Shweta Mishra – Good evening and welcome to CureTalks.  I am Shweta Mishra, your host, joining you from India; and this evening on CureTalks’ 110th episode and our seventh talk on fertility and reproduction, we are discussing male infertility and sexual health.  Male infertility is the concluding cause in almost half of the cases of couples who have been unsuccessful in conceiving after trying for more than six months.  Despite this high prevalence, male infertility remains an issue that not many men or women like to discuss openly; however, the good news is that our medical fraternity made sure it never takes a backseat.  The rapid advances in male reproductive research have allowed us to diagnose and treat male fertility way better than earlier times, helping more and more couples to conceive.  Our eminent guest and expert today, Dr. Jamin Brahmbhatt, is a male infertility specialist who is considered a national authority on men’s health.  Dr. Brahmbhatt is here with us today to talk about the causes and latest advances in treatment of male infertility.  He will also talk about some of the most common inhibitions that men harbor when it comes to taking care of their bodies, more specifically their sexual health.  On our last show at CureTalks, we discussed fertility in older women with Dr. Richard Paulson of USC Fertility.

Shweta Mishra – Our expert today, Dr. Jamin Brahmbhatt, is a board-certified urologic surgeon, specializing in chronic testicular pain and infertility.  Dr. Brahmbhatt completed his urology residency at the University of Tennessee Health Science Center followed by a clinical fellowship in robotic microsurgery and male infertility at the University of Florida.  An active member of several professional organizations, he also is active in public engagement.  He is a TEDx speaker, on-air expert, and a national authority on men’s health.  Every June during men’s health month, Dr. Brahmbhatt and his partner organize the Drive 4 Men’s Health, a 10-day, 6,000-mile, public engagement road trip encouraging men to eat better, to get active, and engage in preventative medical screenings.  Currently, he is the co-director of PUR Clinic, Personalized Urology & Robotics Clinic, at South Lake Hospital & Orlando Health.  Thank you for finding time to be with us today, Dr. Brahmbhatt.  Welcome to the show.

Dr. Jamin Brahmbhatt – Thank you so much for having me.  Appreciate it.

Shweta Mishra – Thank you, doc.  My co-host for today’s show is Kristen Darcy.  Kristen is a noted author, fertility coach, motivational speaker, divorce coach, and an expert on emotional aspects of both infertility and divorce recovery.  Kristen is the author of “Girlfriend To Girlfriend: A Fertility Companion” and the award-winning book, “Love and Infertility: Survival Strategies For Balancing Infertility, Marriage, and Life.”  Kristen has served as an expert on emotional aspects of infertility, testifying before the US senate in 2000 about the importance of government funding for fertility research and holistic treatment.  She has been highlighted in national publications and broadcast media, including NBC’s The Today’s Show, Woman’s World magazine, PBS Health Week, and the Boxing Glove.  She is also a former board member and a volunteer for RESOLVE New England.

Shweta Mishra – On the panel we also have with us, Jonathan Boldt.  Jonathan is a writer and a journalist who turned to writing to share the humor that comes from such pain that only infertility can cause.  He is the author of the Book, “Shooting Blanks:  A Husband’s Perspective on Missing the Mark and Dealing with Infertility,” which he wrote with his friend, Steve Ruiz.  He has been interviewed about his experiences with infertility.  We also have Sara Naab.  Sara who comes from San Francisco Bay area is an outspoken advocate for men’s reproductive health.  She is the editor of Don’tCookYourBalls.com, the leading online resource for male fertility.  She is also a co-founder of Sandstone Diagnostics, the startup behind Trak, an award-winning system that allows men to measure and improve reproductive health from the comfort and privacy of their home.  We also invited Valerie Landis, but unfortunately due to some unforeseen circumstances she will not be able to join us today on this call.  So, welcome to the show, Kristen, Jonathan, and Sara; and I extend a hearty welcome to all our listeners and I would like to remind them before we start discussing that we will be discussing questions sent in via email at the end of the show.  So, you can email your questions to priya@trialx.com; and if you want to ask a question live, please press 1 on your keypad and we will bring you live on air to ask them or you can also post your questions on CureTalks’ website as you listen in.

Shweta Mishra – So, let’s begin this talk by discussing a little bit about your Drive 4 Men’s Health Program, Dr. Brahmbhatt.  I read that, through this program along with your friend you try to motivate men to give their bodies as much attention as they give to their cars.  That’s interesting!  Can you please tell us a little bit more about it?

Dr. Jamin Brahmbhatt – Yeah, I mean its…, its something that we discovered just by chance a few years ago.  My partner bought a Tesla, which is an all-electric car, really sexy car and what we realized was when we would be out and about, men would get attracted to it and then the conversation always went into from the Tesla to the technology to…, hey, by the way, what do you…, what do you two…, what do you guys do and then the conversation always led into urology and men’s health.  So, we saw it as a kind of a male magnet and the idea just clicked in our head that we should use it to fire men to improve their health.  Now, you may be asking why is that?  Well, here in the United States, there is a five-year life expectancy gap between men and women, so women are doing a much better job controlling what they eat and exercising and making sure they are getting their preventive cancer screening and that’s why they are living that extra five years versus guys just kind of, in truth, ignore these things and that may be contributing some to what we are going to talk about little bit later is the infertility in men as well, but its a pretty cool initiative called the Drive 4 Men’s Health.  Every June, we start driving across the country over 10 days and engaging as many men, women, and families as we can on social media, on ground, and even in the media, local and national media.  So, its a great effort.  Come, check this out at drive4menshealth.com and learn a little bit more about this amazing non-profit event that we put together to inspire men out there across the world to lead healthier lives.

Shweta Mishra – Hello?

Dr. Jamin Brahmbhatt – Yes.

Shweta Mishra – Doctor, there?  Okay.  All right.  Sorry.  There is some static noise in between, so we are kind of trying to figure out what that is.  Okay.  Well, thank you.  Thank you so much for your answer.  Let’s just start discussing about some of the major causes of male infertility and what are some of the warning signs that men should be aware about, if there are any?

