Stesura Seveso Archivio Italiano di Urologia e Andrologia 2016; 88, 156 SHORT COMMUNICATION Do cigarette and alcohol affect semen analysis? Mehmet Zeynel Keskin 1, Salih Budak 1, Saim Gubari 2, Kalender Durmaz 3, Mehmet Yoldas 1, Orcun Celik 1, Evrim Emre Aksoy 4, Yusuf Ozlem Ilbey 1 1 Urologic Clinic, Tepecik Training and Research Hospital, Urology Clinic, Izmir, Turkey; 2 Assisted Reproductive Techniques Department, Tepecik Training and Research Hospital, Izmir, Turkey; 3 Urologic Clinic Yenişehir State Hospital, Turkey; 4 Urologic Clinic Kırkagac State Hospital, Turkey. Objectives: There are a number of studies about the effect of cigarette and alcohol on semen parameters in the literature. There is not a consensus on the relationship between use of cigarette and alchol and semen parameters in those studies. The number of studies in which cigarette and alcohol use are evaluated together is limit- ed. This study was aimed to analyze the effect of cigarette and/or alcohol use on semen parameters. Methods: In this prospective study, 762 patients who applied to an hospital urology polyclinic between January 2015 and March 2015 due to infertility, were questioned for alcohol and cigarette use in anamnesis. The remaining 356 patients were included in our study. Then, semen analysis of the patients was performed. The patients were divided into five groups according to cigarette use, into five groups according to alco- hol use and into four groups according to cigarette and/or alcohol use. Significant differences were analyzed between the groups in terms of semen volume, semen concentration, total motility, forward motility and morphological (normality, head anomaly, neck anomaly, tail anomaly) values. Results: According to cigarette use, only in group 4 (who use more than 20 package-years cigarette) semen volume was sig- nificantly lower than the control group (Mann-Whitney U, p = 0.009). There was no significant difference in any of the other parameters and groups compared with the control group (Mann-Whitney U, p > 0,05) Conclusion:According to our study, using more than 20 pack- age-years cigarette decreases semen volume. The reason of this result might be the fact that the threshold value, from which the effect of cigarette and alcohol use on the semen parameters has to be determined. KEY WORDS: Alcohol, Infertility, Semen analysis, Cigarette. Submitted 15 October 2015; Accepted 4 December 2015 Summary No conflict of interest declared. Although the effects on especially liver and cardiovascular system are known, its effects on semen parameters is con- troversial (6-9). METHODS In this prospective study, 762 patients, who applied to our hospital urology polyclinic between January 2015 and March 2015 due to infertility, were questioned for alcohol and cigarette use. At least two semen analyses were requested from patients at their first application to the polyclinic as a routine analysis after medical history col- lection. The patients who were detected with a factor which might affect semen parameters (systemic disease, drug use, inguinal or testicular surgery history, varicocele, undescended testis, hypoplasic testis at physical examina- tion, abnormality in serum gonadotropin, androgen and prolactin levels, and pathology in genetic analysis) were excluded from the study. The remaining 356 patients were included in the study. The patients who had 1 