M A Emokpae and Lifestyle behaviors and fertility 2:1 R13–R26

S I Brown

REVIEW

Effects of lifestyle factors on fertility:

practical recommendations for modification

Mathias Abiodun Emokpae and Somieye Imaobong Brown

Department of Medical Laboratory Science, School of Basic Medical Sciences, University of Benin, Benin City, Nigeria

Correspondence should be addressed to M A Emokpae: [email protected]

Abstract
The role that lifestyle factors play in fertility issues has generated some amount of interest and questions among
stakeholders. This review aims to highlight the impact of lifestyle behaviors on the fertility potential of an individual and
what can be done to prevent or improve reproductive outcomes. Relevant published articles on the effect of lifestyle
behaviors were obtained from Medline, Pubmed and Google scholar search engines for the study. The review of the
literature indicates a negative impact of modifiable lifestyle factors such as fat-rich diets, delayed childbearing/age of
starting family, smoking, alcohol misuse, sexual behavior, anxiety/depression and perception/beliefs were associated
with fertility. The ensuing stress precipitates social behaviors such as excessive alcohol and caffeine consumption,
tobacco smoking, misuse of recreational drugs/medications, which increases the risk of sexually transmitted diseases and
infection leading to infertility. Practical recommendations to modify lifestyle behaviors and the impact of misconception of
Assisted Reproductive Technology in the treatment of infertility are discussed. The need to make appropriate behavioral
changes to stem the tide of infertility in Nigeria is imperative. More reproductive health education is needed to create
the necessary awareness of the etiologies of infertility and the importance of in vitro fertilization treatment as a means of
conceiving ‘natural’ babies is suggested.

Lay summary

Scientific evidence has suggested that modifiable lifestyle factors (consumption fat-rich diets, delayed childbearing/age of
starting family, smoking, alcohol misuse, sexual behavior, anxiety/depression and perception/beliefs) play important roles
in the general health and wellbeing of individuals including fertility. Evidence exists of an association between lifestyle
behaviors and infertility in both men and women. Understanding the various processes through which modifiable lifestyle
behaviors impair fertility will help to assist in the management of affected individuals. We conducted a comprehensive
review of published studies to assess how lifestyle factors inhibit fertility and practical ways to ameliorate them. This
review also deals with the misconception of Assisted Reproductive Technology in the treatment of infertility. The need
to make appropriate behavioral changes to stem the tide of infertility in Nigeria is imperative. More reproductive
health education is needed to create the necessary awareness of the causes of infertility and the importance of in vitro
fertilization in the treatment of infertility.

Key Words:  lifestyle behaviors   infertility   humans

Reproduction and Fertility (2021) 1 R13–R26

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 M A Emokpae and Lifestyle behaviors and fertility 2:1 R14
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Introduction Ilacqua et al. 2018, Ikyernum et al. 2019, Silvestris et al.

2019, Alabi 2020) (Fig. 1).
Reproduction is an important biologic event in all living According to the World Health Organization, about
organisms. Anything that threatens reproductive health 20–30% of couples worldwide are infertile, and up to 80
will trigger a significant response from the scientific million women are affected by the condition with about
community, since the continuous existence of any 50% of all women in developing countries are infertile
species is dependent upon the sound reproductive health (Ombelet et al. 2008). The prevalence of infertility in
of the parent species. There are reports of deteriorating sub-Saharan African ranges between 20 and 40% and
reproductive health indices since the last 5–6 decades the problem is shared equally by both men and women
ago from different parts of the world especially in (Emokpae & Uadia 2015). It has been estimated that
industrialized/developed countries as a result of modifiable about one in six couples or approximately 15% of the
lifestyle factors (Kumar et al. 2018). population in industrially developed countries is affected
Lifestyle factors refer to the modifiable behavior (Sharma et al. 2013). Infertile couples suffer both emotional
and ways of life that could influence the general and psychological trauma due to pressure from family
health and wellbeing of individuals including fertility members and society. Fortunately, most of the causes of
(Acharya & Gowda 2017). The role of lifestyle factors infertility are treatable with major procedures belonging
in the etiology of infertility has generated a growing to the assisted reproductive technology (ART) methods.
interest among researchers. Several authors have However, the normalization of some modifiable lifestyle
provided evidence of an association between lifestyle factors could restore normal oocyte maturation in women
behaviors and infertility in both men and women, they and improve semen quality in the males (Ilacqua et al.
include; delayed childbearing due to pursuit of career 2018). The understanding of the various mechanisms
or education, age of starting a family, smoking, eating whereby modifiable lifestyle behaviors impair infertility
of fat-rich diets, alcohol and caffeine consumption, in both males and females will go a long way to assist in
exercise, risky sexual behaviors, drug misuse, anxiety/ the management of affected subjects. This review seeks to
depression, cellular phones and radiation among others highlight the adverse effects of some lifestyle behaviors and
(Araoye 2003, Adewumi 2017, Fehintola et al. 2017, suggests ways to optimize the infertile couple’s chances of
Durairajanayagam 2018, Emokpae & Chima 2018, obtaining conception and live a better quality of life.

Figure 1 Schematic representation of lifestyle behaviors on infertility in both males and females.

