Posted on April 1st, 2021by RMANY

Ep 56: Male Reproductive Medicine Insights with Dr. Natan Bar-Chama

Fertility Forward Episode 56:

Even though men contribute to more than 50% of instances of infertility, there is not the same culture around male fertility testing as there is around female fertility testing. Here to discuss this and many other topics around male reproductive health and fertility is the esteemed Dr. Natan Bar-Chama, Director of the Center of Male Reproductive Health at RMA of New York. He is a board-certified urologist and male infertility specialist and his practice is dedicated to the fields of male infertility and sexual medicine. He has published extensively and lectured throughout the world on these topics. Since 2005, Dr. Bar-Chama has been listed in New York Magazine’s Best Doctor list of urologists. In this episode, we discuss some of the positive changes around fertility testing which have been brought about by the pandemic. When men feel more at ease, they are more likely to get tested. Dr. Bar-Chama discusses what semen analysis entails and explains the process that would follow after receiving irregular results. Lifestyle impacts sperm tremendously and as Dr. Bar-Chama points out, research shows it also impacts children's health. Our conversation also touches on how Dr. Bar-Chama makes his patients feel comfortable through education and testing, some sperm-related myth-busting, and the aspects of your lifestyle that impact sperm. Male infertility issues are starting to become more openly spoken about, but we still have a way to go. We hope this discussion creates a space for these challenges to be addressed more openly.

Transcript of Episode 56

Rena: Hi everyone. We are Rena and Dara, and welcome to Fertility Forward. We are part of the wellness team at RMA of New York, a fertility clinic affiliated with Mount Sinai Hospital in New York City. Our Fertility Forward podcast brings together advice for medical professionals, mental health specialists, wellness experts, and patients, because knowledge is power and you are your own best advocate.
Dara: Dr. Natan Bar-Chama, director of the Center of Male Reproductive Health at RMA of New York, is a board certified urologist and male infertility specialist. Following his urology residency at the Albert Einstein College of Medicine, he was awarded the New York Academy of Medicine, FC Valentine Fellowship and subspecialized in male reproductive medicine and surgery at the Baylor College of Medicine in Houston, Texas. For the last 20 years, Dr. Bar-Chama has been a director of male reproductive medicine and surgery, and is on faculty in both the department of Urology and Obstetrics, Gynecology, and Reproductive Sciences at the Icahn school of Medicine at Mount Sinai. Dr. Bar-Chama’s practice is exclusively dedicated to the field of male infertility and sexual medicine and he has published extensively and lectured throughout the world in these areas. Annually since 2005, Dr. Bar-Chama has been listed in New York Magazine's Best Doctor list of Urologists. Wow, Dr. Bar-Chama, we are super happy to finally have you on our podcast. Thanks for being here today.
Dr. Natan Bar-Chama: It's my pleasure. I think that one of the things that's important to highlight is that a collaborative approach looking at female and male fertility from a scientific medical perspective, as well as nutrition and the psychological components is what we do here at RMA and this just highlights that integration and collaboration.
Rena: Yes. So excited to have you on and to talk about the male perspective since, you know, I think that's obviously one half of the equation and super underrepresented, so really happy to have you on and hopefully have men feel comfortable about this. You know, you're such a powerful force.
Dr. Natan Bar-Chama: I think you touched upon an important issue in which is comfort level. And I think that psychologically men and women approach health in a very different way. Women very early on go for an annual checkup. Then they go be evaluated on how not to get pregnant and then transition on what it's going to take to get pregnant. And men are very different. There is no concept ingrained about an annual evaluation or checkup. It’s an unfortunate reflection in disease states, and mortality rates and health status differentiation between men and women. And many men, unless they have a heart attack or they break our limb, they're not going to see a physician. And this really...
Dara: I was going to say, that's so true. I mean, it's, it's interesting to say that cause my, my husband, if I don't remind him to get his annual physical, he'll forget. And it's unfortunate. I don't even think in terms of like an annual physical, if there is ever a discussion for men in terms of, you know, reproductively, if they should be checking up on anything.
Dr. Natan Bar-Chama: Look, I think that it's a bigger societal issue. I think that progress has been made, but I think that it's important to realize that from a fertility perspective, the male is not, is a cause or contributes to infertility in over 50% of cases. It's not an isolated contribution and it's painful. It's painful to see women try month after month and go through testing and evaluations and a simple male evaluation is really recommended by societies, such as the American Society for Reproductive Medicine. I had the pleasure of serving as president of the Male Fertility Society last year and new guidelines have been issued and update. And it's very clear that for the benefit of couples who are seeking fertility, that both the male and the female be evaluated initially at the same time. This notion of let's do him first, let’s do her first and vice versa is not optimal and not recommended.
