Why Men’s Fertility Is Declining: The Truth About Testosterone | Dr. Larry Lipshultz

Dr. Gabrielle Lyon: 00:00

Have you ever thought about male fertility as a man's final frontier, not just sperm count or testosterone levels, but how modern life is quietly dismantling men's ability to create life, sustain energy and age? Well, what if everything we thought we knew about male hormones and aging and virility was either outdated or flat wrong. Dr. Larry Lipshultz is one of the most respected male reproductive health experts in the world. For decades, he's been on the front lines of Andrology, working with Olympic athletes aging men and everyday couples struggling to conceive, he doesn't just study testosterone. He wrote the rules for how it is treated. We

Dr. Larry Lipshultz: 00:50

are making such advances in female fertility and IVF, and we have nobody to take care of the men. So a light bulb went off. Is

Dr. Gabrielle Lyon: 01:00

it true that male fertility is declining? For sure, today, he breaks down the real cause of male infertility, the decline how testosterone therapy impacts sperm and what men can do to reclaim performance and purpose from Shocking Truths About how male fertility is tested or often ignored to why some of the most motivated men in the world are secretly burnt out, hopeless or misdiagnosed with depression. Dr Lipshultz exposes the blind spots in modern medicine that are quietly ruining men's lives, and how we fix it. We talk libido, aging, legacy and the emotional weight men often carry in silence. Dr Larry Lipshultz, welcome to the show. Thank you so much. I am very excited to have you on, and I want to tell you why. Why right now, when? Well, for many reasons, but right now, when people hear Men's Health, what they often think about is testosterone. However, what I have learned from you is there's so much more to men's health, and you have been an innovator when it comes to many things, whether it's environmental, infertility, erectile dysfunction. But I want to start with infertility, and I wonder a little bit, a little bit about your background, because at the time, I'm not so sure it was even a field male infertility.

Sp

Dr. Larry Lipshultz: 02:29

Well, the whole thing wasn't a field. But should we go back to when this whole thing started? Yes, so we go back to when I was an intern at the University of Pennsylvania, and I was rotating on OB GYN, and they had grand rounds like all specialty. And I was sitting there, and they had a lecturer, a PhD from New York, whose basic science research was on sperm, and, of course, was OBGYN. It was appropriate. And he started talking. It was fascinating, things I never even thought about. And at the end, the chairman, who was very early in the IVF world, said, you know, that is such a fascinating lecture. He said, we are making such advances in female fertility and IVF, and we have nobody to take care of the men, right? So a light bulb went off. Hey, I'm an intern. I'm starting my residency. No one's doing infertility. What a great entree into an area that's been basically untouched.

Dr. Gabrielle Lyon: 03:27

Were you doing a residency? Was it obviously Urology at the time, or was

Dr. Larry Lipshultz: 03:33

it? No, it was the so then your PGY one year was called an internship, and then you went into your but you were already in the residency program. So I was in the urology program.

Dr. Gabrielle Lyon: 03:46

You heard about this male infertility. You thought it was amazing, very interesting. But you were only PJ PGY one, right? How did you then go on to create, arguably, the first fellowship?

Dr. Larry Lipshultz: 03:59

Well, the fellowships, way later, the thing we had to first create was the area, the focus. I mean, there was zero focus. So in my program, we did PGY one. PGY two was a research was a clinical year. PGY three went into the lab. So I had one whole year, and I decided I was going to devote that year to learning all I could about male infertility. So there were two urologists in New York who were doing nothing but fixing varicose veins in men's around men's testicles, because that was felt to cause infertility, overheat the testicle, etc. So when I went up and spend a day or two with them and realize it was very narrow. I then spent another day with a man in New York who was focused on anti sperm antibodies, which was hot at the time. Is it now? No, but it was then. But the whole idea was I was opening up all these doors, all these boxes of. Information I didn't even know existed. So I got back to Penn, and this is my research year, and I started setting up a lab to do semen analysis. They did not have a lab. So my good friend, What year was this ballpark? I'm saying mid 70s, 70s. So a good friend of mine was then the next to the top of the program, and he allowed me to use his nurse one week, one day a week, and I ran, started a clinic, wow. And I would and we would develop she, I taught her how to do semen analysis. So she, as an RN, had the job of doing a semen analysis, and since I was just fledgling, but yet, the only person in the city, I started seeing men with fertility problems as a resident.

Dr. Gabrielle Lyon: 05:52

Wow. So you almost had your own clinic. I did have my own clinic, but

Dr. Larry Lipshultz: 05:56

I had to build everything under my friend because I was a resident. But the point was I started learning as I was seeing these people, because each patient I learned something from, and that was the beginning of it. And so by the time I became a chief resident, I did have my own clinic, and I would admit people to the hospital under my friend who was a urology staff member, and we would operate on these people, because no one else knew what to do. It was a great, fascinating time.

Dr. Gabrielle Lyon: 06:24

Did you the landscape was when someone was struggling to get pregnant? It was really they were focused on women, IVF and women? Is that? Is that correct? Yes, there were, from what I am understanding, no clinics, no specialty focused on men and infertility, correct?

Dr. Larry Lipshultz: 06:43

Wow. And you say, wow. Think about how long ago that is, and we're still struggling with getting to see the male patients. It's crazy. What do you mean by that? By you know, as IVF has become gigantic, and with venture capital, and whatever the move is to get the couples into IVF programs, ostensib, obviously infertile couples, and to take them through the journey of IVF. And if the husband had sperm, any that couple was with the IVF program until they released the patient to us because we did not have the we don't, right now, have the control. Now, going back to when it all started, the women would go to the gynecologist, the gynecologist would send the man to us. So it was a much different paradigm of how the infertility was approached, I think it was much better, because the men got better care. And pushback from

Dr. Gabrielle Lyon: 07:48

whoever. What were they thinking? Oh, here's Dr lip Schultz. He's kind of crazy. He's back then. Yeah,

Dr. Larry Lipshultz: 07:53

no. Pushback. Very supportive, because all the OB GYN who were in the field realized there was a need. I mean, they knew there was a need. There still is a need. But the thing that changed was the ability to offer couples fertility care, ie, IVF, with very few sperm. Remember, you only need one sperm for each egg that that woman produces. And then in the 90s, it was discovered that you could actually extract sperm from the testicle and use those sperm and inject a sperm into an egg and get a pregnancy. So then the number needed went way down, even to zero, because we could go in and extract the sperm. How

Dr. Gabrielle Lyon: 08:38

has infertility changed in terms of now versus then. And I'm gonna ask this question differently. Is it true that male fertility is declining,

Dr. Larry Lipshultz: 08:50

for sure? So if you look at the data, I mean, and most of the data, for some reason, goes from 2000 to 220, or from 1980 it doesn't go like go back to 1950 1960 but even if you just look 1980 to now, 50% drop, 50% 50% drop in sperm density. And it's like, it's not just the US, it's Denmark, it's Finland, it's Israel. These studies are like all consistent. It is frightening.

Dr. Gabrielle Lyon: 09:26

Why do you think that is

Dr. Larry Lipshultz: 09:29

I think there's a host of reasons. I mean, people are not taking care of themselves the way they should. There's an increase in obesity, increase the use of illicit drugs, theirs, and, of course, you cannot ignore the environmental factors, which, you know, all these, you know, there's environmental chemicals. There's plasticized. I mean, there's a chemical. I think it's either a phthalate or ethylene dibromo I don't remember which one that's used to soften up a. Uh, plastics. When people talk about not using plastic bottles, it leaches out of the plastic bottles. So it's but it's essential to make the plastic bottles. But on the other hand, it can be an estrogen mimic. So you've heard of estrogen mimics? Of course, yes. So that is the problem with a lot of these chemicals, is they mimic estrogen, which is counterproductive to sperm production. And I think that's kind of globally what we see.

Dr. Gabrielle Lyon: 10:26

Because when you had mentioned these other countries, the US, we know that we have a massive obesity problem, right? But Denmark and some of these other countries, they seem to be very fit and not necessarily nearly as overweight or sedentary, right?

Dr. Larry Lipshultz: 10:40

So we can check off no obesity, but we're left with everything else. We're left with all the estrogen mimics in the environment. They may be worse over there. I mean, I don't know. I don't know anything about what they do culturally, but they may have some habits that are actually not productive for a helping sperm. I don't know. But, I mean, there are so many things like, remember, sperm are being produced millions and millions a day, and anything that's produced so rapidly is more susceptible to environmental factors because the cells are dividing. It's the same thing with like, red blood cells, white blood cells, and people getting chemotherapy, you know, and a taxi is reproducing, rapidly reproducing cells.

Dr. Gabrielle Lyon: 11:26

I mean, that's that's very fascinating. When you do, you remember when you first really thought about environmental factors? Because I remember, not even too long ago, people would make fun of that idea. Oh, come on, it's not plastic doesn't create estrogenic activity, right? I'm I, again, I don't know if you were so exposed to that, because you really have had a academic legacy. No, but I'll

Dr. Larry Lipshultz: 11:53

tell you how it happened. Yeah, it's very interesting. I got contacted in the early 70s because two very large chemical companies were producing a pesticide, a soil fumigant that they found was sterilizing the workers who were making it in the plant, sterilizing, sterilizing, zero sperm. Wow. So I went out and to California where it was identified, and got involved as an expert for the defense, which were these two or three large companies who were making this. And what we found out was, indeed, the men on the assembly line who were literally handling it or breathing it by either skin absorption or inhalation, were sterile, and it was a big, a big trial out in California, very exciting, because it's a very famous courtroom. And anyway, so obviously the men won. I mean, it was a lawsuit. It was settled. But then going forward, the plaintiff attorneys got wind of this. Oh, well, if the guys there are getting exposed, how about the men who were applying it in the fields all over Central America, in the banana crops and the pineapple crops, because it was a soil fumigant. So then we started these lawsuits, massive lawsuits, and unbelievable. It's still going on today. We are still examining men for a lawsuit from a Central American country. These men are now 6060, and they're complaining about inability to have children. When you go back to when they were in their reproductive years, fully sterile. No, they're not. This is the issue they because they're now pulling these men out who just have a history of, yes, I worked on this Banana Farm. Yes, I had difficulty having kids. Was I really exposed to something? Were they really exposed? Because, don't forget, you know, a large 2% of the world's population are sterile. Male population, naturally, naturally, well, you know, not because of external whatever, yes, not Yes, more naturally than something like exposure to a specific pesticide. And when

