455

RBMO VOLUME 41 ISSUE 3 2020

ARTICLE

Birth characteristics in men with infertility

BIOGRAPHY
Gunilla Sydsjö is Professor at the Faculty of Health Sciences, Linköping University, and
Certified Cognitive Behaviour Therapist, Department of Obstetrics and Gynaecology,
University Hospital of Linköping. Her research focus is bio-psychosocial risks for women
and children, reproduction, infertility, women's mental and somatic health, and short- and
long-term outcomes for children.

Susanne Liffner*, Elizabeth Nedstrand, Marie Bladh,

Heriberto Rodriguez-Martinez, Mats Hammar, Gunilla Sydsjö

KEY MESSAGE
Men with restricted intrauterine growth may be at risk of male factor infertility in adulthood. Men with male
infertility factor had a higher prevalence of non-optimal birth characteristics than the reference group.

ABSTRACT
Research question: Are low birth weight, prematurity, being born small for gestational age, or both, associated with a
higher risk of male factor infertility in adulthood?

Design: Retrospective study of a clinical sample of 892 men, diagnosed with an infertility factor (male, female,
combined or unexplained) together with their female partner at a University Hospital clinic in Sweden between 2005
and 2010. Data on birth weight and gestational age at birth were retrieved from the Swedish Medical Birth Register.
The distribution of non-optimal birth characteristics in relation to infertility factor was described. A control group was
created consisting of two men for each index man, born in Sweden in the same year as each index men, as well as a
reference group consisting of all men born in Sweden the same years.

Results: The likelihood of having been born small for gestational age was almost fivefold higher in men with male
factor infertility than in men with unexplained infertility (OR 4.84, 95% CI 1.32 to 17.80). Men with male factor
infertility were more often born with non-optimal birth characteristics than the control group (14.8% versus 8.5%;
P = 0.010) and the reference group (14.8% versus 11.4%; P < 0.001). Men with azoospermia were more often born
with non-optimal birth characteristics, compared with men without azoospermia (21.3% versus 12.1%; P = 0.038).

Conclusions: The results suggest an association between intrauterine growth restriction and male factor infertility in
adulthood.

Obstetrics and Gynaecology, Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health Sciences, KEYWORDS
Linköping University, Linköping SE-581 85, Sweden
IVF
Low birth weight
© 2020 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.
Male factor infertility
*Corresponding author. E-mail address: [email protected] (S Liffner). https://doi.org/10.1016/j.rbmo.2020.04.026 1472-
6483/© 2020 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved. Preterm birth
Declaration: The authors report no financial or commercial conflicts of interest. Small for gestational age
456 RBMO VOLUME 41 ISSUE 3 2020

INTRODUCTION 2001) found no association between To evaluate the distributions of the birth

