Infertility and Lifestyle Among Finnish Men and Women

Infertility and Lifestyle Among Finnish Men and Women | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Infertility and Lifestyle Among Finnish Men and Women Titta Vilanti, Reija Klemetti, Ervasti Eetu, Päivikki Koponen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4206832/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Dec, 2024 Read the published version in Discover Public Health → Version 1 posted 9 You are reading this latest preprint version Abstract Background: The aim of this population-based study is to examine lifestyle factors (smoking and alcohol consumption) and body mass index (BMI) among fertile and infertile Finnish women and men. Methods : Infertility was defined based on reporting having ever tried to become pregnant or to get a child unsuccessfully over a year. Logistic regression analysis was used to investigate the association of smoking, alcohol consumption and BMI with infertility when adjusted first for age and then additionally for marital status, education and employment status. Men (n=201) and women (n=267) who had ever experienced infertility were compared to those with no experience of infertility (n=1677 men and n=1257 women) and further separately for those who had despite the infertility experience received a child or not. Results: No significant differences between smoking or BMI were found in men by the infertility experience, compared to childless infertile and infertile men with a child. However, men with infertility experience had higher total alcohol consumption (g/year) than fertile men (p=0.005). The odds ratio for total consumption of alcohol at an average or high level was 2.49 (95 % CI 1.39-4.45) in the age adjusted model and 2.01 (CI 1.11-3.67) in the fully adjusted model for males who had experienced infertility by using the fertile men as a reference group. No differences in smoking, alcohol consumption or BMI were found between women with or without infertility experience. Conclusions: The results indicate that in fertility counselling and care given by midwifes and health care professionals, attention should be paid to men’s lifestyle, especially to alcohol consumption. The small numbers of those having experienced infertility limited analyses in this study. Infertility fertility lifestyle pre-conception care midwifery 1. Background Both women’s and men’s knowledge about factors influencing fertility and lifestyle choices has been indicated to be poor in previous studies. 1-3 Domar et al. found that women continued smoking and used alcohol during infertility treatments. 4 A prospective study by Gormack et al. indicated that the women who quit or reduce alcohol consumption had twice the odds to become pregnant compared to those who did not make changes to their drinking habits. 5 Pre-conception care provided by midwifes and nurses has been proven to be effective and different tools and patterns have been developed. 6,7 Correcting unhealthy habits related to lifestyle can be helpful to many infertile women and couples. 8 Adequate evaluation of health promoting lifestyles should be offered to everybody by midwifes and other healthcare specialists, at the latest when attending fertility clinics. And as one review found out, discontinuing smoking and alcohol use should be suggested to all who are undergoing investigation for infertility in order to provide the best outcomes. 9 Smoking, alcohol consumption, and overweight are known to have a negative influence on fertility. A systematic review by de Angelis et al. concluded that smoking is associated to decreased fertility among women. 10 The review stated that smoking has effects on almost all domains of female fertility. In women, negative effects have been shown to depend on the amount consumed. 11 Obesity has an effect on women´s fertility in many ways in both natural cycles and fertility treatments. It has been found that obese (BMI > 30) women have a greater probability of infertility. 12 Infertile women have a 3.8 times risk of being overweight and 4.8 times risk of being obese compared to fertile women. 13 In men, body mass index has shown to be related to semen quality and reproductive hormones. 14,15 It has also been shown that among men, obesity increases the risk of infertility 1.4 times and overweight 1.2 times. 16 A review article on smoking and alcohol addiction concluded that these habits influence men´s fertility in a negative way. 9 Another review by Balawernder and Orkisz also indicated that the most significant factors that cause male infertility are lifestyle-related; being obese, nicotine addiction and alcohol consumption among others. 17 Further, smoking has a negative effect on semen quality and I has been found that time to pregnancy was two-fold longer if the man consumed more than over 20 units alcohol weekly. 11, 18 In a previous Finnish population-based study, no differences in cigarette smoking between fertile and infertile men were found. Women under 35 years who had experienced infertility reported more hangovers than fertile women. Hangovers and alcohol consumption were not associated with infertility among men. 19 Several earlier studies have indicated that lifestyle has an influence on fertility in many ways, but most studies have focused either on men or on women. We found no published studies on lifestyle factors and BMI of both women and men having experienced infertility, and further separately for those with or without a child. Thus, this population-based study aims to examine lifestyle factors (smoking and alcohol consumption) and body mass index (BMI) among fertile and infertile Finnish women and men and separately with and without a child or children. 2. Methods This study uses data from the Finnish Health 2011 Survey, which is a comprehensive nationally representative health interview and examination survey proving an up-date overview of health, functional capacity and welfare of the population including experience of infertility. A two-stage, stratified cluster sample design was used. Fifteen of the largest towns and 65 health care districts were sampled as clusters, from which a random sample of all individuals aged 18 years and over was drawn. 20 The sample of Health 2011 Survey included 10 171 individuals. 20 The response rate was 74% for those who were aged 29 and over and had been invited to the health interview and examination, but 42% for the youngest age group. For the youngest group (aged 18–28 years), only mailed questionnaires were used. Data on questions concerning infertility was available for 1878 men and 1524 women aged 18–69 years. The respondents were defined as having experienced infertility if they reported (in the interview or self-administered questionnaire) that they had ever tried to become pregnant or to have a child unsuccessfully for over a year including both primary and secondary infertility; hereafter referred to as 'infertile men and women', for the sake of brevity. The respondents who did not report infertility are hereafter referred to as 'fertile men and women'. In the survey women and men were asked whether they currently have a child (or children) including also non-biological children. To be able to control the possible effect of having a child on the lifestyle habits men and women with the experience of infertility were further classified as “childless infertile women and men” and “infertile men and women with at least one child”. These two groups were compared to a third group of “fertile men and women”. The cause of infertility was not specified. Questions on sociodemographic factors such as marital status, education and employment status were included in the interview and the mailed questionnaires. Marital status was divided into two categories: married/cohabiting and others. Education was divided into three categories: lowest, middle and highest; and employment status into two categories: full- or part-time job and others. Height and weight were measured at the health examination for most of the participants or self-reported (in the mailed questionnaire) for those who did not participate in the health examination and for all in the youngest age group. Body mass index (BMI) (kg/m2) was calculated and categorized into normal weight (BMI 18.5-24), overweight (BMI 25-29) and obesity (BMI 30+). Among the participants, none of the infertile men and only one infertile woman was underweight (BMI <18,5), thus this category was dropped out from the analysis. Smoking was analysed by the questions 'Have you ever smoked daily over a one-year period?', 'Are you a current smoker?' and further 