#969 - Michael Eisenberg博士 - 男性如何保护与提升生育力

过去四十年间，全球精子数量下降了超过百分之五十。这是真的吗？

Global sperm counts have declined by over fifty percent in the last forty years. Is that true?

确实如此。近几年来，学界对此已形成广泛共识。上世纪九十年代发表的一项著名研究首次揭示了这一现象——我和几位作者交流过，当时发布会在大型媒体厅举行，引发了巨大恐慌。

You know, it really is. I think, you know, in the last few years, there's been a lot of consensus around that. You know, one of the most famous studies that looked at this was published in the nineties. And when it was released, I've talked to some of the authors about it, there was a lot of feign fear around it. They had it in a big media hall.

现场电视摄像机林立。但此后这项研究争议不断，原因有多方面。比如全球精液质量存在地域差异——难以置信的是，美国有研究表明纽约的精子质量竟高于中西部地区。

There were television cameras. But since then, there was a lot of controversy around it. You know, for a few reasons. You know, there is you know, there are differences in semen quality around the world. Like, for example, there's a study in The United States that showed, if you can believe it, sperm quality is higher in New York than in the Midwest.

具体原因尚不明确，可能与生活方式、活动量或种族构成有关。美国存在这种现象，全球范围内亦是如此。这些变量如何纳入研究设计引发质疑——毕竟四十年来精子检测技术已有所改进。

And I think reasons for that are not certain, whether it's lifestyle, activity levels, there may be differences in just sort of raceethnicity composition. I think the reasons are not known. But in The US, we see that, but around the world, we see that too. And so there were some concerns about how all that was incorporated to some of these studies. You can imagine over forty years, some of the methodology for testing sperm has probably improved a little bit.

统计方法和计算能力也在进步。九十年代时这个结论颇具争议，连我的导师们都质疑。但2017年及2023年的最新研究夯实了证据，如今学界已公认这种下降趋势确实存在。

And even our statistical methodologies, computational abilities have improved. So know, initially in the nineties, I think it was somewhat controversial. Even some of my mentors questioned this. But I would say over the last, you know, few years, there's another study in 2017 and even 2023 most recently, and it's really kind of solidified. And now there's consensus in the field that we're seeing this decline.

过去五十年间年均下降约1%，相当于每年减少百万级精子数量。而近十到二十年降幅加速至2%。既然学界达成共识，现在关键是要查明原因——这绝非好事，某种程度上关乎人类存续。

You know, over the last fifty years, maybe it's called about one percent, so maybe about 1,000,000 less sperm per year on average every year. But over the last, you know, ten, twenty years, it's accelerated actually about 2% decline. And so I think it's you know, now that there's a little more, you know, again, sort of consensus around it, I think it's really up to us to understand why because, yeah, it's not not a good thing. Existential, I think, in a lot of ways.

明白了。除了统计检测能力提升外，你认为这种现象背后的生理原因是什么？

Okay. Why do we think that this is happening beyond the ability to detect statistical improvements physically, what what what's happening?

这确实是价值连城的核心问题。变化速度远超进化节奏，基本可排除遗传因素。

Yeah. I mean, I think that's the million dollar question or billion or trillion dollar question, really. I think there could be a few reasons. You know, the pace of change is probably too quick for evolution. I don't think it's a genetic factor.

研究者们将焦点转向环境暴露因素——无论是生活方式改变（虽然新型药物可能逆转肥胖趋势）、环境化学物质还是微塑料污染，这些都可能通过内分泌干扰机制产生影响。

You know? So I think people have really honed in on exposures, you know, whether it's, you know, lifestyle factors. I mean, I think that, you know, we're probably a little less sedentary than we used to be. You know, obesity was going up, although maybe with some of the new medications, we'll see a reversal of that trend. But I think there's a lot of concern about just some of our exposures, you know, some of the chemicals in the environment, microplastics, I think those sorts of things.

目前认为内分泌干扰物可能是元凶，但仍需深入研究来验证——这就是现阶段的研究现状。

You know, there's some endocrine disrupting factors that are at play here that may be the culprits. But I think, you know, we need to really do more work to try and understand it, and I think that's kinda where we are.

所以站在前沿的你们视野广阔，清楚情况并不乐观，各项指标都在朝错误方向发展。我们大致了解现状，但要真正找到一个或几个可以干预的具体目标，听起来是个相当复杂且难以解决的问题。

So you at the forefront of this have a broad perspective that stuff's not great, numbers are going in the wrong direction. We kind of have an idea of what's going on, but actually finding an individual target or a couple of targets that we could intervene with, it sounds like a pretty complex problem to try and solve.

是的，这么说很公允。我想当患者来诊所时，我们会和他们泛泛讨论一些事情。显然，患者找我咨询生育问题，他们想提高精子数量——这最终也是我们的目标。因此生活方式、健康状况等因素都会产生影响。

Yeah. I think that's fair to say. I mean, I think there's, you know, there's things that we talk to patients about, I think, just sort of broadly when they come into the clinic. You know, obviously, patients come to see me for fertility, they want to figure out how to get better sperm counts, And I think that's ultimately what our goals are. So I think lifestyle, health, I think all those things are gonna come at play.

我常告诉男性，任何有益心脏的事都对生育力有益。我们会讨论饮食、运动、保持健康体重。比如摄入全谷物、水果蔬菜很重要，多走动少坐沙发——这些都是简单易行的建议。

I always tell men, anything is good for your heart, good fertility. So we talk about diet, exercise, maintaining good body weight. So, you know, I think things that you can do, you know, like whole grains, fruits, vegetables, I think those are important. You know, try and spend more time, you know, walking around and, you know, less time on the couch. I think those are sort of easy, actionable things.

在可行范围内尽量减少暴露风险。如今我们对塑料制品危害有了更多认知，比如尽量避免使用塑料水瓶。但我不想危言耸听，过度焦虑反而会损害精子生成。

I mean, think to the extent possible, try and limit exposures. You know, I think we've gotten a lot more awareness of, you know, some of the harms of, like, plastics, so trying to minimize, like, plastic water bottle exposures. You know, but I don't wanna be alarmist or scare people. Think, you know, can very easily increase anxiety, which also isn't good for sperm production.

没错。这成了恶性循环——担心精子数量反而导致精子数量下降。

Right. Yeah. A vicious a vicious cycle where worrying about your sperm production reduces your sperm production.

正是如此。

That's exactly right. Yeah.

你提到的暴露风险中，微塑料是其中之一。我看到过相关研究...

What are the you mentioned exposures. Mhmm. Mic microplastics being one of them. Yeah. I saw this study.

在狗睾丸和人类老年捐赠者睾丸中都发现了微塑料。这对生育力产生影响的可能性有多大？

Microplastics found in dog testes and old donor testes from men. What's what's the likelihood that this is having an impact on fertility?

新墨西哥州那个研究很有意思。他们分析了绝育手术中获取的狗睾丸，以及人类尸检睾丸样本——有趣的是所有样本都含有微塑料，说明这种暴露无处不在。

Yeah. I mean, I think, you know, that was a really interesting study from New Mexico. They looked at, you know, dog testicles that were taken at the time of neutering, And then they looked at testicles from men, you know, that were taken like from autopsy. And it was interesting, all of them actually had microplastics within. So, you know, it's very ubiquitous exposure.

我们通过环境和食物链持续接触微塑料。虽然塑料本身被认为是惰性的，但其中常含有具有内分泌干扰特性的化学物质，有些还是致癌物。现有关于其功能影响的研究确实令人担忧。

Again, we get it from just the environment and Talk to experts in the field, probably in our food supply. So it is difficult to the extent possible to eliminate it. But, you know, I guess it's a question of, you know, what it's doing. And, you know, plastics are thought to be somewhat inert, so maybe it's doing nothing, but there are also, you know, there's lots of other chemicals that are usually at play that have endocrine disrupting, you know, properties, some of them are carcinogens. You know, the I think the studies that we have that look at function of this, I think, are are concerning.

所以，你知道，遗憾的是他们并没有关于狗或人类的精子质量数据，但有个大致估算。在狗身上，他们发现较大的睾丸比小睾丸含有更低水平的微塑料。我们知道睾丸大小主要与精子产量相关，较大的睾丸通常产生更多精子。因此，如果发现这些睾丸含有较少微塑料，可能意味着存在某种功能性影响。

So, you know, they don't have, you know, semen quality on the dogs, unfortunately, or the people, but, you know, there's sort of a rough approximation. So in the dogs, they saw that larger testicles had had higher levels than or sorry, had lower levels than smaller testicles. And so we do see this sort of most of the size of the testicles devoted to sperm production. So larger testicles usually make more sperm. And so if we're seeing that those have you know, less microplastics, maybe there is some functional consequence to that.

还有些附加研究检测了精液样本，确实显示微塑料水平较高与精子质量下降（如数量、活力、形态）存在相关性。我认为，这些全都是故事中令人担忧的要素。

And there have been some add on studies where they've looked at, you know, semen samples and actually did show correlations between higher levels of microplastics and lower semen quality like counts, movement, shape. So I think, you know, again, all these are are are concerning elements to the story.

明白了。人们还应该警惕哪些其他暴露风险？

Right. What other exposures should people be worried about?

我认为可以考虑一些食物暴露风险。比如尽量限制农药接触——虽然有机农产品的数据支持有限，但确实存在有力证据。在条件允许时选择有机食品，某些果蔬的农药残留本就更高。

Well, I think, you know, the things that you can, you know, sort of think about are some food exposures. So I think trying to limit, like, pesticide exposure. So, you know, again, I think data around organic produce is not great, but I think there, you know, there is some, you know, pretty good evidence. So to the extent possible trying to eat organic. I mean, there are some foods or fruits and vegetables that tend to have higher pesticide exposures than others.

比如需要连皮食用的草莓，因其表面沟壑难以彻底清洗而农药残留量惊人。虽然我家人都爱吃草莓，但还是建议尽量选有机的。此外还需注意邻苯二甲酸盐、酚类等其他化学物质。

So, you know, like foods where you eat, like, the peel, like strawberries are notorious for having very high pesticide levels just because, we eat the whole thing. There's all these nooks and crannies, so it's hard to adequately wash them. Although I love strawberries, so does my family. But try and get organic when you can. And then sort of being more aware of some of the other chemicals that we talk about, phthalates, you know, different phenols as well.

比如护肤品包装，防晒霜这类产品中，相比矿物防晒霜，某些有机类型可能具有内分泌干扰特性。条件允许时建议转换使用，这个思路也很合理。

So, you know, looking at packaging, I think, you know, for, like, skincare product for, you know, sun you know, sunscreen, I think, you know, there's organic types that do have some endocrine disrupting properties compared to mineral sunscreens are thought to be potentially safer. So, know, when possible, try and switch to those as well. I think that also makes sense.

好的。回到核心问题——精子数量问题。人们谈论的精子数量具体指什么？是指精子总体积吗？

Right. Okay. Getting back to the question at hand, the problem of sperm counts. What do people mean when they're talking about sperm count? The total volume of sperm are we talking about?

我知道影响精子健康和男性生育力的因素很多。大家具体在讨论哪些指标？

I know that there's a lot of different contributing, constituting facts when it comes to sperm health, male fertility. What what are people talking about?

这是个非常基础的好问题。我们到底在测量什么？精液分析包含哪些内容？

Yeah. This is a great question. Sort of fundamental. So, you know, what are we measuring? What's what is a semen analysis?

常规操作是让男性采集样本后等待液化——刚排出时较粘稠，几分钟液化后开始测量。我们会测量精液体积这个重要指标，同时计算每毫升的精子浓度（百万级单位）。

So there's a few things that we do, you know, just logistically, we ask men to collect, and then we let it liquefy so it comes at, you know, somewhat viscous. And then after a few minutes, it'll liquefy, then we can measure it. So we measure how much there is, the volume. You know, that's an important measure. We also measure the concentration, so how many million sperm per milliliter.

我们会观察精子的运动力，也就是有多少精子在游动。同时也会评估形态，即精子的形状。还有其他一些检测项目，比如检测精子中的氧化损伤迹象，以及DNA碎片率——顾名思义就是检测DNA内部的损伤程度。

We look at the motility, you know, how many are moving around. And then we look at the shape as well, or called the morphology. There's some other tests as well. You can look at sort of evidence of oxidative damage in the sperm. You can look at something called DNA fragmentation, which looks at, as the name implies, damage within DNA.

