Tobacco and alcohol as factors for male infertility—a public health approach

Abstract

Background

The study of reproductive characteristics of 430 male subjects of different age, fertility status and educational level who were involved in the program of extracorporeal fertilization at the Clinic of Gynecology and Obstetrics, Clinical Centre Niš, examined their knowledge, attitudes and behavior regarding tobacco and alcohol consumption as lifestyle risk predictors of their partial or full infertility.

Methodology

Consisted of the analyses of spermiograms to establish their fertility status and a survey of their attitudes towards smoking and alcohol use (behavior, knowledge of the general health and reproductive health consequences of such a lifestyle, and their determination to change it).

Results

The proportion with higher tobacco consumption and more severe forms of infertility increased significantly with ageing (P < 0.001); the highest daily consumption of alcohol and the incidence of intoxication was seen among azoospermic patients; the level of awareness of the harmful effects of tobacco was highest among normozoospermic subjects and the highest level of determination to quit smoking was statistically significantly present among azoospermic subjects.

Conclusion

Appropriate use of health promotion activities in relation to alcohol and tobacco use is through specially designed programs.

Introduction

According to the World Health Organization (WHO) definition, a man is infertile (sterile) if his sperm parameters are lower than the parameters prescribed by the relevant criteria.¹

The increasing tendency of male infertility has been observed mainly in the developed countries, with a wide range of differences between the individual WHO regions as well as nationally, reaching the percentage of even 70%.²

Unhealthy lifestyles and health risk factors such as smoking, alcohol and substance abuse, obesity and exposure to adverse elements in the general and working environment^3–6 are considered to be the dominant risk factors for male infertility today. Exposure to harmful effects of tobacco and alcohol here plays the principal role worldwide.

The mechanisms of adverse effects of certain ingredients of cigarettes on sperm parameters are complex and involve the effects on the secretion of reproductive hormones thereby compromising their impact on spermatogenesis and sperm quality and intrastructural abnormalities occur.^7–11

Tobacco use is held more responsible (than in non-smokers) for the partner health as well, pregnancy, and even the possibility for a successful assisted reproduction, as well as for future fertility.¹⁰

Primary male infertility correlates with alcohol intake as well, which is on the rise especially in male populations in their reproductive years.^11,12

Excessive and long-term alcohol intake adversely affects the testes and induces azoospermia. In such circumstances, if there is no recovery, fertilization is possible only with ICSI within assisted reproduction attempts.^13,14

The WHO adopted in 1999 the Strategy ‘Health for all in the 21st century’ and program tasks, which bound all the members at the national and international level to accomplish certain goals, among which there were the ones directly or indirectly oriented towards healthy beginning of life, healthy and safe physical environment, fight against smoking, alcohol consumption and drugs, tending to promote general, but also reproductive health.¹⁵

Aim of the paper

Our aim was to establish the significance of male population responsibility for one’s own fertile status, taking into account alcohol and tobacco use, years of age, level of general education as a hallmark of health culture, as well as to predict the attitudes and health behaviors related to this lifestyle segment. The results should indicate the areas for possible intervention aimed to ameliorate and reduce their harmful effects on fertility and promote healthy lifestyles in male populations.

Methodology

From the corpus of patients examined by embryologists at the Department for Assisted Reproduction, Clinic of Gynecology and Obstetrics, Clinical Centre Niš, for problems with partner absence of pregnancy, 430 male subjects with different levels of fertility (oligozoospermia, azoospermia and normozoospermia) were selected.

After a preliminary spermiogram analysis was done and results were obtained and checked against the adopted reference values for the individual elements of semen and spermiogram, a committee chose the couples to undergo the appropriate assisted reproduction procedure. All examinees were surveyed regarding age, educational status, knowledge, attitudes, current and predicted behavior concerning alcohol and cigarette consumption.

Statistical analysis involved the preparation and presentation of data as arithmetic means, standard deviations, minimal and maximal values, i.e. in the form of absolute and relative numbers. Comparison of response distribution between the studied groups was performed using the Chi-squared test. Unilateral logistic regression was used to determine risk factors for developing a level of fertility. The hypothesis was tested with a significance threshold of P < 0.05. EPI INFO v 7.2.2.6 software package was used for statistical processing.

Results

The study involved 430 subjects, with an average age of 33.98 ± 9.99 years (min 17 and max 55), with the following age structure: 77 (17.9%) in the group < 21 years; 196 (45.6%) in the group 21–39 years and 157 examinees belonged to the category of over 40 years of age (36.5%).