Rena: Oh, I think that's fantastic. So what can you tell us what that looks like, an evaluation for male fertility?
Dr. Natan Bar-Chama: Well, I think that's a great question and I, I think the first thing that a couple should ask themselves, is there anything in the history that we're raising along? Was there a history of sexually transmitted diseases? Did this individual have undescended testicles,scrotal injuries? Was he treated for conditions like cancer? Is he taking any testosterone supplementation which are counter-productive to sperm production? Is there a history of dilated veins or varicose seals that may have an effect on fertility? So a lot of introspection, open discussion, evaluation, you know, that is what we initially do. And then of course is the semen analysis. Okay. There is no substitute for that. It is not difficult to obtain these days and we'll get into details of why I say that now. But a semen analysis is the foundation for assessing there is a problem. It's not pleasant to see, you know, an individual for whatever reason was for example, born without a vas deferns or has obstruction and is producing, you know, normal sperm in the testes, but nothing is coming out in the ejaculate. And for an extensive period of time, the couple has no chance of getting pregnant, but are trying and getting frustrated. So a semen analysis is important and if a semen analysis is performed and if it's abnormal, then there's a further and further testing and evaluation is warranted.
Dara: Let's discuss it further for our listeners what exactly are we testing during a semen analysis?
Dr. Natan Bar-Chama: So the main parameters are sperm count. How much sperm is in the ejaculate. And that is important to appreciate. It is not related to volume. Volume can, you can, have a large volume and no sperm at all and vice versa. So concentration and count. The next is the sperm have to move. They can't, you know, they have to travel through the female anatomy and that's a very long journey. So movement and optimal movement, good movement and that we call motility is important. And then the shape of the sperm. A normal count is about a hundred million. The minimal from a fertility perspective is 40 million, but only a small fraction, small percentage of those are competent and morphologically or from a shape perspective or capable of fertilization. The other thing that I think is important to highlight are that very often, men are uncomfortable seeing a physician, setting up an appointment, going into an isolated room somewhere and producing an ejaculate, provide and give it to a technician who they don't know. And that is a barrier. And what I'm very pleased to see in the unfortunate COVID pandemic era is the emergence of new technologies. And I think that that is important for our listeners to appreciate that right now, you do not need to have a physician's appointment. We'll make an appointment, go to the doctor or get, even get a prescription for a semen analysis. Broadly there's two types of tests available. Okay. They include home testing and home collection. And I just want to differentiate between the two, but I think that you can do a semen analysis in the privacy of your home. There are apps and home testing devices that enable you to produce a sample, put it on a slide. The device is actually wifi capable to interact with your iPhone, your Android phone, your laptop. And you can see, you know, right there in the privacy of your home, what your sperm count looks like. And if, you know, and real motility. So that's, there are several home testing capabilities and then there's home collection. So you have access to, there's numerous companies that do this now, where they send a kit to your home. That kit has a media or solution that enables that to put it for you to produce a sample, to ejaculate and provide the sample into this media. And then it gets shipped to a facility where it's a semen analysis performed and both of these options, okay, do not require you coming into a physician's office, interacting or getting a prescription and producing a sample in an andrology lab. Now there are some faults I know in each of these systems, but they're better than nothing.
Dara: That's what I was going to ask. Is there in terms of the efficacy are they pretty...
Dr. Natan Bar-Chama: So the home collection kits provide all the parameters that I described, including count, volume, motility and morphology. And that technology has advanced to the point where I would say it's competent.
Rena: That's great. So say a couple does that, or a male does that. They do the test and it comes back and some of the numbers are off. Okay. So then what would the next step?
