What Men Need to Know about Sperm Health, IVF & Miscarriage with Professor Jonathan Ramsay ​

Lorne Brown

By listening to the Coherence Code Podcast, you agree to not use this podcast as medical advice to treat any medical condition either in yourself or others. Consult your own physician or healthcare provider for any medical issues that you may be having. This entire disclaimer also applies to any guests or contributors to the podcast. Welcome. Welcome to the Coherence Code Podcast. To Coherence Code Podcast. Where we explore how the mind and body work together so you can move from stress and inner conflict to clarity, calm and alignment. My name is Lorne Brown. I’m a doctor of traditional Chinese medicine and a clinical hypnotherapist. And through my work, I’ve seen that healing happens when we remove what gets in the way and allow the body and the nervous system to do what they’re designed to do to heal. Welcome to the Coherence Code Podcast.

Today we’re talking about the often overlooked half of fertility, sperm health. Male factor contributes to about half of infertility cases, yet fertility investigations often focus primarily just on the woman. For many heterosexual couples struggling to conceive or even experiencing miscarriage, understanding the male side of fertility can be an important piece of this puzzle. My guest today is Mr. Jonathan Ramsay. He’s a consultant urologist who has spent more than four decades specializing in male fertility. His research focuses on sperm DNA quality, inflammation in the reproductive tract, the microbiome, and surgical treatments for male infertility. And just a quick note for our listeners outside the UK like me here in Canada, when you see the title Mr. Before the name of a surgeon, it reflects a longstanding British surgical tradition. It actually signifies a senior consultant surgeon. So Mr. Ramsay is a highly experienced medical doctor and urologist.

Mr. Jonathan Ramsay, welcome to the podcast.

Jonathan Ramsay 

Welcome and thank you very much for that kind introduction, Lorne.

Lorne Brown 

So we’re recording off the record and it was really interesting, so we had to get this intro in so we could start. And when couples struggle with fertility, the conversation often focuses on the woman, even though we know sperm contributes half to the embryo is genetic. I always thought it’s because reproductive endocrinologists are gynecologists where you’re a urologist. What’s your take on why the focus has always been on the woman and not on the guy?

Jonathan Ramsay 

Oh, well, I think, of course, it starts way back in history, almost biblical, where an infertile union between a man and a woman was blamed or attributed solely to the female situation. So that terrible word barren that is used biblically. So it was just assumed that this was the way it was. And indeed if we look back at the man who discovered the microscope of Von Lervenhug, it’s a great story. He had a factory that made dresses. This is in the late 1600s. And in those days, women’s dresses had little glass adornments, pieces of glass that were cut into crystal shape. And he noticed that when the sun came through the window and hit these crystals, it might start a fire as the children boys will often use a magnifying glass to get some leaves burning outside in the summer. And he thought, well, if I turn these bobbles, these crystals round and orient them, I might be able to do the reverse.

And what did he choose to look at when he’d made the microscope, but his own sperm? Now here’s the thing. When he looked at the sperm with the head and the tail, he thought he could see the image of a man in the sperm, which he called a homunculus. And so it was thought from that moment on that the default position was male and that something happened in the womb when the sperm got in there to create a woman. So everything that was known and written about was about effectively the supremacy of men in terms of creating fecundity or babies. And so it was a big leap for historians, for religious people, even for some scientists to take the view that men might be responsible, let alone equally as responsible. And then as you say, because fertility was run by gynecologists because they were the ones who developed fertility units and IVF and ICSI, IUI before that, the word was with them.

And because as you point out, they really only wanted to deal with women with whom they felt comfortable and trained. So it has taken a very long time for us to finally admit rather than acknowledge that 50% of the problem or indeed the success must be resting with the male gametes as well as the female.

Lorne Brown 

And that’s what I want to really unpack today, not only explain that guys are contributing half the DNA. Chinese medicine got this. This is why it was easy for me in my practice. It takes two to make a baby, sperm and egg, and they both need to be high quality to create a healthy child. So both needed to be healthy at the time of conception and also the period of time leading up to conception. After that, it’s the woman, she’s carrying the baby. So with fertility though, as we unpack, I want to talk about testing, things guys can do, things we’re missing. But one of the things I had Dr. Paul Turek on it as an episode and I think, I don’t know if it’s his quote or he got it from a study, but he often would say that the sperm or infertility, male factor infertility was the canary in the coal mine for men’s health.

And because of your background research, we’re not just talking about, “Hey, can we make a baby?” But if the guy’s contributing to infertility, like we know he has male factor as a physician, are there other things or a consultant, are there other things that we need to let this couple know and the man know and even do further testing if it is the canary in the coal mine? And maybe if you can unpack what we mean by that term Canary in the coal mine.

Jonathan Ramsay 

Well, it’s a great quote and it is probably one of the simplest and most compelling markers of health for men easy to measure, perhaps easy to measure in the laboratory, perhaps not so easy to encourage men to produce the specimens of their ejaculate because it’s all a bit upsetting and worrying and what might it show and men aren’t terribly good at being tested for anything. But if you look at men in general with poor quality sperm as measured by a simple analysis, then we know that the outcomes for their health throughout their lives will be reduced, reduced because they will tend to have more hospital admissions, they will have a tendency to high blood pressure, they will have a tendency to diabetes. They will therefore have all of those features of poor cardiovascular health, but it’s more complex than that and probably relates to the DNA quality in their sperm because they will have more fractures, more accidents, and their overall longevity will be significantly reduced.