我们会对这些指标进行全面评估。当讨论精子数量下降时，核心关注点确实是数量指标。实验室会检测精子浓度——每滴精液中含有多少百万精子，同时统计精子总数，也就是所谓的有效载荷量及其随时间的变化趋势。其他参数由于存在测量标准变动的情况，我们尚未系统追踪。至于形态学评估，随着对正常精子形态认知的进步，这方面的标准也在演变。

So, you know, we look at all that. Now, when we're talking about declining sperm counts, it really is the counts. So they look at, the concentration, how many million sperm are in each drop of sperm, and then also just look at the total sort of number of sperm, kind of the payload and how that's changed over time. We haven't looked at some of the other parameters because those have been kind of a moving target to some extent. Morphology, the shape, I think we've advanced a little of what we think sperm are supposed to look like.

这使得形态学测量较为困难。同样地，精子运动能力的评估方法也历经变革，导致长期追踪数据存在挑战。因此当我们讨论生育力下降时，实际主要指精子数量的减少。

So that's sort of hard to measure. And then the way that we measure sperm movement has also changed over time. So that's also been a little bit more challenging to measure over time. So when we talk about declining fertility, really, we're talking about the counts.

明白了。在评估男性生育力和精子质量时，这些影响因素是否有优先级排序？哪些指标最具决定性意义？

Right. What is there a triage list of priority here in terms of all of the different contributing factors? What's most important when it comes to assessing male fertility and sperm quality?

通常我认为数量是最关键的指标。我们向患者解释时主要关注两点：一是精子总数，二是活动精子数量。健康男性平均拥有约5000万至1亿活动精子。对于自然受孕的夫妇，建议至少需要2000万至4000万活动精子。当数值低于这个范围时，就需要考虑借助生殖辅助技术了。

Well, you know, usually I think the count is probably the most important. That's usually how we talk to patients about it, or at least, you know, the number of moving sperm. You know, top you know, sort of on average, you know, men have probably about 50 to a 100,000,000 moving sperm. And, you know, for couples trying on their own, you probably want at least 20 to 40,000,000 moving sperm. Now when you get lower, then you need to start thinking about some assistance, you know, to get pregnant.

例如当活动精子数低于2000万，特别是500万至2000万区间时，可以采用宫腔内人工授精技术——在女性排卵期将处理后的精子直接送入子宫。若仅有几十条精子，则需进行体外受精，即在培养皿中使精卵结合。虽然这看似是数量问题，但有趣的是，精子数量与生育力并非绝对正相关。有些男性尽管拥有上亿精子仍难以受孕。

So, if you have like, less than, again, than kind of the 20,000,000, five to 20,000,000, there's something called intrauterine insemination, where you can take sperm, put it inside female partner's uterus when she's ovulating. Or with just a few dozen sperm you can do in vitro fertilization where you mix sperm and eggs together in a dish. Ultimately for men, I always say it is somewhat of a numbers game. Although it's interesting when you look at it, it's not a perfect measure of fertility. So, if you look at men with hundreds of millions of sperm, some of them won't get pregnant.

而有些仅存一两百万精子的男性，反而能自然受孕。这说明生育是个复杂系统。需要强调的是，生育本质上是双人协作——女性伴侣的生育条件同样至关重要。精子参数更多是帮助我们评估可能存在的受孕障碍概率。

And then when you look at men with just a few sperm, like a million sperm or 2,000,000 sperm, some of them are able to get pregnant without difficulty. So, it's a complex problem. Think also fertility is ultimately a team sport. So I think what the female partner brings to the table is also gonna be very important to some of this. But it does give us just sort of an overall assessment of, you know, likelihood of having issues or not.

原来如此。那么影响男性精子质量的核心决定因素有哪些？

Right. Okay. What are the biggest determining factors that influence a man a man's sperm quality then?

遗传因素起着重要作用，某种程度上这是与生俱来的潜力。过去十到十五年有个突破性发现：健康状况与生育力存在惊人关联。精液质量简直就是男性健康的晴雨表，这种紧密联系非常值得关注。

Well, I think genetics play a big role. I think, you know, you're kinda born with, you know, some potential as well. You know, I think one thing that is really interesting that we've come to understand over the last maybe ten, fifteen years is how important health is with fertility. I think, you know, this link between semen quality and health is just so tight. It's really interesting.

健康状况不佳的男性，其精子质量普遍较低。患有高血压、糖尿病、高胆固醇等疾病的男性，精液质量明显下降。肥胖或超重人群同样存在精子参数偏低的现象。某些药物也会产生负面影响。更引人深思的是，精液质量甚至能预测个体未来的健康走势。

If you look at men that are less healthy, their sperm quality is lower too. So men with like hypertension, high blood pressure, you know, diabetes, high cholesterol, all those are definitely correlated with semen quality, and it goes down. Men that are more obese, you know, overweight, we do see also lower levels of semen quality with that too. And all, you know, men that are on different medications, we see some of those can have an effect as well. And then what's also interesting is that semen quality is actually correlated with later health too.

因此，精液质量较低的男性晚年出现健康问题的风险更高。例如，精液质量较低的人患睾丸癌的风险略高。这可能说得通，因为睾丸负责生成精子。如果它们功能不佳，可能还存在其他问题，导致患癌几率上升。而且不仅限于睾丸癌，还包括其他男性癌症，如前列腺癌。

So men with lower semen quality have higher risk of problems later in life. So for example, if you have lower semen quality, slightly higher risk of testis cancer. And maybe that makes sense, you know, because the testicles make sperm. And if they're not doing that well, maybe there's other problems too, and it leads to a higher chance of cancer. But it's not just testis cancer, you know, another male cancer like prostate cancer.

我们确实也观察到这些关联：精液质量较低与晚年患前列腺癌风险更高、心脏病风险更高有关，令人惊讶的是，精液质量较低的男性患糖尿病的风险也更高。这些男性来就诊时看似正常，但多年后追踪发现，精液质量较低者患糖尿病的风险更高。实际上存在剂量效应关系——精液质量越低，风险越高。

We do see those correlations as well with lower semen quality, higher risk of prostate cancer later in life, higher risk of heart disease, surprisingly, higher risk of diabetes for men with lower semen quality. So these are men that have, you know, that are normal when they come to see us. And then if you follow them years later, the ones with lower semen quality have a higher risk of developing diabetes. And it's actually sort of a dose response. So, the lower the semen quality, the higher that risk is.

最令人震惊的是，连死亡率甚至死亡都与精液质量相关。几个月前丹麦发表的一项研究跟踪了超过5万名有精液数据的男性数十年。如果这些男性精液质量较低，可以预测他们未来四十年的死亡风险。精液质量稍好的男性寿命更长——虽然不至于多活几十年，但比精液质量差的人多活三到五年。

And what's fascinating is even mortality, even death is correlated with it. So, there is a study published, I think a few months ago actually, in Denmark, where they have this sort of large cohort of over 50,000 men with semen data and follow them for decades. And if these men had lower semen quality, you could predict their death up to forty years later. So men with a little better semen quality tend to live. Now this is not decades longer, but they live three to five years longer than men with poor semen quality.

这确实是个生物标志物。我关于这个主题的演讲题为《第六生命体征：精子试图告诉我们什么》。因为我认为它真实反映了我们的健康状况，既关乎遗传适应性，也体现了那个时间点的整体健康状态。

So it's really a biomarker. One of the talks that I give on this topic is called the sixth vital sign, what our sperm is trying to tell us. Because I think it is really you know, it's it's a measure of how we're doing. I think, you know, it talks about genetic fitness, but also just, you know, overall health, where we are at that point in time.

如果患者看似健康但精液质量低却能预测死亡率，这会不会很奇怪？听起来除了可能通过精液质量显现的遗传因素外，还有其他原因。如果所有外在健康指标都正常，唯独精液质量异常却能预测死亡率，你会觉得其中必有蹊跷。

Is it strange to have patients come in who seem to have their health in order and have low sperm quality and then that be predictive of mortality? It sounds like there's something outside of well, I guess this could maybe be the genetic factors rearing their head through sperm quality. But other than that, if outwardly all of their health markers are in line, but sperm quality isn't, but it's predictive of mortality, you think, well, there's there's something going on here.

是的，这是个很好的问题。因为很多男性来看诊时外表看起来非常健康。

Yeah. I mean, that's a great it's a great question. Right? Because a lot of guys come in and they look, you know, they look perfect. Right?

要知道，让男性主动就医很不容易。通常只有出血或其他危机时他们才会来。所以当他们因不育问题就诊时，其他方面看起来都很健康。这正是这个指标的意义所在。

I mean, I think, you know, it takes a lot to get a man into the doctor. And so usually, they only come in if, you know, really if they're bleeding or if there's some other crisis. So, you know, when they come in, there's a problem with fertility, right? And otherwise, they look, you know, the picture of health. And I think that's really the question of what this is telling us.

他们可能有些潜在病症。有些人从未看过医生，可能有未确诊的高血压等问题。但另一些人经过全面检查也找不出明显问题。这可能更多反映了他们的整体状态。

You know, they may have some underlying conditions. Some of them have never seen a doctor before, so maybe they do have undiagnosed blood pressure problems or something. But others, you know, again, we do an extensive evaluation. There's nothing that we can necessarily find. And so I think it's really and that may kind of tell us more about just sort of just overall how they're doing.

我姐姐常说我对这些发现有些危言耸听，不该在男性脆弱时打击他们。这其实是相对风险与绝对风险的问题——风险确实有所上升，但多数人最终会安然无恙。就像买两张彩票中奖几率翻倍，但仍是小概率事件。

Now, you know, my sister always tells me, you know, you're kind of being alarmist about some of this. You don't want to kick a man while he's down. So I think just to say that this is sort of a relative risk versus absolute risk kind of thing, I think the risk goes up, you know, a little, but overall, of these men are gonna do fine. So it's like buying two lottery tickets instead of one. If you buy two, your chance of winning doubles, but still unlikely event.

重申一次，大多数人状况良好。但这是个契机——如果我们能告知这些发现，帮助他们重获健康主动权，未来他们或能改善状况。我们都可以在运动、饮食和生活方式上做得更好，比如戒烟、适度饮酒等。

So again, most of these guys are great, but I think there's a sort of an opportunity here. If we can sort of tell them about some of this or just help them sort of recapture and get more ownership of their health, hopefully they can do better, know, kind of moving forward. Hopefully they'll be able to, you know, change some things. I think we all can do a little better with exercise, with diets, just with lifestyle. You know, if they're smoking, stop, you know, moderate drinking, things like that.

我认为，希望这能稍微改变一下他们的轨迹，让他们走上更好的生殖健康之路，这也是他们来找我的原因，但同时也希望整体健康也能改善。

I think, hopefully, that can just change trajectory a little bit and put them on a path to better reproductive health, which is why they came to see me, but then hopefully overall health as well.

当一名男性因精子质量低下前来就诊时，你首先会检查哪些方面？你评估的内容有哪些？

What are the first places that you look at when a man comes in, low sperm quality? What what are the things that you assess?

这个过程相当全面。我们要讨论生殖史，确保他们的一切操作都是正确的。我觉得有些事我们可能视为理所当然，但我们要确保他们了解所有的生理结构和解剖知识。然后我们会全面审视他们之前的暴露史、健康史，看看他们是否在服用什么药物，是否曾经服用过什么。我们经常发现的一个情况是睾酮的使用。

So it's pretty comprehensive. You know, we wanna talk about, you know, the reproductive history, make sure they're doing everything correctly. I think not every you know, we take some things for granted, but we wanna make sure they know, you know, all the machinery and the anatomy. And then we do a comprehensive look at, you know, prior exposures, their health history to see if they're on anything, if they ever took anything. I think one of the things that we find not infrequently is testosterone.

你知道，睾酮实际上曾被测试作为一种避孕药，效果相当不错。有些男性服用它是为了提升健康和活力，也许还有运动表现，但它实际上会降低精子数量。所以我们也要评估这一点，看看其他可能影响精子质量的药物。

You know, that's actually been tested as a contraceptive. It's actually fairly effective as such. And some men are on it, you know, to boost health and boost, you know, vitality, maybe sports performance, but it actually lowers sperm count. So we wanna, you know, evaluate for that as well. Look at the other medications that can affect things.

这让我想起一个不太直接与生育相关但很有趣的事。昨天我在诊所见到一位患者，他因为自身免疫性疾病在服用一种药物。他说他突然发现自己的精液变成了亮蓝色，于是来找我。他和他的自身免疫医生谈过，但他们也不知道是怎么回事。

It actually reminds me of a this is not related to fertility directly, but this is interesting. I saw a patient yesterday in clinic that's on a medication for for an autoimmune condition. And he said that, you know, he was coming in because he talked to his autoimmune doctor. They didn't know what was going on. But he said all of a sudden, his semen turned bright blue.