Dr. Gabrielle Lyon: 14:13

you say sterile, does that mean they still produce sperm, but fragmented, or something

Dr. Larry Lipshultz: 14:17

like, no? I mean they have no sperm in the ejaculate, okay? And maybe some of them, we can go in and find little pockets of sperm in the testis, but they could not naturally have a baby. 2% of the population, yeah, male population. So here you come up with the positive aspect of IVF, because now we can go and some of these men extract sperm from the testicle. Give it to the IVF programs. They can inject it into the eggs. And

Dr. Gabrielle Lyon: 14:46

they called you. Yes, they called you, and they did. They say, was the experience? Was it a known entity at the time? Meaning that was one environmental factor in the 70s? Were there others? Well, if. Aware

Dr. Larry Lipshultz: 15:00

I was, I don't think I was involved with any others directly, because this was known, because it had been demonstrated in the factory workers and the plaintiff attorneys were gathering these sugar cane workers, but not at crop workers, to do these class action suits. So there was a tremendous amount of work to be done just on the one chemical. So I don't really think maybe I got involved with the second one, but I don't remember nothing like

Dr. Gabrielle Lyon: 15:28

this. How do you think about that for the modern day? Now we probably have more chemicals. We're trying to make things easier where we have a bigger population, that means we're mass producing foods, right? How do you think about fertility now and just the environmental exposures? Yes,

Dr. Larry Lipshultz: 15:45

of course, it's a factor. I just wish that there were more people looking at what's doing it. But you know, we go back to our initial discussion, they don't care about the men.

Dr. Gabrielle Lyon: 15:56

You know, only when the women fail well

Dr. Larry Lipshultz: 16:00

and only when they present with xerosperm, then they call us. So I just think there's not enough focus on the why, and not enough basic research on the why. It's interesting. But I have a former fellow who is at Stanford, Mike Eisenberg, his whole career, since he left me, primarily research wise, has been devoted to looking at fertility in males as a metric of men's health. I think it's a great idea, but his publications have been groundbreaking. Increase cancer, increase all types of health issues, increased mortality in men who have no sperm, wow, and he could only follow them for, you know, eight years, 10 years. But it's really frightening.

Dr. Gabrielle Lyon: 16:52

Where do you start when you talk to patients about the the infertility problem when it comes to environmental exposure? So someone is coming to you, they're young, they're 30, they can't the wife checks out. How do you then go about approaching all of the is it just environment? Is it? What are the domains? Well, see,

Dr. Larry Lipshultz: 17:14

you can't, because there's no test. There's no specific test. I think most important is, what does the man do? I mean, you know, if he is a lawyer, he's unlikely to be over exposed to toxins that are not the same with somebody who you know is working in we have huge chemical plants all around Houston. I see a lot of these guys. Wow.

Dr. Gabrielle Lyon: 17:37

So there's the chemical plants. What about there's the petroleum

Dr. Larry Lipshultz: 17:40

plants, you know, because we do, we have so many refineries, but there's no real, no one has really gone into these places and done these type of studies that they did back when we were looking at the chemicals in California. And certainly it should be done, but it's very litigious. You know, potentially no one wants to get I don't think anybody wants to really go there. So how do people

Dr. Gabrielle Lyon: 18:06

protect themselves now? Do you say don't drink out of water bottles, don't heat plastic? Have you thought about what we need to do? Just

Dr. Larry Lipshultz: 18:16

thought about it. It's just onerous. I mean, how do you how do you tell people to not drink out of plastic bottles? When every time you ask for a bottle of water, or you ask for water, you got a plastic bottle, right? Yeah. I mean, I don't think we can go back. I'm not sure. I just don't I mean, do you think we could go back? What are we going to do to all the people who need water?

Dr. Gabrielle Lyon: 18:38

I think it's a really important discussion. You know, we I have a, by the way, I have a clinic. I don't know if you know that, but I still see patients, and one of the things that we do is we do environmental testing right in their blood and their urine, right?

Dr. Larry Lipshultz: 18:51

Well, we're gonna have to talk about that, because I don't even know where to send it. Yeah, I

Dr. Gabrielle Lyon: 18:57

Well, I can certainly help with that. But then the question is, what, you know, there are things like Agent Orange. So once it's in the body, what are you going to do? So you're going to try to chelate it, right? But it becomes very challenging. And then if it's at this level that it's so we don't even know if

Dr. Larry Lipshultz: 19:13

that's what's causing the man's fertility, that's right. So we another whole area that we're just starting to look at is changes in their genome, genetic changes in men that may be causing problems with fertility and epigenetic changes. So the fellow who runs our lab also has an NIH grant to look at genetics of infertility. So if I see somebody now who has no sperm or hardly any sperm. We send over a blood sample, and he'll do their entire genome.

Dr. Gabrielle Lyon: 19:45

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Dr. Larry Lipshultz: 21:37

but you get so many blips of abnormalities. It's now like which one's really important. So that's a big job, when you look at this whole genome, to figure out which of the there's a list of infertility genes that's been published. And I don't I think there's 140 so certainly that's the low hanging fruit. Do they have any of those? But

Dr. Gabrielle Lyon: 21:58

it doesn't make sense if it is true that male infertility is declining by 50% since when, since the 80s. I'm looking at the 80s, and that is drastic and tremendous. So

Dr. Larry Lipshultz: 22:11

no doubt you have to differentiate and differentiate between male fertility decreasing. We're talking about semen quality decreasing, right? It's just numbers of sperm. So is a man going to have infertility problems if his normally 100 million goes to 50 million? No. So the fact that these counts are dropping by 50% does not mean these men are ever going to show up in my office. It's just a metric of their health, right? Which is fascinating. It is fascinating, but it's not necessarily the reason one of the couples sitting in front of me,

Dr. Gabrielle Lyon: 22:47

what percent do you think? And I know you only see men, and this is probably a very difficult question, what percent is the woman typically versus the man? So,

Dr. Larry Lipshultz: 22:56

and I have this is like one of my early slides when I give a talk. So the male just by himself 30% of the time, the woman just by herself, 50% of the time, and another 20% it's both of them. So half the time the male should be evaluated,

Dr. Gabrielle Lyon: 23:18

and it's not standard of care right now. Is that true, correct? Is there a amount of time, so if someone is listening to this, am I gonna

Dr. Larry Lipshultz: 23:24

get in a lot of trouble with a gynecologist, per se? No, we love our gynecologist.

Dr. Gabrielle Lyon: 23:28

Besides, you guys are looking we're looking at different things. And also the at the end of the day, people want families, right? And if they have environmental exposures, and honestly, I don't know the answer to what to do about it, but it is, you know, I worry about my kids, yes, but

Dr. Larry Lipshultz: 23:45

you do. I mean, you do focus on on those type of healthy I do, and you measure things, and I think that's working to you. But what? But what more can you do other than looking scientifically at what's going on with the individual right now, it's important to just gather data and look

Dr. Gabrielle Lyon: 24:02

but then you think about things in terms of, for example, receipts, transactional receipts, these all have chemicals on them. They're the amount of exposure that we have is tremendous. And then the other question is, what are we doing to offset that? And I don't, I mean, you have to be really diligent. Is it that you have to sauna? Do you? I mean, you have to get rid of these toxins to the best of one's ability. Do they have to go to the bathroom and have good digestion? I mean, we have to be able to process it right? I think it's a real it's a real challenge. I

Dr. Larry Lipshultz: 24:38

know it is. It's a huge challenge, and we're just scratching the surface of what these things are that are unhealthy.

Dr. Gabrielle Lyon: 24:46

There is the fertility aspect, which you define is infertility? What is the definition of infertility?

Dr. Larry Lipshultz: 24:52

It's a couple that's a couple related phenomena. It's a couple who have tried for one year to establish a prep. Pregnancy with unprotected intercourse, and nothing has happened, or if the woman's over 35 six months, okay? And I cannot tell you how many women I see as I'm seeing their husbands. The women are there. They're 41 they're 42 and it's tragic because no one is talking to these women about the fact that they've got to think about maybe freezing eggs, or if they're professional something, because after 35 it's not like their 35th birthday, something happens, but there's a gradual decline in egg quality, and the guy can be borderline, and if his wife is 21 he may never have a problem. If she's 41 they're going to show up.

Dr. Gabrielle Lyon: 25:46

How does someone address sperm quality? For example, what are the things that a man could do to improve their sperm quality?

Dr. Larry Lipshultz: 25:55

Number one, get tested. Because if there's nothing wrong, don't worry about

Dr. Gabrielle Lyon: 25:58

it. Number should they be looking for, and who do they they go to a they

Dr. Larry Lipshultz: 26:02

go to a urologist, they go to their primary care doctor. We do not sperm tests. So let me tell you what happens they they go to the primary care doctor. He sends them to an IVF program, knee jerk. The IVF program does his semen analysis. If it's low, the couple are shunted, I'm not saying every IBM, but in general, they are shunted into IVF. Because if you're selling Cadillacs, who comes comes, somebody comes into your showroom, you're not going to sell them a Ford or even a Mercedes. You're only going to sell the Cadillac. And that's what happens using our IVF programs as a clearinghouse for semen quality.

Dr. Gabrielle Lyon: 26:44

What would you like to see happen?

Dr. Larry Lipshultz: 26:47

I would like to see more patients referred to their urologist. Don't have to be a specialized urologist. Any urologist knows how to get a semen analysis and then how to triage the patient?

Dr. Gabrielle Lyon: 27:02

Would it be safe to say that? I mean, a woman could go through IVF and that would be, I mean, that seems like it's really difficult, as opposed to a man getting a semen analysis and then treating it from the male perspective, right?

Dr. Larry Lipshultz: 27:19

But the thing about it is, and I have to be honest, and that is, the the IVF programs can actually do something for everybody in that way. In other words, they can offer the couple the ability to at least put the sperm into the eggs, get embryos, but we don't. We can't treat a lot of the men we see, even though we identify the fact that they're not normal, but you know, we have to the message is, if a man is not normal, he's at health risk for other things. So at least get tested. Maybe you're not going to get cured, but you're going to know you have an issue. Because, you know, when we do our gene sequencing, we also look for what we call actionable abnormalities, things that the man we may pick up like a predilection to have cancer or a predilection to get diabetes. We pick these up in their gene screening. Wow, and then it changes the way that man gets treated in his subsequent, you know, years of of health. And don't forget, these guys are usually young, so it's better to know early than to know late. Is,

Dr. Gabrielle Lyon: 28:30

do you think that that could become a standard practice? No,

Dr. Larry Lipshultz: 28:35

it's too expensive. But I can tell you there, I've seen movements in some cities and some countries to use a semen analysis as a screening tool for a man's health.