And this is a very recent study from Denmark where of course every healthcare intervention is logged so you can actually track a Danish person in their healthcare system for their lives. So a longitudinal study like this, and there were nearly 75,000 men in this study published last year, shows quite clearly that Paul Turek’s line about the canary in the coal mine is absolutely right. So this is a big deal. It’s not just about having a few too many sperm. It’s not just about having reduced motility. It is about the health of the individual and all the things that might influence his health either genetically or as a result of his lifestyle in the environment.

Lorne Brown 

And we should explain for those that don’t get the proverb here or the canary in the mind is the miners would take canaries into the mine because they couldn’t smell the gas and the canary would die and they knew they had to get out because there’s danger. So in this metaphor, if the sperm don’t look great, then there may be other things going on with the organism. It’s a beautiful, again, concept in Chinese medicine, the microchism and the macrocosm. And so the sperm is the microcosm. By understanding the sperm, we can get a better understanding as to the man’s health. So would you then, in this idea, if somebody has sperm quality issues, so they’re going to be focusing on improving sperm, we’re going to talk about that for their fertility, but then do you look at metabolic health? Well, you run blood sugar tests, cardiovascular lipids.

Do you look at inflammatory markers when somebody has bad sperm, knowing that these are the health risks they have throughout their life, do you start to test these in men and follow them through their history or is that something that the medical system should if they’re willing to pay for it?

Jonathan Ramsay 

I certainly agree with the last statement. The medical system, physicians, and primary care doctors should be very aware of this. I always look at a man’s hormonal status quite closely because you will often find a relatively low testosterone or a relative increase in the luteinizing hormone that drives the testosterone production. So there is often a hint that spermatogenesis, which of course is happening in the same place as androgen production is reduced alongside not necessarily causation, but alongside a reduction in testosterone. And all the things I was pointing to in terms of men’s health outcomes, a lot of those, of course, as we know, are related to a relatively low testosterone as a younger man and therefore this man as he gets older into his late 30s, 40s and 50s is more vulnerable from having a demonstrably low testosterone, which by then may well be out of range and therefore contributes to all of those metabolic disorders.

Lorne Brown

It makes me think of individualized medicine where medicine is going, that it’d be nice if we had these tests done in your 20s, your 30s, because that way rather than comparing ourselves to the general population, we can start to compare ourselves to ourselves. So if you’re relatively low in your 20s and we can see it continue to go, you can see that

Jonathan Ramsay 

Shift- Absolutely. And of course the great thing about this simple observation related to fertility is that as you know in your practice, men can do a great deal often with the help of their partners to restore far better health and particularly better endocrine health, higher levels of testosterone. They tend to gain weight from muscle bulk to exercising without, of course, absolutely we have to say resort to exogenous steroids. We don’t want any of that because that’s a disaster, but men can do an awful lot to help themselves. And the first sign that they can start improving their situation may well be when there’s a failure to conceive in their mid, late 20s or even early 30s. And this is a moment, a classic and important moment for straightforward lifestyle intervention.

Lorne Brown 

You mentioned 20s and 30s. Often when we see people in our practice, they’ll be coming into their 40s, 50s, and beyond the age of the man. We focus so much on the age of the female, of the age. What about men? Men definitely can father children until they die pretty much like we see that, but does that necessarily mean we’re contributing quality sperm that will create that healthy child we want? Do we now see that age also impacts sperm quality and that if men are in their 40s or 50s or beyond, again, more reason to do lifestyle to try to give that sperm its best chance therefore the child’s health blueprint, the epigenetic impact on the child?

Jonathan Ramsay

Sure. Lorne, I couldn’t have put it better myself.

The answer is absolutely yes. People, proper scientists, unlike me, have been looking at DNA quality of sperm and the outcome in terms of live births and the health of the next generation, particularly a great scientist called John Anderson has been looking at this for many years. I think it is now pretty clear and generally accepted just as you say that after the age of 35, 36, 37, and onwards, the simple DNA quality of the sperm is measured by single strand breakage, the usual typical case for DNA fragmentation, this deteriorates and there seems to be a relationship to that particular deterioration, not entirely dissimilar from the deterioration in egg quality and firstly, the ability to conceive, but secondly, the quality, the conditions that might affect the next generation, the offspring of that man with impaired DNA quality.

Lorne Brown

Now, I would love for you to talk more on this because the eggs are accurate to current science, how we understand it, a woman is born with all her eggs. So age and stuff, that’s the age of that. That egg has been around for a while in utero. Guys, I’ve been told that we make somewhere between 1,000 and 1,500 sperm a heartbeat. So when a guy is 40, it’s not like that sperm’s been sitting around for 40 years in his body, but the system that’s going to help with the maturation of the sperm is old, the 40-year-old system. So I would think that men are easier to correct because we’re constantly making new sperms. So for example, if you’re a smoker, if you’re overweight, if you have a poor diet, things like that could change. And then there’s probably other interventions you can add and therefore if that system, the biological system becomes optimal younger, then the new sperm that are being made and then matured in that system theoretically could improve greatly.

It’s a little bit harder to do it for females because it is that old that the egg has been there for 40 years, but the sperm, we’re constantly turning over sperm. So we have to differentiate that. It’s a little different for the guys. So why is it that age impacts the sperm quality? Is it the cellular environment that’s old that’s impacting it? Then that’s my thinking.