Dr. Natan Bar-Chama:So I, I think, you know, the first time a male produces a sample, it's awkward. That's why doing it at home might be more comfortable, but you know, if you miss the container or if it was not a good sample, let's, let's give him another chance at bat. Okay. That's always a good idea. So I think that it's important to say, okay, let's get a second sample. And if it's adequately provided and it reflects an abnormality, I think at that point, seeing, you know, these, and this is now coded into the guidelines that have just been recently released, the AUA and the ASRM, or at least male fertility, fertility guidelines that are new, that published in the last month. I urge, you know, patients to use it, to look and understand them. But the bottom line is that an abnormal semen analysis should trigger seeing a male fertility specialist. Okay. That individual then will move forward with a comprehensive evaluation to try to understand a couple of things. And foremost, is this sub-fertility or infertility of the male associated with potentially a cancer such as testicular cancer? Is it associated with other medical conditions that have an impact on one's health that are separate from, you know, fertility? So we want to assess and rule out comorbidities that have been previously not diagnosed, including life threatening conditions. We also want to ask questions like, what is the cause? Is there other contributing that we can impact upon? Right? So we can affect and improve one's fertility status. On the other hand, there are scenarios where there are genetic conditions, extra chromosomes, deletions, or missing pieces of chromosomes. That's how you’re born. Those are the medical genetic conditions that exist in your individual case and we now know that we each utilize what we have and try to achieve a pregnancy, knowing that there isn't anything that we can do. And also be honest and say, look, there are a percentage of cases and they're not small, they're probably around 20% of the time where we just don't know what is the causative effect of a sub, sub-optimal semen analysis or fertility status. But the positive news is we know what's going on. We get an assessment of the male and the female and the technologies available are so potent. Okay. IVF with ICSI, intracytoplasmic sperm injection, the ability to take one sperm and inject it directly into an egg, and then subsequently make sure that the embryo is a healthy, genetically is a godsend for male infertility, right? Because if you think about it, a woman will produce 10, 20 eggs? Okay. So yes, a normal sperm count is a hundred million. We need, we want 40 million. We could wish for but at the end of the day, what we need is only one sperm and egg, per egg. Okay. So these technologies have really, you know, from when I started, when that was the early days of ICSI to where we are now, it's been really a field that has enabled us to offer many couples a path to parenthood that without these technologies you would have been available.
Dara: Dr. Bar-Chama is this something, I mean, we're seeing more in general for men and women, whether it's necessarily a male factor that we're, we're doing using ICSI more frequently?
Dr. Natan Bar-Chama: I think that it very well, I think that we are using more ICSI, ICSI more frequently because there is a still an increasing percentage of men with infertility. We find that if we are concerned about the outcome, if we don't do ICSI and we do regular IVF and we made that mistake, we can't go back in time. Okay. You can't wake up the next morning and say, Oh my God, those eggs were wasted for IVF process. Didn't work. We should have done ICSI. So there is a tendency to, you know, achieve normal embryo fertilization with, I mean, if there's any question about the sperm capability, we hedge to doing ICSI.
Rena: And what about TESA maybe, can you, can you walk us through that and that option?
Dr. Natan Bar-Chama: I think that that's a great question. I think that, you know, there are scenarios where there's no sperm in the ejaculate. Okay. And when you think about it, there's basically three, three options of what's going on. Number one is the individual has no sperm. He has gone with the absence of the cells that make sperm. The other scenario is that there's a blockage. Okay. That obviously if he had a vasectomy, that explains why he gets sperm from testicle or do reconstructive surgery. There are individuals who are born without the vas deferens which is the tube that connects the testes to the body. Those individuals often have a mutation associated with cystic fibrosis and we do genetic screening. But there in those two scenarios, sperm is normally produced, it's just not able to get into the ejaculate. And then the third scenario is where there is some sperm production, but not a lot. It's almost like a teacup that has to overflow for us to see it in the ejaculate and if the teacup is only a quarter full, we've got to go to the bottom of the cup to get the sperm. It's not coming out in the ejaculate. So that's where we use technologies, surgical interventions, microscopic extraction, to find those areas in the testes that are producing sperm. What's fortunate is that I'm able to do this onsite with immediate intervention and interpretation and evaluation by the embryologist. So I am able to provide tissue. It’s in a room next door to the IVF lab. They’re using the same microscopes and capabilities that are used for ICSI to let me know if there’s sperm, if they see it, then I can stop the procedure. If they don't, I will proceed further and possibly go to the other side. So TESA is really, the situation arises where we need to go directly to the source to retrieve sperm for IVF and ICSI. But I think that, you know, I think going back to what might be helpful for couples looking at fertility is that it's a point more importantly for us to appreciate that there is a general decline in male fertility and that lifestyle and diet is really, you know, one of the modifiable things that I think is important for men to appreciate and to be proactive about. And I'll just, you know, we can talk about that in more detail, but I think one of the things that is emerging in the scientific literature, that is what I find quite helpful for men to appreciate that they need to take on more of responsibility is that lifestyle changes and modifications not only improve your chances of getting pregnant, okay, meaning that the sperm count and sperm quality may improve, but that it has an effect on the health of your children.