Dr. Jamin Brahmbhatt – Well, the biggest one in kind is, if you and your partner have been trying to have children and nothing has happened after one year and there are certain cases where we would require workup at six months, but usually we ask one year of unprotected routine intercourse and then no pregnancy, we do start a workup and the workup is, is both male and female.  So, one important thing for people to know out there is that its almost 50:50 when it comes to the risks and the risk factors that are associated with overall infertility.  So, its not just a guy problem.  Its not just a girl problem. Its usually 50:50 and then we look at all numbers, where about 30% is just the males, about 33% is just the females, and the other 33% is.., is kind of like, you know, unknown, but when you clump it all together, its about 50:50, that’s male versus female.  So, there are no true warning signs.  I mean, there is obviously life events that could have happened throughout the male growing up that could have led to their infertility where there would be some…, some trauma to the testicles, where there would be some medication they had been put on.

Dr. Jamin Brahmbhatt – There are many different factors that we take into account when we are…, when we are thinking about their overall…, overall history, but if you look at just infertility overall, you know, there are a lot of reasons behind infertility, but we could probably blame 90% or so on our little swimmers, our little sperms, whether there are…, there are either not enough of them, they are not floating as much as they want them to, or they have abnormal morphology, they just look a little weird.  So, that’s about 90%, somehow there is some issue in there and the other 10% could be genetics, hormones, or anatomic issues that could be leading on to their infertility.  One thing that I always like to mention in the beginning is testosterone.  I see a lot of young men that are taking testosterone replacement therapy.  I am not…, you know, I am not even sure who is prescribing it to them, but they come in and they are infertile.  Well, when…, when men are taking exogenous testosterone, what essentially happens is it shuts down, your body basically thinks it has too much.  So, it shuts down its natural mechanism of…, of creating testosterone, which at the same time shuts down its natural production of sperm because both essentially go hand in hand.  So, when…, when we ask for a history, we ask three or four times and I would say, a lot of my men eventually, when their wife is not around or their partner is not around, admit that, “Hey, actually I am taking the stuff at the gym.”  So, you’ve got to be honest with your doctor because, you know, the things you may be doing for vanity to help you at the gym may be causing a major emotional burden on your overall family.

Shweta Mishra – Oh, okay.  That’s a good message out there.  Well, let me…, let me bring in Kristen Darcy at this point.  She will be taking the discussion forward.  Kristen, are you there?

Kristen Darcy – I am here.  Hello, everyone!

Shweta Mishra – Hi, Kristen!

Kristen Darcy – I am so excited to…

Dr. Jamin Brahmbhatt – Kristen, how are you?  Long time, no see.

Kristen Darcy – I know!  Its been…, its been since our meeting at_____[00:10:58] _____ which I feel like we’re getting the band back together from, you know, having this great invite to be on this important radio show.  So, I know Sara and Jonathan are waiting to jump in too in a minute, but I wanted to piggyback on that comment that you just said, you know, about how sometimes you keep a little bit of privacy between the patient and you get that patient to admit some of the lifestyle issues that they might have and you know where I live, my whole health is about the emotional component of infertility and…, and you have been so supportive and helpful for…, for so many people and the question that I wanted us to discuss or to have a discussion about is, you know, what…, what can you see in your practice, which is the typical reaction from men when they get…, receive that diagnosis of infertility?  I think its so important to hear from your…, your…, you know, point of view about the emotional, you know, component of receiving this medical diagnosis.  So, if you can fill us in on that, that would be wonderful.

Dr. Jamin Brahmbhatt – Yes, so I would say there are two types of men I see in my office.  One, they are very anxious and very stressed out and feel this is the end of the world and I actually like those men because they are more likely to adhere to treatment plans and get their imaging, if its necessary, done and…, and follow up.  Then, there are the other guys that have essentially been dragged there by their partners to get the full evaluation done.  Regardless of which one it is, my job to either, you know, they are very anxious, so should calm them down and spend some time with them or the other patients get them motivated and what that takes is, is just time and patience on our part and actually listening to the entire story because honestly, I already know what I am going to do in majority of the cases even before I have actually even shaken hands with my patient because I…, I look at what I already have in front of me and then its kind of like an algorithm that we follow to get them, you know, optimized from a fertility standpoint.  So, I take the time that I have in the office to build a relationship with them so that they trust me and then they are willing to open up.  You know, guys are very difficult.  You know, they…, they like to kind of keep their feelings all…, all inside of them.  So, I try to see something that they are wearing or…, or see or find something that I can relate to and start…, start conversation where they see me more as a friend rather than someone dictating medical care to them.

Kristen Darcy – Oh, I think that…, that’s such a strong point about you and…, and, you know, your clinic because it is bridging that way of communicating to your patients so that your patients can communicate to you with ease and I know that you know that I, you know, focus on the emotional component and…, and I have the two things or variances, either you have a man who is very proactive coming to me for coaching, you know, practice so that they can learn more how to move through this with…, with ease or the other side of the coin, which is really someone who doesn’t want to talk about it and I think it would be so helpful to just, you know, to talk about some of those emotions. I find their fear, their shame, their protectiveness of their wives, and their protectiveness of their…, their marriage and. A lot of men say they just want their wives back, that that they found themselves, regardless if its male infertility or female infertility, in a place that they have really no control over and was unexpected.  You know, there’s such uncertainty and I think what you do and what I try to do and Sara and Johnson who are on the line, is really to shine a light on this topic in a way that, you know, brings out in the forefront to know that you are not alone, that there are so many things that can be done to create a family.  So, I so appreciate that because I think one of the other topics that’s so important and I really feel like its your…., your sore spot is really the correlation between men’s reproductive health and their overall health and that goes, of course, hand in hand with lifestyle and we kind of touched on that, but, you know, how can you speak to that, you know, your overall health and your reproductive health are…, are one and the same basically.  Is that a true statement?

