A Cross-Sectional Study on the Effect of Smoking on the Semen Analysis of 21 year old males
and older in Barangay Cembo, Makati City from May – June 2009
A Research Paper Submitted in Partial Fulfilment of the Requirements
Of Community Medicine
At
Makati Medical Center
Baraan, Amadeus
Capco, Diorella Anne
Manotok, Ma. Veronica
Mata, Cecille
Moderes, Vincent
Nova, Isabelle
Ortiz Luis, Guinevere
Osias, Jerny
Pabalan, Jorja
Palis, Alexandra Jean
Pallera, Julius
Peñaflorida, Andrea
May – June 2009
PROJECT PAPER
ABSTRACT
A cross-sectional study was performed to investigate the effect of
cigarette smoking on semen parameters of semen volume, sperm
morphology, sperm motility, and sperm count among males residing at
Barangay Cembo, Makati City. Previous studies that tackled various
factors that affect the semen analysis among male subjects of various
ethnicities and health groups was recognized in this study, which aimed
to investigate the effect of cigarette smoking on the semen volume,
sperm morphology, sperm motility, and sperm count among the selected
subjects. A routine sperm analysis was performed on the 30 subjects with
their consent. Data showed that smoking was a risk factor for abnormal
semen volume (PR = 1.25), abnormal sperm count (PR = 1.10), and
abnormal sperm morphology (PR = 1.10) as suggested by the resultant
values of the prevalence ratio.
INTRODUCTION
Community Dimensions Secondarily Related to Health
Barangay Profile
The first batch of enlisted men from the Philippine Ground Force was given a settling area in
1949, adjacent to the North Gate of what was then Fort William McKinley. It was known as the Central
Enlisted Men’s Barrio, and now that big rolling open tract of land which was the housing area of these
enlisted personnel is now known as Cembo. Other similar housing areas came about to be the adjacent
communities of West Rembo, East Rembo, Comembo, and Pembo to provide housing for the increasing
population of the enlisted forces.
Geography
Currently, Barangay Cembo has a population of 25,815 with a population growth rate of 2.9%, a
population density of 1201 persons per hectare. The number of households is 5,887. The land is situated
over a moderately undulating and rolling land sloping in many directions in a tuffaceous plain. Flood is
not a problem in the community, and earthquakes are a rare occurrence. The bodies of water near the
community are the Pasig River and San Jose Creek. The Barangay is bounded by the Pasig River
(Mandaluyong City) in the north; South Cembo to the south, West Rembo in the East and Guadalupe
Nuevo in the West.
Government Offices
Government offices and edifices in the Barangay are: Barangay Hall; Solid Waste Management
Division – District II; Makati Plant Nursery; Veterans’ Center/Cembo Multi-Purpose Hall; Cembo
Elementary School; Bantay Bayan/MAPSA Headquarters; Bantay Bayan Outpost (2); Daycare Center;
Cembo Talipapa Market; National Teachers Center; and Comelec District 2 Field Office.
Transportation and Communication
Transportation in the community was possible with jeepneys and taxi cabs at Kalayaan Avenue,
and tricycles that course through the interior streets of the Barangay. There are structures for phone
lines and electricity that contribute to the means of communication within the community. Wireless
landline phones and cellular phones provide alternatives for the populace.
Leadership Pattern and Structure
Leadership of the Barangay is headed by Barangay Captain Leonardo Magpantay, with seven
Barangay Councilors, a Barangay Secreteary, Barangay Treasurer, and members of the Sangguniang
Kabataan, headed by Ruben Talosig, with seven councillors.
Community Dimensions Directly Related to Health
Table 1. CEMBO HEALTH CENTER VITAL HEALTH STATISTICS, 2007
TOTAL POPULATION: 21, 623
Specific age distribution by sex
M
F
<1 yo
367
367
1-4 yo
1449
1406
5-9 yo
1557
1535
10-14 yo
1362
1298
15-19 yo
1059
1146
20-24 yo
856
1017
25-29 yo
778
909
30-34 yo
670
693
35-39 yo
540
562
40-44 yo
432
454
50-54 yo
281
367
55-59 yo
238
346
60-64 yo
195
281
65-69 yo
130
195
> 70 yo
151
216
TOTAL POPULATION:
10,419
11,204
Both
734
2855
3092
2660
2205
1903
1687
1363
1102
886
648
584
476
325
367
21623
Barangay Cembo has a total population of 21,623 in the year 2007 and has a relatively young
population composed mostly of school aged children, adolescents and young adults. The age bracket 5-9
years old has the highest number and the age bracket 65-59 years old has the least number. There is
also greater number of females compared to males.
Figure 1. Barangay Cembo Age Distribution (male), 2007
Figure 1 shows the age distribution of citizens in Barangay Cembo with the greatest number in
the age bracket 5-9 years old (1,557)and the least number in the age bracket 65-69 years old (130).
Figure 2. Barangay Cembo Age Distribution (female), 2007
Figure 2 shows the age distribution of citizens in Barangay Cembo with the greatest number in
the age bracket 5-9 years old (1,535) and the least number in the age bracket 65-69 years old (195).