'How many cigarettes do you smoke or smoked daily?, if the respondent answered yes to the previous question. This continuous variable was rescaled equally into three categories: low (0-6 cigarettes/day), average (7-15 cigarettes/day) and high (16 or more cigarettes/day). Non-smokers were included to the group low (0-6 cigarettes/day). Alcohol consumption was measured using AUDIT-C questions about the frequency of alcohol use, the amounts consumed, and consuming over 6 units at one time. 21 Risk drinking was evaluated according to the AUDIT-C cut point as ≥6 units for men and ≥5 for woman. The participants who did not consume alcohol at all were included into categories ≤5 in men and ≤4 in women. In addition, alcohol consumption was analysed using an estimate of total alcohol consumption in g/year based on reported consumption of different types of alcoholic beverage, and this continuous variable was rescaled equally into three categories: low (0–335 g/year), average (336–2482 g/year) and high (2483–568 029 g/year) alcohol consumption. Statistical Analysis. All analyses were performed by gender and conducted using Rstudio version 4.1.1. Analyses were made by comparing infertile men and women with or without children to the fertile men and women. Inverse Probability Weights (IPW), based on register information on age, gender, and marital status were used in the analysis, correcting for the effects of nonresponse and taking into account the stratified sampling method. This method is widely used in national surveys in Finland. 22 First, chi square tests were used to compare weighted unadjusted prevalences. P-values ≤0.05 were considered significant. The number of respondents varies in different analyses, as the participants responded either on the full or on the short interview, or by the mailed questionnaire; only the full interview contained all survey questions. For the logistic regression analysis, analysis was first made separately for male and female and using all three groups by using fertile men and women as reference groups. Because no significant differences were found between the two infertile groups and the small group sizes limited making any conclusions of their differences and didn’t allow adjusting for the potential confounders, number of groups were then reduced to two groups by combining the two groups of infertility. Odds ratios (OR) and 95% Confidence Intervals (CI) were calculated by logistic regression to investigate how smoking, alcohol consumption and BMI were associated with infertility among men and women. The model was adjusted first for age, and then additionally for marital status, education, and employment status. Ethics. The Health 2011 survey was approved by the coordinating Ethical Committee of Helsinki and Uusimaa Hospital District. All participants were fully informed of the survey and gave informed consent. 3. Results Background Characteristics. Out of all participants, 11 % of men and 18 % of women had experienced infertility. Out of the infertile men 76% and out of women 80% had at least one child at the time of the data collection. Infertile men and women having at least one child were more often married or cohabiting than fertile or childless infertile men and women. Infertile men with a child were more often employed and belonged to the group of highest education than fertile men. In addition, fertile women and infertile women with a child had higher education than infertile childless women. (Table 1). Smoking, alcohol consumption and BMI. Infertile childless men were more often obese and their daily consumption of cigarettes was higher than that of the other men, although these differences were non-significant. Total alcohol consumption (g/year) was highest in infertile men with a child. In women, no significant differences were found in smoking, alcohol consumption and BMI between the three groups. (Table 2). Logistic regression models. Infertile men had higher odds (OR 2.49) for average and high alcohol consumption when adjusted by age (Table 3). The odds ratio was diminished when adjusting further by marital and employment status and education, but it remained significant (OR 2.01, p=0.02) (Table 4). Among women, infertility was not associated to none of the lifestyle factors or BMI in either model (Tables 3 and 4). 4. Discussion According to this population-based study infertile men had higher risk for average and high alcohol consumption than fertile men. High alcohol consumption was more common among infertile men and most common among infertile men who had at least one child. No associations and increased odds for high consumption of alcohol, heavy smoking, or higher BMI were found for infertile women. Smoking has been shown to have the strongest negative effect on fertility than any other risk factor (Sadeu et al.) further both among females (Homan et al.) and males (Ramlau-Hansen et al.). 23-25 Smoking (current smoking or daily consumption of cigarettes) was not associated with infertility among men or women in our study. This result is in line with a previous Finnish study with no differences between infertility among never, former, or current smokers in men or women. 19 Earlier studies have shown an association between alcohol consumption and fertility; for example, the time to pregnancy is longer and testosterone levels lower. 9, 10, 17 In the previous Finnish study hangovers were associated with infertility among women. 19 In our study, alcohol consumption was associated with infertility only among men. The infertile men were over two-fold more likely to consume more than the average amount of alcohol. We did not find any association in alcohol consumption and infertility or higher odds for alcohol consumption among women. Even though it was less usual than among men, risky consumption of alcohol was rather usual (20-27 %) in our study, in line with previous results among all Finnish women aged 30-54. 26 Obesity has been associated with infertility both among men and women in many ways in several studies. 12, 13, 16 According to this study BMI was not associated with the experience of infertility except for the weak, non-significant association found for infertile childless men. BMI may vary a lot during a lifetime and in this cross-sectional study we had no information about BMI at the time of the infertility experience. BMI did not differ significantly between fertile and infertile men and women either on the previous study by Revonta et al.or in ours. 19 The waist-hip ratio was found to be smaller in infertile men aged over 34 years in the previous study but data on these measurements was not available in the Health 2011 Survey. The strength of this study is that the data are representative of the Finnish adult population as the response rate was rather good for those aged 29 years and over. Therefore, data are also representative to study experience of infertility in adult Finnish population. Additionally, Inverse Probability Weights (IPW) was used to reduce non-response bias. 22 A main limitation are the small group sizes, not allowing adjusted models for the two groups with infertility experience, i.e. those having at least one child and childless women and men. Due to small group sizes, it wasn’t possible to specify levels of alcohol use or smoking. Another main limitation is that due to the cross-sectional study design we had information on lifestyle factors and BMI at the time of the survey but no information on the timing of the experience of infertility, or whether the respondents had children before or after the infertility experience (primary vrs. secondary infertility). Thus, any interpretation of the causality of the association of infertility and these lifestyle factors cannot be made or infertility cannot be predicted This study only aimed to show if there was any association between lifestyle and infertility. Our study, however, indicates the need to study infertility from the public health perspective. When - as in our case was - the prevalence of infertility and lifestyles are monitored in regular public health surveys, this information can be used to inform young men and women of their risks for infertility. The linkage of survey data to birth register data would also allow longitudinal analyses, which are needed to confirm these risks. Lifestyle factors such as smoking and alcohol abuse and self-reported weight might be influenced by a tendency for under-reporting. For most participants in our data weight and height were measured, and thus the effect of under-reporting on BMI is unlikely. Alcohol consumption was measured with the self-administered questionnaires for all participants, while the questions on smoking were included in the interviews for those aged 29 and over. The response rate of the youngest group (aged 18-29 years) was rather low and due to the small group sizes, it was not possible to make comparisons between the age groups. The small number of respondents who had experienced infertility may also have led to low statistical power in our analysis, even when combining the two infertile groups. This may partly explain the differences with the results from the previous Finnish survey, where the response rate was higher. 