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Melanie Cole (Host): The sperm count of men in western countries has been declining according to new research, bolstering a school of thought that male health in the modern world is at risk, possibly threatening fertility for many couples. Today we are speaking with Dr. Hagai Levine on this episode of Hadassah On Call.

Welcome to the show. My guest today, is Dr. Hagai Levine. He is the head of the Environmental Health Track at the Hadassah Hebrew University Braun School of Public Health and Community Medicine in Jerusalem Israel. Welcome to the show Dr. Levine. When did sperm count start being investigated as a factor in male infertility?

Dr. Hagai Levine (Guest): Actually, the method of counting sperm was first described in 1902 and the method did not change much since because it is very simple and validated method. You put sperm on the slide and count under the microscope the number of sperm. Very simple, very accurate and a very good marker for male fertility.

Melanie: I mentioned in my intro that research is showing that we are seeing a decline in western countries. So, what are you seeing as a difference now and what do you think and what have you found as the reason for this decline?

Dr. Levine: So, here we have a very good measure. The measurement system did not change. So, we can really see whether or not there was a change over time. Now there was a previous report 25 years ago Nicholson et al that claimed that there was a decline in sperm count in the world since the since the 30s. However, this report was accepted with a lot of criticism and actually was not accepted by the entire medical and scientific community. So, we conducted the most comprehensive and using state of the art equipment to model and study the trend over time of sperm count around the world. We did this systematically to help review including more than 7500 studies that we screened and what we found is a clear and steep decline of over 50% in two measures both the total sperm count and the sperm concentration of western men unselected by the fertility status from 1973 to 2011. Can you imagine any other biological measures that decline by more than 50% in 40 years?

Melanie: It’s really amazing and so why are western countries seeing this decline? Is it environmental and lifestyle influences? What is it?

Dr. Levine: So, first of all, we looked for information for non-western countries and simply there is not enough data because you need a lab and a researcher to collect and conduct such studies and we did not have enough studies from non-western countries to conclude the trend. Actually, recent studies from East Asia did find declines there as well. So, I cannot say much about non-western countries. In western countries, although we did not study the causes, we see a clear decline. We should remember that when we looked for the causes, to elaborate hereafter, when we look at the causes, we should also think about 20-30 years before the men were studied, when they were born, because actually we know that the prenatal period is a critical period for the development of the male reproductive system. So, something is disrupting this development and indeed the modern lifestyle and environment surrounding the development of the male reproductive system, we should look for the change over time, 20-30 years before 1973. So, from the 40s, from the 50s. Now we know, we all know that exposure of fumes and to manmade chemicals among other factors have changed dramatically over this time and men are exposed now to chemicals in an extent and viabilities that they have not been exposed ever before in evolution.

Melanie: So, what important public health implications do these findings have and let’s speak about some of those influences that are more of a factor now.

Dr. Levine: So, before speaking about the causes, I will speak about three implications. First and above all, as you said, we have a clear public health problem of male subfertility and infertility. We know it in Israel and in other states and in many other countries, a huge proportion of couples are unable to conceive naturally. And many more takes a longer time than they want to get pregnant. So, we have a fertility problem and we should understand and understand that the solution a long-term solution could not be only technological solution, because there is something causing it. So, this brings us to the other public health implication, that there is something wrong with our environment in a broad sense that caused this decline. It could not be genetic. So, this is the candle in the coalmine to put the signal for us that we need to change something with the way that we are living around the world. And the third implication is that new studies are showing that sperm count is a predictor and the marker of male general health and men with lower sperm count are more likely to die, to be hospitalized and to suffer from diseases. So, if we see this decline in sperm count, it most probably indicates a decline in the health of men in western countries. So, we have three implications; the fertility problem, the causes that we must address and the health problem of men around the world.

Melanie: That’s fascinating. So, what would you like men to know about these environmental and lifestyle influences and are we even looking at things like cell phones and alcohol and sedentary lifestyles? So, speak about some of these influences and how they might change a man’s mind about those lifestyles.

Dr. Levine: So, first we should separate the suspected causes into two. The causes that may affect in the prenatal life and causes that may affect in the adult life. Some of them are the same but not necessarily. I would focus, first of all, in research and in prevention on the causes in prenatal life. This is probably the more important factor. For example, studies have shown that smoking of the mother during pregnancy is a worse risk factor for lower sperm count than smoking of the man himself when he is an adult. So, smoking of the mother is worse than smoking of the man himself later on. So, this is an example how disruption in early life, this is probably the most critical. However, our listeners want to know what they can do besides blaming their mother.

So, in adult life we know that exposure to pesticides and specific toxic chemicals harm the production, the spermatogenesis and men produce sperm every day by millions. So, exposure now can affect your sperm for the next three months. So, you can do – so you can change your exposure now so if you are exposed occupationally or by other ways to pesticides or other chemicals that are known to be toxic to sperm such as drugs – medical drugs and drug use, you should avoid them. Smoking of course, lack of physical activity, even TV viewing was linked to lower sperm count and the basics of keeping a normal weight and a good diet can improve your sperm count. Now for the cell phone. This is not proven. We know that heating your testicles is not good for them and we know that cell phones and mobile computers are heating your testicles if you put them directly next to your testicles, so you should definitely avoid that. We don’t know yet about the possible impact of non-ionizing radiation, so I would focus on what we know for sure you can do for your little one.

Of course, the other side is that we need to protect the babies, the fetuses now, to prevent from exposure to phthalate or other chemicals or even stress or smoking of the mother that we know that disrupts the development of the male reproductive system.