Dr. Jamin Brahmbhatt – Yeah, absolutely and…, and one thing just to…, to touch on what you said is, you know, its very important for us as clinicians to be able to decipher whether the partners even want to have children because sometimes, you know, they may…, they may just not be ready in their relationship to have children and that’s why they are kind of dragging their feet.  So, again, that’s where the open communication comes in and…, and in trying to figure that out and also letting them know that its not the end of the world, you know, because I always try to focus on, everyone’s just so focused on natural…, natural birth, natural birth, natural birth because, you know, that’s…, that’s what they see on TV and that’s how its supposed to be and that’s…, that’s the norm, but the reality what we are trying to do is get them to be compared, so there are other ways to do that.  There is assisted reproduction, there are other techniques, there is even adoption, there is donor sperm, donor egg, so we can get you to…, to what you want, which is to be parents.  So, its about painting a more global picture in their head and I think once I hit on those few points, everyone just kind of relaxes and…, and then we kind of move forward, but, you know, to answer your question about…, okay, is health tied to reproductive health, yeah, absolutely.

Dr. Jamin Brahmbhatt – You know, your sperm, you have, you know…, you may have 10 million, 30 million, sometimes even 300 million sperms in there and they are kind of like your soldiers and…, and…, and when you ejaculate, they are ready to go and fight their way to that egg and, you know, even 300 million may start that journey, but only about 40, only the 40 strongest on average will make it to the egg and in the end only one will win, so only one will conquer that egg when its time to fertilize that egg.  So, if you can imagine what the…, the sperm has to go through from the time they leave where they are being stored to getting all the way to the egg, they have to be strong and they have to be healthy and they have to be motile and ideally they have the perfect morphology.  Well, if you, your overall body is little round and you are suffering from obesity and you are smoking and you are drinking and you are not taking care of your testicular overall…, testicular health, your overall health, your mental health, but then your sperm which are your soldiers, which are basically trying to keep you strong. So, you know, the habits such as smoking, drinking, marijuana use, putting laptops over your testicles, you know, sexually transmitted diseases, chemicals, toxins, all of these things can affect your overall thing.

Dr. Jamin Brahmbhatt – So, both are basically tied hand in hand and there are multiple studies showing that obesity leads to, you know, poor sperm counts and motility.  Lack of exercise even leads to the same thing.  Stress leads to reduction in your sperm quality.  So, all of these things are research proven.  So, if the first thing you have to do, is you have to make sure that you are healthy and that you can do it.  The other thing is, you have to have sex to get pregnant.  I see couples that suffer from infertility that only do it like once a month, twice a month.  They can’t even get their schedules together, so I am like why are you wasting your time and money because you have to actually go through the natural process to get the ejaculate in there into…, near the cervix and then overall into the egg.  So, if you are not even doing that, then…, then why spend all this money and time on a workup?

Kristen Darcy – That was, that was spot on, you know, just listing all those items that a male and female need to bring into awareness.  So, I wanted to piggyback on one more question, then bring Jonathan Boldt in.  So, I had a client ask this question and I knew I would be with you today.  So, what the question was, when you said have to have sex, the question was, should they have sex everyday or every other day and I think after your’s, you know, I just wrote that to tweet it, have to have sex, what do you recommend?

Dr. Jamin Brahmbhatt – Well, you know, there are all these different theories out there and I don’t know if one is better than the other one.  There is, oh, you have got to follow your temperature and, you know, by all these things and, you know, go around your ovulation cycle and that’s great if that’s the path you want to take because actually after that you got on your phone as well, but what I recommend is every other day.  Have sex every other day, you know, at least because when I usually recommend every day, you know, the…, you know, either the guy or the lady are like, “Oh, my God!  This is going to be a chore.”  So, I really recommend every other day and it works out fine.  I mean, yeah, you can follow the science and all that stuff, but its very hard to actually track all that stuff all the time and a word of caution about apps, medical apps, just some ovulation apps out there.  You know, those things are not actually regulated and, you know, I would always take that with a word of caution, why these things are, if you look at it, are marketed as entertainment.  So, they are not really medical grades.  I would always before taking up something on your own, talk to your healthcare professional and see whether its something that’s going to work for you, but, you know, my general thing is, every other day I don’t know if there is any perfect science behind it, but that seems to be what my patients are most receptive to in terms of my suggestions.

Kristen Darcy – Great!  Thank you so much.

Shweta Mishra – Yeah.  I am…, I am sorry to interrupt, Sara…., sorry, Kristen.  I think there is some static noise from your end.  Would you mind just keeping your phone away from other electronic items or something?

Kristen Darcy – Oh, I am so sorry.  I moved, honey.  I got that message from you when I moved.  Its so bad.

Shweta Mishra – Oh, really.  Okay.  Okay.

Dr. Jamin Brahmbhatt – You know, why don’t you try muting it?  You want to try muting it and see if that works?

Shweta Mishra – Yes.  Yeah.  That’s how we discovered it actually.  When we are muting, Kristen’s voice is gone, so I think its coming from her phone, but…  Yeah, anyways, see if you can do something about it, Kristen, or let’s just continue.

Kristen Darcy – I’ll call you from another phone.

Shweta Mishra – Well, no.  I think I…, let’s just continue the discussion and then we’ll see. Okay.  Sara, let’s just…  You can call in…, drop the call and call in again and until then let’s invite Jonathan.  Jonathan, are you there?  Let’s start with your questions for the doctor.

Jonathan Boldt – Can you hear me?

Dr. Jamin Brahmbhatt – Yeah.

Shweta Mishra – Yeah.

Jonathan Boldt – Okay.  We started trying about 10 years ago and haven’t really done any kind of birth control ever since then, but after probably six or seven years of not being able to do much mainly due to the treatments getting more and more expensive, that we kind of backed off and the frustration was building on that.  Now that its been a few years of not going to the doctor’s, what’s new out there and what can you expect to go back and try now as we try to…, to have kids again?  That makes sense?

Dr. Jamin Brahmbhatt – Do you…, do you…, do you have a child or have you adopted or…

Jonathan Boldt – Oh, no.  Sorry!

Dr. Jamin Brahmbhatt – You guys just kind of pulled up on it.

Jonathan Boldt – No, we haven’t adopted.  Yeah and with all the stress of it, we decided just to kind of not worry about it for a little bit while and now its been three years and now we are thinking about what we can do and how we can get back out into trying again.

Dr. Jamin Brahmbhatt – Did you…  Did you all try like IVF cycles or stuff or…, because I don’t know your whole history, or if I missed that.