I
LBW and male infertility (diagnosed characteristics in the study population,
t is well known that preterm birth using World Health Organization criteria information on birth characteristics on all
(PTB) defined as birth before [WHO] from 1999, when the cut-off levels men born during the same period were
gestational week 37 (Keller et al., for a normal semen sample were higher). retrieved from the MBR (n = 538,839).
2010) and restricted fetal growth, If the fetus is exposed to an unfavourable These men are referred to as the
represented by variables such as small environment, the risk of altered reference group. In addition, from these
for gestational age (SGA) (defined as development of genital organs increases, MBR data, a control group of two men
a birth weight less than –2 SD of the which might affect reproductive function were matched on year of birth to each
mean weight for the gestational length) (Francois et al., 1997; Cicognani et al., of the index men (n =1784). The birth
(Marsal, 1996), low birth weight (LBW) 2002; Main et al., 2006; Faure et al., characteristics of the men in the control
(defined as birth weight <2500 g), or 2015). group and the reference group were
both, can increase the risk of diseases compared with birth characteristics for
later in life, e.g. those inherent to the The aim of the present study was to men diagnosed with infertility at RMC.
metabolic syndrome (Barker et al., describe the birth characteristics of male Men in the study group were excluded
1993; Barker, 1998; Hodgson and Coe, partners in couples with infertility. The from the reference group material but
2005; McMillen and Robinson, 2005). hypothesis being tested is that non- it was not possible to exclude men with
According to a Swedish population- optimal birth characteristics, in this study undiagnosed male factor infertility.
based study (deKeyser et al., 2012), men represented by LBW, PTB and SGA, are
born preterm, SGA or with LBW, were associated with a higher risk for male- Infertility treatment at Reproductive
also less likely to reproduce than those factor infertility in adulthood. Results of Medicine Centre, Linköping University
with normal birth characteristics. Being assisted reproductive technique (ART) Hospital
born large for gestational age (LGA) interventions are explored to compare Couples experiencing infertility according
(defined as birthweight over +2 SD of men with or without non-optimal birth to the WHO criteria (Zegers-Hochschild
the mean weight for the gestational age) characteristics and men with different et al., 2009) and residing in the south
has not been shown to affect future infertility factors. east healthcare region of Sweden
reproduction (deKeyser et al., 2012). In can be referred to RMC for infertility
a previous study using Swedish national MATERIAL AND METHODS intervention. The region has a large rural
registers (Liffner et al., 2017), it was found area but also urban areas in which the
that men who became fathers after Participants three largest cities combined had around
intracytoplasmic sperm injection (ICSI) All men participating in this study were 380,000 inhabitants at the time of the
were more often born SGA than men male partners in couples who, after study.
who became fathers after conventional clinical assessment, were accepted
IVF, suggesting that restricted intrauterine for infertility intervention at the Most of the ART cycles carried out at
growth increases the risk of male Reproductive Medicine Centre (RMC), RMC were publicly funded. Couples
infertility. University Hospital, Linköping, Sweden, must fulfil certain conditions to become
between 2005 and 2010. Their female entitled to publicly funded treatments.
Although these data on non-optimal partners have been studied and reported These conditions are the results of
birth characteristics (used as a grouping- previously (Vikstrom et al., 2014). At political decisions and therefore change
term for PTB, LBW and SGA) are risk the start, 1152 men were identified and over time. At the time of the study, the
factors for lower reproductive rate, it 1070 provided written consent to access conditions included female age younger
is still uncertain whether birth weight information from their medical charts as than 38 years, male age younger than 55
is associated with semen quality or well as from the Swedish Medical Birth years and female body mass index (BMI)
with other causes of subfertility. Sperm Register (MBR) (National Board of Health below 30. No serious medical condition
parameters did not seem to be related and Welfare 2003; 2009), a national that could be worsened by a pregnancy
to birth weight when analysing semen register created in 1973. A total of 926 of was allowed. Only two embryo transfers
samples from men without a diagnosis of these men were identified in the MBR, were publicly funded, fresh or frozen
infertility (Ramlau-Hansen et al., 2010; using the unique personal identification thawed. Couples who had not conceived
Whitcomb et al., 2017). In a study of men number assigned to each person residing after two embryo transfers were allowed
with unexplained infertility, all born at in Sweden. Men not identified in the to continue with privately financed
term with normal birth weight (>2500 MBR (n = 144) were either born outside treatments.
g), birth weight was inversely correlated of Sweden or before 1973. The final
to total sperm count and positively study sample consisted of 892 men, as Couples accepted for ART intervention
correlated to sperm fragmentation information on birth weight, gestational were asked to complete a health
(Faure et al., 2015). In another study, the age, or both, was missing in 34 cases. questionnaire that contained questions
proportion of infertile men born with A total of 350 men had either been on age, marital status (married/co-
LBW was higher than for fertile men diagnosed with azoospermia (n = 61) habiting), height and weight, smoking and
(Boeri et al., 2016). Also, sperm motility or had not undergone any infertility snuff habits (yes/no), chronic illnesses,
and morphology were lower for infertile intervention (n = 289) and were thus and regular intake of medication and
men born LBW than for infertile men excluded from analyses pertaining to allergies. All men and their partners
born with normal or high birth weight treatment. Men with azoospermia who underwent a medical investigation aiming
(Boeri et al., 2016). On the other hand, had undergone sterilization were not to find the cause of infertility, which
a registry study from 2001 (Ozturk et al., included in the study. for the men included spermiogram
 RBMO VOLUME 41 ISSUE 3 2020 457

