Episode #14
Fertility with Dr. Amy Pearlman
In this episode:

Dr. Pearlman returns as a guest to dig deep into the major complications of fertility and how testosterone plays an important role in men’s health.

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Show Highlights
  • Fertility & Urology
  • Men's Sexual Health
  • Hormones & Testosterone Replacement Therapy


Aaron Tharp 0:00
The information provided in this episode is provided for informational purposes only, and is not intended to replace professional medical advice. If you have questions regarding your health, please contact your medical provider. All right, welcome back. We have Dr. Perlman again. So, Amy, you are our you were our first actual guest here at Men Explained. And you are also our first returning guest. So take a bow the applause if we can inject some like, you know, applause here, though, so very excited to have you back. Today’s topic is going to be around in fertility. So, before we jump into that, what have you been up to since the last time that we chatted has probably been about four months ago? Or you’ve been doing? Oh, gosh,

Dr. Amy Pearlman 0:55
what have I been up to? I got a puppy. I don’t remember if I had a puppy last time. Hold on. Hold on a second. Hold on. I got a puppy. She’s too on her bone. Her name is Lexi. She has a bow here. So she’s my buddy likes. He’s my buddy. So hopefully she won’t bark during the segment. She was kind of a an impulse buy. You never want to go to a puppy store without feeling you know, being ready to buy a puppy. And that’s what I did. And yeah, not much else going on.

Aaron Tharp 1:34
Right. So puppy life. Since then. I’m in the same boat. I’ve been getting to get a puppy for a good year and a half. So I’m sure I’ll have my day at some point. But thank you for joining us again. Again, today’s gonna be around infertility. So candidly, I don’t know a great deal about this. But that’s this is what you do, you have a great deal of expertise in it. My my goal for today is just to make this conversation really simple. Just normalize it a little bit. And, you know, get over some of the awkwardness, we’re not going to fix the problem, but we can do our part to just make it okay and provide resources. So I guess where we could maybe start with this is how you’re working with your patients on an ongoing basis. With regards to infertility, how do they show up at your office? How does this land in your, in your court?

Dr. Amy Pearlman 2:33
Yeah, you know, these patients show up in a variety of different ways. But most of the time they show up because I specialize in male hormones. So they come in for the same reasons that they would show up to any, you know, Men’s Health and hormone clinic, which are the common symptoms related to low testosterone, the fatigue, the I’m going to the gym and not seeing any progress and the mood changes and the low sex drive and the erectile dysfunction. So those are the most common reasons why people come in. And then I usually tease out the infertility component when they’re in the office. So there is a colleague of mine who does the majority of male infertility where I work. And so most of the men who have already identified as having a concern about infertility, they actually tend not to show up in my office, they show up in one of my colleagues office. So when I find it in my patient population, it’s just part of some of the follow up questions that are really critical to have in these Low T conversations.

Aaron Tharp 3:37
You Yeah, so. And, you know, it’s we’ve been talking about before we started recording sort of the the real need and the real recognition for working with, with specialists in this area. Because obviously, that’s going to be who’s going to be listening to this and some of these patients, it’s if they have an interest in having children someday. So talk a little bit about that. And in the importance of that.

Dr. Amy Pearlman 4:04
Yeah, you know, hormones are really important and critical to be able to have a child. And if the hormones are out of whack or low, then the semen parameters are the built in the ability to have a child’s can be can be impaired. And the important thing that any health care provider needs to know who’s going to be seeing these patients for hormonal concerns, is asking the question, are you currently trying to conceive? Have you had issues in the past trying to conceive? Are you interested in future conception of a child? Because the answers to those questions will greatly change how we can optimize hormone levels? What a lot of people don’t realize men and people of other genders is that when you give someone testosterone therapy from the outside, regardless of how you give it injectables, topicals you know buccal, intranasal whatever is that they all have the ability to shut down downstream production. Because your body, your brain sees the testosterone that you’re getting from the outside and says, oh, we’re good. We have plenty of testosterone, we’re gonna shut down production. And you can actually make men infertile. When you put people on exoticness, testosterone therapy. A lot of men don’t know that information. We as healthcare providers, whether it’s related to infertility, other sexual health concerns, other problems. In general, we assume that if our if there’s something important to our patients, they will bring it up during the office visit, our patients assume that if there’s something they should know, regarding a therapy, that we as healthcare providers will bring it up. And oftentimes, what happens with all of those assumptions is very key pieces of information are lost, because we just haven’t asked those questions. So anyone who is treating testosterone must address the fertility component. Because when it comes to the art of medicine, that’s why I enjoyed treating hormonal deficiency so much, because we use a lot of these medications off label, we can be creative with it, and the Low T patients are the ones that high five me in the office, but they I wish Low T patients on everyone, because when they feel better, they are the happiest patients, you know, and so that they’re fun to treat. But a lot of them don’t realize that we can be making them infertile in the process and have never been told that information. Yeah, that’s, we have to ask that question.

