Family Planning: How to Improve Sperm Health with Raevti Bole, MD

Podcast Transcript

John Horton:

Hello and welcome to another Health Essentials Podcast. I'm John Horton, your host.

Biologically speaking, we all start from two ingredients: one sperm from a man and one egg from a woman. That's the basic recipe for creating human life. But like any recipe, success depends on the quality of the ingredients, which is why we're going to spend today talking about sperm health. Studies show that sperm health has been in a steep decline around the world for the past 50 years. Lower sperm count and reduced motility — or the ability of sperm to swim — are two significant factors behind this infertility trend. But there are ways to improve sperm health, as urologist Raevti Bole is with us to explain. Dr. Bole is one of the many experts at Cleveland Clinic who join our weekly podcast to talk about health issues affecting our lives, or in this case, our ability to create life. So let's learn what we can do to improve sperm health and address the growing issue of infertility. Welcome to the podcast. Thanks for joining us today.

Dr. Raevti Bole:

Thanks for having me on your show.

John Horton:

The research on sperm health and male infertility offers some pretty startling statistics, but I want to set those broad numbers aside here for a moment and talk to you about what this data means for individual people. I imagine you sit down and talk with a lot of patients who are just really concerned about their ability to start a family.

Dr. Raevti Bole:

Yeah. This is a really big part of my practice, in male sexual and reproductive health. So just to give you broad numbers, about 15% of couples in the U.S. have trouble with infertility at some point. And there's a slightly broad, but also slightly specific, definition of what that means. But in general, we're talking about couples who have tried for a whole year to conceive with unprotected intercourse and they haven't gotten pregnant. Importantly, that also means that the female partner is under the age of 35. If she's over 35, then we shorten the timeframe to looking at six months instead of a whole year. And the reason for that is that, honestly, the vast majority of couples are able to get pregnant after 12 months of trying. Something like 85% of couples can. So that's why when someone comes to see us in the office to get a little bit more expertise, they're usually at that point that they've reached a year and have not been successful. So now we're really wondering why.

John Horton:

Yeah. I'd imagine this is one of those issues that you don't really think about it until you're trying to have a kid and then all of a sudden it's like, "Whoa. What's going on here?"

Dr. Raevti Bole:

Yeah. Exactly. And I think it's one of those things that's supposed to work and you hear mostly about people starting to try and then they're pregnant and they didn't necessarily do anything special for that to happen or it doesn't sound like they did. And so I think there's a lot of information swirling around out there on social media, on the news or people who tell you what they did or didn't do in order to get pregnant. And so it can be really confusing for people who are actively trying when they haven't been successful.

John Horton:

Yeah. Well, we're going to try to untangle, then, some of that confusion today with this discussion. And let's dive in and talk about this whole concept of sperm health, which just isn't a phrase most of us use all the time. So what does that mean?

Dr. Raevti Bole:

Yeah. So that's a really good question and that's really where we start for male fertility is looking at the sperm and doing a sperm test.

So there are a number of different parameters that we look at on the basic evaluation for male fertility — tells us a number of different things. So one thing, the first thing that you usually see at the top of your test when you get a male fertility test done is the volume. So how much fluid is there for the sperm to swim in? That fluid has energy in it for the sperm, it has antioxidants, it has things that stabilize the DNA of the sperm. So we're not necessarily testing for all those things in the basic evaluation, but we will test for, well, how much is there?

John Horton:

More is better, it sounds like.

Dr. Raevti Bole:

Well, there's a normal range. Certainly, if there's just very, very little fluid, that's a problem. And I think that's why it's also really important for when men are going to do the test to try and do their best job at collecting. If you miss a little bit of the sample, it's OK, but let the lab know because that's important for us to analyze. So that's one parameter that's important.

Other parameters that we test are things like acidity level. So the vaginal area is more of an acidic level, and so the fluid that sperm swim in is going to be more basic, so that helps the sperm survive and the female body. So that's something else that we test in that basic report.

Then, we test the concentration of sperm. So how many sperm are there in the ejaculation? And it's a crazy number. It just sounds like so many.