Jonathan Boldt – No.  Oh, no.  Sorry.  Yeah, we just did kind of a basic testing and some amount of the real things.  We weren’t able to afford any of the more expensive trials at the time, but we were wondering…  Actually, we have to kind of start back at ground zero after a little while.  Do we have to kind of just go through the whole ringer again?

Dr. Jamin Brahmbhatt – Usually you don’t.  I mean, usually its up to you, like if you want to get aggressive because I am not sure exactly what the issue was with you.  I don’t know if its a sperm issue or anatomic issue.  Did they ever figure out like a cause or did they tell you what a diagnosis would be or…

Jonathan Boldt – As far as anyone would tell, it was just idiopathic.  They could not figure out one way or the other, which was how it was, but I guess that kind of leads into my next question would be, I have an autoimmune disorder that I haven’t been able to get an answer on it.  It sounds like you might be the guy that would let me know, but its called common variable immunodeficiency and so I just don’t really produce immune system and have to do every-six-week cycles of gammaglobulin infusion and from what you were saying earlier, it sounds like overall health is really important.  With something like that, is it going to be more beneficial just to kind of resign ourselves to maybe looking at the adoption now?

Dr. Jamin Brahmbhatt – No, I mean, so many discussions are lot longer than this hour-long blog talk, but, you know, to answer your first question, you don’t have to start from scratch to begin with and you have not tried…, seems like you have not tried IUI or IVF or ICSI and again just a disclaimer here, these all are just kind of discussions.  I am not being your medical provider or anything here.  I am just kind of discussing overall things here.  So, you know, its one of those things where if you guys before actually giving up, and want to try something, then IVF may work for you and, you know, when you think about what you have, you have something that even though its called common variable immunodeficiency, its actually very uncommon.  I think the last statistic I read was 1 in 25,000 may have it and its a very tough disease to diagnose.  That’s why it takes so long sometimes to diagnose people with it and then there is really no great treatments out there for it, so you know, its one of those things where, you know, perhaps your immune system, because there is an abnormality in your immune system, that’s not causing your sperm to, you know, essentially get to where they are supposed to or be at function if you want to.

Dr. Jamin Brahmbhatt – So, to whole bypass that entire pathway, you know, IVF is one of those things where I would definitely look into that, at least start the discussion where they can just take your sperm that are coming out and inject it straight into the egg and then bypass everything else.  That could be causing your infertility issues.  So, you know, I don’t think its the end of the road.  Obviously, if you want to adopt, great.  I mean, that’s a great path to take, but I would say based on what little history I know, you have not exhausted every option out there when it comes to intervention for your…, for your infertility and in terms of, is anything else new out there, I would say probably its pretty much all really the same.  In terms of, you know, working up the male and if its a varicocele, fix the varicocele, work on the environment and social things, and then in terms of, you know, treatments, if there are blockages, we can do surgeries, we can do microTESEs to find sperm, or there is IVF and ICSI and I would say in the past periods what’s probably happened is people are getting much, much, much better at the outcomes when it comes to IVF, but, you know, that would be a discussion you would have with your local, you know, reproductive endocrinologist before you kind of went out that path, but I don’t think its the end of the road for you guys, you know, at least from what little I know, I would say that’s not the case.

Jonathan Boldt – Okay.  That sounds good and also I can go ahead if you have…

Kristen Darcy – Go ahead.  Keep going, Jonathan.  You have something else to ask?

Jonathan Boldt – Okay.  Yes.  So…  You know, as a journalist, sometimes you like to pretend like we know everything, but…

Dr. Jamin Brahmbhatt – As a doctor sometimes I pretend to act like I know everything, so…  (Laughter)

Jonathan Boldt – So, when I started to write a book, I knew I have no authority or expertise on infertility at all except for the emotional side of what we went through and so one thing I thought was really interesting is since I have written it, its…, literally its all just the things, the conversations I wish I could have with people when they say the dumbest things to you about not having kids yet or why have you done this, have you done that, and you know, just getting the frustration of those out and so I…, I talked to a friend about it who also has some fertility stuff and so that’s how we got together about it and one thing I have been fascinated with is everybody that reads it, its like they identify with 99% of it and the emotional response received from the guys that you talk to is that pretty much they think they are alone, but everyone’s kind of going through the same thing and dealing with the same issues.

Dr. Jamin Brahmbhatt – Yeah, I mean, they do feel like they are alone and that’s why I…, I know you use a lot of humor which is good, you know, to kind of break down those barriers because overall society, you know, and…, and…, and a lot of people just look on Facebook and…, and see pictures of people’s kids and everyone is happy on social media and…, and…., and then they have to be in this room where they can’t post pictures of their kids, you know, or Mother’s Day or Father’s Day, all these commercial holidays that have been created really take a big emotional, you know, turmoil on them and then, you know, its guys, most guys don’t like to be honest about their feelings and I applaud you for, you know, looking into this matter and…, and publishing your book where it makes guys feel like, “Hey, you know what?  I am not alone in this journey,” but the eggs, its…, you know, it just sucks, also as guys just really don’t do a good job being honest with each other.

Jonathan Boldt – That’s very true.

Kristen Darcy – Thank you so much.  I think the humor is a way, of course, to bridge this conversation, but what I have found…, and this is Kristen, what I have found with my, you know, coaching practice is that once the gentleman is aloud or given permission to share his feelings in a way that they feel safe or a way that they can, then its like the flood gates come out, but its not until either like, what you said, either they are forced or they are at the end of the rope.  You know that they will do that.  So, I am so grateful, you know, that Jonathan did share his story with…, with such a way of…, of…, of breaking down that barrier so people can talk.  You know, one of the things that I still chuckle about is when you talk about, you know, the…, the…, the compartmentalizing of everything and how, you…, you know, you and Steve talk about how you have to go and close the box and put that box away and then get the other box out.  You know, if you really want some…, a male effect and you can correct me, Jonathan, if this isn’t right.  You know, if you really want a male to talk about it, you have to give them the opportunity to go get that infertility box out and open it up.  So, I…, I just love that story that you shared.

Jonathan Boldt – Yeah.  Usually, we put that one on the bottom shelves in the back.  So, we don’t even like to get that box out very often.