pack- age-year and over cigarette use and the patients who did not ever smoke cigarette were included into the study, the patients who use less than 1 package-year level were excluded from the study. The patients whose alcohol use rate was over 1 units/3 months and the ones who do not drink alcohol were included in the study, the ones who had use rate less than 1 units/3 months were excluded from the study. In our study, all semen analyses were per- formed after 3-6 days of sexual abstinence. Spermiograms were analyzed by the same embryologist in the spermiogram laboratory in our in vitro fertilization center. Semen analysis were evaluated according to WHO 2010 criteria (semen volume ≥ 1,5 mL; sperm concentration ≥ 15 × 106/mL; total motility ≥ 40%, forward motility ≥ 32% and morphology ≥ 4%) (10). The ethical committee approval of the study was obtained by the Local Ethical Committee of our hospital and registered at number 29/12/2014-21/14 together with the form for informed consent form taken from patients included in the study. Statistical analysis The statistical relationship was analyzed by using IBM Statistical Package for Social Sciences (SPSS, New York, USA) Version 22.0 software programme: p < 0,05 values were accepted as statistically significant. DOI: 10.4081/aiua.2016.1.56 INTRODUCTION Cigarette is a significant health problem, which is a com- mon habit that results in early deaths (1, 2). According to data of Turkish Anti-Smoking Association, cigarette use rate is 40% in our country (51% in males, 25% in females) (3). The evidences which show that a number of toxic compounds might disrupt sperm quality, and thus male fertility, in both animals and human are increasing in the last 20 years (4). According to data of World Health Organization (WHO), 1.8 million people die in a year due to alcohol use (5). Keskin ok_Stesura Seveso 05/04/16 15:54 Pagina 56 57Archivio Italiano di Urologia e Andrologia 2016; 88, 1 Do cigarette and alcohol affect semen analysis? RESULTS When the semen parameter mean values of 356 patients who were included into the study were analyzed, the mean semen volume was determined as 2.96 mL, sperm concentration 36.34 x 106/mL, total motility 47%, forward motil- ity 33%, anomaly of the morphology of the head 2.47%, anomaly of neck 43.82%, anomaly of the tail 3.69% (Table 1). The patients were divided in 5 groups according to cigarette use. The patients who do not use cigarette were determined as group 0 (control) (n = 172), the patients who use cigarette less than 5 package-years were determined as group 1 (n = 39), the patients who use cigarette 5-10 package- years were determined as group 2 (n = 52), the patients who use cigarette 10-20 pack- age-years were determined as group 3 (n = 79) and the patients who use more than 20 package-years were determined as group 4 (n = 14). The control group was statistically compared with the others respectively. Only in group 4 (who use more than 20 package- years cigarette), semen volume was signifi- cantly lower than the control group (Mann- Whitney U, p = 0.009). There was no sig- nificant difference in any of the other parameters of the other groups compared with the control group (Mann-Whitney U, p > 0.05) (Table 2). The patients were divided in to 5 groups according to alcohol use. The patients who do not use alcohol were determined as group 0 (control) (n = 256), the patients who