Paul Turek
Appearances
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And 98% of sperm are typically normal. In a guy with infertility, it might be 95%. Here's an example. If you have a patient with Klinefelter syndrome, a male with an extra X chromosome in every cell in their body, or a transgenic model with that feature.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Okay.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
That's the MCAT question. Yep, yep. All right. So in these men, if you look at their sperm aneuploidy, right? So every cell in their body and in the mice, in the transgenic mice, all have an extra X chromosome. Only about 10% will have it in the sperm.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
That's math, Peter. That's math. Biology is not math, remember? And I had two Kleinfeldt patients yesterday that I operated on, and they're not doing pre-implantation genetic diagnosis of the embryos that they're going to create from their sperm because the chance is not that high. So it goes from, in mice, 0.1% chance of normal men having XXY sperm or an aneuploid sperm, an abnormal sperm, to 1%.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
In humans, it goes from 1% or so to 10%. But 90%, that's remarkable. That's amazing. It's remarkable how efficient this is.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Yeah.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
We don't know is the answer. Right. And it's interesting that ovaries are inside. So men get in hot baths and they're cooked.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Spermiogenesis is when You go from the round cell stage and you get half the number of chromosomes and then you have to make a tail and then a whole motor assembly. And that is the most profound transformation of a cell in the body. It takes about three weeks to go from that stage. And we're learning now it's a lot of it's vitamin A driven. Three weeks? Of the six or seven to make a sperm.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Then it's complete and non-modal and it's packaged.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And then the tail makes it... 35 micron tail, yeah. So really magnificent engineering feat. It's got microtubules in the middle and there's these links to the tail. It's like a kite and the engine runs it and the tail wags. Remarkable. 300 genes control movement of sperm alone. There's mitochondrial DNA in there, all that stuff.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
It's just wildly compact, 10 times more compact than any other cell in the body. From a mitochondrial density standpoint? From a cytoplasmic standpoint and nuclear standpoint, it goes from histones, the protamines, the DNA is condensed a lot more because it's got to go on the road.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So it's got to be packaged really well to survive outside the body and be in good shape because it's transgenerational. So a lot of energy in that. And then during the epididymis, which is a collecting duct.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So that's going to bring the physics in. So then there's a two-week period where it stays in the epididymis, which is a 35-foot tubule with estrogen, and there's a lot of post-modification of the sperm.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Epididymis has been relatively understudied, but it has actually become very important. Epididymisomes, and there's a lot of modifications we don't really understand. I wrote the chapter for our textbook on reproductive physiology, and it really is a lot of work in the 50s and 60s, but now we're beginning to understand epididymis.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
DNA fragmentation and the quality of sperm is driven by the epididymis. A lot of the quality of sperm, not the shape and stuff like that. Meaning based on its residence time within the epididymis? And what other environmental influences that occur there? Because the epididymis is not as walled off from the body as the testis is. immunologically and otherwise.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
It's more susceptible to drugs, exposures, heat, et cetera. Testis is very walled off. Very little happens in the testis because the sertolo cells that line the tubules have a blood-brain barrier, a blood-testis barrier. Same as the brain, it's highly protective. It's as protective? Yes.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Harvey Cushing at Yale did that in the late 18th century, took brain-dead patients, injected them with dye, methylene blue, I think, The blood-brain barrier came about when nothing went into the brain and nothing went into the testicle. Two areas of the body that were completely immune from normal transport processes. Wow. Blood-testis barrier.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So the two things that we know happen in the epididymis after production of sperm are motility improves. So sperm begin to learn progressive motility. So they start moving forward as opposed to not moving or moving in circles, which is important. And the most curious thing is they learn how to smell.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So they actually detect follicular fluid. So if you take testicular sperm and inseminate it into a uterus with insemination technology, it'll just be killed. If you take an epididymal sperm and you do that from the top of the epididymis, it'll maybe run in circles and it'll be killed by the immune system of the female. It has to go through that whole epididymal cycle.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Once it's at the end of the epididymis where it's stored. And that's how many weeks? Two, 10 to 14 days. 600 million sperm live in a bucket, a pot of soup to call it epididymis. And you ejaculate from that pot, which tells you a lot about sperm quality because it can get old.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
But that sperm, if you put in it, will know exactly where to go and it'll move forward because it's like a shark sensing blood in the water. One part per billion of follicular fluid can be sensed by a sperm. That's incredible. It's literally an olfactory sense. It's a smell sense that sperm have for particular food.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
It was published in Nature recently and stuff like that. So it's really interesting. It's an olfactory type receptor.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Is there any smell, Peter?
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And I'd also say that if you block a sensory bank of the five, others increase remarkably like braille. I'm a microsurgeon. This stuff matters a lot, but I can't do braille or hearing. I think you can crank it up if you lose a sense and you see that with people who are deaf. Your ability to see and I don't think seeing better is really the issue, but hearing and smell, I think it can crank up.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So that's a great extrapolation of the pot of soup idea. And so on that note, I would say... Typically, we recommend two days of abstinence, sex every other day.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
But not for the semen analysis. That's for conception. Depends how old you are in your biology, but most men need a day or two to recharge completely, a day or two. That's why we recommend that. That's sort of a generalization. Some men are fine every day. I had a guy once who had to bank sperm for hepatitis treatment. And he was like Mickey Rourke, and he had a wooden leg, and he was about 50.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And I said, you're going to need to abstain for a couple, three days to do this semen analysis so we get a good sample. I want it to be an optimized one. And he looked at his partner, and she looked at me, and she grabs him and says... he can't do that. He's every day. He can't do that. I'm always going to do. So he's like, he was panicking that he had to hold off for a day.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
I said, how often do you have sex? He said, twice a day, every day. I'm like, okay, that was great. Then I had one man, wonderful orthopedic surgeon at Stanford. And I asked him on my questionnaire, I said, how often do you have sex? And he wrote 0.00001356. I was like, He divided once a year. 0.00 weekly, 0.00155, Avogadro's number, right? Which meant he was so frustrated.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
A beautiful way to say that was the 0.001355. So anyway, for a semen analysis for diagnostics for infertility, when you abstain longer, your sperm count will rise.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
When you're not going to gain that much, you're not going to lose that much motility after that. So there's biological variability, which we try to minimize when we do the semen analysis. So two to four days of abstinence. That's a different period than what we're recommending for sex, which is every other day.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And that's based on the New England Journal paper where they looked at, I think, 700 couples and they had them keep diaries. It was a Boston-based paper. Keep diaries of how they had sex, when they ovulated, and when they got pregnant. And then they said, do what you normally do and then give us the diaries.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And then they evaluated them and they found that having sex, say ovulation is day 15 of the cycle. When they started having sex on 9, 11, 13, there were significant pregnancy rates. And every other day was the optimal interval. But even five days before and three days before, there were substantial pregnancy rates. before ovulation.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
But if you waited to ovulation and then had sex, that's about 20% of conception. So when you get the kit, don't react to it. Predict in front of it. So front load the sex. Very important. And why is that? Is that because... There's a reservoir effect in this uterus. It's managed. Sperm will survive for a day or two.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Remind me where the oviduct is. So there's the uterus and the fallopian tubes.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And that's the oviduct. The oviduct is right below where the ovaries sit.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
They bind to the endothelium and just park.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
80% of conceptions naturally or at home occur when sex is front-loaded as opposed to reacting to ovulation. And most of the apps that are available nowadays will tell you that. Peter, you're drawing a graph. I am. I have to draw.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
There was a study that showed how long it took to make a sperm. And it was published in Science, I think, in the 60s. And they gave men tritiated water. They gave men radioactive hydrogen. And then they biopsied their testicles, which could never be done nowadays. But I did it all different. I gave deuterated water with a group at Berkeley, and we gave healthy men deuterated water for a week.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
That's wild. But that was the best data. And we did deuterated water, which is not radioactive, and we could measure that. So we gave them a dose and then we watched their ejaculates weekly. And we looked for when deuterated, the hydrogen showed up in the DNA. And it was an average of 74 days. So normally say three months to make a sperm.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So some went for 42 days, and that's going through the epididymis and getting ejaculated. We talked about maybe two months in the testis and two weeks, a week or two in the epididymis, and then maybe a couple of weeks to ejaculate. And this was all the average 74 days. So it actually changed the timeline enormously to a much faster one. So 74 days.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So when you do anything to a man fertility wise, you're not going to expect to see anything change for at least two and a half months. And when you talk about full replacement of that semen, it's probably in the being 90 days when it's all replaced, the pot is replaced. That's a limitation of what we do. 42-year-old women want now. And we have three to six months.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
When I did a study on fixing varicoceles, which is an infertility problem in men at surgery, and I looked at the mean time to conception, it was about seven months after repair, which is two cycles of sperm production.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Okay. Doesn't have to be timed intercourse, just has to be whatever the couple does when they think they're trying to conceive.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
There's a large bias in Western worlds about how infertility is evaluated. The reasons are complex, but I would say my practice is not typical. So most of my patients have been through a lot before they come to me. And typically, I think Keith Jarvie's data was good at about 23% of men get a formal evaluation for infertility before couples go through IVF in North America.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And how does that differ from the rest of the world? I don't think it's been studied in the rest of the world. But there are countries like Germany and Spain with single insurers and government pays. And it's also recommended by society guidelines like American Society of Reproductive Medicine, WHO, et cetera, that both partners get evaluated simultaneously.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
But the bias is female gets very evaluated for lots of money. And the men typically may get a semen analysis, but may not. And it's very complex reasoning there. It's a different beast. They're not part of the problem. They refuse to do it. There's a lot of denial. It does get at your masculinity a little bit to get checked out and things. So it does go deep.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
For men, it can be a little bit of a problem. So I would say that lately with... large insurers coming in, Progeny, Maven, and things like that, you're seeing a lot more men up front, which is fabulous. And we can have long discussions about the biomarker concept, why that's good for the field and good for men's health and good for longevity.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Usually they're dragged in by their partners. Usually the partners come along to make sure they show up. For me, it's one visit. So we do one visit and I do everything else where they are, where they are. I don't ask them to come in a million times anymore. So it's a very different kind of practice.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
But I try to get everything done in one visit because when you get them there, it's rare to get them there. And the physical exam, so you do a history, a very thorough history, which is usually preceded by a questionnaire. I give 200 questions and that has all the hot bath stuff and all the exposures they have. And they have to do that before they see me. That's a really important part of it.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
If you could pick one in a multiple choice question, what matters the most is probably the history. History of paternity matters, a history of exposures matters, et cetera. Physical exam, very important. One to 5% of male infertility can be due to a major medical issue, testis cancer, diabetes, things like that. So physical exam, varicoceles, is very important.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
You could be missing a vas deferens. One in 500 men have perfectly normal testicles, but they have a natural vasectomy. It's congenital absence of the vas. They're going to be sterile or infertile.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
It's about 10% vasofluid with sperm. It's about 80% seminal vesicle fluid, which is an accessory sex gland in the back of the prostate, and about 10% prostate. So typically during ejaculation, prostatic fluid, which is clear and sticky, will grease the barrel of the urethra pre-cum.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Then during the ejaculation process, the pellet of sperm gets pumped from the vas deferens into a chamber called the ejaculatory duct. And this happens quickly. And then the seminal vesicle, which is like a bladder, contracts, sends it into the prostatic urethra between the bladder and the outer world. There's two valves. One is the bladder neck. It closes.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And one is the urethral sphincter that we pee through. And that opens.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So in 3,000 men I've done vasectomies on in 30 years, two men have said, my volume went down. And I said, really? One of them banked sperm, and he had a semen analysis before and after, and he did go down by 15%. And he noticed it, and I said, good for you. What do you want to do now? So it can be noticeable, but not usually.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And so the color is the same, the opacity is the same, the whole process of liquefaction is the same, viscosity, et cetera.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So my fingers can feel two and a half millimeters The vas deferens is like a piano wire. I mean, it is different than anything else in the cord. I did a study, a third of my men with absent vas were only found out having procedures until I saw them. I usually just do the exam, but it is an expertise thing. Yeah, it's not like the PCP can figure this out.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So reproduction is an incredibly highly evolved million-year process and remarkably conserved among mammalian species, even among land species and water species of animals. vaginas, cervixes, uteruses. And the question is, why is it so much work for a sperm to get into the vagina, especially in, say, water, and then have to go through a cervix?
