The Invisible Patient: Supporting Men Through Fertility Treatment, with Dr. James Kuan

Male factor infertility accounts for nearly half of all infertility cases — and yet the male partner’s experience is often an afterthought, from the design of the collection room to the timing of the workup.

Dr. James Kuan is a board certified urologist with more than twenty years of experience in men’s sexual health, founder and CEO of Sexual Medicine for Men in Seattle, and medical director of the Seattle Sperm Bank. He joined Dr. Erica for an incredibly candid conversation.

This episode is for couples navigating the fertility journey together — and especially for the male partner who has been quietly struggling on the sidelines.

In this episode:

• Why male factor evaluation is still treated as an afterthought — and why that needs to change
• The parking lot moment: what happens when a male partner can’t produce a sample on retrieval day, and why it’s more common than anyone talks about
• Nearly a third of men develop new onset erectile dysfunction during fertility treatment — and what to do about it
• Why simply being told “this is normal” resolves ED in a third of those men without any medication
• The case for REIs prescribing Viagra: it’s safe, it doesn’t affect sperm, and it’s no different than a pair of crutches for a sprained ankle
• Why the male workup should happen in parallel with the female workup — not as an afterthought
• Sperm as more than a USB drive: new data on what healthy sperm actually contribute to conception
• The four I’s framework for inviting male partners into the process: invite, inform, involve, intervene
• Why sex during fertility treatment shouldn’t only be mechanical — and what actually happens to outcomes when intimacy declines
• The two to four day rule for abstinence before a sample — and how most couples are making it harder than it needs to be
• Desire mismatch, communication, and why foreplay starts at the kitchen sink
• ED and abnormal semen analysis as canaries in the coal mine for broader men’s health — including cardiovascular disease and testicular cancer
• A critical warning: testosterone replacement therapy (TRT) is bad for sperm — if your partner is on it and you’re trying to conceive, see a urologist now
• Why it’s okay for the fertility journey to be a little messy — and why that messiness doesn’t mean you caused it to fail

Find Dr. James Kuan:

• Instagram: @drjameskuan
• Newsletter: sexafterretirement.com
• Practice:  https://jameskuanmd.carrd.co/ (Washington state patients only)

Transcript

Erica Bove, MD (00:01)
Hello, my loves, and welcome back to the Love and Science Podcast. I have a distinguished guest today. He's a friend, he's a colleague, and we're gonna talk about something today that we don't get to talk about, which is men's sexual health in the fertility journey. And so Dr. Kwan, thank you so much for joining us today.

James Kuan MD (00:19)
Thank you. It's great to be here.

Erica Bove, MD (00:20)
Yes. So let me

yes, I'm so glad to be here with you. And you know, I I think that we should really introduce you because that's important. You have a lot of accolades. You are a board certified urologist with more than twenty years of experience in men's sexual health. You're the founder and CEO of Sexual Medicine for Men, which is a physician led direct care practice in Seattle. and since twenty twenty two you've served as the medical director of the Seattle Sperm Bank, which I mean I have my clinician hat and my coach hat and man

Do I do a lot of counseling about sperm donor selection? So I'd love to get into some of that. and also, you know, you have a newsletter which is amazing, which is called Sex After Retirement, and we'll get into it. I think there's a lot of parallels between sex during the fertility journey and sex after retirement. And I would say, just from a like gestalt, that you have a very candid perspective. And I know this, I know this not just professionally, but personally from knowing you, that you take this very

passionate, very practical perspective to conversations about erections, testosterone, prostate health, sexual function and and the various issues men struggle to talk about. And like I said it's it's sensitive and so I'm really really grateful that we can have this conversation today. Yeah.

James Kuan MD (01:35)
Thank you for having me.

I I appreciate the work that you're doing for colleagues, right? Colleagues who are in the midst of running practices, taking care of patients, but also looking to family plan. And so I want to be of service to you and to your listeners today and and their partners

Erica Bove, MD (01:55)
Yeah.

James Kuan MD (01:55)
because because I think family planning, we need to think of it as a team sport.

Erica Bove, MD (02:00)
Yeah, absolutely. You know, I I was thinking this story just came into my mind. I was a fellow and I remember taking care of this dual physician couple and I was doing the egg retrieval on the female partner that day and as is very typical the male partner needed to produce a sperm sample that same day so we could do the fertilization that afternoon. So I remember I was sitting in my office and I had a window there. You don't always have a window, but I did that day, and I looked outside and I saw

The

male partner in the parking lot in the parking lot, literally shaking his fists at the universe and like cursing God. And I'm not being dramatic. Like he was trying to produce a sperm sample, he was unable to, he had not anticipated not being able to produce a sperm sample that day. And you know, male physician, high achievement, high achieving, wanted to do well by his wife in the process. And I just I truly remember him shaking his fists, getting down on his knees, and and just so broken at the

His inability to produce sperm that day. And you know, I remember I went outside, I think I still had my scrubs on. I was like, hey, and I knew him. I was like, hey, how can I help? And you know, you know, I'm so sorry that this has been so stressful, and let's see what we can do. And you know, we pr we provided some Viagra for him. He went to the pharmacy. that actually did the trick, produced the sperm, and they were so apologetic after the fact. They're like, I'm so sorry we caused you so much grief. I'm like, no, I'm so sorry, this was so awkward and stressful for you. And so I maybe.

that's a good place to dive in is just to talk about how you know how awkward it can be to have these conversations, to ask men to produce sperm on command, and also the shame that can come when that's not happening.

