All language subtitles for Sex.Explained.S01E04.WEBRip.x264-ION10

This is a 17th-century Dutch
scientist's sketch of a "homunculus,"

a tiny, fully-formed human being

that according to one popular theory
of the day

was curled up
inside the head of each sperm.

Once the miniature person
entered the woman's body,

it grew into a full-size human.

A competing theory at the time claimed

that the miniature human actually lived
in the egg, not the sperm.

For 100 years,
so-called "spermists" and "ovists"

duked it out over who held the key
to creating new life,

until both theories died
with more powerful microscopes.

Then in the 19th century,

a German zoologist discovered how babies
are really made:

a sperm and an egg fusing together,
each playing an equal role.

We'd solved the mystery of life.

Well, at least one part.

I will never forget
the phone call I received

that kind of started this whole process.

Immediately, I heard her crying,
and she said they didn't find sperm.

She said they... they found zero.

And...

that's when my heart dropped.

I remember falling to the ground
in the lobby on my knees and just...

You just don't want to believe
that it could happen to you.

Male infertility around the globe,

even though it's so important
in terms of infertility,

is a hidden reproductive health problem.

It was really hard.

You go through really dark times

when you see, you know,
your friends having kids,

and here you are
almost six years down the road

and... still trying to figure it out.

Our species only exists
because we reproduce.

So, why can't so many of us do it?

What part of the mystery of life
is still unsolved?

- Dad.
- Yes?

Where do babies come from?

The whole field of fertilization
has expanded and advanced.

We help couples have babies in ways

that we wouldn't have thought possible
years ago.

I can't believe that she's ours
and that she's in our lives.

The patients here, they say,
"Doctor, it's... it's a crucial thing.

I want to keep my fertility."

For most people,
if you have sex at the right time,

there's a decent chance
this will happen...

a sperm meeting an egg.

But we're pretty bad at having sex
at the right time.

The truth is that your egg is only good
for about eight hours after you ovulate.

That's it.

And you'll never get that timing right.

It's impossible to get that right.

You're better off just having
intercourse regularly,

three times a week at least.

After intercourse, the sperm are good

for about three days
in the female's tract.

So, you always want to have
sperm there when you ovulate.

And that's because fertilization
isn't a sperm battle royal,

a frantic sprint between millions
of aggressive sperm to penetrate the egg.

It's more like the labyrinth
in the 1986 classic Labyrinth:

full of obstacles that sometimes hurt
and sometimes help.

I think I'm getting smarter!

This is a piece of cake.

Stop it! Help!

What do you mean, "help"?

We are helping.

We're helping hands.

And the labyrinth is unsolvable,

except in that brief golden window
or terrifying window.

Depending on whether or not you want
to get pregnant,

a delicate hormonal cocktail
has put everything in place.

First, the cervix,
the gatekeeper to the uterus,

is slightly open.

It denies entry to 99.9% of the sperm,
who die in the vagina.

It's not necessarily the fastest sperm
who get in or the strongest.

But you'll probably get kicked out
if you're a real freak.

And it's not always a mad dash.

Some sperm laze around for days
in a canal in the cervix

in little inlets called crypts.

It's a brief cervical Riviera vacation.

And then the sperm begin their quest
into the uterus.

But first, the cervix outfits them
with armor, a nutrient rich fluid.

Without it, they'd all die.

Once the sperm are in,

they're not so much swimming frantically
as they are pushed.

Sperm do crawl up the uterine wall,

but they're propelled forward
by uterine contractions.

So the ones that make it
to the Fallopian tubes

may not be the fastest swimmers.

They may have just gotten a good nudge.

The tubes keep the sperm nice
and safe in their walls

until the egg enters,

making the sperm hyperactive.

And they get one last assist
from the labyrinth.

Little hairs in the tube
point them the right way,

and then they swim like hell.

The ones that make it to the egg latch on,

- and maybe one gets through.
- Whoo-hoo!

The lucky sperm is just that: lucky.

"Powerball lottery winner" lucky.

Literally,
their chances were one in 250 million.

And it's tough for a reason.

If more than one sperm manages
to fertilize an egg,

the resulting embryo can't survive.

That's why scientists think all these
obstacles evolved in the first place.

And it's why it can take a little while
to get pregnant.

There was no reason to believe
that we were gonna have any issues.

For an average couple
having unprotected sex,

it happens within six months.

Even after trying for a few months,
we just kept thinking

that next month will be the month.

Then next month turned
into six months later, turned into a year.

After 12 months, around 15%
of couples still aren't pregnant.

I'd say around a year,

we started to get concerned
that maybe something might be off.