screening. All spermiograms from men through all their treatment cycles. This against the above-mentioned birth
who initially were diagnosed with male includes using all their frozen embryos. characteristics, including adjustment for
or combined infertility were re-assessed BMI and tobacco consumption habits. All
according to WHO standards from 2010 Birth characteristics of the male patients analyses were carried out using IBM SPSS
(semen volume >1.5 ml, total sperm and controls were retrieved from the version 22 (Armonk, NY, USA).
count >39 million, sperm concentration national MBR, which includes information
>15 million/ml, progressive motile >32%, on 97–99% of pregnancies that have RESULTS
total motile >40%, normal morphology resulted in deliveries in Sweden since
>4%) (Cooper et al., 2010). If the first 1973. The register contains information The sample of men included had 1976
semen sample was normal according to about the pregnancy, delivery and as the median birth year (range 1973 to
previously mentioned WHO criteria, this antenatal health of the child and is 1986) and thus were between 29 and
was considered sufficient. In the case of based on the medical charts from 37 years old at the time of inclusion.
azoospermia or severe oligozoospermia maternal health care, obstetric care The median year of birth for men with
(<5 million/ml), an extended examination as well as infant care (National Board different infertility factors were 1975
was conducted, including hormonal of Health and Welfare 2003; 2009). (unexplained) and 1976 (male, female
screening and karyotyping. The information retrieved included and combined). Their partners were
height, weight and gestational week at on average one year younger (median
Their female partners went through birth. When birth characteristics are year of birth for women with different
a gynaecologic examination and described in the present study, the birth infertility factors were 1976 (unexplained),
ultrasound scanning, including tests for characteristics of the male partner and 1977 (male and female) and 1978
fallopian tube patency. The physician not of the offspring are referred to. (combined). Infertility related to female
conducting the infertility investigation of causes accounted for 33.3% of the
the couple then determined the factor Ethics cases, male causes for 20.4%, combined
of infertility. The study was approved by the Regional causes for 22.2% and those remaining
Ethical Review Board in Linköping, 03- unexplained accounted for 24.1% of the
Female factor infertility included tubal 556, 07-M66 08–08-M 233-8, 2014-112/31 cases (TABLE 1). The BMI was normal in
occlusion, anovulation and ovarian on 26 March 2014. 47.4% of the men (BMI 18.5–24.99 kg/
insufficiency according to clinical routine. m2), whereas 52.0% were overweight or
Men were diagnosed with male factor Statistical analyses obese (BMI ≥30.00 kg/m2) and 0.6 %
infertility when two or more semen The distribution of BMI, LBW, SGA, underweight (BMI <18.5 kg/m2) (TABLE 1).
analyses had shown sperm parameters LGA, PTB and any non-optimal birth No significant differences were found
below the normal range (Cooper et al., characteristic (either LBW, SGA, LGA between the groups of men divided
2010). When both a male and a female or PTB, which are not mutually exclusive by infertility type in BMI or smoking
factor were present, the term combined birth characteristics) divided by the habits, but men with male or combined
infertility was used. When no factor was number of individuals in the categories factor infertility used snuff less often
found, the infertility was categorized as female, male, combined or unexplained (P = 0.040) (TABLE 1).
unexplained. infertility were calculated. Chi-squared
tests were used to determine any The proportion of men born with PTB,
Data collection differences between the category groups. LBW or SGA stratified according to
Information on type of infertility (female, The analyses were two sided and the their infertility diagnosis is presented in
male, combined or unexplained), default significance level was set at P TABLE 2 . Men with male factor infertility
smoking and snuff habits (yes/no) < 0.05. Because of multiple testing, were more often born with non-optimal
and weight and height was retrieved however, the P-values were adjusted using birth characteristics than men in the
from medical charts and from the Bonferroni's correction and the P-values control group (14.8% compared with
questionnaires completed by patients. from these adjustments are presented 8.5%; P = 0.010). The proportion of men
All spermiograms from men who were in the tables. The male and combined with non-optimal birth characteristics
initially diagnosed with male or combined categories were added together to form in the reference group, was 11.4% (P
infertility have been re-assessed and re- a separate category to include all men < 0.001). When excluding men born
diagnosed according to WHO standards diagnosed with a male factor contributing LGA from the group of men born with
from 2010, before statistical analyses to infertility in the same category. The non-optimal birth characteristics, 12.1%
were carried out. The patient´s body distribution of the above-mentioned of men with male factor were born PTB,
mass index (BMI) was calculated from variables was also calculated for this SGA or with LBW compared with 8.2%
the height and weight and divided into category. in the control group (P = 0.077) or 8.8%
four categories (underweight <18.5 kg/ in the reference group (P = 0.0042).
m2; normal range 18.5–24.99 kg/m2; Single logistic regression analyses were The proportion of men with PTB, LGA
overweight 25.00–29.99 kg/m2; and obese used to study differences between and LBW was similar in all groups with
≥30.00 kg/m2) (WHO, 2000). the categories of diagnosed infertile different infertility factors. Out of the
men (male factor or combined, female men born SGA or born with LBW, 55.2%
To be able to study the results of factor or unexplained) against PTB, LBW (21/38) and 52.9% (18/34), respectively,
the treatments, i.e. ART method or SGA. Multiple logistic regression had male or combined factor.
used, pregnancy rate and number of was used to compare men with male
interventions, the study was closed in or combined infertility with those The likelihood of being born SGA was
March 2016 when the couples had been with female or unexplained infertility almost fivefold higher for men with
458 RBMO VOLUME 41 ISSUE 3 2020