Aaron Tharp 6:44
Right. And obviously, that that also requires a bit of an admission then to on the patient side. It’s because this is just a sensitive topic, you know, we’re not, it’s not going to be a lot of guys that are going to raise their hand and admit that in a crowded room. And so let me ask you this, when they’re showing up, they’re in your office or when you’re seeing them? Are they? Are they going about it by themselves? Or should they be going about it with their partner? Do you see both? What’s the best strategy to approach that if you are too, if you are both interested in having a child someday,

Dr. Amy Pearlman 7:22
most of the time the men are coming in by themselves, but it would be really helpful if the partner were there with them. For the telemedicine visits that I do sometimes those are even nicer because the person’s at home. And so they’re partners around the infertility discussion is is quite an extensive discussion, you have to go through their adolescence and how they went through puberty and if they’ve ever had chemotherapy or any type of genital surgery. And if they’ve been on performance enhancers, or you know, look at their medication list to see if that can affect anything, looking at their sexual health. Like if a guy can’t get good erections to be able to maintain and ejaculate in a vagina, then there’s no way he might have great semen parameters. But if he doesn’t have the good function, it’s gonna be really difficult, you know, to conceive a child. And then you have to not only because infertility is a couple’s thing. And so it doesn’t matter if you have a great history on the female or the mail, you really need that comprehensive history on both. So you got to ask both people these questions related to them growing up and developing? And also, have you had children before? Have you had children before? Did you have any difficulty having children? Was it with the same partner, a different partner? How do you have sex? How often do you wait between having sex? Do you track the population? And so many of these questions have to be answered, you know, by the by the female partner, and oftentimes the guy has no idea. So you ask him, like, Are your partner’s periods regular? And they’re like, I don’t know, you know, or Yeah, like every, I don’t know, 27 to 30 days, well, you know, that’s regularly irregular. And so it might And oftentimes, in a lot of these couple situations, there’s a female and a male components. You know, it’s on both people’s parts where you can optimize. And some of the patients that I see in my office, they get in with me, because they’re the female partner has been seen by a reproductive endocrinologist. And they’ve gone through that whole workup. And maybe their workup is totally normal. So they check the semen analysis on the man. And they see that the semen analysis is abnormal. So they’ll reach out to me and say, and get the labs and say, can you work with this guy to optimize his hormones? And the important thing there is there actually are a lot of things that we can do for those guys. But depending on where that couple goes, there are specialists who might be more aggressive or less aggressive with talking about those options. When you think about IVF for example, you know, that’s a big industry that’s it’s a very expensive process to put people through depending on where you’re getting IVF throughout the Country, you know, it can be 1015 2030 grand to do IVF. And so you know, some centers may just say, Oh, we need to do IVF, we’ll get you a baby. But they may not be, they may not be doing the whole comprehensive workup of looking at the female components, and the male components. And so I see that that gets missed a lot. The medications that we use are different. When it comes to those who want who were actively trying to have a child, I would never put someone a man who’s actively trying to have a child on testosterone therapy. Now, yes, there are plenty of men who have had children while they’re actively on testosterone. So not everyone becomes infertile, infertile, or has no you know, gets rid of all their sperm counts when they’re on therapy, but plenty of people do, you know, so I wouldn’t put someone on testosterone therapy as a method of, you know, contraception to say, Oh, don’t worry about the condom will just put you on some testosterone, and you’ll feel great. You don’t have to wear a condom. So it’s not a method of contraception. But But I would never actively and our guidelines, the American urological Association guidelines which are free to the public, I recommend everyone listening in to look up their guidelines on male infertility to look at those algorithms, their guidelines on low testosterone, those are evidence based guidelines. So be informed read the guidelines, I feel like the patient and the provider for all in the same room, hoping to reach the same outcome, we all have to look at the same information so that we know that we’re all on the same page. So I encourage you all to look at those those guidelines. But they will say, you know, don’t put someone on testosterone who’s actively trying to conceive because it’s not going to set that person up for success. The other medications, though, that we can use to make those numbers look better make that semen those semen parameters look better, or medications that also we as hormone specialists put people on commonly, HCG is a common medication that will put our testosterone patients on to preserve some testicular volume, HCG, as the body sees it as a pituitary hormone that sends some signal to the testicles to say, Hey, boys, we’re not done yet. Let’s keep up some stimulation, you know, so those testicles don’t shrink. And so we’ll use HCG in men to stimulate the testicles to produce testosterone, which can make you know, which can improve ability to have a child will use Clomid will use a remet x, you know, so those three medications, right, there are medications we actually commonly use in the Low T patients at all these men’s health clinics See, but they boost they have the ability to boost endogenous production of testosterone, meaning they’re on these medications, they won’t make you infertile, they’re going to work on your hormone system to try to boost your own body’s ability to produce testosterone. So that’s where we really get into some of those other medications. We hold off on giving testosterone while someone is actively trying to conceive.