Jonathan Ramsay 

Sure, I think you’re quite right. So what’s happening to the sperm in terms of relatively mild degrees but significant degrees of DNA damage, not dissimilar to the DNA damage that happens with aging, which results in all kinds of conditions, a tendency to the earlier onset of some malignant conditions, inflammatory conditions, things as simple as losing skin quality. And so we are back to the canary in the coal mine. The breaks, the single strand breaks in DNA are very susceptible to lifestyle and age. And as you point out, in an organ as active as the testicle that is making hundreds of thousands of sperm per hour, then this single strand DNA breakage, which we measure in the standard tests is something that will be very amenable to improvement. And of course, the amount of DNA damage that is acceptable single strand DNA damage in sperm is really quite high.

I mean, we tolerate quite high breakage rates in the sperm, which means that this is a naturally occurring process, but what we are doing by improving the lifestyle is largely improving our ability to repair those defects. So there are several angles, if you like, to actually strengthening that canary in the coal mine, making that canary a bit more resilient. And of course, the coal mine is a very opposite analogy because in the coal mine, you are indeed surrounded by fossil fuels and their byproducts have an awful lot to do with everything. I

Lorne Brown 

I want to talk about testing, but maybe we should go down that path first about the environment. So can you share, because you have a paper that you were showing me earlier years ago, I’ve been doing this since 2000, so I’m over two decades into this and some of the IVF docs, the reproductive endocrinologists, when I would consult the guy to stop smoking, would tell the guy, “Don’t worry about it. You can smoke because your semen analysis looks normal.” Here we are many years later. What is science now saying about the environment? Not only can we talk about smoking, but how is sperm being infected by the environment? And I’d love you to bring in, there’s been stuff people have seen on social media, sperms dropping by 50% from so many years ago, the drop in sperm quality or count and the environment. I think it’s important to share household products, the environment, what is it doing to sperm or is it okay to just ignore that?

Jonathan Ramsay 

So I think the point about the environment and fertility is largely about multiple exposures throughout life where life is actually beginning at the time of conception or even before. So it’s about the lifestyle of the parents which may be affecting both the quality of their gamut and their ability to conceive, but then it is about the environment to which the fetus is exposed, particularly a male fetus at a time in the first few weeks of this little fetus’ life is crucially dependent upon the production of testosterone. And if in the environment there are endocrine disrupting chemicals, then this is going to adversely affect the development of that fetus’ gonads. And then again, so there’s a first hit, if you like, that might have affected the sperm that went to make the fetus. Then the fetus is exposed via the maternal environment and then the infant may be exposed to the external environment after birth when again, there should be another testosterone surge and then during adolescence when testosterone again is important for further development in adolescence, there’s a further environmental exposure to the same toxic substances in endocrine disrupting organs, agents.

And then of course there may be weight gain and all the other adverse lifestyle factors might start to affect that developing adolescent and young man. So the difficulty with the environment and sperm and the development of the testicles is that it is a multi-hit phenomenon. Now in order for all of these things to be relevant, it is argued and it is probably true that a genetic predisposition, so some kind of genetic or epigenetic damage, which is preexisting, then enhances and amplifies the environmental effects throughout life. So we’ve got a multiple environmental hit going on, cereal, but we’ve also got an epigenetic or a genetic predisposition and you put those two things together and of course this is a very powerful combination and over the last 50 years indeed the simple measurement of fertility, which is with semen analysis, has shown worldwide a 50% decline. Now I would relate that in part to a worldwide decline in faculty or birth rate.

But as soon as you say that, then of course there are economic aspects that are also very powerful drivers. The cost of a family, some couples choosing not to start a family, the maternal age at the start of the fertility journey because of economic consideration. So it’s quite difficult to relate the environment to fertility rate, but I think we have to all accept that we relate the environment to a declining sperm count and probably therefore for the reasons described declining sperm quality.

Lorne Brown 

And there’s some things you can control and some things you can’t are water or air, but there’s filters. But I think of things like in our practice, we like to use glutathione in our IVs because it’s such a good detoxifier, the mother antioxidant, just antioxidant therapy. But again, it’s choosing more clean foods, being cautious of what kind of bottle you’re using, the plastics. Earlier when we were off kind of camera, you were sharing that they’re finding plastics in, is it in the testes or in the seminal fluid or both?

Jonathan Ramsay 

Well, the metabolites of plastics and in particular of rubber particles which are much more prevalent in the atmosphere than they used to be. And therefore, of course, get into the atmosphere and end up in the sea and metabolites of phthalates of bisphenols, bisphenol, there used to be A, B, but now we got bisphenol S. So all of these metabolites have recently been found in seminal fluid. And if we add to that the findings of microplastics all over the body, whether it be in the plaque, the deposits of fat that line blood vessels, which means that they are ubiquitous or even in the substance of the testicles, once you are saying the plastics are getting in and the metabolites of those chemicals are within the body fluids, then one is beginning to get to the point of causation rather than where we’ve been stuck for many years, which is a very strong association.

Lorne Brown 

Small tangent on what you’re sharing about the epigenetics in Chinese medicine, why I was so drawn to it because there’s so much wisdom there. I can’t be certain of it, but I’m pretty sure in the classics they talk about the lifestyle, the woman and the man will impact seven generations. So that’s 2,000 years ago. Now we know for at least three because the grandmother, the mother, and the daughter, that’s all we know that when somebody’s of a woman, when she’s carrying her daughter and the daughter’s carrying the granddaughter, in one person, there’s three generations. So at least we know from science there are three, but I’ll share that Chinese medicine says what we do now impacts seven generations. I don’t know how they know that, but it’s something that’s documented. It makes me think though, when you talk about these plastics, do we know then they act as endocrine disruptors?