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 M A Emokpae and Lifestyle behaviors and fertility 2:1 R15
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Materials and methods men and women as they grow older (Emokpae & Uadia
2017, Emokpae & Igharo 2020). This is compounded by
Over 1000 articles were initially identified from the the powerful effect of socioeconomic and environmental
Medline, Pubmed and Google scholar search engines and factors which have not helped to improve reproductive
after review of the titles and abstracts, about 150 articles potential despite improved technology and advancement
that met the inclusion criteria of major lifestyle factors in science.
associated with both male and female infertility were Delay in starting a family/aging among men may lead
systematically reviewed. This narrative review is largely to the production of poor quality spermatozoa. Semen
focused on Nigeria and the recommendations could be parameters begin a steady decline as early as age 35
country-specific. The need to change the erroneous belief (Stone et al. 2013). Semen volume and motility decrease
and perception of some Nigerians that children conceived and morphology may become increasingly abnormal.
through the assisted reproductive technique are ‘artificial’ Although age affects both males and females, the most
is emphasized. significant impact on reproduction is maternal age.
A woman is born with all egg cells she will ever have.
They reduce in number and quality over the years and
Major lifestyle behaviors that may affect fertility
by the time she gets to 35 years, her fertility is declined
Lifestyles factors are obviously under the control of the (Baird et al. 2005). Incidence of genetic abnormality and
individual and are modifiable to improve the wellbeing of spontaneous abortion also increases with maternal age
humans. Lifestyle factors could affect reproductive health (Kroon et al. 2011). A benchmark of natural fertility is
either positively or negatively (Ilacqua et al. 2018). Infertility usually provided by the Hutterite population which lives
can be defined as the absence of conception within one a relatively simple communal lifestyle that excludes the
year of unprotected sexual intercourse, while fertility is the use of contraception. They showed a progressive decline
capability of producing an offspring (Aydin et al. 2014). in the rate of pregnancies with an increase in female
The new trend of modern lifestyle is that people delay age (Tyden et al. 2006). The data of Wood demonstrates
starting a family due to educational and career pursuit, such that delay in starting a family and aging could lead to
individuals are older and overweight. Aging is associated a 50% decrease in apparent fertility potential at age 35
with degenerative changes at the levels of all organs and years. Fecundability is the ability to achieve a pregnancy
systems, and as such fertility may be affected (Balasch & within a menstrual cycle. This effect is also similar in
Gratacós 2011). Consequently, such individuals engage in women undergoing ART with decreased pregnancy rates
excessive alcohol consumption, tobacco intoxicated, and with age (Liu et al. 2017). The biological clock regulating
abuse illicit substances (Harris et al. 2011). These lifestyle the female reproductive life span has existed to reduce
behaviors expose one to the risk of infertility, but because the complications associated with abnormal pregnancy
of the financial stability that comes with having a career; outcomes in advancing age and to save energy for somatic
most believed they can afford assisted reproduction. The maintenance (Luo & Murphy 2011, Emokpae & Igharo
causes of infertility are varied ranging from endometriosis, 2020). Despite this substantial evidence of a decline in
ovulatory disorders, poor sperm quality, and unexplained fertility with age, men and women are often unaware
conditions among others. Some authors suggested of the risk associated with delayed childbearing due
that adverse lifestyle factors such as smoking, alcohol to the increasing social behavior where education and
consumption, and caffeine can have an additive effect on career pursuits coupled with economic factors keep both
fertility (Ilacqua et al. 2018). A study that examined couples gender out of relationships and childbearing until the late
who were trying to conceive naturally over 12 months, thirties and early forties (Luo & Murphy 2011). Couples
reported that only 38% of couples with 4 adverse lifestyle need to understand the biology of aging concerning
factors conceived compared to 52% with 3, 62% with 2, fertility in both sexes to enable them and healthcare
and 71% with one. Where no adverse lifestyle factors were givers to make an informed decision regarding delayed
present, 83% of couples became pregnant (Burton 2014). childbearing, age of starting a family, and counseling
of those seeking fertility treatments (Emokpae & Igharo
2020). Although men could produce semen even at an
Delayed childbearing/age of starting a family
older age, increased paternal age has been reported to be a
Human reproduction is greatly influenced by age. This is major determinant for testicular function, sex hormones,
because so many physiological changes take place both in sperm quality, sperm DNA integrity, telomere length, and