这是我之前从未听说过的情况。我们在网上查了一下，诊所里也没人听说过。但Reddit上有一些相关的讨论，这算是互联网的一个优势吧。他们确实找到了一些关联。

And it was something I'd never heard of before. We looked it up on the Internet, and nobody in the clinic had heard that before either. But there were some Reddit threads about it, which is sort of the, you know, kind of the advantages of of that. And they and they did. They sort of correlated it.

他们说这有点像佳得乐的冰川蓝颜色，非常鲜艳。这真是有点疯狂。所以你知道是什么原因导致的吗？

They said that it was I think they likened it to Gatorade Glacier Frites. So there's bright blue color. So it's sort of sort of wild. So Do know what

是什么导致了这种情况？那种药物是什么？

it is that causes that? What's the what's the drug?

不，我们试着查了一下。可能有一篇关于这个的出版物，但真的很罕见。Reddit上的讨论也挺搞笑的。

No. I mean, we tried to look it up. I think there'd maybe been one publication about it, but just a really wild thing. Right? And I think people are was you know, Reddit is hilarious.

对吧？他们还开玩笑说他可以开个OnlyFans账号。不，外星人什么的。

Right? They talked about him getting an OnlyFans page and No. Alien

精液。对。对。对。

semen. Yeah. Yeah. Yeah.

但并非如此。我是说，但你知道，我认为很多时候，药物的生殖影响或精液影响确实没有被充分研究。我想有一些在动物模型上进行的临床前工作，如果没有出现异常表型，那么在进入实际的人类临床研究时就不会被关注。不过，你知道，只是提一下，算是题外话，但其中一些药物可能会以某种方式影响精液质量。比如颜色变化或者可能

But no. I mean but, you know, I think a lot of times, you know, reproductive effects of medications or semen effects certainly are not really studied. I think there's some preclinical work that's done in animal models, and if there's not a strang phenotype, then it's not really looked at when it goes into, you know, actually, you know, studies, clinical human studies. But, you know, just to say that, you know, kind of a tangent, but some of these medications can affect semen quality in some ways. You know, again, colors or maybe a

次要的。对。好的。所以药物、睾酮、过去的睾酮使用，我猜也是因素之一。

Secondary. Yeah. Okay. So medications, testosterone, past testosterone use, I'm going to guess as well.

没错。完全正确。我们也会关注暴露因素，对吧？比如他们喝酒的量有多少？我们会查看烟草使用情况、其他药物使用情况，以了解是否有这些行为。

Yep. Exactly right. And we look at exposures as well, right? If they, you know, if they drink, how much? We look at, you know, tobacco use, other drug use to see, you know, if that's going on.

我认为这些都是我们想要优化的方面。我们会讨论一些生活方式因素，比如他们是否锻炼。然后我们也会进行体格检查，确保一切都在应有的状态。有时我们还会发现其他问题。比如有些男性阴囊内有较大的静脉，称为精索静脉曲张，这会干扰该区域的正常温度调节，影响毒素排泄。

I think those are things that we wanna optimize. We do talk about the sort of lifestyle factors that they exercise. And then we'll do a physical examination as well to make sure everything is where it's it's supposed to be. There can be other, you know, conditions that we sometimes detect. You know, some men have larger veins in the scrotum called a varicocele, and that just sort of impairs normal temperature regulation in that area, impairs, you know, kind of toxin excretion.

因此，这也可能影响生育能力。然后，我们还会进行非常全面的激素评估。睾丸有两个功能：制造精子和睾酮。我们会检查睾酮水平以及相关轴系的其他激素。

And so that also can affect fertility. And then, you know, we do a very comprehensive hormone assessment as well. The testicle does two things. It makes sperm, but it makes testosterone as well. We'll So check testosterone, some of the other hormones involved in that axis.

然后，这算是我们的基线。我们也会与女性伴侣的医生沟通，再次获取信息，因为这是一项团队运动。然后制定一个计划，看看存在什么问题，哪些是可以纠正的，以及如何帮助他们实现生育孩子的目标。

And then, you know, that's kind of our baseline. Also talk to, you know, the female partner's physician as well to get that information again because it's a team sport. And then come up with a plan to see, you know, what there is, what's correctable, and how to get them, you know, the path to having a child.

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所以，我通常会这样解释：它们非常常见，大约15%的男性会有这种情况，也就是大约七分之一。它们通常在青春期左右出现。大多数有这种情况的男性没有任何问题，但大约20%到25%的情况下它们会引起问题。

So, you know, kind of the speech that I tell is that, you know, they're very common. Probably fifteen percent of almond have them. You know, about so one in seven. They they usually arise around puberty or so. You know, most men that have these don't have any problems, but maybe about twenty, twenty five percent of the times they cause problems.

所以，这是阴囊内的静脉扩张，左侧比右侧更常见，不过有些男性可能两侧都有。你知道，它们其实就是些较大的静脉，一般认为会使睾丸温度略微升高。这就是关于它们如何导致生育问题的普遍看法。它们与精子数量减少有关，有时还与睾酮水平降低有关联。

So, it's dilated veins in the scrotum, more common on the left side than the right side, although some men can have them on both sides. And, you know, again, they're just sort of larger veins, and so it's thought to warm up the testicles a little bit. So that's the sort of the the common thinking about how they lead to reproductive issues. So they're associated with lower sperm counts. They're sometimes linked to lower testosterone levels.

但我们进行修复的原因、我们担忧的几点在于：显然生育问题是常见的手术指征。有些男性会因此感到不适，比如描述为隐痛，你知道，傍晚比早晨严重，活动时加剧。只要血液可能淤积，静脉就会扩张，有些人能感觉到这种胀痛。

But the reasons that we fix them, the reason we worry are a few. So obviously for fertility reasons is a common reason that we would do that. Some men have discomfort from them. Like they describe an ache, you know, worse at the end of the day than at the beginning, worse at the activity. Anytime blood can pool, it can stretch, and some men feel that.

信不信由你，通常症状也就到此为止了。不过我确实接诊过静脉破裂的病例——你可能难以置信——导致...是的，虽然不致命，但会造成严重肿胀和淤青。听起来相当...

Believe it or not, usually they don't have any sort of that's sort of the extent of it. I actually have seen, you know, patients before where it actually popped, you can believe it, and led to, yeah, nothing devastating, but, you know, a lot of swelling and bruising. Sounds pretty

对我来说已经很可怕了。

devastating to me.

是啊。嗯，确实。不过那位患者最终恢复得很好。好吧。

Yeah. Well, yes. Yeah. Ultimately, he did great. Okay.

但没错，我也遇到过这种情况。而对于儿童患者，我们更关注睾丸发育问题。对于青春期前出现静脉曲张的孩子，它确实可能影响生长发育轨迹。这些就是我们关注和治疗的主要考量。

But, yeah, I have seen that as well. And then in kids, we worry about testicular growth. So it can actually you know, for kids before puberty who who develop them, it can actually affect trajectory of growth. So those are the reasons that we kinda think and worry about those.

明白了。那么修复精索静脉曲张的效果如何？考虑到很多男性就诊时可能正面临生育难题，或者考虑备孕时做了精液分析发现指标不理想。当你告诉患者'你有精索静脉曲张'时，整个治疗过程是怎样的？

Right. What is the impact of fixing a varicocele, given that this is something that I imagine a lot of the guys that come in if they're thinking was struggling to get pregnant or I'm thinking about getting pregnant or did the sperm analysis, my numbers aren't where I want them to be. And you say, hey, man. You've got a varicocele. What is the process of fixing it like?

治疗效果如何？诸如此类的问题。

What are the outcomes like? All of that.

好的。在美国通常采用手术治疗，有些地区也可以通过放射介入手术来修复。本质上这是个门诊手术，通常不到一小时就能完成。

Yeah. So, you know, in The United States, usually, it's fixed surgically. In some other places, there's also a radiology procedure that can be done that can that can help repair it. But essentially, it's an outpatient procedure. It usually takes less than an hour.

当天就能回家。我一般建议患者术后静养——我通常在周五做这个手术，这样他们能休息整个周末，周一就能复工。要知道精子生成需要两到三个月，所以我们不指望立刻见效。但在接下来几个月里，精液质量应该会逐步改善。

Go home the same day. I usually have men kind of relax. I usually operate on Fridays, so relax over the weekend back to work on Monday. You know, it takes two to three months to make a sperm, so we don't expect it to improve immediately. But, you know, over the next few months, we'll expect to see improvements in semen quality.

这种情况大约发生在70%的情况下。然后，他们可以再次尝试。我认为，并非每个人都能立即自然受孕，因为生育涉及许多因素。但大约三分之一到一半的患者能在无需其他辅助的情况下受孕。同时，这也改善了我之前提到的宫腔内人工授精的效果，甚至对患有这些病症的男性进行体外受精也有帮助。

That probably happens about seventy percent of the time. And then, you know, they can again start to try. I think, you know, not every again, because there's a lot that goes into fertility, so not everybody is just going to be able to conceive instantly on their own. But, you know, about half of patients, a third to a half of patients are going to be able to just conceive without other assistance with that. But it also improves, you know, some of our outcomes for, you know, the insemination that I talked about earlier, even in vitro fertilization as well for men with these conditions.

这是否意味着大多数想要孩子并发现自己有精索静脉曲张的男性应该进行治疗？

Does that mean then that most men who want to have kids and find out that they've got a varicocele should probably get it fixed?

你知道，每个人的感受和愿望都不同。怀孕有多种途径。有趣的是，精索静脉曲张的治疗效果存在时间滞后，这会影响一些夫妇的决定。当面临选择时，你可以选择治疗以获得改善，或者直接进行体外受精。

You know, I guess there's everybody has sort of different, I guess, feelings and sort of desires. Think there's lots of pathways to get pregnant. You know, I think one thing interestingly about varicocele is that, you know, there is this sort of time lag for benefit. And I think that does affect some couples. So if you come to this crossroads, you find you have a varicocele and your sperm count's a little low, so you can either get it fixed, you know, and and get that improvement, or you can move right to IVF, for example.

我认为不同夫妇对此的权衡方式不同。有趣的是，大约20年前，我们曾尝试开展一项关于精索静脉曲张的研究，但经过18个月在全国招募，只有三对夫妇参与。

I think couples, you know, kind of weigh that differently. You know? It's interesting. We tried to do a study on varicoseal, we as a community, about, I think, twenty years ago. And, you know, after eighteen months, you know, to try and recruit couples from all over the country, only three couples enrolled.

延迟的一个有趣原因是，男性在生殖评估过程中往往被较晚关注。大多数夫妇不愿等待，特别是考虑到治疗效果的时间滞后。在这项研究中，他们不愿被随机分配到不采取任何措施的组别，因此参与意愿很低。他们更希望直接推进治疗。

And one of the reasons for that delay was sort of interesting is that because men are seen so late in the process of, you know, the reproductive evaluation, you know, they just most couples didn't want to wait for their time just because of this time lag we talked about. You know, for this particular study, they didn't want to be randomized to do nothing. So there was just a lot of reticence to do that. They just wanted to move forward. And it's interesting, if you look at couples, you know, there's sort of this perception for a variety of reasons, I think sort of, you know, cultural and, you know, sort of gender norms and biases, that men are not always evaluated.

在美国，大约四分之一到三分之一的男性从未接受过评估。当出现问题时，夫妇通常会立即接受治疗，如人工授精或体外受精，但男性往往未被检查是否存在可纠正或优化的问题。这种延迟导致许多夫妇在尝试一年后发现问题才就诊。

You know, in The US, probably a third of the time, a quarter of the time, men are never seen. So if there's a problem, couples are treated immediately, you know, through maybe insemination, maybe IVF. But, you know, the men are not seen to see if there's things that could be corrected or optimized. And I think it's just sort of that delay, right? If couples are trying for a year and then, you know, they figure out there's an issue, then they go in.

通常从妇科医生开始评估，有时男性会被忽略。希望通过更多教育和像今天这样的平台，我们能提高意识：当夫妇遇到生育问题时，约一半原因来自男性因素，因此男性必须接受评估。

It starts with the gynecologist, and then, you know, sometimes the males bypass. So, hopefully through, you know, attention, just through more education, you know, through the platform that you're providing here today, we can sort of educate that, you know, when couples are having a problem, about half the time, it's a male factor. So the men should definitely always be evaluated.