19 Lower response rate may cause bias especially in lifestyle factors, as survey nonparticipants have been found to use more alcohol and be more often smokers than participants. 27 Our study could not confirm the findings of the previous Finnish study regarding the women, as we found no association between alcohol consumption and fertility among women. 19 The previous study did not find differences in alcohol consumption or hangovers between men with or without infertility experiences, whereas higher alcohol consumption among men was statistically significantly associated with infertile men with a child in our study. In line with the previous Finnish study, there were no differences in smoking between infertile and fertile men or women. 19 Conclusions: In the Finnish Health 2011 Survey, 19% of all women (aged 30-69) and 11% of all men (aged 30-69) reported an experience of at least one year period of infertility during their lifetime. The proportion had increased after the year 2000 in both women and men, but no major increase was later observed in the FinHealth 2017 survey. 28, 29 Age of the female is known to have a major effect on fertility. 11, 12, 30 Therefore, focus should be given to raise awareness of the lifestyle effects, especially for people who are postponing childbearing as higher age is also a risk factor for infertility. The accumulation of risk factors and their impact on fertility has been rarely investigated earlier and would need more research from both the individual’s and couple’s point of view. 11, 31 Longitudinal studies are needed to find out whether poor lifestyles are the cause of the infertility or if infertility leads to unhealthy habits. Becoming pregnant and having a child is a composition of multiple factors in which lifestyle plays an important role. The motivation to improve fertility and make healthier lifestyle choices can be assumed to be high when trying to have a baby. It is important to advise both men and women even before trying to get pregnant to quit or reduce smoking and alcohol consumption. Based on this study, attention should be paid especially men’s alcohol consumption. This could reduce infertility and improve the health of both men and women and also the health of the future child. Discussion about fertility issues and increasing knowledge of factors affecting fertility should be a part of routine health care visits of all fertile aged men and women but especially among those who have risk factors for infertility or have already experienced infertility. Health care and societal costs can be saved if at least some of the expensive and intensive infertility treatments can be avoided if proper pre-conception care given by midwifes or other health care specialists is available to help people in changing unhealthy lifestyle habits. It is known that infertility experience is not only associated with poorer lifestyle habits but also for poorer mental health. 32-34 Therefore, both in fertility counselling and during infertility treatments, an adequate psychosocial support given by professionals, as well as a wider public health perspective for fertility and lifestyle is needed. Conclusions In the Finnish Health 2011 Survey, 19% of all women (aged 30–69) and 11% of all men (aged 30–69) reported an experience of at least one year period of infertility during their lifetime. The proportion had increased after the year 2000 in both women and men, but no major increase was later observed in the FinHealth 2017 survey. 28 , 29 Age of the female is known to have a major effect on fertility. 11 , 12 , 30 Therefore, focus should be given to raise awareness of the lifestyle effects, especially for people who are postponing childbearing as higher age is also a risk factor for infertility. The accumulation of risk factors and their impact on fertility has been rarely investigated earlier and would need more research from both the individual’s and couple’s point of view. 11 , 31 Longitudinal studies are needed to find out whether poor lifestyles are the cause of the infertility or if infertility leads to unhealthy habits. Becoming pregnant and having a child is a composition of multiple factors in which lifestyle plays an important role. The motivation to improve fertility and make healthier lifestyle choices can be assumed to be high when trying to have a baby. It is important to advise both men and women even before trying to get pregnant to quit or reduce smoking and alcohol consumption. Based on this study, attention should be paid especially men’s alcohol consumption. This could reduce infertility and improve the health of both men and women and also the health of the future child. Discussion about fertility issues and increasing knowledge of factors affecting fertility should be a part of routine health care visits of all fertile aged men and women but especially among those who have risk factors for infertility or have already experienced infertility. Health care and societal costs can be saved if at least some of the expensive and intensive infertility treatments can be avoided if proper pre-conception care given by midwifes or other health care specialists is available to help people in changing unhealthy lifestyle habits. It is known that infertility experience is not only associated with poorer lifestyle habits but also for poorer mental health. 32 – 34 Therefore, both in fertility counselling and during infertility treatments, an adequate psychosocial support given by professionals, as well as a wider public health perspective for fertility and lifestyle is needed. Declarations Ethics approval and consent to participate: The Health 2011 survey was approved by the coordinating Ethical Committee of Helsinki and Uusimaa Hospital District. All participants were fully informed of the survey and gave informed consent. Consent for publication: Not applicable. Availability of data and materials: The data that support the findings of this study are available from Finnish Institute for Health and Welfare but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Competing interests: We wish to confirm that there are no known conflicts of interest associated with this publication. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors' contributions We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us. TV analyzed and interpreted the data and was a major contributor in writing the manuscript. EE processed the data. RK and PK contributed to writing the manuscript and interpreting the data. All authors read and approved the final manuscript. Acknowledgements: Not applicable. Availability of data and materials The data that support the findings of this study are available from Finnish Institute for Health and Welfare but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. This data can be made available from the Corresponding Author on reasonable requests. References Bunting L, Tsibulsky I, Boivin J., 2012. Fertility knowledge and beliefs about fertility treatment: findings from the International Fertility Decision-making Study. Hum Reprod 2012. 28(2). pp. 385-97. Daumler D, Chan P, Lo KC, et al., 2016. Men's knowledge of their own fertility: a population-based survey examining the awareness of factors that are associated with male infertility. Hum Reprod. 31(12). pp.2781-90. 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Koponen P, Klemetti R, Luoto, R, et al., 2012. Lisääntymisterveys. In Koskinen S, Lundqvist A, Ristiluoma N, eds. Terveys, toimintakyky ja hyvinvointi Suomessa. Report 68/2012. Terveyden ja hyvinvoinnin laitos. pp. 111-18. Koponen P, Borodulin K, Lundqvist A, Sääksjärvi K, Koskinen S., 2018. Terveys, toimintakyky ja hyvinvointi Suomessa: FinTerveys 2017 -tutkimus. Terveyden ja hyvinvoinnin laitos, raportti 4. https://urn.fi/URN:ISBN:978-952-343-105-8. ESHRE Capri Workshop Group; Fertility and ageing., 2005. Hum Reprod Update. 11(3). pp. 261-276. Alvarez S., 2015. Do some addictions interfere with fertility? Fertility and Sterility. 