James Kuan MD (03:45)
Yeah, I think that is a more common story than that guy felt in the moment.

Erica Bove, MD (03:51)
Yeah.

James Kuan MD (03:52)
and I think that that story highlights so many of the aspects of the partner, the male partner side.

Of this fertility journey. I think just from a statistical point of view, a performance alone point of view, almost 10% of men aren't able to produce the sample on the day of egg retrieval or IUI. And so simply normalizing that and just thinking about that, and it comes down to a performance anxiety. I think it comes down to the environment, it comes down to the weight and the

gravity of what is happening on that day. And and the reality is is when there's a lot of adrenaline in our system, physiologically things like erections don't happen. You know, when we're worried when the house is burning down, you know, we're not feeling that in the mood. And so so just the stress and the anxiousness can affect erections and the orgasm and the ejaculation part. And and I think, you know

We might talk about this a little bit more, but but just even on its own, almost a third of men experience new onset erectile dysfunction during fertility treatment. And you know, and then put on top of that the need to perform in your office and to provide the sample into a cup. And there's kind of this burden of it's just it's just a sample into the cup.

And then there's the failure that I couldn't provide that sample, which is so simple. And so so the whole process and the data show is is is really an emasculating procedure. It's it it is a real threat to men's identity, even when there's not a male factor in the infertility puzzle.

The threat to identity, the the need to have sexual activity on the schedule, the need to ejaculate into the cup. Being told that their part is fine. Maybe even, let's say this guy was able to produce a sample. It's like, great, we got the sample.

Meanwhile, there's the disconnect that they're then observing, you know, their partner, their wife, going through many invasive treatments and much more involved therapy. And so so there is a real kind of disconnect and and and men feel lost in this and and and so and then high performing men, you

Erica Bove, MD (06:35)
Yeah.

James Kuan MD (06:35)
know, people who are in their quote unquote prime that should be able to perform.

can't. And and and and I think one of the things that I was thinking about before this, and and your story as you said he was in the car, reminded me of of just some feedback of of of some patients who who who ha are part of their own fertility journey who go to the fertility clinics and they say, this is designed for women.

the atmosphere feels like it's for families and women and and then I'm supposed to go down the hallway in this place where it's all branded for women. And that was a disconnect as well. And so so I think

I'm not asking, you know, you and your colleagues, but I'm just to to change, you know, your office and things like that. But it's more just to share to your listeners that this whole experience

I don't wanna say asymmetrically, but is designed and and and by design it should be in many ways, for the female experience. I and I don't I don't wanna offend anyone by that, but but it's it's sort of the reality and the experience of of what men, you know, are reporting in the data and just anecdotally to us.

Erica Bove, MD (08:02)
Yeah,

no, I think that's a great point. And I you know, even if you have the room that's like tucked off in the corner of the clinic, like our room right now, we just had discussions about it at the University of Vermont because it's literally the hallway that's the throughway between where the patient area is and where our IVF suite is. And it's this actually has a fun fun fact, as a med student I actually wandered in there thinking it was the bathroom. And then people are like, No,

James Kuan MD (08:24)
Right.

Erica Bove, MD (08:25)
that's the sperm collection erec area, Erica. Like I just like it's like this very trafficked area. And I I feel so badly. I mean, thankfully with COVID now we have

Have the ability for some men to produce sperm in the comfort of their own homes, which is I think an improvement. But you know, there's just like the noise and what kind of materials do you provide, and what's the Wi-Fi connection, and all those things, like that may not even hit people's radar. You know, sometimes materials are outdated, and we have to talk about that too. And so it's just a very artificial process that I think I think you hit it. Like it really hits the core identity of the person who may be feeling helpless to help in this process where things may be.

Aren't working or they're seeing their wives undergo all these procedures. I find that even getting the first sperm sample in the first place is a challenge. And I've always wondered about that because I'm I'm thinking about it, okay. You know, the this is this is thinking about, you know, that's it's not necessarily a painful experience, but it's an awkward experience. Like sometimes the female will come in and her whole thing is done, and I'm like, okay, we're just waiting on the semen analysis, and but I think I think it's not a physical barrier. I actually

think it's an emotional barrier because there was those questions, what if I am part of this equation? What if my sperm, you

James Kuan MD (09:39)
Mm-hmm.

Erica Bove, MD (09:40)
know, aren't aren't good? I think there's something very deeply like like biological and evolutionary that comes up in those moments. What do you think about that? Do you see that?

James Kuan MD (09:49)
I I I I do.

Erica Bove, MD (09:51)
Yeah.

James Kuan MD (09:52)
and and I think that that just

You know, there's a couple things, and and and the the word that came to my mind is you were describing the collection room. And then you were describing couples coming where the female workup is near complete, is in both of those scenarios the word afterthought came up. And

Erica Bove, MD (10:12)
Yeah.

James Kuan MD (10:12)
and that that designing or the collection room is an afterthought to design of the whole clinic. And

Erica Bove, MD (10:18)
Yes.

James Kuan MD (10:20)
and and and and the workup of the male is an afterthought.

Thought. And and and this is not to say that the work up historically, I think and probably incorrectly, we have placed the burden of fertility on the female partner, right?

Erica Bove, MD (10:42)
Yes.

James Kuan MD (10:43)
It it must be the egg, it must be her body, it must be that she is doing something wrong.

Erica Bove, MD (10:50)
Yep.