And when a couple has tried
for a year with no success,

most health officials
consider them infertile.

But one half of the couple tends
to get most of the attention.

There is a connection
between a woman's stress

and her ability to get pregnant.

Fast food could be slowing down
how quickly some women become pregnant.

We don't want women to panic,
but it is true.

Just go and ask. Don't be scared
to ask the question and say,

"Doctor, can you help me
figure out what's going on here?"

One reason for the focus on women

is that their bodies are the labyrinth.

It keeps changing!
What am I supposed to do?

The sperm shoots in
at around 30 miles an hour,

but sometimes they're doomed
from the beginning,

like when the ovaries don't produce
an egg,

perhaps because of a hormonal imbalance.

If the ovary does release an egg,

the sperm may not be able to get to it,

because something made the labyrinth
impossible...

like a damaged or blocked tube.

And if the sperm does get to it,

and a fertilized egg travels down

to snuggle into the thick uterine lining,

the lining might be damaged,

so the egg can't stick.

But it isn't just an issue
with the labyrinth

that can cause infertility.

In at least 40%
of the cases of infertility,

there's a male factor involved.

For men,

infertility basically comes down
to one thing: sperm.

Chances of conceiving in a given month

go up with sperm count...

till about 40 million.

After that,
there's not much extra fertility boost.

And 15 million is a low count,

according
to the World Health Organization.

The morphology of a man's sperm,

its size and shape, may also play a role.

This is a normal sperm:

an oval head with a long tail,

while an abnormal sperm may have
a weird-looking head...

or two tails.

There's such a variety of normal sperm

and abnormal sperm
in any particular ejaculate

that it's really hard to say
morphology's a problem.

Poor motility is very important,

but poor motility is always associated
with a low count.

So, if the actual numerical count
is good... good enough,

then even a low motility
doesn't mean anything.

On TV, low sperm count
is often treated as a joke,

like the risk posed by hot tubs...

- Mr. Truman.
- Yes.

We need to talk about your sperm.

I knew it.
It's the Jacuzzi at the gym.

He boiled them, didn't he?

...and too-tight underwear...

Look, you gotta help me.
I have to get off jockey shorts.

- What, you have a low sperm count?
- Very low!

...and excessive masturbation.

Sample hardly had any swimmers.

That's probably
from excessive masturbation.

Guy's been outpacing
his ability to produce... sperm."

Daily ejaculation
has no major negative effect

on semen parameters,

as in sperm count or quality.

As for tight underwear...

one study found
"semen parameters gradually decreased

while the subjects were
in tight conditions,"

but they “gradually increased
while they were in loose conditions."

And the "wet heat" of hot tubs
can also temporarily lower sperm count.

But only DJ Khaled levels
of Jacuzzi time could do that.

For the record,
DJ Khaled's sperm seems totally fine.

See? He's got a son.

But some things can cause lasting harm,

like the kind of steroids sometimes used
by bodybuilders.

Those steroids build muscle fast
because they pump you up

with synthetic forms of testosterone.

And studies have found
that heavy long-term use

can cause
"some degree of gonadal impairment."

So "the impact on male fertility
is not solely a transient condition."

Male fertility can also be
permanently impacted

by accidental exposure to chemicals,

like the pesticide dibromochloropropane,

or "DBCP," banned in the US in 1979.

But banana plantations in the Philippines
and at least a dozen other countries

still used DBCP well into the '80s.

Thousands of workers were left sterile

and sued the American companies
who made and exported the pesticide.

After I started working
on the banana plantation,

I wasn't able to have kids anymore.

What do you want to happen now?

Since we are claimants
against that pesticide,

we want to be paid
because of our sterility.

The workers
in that lawsuit were eventually paid,

depending on how low
their sperm count was.

And it's not just men who work
with chemicals who are at risk.

Their biologies are being exposed
to things

that are not good
for male reproductive health.

In 2017, researchers reviewed data

from more than 50 countries

and found that the average sperm count
has been dropping for decades.

It's still above a totally fertile level,

but the average man today
has half the sperm his grandfather did.

So, the other important thing
about this is to ask,

"Well, is it getting better?

Is the decline stopping?"

And so we looked at that,
and the answer is no.

One likely culprit... plastics.

Production ramped up
during the Second World War...

Here is a plane containing hundreds
of plastic parts.

...and it hasn't slowed down since.

Plastic. Plastic. Plastic.

Gradually, there were signs

that maybe everything was not... right.

Phthalates are the group of chemicals

that make some plastics soft and flexible.

And another chemical, BPA,
is what makes other plastics strong.

They get into our bodies through our food,
our skin, and even the air.

