we'll talk about the high points so I think one is that a lot of sauna use is up right now and we know heat is not great for for testicles so are you seeing more infertility in SAA users are you worried about this yeah heat kills speed Thrills the um yeah the more modal the sperm the better off your chances of conception are and anything that raises your scrotal temperature even a degree Fahrenheit can can has pretty dramatic effect for a long time now the thing about sauna is that you're at least you're not in there for that long so your exposure should be you know less than 15 minutes or so and your testicles are probably somewhat SPL out so you're not in bike shorts when you're in there so and and the fins are a pretty fertile lot you know and and the fins have been doing sauna for 2,000 years plus I mean ever since they you kind of moved up to lap land area and so it so there is some cultural significance the the the benefits of sauna the uh heat shock protein release and all of this the longevity data coming out on sauna it's a very compelling anti-aging anti-inflammation anti-stress way to to relax you know to be in that that hot environment and Then followed up with a cold plunge right to do did the real true finish experience of going from 106 degrees or 120° to you know to 35 but uh but yeah in terms of sperm production I do see and More in any other work or Sports where the testicles are constantly compressed for a long period of time uh in hot yoga for example when people are in hot yoga rooms for a long period of time that I've seen diminish sperm Counts from that um saas not as much hasn't been as is well studied and again I think that it probably is that there's a little bit of cooling that uh that goes on but but yeah that is the hottest thing these days and so I think it's everything in moderation especially with heat exposure is what I typically tell my patients to do but they're doing something for them that's healthy and I usually say healthy you healthy sperm and so I I think anything in moderation we need to do the studies to really look at that but also we need to look at our cultures that have doing saas for years and seem to be doing okay yeah that's a good point and uh what about red light to the testicles so yes that boy the the data for red light therapy was a paper from about 1938 of eight men it's amazing you know when when influencers get a hold of PubMed you know and you just go back and even to the Cochran database you go back pre 1964 and you see what comes up wow there's this one study where totally uncontrolled where yeah you just did some testicular tanning and and saw tea levels go up not a fan don't see the data behind it there's so many better ways to improve your testosterone even holistically not not even you know through medication that uh that I I don't don't recommend testicular tanning and uh but you know again any observation then let's let's actually do a clinical trial instead of just an eight patient from 1936 observational study well if you're looking at red light specifically I don't think it penetrates deep enough to get to the testicles there's that too yeah the lighting cell to do tanning is separate but I think people are like doing this whole body red light and some of the reason being they think it's going to boost testosterone I don't think it's getting deep enough the data at least on red light is for skin level right for for red light yeah exactly I'm sorry is is you're looking at just maybe some kind of upregulation of collagen synthesis for for skin Improvement but yes but yeah but you're right they're doing uh the idea being that somehow you're going to improve um both sperm production and and testosterone production through tanning or through red light yeah yeah and you've done some work on looking at supplements uh supplement promotion for infertility and misinformation in that space what supplements are going to help people if they're trying to conceive versus which ones are not really that helpful so supplemental sleep is one of the best ones I love supplemental sleep so you know I wrote a book a couple years ago and essentially was you know the kind of Field Guide to man's health but it was all basically it's eat move sleep you know whatever you look at you know before you start talking about supplements before you start F tuning your lifestyle look at the big stuff first and and so then you say okay well are you missing anything nutritionally are you not eating vegetables at all because we know from a fertility standpoint that high levels of antiox oxidants really good for the seminal environment and one of the things we look at in men even with normal seam analysis can have an elevation what's called reactive oxygen species which basically causes the DNA to be more fragile and lead to poor fertilization and even poor embryo development and and we can fix that we can decrease the reactive oxygen species with really good healthy diet increasing poly unsaturated fatty acids so tree nuts are great any dark Ley vegetable any blueberries what does that mean on the supplement level then if you say look doc I can't stand vegetables kale is an aom to me I don't want to spend 20 bucks for a smoothie at aroan then what can I do and and then right some of the ones that have been studied forever CoQ10 ALC carnitine folic acid vitamin C is a pretty heavy hitter because it's such a good antioxidant and there's really good data show just vitamin C alone 500 milligram can reduce your reactive oxygen species there are a lot of supplements that are out there that are com combination therapy and they are just basically one or usually two capsules of of all of those antioxidants rolled into one and so I usually what I do is I think one of the supplements that without any financial interest I should say is a is a supplement of Austria called Pro fertile the reason I like it is they actually do data in European studies you know the governments often sponsor neutral studying so if you want to look