Dara: I love that you're saying that.
Dr. Natan Bar-Chama: Okay. So that, you know, you need to own your lifestyle because what you do, if you smoke a lot, if you are using a lot of marijuana, if you're overweight, the changes that are, it's not just that your sperm count may be less or it may take you, you know, you know, it may take you two or three months longer to get pregnant or that we need to use IVF and we can fix the problem. There are changes that are occurring to the sperm, the core epigenetic changes that ultimately are manifest in birth defects, health of the child and the wellbeing of your children. So you need to up your game, you need to own your health, be proactive because it's impacting not just your, your ability to achieve a pregnancy, but the rest of your life and how your children are going to fare in terms of health.
Dara: That’s great that you’re saying that.
Rena: And so say, sperm regenerate every 90 days, right?
Dr. Natan Bar-Chama: Yes.
Rena: Okay. So say you're a smoker and you have a diet that's fried foods, high in sugar, high in carbohydrates. You know, you're not, you're, you're pretty sedentary. Say you make a conscious change. You know, you cut out smoking, healthy eating, activity. So if you do that, does that mean that the next time your sperm regenerates you'll start to see a real difference because you've changed your lifestyle?
Dr. Natan Bar-Chama: Well, the answer is yes, that, that fortunately, because, you know, when making millions and millions of sperm on a daily basis and the turnover is about 72 days that there's a window of opportunity, but it usually takes more than one or two cycles, okay, for that to be an impact. We may not see the impact for 72 days so it's not going to be immediate. But the point is, is the sooner you start, you know, the sooner we will be able to hopefully see an improvement. And so the, you know, the literature is clear that men who are obese, lose weight, their fertility improves, and not only does the count improve but measurements of sperm quality, like DNA fragmentation, which is a test that looks at the quality of the sperm, improves as well with weight loss. We know that smoking, excessive marijuana usage also has a negative impact on fertility. And as we just said, on the changes that are found in sperm that are associated with disease and bad health outcomes now in children.
Dara: I know you mentioned testosterone and I would love to touch upon that a little bit because I feel like that's something that I've heard a lot about - men taking extra testosterone. And, you know, I think for the average person, they would think, Oh, that could be great. That would give them more stamina. And, and, you know, but you know, you're saying that it actually can impair your quality of your sperm. Let's talk more about that.
Dr. Natan Bar-Chama: Yes. So the testosterone market is huge. It is marketed. There are new technologies, even in the last two, three years, you know, we see the emergence of new delivery systems. For example, in the past we had gels or just, IM injections. In the last two years, we've seen intra-nasal delivery systems. We've seen for the first time ever safe and effective oral therapies for testosterone in men. So that's new. And therefore, you know, we're going to be seeing more and more utilization of testosterone supplementation. And why is that? You know, as men get older, testosterone tends to decline. It manifests itself, you know, in a very significant way. It manifests itself in decreased libido, but also decreased cognitive function, loss of muscle mass, bone density that is related to testosterone. So it's a very, you know, impactful physiological hormone and, you know, and it's associated with diseases, right? If you're obese, you have more estrogen and higher the estrogen, the lower the testosterone. And then it's sad to see these men who try to lose weight and exercise and they're not going to be able to achieve anything because if you have a low testosterone, you can't, you can't burn fat. Fat is burned in men predominantly via testosterone. So, you know, it's a chicken and the egg. You gain weight, you lose it, you have a low testosterone, you have a low testosterone, you gain weight.The other important thing to appreciate is that low testosterone, has a adverse event on cardiovascular disease, mortality, a lot of diabetes, the prevalence of low testosterone and diabetes is very high. So there's a lot to be said for normalizing testosterone levels to achieve optimal health. And, you know, you want to use it as anti-aging, we'll just maintain normal male function and physiology. So, you know, it's not to be belittled. It's a real condition. However, however, I, unfortunately, the body cannot tell whether the testosterone that it has was made by the body or whether it was given as a drug. So the body's very fine tuned. It has a lot of feedback mechanisms. So when it has a normal testosterone level, the brain sees that and says, okay, great. I have enough testosterone. Let's shut down the factory. And so the message to the testicle is we don't need any more testosterone because we're, you know, we have enough. So the LH and FSH, which are the signals to the testes, are lowered. The problem is, is that when the testicular factory shuts down, it shuts down not only testosterone production, but also sperm production. So it's unfortunate to see many men who get placed on testosterone, getting the benefits, but not realizing that their sperm count is over 99% of the well, 97% of the cases it's going to go to zero. It's not a subtle change. Over time, you know, they looked at testosterone as a contraceptive and it was pretty good. You know, so the, you know, twice a week, three times a week, I see men, you know, they've had a child in the past, all of a sudden their sperm count’s zero. What's going on? Am I really the father? Yeah, you're really the father, but you started taking testosterone, you know? And so we have to acknowledge that this is a medical condition. Fortunately, we have medications that can do both. We have medications that enable the body to make more testosterone and also either, you know, impact in a positive way will not hamper sperm production. So we're not left. One of the most difficult scenarios is for a male who's been on testosterone, feels great is at the top of his game and comes in thinking that I'm going to stop testosterone completely and he's going to go back to feeling tired, fatigued, depressed, and with a low libido. That's not how we transition to users to optimize fertility. We fortunately have medications Clomid or Rimidex, ECG to kind of fix both issues.