John Horton:

I read 200 million to 500 million, which is just mind-boggling that all of that is in there.

Dr. Raevti Bole:

Yeah. That would be probably more on the upper end, but yes, there's a whole range and yeah, it is mind-boggling. I think that's the exact right word to say when you think about how many sperm are available and they're all trying to get to one egg, so that's a big number for us.

Other numbers are going to be how many of the sperm are swimming? So you actually only need 40% of the sperm in there to be swimming because, of course, they're going to be at different stages. Sperm don't live forever, so within a given ejaculate, some are going to be alive and some are going to be toward the end.

John Horton:

Sperm is in stages. You almost make it sound like it's like a living organism, like a tadpole. Like the different stages. So there are some that have a little bit more of a tail and can swim a little better than others, depending on where they're at in the process?

Dr. Raevti Bole:

Yeah, exactly. Yeah. They're all going to be swimming or they're all going to have the ability to swim by the time they're mature and getting to the point that ejaculated out. But of course, they're going to be at different stages in their lifespan after that point. So that's a big number for us to check and make sure that, of course, there are enough swimming sperm to get to their final goal, which is the egg.

We look for infection. So we want to know is there a possibility that there's an infection that's stopping someone from achieving their optimal fertility?

And then finally, a number that gets a lot of attention but isn't always so important for fertility is the appearance of the sperm. So what does it look like? And I would say that one looks very alarming if it's off, and that one is probably one of the ones that's the least important for fertility. So a number of different parameters in effect that we're going to look at when we do the basic semen test for men coming in talking about fertility problems.

John Horton:

Yeah. I have to say, I had no idea all of that was happening. It just seems like a natural process that just happens, but there's a lot going on.

Dr. Raevti Bole:

There is. And I think, even within one guy, month to month, depending on what he's been doing, what his stress level is, diet, exercise, even within one person, those numbers are going to vary a lot. So one thing that I think we don't always talk about is if you get one sperm test and it looks a certain way, that's almost like a snapshot in your life at that point. And if it's really not what you expect, it almost makes sense very often to get another test about a month later and see if it's the same because those numbers can change quite a bit, even just within one person.

John Horton:

Now, the one thing I want to focus on a bit is how those numbers have been declining for so long. While they may change day to day, it seems like around the world, the trend for the last 50 years is that sperm health has been going down. So do we know why this has been happening?

Dr. Raevti Bole:

Yeah. It's a really interesting topic. I think it's still the subject of a lot of debates at all the conferences I go to and the people I talk to who are experts in the field. And I will say, I don't think anyone's saying that sperm counts are going to zero. It's not-

John Horton:

…we're not in trouble as the human species yet, right.

Dr. Raevti Bole:

…right.

John Horton:

OK, that's good to know.

Dr. Raevti Bole:

Yes. It's not like it's that dire. But I do think that there is compelling data of this small persistent decrease over time. And it's important because even if it is a small decrease that we're noticing, we might be at the point where we can identify that and then make changes that, ultimately, are going to have a big effect on the human population worldwide.

In terms of why it's happening, that's a good question. A lot of different thoughts for why it might be happening. I think one of the big things that people talk about is the environment and potential pollution or toxins in the environment. Things that we call “endocrine disruptors.” So a really well-known one is in plastics, BPAs, and plastic bottles that are single-use. Those things can disrupt your hormonal signaling. Chemicals in nonstick cookware. Different chemicals in the environment that we're in contact with that we think might be affecting our health. Not just from a fertility standpoint, in other ways as well, but this might be one of the reasons that we're seeing a difference in sperm health. Other potential causes that people think about, are we, in general, doing more sedentary jobs and activities and that potentially is affecting our health? Is the rate of obesity rising? We know that obesity is something that can affect fertility pretty significantly. So when we see those rates rise, could that be one of the things that would explain why sperm counts are declining just slightly?

John Horton:

That makes a lot of sense. Yeah, I know we talked about that with everything on here, it seems like just the overall health that we're seeing in the population has been going down, which leads to a lot of problems. There's that trickle-down effect.