Dr. Gabrielle Lyon: 28:45

I mean, that is, that's an incredible and

28:48

it's painless, you know,

Dr. Gabrielle Lyon: 28:52

I don't know, but anyway, but the other question is, you said that sperm are produced very quickly, very often, that would make it sensitive to both environmental exposures, but also sensitive to positive things like well, but exercise potentially, exactly.

Dr. Larry Lipshultz: 29:13

But if, if somebody comes to me and I identify a problem and I treat it, we're not going to see an overall new community of sperm for three months. That's how long it takes a sperm to get from the baby sperm in the testicle into the ejaculate. So

Dr. Gabrielle Lyon: 29:34

if I think about there's the good the good diet, nutrition. Do we know, does diet and nutrition impact sperm quality? And when you talk about quality, are you talking about how fast it moves? What? What are the things I'm talking

Dr. Larry Lipshultz: 29:50

about its ability to actually penetrate the egg and make a baby? And we do know that oxidative stress is bad. Oxidative in. Increase oxidants in the individual can cause increased breakage in their DNA. DNA fragmentation causes poor fertilization, increased miscarriages. So, yes, there are things that you can do, and I'm sure you know how to treat excess oxidants in the individual. I mean, are

Dr. Gabrielle Lyon: 30:20

there Yes? And are there supplements and things that you think have good evidence when you when you sit down with a individual and you say, You know what, I need to improve your sperm quality, or we need to do that, what are the domains and what are the things that you recommend that have good scientific evidence?

Dr. Larry Lipshultz: 30:36

So number one, don't get into hot tubs, really? Yeah, you're

Dr. Gabrielle Lyon: 30:44

looking at me like I should know that. Well, I mean, I don't know if it's fake news or what. No,

Dr. Larry Lipshultz: 30:48

it's increased heat to the testicle hurt, sperm production. Now, saunas, they're okay. You're not applying it, but hot water, you are applying it. So if I want to try to optimize everything, stay away from direct heat. No hot tubs, no baths. Well, I mean, a warm bath is not going to hurt anything. Take showers, stay clean. But I mean, you know, we know that heat is bad. That's why the testicles are outside the body, right? Because they're kept at a lower temperature. What about cold plunging. You know, there's no data on it yet. I don't know. I could never do it. I mean, the idea is just what it's a blast, I know, but every but everybody's doing it now, I know, but you're not concerned about Well, I mean, I think we need to look at the data. It could be bad. It could be a shock, right?

Dr. Gabrielle Lyon: 31:40

What about drugs? Drugs, cannabis, use, alcohol, bad, bad, bad.

Dr. Larry Lipshultz: 31:46

Alcohol in moderation, I don't think is bad. The other stuff, we don't have a no effect level. So I would say, if you're trying to have a baby, stay away from drugs. Well, stay away anyway. But I mean, it really becomes important when you're trying to

Dr. Gabrielle Lyon: 32:03

have a baby, so you are not a fan of marijuana. It just seems that everybody's using cannabis nowadays. I mean, again, everybody might be a really large statement, but people are always talking about how it's good for this or that. What's it good for? I mean, because I don't know. I mean, from my perspective, I don't recommend it. I don't think it's a great choice. I don't care how you're getting it right, but I do know that people seem to like it and use it right.

Dr. Larry Lipshultz: 32:32

I actually do not see a lot of people who are using cannabis. You don't know. I don't think it's a big thing in Houston. I think maybe it's more bi coastal, East Coast, West Coast. I don't, at least in the patients I see, I don't see a lot of it, or they're not telling me, but, you know, they're usually pretty honest.

Dr. Gabrielle Lyon: 32:50

Do are there certain kind of supplements you recommend? Would it be glutathione or vitamin C? Do we have data for they're

Dr. Larry Lipshultz: 32:56

both good. There are studies showing that the use of antioxidants can improve semen quality. Wow. So, I mean, why not, right? Why not use them? So we tried to make one. So we have one called,

Dr. Gabrielle Lyon: 33:10

you did? You didn't even bring me any, not that I but still,

Dr. Larry Lipshultz: 33:14

no, but it just consists of a lot of antioxidants.

Dr. Gabrielle Lyon: 33:19

Okay, I think that we have

Dr. Larry Lipshultz: 33:23

one pharmacy that will make it for us, because a lot of the pharmacies can't make over the counter, as well as prescription they can't do it in the same facility. Do

Dr. Gabrielle Lyon: 33:36

medications, depending on the kind of medication affect sperm? Are there things where you say, Okay, if you know, like for women, when I think about women, for example, a woman, you don't want a woman on retinols for pregnancy, or Accutane, sorry, Accutane, things of that nature are there is Thinking about male fertility through the lens of female fertility, kind of the same. No, it's not good, great. I

Dr. Larry Lipshultz: 34:05

say that flippingly, but I don't really know. I mean, I know that a lot of my guys go on Accutane, but they're not the infertility guys. They're the testosterone guys. We're gonna

Dr. Gabrielle Lyon: 34:17

get to that. I know it's not your favorite topic. No, it is. I mean, I like it. You don't have concern about using, I don't know antidepressants, but

Dr. Larry Lipshultz: 34:26

there's been a lot of data on finasteride, you know, which blocks the HT, yeah, and showing, but not fertility, erectile dysfunction, I just don't see it very often. But men who do experience that post finasteride syndrome, it can be devastating. And I do tell my patients, but I honestly, I've never seen it. And we see lots of people,

Dr. Gabrielle Lyon: 34:49

what are the biggest things that you think people are doing that are improving their sperm? I guess what I'm asking is, how many. I've heard through the grapevine, ah, that you there are days you see 70 patients in a day. Is

Dr. Larry Lipshultz: 35:08

it 70? Maybe? But you know, don't forget, my day goes till seven, 730 Unbelievable.

Dr. Gabrielle Lyon: 35:12

How have you been in practice? I'm not gonna tell you and and if I actually know his answers, but I know,

Dr. Larry Lipshultz: 35:19

and if, if the man is there just for refills, right now, it's kind of like I see them on the way out because they don't want to wait just to get refills right to see

Dr. Gabrielle Lyon: 35:28

me. I don't know people have been with you for a long time. I do think that they want to know. So some You're

Dr. Larry Lipshultz: 35:32

right. Some people do just because they become friends, yes, but we see them because I have excellent, excellent help, like, as you do. I mean, I've got support, I've got I've got a resident, and I've got two fellows, so and, you know, and we often have med students, you know, and they're usually senior ish med students, so they know kind of what they're doing. And that really helps move the because for me to go in and have, you know, everything's typed, everything's on the computer. We use epic like everybody else, which, by the way, for those who don't know, is a system for seeing patients. And I type very slowly. So for these people to go in and do all that, I can just go in and fiddle, but I can actually make the decisions regarding

Dr. Gabrielle Lyon: 36:16

care. But, and you see, the reason I asked you and kind of set you up is that you've seen 1000s of patients, and you've seen the landscape change. And I'm curious as to what the people are doing right that are becoming more fertile, versus what they're doing wrong. And you know, I do think utilizing things like testosterone, I'm really curious about testosterone use and fertility, and also age. A woman goes through menopause, she is not getting pregnant again, is I mean that would be that it just doesn't happen. Her egg quality, her ability to get pregnant, is not there, right? Will not happen, right? Does a man go through a period of time where he has a equivalent to menopause.

Dr. Larry Lipshultz: 37:03

No. I mean, look at, look at unnamed movie stars who, in the past couple years, over the age of 70 or 80, have had kids. So the problem is not that they can't have kids. The problem is they have genetic changes as they age in the sperm that can be passed on to the kids, you know, maybe increased autism. So, you know, I think men over the age of 60 have to be very careful. And it's especially bad if their wife's over 40,

Dr. Gabrielle Lyon: 37:36

and there's a risk. So the combination, it would be a risk for increased autism, increased

Dr. Larry Lipshultz: 37:41

increased genetic abnormalities in the offspring, okay,

Dr. Gabrielle Lyon: 37:45

but still viable sperm. Yes, viable pregnancy.

37:49

The man does not stop making sperm.

Dr. Gabrielle Lyon: 37:53

Isn't that wild? Yeah. But well, it's,

Dr. Larry Lipshultz: 37:56

you know, survival of the species. And you know, you have have a bull and all the cows. I mean, you know, it's the same thing, the men, sperm production goes on. And I think when you mention the woman, that's why it's so important that women think about this and freeze eggs if they're not, if they're going to postpone having kids, it's just men can't. Well, you can freeze sperm. Do you recommend it? We don't, because, you know, it's not the same thing where they're going to stop. You know, women are going to stop, or their eggs are going to have increasing genetic abnormalities, and they can't change it much earlier than men. When

Dr. Gabrielle Lyon: 38:30

do you would you say that around 60 is when that sperm quality changes for men?

Dr. Larry Lipshultz: 38:34

I think it starts over 50. I think it becomes a significant problem over 60.

Dr. Gabrielle Lyon: 38:39

What about erectile dysfunction and infertility? Right? Do Are those really hard? Well,

Dr. Larry Lipshultz: 38:45

it's hard to have a baby if you can't. I know we're getting very basic here, yeah,

Dr. Gabrielle Lyon: 38:50

but would that be so if someone has erectile dysfunction, you would say that that's a marker of their health and probably an indicator of sperm quality. No. Oh, good. Totally

Dr. Larry Lipshultz: 39:01

unrelated. Great. You know, I think a lot of the time when we see problems with erectile dysfunction, it's blood flow problems. You know, when you look at the actual physiology of the erection and the blood flow problems to the testes are much, much different, not that there aren't some, but totally unrelated to the blood vessels that go to the penis. So we don't really think in this field. We don't think about the two being very closely related, except for the fact that a very frustrating trying to have a baby if you can't get an erection, right, which does happen a lot of times, just because so much pressure, hmm,

Dr. Gabrielle Lyon: 39:41

well, again, you've been doing this for a long time, so they definitely know to come to you to talk about,

Dr. Larry Lipshultz: 39:48

but we don't have to keep emphasizing the long time. Yeah, yeah,

Dr. Gabrielle Lyon: 39:51

yeah. That's that's so true. That's okay. What about when an individual uses testosterone? How does. That affect testosterone and or other anabolics. We have anabolics like neanderal and anabolic agents like neanderthalen. What about things like antivar do? So number one, what impact does testosterone have on fertility? And then the follow up would be, what about other anabolic agents?