James Kuan MD (10:52)
But I think more recent data coming out about the paternal gamete, the sperm donor, the the father, is suggesting that it's way more than just the egg. We we used to think the egg was this mighty thing, and the sperm just kind of knocked on the door and was like a USB drive, and here's the information, here's the DNA.

Erica Bove, MD (11:12)
Yep.

James Kuan MD (11:15)
I can't get into the deep part of the science, but one way that it was explained to me is that, yeah, there's the USB, the information part, but the sperm actually has a whole operating system as well. That the sperm actually primes the immune system and primes primes for the first cell division. And so so the a healthy sperm is as important. And why I bring this up is

timing and the workup. It's it's not as much of an afterthought, I think, as we used to to to call it.

Erica Bove, MD (11:48)
Definitely.

James Kuan MD (11:48)
and and that that the male partner should be evaluated parallel and alongside the female

Erica Bove, MD (11:56)
Yes.

James Kuan MD (11:57)
partner. And and the reason I think for this as as someone who has seen men for male factor evaluation

If I find something on that early semen analysis, it may actually avoid an extensive evaluation on the female partner that they maybe didn't need right now. And

Erica Bove, MD (12:17)
Yeah.

James Kuan MD (12:18)
and and I think we're a little bit trapped by our guidelines that say we should wait, you know, six or twelve months before we even initiate that investigation.

A semen analysis, you know, we've just talked about how challenging and awkward it can be, is not a hystrocell pingogram,

Erica Bove, MD (12:39)
Right.

James Kuan MD (12:39)
is not transvaginal ultrasound, is is is not these very invasive tests, it's it's the out-of-pocket cost and the awkwardness, but

Preparing and doing that journey parallel, if there is male factor there, might actually inform better the female evaluation, in my opinion. And

Erica Bove, MD (13:01)
Yeah.

James Kuan MD (13:01)
so so I think I think the message is that male factor evaluation, male factor fertility or infertility shouldn't be an afterthought, sort of in in how we access the clinic, in how we access the evaluation, and and then and then proceed through the care.

Erica Bove, MD (13:20)
I

think that's that's absolutely right. And I I I guess my question then is how do we make it less awkward? I think certainly home collection does does make it less awkward. I mean, as the director of a of a major sperm bank, what are your thoughts about like helping to reduce that and making mail evaluation not an afterthought but more central, more centered?

James Kuan MD (13:44)
Well, I I I think it's just we have to normalize the the role of the male factor in the family planning, right? That that that

Erica Bove, MD (13:51)
Yeah, yeah, yeah.

James Kuan MD (13:53)
I I even as a urologist who I I didn't have a practice that was just infertility. You know, infertility was was a smaller part of my practice than sexual dysfunction. but but it often happens elsewhere.

you know, the the mail factor happens in our offices and I actually think that's not a bad thing. I think I think in some ways if we're if we're talking to physician

families, intended mothers or mothers who are physicians, I think it's sometimes hard to shed your white coat, even when you're home. And and

Erica Bove, MD (14:31)
Yeah.

James Kuan MD (14:32)
there is this this ability to have researched, this ability to have understood and and and then to have explained scientifically to their partners what they know and and and sometimes I think that leaves especially non physician partners

Male partners, maybe three steps behind. Or

Erica Bove, MD (14:52)
Mm, mm hmm. Yes.

James Kuan MD (14:55)
the your sperm are the problem, you know, you have DNA fragmentation or your semen analysis as is abnormal is really saying, you know, your sperm are the problem. And so scientifically, a guy can hear that, but are they emotionally ready? So where I'm going a little bit though is is I know that a lot.

of the male factor evaluation starts in offices like yours, not necessarily with with an andrologist or your or a urologist. And so so I think some of I'm gonna put the I'm gonna put the burden back on you

Erica Bove, MD (15:33)
Yes.

James Kuan MD (15:34)
to say that what can you do in your

Erica Bove, MD (15:36)
Yeah.

James Kuan MD (15:37)
practice? And and I think that that it can start just with inviting men into the process earlier.

Erica Bove, MD (15:45)
Yeah.

James Kuan MD (15:46)
I think that it can be about informing them. You know, there's a there's a study that came out of Denmark and they talk about the four eyes. Invite, inform, involve, and then intervene with with with the male partner. And so

Erica Bove, MD (15:59)
Mm-hmm. Mm-hmm. Yeah.

James Kuan MD (16:01)
so I think to your point, that sort of communication part, but but I think more even more practically

Like I said, thirty-five percent of men have ED, new onset ED, you know, providing a Viagra sample.

Erica Bove, MD (16:18)
Right, right.

James Kuan MD (16:20)
and and it's not hard to prescribe these drugs are safe. You know, they they've been there since the late nineties.

They do not impact sperm. There's there's actually some small data that says it may increase motility and morphology. I'm not sure I would use it as an intervention for abnormal semen analysis, but I think just knowing that it is safe to use and it will not

Erica Bove, MD (16:44)
Yeah.

James Kuan MD (16:44)
impact fertility. And it is, it

Erica Bove, MD (16:46)
You know, yeah.

James Kuan MD (16:48)
is, it's no different than a pair of crutches if you sprain your ankle. it's like

Erica Bove, MD (16:53)
Yeah.

James Kuan MD (16:53)
we we have to get through this phase.

And then and I think sort of being I think another part that gets awkward for men is is women historically, as we've said, own this journey in a lot of and and and are asked to be the the tour guides through that journey. And and and and I think sometimes, you know, how can we be a partner?