TABLE 1  DISTRIBUTION OF BODY MASS INDEX AND USE OF TOBACCO AMONG INDEX MEN BY DIAGNOSED FACTOR
OF INFERTILITY

Variable Diagnosed factor of infertility Total P-valuea

Unexplained Female Male Combined

n % N % n % n % n %
Infertility type 215 24.1 297 33.3 182 20.4 198 22.2 892 100.0
BMI 1.000
<18.5 1 0.5 1 0.4 2 1.2 1 0.6 5 0.6
18.5–24.99 90 47.4 117 43.8 85 52.5 87 48.1 379 47.4
25–29.99 85 44.7 120 44.9 56 34.6 75 41.4 336 42.0
>30 14 7.4 29 10.9 19 11.7 18 9.9 80 10.0
Missing 25 30 20 17 92

Habitual smoker
Yes 13 6.7 12 4.2 10 5.8 9 4.6 44 5.2 1.000
No 182 93.3 272 95.8 161 94.2 185 95.4 800 94.8
Missing 20 13 11 4 48
Habitual use of snuff
Yes 62 31.8 82 28.9 34 19.9 39 20.2 217 25.7 0.040
No 133 68.2 202 71.1 137 80.1 154 79.8 626 74.3
Missing 20 13 11 5 49
a  Significance level P < 0.05; Bonferroni adjusted P-values from Pearson's chi-squared test.