Dara: So is it kind of finding that that balance of providing enough testosterone, but not enough that it will shut down what needs to be kept on?
Dr. Natan Bar-Chama: So the system is, is, is not so finely tuned. So it's, you raise a great question. So, you know, there are protocols, for example, that we combine both testosterone utilization with a little ECG, right? So proactively the men can have testosterone replacement, but we're protecting spermatogenesis with ECG. Sometimes we just use ECG alone. Sometimes we can use pills. So, you know, it's, it's, it is a balance, but typically we have to choose one path or the other. And on occasion we play both at the same time.
Rena: I want to talk about the psychological perspective for a second. And have you maybe, you know, say what, what words of comfort or advice would you offer to someone that comes to see you? And you can tell us, you know, markedly very uncomfortable, you know, how do you sort of comfort patients and put them at ease? Because I know for many males, this is extremely uncomfortable and sensitive. So what would you say?
Dr. Natan Bar-Chama: It's understandable. You have to first acknowledge that fatherhood and fertility is integrated to one's ego and self. So it's a, it's not a simple issue in terms of saying, well, you know, let's, let's move on. No, I think the first step is to say, okay, this is let's understand it better. Okay. So many men are told, you know, by their wives and by the OB GYN. And we'll call that a couple that he's in for, or he's, you know, he's the reason why you're not getting pregnant and that the count is low or the motility is poor, you know. So there are generalities and generalities are frightening and they are not. So the first step that I find helpful is let's understand. You know, I mean, if you have a count of 200 million and your motility is 35% and you were told that you're infertile because your motility is low when normal is 40% of 40 million, right? So if there was a financial equation, which would you rather have 35% of 200 million or 40% of 40 million. So let's take a deep breath and realize that, you know, we have to understand what the numbers are and this isn't not a compelling argument or data set to convince or to, you know, to point the finger that you're the cause. Many times there are, you know, the more testing we do, the more things we find and let's, you know, there's a variable that could be optimized on the male and there's one on the female and let's focus on what we can do to improve things. Let's get a second analysis. Let's do a more in-depth assessment. Is there an infection? Is your testosterone normal? What is your lifestyle? What is your diet? Are you eating hamburgers every day? Or are you having a Mediterranean diet? Are you taking any nutraceutical supplements? Do you smoke? You know, let's, let's go back. Once we start dealing with details and have ownership and, and understand what data is important, what's not. And then also, I think is also very helpful is, is to really describe how potent the technologies are. So even if you count is 10 million or even if your count is 1 million, okay? And you were told, Oh, you're the re this is the, you know, there's just no way you're going to conceive. You sit down and you describe IVF and you describe the ICSI procedure and highlight that we need one sperm per egg, and next in a month or two, we can do IVF. That person feels better about his condition and the prospect of having a family. So education, additional testing, or putting the testing in perspective. I think that's the path that I find helpful to reduce the anxiety.
Rena: I don't know if this is a fair statement and Dr. Bar-Chama I'm curious to hear your opinion, but it almost sounds like it's almost unfair a little bit, and that there are more concrete things for a male to do to fix sperm and perhaps male fertility than a female.