103(1). pp. 22-6. Chachamovich J, Chachamovich E, Ezer H, et al., 2010. Investigating quality of life and health-related quality of life in infertility: a systematic review, Journal of Psychosomatic Obstetrics & Gynecology. 31. pp. 2,101-10. Klemetti R, Raitanen J, Sihvo S et al., 2010. Infertility, mental disorders and well‐being – a nationwide survey. Acta Obstetrica et Gynecologica. 89. pp. 677-82. Psaros C, Kagan L, Auba E et al., 2012 A brief report of depressive symptoms and health promoting behaviors among women with infertility attending a clinical mind-body program. Journal of Psychosomatic Obstetrics & Gynaecology. Mar;33(1). pp. 32-6. Tables Tables 1 to 4 are available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files BMCWomensHealhresultsTABLE1INFERTILITYANDLIFESTYLE.pdf BMCWomensHealhresultsTABLE2INFERTILITYANDLIFESTYLE.pdf BMCWomensHealhresultsTABLE3INFERTILITYANDLIFESTYLE.pdf BMCWomensHealhresultsTABLE4INFERTILITYANDLIFESTYLE.pdf Cite Share Download PDF Status: Published Journal Publication published 26 Dec, 2024 Read the published version in Discover Public Health → Version 1 posted Editorial decision: Revision requested 30 Jul, 2024 Reviews received at journal 01 Jun, 2024 Reviewers agreed at journal 24 May, 2024 Reviews received at journal 01 May, 2024 Reviewers agreed at journal 25 Apr, 2024 Reviewers invited by journal 20 Apr, 2024 Submission checks completed at journal 15 Apr, 2024 Editor assigned by journal 15 Apr, 2024 First submitted to journal 02 Apr, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Vilanti","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7klEQVRIiWNgGAWjYDACZgjFwwciEypAIswNeHXwMDMzglTwsDEwMDYknAFpYSSgBaYCrIWxDcQkoMWenf/4gx8Mh2XY2M8ef/BwXm00fztQy4+KbXgd1tjDcJiHjScvsSFx2/HcGYeBtvWcuY3fLzwMaUC/5BgCtRzLbQBqYWZsw6+l8Q9IC/8boJY5x3LnE6OlmYfBhodNAmRLQ03uBoJaDjMbzpYxAGl5Yzgj4diB3I1ALQfx+YW9/+CDj28qJOz5+XMMPv6oqcudd/7wwQc/KnBrgQADOOswmDxAQD0KqCNF8SgYBaNgFIwQAACmPVCaOPSWkgAAAABJRU5ErkJggg==","orcid":"","institution":"University of Helsinki","correspondingAuthor":true,"prefix":"","firstName":"Titta","middleName":"","lastName":"Vilanti","suffix":""},{"id":292549791,"identity":"4b4aca15-972a-4545-b50d-983a4d832bb0","order_by":1,"name":"Reija Klemetti","email":"","orcid":"","institution":"Finnish Institute for Health and Welfare","correspondingAuthor":false,"prefix":"","firstName":"Reija","middleName":"","lastName":"Klemetti","suffix":""},{"id":292549792,"identity":"9d479313-a86e-452f-abb9-4602ee4c2d2e","order_by":2,"name":"Ervasti Eetu","email":"","orcid":"","institution":"Finnish Institute for Health and Welfare","correspondingAuthor":false,"prefix":"","firstName":"Ervasti","middleName":"","lastName":"Eetu","suffix":""},{"id":292549793,"identity":"5916d2b3-9e4e-458e-8b4e-271ff53f3e97","order_by":3,"name":"Päivikki Koponen","email":"","orcid":"","institution":"Finnish Institute for Health and Welfare","correspondingAuthor":false,"prefix":"","firstName":"Päivikki","middleName":"","lastName":"Koponen","suffix":""}],"badges":[],"createdAt":"2024-04-02 12:54:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4206832/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4206832/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12982-024-00376-7","type":"published","date":"2024-12-26T15:57:09+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":72640517,"identity":"5b8ac053-c6da-4a21-b87c-89d9560c6633","added_by":"auto","created_at":"2024-12-30 16:06:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":265268,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4206832/v1/49904a8d-7e2e-4060-a3ea-5eb3f6e48b24.pdf"},{"id":54951105,"identity":"6e0c4b18-24c0-484f-b02b-a210e1c48fcd","added_by":"auto","created_at":"2024-04-19 05:31:32","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":68891,"visible":true,"origin":"","legend":"","description":"","filename":"BMCWomensHealhresultsTABLE1INFERTILITYANDLIFESTYLE.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4206832/v1/cf23aa63ed855ebf2332a0c1.pdf"},{"id":54951107,"identity":"60da1717-30c3-4e2d-a981-a3cf77044e15","added_by":"auto","created_at":"2024-04-19 05:31:32","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":109355,"visible":true,"origin":"","legend":"","description":"","filename":"BMCWomensHealhresultsTABLE2INFERTILITYANDLIFESTYLE.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4206832/v1/b3446b3b2180667e29491b52.pdf"},{"id":54951106,"identity":"bddaf242-f4cd-4187-8fe3-8c72bebe0752","added_by":"auto","created_at":"2024-04-19 05:31:32","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":106086,"visible":true,"origin":"","legend":"","description":"","filename":"BMCWomensHealhresultsTABLE3INFERTILITYANDLIFESTYLE.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4206832/v1/8f51fcd54787708bd3816d5c.pdf"},{"id":54951108,"identity":"b00149a3-ac0d-4cc8-b726-5b71a69689d2","added_by":"auto","created_at":"2024-04-19 05:31:33","extension":"pdf","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":105544,"visible":true,"origin":"","legend":"","description":"","filename":"BMCWomensHealhresultsTABLE4INFERTILITYANDLIFESTYLE.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4206832/v1/728572dedd0a41d5555759e2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eInfertility and Lifestyle Among Finnish Men and Women\u003c/p\u003e","fulltext":[{"header":"1.\tBackground","content":"\u003cp\u003eBoth women’s and men’s knowledge about factors influencing fertility and lifestyle choices has been indicated to be poor in previous studies.\u003csup\u003e1-3\u003c/sup\u003e Domar et al. found that women continued smoking and used alcohol during infertility treatments.\u003csup\u003e4\u003c/sup\u003e A prospective study by Gormack et al. indicated that the women who quit or reduce alcohol consumption had twice the odds to become pregnant compared to those who did not make changes to their drinking habits.\u003csup\u003e5\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003ePre-conception care provided by midwifes and nurses has been proven to be effective and different tools and patterns have been developed.\u003csup\u003e6,7\u003c/sup\u003e Correcting unhealthy habits related to lifestyle can be helpful to many infertile women and couples.\u003csup\u003e8\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eAdequate evaluation of health promoting lifestyles should be offered to everybody by midwifes and other healthcare specialists, at the latest when attending fertility clinics. \u0026nbsp;And as one review found out, discontinuing smoking and alcohol use should be suggested to all who are undergoing investigation for infertility in order to provide the best outcomes.\u003csup\u003e9\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSmoking, alcohol consumption, and overweight are known to have a negative influence on fertility. A systematic review by de Angelis et al. concluded that smoking is associated to decreased fertility among women.\u0026nbsp;\u003csup\u003e10\u003c/sup\u003e The review stated that smoking has effects on almost all domains of female fertility. In women, negative effects have been shown to depend on the amount consumed.\u003csup\u003e11\u003c/sup\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eObesity has an effect on women´s fertility in many ways in both natural cycles and fertility treatments. It has been found that obese (BMI \u0026gt; 30) women have a greater probability of infertility.\u003csup\u003e12\u003c/sup\u003e Infertile women have a 3.8 times risk of being overweight and 4.8 times risk of being obese compared to fertile women.\u003csup\u003e13\u003c/sup\u003e In men, body mass index has shown to be related to semen quality and reproductive hormones.\u003csup\u003e14,15\u003c/sup\u003e It has also been shown that among men, obesity increases the risk of infertility 1.4 times and overweight 1.2 times.\u003csup\u003e16\u003c/sup\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA review article on smoking and alcohol addiction concluded that these habits influence men´s fertility in a negative way.\u003csup\u003e9\u003c/sup\u003e Another review by Balawernder and Orkisz also indicated that the most significant factors that cause male infertility are lifestyle-related; being obese, nicotine addiction and alcohol consumption among others.\u003csup\u003e17\u003c/sup\u003e Further, smoking has a negative effect on semen quality and I has been found that time to pregnancy was two-fold longer if the man consumed more than over 20 units alcohol weekly.