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
You have to be doing this all day, every day. Yeah, I think you need to be trained on that. But if you're well-trained, it should be purely a physical exam.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
The most common genetic disease in America is cystic fibrosis. So the big implication is these men can't conceive naturally. They have a natural vasectomy. We use sperm retrieval techniques and IVF. but they definitely have the chance of passing on cystic fibrosis to a child. Why is that?
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
It's a very interesting biology, but men with cystic fibrosis, the most common genetic disease in America, have no vas deferens.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
It's a chromosome 7. There's 1,700, 1,800 mutations, maybe 2,000. So they cloned the genes and got the variants in the late 80s. And then they found that there's another group of men who are perfectly healthy, do not have cystic fibrosis, which is a major metabolic disease with a short life expectancy, better now. Those men had absent vas deferens in the absence of disease.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
They took the gene sets and looked at them, and they were the same, just not as many. So you have homozygous or heterozygous. So you have a carrier for cystic fibrosis will have an absent vas, but a full-blown CF patient, cystic fibrosis patient, will have no vas deferens too. So it's a form fruit of cystic fibrosis, but it doesn't have all the chemical and metabolic side effects.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Yeah. And then you have to worry if there's a 4% chance in America anyway that a partner might carry it. There are two carriers. You have a one in four chance of having a very affected child. So that's the big concern in my practice. And I'm proud to say in 30 years, we have no CF children. It's all about good engineering and doing it right. So that's the vast difference part.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
What else on physical exam are you looking for?
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Yeah. So among viruses in the world, There aren't many that get into the testicle like other things. Very little gets into the testicle, similar to the brain. But the mumps virus does it about a third of the time when you're a child with mumps, the parotid gland infection. It's a glandular disease. So it really only matters when you're pubertal and you get mumps. Then it goes to lots of glands.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
It goes to your pancreas, cause diabetes. It can go to the salivary glands. It can go to the testicles.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And it will cause viral necrosis and edema of the testis. And similar to a brain, it's in a calvarium, right? The brain is in a fixed space. So when it swells, you got to do something because it can die if it swells too much. Testicle is a fixed cavity with the tunica albiginea. And so if it swells too much, it necrosis, and then you get fibrosis, and then you get sterility.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
I've got techniques where I can find sperm in lots of these men, little pockets, but most of it, you're ablating the testis. It's going to scar and die from ischemic necrosis. Zika, Ebola. I mean, the CDC called me when these were coming around. Zika has been transmitted through semen. It causes the anencephaly issues. When these pandemics were occurring, Ebola too.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And then the immune system in the uterus is very active because there's a hole in the woman to the peritoneum, to the abdomen. So it has to be highly protected. And then you have to go through the uterus. So there's a 10-inch, 12-inch swim, which is equivalent to about a 20-mile swim for a human. Based on the size of the sperm. And how much distance they have to go.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
I got a call that there was an Ebola patient who survived, went to the institute, survived hemorrhagic fever. And then a year later, transmitted Ebola to a partner who transmitted to six other men. And it was another outbreak in South Africa.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Right. We don't know about testes, but we know that mumps will do that to the testes, but Zika is also persistent in the semen.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Or at low levels, like low viral loads where there's no disease. I'm not sure. But these are concerning cases. But then it was transmitted at a low viral load, an even lower viral load. Right. So it's tricky. There may be bulbar urethral glands. Maybe it's somatovesical. It's hard to know. But yeah, it's getting away. But most viruses don't go there. So the big one would be COVID.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
What did COVID, there was a big deal about the AC receptor being in the lung and being in the testicle. And maybe COVID infection would make you sterile. There was one Zika paper in Nature that looked at if you infect mice or was it rats with Zika, the testicles shrivel up and they get infertile. And that caused a huge scare in the field. But we really didn't see it.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
maybe see it and see if we don't see it in fertility. And what is it about the Zika virus that does this? We're not sure. Why did it in rats? It's a blood testis barrier thing. It's an amazing barrier and nothing really gets through, including viruses, but mumps does, only at puberty. And Zika does. Zika doesn't in animals, but we didn't see it in humans.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
But I thought you said that Zika was leading to anencephaly in cases. Yeah, but that could be seminal. That could be just in the semen itself, not in the sperm. Like Ebola is probably seminal, not testicular. It's not on sperm. It's around sperm or in the fluid. That's the conclusion so far. So...
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
COVID, the big worry was when this Chinese paper came out, like, oh my God, it's going to the lung, buying to the AC receptor. It's testicle has it too. It's going to make men sterile forever. And there were cases of infertility with bad infections. Was that just the fever, which typically does it even after a flu, or was that COVID specific? And we didn't know.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
A couple of colleagues did some papers. One which impressed me was out of Cedars was a bunch of men, maybe not reproductive age, died with florid COVID. So they got autopsies and they looked for virus in different locations in the body. And I think out of 10 men or seven men, one had it in the testicle. So these are the men with the highest viral load you can imagine, and only one of them had it.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So I believe that there is a risk of it. But I'd say in the thousand men I've seen since COVID, I think there were two cases that I would say were unexplained where men were either fertile or had normal semen quality, had a bad COVID infection, maybe hospitalized, and three months later, sterile. So I think there's a low perfusion rate there.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And they do that in minutes, which is crazy. So it's an interesting challenge that nature has kept in place for a million years. And I really respect evolution. And it is why we're here for, you know, eat, sleep, reproduce. So basically, with ejaculation, the penis is shaped to fit into the cervix. Everyone wonders, is it getting to the right spot?
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So the third thing we do, history, physical semen analysis is a third. Fourth would be hormones. And that's what we check in men too, because production of sperm is driven by the brain. So nothing happens to sperm being made without the brain telling it what to do. Similar with eggs and controlling. It's all a homeostatic mechanism with negative feedback.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
I consider it sort of a poker hand. There's a volume, how much of the semen volume. There's a count, concentration of sperm. That's numbers per mil. And then there's motility, which is percent motion. You do a forward progression. So how good is the quality of motion? And typically some measure of shape called morphology. There's three liquid issues, liquefaction, agglutination, and viscosity.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And then you look for other cells that aren't sperm. They're called round cells. And either they're going to be pus cells or immature germ cells that are ejaculated early. And presumably you want to see fewer of those? There's a number, like less than a million is normal. Okay. So if you ask me, well, how do I look at a semen analysis? That's a little different.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
I look at that as a poker hand with each card has a meaning, but they have a look. So if you said, what do you mean by that? So if the volume is low... It's one of five things. You're always going to find something. It's at the collection error. I call it first sample syndrome. Guy's not good at it. You know, it's like, okay, I got to put it in the cup and I got to stop doing what I'm doing.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So you do a second sample. And then there's low testosterone can cause it. There's an absent vas deferens, which means you have an absent seminal vesicle. There's ejectory. And by the way, do you ever have that on one side and not the other? No, it's very variable. It's segmental. So there's five real issues. So when I see a low volume semen as a surgeon, I'm going to find something.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So that's really good. Other than that, the semen analysis, I think I've been published as saying it's a blunt instrument for fertility. Unless it's zero, you can't really say much about their fertility because people conceive at all levels.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So one of them is called, I call it syndromic sperm shape problem. So you can have a perfectly normal semen analysis, count motility, volume, progression, and the sperm look terrible. And so there are rare conditions, one in 5,000, where you might have globosospermia or two-tailed sperm or pinhead sperm. So if you look at shape, 4% should look normal, which is terrible.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
We can have a whole discussion about why 4% of human sperm being normal is normal when 99% of animal species in the wild have normal-looking sperm. But it's all a construct. It's all a construct of someone decided what normal is. But in men who have large abnormal forms, like 4% is normal if they're 1% normal, and you look at the abnormalities.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
It's also interesting that the semen is coagulated and then it liquefies. And that's because there's a lot of species of lower phyla. that they have to leave as soon as they have sex, otherwise they'll get killed, like praying mantises and black widow spiders. So you got to get out of there as a guy. So our ejaculates in humans are sticky.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
But again, it's a construct. It's like putting stars, ordering stars in the universe, Cassiopeia. Someone named Kruger said, this is what a normal sperm looks like.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Yeah.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
But most of them are going to be amorphous. Head's a little rounder, head's a little narrower. Those are called stress patterns. And things like hot baths and varicoceles and smoking will do that, which isn't that bad. In the case of 1% normal, you've got to look at the 99%. Because that's not the story. The story's in the other chunk. And if they're all looking the same, then it's syndromic.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And then you have a problem.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And that's hard to fix. I mean, they'll fail with sex. They'll fail with inseminations. They'll fail with IVF. They'll fail with IVF. Yeah, they'll fail with IVF and ICSI. Sometimes with globosuspermia, where they're called lollipop sperm, they just have a big round head with no acrosome. If there's all nucleus and there's some of the components, they'll just bounce off an egg. They'll never work.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
They'll never work naturally. And to get them to work with IVF, you have to single sperm inject them into the egg and then shock the egg with calcium, do a calcium or piezoelectrics to get it to actually fertilize. Because the sperm is important with fertilization, not only has to bind, but the calcium channels are regulated by sperm.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And what shuts the doors to polyspermia in an egg is calcium activation.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So morphology can matter a lot, but it's very rare. So I'd say twice a year in my practice, I'll see this Because everything's failing and everything looks normal. And they ask me what's going on. And I'll look at it really closely and say, you have this issue and there's not much we can do to treat it.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Now we're going to try sperm sorting technologies, which are out new in the market, microfluidics and things like that. And I've been throwing that at them. Sometimes it works, sometimes it doesn't.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
PLZ's data deficiency is one of them recently discovered that runs the calcium channel, which tends to be associated with a certain look like globals of spermia.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
That's one of the 50 we throw off each generation, 50 mutations.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
I think what I would like to emphasize in this podcast is how fluid evolution actually is. And it's sperm driven and it's transgenerational. So if you ask me, what's the theme for today? I'd say sperm matter a lot, a lot, a lot more than we've given them credit for.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
I have no idea, Peter. I have no idea why you would do that. I don't know why one queen bee and the bees in the hive die after mating. I have no idea why that's an advantage. But I guess females are prioritized in evolution. And that makes sense. The anatomy is perfectly defined. So a lot of men think they're having trouble placing things.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So I look at, in my poker analogy of the hand, if everything looks good but the motility is low, I think of short-term toxins. Severity. So things like exposures. So medications. I think about habits, pot, smoking, hot baths. I think about behaviors, lifestyle. So I look for an exposure in that individual. Basically picked up on the history. Varicoceles and exposure, things like that.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And if the count's down and the motility's down, I think of a large severe exposure. There's royal flushes and there's four of a kind. My goal when I see that semen analysis and see that patient is to figure out if he's not normal, why?