To the male partner instead of the tour guide. I think those are tough things, those are communication things. But sort of like we talked about the mismatch between the semen analysis and invasive treatments. You know,

Erica Bove, MD (17:39)
Right.

James Kuan MD (17:41)
the difference between, well, you're not the one having all these procedures, to,

Erica Bove, MD (17:45)
Right.

James Kuan MD (17:46)
I know this is hard for both of us in different ways.

Erica Bove, MD (17:49)
Yes,

absolutely. So I I just want to reflect back a little bit what you said. So I'm hearing you say normalizing and inviting on the earlier side, which I love. You know, I I usually give the stat, you know, about forty percent of infertility is male and female factors combined. So if we're just focusing on the female, we're missing a huge part of the equation. And so s you know, what we've started doing actually because our wait list has gotten so long, we've started actually calling people ahead of time or sending a portal message and saying, Hey, these are the tests that we like to generally see. It's not a one

One size fits all approach, but you know, we're probably gonna want an AMH on the woman, we're probably gonna want some sort of cavity evaluation, we're probably gonna want a semen analysis, you know, if it's that type of family. And so now

James Kuan MD (18:29)
Mm-hmm.

Erica Bove, MD (18:29)
I love it now because I can do my new patient consultations and I have all the data in front of me, and it's more just like, you know, if you even try to buy solar panels, they're gonna want your electric bill before you do. So it's like check, check, check.

James Kuan MD (18:41)
Right.

Erica Bove, MD (18:42)
And so I think about it like, okay, these are the building blocks we need to start your first consultation off at a higher level, like that in.

James Kuan MD (18:48)
Mm-hmm.

Erica Bove, MD (18:49)
And of itself is very normalizing because then we can have that data to begin with. And then, you know, also this is something I'd never considered as an REI that I could be the one to write the Viagra. I mean, I did that day when I was a fellow, but like I would say, yes, one in three of my couples have this problem of erectile you know sexual function issues that are new onset. And you know, I think, yep, yeah, I I normalize it, but I'm not like, I I could do something about it, right? Like, so I think that's something I'm gonna change moving forward.

To say, okay, sure, if your semen analysis is abnormal, we can get you to see the urologist, but that might be, you know, two, three months. I don't know what your wait wait times are in your practice, Dr. Kwan. But I think you know, just saying, hey, while you're trying, I can help you, like that feels empowering to me as an REI. Right, right, right.

James Kuan MD (19:36)
Well, and it's it's easy, right? You know, primar primary cares write those prescriptions every day. And I think I

think the one thing is if you have someone who ha is using nitroglycerin and this is not your population and

Erica Bove, MD (19:47)
Correct. Right.

James Kuan MD (19:49)
your listeners are are very educated people who understand the contraindication to Viagra, it's that easy.

Erica Bove, MD (19:56)
Yeah.

James Kuan MD (19:57)
I think it something else I I brought to mind is simply normalizing it and there's data for this, simply normalizing that, you know, this thirty five, forty percent of men will have nuance at E D and telling men that, that they are part of

a group of men who experience the same thing, a third of those men will get better and not need something like Viagra just by telling

Erica Bove, MD (20:20)
Amazing.

James Kuan MD (20:21)
them this is normal. And I and I think the other thing that comes to mind, you know, is we're talking about sex on demand, whether it's on the calendar because the window of time is there, or it's in the collection room and the cup is there. it's important

Especially as the journey gets long, and and you know this better than I do, that these this journey can be very long, that that there is still time made for sexual activity outside of baby making,

Erica Bove, MD (20:58)
Yes.

James Kuan MD (20:58)
outside of the collection room, outside of that window on the calendar.

Because there's also data to show that when that declines, when the intimacy that that couples shared before the fertility journey declines, sexual performance worsens.

Erica Bove, MD (21:18)
Mm.

James Kuan MD (21:18)
And and and so I think that's a little bit of agency. I think that's a little bit of couples regaining, reclaiming, or just hanging on to some of their control in the relationship. When the fertility journey, as you know, and coach feels so out of control, so

Erica Bove, MD (21:36)
Yeah.

James Kuan MD (21:37)
so out of control for for us who we've plotted and planned our whole lives, and then this happens. And so so I I I think it's the normalization, but it's also

trying to find, and I think this is easier said than done, a little piece of normal life in that journey, because that contributes to the success as well.

Erica Bove, MD (21:58)
Absolutely. No, I'm so glad that you said that. And do you ha have any particular strategies that you recommend for couples to help enhance that aspect of their lives? You know, I think that this journey can drive a wedge between people. So sometimes I see couples in the office and they're truly like facing apart from each other. you know, that's its whole other, you know, issue to tackle. But I think that there's so many windows, it's like, Okay, you're about to have your egg retrieval, don't have sex, or like, okay, you you know, there's all these I think myths really about how

how

long people need to be abstinent before a sperm sample and so people are ejaculating in cars and they I mean it's there's this just this whole so many layers of like the rules about and and many of them

James Kuan MD (22:40)
Yeah.

Erica Bove, MD (22:40)
are not even based on science. But like what what would you say to a couple that's like, yeah sure that sounds great but like how do we actually do that?

James Kuan MD (22:49)
So the thing that I always tell men is first and foremost, and this is this is where I think it's okay for the female partner to be a bit more instructive, I say, first and foremost, whatever your partner's OBGYN has said in terms of how frequently you should have intercourse during ovulation, follow that.