Melanie: Dr. Levine, so along those lines, if 30 years ago women didn’t realize that smoking during pregnancy was so detrimental and you are seeing this decline now, now that there is more of an awareness, of smoking during pregnancy, do you think, in your opinion that in another 20 years, you might see this trend head back up because women are not smoking as much during pregnancy or do you think they are?

Dr. Levine: I think that we must use surveillance methods like we do for cancer and for infectious diseases as a public health physician and I used to be Chief Epidemiologist for the UN Defense Forces, so I did a lot of surveillance and so in the studies, we need also to follow the reproductive health trends continuously, including semen quality indicators for example and we don’t do it at all at the moment. So, we will not be able to answer this question unless we start following it now. Now I am worried, I am very worried because we know that there are epigenetic changes. The effect, the detrimental effects for example smoking during pregnancy do not only affect the sperm but also affect the grandson and maybe also the grand grandson. So, we already see an effect in the contour of the genes at the epigenome level that is changing, and this may be the reason why the effect may be cumulative. If you are exposed to toxins in smoking or to chemicals such as phthalates and in intersect the developing fetus, it also affects his son and his grandson, etc. and we may see even if we stop now the exposure, we may not see any improvement. So, it is a very serious issue of the question of the extinction of the human species. Okay, so we don’t know what will happen, but we can’t necessarily be sure that we can reverse the damage. We can stop the continuation of the damage, but not necessarily reverse. So, we must understand this is a clear and present emergency to humans the possibility that we will become less and less fertile and we will not be able to reverse.

Melanie: So, do you think this is a wakeup call for health professionals and for men with a goal in reversing this change and if it is a wakeup call, what is the take home message for men, their partners and health professionals? What would you like to see happen immediately and in the future?

Dr. Levine: Okay so immediately at the personal level, like we understand that a woman is planning a pregnancy and we say, the doctors, that pregnancy is twelve-month period because there is three months of preparation and even before. So, women are trying to keep better health before they are trying to conceive. We should so exactly the same for men. We should take this opportunity that if the man wants to bring life to improve his own health and you can do more physical – the same recommendations for general health like physical activity, keeping normal weight, keeping a healthy and balanced diet, avoiding smoking and drug use etc. are good for your sperm, for your fertility, for your future kids and for your own health. So, that’s one thing that you can do now, and we should restructure the medical system to focus not only on treatment but also prevention.

I know for sure, that in many clinics, the standard I visited when I was in Mount Sinai in New York and in Israel and in other countries there is much focus on the treatment side and technological solution and not on health promotion. So, we should think differently and put much more focus and attention to male fertility. So, this is one side of it and study of course, much more male fertility in animals and in humans and what are the causes. Now, we already know some of the causes. So, this is a wakeup call to address the causes. Now currently, we are doing a mass experience on mankind by exposing mankind to many, many chemicals that for many of them we know that they have serious effects on our health and the health of future generations. We must change this frame of thought and put our health before other considerations, for example economical consideration. So, the needs for proof should be on the producer of this chemical and not on the consumer. So, we must, like Europe is starting to do, we must regulate much better regulate chemicals and that is something that I hope that the studies like our own study will help change this way of thinking because I’m really worried now what this is beginning of the much larger problem later on.

Melanie: And where do you see research going from here? What’s your next move in this case?

Dr. Levine: So, I’m studying specific possible causes of poor sperm count for example in Israel, there is much exposure to pesticides. So, we are conducting a study on the effects of pesticides on semen quality in Israeli men and my colleagues are doing other studies around the world, but there is really not much funding in this area. Now that like women were neglected – or females were neglected in medical research for many years. The issue of male fertility or reproduction is considered a female issue and this trend is neglected in research so there is maternal and child health funds and clinics but not for paternal.

So, I think we should study much more paternal effect, we should study much more the impact of prenatal exposure including exposure to environment in the broad sense and the effect on health later on in life for both males and females and we should integrate fertility and semen studies within current ongoing studies as an important outcome. You can take a cause study of this conduct and then add an evaluation of the semen and actually this is a great source of learning because it is so susceptible to the environment. it is not only important by itself, it’s a good model to study the effect of the environment on our own health. It’s complex.

We should first start with research agenda. Currently, there is no research agenda in the field at all. So, once we work with researchers and governments from all around the world we can set the agenda for research.

Melanie: It is such great information Dr. Levine. So, just summarize it, restate this research study about the declining sperm count in western countries and really what you want men and other health professionals to know about this and things that they can do right now.

Dr. Levine: One of the most important things is life, the finishing of life itself is the ability to reproduce. We men reach to a state that cannot reproduce naturally. This is a wakeup call for each and every one of us. And of course, to the decision makers to identify male infertility as a major public health problem, to act on the personal level, to study and examine your fertility and what you can do improve it and to change in the global level and the country level to take action to reverse this decline by better regulation of chemicals, by health promotion activities and by research, a lot of research into the causes of this decline.

Melanie: Thank you so much Dr. Levine for being with on with us today. This is Hadassah On Call New Frontiers in Medicine brought to you by Hadassah, the Women’s Zionist Organization of America. The largest Jewish women’s organization in America, Hadassah enhances the health of people worldwide through medical education, care and research innovations at the Hadassah Medical Organization. For more information on the latest advances in medicine please visit Hadassah.org, and to hear more episodes in this podcast series, please visit Hadassah.org/podcasts, that's Haddasah.org/podcasts. I’m Melanie Cole. Thanks so much for listening.