Dr. Raevti Bole:

Yes. Absolutely. And I do think that, also, there are some people who are going to be more susceptible to some of these things. Certainly doesn't mean that anyone who has reheated their food in the microwave is suddenly going to be infertile. Or anyone who has a little bit of overweight is suddenly going to be infertile. There are people who might be more susceptible to some of these environmental things and some people who are going to be a little less susceptible. But I do think that it's something that we need to understand a little better in our research.

John Horton:

Is that the reduction in sperm health across all ages, too? Or when we talk about infertility, is it something that's popped up more as people are maybe waiting a little longer to have children?

Dr. Raevti Bole:

Yeah. That's a good question. I think we do know now that there are changes in sperm health with age. Traditionally, we would just think, well, it's women that have a change in their fertility as they get older, but not men. And now, we know that that's not true. There are changes in semen parameters as men get older; they're not as drastic as for women. With women, you go through menopause and men don't have a specific shutoff like that for their fertility. But we do see that around the age of 45, 50, there are some changes in sperm health that would eventually even affect offspring health that are slight, but they're there. And those are things that, as people have children later in life, that could also be considered in terms of how the population's sperm health is changing.

John Horton:

So we have all these issues that could be affecting sperm health. You laid them out very well, but I'd like to be an optimist. So Dr. Bole, let's talk about some potential solutions. What can guys do to increase their sperm count and get those little swimmers moving?

Dr. Raevti Bole:

That's a great question, and I like to focus on optimistic things, too. And I'll say this with the caveat that if there is actually a medical problem that we can identify for the abnormal sperm health, so an infection or a genetic issue or damage to the testicles or something like that, that will require medication or a surgery or something else, then that's what I would focus on. But if we haven't really identified anything and we're just saying, "Well, you're not getting pregnant. We don't really know why." Or "You're doing everything right. We're not really sure what else to tell you." Then, I think there are some potential strategies that you can do in your lifestyle that could try and improve your sperm health.

The other important thing to know is the life cycle of sperm. So in general, it takes your body about two and a half to three months to make a sperm from start to finish. So if you're going to-

John Horton:

…really?

Dr. Raevti Bole:

…yeah.

John Horton:

That's a long time. I barely focus on any project for that long.

Dr. Raevti Bole:

Yeah. It's pretty neat, and it's just going on all the time. And so what I generally tell folks is if you're going to make changes to your lifestyle, you want to do something consistently for at least three months before you're going to try to conceive because it's going to take that long for it to affect your new sperm as they're developing. So a lot of different things that we could cover, but diet is something that's important. General fitness.

John Horton:

On diet, on diet, are there certain things that are good to eat? Is there a magic food everyone's looking for? If you eat broccoli, your sperm count’s going to jump. Is there something that simple?

Dr. Raevti Bole:

I wish I could say yes, but no. I wouldn't say it's simple. There isn't just one food. But I think it's really important to have a balanced diet. And I'll tell you why. It's because a balanced diet is more likely to have some of the really big supporters of sperm health. So things that are antioxidants, things that are good for your hormonal profile, things that are anti-inflammatory and non-carcinogenic. The things I'm talking about that have been better studied than others are things like lycopene. You find that in cooked tomatoes, walnuts have good omega-3 fatty acids, leafy greens like kale, they're going to have a lot of good antioxidants and vitamins in there. And so it's not that you want to eat just one thing all the time, but you want to have that balance of whole foods that are unprocessed, that have this wide variety of good things that are all good for sperm health.

John Horton:

Yeah. I'm guessing you want to avoid things like saturated fats and those fried foods and things like that. It sounds like those would probably undermine sperm health a little bit.

Dr. Raevti Bole:

Yeah. Absolutely. And also, importantly for your own life and overall health, those are bad for your heart, too. But also, specifically regarding sperm health, there's also factors like vitamins and minerals, too, that you get in a lot of these well-balanced diets — things like vitamin C and vitamin E, L-carnitine, zinc. So a lot of different factors that, again, you don't want to go overboard on, but are going to be present in a well-balanced, varied diet that specifically has a lot of fruits and vegetables in it.