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 M A Emokpae and Lifestyle behaviors and fertility 2:1 R16
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epigenetic factors (Arslan et al. 2017, Ilacqua et al. 2018). axis be closely linked to the nutritional status as it is in
These changes due to aging adversely impact fertility and living organisms (Giahi et al. 2016). Several factors such
reproductive outcomes such as congenital birth defects, as genetic, environmental and behavior contribute to the
fetal death, recurrent abortion, and infertility. Paternal increasing trend in overweight and obesity. In some cases,
age has also been linked with autism, schizophrenia and the preponderant of cheap high-calorie but nutrient-poor
bipolar disorders, and achondroplasia (Arslan et al. 2017). foods in the last four decades has contributed to the high
Higher oxidative stress occurs in aged couples as a result of prevalence of obesity all over the world (Giahi et al. 2016).
an imbalance between reactive oxygen species generation In females, reproduction involves much greater
and available antioxidants in the circulation. This was energy expenditures than for males and as a protective
aptly demonstrated in an experimental study that showed mechanism against under-nutrition, ovarian activity
that aging leads to a decline in fertility and the numbers is suppressed in women with eating disorders and
of Sertoli and germ cells in mice with the complete exercise-induced amenorrhea through pathways in the
absence of catalase (CAT-null(cat−/−) or/and superoxide hindbrain. The combined prevalence of Bulimia nervosa
dismutase 1 (SOD-null(sod−/−) (Tyden et al. 2006). This and Anorexia nervosa is approximately 5% among women
is an indication that these antioxidant enzymes are vital of reproductive age. Bulimia nervosa is an eating disorder
in the maintenance of germ cell quality in advanced that is characterized by binge eating which is followed
age. Paternal age is reported to adversely affect testicular by fasting or self-induced vomiting or purging. It is an
volume, alters the structure of seminiferous tubules emotional disorder that makes one have a distorted body
(Janevic et al. 2014), and reduces blood supply to the testes image and an obsessive desire to lose weight. Anorexia on
(Wasiu et al. 2012). Sex hormone secretion is affected the other hand is also an eating disorder that is more of a
by aging; there is a decline in the secretion of testicular psychological condition marked by extreme self-starvation
inhibin B by Sertoli cells coupled with increased secretion due to a distorted body image. The likelihood of cure
of follicle-stimulating hormone (FSH) (Ilacqua et al. 2018). is higher with Bulimia nervosa. Both disorders suppress
Since there are reductions in the numbers of Leydig ovulation in severely affected women and account for
cells, the biosynthesis of testosterone is affected. Aging up to 60% of women with anovulatory infertility (Tabler
was also reported to alter the hypothalamic–pituitary– et al. 2018).
gonadal axis function, hence leading to changes in the Some nutritional factors may affect male fertility
other reproductive hormones. The exacerbated effect of and evidence suggesting a direct association between
aging on increase DNA fragmentation was reported to be nutritional altitude and poor semen quality has emerged.
a contributing factor to the low success rate of assisted High-fat diets inhibit reproduction by affecting the
reproduction technology (ART) treatment in infertile physical and molecular structure of not only sperm
couples (Alvarez Sedó et al. 2017). Individuals should be cells but also the developing fetus and offsprings (Rato
counseled to start a family at the peak of reproduction et al. 2014). Some experimental studies have shown that
period as delay can adversely affect fertility potentials. feeding mice with high-fat diets resulted in long-term
Also, caution may be applied when using spermatozoa of alterations in the reproductive system, and the metabolic
aged-men during treatment with ART to avoid the risk of programming mechanisms; such as a decrease in both
possible transmission of genetic disorders to offsprings. height and diameter of the seminiferous epithelium, and
seminiferous tubules, respectively (Ibáñez et al. 2017).
This also resulted in decreased sperm concentration,
Nutritional factors
viability, and DNA integrity. It has long been recognized
Nutritional problems are strikingly different in that normal testicular function is responsive to changes in
developing nations where deprivation, undernutrition, whole-body metabolism, and that testicular metabolism
and malnutrition are the major problems while eating can be affected by the intake of high-energy diet (Rato
disorders and obesity are very common in developed et al. 2013) and in people with obesity. Studies have
countries. Obesity is, however, increasingly common suggested that reproductive health can be enhanced
in developing countries due to globalization. The by modification of dietary intakes such as fruits and
reproductive system is extremely sensitive to influences vegetables, legumes, and fish. The regular intake of foods
from the external environment. This is because it involves rich in fruits, vegetables, legumes, and fish was associated
energy expenditures and it is only sensible that the with better sperm quality (Karayiannis et al. 2017) and a
physiological control mechanisms of the reproductive lower DNA fragmentation index than subjects who do not

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 M A Emokpae and Lifestyle behaviors and fertility 2:1 R17
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take such foods regularly. Regular intake of red meat was excess biosynthesis of androgen and lipids from the theca
inversely associated with sperm quality. Table 1 shows the cells. Increase production of estrogen by the fat cells and
schematic representation of various lifestyle behaviors on primary sex organs that occur in a state of high body fat
infertility. is interpreted as birth control by the body, hence limiting
In a study of health and lifestyle among Finnish men the chances of conception (Wasiu et al. 2012).
and women with infertility, it was reported that infertile
women under 50 years consumed more unsaturated
Smoking
fat, less saturated fat, and consumed more alcohol than
their fertile counterparts (Revonta et al. 2010). The Cigarette smoking has been associated with adverse
effectiveness of lifestyle intervention was assessed among effects on fertility although not widely recognized. It
some infertile women with obesity, and the authors also increases the risk of congenital cardiac disease.
reported that lifestyle intervention increased the natural In males, smoking has been observed to reduce sperm
conception rate among anovulatory infertile women concentration, morphology, and motility as well as
with obesity, but did not affect the rate of healthy live increased DNA damage (Caserta et al. 2013). The exact
birth (van Oers et al. 2016). Infertile women are therefore mechanisms underlying the impact of smoking on sperm
counseled to maintain a healthy eating habit to avoid the quality is not completely understood. Tobacco smoke
accumulation of body fats with may impair ovulation (van contains several substances such as nicotine, cadmium,
Oers et al. 2016). The evaluation of lifestyle habits and lead, superoxide, and hydroxyl radicals that can adversely
the modification of unhealthy habits by trained health affect reproductive health. Superoxide and hydroxyl
providers with specific management, like systematic folic radicals can take part in the Fenton reactions to produce
acid supplementation in females attempting to conceive hydrogen peroxide and ultimately caused oxidative stress
may yield the desired outcomes (Silvestris et al. 2019). and cause DNA damage (Taha et al. 2012). Cadmium and
High insulin levels and insulin resistance are associated lead have been reported to cause DNA strand breaks while
with body fat accumulation, polycystic ovarian syndrome, nicotine, superoxide, and hydroxyl radicals can induce
metabolic syndrome, and all have serious implications dsDNA breaks in sperm DNA (Ilacqua et al. 2018). A study
for female infertility. Hyperinsulinemia enhances the that evaluated the levels of DNA fragmentation index (DFI)

Table 1 Summary of study findings of lifestyle behaviors on infertility in Nigeria.

