Cigarette smoking and infertility

Cigarette smoking and infertility

FERTILITY AND STERILITY Copyright Q 1986 The American Fertility Society Vol. 46, No. 3, September 1986 Printed in U.SA . Cigarette smokin-g .and inf...

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FERTILITY AND STERILITY Copyright Q 1986 The American Fertility Society

Vol. 46, No. 3, September 1986 Printed in U.SA .

Cigarette smokin-g .and infertility

Anne Colston Wentz, M.D. Professor of Obstetrics and Gynecology Director, Division of Reproductive Endocrinology Vanderbilt University, Nashville, Tennessee

Received June 30, 1986. Reprint reques.ts: Anne Colston Wentz, M.D., Department of Obstetrics and Gynecology, Vanderbilt University, Nashville, Tennessee, 37232. Vol. 46, No.3, September

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I had dinner last night with a couple who are heavily involved with committee work toward ~~A Smokeless Alabama by the Year 2000." Also at dinner were two other physicians who smoke heavily. It brought to mind just how emotional and irrational the whole issue of smoking really is. No one disagrees any longer that smoking during pregnancy has deleterious effects upon both mother and baby. Smokers who use oral contraceptives clearly run a greater risk of arteriosclerotic cardiovascular disease after age 35 than do nonsmokers. Smokers have more problems with osteoporosis. Lung cancer in women is on the rise and clearly associated with smoking. There is one group of women, highly motivated and highly compliant, to which we should be able to appeal. And-wouldn't you know it?-a real association between smoking and female infertility is hard to find. Infertile women, and particularly in vitro fertilization patients, assure me that should they become pregnant, they will quit smoking. Of course, this is a form of bargaining, and part of the psychology. However, when they do achieve pregnancy, they do stop smoking, usually ~~cold turkey." Unfortunately, I have hardly a leg to stand on when I condemn smoking in the infertile couple. There are few good hard data that show that smoking impairs fertility. Published data are weighted in the direction of showing no deleterious effect on fertility in the woman. It may even be true that studies not showing an effect are less apt to be published, and are therefore underrepresented. Studies tend to be retrospective, and not much prospective work has been done in the study of fertility in women who smoke as compared with those who do not. Harlap and Barras 1 and Linnet al. 2 did not demonstrate a significant increase in the time necessary to conceive among smoking women in large studies of couple cohorts seeking conception after stopping contraception. Baird and Wilcox 3 did, however, report a decreased fertility among 678 women smokers. Variables are difficult to control, including age, number of cigarettes smoked, and life-style. For example, Cramer et al. 4 found a significantly increased risk of sterility of tubal origin for smokers, which suggests that life-style and sexual behavior also have to be taken into consideration. One of the few prospective studies is the Oxford Family Planning Association Contraceptive Study 5 of 4104 couples interrupting contraception to attempt pregnancy (6199 attempts) between 1968 and 1983, showing a decreased fertility among smokers with a signifiWentz Editor's corner

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cant dose-effect relationship. However, the decrease appeared to exist only for women smoking more than 16 cigarettes daily. Another case-control study, that of Olsen et al.,6 can be interpreted either way, depending on how one sets up and compar.es the groups; there appears to be a delay in conception among smokers without any evi.dence of lowered fecundity. The article by Baird and Wilcox 7 that appears elsewhere in this issue says essentially the same: prenatal exposure to smoking does not appear to influence future fer. tility in women. The situation seems to be different for men. Sperm counts, morphology, and other parameters of the semen· analysis seem to be different, although even this is controversial, in men who smoke significant numbers of cigarettes. Hoidas et al. B used scanning electron microscopy with an image analysis computer to score photographs of sperm preparations, measuring head area, head p.erimeter, midpiece area,midpiece perimeter, and tail length, deriving a "form factor" mathematically from the area. and perimeter length. The derived measurement roughly equates with roundness or regularity of the shape. The form factor is significantly different in samples from fertile and infertile male populations, without any difference between smokers and nonsmokers. However, Evans et al. 9 compared semen samples from a matched infertile group of smokers and nonsmokers and found significantly abnormal morphology in the smokers; others 10, 11 have found decreased motility and count, confirmed in another study only in heavy smokers. 12 Shaarawy and Mahmoud 13 found lower testosterone and higher follicle-stimulating hormone in cortisollevels in smokers, and thought that nicotine depressed androgenic steroid production at the testicular level by affecting Leydig cell function. Klaiber et al. 14 showed that serum estradiol levels were significantly elevated in smokers compared to non-smokers. Again, life-style may be a factor in this analysis, because smokers consumed significantly more alcohol than nonsmokers; when controlled for alcohol consumption, serum estradiol levels still were elevated in smokers. So maybe we can appealto infertile men, on the basis of testosterone, testicular damage, or other sperm-oriented associations. But what can we do for our women? Clearly, almost everyone agrees that smoking in pregnancy is harmful, a risk to health, and associated with an increased risk of 366