In the studied population, there were 77 students and pupils (17.9%), 65 with completed primary education (15.1%), 159 with completed secondary education (37.0%) and 124 men who had completed a higher school or college (28.8%). Education data were not obtained from five subjects (1.2%).

As for tobacco consumption in the study population, the frequency of smoking was statistically significantly different related to subject age (P < 0.001); 23.2% of the youngest examinees did not smoke, as well as 27.6% of those aged 21–39, and 38.9% of the oldest examinees.

When considering answers to questions about the state of awareness of the effects of smoking on fertile health, we registered as ‘fully’ aware those having knowledge about the consequences of tobacco consumption on their own general and reproductive health, as well as on the health of their partners, by being able to provide positive information (at least three pieces of information, with examples regarding male gender: effects on the heart, blood pressure, lungs, potency, fertility, etc., and factors related to females: fertility, development of pregnancy, foetal status, risks of miscarriage or bleeding in pregnancy).

Furthermore, there were no statistically significant differences in the examined categories regarding the plans for behavior in the future as to tobacco use (P = 0.134).

The obtained responses about the frequency of alcohol intake, knowledge of its effects and plans for the future as to alcohol use, suggested that there were no statistically significant differences among the studied age groups, as demonstrated by the Chi-squared test results (P = 0.077, P = 0.082 and P = 0.568).

Compared with alcohol intake, the knowledge of the effects of tobacco on general and reproductive health did not vary among the studied age groups, i.e. there were no statistically significant age-related differences (P = 0.082; Table 1).

Table 1.

Current behavior, knowledge and further plans concerning tobacco and alcohol consumption by age category

	Age (years)						χ2	P  1
Current tobacco-related behavior	<20%		21–40%		≥41%
Not smoking	41	23.2	87	27.6	51	38.9	43.43	<0.001
Up to 10 cigarettes a day	20	42.9	54	44.4	45	51.0
Up to two packs a day	13	2.6	35	17.9	48	8.3
Over two packs a day	0	0.0	5	2.6	13	1.9
Without response	3	0.0	15	7.7	0	0.0
Awareness of the effects of smoking on health
Fully informed about effects on their health	48	42.3	107	70.9	101	77.1	8.78	0.163
Partially informed about effects on their health	25	32.5	81	25.5	50	21.0
Without basic knowledge	0	0.0	3	1.0	3	0.0
Without response (unknown)	4	5.2	5	2.6	3	1.9
For smokers: prediction of behavior
Quitting smoking	20	14.3	25	24.0	26	19.7	10.16	0.137
Decreasing the number of cigarettes	21	14.3	44	22.4	44	22.3
No change in behavior	27	62.3	24	50.0	17	54.1
Without response (unknown)	9	9.1	6	3.6	10	3.8
Current alcohol-related behavior
No consumption	25	45.5	59	31.6	54	40.1	11.38	0.077
Up to two drinks a day	43	49.4	104	55.1	84	53.5
Regularly over two drinks a day	6	3.9	22	9.2	14	5.7
Intoxicated at least once a month Without response   (unknown)	1 2	1.3 0.5	8 3	4.1 0.0	3 2	0.6 0.1
Knowledge of the effects of alcohol consumption
Fully informed about effects on their health	48	62.3	110	66.3	102	77.7	11.23	0.082
Partially informed about effects on reproductive health	24	31.2	67	29.1	42	20.4
No information	3	0.0	12	1.0	10	0.0
Without response (unknown)	2	6.5	7	3.6	3	1.9
Future behavior concerning alcohol
Quitting alcohol	6	10.4	20	10.7	22	12.1	4.81	0.568
Decreasing consumption	39	20.8	84	20.9	78	15.3
No change in behavior	26	58.4	82	61.7	46	67.5
Without response (unknown)	6	10.4	10	6.6	11	5.1
Fertility diagnosis
Oligospermia	6	7.8	54	27.6	49	31.2	24.08	<0.001
Azoospermia	1	1.3	14	7.1	14	8.9
Control group	70	90.9	128	65.3	94	59.9

Frequency of smoking statistically significantly differed related to diagnostic status, with the largest proportion of smokers among the infertile examinees (72.4%).

Information as to the effects of smoking was statistically significantly different among the studied groups (P = 0.003). The examinees with normozoospermia (from the control group) were the best and fully informed group (76.7%), whereas the level of information was lowest in those with azoospermia (41.4%). Further behavior plans regarding fertility were statistically significantly different (P < 0.001), with most of the examinees from the control group unwilling to change their behavior, whereas a much smaller proportion of those with azoospermia was unwilling to change their behavior (28.0%).

Examinees with azoospermia were the ones most willing to quit smoking (48.0%), while oligospermic ones were mostly willing to reduce smoking (36.4%).

