In this quarterly podcast summary (QPS) episode, Peter summarizes his biggest takeaways from the last three months of guest interviews on the podcast. Peter shares key insights from his discussions with Paul Turek and Paula Amato on male and female fertility; Rachel Rubin on menopause and hormone replacement therapy; Brian Kennedy on the biology of aging; Tanuj Nakra and Suzan Obagi on facial aging and skin rejuvenation; and BJ Miller and Bridget Sumser on lessons we can learn from the dying about how to live. Peter highlights the most important insights from each episode and any behavioral changes he’s made for himself or his patients as a result of these fascinating discussions.
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We discuss:
- Summary of episode topics [1:15];
- Episodes on fertility with Paul Turek and Paula Amato: insights on all things male and female fertility [4:45];
- How men can optimize fertility [20:15];
- How women can optimize fertility [26:00];
- Rachel Rubin episode: insights on women’s sexual health, menopause, and HRT [31:45];
- How women can prepare for menopause: proactive care, evidence-based HRT, and more [41:45];
- Brian Kennedy episode: understanding aging, role of inflammation and mTOR, and current limitations of aging clocks and biomarkers [46:30];
- Advice from Brian Kennedy on testing longevity interventions [56:45];
- Tanuj Nakra/Suzan Obagi episode: causes of facial aging and practical strategies for prevention and treatment [57:30];
- Skincare: making sense of the wide range of skin resurfacing treatments [1:06:45];
- How to create a realistic, sustainable skincare routine [1:12:30];
- The dangers of following unqualified aesthetic advice online and the importance of getting professional medical guidance for cosmetic treatments [1:18:00];
- BJ Miller/Bridget Sumser episode: lessons about living from the dying [1:21:45]; and
- More.
Show Notes
Summary of episode topics [1:15]
REMINDER: These quarterly podcast summaries are a way listeners can hear from Peter about insights he took from guest episodes such as where Peter’s behaviors have changed and how his thinking may have changed, but the QPS episodes are not necessarily a replacement for listening to the full episodes.
Overview of Episodes to be Discussed
- Paul Turek ‒ male fertility
- Paula Amato ‒ female fertility
- Rachel Rubin ‒ women’s sexual healthy, menopause, HRT
- Brian Kennedy ‒ biology of aging
- Tanuj Nakra and Suzan Obagi ‒ all things skincare, facial aging, rejuvenation strategies
- It is now 2.5 months since this episode and Peter is looking forward to discussing exactly what he has done
- Of all of the episodes, this would be the one where he’s had the greatest change in his personal behavior
- BJ Miller and Bridget Sumser ‒ all around death and dying
- What you can learn from people on their death bead
- The last 2 episodes could not be more apart in terms of relevance and superficiality
- Not to bring any sort of judgment against aesthetics
- Ultimately talking about end of life and lessons about life through death versus how to make your skin look better are about two opposite ends of the spectrum
- Nevertheless, it is a spectrum and we can find value in talking about everything along it
- We try not to do too much summary in these episodes because the show notes do such a great job of that
Episodes on fertility with Paul Turek and Paula Amato: insights on all things male and female fertility [4:45]
***
From a story standpoint, the idea that conception is difficult is an understatement
- A single ejaculation releases about a 100 million sperm
- Fewer than 5 million of them even make their way past the cervical mucus
- Ultimately only somewhere between 100 and 500 reach the fallopian tube
- Then only 1 goes on to fertilize the egg
- Now, there might be 20 that reach the egg, but there’s this really cool force field that comes up the minute the first sperm touches the egg
- It creates a chemical barrier that prevents any others from fertilizing, otherwise you’d have this devastating situation of too much genetic material being brought in
A couple of interesting things that made Peter go “Wow!”
Sperm are chemotactic
- They’re basically chemical guided missiles that make their way to the egg, and they can traverse 15 centimeters of distance within the vagina to the fallopian tube within minutes
- It’s important to understand, given how small a sperm is, that is the analog of a human swimming 20 miles in the ocean in that same period of a few minutes
- By the way, even though we didn’t go into this in the podcast, think about the energy requirement to do that and you kind of understand what the motor and the ATP generation is like in one of those things
Testes, like the brain, have kind of a specialized blood tissue barrier
- It’s very immune privileged and it protects developing sperm from antibodies
- It also means that drugs or toxins that can cross it such as certain types of chemotherapies can actually be disproportionately damaging
- It’s for that reason that a lot of men who are undergoing chemotherapy will choose to do a sperm donation prior
Spermatogenesis (or the generation of sperm) follows a clock of about 74 days
- If a guy gets his sperm tested and it comes back that something’s not right, and if you’re trying to make interventions around sperm health
- You’re going to need 2-3 months of trying a corrective intervention before you can determine if it’s worked
- That’s how long it takes to go through the cycle
On that intervention piece, one of the things that was talked about was bike seats. As someone who spent a lot of time on a bike, did that surprise you?