我读到过关于尽早治疗精索静脉曲张对男性结果更好的说法，其机制是什么？

What is the that I've read about varicoceles being fixed sooner rather than later for outcomes in men. What what's the mechanism there?

我认为这是因为精索静脉曲张被认为是一种渐进性病变。存在时间越长，造成的损害可能越大。就像我提到的，有些孩子也有这个问题。如果我们能早期发现，就能改变其发展轨迹。预防问题的发生比事后修复要容易得多。

Well, I think, you know, it's it's they're thought to be a progressive lesion. So the longer you have it, the more opportunity there is to do damage. So, you know, when, like I talked about, you know, there's kids that have these as well. You know, I think if we identify that early, hopefully we can just alter that trajectory. Because it's much easier to prevent a problem from occurring than to fix it once it does.

再次强调，即使只有70%的改善率，如果我们能阻止进一步恶化，这就是我们的目标。因此，如果男性患有此症，我们应评估其影响。我们会检查精液数据和激素水平，以确定哪些人真正需要治疗。

Again, if we only see improvement seventy percent of the time, if we can sort of freeze it and prevent further decline, I think that's our goal. So I think if men have it, again, it affect or negatively impact everybody. You know, we do evaluate it. We check semen data. We check hormone data when we see these men to figure out who really needs it or not.

但每个人的选择方式各有不同。有些男性不愿终生与之相伴，而选择进行矫正手术。显然，很多人对手术有抵触情绪，所以有些人会说‘我就这样凑合过吧，以后再说’。

But everybody kind of chooses it differently. And rather than follow it for the rest of their lives, some men choose to have it fixed. Obviously, a lot of people have an aversion to surgery. So some will just say, I'll just live with it, and we'll we'll we'll figure it out later.

当男性患者因精子质量不达标前来就诊时，你们最常提供的干预措施有哪些？他们通常会接受哪些治疗？

What are the most common interventions that you offer when guys come in, sperm quality isn't where it needs to be? What are the most common interventions that they get?

精索静脉曲张是非常常见的病因。我们接诊的患者中约三分之一存在这个问题。其次是激素水平优化——这也是我们常做的治疗。许多男性激素水平偏低，通过优化可以改善状况。

So a varicocele is a very common one. Probably about a third of the time, we identify those for the patients that we see. And then, you know, hormone optimization. I think that's also a common one that we'll do. You know, men will have low levels, and if we optimize it, that can improve things.

我们还能进行其他手术。比如输精管复通术就是生殖泌尿科常见手术——有些男性做过结扎后因感情关系变化或夫妻想要孩子而来就诊。还有一类患者是精液中完全无精子。

You know, there's also other surgeries that we can do. You know, vasectomy reversal is a very common, you know, thing that men come to reproductive urologists for. So had a vasectomy, maybe changed relationship, or maybe that couple decides they want another child. So that's something that we'll do. And then another, you know, group of patients that we see are men that don't have any sperm in the ejaculate.

这种情况称为无精症。我们可以通过手术尝试改善，或直接从睾丸获取精子用于体外受精。这些就是主要的治疗方向。

So it's called azoospermia or no sperm in the ejaculate. And so there's procedures that we can do to try to either improve that or to get sperm directly from the testicles that we could use for in vitro fertilization. So that's sort of the flavor of things.

直接从睾丸获取精子听起来是个相当重大的手术。

Getting sperm directly from the testicle sounds like a rather serious intervention.

是的，听起来确实吓人。我在医学会议上展示相关视频时，有些人会感到不适。但多数患者恢复良好。想象一下——当不孕患者拿到‘精液无精子’的诊断报告时，那种打击有多沉重。

Yes. Well, I think it sounds scary. And, you know, when I've showed videos of this at sort of mixed medical conferences or others, I think some people do get a little queasy just to see what we do. But most men do great. You know, there's actually, you know, it's so you know, you can imagine how devastating it is when you do a semen analysis, you know, because you haven't gotten pregnant and you're told that there's no sperm.

确实如此。我见过男性患者崩溃的样子——这关乎婚姻目标、男性自尊等深层问题。

So it can be yeah. You know, I've seen men break down and you can imagine. I mean, you know, there's there's so much tied up. I mean, obviously, you know, goals of the relationship. I think there's a lot of, you know, concerns about masculinity as well.

我们首先要做的就是给予希望。约半数病例能找到精子，有时只需手术疏通阻塞就能自然受孕。本质上，我们会定位睾丸内的生精区域——精子需要达到最低产量阈值才会排出。

So one of the first things that we do is just try and be hopeful about it. About half the time, we can actually find sperm. Sometimes there's like a correctable blockage that we can actually bypass so they can then achieve without any other assistance besides the surgical correction. But essentially, what we do is you can find within the testicle where sperm is being made. So there's like a minimum threshold of production that's necessary before it actually gets out.

若产量低于阈值且无法通过药物刺激，我们就进行显微取精。这是门诊手术，约两小时完成。难以置信的是，很多患者次日就能上班——有人甚至当晚就乘红眼航班出差。

And if you're below that threshold and we can't sort of medically, you know, induce more production, we can go inside and try and find it. But it's an outpatient procedure. It usually takes a couple hours. You know, most men I've had men, you know, go back to work the next day, if you can believe it. Take a red eye out of town and then back to work the next day.

所以，你知道，这并不愉快，但大多数男性大多数男性表现得很好。

So, you know, it's not pleasant, but most men most men do great.

好的。男性应该做什么，或者在提高精子质量方面，大多数男性忽略了哪些方面？你知道，在改变生活方式、进行自我评估时，他们首先应该采取的措施是什么？

Okay. What should men do or what what are the areas that most guys are overlooking when it comes to improving sperm quality that they you know, the first port of call that you should be doing in terms of changing lifestyle, making a a self assessment there?

是的。嗯，我认为首先要对自己的精液质量有一些了解。我的意思是，当你第一次不太了解，或者当你观看这个视频或第一次想到这个问题时，我认为尽早获取一些初步信息，了解自己的情况永远不会太早，因为它也会随着时间的推移而变化。然后，我认为如果存在问题，应该考虑去看医生，试图找出原因。我的意思是，我认为进行基本的健康检查也很重要，因为男性通常不会主动去做这些。

Yeah. Well, I think just having some awareness of what your semen quality is. I mean, I think that, you know, looking at it when you first kind of don't know, when you're watching this or when you first think about it, I think it's never too early to just get some initial information about it, to find out where you are because it can change over time as well. And then I think if there's an issue, think going to the doctor to try and figure out. I mean, I think getting basic health screening, again, because men don't always do that.

我认为女性会去看医生，她们习惯了每年或每半年做一次宫颈涂片检查，但男性除非有问题，否则不会去。我认为常规的健康检查没有被重视。所以，检查一下这些。但我还是认为，我总是回到健康这个话题。我不想对任何事危言耸听，但确保你以正确的方式生活，保持健康的体重，饮食上不只是吃超加工食品或快餐，对自己的健康负起责任。

I think women go to the doctor, they're used to annual pap smears or semiannual pap smears, but men don't unless there's a problem. I think routine health screening is not done. So checking that out. But again, I think I just always go back to health. Again, I don't want to be alarmist about any of this, but just making sure that you're living life the right way, you know, that you're good body weight, that you're eating, you know, not just ultra processed foods or fast foods, that you take some ownership of your health.

我认为这些都是很好的起点，而且相当可行且容易。

I think those are good places to start and pretty actionable and easy.

那么药物干预呢？比如HCG和克罗米芬之类的？

What about pharmaceutical interventions? Stuff like HCG and clomiphene? Yeah.

我认为对于合适的患者，这些药物可能会有帮助。你知道，对于那些自身无法产生足够激素的患者，我认为这些药物可以有所帮助。睾酮对精子生产很重要。所以，对于睾酮水平低于平均水平的男性，我认为有一些合理的数据表明，如果我们给男性这些药物，我们可以看到改善。不仅仅是睾酮水平，有时他们会感觉更好，而且我们也能看到精子质量的改善。

So I think for the right patient, I think those can help. You know, for patients that aren't making enough of those on their own, I think that can help. You know, testosterone is important for sperm production. So, for men that have lower than average levels, I think there's some reasonable data that if we give men, you know, those medications, we can see improvements. Not just in testosterone, so sometimes they'll feel better, but also we can see improvements in sperm quality.

但我认为重要的是，男性应该去看医生，在医疗监督下进行这些治疗，而不是自行用药。

But I think it's important for men to, you know, go see a doctor and have that done under, you know, kind of medical supervision rather than treating themselves.

是的。这通常是个好规则。关于年龄和男性生育能力之间的关系？那里的曲线是什么样的？

Yes. Yeah. That's that's generally a good rule. About the relationship between age and fertility for men? What what's the sort of curve look like there?

是的。据说，有史以来最年长的父亲是96岁。所以我认为生物学上的潜力是永远存在的。当我们回顾美国过去五十年的数据时，最年长的父亲是88岁。所以，男性可以一直生育，我们基本上一直在产生精子。

Yeah. So the oldest father ever is 96, allegedly. So I think the biologic potential does persist forever. When we looked at The US over the last fifty years, the oldest father was 88. So again, men are doing it again, we always make sperm, essentially.

要知道，虽然数量确实会有所下降，精液量减少，但我们仍在坚持。有趣的是，过去五十年里，最年轻的父亲只有11岁。所以这种情况可能比我们预期的更早发生。不过我认为，重要的是让男性意识到，尽管他们可能觉得生育期限是无限的，但实际上并非如此。拖延生育时间确实会带来受孕难度增加的风险。

You know, the numbers do go down a little bit, volume goes down, but we persist. Interesting, over the last fifty years, the youngest was 11. So it can start sooner than we'd like. But, you know, I think it's important for men to know that, you know, even though, again, they think the runway's unlimited, it's probably not. So there are risks of taking longer to get pregnant.

我们的生育能力确实会衰退，因为随着时间的推移，精子质量会逐渐下降。同时某些罕见疾病的风险也会轻微上升。传统认知里，大家常听说自闭症发病率会增高。还有其他一些罕见遗传疾病的发生率也会略有增加。需要强调的是，这些疾病本身很罕见，但我们确实能观测到明显的增长趋势。

So our fertility does decline because we do see lowering of sperm quality over time. But also risks of sort of rare disorders go up a little bit. So I think classically, know, hear about autism, which goes up. There's other rare genetic conditions which can increase a little bit. Now, again, these are rare conditions, but we do see a measurable increase.

从国家和社会层面来看，父母生育年龄正在逐年攀升。对个体而言，多数男性希望拥有血缘后代，因此可能不会过分担忧这些风险——毕竟这些风险相对较小。但就整体人口而言，如果越来越多的男性不断推迟生育，我们可能会看到这些疾病的发病率随时间推移逐渐升高。所以关键是要明白：虽然六七十岁甚至八十岁仍可能生育，但早些生育确实存在某些优势。

As a country and as sort of a society, we are parental age is increasing, paternal age is increasing over time. So, you know, for an individual, I think most men wanna be genetically related, so they would, you know, sort of not be as concerned about these risks because, you know, these risks are relatively small. But, you know, as a population, if more and more men are waiting longer and longer, we may see, you know, more of these conditions become a little more prevalent over time. So I think that's kind of the thing just to understand that, you know, while you can have a child, you know, late into your sixties, seventies, eighties, it's you know, there are some advantages to doing it earlier.

男性生育力从巅峰期开始下降的转折点是什么时候？

When does the drop off begin from peak male fertility?

美国生殖医学学会作为我们的指导机构，将40岁及以上定义为高龄父亲，这也是精子库采用的标准。但衰退可能更早就开始了，我认为这是个缓慢的过程。从进化论角度看，男性的生育巅峰期应该在青春期晚期到二十岁出头。

You know, I think it the the our sort of governing board, the American Society of Reproductive Medicine, defines an older father at 40 or over. That's also what sperm donor sperm donation companies do as well. But it probably doesn't just start there. I think it's sort of a slow decline, you know, probably. From an evolutionary standpoint, our peak fertility is probably late teens, early twenties.

