, when there are changes in fertility, there’s a higher likelihood of developing other conditions down the road. So, if there is a problem with fertility get checked out and be seen, go through the motion, it’s sometimes uncomfortable to think about going to a doctor’s office to talk about fertility something so intimate. But it’s not a condition that should be taken in isolation like that. It’s something that there are reproductive urologists that are very sympathetic to the condition and are happy to see and evaluate and screen for all these other conditions. So, it’s something that I would encourage guys that are listening. And, women if they’re listening to send their male partners over to get checked out early and often.
Ben: Yeah, yeah. And, you guys have had a super helpful team. You made it pretty simple. And, I realized for you ladies listening in, I mean, you can forward this to the male in your life who you would like to see stepping up their game in the fertility department. I fully understand that we stayed pretty one-sided when it comes to which sex that we were speaking to on this podcast. There’s a lot of information out there. I think more information at least from what I’ve seen in the podcasting realm for female fertility and endocrine balance than for males. And so, selfishly enough, I’m also a dude, so I had a whole bunch of questions in the back of my mind I wanted to ask Dr. Herati. So, I think this has been super helpful.
So, what I’m going to do in the show notes at BenGreenfieldFitness.com/D-A-D-I is I’m going to link to a few things. I’m going to link to some studies that we talked about that take a deeper dive into a lot of the different drugs that’ll have an impact on male fertility. I would recommend that if you are using any pharmaceuticals or any drugs, you go and review that list. I’ll link to some of the other research articles that we talked about related to CoQ10, vitamin E, et cetera. I’ll link to the previous podcast I did with Adam Wenguer where we talked about all the different kind of fringe stuff that he was doing for fertility and some of our discussion about things like kisspeptin, and FSH, and HCG, and things along those lines. And, that’s all going to be at BenGreenfieldFitness.com/DADI. That’s BenGreenfieldFitness.com/D-A-D-I where you guys can also leave your own comments, questions, feedback, things that you’ve found, studies you’ve noted that maybe we didn’t get to, et cetera. Just don’t go sit in a hot tub or a sauna while you’re reviewing the shownotes, alright. Do it in a cold bath or with these ice ball packs applied. And, we’ve established that would be prudent.
Dr. Herati, thank you so much for coming on the show and sharing all this stuff with us.
Amin: Thank you for having me. This is wonderful.
Ben: Yeah, I agree, I learned a ton. So, go to BenGreenfieldFitness.com/D-A-D-I for the shownotes. Go to BenGreenfieldFitness.com/D-A-D-I-kit if you want to order your kit, you can use code BEN20 for 20 bucks off. And, until next time, I’m Ben Greenfield along with Dr. Amin Herati signing out from BenGreenfieldFitness.com. Have an amazing week.
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I get asked a lot of questions by both males and females about fertility (or, perhaps more accurately, infertility), including how to increase sperm count, how to store and freeze sperm, the best diets and supplements for fertility, and much more.
So I decided it was high time I recorded an episode for you fellas who want your swimmers just a bit more dialed in, and for you couples who may be wanting to conceive. Dr. Amin Herati, MD is an Assistant Professor at the James Buchanan Brady Urological Institute and works at the Johns Hopkins Hospital. where he is the Director of Men’s Health and Director of Male Infertility. Dr. Amin Herati is also an advisor to Dadi, the leading at-home male fertility services company for sperm testing and storage. He is active in basic and clinical research with an interest in the fertility of patients with spinal cord injury, the genetic basis of male infertility, hypogonadism, and pelvic pain syndromes.
According to the Mayo Clinic, problems with male fertility can be caused by a number of health issues and medical treatments including:
- Varicocele. A varicocele is a swelling of the veins that drain the testicle. It’s the most common reversible cause of male infertility. Although the exact reason that varicoceles cause infertility is unknown, it may be related to abnormal blood flow. Varicoceles lead to reduced sperm quantity and quality.