Kristen Darcy – No.  Its pretty dusty, isn’t it?

Jonathan Boldt – Yeah.

Kristen Darcy – Yeah.  Well, thank you, Jonathan.  I did…  I know Sara is on the line and I…, I am so excited for her to talk a little about what she is doing and…, and ask her questions.  So, hi, Sara.

Sara Naab – Hi!  Its so fun to be all back with everybody.  I have missed you guys.

Kristen Darcy – I know.  This is great, like midway through to June, we get to…, you know, we get to talk again.  So, good to hear your voice.

Sara Naab – Yeah.  So, you know, this…, I think this conversation about guys having faith to talk about stuff is…, is kind of an important one because, you know, I have seen that too on…, on Don’t Cook Your Balls.  We have really had an explosion of men coming there to pose questions and things because its anonymous and…, and its a safe place to do it and I think…, I think we should continue to create safe places to allow men to…, to…, to share things and, you know, I really love what…, what doctor is doing with it, with the Drive 4 Health.  You know, its an another way of making a safe place.  So, I am just…., I am really excited about all the new developments to make medicine and help more accessible to men.  So, one of the things that, you know, I actually see quite a bit of on…, on Don’t Cook Your Balls is just really one-o-one, understanding the semen analysis.  I think people walk away sometimes and they don’t want to like look like they don’t understand something and so they’ll…, they’ll walk away with it and they have no idea what they are looking at when they are looking at it and they come on to…, on to the site and I mean, thousands of people ask, you know, what does this semen analysis mean.  So, I was wondering, Dr. Brahm, if you have tips that you have used with people that you can then share to help people kind of understand what their semen analysis results even mean.

Dr. Jamin Brahmbhatt – Yeah, I would say that the most awkward part of my day is telling them, “Hey, here’s the cup.  Can you go masturbate in it and you can’t use lubrication and you are going to be stuck in a little closet until you can get it done.”  So, it definitely…, I definitely need some humor when I am explaining it, Jonathan, and I am sure you have done several in your time, but, you know, all joking aside, the semen analysis is, I would say, the first test that most men get done to evaluate their…, the health of their sperm and then from there you go and take million other branches to exactly figure out what’s causing the infertility and what essentially happens is, you…, you masturbate into a cup and then the technician will take samples of the sperm, put it under a microscope and then just count.  They don’t look at everything.  They just basically extrapolate based on a few areas that they look at the numbers and from that you get this big, long list of…, of things and I basically just look at a few things.

Dr. Jamin Brahmbhatt – The first thing I look at is how many are in there.  Then, I look at the….  So, first, I look at the volume, how much you actually ejaculated, how many total sperm are actually in there, how many of those sperm are moving, and how many of those look normal.  So, basically we are looking at the volume, the…, the count, the motility, and the morphology and based on what we see there, you know, that may trigger us, you know, saying like okay, this is what’s going on, you don’t have enough, or not enough are moving, or you have morphology issues.  There are some things that people look at, but I don’t think it has much clinical utility for me.  You know, it has utility from a research standpoint or a rare…, if he has something rare going on standpoint and then we will kind of look, delve much…, much more into it, but I basically just look at those four things when I am initially starting.  Important thing to remember is, you need at least two semen analyses because you can have variations based on what you are doing.  I mean, if you have had sex with your wife 10 times and then do a semen analysis for me, you are probably not going to have that much in there.  So, we usually ask you to refrain from sexual activity for at least two days before you give us an analysis and then we look at the analysis and then that usually prompts a discussion about, you know, what we should do next.

Sara Naab – Okay.

Dr. Jamin Brahmbhatt – Now, Sara, one thing before I forget is, you know, there is this World Health Organization criteria that was updated back in 2010 and, you know, its a great thing that we use to basically use cutoffs for what’s normal and not normal, but if you look at how those numbers are found and all that stuff, there’s a lot of variation that could occur.  So, I had guys with very few sperm counts that have had multiple children and I had guys with very high sperm counts that have had no children.  So, take the grade test to start off with, but its not the end all, be all in terms of diagnosing on what’s causing your problem.

Sarah Naab – Thank you for that.  I think that’s an important…, an important point because people that I see can get really stuck on a number that looks abnormal, particularly in cases where they might have lots and lots and lots of sperms, but, you know, kind of a little bit lower motility or little bit lower morphology, you know, and then they are really kind of conflicted about all of this, even…, what this even means and it, you know, can be confusing when you have kind of cases like that.

Dr. Jamin Brahmbhatt – Exactly!  Exactly!  And a lot of people, I mean just to be very frank with you, worry that they don’t make enough ejaculate because they are watching, you know, adult films where they see, you know, mounds and mounds of stuff come out and the reality is, joking aside, you know, that’s…, that’s a rare thing.  So…, so…, so, don’t base what you are doing or how you are doing on what you see in some of those things.

Kristen Darcy – I have…, I have a….  Oh, Sara, I am sorry because I have a question.  So, the sperm that is in the analysis in the ejaculation, how old was that?  Was that a month old?  Was that from what you were doing a month ago or I…, I don’t remember the time frame for that.

Dr. Jamin Brahmbhatt – What do you mean?  Oh, like…, like…, like how long it takes to…, to get to where it is?

Kristen Darcy – Yes.  Yes.  Yes.

Dr. Jamin Brahmbhatt – That’s a great question.  What I…  I just sort of keep it easy for my patients is, whatever you are doing, whatever ejaculate you have today is kind of a sign of what happened about three months ago.  So, if we were to do any interventions on you today, usually it takes a few months for us to actually see it because the life cycle of the whole pathway is, I would say, about three months because the sperm actually had to grow and then they mature in something called the epididymis and once they mature and…, and…, and get their wings to fly, they…, they kind of get stored into the vas deferens and they travel into the seminal vesicles and then you see it out in your ejaculate and actually, you know, what you see come out is not…, sperm is only 10% or 20% of that.  The rest is just fluids and nutrients that are necessary to keep it viable, but yes, its usually I would say about a three-month process to get to where it is today.

