Today, one of my favorite guests comes back to the podcast: Dr. Paul Turek, also known as The Sperm Whisperer.
Dr. Turek is a multi-award-winning urologist and an internationally renowned expert in men’s sexual health and reproductive urology. His work has helped so many people create the families they’ve always wanted, and it all comes down to his care for his patients.
He also shares his expertise and wealth of knowledge on his blog, Turek on Men’s Health, which has been named one of Healthline’s top men’s health blogs (2016 to present) and one of the Top 30 Men’s Health Blogs.
When it comes to men’s health and fertility, there is no one better to talk to, and I know you will get so much valuable information from my conversation with Dr. Turek.
Here’s what Dr. Turek and I talked about, with timestamps:
00:00 Welcome to the Egg Whisperer Show
00:37 A Day in the Life of Dr. Paul Turek
01:03 Understanding Male Fertility
01:28 The Importance of Male Fertility Care
03:50 Advanced Paternal Age and Its Implications
07:22 Epigenetics and Male Fertility
09:37 Improving Sperm Quality
12:56 ICSI and Sperm Quality
14:02 Common Causes of Oligospermia
15:25 Lifestyle Factors Affecting Sperm Quality
20:36 Preparing for IUI and ED Solutions
23:54 Final Thoughts and Farewell
Full Transcript:
Dr. Aimee: Welcome, Dr. Turek.
Dr. Paul Turek: Thank you, Dr. Aimee. It’s great to be back.
Dr. Aimee: Tell me about your day today. What did you do?
Dr. Paul Turek: Today was busy. We have a mobile care unit because guys don’t like to come to me, so I go to them now.
Dr. Aimee: That’s really cool.
Dr. Paul Turek: We saw some patients around the San Francisco Bay area. Then I went into surgery for a complicated case where a man had no sperm, and I mapped him and then I went for a sperm retrieval. It was tough, but very highly successful, and everyone is happy.
Dr. Aimee: Awesome. People know what a female fertility expert is, but tell me a little bit more about what you do. Your job is really important.
Dr. Paul Turek: I’m “pecker-checker string team.” We devote ourselves to men. I don’t have any female patients; it’s all about the guys. It’s a whole different breed, the wild animal that you have to get in.
The problem with my field is no one knows about it because no one knows about it. If you look at couples who are infertile, they’re supposed to each be evaluated with care. Women get the care because they’re proactive. Men typically don’t. Only one out of five who are infertile actually gets any care. You may say, “What are you talking about?” The answer is in America they do get a semen analysis, but in my opinion, and those in my field, that’s not care.
We can find things if we see them, but we can’t find them if we don’t. That’s a bit of a stump for me. The idea is to pick a moment and really take care of these men and see what you find, and you’ll be amazed at what you find.
Dr. Aimee: Right. I call it personalized fertility care, which is understanding you. For women, a lot of people think that just checking an FSH, estradiol, AMH is fertility screening, and certainly that’s not all of it. I’m glad you brought that up.
It seems like we talk so much about women, we have the Me Too movement, clearly we need the Men Too movement, too.
Dr. Paul Turek: We do. We’ve been working quietly in the background for years, serving the underserved. I call men medically underserved. We can have a conversation with whiskey over this one, but it’s complicated.
Dr. Aimee: Yes, in your mobile unit.
Dr. Paul Turek: Men are built for providing and not complaining and there are cultural issues, part of it is internal, part of it is external. They just don’t do well. Boys get their care from a pediatrician, they go off to college, and then you don’t see them until they’re 45 or they have a problem. That’s the honest truth, and it’s just really sad.
Our system isn’t preventative enough to do that. Men aren’t bound to a cycle like women are every month where they know something is wrong. They’re like old Maseratis; they’re not going to bend or make noise, they’re just going to break eventually. We’re trying to catch them before it happens. That’s what the whole biomarker movement that we’re starting is.
Dr. Aimee: That’s so true. For me, I tell my patients when your period starts, think of me. There’s no analogy for guys. I guess you could say when your wife’s period starts, think of me, but I don’t know how well that will work. You could try that.
I have so many people around the country, and even the world, who have sent in their questions because they all knew that you were going to be on tonight’s show. So, I just want to ask you some of the questions that people have asked.
Dr. Paul Turek: Sure.
Dr. Aimee: One of them is, “How old is too old to have a baby for a man?”