Aaron Tharp 12:55
Wow. And that’s such a critical information, especially for young guys that would be listening in because, you know, even if it was just left to a simple educational gap, you know, I’m sure, it’s thought of by many that it would be Oh, because I’m on testosterone, I’m more likely to have a kid and I’ve greatly improved my chances. And that’s a generalization, it could be much more specific, much more optimized, and treated in a very different way, if I’m understanding you, right.

Dr. Amy Pearlman 13:27
Yeah, definitely. I mean, and those guys, I might say, look, I think you will do great when we put you on testosterone therapy, but when you’re actively trying to have a child now is not the time, you know, because of your current life goals. But but but the way that we decide which medications to put patients on, depend on that whole hormone panel, it’s not enough just to check a morning testosterone or even twice, we got to look upstream of the testicles. What is the luteinizing hormone for people who are interested in fertility? What is their FSH, your follicle stimulating hormone, because if those levels are high, meaning the the brain is sending signals, but the testicles just aren’t responding, and we check a semen analysis, if those levels are really low in the semen analysis, when it comes to sperm, then we have to do more of a genetic workup. What is the underlying issue here? You know, and so it requires a little bit of a different workup depending on those levels. The other thing to keep in mind too, is that Lh is is a really important level to look at. So if someone’s Lh, or luteinizing hormone is high, then it doesn’t make sense for me to put them on something like Clomid. So Clomid is a medication that blocks some of that negative feedback of estrogen up in the brain to try to increase pituitary signaling. But if they already have plenty of pituitary signaling, it doesn’t make sense to put someone on actually HCG or Clomid. So it’s looking Get that whole hormone compliment to understand, what does it make sense? I can use all these medications. But what does this patient really need? So are you able to pull some it’s combat? It’s complicated. Yeah.

Aaron Tharp 15:11
Clearly, because you get a different reading at lunch than you did at breakfast. I mean, even is multiplied in that way too. Okay, yeah, you kind of scrambled my brain there for a second, but it’s very critical. And it draws a lot of attention to the levels. And again, these things are treating in a very different way. So,

Dr. Amy Pearlman 15:36
yeah, and but the other thing to keep in mind and and why a lot of us like treating, you know, men who come in with low testosterone is because again, it’s it’s the art of what we do. And if we ask ourselves, and I encourage my trainees to ask the same question, how can I hurt this person, we have to know how we can hurt people. And then once we identify those ways, then everything else is fair game. And so many of the medications that we use for men, when it comes to low testosterone and fertility, we’re using them off label, they’re not FDA approved for those indications. But the way that we can hurt our male patients, if we are treating them for low testosterone is if they are interested in having a child and we put them on testosterone therapy without having this informed conversation. Now, there are some guys that I see that say, I want to be on testosterone, and I understand it can worsen my fertility. And I’m interested in maybe having a child maybe, and if I do, it might be 510 years from now. So I understand that risk, okay, then that person has been informed, and they’ve been told. But as much as I can get those patients who are not actively trying, but are considering a child in the future, well, they should freeze their sperm. So if they cry or preserve their sperm, they ejaculate into a cup and they freeze it, then we have a safety measure there. And if they have enough, we can potentially use that sample for something like intra uterine insemination, which can cost someone maybe a few $100, you know, but if you put them on testosterone therapy, and really not their counts down, even if you take them off testosterone therapy, some men will never recover their counts. And so they might then require something like in vitro fertilization, or IVF, which again, could be on the order of 10 1520 $30,000, depending on where you go. So another safety measure here is in guys who say at prom, and I understand what you’re saying, I still want to be on testosterone therapy. But how can we do this in the safest way possible? It’s to bank sperm. So you have a safety measure.

Aaron Tharp 17:41
Okay, so two questions, two follow up questions to that. And this is going to prove my lack of knowledge or knowledge gap in mind. So is that a sample? So if you’re going to go and donate into a cup? Is that a sample that can be reusable? in any sense? Or is it just kind of, it’s a one, you get one shot at it?

Dr. Amy Pearlman 18:05
Hope so you can do it as many times as you need to, to get enough sample. And and so you want to abstain from ejaculating for two to seven days, you don’t want it to be too soon, you know, like the day after you last ejaculated because your volume might be low, and you don’t want to wait too long, because then some of the nutrition for that sperm is not there anymore. And so those counts can be different. And so you want to wait two to seven days. And then you want to go to a place that routinely does this. You want to go to a dedicated IVF center to make sure they do it the right way. But then they they freeze the sample, and then you can you just pay a monthly storage fee. There’s a big misconception that it’s a very expensive process. And it’s actually not that expensive. And over the long term, it’s gonna save you a lot of money. If it then allows you to do something like are you why instead of IVs. Now, you may not need that sample in the future, it might be that you can still have a child on testosterone therapy, or you get off testosterone therapy and you’re able to conceive, but at least you have something depending on what those counts look like when they spin it down and they wash it and everything. Like at the University of Iowa, they’ll send me back a message and say, This patient has enough sample for this many rounds of IU II. And so we get a sense of you know, how many children does this patient want to have, they want to have one child or five children. And so depending on when they might want to start testosterone therapy, they might come in on several occasions to freeze as much sample as possible.