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Either they give it to me or I get one. I want that there because that's when I look at them, I'd like to have that in front of me to say, what kind of poker hand are you playing?
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And now it's done with hemocytometers. It's done with machines. Computer-assisted semen analysis does most of them in IVF groups. It's really standardized. Oh, yeah. I like the bespoke suit. So when I have mine repeated, I usually have someone do it by hand because there's observations I like, which is, hey, you know what? 1% morphology, but all the others look like this.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Those comments are incredibly valuable. that you don't really get from a computer-assisted semen analysis. But it's faster, and you don't have a lot of human effort involved with a computer. Are they using AI for this yet? Yeah. I mean, some people are for sperm selection a little bit. But yeah, there's a lot of stuff to help out.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And that will be really helpful for morphology to standardize it, because one man named Kruger in South Africa... correlated bad sperm shape with IVF outcomes and did not find that they were good when the sperm looked bad. That's where the 4% came from. But it's really hard to do that every time and do it well because it's so hard to do.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Hoping AI and machine learning can help standardize the look because sperm is hard.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So to make normal amounts of sperm, you need proper amounts of testosterone and FSH. Think of it as flowering a plant. You need the water and you need the sunlight. So testosterone and FSH are key. To get normal amounts of T, testosterone, you're going to need LH, which drives it. Same in women. These are all named in women. In females. So that signaling is really important.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So there are cases of genetic infertility like Kalman syndrome where men aren't making any sperm, but they're just not sending the signals down and you can just give them the signals with injections.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So HCG, FSH injections, and they will be fertile.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
No, it's the olfactory node in the hypothalamus. So they don't smell either.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
No. No. Pituitary is not working. Yeah. The GNRH is the essential pituitary. Okay. Got it.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
I usually don't worry about it because the cervix and the penis expands. It forms a seal. Then there's a crypt. Sperm have to go through a crypt, a channel, which is only a few sperm make it. So 100 million sperm may start out. Maybe 5 million make it through the first barrier, which is the cervical barrier. The vaginal fluid is acidic. How acidic? 5, pH of 5, and the semen is a pH of 7.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Yeah. So estradiol is sort of a mild poison for male infertility. So everyone needs estradiol level, female hormone levels. Testosterone gets converted to estradiol. So that's a byproduct of it along with DHT. And then estradiol goes back to the brain and is a feedback. So if it's there, the brain knows how much testosterone it's making.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So if there's too much estradiol, the brain senses it's a negative feedback, senses, hey, there's too much of this, so let's make less testosterone. So it will lower your testosterone to have high estradiol. When estradiol is made, it gets metabolized differently than testosterone. It goes to the liver or to fat.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And aromatases convert it to something else, or testosterone gets converted to female hormone aromatases. So you can get high levels being obese or having liver dysfunction, so alcohol, alcoholic cirrhosis, hepatitis. It'll rev it up and it'll make a lot more estradiol level. And there's some medications that do it too.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And that will act and lower your testosterone, which will lower sperm production because you're not watering the plant.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
If you see that there's a low count and the testosterone's low, and you could say you need to lose 100 pounds. which is the key secret for everything, right? But you can also give aromatase inhibitors like weightlifters use to keep their levels down. Okay.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So I usually do two semen analyses three weeks apart or more to get a sense of things because it varies quite a bit. So a very important point is that the semen analysis, any feature of that semen analysis vary by 50 to 100%.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So I do a lot of consulting for the FDA and they do medications in reproductive age men and they're trying to show the semen analysis. They're going to the FDA and they're saying, can you help us interpret this data for the FDA? I said, garbage in, garbage out. I mean, there's so much variability, you really can't say anything. So you have to do at least two samples.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And it still varies quite a bit. There's inter-observer variability, who does the semen analysis. There's biological variability on what your system's like. So that's the big problem with studies.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
If they do, they'll do animal models. They won't do human studies, they'll do animal models. They'll do beagles, mice and beagles. And if there's no fertility effects, they don't really look at semen analysis in those. They'll look at fertility effects in the animals. If there's nothing there, then they'll probably not require human studies.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
If there's any suggestion of a problem in the animal models, which is a million dollars of work. So if you ask me why I patented the Somatic Colonial Stem Cell, I want an in vitro test for human infertility that we could use instead of animal models, save the animals, save a million dollars, do an in vitro spermatogenesis model and see if there's an effect at all.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
It's all buffered as a hostile environment, so it has to get out of there quickly. As soon as it liquefies, there's sugars in there, and then they go through the cervical path. So 5 million will make it. One out of 20 makes it through the cervix. Then 100 make it to the fallopian tube, and then one will make it to the egg. Literally only 100? Right.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Absolutely.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And you know, there are 80,000 chemicals out there that are not been studied reproductively that are commonly in use in industry. European commissions are a little better off. They've screened them and they've warned about them, but America, mm-mm. Why is that? I don't know. It's attention to detail. It's one of those things that just doesn't, I don't know. Is it under the purview of the FDA?
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Or the EPA? Probably a combination or maybe everyone's thinking it's the other person's job. I'm not sure, but they're untested and they're out there.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So, although sperm are made constantly and are susceptible to that, we know the testicle is a pretty good place, excuse me, and insulated from exposures. I also think there's a lot of smoke there and it needs to be sorted out, but especially with the 80, 60 to 80,000 chemicals that are being used that aren't really tested at all.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
I think the only way to know is to do stem cell in vitro testing as much as you can before you put it on at the ID investigational drug stage, not at the final stages for clinical trials, but early on do it. So you're screening way in advance of getting into clinical trials and where the money gets big.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
But I think that there are windows of susceptibility in men, unlike maybe with women whose eggs are constantly exposed to toxins. men have windows. And one of those windows is birth and early development, the first 12 weeks of life. That early? When all organ systems are developing, including testicles. I mean, Shauna Swan did this one with maternal beef consumption, estrogenized beef consumption.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Their sons had lower sperm counts when they were 20 years later or something. So I think that's a window of susceptibility. I also think puberty is a window of susceptibility when things turn on So I think if exposures in those moments are probably going to matter the most to men, I don't know about other times.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And this Settlage studies in the 50s had women have sex before hysterectomies. And then he swabbed different parts of the reproductive tract. These are young women for different reasons, not infertility, and found these numbers. And that's the basis for our move to technology from 5 million moving sperm is when we start doing inseminations versus sex, et cetera.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And I think the stress- Counterbalances any amount of microplastics you save. Double the stress in a man and testosterone level will fall. And then the sperm production falls for a whole different reason.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
33.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So what does stress do? Stress is the sympathetic nervous system. It's fight or flight. You're running from a woolly mammoth. It doesn't know what you're running from. It doesn't know whether it's sleep or travel or financial or emotional. It's just the body. We are cats and dogs. We have the same binary nervous system. Either you're on or you're off. And when you're on, do you want testosterone?