John Horton:

Do you ever recommend supplements then for guys who are trying to boost their sperm health and to help deal with that fertility issue?

Dr. Raevti Bole:

Yeah. I think that's a really good question. I think most fertility specialists would say that a good quality men's multivitamin is a good idea. But the reason for that is that it's very difficult for a lot of people to know exactly what they're eating. And supplements essentially are designed to balance out any deficiency that you might have in your diet. So if you're not quite sure whether your diet's well-balanced or if you're eating a very specific diet ... so now, I hear about a lot of people just eating protein. They're eating chicken all the time. They're not really eating too many vegetables. They're going super low-carb. Not a lot of fiber or something like that. Then, you might need a supplement with some antioxidants in it because normally you'd be getting those from fruits and vegetables and maybe you're not. Or if, for example, you're on a mostly plant-based diet, then maybe you're low in some of the co-factors that you typically get in animal product. So in that case, you either have to intentionally eat plant-based foods that have those factors or maybe that's where you take a supplement. So I think it's very individual as well.

John Horton:

Now, let's get into some of the other factors since we touched on diet. The other things that you can do to address sperm health. And I think you were going into fitness. So I take it, just getting out exercising a little more might help things along?

Dr. Raevti Bole:

Yeah. Absolutely. And so there's good research in terms of weight. And so that's part of the reason that fitness can help. So we know that obesity will disrupt hormonal balance. It's pro-inflammatory. It can impair metabolism. And there's some data to show that for every 20 pounds of extra weight, there might be a 10% increase in the risk of fertility problems.

John Horton:

That does seem like a pretty direct correlation there.

Dr. Raevti Bole:

Yeah. So fitness is part of that. Of course, it's good for your cardiovascular health, but it can be good for your fertility, too, which is not always something that we know about or talk about. Other things that are important, sleep. Sleep deprivation is bad for your immune system. It's bad for your hormonal signaling. Ideally, you want to be getting seven, eight hours of good quality sleep at night if you can.

John Horton:

I think earlier you had mentioned stress. I take it that's the thing, too, that can also, I guess, undermine your sperm health.

Dr. Raevti Bole:

Yes. That's a big one. It can really affect sperm production, even in someone healthy. And there have been studies looking at populations of men who are otherwise healthy and looking at how their sperm count varies over different stressful time periods in their life, for example. And it'll really affect the sperm numbers. And I understand that especially for couples who are struggling with fertility problems, it's difficult when you say, “Well, don't stress about it.”

John Horton:

Don't stress about the thing you're stressing about.

Dr. Raevti Bole:

Yes. Exactly. And I feel like we all know of couples who have tried actively to stop stressing about conceiving and then that's when they get pregnant. And I think there is some truth to that because stress in the body is bad for your hormones and hormones are important for sperm health. And so that can really be thrown off balance if you're just living a state of constant stress, whether it's from fertility problems or even from job stress or relationship stress or any other stress in your life, it really takes a toll.

John Horton:

So do a little yoga. If you're a guy and you're having some issues right now, maybe bring things down a little bit, calm down and just relax.

Dr. Raevti Bole:

Yes. Just relax, as easy as that sounds.

John Horton:

Let's talk about the vices, too, because I know we all have them. But I'd imagine things like alcohol, tobacco use, marijuana use, which is on the upswing, I'd imagine those all can play a role, too.

Dr. Raevti Bole:

Yes. Absolutely. I would say in terms of alcohol, most of our data is showing that this affects fertility in a bad way, is from regular or chronic or alcohol overuse. So multiple drinks several days a week, not as good for sperm health, apart from other things, of course. The occasional drink, one or two drinks once in a while is likely OK, as far as we know. But effectively, alcohol is causing stress in the body. It's not good for your liver. And so large amounts at some point could overwhelm your system and then ultimately downstream affect your sperm health.