Reference Study design Population size Type of lifestyle behaviors Reproductive health effect

Alabi (2020) Qualitative 15 Social, traditional and Low acceptance of surrogacy practice
religious beliefs
Emokpae et al. (2020) Cross-sectional 400 Nutrition Poor semen quality
Akande et al. (2019) Cross-sectional 202 Perception and beliefs Poor acceptance surrogacy and
negative attitude toward IVF
treatment
Ikyernum et al. (2019) Cross-sectional 600 Risky sexually behavior Poor semen quality
Emokpae et al. (2019) Experimental 24 adult rabbits Drug abuse (tramadol) Increased lipid peroxidation
Osabuohien & Experimental 30 adult rabbits Alcohol abuse Low sex hormone levels
Emokpae (2018)
Emokpae & Chima Cross-sectional 122 Paternal aging High oxidative stress and apoptosis
(2018)
Adewumi (2017) Review Several articles Cultural beliefs/cost High emotional/financial stress
Okafor et al. (2017) Cross-sectional 589 Perception and Unscientific perception,
survey traditional belief misconception of IVF treatment
Emokpae & Egho Experimental 30 adult rabbits Alcohol abuse Increased oxidative stress
(2017) study
Osian et al. (2019) Survey 348 Perception Low knowledge of IVF
Oremosu & Akang Experimental 36 adult Sprague– Alcohol abuse Low sex hormone levels, poor semen
(2015) Dawley rats quality and high oxidative stress.
Omoaregba et al. Cross-sectional 100 Anxiety and depression High psychological distress
(2011)
Makanjuola et al. Case–control 320 Anxiety and depression High rate of psychiatric morbidity,
(2010) lack of support from husbands’ and
husband’s relatives.

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 M A Emokpae and Lifestyle behaviors and fertility 2:1 R18
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in infertile smokers and infertile non-smokers reported the type, amount, and duration of alcohol consumption.
a significantly higher (P < 0.001) DFI (37.66%) among Alcohol depletes many essential nutrients from the
infertile smokers than infertile non-smokers (19.34%) body such as vitamin B, zinc, iron, magnesium, calcium,
and controls (14.51%) (Wright et al. 2014). The study sodium, potassium, etc., and these vitamins and minerals
demonstrated the contribution of smoking to infertility. are needed for most functions including reproduction.
The effect of smoking on sperm quality was reported to There is excess estrogen and decrease testosterone in all
be more pronounced in heavy smokers (those who smoke types of alcohol misuse (Ilacqua et al. 2018). Alcohol
>20 cigarette sticks/day) and moderate smokers (10–20 is a known teratogen and its consumption has been
cigarette sticks/day) than mild smokers (1–10 cigarette reported to decrease fertility (Oremosu & Akang 2015). An
sticks/day) (Sharma et al. 2016). animal study that evaluated the effect of chronic alcohol
In females, smoking can lead to the increased consumption on reproductive hormones and semen
thickness of the zona pellucida in smokers which characteristics, it was reported that serum testosterone,
makes sperm penetration difficult (Ilacqua et al. 2018). follicle-stimulating hormones (FSH), luteinizing hormone
Menopause has been reported to occur 1–4 years earlier (LH), sperm count, and motility correlated inversely with
in smoking women when compared to non-smoking increasing concentrations of alcohol consumed. Also,
women (Vanegas et al. 2017). Cigarette contains several the concentration-dependent testicular morphological
harmful constituents that have been detected in the changes were observed (Osabuohien & Emokpae 2018).
follicular microenvironment of smokers such as cotinine It was observed that chronic consumption of alcohol
and cadmium thereby altering hormone levels in the did not only lower the levels of sex hormones and
luteal phase and could affect the developing follicle. sperm quality but also led to weight loss in the animals
Smoking in women significantly decreases the chance of as a result of changes in dietary habits (Osabuohien &
conception by disrupting ovarian function and depleting Emokpae 2018). Chronic alcohol consumption also alters
its reserve. macronutrients and micronutrients absorption in the
Oxidative stress is one of the main causes of DNA small intestine. Studies have shown that the absorption
fragmentation in male infertility but maybe modifiable of amino acids, lipids, and glucose is impaired during
in several ways. Sources of oxidative stress as outlined chronic over-consumption of alcohol. An earlier report
in this paper should be evaluated in infertile men as indicated that chronic consumption of alcohol above
part of a treatment protocol. The use of antioxidants 12% v/v concentration has the potential to increase serum
supplementation has been reported to have some benefits, markers of iron status and oxidative stress in experimental
but these antioxidant levels have to be determined whether animals (Emokpae & Egho 2017). The authors suggested
there are deficiencies or not so that over-supplementation that chronic ingestion of high concentrations of alcohol
is avoided. It is important to maintain a delicate balance may have adverse effects on sex hormones, testes,
between oxidants/antioxidants to ensure fertility, epididymis, and ultimately fertility potential (Oremosu
successful fertilization, and pregnancy. Quitting smoking & Akang 2015, Osabuohien & Emokpae 2018). Therefore
may improve fertility in those who smoke previously. A careful use of high concentrations of alcohol or better
follow-up study of men who quitted smoking revealed still abstinence is advised since alcohol suppresses the
that every additional year following cessation of smoking synthesis of hormones at the levels of the hypothalamus,
reduced the risk of ART failure by 4%, especially between the anterior pituitary, and the gonads (Oremosu & Akang
clinical pregnancy and live birth (Vanegas et al. 2017). 2015, Osabuohien & Emokpae 2018). Damage to the
Therefore, cessation of smoking and avoiding exposure to nervous system in men can results in sexual impotence
tobacco smoke among couples may improve the chances due to loss of libido and erection (Durairajanayagam
of conception. 2018).
Alcohol is commonly consumed by women of
reproductive age and is associated with several reproductive
Alcohol consumption
health risks. There is no data on the prevalence of alcohol
Alcohol is the most commonly abused substance known use and misuse in Nigeria but 86.4% of people aged 18
and used for celebration and relaxation since ancient years and above are reported to have consumed alcohol
times. Apart from damaging other organs of the body at a point in their lives while 56% are current users in
such as the liver, heart, and nervous system, it also affects the United State of America (Abuse 2015). Studies in both
reproductive health. The kind of damage done depends on human and animal models have observed that chronic