use alcohol 1 unit/3 months were determined as group 1 (n = 62), the patients who use alcohol 1 unit/month were deter- mined as group 2 (n = 16), who patients who use alcohol 1 unit/week were deter- mined as group 3 (n = 3) and the patients who use alcohol 1 unit/day were determined as group 4 (n = 19). There was no significant difference in any of the parameters and groups compared with the control group (Mann-Whitney U, p > 0,05) (Table 3). The patients were divided in 4 groups according to cigarette and/or alcohol use. The patients who do not use cigarette and alcohol were determined as group 0 (control) (n = 139), the patients who use only cigarette were as group 1 (n = 117), the patients who use only alcohol were as group 2 (n = 33) and the patients who use both cigarette and alcohol were as group 3 (n = 67). There was no statistically significant difference between group 0 and groups 1, 2 and 3 respectively, in terms of semen parameters according to the statistical analysis of semen parameters (Mann- Whitney U, p > 0.05) (Table 4). DISCUSSION There are a number of studies about the effect of alcohol on semen parameters in the literature, but there is no con- sensus on the relationship between the semen parameters in those studies (11-14). A full recovery was reported in Minimum Maximum Mean Std dev. Age (year) 20 50 33.04 5.43 Volume (mL) 0.30 11.00 2.96 1.53 Concentration (x106/mL) 0,00 170,00 36.34 36.92 Total motility (%) 0.00 90.00 46.54 24.72 Progressive motility (%) 0.00 80.00 32.61 21.24 normal morphology (%) 0.00 10.00 2.47 2.25 head anomaly (%) 0.00 100 43.82 40.13 neck anomaly (%) 0.00 18 5.18 5.10 tail anomaly (%) 0.00 14 3.69 3.86 Table 2. Mean values of semen parameters and p values according to the cigarette use groups. Min. Max. Mean Std. dev. p value Group 0 Volume (mL) 0,30 11 3,14 1,66 (n = 172) Concentration (x106/mL) 0,00 170 38,08 37,81 Total motility (%) 0,00 90 46,10 24,99 Progressive motility (%) 0,00 80 32,94 21,67 Normal morphology (%) 0,00 10 2,40 2,20 Head anomaly (%) 0,00 89 42,50 39,99 Neck anomaly (%) 0,00 18 5,43 5,44 Tail anomaly (%) 0,00 14 3,80 4,13 Group 1 Volume (mL) 0,50 8 3,05 1,59 0,658 (n = 39) Concentration (x106/mL) 0,00 168 42,18 42,10 0,683 Total motility (%) 0,00 85 48,84 25,58 0,531 Progressive motility (%) 0,00 75 34,87 21,35 0,909 Normal morphology (%) 0,00 9 2,97 2,61 0,230 Head anomaly (%) 0,00 100 49,20 42,02 0,511 Neck anomaly (%) 0,00 12 4,86 4,91 0,705 Tail anomaly (%) 0,00 8 3,26 3,39 0,674 Group 2 Volume (mL) 0,50 7 2,92 1,32 0,752 (n = 52) Concentration (x106/mL) 0,00 110 30,84 33,10 0,353 Total motility (%) 0,00 80 47,65 23,40 0,852 Progressive motility (%) 0,00 65 30,48 20,47 0,447 Normal morphology (%) 0,00 7 2,40 2,27 0,997 Head anomaly (%) 0,00 91 36,30 41,27 0,729 Neck anomaly (%) 0,00 12 3,85 4,64 0,258 Tail anomaly (%) 0,00 11 2,90 3,59 0,389 Group 3 Volume (mL) 0,30 7 2,70 1,35 0,068 (n = 79) Concentration (x106/mL) 0,00 120 32,21 35,05 0,326 Total motility (%) 0,00 80 45,21 24,84 0,766 Progressive motility (%) 0,00 70 31,37 20,73 0,548 Normal morphology (%) 0,00 8 2,22 2,02 0,663 Head anomaly (%) 0,00 91 43,71 40,79 0,630 Neck anomaly (%) 0,00 13 4,82 4,72 0,549 Tail anomaly (%) 0,00 11 3,74 3,79 0,986 Group 4 Volume (mL) 1,1 3,4 2,08 0,79 0,009 (n = 14) Concentration (x106/mL) 0,00 112 42,32 34,03 0,484 Total motility (%) 0,00 80 48,92 25,88 0,561 Progressive motility (%) 0,00 