Dr. Larry Lipshultz: 40:19

So I think you have to just keep them all together. They're all going to do the same thing, because what they do is they turn off the production of FSH and LH from the brain that are essential for sperm production. So yes, it's a problem. And I tell men, when I give them testosterone, regardless of their age, I tell them, Look, this is going to lower your sperm count. Maybe it's going to make it go to zero. So I said, we can treat it. And I give them something called HCG, which is LH, to take while they're taking testosterone. Offer it to every man, because when you take testosterone, you turn off your own production, and when you turn off or lower significantly, and when that happens, the testicles get smaller.

Dr. Gabrielle Lyon: 41:07

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Dr. Larry Lipshultz: 42:32

And a lot of men don't like their testicles shrinking, right? Not a good look, not a good look. So I tell them, if they don't want that, once a week, give yourself a shot of hCG. It's not expensive

Dr. Gabrielle Lyon: 42:46

once a week, as opposed to three times a week, about three times a

Dr. Larry Lipshultz: 42:49

week if you're trying to get sperm production for just maintaining size for some crazy reason, once a week does it? Because it only lasts for 48 hours. But that single pulse once a week does manage to obviate the shrinkage that you get from turning off gonadotropins. What dose do you typically so I usually start 15 unit, 15 international units, sub q, once weekly, 15 International,

Dr. Gabrielle Lyon: 43:18

1500 1500 when did you start utilizing testosterone therapy? So we had Abe Morgentaler on the podcast. And, I mean, it's not right now, pretty much testosterone therapy is not off limits, but it seemed like it was for a very long time

Dr. Larry Lipshultz: 43:39

off limits or discourage? I mean, I don't know. I mean, since I've been in the field, it's never been off limits. It's just been cautionary.

Dr. Gabrielle Lyon: 43:48

But did people believe that if you were to offer testosterone that it would give individuals prostate cancer? Yes,

Dr. Larry Lipshultz: 43:54

but I mean, I when I got involved in the field, first of all, the fertility was first, the testosterone and the erectile dysfunction came on later as patients realized that it was all kind of intimately related one way or another. So with the testosterone, when I started using it, Abe had already started publishing things like, you can take it and you're not going to get prostate cancer. But I'll tell you, there is, there is a study that he and I did showing that you could take testosterone if you have prostate cancer, and it's not going to get worse. And he and I just happened to be at a same course, and I started mentioning that I have these patients that I'm treating, and he said, Oh, I have these patients that I'm treating. Let's, let's publish it so we that's was the publication showing that you could still take testosterone and not hurt your chances. Of your prostate cancer getting worse

Dr. Gabrielle Lyon: 45:03

that, I mean, in my mind, that's landmark, yeah.

Dr. Larry Lipshultz: 45:07

I mean, it was a really important finding. It was kind of serendipitous that we both did at the same time, and that we both talked about it at the same time, and that has led to many other publications that are similar. You know,

Dr. Gabrielle Lyon: 45:21

I I'm really curious as to what your what you feel, and, you know, this is kind of a weird question, but, you know, I look at my longtime mentor, and his name is Dr Donna Lehman, the individuals that listen to this know him very well. And really, his contribution, he's had many, but his biggest contribution was that determining leucine's impact, the amount of leucine's impact on skeletal muscle, which really shaped went on to shape how we think about nutrition and muscle mass, right? And I'm just curious, from your perspective, as someone who has been very innovative in the field, what do you feel that your biggest contribution has been? Oh, I don't know. I know so tricky. It's

Dr. Larry Lipshultz: 46:01

not tricky. It's just something I've never thought about. I mean, you've tremendous, I'm sorry,

Dr. Gabrielle Lyon: 46:06

how many fellows have you trained? Over 100

46:12

but that's not, that's, that's like

Dr. Gabrielle Lyon: 46:14

a side road, I know, again, we're just chatting. Yes, we're just trying. But, I

Dr. Larry Lipshultz: 46:18

mean, I think I'd have to think about what I think my biggest No, I think, and that, I think you brought up something very interesting. I think my biggest contribution has been my fellowship, because we've sent people out there now to all your major academic centers who are now training their people. So it's been kind of like a family building type of thing. So yes, let's, let's go with training other fellows to carry on the kind of the same message.

Dr. Gabrielle Lyon: 46:47

Yeah, I like that. I think it's just really important paying it forward. And you do publish quite a bit, and you've published hundreds of papers, but I, I believe in this is one of the reasons I was so excited to have you on, is the way that you think about things, and then teaching that to the fellows and really thinking outside the box. You do teach a lot of your fellows about peptides and other anabolic agents, which I've been a physician for 20, almost 20 years, and I think that that is unusual. And what do I think is unusual about it? There is testosterone, which is, you know, really have this legacy, but peptides and other anabolic agents I think are very important. And I'll start with the anabolic agents, things like win straw now, nandralone, but

Dr. Larry Lipshultz: 47:44

I think we have to preface this discussion with the fact that these are not FDA approved for the most part. Now, anovar is

Dr. Gabrielle Lyon: 47:52

Neanderthal? Is FDA approved? Yeah, so we're

Dr. Larry Lipshultz: 47:54

using some of the things we use are proven to be effective, but they're not proven to be 100% safe, hence no FDA approval, if that matters to somebody. I mean to me, as long as I am carefully monitoring the patient, you know, doing regular blood checks, looking at blood pressure, hematocrit, etc. I don't care that it's not FDA approved, because I'm doing what they would have done had they sent it out for some type of approval. But on the other hand, I think, I don't think you, I don't think it should be used without Yes, cavalierly, I

Dr. Gabrielle Lyon: 48:34

agree with you, yeah, when you do, you remember when you started using other kind of anabolic agents. And how can we preface this? How can we bring the conversation to a place where we help people understand that anabolic agents and we can decide whichever ones you would like to talk about are there are ones that are safe, right? They are very similar. For example, testosterone, we know pretty much what its safety side effects are. Neanderal, FDA approved, we know what its safety profile is. There's still somewhat of a stigma, even though I think that these agents can be very valuable, I'm gonna pass it over to you,

Dr. Larry Lipshultz: 49:22

but I agree. I mean, I agree. I mean, I think they're useful, and I think you have to be careful. So historically, what happened? I was treating men only with testosterone deficiency, classically, the older man low testosterone satisfied The Endocrine Society and the a US criteria of lower than 300 nanogram per deciliter around prior to 11am and following it by the book. And then I started realizing that, you know what? A lot of it didn't make sense to me. Why was I? By not treating a man whose testosterone was 200 in the afternoon, if his testosterone was 400 in the morning, he was still low in the afternoon, right? I don't know how you feel about it. Just didn't make sense to me. I feel the exact same. Because if they have classic symptoms of low testosterone, and they have an afternoon 200 he should be treated, but that goes against the party line. So whoever is listening has to understand that that is not mainstream, but I would think it's becoming much more acceptable. And then, you know, as I got into that, I think I started attracting people who were fringy in terms of low T for instance, athletes who had who were on testosterone, who wanted other things. And my rule is, and still is, I'm not going to treat somebody who comes in on testosterone if they don't have historically a low testosterone, and I want to see that lab slip, because otherwise, I'm acting as a store, right? I'm selling and I don't want to be a store for combating pharmacies. So I'm very careful about who I treat. I'm not going to treat people just because they show up, having said that, the majority of these people that you see who look so healthy and so ripped in the gym will tell you at one point they had low testosterone, and they'll show you the lab slip. So you can't just assume someone is taking something frivolously until you look at their history, because they may actually come from a low testosterone background.

Dr. Gabrielle Lyon: 51:45

And when someone comes they have low testosterone, they're treated. And I am curious. You know, I have a former patient of mine. I think he listens to podcast Brandon, amazing young man. You know, low testosterone you could see in their 20s. But I will come back to the age at which you treat. When did you first start seeing other anabolic agents? Because in the HIV community, they were using, oh, they were using anabolic agents to prevent death from anemia

Dr. Larry Lipshultz: 52:18

and anemia and anemia muscle wasting. Yes, they're

Dr. Gabrielle Lyon: 52:22

all being used. So when did you start to use it in practice? Obviously, very safe, safely. And how do you administer it now? How long have you been using other anabolic agents?

Dr. Larry Lipshultz: 52:36

So I would say I've been using them since I started working with compounding pharmacies, because the compounding pharmacies were making them, whereas if I just went to CVS, Walgreens, I would never even have heard of them. And the compounding pharmacies I use are the best. I mean, I've toured them. I'm thoroughly impressed by everything they do. And the thing that you don't realize, and I didn't realize,

Dr. Gabrielle Lyon: 53:03

empower, is probably one. I mean, empower

Dr. Larry Lipshultz: 53:06

So, but we'll get back to that. But anyway, these pharmacies who are compounding have to get their raw material from FDA approved facilities, albeit China and India, right? So it's not like they're getting a bad drugs from Mexico and then selling them by mixing can be the alternative, yeah, but they're using pharmaceutical grade materials, or else I wouldn't use these pharmacies. You

Dr. Gabrielle Lyon: 53:37

started using anabolic agents when compounding became available. So how long ago was that? Wanted to think 20 years you've been using anabolic agent, maybe 15 or 15 or 20. I started with Empower pharmacy. Shout out to empowerment. We've had just so, you know, Sean, I'm a huge he's been on your podcast of Sean Norian. Has he been on? Yes, yeah. So I there was, by the way, one, I just want to say that there was the mass media is talking about how they were getting rid of ozempic and all of this stuff. And none of that true. I know, right, and that is why Sean and I spoke, because and again, now you are coming on the podcast talking about the positives of a company. But let

Dr. Larry Lipshultz: 54:20

me tell you I met when I met Sean nurion. He had a facility in a strip center, so that's that, but he could tell you when that was that's what started me. Actually, the first time prescription I ever used from a compounding pharmacy was from him. And through the years, they started adding more as they added more, I used more because they became available. And I don't know whether you've ever toured their facility, but it is mind blowing, the sophistication they have there, and the goal is to be at the level of a major big pharma company. I mean, we're not talking. About a little mom and pop shop. We're talking about really sophisticated manufacturing.