And they can change
our body's hormonal balance,

which can have an especially huge impact
on a developing fetus.

In a six-week-old fetus,

the cells that eventually produce
the testes and ovaries,

germ cells, are identical.

In the following weeks,
they usually pick a lane,

their development guided by the balance
of hormones in the uterus.

In the body, phthalates
and BPA can throw off that balance,

potentially impacting the number
and quality of eggs that develop

or the testes' ability
to produce sperm later.

You can imagine that if you mess

with that critical hormonal development
at that time,

you will mess up a lot of systems.

So, I like to think
of declining sperm count

as the canary in the coal mine.

Because they represent a disruption
that happened very early

that disrupted a lot of things.

And the way germ cells develop
in the uterus

also explains another huge factor
affecting fertility: age.

Male germ cells in the testes
don't start producing sperm until puberty.

A germ cell divides
into two identical copies.

One keeps dividing,

and those cells become sperm.

But the other stays a germ cell,

so they don't run out.

And a man can produce new sperm
until old age.

But in a female fetus,

those germ cells in the ovaries start
turning into immature eggs right away.

A 20-week-old fetus has
roughly seven million of them.

But they quickly start wasting away.

A female newborn is left
with about two million.

And by the time the first one makes
its debut in puberty,

she's down to 300,000 or 400,000.

And then every month,
one egg is released,

and a thousand or so more die off.

And that's why most women
have a much harder time

getting pregnant after 40

and are pretty much out of eggs
by the time they're 50.

Age also hurts male fertility,
though not as much.

It takes older men longer
to get their partners pregnant

especially after they turn 45,

and that's controlling
for their partner's age.

But flip through any tabloid magazine,

and you can see
they can still have kids.

Sperm production may not stop,
but sperm quality can change.

We know there are some terrible,
terrible genetic mutation diseases

that, uh, can occur from older sperm,

because we know
there's about two mutations

that occur every year.

And so, over time, that builds up
and builds up and builds up,

so that there will be more mutations
in a 60-year-old's sperm

than in a 20-year-old's sperm.

But headlines

about birth defects tend to focus
on older women.

There just hasn't been
nearly as much research on men.

Male infertility
has been poorly understood,

and the public and even doctors
don't understand it very well.

Most of the time, the quality
of the sperm and the quantity the sperm

is genetically determined.

Now we don't have all the genes
figured out, obviously.

They diagnosed it:
non-obstructive azoospermia.

Which I had to immediately look up
and see what that meant.

Azoospermia is when there's
no sperm in the ejaculate.

Sometimes it's because there's a blockage,

but often,
it's because the testes aren't producing

enough sperm to begin with.

That's the case for Myles.

Nothing came back,
“You'll never have kids.”

Everything came back,
"Oh, there's a chance. There's a chance."

Myles had two surgeries

to try to find any sperm
that might be in the testes.

But no luck.

It changes a couple
when you have an infertility diagnosis.

It takes a toll on you, on your marriage.

When you love somebody
with all your heart,

but you can't give them what they want...

I was pretty destroyed
after the second surgery.

There really isn't a lot of things
that treat azoospermia.

For centuries,

because fertility research
has focused on women,

so have fertility treatments,

figuring out how to get around
different obstacles in the labyrinth.

You don't, by any chance,

know the way
through this labyrinth, do you?

Who, me? No, I'm just a worm.

I have to solve this labyrinth.

One shortcut is
to let the sperm skip the cervix

by putting them directly into the uterus,
called "intrauterine insemination."

Later, scientists developed treatments

that removed more barriers
from the labyrinth,

drugs that stimulate the ovaries
into producing an egg,

surgery to remove blockages
in the Fallopian tubes.

Then in 1978, we figured out how
to skip the labyrinth entirely.

You are about to see
a historic birth

following in vitro fertilization.

The achievement was so historic,

the entire birth was filmed
at the British government's request.

Heart sounds
and the lung sounds are normal.

Lovely pink color.

Plenty of fat underneath the skin...

Good mature baby.

In vitro fertilization comes
from the Latin "in glass,"

otherwise known as "IVF."

A doctor retrieves an egg
from the ovaries through the vagina

and then mixes it with sperm in a lab.

The fertilized egg is then implanted
directly into the uterus.

And another major breakthrough happened
in the 1990s:

"Intracytoplasmic sperm injection"
or ICSI.

By using a delicate hollow needle,

doctors can now pick up a single sperm
and implant it into the egg.

I'm not talking about five million,
or 50,000, or 1,000, or 100...

If he has two or three sperm
or one sperm, we can find it,

and we can inject it directly
into the egg,

and you have a normal pregnancy rate.