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
No, you want cortisol. You're running for your life. And do you want fertility when you're running for your life in any species? No, you're trying to save your life. So cortisol goes on, testosterone is nowhere to be found, fertility is nowhere. You turn off all that stuff.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Then when you outrun the woolly mammoth and you're behind a rock and you grab the berries and you catch a nap, boom, testosterone shoots up because it's rest and restore and you have to rebuild for the next run. How quickly do you think that occurs in humans? Days, easily. Chronic stress is it. We love acute stress. All species love acute stress. We love that starvation, intermittent fasting.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
It's really healthy, but not low-level chronic stress, not connected to your computer, not your emails, not the workday that never ends. Terrible for us. And the best manifestation is erections because the erections will fall if you're under stress too. Penis has a mind of its own, according to Da Vinci. I had a guy come in, 25 in San Francisco, a startup guy.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And he comes in and says, I got to see you. I said, why? He said, I lost my erection yesterday. He's 25. I said, first time? He said, yes. I said, all right, come on in. So he comes in. And he's got his act together. It looks good. And I said, what happened? He said, I just lost my erection. It's never happened to me before. I think something's wrong. I said, okay, tell me about yourself.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
He's just getting his A round of funding. He's traveling half a million miles a year. He sleeps three or four hours a night, if any. And he's constantly running. And I said, congratulations. Welcome to the human race. And she's like, what are you talking about? You're not impervious. Stress has its effects. So clearly, fertility. Oh, the great study was a moderate exercise, moderate exercise, man.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
I wrote a blog on this called Can You Be Too Fit to Be Fertile? Moderate exercise went to extreme exercise, measured as two hours a day of VIO2, 80% maximum capacity. So pretty heavy workouts for 12-week periods. So moderate to extreme, and then back to moderate. Sperm counts fell by 40% when moderate to extreme, and testosterone fell by 50%, and then went back up.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And there's also military studies of men under acute stress during hell weeks in training where they were taking their testosterone and LHs, and they were dropping by about 50%. With severe stress. And that's okay for a day or two or a week. But when you're doing it chronically, we're not built for that, Peter. We're not built for chronic stress. That's a longevity issue.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So those are based on numbers of sperm that reach the uterus and reach the thing. What's really interesting is there's some fascinating research. Everyone thought the Vanguard sperm wins, right? So it's the Phelps sperm that's going to make it. And there's a company out of Boston called Eric's Biosciences, and I'm consulting with them, disclosure.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
All natural production.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And the two different classes are the LH and Clomid versus testosterone. So unlike testosterone shutting off the natural production, the LH, the ACG and the Clomiphene and Clomiphene will stimulate natural production. So you keep your testicular size, you maintain your fertility. Whereas the others, you're going to shrivel up your testicles and not maintain your fertility.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And you can't generate levels that you can with the exogenous testosterone with these. You'll never get to 3,000. You can't do that.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
No signals, no gas to the engine. It's nuanced. There are formulations that are topical that are less potent that way, less inhibitory than injectables. So there are variations in the spectrum of exogenous testosterone that will maintain some of your fertility.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
They're in the normal range more. What gives you side effects from testosterone, including sterility,
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
But they've discovered that sperm work in phalanxes. So because the immune system is so vibrant in the uterus, the first round of sperm gets through the cervix
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Testosterone, I can wait. And it was not available in America for 50 years. It was available in Europe. And a couple of researchers at UCLA, a husband-wife team, beautiful. What happened was we were worried when we took oral testosterone.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Yeah, we'd go to the liver.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Right, to the biliary system and go to the liver, cause liver cancer. So it was always verboten. Even though there was no evidence this was happening in Europe for 50 years. Yeah, not much. It's FDA approved. The EEA approved it. So this group came up with a way to get it metabolized through the lymphatics. So it could absorb through the lymphatic and never hits the liver. And it's really good.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
I mean, there is a non-response rate of around 10%. So 10% of men, some like gels too, 15% won't respond. There's groups that won't respond that well, but it is really good.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Usually you don't want to do it right away too. So you want to give him a couple of weeks to stabilize hemostatically, right? But usually you can get pretty good levels because the half-life isn't that short. They say it peaks in five hours. So I don't know what the half-life is. Probably like 12, more like 12. You wouldn't dose it at 100% decay. You would dose it at 50%.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So he's probably not responding. We can check it at different times, but it's probably not much of a response.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
It depends. I usually go to the mid-dose 298 twice a day. And then you can double it or whatever. I usually start out at not the lowest dose. And it depends what you're trying to solve too in the problem, right? If you want them, you're not going to get them to 800 or a thousand very easily. You can get them 400 to 600, 600, 700 pretty well, but no side effects.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
I haven't seen anything that maybe a couple dozen men really well tolerated.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
I've never, no one tolerates that.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Well, have a flu and try to get your testosterone level up. You can't do it. You have to spray it in your nostril, each nostril three times a day. And it's gooey and it's gel-like and men within a week will call and say, can't do this. Yeah. We've had more luck getting women to use this. So the other big difference is between the two types of testosterone replacement or supplements.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
one is, we'll call it the natural ones versus the exogenous ones, is side effect profiles differ widely. It's very difficult to get polycythemic or thickening in your blood with the physiologic levels. It just doesn't happen very often. I've seen it once or twice, but if you take testosterone exogenously, you're at risk for polycythemia or blood thickening.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So testosterone stimulates epipotent in the kidney, you make more blood. Athletes love it, but if you went on a long flight and you're dehydrated, you're going to throw a clot. And people look at it for longevity, and it's like, be careful. Because I've seen 70-year-old men want longevity in taking this stuff, and then they have a clot, and they have a stroke, and now they're 71.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So, I mean, the studies aren't broad, but Ramasamy just did another paper on it. The most significant event occurring with testosterone replacement or supplementation is polycythemia and events. The high level for hemoglobin 17, Maticrit 50, you start seeing events happen about 18, definitely 19.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And there's also a mucus plug that exists for 28 days a month to prevent anything from going through because it's a hole into the woman's body and peritonitis is severe, right? And the cervical mucus thins and that's to let sperm through for two days a month. It's incredibly detailed, perfectly orchestrated system.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So once a week, and I think twice a week, you can have the dose, right? So that is a little safer, but then it becomes the intensity and just, I can't do it like that or whatever. I want a pellet instead. Do you put pellets in?
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
You know, in the arm, they put it in subcutaneously. We put it in the butt, and it's a couple-minute procedure in the office. You don't have to worry about anything. There's no compliance issues. We don't have a lot of side effects or consequences from it. It's done with a trocar and a thick needle.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And pretty quickly, within a couple days, you'll get a level, and then it'll slowly decay, pretty much half of it by three months or so, and then the rest by four to six. It's supposed to be a six-month physiologic level. But normally it's four, four or five. And men feel great for a while and they can feel it because it's slow, but it is even.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And you do have this risk of polycythemia and things like that. But there's a three-month perivariate risk. And then usually when you're in the normal range, it kind of goes away. So I don't see a lot of consequences with that if it's six months.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Might even improve it. HCG depends on the dose. So like you said, high doses suppresses. Normally, for all you want LH and FSH going to the testicle, you want the water and the sunlight. You want the testosterone. If you've got the testosterone, but your FSH is, if you don't have any sunlight, you're not going to bloom.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So I usually add Clomid to HCG if the dose is above 1500 units three times a week, because that's going to start suppressing the FSH and Clomid will keep it going.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
I shoot for the normal range of 500 to 1,000. I'm not an anabolic guy. I'll melt it today.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Well, it's HCGs that's driving the T. We're just trying to protect it. If you said, what do you give on isolation as monotherapy? Yeah, what would you give for a Clomid monotherapy? 12.5 to 25, typically, depending on how sensitive the system is. And do you prefer Clomid and Clomiphene? So it's very interesting. Clomiphene's really good. It's an interesting FDA story.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So it looks like the first round of sperm get through the cervix, get into the uterus, and they get demolished like a phalanx, like a Roman phalanx. And maybe a second round goes through and they get demolished and they're secreting the FCR receptor on the immunoglobulin because that's what antibodies bind to. So the female antibodies bind to that.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So Clomid is not approved for men. And clomiphene isn't either. Clomid's approved for women and clomiphene's not approved for either. Clomiphene's compounded. Clomid is available for 50 years. So a lot more data. And once a cis isomer was a trans isomer. So they're different. And the estrogenic effects are slightly different. So I have enormous experience.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
I have 560 men on clomid and I have fewer in clomiphene. But it was developed for older men to preserve their testosterone levels as they age because the signaling tends to get weaker. The pituitary tends to get lazier. And this is to keep your testosterone levels up more physiologically than taking testosterone. So it went through some very good randomized trials that were published.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
This was clomiphene? And clomiphene citrate. And they were done by reputable people in the field. and published, and then it went to the FDA for approval for secondary hypogonadism, sort of age-related changes, not primary testicular failure, in age-related androgen deficiency of the aging male or Adam. FDA sat on it for a couple of years and said, nope. What? Good question.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So it's published, they're good trials, it's safe, it's as good as Clomid, and they didn't approve it. And I think it's hard to know, but I think the reason was that there's such an uproar about testosterone in America right now, and the FDA doesn't like what's happening. What happened is you can advertise your drug to the consumer now,
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So you know all the biological response modifiers for psoriasis, all those drugs go on and they give you five seconds on the benefits and the lesions go away and then 25 seconds on side effects, right? So you can do that. If you do that with testosterone, what you hear is, do you fall asleep after dinner? Are you not as athletic as you used to be? Are your erections not as good as they used to be?
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
There's 10 questions in the Adam questionnaire and everyone who ages- Every guy's going to be like, yeah. Everyone who ages has those issues, right? So it's a no-brainer if they go on TV, they're going to want this stuff. So the cat's out of the bag. They're stuck.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And so now when any testosterone trial comes back, they're going to point out, the FDA makes sure that we point out the dangers of testosterone replacement. So this is part of that energy, which is, you know, we don't want another testosterone.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And we don't know how many phalanxes go through, but then it's like a run up the middle. And then eventually a couple of sperm or fourth make it and the immune system's deactivated and they get there. It's wild. And that can be measured now. And there's actually going to be an assay available to look at whether you're doing this.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
They're really safe drugs. My effect is someone comes in who's young, who maybe wants kids, hasn't had them, And they have a low testosterone of 220. You measure their LH, which no one does. It's low. Secondary hypogonism. So it's not a testicle failing. It's a signaling issue. And that's probably stress. So I said, get rid of your stress. And they say, how do I do that?