衰退可能从那时就开始了。如果观察精子DNA，我们每年会积累约两个突变。所以比较30岁和20岁的男性，30岁男性的DNA会多出约20个突变。考虑到我们拥有数十亿DNA分子，两个突变对个体影响不大。但在人口层面，我们可能会观察到某些变化。

So it probably starts at that point. You know, if you look at, you know, sperm DNA, we accumulate about two mutations a year. So, you know, if you look at somebody 30 compared to 20, it's gonna have the 30 year old's gonna have about 20 more mutations in their DNA. Now, given the fact that we have billions of, you know, molecules of DNA, you know, two mutations is not gonna make a big difference over time for an individual. But again, when we're talking about a population level, we may see some changes.

明白了。自闭症风险的具体增幅是多少？在40岁、50岁、60岁时分别是多少？

Okay. What's the increase in autism risk? Do you know that at at 40, at 50, at 60?

具体增幅比例我记不清了，但确实会有所上升，幅度不大。

You know, I don't recall the specific, you know, increase, like the actual percentage, but it does go up, you know, a a little bit.

好的。我还听说子女性别比例会随男性年龄变化，这个说法正确吗？

Okay. I'd also heard that the sex ratio the likelihood of the sex ratio changes with male age. Is this right?

没错。这也是个非常有趣的发现。我们讨论男性生殖健康衰退时，之前提到过精子数量问题。

Yeah. That's also yeah. It's a very interesting finding as well. We talk about sort of declining men reproductive health. So we talked about sperm counts.

几十年来，睾酮水平也在下降。有些研究表明，性别比例同样发生了变化，某种程度上与年龄无关。但如果你具体看年龄因素，随着男性年龄增长，生育男孩的几率会略微下降。所以，超过70岁后，这个几率确实会降低。大约下降几个百分点，但这是可测量的。

Testosterone levels have gone down over the decades as well. And there's some studies that show that the sex ratio has as well, sort of independent of age. But if you look specifically at age, as men get older, the chance of a male birth goes down a little bit. So, over age 70, it does go down. It goes down sort of a few percentage points, but it's measurable.

任何改变性别比例的因素对人口来说都是大事，考虑到这个比例对物种繁衍的重要性。有趣的是，如果你观察一些社会压力事件，也能看到这种现象。比如经济衰退或战争期间，性别比例会下降。我们确实能看到性别比例的变化，这是个真实存在的现象。

And anything that changes a sex ratio is sort of a big deal to a population, just given how important, you know, that ratio is for the propagation of the species. And interestingly, there's if you look at sort of like stressful, you know, like sort of societal events, you can see that as well. Like, you know, the sex ratio goes down during like economic downturns, for example, wars. We see changes in the sex ratio. So it's a real phenomenon.

而且这个现象与父亲年龄相关的事实，我认为非常能说明问题。

And the fact that it, you know, tracks with the father's age, I think, is very telling.

机制是什么？你知道原因吗？

What's the mechanism? Do you know why?

我认为这被认为是子宫层面的选择性胎儿流失。至于为什么更倾向于选择男性而非女性，目前还不完全清楚，但确实是可以测量到的现象。

You know, I think it's thought to be kind of selective fetal loss at the uterine level. And, again, why it sort of selects the males more than females, think, is not not totally known, but it's, yeah, it's it's measurable.

但随着男性年龄增长，生育女孩的可能性会增加。是这样吗？还是说反过来了？

But it's as males age, female likelihood increases for children. Is that right, or is it the other way around?

呃，我想我刚才说的其实包含两个方面。可能我没表达清楚。在社会层面，我们看到的更多是子宫层面的选择机制。

Well, so I guess so I I think there are kinda two things I was saying. So I I wasn't clear. So, you know, for a societal level, I think that we see that kinda, I guess, calling it the uterine level.

嗯。

But Mhmm.

我们认为就父亲年龄而言，问题更多出在精子层面。携带Y染色体的精子似乎因为某些原因，在最终形成活产婴儿的效率上不如其他精子。

We think that for for paternal age, it is kind of the it is sort of the sperm level. Just that those sperm, for whatever reason, the Y bearing sperm don't seem to be as efficient as making it all the way to live birth.

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哦，有意思。你觉得——现在试管受精无处不在。我在安德鲁·舒尔茨的现场秀上了解到宫腔内人工授精(IUI)，当时就产生了兴趣。还有种技术叫ICSI或ISSI什么的？现在正掀起一场试管受精革命。

Oh, okay. That's interesting. How do you think I mean, IVF is everywhere. IUI, I learned about at Andrew Schultz's, live show, which was, kind of an interest and then there's I s c I or I s s I or something as well. There's a whole there's an IVF revolution going on.

你如何看待这项新技术正在改变生育领域的格局？

How do you come to think about that new technology changing the landscape here?

确实。我认为卵胞浆内单精子注射技术(ICSI)——即选取单个精子直接注入卵子的技术——堪称过去半个世纪医学界的革命性突破。它让那些精液中无精子或睾丸中仅有极少量精子的男性，比如我们讨论过的某些遗传疾病患者，也能成为生物学父亲。这项技术大幅降低了男性成为父亲的门槛，比如那些童年接受过癌症治疗导致精子生成障碍的人。虽然依赖这类技术的夫妇数量在增加，但这些技术确实意义非凡。

Yeah. I mean, I think, you know, that ICSI, I c s I, the intracytoplasmic sperm injection, where you can take a single sperm and inject into an egg, has really been, in my opinion, one of the revolutions of medicine in the last, you know, quarter half century because it allows, like, these men that we talked about where there's no sperm in the ejaculate, very rare sperm in the testicle to be able to become biologic fathers. So it really, you know, allows it really lowers the bar significantly for who can become a father, you know, for men that have had, you know, some guy we talked about, again, some genetic conditions, but other conditions too. If they were treated for cancer as a child, and now they can't make sperm as efficiently, I mean, allowing these men to be able to become parents, I think, is terrific. But we are seeing increases in the number of couples that are requiring these technologies, and I think they are great.

在美国，试管婴儿的比例已从过去的1%上升到现在的2%，且持续增长。原因多样：精子数量下降是因素之一，但社会层面上，夫妻生育年龄推迟也是关键。随着年龄增长，男女生育力都会衰退，这使得更多夫妇需要借助辅助生殖技术。

In The US, it used to be that maybe one percent of births were conceived by IVF. Most recently, it's about two percent of all births in The US are conceived by IVF, and those numbers are only increasing. I think there's a variety of reasons. I mean, I think, you know, falling sperm counts are probably a contributor. But, you know, also couples, you know, from a social standpoint are just waiting a little bit longer.

从进化角度看这或许不算最优解，但试管受精确有优势：它能筛选特定胚胎规避遗传疾病，比如那些导致精子数量下降的基因缺陷。斯坦福伦理学家汉克·格里利在《性爱的终结》一书中预言，未来性行为将仅保留愉悦功能，而我们可以通过皮肤活检制造精卵，在培养皿中培育胚胎。

And as we age, both men and women, fertility declines. And so I think more couples are becoming reliant on needing these technologies. But, you know, I think there's you know, it just I guess from an evolutionary standpoint, it doesn't sound like it would be the best, but I think, you know, there are some potential advantages to IVF. It allows, you know, sort of selection of specific embryos to try and, you know, avoid, you know, kind of heritable conditions, you know, some of these genetic conditions that lower sperm counts, for example, that we could be able to avoid those in the future. There's this ethicist at Stanford, Hank Greeley, that wrote this book called The The End of Sex.

他推测未来性爱将仅用于享乐，而人类可以通过男女皮肤活检制造精子和卵子，在培养皿中培育胚胎。

And so he rationalized in the future that sex will just be for pleasure, and then in the future, we'll be able to take, you know, skin biopsies from men and women, make sperm and eggs, you know, grow embryos in a dish.

那就是IVG（体外配子发生）技术吧？

That's IVG. Right?

没错，正是体外配子发生技术。社会推广这项技术的动力在于它能消除遗传疾病——不仅是已知的囊性纤维化等疾病，甚至可能筛选高血压、糖尿病等疾病的易感基因。虽然这有点《美丽新世界》的意味，未必是人类社会的理想方向...

Yeah. Yeah. In vitro in vitro gametogenesis. Exactly. But the advantage to doing this and why sort of society will be, you know, incentivized to do this is you could eliminate sort of genetic diseases.

我们讨论过囊性纤维化等已知遗传病，但该技术甚至可能筛查高血压、糖尿病等疾病的易感基因。虽然这开始有点像反乌托邦小说，未必是社会发展的理想方向...

You know, we talked about things we know about like cystic fibrosis or certain genetic conditions of lower sperm. But, you know, maybe you could even look at, you know, susceptibility to high blood pressure, diabetes, and things like that. So really try and root out, you know, again, it kinda gets a little bit brave new world, and maybe it's not where we wanna be as a society. But

这真是个棘手的问题，老兄。我...你知道乔纳森·阿诺玛是谁吗？你熟悉他吗？不。他参与的一家公司正在为某些特征进行胚胎筛选。

It's a difficult one, man. I I've had a do you know who Jonathan Anomaly is? Are you familiar with him? No. The there's a a company that he is involved with that is doing embryo selection for certain traits.

他用了这个例子，我觉得非常聪明。关于近视的问题很有意思，就是那些视力较差的人。是的。你知道，这并没有太多道德负担。我知道有些人，比如聋人群体，会把这视为身份认同的一部分，这接近于他们的自我认知。

And he he uses this example, which I thought was really smart. It was really interesting around myopia, like people that just have worse eyesight. And Yeah. You know, there's not really much moral weight that's put on that. I know that some people, you know, sort of the deaf community identify as that, and that's kind of close to their sense of self.

我不认识任何以近视作为自我认同的人。你知道，这只是让他们需要戴眼镜或隐形眼镜，或者在光线太暗时眯一下眼睛的事情。对吧。而且，是的，选择的机会来了。你可以选择让孩子拥有非常好的视力，或者让孩子从11岁开始就需要戴眼镜。

I don't know anybody who has shortsightedness that identifies with their shortsightedness. You know, it's just it's a thing that requires them to have glasses or wear contact or, you know, squint a little bit when the lighting is too dark. Right. And, yeah, the opportunity to select, hey. You have the choice between your kid having really great eyesight or your kid needing glasses from age 11.

但你说得对。这项技术和这种方法在历史上并不光彩、公平和人道。所以这很危险，但你知道，我认为这可能是一个...我想说，虽然缓慢，但会是一个相当快的转变，我认为，胚胎筛选，尤其是针对特定特征的筛选，会因为高龄父母的可能性而变得更加普遍，他们叫什么来着？高龄妊娠叫什么？

It but then you're right. This technology and this approach has not exactly had an illustrious, fair, and humane history. So it gets perilous with with this, but, you know, I think it is a probably, I chose gonna say, like, a a slow, but it's gonna be a pretty quick transition, I think, to a world where embryo selection, especially for for particular traits, is gonna become even more common given how likely it is for older parents, whatever they're called what's the elder pregnancy called?

女性的话，是高龄父亲还是老年妊娠？

What a woman Like, advanced paternal age or geriatric?

老年妊娠。就是这个。是的。这是所有术语中最不公平的一个。但是，是的，我认为这会变得非常普遍。

Geriatric pregnancy. That's it. Yeah. The the most unfair term of of all of them. But, yeah, I think I think this is gonna be this is gonna be pretty pretty common.

好的。所以一方面，我们有精子质量。嗯。但另一方面，大多数男性也关心的是睾酮水平。是的。

Okay. So we've got, on one side, sperm quality. Mhmm. But the other side that most guys care about as well, testosterone levels. Yes.

睾酮水平发生了什么变化？它与男性生育能力有什么关系？目前的情况如何？

What's happening with testosterone levels? What's the relationship between that and male fertility? What what's the sort of current state of play there?

是的。就像我们之前讨论的，我们也看到睾酮水平随时间下降。我认为人们将其归因于类似的因素。你知道，暴露于某些环境、久坐的生活方式、更多的肥胖。睾酮在睾丸中产生，然后在体内转化为不同的物质，比如在外周被芳香化为雌二醇。

Yeah. So I think, just like we talked about it, we are seeing declines in testosterone over time as well. And I think when people look at it, I think they they sort of attribute it to similar things. I think that, you know, exposures, sedentary lifestyle, more obesity. So testosterone, again, made in the testicles, and then it's converted to different things, you know, in the body, like it's aromatized peripherally to estradiol.