male factor infertility than for men with with other infertility diagnoses (TABLE characteristics in the whole reference
unexplained infertility, OR 4.84 (95% CI 4 ). No statistically significant difference group is therefore also reported. Because
1.32 to 17.80; P = 0.018), when adjusted was found in treatment outcome of the large size of the reference group,
for BMI and smoking (TABLE 3). The between the different infertility factors this number of men with ‘unknown male
unadjusted OR for being born SGA for (TABLE 4). Being born with non-optimal factor infertility’ probably does not affect
men with male infertility was 3.05 (95% birth characteristics did not affect the the results. Hence, our results suggest an
CI 1.05 to 8.23; P = 0.040), and OR with chance of conceiving after ART. Rates of association between non-optimal birth
adjustment for BMI alone was 4.84 (95% either pregnancy or live birth were also characteristics and male factor infertility.
CI 1.32 to 17.76; P = 0.017). Men with male similar between groups (data not shown).
or combined infertility also seemed to One possible explanation of this
have an increased likelihood of being born DISCUSSION association is that cryptorchidism,
SGA or with LBW compared with men in more common among children born
couples with female factor infertility but In this study, men with male factor with non-optimal birth characteristics,
the sample size in this analysis was too infertility were more often born SGA relates to lower sperm concentration
small to establish a significant difference. compared with men with unexplained and motility (Depue, 1984; Main et al.,
infertility. Men with male factor infertility 2006; Hart et al., 2015; Adomaitis et al.,
To further elucidate the effect of non- were more often born SGA than men with 2016; Olesen et al., 2017). We do not,
optimal birth characteristics on male all other causes of infertility, although this however, have data on how many men in
infertility, subgroup analyses of men with did not reach statistical significance. this study were born with cryptorchidism.
and without azoospermia was carried Males born SGA also have a higher
out. These analyses showed that 21.3% More men in couples with infertility risk of developing metabolic syndrome
of the men with azoospermia were born were born with non-optimal birth and obesity later in life (Barker et al.,
with non-optimal birth characteristics characteristics compared with the 1993; Barker 2007; Labayen et al.,
compared with 12.1% of the men without reference group consisting of all Swedish 2008; Simmons, 2008; Ross and Desai,
azoospermia (P = 0.038). Men with men of the same age; the difference was 2013). The metabolic syndrome was,
azoospermia also seemed more likely to most pronounced for men in couples in a study of primary infertile men,
be born SGA or with a LBW, although with male or combined factor infertility. associated with a lower general health
these differences did not reach statistical Men with infertility diagnoses were status and lower levels of testosterone,
significance (data not shown). excluded from the control group, but anti-Müllerian hormone, sex hormone-
some of the men may have unknown binding globulin and inhibin-B, without
Men with male or combined cause of poor semen parameters because evidently affecting sperm parameters
infertility were, as expected, more often they have not yet tested their fertility. (Ventimiglia et al., 2016). Studies focusing
treated with ICSI than men in couples The proportion of non-optimal birth on inflammation, insulin resistance and


TABLE 2  BIRTH CHARACTERISTICS IN MEN BY DIAGNOSED FACTOR OF INFERTILITY AND AMONG MEN IN THE REFERENCE GROUP AND CONTROL GROUP
(ABSOLUTE NUMBER AND PER CENT).

Index men Reference group Control group

Diagnosed factor of infertility

Unexplained Female Male Combined Total Male + Combined MBR MBR, 2 controls Male versus Male versus
reference control

n % n % n % n % n % n % n % n % P-valuea P-valueb
215 24.1 297 33.3 182 20.4 198 22.2 892 100.0 380 42.6 n = 538839 n = 1784
PTB (< week 37) 0.890 0.962
No 204 94.9 279 93.9 173 95.1 184 93.4 840 94.3 357 94.2 510941 94.8 1698 95.2
Yes 11 5.1 18 6.1 9 4.9 13 6.6 51 5.7 22 5.8 27898 5.2 86 4.8
LBW (<2500 g) 0.732 0.424
No 208 96.7 288 97.0 175 96.2 187 94.4 858 96.2 362 95.3 520415 96.6 1734 97.2
Yes 7 3.3 9 3.0 7 3.8 11 5.6 34 3.8 18 4.7 18424 3.4 50 2.8
SGA 0.059 0.087
No 207 97.6 277 95.8 163 93.1 185 95.4 832 95.6 348 91.8 517051 96.0 1711 95.9
Yes 5 2.4 12 4.2 12 6.9 9 4.6 38 4.4 21 8.2 21788 4.0 73 4.1
LGA
No 207 97.6 280 96.9 170 97.1 187 96.4 844 97.0 357 96.7 523915 97.2 1751 98.2 0.886 0.712
Yes 5 2.4 9 3.1 5 2.9 7 3.6 26 3.0 12 3.3 14924 2.8 33 1.8
Non-optimal birth
characteristics
No 194 90.2 259 87.2 155 85.2 171 86.4 779 87.3 326 85.8 477461 88.6 1632 91.5 <0.001 0.010
Yes 21 9.8 38 12.8 27 14.8 27 13.6 113 12.7 54 14.2 61378 11.4 152 8.5
a 
P-value refers to comparison of men with male factor infertility and men in the Medical Birth Register (MBR). Significance level P < 0.05; Bonferroni adjusted P-values from Pearson's chi-squared test.
b 
P-value refers to comparison of men with male factor infertility and two male controls from the MBR, matched on year of birth. Significance level P < 0.05; Bonferroni adjusted P-values from Pearson's chi-squared test.
LBW, low birth weight; LGA, large for gestational age; PTB, preterm birth; SGA, small for gestational age.
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460 RBMO VOLUME 41 ISSUE 3 2020