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So exercise, acupuncture, massage, or yoga. I mean, for men, I say physical activity is the best thing for sex. So as an aside, during COVID, I had two groups of men. They said, what do I do? My life's a mess. You know, everyone's life's a mess. So half of them had drinks at five o'clock, started drinking a lot. And the other half went out for runs or got a Peloton, which most of the country did.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
That's a great story, the Peloton story. And then about six months later, these guys realized it's not working. And they started shifting over to exercise. So I was very proud of them. These guys I was really happy with, like nice, because that's the best way to handle stress is when you have no control over things. go for a run, go for a walk, get out there. So good for you.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
It's decompressing, get your mind off something, anything, surfing, whatever. They don't do that. So I said, well, let's do this. I think what's happening is this. I think it's just stress. Maybe try traveling less or whatever. And then I'll give them Clomid. I'll say, let's try this for three to six months and let's see how you feel. Sometimes it's sexual health issues.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Erections aren't typically that dependent on testosterone. Typically, it's other things. I'll give you the benefit of the doubt. Maybe you were higher before and we don't know that, but let's do something pretty safe and easy and I'll double your testosterone or triple it. Let's see how you do. And then I'll check in with them at three and six months. How are you feeling? I feel great.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Or, hey, it's not working. I feel the same. It's like, well, it's not testosterone related. Whatever the symptom is you're having, you wouldn't have it with a testosterone. We know levels of testosterone above which you should not have symptoms. We know libido, we know erections, we know fertility, things like that.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
I don't know. Erections, I would say the best study is about 290. Yeah.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
You're convincing them. And then what about libido? Libido, I'd say 350 is sort of a range. It's pretty sensitive and it's harder to call. Libido is driven by so many different things. Fertility, I'd say 300 is a good one.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
I think there's myths around testosterone and those are some of them, but it's sort of a Morgan Taylor and equilibrium story where if you're low- You have symptoms and you're low. Those symptoms will get better when you go up. But then there's a point where it flattens out. There's no increase or improvement in symptoms. Sexual health symptoms are classically ascribed to that.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
There also is a linear relationship between testosterone, and that would be blood and muscle. So more is better for making blood, doping, and also blood doping, and also for muscle. Absolutely linear.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
They're calling it a sperm cycle, almost like ovulation, spermulation. But it's an hour and a half cycle when the phalanx is working, sperm are deactivating the immune system, and then maybe they don't. So there are jaculates, which is a group of sperm, some of which do this well and some of which don't. And that can be a whole reason for infertility.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Effect of testosterone muscle mass is indirect. It's not that you're going to do it and create mass. You don't just create mass. what it allows you to do is recover from injury. So if you push the system and you need two days to recover, you can go to one day, you can push it again harder. So that's what testosterone does in the primitive world.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
I'm not sure that's receptor-driven at all. It might be several pathways going on that are logarithmically better but it allows you to push the system and go back and then push it again. And that's how you build muscle.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So it's funny because a lot of guys come in and they look good. When I examine, I'll say, are you taking anything? Because they never put it on their medications, right? They never write it out on the history.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So I will look them in the eyes. So are you taking testosterone? And I'll look them in the eye until they answer. And if they look down and they don't say anything, I know they're on it. If they look me in the eye and say no, then I know they're not. But they'll always look away. It's this verboten thing.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Yeah, yeah, yeah. So my theories about this is why is he taking it? So if he's taking it for anabolics and, you know, he probably has a pretty good idea. I want to give you a little research we're doing on the lifespan of anabolic steroid users. So remind me at the end of the story, give you a little brief about what I know about that. So how he takes it matters.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So if he's been in constant use injectables, that's the most suppressive of fertility. And if you turn a gland like a testicle off long enough, it's off. So I gave a lecture to the Antigran Society on recovering men from hypogonadism in young men. And I asked them a question at the end. My whole procedure comes from steroid users.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
I take notes when the anabolic guys come see me because they're really smart and they know a lot about reactions, biology. Yeah, it's incredible.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
But it's a science. Some of them are PhDs. I took notes for years and it came up my approach along with what I know. So it's very much in concert with concert with them. So everything I say is built on a large experience and it's called getting off the juice, the blog. And I have people read that blog, do it and say, get about 80% of the way. And then call me and say, I need help here.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Now I'm here. We'll link to this in the show notes for sure. Getting off the juice. And there's a PowerPoint in it. So the recovery is usually possible in young men, but it depends on how much they took, how long they took it, and how they took it. If they do it like a cycling effort, that's the best.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So if you cycle steroids, you recover the pituitary, you get back to normal, and then you hit it again, that's actually quite smart. Constant use is not. Constant use for longevity or whatever is not a good idea for fertility. So that's going to be much more suppressive. Injections are worse than orals or any gels.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So the next thing is how long, so I asked the Endocrine Society, since I answered all their questions, I said, I have a question for you. Can you turn a testicle off like in a thyroid or an adrenal gland if you suppress it enough? Can you turn it off for good? And they said, yeah, that's an important question of ours. We can do that.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And I said, because we believe it's always reversible in the field of infertility in men. And so that got me a little worried. And so now I kind of worry about five to 10 years of use. After five or 10 years of use, you may not get it back.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Depends on dosing and everything, right? If they're doing 250 a week. No, I mean, in our practice, it would be 50 twice a week. Published a study when I was a fellow in Houston of a guy who took it for 25 years. And we drove at him with gonadotropins as HCG and FSH. And we didn't get anything, but we got a low number of sperm back.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Yep. 100 to 500 get to the fallopian tube and one gets to the egg. Wow. Why do you need so many sperm? The classic answer used to give is they don't like to ask for directions. Men don't like to ask for directions, but this is probably why.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And I just had a guy from Louisiana come in, 25 years of chronic use. I did a mapping procedure to find sperm in his testicle and he's going to be having a kid, but he made a couple of sperm. But you pump him full of HCG and synthetic FSH. And get nothing. And then you have to look in the testicle because production can be low enough to be there, but not coming out.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
But this is the rescue protocol. It's LHFSH. Basically, there's three ways to do it. One is never stop the testosterone suddenly. Interesting. Because men will hit the doldrums and go, and they'll flop over like they have the flu. They'll feel like shit and they'll get right back on it. They'll feel terrible because they have nothing going on.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
If you take the testosterone away, their system's turned off. They're not making their own. It takes time to get the system to reactivate. So that's the hardest. So I always taper testosterone. Over what period of time? Six weeks, typically. You have the dose for two, have the dose for two, and then off for two. And then you measure.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And that's getting out of the white water into the green wall a little bit. So that's a little smoother. So taper. And then I offer them two options. One option is taper alone. Taper with Clomid or in Clomiphene, which is a little quicker, getting the pituitary to turn back on. So that will soften the blow of the feeling of feeling completely fatigued. Or more aggressively, HCG and Clomid.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So for most people, that's not a price worth paying. With that taper over a month or two, I usually check their T levels at around two weeks off of the last testosterone, and that's the lowest they'll be. And if they're in a good range there, you can use that as a predictor of their response. What would be good?
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Okay. All right. But then to get them to where they want to be depends on their symptoms and what they're happy with. You won't know until you wait longer to see how high you can get them. That's the lowest they'll be, but they'll be off of testosterone. And if they go along that taper and they're not tolerating, I try to tell them, don't go back. Just stay there because time will help you.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
You're not going to feel maybe that great, but try to do this. Because if you don't, if you go back, then we have to start over. But if you just maintain it for a while, you'll feel better. And some of them dip a little bit, but remarkably, most men do really well with that taper.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Yesterday, I operated on a man, testicular sperm retrieval on a man who's azoospermic for genetic issues, and he was on testosterone for 10 years because he needed it. His testicles were failing. And I said, you're not going to make sperm on this. So... We put him on HCG, which didn't do anything for him, felt terrible, and did that for a year. And he said, I can't do this anymore.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
I said, okay, or maybe it was six months. And I said, I need a little more time for you to be off testosterone. But since you've been on HCG for six months. And what dose did you have him on? 3,000, three times a week. That's a whole vial a week. Wow.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Interesting. You can maintain whatever's going on in the testicle with HCG and take any testosterone you want. That's an important lesson. Yeah. Here's the catch though. The caveat is it was done in, I think, Finnish bodybuilders. They were doing a cycle of steroids, huge amounts. They took Lotus HCG 500 twice a week.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And John Amory has worked out and Washington has worked out all the exact doses, but 250 to 500 twice a week is a good dose for that. It keeps your intertesticular testosterone high, keeps your sperm production going. And they went on both concurrently for 12 weeks and their sperm counts were normal the whole time. At any dose of tea.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Now, what happened after that is people start saying, you can preserve your fertility on testosterone replacement, which is possible. They missed half the story. But it was only 12 weeks. And if you're doing it for three years and you miss your dose of HCG, boom, you're done. You're cooked. You're going to go to zero. So unopposed testosterone without it. So you have to be... 95% compliant.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
The Clomid doesn't work. HCG is the one. Yeah. Clomid doesn't improve intertesticular testosterone levels like HCG does. It's ineffective. Got it. It will potentially make you more recoverable. If you do it 80%, you'll be zero, even though you thought you might have a superb count, but your recovery will be faster because it's done something.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
It takes about 60 to 70 days. And it's a process called meiosis. So in a car assembly line, the Model T assembly, you know, mass produce, you want to all be the same. In meiosis, which is unlike mitosis, you want things to be different and to be a little easy peasy. So you get what's called recombination. And so that's the source of evolution.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
But the only way to maintain your current fertility is you have to be 100% compliant with dual therapy. You can't go on monotherapy with testosterone.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Well, I think muscle mass. So with aging, it's a great one. I mean, it used to be like growth hormone with age wasting syndrome, things like that. I mean, muscle mass is a key for men.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
No, I think the only reason would be if you want testicles to be big. Okay. So just volume. I just created a new procedure to make testicles larger naturally by putting a fat injection in the hydrosil space in men on testosterone because they don't like their small testicles.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So it's all natural and there's no prosthetics and you can't tell. It makes them nice and big and testes fat grafting and it's fabulous.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So the test that says outside the body, it's three degrees cooler than the rest of the body. So 95 versus 98 degrees Fahrenheit. And then there's a reason for that unknown. We had that conversation. We don't really know why, but it may be that it's an immunologic sanctuary and that's the only way to do it and that God or Darwin could figure out.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
But if you heat up the testicle, it's also close to the skin. So it's a radiator. So when the heat comes down the arterial blood, it has to cool. So it raises and lowers. And there was an article in the Journal of Irreproducible Results about 20 years ago. A man went to Big Sur and wore nothing. And he measured ambient temperature.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And then he marked on his leg with a marker where his scrotum hung, how low it hung. And he could tell the ambient temperature by how high or low his scrotum hung. He became a thermometer. So it does go up and down. Is that Peter or Tia Laffick? Journal of Irreproducible Results. Oh, God. Really cool. But it showed that it's very temperature sensitive.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And it goes up and down to regulate it closer to the body when you want it warmer, et cetera. You go into a cold shower or a plunge, where are your testicles? They're way up there. In my abdomen, yeah. And that's all the cremasteric muscle and it's all temperature driven. So it spends all of its time regulating its temperature to stay at 95%.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Now, saunas, baths, hot tubs, jacuzzis, steam rooms, change that. The worst one of those is anything underwater, submerging underwater, because you're one centimeter away, you're a liquid, it's a liquid, you're going to turn that temperature, maybe not the inner part of your body, but little kids going into hot tubs, right?