It’s one thing to say we see them in the testes or in the seminal fluid, but have we shown that this then does cause subfertility in men or is it just something that’s in the semen nozzles but has no impact?

Jonathan Ramsay 

Once again, we can look at the quality of the sperm in the men who have these substances at certain levels and nobody really understands yet the cutoff because the publication that you and I were talking about is extremely recent. And there is another publication that is suggesting the same thing, a big, big publication from some researchers in China where the interest in this topic has been much broader and indeed deeper than in other countries. So we can relate the presence of these compounds and their metabolites to semen analysis, but it will take a bit longer to be clear about the relationship not only to fertility and what it might take to create live births in these men and as you correctly point out, the health of the next generation.

Lorne Brown

And so it makes me think that regardless, it’s like somebody wants to run a marathon, they train before they run the race. If you want to have a child, women already are actively getting healthier usually before they try to conceive, but it seems like men also would benefit through diet, lifestyle, losing weight, and stopping smoking. If you want to have your child have the healthiest potential because you are setting the health blueprint of your future child at least three months before conception at the time of conception, if you’re the male, you’re participating, which we call now epigenetics in science and Chinese medicine, they called it preconception, sorry, prenatal G is what it was called or prenatal ging. That’s epigenetics. But this makes me go into the testing part. So many heterosexual couples, when the male does a semen analysis, they assume it tells the full story.

They’re looking at the count, mortality and morphology, but we know that heterosexual couples where the man has a normal semen analysis can still struggle with infertility so they become designated as unexplained infertility or they even sometimes conceive but quickly miscarry. Are there limitations to the standard semen analysis?

Jonathan Ramsay

Absolutely. So the case that you point to, which is of course styled in fertility units as unexplained infertility where there may be a normal or indeed very near normal semen analysis where really this should have … Been associated with relatively easy natural conception. I think that there is increasing data to show a very clear association in maybe 20% of these normal semen analysis cases called unexplained, which actually is due to the DNA quality of the sperm. And so a straightforward semen analysis, even when it’s normal, may not be helpful. And it’s got to be looked at in the context I think when I see a couple of two things. Firstly, should this couple have conceived? How old is she? And if she’s under 30 and he’s got a normal or near normal semen analysis they should have conceived. There’s something that matters here. And the old wisdom which was there, there, try harder.

It’ll come right. I think we should not be giving that advice any longer. And then the second very important pointer to a possibility of disturbed male fertility is the, again, usually younger couple who conceive relatively easily, naturally, but who then have early miscarriages. And it really was believed and to a certain extent still is believed that this business of miscarriage was purely a female issue. And I think the time has come for us to reexamine that statement because we know that when our gynecological colleagues have really thoroughly investigated a woman who may have had three miscarriages or more, they’ve thoroughly investigated her. They find no abnormality in terms of endometrial receptivity or the other female factors in 50% of those women. So that does beg the question after three natural, naturally conceived miscarriages. If you don’t find anything wrong in 50% of the women, 50% should be a little signal.

It should be sending a little sign that perhaps that could be to do with the male factor and the DNA quality of the sperm. And it seems, again, I’m quoting data, not evidence, that there is a strong association between double-stranded DNA breakage and these recurrent early miscarriages in the presence of a normal semen analysis.

Lorne Brown 

And so I think of the semen analysis often as it’s the contents of the book. You’ve opened up the book, you looked at the contents, but you haven’t read the book. And then there’s other tests where you’re now looking at the DNA. So we’ll talk about DNA fragmentation tests. Oh, and the other thing I want to ask you from your experience, I’m going to pull on Paul Turek. When I interviewed him, and this is jumping around to the varicoceles, but when a guy had issues and he likes the DNA epigenetic type testing and DNA fragmentation, he said that theoretically when we do these interventions, we should see an improvement within at least 90 days, one cyclospermum genesis, 72, 90 days. But he says, interesting enough, clinically it sometimes takes two cycles. So when he would do a varicocele repair and they retest the sperm three months later, not great improvement yet, but six months later he would see great improvement.

And so I’m curious because so when I consult patients and they’re doing all these changes, I tell them, do this, but don’t just do it for three months really to give it a chance, let’s see what happens over six months of following these new changes, dietary supplements, all these things. Do you see it also sometimes takes two cycles of spermagenesis? And varicose repair is the perfect one because they have the issue, you surgically repair it, they no longer have the issue. It’s not like we’re taking time to lose weight, for example, this is immediate. So can you unpack that a bit for us of why it may take six months versus three months? And I should ask, have you seen that? Because that was something in the interview Paul Turek discussed.

Jonathan Ramsay 

So I entirely agree with Paul over this. I think that the three months has become a bit of a law, not an LAW but an L-O-R-E in fertility treatments. And I think that it often and probably more often than not takes more than three months. And the one cycle for spermatogenesis is something that gets fixed in the minds certainly of doctors, but also of the patients because they want a resolution and often when one’s working in cooperation with a fertility unit, then particularly the female partner who’s worried about her age will be booking the next treatment after one spermatogenic cycle. She will be making the bookings 70 days to the day after the guy’s had his varicocele treated. And then of course, there’s terrible disappointment when the next cycle doesn’t work or when there isn’t the sort of improvement that one might expect both in the semen analysis and in the DNA fragmentation.