Aaron Tharp 19:37
So yeah, that goes for anybody out there that has like that Netflix subscription that they don’t even know that they’re paying for I mean that to me what you just that subscription costs or rental fee would be clearly worth it. Not least because obviously produces a bundle of joy but could really save you some money down and hassle down the road. So when they do the analysis What, like just for the weirdos out there that are curious about that, when they do an analysis of your sample? What are they? How are they doing that is like volume. Tell us?

Dr. Amy Pearlman 20:12
Yeah, so they look at a variety of factors, they look at the volume of the ejaculate, they look at the pH of the sample, they look at, you know, the motility of the sample. And, yeah, they look at just the quality of the sperm. And then you can get your, you know, you make some calculations, and you get this, you know, total motile count. And that’ll sort of dictate what someone would be a candidate for in terms of your IVF. And even people with low total motohio counts, you know, if their hormones are not optimized, oftentimes just putting them on something like Clomid and optimizing their hormones, you can then get them high enough, and ideally, you want at least 10 million for them to be a candidate for intrauterine insemination, because with the whole process, and you’re going to lose some of that some of that sperm. Um, you know, with just some simple medications that don’t cost a lot of money, you can save someone 1000s of dollars if you optimize their hormone profile. And I think a lot of people miss out on that just simply because, you know, these IVF centers are not working directly with a male hormonal specialist to optimize those numbers with these medications. But that is always that’s a big part of our goal is to get them high enough, you know, where they can get a treatment that doesn’t cost as much or even for a spontaneous pregnancy.

Aaron Tharp 21:32
So is is a lot of this detail and information as a consequence of the technology that we have that is now readily available and for testing. And I mean, is that do we now know that? Or is this kind of been the case and been around for a while? Because this is all due to me?

Dr. Amy Pearlman 21:52
Yeah, it’s been around for a while.

Aaron Tharp 21:54
Okay. Yeah, very good. So we’ve gone into, you know, if you’re, if you’re, if you’re getting testosterone treatments, and what things you want to be cautious of in the protocol, some things you want to be doing from preventative measures. Now, going back to like, just the basic fundamentals, like you know, lifestyle choices, and, you know, lack of exercise over exercise under an overweight, some genetic predispositions. Can you talk about some of the things that are, I guess, genetic? Wouldn’t be preventable? Can we talk about some of the things that are preventable, everybody has bad habits, and they consciously or subconsciously, they know that they shouldn’t be doing them. And it’s having adverse side effects on their, on their life? So talk about some of the factors that are preventable, and give us some suggestions, by way of good, better choices.

Dr. Amy Pearlman 22:54
Yeah, you know, there’s not great research out there in terms of like nutrition and this early exercise that look at fertility and testosterone, but we can’t I think all of us already know, sort of the answers when it comes to you know, what to do. We’re all looking for that, you know, sort of magic answer, and there is no magic answer. Um, there is, someone was, I was talking to someone yesterday, and they said, Whatever is healthy for the hearts is going to be healthy for the penis. And that is actually that is true, you know, and I think for for the information that, you know, I’m about to sort of go into a little bit, we may not have research to say it, but it just, it scientifically makes sense. And it’s just going to be healthy for the overall body. So we know, it’s important to move your body, it’s important for blood flow, you know, systemically it’s important to get good erections for the overall tissue, you know, for the overall, you know, penile tissue and health in terms of eating, you know, no one is going to, no one ever died of eating too much produce, okay? And so we know what’s healthy. When we go in the grocery store, there is when you look at a protein bar, and my sister does medical weight management. So she talks to me about this all the time. And it’s where I have a lot of my knowledge, but she’s like, Amy, look at all the stuff is written on that protein bar and gluten free and high protein and high fiber and low sugar and net carbs, and, you know, and low calories. And she’s like, there’s a lot of marketing on that protein bar that has to convince you that that chocolate bar was healthy. You know, she’s like, what’s the packaging on the broccoli? And I’m like, Michelle, I don’t think there is any packaging on the broccoli. And she’s like, yeah, no shit. Broccoli doesn’t have to tell you it’s healthy. You know, that information? You know, so produce is healthy. We know that green leafy vegetables are healthy and you know, fruits, but not super high sugar fruits are going to be healthy. So whether or not there’s data to say that helps us fertility. We know that eating well and moving our bodies is going to help every aspect of our life. And I don’t care if there was a study or no study to tell me that information. It just makes sense. And it’s going to make us feel Better, you know, um, and then. So so i think i think that’s the major point there in terms of, you know, sleep apnea, if you have sleep apnea that can lower oxygenation to your brain at night and cause hormonal issues. And you know, whether or not treating the sleep apnea increases testosterone level, there’s not great data to show that, but you can imagine, it’s just really important to get oxygen to your brain at night and to treat the sleep apnea. Even if you don’t necessarily see higher numbers of testosterone levels. There’s more data coming out now, when it comes to hormones and what we call like functional hypogonadism, which are like preventable things that you can do to improve your hormone parameters. And, and that’s kind of what we’re talking about here is we actually have a lot of control over our lives and our daily decisions, and, and all the symptoms of having low testosterone or all the symptoms of having sleep apnea, eating poorly, and not exercising and having, you know, depression. And so they’re all related. And we just have to take better care of ourselves.