The frequency of alcohol intake statistically significantly differed related to studied diagnoses; alcohol intake was the least frequent in individuals with normozoospermia (47.6%). Azoospermic subjects were the ones who regularly drank more than two alcoholic drinks a day (45.0%), whereas almost a third of them used to get drunk as well (31.0%).

The knowledge about alcohol statistically significantly differed related to the diagnosis of fertile status (P < 0.001).

Further alcohol-related behavior statistically significantly differed related to diagnosis (P < 0.001). The proportion of azoospermic subjects was the largest among those who reported the wish to quit drinking alcohol completely, whereas the reduction of alcohol intake was reported mostly by oligospermic subjects (31.0%; Table 2).

Table 2.

Frequency of smoking and alcohol consumption, awareness on health effects of smoking and the further behavior in the study population in relation to diagnoses

	Dg						χ2	P
	Oligospermia		Azoospermia		Control group
Smoking*
Not smoking	24	4.6	0	0.0	131	44.9	227.78	<0.001
Up to 10 cigarettes a day	57	49.5	11	37.9	129	44.2
Up to two packs a day	17	36.7	11	37.9	24	8.2
Over two packs a day	3	2.8	7	24.2	0	0.0
Without response	8	6.4	0	0.0	8	2.7
Awareness of the effects of smoking on health
Fully aware	72	66.1	12	41.4	224	76.7	16.10	0.003
Partially aware	32	29.4	8	27.6	66	22.6
None  Without response	5 0	4.5 0.0	9 0	31.0 0.0	2 0	0.7 0.0
Future smoking-related behavior†
Quitting smoking	16	18.4	12	48.0	31	17.8	37.82	<0.001
Decreasing the number of cigarettes	47	54.0	17	51.9	49	16.8
No change in behavior  Without response	24 *	27.6 *	0	0.0	29 *	65.4 *
Alcohol
No consumption	21	19.3	0	0.0	139	47.6	105.78	<0.001
Up to two drinks a day	72	66.0	10	34.5	148	50.7
Regularly over two drinks a day	13	11.9	12	41.4	5	1.7
Intoxicated at least once a month	3	2.8	7	24.1	0	0.0
Awareness of the effects of alcohol on health**
Fully aware	64	58.7	10	45.5	226	78.2	26.03	<0.001
Partially aware	29	26.6	18	50.0	66	21.8
None  Without response	1 15	0.9 13.8	1 0	4.5 0.0	0 0	0.0 0.0
Future alcohol-related behavior††
Quitting alcohol	16	14.7	11	37.9	21	7.2	50.45	<0.001
Decreasing consumption	31	28.4	4	13.8	46	15.8
No change in behavior  Without response	53 9	48.6 8.3	7 7	24.1 24.1	212 13	72.6 4.4

It was found that there was a statistically significant difference in the incidence of concurrent consumption of cigarettes and alcohol among the study groups (χ² = 91.97, P < 0.001). At the same time, tobacco and alcohol were consumed by all azoospermic subjects, 76.8% of those with oligospermia and the percentage was lowest for control group subjects (29.5%; Fig. 1).

Fig. 1.

Graphical representation of response structure by observed types of health behavior.

Smoking awareness was statistically significantly different depending on the level of education (P < 0.001). It increased with the level of education, but at the same time, there was no statistically significant difference in further behaviour related to cigarette consumption. Furthermore, the knowledge about alcohol statistically significantly differed in relation to the level of education (P < 0.001), with the highest level of knowledge shown by the most educated examinees. However, the availability of adequate information did not lead to a significant degree to the adoption of healthier lifestyles in relation to the examined risk factors (P = 0.060; P = 0.617 and P = 0.742; Table 3).

Table 3.

Behavior, awareness and intentions for future behavior in relation to education level