Kristen Darcy – So, its a three-month-old selfie (laughter) from what you are doing with in your lifestyle and its reflected in your overall health and your sperm.  See that’s important because if you remember old things back, “Oh, I was on a vacation and…, and I was in the hot tub.”  You know, so that was, you know, my reflect there.  Sorry, Sara, I just had that moment come up.

Dr. Jamin Brahmbhatt – You know, its…, its…, you know, that is the case in a lot of cases, but, you know, there could be a few things as well that decrease your sperm count and…, and how much you are putting out, whether its new medications, if you had a stress in your life, or if you had a recent surgery in your urethra or your prostate.  So, 99.9% of the time the answer I give is, true, but then there are other rare cases and, you know, medicine is…, is more an art and its a very dynamic thing.  So, a lot of what we say may not account to you or whoever is listening, so….

Sara Naab – That’s great!  That’s…, that’s great!  You know, I love…, I just love the way you kind of  break it down and make it…, make it simple.  So, I wanted to like…  So, another question that we get a lot or that I see a lot is, you know, guys have a common thing that they get diagnosed with is a varicocele which is a mouthful in and of itself, but a lot of guys have them, lot of guys get them and lot of the times they are not…, they don’t cause any problems and/or, you know, issues and then sometimes they do and so I am wondering if you have kind of criteria that you use to work through, you know, what…, when is it a good idea to try to treat the varicocele and…, and when is it not really the best idea?

Dr. Jamin Brahmbhatt – Yeah.  So, you know, varicoceles are basically big veins.  So, the best way to describe to my patients is just like the veins you may see on someone’s legs, but these are around your balls and your testicles and your testicles are very sensitive.  So, as guys really are very sensitive, our testicles are even more sensitive.  They like to be in a certain temperature in a certain location, doing certain things and that’s it.  They don’t want any other influences or any other things around them bothering them because they just want to focus on sperm production.  So, when you have these varicoceles, there are a lot of theories on what it does.  One of the things that it does do is alter the temperature in that area and can create a sense of like, what we call oxidative stress and that can be to the fact you are not being able to optimally produce sperm.  We don’t operate on every varicocele because the smaller varicoceles…  There are different types of varicoceles, grade 1, grade 2, grade 3; there is palpable, nonpalpable; there are ones that are just found on ultrasounds.  The ones we usually operate on are the ones that are causing problems in people’s lives.  So, you know because I specialize in chronic groin and testicular pain, I…, I may have a guy that doesn’t come in for fertility, just comes in with these huge varicoceles that’s causing him some pain and discomfort, but in most cases, guys don’t even know they have these varicoceles.  They get diagnosed with an abnormal semen analysis.  We do an exam where we are like, woah, you’ve got varicoceles either on the exam and then sometimes its confirmed on ultrasound and then we may decide to treat it, but we only really treat it if in most cases it is palpable or really visual, if there is documented infertility and if…, if there is an abnormal semen analysis, so not all of them get…, get fixed and not all of them need to be fixed.  So, its more of a discussion you have based on what you find and what you see.

Sara Naab – Yeah.  That’s great.  That’s a great…  That…, that clarifies.  I did see that some guys have posted that thing, do have an impact on their testosterone.  So, do you see that often as varicocele scan impact testosterone production as well?

Dr. Jamin Brahmbhatt – Well, they can because again, the factories are related.  So, your…, your…, you’ve got these two wheels in your testicle where the sperm grow or born, grow and mature and then you have these other cells and there where your testosterone is made.  So, they kind of work hand in hand.  So, yes, there.., there is the possibility that the alteration in temperature will affect the overall factory.  So, it may affect the testosterone production as well.  So, but again, just like semen analyses, I have guys with really low testosterone that…, that you just find, have no symptoms and guys with high testosterones that…, that may have a lot of symptoms.  So, its just…, there is a lot of variance, but one thing I forgot to mention is, when you fix varicoceles and they are fixed for the right reasons, there is a significant increase in fertility rates and pregnancy rates in the couples.  So, there are multiple studies showing that freeing these things if they are in there leads to higher rates of pregnancy and live births.  So, its…, its…, its a great thing, but at the same time, you know, you…, you fix a…, you see the doctor, you get scheduled for surgery, you fix the varicocele, you go through the process, you know, you may have potentially delayed normal semen analysis for three, six, nine months depending on how you react to it.  So, we have to take into account the partner’s age as well.  So, you have to always ask like how old is your partner because if there are certain things going on with the partner as well or age is limitation, you know, then something like IVF is probably the best option, but again this is more a deep discussion you have with your infertility specialist in the office before you jump to anything.

Sara Naab – Yeah.  Some of the other urologists that I…, that I hang out with have all been using the phrase, you know, that…, that they have been making as a team sport and you…, you really do need to consider, you know, call everybody on the team when you are…, when you are trying to make decisions about treatment.

Kristen Darcy – I…, I have a question about that.  How…  If…, if you are a gentleman or a man listening to this and we are talking about the varicocele, which, you know, you’ve got, we…, we normally do when we are together, what are some ways that a man might be aware of that, you know, self-exam or what are some of the symptoms of a varicocele?  I know you mentioned pain, but what are some of the other things that a man would probably go, “Oh, my gosh, this might be what’s going on with me?”

Dr. Jamin Brahmbhatt – But most…, most varicoceles don’t cause pain.  I mean that’s very…

Kristen Darcy – Okay.

Dr. Jamin Brahmbhatt – Its a rare subpopulation of these where they may be so big that they may, but most…, most don’t cause pain but, you know, you should as a guy, regardless of the fertility status, be examining your testicles once a month.  You’ve really got to know the anatomy down there, what it feels like, because you should be self-screening for testicular cancer every single month in the testicles.  Now, from there, if around the testicles, you know, if you have grade 3 varcicocele, you will see it looks like snakes around it or you may feel like snakes around your actual testicle and, you know, that in a lot of cases is varicocele.  So, I mean its one of those things where if you have it, you will know it and if you want to know what it looks like, you can always go on to Dr. Google and…, and find images but just don’t do it on a plane or in front of a thousand people.

Kristen Darcy – Yeah.  Yeah.  Yeah.

Kristen Darcy – Or in a restaurant or….