Dr. Natan Bar-Chama: I think that from women, the unfixable is age-related ovarian reserve which is why there's a real emphasis on time. And once we reach a point where the eggs have aged, science doesn't have that much, anything really substantial to offer. And that is not the same as for men. The technology is biased to compensating for the male because we can inject, as I said, one sperm per egg. And that really for the vast majority of men takes them out of the equation. On the other hand, I think it's important to realize that aging is not just a female concern and that's something that we didn't realize 20 years ago. And 10 years ago, it was just an emerging issue, but male aging or the paternal aging factor for fertility is real and something to take into account. So for example, in the new guidelines, okay, they're clear about stating that if a male is over the age of 40, you should be counseled that there is an increased risk for autism, schizophrenia, other genetic conditions. We know that as men age count, and quality, DNA fragmentation, declines as well. It isn't as dramatic and the impact is something not as, as, as clinically relevant as it is in the women with aging eggs. But, you know, there is a male biological clock. One of the things that I would like to put into that equation is that you can have a 30 year old, obese, two pack a day smoker, and, and you can have a 45 year old, you know, being healthy, fitness freak and I would certainly make the argument that the sperm from the 45 year old is going to be much better than this 25 year old based on all of the components that contribute to fertility. So you know, age is a variable, but there are even within that contributing factors.
Dara: I want to go back to speaking like fitness freaks and health and wellness. You know, I, I see a very small component of men in my practice, but I'm still very intrigued and interested because we're seeing a lot more nowadays the intermittent fasting and the keto diet. And, you know, I speak to my female patients on the potential negative part of that for female fertility. But in terms of male fertility, I feel like male health, we're seeing a lot more promising research, but in terms of fertility, I would be interested to see...
Dr. Natan Bar-Chama: I think in general, men society eats way more than they need to.
Dara: The American, at least, diet.
Dr. Natan Bar-Chama: So if you're already, you know, there's, there's common sense here and common sense is really important. And if you're eating a, you know, fruits and vegetables and hydration and fish, yes. I mean, the data's there. Fish, you know, omega three, fatty acids, antioxidants, vitamin B or C, zinc, you know, these are all helpful. So if one fasts every two, three days and keeps their weight down, I don't think there's any. I think the female reproductive system is much more sensitive to both, you know, high-end, you know, competitive athletics or dietary fasting and keto. It's not the male system is not as finely tuned or as sensitive. And so I think that's, that's, that's, you know, important to highlight.
Dara: And that's why a lot of the research non-fertility related typically is done on men. But I, I just love that you pointed out the Mediterranean diet, because I think that overall is quite well-rounded in terms of including lots of the vegetables and the nuts and the oils and the, and the fish over over the meats. I I'm happy to see that we're aligned on that.
Dr. Natan Bar-Chama: You know, because of COVID, everything was virtual, but the ASRM this year specifically has publication regarding walnuts that were beneficial to sperm quality. You, where I would highlight that if you, if you think about human cells, right? You know, think about your basic anatomy and biology classes. You're looking at a cell that has a circle and then has an inner circle, right? So there's the nucleus where the DNA is and there’s the rest of the cell, which is the cytoplasm, right? For most cells, the cytoplasm is where they produce chemicals or they receive some messages but also where they have defense mechanisms, right? So the defense of the cell is in the cytoplasm. That's where you have reactive oxygen species breakdown and, and, and that's where the, the battle for survival exists. Think of a sperm. It has no cytoplasm. It's just, it's, it's just a DNA package attached to a rocket ship with a tail. Okay. There is no cytoplasm. So the sperm is a unique cell. It has no defense mechanisms against reactive oxygen species or anything that's going to be in the fluid surrounding it. So that is why anything that interferes or increases the damage within that fluid or potentially supplements that might be in that fluid or what the cells or sperm depends on okay to protect it. So, and that's not the case for the normal cells in the rest of the body. So diet, smoking, you know, potentially supplements and antioxidants need to get into the fluid to protect the sperm cell.
Rena: Well, let me ask one more question, because I know this is sort of what everyone always asks., Say you have a female patient. And I say, well, I'm trying to see what should I tell my partner? You know, what should my male partner be doing to help us from, you know, questions about hot or cold, or, you know, tight underwear, like all these sort of myths floating around, it sounds like walnuts are kind of this new super food. I think walnut questions are going to be on the rise. What are any sort of...
Dr. Natan Bar-Chama: So I think, I think that the, the myth that I think is important to take down is the issue of loose versus tight underwear. It does not matter and there is no benefit to wearing loose versus tight underwear and there are many men who are more comfortable with more support, especially when you're doing athletics. And if you have dilated veins, varicoceles, or some type of intermittent testicular discomfort from cysts or scar tissue, support is critical in those cases to feel comfortable and one should not subject themselves to loose underwear when it's gonna, you know, when that's not really, there is no data to support that he'd benefit.
