Burdens and Awareness of Adverse Self-reported Lifestyle Factors in Men With Sub-fertility

A Cross-Sectional Study in 1149 Men

Channa N. Jayasena; Aditi Sharma; Ali Abbara; Rong Luo; Christopher J. White; Sophie G. Hoskin; Shirin Khanjani; Mike J. Crawford; Jonathan W. Ramsay; Sukhbinder Minhas; Waljit S. Dhillo


Clin Endocrinol. 2020;93(3):312-321. 

In This Article

Abstract and Introduction


Background: There are no current pharmacological therapies to improve sperm quality in men with sub-fertility. Reducing the exposure to lifestyle risk factor (LSF) is currently the only intervention for improving sperm quality in men with sub-fertility. No previous study has investigated what proportion of men with sub-fertility are exposed to adverse lifestyle factors. Furthermore, it is not known to what extent men with sub-fertility are aware of lifestyle factors potentially adversely impacting their fertility.

Methods: A cross-sectional anonymous questionnaire-based study on self-reported exposure and awareness of LSF was conducted in 1149 male partners of couples investigated for sub-fertility in a tertiary andrology centre in London, UK.

Results: Seventy per cent of men investigated for sub-fertility had ≥1 LSF, and twenty-nine per cent had ≥2 LSF. Excessive alcohol consumption was the most common LSF (40% respondents). Seventeen per cent of respondents used recreational drugs (RD) regularly, but only 32% of RD users believed RD impair male fertility. Twenty-five per cent of respondents were smokers, which is higher than the UK average (20%). Twenty-seven per cent of respondents had a waist circumference (WC) >36 inches (91 cm), and 4% had WC >40 inches (102 cm). Seventy-nine per cent of respondents wanted further lifestyle education to improve their fertility.

Conclusions: Our data suggest that men with sub-fertility are as follows: (a) exposed to one or more LSF; (b) have incomplete education about how LSF may cause male sub-fertility; (c) want more education about reducing LSF. Further studies are needed to investigate the potential of enhanced education of men about LSF to treat couples with sub-fertility.


Male sub-fertility is defined as the inability to conceive following 1 year of regular unprotected intercourse, due to poor sperm quality in the male partner.[1] Male sub-fertility is one of the major indications for assisted reproductive techniques (ART) in the UK.[2] Despite this, there are currently no approved pharmacological therapies to directly stimulate spermatogenesis;[3] anti-oestrogens and aromatase inhibitors have limited effectiveness for the treatment of oligospermia[4–6] and their usage is not supported by current guidelines.[7,8] Consequently, couples with male factor sub-fertility unable to conceive naturally, require to undergo ART[9] such as in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI). ART is highly effective, but confers potential health risks, and is unaffordable for many patients[10] and healthcare systems worldwide. It is therefore critical that couples with male sub-fertility are given effective advice to optimise their own fertility using non-pharmacological approaches.

Lifestyle factors play an important role in male fertility. Large cross-sectional studies demonstrate that adverse health behaviours such as excessive alcohol intake,[11,12] smoking,[13,14] recreational drugs[15,16] and obesity[17] are associated with reduced fertility in men.[7,18] Furthermore, recent evidence suggests that amelioration of adverse lifestyle factors may improve markers of male fertility[19–21] and quality of life.[22] Despite observed improvements in semen parameters, the effects on pregnancy and live birth outcomes are scarce.[23,24] Therefore, in the absence of approved pharmacological therapies for male sub-fertility, it is essential that men with sub-fertility are aware of adverse lifestyle factors that impair sperm quality. In this paper, the term 'lifestyle factor' is used to refer to adverse health behaviours to appreciate the complexities of health behaviours as not solely a result of individual choices.

Recently published European Society for Human Reproduction & Embryology (ESHRE) consensus guidelines recommended that clinicians should elicit a history of adverse lifestyle factors in all couples with male sub-fertility.[25] Previous studies have reported the prevalence of specific adverse lifestyle factors such as smoking[13,14] in men with sub-fertility. However, no previous study has investigated to what extent men with male sub-fertility have as follows: (a) awareness of lifestyle factors implicated in causing male sub-fertility (b) exposure to lifestyle factors implicated in causing male sub-fertility. Such data have important healthcare implications for the overall effectiveness of treatment given to couples with male sub-fertility.

We conducted a large cross-sectional single-centre study investigating the clinical burden of self-reported lifestyle factors in men undergoing diagnostic semen analysis for investigation of sub-fertility. Additionally, we explored the level of pre-existing knowledge of adverse lifestyle factors associated with sub-fertility amongst these men, and their views on further education on adverse lifestyle factors implicated in causing male sub-fertility.