Aaron Tharp 26:04
Yeah, the the number one key there, and I maybe I thought this was implied, but it’s probably the critical point is, there has to be some ownership of like, your decision making in the process. There’s no quick fix, there’s no magic pill, you know, and the, the options that you’re suggesting are fundamental, and we all know them. And they’re pretty much unavoidable. It’s really that simple. But far too many don’t want to take accountability, I don’t take any responsibility, because it’s easier to just to go into get plugged to get shot and call it good. So yeah, it requires

Dr. Amy Pearlman 26:43
there’s and there’s nothing wrong with being on testosterone therapy, or coming in and needing help and extra medications to boost someone’s fertility. But those things won’t give you the optimal results unless we’re really treating everything. And that’s the real answer is we have to do sort of everything all at once. It’s like, what is the role of the healthcare provider? What is the role of the patient? And how do we meet somewhere in the middle to optimize those results when it comes to fertility and hormones and sexual health and really any health condition?

Aaron Tharp 27:13
I read somewhere that on average, and I keep me honest on this, that I think it’s what semen quality or production, not production, that’s not the best word for it, quality, or maybe in the the analysis is 40% decrease than it was even 50 to 60 years ago. And that’s just one study. So keep me honest, maybe that’s right or wrong.

Dr. Amy Pearlman 27:40
I think that I forget where that was published. I think it was a big deal when it was published a couple years ago saying that, you know, there’s concern for, you know, big issues with infertility. Now, and, and actually, that data for talking about the same study was flawed in many ways and wasn’t based on a good data set. That in terms of semen parameters going down, but just in general, we as a population, a worldwide population are getting unhealthier. So if our in general, our bodies are becoming unhealthier, obesity is going up, diabetes is going up Heart disease is going up, you know, then that’s going to affect fertility potential. And so I wouldn’t be surprised if those numbers are going up and the semen parameters are getting worse. The beauty of it though, is that we have so much control over these factors, that is the beauty of it, that we can actually change the health of ourselves by making simple choices, intentional choices on a daily basis. And for those of us who don’t want to be on medications or require surgery, oh my god, we have the power not to do that for so many conditions. And I’m that makes me optimistic, that makes me hopeful for the future of medicine.

Aaron Tharp 28:51
So, and I’m gonna piggyback off of the future of medicine. Cuz that is that leads right into my next point. On one of our last episodes, we had the medical director here at limitless on Dr. labkey. And we got into, you know, the, the introduction of of females to the medical system all earlier and then just being more in touch and more involved. And we got into the idea that okay, was originally seen that about 40, you know, testosterone level started to decline with men. And that was kind of the the narrative around it. And it seems like that’s gotten earlier and earlier. So when we talk about the future of medicine, my question to you is, how do you envision or what would you like to see in terms of men kind of going into puberty? Or what does that look like from getting them introduced and, and getting them in touch with some of that stuff earlier than when shits hit the fan and they got problems? Because we could probably spot cases, capture a lot more data find a lot more similarities by going with that approach, rather than what kind of what we have. Now cuz it’s late onset