Because if I say something different, I don't want you to get in an argument about that. Follow follow

Erica Bove, MD (23:16)
Yeah, sure.

James Kuan MD (23:17)
that person's advisor. I always say this, two to four days is ideal. But but

But he doesn't know when two to four days, that two to four day window exists if you don't tell him when that two to four day window exists. And so

Erica Bove, MD (23:35)
Right.

James Kuan MD (23:35)
so this is part of the informing and inviting them to be along with the journey. And so so I often see the couples, I I'm not sure and I'd be curious what percentage of the time you see the male partner or just the female partner. But but I will then turn to the female partner and say, I need you.

to let him know with some range of variation when you think your next cycle will be.

Erica Bove, MD (24:05)
Yes.

James Kuan MD (24:06)
And then I look at him and I say, I need you to plan for that. I need you to understand that this is not necessarily going to happen on that exact day. Or maybe it does, right? But but you understand the variability of that more.

And to be prepared and to plan for it. And not just plan to take a Viagra, but plan to take a Viagra if need be. But also plan a date night. I think what unfortunately happens is it's the professional couple that gets home, the other kids are now in bed, the dishes are done, it's nine thirty or ten, and it's like tap tap tap. We

have to have sex tonight.

Erica Bove, MD (24:46)
Yep. Right.

James Kuan MD (24:49)
And you know, there's all the demands of life, but you know, we can make time for priorities and if if this is a priority, knowing when it might be

Intercourse for f to make family doesn't have to just be mechanical. It can be as a result of a planned date night, even if it's just every four weeks, if the you know the cycle's regular. And so so planning for that, maybe even using something like Cialis instead of Viagra, you know, Cialis, you know, taking like so let's say that

That female partner says, I think I'm gonna, you know, I think we need to have sex on Friday night, you know, taking a low dose of a Cialis or even Viagra just every day. And just having it in the system, because we know that these drugs take at least an hour. And sometimes if both partners are tired at 10 o'clock at night, there's not an hour to wait for the medication to absorb.

Erica Bove, MD (25:49)
Sure. Yeah, that's a good point. Yeah.

James Kuan MD (25:52)
And so it's planning. Having the prescription available.

before. You know what it's like when someone calls on a Friday afternoon for a refill. having the prescription days and weeks before so that you can prepare for that. Having time on the calendar and just knowing that don't plan an evening meeting or a dinner out. Don't plan a time out of town unless you absolutely have to. And then romance still matters. I I always I always kind of I think there's a statistic that says four or five percent of couples

Who are undergoing fertility workup and treatment, you know, anticipating ART get pregnant through intercourse, that that when sort of spontaneity and romance and fun come back into the bedroom, that the sexual response for both partners.

You know, I think we're foolish to think that that sexual response is not part of what is you know, the the juju or what is happening.

Erica Bove, MD (26:57)
Yes.

James Kuan MD (26:58)
and and and it is it is probably pheromones, it is chemistry, it's intensity of orgasm, it's the receptiveness of of the you know, the female canal to I

I you

Erica Bove, MD (27:11)
Yes.

James Kuan MD (27:11)
know, I I

I'm just putting that out there also. And so so it gets back to n normalization as much as we

Erica Bove, MD (27:14)
No, I I think I just just did a podcast, yeah. Yeah.

James Kuan MD (27:18)
can.

Erica Bove, MD (27:19)
Yeah, no, I I just did a podcast, a s one of my clients who had had an unsuccessful IVF for a year and a half and then she took one month off and she and her husband were starting to feel like they were living a normal life again and that's the month that she conceived and they had their daughter. So at thirty-nine, she and her husband conceived a beautiful daughter when a year and a half of of IVF treatments had not worked. And it's like why is that? You know, there is something about that mind-body connection and you know, if we need IVF we need IVF, but yeah.

James Kuan MD (27:45)
It's nervous system, it's hormonal, it's inflammatory,

it's all of those things, right? It's epigenetic.

Erica Bove, MD (27:49)
It's everything. It's everything. Yeah.

James Kuan MD (27:52)
If your body is so stressed out, you know, epigenetically, what is the impact of that on our fertility? If if

Erica Bove, MD (28:01)
Yeah.

James Kuan MD (28:01)
we are telling our system, this family unit is really stressed out, does that pull back, does that speed bump or handbreak our fertility?

Erica Bove, MD (28:11)
Yeah.

James Kuan MD (28:11)
I wouldn't be surprised if it does.

Erica Bove, MD (28:14)
Right.

Right, no, I think that's an excellent point. So I I wanted to also ask your perspective, because this is something I talk a lot about with with patients and couples, is people feel like they're gonna be messing up the process, right? So they're just like, okay, but if we have sex at this time, and again, I know that the fertility clinic has their rules and everything, but I think that people are spending tens of thousands of dollars on this process. The emotional aspect of it, people feel they're running out of time. So, you know, I want to normalize a little

bit

that like this actually might be helpful and that there's a lot of ways not yeah and like there's a

James Kuan MD (28:49)
The messiness Yeah.

Erica Bove, MD (28:52)
lot of ways not to mess it up if you're leading like a healthy sexual life. It's just how to get from where most people are. I mean even new pregnancy people are so afraid to be intimate that many people haven't had sex for months because they're afraid of messing things up and so I think also normalizing sure there's a few quote unquote wrong things to do right like you don't want to be having vigorous sex when the

Ovaries are giant about to be retrieved, that can that can do some damage. But there's

James Kuan MD (29:18)
Mm-hmm.