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So the genes, the chromosomes blend in a different way and separate a different way. And through that process of a couple of those, you get half the number of chromosomes, which is required to join the other half.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So I did a study, published it in the Brazilian Journal of Urology. I published 200 studies. This was the hardest one to get in. Everyone said, we know that it affects fertility, so we're not going to publish it. So I went into Brazilian Journal of Urology. It then went to the New York Times as a press release. That's how popular it was.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
It's probably my most cited paper ever, and it's certainly not my best. It's very interesting. I took infertile men with low sperm counts and stopped the tubs. They were in hot baths. I used the word jacuzzi. Jacuzzi called me up and said, stop. Don't use that word. So I don't use that word. So hot baths or tubs. And I told them out and they went up 300%. Semen quality went up 300%.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Total mold count in three months or four months and 600% in six months. They have to give us some time. And that's that curve, the recovery curve. And we didn't look at fertility. We just looked at that recovery. And some men were zero and went up to close to normal.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
35.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Interesting. So it's motility that the price- Then I calculated after that, I calculated a lethal dose of tubbing. So what's the lethal dose?
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Yeah. So lethal dose to me means you're zero. You do it enough, you have no sperm. And it came out to be 20 minutes of a hot bath or a tub, 20 minutes, 104 degrees, three times a week would probably make you zero.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Correct. It's a loosey goosey.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And interesting, the largest group of people in tubs in Northern California who did the study were environmental lawyers. Is your job that stressful? I said, yeah, it is. I mean, it probably is in California. All right.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So the only study ever done prior to that was a PhD thesis at Vassar College where someone had a guy dip their testicles into a bucket for 20 minutes at really hot and looked at their sperm counts or their fertility. And they went, that was the only, and I couldn't even find it, it wasn't published. You had to figure out this thesis thing. But that's how little was written about it.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And they gave me so much flack for publishing this. It was really funny. And the New York Times had an article said, drew a condom and it drew birth control pills and it drew a guy in a tub. It's like, pick your contraceptive. So it's huge. I'd say 10% of my population's in it. And then the next question is, what about saunas? So saunas is not underwater. It's not submersion.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
But saunas are, you're in a hot room. It's going to affect it. And I would say the effect is one quarter to one third as profound as a hot bath or submersion.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Yeah. And then I would say steam rooms, showers are probably fine. Urine and ambient temperature is normal. And I think steam rooms are probably between saunas and depends how much time you spend, but it's probably not normal, but not a hot bath. Hot baths are terrible. Okay. And then what about the cold? I don't worry about cold.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
I remember Surfer Magazine called me and said, I'm a Northern California surfer, right? Not an LA surfer. The editor of Surfer Magazine called me and said, are surfers infertile? I said, is that water bad for them? Because California water is 60 degrees. I said, no, I've never met an infertile surfer. So I don't think it's bad at all. All right. So the cold is okay.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Especially plunge where you're talking seconds. Yeah, yeah. You know, your testicles are going to go up and you're going to be able to maintain that heat. I think if you did it All the time, it would probably be bad, yeah. Because enzymes work in the testicle at that one temperature.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
I have old vintage bikes that I used to race in Connecticut and I had them rehabbed and they're all Italian and they're all steel and they weigh a ton. And the seats are from Britain and they've got 10,000 miles on them and they weigh four pounds as much as like- It's just like a Brooks saddle, these Brooks leather saddles.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And you know, all worked out and it's like, That saddle nowadays is about half the weight of a carbon bike. But I love it. And I was thinking of maybe going senior league and doing this gorgeous steel frames and trying to keep up with those guys. Because it's not about the bike, really. It's like when you get golf clubs. And I got $150 set of golf clubs.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
I'm going to be as bad a golfer with $1,000 club as 100. So it's really about the biker. But there are some differences, you know, in terms of momentum and the wheel force and all that. But I love my old steel bikes. And they see this. It's like I hang at my office when I come to work in the morning and I bike in San Francisco. And I have the seat. It's like, that's a bad saddle.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And so the issue really is it got started that biking was bad for reproductive health. with a Spanish competitive cycling study. Competitive Spanish cyclists, Tour de France caliber cyclists, their sperm counts were examined.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Not a good group to study. Yeah. So their sperm counts were low, their morphologies were off, and they're extreme athletes. So we know that, and we know maybe they were on drugs, maybe they were, you know, it's a big industry. They're super fit. They're certainly exercising two hours a day. And so they said, look at these guys who are really healthy and look at their sperm counts.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
But this other data didn't come out. So I did a blog called Cycling into Childlessness. And I looked at a more comparable study, which was British commuting cyclists, everyday people bicycling to work in Britain. on different saddles. And I looked at their fertility and their fertility was far better than the average Brit.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Yeah, I don't remember what they controlled for, but I think they did a lot of the socioeconomics. It may just have been activity, but the bicycle- So is this a myth? Yes. Now, if you said, am I worried about biscus? Yes. So I worry about sexual health. I worry about the pudendal nerve and I worry about seat anatomy. So the best seat for a biscus. So if you're biking a lot, that's good.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
If you're biking and you're getting pelvic numbness, that's bad. Okay. So you need to get a better seat. The best seat was studied by the NACH, the NA, I forgot, it was Dr. Schrader at the NIH. The best seat is the saddles that are shaped like this are bad for your sit bones because they come into the middle where the arteries and nerves are to the penis. So it's an erection issue.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Those aren't good saddles. The saddles with the two little tongs that hold your iliac crest bones with no nose. Perfect. So it's pressure where the pressure is outside facing, leaning in. So we gave those to police in Washington, the bicycling police down in National Cathedral area in the parks. And they all gave the seats back a week later, said, you're not doing this. He said, what's going on?
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
He said, we don't know where the seat is. We go sit down and it lands somewhere. You have to have the nose for bicyclists because they use it to guide when they sit down. They use it to guide where they sit. So The best saddle is flat or gel in the back, cut out in the middle and some kind of lean in like this. So cut out saddles and then you should get your bones fit. You can do this online.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
You can ask them to send you a pressure pad and you sit on it and then you send it back and they measure the distance. And there's only a couple of different saddles, maybe 12 widths that you could do and you get it done. Or like me, you use a saddle used for 30 years and it's perfect, but it weighs four pounds.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So fertility-wise, I'd say the government wants men. I'm going to talk about men to less than two glasses of alcohol a day is okay. They consider four binging. Now, alcohol is a small molecule, goes right into the brain, goes right into the testicle. It's definitely a poison. It goes everywhere. The testicle doesn't limit it. So I worry about it a lot.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
The effects I see are direct when it's abused. So I would say you see morphology, motility, and count issues. So that's a direct effect as a direct toxin. It's one of the few things that's into the testicle. Second would be a hormonal effect. So alcohol use tends to cause the liver to rev up, tends to cause more estrogenization. So you tend to get low testosterone from that.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So it's a hormonal effect and a direct effect.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
That's the worst player for me. So THC, same thing, count motility, morphology, and it probably has an effect. We know it has an effect on fragmentation, which is a quality measure of sperm, not only the way it looks descriptively, but quality, and also probably an epigenetic effect. Some of the early studies on sperm epigenetics showed alterations with nicotine and with pot.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
What I don't like about pot is you ingest it and however you ingest it, you get a peak, you feel it, it goes away, you feel it's out of your system like nicotine, but it sits in your fat for a month or three weeks and it's a depot effect and it keeps coming back. So you get a low level toxicity, which I don't like at all. So I am not a fan of pot.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
The other thing that really concerns me about pot and reproductive age men is I wrote a couple of blogs on this called The Weed Worries. And there's some compelling evidence from epidemiology and two studies 10 years apart validating each other that chronic pot use is associated with testis cancer.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
I mean, it's an interesting phenomenon. It's medical marijuana, right? So medical means safe. But I asked someone, I have a lot of pot growers in the Emerald City up in Northern California, and they have the artisanal stuff that wins awards and stuff. And it's like, which is worse for driving, being stoned or being drunk? undoubtedly being drunk. Yeah.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So it looks like reflexes, but you know, like he said to me, well, we tend to stop at stoplights and wait for them to turn when we're stoned.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And I think the signs, the LA story signs, and they have the lit up signs about open season traffic and the movie LA story. They do say now drunk or stoned, watch out. We're going to get you.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
I don't think it's the root. So I don't think it's toking or edibles, but it might just be the chronic exposure. And I don't see, there's some evidence that THC acts like LH and binds the receptor and blocks it. But blocks it from LH.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
It's nicotine. Nicotine per se. Is the issue. And it doesn't last as long as THC. It does have count motility effects and fertility effects. We think probably both of these are oxidants.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Probably all of them. I don't think we know exactly, but I'd say that I diagnosed diabetes in a lot of infertile men. I make the diagnosis.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So for me, it's usually their weight and their count maturity are low. I'm looking for a chronic exposure. And then they have polyuria or polydipsia or something like that, where they're drinking a lot and they're peeing a lot because the sugar is dragging it out and you check their UA and it's full of sugar. And then some of them have an A1C that's a little pre-diabetic.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
But I think a lot of it is neurogenic too. They can develop an ED. A third of type 2 diabetics have low testosterone. So that's a clue. And that's secondary. So you can clone it. You can bend them right back. But that's probably the common one is the look, the sugars, and then the low T and the low sperm count.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
You can develop varicose veins in your leg and need treatment. And this is the same thing in the scrotum, but it's not related. And it happens typically at puberty. You'll develop this. You won't know it sometimes unless it hurts. It's a reflux of blood in the wrong direction. So the testicle drains to the kidney, which is uphill, and it wants to drain back down.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
The reason why it drains back down is because as a species, we stood up a half a million years ago, maybe three quarters of a million years ago. And when you're an animal, your kidney and your testicle drains this way. There's no gravity. But when you stand up, you're now draining uphill. The system was never made for valves. And if you said to me, what's the reason our sperm counts are falling?