Dr. Paul Turek: It’s a great question. It’s a very active issue called advanced paternal age. Advanced paternal age has been linked to diseases in offspring, so it becomes very important. Health of sperm, too. There are issues as men get older, similar to women, but different.
What happens as men age is their sperm incur more problems. One of them is DNA fragmentation. Another one is they have a lot more single-gene mutations, which lead to debilitating diseases in children and offspring. Unlike women, who basically have a lot of chromosomal errors in their egg, which usually lead to miscarriage or fetal death, things like that, so it’s less subtle. You can detect women’s issues prenatally, but you can’t detect a lot of men’s issues prenatally.
The men’s issues can cause problems with fertilization and embryo development, so along the whole path of is the egg fertilizing, am I getting pregnant, are you getting miscarriages, every single stage of the way there is a higher rate of problems in women with older paternal age, everything from miscarriage to embryo development, to early prenatal death, to late trimester deaths, to birth defects. It’s wild.
What’s really interesting to me is that this field is new. It’s new for several reasons. One is men never lived long enough to be of older paternal age because we don’t even have a definition for that. But 50 would be considered older, and in a lot of books, 40. I know this because I wrote a review article that just got published in The Journal of Assisted Reproduction and Genetics, and it will be available for everybody in a couple of months as an open access paper called Reproductive Genetics and the Aging Male.
When I submitted it, they asked me, “What’s your definition of older paternal age?” I said something, and they said, “We don’t agree with that,” and we all had this discussion on the editorial staff about what is the definition, and the answer is we don’t know. The way risk runs with men and women, these risks that they bring to bear in kids, they’re hockey stick shaped curves, so they’re flat for a while and then they go up pretty dramatically, like a hockey stick. It’s flat for the longest time, then it starts taking a curve, and we don’t know exactly when.
But I would say that if you’re worried about reproductive risk to children as a man, 60 would be an age where I wouldn’t freeze sperm after that. 40 to 50 seems to be an age when you start thinking about it. In the literature, I’d say 40 is considered advanced paternal age. As a reference point, the average age of a man who is a first father in America is 30 right now. It was 25/26, now it’s 30, so it is moving up.
The other interesting fact is we never lived long enough to be older paternal age fathers. If you look at our lifespans in America and developed countries, 50 years ago we lived 50 years. In the ‘70s it went to 60 or 70. Now we’re 75 to 80. But 100 years ago, the average age was that you lived to 35. Cavemen, probably to 25 maybe, any infection would kill you. The whole concept of what’s old is just so new, we’re really only dealing with this for 30 or 40 years and it is a real new issue.
The other interesting fact is we now know that epigenetics, which is a new field in medicine that came after genomics, which is after the Human Genome Project, is actually explaining a lot of what is happening both for women and with men. Day by day, we’re learning more and more.
The way sperm are built and the way their DNA is marked changes with age, it’s not mutations, it’s not chromosome issues, odd DNA fragmentation, it’s just the markings on the DNA, they change with age and they’re instrumental in fertilization, embryo quality, miscarriage, and probably a lot of the neural developmental diseases in children like autism, schizophrenia, dyslexia, and bipolar disorder, probably a chunk of those are male-driven. It’s fascinating what’s happening.
Dr. Aimee: I have patients that come to me, let’s say a woman is 43 and she asks me, “Am I too old to be pregnant?” I can certainly do standard fertility screening tests and tell her what her chances are of having a healthy pregnancy. If let’s say there was a man who was 43, or even 53, or you can pick an age, is that something that they can come to you for and say, “Dr. Turek, I’m just curious, am I too old to have a baby, and what would be my risk if I did?”
Dr. Paul Turek: I don’t think that science is granular enough to say that, but it might be. There’s a company called Episona in Los Angeles, which is coming out with a second-generation test which will tell you as a man what the chronological age of your sperm is. I don’t know if it will ever come out, but it’s a really cool idea, which is just what you’re saying, basically. It doesn’t tell you specific risk, but it tells you “am I a 50-year-old-40-year-old or am I 60-year-old-40-year-old or am I a 30-year-old-40-year-old.”
I’m all over that one. I think that’s going to be a really informative thing for men to use to say, “Should I freeze my sperm or not? Should I try to have a kid now or not?” It’s all risk evaluation.
Dr. Aimee: Right. For women, when I see a 43-year-old, she might have the levels of a 25-year-old, but her eggs will still behave like a woman that’s over 40.
Dr. Paul Turek: Right. We’re going to be able to do that with sperm using epigenetic science within five years.