Dr. Jamin Brahmbhatt – Exactly!

Kristen Darcy – Yeah.  I was posting an article about that and one of my friends called me and said, your darn penis thing showed up on my Facebook page.

Oh, my God!

Kristen Darcy – So, yeah, Dr. Google, you have to be careful when you are…, when you are detailing the stuff out.  Sara, did you have a followup question?

Sara Naab – I did.  Well, I…, you know, its kind of a tangential question, but, you know, doctor, you know, specializes in…, and this is just to toot your horn a little bit.  You are just world renowned in…, in treating testicular pain and…, and so I was wondering, you know, if you see correlation besides varicoceles, do you see correlations between guys that have testicular pain and…, and infertility?

Dr. Jamin Brahmbhatt – You…  I would say there…, there probably is a cause that we may see little bit more research on…, to kind of say affirmatively yes.  There is a direct relation, but if you just think about it in general, a lot of these testicular pain guys are either on some form of chronic medications and they have a lot of stressors in their life.  So, when you put both of those together, I mean yes, they may have some issues and a lot of them can’t even have sex, I mean because they are…, they are in so much pain.  They are just miserable.  So, they are not even thinking about having kids or anything like that.  So, you know, there may be some correlation that we’ll…, we’ll know years from now when we, you know, do the…, you know, compile our research on it, but I would say just from a stress and emotional standpoint, yeah, there probably are some issues with infertility related and, you know, testicular pain is a very common problem that not a lot of people like to talk about, just like infertility.  You know, most of our patients will see three or four doctors before they end up coming to see us.  So, if you have testicular pain, please visit our website or go to myballs.com, you know, and educate yourself.  You don’t have to come see us but just know that this is a forum just like this is for men with men that pain that…, where…, where hopefully we will make you feel like that you are not alone.

Shweta Mishra – I do have a followup question, Dr. Brahmbhatt, on this testicular pain.  So, how…, how soon can somebody get…, can know whether they are going through this kind of a pain or something, I mean my question is about the teenagers.  What are the symptoms that they see or they should be looking out for to get to know whether…

Dr. Jamin Brahmbhatt – Well, if any teenager or any male has acute, so all of a sudden pain in their testicles, you have to get yourself to an emergency room because the first thing that we have to rule out is testicular torsion, where the testicle kind of twists on each other.

Shweta Mishra – Okay.

Dr. Jamin Brahmbhatt – Then, in teenagers, some of the most common causes, at least here in the United States, could be sexually transmitted diseases into the testicle.  We diagnose people with chronic testicular pain usually after three months of pain where they have gone through exams and workups and ruled out things such as hernias or tumors or certain causes of pain.  That’s when we would label it and that’s when usually we recommend getting aggressive with management.

Shweta Mishra – Okay.  Yeah.  Thanks.  All right.  Kristen, do you have another question for the doctor?

Kristen Darcy – I do, always.  (Laughter).  Its not a question.  Its more of a conversation, you know, part of what we have been watching is your drop your excuses and the transformation about, you know, you are walking…, you are walking your talk.  You know, you are…, you are doing what you are asking all your patients and clients to do, which is be mindful of yourself and…, and take care of yourself and…, and commit to health and I…, you know, Sara and I just the other day, wow, you know, you are on that cover of that magazine and your…, you guys are looking amazing!

Dr. Jamin Brahmbhatt – Thank you!

Kristen Darcy – So, I…, I just wanted to talk about, you know, how you parlayed this non-profit movement of, you know, Drive 4 Men’s Health and how you took that and now are applying daily to your existence.  So, I think, you know, maybe you could share a little bit about where, you know, drop your…, drop your excuses.

Dr. Jamin Brahmbhatt – Yes.  So, its…, you know, what you realize is, you have…, you are definitely making an impact, but are patients really going to take you seriously if you are overweight yourselves or if they see you out eating fast food and if you are not exercising.  You know, when I tell my fertility patient, you have got to lose weight, are they really going to believe me when I am overweight myself and so, you know, there came…, the revelation came about a year ago when we realized that we definitely had a momentum with the Drive 4 Men’s Health and we were becoming individuals of influence, but we didn’t want to be individuals of hypocrisy.  So, a decision that me and my partner made is, we have to look the look.  We have to start walking the walk and we did and, you know, Sijo, my partner, lost over 50 pounds, I have lost over 30 pounds and it was really for my patients and…, and it was really for my family because I don’t want to be a statistic where I am living 5 years less and not be able to cherish five more years of memories with my children, but more importantly, when I am in that room with my patients now, they listen to me.  If I tell them they need to lose weight, they are like, wow and now I am able to give them better advice on how to do it because I went through all those struggles myself.  So, you know, what started off as, you know, just an idea like the Drive 4 Men’s Health has led to now a global impact, but at the same time a more personal impact on us as individuals as well.  So, its…, its been cool and its hard to keep the weight off men because now you feel like, oh, yeah, I can eat now and its difficult.  (Laughter)

Kristen Darcy – I have to jump in on this because, you know, our CEO did the same…, did the same thing.  So, one of our co-founders, Greg, who was, you know, a little bit overweight and the same thing.  We were going out and yeah, if you lose weight and do all these lifestyle things, you can improve your sperm count and so he decided, I am going to walk the talk and he…, he actually tracked himself over the course of, I am going to say, four months or five months and doubled his sperm count when he…, when he lost his weight.  So, you know, just to say, like, you know, small changes like that really can be a big difference because for some people that doubling of your sperm count is the difference between having a kid and not.

Dr. Jamin Brahmbhatt – Yeah.  Exactly and, you know, some of these technologies that you can use are very expensive, like, you know, an IVF cycle may cost upwards of 20,000 dollars.  If you really need to lose weight and become more active and try more natural approach, then, you know, it could be a free treatment for you, you know.  So, its…, you know, people sometimes don’t think about the economics and the practicality, you know.  They just want solutions, but sometimes patience is a virtue when it comes to these things.

Kristen Darcy – Because your transformation, although it was easy for us to watch your transformation on Facebook and…, and track you from the Drive4…, you know, Drive 4 Men and your amazing transformation to us rapidly, probably not for you, but how many months over the period of time was that?