So I say to my patients that we should be seeing some improvement in three months, but you’re not going to be at your best until five, six, seven, maybe even eight months. Of course, that business of being at your best slightly depends where you’re starting and how much lifestyle change you can make in addition to having the varicocele treated. But I would agree with Paul that generally speaking, it’s longer rather than shorter. Now, of course, the other thing about this is that with variceal repair, even large varicoceles, you don’t sometimes see the sort of improvement you would expect. And so it’d be interesting if Paul were here too. So you’ve got a big varicocele, one that you can actually see, let alone measure with ultrasound. And you look at this guy with perhaps a reduced sperm number, bit of reduced motility, morphology roundabout one or 2% and you think to yourself, I can make this guy better.

And you look at the DNA fragmentation and it’s raised and you think to yourself, I’m sure I can make him better. But in fact, it is only recently that we’ve been able to look at this double strand DNA breakage because if he’s got that, then we are far less likely to make him significantly better just by treating the varicocele. So in my practice, I’m beginning to look at both types of fragmentation to better predict which of the men are expected to be better because those ones who didn’t get better despite treating a big varicocele properly, then they’re the ones I think that we should be extending the extensive tests a bit further to learn more about what actually is going on in the sperm. Because as you point out, the sperm are merely carriers of the DNA material. And of course you need a decent delivery system, but of paramount importance is the payload of those little sperm vehicles.

Lorne Brown 

So what are the extra testing? And I know sperm DNA fragmentation are all tests equal with DNA fragmentation because I’m kind of hearing for the first time there’s two types of things that you’re looking at like you talked about the double spindle I think you were sharing with the DNA. So can you go into testing? Because when somebody has a normal cine analysis, unexplained infertility diagnosis for current pregnancy loss, we often will look at the microbiome. We’ll look at issues. If they have other health issues, we look at their gut microbiome. So we’re looking at other things that can be impacting their overall health. We’ll look at some inflammatory markers. Can you talk a little bit more about what the sperm DNA fragment test is testing?

Jonathan Ramsay

Okay. I think the other tests that are helpful, let’s start with the cheapest and the simplest. We can easily look at the levels of oxidative stress in seminal plasma and this is looking at the oxidative versus the reductive chemicals in the fluid. Sometimes this test is referred to as the reactive oxygen species and sometimes it’s a redox test and the commonest one of those is called MiOXSYS. So this is not expensive and it gives us some idea of the levels of oxidative stress, which can relate to lifestyle, which can also relate to varicocele, but generally there is a pretty clear relationship between oxidative stress and single strand DNA damage. That’s the sort of damage that we were talking about earlier, which is happening really all the time and the body’s repair mechanisms are treating this. So I get a semen analysis and a level of oxidative stress because if I know that there’s oxidative stress in the seminal plasma, then I know that there must be something else going on.

This could be heat stress. It might be, again, due to lifestyle, it might be due to an inflammatory process. There may be some white cells in the seminal fluid. So all of this little package of events with oxidative stress is telling me that something’s happening to the sperm probably after it’s been produced and I’ve just got to look for it and try and treat it and we should be able to make this bloat better. Now, if he hasn’t got oxidative stress and I’ve examined him and he hasn’t got a varicocele and there is nothing really to suggest in either party that they have had overt inflammation of their genital tracts, I’m beginning to think to myself, if you’ve got a bad fertility history and your semen analysis isn’t too bad and you don’t have oxidative stress and you’ve not got anything in your story that suggests an inflammation of the prostate or pelvic inflammatory disease or anything like that and you don’t have a varicocele, then I might want to know whether you’ve got double strand DNA damage, which is a much more subtle thing but is a function of the process of spermatogenesis more than what might be happening to the sperm after production, which therefore to a certain extent may be correctable.

So this is entirely new. The availability of these tests is reduced. The cost is more than an ordinary single strand breakage test, but in circumstances where you are not explaining the unexplained, then I think it is a useful test.

Lorne Brown 

I’ve often heard, and I never really totally understood this, that it used to be when they did a DNA fragmentation test, the recommendation would be IVF. And I always thought, well, if it’s the DNA issue, how does IAVF fix that because you’re putting the DNA into the egg? And so I would think that there must be something that walks with DNA fragmentation that’s causing infertility naturally that yet IVF bypasses. And this is just me asking you from your experience, why is it if somebody has DNA fragmentation, at least the single one that IVF would fix if it’s the DNA?

Jonathan Ramsay

Okay. So I think it probably, you’re absolutely right, I think it’s probably the things that go with it.

So with single-strand DNA breakage and high levels of oxidative stress, all those things that you’re talking about will of course improve the thing. But in the days before we took any notice really of lifestyle or indeed much of antioxidants, then we were getting beyond the time often in terms of time lapsed that there was going to be enough sperm for this lady now in her mid-thirties to get pregnant naturally. And so there was an assumption that it had to be Ixy, bearing in mind that in those days, we’re thinking even five, six years ago, then the accent was not on lifestyle because it was genuinely thought that you couldn’t do anything about male fertility, but that ICSI would fix it. So what you’re describing is because IKSI, I think, became a self-fulfilling prophecy in men who probably, had we started early enough, could have been improved to the point of natural conception.

Of course, that’s not true when we’ve got a severe oligospermia. So we’ve got something running in parallel with the oxidative stress and the DNA breakage. So I think it has come to be written that ICSI solves DNA fragmentation, but I think it’s only come to be written because nobody tried to solve it before the ICSI.