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alcohol consumption resulted in changes in ovulation intra-fallopian transfer (GIFT) reported a 13% decrease in
and menstrual cycle regularity (Oremosu & Akang 2015). the numbers of oocytes retrieved, a 2.86 times likelihood
Although acute alcohol consumption may not harm the of not achieving pregnancy, and 2.21 times of higher
menstrual cycle, it has been reported to negatively affect risk of abortion among women who consume alcohol
fertility treatment outcomes. Chronic over-consumption than controls (Klonoff-Cohen et al. 2003). These findings
of alcohol may lead to a decline in ovarian reserve and suggest fertilization failure, as alcohol intake can reduce
fertility potentials in women. Markers of ovarian reserve the success rate of IVF treatment by decreasing oocyte
and fertility potentials (FSH, anti-mullerian hormone yield and live birth rates. Therefore, women seeking IVF
(AMH) and antral follicle count) were reported to be treatment are encouraged to abstain or minimize alcohol
lower among alcohol users than non-users (Abuse 2015). consumption before commencing treatment.
This was supported by evidence indicating that women
who drink alcohol experience menopause at an earlier
Caffeine
age than non-drinkers. On the contrary, there is no
evidence linking mild or moderate alcohol consumption Caffeine is a stimulant that has enabled it to be used as
with female infertility. Some authors have reported no a beverage (tea, soft drink, chocolate, etc.). It affects the
association between alcohol consumption and ovulation nervous system and various other organs including the
and fecundability (Mikkelsen et al. 2016). Even though the reproductive system. It has over 1000 active compounds
findings are inconsistent, individuals who are currently (stimulants), and a high intake of caffeine more than 5
being treated for infertility maybe enjoined to abstain or cups or 500 mg per day delays pregnancy. It interrupts
reduce alcohol consumption. egg fertilization and implantation process (Olsen 2018).
A woman may suffer from infertility due to the Several observational studies and meta-analyses have
derangement of the hormonal system by alcohol even reported that maternal caffeine consumption may be
with mild consumption. If she is pregnant there may be associated with major adverse pregnancy outcomes. Some
a risk of abortion and could also cause a low birth weight authors reported significant dose-dependent associations
of the child with various congenital abnormalities if the that are suggestive of causation while others observed
pregnancy progresses. no threshold of consumption below which associations
Those who misuse alcohol early in life are more likely were absent. Consequently, available data does not
to indulge in risky sexual behavior which can expose support health advice that assumes ‘moderate’ caffeine
them to sexually transmitted diseases such as Chlamydia consumption during pregnancy is safe. However, current
trachomatis and HIV/AIDS. Sexually transmitted evidence supports pregnant women and would-be mothers
infections have been associated with infertility in several to avoid caffeine consumption (James 2020). Conversely,
studies (Okonofua et al. 2005, Umeora et al. 2007). Genital the American College of Obstetrics and Gynecologist
tract infection is an important etiological factor for sub- (2010) implied that moderate caffeine did not harm the
fertility and infertility in Nigeria. It can lead to poor semen fetus of pregnant women but its high intake (more than
quality (Owolabi et al. 2013), obstruction of seminal tract 540 mg every day) resulted in low fetal weight and length.
(Okonofua et al. 2005) and tubal blockage (Umeora et al. It also causes withdrawal symptoms such as headaches,
2007, Wasiu et al. 2012). Chronic dehydration is usually nausea, irritability, etc. It may also increase the risk of
associated with heavy drinkers but appropriate hydration miscarriage because it can cross the placenta barrier. A
is important for a healthy reproductive function. Without high level of caffeine consumption has been associated
enough water, men may experience poor quality erections, with an increased risk of stillbirth (Minguez-Alarcon et al.
low seminal volume, and prostate infections. Women 2018). There is no definite amount or safe level of caffeine
can develop persistent vaginal dryness and suffer greater consumption but about 200 mg is considered moderate
susceptibility to a yeast infection. for those breastfeeding, pregnant, or trying to conceive
women.
The regular consumption and abuse of high caffeine
Alcohol consumption and the effectiveness of energy drinks are increasingly popular. These caffeine-rich
IVF treatment
energy drinks have been reported to readily pass through
There is evidence that suggests that alcohol consumption biological membranes and rapidly distributed all over the
negatively impacts ART treatment outcomes. A prospective body and may impair male gonadal development and
study of 221 subjects undergoing IVF or gamete function (Minguez-Alarcon et al. 2018). The mechanism by