TABLE 3  LOGISTIC REGRESSION FOR NON-OPTIMAL BIRTH CHARACTERISTICS AMONG DIFFERENT DIAGNOSED
FACTORS OF INFERTILITY AMONG MEN

Male versus unex- Combined versus Male + combined Male versus female Male + combined
plained unexplained versus unexplained versus female

Crude OR OR (95% Crude OR OR (95% Crude OR OR (95% Crude OR OR (95% Crude OR OR (95%
(95% CI) CI)a (95% CI) CI)a (95% CI) CI)a (95% CI) CI)a (95% CI) CI)a
PTB
No Reference Reference Reference Reference Reference Reference Reference Reference Reference Reference
Yes 0.96 0.66 1.31 1.36 1.43 1.25 0.81 0.53 1.07 0.88
(0.39 to 2.38) (0.23 to 1.86) (0.57 to 3.00) (0.58 to 3.20) (0.65 to 3.12) (0.54 to 2.90) (0.35 to 1.84) (0.20 to 1.38) (0.56 to 2.01) (0.45-1.70)
LBW
No Reference Reference Reference Reference Reference Reference Reference Reference Reference Reference
Yes 1.19 1.08 1.75 1.62 2.18 2.11 1.28 1.06 1.94 1.37
(0.41 to 3.45) (0.33 to 3.53) (0.66 to 4.60) (0.56 to 4.68) (0.81 to 5.86) (0.70 to 6.42) (0.47 to 3.50) (0.36 to 3.14) (0.85 to 4.45) (0.60-3.15)
SGA
No Reference Reference Reference Reference Reference Reference Reference Reference Reference Reference
Yes 3.05 4.84 2.01 2.15 2.34 2.98 1.70 1.84 1.47 1.24
(1.05 to 8.23) (1.32 to 17.80) (0.66 to 6.12) (0.53 to 8.78) (0.87 to 6.27) (0.86 to 10.39) (0.75 to 3.87) (0.76 to 4.47) (0.70 to 3.09) (0.56-2.77)
Non-optimal birth
characteristic
No Reference Reference Reference Reference Reference Reference Reference Reference Reference Reference
Yes 1.61 1.60 1.46 1.37 1.60 1.54 1.19 1.07 1.13 1.00
(0.88 to 2.96) (0.83 to 3.09) (0.80 to 2.67) (0.71 to 2.64) (0.92 to 2.76) (0.84 to 2.80) (0.70 to 2.02) (0.61 to 1.89) (0.72 to 1.76) (0.62-1.60)
a 
Adjusted for body mass index and smoking.
LBW, low birth weight; PTB, preterm birth; SGA, small for gestational age.