Dr. Aimee: Awesome. Along the lines of epigenetics, what can a guy do to improve his profile, so to speak?
Dr. Paul Turek: Hard to say. But the early data from the last year or two looks like lifestyle, lifestyle, and lifestyle. It’s really funny, I started in this field and about half of the time we could figure out what’s going on with a guy and half the time we couldn’t. I’m thinking this chunk of stuff with lifestyle all of a sudden becomes really important. Preconception care, fertility supplement, we know it helps fragmentation rate and things like that.
I think that the deal with epigenetics is it’s the same idea, but a longer timeline. So, you need to take care of yourself for a longer period of time to change the epigenetics to make it more favorable. We’re talking not three to six months, but more like six to twelve months.
Dr. Aimee: That’s perfect. So, men should be taking a prenatal vitamin for three to six months before they get pregnant, similar to what we recommend to women.
Dr. Paul Turek: Right. I’d say especially if there is an older maternal age issue, if a woman is over 35 to 38. You want the best sperm for that egg. It’s not about numbers, it’s not about the semen analysis. This is a deep dive, this is looking closer at sperm function, which is actually what we’re talking about.
If you look at older men, their semen analyses can be very good. Generally, the volume goes a little bit down, the counts stay the same until you stop making it, and the motility drops by about one-tenth of a point per year, so one point per decade. Maybe one point per year, I’d say that, roughly, after age 40. So, the motility might fall 10 points per decade, but very little change, but the infertility goes up, and other things go way up. It’s not about the look anymore, it’s going deeper into the sperm.
Dr. Aimee: Right. Taking a deep DNA dive. That’s along the lines of this next question that we had sent to us, “Can good egg quality overcome high DNA fragmentation of sperm?”
Dr. Paul Turek: That’s a great question, too. The answer is yes, I think. Think of it as a dance, think of it as a rumba or a really nice dance, and you have to have at least two good legs out of four to make it happen, otherwise you’ll fall over. If the woman is a little older and her knees aren’t as good, but the guy is really strong, it will probably go fine. Likewise, if the woman is young and has good knees and the guy doesn’t, it may also go well. But if they both have a problem, they might not finish the dance.
That’s exactly what’s going on. Sperm introduce errors in their DNA as they present it to eggs, eggs filter those errors and have deviant mismatch repair enzymes, about 3,000 of them, that turn on and spend the first two days fixing things. Maybe that’s typical of the species, but when that’s done, it’s either going to be go or no-go, and the egg is going to make that decision after fertilization. That’s why the sperm has to be the best it can be.
Dr. Aimee: That’s what I tell my patients, we have to put sperm through a fitness challenge before we do IVF to make those eggs look as good as possible.
Dr. Paul Turek: The fitness challenge has been invented, it’s going to be out on the market now. It’s a little obstacle course for sperm.
Dr. Aimee: I love it. The next question says, “If ICSI is unsuccessful, is it more egg quality or sperm quality that is to blame?”
Dr. Paul Turek: That’s a good point. ICSI is basically removing the barriers of fertilization, so you’re really looking at mano-e-woman, since sperm is different kinds of DNA, but it’s still quite a dance.
I’d say our classic thinking was that sperm had very little contribution to what happened in a dish after the sperm was introduced to the egg. We thought of it as a DNA payload that once delivered, the rest was up to nature, and nature was the egg. But now we know more, and that has to do with DNA fragmentation and epigenetics, and it can certainly be instrumental. There are little micro RNAs that are in the sperm that were made earlier that get delivered to the egg. A lot of the logistics of embryo development are sperm-driven, that’s pretty clear now, and that’s new.
So, 10 years ago, I would normally say 5% chance that the sperm was causing the problem. Now, I might say 45%.
Dr. Aimee: Wow. Then what can be the cause of oligospermia if, let’s say, genetic testing has been done? When I say genetic testing, I mean karyotype or Y-chromosome microdeletion. If those things are normal, what else could cause oligospermia?
Dr. Paul Turek: Typically, it’s not bad. That’s probably 10% of the explanation. The most common is a varicocele, which is dilated veins in the scrotum that are acting like varicose veins in the leg, but they’re in the scrotum, detected on a two-minute physical exam and quite correctable surgically.
Dr. Aimee: I tell people not to Google varicocele, because you’ll see some scary pictures.
Dr. Paul Turek: Yes. Think of it as ropey veins in the scrotum. They occur at puberty. It’s benign. That’s about 40% of the time, so that’s going to be four times more common than genetics.