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 M A Emokpae and Lifestyle behaviors and fertility 2:1 R20
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which caffeine impairs infertility is not well understood, concentration, and motility (Aydin et al. 2014). There
and there are conflicting reports on its harmful effects by are however conflicting data on the effect of physical
some authors (Ilacqua et al. 2018). exercise on male fertility potential. Earlier studies have
indicated that regular vigorous exercise can adversely
affect semen quality and testicular function, a situation
Physical exercise
attributed to testicular heating, oxidative stress, DNA
Regular exercise affects all individuals’ general health fragmentation, and gonadotropin inhibition (Silvestris
and wellbeing and probably provides some protection et al. 2019). Conversely, some authors have observed that
from obesity, cardiovascular disease, type 2-diabetes, individuals who engage in regular exercises had better
psychological stress, etc. Exercise increases insulin semen quality than sedentary control subjects (Lalinde-
sensitivity and improves ovarian functioning and may Acevedo et al. 2017). Others have reported that moderate
improve the chances of achieving conception. There regular training may reduce seminal plasma oxidative
is evidence to suggest an association between physical stress than rigorous regular exercise (Silvestris et al. 2019).
exercise and infertility, as exercise may contribute to a Regular moderate exercise is recommended and may
reduction in energy balance, leading to amenorrhea and improve fertility potential among infertile subjects since
irregular ovulation (Silvestris et al. 2019). Physical exercise rigorous physical activities might expose individuals to an
is beneficial to overweight or obese infertile women. increased risk of poor reproductive function.
The findings from an interventional study indicated
that physical exercise combined with weight loss was
Sexual behavior
associated with improved fertility among obese women.
On the contrary, a cohort study of over 5000 women with Sexual promiscuity greatly increases the risk of sexually
a healthy BMI range (<25 kg/m2) showed that rigorous transmitted diseases, such as gonorrhea, chlamydia
exercise was inversely associated with fertility potentials, trachomatis, herpes, syphilis, and HIV. Many of the sexually
but was positively associated with fecundability among active individuals are less likely to use contraceptives
overweight and women living with obesity (Wise et al. which may lead to sexually transmitted infections
2012). Sedentary lifestyle behavior refers to time spent (STIs), and unintended pregnancies. The increased risk
doing little or no movement while awake or sitting. It is of unplanned pregnancy and criminal abortions further
one important modifiable risk factor for infertility since aggravates the risk of STIs and infertility. Sexually
biological evidence supports the association of physical transmitted infections (STIs) are common problems often
activity and infertility. Women who engage in rigorous associated with infertility in Nigeria (Emokpae & Uadia
physical exercise may be at risk of infertility due to 2015). Studies have associated STIs with risk for male
anovulation and implantation defect. infertility in southern Nigeria (Okonofua et al. 2005),
Most researches about physical fitness and and men who reported having chronic penile discharge,
reproduction are primarily focused on athletes rather than painful micturition, genital ulcers, and testicular pain
those with moderate level fitness. After BMI adjustment, were more likely to be infertile. Another study reported
each hour of vigorous exercise per week was reported 173/500 (34.6%) of STIs prevalence among males
to be associated with a 5% reduction in risk to protect investigated for infertility in Kano, Northern Nigeria
ovarian functioning. However, in obese infertile women, (Emokpae et al. 2009). Early diagnosis and treatment
increased physical fitness, and psychological wellbeing of STIs is key to the prevention of sexually transmitted
resulted in significant improvement in ovulation and infections-induced infertility.
conception (Silvestris et al. 2019). Female athletes who
engage in excessive exercise and have poor dietary habits
Drug abuse
are at risk of developing a low BMI which may result in
a low estrogen level. This affects the menstrual cycle and Women are more vulnerable to long-term drug abuse
ovulation. compared to men due to the difference in physiology,
The quality of sperm parameters of men performing weight, hormone levels, etc., that can affect the breakdown
the exercise for one hour, at least three times a week of these drugs in the body (Center for Behavioral Health
were 15.2% better than that those who perform exercise Statistics and Quality 2017). Heroin and methadone are
less frequently or excessively (9.7%). The parameters known to cause amenorrhea. Intravenous drug use exposes
investigated by the authors were the morphology, count, one to HIV and AIDS and also when someone is under