Dr. Amy Pearlman 30:03
we have to have men’s health specialists just like we have women’s specialists, just like we have, you know, ob gyn who you get plugged in as an adolescent, we have to have people and that has to be part of the education. So like right now in medical school and education and, and those who go to like PA school for education, like, there’s very little male specific, if any education in those courses, but the female education, those are requirements. So for every medical school, everyone has to go through, you know, a women specialty rotation, and oftentimes, it could be four to six weeks, for example, there are no mandatory rotations when it comes to men’s health, even though there is are a lot of people who come into our health care system. So we have to train people, pediatricians, adolescent medicine specialists, primary care Doc’s urologist who have specialty expertise in men’s health, because what goes on in the male body, even though we have a lot of the same organs compared to women, there’s also a lot of differences. And we have to catch those things, as you said early and educate people, we’ve missed out on this opportunity of men in their adolescence and 20s and 30s, to educate them. When do you worry when can you wait. And so oftentimes, these are hard working men, they don’t want to go in to see a doctor, because because they know if they go in and they talk about their concerns, what are they going to do, they’re going to get tested for a sexually transmitted illness. So you come in with sort of any pelvic floor urinary concern, and everyone’s worried that you have an STI. There are so many other male specific health concerns that show up in a young man other than STI. And we just haven’t done that education for providers to ask those other questions about pelvic floor issues, and bladder issues. And, and we’ve, we’ve missed out on a big opportunity. But I think now with men’s health clinics popping up and direct to consumer marketing when it comes to testosterone and other products, industry and pharmaceuticals, I mean, they’re going directly to the male patients, they’re bypassing the health care providers, they’re going directly to the consumer, the men and they’re saying, We want to help you. And so it’s bringing a lot more men into the office saying, I want some help, I want some answers. A lot of these men go to a variety of different specialists, because they’re not happy with the answers they’re getting. And they’re gonna go and go and meet with a lot of different people until they find their answers. And I love those patients. I think sometimes as healthcare providers, we say, oh, they’re doctor shopping, and they’ve already you know, they’re coming in for a third opinion, it’s like how give, they’re coming in for a third opinion, like, who just go see someone to fix something or buy a house and you only go to one house and assume that’s your only option. You know, and a lot of men, they’re insightful. They ask good questions, they want to be engaged in their health care, they want to take accountability for their health, but they’re struggling to find providers who will walk them through that process. I love seeing men in the office. And the guys who wait to see me and show from my office are some of the most engaged accountable people I’ve ever worked with. My sister who I mentioned as medical weight management, her most successful patients are the middle aged, overweight male who says I don’t accept this for my life anymore. And I want to do better, you know, and it’s just making these simple changes in their life of going in their pantry, and getting rid of the shit in their house and dumping it out. And they’re doing so poorly at baseline with what they’re eating, that they make these simple changes, they drop weight, like they’ve never done it before. But it’s because you know, they don’t accept the status quo anymore. I think that’s a beautiful thing that we’re seeing. My hope, though, is that it doesn’t take it until they’re middle aged man to start asking these questions. We want to get them engaged when they’re in their teens, and 20s and 30s. Because the questions they’re asking in their 70s and 80s are the same things they wondered 50 years before, we just don’t want them to wait that long.

Aaron Tharp 33:57
Yeah, and I would say that between the two women are they you’re just not only introduced introduced to it more, but you’re just more comfortable with it. Because clearly, there’s been some experience and But yeah, I mean, obviously, there’s, there’s a big hole to fill there in terms of, you know, awareness and engagement. And that’s what we’re doing today. So yeah, it’s there’s not a quick fix, either. It’s got to be you know, if you’re gonna start eating right, and you’re gonna start doing better, and you should be actually really determined about it. If you actually give a shit if you know, especially if there’s going to be kids involved. He’s trying to do that, or you’d like to have kids someday, you should be determined, you only get one shot it at your at your health, right? You can make as much money in the world as you want, but you’re not healthy. It’s not going to mean shit to you. And it shouldn’t because you haven’t taken care of yourself personally. So get it under control. What else so I read, they keep me honest on this. I have a concern because I really struggle with taking days off. I’m an I’m an extra sighs junkie, I can’t get enough of it, is there a risk that that I run somebody that is as active as I am, that I could be causing some undue harm by way of my fertility?

Dr. Amy Pearlman 35:16
Yeah, um, you know, a lot of it is just paying attention to your body. And that’s a tricky thing. And we actually see this in endurance athletes. So you take a cyclist or cross country runner who’s who’s, let’s say, running in high school or college. And some of those guys will develop a phenomenon that’s actually similar to like this female triad, which you take like a gymnast or an endurance female athletes, and, and there’s concerns about bone density and hormone levels, and she stops menstruating. So she knows when there’s a hormonal issue, or her health care physician provider knows when there’s a hormonal issue, because she used to have a period, and she no longer has a period. We don’t, we’re not as good as identifying and identifying that in men, because men don’t have periods and we’re not routinely checking their semen analyses. So I think we’re very, you know, we can identify it more easily. And women were missing out on that endurance, Male Athlete when he’s young, who I suspect also has hormonal issues, low testosterone, and even his low testosterone, you know, once he stops doing the endurance, it actually may never go up. But I see some of those guys in my office, they’re like, really skinny guys. They’ve been doing endurance, you know, athletics for a long period of time. And no one’s they haven’t been actually trying to have a child, so no one has checked their semen analysis. And I think we’re missing out on that whole population of men. Just because there’s no, we’re not screening for it. And I think we need to do that. But then it’s also tricky, because if they have low levels, what do you do about it? You know, like, in with the whole taboo of putting people on testosterone therapy, who were athletes, that can also make it a little bit tricky as well.