Dara: That’s news to me! Wow. That's good to know. I'm happy for our listeners.
Rena: Or people say, you know, my partner is an avid cycler, a cyclist, you know, and I told him no more cycling because I don't want him wearing the tight clothes and….
Dr. Natan Bar-Chama: Oh, no, I'm a, I'm a cyclist myself and fortunately fertile, but that's not the issue. The issue is that exercise is key. Okay. You know, if someone is running or biking or whatever you're doing to keep yourself healthy is important. Biking is not in my mind a major issue. I think that again, let's use common sense, right? Okay. Alcohol in moderation, right? Alcoholic over-usage is going to have a very detrimental effect on your health, on your liver and on your fertility. Same thing with caffeine. Caffeine moderation is fine. You know, there's just, no, you know, the data is very clear that it's only excessive use that is going to have a detrimental effect. And diet, you know, a good diet, a healthy diet, a common sense diet is beneficial. So hot temps, exposure to high temperatures is something you'd want to avoid. Okay. That is true because you really let's put it this way: the testes are positioned in a very vulnerable place and it makes no sense from an evolution perspective, evolutionary perspective, put something that valuable in such a exposed area. But when you look at, when you look at women, the ovaries are really, well-protected behind a pelvic bone and they're not, or they're not easily damaged. And unfortunately there's a requirement that the testes in order to produce sperm, need to be two degrees cooler than the rest of the body. So if the testes don't descend or they don't develop, or they are inside the body, there is no chance of having sperm being produced.
Dara: What about on the flip side, in terms of going into cold? You know I feel like ice baths are the trends these days. Cryotherapy. It’s extreme.
Dr. Natan Bar-Chama: It’s extreme and you know, I think it's, it's, you don't spend much time there. I'm not sure. You know, I think the body's temperature, you know, how much does the body temperature drop, you know, before you get out, you find yourself dragged out. You know, it’s hard to to... I don't think that intermittent all cold exposure is the same. I think that anything that heats the scrotum is going to definitely have an impact and people more often sit in hot tubs, then they jump into polar bear clubs. So I think that, that's a more common issue and smoking. Smoking I feel there’s no room there. It’s not like coffee or alcohol. Smoking in my mind is potent and one should abstain completely or do the best they can because of not only as it has been talked about current fertility, but also the health and the future of progyny.
Rena: Is that for nicotine and marijuana?
Dr. Natan Bar-Chama: Yeah. The marijuana literature also, you know, there was early literature regarding marijuana that suggested that it didn't have an effect on fertility. What I think is important to appreciate is that what would deal with now with marijuana usage is so much more potent. It's not the same as 15 or 20 years ago. So it's a whole different level of exposure. And there's very clear data that changes to sperm DNA or epigenetic changes occur in marijuana-exposed men in human sperm. So I think that the change in the potency combined with the scientific literature puts marijuana usage in my mind as a clear, no, no, no in terms of trying to optimize health and optimize fertility.
Dara: What about any type of medications, other types that could potentially pose a risk?
Rena: Yeah I was going to ask that too, especially antidepressants or antianxiety?
Dr. Natan Bar-Chama: So I, I think that testosterone, as we discussed is, is a major one. Certain hypertensive medications that fall into the category of calcium channel blockers will have, will prevent the sperm from attaching to the egg. So men on that should be switched to other classes of antihypertensive drugs. Fortunately, there's no shortage of other options. You know, antidepressants can cause issues with ejaculation or delayed ejaculation, sometimes no ejaculations at all, but not, not really an impact on sperm production or quality. So I think that the side effects, you know, may have an effect on sexual performance and ejaculation which obviously are important to you if you're conceiving naturally.
Rena: And what about any super foods? You know, I know you mentioned walnuts.
Dr. Natan Bar-Chama: I think superfoods is healthy fruit. I mean, you know, I've got some foods that have high levels of antioxidants and have a, a high concentration of CoQ10 and zinc and, you know, so to me, a superfood is, is one that is green and healthy and when that you’re willing to take. That's, that's what I would put into that bucket.