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 M A Emokpae and Lifestyle behaviors and fertility 2:1 R21
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the influence of such drugs that individual can partake infertile women. Procreation is considered as a means
in risky sexual acts that make him or her susceptible to to enhance or solidify a woman’s status in the family
sexually transmitted infections (STI), including Human and community in Nigeria (Makanjuola et al. 2010).
Papilloma Virus (HPV). This is linked to increased cervical When this is not achieved as desired, marital harmony is
cancer risk among women. Drugs such as marijuana, threatened, anxiety and depression may occur. In a study
heroin, methamphetamine, cocaine could easily pass of predictive factors for psychiatric morbidity among
through the placenta to the fetus thereby increasing the infertile women, it was observed that 48.8% out of 160
risk of low birth weight, birth defects, premature birth, respondents presented with psychiatric morbidity. Also,
sudden infant death syndrome (SIDS), and changes in the absence of support from their husbands and husband
physical features of the fetus. Women who use illicit drugs relatives, unfair treatment, discrimination, and induced
during pregnancy are up to two times more likely to have abortion were significantly higher (P < 0.001) among
a stillbirth, as prescription drugs such as non-steroidal infertile women than control subjects. The psychosocial
anti-inflammatory drugs NSAID show a correlation with challenges were not different between primary and
female infertility (Forray 2016). secondary infertile women. The authors emphasized
In males, this risky behavior produces similar early identification of psychiatric morbidity and more
outcomes of STIs and infertility which usually presents public enlightenment to enhance moral and psychosocial
with problems of sexual dysfunction. The use of support for women with infertility in Nigeria (Makanjuola
methamphetamine and cocaine can lead to erectile et al. 2010). Surprisingly, the reported rate of psychiatric
dysfunction and delayed orgasm in men who initially may morbidity (48.8%) was higher than previously reported
have experienced benefits such as heightened arousal. from the same center. Some authors have reported a rate
Chronic use of marijuana decreases testosterone secretion of 47.3% of psychiatric morbidity among infertile women
from Leydig cells, spermatogenesis, sperm motility, etc. from Akwa Ibom State in Nigeria. This is an indication
(Forray 2016). Marijuana contains ‘hashish’ which also is that the challenge is widespread in Nigeria. Lack of
capable of binding to receptors in a reproductive organ support from their husbands, unfair treatment, and
such as the uterus and ductus deference (Aydin et al. discrimination from their husbands and their relatives
2014). toward infertile women were associated with anxiety,
depression and other psychosocial problems (Abasiubong
et al. 2008, Bhonage et al. 2014).
Cellular phones and radiation
There is enough scientific evidence to suggest
Emerging evidence suggests the detrimental effect of that anxiety and depression could severely affect
cellular phones on fertility. The numbers of mobile phone spermatogenesis, mainly by depressing testosterone
users are increasing by the day and several users keep secretion. The hypothalamic-pituitary-adrenal (HPA)
and/or store mobile phones in their trouser pockets. The axis has a direct inhibitory action on the hypothalamic–
mobile phone has been suggested as a source of damaging pituitary–gonadal (HPG) axis and Leydig cells in the
radiation to the male reproductive organs. Increased testes. The gonadotropin inhibitory hormone (GnIH) also
levels of DNA fragmentation index have been reported in has an inhibitory effect on the HPG axis which results
mobile phone users (Wright et al. 2014). These gadgets in a fall in the testosterone levels, which causes changes
transmit or receive radiofrequency electromagnetic waves in Sertoli cells and the blood-testis barrier leading to the
that have adverse effects on sperm motility, number, and arrest of spermatogenesis (Makanjuola et al. 2010).
morphology. Higher serum free testosterone and a lower Anxiety and depression could activate an inhibitory
luteinizing hormone (LH) level were reported among effect on the female reproductive system. Corticotrophin
some users of cellular phones than control subjects who releasing hormone (CRH) inhibits hypothalamic
do not use cellular phones (Ilacqua et al. 2018). gonadotropin-releasing hormone (GnRH) secretion, and
glucocorticoids inhibit pituitary luteinizing hormone
and ovarian estrogen and progesterone secretion. These
Anxiety and depression
are responsible for the ‘hypothalamic’ amenorrhea
Some authors have observed that anxiety, depression, (Abasiubong et al. 2008).
and violence could adversely impact fertility (Makanjuola It is recommended that infertile couples desiring
et al. 2010). Studies in Nigeria have revealed how the conception are encouraged to avoid anxiety and depression
varying forms of these habits affect fertility among and management programs such as periodic relaxation

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 M A Emokpae and Lifestyle behaviors and fertility 2:1 R22
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activities are encouraged to improve conception rates system being practiced. As a result, there is usually a
(Silvestris et al. 2019). delay in the willingness to access treatment because
they want to ‘wait on God’ for the natural process of
conception (Adesiyun et al. 2011, Omokanye et al. 2017).
Perception and belief
This practice further reduces the chances of hitherto
Another major challenge is the wrong perceptions and healthy individuals that would have benefited from the
beliefs among the non-enlightened majority in developing treatment particularly those with unexplained infertility
countries particularly in West Africa about infertility and who could afford the cost of the technique. Therefore,
some of the available treatments (Adesiyun et al. 2011, individuals have a responsibility to preserve or increase
Okwelogu et al. 2012, Okafor et al. 2017, Omokanye et al. their fertility potential to some degree by modifying their
2017, Akande et al. 2019). Some believed that infertility lifestyle behaviors which may improve or hamper their
is caused by evil spirits, predestined by God, punishment reproductive health. The authors advocate reproductive
from God and supernatural challenge. Other perceived health education to create the necessary awareness of
it as a curse that requires prayers and patience to be the etiologies of infertility and the importance of IVF
resolved (Okafor et al. 2017). This perception may not be treatment as a means of conceiving ‘natural’ babies.
limited to West Africa or Nigeria as a study from Karachi,
Pakistan also revealed that evil forces and supernatural
forces were considered as causes of infertility especially Some factors impairing effective treatment
among people with low educational status (Akande et al. of infertility
2019). On the contrary, findings from several studies have
shown infertility to be a disease condition or medical Some of the identified factors militating against the
challenge rather than a social problem (Umeora et al. effective treatment of infertility include; high cost and
2008, Okwelogu et al. 2012, Osian et al. 2019). inaccessibility of most couples in need, absence of specific
Advances in medical sciences have proven that objectives, priorities, and strategies for infertility care in
infertile conditions are treatable. Various types of most countries in sub-Saharan Africa, absence of reliable
assisted reproductive technologies are available in the data and good follow-up mechanisms, lack of integration
management of infertility. However, negative altitude, of infertility services into the reproductive health services,
wrong perception and beliefs have been associated with absence of proper coordination of healthcare system,
IVF, which has been successfully used in the treatment inability to accurately target those at risk for infertility
of infertility especially among the un-enlightened and inadequate training and research in infertility (Leke
individuals. Majority of respondents surveyed by some 2019). Some authors in Nigeria have observed that despite
authors perceived IVF as un-natural and not cultural. the great burden of the condition, only very few infertility
The held perception of children conceived through this management programs are available (Okafor et al. 2017).
procedure is abnormal or inferior to those conceived Fertility care, development, and access are limited.
naturally (Okafor et al. 2017, Akande et al. 2019). Despite Therefore, the burden of infertility lies sorely on the couple
the suggestion by earlier study that the wrong perception (Akande et al. 2019). It was observed that most infertile
of IVF was due to the nascent nature of the technology couples belong to the very poor in the society, hence would
(Giwa-Osagie 2002), the negative altitude and wrong not be able to afford the high cost of treatment (Agholor
perception still exists. As a result of misconception, lack of 2017), as a result, most couples discontinue or abandon their
awareness and beliefs, ART treatment is conducted secretly treatment. The most common cause of female infertility in
to avoid stigmatization in Nigeria (Okafor et al. 2017). Nigeria is a pelvic factor especially tubal blockage (probably
This may adversely impacts the treatment since seeking due to post-infectious causes such as sexually transmitted
care for infertility is associated with supernatural forces, infections, post abortal, and puerperal sepsis) and the
which requires supernatural methods to resolve. Lack of best treatment is by Assisted Reproductive Technology
awareness of IVF in most countries of sub-Saharan Africa methods. The cost of a cycle of in vitro fertilization is above
has posed a very strong challenge to its acceptability and one million Naira. To make matter worse, the success rate is
utilization (Okafor et al. 2017). low (20–30%), and as such a couple may require more than
The misconception and belief is very common among one cycle to achieve success. This does not only lead to
the uneducated and so strong that even the educated ones emotional and psychological trauma but increase poverty
have some reservations due to the strong family support (Agholor 2017).