Aaron Tharp 37:06
Yeah, I hadn’t even thought about that. I mean, especially if they are professionally training, or their they’d like to someday you they got to abide by tests and UAS, and those could show up at any time. And if you’re pouring into that cup, hoping that it pours back someday, you care about that, because you don’t want to piss dirty. So very good. So we’ve covered quite a bit. And I wanted to make this very simple. And take the sting out of the conversation, which you’ve done quite clearly, you’re very comfortable talking about this stuff, which makes it easy, but what are some other things that that you think are important to address, cover be aware of know about resources? Phyllis, in

Dr. Amy Pearlman 37:50
when a couple is trying to have a child, it is a very, it can be a very stressful time. And, and because both of those people are involved, and you have to have sex, oftentimes for it to occur. It becomes all about timing. And you know, when are we going to have sex? And what is the timing of the oscillation? And can I maintain the erection? And can I you know, ejaculate into the vagina? And what is the positioning of her body when I ejaculated in there? And so all of that stuff can obviously ruin the mood of something that for so many people is such an enjoyable experience. There’s also a lot of Is it a male components? Or is it a female problem, like whose problem is causing the infertility? And oftentimes, as I mentioned before, it’s it’s both it’s a combination of both. But I think there’s some of this of like, well, it’s a male problem, or it’s a female problem. And and so that can be a tricky subject as well. And because, you know, oftentimes the women are coming in through an infertility clinic, it’s how do you get the man to come in to get checked out part of that infertility conversation and talking about someone’s sperm can can hit home when it comes to someone’s masculinity, saying you don’t have good sperm, the quality of your sperm isn’t great, you have low sperm counts, and some people are going to tie that into how they define themselves as a man, that can be a sensitive topic. I see some men in my clinic who are from, you know, other countries where it is normal and acceptable to have 50 children and dad had 50 children with a lot of different partners, and he’s only had two and he’s struggling, and maybe in his culture, it’s not acceptable to do IVF for IU II, or with a lot of infertility treatments. It can be cost prohibitive, where a lot of people can’t afford it. And so having these conversations when someone is trying to start a family, and you have to then bring in the cost conversation of this is how much the medications are going to cost. This is how much the treatment is going to cost and you see the local on their faces where they’re like, well, I can’t afford that. So how am I going to have a family? You know, those conversations are so tough to have. But they’re critical. And both parties have to be involved in this conversation. And it’s best had when both people are all of those appointments. So the partner should be at the female appointments. And the partner should be at the male appointments so that everyone knows what’s going on. And so the partner can chime in to say, well, this has been my workup. And this is where I stand. And then you can focus on you know, what, what the patient’s and their concerns are in that moment. So that’s super important is, is just having that team. And then the other thing is, if you’re interested in having a child, you got to tell your the person you’re seeing about your hormones, that information, because the treatment will be drastically different, and we can hurt you, if you don’t tell us that information. And if we don’t ask and we put you on testosterone, and we’re not taking the safety measures, we can make you infertile, which then is going to cost more money and trauma down the line when it comes to actually wanting to have a child. So whenever we’re talking about hormones, we have to talk about the fertility components. And we can’t assume based on someone’s age that they’re done having kids, I have some guys in my office who are in their 40s and 50s. And and if I just say, oh, they’re, they’re, you know, middle aged, they must be done having kids, I’ll put them on testosterone. I’ve been shocked by some of those patients, they say, No, no, like, if I find a partner, I want to have a child. And then we’re going down a different conversation path. So we can never assume based on the age of our patient, that they’re not interested in having future children, it must be a part of the conversation. And and then we just have to figure out how can we meet the quality of quality of life goals of the person sitting in front of us, we obviously want them to feel better, some of the medications we use to boost their own production. Clomid, Arimidex HCG, may not help that person feel as well as if you put them on testosterone. So they have to understand that that the short term goals are right now we’re going to put you on these medications, because you’re trying to have a child. But once you’re able to have a child, then our plan is going to change. And this is how it’s going to change. And people have to be aware that over time, that plan can change and the reasons why it may do that. But those are the key concepts.

Aaron Tharp 42:25
Yes. And thank you for going through each one of those. There’s a treasure trove of really good information in there. You mentioned something halfway through about the bruise on somebody’s masculinity. And I think that in this room goes without saying, but it is really big, because it’s a prideful, it’s just a prideful thing. But it’s the reality is that it affects people and it’s an important conversation to have. So I have a question for you about when you’re working with if you’re able to work with both of them, like we’ve been talking about having the partner join and determining Is it is it male or as a female? Or is it both? Is there a side of this where like you’re so you’re amping up the guy, you’re amping him up in a specific way. And is the ideal to also be working with the partner, um, with her hormone levels, so that way you’re optimizing and getting the best possible result sounds like?