Lorne Brown 

Right. And we talked earlier, if your goal is a healthy child, you’d want to do all these things before the ICSI to give your child the best health blueprint. And theoretically, if it’s not, like you said, severe count issues or something more severe, that often when you do this, if you correct the fragmentation, you’d be able to conceive naturally. So a couple hundred dollars in hiring a trainer, maybe a dietician taking some supplements is a lot cheaper than an IVF cycle and your wife would not have to go through IVF. We always forget that. If it’s the male factor and the woman’s perfectly fine and healthy, she’s the one that takes the brunt of the treatment surgically and medically.

Jonathan Ramsay 

But in my long career and association with my colleagues in fertility medicine, reproductive medicine and the gynecologists, it’s very easy for us, the two of us who have spent a long time looking at all of these lifestyle issues and the reasons for unexplained infertility is easy for us to chide the gynecologists and possibly accuse them of being too keen to do IVF and ICSI, particularly ICSI. But of course they have brought millions of couples the joy of a baby and it wasn’t that they were doing anything wrong because after all, when a woman gets to be 35, 36 or older, then the state of her eggs is becoming critical because only half of them are going to be chromosomally okay and therefore it wasn’t just an excuse that the gynecologists were using to do ICSI because if you unpack what they were actually doing, they were taking a year’s egg production maybe in one hit.

And if at the same time there was a problem with oxidative stress and single strand damage, at least they were getting what they had selected to be the better sperm into the available normal eggs sooner rather than later. So there was some rationale from that and it’s only you and I who’ve been interested in doing what we are doing who can take a different view because after all the data that says that ICSI works with poor DNA fragmentation is very old, it’s historic. And if the two of us are being honest about how long we’ve really thought that we’ve understood this and have worked with men, it’s not that long compared with the history of ICSI, which is now, as we were speaking earlier, is now in excess of 30 years.

Lorne Brown

I would like to ask you stuff about just the science behind this, the evidence, because that’s your medicine. You’re a consultant, you’re a mister. So does weight and metabolic health impact sperm quality, therefore miscarriage risk or unexplained infertility? What about smoking, alcohol, diet, heat exposure? Can we just touch on each of these just so they understand what’s happening and why? 

Jonathan Ramsay 

I think the first thing to the statement, the opening statement has to be that the doctors, all of us, quite rightly, are more and more interested in an evidence base for what we do and therefore those two words, evidence and base have become extremely attractive. They’ve become the new currency of medical practice and that is quite right and proper. But of course, evidence as opposed to data is really difficult to get in the context of fertility. And I would suggest it’s almost impossible when you cannot make a clear diagnosis. Now, why can’t you make a clear diagnosis? It’s very difficult to make a clear diagnosis when unlike any other disease state in an individual, you and I are dealing with a couple. So there’s another set of variables which it is extremely difficult to control for. And then we’re dealing also with a condition, an absence of a baby infertility, which once again may have a basis in either partner or both.

And then we’re dealing with a condition of infertility, which is very much open to, as we know, lifestyle changes. And therefore there are variations in the condition which may be happening unknown to the observers, unlike a condition like rheumatoid arthritis, even psoriasis, of course, all the malignant conditions which have a progression and a natural history, which isn’t dependent upon anybody else and isn’t really dependent upon external factors. So it’s really difficult for us to talk about evidence. We’ve already been talking about how variable and ill-defined semen analysis is. So really when it comes down to it, the only real measurement of fertility is fertility. That is a live birth, but you may have to wait for years to get that and the attention span of a researcher is often not long enough to really understand what interventions resulted in live births. So I say to my patients that evidence is a very slippery phenomenon of infertility.

Data, we’ve got loads of data and I think what we need to do within our profession is to ask the right question. Now we’ve been asking the wrong question, the whole of my professional life. It’s not an unreasonable question, but when faced with a couple, the question that we’ve been asking ourselves and they’ve been asking us is, how do you make it better? Now, if that’s the only question you ask, then inevitably you just throw things out in the fertility unit, you try this technique for sperm selection, that one, the other one, and therefore we’re not really doing this in a scientific basis, but then we ascribe evidence to our results, which is inconsistent. And the reason we get ourselves into this mess, I think, is because the question we should have been asking is not, how do I make it better, but why did it go wrong?

What was it about this sperm and this egg? Let us work hard to try and understand that because until we do, we’re not going to get real evidence. We’re just going to get more and more data. So I’m the first to admit that much of what I have wanted to call evidence-based practice actually hasn’t been because I haven’t known what it was that went wrong.

Lorne Brown 

So from the data and from what do we know that’s gone wrong? Because I know in preparing for our meaning that you’ve talked in the past about metabolic health and weight, smoking is a non-negotiable.

Jonathan Ramsay 

Well, I think the data tells us pretty clearly that all of the lifestyle is used and we can extend those beyond smoking into vaping, I think, but I think that the data is telling us very clearly that we can make a big difference to male health and therefore to male fertility, I have no doubt about that. And all of that stuff, given reasonable spermatogenesis should result in fewer rounds of IVF and ICSI and more natural pregnancies. And if I could go out and make a big play for world fertility and therefore at a microcosmic level couple’s happiness, I would cease to spend so much educational time with teenagers telling them how wicked it was to get pregnant, but actually start to explain to them when it is best to think of starting a family. Don’t leave it too late. Look after yourselves, guys. It’s 50% male.

And I think a little bit of that rather than concentrating on how wicked it is to get pregnant might go a long way to helping the cause.