- Infection. Some infections can interfere with sperm production or sperm health or can cause scarring that blocks the passage of sperm. These include inflammation of the epididymis (epididymitis) or testicles (orchitis) and some sexually transmitted infections, including gonorrhea or HIV. Although some infections can result in permanent testicular damage, most often sperm can still be retrieved.
- Ejaculation issues. Retrograde ejaculation occurs when semen enters the bladder during orgasm instead of emerging out the tip of the penis. Various health conditions can cause retrograde ejaculation, including diabetes, spinal injuries, medications, and surgery of the bladder, prostate, or urethra.
- Antibodies that attack sperm. Anti-sperm antibodies are immune system cells that mistakenly identify sperm as harmful invaders and attempt to eliminate them.
- Tumors. Cancers and nonmalignant tumors can affect the male reproductive organs directly, through the glands that release hormones related to reproduction, such as the pituitary gland, or through unknown causes. In some cases, surgery, radiation, or chemotherapy to treat tumors can affect male fertility.
- Undescended testicles. In some males, during fetal development one or both testicles fail to descend from the abdomen into the sac that normally contains the testicles (scrotum). Decreased fertility is more likely in men who have had this condition.
- Hormone imbalances. Infertility can result from disorders of the testicles themselves or an abnormality affecting other hormonal systems including the hypothalamus, pituitary, thyroid, and adrenal glands. Low testosterone (male hypogonadism) and other hormonal problems have a number of possible underlying causes.
- Defects of tubules that transport sperm. Many different tubes carry sperm. They can be blocked due to various causes, including inadvertent injury from surgery, prior infections, trauma, or abnormal development, such as with cystic fibrosis or similar inherited conditions. Blockage can occur at any level, including within the testicle, in the tubes that drain the testicle, in the epididymis, in the vas deferens, near the ejaculatory ducts, or in the urethra.
- Chromosome defects. Inherited disorders such as Klinefelter’s syndrome — in which a male is born with two X chromosomes and one Y chromosome (instead of one X and one Y) — cause abnormal development of the male reproductive organs. Other genetic syndromes associated with infertility include cystic fibrosis and Kallmann’s syndrome.
- Problems with sexual intercourse. These can include trouble keeping or maintaining an erection sufficient for sex (erectile dysfunction), premature ejaculation, painful intercourse, anatomical abnormalities such as having a urethral opening beneath the penis (hypospadias), or psychological or relationship problems that interfere with sex.
- Celiac disease. Celiac disease is a digestive disorder caused by sensitivity to a protein found in wheat called gluten. The condition may contribute to male infertility. Fertility may improve after adopting a gluten-free diet.
- Certain medications. Testosterone replacement therapy, long-term anabolic steroid use, cancer medications (chemotherapy), some ulcer drugs, some arthritis drugs, and certain other medications can impair sperm production and decrease male fertility.
- Prior surgeries. Certain surgeries may prevent you from having sperm in your ejaculate, including vasectomy, scrotal or testicular surgeries, prostate surgeries, and large abdominal surgeries performed for testicular and rectal cancers, among others.
Overexposure to certain environmental elements such as heat, toxins, and chemicals can reduce sperm production or sperm function. Specific causes include:
- Industrial chemicals. Extended exposure to certain chemicals, pesticides, herbicides, organic solvents, and painting materials may contribute to low sperm counts.
- Heavy metal exposure. Exposure to lead or other heavy metals also may cause infertility.
- Radiation or X-rays. Exposure to radiation can reduce sperm production, though it will often eventually return to normal. With high doses of radiation, sperm production can be permanently reduced.
- Overheating the testicles. Elevated temperatures may impair sperm production and function. Although studies are limited and are inconclusive, frequent use of saunas or hot tubs may temporarily impair your sperm count. Sitting for long periods, wearing tight clothing, or working on a laptop computer for long stretches of time also may increase the temperature in your scrotum and may slightly reduce sperm production. But, the research isn’t conclusive.
Some other causes of male infertility include:
- Drug use. Anabolic steroids taken to stimulate muscle strength and growth can cause the testicles to shrink and sperm production to decrease. The use of cocaine or marijuana may temporarily reduce the number and quality of your sperm as well.
