BY Mohammad A. Emam Prof. of Obstetrics and Gynecology Mansoura Faculty of Medicine Mansoura integrated fertility center (MIFC) – EGYPT Smoking And Infertility

Smoking as a major health problem. High prevalence of smoking among women in their reproductive years Unawareness of effect of smoking on reproduction. Smokers may be active or passive. Introduction &Rationale

Smoking as A Health Problem Kills over 400,000 people every year (more than 1 in 6 people in the U.S.) More lethal than AIDS, car accidents, homicides, suicides, drug overdose, and fires combined Smoking Killed Five Million Worldwide in 2000 U.S. spends $50 billion each year on smoking-related costs.

Prevalence of Smoking 30% of reproductive age women and 35% of men are cigarette smokers (Centers for Disease Control and Prevention 2001) Nearly 30% of middle school children and over 63% of high school students had tried smoking (American Heart Association statistics 2001).

Prevalence of Smoking con…. In Egypt: 20% of reproductive age women and 35% of men are cigarette smokers. Shesha smokers are increased among adolescents teenage girls.

Awareness of The Health Risks of Smoking Questionnaire for 388 female hospital employees including health care professional (Roth and Taylor 2001): Most women are aware that smoking causes: Respiratory disease (99%). Lung cancer (99%). Heart disease (96%).s Pregnancy complications (91%).

Awareness of The Health Risks of Smoking cont… Few women are aware that smoking is associated with: Osteoporosis (30%). Early menopause (17%). Spontaneous abortion (39%). Ectopic pregnancy (27%). Cervical cancer (24%). Infertility (22%).

Smoking & Reproduction More Than 40 Published Studies In Medical Literature

Smoking & Female Infertility Meta analysis (21 studies) (Augood et all, 1998) Smoking reduce the natural fertility Earlier menopause (average 2 years). Damage of ovarian reserve increase with smoking (the amount and the period of smoking ). Increase in risks for ectopic pregnancy and spontaneous abortion.

Smoking & Female Infertility con…. Women who quit smoking before or during pregnancy reduce the risk for adverse reproductive outcomes, including: Difficulties in becoming pregnant. Infertility. PROM. Preterm delivery. Low birth weight. (Cochrene review,Lumely et al,2003)

Smoking & Male Infertility (ASRM=AFS 2001) Heavy smoking contributes to: Development of impotence (decrease blood flow to the penis) Abnormal semenogram : Decreased sperm count, alteration in motility, and increase in the abnormal forms.

SMOKERS & ART A prospective cohort study ( Zitzman et al 2001) : High basal and post cc serum FSH. Weak ovarian response to stim. Need higher doses of GN Impaired fertilization and delayed conception, resulted from: Interference with gametogenesis Failure of implantation Early miscarriage.

How Smoking Affect Fertility? Maternal smoking affects: In utro ovary of female fetuses Reduced Semen Quality and Testis Size in Adulthood (Jensen,2004) Increase ROS inside Graafian follicle Affect meiotic maturation of human oocytes

How Smoking Affect Fertility? Con… Interfere with estrogen synthesis, Endothelial abnormalities (atherogenic and thrombotic problems). Oocytes (pre-zygotic genetic damage) sperm DNA damage (substances in smoke).

Substances In Smoke (active and passive ): > chemical compounds, 43 carcinogens or poisons > 300 polycyclic aromatic hydrocarbons. methyl isocyanate( lethal poison). bezene,( a potent toxicant ) Nicotine and its metabolites, cotinine Polonium 210 (a carcinogenic radioactive elem), Cadmium Cigarette smoke

Update Maternal Smoking Increases the risk of asthma during the first 7 years of life (Laurberg P, 2004) Impairment of iodine Nutrition in Breast-Fed Infants (Nohr, 2004). Increased risk for sudden infant death syndrome (SIDS).

Mansoura integrated Fertility Center (MIFC) RESEARCHE Egypt

Could Female Passive Smoking Compromise The Outcome of Assisted Fertilization? ( Middle East Fertility Society 10 th a\Annual Scientific Meeting Lebanon,December 10-13,2003) o-76

Characteristics Passive Smokers Non-Smokers Number of cases3638 Number of cycles5060 Mean±SD Mean ±SD P Mature follicles / Cycle 10.3± ±1.13<0.001 Oocytes retrived / cycle 7.2± ­­±1.19<0.001 Oocytes Metaphase II/ cycle 4.1± ±1.22<0.05 Oocytes fertilized/ cycle 3.2± ±1.12<0.001 / Embryos grade Acycle 2.1± ±0.878<0.05 Clinical pregnancy rate (%) 7(19.4%)12(31.5%)<0.001 Table-2: The Outcome of ICSI in Passive Smokers & Non Smokers

Conclusion Female passive smoking could decrease the success rates of ICSI either through: The negative effect on the egg and embryo quality via passive exposure to smoke (second hand exposure). And/or through the defective sperms of the male active smoker.

Could Cadmium Be The Culprit of Defective Male Reproduction Among Smokers? The Egyptian Journal Of Dermatology and Venereology vol 22,N 2&3 2002

Conclusions A high cadmium level is observed in plasma of heavy smokers which may cause a direct cytotoxic effect on spermatozoa, impairing their functions.

Conclusions cont…. Smoking cessation may improve fertility and success rates with infertility treatment.Moreover it is healthy for the growing fetus, and will create a smoke-free environment for an infant. Smoking may be a forgotten explanation for some cases of unexplained infertility.

Conclusions cont…. It is not known how long the damaging effects of smoking last after quitting but One important investigation showed that cessation of smoking for at least two months before attempting IVF significantly improved chances for conception.

Recommendations 1. The phasing out and banning of smoking in home should be an integral part of human infertility treatment. 2. Further studies to show the correlation between the duration of exposure to cigarette smoke and the fertilization rate, are needed. 3. Further studies on the levels of reactive oxygen species (ROS) in the follicular fluid in passive smokers are needed.

OB& GYN, Mansoura Faculty of Medcine Mansoura Integrated Fertility Center (MIFC) EGYPT Telfax &