Dr. Gabrielle Lyon: 55:07

And is that what brought your interest in anabolics? Yes, I think it's a really there is no one better to have this conversation with, which is why I want to talk to you about it. It is not commonly used in Andrology practices or urologist practices not commonly used across the board, right? And I think that they are life saving and life changing. And you, from my perspective, have been one of the first doctors to use it well,

Dr. Larry Lipshultz: 55:38

I think they're one of the first to use it legitimately, yes, and carefully. I mean, every one of my patients, if they're on any of the I don't know what you would call them, they're anabolic steroids, but so is testosterone, I would say, the more

Dr. Gabrielle Lyon: 55:54

what word would be used, anabolic. I mean, they're anabolic agents, but so is testosterone, right? But it's more androgenic versus anabolic? No,

Dr. Larry Lipshultz: 56:04

they're more cutting edge. I don't know. But the point is, all those people are seen three times a year, and every time, yes, at least, if not four, it's three or four, and they get carefully screened every time. And for the ones that I have any concern for, they go to the cardiologist for a complete checkup before I continue treatment. But

Dr. Gabrielle Lyon: 56:27

is it fair for someone to come in and say, Dr Lipshultz, I've had low testosterone. I can prove to you I've had low testosterone. I have been on testosterone. I feel good. Do they say I'd like to improve my muscle quality? How does one go and for what reason from testosterone to an agent that is anabolic to build muscle versus cutting? Where do you think that it becomes okay and effective? And I'll give you my thoughts

Dr. Larry Lipshultz: 57:01

too, but, but okay, but okay. Safe to use. Safe to use if the doctor who's prescribing it understands what he's supposed to be checking. You know, it's, I think if we're giving out the message, it's safe for anybody to write this, these drugs, it's wrong. It's only good. It's only safe to write them if you understand what, you need to be monitoring because they're potentially dangerous because of elevated hematocrit changes in lipids, changes in estrogen. I mean, you really got to watch that. So I rarely have a patient who come and uses the word, I want to build muscle. They'll usually say, I'm trying to bulk, bulk, which means they're trying to get bigger for whatever purpose. And, you know, everybody has their own reasons, and I don't want to get in. I don't want to personally with them, try to understand where their mindset is, but I don't have a problem with that, if they're doing it judiciously, if they're if they're healthy, but I don't want them taking up the room in my office of patients who are really hypogonadal. So you have to be careful when you get into this area that you don't open the door to patients who really don't need your care. I mean, I want my patients to be serious about their health, because you can look great and be terribly diseased inside. Yeah, so my patients have to be really health oriented. I mean, don't you agree? I'm sure

Dr. Gabrielle Lyon: 58:29

you, I do, and I I also believe that the there should be an equal playing field. For example, if someone could come into my office or your office and say, I want to lose fat, then they should equally be able to come into an office and say, I want to build muscle. And I think there should be, quite frankly, a significant, significantly less stigma around these agents, because I think that they are transformative for people if they are used safely. And you know, when there was, you know, when we talk about that, there are things like antivar, which, you know, we personally don't use in the clinic, but I know that it has been FDA approved. Does that's

Dr. Larry Lipshultz: 59:14

very No, I know, and I don't do it for this reason, but I know a lot of them, the doctors who treat women, do use low dose. They do for increasing lean muscle mass. They do, but you don't,

Dr. Gabrielle Lyon: 59:25

I don't, because, because, again, you know we could, but there are, you know, it's an oral agent. There can be changes in lipids, not just lipids, but liver function, right? I think interesting.

Dr. Larry Lipshultz: 59:40

I've never seen, maybe one patient who had elevated enzymes from antivar, what? But it has a bad reputation. But I just, I just don't see it. And the other thing is, you know, I'm not just trying to build muscle mass, I'm also treating the fat. Oh, yeah. I mean. You know, we make we do a lot with the with the stomach, glutathione center, to try to get a balance. But you know, if you want to look better, if you want to get leaner, let's get rid of the fat, not just look at building the muscles. So we try to do it all for these patients, so they don't have to keep going from doctor to doctor.

Dr. Gabrielle Lyon: 1:00:19

Oh, absolutely. When, when will a patient? And how would you, I

Dr. Larry Lipshultz: 1:00:24

gotta say, I don't like the reputation of being a doctor who can write anabolic steroids, because you, you can attract a lot of people you don't want in your office, yeah, and so you have to be careful.

Dr. Gabrielle Lyon: 1:00:37

But also, I mean, quite frankly, I would say you do not have that reputation, right? I mean, you have a come from an academic background. Well,

Dr. Larry Lipshultz: 1:00:45

I think that's what makes it different, right? Because a lot of the things we do, we look at research wise and academically to make sure that what we're look doing is not only safe but innovative, yes, and has positive outcomes, yes. So a lot of the a lot of the patients we see, the data we use to, you know, actually write papers, give abstract Well,

Dr. Gabrielle Lyon: 1:01:08

speaking of that, you know, we're publishing a paper on muscle mass and sexual function. I heard that. Yeah, I'm excited about that. Yes, I'm going to be presenting it where at the androgen society. Oh, good, yeah, maybe you'll come to the talk, sit there in the front row. I'll be very nervous. I'll be there. Also, you know, you'd mentioned that you don't like this idea that they would come in and just say, hey, I want to bulk up or build muscle. But I would also argue, and I think you agree with this, that we have to protect muscle mass as they age. You have seen it? Oh yeah for sure, and I don't know a better way to do it. Yes, you can do diet and exercise, but from again, my perspective, and I would love to hear yours, is you, it is nearly impossible to do with an aging individual without some kind and again, unless they are a monster in the gym, and have always been, that it's not that these anabolic agents are just for esthetics. That is absolutely not true. You

Dr. Larry Lipshultz: 1:02:15

know, it's so interesting. You mentioned this because I saw somebody today who was like 56 and he was complaining about his inability, even though he works out five days a week each, right to put on muscle. And I'm telling you, it is very difficult for men.

Dr. Gabrielle Lyon: 1:02:31

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Dr. Larry Lipshultz: 1:03:52

over 50, I don't know about women, yeah. For men over 50, it is very difficult, and speaking as one, to put on muscle mass. No matter what you do, it's just really, really hard. And you know, and I think you know, you can do what you can, but you have to judiciously use anabolic agents. Tell me about that. Well, you just can't go, you know, crazy, like you could when you were 35 because your body, you have other things going on in your body. You have, you know, maybe borderline diabetes or blood pressure issues, and you don't want to take in stuff that's going to retain water and bump up your blood pressure, and that's one of the problems with some of the anabolics.

Dr. Gabrielle Lyon: 1:04:39

Can we talk? I know you like to kind of bunch them together, but are you comfortable with us separating a few of those agents? So say me depends well as your comfort is, how would you what would you say the best choice would be? You've got testosterone on board. What would your next choice be for a man who wants to bulk. Yeah, because you don't see any women,

Dr. Larry Lipshultz: 1:05:01

no, well, first kidney stones, but if he's already taking testosterone and he has a decent blood level and he's I would really worry about his diet. I'm not. I'm not so anxious to add a second agent until I'm sure, but how do we know that's the problem? Because the guy, and I'm telling these men, go get a trainer. Go get someone who has a really good reputation as a trainer, let him work with you on not only your diet, I mean, not only your exercise, but also your diet. If you're not eating right, you're not going to build muscle, right? I'm preaching to the choir. You know, that's true, but I think that's a big fallacy. I think the over 50 year old male thinks they're going to come and get something magic. And there is, there's nothing magic, Ah,

Dr. Gabrielle Lyon: 1:05:56

I see right? I actually, I see that in clinic all the time, that people will want testosterone, and they believe that testosterone alone, I think we see this in the menopause community, where they will go on hormones and they will expect a body composition transformation that is not going to happen,

Dr. Larry Lipshultz: 1:06:11

right? And in the man they're going to make. And they think, and I don't think it's I think it's general, generally thought that testosterone builds muscle, wrong? You've got to do something. It's a building block. You've got to do something to make the wall be with your building blocks, or else you're going to, you know, you can't take a shot of testosterone, sit on the couch and watch TV. Nothing's going to happen. No increase in lean mass. I don't think so. Do you? I mean, I don't think so, and it may be different with men and women, yeah, but I don't think guys get a whole lot of positivity. Except now, let me change that. If we're talking about libido, if we're talking about a sense of of health, yes, but not muscle mass. I think muscle mass requires exercise? Yes,

Dr. Gabrielle Lyon: 1:07:03

I would agree with that. What would you So,

Dr. Larry Lipshultz: 1:07:07

in answer to your question, before I jumped to a second agent, I would want that individual to absolutely prove to me that he's doing everything he can to optimize his diet and his exercise, and then if still nothing's happened, then maybe add deca, which is on Mandarin decano Eight, because it's going to get those muscle fibers pumped up a little bit. I would also want them to do testosterone cypionate, and not an anthem, because I think the cypionate holds a tiny bit of water, and it does give you that fullness that these people are looking for that is a positive reinforcement when they work out.