65 37,14 22,93 0,416 Normal morphology (%) 0,00 10 3,50 2,68 0,109 Head anomaly (%) 0,00 82 67,71 30,01 0,173 Neck anomaly (%) 0,00 13 9 4,20 0,76 Tail anomaly (%) 0,00 11 5,57 3,40 0,217 Table 1. Mean values of datas (n = 356). Keskin ok_Stesura Seveso 05/04/16 15:54 Pagina 57 Archivio Italiano di Urologia e Andrologia 2016; 88, 1 M. Zeynel Keskin, S. Budak, S. Gubari, K. Durmaz, M. Yoldas, O. Celik, E. Emre Aksoy, Y. Ozlem Ilbey 58 sperm parameters in only 3 months after giving up the alcohol in a 44-year old patient who was an alcohol addict in a case study conducted in 2010 (15). We have not detected any statistically significant relationship between the alcohol use and semen parameters in our study. Li et al. determined that cigarette affects all the sperm parameters negatively in their meta-analysis but effects on semen volume and density display geographical dif- ference (16). Sergeri et al. reported that cigarette does not affect semen parameters in their study (17). When the groups who use cigarette and who do not use cigarette were compared in our study, we have found a statistical- ly significant difference between the control group and group 4 (who use more than 20 package-years cigarette) in relation to semen volume, but there was no significant difference in any of the parameters and groups compared with the control group. Although the number of studies in which cigarette and alcohol use were evaluated together, effect of use of both were not shown on the semen parameters (18, 19). In our study, the patients who do not use cigarette and alcohol were compared to patients who use both of them or only one of them respectively and no statistically sig- nificant difference was detected in any of semen parameters among the groups. In conclusion, a statistical significance was not determined between the ones who do not use neither cigarette nor alcohol and the ones who use cigarette and/or alcohol in terms of semen parameters (semen vol- ume, sperm concentration, total motility, forward motility, morphology). According to our study, using more than 20 package- years cigarette decreases semen volume. The reason of this result might be the threshold value, from which the effect of cigarette and alcohol use on the semen parameters become to be evident. Although no relationship was determined in our study, except the one between semen volume and chronic smoking, in consideration of the publications about the negative relationship of cigarette and alco- hol on the reproductive organs and fertili- ty, young individuals in the reproductive age should be careful about cigarette and alcohol use. REFERENCES 1. Tawadrous GA, Aziz AA, Mostafa T. Effect of smoking status on seminal parameters and apoptotic markers in infertile men. J Urol. 2011; 186:1986-90. 2. Mostafa T. Cigarette smoking and male infertili- ty. J Advanced Res. 2010; 1:179. 3. Cinar O, Dilbaz S, Terzioglu F, et al. Does ciga- rette smoking really have detrimental effects on out- comes of IVF? Eur J Obstet Gynecol Reprod Biol. 2014;1 74:106-110. 4. Sepaniak S, Forges T, Gerard H, et al. The influence of cigarette smoking on human sperm quality and DNA fragmentation. Toxicology. 2006; 223:54-60. 5. World Health Organization. Alcohol: Facts and Figures. 2009; Available from: (accessed 20.10.09). 6. Dawson DA, Li TK, Grant BF. A prospective study of risk drink- ing: at risk for what? Drug Alcohol Depend. 