John Horton:

And what about smoking? Tobacco, marijuana, I take it those are probably not great for it.

Dr. Raevti Bole:

Yeah. Exactly. So we have good data in terms of smoking cigarettes. That's actively going to damage sperm DNA. With marijuana, I think we have more and more data now and probably more coming out as people talk more about it, about using it, especially at younger ages. There are things probably that we don't know now as well as we will know in the future. But there are animal models of marijuana use showing that chronic use can affect testicle function, it can affect sex drive. So what I say is, in general, if you can avoid having extra chemicals in your body, you want to try and avoid that, especially around the time that you're trying to conceive.

John Horton:

Do you have patients where they've come in and they have a low sperm count and they cut some of those things — they go alcohol-free for a stretch or decide they're going to stop smoking — does it make an immediate difference?

Dr. Raevti Bole:

Yeah. So with immediate, I would say the soonest you would know, of course, is three months. But yes. If you can make a sustained change, that actually means cutting it out, then yes. And it depends on what parameter you're looking at. So smoking's a good example, which we talked about, that affects the DNA of the sperm. Smoking can cause damage to that DNA. And that's something you can check the level of after cutting out smoking or introducing an antioxidant into your diet. If you can do that consistently for at least three months, then, absolutely, it makes a difference.

John Horton:

And another issue I know we hear about a lot are steroids. There's guys that they want to get buff, they want to do whatever, and maybe they dabble in some of that. Obviously, I'm guessing it has an immediate impact. But can it also have a long-term effect if you did that early on and then years later, you're trying to get pregnant?

Dr. Raevti Bole:

Yes. So steroids, like taking testosterone for example, that's going to suppress your testicle function. And I think a lot of times, I'm surprised by folks who didn't know that or weren't told that. A lot of times, I hear of guys saying, "Oh, well, I thought I was boosting my testosterone." But in fact, what you're doing is suppressing your natural production of your testicles, and so you're not intending for the testicles to also stop making sperm, but that's effectively what happens. The sperm count gets driven way, way, way down. Now, in most cases, you are able to stop the testosterone and then recover your testicular function, but certainly if you've been on it for a long, long period of time, it gets difficult for your body to recover. And then in some cases, some men aren't able to recover, and those tend to be men who might have been predisposed to infertility and then went on testosterone. And then the two things together made them just susceptible to long-term or permanent fertility problems.

John Horton:

And you said that's just testosterone. We're not even getting into the antibiotic steroids and things like that.

Dr. Raevti Bole:

Yep. Exactly. So testosterone will be the best studied, but certainly the other steroids would work similarly in terms of effect.

John Horton:

Yeah. Something you hear about all the time, too, are cell phones and laptops. You have that phone in your pocket all day and it's going to drive down sperm count or you're sitting on the couch, you have the laptop on your lap and you're frying them. Is tech really going to make a difference with what's going on down there?

Dr. Raevti Bole:

Yeah. That's a good question. I think in terms of the studies we have, the data on something like electromagnetic radiation from cell phones is a little weaker, but I would say in general, it's such a weak signal that even moving the phone three, four inches away from where the testicles are would help. I don't think that it would have a major effect on sperm health, but it's probably easy enough to move it to a different pocket, like a back pocket or something like that.

In terms of the laptop on the lap, I think laptops can generate a lot of heat. And so if you're constantly having your laptop on your lap when you're working and you're sitting there for hours and hours, which sometimes you do, depending on the job you have, that actually could cause heat stress to your testicles in terms of production of sperm, because sperm don't like to be too hot. It really is something that we know clearly affects sperm health. And so I think anything that you do repetitively and chronically can have that ability to be too hot for sperm. And that would include things like saunas, hot tubs, if you're repetitively going to the sauna multiple times a week, that's going to be too much around the time that you're trying to conceive.

John Horton:

So you just need to cut it out for a little bit. It sounds like if you make these little changes, it's not going to guarantee anything, but it sounds like they'll improve your odds just ever so slightly.