很多这种转化发生在脂肪组织中。所以你可以想象，如果脂肪组织更多，这种芳香化会更频繁，因此睾酮水平会下降一些。随着这些水平下降，我认为它会在一定程度上影响精子的产生。所以我认为这两者之间也有关系。而且，当男性寻求治疗时，当他们开始使用睾酮补充剂或睾酮疗法时，我们也可以看到与精子数量的直接相关性，因为睾酮补充或治疗会直接减少精子的产生。

And a lot of that happens in fatty tissue. So you can imagine if there's more fatty tissue, more of that aromatization will occur, and so the levels will decline a little bit. And so, you know, as these levels go down, I think it does you know, it can affect, you know, sperm production to an extent. So I think there is a relationship to that as well. And, you know, again, when men sort of seek out treatment for this, when they start on testosterone, we can also see, you know, direct correlation with sperm counts just because testosterone supplementation or testosterone therapy can directly, you know, decrease sperm production.

嗯，有时候还会出现这种奇怪的负相关现象——睾酮水平越高，精子质量反而越低，但几乎没人会希望自己的睾酮水平降低。对，确实如此。

Well, you've got this weird inverse relationship sometimes as well between higher testosterone, lower sperm quality, but also very few guys say that they want that testosterone level to be lower. Yeah. Yeah.

是啊，有意思。我接诊过抱怨阴茎太大的患者，不过这种主诉很罕见。

Yeah. Interesting. I've had patients come in that said their penis is is too big, but it's a rare complaint.

我也这么觉得。不过说到阴茎变大这个话题，之前不是有相关研究吗？

I imagine so as well. Yeah. Alright. Though, actually, the penis is getting bigger thing. Was there not a study about that?

是的。

Yes. Was

统计数据不是显示睾丸在变小、肛门生殖距离在缩短，但阴茎却在变大吗？

there not is it not statistic statistics that is it testicles getting smaller, anal genital distance getting smaller, but penis is getting bigger?

对，这是个很好的过渡。我们确实做过这项研究。

Yeah. Yeah. It's a good segue. So we yeah. So we did a study on this.

有趣的是，就像精子数量研究那样——多年来不同群体都有精液质量测量数据发表，我们可以综合分析这些研究观察随时间的变化。同样地，多个群体也长期测量过阴茎长度。我们分析近几十年的数据时，原本预期基于这些因素（如男性生殖器发育迟缓、精子数量减少、睾酮水平下降、肥胖率上升）会导致阴茎缩短。

So interestingly, there are lots of know, just like the way the sperm count study was done is that over time, people have measured semen quality in different populations and published it. And then you can look at all these studies together and just see if there's changes over time. So similarly, penis length has been measured over time in a variety of populations. So we looked at it, over the last several decades and found, you know, we expected it to decline for all these reasons, right? We're seeing the lower sort of development, male genital development, lower sperm counts, lower testosterone levels, more obesity.

按理说这些都会使阴茎变短对吧？因为测量方法是拉伸阴茎后从尖端量到耻骨。但出乎意料的是，数据显示阴茎长度反而略有增加。虽然趋势明确，但具体原因尚不确定。

All those things should necessarily lower penis length, right? Because the way that penis length is measured is you kind of pull the penis on stretch and measure from the tip to the pubic bone. But much to our surprise, it had actually gotten a little longer over time. And so, you know, why that is, is not certain. You know, we saw it pretty consistently.

我们有个假设：青春期时间点正在提前，这意味着生殖器发育时间更长。这可能是解释该现象的原因，当然这只是我们的推测。

You know, we had one hypothesis we had is that puberty is changing over time. The timing of puberty is changing, and it's actually gotten a little bit earlier. And when it gets earlier puberty, leads to kind of more time for genital development, longer genital development. So that's sort of our hypothesis why that may explain it. But yeah, that was a finding.

这结论肯定引发了不少讨论吧。好了，现在聊聊勃起的问题。

Yeah. I imagine that that caused some ructions. Okay. Erections. Talk about erections.

好的。

Okay.

勃起功能障碍有多少比例是由生理或心理因素引起的？

How often is erectile dysfunction due to physiological or psychological factors?

是的。过去我们以为全是心理问题，但现在知道心理因素可能只占10%，大部分其实源于器质性病因。血流问题才是主因。我认为任何影响心脏血流的因素同样会影响阴茎血流，比如糖尿病、高血压等血管性疾病都很常见。

Yeah. So we used to think it was all psychologic, but now we know that it's probably only 10% psychogenic, and most of it's actually due to organic causes. So, you know, blood flow issues are the main culprit. And I think anything that affects blood flow in the heart can also affect it in the penis. So, you know, diabetes, high blood pressure, all those vascular conditions are very common.

某些药物——那些降低全身血压的药物也会降低阴茎供血压力导致问题。盆腔手术如前列腺手术在这方面臭名昭著，结肠手术、膀胱手术同样可能影响阴茎接收神经信号和充血功能。至于常被提及的激素原因，其实占比不足5%，虽然低睾酮也可能导致，但这类患者在就诊者中确实是少数。

Different medications, you know, medications that lower blood pressure anywhere in the body lower the blood pressure head the penis sees and can also cause those issues. Sometimes pelvic surgeries, you know, in that area, like prostate surgery is notorious for that. You know, colon surgery as well, bladder surgery, those things can also affect, you know, the ability of the penis to get erect, to, you know, get those signals, get the blood flow where it needs to be. And then, you know, the thing that I think is commonly thought of as, you know, hormonal causes are probably less than five percent, but sometimes low testosterone can also do that. But it's really the minority of all patients coming in.

明白了。如果要给就诊患者的勃起功能障碍主因排序，会是哪些？

Okay. So what the main reasons for erectile dysfunction, if you were to rank order them for the patients that come in to see, what are they?

我认为主要还是血管性共病。典型代谢综合征要素：高血压、高胆固醇、糖尿病、肥胖，还有吸烟等。这些可能是最常见的诱因。

I think mostly it's just due due to these vascular comorbidities. You know? So kind of the classic metabolic syndrome. So high blood pressure, cholesterol, diabetes, obesity, you know, again, other things like smoking. I think those are probably the most common causes for erectile dysfunction.

但这现象其实非常普遍。许多男性就诊时觉得难以启齿，但数据显示40岁以上男性超半数存在勃起困扰。所以我常告诉患者：只要阴茎还在，我们总有办法让它硬起来。

But it's also very common. I think, you know, when men come to see me, they feel like they're all alone. But if you look at it, over the age of 40, over half of men have some trouble with erection. So, it is very, very common. I always like to tell men, as long as you have a penis, we can always make it hard.

所以方法很多，请保持乐观。

So, there's a lot. Try and be optimistic.

明白了。普通男性该如何改善血流？比如有人觉得自己抽烟喝酒都不多，但想提升血流功能，具体该怎么做？

Okay. What should men do to improve blood flow? Normal guy, he's like, I'm not smoking that much, I'm not drinking that much, I should improve my blood flow. What what does that mean?

对，其实可以做得更好。首先尽量戒烟或减量。酒精方面，有句俗话叫'威士忌阳痿'...

Yeah. So, I mean, I think you can do better. Right? So, I mean, you should try and stop smoking or cut down if you can. You know, alcohol, I think, know, there is an expression like whiskey dick.

对吧？所以如果你饮酒过量，肯定会降低那个。但我觉得适量的话，可能影响没那么大。不过，如果有改进的空间。然后我认为任何对心脏有益的东西都会有帮助。

Right? So if you drink to excess, it can definitely lower that. But, you know, I think in moderation, it probably doesn't have as much of an effect. But, you know, again, if there's room for improvement. And then I think just anything that's good for your heart.

所以我认为更多的运动可能是有益的。我觉得那肯定会改善情况。

So I think more exercise, I think, could be beneficial. You know, I think that will definitely improve things.

好的。荷尔蒙在这里扮演什么角色？我觉得很多时候，男人们会直接假设勃起功能障碍是荷尔蒙失衡，然后加速器被按下，我们就直奔主题了。

Okay. What what's the role of hormones here? I think a lot of the time, guys would just assume erectile dysfunction, some hormonal imbalance, then the accelerator gets pressed, and we're off to the races.

没错。所以，当你接受评估时，我认为这是我们总是会做的一项筛查测试，因为我们确实有时会看到这种情况。我们会检查睾酮水平。如果水平低，我们会讨论让这些男性接受睾酮治疗以尝试改善情况。对于那些睾酮水平处于边缘低或低正常范围的男性，这不太可能是全部原因。

That's right. So, you know, when you get evaluated, I think that's one of the screening tests that we always do, just because we do see that some of the time. So we will check the testosterone level. And if it's low, know, those are the men we do discuss, you know, putting on testosterone therapy to try and improve things. Now for men that have, you know, kind of a borderline low or maybe low normal level, it's unlikely that's gonna be the whole story.

但对于一些睾酮水平非常低的男性，这可能是完全没有勃起和有勃起的区别。如果你熟悉这个范围，大概300到900是睾酮的平均水平，单位是纳克每分升。所以对于睾酮水平在200左右的男性，睾酮治疗可能有点帮助，但我认为这些男性也会从西地那非或伟哥这类药物或治疗中受益。但当他们的睾酮水平在100左右时，我认为这些男性会看到睾酮治疗在勃起功能和性欲方面的显著改善。

But for some men that are very low, you know, that can be, you know, the difference between no erections and erections. You know, men that are you know, if you're familiar with sort of the ranges, probably 300 to 900 is sort of the average levels of testosterone nanograms per deciliter. And so for men in the 200 range, testosterone level may help a little bit, but I think those men will also benefit from like Sildenafil or Viagra, you know, those kind of medications, those therapies. But when they're in the 100 range, I think those men will see, you know, significant improvements in erectile function and sex drive as well with testosterone therapy.

是的。这是个很好的观点。勃起功能和性欲在身体里是一回事吗？它们有什么相似之处？又有什么不同？

Yeah. That's a great point. What's the is is erectile function the same thing as libido in the body? What how does this what's similar? What's different?

是的。我认为它们有很多重叠，因为我觉得有一种负反馈机制。如果你没有勃起，你就会变得不那么感兴趣，但它们是不同的实体。所以我有些病人来就诊时只有性欲或性冲动的问题，而其他男性则没有性欲问题，只是功能上不行。

Yeah. I think there is there tends to be a lot of overlap because I think there is kind of like just negative feedback. If you're not getting erections, you just become less interested, but they are distinct entities. So I have patients that come in just with, you know, isolated, you know, sex drive, libido concerns, and then other men coming in, no problem with sex drive. It just just doesn't work.

它不像以前那样好用了。所以，是的，我们对这些情况的处理方式会有些不同。

It doesn't get as used to. And so, yeah, we we approach those a little bit differently.

是什么影响了性欲？我的意思是，它似乎是那种行为性的东西，对吧？我猜有很大的心理成分。是的。

What contributes to libido? I mean, it it seems to be one of those sort of it's behavioral. Right? It's the huge psychological component, I have to imagine. Yes.

但并不完全是。所以，到底是怎么回事？

But not exclusively. So, yeah, what's going on?

是的。所以，我们打算进行一项激素评估。我认为睾酮是我们需要关注的一项指标。有时我们会进一步检查其他项目，比如雌二醇和泌乳素也很重要。另外，我觉得非常有价值的一点是，当我们讨论时，你提到了某些心理因素的作用，这时候引入性治疗会很有帮助。

Yeah. So, I mean, we are gonna look do a hormone evaluation. I think, you know, testosterone is something that we look at. Sometimes we expand that a little bit to looking at other things, like estradiol is important in that, prolactin as well. The other thing I think that's very valuable is, you know, when we're talking, you mentioned sort of the psychogenic components of some of this, is to involve sex therapy.

我认为全球各地都有很多优秀的性治疗师，我们本地也有合作密切的专家团队。对于这类障碍，我们通常采取多管齐下的治疗方式。既要优化器质性病因的治疗，也要改善心理性因素。要知道这不会一夜之间就见效。

I think there's a bunch of excellent ones, you know, all over the world. There's excellent ones in our area that we collaborate with a lot. So, for some of these disorders, we, you know, kind of do it as sort of a multi pronged approach. So, you know, we want to optimize the organic causes and optimize some of the psychogenic causes. And just know that it's not going to get better overnight.

不太可能靠一片药就解决所有问题，这可能需要时间。但我们也会尝试关注伴侣关系等其他方面，因为我认为这些因素都在共同起作用。

Unlikely, a pill is gonna solve some of these issues, and it, you know, may take some time. But, you know, we try and, you know, look at relationship and other aspects to it as well because I think all those are contributing.

当你提到心理性病因时

When you're talking about psychogenic causes there

嗯哼。

Mhmm.