2008; 95:62-72. 7. Gaur DS, Talekar MS, Pathak VP. Alcohol intake and cigarette smoking: impact of two major lifestyle factors on male fertility. Indian J Pathol Microbiol. 2010; 53:35-40. 8. Hansen ML, Thulstrup AM, Bonde JP, et al. Does last week’s alco- hol intake affect semen quality or reproductive hormones? A cross- sectional study among healthy young Danish men. Reprod Toxicol. 2012; 34:457-62. 9. Povey AC, Clyma JA, McNamee R, et al. Modifiable and non- Min. Max. Mean Std. dev. p value Group 0 Volume (mL) 0,30 11,00 2,94 1,51 (n = 256) Concentration (x106/mL) 0,00 170 37,51 38,68 Total motility (%) 0,00 90,00 46,26 25,21 Progressive motility (%) 0,00 80,00 32,79 21,72 Normal morphology (%) 0,00 10,00 2,49 2,32 Head anomaly (%) 0,00 100 43,04 40,34 Neck anomaly (%) 0,00 18 4,94 5,00 Tail anomaly (%) 0,00 14,00 3,60 3,87 Group 1 Volume (mL) 0,30 8,00 2,96 1,56 0,865 (n = 62) Concentration (x106/mL) 0,00 110 30,77 31,68 0,400 Total motility (%) 0,00 85,00 48,14 22,56 0,834 Progressive motility (%) 0,00 75,00 32,01 19,57 0,748 Normal morphology (%) 0,00 7,0 2,40 2,16 0,900 Head anomaly (%) 0,00 91,00 46,58 40,35 0,812 Neck anomaly (%) 0,00 14,00 5,91 5,53 0,352 Tail anomaly (%) 0,00 11,00 3,83 3,80 0,769 Group 2 Volume (mL) 1,00 7,50 3,26 1,73 0,427 (n = 16) Concentration (x106/mL) 0,00 110,00 33,15 30,12 0,971 Total motility (%) 0,00 85,00 48,43 23,57 0,949 Progressive motility (%) 0,00 70,00 32,37 21,04 0,890 Normal morphology (%) 0,00 6,00 2,43 2,15 0,988 Head anomaly (%) 0,00 86,00 53,50 41,56 0,568 Neck anomaly (%) 0,00 12,00 6,66 5,35 0,346 Tail anomaly (%) 0,00 7,00 4,00 3,46 0,727 Group 3 Volume (mL) 2,00 3,50 2,83 0,76 0,867 (n = 3) Concentration (x106/mL) 0,00 70,00 27,33 37,43 0,622 Total motility (%) 0,00 75,00 40,00 37,74 0,797 Progressive motility (%) 0,00 50,00 26,66 25,16 0,618 Normal morphology (%) 0,00 3,00 1,33 1,52 0,431 Head anomaly (%) 0,00 0,00 0,00 - 0,331 Neck anomaly (%) 0,00 0,00 0,00 - 0,337 Tail anomaly (%) 0,00 0,00 0,00 - 0,337 Group 4 Volume (mL) 1,10 8,50 3,02 1,73 0,948 (n = 19) Concentration (x106/mL) 0,00 100 38,72 34,72 0,758 Total motility (%) 0,00 80,00 44,57 26,01 0,788 Progressive motility (%) 0,00 65,00 33,26 21,72 0,862 Normal morphology (%) 0,00 5,00 2,63 1,83 0,579 Head anomaly (%) 0,00 82,00 44,57 41,75 0,799 Neck anomaly (%) 0,00 13,00 6,00 5,74 0,507 Tail anomaly (%) 0,00 11,00 4,85 4,91 0,440 Table 3. Mean values of semen parameters and p values according to the alcohol use groups. Keskin ok_Stesura Seveso 05/04/16 15:54 Pagina 58 59Archivio Italiano di Urologia e Andrologia 2016; 88, 1 Do cigarette and alcohol affect semen analysis? modifiable risk factors for poor semen quality: a case-referent study. Hum Reprod. 2012; 27:2799-806. 10. World Health Organization. WHO Laboratory Manual for the Examination and Processing of Human Semen. 5th edn. WHO, 2010. 11. Jensen TK, Gottschau M, Madsen JO, et al. Habitual alcohol consumption associated with reduced semen quality and changes in reproductive hormones; a cross-sectional study among 1221 young Danish men. BMJ Open 2014; 4:e005462. 12. Jensen TK, Swan S, Jørgensen N, et al. Alcohol and male repro- ductive health; a cross-sectional study of 8,344 healthy men from Europe and USA. Hum Reprod 2014; 29:1801-9. 13. Li Y, Lin H, Ma M, et al. Semen quality of 1346 healthy men, results from the Chongqing area of southwest China. Hum Reprod. 2009; 24:459-69. 