Erica Bove, MD (29:19)
a lot there's the it's really hard to mess it up, really. And I think that people get these complexes which add to the stress, and then that adds a whole other layer because it's like again, sex is bad, or like we're back in Catholic school or something like that. I don't know. You know what I mean? So it's like I think we have to think about all the rules and which rules are actually important, and which ones we've imposed on ourselves because we want to be doing everything, quote unquote, correctly.

James Kuan MD (29:45)
Well and I think, you know, this is sacred and precious work, right? Making making family, and all the cultural stuff that goes around with that.

But imagine a couple who is used to having lots of sex and and and we're now placing this thing on this pedestal and it's really expensive,

Erica Bove, MD (30:03)
Yes. Yes.

James Kuan MD (30:05)
as you say, and it's almost too precious. And and and and I think, you know, getting back to the question that I only partially answered, when I said the two to four days, I if what I would say like from

From getting a semen sample, you know, you don't want anything you don't want more than five days of male abstinence before getting the sample. And you don't want twelve hours ago to be your first ejaculation, you know, during ovulation. And so so I say two to four days. And and and I say so so if it's if if if your if your wife is ovulating on a Friday, you know, you need to ejaculate Monday, Tuesday, or Wednesday, but not after Wednesday.

Erica Bove, MD (30:48)
Right.

James Kuan MD (30:49)
and and and it's it it can be that simple. And so so that very sexually active couple just has to say there is a three to four day period here where maybe at minimum two-day period where we can't be very sexually active, and that might normalize the rest of the month. And

Erica Bove, MD (31:07)
Right.

James Kuan MD (31:08)
then we get to be sexually active again because we're

Erica Bove, MD (31:10)
Right.

James Kuan MD (31:11)
inside that window. And and I think you would probably tell couples every 48 hours.

Erica Bove, MD (31:16)
Yeah, absolutely.

James Kuan MD (31:16)
I've had some people come

back, yeah.

Erica Bove, MD (31:18)
Yeah. And I think too, like, one thing I tell my patients all the time, my clients, is there's other ways to be intimate too. I think we've sort of have this like, you know, penis and vagina intercourse as kind of like the what

James Kuan MD (31:30)
Mm-hmm.

Erica Bove, MD (31:30)
we define as sex and you know, if I'm doing a necro-treval on somebody and they want to have intimacy in other ways, by all means go for it, you know? And so that's

James Kuan MD (31:39)
Mm-hmm.

Erica Bove, MD (31:40)
one thing that I think we can help people with is to say, think about all the ways that you like to be intimate. If we're trying to avoid so so I guess I'm talking about

About

it from the lens of IVF, when at some point we actually do want to avoid, you know, the the chance of having multiple gestation and things like that. So there are sort of guidelines around when people have intercourse or don't have intercourse around an egg roble, which honestly most of my clients are already at the point of IVF. And so but thinking about it, okay, if you and your partner really enjoy oral sex, then by all means enjoy that. You're not gonna do anything harmful

James Kuan MD (32:11)
Hm.

Erica Bove, MD (32:11)
by having oral sex. And so I think just thinking about, or like maybe it's a night for physical touch and and physical intimacy, but not

sort of the, you know, intense sexual kind that might happen at other times of the month. And so broadening what it is to be intimate I think is also really important. And I would imagine you do that a lot in your sexual health practice.

James Kuan MD (32:30)
Well, I you know, I I I trained in in rural Canada and and I graduated in the late nineties and so so I still think that that the sexual medicine training that I had was actually quite progressive. and we had this couple who were sexologists and they wrote a book and it was called Sex is a Thirteen Letter Word, and we all received copies, and the thirteen letter word is communication, and and this is what you're talking about. you know, silence is optional here.

And and so is distance. Distance is optional. Distance is the default, I think, when when we lose control, when we feel alienated, when we feel instructed by our partners, when we feel like we're falling more and more into our silos. And so the communication is the remedy to the silence, which is optional. And so what you're saying is

It's okay for couples to say, I still want to be close and intimate and sexual with you, but there's this window of time. Let's talk about how we can't be sexually active, but then let's explore how we can be sexually active. And and so

Erica Bove, MD (33:39)
Yes, yes.

James Kuan MD (33:41)
what it's really coming down to is we have roadblocks and and we place them there because they feel safe or they feel appropriate to protect this thing.

But sometimes just challenging that and and allowing it as you questioned to be messy and and to not be perfect. There is no perfect way to do this.

Erica Bove, MD (34:04)
Makes so much sense. I love that perspective, and it's something that I think I want to echo from the rooftops. I'm curious. So your sexual health practice focuses a lot on sex after retirement, which we know is is super important. People are living longer. We all, I say we all, many of us want, you know, healthy sexual lives well, like for the rest of our lives, right? And so I think thinking about the parallels between how you help people, which is the bulk of your practice, which is in retirement.

Like,

can you share some pearls of that work with, you know, sort of how that relates, what what we can borrow in the realm of helping people have their best possible sexual lives while they're undergoing fertility treatments?

James Kuan MD (34:51)
Yeah, I I just jotted I think

Five top things that kind of came to my mind.

Erica Bove, MD (34:54)
Amazing.