We'd gotten around the labyrinth,

but a couple still needs
to find that sperm.

Give me the child.

I figured there had to be a way somehow.

So, I had done research from the start.

And she came across
a less common procedure,

which could potentially locate sperm

that the other surgeries might
have missed.

She's like, "It's gonna be $13,000,
and it's a maybe,

and we've already been told no twice."

And I was like, "Wow."

I knew, at this point,
it was the last hurrah.

If... If we got bad news,
that... that was it.

But, um, you know just, I'm also,
like, the epitome of optimism.

So, I was like, "Oh, yeah,
we'll figure it out. This is gonna work."

All this technology
also opens up the possibility

of biological parenthood
for couples where both partners have eggs

or both partners have sperm,
and for people without a partner.

A changing face of parenthood
is emerging

as more women are using
in vitro fertilization

to become single mothers.

Joseph Tito's journey to fatherhood
via surrogacy in Kenya

is drawing attention to the diverse ways

in which people may choose
to have children.

We're able to take the eggs
from one woman,

fertilize them with the donor's sperm,

and transfer them
into her same-sex female partner.

We both participated in our own ways
in creating her.

This is Zachary. This is David,

and we are very happy to be here.

- Hey!
- Hey, Zachary.

But the new tech doesn't come
with a guarantee.

For example, IVF's success depends a lot
on the age of the eggs.

For women under 35,
it works 29% of the time.

For women 40 to 42, the success rate
is around one in ten.

The chance of success goes up
when using eggs frozen at a younger age.

But according to one study,

the real way to maximize the chance
of success is to freeze a ton of eggs.

For most women, 40,

which would usually require several rounds
of egg extraction

and months of hormone injections,
which can take a physical toll.

Though you may not know that looking
at ads on social media,

from boutique startups urging women
in their 20s

to freeze their eggs
as an insurance policy.

One compared egg freezing
to the cost of an acai bowl,

as if the procedure was as easy
to buy into as any wellness trend.

I think it's unfortunate
that it's become commercialized.

So, there's a lot of really kind of
atrocious marketing going on.

Because it's not a guarantee of anything.

But there's a new promising therapy

that could help even more women
transcend their biological clocks:

not freezing their eggs,
but freezing a piece of their ovaries.

This was originally developed
for cancer patients,

whose ovaries can be destroyed
by chemotherapy or other treatments.

So, we freeze the ovarian tissue,
and within a matter of days,

they can start on their cancer treatment.
And then 20 years later...

The tissue is transplanted
onto the dead ovary,

where incredibly, the transplanted tissue

starts functioning like its own new ovary.

And lo and behold, they start ovulating,

and they get pregnant spontaneously
with no IVF.

As of 2016,

84 babies had been born
through ovarian tissue freezing,

two-thirds without IVF.

And doctors hope that one day
this could be a mainstream therapy.

And while each new technology

is helping more and more people conceive
who couldn't before,

some are always left out.

As a black lesbian woman
who desperately wants to be a mother,

I've had to look at, like,
"What does insurance provide?"

How much money is this going to cost?
How accessible is this really for me?"

In most countries,

a single round of IVF will run thousands
of dollars,

and many people need multiple rounds
for it to work.

It's a very expensive procedure,

and we're talking about black women
only making 64 cents on the dollar.

And some countries can ban
certain groups from getting IVF

or other fertility treatments.

Because these aren't
just medical procedures,

they challenge the traditional idea
of family.

Remember, health officials have
long defined infertility

as an inability to get pregnant
after one year of unprotected sex,

which obviously doesn't apply
to single women

or a lot of the LGBTQ couples.

The route for single women
in France is an obstacle course.

We're not accommodated
because it's been illegal up until now.

And you have to go abroad.
You have to research a clinic.

In 2017,
some doctors changed the definition

to an impairment
of a person's capacity to reproduce

either as an individual
or with his or her partner."

Which may lead the way
to broader access to treatments.

And no doubt, more research
and new discoveries will offer hope

to more people who long
for a biological child.

We had a bottle of champagne
in the fridge if the news was good,

uh, and we probably
just would havesmashed it

on the floor if the news was bad.

So, we get the call from the doctor,

and he literally just said,
"Hey, you know, how have you guys been?"

And then it was,
"I got some good news for you."

And we both fell to the floor in tears.
I don't...

I mean, it was just...

it was probably one
of the best moments of my entire life.

We still have a very long road ahead of us
with IVF and everything.

And, um, we're hoping
to have our finances in place

to go out in October
and hopefully get pregnant.

- September.
- September.