14. Karmon AE, Toth TL, Afeiche M, et al. Alcohol and caffeine intake in relation to semen parameters among fertility patients. Fertil Steril. 2013; 100:Supplement:p12. 15. Sermondade N, Elloumi H, Berthaut I, et al. Progressive alco- hol-induced sperm alterations leading to spermatogenic arrest, which was reversed after alcohol withdrawal. Reprod Biomed Online. 2010; 20:324-7. 16. Li Y, Lin H, Li Y, Cao J. Association between socio-psycho-behav- ioral factors and male semen quality: systematic review and meta-analyses. Fertil Steril. 2011; 95:116-23. 17. Sergerie M, Ouhilal S, Bissonnette F, et al. Lack of association between smoking and DNA fragmen- tation in the spermatozoa of normal men. Hum Reprod 2000; 15:1314-21. 18. Martini AC, Molina RI, Estofan D, et al. Effects of alcohol and cigarette consumption on human sem- inal quality. Fertil Steril. 2004; 82:374-7. 19. Gül T, Yılmaz G, Bayram S, et al. The Effect of occupational groups and use of alcohol and smoking in thrace on semen parameters. Turkish medical stu- dent journal. 2014; 1:8-12. Correspondence Mehmet Zeynel Keskin, MD zeynel_akd@hotmail.com Salih Budak, MD salihbudak1977@gmail.com Mehmet Yoldas, MD yoldas_2297@hotmail.com Orcun Celik, MD orcuncelik82@hotmail.com.tr Yusuf Ozlem Ilbey, MD ozlemyusufilbey@hotmail.com Urologic Clinic, Tepecik Training and Research Hospital, Izmir, Turkey Saim Gubari, MD saimgubari@yahoo.com Assisted Reproductive Techniques Department, Tepecik Training and Research Hospital, Izmir, Turkey Kalender Durmaz, MD kaldurmaz@hotmail.com Urologic Clinic Yenisehir State Hospital, Turkey Evrim Emre Aksoy, MD dreaksoy@yahoo.com Urologic Clinic Kırkagac State Hospital, Turkey Min. Max. Mean Std. dev. p value Group 0 Volume (mL) 0,30 11,00 3,10 1,67 (n = 139) Concentration (x106/mL) 0,00 170,00 38,64 38,90 Total motility (%) 0,00 90,00 44,81 25,11 Progressive motility (%) 0,00 80,00 31,83 21,99 Normal morphology (%) 0,00 10,00 2,41 2,24 Head anomaly (%) 0,00 89,00 41,72 40,14 Neck anomaly (%) 0,00 18,00 5,18 5,31 Tail anomaly (%) 0,00 14,00 3,83 4,25 Group 1 Volume (mL) 0,30 7,00 2,74 1,27 0,170 (n = 117) Concentration (x106/mL) 0,00 168,00 36,84 38,57 0,740 Total motility (%) 0,00 85,00 47,99 25,33 0,228 Progressive motility (%) 0,00 75,00 33,94 21,43 0,549 Normal morphology (%) 0,00 10,00 2,58 2,41 0,615 Head anomaly (%) 0,00 100,00 44,69 40,95 0,536 Neck anomaly (%) 0,00 12,00 4,65 4,62 0,619 Tail anomaly (%) 0,00 10,00 3,32 3,36 0,628 Group 2 Volume (mL) 1,00 8,50 3,31 1,65 0,303 (n = 33) Concentration (x106/mL) 0,00 110,00 35,76 33,32 0,856 Total motility (%) 0,00 85,00 51,57 24,06 0,127 Progressive motility (%) 0,00 70,00 37,63 19,89 0,186 Normal morphology (%) 0,00 7,00 2,36 2,08 0,990 Head anomaly (%) 0,00 86,00 47,30 40,83 0,855 Neck anomaly (%) 0,00 14,00 7,00 6,27 0,249 Tail anomaly (%) 0,00 8,00 3,60 3,47 0,951 Group 3 Volume (mL) 0,30 8,00 2,87 1,54 0,376 (n = 67) Concentration (x106/mL) 0,00 110,00 30.98 31.21 0,404 Total motility (%) 0,00 85,00 45,14 23,14 0,854 Progressive motility (%) 0,00 75,00 29,44 19,74 0,429 Normal morphology (%) 0,00 7,00 2,44 2,08 0,779 Head anomaly (%) 0,00 91,00 45,64 40,37 0,655 Neck anomaly (%) 0,00 13,00 5,50 5,13 0,702 Tail anomaly (%) 0,00 11,00 4,07 4,08 0,769 Table 4. Mean values of semen parameters and p values according to the cigarette and/or alcohol use groups. Keskin ok_Stesura Seveso 05/04/16 15:54 Pagina 59