James Kuan MD (34:55)
I I think it's normalization, as we've already talked about. Normalize that there are, you know, 30 i i if we just look at erectile dysfunction, we we talked about this group with new onset erectile dysfunction during fertility. A third of men in their 30s, not even in fertility treatment, have ED. 40% of men in their 40s, 50% in their 50s. That's the first thing. Just normalize that sexual dysfunction happens to men who are otherwise healthy.

Who are otherwise capable and able. And we're not talking about the one or two off nights after too much wine or a particularly stressful meeting. We're sort of talking about a pattern of dysfunction. The second thing is that this erectile dysfunction and infertility, male factor infertility,

Are canaries in the coal mine. For erectile dysfunction, it's the canary in the coal mine for vascular health. And I don't have to expand on what that means to your audience, but getting an erection is a vascular phenomenon physiologically. And the penile arteries are much smaller caliber than the coronary arteries. And the signs of decreased blood flow, arteriogenic erectile dysfunction, show up in the penis often years before the heart. And so erectile dysfunction.

Is an opportunity to be evaluated by an internist to just or a family doctor to make sure that he is healthy. Infertility is a precursor to male disease as well. Like one to

Erica Bove, MD (36:32)
Yes.

James Kuan MD (36:34)
eight percent of men who are evaluated with abnormal semen parameters go on to have underlying pathology, which could even be something like a testis cancer.

Erica Bove, MD (36:44)
Mm.

James Kuan MD (36:48)
Many of these men have been healthy their whole lives. For them, this may be the first opportunity for them to actually undergo a physical exam. And that's an important thing, too. Semen analysis alone is not enough. But to undergo a physical exam to make sure that they are otherwise healthy. Men with infertility have higher rates, they're at higher risk of early mortality. They have higher rates of testos cancer. And and and so

So infertility, abnormal semen analysis should prompt referral to an andrologist or a urologist for additional workup to make sure these things aren't happening.

Erica Bove, MD (37:29)
Bone health too,

right, Doctor Kwan? Like bone health, with low testosterone, bones like testosterone. I I've read some data that men we need to be thinking about men's bones as well.

James Kuan MD (37:38)
Yeah, and I I I think you know, w we we may talk about testosterone replacement in a minute, and I think that where often that helps or that becomes a factor is in people who aggressively manage the estrogen levels with testosterone. But but but but getting back to sort of the the cor you know, the correlates between the two, we've already talked about

Erica Bove, MD (37:57)
Yes.

James Kuan MD (37:57)
the commu communication, that it's optional, but

But I think what couples in infertility experiences, what a lot of couples in retirement experience is is desire mis mismatch. and

Erica Bove, MD (38:10)
Yes, yes.

James Kuan MD (38:12)
and whatever causes that mismatch, you know, in this case is the fertility journey.

In retired couples, you know, there's many reasons, but the the low-hanging fruit is is the impact of menopause on on female sexual function and and and historically in desire mismatch. And and and that's a difficult thing to overcome. And that's that's something that does require communication, that may require involving, you know, mental health professionals and couples therapy. But but I will say this to to the men who

may be listening over their partner's shoulder. doing the dishes without being asked is foreplay and does help. And and and that that there are those small things that that that

That do go a long way, and that that foreplay doesn't start in the bedroom, it starts after dinner at at the sink. And so so being aware of that cognitive and that household burden. I'm saying that because it's so obvious, but it's true. and so

Erica Bove, MD (39:24)
It is true.

I will a hundred percent validate that. Thank you for saying that. I tell that all the time to my people. Yeah.

James Kuan MD (39:30)
Yeah.

And then I think the other thing is is is the stigma, right? We talked a little bit about how this is emasculating and how this feels like loss of control or identity. what I say to men who are hesitant say to use something like a Viagra or get an implant or something like that in in more severe cases is using a crutch

is something that you can get upset about or you can have thoughts about. But but you know, when you were thirty five you used to golf without a cart and you called it golfing.

And now you're 75 and you golf using a cart and you still call it golfing. And I

Erica Bove, MD (40:13)
Rates.

James Kuan MD (40:13)
think the same can be said for Viagra, that you know, when you were 25 and you and your partner were dating and you had sex and you had an erection, you called it sex. But when you're 38 and you're having sex on the schedule and you need a Viagra to have sex, you're still having sex.

Erica Bove, MD (40:35)
That's brilliant.

James Kuan MD (40:35)
And so I think those are

kind of the things because, you know, the older I get, the more I realize I'm more the same as I used to. So so I would say the normalization of the dysfunction, the distance, the mismatch, the communication, the E D and then using the tools. I think those are the the parallels that happen between, you know, aging couples and then couples pursuing fertility.

Erica Bove, MD (41:00)
Yeah, I mean what strikes me in that is it's something like we talked about agency before, we can have agency in each of those areas, which I think is, you know, so much of this journey we feel out of control, right? It's like we don't know when the embryo report's gonna come or might not be what we hoped it would be, or we're waiting on this paperwork so that the embryos can be shipped. Whatever it is, like this is a largely a journey where people feel very powerless, especially female physicians and male physicians who are used to be like the drivers of the care, right? It's a very vulnerable position and I think

I think with each of those areas there's actionable things we can do at each step and I think you know when we can take back our power so much else change changes for the better.

James Kuan MD (41:40)
And

and sometimes I think i it's hard, it has to be hard.

To step out of the I, you know, this I alone can fix this. You know, we inherently

Erica Bove, MD (41:50)
Mm.