具体是什么机制让大脑能够干扰阴茎功能？到底发生了什么？听着，每个正在收听的男性都经历过这种时刻——突然发现自己今天就是不行。但这根本不是你能控制的。

What is the what's the mechanism that's occurring that your brain is somehow able to intervene with your penis? What what's happening there? I mean, look. Every guy that's listening to this has, at some point, just gone, I I not today, apparently. And but you it's not your choice.

你完全不明白背后的运作机制。所以给我们揭秘吧，拉开帷幕让我们看个究竟。

You didn't have any idea what the mechanism that was going on. So liberate us. Show us behind the curtain.

就我们目前所知的范围来说。

To the extent we can. Yeah.

没错。

Yeah.

我认为消除勃起最有效的方法之一就是过度关注它。当你有任何担忧时——确实如此。比如在新恋情初期，或者工作压力大的日子，出现这种情况并不罕见。

Well, I think one of the best ways to get rid of erections is to think about it. So I think if there's any concern you know? Yeah. Yeah. So, like, you know, anytime you're kinda worried about it and I think it's not unusual, like in a new relationship or other situations, if it was a stressful day at work, you know, you may have some problems.

要知道，如果某天晚上你没睡好，我觉得偶尔出现些问题并不罕见。然后这几乎会形成一个恶性循环。如果你为此担忧，下一次它就会真的成为问题，接着你就会陷入那种螺旋式下降的状态。来找我看病的患者们，他们显然已经为此焦虑了，对吧？这种情况往往已经持续好几个月了。

You know, if you didn't get a good night's sleep, I think it's not unusual, you know, every once in a while for there to be problems. And then it can almost be a vicious cycle. So if you worry about it, you know, the next next time then it becomes a problem and then you kinda, you know, go down that spiral. You know, certainly by the time patients have come to see me, you know, they're worried about it, right? And so it's been going on for months.

所以我认为这些患者需要某种程度上被‘重置’。我们会先做评估，通常没有明确的器质性病因。可以尝试用药物帮他们重启，比如西地那非（万艾可）、他达拉非（希爱力），这些药物效果不错。

And so I think those are the guys we need to sort of reset to some extent. So I think, you know, we do an evaluation. You know, oftentimes, there's not a clear organic cause. You know, we can try and reset them. Think like, you know, Sildenafil, Viagra, Tadalafil, Cialis, I think those work well.

然后我们会逐步减少药物依赖。同时配合性治疗师指导的特定训练和技巧，来缓解那些焦虑反应。想象一下，一万年前我们住在山洞里，当老虎出现时，你肯定不希望自己勃起对吧？这是皮质醇应激反应在起作用。

You know, and then we kind of gradually wean them off. And then also, you know, work with sex therapists as well for, you know, different exercise and techniques to sort of minimize, you know, some of those sort of anxiety responses. I mean, you know, if you think about it like ten thousand years ago, when we lived in caves and a tire comes around, you don't want erection, right? I mean, there's a cortisol stress response.

可能会把老虎吓跑。

It might scare it off.

对，但愿如此。不过这也取决于你对老虎的想象。总之当时你需要逃跑，对吧？

Yeah. Yeah, hopefully. Mean, yeah, I guess it depends how you think about tigers. But yeah. So, you know, you wanna run away, right?

人体机制会将血液调配到其他部位以便逃生。现在当你焦虑时，同样的机制会让勃起功能暂时失效。虽然需要些时间调整，但这类患者通常都能找到有效的治疗方案。

And so, you know, the body is designed to shift that to the rest of your body so you can escape. And so that same thing happens now, you know, when you're worried about it. It's just it you know, erections are just not not functional. And so we did take some time, but usually, you know, these are guys that we can't come up with an effective regimen for.

现代社会中，年轻男性的勃起功能障碍发病率是否在上升？目前有什么趋势吗？

Are we seeing an increase in erectile dysfunction in the modern world, in younger men? Are there any trends occurring at the moment?

有些研究显示——虽然还在进行中——社交媒体隔离和现代约会方式确实引发了一些担忧。但总体而言，发病率保持相对稳定。心理因素确实有影响，但更多与血管健康状态相关。

Are some studies. I think those studies are still ongoing. I think there is certainly some concern about some of that with some of the isolation in social media, just kinda how we're living dating practices now. But I think that, in general, I think, overall, the rates have stayed, you know, pretty consistent. And I think, again, a lot of the causes psychogenic does contribute to some extent, but I think a lot of it has to do with just vascular health.

科技发展在某种程度上让我们更健康了。比如现在的运动方式更有趣，不再是单调的跑步，你可以听播客，或者通过屏幕加入社群一起锻炼。这些变化让运动更有吸引力，也带来了很多积极影响。

So hopefully, you know, this technology has made us, you know, to the extent it can, you know, a little healthier. I mean, I think that exercise has gotten more fun over time, right, instead of just like running in front of nothing. You know, now you can listen to an interesting podcast, for example, or, you know, you can, you know, exercise, you know, with, you know, a community, you know, on the screen. So I think those things, I think, I find more engaging. So I think there's certainly some good that comes with a lot of that as well.

本期节目由Element赞助播出。真正补水后的夏天体验截然不同。人们常把那种疲惫、头晕、肌肉抽筋归咎于炎热或劳累，其实可能是电解质失衡——而单纯喝水无法解决。Element无糖电解质饮料含有精确配比的钠、钾、镁，零糖分、零食用色素、零人工添加剂，彻底改变补水方式。

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今年夏天，他们推出了新品——柠檬盐。就像柠檬冰棒长大了，整顿好生活，开始支持你的肾上腺系统和补水功能。最棒的是，他们提供无条件退款政策。你可以购买后随意试用，如果不喜欢，他们会退款，甚至无需退回包装盒。

And this summer, they've dropped something new, lemonade salt. It's like a lemon popsicle grew up, got its life together, and started supporting your adrenal system and your hydration. And best of all, there's a no questions asked refund policy. So you can buy it, try it for as long as you want. And if you don't like it, they'll give you your money back, and you don't even need to return the box.

他们对你会爱上这款产品充满信心。此外，美国境内免运费。现在通过下方描述中的链接或访问drinklmnt.com/modernwisdom，首单可免费获赠八种口味的样品包。网址是drinklmnt.com/modernwisdom。你刚才隐约提到了新技术和生活方式可能带来的影响。

That's how confident they are that you'll love it. Plus, they offer free shipping in The US. Right now, you can get a free sample pack of all eight flavors with your first box by going to the link in the description below or heading to drinklmnt.com/modernwisdom. That's drinklmnt.com/modernwisdom. You've sort of hinted there at potentially new technology and lifestyles having an impact.

关于色情内容使用与勃起功能障碍之间的机制，有多少证据支持？这在文献中确实有记载吗？我知道网上这类说法很多。

How much evidence is there for a mechanism between porn use and erectile dysfunction? Is that does that actually appear in the literature? I know it kind of appears a lot on the Internet.

抱歉，你刚才问的是哪两者之间的关联？

About sorry. What was the between what?

色情内容。勃起功能障碍。

Porn. Erectile dysfunction.

是的。我认为确实存在这种现象。现在获取色情内容容易得多，数量庞大且种类繁多。问题在于它可能无休无止且强度极高。

Yes. Yes. So I think, yeah, we do see that. I think that, you know, basically, it's a lot more accessible now, and, you know, you can can find lots of it. And it's, you know, the obviously, there's varying kinds, but, you know, the issue is that there's just, you know, it's nonstop, it can be, and very intense.

如果男性习惯了这种刺激，之后要重新适应就变得困难。因为这种强度可能超过常规伴侣关系能提供的。在没有同等刺激的情况下，他们在正常伴侣关系中可能难以维持勃起。这需要像治疗其他心因性勃起功能障碍那样的康复训练，最好与性治疗师合作。虽然文献中有相关研究，但个体差异很大。

And so, you know, if men kind of are attuned to that, it's difficult to sort of retrain after that because, you know, it can give you it can give men sort of more than they can get with a sort of a, you know, partner on a routine basis. And so, you know, without that level of intensity, sometimes they have trouble, you know, maintaining erections, you know, kind of in a normal partner setting. And so that also is gonna take, you know, just some retraining. Again, think sort of the same regimen we use for other forms of psychogenic ED, but, know, collaborate with sex therapists. But, you know, I think it's in the literature, I think there are some associations.

我认为某些男性可能更易受影响，并非所有人都会如此。但这是需要警惕的现象。许多来就诊的患者自己都隐约意识到这个问题，这些患者通常更愿意配合治疗改善状况。

I think, you know, some men are probably more susceptible than others, so it's certainly not gonna affect everybody. But it is something to be aware of. And I think a lot of patients that I've come in or that have come into clinic to see me, I think they have some sense that it may play a role. And I think those are the ones that are gonna be a lot more, willing to, you know, kinda go through the the measures to get it better.

如果像他达拉非这类药物能解决问题的话

If, something like tadalafil fixes things

嗯。

Mhmm.

这是否暗示存在其他心血管问题？如果改善血流就能解决你维持勃起的主要问题，那可能意味着你身体其他部位也存在血流相关的问题。

Does that suggest other cardiovascular issues? If the primary issue in you maintaining an erection is fixed by something that improves improves blood flow, that suggests that other issues with regards to blood flow may be elsewhere in your body.

有可能。我是说，这要看情况。这些药物效力很强，有些人甚至为娱乐目的使用，因为它确实能在生理上起作用——具体来说，它能维持那种本质上负责扩张阴茎血管的化学物质。

It could be. I mean, I think it depends. You know? I think these medications are very powerful. Some people use them recreationally, you know, because it does help you you know, physiologically, what it does is it, you know, keeps the chemical that basically opens up the blood vessels in the penis.

只是让这种化学物质作用更持久。所以无论你是否存在勃起障碍，药物都应该能增强勃起功能。但要知道，勃起功能障碍可能先于其他血管疾病出现，因为阴茎血管比身体其他部位（如颈动脉或心脏）的更细小。有研究表明，患有勃起功能障碍的男性在未来五到十年内心脏病发作风险更高。所以这可能是个预警信号，也是建议你找医生评估是否存在潜在血压问题的另一个理由。

It just keeps that there for longer. So regardless of whether you have a problem or not, it should make erections better. But, you know, erectile dysfunction can precede other vascular conditions just because the peanut the blood vessels in the penis are smaller than they are in the rest of the body, like in our carotids or in our heart. So there have been some studies that say that men with erectile dysfunction, you know, are at higher risk for a heart attack in the next, you know, five to ten years. So I think potentially it could be a warning sign, and again, another reason to get evaluated by your doctor to see if there's underlying blood pressure issues

或者，

or,

比如说血糖问题。

you know, blood sugar issues, for example.

我想了解睡眠如何影响睾酮水平和生育能力，或者说它们之间存在什么关系。

I'm interested in how sleep impacts testosterone and fertility, or what the relationship is there.

是的，睡眠也很重要。这并不意外，我们给患者的建议中总会强调睡眠。虽然它不是全部原因，但确实是个影响因素。

Yeah. So it's also important. I mean, not surprising. I think that, you know, when we talk to patients about things they can do, sleep is certainly one of them that we'll we'll focus on. But, you know, it tends not to be the whole story, but it can be definitely be a contributor.

有趣的是，睡眠与精子质量呈U型关系。睡眠过多或过少都不好，理想时长大约在6到9小时。职业运动员可能每天睡12小时，但对普通人来说，过度睡眠时精子数量会下降。

Interestingly, it's for sperm, it's sort of a U shaped relationship. So it's possible to get too much sleep and then not enough sleep, right? There's sort of a sweet spot, probably like six to nine hours is good. You know, if you sleep twelve hours a day, I mean, I think some professional athletes do that, but for other people, there may just be other things going on. And so we do see declines in sperm counts at those levels.

而睡眠不足（少于6小时）的男性精子数量也会降低。虽然'多睡觉少压力'说起来容易，但实践起来可能更难。睾酮水平同样受此影响——压力会通过皮质醇作用对抗睾酮分泌，睡眠不足时这种负面影响更明显。

And then for men that don't get enough sleep, you know, less than six hours, we see lower sperm count as well. So I think there's you know, again, it's easy to say more sleep, less stress. It's probably a little harder for some to, you know, to actually, you know, put that into action, but it certainly can play a role. And for testosterone, it's the same thing. I think that we do see stress negatively impact testosterone levels because cortisol, you know, you know, is at play with stress and sleep, and it sort of antagonizes testosterone to some extent.

所以男性若能优化这些因素，必然大有裨益。

So, I think if men can optimize those things, it'll only be beneficial.