\u003csup\u003e11, 18\u003c/sup\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn a previous Finnish population-based study, no differences in cigarette smoking between fertile and infertile men were found. Women under 35 years who had experienced infertility reported more hangovers than fertile women. Hangovers and alcohol consumption were not associated with infertility among men.\u003csup\u003e19\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSeveral earlier studies have indicated that lifestyle has an influence on fertility in many ways, but most studies have focused either on men or on women. We found no published studies on lifestyle factors and BMI of both women and men having experienced infertility, and further separately for those with or without a child. Thus, this population-based study aims to examine lifestyle factors (smoking and alcohol consumption) and body mass index (BMI) among fertile and infertile Finnish women and men and separately with and without a child or children.\u0026nbsp;\u003c/p\u003e"},{"header":"2. Methods ","content":"\u003cp\u003eThis study uses data from the Finnish Health 2011 Survey, which is a comprehensive nationally representative health interview and examination survey proving an up-date overview of health, functional capacity and welfare of the population including experience of infertility. A two-stage, stratified cluster sample design was used.\u0026nbsp;Fifteen\u0026nbsp;of the largest towns and 65 health care districts were sampled as clusters, from which a random sample of all individuals aged 18 years and over was drawn.\u003csup\u003e20\u003c/sup\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe sample of Health 2011 Survey included 10 171 individuals.\u003csup\u003e20\u003c/sup\u003e The response rate was 74% for those who were aged 29 and over and had been invited to the health interview and examination, but 42% for the youngest age group. For the youngest group (aged 18–28 years), only mailed questionnaires were used.\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData on questions concerning infertility was available for 1878 men and 1524 women aged 18–69 years. The respondents were defined as having experienced infertility if they reported (in the interview or self-administered questionnaire) that they had ever tried to become pregnant or to have a child unsuccessfully for over a year including both primary and secondary infertility; hereafter referred to as 'infertile men and women', for the sake of brevity. The respondents who did not report infertility are hereafter referred to as 'fertile men and women'.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the survey women and men were asked whether they currently have a child (or children) including also non-biological children. To be able to control the possible effect of having a child on the lifestyle habits men and women with the experience of infertility were further classified as “childless infertile women and men” and “infertile men and women with at least one child”. These two groups were compared to a third group of “fertile men and women”. \u0026nbsp;The cause of infertility was not specified.\u003c/p\u003e\n\u003cp\u003eQuestions on sociodemographic factors such as marital status, education and employment status were included in the interview and the mailed questionnaires. Marital status was divided into two categories: married/cohabiting and others. Education was divided into three categories: lowest, middle and highest; and employment status into two categories: full- or part-time job and others.\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHeight and weight were measured at the health examination for most of the participants or self-reported (in the mailed questionnaire) for those who did not participate in the health examination and for all in the youngest age group. Body mass index (BMI) (kg/m2) was calculated and categorized into normal weight (BMI 18.5-24), overweight (BMI 25-29) and obesity (BMI 30+). Among the participants, none of the infertile men and only one infertile woman was underweight (BMI \u0026lt;18,5), thus this category was dropped out from the analysis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSmoking was analysed by the questions 'Have you ever smoked daily over a one-year period?', 'Are you a current smoker?' and further 'How many cigarettes do you smoke or smoked daily?, if the respondent answered yes to the previous question. This continuous variable was rescaled equally into three categories: low (0-6 cigarettes/day), average (7-15 cigarettes/day) and high (16 or more cigarettes/day). Non-smokers were included to the group low (0-6 cigarettes/day).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlcohol consumption was measured using AUDIT-C questions about the frequency of alcohol use, the amounts consumed, and consuming over 6 units at one time.\u003csup\u003e21\u003c/sup\u003e Risk drinking was evaluated according to the AUDIT-C cut point as ≥6 units for men and ≥5 for woman. The participants who did not consume alcohol at all were included into categories ≤5 in men and ≤4 in women. In addition, alcohol consumption was analysed using an estimate of total alcohol consumption in g/year based on reported consumption of different types of alcoholic beverage, and this continuous variable was rescaled equally into three categories: low (0–335 g/year), average (336–2482 g/year) and high (2483–568 029 g/year) alcohol consumption.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eStatistical Analysis.\u003c/u\u003e All analyses were performed by gender and conducted using Rstudio version 4.1.1. Analyses were made by comparing infertile men and women with or without children to the fertile men and women. Inverse Probability Weights (IPW), based on register information on age, gender, and marital status were used in the analysis, correcting for the effects of nonresponse and taking into account the stratified sampling method. This method is widely used in national surveys in Finland.\u003csup\u003e22\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFirst, chi square tests were used to compare weighted unadjusted prevalences. P-values ≤0.05 were considered significant.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe number of respondents varies in different analyses, as the participants responded either on the full or on the short interview, or by the mailed questionnaire; only the full interview contained all survey questions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor the logistic regression analysis, analysis was first made separately for male and female and using all three groups by using fertile men and women as reference groups. Because no significant differences were found between the two infertile groups and the small group sizes limited making any conclusions of their differences and didn’t allow adjusting for the potential confounders, number of groups were then reduced to two groups by combining the two groups of infertility. Odds ratios (OR) and 95% Confidence Intervals (CI) were calculated by logistic regression to investigate how smoking, alcohol consumption and BMI were associated with infertility among men and women. \u0026nbsp;The model was adjusted first for age, and then additionally for marital status, education, and employment status.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eEthics.\u003c/u\u003e The Health 2011 survey was approved by the coordinating Ethical Committee of Helsinki and Uusimaa Hospital District. All participants were fully informed of the survey and gave informed consent.\u0026nbsp;\u003c/p\u003e"},{"header":"3. Results ","content":"\u003cp\u003e\u003cu\u003eBackground Characteristics.\u003c/u\u003e Out of all participants, 11 % of men and 18 % of women had experienced infertility. Out of the infertile men 76% and out of women 80% had at least one child at the time of the data collection. Infertile men and women having at least one child were more often married or cohabiting than fertile or childless infertile men and women. Infertile men with a child were more often employed and belonged to the group of highest education than fertile men. In addition, fertile women and infertile women with a child had higher education than infertile childless women. (Table 1). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eSmoking, alcohol consumption\u0026nbsp;and BMI.\u003c/u\u003e Infertile childless men were more often obese and their daily consumption of cigarettes was higher than that of the other men, although these differences were non-significant. Total alcohol consumption (g/year) was highest in infertile men with a child. In women, no significant differences were found in smoking, alcohol consumption and BMI between the three groups. (Table 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eLogistic regression models.