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
I would say, we stood up as a species. Probably not a good idea for male fertility because that would... that's supposed to be staying up there, comes back down to the testicle, pulls around it like a hot bath, is warmer. And usually the first sign is a testicle on that side, which is the left, usually is smaller than the right. So the physical exam will reveal a testicular discrepancy in size.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
That's the first thing you see. And then you feel above it and you feel a bag of worms.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
But there might be a few during puberty, but the growth spurt, those blow the angle of the renal vein and there's a right angle. The right side has a natural valve off the vena cava. So it's kind of has to go around 270 degrees. So you don't reflux on the right. Left-sided lesion in most men. You can be perfectly fertile with it.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
If you look at statistically, 85% of men conceive naturally without varicoceles, 80% will conceive naturally about a year. So the curves are very similar. Clinically, maybe insignificant, but there is a difference and it's statistical. But if you multiply that by millions of people, it becomes important. And you'll figure that out easily on a physical exam? The best way is easy.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
I don't order ultrasound. If I can palpate it, then it's clinical. That's an office repair? It's an outpatient surgery. It takes an hour. We do microsurgery.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So it's more involved than a vasectomy. Yes, it is. And you're doing it at microsurgery at the level where you don't cut muscle. You want him to recover quicker. It's an involved area with lots of veins. But he's not under general. I use twilight sedation. Yep. So that's the most common.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Wow. And most men are fertile. But so again, you look at the semen analysis as a poker hand and you see count motility being down, nothing else going on. And you see a varicocele and it's implicated. All right, have we missed any other of the major? Yeah, I'd say the major ones are varicocele, and then I would look for hormonal issues. So varicocele's maybe 40, hormonal maybe 10 or 15, genetics.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
The most common one is for zero sperm is client filter, is extrax chromosome. The most common one for low sperm count is Y chromosome deletions. This is an interesting area. What does that phenotype look like?
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
In general?
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Yeah. Because it's only the long arm and it's only a couple of floors on the building. There's regions that are missing. I see. Okay.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Got it.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So it's the long arm and it's deletions, regions. Yeah. Rhyme of deletion. You're right. So Randy Riopera found... at MIT 20, 30 years ago now that the Y chromosome is a hall of mirrors. And in meiosis, every chromosome has a partner, except the Y and the X and a man. The Y plays with itself. It combines with itself. Instead of finding a partner, it has to do the dance too.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And so it changes a lot. So it's very adaptable. It actually comes from the X through evolution. So there's a lot of X genes that are on the Y, and the Y, we thought it was sort of a wasteland, maybe hairy ears and tooth decay and things like that, but now it's probably more important. So there are regions on the long arm of the Y. The short arm of the Y is very important.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
It has a gene called SRY, which makes you male. The SRY is the male sex-determining gene. If you have that gene, your phenotype will be male. If you don't have that gene, you're probably going to be female. It's complicated now, but that's sort of what it is.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
But the long arm has these genes that control fertility, and some of them, so typically we order it in men with a low sperm count of below 5 million. That would be a pretty common cause of a sperm count lower than 5 million.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And I published a study that if you have a Y chromosome deletion and you have a varicocele and they both cause low sperm counts and you fix the varicocele, you're not going to improve because it's non-modifiable in all ways. It's who you are. But if you didn't have the Y chromosome deletion and you fix the varix, you'll expect a good response.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Two-thirds will improve, one-third or more will conceive naturally. So you could take guys with low sperm counts and you can fix them or not, but the driver's genetics. And the phenotype in offspring is simply inherited as a Y chromosome deletion. It'll either be, I just had a couple from Texas, actually. He had a Y chromosome deletion. He conceived with help of technology with a low sperm count.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Sons have it. They have no sperm. So you can inherit the deletion, but it might increase. So you're going to get what your dad had, or it might be worse because mutations tend to get larger.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Yeah, that's a big one. in terms of the percent of sperm with the lifestyle issues. And then lousy diet is probably something that, so obesity and diet, lifestyle, recreational drugs. What else do I review with them? Toxic exposures at work. So any smelly solvents, I'm really worried. Some airport fuels, airline stuff, machine shop oils, anything benzene derivatives.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Used to be pesticides and stuff like that, but they're pretty well controlled. So environmental exposures are kind of an unknown. I think viruses have a role. That's how you recently wrote about HPV. And I've been thinking about that for years because there are men, it used to be half the men who came in when I entered the field 30 years ago, we didn't know what was going on with them.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
But now it's probably 10 or 20% with lifestyle issues and stuff like that. You can pretty much sort it out. It's not that unknown. But there are men who are like, what is going on here? He's a perfectly healthy guy. Practicing in California is incredible because everyone's so healthy, you have to look elsewhere. You have to ask other questions.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And when there's obesity, it's always the elephant in the room, but everyone is so healthy in eating. So I get to poke around places where no one else goes because I have to explain it and there's nowhere to go. But I did a study. So HPV is the most common. You wrote about that. Is that What's the link? It's hard to know. There's herpes, very common.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
The STDs that we know about, like the 11 common beasts, chlamydia and gonorrhea and syphilis, those we know a little more about, and they're pretty obvious. But some of these trichomonas and stuff are pretty subtle. really concerned about this because one guy 20 years ago, and now it's a professor at UCSF, he sent me a picture of electron photograph of a sperm with a hexagonal herpes virus in it.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And I don't even know if it was Photoshop, but there's this virus in a sperm. I'm like, yeah, it looks like there's a virus in that sperm. You think that's what's causing it? I said, I don't know. I don't know. But normally when you see infections as a cause, viral or bacterial, as a cause of semen analysis, you'll see pus cells.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So you'll see what's called pyospermia, leukocytospermia, the round cells we talked about. And the semen analysis will show up in higher numbers. They tend to be destructive and they tend to lower motility. So you tend to see a certain look to the semen analysis, volume, normal count. Motility is really low.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
A lot of the sperm are dead because they've been wiped out by these cytokines and all the white cells. And then maybe you'll find the pathogen somewhere. But culturing, mycoplasma, CMV, all these viruses. So Joe DeRisi, really bright guy, UCSF, went to MacArthur Ward. He took my patient's semen. This was back when microwaves were popular in the 2000s.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And he had like 2,000 all mammalian viruses on his chip. Everything. And we ran fertile guys and we ran infertile guys and looked at semen, not sperm. And 99% of the infertiles were positive for something and 98% of the normals were positive for something. So ubiquitous was the word. And so it left us high and dry because you can't really do much with that. So it's out there.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
But I do agree with your assessment that the pathologic phenotypes, the worst ones, are probably doing something. The question is, how do we measure it? What do we look for? And with semen analysis, as I said earlier, it's a blunt instrument. It varies a lot. It's tough to do it, but I'd love whether we do genotyping on recent sperm, probably not. I don't know.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And when you look at HPV, it's probably one of those things that might be in the ejaculate after ejaculation. might be coming from another fluid source and not in the sperm itself. So its effect would be post-ejaculation, which could still have a fertility effect, but it won't be probably as deep.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
I mean, the problem with the male system is it's all through the same tube. So urine comes through that tube and semen comes through that tube. So you have to look for infections in the urinary tract and anything like that when you're doing fertility because pus cells kill whatever they see. So if your urine's infected, that's a big deal.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Five million eggs at conception, one million eggs at birth, and you basically ovulate a thousand in your lifetime. Okay. So by the time you're 45, you're out of eggs. You actually ovulate one a month, but you actually produce 10 a month. So you lose 10. For every one. Right. So a lot of waste.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Not a big fan. As a trained stem cell biologist and someone trying to make sperm from skin and working with some of the best stem cell scientists in the world, I have a lot of respect for them, but it's not that simple. There's 560 offshore stem cell companies in the world that will take your money and do things like stick PRP in there. They'll stick bone marrow aspirates fat in your testicle.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And I'd say my experience has not been favorable. Some of the toughest cases in the world and they come to me after that and I do my techniques and I don't find anything and the trials aren't really real. come here, we're going to do this, and then we're going to do a microdissection on your testicle, but they didn't have one beforehand.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So the chance of finding it even without that is X and they're finding X. So it's just not well done. And I have my patients investigate all that. And I say, you do the work. You tell me who you found. Let me call them. I'll let them be the workers. And then I'll call them and I'll say, hi, I was just wondering about, do you have any papers or what's the science behind it?