dyslipidaemia, all known contributing i.e. men born SGA were not more often but are still abnormal). The matter would
factors for the metabolic syndrome, have overweight or obese than men in the be clarified if data on previous snuff use
shown elevated oxidative stress leading population. The analysis comparing the were available, but this information could
to increased sperm DNA damage and likelihood of being born with non-optimal not be retrieved from the questionnaires.
negative effects on sperm development birth characteristics between men with
(Morrison and Brannigan, 2015). different infertility factors was adjusted The outcomes of the intervention with
for BMI (and smoking). The results after IVF/ICSI in the present study did not
Obesity affects male fertility, for which adjustment are similar and the association differ between men born with optimal
alterations in sperm parameters, including found in our study between male infertility versus non-optimal birth characteristics,
DNA fragmentation, epigenetic changes and SGA can, therefore, not be explained nor between men with different factors
and down-regulation of the androgenic by obesity per se. The unadjusted OR was of infertility. This positive result for both
axis have been shown (Craig et al., 2017). 3.05 (95% CI 1.05 to 8.83), indicating that groups is an indication that ART is an
Obese men have a reduced rate of live BMI in adulthood is related to intrauterine equally effective method for men born
birth per cycle of ART (Campbell et al., growth, which was discussed previously. SGA, as it is for men with normal birth
2015). More than one-half (52%) of the characteristics.
men in the present study were either A previous study on a Nordic population,
overweight or obese. This, however, for whom snuff use is common, showed In the present study, no adjustments were
was a trend in the entire clinical sample that men using snuff had lower total made for female factors such as age,
studied, not only in those with a male sperm count, sperm concentration and number of oocytes retrieved and dose of
cause of infertility. In an annual survey motility (Parn et al., 2015). This is also gonadotrophins. The median birth year of
conducted by the Public Health Agency consistent with the known fact that the female partners was 1976 (between 29
in Sweden, men aged between 16 and 84 tobacco smokers have lower sperm and 34 years of age at the first treatment),
years reported BMI and other health data. parameters (Borges et al., 2018). The and 71.5% had a BMI less than 25 kg/
Between 2005 and 2010, the self-reported association between snuff use and sperm m2 (Vikstrom et al., 2014). Women with
prevalence of BMI over 24.9 was between parameters in the present study is high ovarian reserve, e.g. women with
52 and 58% in the southeast of Sweden, actually the opposite. Men with male and anovulation because of polycystic ovarian
the region of residence of most patients combined factor infertility more seldom syndrome, as well as low ovarian reserve,
in the present study (Public Health used snuff than men with normal sperm were included in the female factor group,
Agency of Sweden, 2015). Hence, the samples. One possible interpretation and, therefore, the number of oocytes
proportion of obese men is roughly the is that men stop using snuff after being retrieved and the dose of gonadotrophins
same in the patient group as it is in the informed about their affected sperm used may have varied between the
population. In the subgroup of men born sample, but sperm parameters have still individuals. The median oocyte number
SGA, 51.5% were overweight or obese; not improved (or they have improved, and dose of gonadotropins are estimated


TABLE 4  TREATMENT OUTCOMES AND TREATMENT CHOSEN REPORTED BY DIAGNOSED FACTOR OF INFERTILITY

Diagnosed factor of infertility

Unexplained Female Male (88) Combined Total (542) Male + Combined Male versus Male versus Male versus Male + combined Male + combined
(101) (220) (133) (221) unexplained female combined versus unexplained versus female

n % n % n % n % n % % P-valuea P-valuea P-valuea P-valuea P-valuea

Pregnancy 0.448 1.000 0.080 1.000 1.000
No 61 60.4 123 55.9 43 48.9 80 60.2 307 56.6 123 55.7
Yes 40 39.6 97 44.1 45 51.1 53 39.8 235 43.4 98 44.3
Child 0.096 0.260 0.116 0.848 1.000
No 69 68.3 140 63.6 46 52.3 89 66.9 344 63.5 135 61.1
Yes 32 31.7 80 36.4 42 47.7 44 33.1 198 36.5 86 38.9
Type of first <0.001 <0.001 0.112 <0.001 <0.001
treatmentb
IVF 65 64.4 125 56.8 24 27.3 60 45.1 274 50.6 84 38.0
ICSI 13 12.9 52 23.6 51 58.0 58 43.6 174 32.1 109 49.3
Other 23 22.8 43 19.5 13 14.8 15 11.3 94 17.3 28 12.7
Type of <0.001 <0.001 0.700 <0.001 <0.001
treatment (all)c
IVF 73 72.3 134 60.9 30 34.1 62 46.6 299 55.2 92 41.6
ICSI 19 18.8 62 28.2 55 62.5 68 51.1 204 37.6 123 55.7
Other 9 8.9 24 10.9 3 3.4 3 2.3 39 7.2 6 2.7
a 
Significance level P < 0.05. Bonferroni adjusted P-values from Pearson's chi-squared test.
b 
The first treatment carried out for each man.
c 
Every treatment carried out for each man included. ICSI was selected if ICSI was carried out once or more than once; IVF was selected if IVF was carried out once or more than once and ICSI was not carried out; and other was
chosen if IVF and ICSI were never carried out.
ICSI, intracytoplasmic sperm injection.
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