for most of the data on neutrals you look outside the United States CU we don't fund any data so it's going to be industry sponsored so whatever company that you're looking at you know maybe look outside of the states and see but but Prof fertile has pretty good data that that their supplement which is a mixture of essentially everything I just said probably with some proprietary ingredients can decrease DNA fragmentation index so it means the DNA is healthier can decrease reactive oxygen species and they even have some live pregnancy data having said that the AA guidelines for infertility still don't recommend any supplement that there's enough good evidence level one data that you should be on it so so for me you know I'm not in general a huge vitamin person unless you've done everything right right so if you're just totally dialed in you're sleeping eight hours a day you're exercising 30 to 40 minutes a day your nutrition is great and you just want to you know super perform then then we can talk about adding supplements but I think unfortunately for most people it it's a shortcut and they're they're missing the long route which is to just take better care of themselves improve improve their overall health but so when I see a man in my clinic I give him a handout of all of the the randomized control data which are basically the four or five I just mentioned selenium is also on there 80 micrograms of selenium and uh and say or you can just buy it all in one and here's a couple companies that that have an allinone and you know you if you go and buy it at a decent reputable supplement shop then you probably save yourself about 30 bucks a month so it's not a huge savings but uh but it's reasonable you just got to choke on about eight pills instead of two in terms of fertility we're seeing at least in Seaman counts they've done some you know pretty major studies that have looked at a decline in in seam in counts and concentration over the last 50 years why do you think that is yeah I mean this is a is is kind of a bit of a chicken little thing for me I mean for one thing I'm kind of excited we're talking about it because as a male fertility specialist and a reproductive urologist we've sort of been back seated since the 80s when when IVF came along and we can take two sperm and make a baby which is still true in fact it's amazing what we can do for men that have really really reduced sperm counts even some that have zero sperm in their ejaculate I can go in with a microscope find sperm in their testicle and still create a biological child for that man and his partner so I love that because we're talking about it but then I also don't want to scare people and thinking is this truly something that is happening is our white chromosome really shortening and is our and our fertility really declining because of what and and I think it goes back to you know is it the carpet we're sitting on are there thades in the carpet is the bisphenol is in our plastic uh in our in our water bottles and there's so many different environmental mutagens but getting back to the big picture we also are not farming and plowing anymore and we're not doing uh walking up seven flights of stairs because we all have elevators and so there's a lot of change just in our overall health one of the things I'm super interested about though is is that our microbiome was also changing pretty dramatically and we have some pretty cool data coming out we've had a couple papers by masachi who our research resident now has been leading this because he had a background in in in gut microbiome and we brought them into Urology and and we actually have studies showing the seminal parameters of of men that have subfertility the microbiome is a completely different biomap than those that are coming to me that are perfectly fertile so we set up the study pretty simply and saying you know hey Dr Mills I had my two kids I'm done would you do my visectomy I said yes but first how about this would you give me a sperm sample uh and I'll do an extra good visectomy and uh and they uh and everyone gets an extra good exactly right everyone does but no I was very grateful to these these uh men that uh that volunteered uh IRB approved of course their uh for us to look at their their their microbiome in the fertile couples and it's totally different and and it's really really cool so maybe it kind of goes into everything else that's wrong with us today is that maybe we have a massive antibiotic exposure you just you know if you're three and you get a sniffle uh you get ear tubes and you get antibiotics and and so we've really changed the way that we interact with our microbiome so I'm super excited with that we want to expand that study to looking now at the partners and seeing you know what their cervical microbiome is and see if there's a mismatch um because they're they are higher rates of of abnormal vaginal microbiomes in the men of infertile couples too and so so it probably goes both ways you know some of the bacteria that we typically see in a in a in a vaginal Flora that maybe are pathologic or ending up in the male seminal microbiome so so that is sort of a a plug for maybe that's one thing we haven't looked at everything else it certainly goes back to just all the environmental mutagens that are around but I'm not an alarm is that way I think again it goes back to before we talk about why your sperm counts are low and and who can we blame let's talk about exercise you know let's talk about weight loss let's talk about what we can do to get you in better shape let's talk about the stress you know you're coming to me on your lunch break or between jobs because you just been overnight working you know down at the uh at the Long Shore and here you're are in my clinic and then you're going to go off and drive Uber for a little bit and then you're going to try to have a baby and so I think you know the idea of of stress and strain especially in in expensive urban urban environments like I practice in is