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And they usually hang up or it's really interesting. But so far I'd say it's unfounded.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
But they're stuck in a stage of perpetual space where they're just, you know, and they get older and they don't evolve really. And then they mature when they're asked to at that time.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And I would say the answer is most. Wow. But the caveat is you got to tell me about the woman because I will defer. This is the only data I can give you. So I did a paper where I saw men for their infertility evaluation, got it done. And I thought they were fine. They had varicoceles and stuff, but their semen analysis was normal. And my investigation of their risk lifestyle, everything was good.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And I said, you're fine. You're cleared. No one's ever said that before. And they went home and they said, Turk couldn't figure out what's wrong with us. I said, that's not what I said. I don't do women. My expertise, I'm saying something positive here. Most people would say, I'm not sure why you're not conceiving. I said, I'm pretty sure you're not the problem. Didn't get interpreted like that.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
That got me a little angry. So I did a study with USC and I took these men that I cleared and I called them up a year later. And I said, what happened last year after Turek cleared you? How did a resident do this? And the answer was 65% had conceived naturally. Another 15 to 20% conceived with IUI or IVF. These women were 35 years old, year and a half infertility.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
They weren't going to wait around. Most conceptions occurred within six months. I didn't do anything for them. I didn't fix their varicoceles. I didn't touch them any medication. I just said, you're fine. So I published it as a lifestyle study. Not that I was right. And the idea was they probably made changes. They probably took a nutritional supplement. They probably timed their sex better.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
They probably got out of hot tubs and all that stuff. And they were taking pills. I have a list of what they did. I had a table in that paper that said that 65% natural pregnancy rate, that is higher than anything I can offer as a treatment that we have published on. So if you fix their varicose seal, you rarely get a 65% natural conception rate.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So I had a table of all the published conception rates for the technologies that work, and I'm saying this is even better. So if that addresses your question, that's the only data I have.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
paternal age and fertility, paternal age. So we can go there, but I don't place value judgments. I say, good idea. A disclosure, I'm on a board of legacy. I love their mission driven. I like the fact they're going for military and exposed patients and this and that and VA. I'm for that. I think it's the lowest hanging fruit in the field, obviously for cancer survivors and things.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
I don't care what you think might happen with your cancer. I would still bank it. I started a nonprofit called Banking on the Future. 16 year olds to 21 year olds with cancer. We'll do it for you. We'll pay for it for five years. Just give us a sample because it's so much harder afterwards or not.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Now, should anyone do it for any reason? Probably not. But again, I don't pass the judgment. If they're worried about something, then they should. What paternal age do you worry about? And you look at national guidelines for sperm donation, 40 is considered older paternal age, 50 for sure.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
If you look at risks to offspring, miscarriages, stillborns, autism, birth defects, things immediately related to conception, prematurity, Those go up with paternal age. Then you look at birth defects. When they're born, those go up one to twofold. And then the worrisome ones are the single gene defects and the epigenetics like psychiatric morbidity.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So the autism, schizophrenia, dyslexia, bipolar disorder, potentially Alzheimer's in offspring. And they're not detectable young. So big issues. I've written a lot about that, published on it. I was actually having my second child at 50 when I was writing this thing. Should I be doing this? Writing a paper on all these risks and with Alan Dechenko from University of Pittsburgh.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
There's a whole issue of what's the source of human evolution. It's really sperm. Yeah. Because they're constantly dividing. They're constantly influenced by the environment. And they're throwing off mutations and epigenetic changes. And what's most interesting for me for this talk is that whatever happens in sperm happens to offspring.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
But I think it's a hockey stick curve for risk to offspring. And you think the inflection is 40 or 50? I think it's more like 60. I think there's a slow linear increase in risk to offspring from 25 to 50 or 60. And then there's an inflection and then there's the blade of the stick. And I think that's logarithmic. Same curve as women with chromosomal.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Yeah, so it's a shorter curve, but the same thing, 40, 38 to 40 is kind of a point where things really ramp up with chromosomes. The men's stuff is not chromosomal. If you take the curves together, they're different spans, same shape, but I think the female curve is on top of the male curve. This is not the same relative risk.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So women, you go from 25 to 40, your chance of a miscarriage, though it's chromosomal, it goes up quite significantly after that. Very significantly. And the consequence of women's issues with offspring related health is basically miscarriage.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And now prevented with pre-imputation genetic testing. Men are different. You can't detect these things. They're single gene mutations. The machinery is constantly working. It's getting old. The quality control of the process goes down and little gene mutations get in there that are always being spun off in the heat of the engine. They're not getting vetted.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So the machinery is not doing a good job. So they're getting through and they're not going to be lethal. They're going to be deleterious. So that's where you get things. And autism is a classic one, paternal age related. Looks like that's the biggest risk factor for it. And that worries me a lot.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So the facts are that human evolution is entirely driven by sperm because eggs are just sitting there correcting the problem. It's entirely driven by sperm. And so 50 mutations a year, a generation usually gets spit out based on a nature paper. probably between generations. And there's always mutations occurring in 14-year-old fathers, but it goes way up with 60-year-old fathers.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So the rate of mutations goes way up with age, but it averages 50 over a reproductive life. And most of them, half of the mutations that we are throwing off as a species are are not ears or hands or feet or height. It's all neurodevelopmental. It's like half neurodevelopmental.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So when you think about what we're seeing, you know, the Martians from the fifties and the movies with big heads, that's kind of where we're headed. It's autism, dyslexia, bipolar disorder. These are neurodevelopmental neurodegenerative issues. And why is that? Well, that's what's going on. I mean, that's where we're being stimulated. That's where we're being asked to evolve.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Look at the last 30 years. Funny. One of the biggest investors in Salesforce said to me, I realized I was dyslexic when my son was born. And I said, really? He said, yeah, but you know what? It helped me be the man I am to realize that Salesforce is going to fly. Gave him the first 500,000, gave him the first million, never took any more money. And he said, it let me focus.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So autism is one of those diseases where you put out, you ignore a lot of input and And you find the gift and it's amazing. If you go down the rabbit hole of what they're good at, it's like their whole brain trust is there. So is that a disease or is that where we're headed?
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Maybe it's where we're headed. Maybe it's the future. Maybe the non-sequiturs that come out of those brains. Look at who's changing the world right now, at least in Silicon Valley.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So when you freeze sperm, it's about a 200-year-old process, regularly used for about 75. I forgot who the Italian scientist was who froze sperm in snow and then thawed it, and it was alive a couple hundred years later after Leeuwenhoek came up with a microscope. They found it was moving, and it was possible. So egg thawing is very new. Egg freezing and thawing is very new. This is very old.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So everyone is thinking about sperm now because eggs are being frozen left and right. but this is much older technology and the cell is much hardier than an egg. So it does a lot better typically. When you freeze it, it's the freezing process that kills sperm before icicles on the inside. And then while it's frozen, there's usually no issue.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And then there's another problem when you thaw it, rapid temperature shifts. So that's where the kill rate comes from. In a good sample, half of it should survive.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So I usually say, depending on what technology you're going to use, but if your sperm counts normal... Three ejaculates is one kid's worth of sperm with insemination technology where you would thaw it and then turkey baste it.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So there's three levels, sex, no tech, high tech is IVF, and then the middle is IUI. That's the stuff that's turkey basting. It's relatively straightforward, relatively cheap. I see. Three kids for that, but plenty of sperm for IVF. So three ejaculates would be more than enough- If they're normal. For IVF. Yeah.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So the population you're talking about, maybe cancer survivors, half of those will not be normal. They're really looking at IVF. Yep. So they don't need that many, but I'd say three is a good number, but it's an insurance policy, right? Yeah.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Well, we started a podcast last year because of the blog of 15 years. And we're just doing timely topics and it's me and my associate Rob Clyde, who's a director in Hollywood. And we're going to be the anti-Bourdain in men's health.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
We're going to just take on the topics, testosterone, et cetera, penis myths, and just talk about stuff that everyone is asking questions about, but no one's talking about. And like you, data-driven answers.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Yes, I think it should be done. That's the first step. There's a lot going on now that the biomarker concept relates a lot to your views on medicine 3.0. The paper came out two days ago looking at longevity based on the semen analysis in Danish, in the Riggel Hospital in Copenhagen.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
That spermatogonial stem cell is actually the first and the bottom of a tube. There's 12 stages of spermatogenesis. That cell is remarkable. It's actually the human male embryonic stem cell. So I have a patent on that cell. Because if you take that cell and you put it in a niche environment like an embryonic stem cell, it'll become embryonic almost like it can become multipotent. It's pluripotent?
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
They looked at 74,000 men over 50 years and found that those guys with, say, normal semen quality lived three years longer, all causes, than men with low sperm counts when they were younger. This was a single payer system, so they have all the data on it. It's very much a landmark study.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So if you ask me what excites me about the field, I would say as the author of the biomarker concept early in my career, I would say I'm really happy that we're scaring couples to realize that their fertility is a measure of their health. And now we have our foot in the door. If we can get a sperm count and get them in the office, we can actually tell them a little bit about their trajectory.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And it's becoming more and more every day. And we've never had a chance to do preventative medicine with young men. So it's a men's health play in a big way because their partners are bringing them in, but who cares? They're in the office. Your father had prostate cancer when he was 50. Someone had colon cancer. So I have now an NP, Molly Jessup, who is medical.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And it's like, okay, there's metabolic stuff and you can pick up diabetes. And we have an opportunity here we've never had ever. is to get men at younger ages. And I was a professor at UCSF for 15 years, endowed chair. I left. And I went to Yousan University, traditional Chinese medicine. I lecture there now. We had a conference last week.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And I lectured and I liked it because I thought Western medicine, maybe your view too, is too reactive. They're always trying to get men out of trouble or get patients out of trouble, but we're not thinking about getting them from unhealthy to healthy, which is the preventative aspect. We're just never good at it.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
your general surgery, every example you give is a guy who did something bad, you get him back, whatever. But you got to think next step, like kidney stones. Great. Urologists, we treat them all day. It's fun. It's endoscopic. It's lasers. It's shock waves. But what are we doing about that stone? I mean, how come we're not preventing these more? It's not on the radar.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
I go to Yosan University in traditional Chinese medicine, fabulous place, and it's all holistic. So I see patients who get referred by acupuncturists and they come in, their diet's under control, their stress is under control, they're doing acupuncture, they're sorted out. And what do I find? Varicoceles, because they don't find those.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
But the phenotype is totally different than the Western referral. I've loved that because that's 3.0. That's medicine 3.0, which they're doing. They've been doing it for 4,000 years. It's interesting how we don't give a lot of street cred to it, but in my view, a much of we don't understand about fertility, certainly men, possibly women, is epigenetic.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And the drivers of epigenetics, which are marks on the DNA, not DNA mutations, 50 DNA mutations a generation doesn't explain it. There's other stuff going on. Epigenetics is all lifestyle and diet driven. It's all lifestyle and diet driven.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
Multipotent. We don't know about pluripotent, but you can form tumors and you can form bone, mesoderm, ectoderm, and endoderm. You can do all three layers of the body. with that adult spermatogonial stem cell.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
No. I mean, there are stem cells in the bone marrow. There might be stem cells in fat, but none of this, we showed the capability of the cell is magnificent. I think it's the source. Women have eggs and embryonic stem cells. That's the male embryonic stem cell, in my opinion. It hasn't been taken advantage of yet with cell-based therapy, but it is really incredible what this cell can do.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So that starts out and it usually reproduces mitotically. And then in puberty, it'll go down the path of meiosis, which is a couple steps more than meiosis. There's mitosis involved with meiosis, but it's the having and the mixing up of the chromosomes and the newness of the genome introduces mutations and stuff. And most mutations are bad and some are good. You don't really think about that.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
But we could have a long talk about genetics versus epigenetics.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
So if you look at healthy human sperm for chromosomal content and what's correct and what's incorrect, probably 2% of them are off. They're still being made. They're just off because it doesn't really click the system to negate it. We don't know at what level of chromosomal abnormalities the system will say this is not. This is absolutely defective. Yeah.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
But I would say if you look at making of sperm, it's very logarithmic. You're probably looking at one out of four that are being made go through the epididymis, which is the next 10 days, which is a collecting duck after the testicle where it matures, gets epigenetically modified, and you'll see these zones, different epididymosomes and things like that happening.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
And there's a lot of post-production modification, not of DNA essentially, but I think there's a filter going on where a lot of the bad aneuploidy comes out because If you look at the chromosome abnormality rate in testicular sperm before it goes through the rest of the system and compared to ejaculate, it's higher. It's two to three-fold higher.
The Peter Attia Drive
#351 ‒ Male fertility: optimizing reproductive health, diagnosing and treating infertility, and navigating testosterone replacement therapy | Paul Turek, M.D.
There are some markers of paternal and maternal origin. It depends on where you're going back in mitosis and meiosis. So they can sort of ascribe it in the embryo. In the sperm, you're really going to have to look at the sperm. And if you see a translocation, some characteristic change in sperm, and you see it in the embryo, then you know it's paternal. But not usually.