- Alcohol use. Drinking alcohol can lower testosterone levels, cause erectile dysfunction and decrease sperm production. Liver disease caused by excessive drinking also may lead to fertility problems.
- Tobacco smoking. Men who smoke may have a lower sperm count than do those who don’t smoke. Secondhand smoke also may affect male fertility.
- Weight. Obesity can impair fertility in several ways, including directly impacting sperm themselves as well as by causing hormone changes that reduce male fertility.
Dr. Herati is on the cutting-edge of male infertility research and treatment. He believes in an individualized approach to care that addresses the whole patient, and, as such, invests significant time into building a rapport with his patients so that they feel comfortable opening up about these issues, allowing him to accurately identify and manage each patient’s needs.
During this discussion, you’ll discover:
-Is infertility a genetic issue to any degree?…07:27
- Gene and epigenetic mutations passed on through generations
- Lifestyle factors that affect fertility are marked on DNA and passed on to future generations
- Our health is a factor of our ancestors’ health
- A simple 23andMe test wouldn’t ID such mutations; there are 3,000-4,000 genes involved in sperm production
- The surface of identifying gene mutations that affect fertility has barely been scratched
-Why infertility is more an issue among men in recent history than generations prior…11:03
- Men are more prone to hesitate to seek help when there are fertility issues
- Fertility is a barometer of a man’s health
- Study: New Insights Into The Genetic Basis Of Infertility
- Nature doesn’t want sick people to make babies
- Low testosterone is related to a higher risk of prostate and reproductive health issues later in life
- If under 35 and no success after 12 months (6 months if over 35), test both partners, not one or the other
- Environmental endocrine disruptors – cleaners, chemicals, etc.
- Genetic info is transmitted up to 3 generations
-Environmental causes of infertility…21:30
- Chemicals, cleaners
- Herbicides, pesticides
- Cleansing agents and wipes containing benzalkonium chloride
- The End Of Alzheimer’s by Dr. Dale Bredesen
- Podcast with Adam Wenguer where we discuss infertility:
- Radiation and x-ray exposure
- Varicose veins may be a sign of infertility
- Non-ionizing radiation such as computers and cell phones can flip the polarity of cells
-Testosterone replacement therapy and its effects on fertility…31:15
- Exogenous testosterone injected into the body can negatively affect the hypothalamus and pituitary gland
- Drops LH and FSH (luteinizing hormone and follicle-stimulating hormone)
- HCG is analogous to luteinizing hormone
- Nasal testosterone is not as disruptive as HCG
- Jatenzo oral testosterone
-Injectable peptides to regulate male fertility hormones…39:45
-Does a cool crotch affects one’s fertility levels?…44:50
-The effects of alcohol, tobacco, and drugs on fertility…48:50
- The impact of drugs on male fertility: a review
- Marijuana affects testosterone levels and fertility
- 50-60% reduction in testes size for users of THC marijuana
- 2/3rds of sperm produced never make their way out; poor quality sperm gets out if using weed
-Monitoring diet and food allergies in relation to fertility…53:10
-Why plenteous semen doesn’t always equate to abundant sperm…56:05
-Strategies for enhancing fertility…59:40
-Why the experts are recommending you cum more frequently…1:06:37
- Constant cell death and turnover
- The more rapid the ejaculation, the better the DNA health
-Diets or foods recommended for fertility…1:09:15
-How to proactively take care of business, even if you’re not ready to have children…1:18:25
- Advanced paternal aging, the effects on sperm
- Avoid secondarily infertility by banking sperm early-late teens early 20s
- Store sperm with Dadi
-And much more!…
Resources from this episode:
- Dadi (use code BEN20 to save $20)
– Podcasts And Articles:
– Other Resources:
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–Seed Daily Synbiotic: A formulation of 24 unique strains, each of which included at their clinically verified dose, to deliver systemic benefits in the body. Save 15% off your first month’s subscription when you use discount code BEN15.