\u003c/u\u003e Infertile men had higher odds (OR 2.49) for average and high alcohol consumption when adjusted by age (Table 3). The odds ratio was diminished when adjusting further by marital and employment status and education, but it remained significant (OR 2.01, p=0.02) (Table 4). Among women, infertility was not associated to none of the lifestyle factors or BMI in either model (Tables 3 and 4).\u003c/p\u003e"},{"header":"4. Discussion ","content":"\u003cp\u003eAccording to this population-based study infertile men had higher risk for average and high alcohol consumption than fertile men. High alcohol consumption\u0026nbsp;was more common among infertile men and\u0026nbsp;most common among infertile men who had at least one child. No associations and increased odds for high consumption of alcohol, heavy smoking, or higher BMI were found for infertile women.\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSmoking has been shown to have the strongest negative effect on fertility than any other risk factor (Sadeu et al.) further both among females (Homan et al.)\u0026nbsp;and males (Ramlau-Hansen et al.).\u003csup\u003e23-25\u003c/sup\u003e Smoking (current smoking or daily consumption of cigarettes) was not associated with infertility among men or women in our study. This result is in line with a previous Finnish study with no differences between infertility among never, former, or current smokers in men or women.\u003csup\u003e19\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEarlier studies have shown an association between alcohol consumption and fertility; for example, the time to pregnancy is longer and testosterone levels lower.\u003csup\u003e9, 10, 17\u003c/sup\u003e In the previous Finnish study hangovers were associated with infertility among women.\u003csup\u003e19\u003c/sup\u003e In our study, alcohol consumption was associated with infertility only among men. The infertile men were over two-fold more likely to consume more than the average amount of alcohol.\u0026nbsp;We did not find any association in alcohol consumption and infertility or higher odds for alcohol consumption among women. Even though it was less usual than among men, risky consumption of alcohol was rather usual (20-27 %) in our study, in line with previous results among all Finnish women aged 30-54.\u003csup\u003e26\u003c/sup\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eObesity has been associated with infertility both among men and women in many ways in several studies.\u003csup\u003e12, 13, 16\u003c/sup\u003e According to this study BMI was not associated with the experience of infertility except for the weak, non-significant association found for infertile childless men. BMI may vary a lot during a lifetime and in this cross-sectional study we had no information about BMI at the time of the infertility experience. BMI did not differ significantly between fertile and infertile men and women either on the previous study by Revonta et al.or in ours.\u003csup\u003e19\u003c/sup\u003e The waist-hip ratio was found to be smaller in infertile men aged over 34 years in the previous study but data on these measurements was not available in the Health 2011 Survey.\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe strength of this study is that the data are representative of the Finnish adult population as the response rate was rather good for those aged 29 years and over. Therefore, data are also representative to study experience of infertility in adult Finnish population. Additionally, Inverse Probability Weights (IPW) was used to reduce non-response bias.\u003csup\u003e22\u003c/sup\u003e A main limitation are the small group sizes, not allowing adjusted models for the two groups with infertility experience, i.e. those having at least one child and childless women and men. Due to small group sizes, it wasn’t possible to specify levels of alcohol use or smoking.\u003c/p\u003e\n\u003cp\u003eAnother main limitation is that due to the cross-sectional study design we had information on lifestyle factors and BMI at the time of the survey but no information on the timing of the experience of infertility, or whether the respondents had children before or after the infertility experience (primary vrs. secondary infertility). Thus, any interpretation of the causality of the association of infertility and these lifestyle factors cannot be made or infertility cannot be predicted This study only aimed to show if there was any association between lifestyle and infertility.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur study, however, indicates the need to study infertility from the public health perspective. When - as in our case was - the prevalence of infertility and lifestyles are monitored\u0026nbsp;in regular public health surveys, this information can be used to inform young men and women of their risks for infertility. The linkage of survey data to birth register data would also allow longitudinal analyses, which are needed to confirm these risks. \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLifestyle factors such as smoking and alcohol abuse and self-reported weight might be influenced by a tendency for under-reporting. For most participants in our data weight and height were measured, and thus the effect of under-reporting on BMI is unlikely. Alcohol consumption was measured with the self-administered questionnaires for all participants, while the questions on smoking were included in the interviews for those aged 29 and over. The response rate of the youngest group (aged 18-29 years) was rather low and due to the small group sizes, it was not possible to make comparisons between the age groups.\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe small number of respondents who had experienced infertility may also have led to low statistical power in our analysis, even when combining the two infertile groups. This may partly explain the differences with the results from the previous Finnish survey, where the response rate was higher.\u003csup\u003e19\u003c/sup\u003e Lower response rate may cause bias especially in lifestyle factors, as survey nonparticipants have been found to use more alcohol and be more often smokers than participants.\u003csup\u003e27\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur study could not confirm the findings of the previous Finnish study regarding the women, as we found no association between alcohol consumption and fertility among women.\u003csup\u003e19\u003c/sup\u003e The previous study did not find differences in alcohol consumption or hangovers between men with or without infertility experiences, whereas higher alcohol consumption among men was statistically significantly associated with infertile men with a child in our study. In line with the previous Finnish study, there were no differences in smoking between infertile and fertile men or women.\u003csup\u003e19\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eConclusions:\u003c/u\u003e In the Finnish Health 2011 Survey, 19% of all women (aged 30-69) and 11% of all men (aged 30-69) reported an experience of at least one year period of infertility during their lifetime. The proportion had increased after the year 2000 in both women and men, but no major increase was later observed in the FinHealth 2017 survey.\u003csup\u003e28, 29\u003c/sup\u003e Age of the female is known to have a major effect on fertility.\u003csup\u003e11, 12, 30\u0026nbsp;\u003c/sup\u003e Therefore, focus should be given to raise awareness of the lifestyle effects, especially for people who are postponing childbearing as higher age is also a risk factor for infertility.\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe accumulation of risk factors and their impact on fertility has been rarely investigated earlier and would need more research from both the individual’s and couple’s point of view.\u003csup\u003e11, 31\u003c/sup\u003e Longitudinal studies are needed\u0026nbsp;to find out\u0026nbsp;whether poor lifestyles are the cause of the infertility or if infertility leads to unhealthy habits.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBecoming pregnant and having a child is a composition of multiple factors in which lifestyle plays an important role. The motivation to improve fertility and make healthier lifestyle choices can be assumed to be high when trying to have a baby. It is important to advise both men and women even before trying to get pregnant to quit or reduce smoking and alcohol consumption. Based on this study, attention should be paid especially men’s alcohol consumption. This could reduce infertility and improve the health of both men and women and also the health of the future child.