Dr. Gabrielle Lyon: 1:07:45

I like that even if they're over 65 because typically we change our patients to enantate if they're older. I know,

Dr. Larry Lipshultz: 1:07:55

and it's probably smart, but depending what the patient once, it's not going to give him, I don't think as big of a change physically as cypionate does, but if you look at the FDA, the FDA has approved testosterone and Nan fate at point five in The ziosted injectable self contained agent, so that we know they are, think that, and it's been proven to be safe, and doesn't have age limit. Well, it could be 65 so

Dr. Gabrielle Lyon: 1:08:27

you're talking about the injection. You're talking about the auto injector. People are, they don't recognize that there is an auto injector. Yes, of testosterone for those people that don't like to do intramuscular and you

Dr. Larry Lipshultz: 1:08:39

never see the needle. Yeah. I mean, you put it on and you don't even press press a plunger, because the pressure of putting it against your abdomen releases the needle. It's just, wow,

Dr. Gabrielle Lyon: 1:08:49

yeah, that's amazing. It is. And it's not for women. It's, from what I understand, the doses. Well, it's point

Dr. Larry Lipshultz: 1:08:56

five. No, it comes less interesting. Yes, you can get point two, five. Okay,

Dr. Gabrielle Lyon: 1:09:01

we'll have to look at that when someone comes in, do you have a starting dose of testosterone? And I, I don't want to ask questions that anyone could look up, and I also don't

Dr. Larry Lipshultz: 1:09:12

want to give information that someone's going to write down and go back and do it, yeah. And then they have a problem here. Well, Dr Lipson said there was

Dr. Gabrielle Lyon: 1:09:18

so anyone listening to this, there are disclaimers everywhere. We are not giving medical advice. We are simply giving education. Okay, just so you know, we're not. People should not be taking this. People should be learning and thinking about how some of right the best. And

Dr. Larry Lipshultz: 1:09:35

I hope what we say creates questions in people's minds, as well as knowledge. You know the again, that's one

Dr. Gabrielle Lyon: 1:09:42

of the things that I really respect about you, is, I think that you are always learning. You, frankly, probably don't have to be in practice. Many you could be like golfing or something, but you're out there still contributing

Dr. Larry Lipshultz: 1:09:57

the I don't know. If I like that statement, sorry,

Dr. Gabrielle Lyon: 1:10:01

but it's true. We're already BFFs. You love how I decorated. I do. I mean, that's it. I know the anabolic agents. You start with DECA. My understanding that it's 50% the use the so if testosterone is, for example, 200

Dr. Larry Lipshultz: 1:10:21

neon would be 100 that's mine. That's my. That's how I do it. I always, I learned, well, I always have the DECA for the testosterone. Is there any evidence? Nowhere, that's purely me. Yeah. Well, the evidence is, there's a there's a people have for a long time, said that the use of nandralone decano Eight can cause erectile dysfunction, and I think it's the way it's metabolized and interferes with your DHT. So what I like to do is to keep it lower than the testosterone to try to safeguard against any effects like that. And I've never had a patient complain of Ed on DECA

Dr. Gabrielle Lyon: 1:11:09

ever. How is it metabolized differently than testosterone? It's

Dr. Larry Lipshultz: 1:11:13

because I think the molecule, and I am not good at this, but the way that molecule is constructed is very because it has a side chain that makes it act differently and makes it degraded differently, and it somehow interferes with DHT, which is important for sexual

Dr. Gabrielle Lyon: 1:11:32

approach function, so it doesn't increase DHT, it lowers DHT. That's what I don't know. It's It's fascinating. What do you what if so we see, well, I use your formula, right? We use 50% if not lower. I might even start lower. Yeah. I do not have patients that come in with erectile dysfunction from that. Nor have I ever had a patient that has it. But you will hear in sport performance realms that they, I don't even want to say it, what it's called, I know where, and I'm going to say it because we don't do jokes like that. But, you know, I mean, it seems to, if used too high of a dose, it can cause erectile dysfunction,

Dr. Larry Lipshultz: 1:12:20

right? So to be that, I mean, if the theory is it causes too high. DHT, I don't understand, yeah, I know it would make sense, yeah, yeah. So we need to, we need to fact check that. Do you have your people? Yeah, they

Dr. Gabrielle Lyon: 1:12:33

could. Hey, guys, if anyone wants to drop that to me, go ahead and look that up. So the question is, does nandalone increase or dec Exactly? And what would be the potential cause? Unique?

Dr. Larry Lipshultz: 1:12:49

Yeah, uniquely related to erectile dysfunction? Yeah.

Dr. Gabrielle Lyon: 1:12:52

I think it's really fascinating. I can tell you all the bodybuilders in the gym know, right? I know we don't know. What would you be comfortable with for a dose? So if someone is thinking, I you know, I think it's

Dr. Larry Lipshultz: 1:13:07

to me, my dosing is very age related. I'm not going to give somebody 60 the same dose. I'm going to give somebody 30. But would there be a reason? I just think I just don't want to deal with the potential side effects in an older man, especially water, water that's mainly water retention, blood pressure changes.

Dr. Gabrielle Lyon: 1:13:27

What about an effect of lipids? You know, I was talking to Nelson Virgil, and he was discussing, was looking at, I mean, this guy, he has all of the papers, I know, you know very well, just wonderful. But it seems to not affect lipids in a negative way. Is that? Is that true? Have you seen neanderthalen? I don't

Dr. Larry Lipshultz: 1:13:45

know, but I can tell you for sure, men on steroids have lower HDL and higher LDLs. And when I speak to the lipid specialist, they can't tell me why, but I know it. And I, you know, I used to say, Well, maybe it's because they don't do enough cardio, or maybe because they don't take, you know, fish oil. There's something about the compounds that somehow interfere with cholesterol metabolism.

Dr. Gabrielle Lyon: 1:14:13

Do you have concerns about that? If you see that, do you tell them,

Dr. Larry Lipshultz: 1:14:17

Oh, I don't take them off. I said, Look, I want you to increase your cardio, which a lot of them don't want to do, and I want you to start taking I like krill oil because it doesn't give a fishy aftertaste, and I think it's more potent than fish oil. So that's what I like. And I tell them to get it and start

Dr. Gabrielle Lyon: 1:14:36

it the and do you see to improve HDL?

Dr. Larry Lipshultz: 1:14:41

I do see it improve. I don't always see it go to where I wanted to go, but I've seen it in single digits, really. Yes, single digits, single digits, and HDL of nine.

Dr. Gabrielle Lyon: 1:14:51

No, yes. Okay. Why are we talking about this? Because both Dr lip Schultz and I, you know, we. With very careful monitoring use very safe doses of testosterone and various agents. And we monitor the HDLs, and there's an indication for use. You know, I believe these agents can be used for sarcopenia, right? And they can be all used safely. How do you rectify that? Do you find those men? I have to, I have to decrease doses, right? Do you find that it changes? Yes,

Dr. Larry Lipshultz: 1:15:23

it's only going to change for the positive. The thing that I can't control, and I'm sure you know this well, there are a lot of boutique drugs out there that I can't even tell you the names of, that are primarily animal steroids that these men would that be trembling or something like that? Well, I don't know if trembling, but I know equipoise and maybe master own, but I can't control what they take, and I can't control the doses. But there's a philosophy amongst people who are trying to change their physique, that if a little is good, a lot is great, and I have no idea what they're taking. I tell them, hey, look, you know, you got to tell me what you're taking, or I can't take care of you because, you know, I can't be giving you something when you're taking right? You know, pounds of something else. But that's where I think the problem, because the people who I think come in with these outrageously abnormal HDLs and LDLs are on a lot of things that we cannot control.

Dr. Gabrielle Lyon: 1:16:26

The I don't think you would see

:: 16:30

it in women as much. I think we don't see, I

Dr. Gabrielle Lyon: 1:16:33

mean, I, you know, frankly, I don't see really bodybuilding women, and I don't see them using all kinds of things. But what I will say is that, you know, the men that I have seen, and I used to have more bodybuilders, we don't really so much in the practice, but what I saw was that they would be taking very, you know, before they were patients, really high doses of testosterone. And when I say hi, let me qualify that, anywhere between three and 600 a week.

Dr. Larry Lipshultz: 1:17:03

Oh, no, that's low. I would they're taking a gram. I mean, it's crazy.

Dr. Gabrielle Lyon: 1:17:10

And the question becomes, when an individual and see, this is amazing, because nobody else sees patients that have been on that train. And when I say no, but I mean, you are probably one of the only doctor. I mean, these guys are not going to the doctor. Yes, when you see patients that are doing that, and they've been on let's just, let's pick a moderate number, let's say between three and 600 which, by the way, you and I would never prescribe that potentially, I don't know, but I would never if they were taking 600 milligrams of testosterone a week, if they said, Dr lipschult, I need you to take over my care. You measure their blood levels in a trough. They, I don't know or not, they have all the signs and symptoms of low testosterone. Would they then feel okay, could you go from 600 for years and then now say, well, we're not going to go over 200 Will they still have the same effect? So what do you do?

Dr. Larry Lipshultz: 1:18:10

I mean, we we compromise. I mean, so we have to go back to my basic philosophy, which should not be used by other people just once they hear me, and that is, I don't care that much what their serum testosterone is. I'm treating their symptoms. And I'm not talking about muscle mass. I'm talking about symptoms, fatigue. I can't sleep. You know, I'm not building any muscle mass. I have no sex drive. It may take more than 200 it may take 400 I'm treating the patient. I'm looking at the side effects, but I'm not focused on their blood levels. I am for the things that can hurt them, for their hematocrit, for their estrogen, for their lipids. I'm not focused on their serum testosterone. I don't I think that's unfair, but also because everybody's different meaning and everybody's receptors have different sensitivity, maybe these this man has a very poor androgen receptor sensitivity, and he can't utilize his testosterone as well as the guy sitting next to him. You know, we just don't know. We do measure androgen receptors now is that the CAG repeats? Yes, CAG repeats. And I think that's going if we did it on a regular basis, which we don't, we should, because it would help us guide dosing, right?

Dr. Gabrielle Lyon: 1:19:38

I think it would be really helpful. Because right now we the standard of care is pretty much, you have to keep testosterone within, you know, 300 is low. You have to keep Is there a number that you would feel comfortable? I mean, the lab value, if it's over 1200 you now of total testosterone. You are now outside the normal range, right? Free testosterone, depending on the lab. I. Don't know could go. Where would you say

Dr. Larry Lipshultz: 1:20:01

that? I mean, testosterone is whatever my labs range of normal is, I don't care. But I think the thing to realize is that these values about keeping it in with this with this range, are so arbitrary.

Dr. Gabrielle Lyon: 1:20:19

But what do we do? How do we close the gap between what is being done for people now and the gaps in care potential? And here's what I mean, because I know that's where you're going. See, we're like, we're in the same wavelength that an individual for all intensive purposes is symptomatic on low test with testosterone, they have symptoms of low testosterone, exactly however, classic symptoms, which are fatigue, low libido, low energy, difficulty sleeping, difficulty Mental fogging, keep going. What else you got for me? Muscle loss, muscle loss. What do you got? Hair loss on their legs? Is that one? Not with guys? All right, okay. Well, anyway, you is there any other major symptoms? Not

:: 21:12

that I can Okay,

Dr. Gabrielle Lyon: 1:21:14

but their total testosterone is 700 Yes, let's just say, and their free testosterone is, I don't know. We'll just say it's what's a good number, 250, I don't know. I

Dr. Larry Lipshultz: 1:21:25

don't measure free unless the individual is borderline and their symptoms are out of line with his total. But for

Dr. Gabrielle Lyon: 1:21:33

that, the possibility of this, this conversation, right? It's normal. You're saying it's free. It's normal or high, okay, but they feel like crap, exactly. And you and I both know that maybe their androgen receptor density, they are someone who has, would it be low androgen receptors, right?