- Yeah
- Peter has always been pretty mindful of bike seats, and he’s been very fortunate despite how much time he used to spend on a bike that he’s never had any issues
Paul points out in the podcast that it’s not really a big concern for fertility, but it is much more a concern around erectile function, based on your anatomy and based on the type of seat you use
- You can really traumatize the arteries and nerves that impact erections
⇒ What we tell all of our patients, if they’re spending a lot of time on a bike, we have recommendations on bike seats that they should be using
- Peter has 2 bikes: one for inside, one for outside
- He has different bike seats on them because he got them at different times, but they’re basically the identical type of seat
A seat that has the middle of the saddle is largely absent so the ischial tuberosities (your sit bones) are doing the supporting but nothing else
A couple brands of bike seats Peter recommends
- Top USA
- Ism [shown below]
- As silly as it sounds, Peter recommends people buy 3 and try them out and figure out the one that’s most comfortable
- Buy from somebody who will let you return them
Figure 1. Bike seat where the middle of the saddle is largely absent. Image credit: ism
Back to fertility, Paul talked a lot about what his workup is for patients. Remind people of that and how you apply that to your patients
- This is not something Peter considers his practice remotely sophisticated in
- We refer out for fertility issues to people like Paul or Paula
- What we learned here is really valuable for everybody listening because you can certainly do a lot on your own to force the issue
“If you remember nothing else from Paul’s podcast, you know what you should remember is that males are often the driver of fertility issues.”‒ Peter Attia
- So when a couple is struggling with fertility, it’s very common to just assume that the issue lies with the woman, and that’s not the case
- In fact, Paul mentioned that only 23% of males are even evaluated for fertility prior to moving to IVF
- When you consider the cost, the economics of IVF, to think that 3/4s of men are not even evaluated for fertility issues before proceeding to that is crazy
- Especially when you consider that 40% of male infertility is driven by one thing: a varicocele
⇒ A varicocele is a very easy thing to correct with a very minor procedure in a male
- To think that 40% of male infertility alone is driven by a varicocele, you realize that there’s an enormous opportunity here
Paul’s workup for male infertility
- Involves a very thorough patient history and physical exam
- A varicocele is something that any urologist will be able to pick up on a physical exam
- Semen analysis, which he typically repeats twice across 3 weeks along with hormone levels, and by looking at FSH, LH, and testosterone
- You can figure out if a guy is taking exogenous testosterone
- Sometimes a guy will just fail to mention that he’s taking exogenous testosterone, that he’s been on it for years and years and years
- It just doesn’t cross his mind what the impact of that could be on his fertility
Exogenous testosterone is effectively male birth control
- Within 2-3 months of taking 200 mg testosterone per week, 95% of men will effectively be azoospermatic or oligospermatic
- It means they basically can’t reproduce
- Peter doesn’t know what that would be at a 100 mg per week
- He doesn’t know how much longer it would take
- 200 milligrams a week is a really big dose ‒ we’ve never had a patient take that much testosterone
- Typically we’re sort of in the 80-120 milligram per week
- So if it takes you 8-12 weeks to become azoospermic or oligospermic, at 200 milligrams per week, it might take twice that long
The point is in relatively short order, exogenous testosterone will render you unable to reproduce
The reversibility of the effects of exogenous testosterone on sperm production
- Basically within 3-6 months of testosterone cessation within the first year, you will resume sperm production
- There are of course other ways around it
- We have men in our practice who are taking testosterone exogenously, but who also want to continue with their reproductive potential, and so we’ll typically add hCG (somewhere between 250 and 500 IU twice weekly) to maintain sperm count
⇒ We prefer using just hCG at a higher dose as opposed to exogenous testosterone if we can in younger men
{end of show notes preview}