Dara: I'll help you out on that, Dr. Bar-Chama. For me, it's more of overall your, your, your diet and your lifestyle. I think a lot of times we want to look at one specific food to go for. You know, I have a lot of women who come to me, Oh, do I need to eat the pineapple core? And you know, there's not the research to back that up, but for me, it's more of a generally well-rounded diet. So yes, including foods from alternate food groups, greens. Great. But you know, if zinc can be great so things like oysters can be wonderful. Selenium is also important for sperm quality. So, you know, Brazil nuts can be good, but that doesn't mean that people should be eating a big bag of Brazil nuts every day. It should be part of a well-rounded diet.
Dr. Natan Bar-Chama: Right. If a person is having is having a hamburger for lunch every day and bacon and cheese in the morning, and then it eats walnuts all day. That's not exactly
Dara: Not gonna help.
Dr. Natan Bar-Chama: Exactly.
Rena: Balance is key. Balance and moderation. The balance is not iteration.
Dara: Exactly.
Rena: Well, this has been so fascinating. I think, you know, I know I learned a lot and I'm sure our listeners learned a lot. It was really, really wonderful. You're such a valuable resource. I'm so happy that we were able to have you on.
Dr. Natan Bar-Chama: Thank you.
Rena: So the way, I mean, I guess, any, any parting thoughts or words of advice before we wrap up for anyone, either male or female going through this?
Dr. Natan Bar-Chama: I think not being intimidated or scared to understand what what's going on. Initial testing of the male is not invasive. It's understanding your medical history, utilizing new technologies and platforms to get a sperm test. And the sooner that, you know, know that there's a problem, the better you're equipped to overcome it because the technology is tremendous. And if you need it, then it's available to you. And then common sense in terms of lifestyle, you know. Men tend to not be proactive about their health. But in this case, you have to look at the future. You want to be a father. You want to have a child. You want to look at your health over the next 20 years and your child's health. So keep that in mind and make that a priority.
Rena: And I guess one thing before we wrap, you know, I know of Track Fertility is an at-home test. Do you have any other recommendations for people to use for these at home test kits?
Dr. Natan Bar-Chama: Sure. So Track is based on a centrifuge. It’ll give you know concentration. The smart app, for example, is called Yo, Y-O. And again, these tests can be purchased directly, even on Amazon.
Rena: Yeah. I know, Track is on Amazon. It’s T-R-A-K
Dr. Natan Bar-Chama: Yeah. So Track, Yo, others, and then there's the home collection. So you have very cute names: Legacy Daddy, Fellows Repo Sauce. You just start Googling home collection and you will find a plethora of options. And again, they split down into home collection where you can produce it and ship it or home testing where you can do the test at home.
Dara:Lots of options.
Rena: Yeah. Thank you so much. So I think, you know, the way we like to wrap our episodes is to go around and say a gratitude. So I guess Dr. Bar-Chama, can we start with you something you are grateful for?
Dr. Natan Bar-Chama: I'm grateful to be in a field that has evolved to the point where it is able to bring to the table effective treatments and interventions for the vast, vast majority of men with infertility. So that has been at least something that I'm appreciative of.
Dara: Kind of piggybacking on Dr. Bar-Chama. I'm just grateful that we're having this discussion and hopefully, you know, helping to destigmatized the topic of male fertility and hopefully opening up this discussion so men can be less ashamed and actually take their health into their own hands. So that's part of it. And although we, we don't record live, it's a Monday today. I'm just, I don't know. I'm happy that it's a Monday, it's a fresh start to the week. So something very simple. I'm happy for Monday. Rena?
Rena: I guess, you know, sort of the same vein. You know, I think I'm grateful for the advent of all these at-home test kits, which makes everything kind of more accessible. I feel like a big pandemic positive is really streamlining everything. I, I feel personally, I've never been more productive in my work and I think it's because everything now is streamlined and we're able to be so much more efficient. So, you know, as difficult as this past year has been, I feel like I've actually produced more work-wise than ever before. So I'm super grateful for that. And, you know, getting the three of us together on zoom. It's so good to see you, Dr. Bar-Chama. So grateful to have you on and really hope this episode helps males, you know, males try and create families in all ways, right? Be it a same-sex couple or a hetero couple and two, I think this is so important. And especially to know too, that you know, it really getting checked out is super important, not even just fertility, but for overall health, too. So thank you so much for coming on today.
Dr. Natan Bar-Chama: You're welcome.
Dara: Thank you so much for listening today and always remember: practice gratitude, give a little love to someone else and yourself, and remember you are not alone. Find us on Instagram @ fertility_forward and if you're looking for more support, visit us at www.rmany.com and tune in next week for more Fertility Forward.

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