real you and I think that's where we're seeing the fertility decline we're having babies later in life too and and one of the things we know is that that as we age our our semen in general does get worse and and that is in fact part of our new AA guidelines for infertility which I don't think are embargoed yet and they may have been the older one but as I'm reviewing them that we really have to recommend to people if you're over 40 you may have impaired sperm production already so if you're trying to conceive at 40 or low at 40 or greater you may already be in some trouble so so that's real and then we also know that as as women age even if they have good ovarian reserve the eggs have intrinsic DNA repair mechanisms that aren't as good so if you have 23y old eggs versus 37y old eggs they may they may be fine if you're dealing with 22y old sperm but if you're 37 and your partner's 46 or 50 then that sets up risk factors where your eggs are not able to to repair the abnormal DNA in the sperm and the sperm itself is already not as good as it used to be when it was 20 so so there's just so much to go in to unpack and and there's a lot of a lot of uh great literature coming out there's there's a uh a new sperm banking relatively new fellow started by Jim Smith again I don't know interest in them but I'm interested in their science because they have repository of tens of thousands and soon 100 thousand Sean analysis for all over the country country where we can actually study this stuff and making a big investment in trying to figure out how we can actually get answers to the question you just asked is there a zip code dependence is there a difference between the the Seaman analysis in Orange County versus Long Beach for versus Santa Monica versus the valley yeah there is why don't know yet these are the things we got to figure out yeah and I think stressing about these things like why is this happening what's in the environment what's like who's to blame is actually just harming us right like there's so much especially on social media there's so much you're guess what you didn't know you know like you're this this water you're drinking is like got whatever minutia of something in it and you're going to be in trouble now um and so I think that stress is really underrecognized like that is causing probably way more problems than whatever they're telling you is causing you problems right well and and you bring up something tangentially which which I see all the time which is is the you know the social media Circles of like here's our baby reveal and here's this and then the the the the fomo of the couples that are in my office saying you know everybody in our group now they all have Toddlers and like we're just sitting trying to figure this out and it's pretty devastating it really is and uh and and just the whole idea especially from male Factor we we had a very nice discussion about the psychological trauma of of ponis and dealing with that but the male that has a difficulty initiating pregnancy is a it's a he's a fragile male I mean it is a devastating thing to say this is what defines me I'm a sperm producer I mean that's what I am as a man that was as a person born with a penis and testicles to not be able to conceive is is something that we we need to spend more time on acknowledging and and trying to help men deal with that and we definitely need more counseling a lot of the counseling and fertility this is my plug for men's health is really mostly looking at the female side of things and the devastation of of infertility but man these guys are direct you know we really have to take care of them really have to you know try to to first of all do everything we can you to to find a good solution for him but also not everybody's able to you know I don't every one of my micro tessis is not successful unfortunately so every time I go to the o trying to find sperm uh it can be a devastating conversation you know it's one of the things it's it is the hardest thing I do I mean is the hardest thing I do in medicine that is one thing I will say I have a lot of female friends who've gone through fertility issues and there's like you know there's T they they support each other there's this great fertility Warriors there's like you know hashtag fertility Warrior there's like all these things right and they they really support each other they become like sisters they become this really bonding support for each other and I don't see that for men for most things right but definitely not for infertility doesn't happen at all and I'm not I don't know the social media world that well but I know enough of uh couples that have struggled for fertility that where there's a male Factor where that isn't mentioned you know so I'm mentioned and it's all you know this is we struggled for fertility and just everybody assumed it was on on her side but it's it's not it's not and uh and there's no place for that guy to go you know I've yet to meet somebody that that wants to be a public figure and say I want to share my struggle I've had men for that for erectile dysfunction for pyron's disease for all I mean my entire career is dealing with the most sensitive issues that men face and I I have not had a spokesperson that wants to come forward and talk about their fertility journey and of course I'll never ask you know I'll never ask I should mention that I I feel bad now for for Anthony I had a great patient who's a um a spinal cord injured man that that I helped and uh he actually has a foundation and so he I think a is an amazing person but B um because he has more of an obvious reason for why he has fertility issues that has nothing to do with his sperm production but we just need a little help to to actually uh create the embryo he's very public about that but but for everybody else that that uh doesn't have an obvious cause it's very difficult for them to share that yeah well if anyone listening wants to share reach out and we'll we'll help you or I'll help you I I love that