Then I would say obesity is a class reason for low sperm count. Anything that keeps the body unhealthy will do it. Anything that lowers testosterone levels, chronic stress, hot tubs, anything that you can think of, social drugs, cocaine, tobacco, marijuana. Marijuana is the one that everyone is like, “Everyone’s doing it, it can’t be bad.” Weed worries. I’m very worried about this. It’s a production problem, it’s a DNA fragmentation problem, it’s not innocent. It’s a risk for testicular cancer. It’s not an herbal remedy, it really isn’t.
Think of sperm production as an engine that wants to run really hard, and anything that you do to bring it down in life with your lifestyle is going to hurt it. So, traveling ridiculous amounts, having ridiculous stress chronically. We’re built for periods of acute stress, as Cavemen, we’re built to survive starvation, that’s probably the key to longevity, but we’re not built for chronic stress, we’re not built to be chronically connected to a device that rings and you answer it every time it goes off. That’s not the way we’re made. All of that stuff adds up.
Dr. Aimee: Right. We’re not made for chronic pizza and beer.
You talked a little bit about essential beginnings, as far as supplements that can potentially help sperm. One of the questions that someone emailed asks, “Are there any medications a guy can take that can improve sperm count and quality?”
Dr. Paul Turek: I would say not really. The way you have to think about it is that sperm want to run hard and all you can do is bring it down. The way to handle it if it is down is to reverse what’s keeping it down. If you’re smoking, you stop smoking. Typically, the healthiest body is the one that isn’t loaded with medications.
On the other hand, it’s clear that antioxidant supplements like herbals, minerals, and antioxidants can help. That’s independent of the sperm count, that’s more of a sperm function issue. So, you can help things by a great diet, that could help things a lot. Eat well, sleep well, take great care of yourself, these are basic things thought to be unimportant until epigenetics came around. Losing 25 pounds changes the epigenetic profile of your sperm a year later, it’s unbelievable, and that’s inherited. It’s crazy what’s going on.
Dr. Aimee: It is. I tell women your fertility isn’t skin deep, it doesn’t matter how good you look on the outside. Certainly, there are health habits that are important to have, but it’s incredible. I tell guys, you’re lucky, so take advantage of this and take advantage of the fact that you can change your lifestyle and that can improve your fertility.
Dr. Paul Turek: One of the classic examples is couples who fail with technology and then go home and have a kid. That’s not insignificant. I think the five-year rate of that is 25%. But they’ve done all the right things and then the stress goes away, and bam. Everyone thinks it’s anecdotally rare, but it’s not, it’s pretty common. There’s a book about people who just decide to eat better, and with that one move, they’re more fertile.
Dr. Aimee: Right.
Dr. Paul Turek: I think a lot of this stuff is just starting to make sense to us. It’s kind of sad that it went through that route of nothing you do really matters, you’re unlucky in love if you can’t, but it’s not like that anymore. You actually have control.
Dr. Aimee: Right. This is another question, “Does the quality of the sperm affect successful fertilization with ICSI?” I see couples come in and say, “I’m just going to do ICSI,” and I said hold on, we have to have you go see Dr. Turek because I feel like I want your sperm to be as awesome as possible. But does it really matter what the quality is when it comes to ICSI?
Dr. Paul Turek: Yes, to that question, but the question was fertilization, and I’d say basically not. Fertilization is probably independent of sperm quality, so that’s my answer, but the events after fertilization are very dependent on sperm quality.
Dr Aimee: Another question says, “How often do you see no fertilization with ICSI?”
Dr. Paul Turek: Typically, it’s 1 in 200 cases. The most common reason is dead sperm. If you put a dead sperm in there, it’s not going to fertilize. You could put a piece of rice in there and it will fertilize. Eggs fertilize pretty easily. You could put dust in there and you could get them to fertilize. You could get them to fertilize without a sperm, you could just put them in a calcium bath and they’ll fertilize, but it won’t be normal.
Dr. Aimee: Here’s another question, “If the sperm count is normal, how can sperm DNA fragmentation be abnormal?” Same for DNA methylation. Do they correlate at all, how does that work?
Dr. Paul Turek: The answer to that question is how often have you been to a bookstore and see a really nice cover, then you buy the book, and you don’t like it that much or it’s not very good? You can’t judge a book by its cover. You can’t judge a sperm by its shape, size, or quantity.