\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDiscussion about fertility issues and increasing knowledge of factors affecting fertility should be a part of routine health care visits of all fertile aged men and women but especially among those who have risk factors for infertility or have already experienced infertility.\u003c/p\u003e\n\u003cp\u003eHealth care and societal costs can be saved if at least some of the expensive and intensive infertility treatments can be avoided if proper pre-conception care given by midwifes or other health care specialists is available to help people in changing unhealthy lifestyle habits.\u003c/p\u003e\n\u003cp\u003eIt is known that infertility experience is not only associated with poorer lifestyle habits but also for poorer mental health.\u0026nbsp;\u003csup\u003e32-34\u003c/sup\u003e Therefore, both in fertility counselling and during infertility treatments, an adequate psychosocial support given by professionals, as well as a wider public health perspective for fertility and lifestyle is needed.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn the Finnish Health 2011 Survey, 19% of all women (aged 30\u0026ndash;69) and 11% of all men (aged 30\u0026ndash;69) reported an experience of at least one year period of infertility during their lifetime. The proportion had increased after the year 2000 in both women and men, but no major increase was later observed in the FinHealth 2017 survey.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e Age of the female is known to have a major effect on fertility.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e Therefore, focus should be given to raise awareness of the lifestyle effects, especially for people who are postponing childbearing as higher age is also a risk factor for infertility.\u003c/p\u003e \u003cp\u003eThe accumulation of risk factors and their impact on fertility has been rarely investigated earlier and would need more research from both the individual\u0026rsquo;s and couple\u0026rsquo;s point of view.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e Longitudinal studies are needed to find out whether poor lifestyles are the cause of the infertility or if infertility leads to unhealthy habits.\u003c/p\u003e \u003cp\u003eBecoming pregnant and having a child is a composition of multiple factors in which lifestyle plays an important role. The motivation to improve fertility and make healthier lifestyle choices can be assumed to be high when trying to have a baby. It is important to advise both men and women even before trying to get pregnant to quit or reduce smoking and alcohol consumption. Based on this study, attention should be paid especially men\u0026rsquo;s alcohol consumption. This could reduce infertility and improve the health of both men and women and also the health of the future child.\u003c/p\u003e \u003cp\u003eDiscussion about fertility issues and increasing knowledge of factors affecting fertility should be a part of routine health care visits of all fertile aged men and women but especially among those who have risk factors for infertility or have already experienced infertility.\u003c/p\u003e \u003cp\u003eHealth care and societal costs can be saved if at least some of the expensive and intensive infertility treatments can be avoided if proper pre-conception care given by midwifes or other health care specialists is available to help people in changing unhealthy lifestyle habits.\u003c/p\u003e \u003cp\u003eIt is known that infertility experience is not only associated with poorer lifestyle habits but also for poorer mental health. \u003csup\u003e\u003cspan additionalcitationids=\"CR33\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e Therefore, both in fertility counselling and during infertility treatments, an adequate psychosocial support given by professionals, as well as a wider public health perspective for fertility and lifestyle is needed.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate: The Health 2011 survey was approved by the coordinating Ethical Committee of Helsinki and Uusimaa Hospital District. All participants were fully informed of the survey and gave informed consent.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication: Not applicable.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: The data that support the findings of this study are available from Finnish Institute for Health and Welfare but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available.\u003c/p\u003e\n\u003cp\u003eCompeting interests: We wish to confirm that there are no known conflicts of interest associated with this publication.\u003c/p\u003e\n\u003cp\u003eFunding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us. TV analyzed and interpreted the data and was a major contributor in writing the manuscript. EE processed the data. RK and PK contributed to writing the manuscript and interpreting the data. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements: Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from Finnish Institute for Health and Welfare but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. This data can be made available from the Corresponding Author on reasonable requests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBunting L, Tsibulsky I, Boivin J., 2012. Fertility knowledge and beliefs about fertility treatment: findings from the International Fertility Decision-making Study. Hum Reprod 2012. 28(2). pp. 385-97.\u003c/li\u003e\n \u003cli\u003eDaumler D, Chan P, Lo KC, et al., 2016. Men\u0026apos;s knowledge of their own fertility: a population-based survey examining the awareness of factors that are associated with male infertility. Hum Reprod. 31(12). pp.2781-90.\u003c/li\u003e\n \u003cli\u003eHammarberg K, Setter T, Norman R, et al., 2013. Knowledge about factors that influence fertility among Australians of reproductive age: A population-based survey. Fertility and Sterility. 99(2). pp. 502-7.\u003c/li\u003e\n \u003cli\u003eDomar AD, Conboy L, Denardo-Roneya J, et al. 2012. Lifestyle behaviors in women undergoing in vitro fertilization: a prospective study. Fertility and Sterility. 97(3). pp. 697\u0026ndash;701.\u003c/li\u003e\n \u003cli\u003eGormack AA, Peek JC, Derraik JGB, et al., 2015. Many women undergoing fertility treatment make poor lifestyle choices that may affect treatment outcome. Human Reproduction. 30(7). pp. 1617-24.\u003c/li\u003e\n \u003cli\u003eOckhuijsen HDL, Gamel CJ, van den Hoogen A, et al. 2012. Integrating preconceptional care into an IVF programme. Journal of Advanced Nursing. 68(5). pp. 1156\u0026ndash;65.\u003c/li\u003e\n \u003cli\u003eStern J, Bodin M, Grandahl M, et al., 2015. Midwives\u0026apos; adoption of the reproductive life plan in contraceptive counselling: a mixed methods study. Hum Reprod. 30(5). pp. 1146-55.\u003c/li\u003e\n \u003cli\u003eBirch Petersen, K, Maltesen, T, Forman, JL, Sylvest, R, Pinborg, A, Larsen, EC, et al., 2017. The Fertility Assessment and Counseling Clinic \u0026ndash; does the concept work? A prospective 2-year follow-up study of 519 women. Acta Obstet Gynecol Scand. 9. pp. 313\u0026ndash; 325.\u003c/li\u003e\n \u003cli\u003eSansone, A., Di Dato, C., de Angelis, C. et al., 2018. Smoke, alcohol and drug addiction and male fertility. Reproductive Biology and Endocrinology volume. 16. pp. 3.\u003c/li\u003e\n \u003cli\u003ede Angelis, C., Nardone, A., Garifalos, F. et al., 2020. Smoke, alcohol and drug addiction and female fertility. Reproductive Biology and Endocrinology. 18, 21.\u003c/li\u003e\n \u003cli\u003eHassan MAM, Killick S., 2004. Negative lifestyle is associated with a significant reduction in fecundity. Fertility and Sterility. 81(2). pp. 384-92.\u003c/li\u003e\n \u003cli\u003eKelly-Weeder S, Cox C., 2007. The impact of lifestyle risk factors on female infertility. Women \u0026amp; Health. 44(4). pp. 1-23.\u003c/li\u003e\n \u003cli\u003eEsmaeilzadeh S, Delavar MA, Basirat Z, et al., 2013. Physical activity and body mass index among women who have experienced infertility. Archives of Medical Science 2013. 9(3). pp. 499-505.\u003c/li\u003e\n \u003cli\u003eJensen TK, Andersson AM, J\u0026oslash;rgensen N, et al., 2004. Body mass index in relation to semen quality and reproductive hormones among 1558 Danish men. Fertility and Sterility. 82(4). pp. 863-70.\u003c/li\u003e\n \u003cli\u003eHammiche F, Joop SE, Laven JSE, et al., 2012. Body mass index and central adiposity are associated with sperm quality in men of subfertile couples. Human Reproduction. 