Dr. Larry Lipshultz: 1:21:53

Let me, let me throw out something else as a possibility. They have sleep apnea. They're not sleeping, so they have fatigue. They can't put on muscle, they feel like crap. They don't have sex drive. Get a sleep study. We do a tremendous amount of sleep studies on my patients.

Dr. Gabrielle Lyon: 1:22:11

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Dr. Larry Lipshultz: 1:23:29

Okay, so I don't think a man's symptoms with a normal testosterone makes it makes it my responsibility to figure out why he's not responding, but rather, what else is going on? What's his thyroid doing?

Dr. Gabrielle Lyon: 1:23:47

Oh, that's perfect. And, and if we zone it, are you creating an impossible situation? No, because we have patients. We I do, yeah. And I, because I don't measure CAD repeats, I personally don't feel comfortable going outside of the limits,

Dr. Larry Lipshultz: 1:24:02

either. But I would send them for a sleep study. We do sure we send all our patients for a sleep study pick up stuff.

Dr. Gabrielle Lyon: 1:24:07

Yeah, okay. And or this would be a case of an individual that has poor androgen receptor density. And the point I'm making is that, how do we manage that. And you know, because we have very clear guidelines, this is the testosterone that you can treat. It's 300 this would be considered high testosterone. This would be considered an elevated hemoglobin hematocrit. You send them for blood draw, but they don't feel good getting 202 50 milligrams of testosterone. Everything else checked out, because that is someone. Do they feel good getting 400 milligrams? Probably do. So let's say they do. I would go to 400 that would not bother me. It would not bother you. But for everybody, every other physician who was not a I'm not saying that you've been in the game long. On OG sorry, we'll edit it out. But how

:: 25:04

is precocious?

Dr. Gabrielle Lyon: 1:25:06

But how do we how do we rectify that? We

Dr. Larry Lipshultz: 1:25:11

don't, I mean, we come to grips with the fact that everybody's level of normal is not the same, that some people require more, and that as long as they don't have any side effects that are concerning, why not go higher? Why not follow them closely? But see this is a bad message to people who are watching the podcast.

Dr. Gabrielle Lyon: 1:25:35

No, it's not. It's, I think it is. It's a conversation. And here's why is that there are, there's more to this story than just the testosterone given and X, Y and Z is what it should be, and it's not the message. I think it is a really important conversation, because I think the science can evolve. I

Dr. Larry Lipshultz: 1:25:55

also think that we've been boxed into a corner, yes, by existing guidelines, and I really do, and I don't think the guidelines are based on taking care of patients. There they are based on avoiding problems, you know. And there's a big difference, you know, you have patient safety, but you also have patient care, yeah. I mean, what if you're if your patient is suffering and you can make them better, no, safely, why don't you make them better? Now

Dr. Gabrielle Lyon: 1:26:26

I know, and you know, I feel this way about the use of these and to be clear, the conversation is my intention was to talk to you about things that nobody else would see, have answers to or talk about

:: 26:43

their fear of getting in trouble, right? But every

Dr. Gabrielle Lyon: 1:26:45

but I mean, these are your unique gifts and skills that I think again, that this is the whole goal, but

Dr. Larry Lipshultz: 1:26:53

I think it's what I have, is an evolving philosophy on care, tempered by what works in patients, and the lack of serious side effects, that's that's how I got to where I got.

Dr. Gabrielle Lyon: 1:27:09

I think it is extraordinary, and I think it's important. And the message isn't okay, take a whole bunch of steroids. That's not it. It's understanding that perhaps we are not where we need to be in the realm of understanding hormone replacement, and this is beyond hormone replacement.

Dr. Larry Lipshultz: 1:27:36

And the other thing I want to bring up before I forget, perhaps this individual would be do better with micro dosing. Tell me about that. So I just see fewer side effects when, let's say I'm going to prescribe one cc, that's 200 milligrams. But if you take that 200 milligrams and divide it by seven and have that patient inject whatever that I'm some point one five sub q daily. I don't see that as much rise in hematocrit, and I don't see as much change in lipids. But you have there's this critical mass when these oil based drugs can't be injected every day because you get too many blebs, so you have to keep the dose low.

Dr. Gabrielle Lyon: 1:28:18

What I'm hearing you say is that, if you dose, would you say how many days a week? It depends

Dr. Larry Lipshultz: 1:28:26

what everything about, five days, seven days, three days, whatever they want to try. I couldn't do it seven days a week. I think three days is reasonable. Maybe five.

Dr. Gabrielle Lyon: 1:28:36

Do you prefer the sub q dosing as opposed to im?

Dr. Larry Lipshultz: 1:28:40

No, I don't prefer it. I think it's an alternative. It's patient choice. But

Dr. Gabrielle Lyon: 1:28:44

if someone does a im injection, they have more there's a bump in hemoglobin hematocrit, because there's a greater response for there's a

Dr. Larry Lipshultz: 1:28:54

big peak, right? But so if the individual comes back and says, you know, at one cc. And we see this with elevated hematocrit, try sub q, because you may not have to deal with it. And again, it's an individual response

Dr. Gabrielle Lyon: 1:29:11

that that's that is fascinating. I typically, you know, I would just have them go donate, as opposed to, which is, you know, perhaps, well, no, I mean, I don't number one, how is the science on elevated hemoglobin hematocrit causing an issue? I mean, if it's, do you think that science is there? But it really is an issue. So

Dr. Larry Lipshultz: 1:29:33

I keep all my patients a try under 50% hematocrit. And everybody we see? We send in at the first visit a donating slip to Gulf Coast blood bank and tell the patient, if it gets above 50% they've got to donate. But we see them regularly so we know when they need to go. And the other thing is, because. So elevated hematocrit has symptoms. The patients start feeling fatigued, they do, and they feel draggy, and they get headaches. So you know, you got to keep them now, if you speak to the hematologist, they say 54% we like them under 50, just to be safe. And

Dr. Gabrielle Lyon: 1:30:17

I know you don't treat women, but I will say there's no guidelines for females that are on testosterone and their hemoglobin, hematocrit for them that would be higher, would be different, right? You know?

Dr. Larry Lipshultz: 1:30:31

Yeah, I would, you know, you know, I think it's safe to use the same guidelines, and

Dr. Gabrielle Lyon: 1:30:35

that is certainly what I hear the other agents. Do you want to talk about them? Because you also, when I say agents, you know you are a scientist, I have to be very particular. You almost feel like I'm talking to my mentor of 20 years. He's very particular. He's like, What do you mean? What exactly I mean? He will call me out. Doesn't matter. We can be on stage and He's busting my job. Doesn't matter. I other agents. We can continue on the annabar discussion if you would like, because that is unusual how you see individuals dose it, if you have interest, or we could talk about peptides.

Dr. Larry Lipshultz: 1:31:18

I would rather go to peptides, okay, but I will give an intro that I don't know as much about peptides as I want to know. I have not used them that long, and I have not used a lot of the different ones as long. So let's read. I would rather in depth, revisit peptides. Great in a year only because, but having saying that I don't want people listening to think it's something to be avoided. I mean, I think they are potentially great additions to do you think females regimens? What do you think they work? Yes, you

Dr. Gabrielle Lyon: 1:31:55

do well, I mean, well, I mean, listen, I was at, I don't know if you know this, but I go to the what is the bark meeting? Yeah, I see you there. I know I'm joking, like tacos or something. So it's the what does it stand for the Baylor

Dr. Larry Lipshultz: 1:32:15

G research group, yes. Consortium, yes.

Dr. Gabrielle Lyon: 1:32:22

Consortium, I attend that.

:: 32:26

We don't talk about this. Yeah, we

Dr. Gabrielle Lyon: 1:32:28

did remember one of the fellows presented a paper, and it was looking at you guys were talking about the data of the collected data of peptides, and if it was effective on testosterone. Do you remember that you went back and you looked at the big data set, and you did group all you guys, grouped all the peptides together, and basically you didn't find an increase in testosterone.

Dr. Larry Lipshultz: 1:32:51

And I never thought it would increase testosterone. Okay,

Dr. Gabrielle Lyon: 1:32:55

but do you think that there are peptides that work? For example, MK 677,

Dr. Larry Lipshultz: 1:33:01

so interesting enough. The M stands for Merck, really, I did not know that I was it was being developed at Merck, synchronous, simultaneously with Celebrex. They both came to fruition about the same time Merck went with Celebrex, shelved. MK 677, my friend was the one that discovered it while he was there, and he discovered it by looking at whatever the ligand is that is useful for it.

Dr. Gabrielle Lyon: 1:33:35

But it never came to market. That never can you tell us a little bit about mk 677, I can give you, I You give me what, a little bit of my experience, but it's much less interesting. Give me your experience. MK 677, I believe, is a ghrelin agonist, yes, makes people extremely hungry. Yes, it causes a significant amount of water retention, yeah. And when I say significant, I mean,

:: 34:01

we're not in men. I mean, maybe women more, so

Dr. Gabrielle Lyon: 1:34:05

maybe 10 pounds, we don't really, oh, no, I never use it a lot for women, if I've never seen 10 pounds. And the reason individuals use it is they want to put on weight. Yeah, I couldn't tell you the mechanism of action, ghrelin. Oh, that's right above and beyond that, if there was some other, I think that's the main so you just eat more, you're just more hungry. Yes, yeah. So that that's pretty much it. But it doesn't uniquely put on skeletal muscle.

Dr. Larry Lipshultz: 1:34:33

No, you have, well, I mean, it's just like any other substance we've talked about. If you take it and don't do anything, doesn't matter. Doesn't make any difference. But if you're trying to put on size and you just some guys just can't eat, and some guys are so ectomorphic that you see them when they walk in the door, I think it helps, and it also helps because we take it at bedtime, they sleep better. And. They wake up the next day hungry, and then if they if it doesn't last all day, I'll give them a second dose early afternoon.