所以这与心理健康、压力、生活方式压力以及睡眠都存在关联。

So there's a relationship here with mental health, stress, lifestyle stress, as well as sleep too.

是的。没错。我认为这完全正确。

Yes. Yeah. I think that's exactly right.

升高的皮质醇对任何方面都不利，如果身体感觉你一直处于战斗状态，它就会降低制造精子的优先级？

That's elevated cortisol is not good for anything at all, and the body just down prioritizes making sperm if it feels like you're at war all the time?

对。就是这样。这被认为是其中的机制。我想，身体是知道的，对吧？

Yeah. That yeah. That's sort of thought to be the mechanism. I think, yeah, you know, the body knows. Right?

你知道，它想要生存。那就是，进食、生存、繁殖。所以生存比繁殖稍微优先一些，尽管繁殖当然也非常非常重要。但如果你处于那种情况下，它会降低繁殖的优先级。

It's you know, it wants to survive. That's, you know, eat, survive, reproduce. So survive is slightly ahead of reproduction, although reproduction is certainly, you know, very, very important. But, you know, if you're in that situation, it'll deprioritize reproduction.

我想这会形成一个恶性循环，如果你因为可能无法生育而感到压力，压力本身会进一步降低生育能力，而这正是你试图积极改善的方面。

I imagine that makes for a very vicious loop if you become stressed about the potential of having kids because the stress itself is going to further decline fertility, which is the precise thing that you're trying to have a positive impact on.

没错。完全正确。所以这非常关键。我的意思是，当我们讨论这些时，尽量保持乐观。

Yeah. That's exactly right. Yeah. And so that's really key. I mean, that's when we talk about these things, try and be optimistic.

尽量给人们一些可操作的建议，但同时不想让人感到不堪重负。再次强调，潜力巨大。如果你读研究，人们会嘲笑流行病学家，因为暴露于X会导致结果Y，有太多相关因素。所以我们只想让它变得非常容易理解和实现。我认为，我们讨论的许多事情，希望会对生殖健康有益，当然也会对整体健康有益。

Try and give people some actionable things, but you don't wanna be overwhelming at the same time. Again, there's so much potential. If you read studies, people sort of make fun of epidemiologists because it's exposure, x leads to outcome y, and there's so many things that are related. So we just wanna, you know, again, make it very approachable and possible. And I think that, you know, a lot of these things that we talked about already, you know, hopefully will benefit reproductive health, but certainly benefit overall health.

而且我认为这些都在我们的掌控之中。

And I think they're all all under our control.

好的。从实际操作的角度，如果要为男性制定一个维护生殖和性健康的清单，你会把哪些不可妥协的事项列在上面？

If okay. From the tactical side, if you had to build a a checklist for men to maintain reproductive and sexual health, sort of what what would be the nonnegotiables that you would put on there?

是的。我认为，锻炼、严格控制饮食这些都非常关键。避免吸烟同样重要。此外，适度控制其他暴露因素，比如适量饮酒，也需要特别注意。这些都是与健康息息相关的事项。

Yeah. So, I mean, I think, you know, exercise, you know, being very conscious of diet, I think those are gonna be really crucial. You know, avoiding smoking, I think, is also crucial. And then, you know, again, moderation with, you know, other exposures, you know, moderate alcohol. You you wanna be kind of mindful of that prioritizing, you know, these are all things I think that overlap with health as well.

但也要注意适度，比如保证充足睡眠，尽可能减轻压力。我认为另一件重要的事是，男性最好在问题出现前就掌握自己的基线数据，比如基础睾酮水平。毕竟我们讨论睾酮时，正常范围非常宽泛——从300到900都是正常的。

But, you know, trying to moderate, you know, like make sure you get a good amount of sleep, you know, try and minimize stress to the extent possible. Think the other thing that I think would be great is if men had, you know, sort of a a good handle on baseline, you know, like trying to get a testosterone level at baseline even before problems arise. Again, because when we talked about testosterone, it's such a wide range of normal. Right? 300 to 900.

当男性来就诊时，如果睾酮值是400，他们可能会说'我略低于平均水平'。但这取决于你的基准位置。统计上，即使从400提升到500，或许能让你把棒球打得更远，但你来就诊的其他症状很可能不会因此改善。所以我们只需要知道你处于什么水平。

And when men come to see me and they're 400, you know, they say, well, I'm a little below average. But it depends where you are. Right? I mean, the range is so wide, and statistically, if we get you from four hundred to five hundred, you know, maybe you can hit a baseball further, but it's unlikely that some of these other conditions that you you came to see me for are gonna get better. So we just wanna know where you live.

我认为这很有帮助。此外我一直提倡尽早进行精液分析。十年前我曾建议美国疾控中心将其纳入全国健康调查，正是基于我们讨论过的这些原因。

I think that would be helpful. And then I've also, again, advocated for doing a semen analysis early. I think that would be very helpful. I talked to actually the Centers for Disease Control about ten years ago, adding it to this national health survey that they conduct. Just again, for all these reasons that we've talked about, right?

精子数量下降的问题，通过这项调查可能找到原因。他们收集血液、尿液样本，涵盖各年龄段男女，能监测各种有毒物质暴露情况。如果能观察精子数量变化的人群特征，将极具价值。不过有人担心这可能会影响调查参与率。

Declining sperm counts, to be able to understand maybe why it is because with this health survey, they track so much. They get blood samples, urine samples from individuals, from men and women, old and young. And they can see, you know, again, what sort of toxic exposures there are and things like that. And so if we could see, who these sperm counts are changing in, I think it'd be really valuable. But, you know, there is some concern that this could affect recruitment in this survey because there's sort of an factor.

其实提供精液样本比抽血要轻松得多——当然这取决于你对针头的看法。但无论如何，我认为这是非常有价值的信息。

Know, even though, right, mean, it'd be a lot more pleasant to give I think, a semen sample than a blood sample. I guess it depends what you think about about needle stick. But but, again, you know, I think those are I think it'd just be I think that'd be a valuable a valuable piece of information.

有哪些被大多数男性忽视的泌尿系统功能障碍征兆？他们应该注意却未察觉的症状有哪些？

Are there underrated signs of urological dysfunction that most men miss? Is there something that they probably should be aware of that they're not?

伟哥的发明是个重大突破，它让男性更愿意谈论勃起功能障碍——过去人们认为对此束手无策。现在男性更愿意与伴侣和医生讨论这个问题。我认为任何健康疑虑都应该及时提出。排尿问题我们有很多解决方案，勃起问题也是。

Well, I think, you know, one of the great things, you know, that's, like, again, a big discovery was Viagra. I think that got men a lot more comfortable talking about erectile dysfunction because there used to be a perception that we couldn't do much about it. And I think now men are a lot more comfortable talking to their partners about it, their doctors about it. So I think, you know, any sort of concern that men have, I think they should bring to the forefront. I mean, I think urinary issues, I think there's a lot that we can do.

有些男性因阴茎弯曲感到难堪，虽然这影响着5%-10%的男性。对此我们也有有效治疗方法。

We talked about erectile issues. There's a lot we can do. Some men have curvature of their penis, and they're very embarrassed about it. Even though it affects probably five to ten percent of men. There's effective treatments we have for that as well.

所以任何异常变化都值得关注。没有人比你更了解自己的身体，发现任何问题都应告知医生——既为消除焦虑，也为及时解决问题。

So I think anything that you think is different. No one knows your genitals better than you, so if you detect any issues, bring it to your doctor's attention because, you know, at least to alleviate anxiety, but also, again, if it's a problem, maybe we can fix it.

这感觉就像一场革命，终于有了能帮助双方的生殖技术。舒尔茨的整个脱口秀都在讲这个，他和妻子可能在前一晚拿到结果或去做检查时，他向神祈祷说‘请让问题出在我身上’，因为他确信如果有生育问题，那一定是女方的问题。结果发现，他的祈祷应验了。自从去年看了舒尔茨的专场后，我也去做了精子检测。

It's so I I didn't it feels like such a revolution at the moment to finally have reproductive technologies that can help both sides. And, you know, for a long time this is Schultz's entire stand up, which is, you know, the night before him and his wife maybe got the results or went in to do the tests or something, he sort of prayed to god and was like, just please let it be me because he was so sure that if there was a fertility issue that it was on the female side of the equation. And then he turns up, and sure enough, his his prayers were his prayers were answered. And, yeah, I think, you know, the more conversations that are on this, I've, you know, waved my flag in the air since watching Schultz's special last year. I then went and got a sperm count done.

后来我发现患有精索静脉曲张，所以今年夏天晚些时候会做手术。这一切之所以能发生，是因为越来越多男性愿意谈论这个话题。

I then went and found that I had varicocele. So I'm gonna get varicocele surgery at some point later this summer. Great. And, you know, all of this is only occurring because there's this increasing territory of guys that are prepared to talk about it. Yeah.

我们父母那一代可能对此更一无所知。你说得对，这涉及隐私和羞耻感，关系到自我认知、男子气概、作为伴侣的合格度以及未来规划等等。

And, yeah, I guess our parents' generation would have been a lot more in the dark. You this is you're right. There is an ache factor, very private. There's a lot of shame associated with it. It's attached to your sense of self and masculinity and and and, you know, aptness as a partner, potential future, all that sort of stuff.

喜剧演员公开讨论自己的低精子数量，我认为能产生积极影响。

And, yeah, long lived comedians talking about their low sperm counts because I think it's a it's a a good impact.

这太棒了不是吗？他以前还担心从马桶座圈上怀孕，现在却需要一群医生操心。哈桑·明哈吉和罗尼·常都做过相关搞笑段子。

Oh, it's been so great, right? I mean, I think, what was his, like, he used to be worried to get pregnant from like a toilet seat, and now it takes like a bunch of doctors wear it and worry. Well, I think that's hilarious. Know, Hassan Minaj had a very funny routine on it. Ronnie Chang talked about it.

这种日益增长的认知和舒适感很棒。你利用平台讨论此事很有意义。就像伟哥那样，目前还没有针对提高精子数量的突破性疗法。试管婴儿把负担全压在女性身上，如果有能普遍改善男性精子的医药技术就太好了。

So I think it's this great growing awareness and comfort. Again, you lending your platform to talking about this, I think all that is gonna do a great thing. And I think, like we talked about Viagra, I think there hasn't really been a blockbuster treatment or drug for, you know, the increased sperm counts, right? I think one of the most effective treatments we have for low sperm counts is IVF, know, puts all the burden on the female partner, you know, given all the procedures and medicines that she's gonna require. So if we had, you know, again, pharmaceutical investment and some technology that could improve male sperm across the board, I think that would be amazing.

这再次说明我们需要更多关于精子数量下降原因及逆转趋势的研究教育。

And again, I think it just goes to, you know, more education research about why counts are falling, what we can do to reverse that trend.

太对了！迈克尔·艾森伯格医生，女士们先生们。我热爱这个话题，感谢你的工作。大家该去哪里关注？

Heck yeah. Doctor Michael Eisenberg, ladies and gentlemen. I I love this. It's a topic that I'm very passionate about, so thank you for all the stuff that you do. Where should people go?

他们会想随时了解你的线上动态。

They're gonna wanna keep up to date with everything that you've got online.

我们有实验室网站，大家可以支持这项事业，了解更多男性生殖健康知识。

Well, we have a lab website, so they can go to that. They can support, you know, the cause, and then learn more about men's reproductive health.

好的，迈克，我很感激你。

Okay. Mike, I appreciate you.

谢谢，非常感谢。

Thank you. Appreciate it.

如果你想读更多书，你可能需要一些既轻松愉快又不会让你感到无聊或沮丧的好书——那种不会让你读不到半页就想放弃的书。这就是为什么我创建了《现代智慧阅读清单》，列出了100本我读过的最棒、最有趣、最有影响力且最引人入胜的书籍，包括小说和非虚构作品，其中有真实的故事。每本书都附有我喜欢它的理由描述和购买链接，而且完全免费。现在你就可以通过访问chriswillx.com/books获取这份清单。

If you're wanting to read more, you probably want some good books to read that are going to be easy and enjoyable and not bore you and make you feel despondent at the fact that you can only get through half a page without bowing out. And that is why I made the modern wisdom reading list, a list of 100 of the best books, the most interesting, impactful, and entertaining that I've ever found, fiction and nonfiction, there's real life stories. And there's a description about why I like it, and there's links to go and buy it. And it's completely free. You can get it right now by going to chriswillx.com/books.

网址是chriswillx.com/books。

That's chriswillx.com/books.