Lorne Brown 

Thank you for that. I have questions that patients wanted me to ask you as I told them I was going to interview you. So are you up for a couple almost rapid fire sessions as we come to the end here? So one was about fevers and illness and hot tubbing. They wanted to know what happened. I use the terms heat and salt, but what happens if a guy has a high fever of an illness or they’ve been hot tubbing? The question they want to know is they’ve heard it can impact motility and potentially even count, but how after or how much time do the needle delay trying to conceive? Is it right now that the sperm’s not great for the next couple of months or is that heat and salt going to impact sperm three months from now? So if my husband had a fever, do I have to wait three months before we try to conceive again or should I start trying now because in three months it’s going to show up?

Jonathan Ramsay 

Okay. So it’s an extremely good question. So let’s take the easier one first, which is the effect of heat because of course we can actually measure that situation much more accurately because we know what temperature the testicles prefer, which is three degrees centigrade below core. So if we think about a hot tub, we think about water that feels pleasantly hot, then we can measure that temperature and we know that it’s probably 38, 39. Those are the temperatures that showers get set at and bath water partially to prevent people burning themselves. But if the testicles like three degrees below core and core is 37, then actually once we get up to 38, 39, there will be an acute effect. And so I say to the people who use hot tubs regularly that they really ought to desist from this for a few weeks and they will begin to recover.

So I think that’s a more acute effect than maybe the fever because the fever, it’s not so much the temperature, which of course will have a similar effect, but it’s also all the cytokines that go with that. So there is a chemical disadvantage to having a fever and then there is a further possible disadvantage to having a fever, which is why you’ve got the fever because we thought up until COVID that there weren’t very many viruses that actually got into your testicles. But then with COVID, we began to realize that possibly you could have a viral effect, a direct effect of the virus. So irrespective of the fever without having any testicular symptoms. So I think that the fever issue is more problematic because that, depending upon its cause, may have actually impaired transient spermatogenesis itself. So it’s not just an effect of the heat on the quality of the sperm, of the cytokines on the quality of the sperm, but it may be depending upon its cause, an effect of the virus itself.

So I think that the issue of virus and fever, what I do is I say, well, let’s look at your sperm. If they’re coming up to a cycle, I say, let’s look at your sperm now, both its simple quality in the DNA frag to see if you are okay to go now.

Lorne Brown 

Thank you for that. That’s great information. And yeah, on that, is there any data you’re familiar with? So I’m using the word data purposely versus evidence data on COVID impacting nail fertility. Do we know that?

Jonathan Ramsay 

So we certainly know about the acute effects because there were opportunities during the first and the second wave of COVID to understand how that spike protein actually affected the seminiferous tubules, the production lines for sperm. I think now it is more difficult to know because of course we’ve got COVID everywhere, but we are not able so easily to test for it and we are not seeing the sort of cases of such severity that we’re able actually as we were in the first wave to look into the testicles because these poor people succumbed. So in my practice, which is probably the best answer here, I’m very careful about viral illnesses because I’ve now understood that whereas before we thought, well, if you’ve got the mumps virus, of course that would damage your testicles because you had a great big swollen painful testicle, but now I’m much more wary.

And again, having seen myself men without any testicular symptoms tested positive for COVID, had five, six days of illness, and then their semen analysis really was substantially affected like 30, 40 million to five million. And you could only observe this if you were actually practicing as I was through COVID.

Lorne Brown 

Thank you. Another question from my beautiful patients, they want to know about these at-home sperm tests. I wasn’t able to answer this and the smartphone apps, are they helpful to analyze the sperm? Are they useful yet?

Jonathan Ramsay 

I think anything that increases a man’s awareness of his situation and allows him to be a bit more comfortable about doing the tests is good. Now having said that, then certainly there are Our erroneous results and perhaps one of the biggest difficulties with home kits is their unsolicited use. The company that makes them will find it very difficult always to have a full picture, a clinical picture, a fertility history that surrounds a one-off test. So whilst there may be benefits of knowing rather than not knowing in the broadest terms, we have to be very careful that we don’t get a result, which out of context seemingly means much more than it actually does. So I worry not so much about the nature of the test because you can argue about whether the preservative they put in it is damaging motility, whether these tests are as good as tests that are done in a laboratory by a person or even in a laboratory by computer aided.

Although one can argue about that. I think just when men are ordering or getting home tests, they must be very careful, I think, to have somebody to interpret it for them in the light of their history. Otherwise, it causes more harm than good. And the other time it causes more harm than good is when men who like to fix things, we all like to fix it. It’s in our power and we can get a bit obsessive about things and we can end up doing our home kits every three or four days and driving ourselves bonkers. So there are caveats about it and it’s largely about where the medical or paramedical advice is to help you through your results.

Lorne Brown 

Yeah, that’s no different than the women that use the at-home apps or the basal body temperature. It can become obsessive. I’m assuming on semen analysis, if it’s poor, you’d want to repeat it a couple times to confirm that. If it’s good, I could take it as good, but you’re the one with the decades of experience. If somebody has a poor versus a good, do you get them to repeat? If time and money wasn’t an issue, would you like more than just one semen analysis to evaluate the man?

Jonathan Ramsay 

The answer to that is absolutely. And I would never encourage a semen analysis without understanding the full fertility history so that I could see the whole thing in context. So do I think in general it’s okay to do home semen analysis in general? Yes, it is providing there’s somebody overlooking it. Do I think that one semen analysis, whether done at home or anywhere else is useful? Most of the time it isn’t because most of the time in our patients there’s likely to be a bit of a problem. The number of times you see plumb normal in a patient who has had cause to do this is relatively rare. Although certainly in my UK practice, I am beginning to see a few people before they’ve even tried.