	Education level						χ2	P  1
Smoking	Primary		Secondary		University
Not smoking	62	43.7	50	31.4	43	33.3	14.972	0.060
Up to 10 cigarettes a day	63	44.4	70	44.0	62	48.1
Up to two packs a day	8	5.6	27	17.0	16	12.4
Over two packs a day	6	4.2	6	3.8	2	1.6
Without response	3	2.1	6	3.8	6	4.7
Awareness of the effects of smoking on health
Fully aware	65	45.8	120	75.5	128	99.2	102.558	<0.001
Partially aware	71	50.0	39	24.5	1	0.8
None	2	1.4	0	0.0	0	0.0
Without response	4	2.8	0	0.0	0	0
Future smoking-related behavior
Quitting smoking	21	14.8	39	24.5	24	18.6	19.664	0.003
Decreasing the number of cigarettes	24	16.9	38	23.9	38	29.5
No change in behavior	93	65.5	82	51.6	67	51.9
Without response	4	2.8	0	0.0	0	0.0
Alcohol
No consumption	51	35.9	59	37.1	48	37.2	4.445	0.617
Up to two drinks a day	76	53.5	80	50.3	73	56.6
Regularly over two drinks a day	10	7.0	16	10.1	6	4.7
Intoxicated	5	3.5	4	2.5	2	1.6
Awareness of the effects of alcohol on health
Fully aware	64	45.1	115	72.3	126	97.7	94.029	<0.001
Partially aware	71	50.0	43	27.0	3	2.3
None	2	1.4	0	0.0	0.0	0.0
Without response	5	3.5	1	0.6	0	0
Future alcohol-related behavior
Quitting alcohol	15	10.6	20	12.6	15	11.6	3.517	0.742
Decreasing consumption	35	23.9	31	19.5	32	24.8
No change in behavior	89	62.7	106	66.7	81	62.8
Without response	4	2.8	2	1.3	1	0.8

Logistic regression analysis showed that independent statistically significant risk factors for azoospermia were age, and smoking and alcohol awareness. For oligozoospermia, statistically significant independent risk factors were age, smoking and alcohol intake. The strongest risk factor for oligozoospermia was smoking. Smokers were 12 times more likely to develop oligozoospermia than non-smokers (odds ratio, OR 12.311). The risk factors for disturbed normozoospermia were age, smoking, alcohol consumption and insufficient knowledge of the effects of alcohol compared to full knowledge of the impact of alcohol. Smoking was also the strongest risk factor for disturbed normozoospermia. Smokers were 14.5 times more likely to disturb normozoospermia compared to non-smokers (OR 14.493; Table 4).

Table 4.

Risk factors for azoospermia, oligozoospermia and normozoospermia (univariate logistic regression)

Risk factors	Azoospermia			Oligospermia			Control group
	OR	95%CI	P	OR	95%CI	P	OR	95%CI	P
Univariate model
Age	1.072	1.026–1.120	0.002	1.053	1.031–1.076	<0.001	1.069	1.046–1.092	<0.001
University degree	0.882	0.380–2.046	0.769	1.097	0.712–1.691	0.673	1.056	0.695–1.606	0.797
Smoking	5.911	0.742–47.121	0.093	12.311	6.492–23.344	<0.001	13.279	7.136–24.710	<0.001
Awareness of smoking effects
Fully aware	RC			RC			RC
Partially aware	2.408	1.090–5.319	0.030	1.399	0.893–2.190	0.142	1.753	1.132–2.715	0.012
None	19.867	1.184–333.271	0.038	2.130	0.132–34.401	0.594
Alcohol				1.571	1.257–1.963	<0.001	1.820	1.458–2.272	<0.001
Awareness on alcohol effects
Fully aware	RC			RC			RC
Partially aware	2.808	1.261–6.253	0.012	1.538	0.989–2.390	0.056	1.987	1.290–3.061	0.002
None	22.462	1.330–379.457	0.031	2.211	0.137–35.716	0.576	–		0.999
Multivariate model
Age	1.255	1.072–1.471	0.005	1.104	1.070–1.138	<0.001	1.138	1.099–1.178	<0.001
University degree	1.034	0.139–7.688	0.974	0.704	0.387–1.281	0.251	0.657	0.353–1.225	0.187
Smoking	—			16.002	7.850–32.622	<0.001	22.828	10.70–48.701	<0.001
Awareness of smoking effects
Fully aware	RC			RC			RC
Partially aware	0.172	0.009–3.405	0.248	1.179	0.382–3.643	0.775	0.642	0.195–2.108	0.465
None	—		1.000	43 899	0.000–	1.000	–
Alcohol	—			1.940	1.105–3.404	0.021	2.556	1.414–4.620	0.002
Awareness of alcohol effects
Fully aware				RC			RC
Partially aware
None	5.577	0.321–96.900	0.238	1.103	0.367–3.312	0.861	2.209	0.692–7.053	0.181
Hosmer–Lemeshow test	0.975			0.290			0.718

Discussion

Our study dealt with aggravating factors related to the emotional and psychological distressing situation in the subjects, especially those who had previously received unfavorable sperm count results. Similar studies implicated these factors as well, but except for the personal responses to the questions asked, it was not possible to ascertain their correctness in view of the lack of adequate measurement tools.¹⁶

Alcohol

According to a 2013 study of the public health of the population of Serbia, alcohol consumption in our country was estimated by the authors to be on the rise compared to the previous period of research, with 8.3% of men drinking daily. At least once a month, 27% of men were excessively intoxicated, and such a behaviour was observed in 17% of adolescents (with more than six drinks in a row). According to the WHO, such data are less favorable than in most countries in the region. As a criterion for medium health risk, our researchers adopted a dose of alcohol of 40 mg of ethanol a day for men, and 20 mg a day for women.¹⁷

According to our study, most of the examinees consumed alcohol in acceptable amounts, reported as most frequent for the European Union area as well (up to two drinks a day in all age groups).