Dr. Amy Pearlman 43:30
Absolutely, it requires a big team approach. Because some of these medications that I’ll put a man on, I might just put them on when he’s actively trying to conceive. And they’re the same medications we actually use in women. So women use Clomid and HCG and other medications. So they’re actually all very similar, if not the same medications. So if you’re trying to boost, you know, the egg, egg production in a woman, you know, in real time, then then they have to time the medication appropriately with that couple. And so the the places that do this the best are when there’s a person who specializes in the male components, and a person who specializes in the female components, and they work together. And that’s when it works well and is almost a necessity if you want to do it. Well.

Aaron Tharp 44:20
Yeah, I mean, in the best possible scenario is to is to work with your partner on this is to be a teammate on it. That’s seems to be the most optimum, but I don’t have any other questions. I think we’ve covered a lot and we’ve done our part in raising awareness and just making this a safe conversation. Very normalized. So that was the goal. Thank you so much for your time. Now you apart from getting a puppy if we want to like learn about what you’ve been doing because I saw you guys created like this new social thing you and your sister. So like you want to fill us in on that or Where should we go to kind of learn more about what what you’ve been up to and what you’re Putting out in the world these days.

Dr. Amy Pearlman 45:03
So much of what I do and where not I wouldn’t I don’t even know that I would call it a legacy. But like, I’m a patient educator, so I do surgery, and I do research. But my number one, the thing that drives a lot of the work that I do is I am an educator in a way that I can meet someone where they’re at in a way that they understand in a way that at the end of that visit, I can say, Bob, what are you thinking? What questions do you have? What else do you want to talk about today? And so, you know, there’s so much information out there that a lot of our community members, they don’t know what to trust, because everyone always has a hidden agenda. They’re always selling something, you know, and I’m, and I’m selling education but for free. And and I do that with my twin sister who’s a gastroenterologist and we launched a website, Perlman, p a, r L, Ma, N, MDS calm. And it is a site that is focused on both of our areas of expertise, which is nutrition, and exercise and sexual health and mindfulness. You know, so many everyone or most people care about those things. And our job is to provide the evidence based information when it comes to those topics, the basics, how if you’re bloated, how do you prevent bloating, you know, and we’ll recommend, you know, some sort of options, but we’re not selling a product. It’s really just educating people where they’re at and where they’re at is on social media. So we have an Instagram page and a Facebook group. And I have information on the site when it comes to testosterone and when it comes to prostate cancer, and heart health and fertility. And my goal is to bring the guidelines that I mentioned before the evidence based guidelines that are really directed to healthcare providers, and my job is to curate it in a way that patients understand it. So that we’re all looking at the same content that we come in the office, our patients are expecting, they know what questions to ask based on the guidelines, and also for providers to provide that evidence based guideline. But if you just tell a patient to go to the guidelines and read them, they may not understand them. So that’s what I’m trying to do is, is make the guidelines and frame it in a way that’s engaging for community members. And so that’s a lot what we’re doing, you know, with this site,

Aaron Tharp 47:26
well, I, we’re going to display that so that people know where to go, because that that’s killing two birds with one stone there. And just by virtue of education, you can tell there’s a clear passion there. It’s a huge, it’s a good service, what you’re doing for the segment of people that really need that information. So,

Dr. Amy Pearlman 47:48
so many people that we see in any of our clinics or interrupt, you know, they don’t come in because they’re overweight, but they so many of them want to lose weight. So they’re coming in with the fatigue and the Low T symptoms. And so, you know, if they’re overweight, I’ll just bring it up in the office. And I’ll say, so in terms of your current weight, are you up down or about the same that you’ve been? And so many of those guys say I’m really struggling Doc, I’m like trying to lose weight. And it’s been really tough. And I’m, it’s I’m struggling to get to the gym, and I’m struggling to eat healthy, can you help me and, and so, so many of these common Low T patients, they want the nutrition advice. And so that’s what this site allows me to do is when I run a busy Surgical Clinic, I still feel like I need to educate patients, because that is first line therapy, behavioral modification, even though I can operate on anyone, it doesn’t mean I should or it’s the right thing to do. And if we’re going to be the comprehensive health care providers that we should be, we have to talk about the nutrition and exercise and mindfulness components.

Aaron Tharp 48:54
Awesome. I think that’s about the most perfect spot to end it. So thank you very much for your time and for what we owe you a debt of gratitude for what you’re doing for for men. It’s again, it goes without saying but it big deal of gratitude towards you and your sister, and, and for coming back and hanging out with us again. I had fun I actually I learned a lot today. So thank you very much, and we’ll catch you on the next one. Cheers. Awesome. Have a good night.

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