In fact, one of my favorite sources of sperm is cryptozoospermia, which is men who may be cancer survivors or it may be genetic, but they have just very few sperm in their semen and to find it in their testicles would be almost impossible. Even with things like mapping or microdissection, it’s almost impossible to find sperm because they’re just maybe coming from one spot in the wilderness. I like to use the sperm they have, and they may only have 10 or 20, but those sperm are fine. It’s not really about the count.
Sperm go through such a quality control process, it’s almost impossible not to have a great sperm after all it has been through to be made.
Dr. Aimee: I see a lot of bumper stickers that I’m going to be making after this show. You’ll see them all over my car driving around the Bay Area.
Last few questions and then we’ll finish up for the night. One question is, “What is the best prep for a guy for an IUI? How much time should he abstain before the IUI?”
Dr. Paul Turek: I’d say the most important thing about IUIs would be why it’s being done, in terms of success. I would say one of the newest things that I’ve figured out is that if you have a long abstinence period, fragmentation rate of the sperm, as a quality problem, goes way up. So, the quality goes way down, fragmentation rate goes way up, and high fragmentation rate will kill an IUI success rate.
It’s not really the abstinence of the sample that you’re giving, but it’s the abstinence that you’ve done for the month or two before that. That’s kind of a new concept, but I’ve seen a lot of couples because two days of abstinence between the last sample and the sample for the IUI, and the motility is really good, but the sperm is old because it hasn’t been emptied out for a month or two. The bin where it’s being collected from, the epididymis, grabs a little bit and shoots it out, it’s not being made and then ejaculated immediately.
So, I would say you should have regular intercourse or regular ejaculation for the month leading up to it, along with a two or three day abstinence period for the sample. To even combat that, if you’re an infrequent ejaculator, and a lot of couples are very stressed out and busy and they don’t get to it as much as they’d like, even a week of abstinence, I’d probably say you need to spool up for this sample. You want to be grabbing a great set of sperm from that pot, and it has to be fresh stuff, so you have to replace it.
Then also, just like with intercourse, I’d use a preconception plan, a great diet like Paleo Mediterranean, and get all those antioxidants onboard. Typically, abstinence right before the IUI doesn’t matter that much. You probably want at least two days to get the count up, the motility is probably good for three or four days, and that probably doesn’t vary that much.
Dr. Aimee: Great advice. What about guys who have problems with ED, is there one particular medication that you recommend over the others?
Dr. Paul Turek: No. I think a lot of the ED is stress related. They typically are fine with recreational sex, but when the partner says, “Be home at 5:00 and we have to deal until 6:00,” they get all stressed out. I tell them to just get home, have dinner, if it’s going well, but tell her “maybe in the morning.” Sperm lasts a day or two in the vagina and in the uterus, so you don’t have to worry too much.
Get the stress off. If you can get the stress off, go for a run first or whatever, decompress a little bit, disconnect. Maybe anticipate a little bit, maybe sext her or do something, send some flowers, make it a little more romantic. When you’re infertile, that’s usually the issue.
Dr. Aimee: I’ll say clean the house for her because that’s a little foreplay.
Dr. Paul Turek: That would work, yes. That’s good.
Dr. Aimee: Do some dishes.
Dr. Paul Turek: Get a lot of guys to do the dishes.
Dr. Aimee: I tell the guys being a fertility patient is so stressful. It’s stressful for both, but for women, it’s just so hard because we think differently. I say to the men to just ask your wife, “How can I help you? What can I do for you?” It’s as simple as that.
I love the perspective you bring, and I just want to say thank you for all the work that you do and thank you for making this subject a little less taboo for everybody. We’ll keep sending patients your way. We hope that anyone who is struggling with fertility watches this episode because the information is really going to be helpful in helping so many.
Do you have any last minute thoughts or comments that you want to make to our audience?
Dr. Paul Turek: To the point of uncovering the rock of male fertility and looking underneath, trying to capture the essence of what it means to be infertile, look at the quality of life impact, it’s intense.
I remember I asked infertile couples in an informal survey when I was a professor, “How many years of your life would you give up to have a kid?” I asked the men that, and that was pretty impressive, but they both said about five years. You’d give up five years of your life to have a kid. It’s that hard. Then I looked in the literature, because there’s not much on fertility, and I looked up what cancer survivors, what cancer patients would do, and it’s the same number, five years they would give up to be cured of cancer and five years they would give up to have a kid.
So, don’t underestimate it, it’s real and it’s gravitationally real.
Dr. Aimee: It’s very real. Thank you for all of your hard work. Thank you for everything you do. Have a great night.
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