James Kuan MD (41:51)
can fix. And and and I I sometimes, when I more generically treat physicians, sort of ask them, what I want you to do is allow yourself to be the patient here. I do, you know, I'm happy to have a discussion at a high level with you, but I'm always going to have a discussion as a patient with you, and I want you to hear it and find some space to feel.

It as a patient that that that you know this, you know, we said, you know, family planning is a team sport, not just you know, man and woman, but but you know, it may even be like female physician whose partner is not medical, let the urologist

Erica Bove, MD (42:37)
Yes.

James Kuan MD (42:37)
Be

the bearer of bad news. Let them

Erica Bove, MD (42:39)
Yes.

James Kuan MD (42:40)
break that. You know, we we always have, you know, it's it's it's that how much do we disclose to the family members when we operate and we found cancer, right? And then that family that says, well, I don't I want to be the one to tell them that always makes me uncomfortable. And I always say, let me talk to them first, and I'm happy if you're

Erica Bove, MD (43:00)
Sure.

James Kuan MD (43:00)
there, but I don't feel that you should be the bearer of this news because that's not.

to the partnership that you have. And

Erica Bove, MD (43:09)
Right.

James Kuan MD (43:09)
so so so I think even as physicians, we we have to allow ourselves to to maybe insert ourselves to say that that that I want to be the person to give this news so that you don't have to, because there's already so much burden.

And and I'm sure you observe asymmetry in your listeners who are who are carrying the weight and and I'm sure are feeling like they are dragging their partners behind. and

Erica Bove, MD (43:40)
Yes. Yeah.

James Kuan MD (43:42)
and so I recognize, you know, the asymmetry there also.

Erica Bove, MD (43:47)
All of that is is so so good and I think you know

I want to listen to this again again, which I obviously will, because I think that there's so many gems in here that are gonna help people practically and it's just so beautiful that you're doing this work. I would

James Kuan MD (44:01)
And likewise to you.

Erica Bove, MD (44:03)
thank you. I mean it's amazing that it works too. I mean I'm sure it's so gratifying when you see a couple that's finally getting their groove back or you know, for me when I see a couple that has had infertility for years and like we reconnect the mind and the body and hey, sexual health is a huge part of that, and all of a sudden they're pregnant.

And it's just like it just makes you think, okay, there are certain things we understand scientifically, certain things that we have a hunch about. We understand the nervous systems involved, like it's it's the HPAX is involved. It's so but I think that it takes the time to sit with people to understand who they are, understand their values, their goals. It's not something that I think really works in the traditional medical system, which is why I'm so glad that you're doing what you're doing with your sexual health practice. And I I just know how many people benefit from it.

From your services. What I wanted to say is I wish we had time to talk about sperm bank things today and testosterone

James Kuan MD (44:58)
Yeah.

Erica Bove, MD (44:59)
replacement. I think we're at at the limit of what we can talk about today, but would you come back and maybe we could have a second conversation about some of the things I was having? I mean, male factor infertility is such a giant topic anyway, but I think that I want to do those topics justice as well. And I think our listeners, those things our listeners really, really want to hear about as well.

James Kuan MD (45:19)
I'll just make the one plug. TRT is bad for sperm. And so if if your partner's on TRT and you're trying to get pregnant, he needs to see a urologist, and that there is no perfect donor, and and

Erica Bove, MD (45:22)
Yes, it's really bad, it's really bad. Yeah, yeah. Yeah.

James Kuan MD (45:30)
and and donor choice is all in my opinion is all about eyes wide open. And that's what I tell so if anyone's considering a donor right now, the first thing I say is our goal today.

Is to get as much good information about you so that intended families can feel confident about their choice to use a sperm donor.

Erica Bove, MD (45:49)
Yes, yes, a hundred percent. And so I I I'm genuine about that. I really would love to have you back and I think those topics

James Kuan MD (45:54)
Yeah, for sure.

Erica Bove, MD (45:55)
really deserve the time and attention. where can people find you and is there anything else you want our listeners to hear based on all the wonderful things we talked about today?

James Kuan MD (46:04)
they can find me on Instagram at dr James Quan D R I always I always get a spell at D-R-J-A-M-E-S-K-U-A-N. my newsletter is www.sexafterretirement.com. And then I do have a practice website. I I I only treat in the state of Washington. and if you're able to share that, it's James Quan D.c-A-R-R-D.co.

Erica Bove, MD (46:32)
Amazing.

We will put all of this information in our show notes as well so people can access it as well. Yeah. Thank you. Anything else

James Kuan MD (46:38)
Thank you, Doctor Bove. Thank you.

Erica Bove, MD (46:40)
you want to share today? Do you feel we're complete?

James Kuan MD (46:44)
I I I feel complete and I I I just feel like yeah there's there's no I I I I loved when you said it can be messy and still work. And I I think it it's usually messy and then it doesn't work. And so then we build all of these protocols.

But a little bit of messy gives couples a little bit of grace to

Erica Bove, MD (47:08)
Yes.

James Kuan MD (47:09)
to not feel like they are the cause for the reason that the journey isn't successful.

Erica Bove, MD (47:15)
Yes, that's exactly it. That's exactly it. my goodness. Thank you so so much for being on the podcast. Thank you for the work that you do. And I cannot wait to continue to collaborate with you. Yeah. And to my listeners,

James Kuan MD (47:26)
I look forward to it. Thank you. Bye.

Erica Bove, MD (47:29)
you know how much I love you. Bye.