27(8). pp. 2365-72.\u003c/li\u003e\n \u003cli\u003eNgyuen R, Wilcox A, Skaerven R, et al., 2007. Men`s body mass index and fertility. Human Reproduction. 22(9). pp. 2488-93.\u003c/li\u003e\n \u003cli\u003eBalawender K, Orkisz S., 2020. The impact of selected modifiable lifestyle factors on male fertility in the modern world. Cent European J Urol. 73(4). pp. 563-568.\u003c/li\u003e\n \u003cli\u003eK\u0026uuml;nzle R, Mueller M, H\u0026auml;nggi W, et al., 2003. Semen quality of male smokers and nonsmokers in infertile couples. Fertility and Sterility. 79(2). pp. 287-91.\u003c/li\u003e\n \u003cli\u003eRevonta M, Raitanen J, Sihvo S, et al., 2010 Health and life style among infertile men and women. Sexual \u0026amp; Reproductive Healthcare. 1. pp. 91\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eLundqvist A, M\u0026auml;ki-Opas T eds., 2016. Health 2011 Survey - Methods. Publications on the National Institute f9or Health and Welfare. Tampere Juvenes Print Oy. 8.\u003c/li\u003e\n \u003cli\u003eLundin A, Hallgren M, Balliu N, et al., 2015. The use of alcohol use disorders identification test (AUDIT) in detecting alcohol use disorder and risk drinking in the general population: validation of AUDIT using schedules for clinical assessment in neuropsychiatry. Alcohol Clin Exp Res. 39(1). pp. 158-65. doi: 10.1111/acer.12593.\u003c/li\u003e\n \u003cli\u003eH\u0026auml;rk\u0026auml;nen, T., Kaikkonen, R., Virtala, E. et al., 2014. Inverse probability weighting and doubly robust methods in correcting the effects of non-response in the reimbursed medication and self-reported turnout estimates in the ATH survey. BMC Public Health 14. pp. 1150. https://doi.org/10.1186/1471-2458-14-1150.\u003c/li\u003e\n \u003cli\u003eSadeu JC, Hughes CL, Agarwal S, et al., 2010. Alcohol, drugs, caffeine, tobacco, and environmental contaminant exposure: Reproductive health consequences and clinical implications. Critical Reviews in Toxicology. 40(7). pp. 633-52.\u003c/li\u003e\n \u003cli\u003eHoman GF, Davies M, Norman R., 2007. The impact of lifestyle factors on reproductive performance in the general population and those undergoing infertility treatment: a review. Human Reproduction Update. 13(3). pp. 209-23.\u003c/li\u003e\n \u003cli\u003eRamlau-Hansen C, Thulstrup A, Aggerholm A, et al., 2007. Is smoking a risk factor for decreased semen quality? A cross-sectional analysis. Human Reproduction. 22(7). pp. 188-96.\u003c/li\u003e\n \u003cli\u003eM\u0026auml;kel\u0026auml; P, Alho H, Knekt P, et al., 2012. Alkoholin k\u0026auml;ytt\u0026ouml;. In Koskinen S, Lundqvist A \u0026amp; Ristiluoma N, eds. Terveys, toimintakyky ja hyvinvointi Suomessa 2011. Raportti 68/2012. Terveyden ja hyvinvoinnin laitos. pp. 47-50.\u003c/li\u003e\n \u003cli\u003eKarvanen J, Tolonen H, H\u0026auml;rk\u0026auml;nen T, et al., 2016. Selection bias was reduced by recontacting nonparticipants. J Clin Epidemiol. Aug;76. pp. 209-17. doi: 10.1016/j.jclinepi.2016.02.026.\u003c/li\u003e\n \u003cli\u003eKoponen P, Klemetti R, Luoto, R, et al., 2012. Lis\u0026auml;\u0026auml;ntymisterveys. In Koskinen S, Lundqvist A, Ristiluoma N, eds. Terveys, toimintakyky ja hyvinvointi Suomessa. Report 68/2012. Terveyden ja hyvinvoinnin laitos. pp. 111-18.\u003c/li\u003e\n \u003cli\u003eKoponen P, Borodulin K, Lundqvist A, S\u0026auml;\u0026auml;ksj\u0026auml;rvi K, Koskinen S., 2018. Terveys, toimintakyky ja hyvinvointi Suomessa: FinTerveys 2017 -tutkimus. Terveyden ja hyvinvoinnin laitos, raportti 4. https://urn.fi/URN:ISBN:978-952-343-105-8.\u003c/li\u003e\n \u003cli\u003eESHRE Capri Workshop Group; Fertility and ageing., 2005. Hum Reprod Update. 11(3). pp. 261-276.\u003c/li\u003e\n \u003cli\u003eAlvarez S., 2015. Do some addictions interfere with fertility? Fertility and Sterility. 103(1). pp. 22-6.\u003c/li\u003e\n \u003cli\u003eChachamovich J, Chachamovich E, Ezer H, et al., 2010. Investigating quality of life and health-related quality of life in infertility: a systematic review, Journal of Psychosomatic Obstetrics \u0026amp; Gynecology. 31. pp. 2,101-10.\u003c/li\u003e\n \u003cli\u003eKlemetti R, Raitanen J, Sihvo S et al., 2010. Infertility, mental disorders and well‐being \u0026ndash; a nationwide survey. Acta Obstetrica et Gynecologica. 89. pp. 677-82.\u003c/li\u003e\n \u003cli\u003ePsaros C, Kagan L, Auba E et al., 2012 A brief report of depressive symptoms and health promoting behaviors among women with infertility attending a clinical mind-body program. Journal of Psychosomatic Obstetrics \u0026amp; Gynaecology. Mar;33(1). pp. 32-6.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Infertility, fertility, lifestyle, pre-conception care, midwifery","lastPublishedDoi":"10.21203/rs.3.rs-4206832/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4206832/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cu\u003eBackground:\u003c/u\u003e The aim of this population-based study is to examine lifestyle factors (smoking and alcohol consumption) and body mass index (BMI) among fertile and infertile Finnish women and men.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eMethods\u003c/u\u003e: Infertility was defined based on reporting having ever tried to become pregnant or to get a child unsuccessfully over a year. Logistic regression analysis was used to investigate the association of smoking, alcohol consumption and BMI with infertility when adjusted first for age and then additionally for marital status, education and employment status. Men (n=201) and women (n=267) who had ever experienced infertility were compared to those with no experience of infertility (n=1677 men and n=1257 women) and further separately for those who had despite the infertility experience received a child or not.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eResults:\u003c/u\u003e No significant differences between smoking or BMI were found in men by the infertility experience, compared to childless infertile and infertile men with a child. However, men with infertility experience had higher total alcohol consumption (g/year) than fertile men (p=0.005). The odds ratio for total consumption of alcohol at an average or high level was 2.49 (95 % CI 1.39-4.45) in the age adjusted model and 2.01 (CI 1.11-3.67) in the fully adjusted model for males who had experienced infertility by using the fertile men as a reference group.\u003c/p\u003e\n\u003cp\u003eNo differences in smoking, alcohol consumption or BMI were found between women with or without infertility experience.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eConclusions:\u003c/u\u003e The results indicate that in fertility counselling and care given by midwifes and health care professionals, attention should be paid to men’s lifestyle, especially to alcohol consumption. The small numbers of those having experienced infertility limited analyses in this study.\u003c/p\u003e","manuscriptTitle":"Infertility and Lifestyle Among Finnish Men and Women","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-19 05:31:28","doi":"10.21203/rs.3.rs-4206832/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-30T07:06:22+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-01T07:00:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"59640438225451494296576689334565221778","date":"2024-05-24T11:49:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-02T02:53:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"9450fecd-02d0-4216-96c7-6a6e5753d550_SNPRID","date":"2024-04-25T23:11:17+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-04-20T15:35:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-15T17:03:42+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-15T17:03:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Public Health","date":"2024-04-02T12:53:10+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"afb141ef-4fd2-4d97-a3a6-06755a811653","owner":[],"postedDate":"April 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-30T15:59:37+00:00","versionOfRecord":{"articleIdentity":"rs-4206832","link":"https://doi.org/10.1186/s12982-024-00376-7","journal":{"identity":"discover-public-health","isVorOnly":false,"title":"Discover Public Health"},"publishedOn":"2024-12-26 15:57:09","publishedOnDateReadable":"December 26th, 2024"},"versionCreatedAt":"2024-04-19 05:31:28","video":"","vorDoi":"10.1186/s12982-024-00376-7","vorDoiUrl":"https://doi.org/10.1186/s12982-024-00376-7","workflowStages":[]},"version":"v1","identity":"rs-4206832","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4206832","identity":"rs-4206832","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}