Our results showed that alcohol is most frequently consumed by those with azoospermia. At the same time, insufficient knowledge and alcohol intake represented an independent, statistically significant factor with adverse effects on reproductive health.

Statistically, most of the responses to our question about further planned behavior related to alcohol intake belonged to the group, which was not going to change their behavior, regardless of age, level of education and fertility status.

Smoking

Investigation of the exposure of Serbian population to the factors harmful to male fertility in the 5-year period in the aforementioned analytical study of the Institute of Public Health of Serbia identified an increasingly important role of adopted lifestyles, among which, in addition to alcohol consumption, is smoking. In Serbia, most men have smoked during their lifetime, of whom as many as 81.7% were daily smokers, one third smoked every day, with the largest proportion of them in their best professional and reproductive years (45%).

The WHO comparison used in this study places Serbia at ninth place in smoking prevalence in the group of selected countries.¹⁸

In our study, the youngest category of examinees belonged to a statistically significant degree to non-smokers, while tobacco use was related to health risks in the category of examinees over 40 years of age.

As for knowledge of the risks smoking posed to general and reproductive health in both partners, the examinees were statistically significantly well informed (measured by personal experience of the degree of health culture in our population); nevertheless, the responses were not satisfactory regarding the willingness to quit smoking. Similar results were obtained in the studies in Canada and the United States.^19,20

The results of studies involving doctors and medical students showed that an appropriate level of information/health education was not sufficient for a lifestyle change; the results were only slightly different from those obtained in the general population, which was explained by the need for stress relief and relaxation.²¹

The research in the student population suggested that there was the knowledge of the unfavorable role of tobacco and alcohol in fertility, but among the answers of the respondents there were many misconceptions (about the importance of diet, physical activity, etc.).²²

The ability to motivate people to adopt healthy changes in lifestyles is limited and requires a longer period of time.²³

Hofman et al. advocated a health promotion program as the first step to modify behavior and achieve a reproductive success.²⁴

According to the experience,²⁵ there is no single, generally acceptable program, which would satisfy the criteria of knowledge and attitude advancement, or succeed in behavior changes in addictions (to which tobacco and alcohol abuse belong in addition to other diseases).²⁵ However, it is not enough just to inform the population; instead, a partnership (active involvement of both sides) in decision-making is essential in that regard.²⁶

The success of decades of campaigns in the US, with a significant decline in the prevalence of smokers, proves the benefit of promoting healthy lifestyles.²⁷

The introduction of modern information technologies has contributed to a successful implementation of actions for the adoption of healthy lifestyles in New York and Australia,^28,29 in accordance with the WHO recommendations.³⁰

Conclusion

Although the youngest examinees showed the best results in our study, it would be of particular importance that all categories at risk of alcohol abuse and smoking become aware of their consequences to their fertility. This would make possible greater coverage by spermiogram controls, monitoring and risk evaluation for those involved.

In the period to follow, continuation of our research will require comprehensive monitoring and innovation of preventive measures in our region, achieving not only a raise in health awareness, culture and behavior in the sense of risk factor elimination, but also in the prediction and increase of the possibilities to become a parent for male population at an early stage, as well as in the planning of further counselling activities by the health system and community. In order to achieve this, it is necessary to implement a specially designed health promotion program, which would be designed and implemented by a multidisciplinary team of experts and scientists, involving also adequate financial, media and political support.

Funding

As far as funding is concerned, we authors financed our own research, we had no sponsors for that.

Authors’ contributions

MB designed the research and application of the appropriate methodology. He also researched the results of other (mostly newer) analyzes of the effects of tobacco and alcohol on male fertility. MK and JC participated in data collection and the establishment of the research base. DM contributed to the analysis of male infertility on a global and national level. All authors approved the final version.

Data availability

All materials related to the manuscript are available.

Conflict of interest

The authors state that there are no significant conflicts of interest.

Ethics statement

There is a decision of the Ethics Committee of the University Clinical Center in Nis attached. We had the consent of all survey participants during the review. We are grateful to all survey participants.

Marin Basic,

Dejan Mitic,

Mirjana Krstic,

Jovana Cvetkovic,