Lorne Brown 

That’s good to hear. Last question, which I think is a big question, but I have you here, so I’m going to ask it. If a couple’s preparing for IVF or trying to conceive naturally, they’re interested in what the male partner can do for the next few months to improve sperm quality. So what would you be counseling the man to do?

Jonathan Ramsay 

Well, I suspect, Lorne, exactly what you’d counsel him and you’d probably do it better. So I-

Lorne Brown 

Are you integrated then, do you have nutrition? Have you

Jonathan Ramsay 

Ever worked with

Lorne Brown 

Acupuncturists or herbalists? Curious what your practice is like.

Jonathan Ramsay

So I work very closely with nutritionists because I’m a believer. So I think that the biggest statement to the man three, four months after he wishes to conceive. So the preconception advice is I say to him, “You just stop eating what you enjoy, processed foods.You don’t have to go on the wagon. Binging is a thoroughly bad idea.”

Lorne Brown 

We’re talking about alcohol here or food.

Jonathan Ramsay 

Well, both. Both.

Both and often the two come together. We’re taking it as red smoking any kind of smoke, whether it be tainted with cannabis, nicotine in a vape, because it’s heated vapor, but above all else tobacco is right off the menu. And then I say to them, “So if you do these things and you begin to lose a little weight, don’t go mad in the gym. Don’t wear Lycra and sweat for an hour, but just go gently and you will begin to feel better. You’ll feel different and you’ll start to sleep a bit better and you’ll say to yourself, perhaps I don’t need all that caffeine in the morning. I just don’t.” And certainly in the health drive, he will have tasted powerful sugary drinks. And I’ll say to him, “Just think about plastics. Just think about foods that could have been cooked in plastic. Just think about the plastic linings in cups and tins.

And then as one explores the plastics issue, you want to drink out of glass. You want to think about where you could be eating things that have been so processed that bits of other plastic could have gotten into them. And with all of this, I know that if they can do this, they will feel better, they’ll see the benefit, and then they’ll go on doing it.

Lorne Brown

And you’ve alluded to it earlier, I’ll add to it for when they’re going to the gym not to take exogenous testosterone to help them bulk up. So be careful of supplements for weightlifting. If you’re going bald, if you’re taking a drug to help your hair grow, you need to talk to your healthcare provider because some of those can have an impact. So be careful the drugs you take and the supplements you take.

Jonathan Ramsay 

Well, I absolutely agree with you. I mean, I will go further. I don’t say talk to your healthcare provider because they may have a vested interest in the hair growth supplements. Really, it’s a question of just not doing it. And topical things, of course, can be absorbed very easily as we know, not just from the scalp, but some of the cosmetics, as I’m sure you know better than Eylon, are full of parabens, which once again can disrupt your endocrine system. So there’s quite a lot of stuff that you can stop with benefits.

Lorne Brown

So diet lifestyle. And do you encourage or would you recommend antioxidant supplements? Do you go to that level or you just do diet

Jonathan Ramsay 

Lifestyle?

So I do tend to use measuring the levels of oxidative stress as a guide because coming back to men who really want to fix it and can be a bit obsessional. I worry that if they start off without levels of oxidative stress, they can take too much antioxidant and then cause reductive stress, which might have the same impact, damaging impact on their DNA. So if they’re already taking an antioxidant, then I say,” You won’t overdo this. Just take one and only one and don’t add a little bit of this and a little bit of that. “But I always feel happier to actually measure their oxidative stress.

Lorne Brown 

People want to learn more about you. I know about your clinic. Your website is jonathanramsay.co.uk. We’re going to put it into our show notes. Is there any other place where people can find you? We got your website. Do you have social media or any place we want to direct people that want to read your papers or learn more about you?

Jonathan Ramsay 

Well, I don’t do social media.

Lorne Brown

Okay. That’s good health advice.

Jonathan Ramsay 

Well, it’s precise. So the website’s a good place and my PA, Allison’s address is on that and I’m quite gettable, but not social media.

Lorne Brown 

Right. Where are your clinics? Where are you working out in the UK? The UK is a big place. Where are you?

Jonathan Ramsay 

Yeah, so I’m in London mostly. And I’ve got another clinic where we actually do a lot of testing on site just to the west of London in a place called Beckensfield. So they’re two venues.

Lorne Brown

Excellent. So we’ve been listening to Mr. Jonathan Ramsay. He’s a consultant urologist specializing in male fertility and investigations and treatments. Jonathan, I really appreciate you making the time to talk to me today and share this with our audience because it is one of the groups. When it comes to fertility, men have seemed to be underserved, underdiagnosed, undertreated, and education’s one of the ways to switch that. And so thank you for your decades of clinical work and again, coming here today and sharing this information. I really appreciate it.

Jonathan Ramsay 

Lorne, thank you very much. We had a good conversation. Thank you.

Lorne Brown 

Thank you. Thank you for spending this time with us on the Coherence Code Podcast. I’m Dr. Lorne Brown and I will see you next week for another conversation on coherence and healing. If this conversation resonated with you, please like, subscribe or follow the show and also share it with someone who might benefit from it as well. Remember to take a moment to breathe, reflect, and stay connected. Welcome to the Coherence Code Podcast.