Dr. Gabrielle Lyon: 1:35:11

What else do you use? What other peptides? BPC, 157

Dr. Larry Lipshultz: 1:35:15

The patients love it. They do. It's an anti inflammatory available as injectable and oral. And the oral, apparently, I haven't used it is really good for people who have bowel issues, yeah, inflammatory bowel issues, but the injectables, to a man, they swear by it. Do you think

Dr. Gabrielle Lyon: 1:35:32

it's placebo? No, I don't, because you can confidently say that it's not a placebo. Yes, and they had also visited, they

Dr. Larry Lipshultz: 1:35:40

could also inject it, like if their elbow and the fatty tissue near that joint, and massage it in. And they could get a local response as well. And you feel afraid I sound like a snake oil sales, yeah,

Dr. Gabrielle Lyon: 1:35:55

we actually covered BPC 157 here. Yeah, it'd be great to see some data about it. It's, we've used it, actually, frankly, in the clinic for 10 years, for a lot of the military operators. I just don't, from my perspective, you used it, it may, it must have worked. I mean, I don't use it so much anymore. People ask me about it all the time. But again, you know, as physicians, we get really interested in certain things, and then potentially we move to other things. What about an individual that has been on to you? What should I call it? I didn't therapy, but not replacing therapy? Well, you're not replacing anything.

Dr. Larry Lipshultz: 1:36:35

Are you? Okay? No, that's not true. You where? What do you mean? What are you replacing testosterone, but you haven't lost it. You're not making it, maybe. But the the whole thing came from HRT, right? Mm, hmm, yeah. So remember when Susan summers do and all the business about, you know, hormone replacement therapy and HRT, and it has to be bioidentical. And women were taking Premarin, and it was horse made from horse

Dr. Gabrielle Lyon: 1:37:08

urine. Yeah, that was great. It was, yeah.

Dr. Larry Lipshultz: 1:37:10

So then they switched, and now they're using bioidentical for testosterone, for estrogen replacement, because they don't have any estrogen. They're menopausal women. You know

Dr. Gabrielle Lyon: 1:37:19

what? That is? A really good point. Nobody has a testosterone of zero, right?

Dr. Larry Lipshultz: 1:37:26

That's okay. I call it replacement. You're inferring that they don't have any.

Dr. Gabrielle Lyon: 1:37:31

That's actually very smart. So you call it testosterone. Let

Dr. Larry Lipshultz: 1:37:35

me tell you something. I got the word testosterone therapy from a Morgentaler, but I still think he does TR says TRT. But at the time we just, we had this discussion, and I thought it made so much sense not to use TRT. And then they have, now they have TRT clinics. And, you know,

Dr. Gabrielle Lyon: 1:37:54

do you get worried about people getting care from those kind of things? And I'm sure, and listen, I don't, you know what? I'm not even asking that question, because question, because you probably think there are good doctors everywhere. You just have

Dr. Larry Lipshultz: 1:38:06

to be No, I don't like TRT clinics. I don't like testosterone clinics because, number one, they make people go in and get their shots there, and they, if they tiny increases in doses, to make the patients think it's going to do something, and they overcharge for the testosterone. It's just, you know, a money maker. It's not patient care. I don't like your you are

Dr. Gabrielle Lyon: 1:38:30

very big in to patient care. Speaking of patient care, is there an age? And I actually, I'm curious, because, again, I'm going to bring up Brandon, and I wish I had known you back then. I had a young guy come in, I want to say, when I say young, he was probably late 20s, and he had low testosterone. He had low free and low total. I measured him. We see it, we see it. But I was very early on in my practice, and I knew that he needed it. But here I am. You know, I might be fellowship trained doctor, but I wasn't trained in Andrology. I didn't have an Andrology mentor. Now I do, but I sent him to endocrinology, and they felt uncomfortable treating him because of his age. So nobody treated him. I mean, he was treated then. But how do we think about those, especially with these environmental exposures? From an age perspective, one is too young to begin testosterone replacement. And, yeah, not replacement. I'm sorry, testosterone wise was pretty replacing, but therapy, testosterone therapy. Well,

Dr. Larry Lipshultz: 1:39:40

I mean, you know, if they need it, we got to think about what we can do to make them feel better. So certainly, in adolescents who don't yet have closure of their long bones, we don't want to give them testosterone because they're going to be short so, you know, we'll give them maybe low dose hCG.

Dr. Gabrielle Lyon: 1:39:59

So we're not. School, these kids that would be using testosterone that would close their bone plates

Dr. Larry Lipshultz: 1:40:05

growth if they haven't closed, ah, kids, you hear

Dr. Gabrielle Lyon: 1:40:09

that, and that means also, probably in college, their their plates might not be closed. I don't know if people are still growing. I don't,

:: 40:15

I don't think, all right, 18 and up, I don't, okay,

Dr. Gabrielle Lyon: 1:40:18

the so you give HCG to jump start their own or

Dr. Larry Lipshultz: 1:40:22

Clomid and Clomiphene, okay, something to stimulate your own production, to make it more physiologic.

Dr. Gabrielle Lyon: 1:40:30

If someone has abused anabolics or been on testosterone for a very long time, is there an ability to recover, to come off, recover, like a reboot protocol, some way to reboot their own production of testosterone.

Dr. Larry Lipshultz: 1:40:45

But I would think hCG. I mean, I have not seen somebody on it who wants to come off it, but there's no reason you want to get someone pregnant. Well, then that's totally different. If you want to talk that about that, that's a totally different issue, right? And we can talk about it. I think it's very interesting. Yes, I'm gonna first get some water.

Dr. Gabrielle Lyon: 1:41:03

Yeah, we've been going for it's 430 already. Yes, I know. Can I? Yeah, you can stretch your legs. You can tell me that you want to quit too, but I would have to bring you back for a part two. You would have to what you are. So, I mean, I'm learning so much because, you know what

Dr. Larry Lipshultz: 1:41:19

you're learning. My, a lot of my stuff is opinions. It's not published science. But Dr lips,

Dr. Gabrielle Lyon: 1:41:28

you have done something that very few people do, and I hope you understand my appreciation for that, because I am a science communicator, which means I look to see what everybody is doing, and you've provided really meaningful innovation. No other doctor is doing this or talking about it or willing to think about it, right?

Dr. Larry Lipshultz: 1:41:50

But it's also open to criticism. Do you care? No, exactly. You have to be careful, though, in academics, yeah, maybe less so in academics and private practice, because, you know, we are doing things in a very academic way. We're just not throwing stuff against the wall and seeing if it sticks.

Dr. Gabrielle Lyon: 1:42:12

Of course not. Nor would you, I promise. I'll let you out of it. Are you good for just a couple more minutes? Because I have to go to the doctors. You do. Okay, so let's just wrap up on your discussion. On You said it was important to reboot too. Yeah, so let's just mention that if you just want to finish that, then we can run through scripts. We'll have Mia come down and we'll, like, knock out some scripts. Do

Dr. Larry Lipshultz: 1:42:37

you have enough intro to go right to it? Yeah, we just have to end it appropriately. No, this. Talk about the HCG and the Oh, yeah. Well, I'll ask you the question, yeah,

Dr. Gabrielle Lyon: 1:42:47

talk to me about individuals that have used anabolics. And I'm saying anabolics testosterone, which is an anabolic or other agents that now want to regain fertility, right?

Dr. Larry Lipshultz: 1:42:57

And this is a very common problem. So what we do? First of all, we've changed our paradigm. Now, anybody in their reproductive years who comes in complaining of low T we get a semen analysis. Because, you know, sperm production when it's impaired is often associated with poor testosterone

Dr. Gabrielle Lyon: 1:43:17

production. Sperm production that is impaired is off, okay? Because the testicle

Dr. Larry Lipshultz: 1:43:22

is just not working well, right? So if someone's starting out with low semen quality, we don't want down the road try to re stimulate and get to a level where that individual never started. So what do you mean? In other words, I think people who come in with low tea when they're young are at risk for also having poor sperm production. So I want to know what they are before I give them tea. Okay, so when it come time for them to have a baby, reestablish, I want to know what my target is. I mean, if their production is 10 million per mil, I don't want to try to stimulate them to 30, because they weren't that way to begin with. I see that's what we're doing now. That's different, okay, but in the before we did it, you know, when people come in now, they haven't done that. The old the old technique was to take them off testosterone. Originally, just take them off testosterone. Well, that was terrible because they had no testosterone. They were miserable. They wouldn't stick to no testosterone. So what we then started doing is adding HCG with Clomid and then later, which is what we're doing now, HCG with FSH, because we found those two hormones, which are the essential hormones for sperm production, we can give parenterally. We can give from the outside. There you can purchase them, and then we can bypass the issue of trying to re stimulate them, so the individuals will get pregnant faster. In addition, we found out we can also add back or allow. Them to stay on their testosterone, because when you think about it, testosterone is bad for sperm production because it turns off FSH and LH, right, right. Well, if I'm giving the individual FSH and LH, why do I care if they're taking testosterone, right? So, and we've published this and shown that it works. So now our individuals can stay on their testosterone. They don't have to go through any of the symptoms they came in for initially of low testosterone, and yet they can re establish sperm production, back to their baseline.

Dr. Gabrielle Lyon: 1:45:35

That is innovative. Do you do you then need to lower the testosterone dose? You just give them LH and FSH, and they're able to maintain fertility. Yes, wow. Dr, Larry lip Schultz, I could talk to you all day,

Dr. Larry Lipshultz: 1:45:50

and I would love to, but we all have other things. Well, I don't know

Dr. Gabrielle Lyon: 1:45:54

this is pretty important, but you know what, I we can come back again. We'll come back for we can have part two, part two. And you know, son of Yes, I am so grateful to you on the way in which you have really led the charge on a lot of this innovation, really extraordinary. Yeah.

Dr. Larry Lipshultz: 1:46:13

Well, I appreciate your appreciation. Well, you're a great interviewer. Very comfortable. Thank you so much.

Dr. Gabrielle Lyon: 1:46:19

I appreciate that, and till next time, yes, till then we will not call it testosterone replacement therapy. Never again. Dr Lipshultz, thank you so much, and thank you. Thank you so much for tuning into this powerful conversation with Dr Larry Lipshultz, if today's episode challenged what you thought you knew about men's health and fertility. Share it with someone who needs to hear it, partner, brother, friend, and if you're ready to take your health seriously, make sure you're subscribed so you never miss an episode. I'm Dr Gabrielle Lyon. See you next time and remember strong bodies, strong minds, strong future. You.