Dr. Raevti Bole:

Yes. I would agree with that. Now, we're not talking about folks who have, again, a major problem or people with a sperm count of ... it's not going to take your sperm count probably to zero if you get in the sauna once in a while. But if there's a little thing that you can optimize, I think it makes sense.

John Horton:

And the reality is we need one good swimmer out of that one hundred million. So whatever you can do to help that one, you should try.

Dr. Raevti Bole:

Yes. Exactly. You do just need one good swimmer, ultimately, yes.

John Horton:

And finally, I think we need to get to the classic question that always seems to come up with this, which is, does it make a difference whether you wear boxers or briefs? Tighty whities seem to get villainized a lot with this. So are they truly an enemy to sperm health.

Dr. Raevti Bole:

That's a funny question, but yes, it is a common question. And I would say no, as long as we're talking about standard underwear, that should not be a big difference, even if with briefs because they're not going to be constricting to push the testicles really tightly against the body.

John Horton:

I hope not. If they are, you're wearing them wrong.

Dr. Raevti Bole:

For most people. If you were wearing something really constrictive or tight that would quite literally tuck the testicles right against the body and you're doing that frequently, that might be too much. But I would say standard underwear, I would not be telling someone to change just for this purpose.

John Horton:

All right. Well, that's good. So whatever your preference is, you can stick with it and you'll be OK.

So I'm guessing that most guys don't find out they have an issue with sperm health until they are trying to start a family and they're not seeing those two lines showing up on a pregnancy test. At what point should you go and see a doctor to see if there's something going on?

Dr. Raevti Bole:

Yeah. So I would say, when we look at most couples, they're able to get pregnant within six to 12 months, assuming that the female partner is under 35. So I would say if you're at 12 months of not using anything for contraception and you haven't been able to get pregnant, absolutely that's a good time. I would say, any time after six months, I would start thinking about it. But it definitely wouldn't panic. If your partner's over 35, then again, that timeframe would be shifted a little sooner. So then, you're going to only wait six months before you say, "OK, maybe we need some more evaluation." And then certainly for any guys who have risk factors that they know about. So they know that they have had some testicle surgery when they were little that may or may not have done something, but they know that something was done or they know that they had some medication that was given to them and their doctor had mentioned a long time ago, well, this might affect your fertility. If something like that, about your health, that would be a possible risk factor. So that would be a reason maybe to get in sooner.

John Horton:

It seems like talking about fertility can just be a really difficult topic for a lot of folks. It's so personal. So before we let you go today, what advice do you have for someone who's worried or concerned about their situation?

Dr. Raevti Bole:

I think it's really good to just be very open with your doctor, and it can be hard because you may not have a consistent doctor. But just know that everyone in healthcare is very familiar with the idea that fertility is important and that if they don't have all the answers, they should know who to refer you to. So the first thing to do is just reach out, make that appointment. Especially if you think you fit one of the criteria that we talked about today in terms of the amount of time you've been trying to conceive or if you have any other risk factors in your profile and just tell them, “Hey, we've been trying to conceive. Would you worry? Is there something we can do?” And then let them tell you where best to go next.

And then I would say, if you haven't been trying for long enough, if it's only been one or two months or something like that, three months, try really hard not to stress about it. Most people do conceive within a year, so the odds are in your favor, even if it does take the full six to 12 months.

And then the last thing I would say to most people is, in any way you can support good research into this area. There's a lot that we don't know about fertility, and I think it's really important for us to study all these questions that people find so important that we all in fertility find so important so that we can find out together for the future.

John Horton:

Well, Dr. Bole, you gave us some great advice today, and with any luck, we will see a baby boom nine months after this podcast. So thanks very much for coming in today and just giving so much great info.

Dr. Raevti Bole:

It's my pleasure.

John Horton:

If you are a guy having trouble starting a family, know that you're not alone. It's estimated that 1 in 6 adults has some fertility issue. Talk to your healthcare provider about options to improve your sperm health and increase your chances of becoming a dad.

If you liked what you heard today, please hit the subscribe button and leave a comment to share your thoughts. Until next time, be well.

Speaker 3:

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