Wentz Editor's corner

miscarriage and with low birth weight. But what can we do about the rest? Education! We need to make sure that everyone knows that smoking causes lung cancer, that it increases the risk of heart attack, that osteoporosis is exacerbated, that chronic lung disease is inevitable. We need to tell women who smoke that they will cough, and when they cough, they will increase the· possibility of stress incontinence. Cigarette smoking is also linked with other forms of cancer, particularly of the mouth, and perhaps even of the bladder. We need to appeal to their vanity and tell them that they will look and feel better if they stop smoking. If nothing else will work, let's appeal to the infertile woman's need to control something. So many of these women feel a loss of control over their lives, their fertility, and their destiny. Let's emphasize that stopping smoking can make them feel worthwhile and successful at something, while contributing to their own health and happiness. I'll try anything to help us have a "smokeless America."

REFERENCES 1. Harlap S, Barras M: Conception-waits in fertile women

after stopping oral contraceptives. Int J Fertil 29:73, 1984 2. Linn S, Schoenbaum SC, Monson RR, Rosner B, Ryan KJ: Delay in conception for former "pill users." JAMA 247: 629, 1982 3. Baird DD, Wilcox AJ: Cigarette smoking associated with delayed conception. JAMA 253:2979, 1985 4. Cramer DW, Schiff I, Schoenbaum SC, Gibson M, Belisle S, Albrecht B,.8tillman RJ, Berger MJ, Wilson E, Stadel B, Seibel M: Tubal infertility and the intrauterine device. NEngl J Med 312:941, 1985 5. Howe G, WesthoffC, Vessey M, Yeates D: Effects of age, cigarette smoking, and other factors on fertility: findings in a large prospective study. Br Med J 290:1697, 1~85 6. Olsen J, Rachootin P, Schiodt AV, Damsbo N: Tobacco use, alcohol consumption and infertility. Int J Epidemiol 12:179, 1982 7. BairdDD, Wilcox AJ: Future fertility after prenatal exposure to cigarette smoke. Fertil Steril 46:368, 1986 8. Hoidas S, Williams AE, Tocher JL, Hargreave TB: Scoring sperm morphology from fertile and infertile cigarette smokers using the scanning electron microscope and im· age analysis. Fertil Steril 43:595, 1985 9. Evans JH, Fletcher J, TorranceM, Hargreave TB: Sperm abnormalities and cigarette smoking. Mar 21, Lancet, 627, 1981 10. Handelsman DJ, Conway AJ, Boylan LM, Turtle JR: Testicular function in potential sperm donors: normal ranges and the effects of smoking and varicocele. Int J Androl 7:369,1984

Fertility and Sterility

11. Karagounis CS, Papanikolaou NA, Zavos PM: Semen p~­ rameters compared .between smoking and nonsmoking men: smoking intensity and semen parameters. Infertility 8:373, 1985 12. Vogt H-J, Heller W-D, Borelli S: Sperm quality of healthy smokers, ex-smokers, and never-smokers. Fertil Steril45: 106, 1986

Vol. 46, No.3, September 1986

13. Shaarawy M, Mahmoud KZ: Endocrine profile and semen characteristics in male smokers. Fertil Steril 38:255, 1982 14. Klaiber EL, Broverman DM, Dalen JE: Serum estradiol levels in male cigarette smokers. Am J Med 77:858,1984

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