Dr. Jamin Brahmbhatt – Well, I am about to hit my…, in October, we hit our one-year mark and so it took, you know, the drive…, around the drive time we were eight months and that’s where we were down 50 pounds, 30 pounds.  So, it took almost eight months.  I would say the first three months were the hardest because of lot of changes happening hormonally, emotionally, and…, and physically, but.., but…, but once you start noticing the change and once you start…, once people start encouraging you and they notice the change and then now Facebook has this horrible thing where…, where it reminds you of what you did a year ago…

Kristen Darcy – I know.

Dr. Jamin Brahmbhatt – …and…, and looking, I am like, damn, like, one year ago I looked like that and so now like, I don’t want to look like that again, you know, I want to stay healthy and I want to stay fit and I want to continue to be an example.  So, its…, but its tough.  Its very tough.  Its not easy.  I don’t know how all the professional athletes do it.  Living healthy, especially in my profession when, you know, you can go to all these dinners for free and eat whatever you want and travel and…, its…, its…, its very, very difficult, but at the same time I found that its very easy once you make it a routine habit.

Kristen Darcy – Right.

Dr. Jamin Brahmbhatt – Once you don’t…, don’t think its a chore, it becomes much easier.

Kristen Darcy – Right.  Right.  I think…, I think the whole conversation that you are such a disciple of, you know, it really comes down to choices, right, and I think you are so skilled at giving your clients and your colleagues, because when I call you, you always have choices for me when I need to solve a problem for a client, its about choices and you are choosing everyday to be a role model for your patients and your daughters and your children.

Dr. Jamin Brahmbhatt – Yes.

Kristen Darcy – …and that is like the ripple effect for generational, you know, influence.  So, you know, yayy, the crowd goes wild.

(Laughter)

Dr. Jamin Brahmbhatt – If everything happens with the team, its not, you know…., the thing is all the stuff is just like patients with infertility have a team around them.

Kristen Darcy – Right.

Dr. Jamin Brahmbhatt – We all have teams around us that build us. I think its always a “we” thing…

Kristen Darcy – Right.

Dr. Jamin Brahmbhatt – …and so, you know, we need to have people understand like, if you are a guy out there listening and suffering from this or even if you are a female suffering from this and you find out everything with the guy is…, is okay, you know, you are not going to…, don’t do this alone.  There are these forums online.  There are people like you, Kristen, like…, like you guys out there, that people can go to and there are physicians involved here to help you, you know, get there, but never lose sight of what you want.  You want to be a parent and there are other ways to do it other than what you may be accustomed to.

Shweta Mishra – What your dream was at the beginning.

Kristen Darcy – And you know what, I think that’s such an important thing.  Thank you!

Shweta Mishra – Well, thank you, Kristen.  I think that was a very interesting discussion and let’s…, I think its time now to move on to the listener’s questions.  We have a couple of questions that have been sent in via email.  I will just read it out.  The listener asks, do you believe any food or drug supplements can help improve sperm quality or numbers as claimed by many and the product?

Dr. Jamin Brahmbhatt – That’s a really tough question because I actually do recommend some form of supplement to my patients…

Shweta Mishra – Okay.

Dr. Jamin Brahmbhatt – …if they want.  I always offer it and a lot of it has antioxidant qualities in it, but if you look at the actual research on, its very inconclusive.  So, if you, you know, I think, you know, its kind of like just one more thing that we can add in there.  Even though, you know, there may not be some hard, perfect science for it, all the ingredients are fairly safe and, you know, I think overall its okay to take, but make sure you take something that’s controlled.  A lot of supplements here are not FDA regulated.  So, you got to make sure that what you are taking is really what you are taking.  So, don’t buy things off some random websites.  Try to go somewhere, you know, where it has some certification or, you know, whatever your doctor recommends from a supplementation standpoint.

Shweta Mishra – Okay.  Thank you for answer, doctor.  The other question says, what are antisperm antibodies and how do they affect fertility?  How common is it and why do both of us, me and my wife, need to be tested?  Is there any permanent cure for this?

Dr. Jamin Brahmbhatt – You know, that’s…, that’s a great question, you know.  From last I read, there is no perfect solution to this, but a lot of, you know, couples when they do test positive for this, a lot of them end up just going straightforward with an IVF cycle where they basically bypass everything in the middle and…, and boom, go and…, go for where the sperm gets extraction to the…, the egg.  So, I know there is a lot of…, there is some testing out there that you can get done, etc., etc., but, you know, I actually don’t see many patients that are positive for those in my office because I think they end up just going straightforward with IVF and not…, not spending too much time on other things because the data shows that a lot of these people do…, do best when they move straightforward with that.

Shweta Mishra – Okay.  All right.  Thank you, Dr. Brahmbhatt.  I think so now we have almost reached the end of our scheduled time.  So, its time to wind up now.  Thank you so much for finding time out of the busy schedule to be with us today and you have educated us on so many issues that are not easily talked about and I just love the way you have explained so many things in a very comprehensive way and it was a very informative discussion and I hope it will serve as an useful resource for many other people who are looking out for authentic information on the topic.  Kristen, I thank you for co-hosting with me.  Jonathan, thanks so much for accepting my invitation and, you know, helping us create a very useful resource with your very practical questions and Sara and…, I thank you so much for your insightful questions as well.  Audience, I thank you for your support and we look forward to having you all join us for our next CureTalk on History and Future Initiatives for High-Risk Smoldering Myeloma on Sep 12th at 12:15 p.m.  For more information on the show and other upcoming shows, visit our website www.curetalks.com and you can email at priya@trialx.com.  I would love to hear your feedback about CureTalks on fertility and reproduction, and I would welcome your suggestions on fertility topic that you feel should be covered here on this portal.  Please email your suggestions on shweta@trialx.com.  The link for today’s show will be sent in via email to all the participants and before you call it a day today, please don’t forget to check our details of the America Walks study.  America Walks study is a mobile-based app research study to determine walking behavior of individuals in the United States and the last day to enroll in this study is 30th September, 2016.  You can also find more details about this study at trialx.com/americawalksstudy.  So, until the next show, thank you, everyone. Goodbye!