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 M A Emokpae and Lifestyle behaviors and fertility 2:1 R23
S I Brown

Stress is a modifiable factor that adversely impact diet should be encouraged. Infertile women should
treatment success of infertility. Stress is regarded as any consume foods low in saturated fat, red meat, and high in
uncomfortable ‘emotional experience’ accompanied by vegetables, legumes, and antioxidants.
predictable biochemical, physiological, and behavioral Recreational and prescription drugs have a significant
changes or responses. Many forms of stress including impact on fertility as most of these drugs alter reproductive
physical, social, or psychological is a modern lifestyle, processes. It is therefore best to avoid all unnecessary
which can lead to reproductive treatment failure. medications and recreational drugs.
Stress does not only lead to treatment failure but can Avoiding excessive irradiation by reducing contact
cause infertility or it may arise from infertility (Aydin with electronic gadgets like mobile phones that emit
et al. 2014). The psychosocial-induced stress can affect electromagnetic waves may prevent infertility. It is not
fertility treatment if not avoided. It can lead to impaired possible to eliminate all hazards in the environment, but
gonadotrophin-release, low serotonin secretion, and efforts can be made to reduce them.
elevated prolactin level. Also, it may cause abnormal
function of the immune system which may adversely
impact fertility-related antibodies (Aydin et al. 2014). Conclusion

Most lifestyle factors are theoretically modifiable habits

that can be reversed with strong determination by affected
Practical recommendations to modify subjects. Public enlightenment by health care providers
lifestyle behaviors will go a long to increasing the knowledge and improve the
awareness of the population since most are not aware of
Age plays a major role in determining the fertility of both
the potential consequences of lifestyle habits on infertility.
partners. Couples need to consider the age of the partners
Counseling of infertile couples may enhance awareness
before marriage so that the chances of conception are
of the risk of lifestyle behaviors and facilitate appropriate
increased. The peak of fecundability is before age 35
lifestyle changes that might improve reproductive health.
for men and 30 for women. Infertile couples should
Educational and career pursuits could be combined
access care early after a maximum of one year without
with childbearing and the government should provide
conception and 6 months among older couples.
facilities such as day-care and nursery within the working
Couples trying to achieve pregnancy should limit
environment to encourage prospecting mothers. Public
or quit smoking since there appears to be a significant
health enlightenment campaigns that will educate on the
impact of smoking on reproductive outcomes. The risk of
harmful effects of drug and substance abuse should be
miscarriage will be reduced and menopause will be delayed
intensified. Appropriate legislation and enforcement of
by 4 years. Also, passive smoking should be avoided.
laws that regulate these drugs coupled with the punishment
Research shows that weight plays a significant role
of offenders may help to check the negative impact of
in fertility, therefore; maintaining a healthier weight will
substance abuse by individuals and society at large.
help to prevent hormonal imbalance which adversely
affects fertility thereby improving ovulation and the
risk of miscarriage and other complications. Overweight
Declaration of interest
infertile women on treatment are encouraged to reduce The authors declare that there is no conflict of interest that could be
weight for effective treatment outcomes. perceived as prejudicing the impartiality of this review.

It is better to reduce or abstain from alcohol

consumption when trying to achieve pregnancy. Caffeine
also appears to have a negative effect and should also be Funding
consumed with caution. This research did not receive any specific grant from any funding agency in
the public, commercial or not-for-profit sector.
Infertile couples should avoid anxiety and emotional
stress, but embark on relaxation programs to reduce other
sources of stress to increase fertility. Moderate regular
exercises could help to release endorphins which would Author contribution statement
help relaxation. This work was conducted and approved in collaboration between the
authors. M A designed the study; M A E, S I B contributed to literature
Nutrition and exercise may impact fertility both in search; S I B drafted the manuscript; M A E wrote the final manuscript; M A
men and women, good nourishment and a balanced E proofread the manuscript.

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 M A Emokpae and Lifestyle behaviors and fertility 2:1 R24
S I Brown

Caserta D, Bordi G, Di Segni N, D’Ambrosio A, Mallozzi M &

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Received in final form 8 December 2020

Accepted 17 December 2020
Accepted Manuscript published online 17 December 2020

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