Figure 3. Barangay Cembo Specific Age Distribution
Figure 3 shows the specific age distribution in general of the citizens in Barangay Cembo. Much
of the population belongs to the age bracket 5-9 years old (3,092) and the least number in the age
bracket 65-69 years old (325).
Figure 4.Specific Age Distribution by Sex, Brge Cembo 2008
In 2008, the total population of Bry Cembo is 27, 098. There is almost equal male to female sex
distribution in the community (48.2 % females and 51.8 % males). The majority of population is 1 – 34
yrs old.
Table 2. MAKATI HEALTH DEPARTMENT VITAL HEALTH STATISTICS
Total live births
Male
Female
Home
lying-in
govt hosp
Private hosp
246
270
516
Distribution of maternal deliveries
71
155
143
147
Assisted deliveries
Physician
Nurse
Midwife
Hilot
304
28
177
7
Table shows the number of total live births in Barangay Cembo in the year 2007 and the specific
gender distribution with more female infants than male infants. Most maternal deliveries were done in a
lying-in clinic with the least deliveries done at home. Assisted deliveries were done mostly by physicians
with the least number of deliveries assisted by “hilot”.
Table 3. Ten leading causes of morbidity, All ages Brgy Cembo, 2007
AURTI
4497
Pneumonia
359
Diarrhea
258
UTI
239
LRTI
194
Dermatitis
156
Hypertension
79
PTB
77
Diabetes mellitus
65
Bronchial asthma
55
In the year 2007 and 2008, acute upper respiratory tract infection remained the leading cause of
morbidity in all ages. This is followed by Pneumonia, diarrhea and UTI in 2007. Pneumonia still ranked
second as the most common cause of morbidity, while diarrhea was replaced with acute lower
respiratory tract infection in 2008.
Table 4. Ten Leading Causes of Mobidity, All Ages Brgy Cembo, 2008
AURI
4950
Pneumonia
518
ALRI
395
Non specific Diarrhea
201
UTI
197
Dermatitis
189
Arthritis
120
HPN
113
Bronchial Asthma
70
DM
53
Figure 5. Ten Leading Causes of Morbidity, All Ages in Brgy Cembo, 2007
In 2007, About 75 % of the morbidity cases in all ages is caused by acute upper respiratory tract
infection.
10 Leading Causes of Morbidity, All
Ages, Brgy Cembo, 2008
113
120
189
197
201
70
53
AURI
Pneumonia
ALRI
395
Non specific Diarrhea
UTI
518
Dermatitis
4950
Arthritis
HPN
Bronchial Asthma
DM
Figure 6. Ten Leading Causes of Morbidity, All Ages in Brgy Cembo, 2008
In 2008, only 38 % was due to other cause of morbidity, these are pneumonia (7 %), acute lower
respiratory infection (6%), Non specific diarrhea (3 %), Urinary tract infection (3 %), Dermatitis (3%),
Arthritis (2 %), Hypertension (2%), Bronchoial Asthma (1%) and Diabetes Mellitus (1%)
There has no abrupt change on the 10 causes of infant morbidity in 2007 and 2008. Acute
Respiratory tract infection is the leading cause of infant morbidity, followed by Pneumonia, Diarrhea and
Dermatitis
Table 5. Ten leading causes of infant morbidity Brgy Cembo, 2007
AURI
Pneumonia
Diarrhea
Dermatitis
ALRTI
Roseola infantum
Otitis media
Conjunctivitis
Viral exanthema
Carbuncle
530
94
57
39
32
30
27
25
20
8
Table 6. Ten Leading Causes of Infant Morbidity, Brgy Cembo, 2008
AURI
1237
Pneumonia
128
Dermatitis
94
Otitis Media
85
Non specific Diarrhea
61
Conjunctivitis
52
Impetigo
48
ALRI
39
Roseola Infantum
35
Systemic Viral Illness
27
Figure 7. Ten Leading Causes of Infant Morbidity in Brgy Cembo, 2007
In 2007, almost 65 % of the total infant morbidity was cause by acute upper respiratory
tract infection. This is followed by pneumonia (10.9 %), diarrhea (8.62 %) and dermatitis
(4.52%).
F
10 Leading Causes of Infant Morbidity, Brgy Cembo, 2008
AURI
393527
5248
61
85
Pneumonia
Dermatitis
Otitis Media
94
Non specific Diarrhea
Conjunctivitis
128
Impetigo
1237
ALRI
Roseola Infantum
Systemic Viral Illness
Figure 8. Ten Leading Causes of Infant Morbidity in Brgy Cembo, 2008
In 2008, acute respiratory infection (68. 5%) tops the list that causes morbidity among infants,
followed by pneumonia (7.1%), dermatitis (5.2%) and otitis media (4.7 %).
The top 10 leading cause of Communicable Diseases mostly involved the respiratory tract.
Pneumonia remains the leading communicable disease in 2007 and 2008. This is followed by PTB, acute
lower respiratory tract infection, mumps and varicella.
Table 7. Ten leading causes of communicable disease
1. Pneumonia
359
2. URTI
194
3. PTB
77
4. Mumps
70
5. Varicella
64
6. Conjunctivitis
57
7. Acute viral illness
42
8. Scabies
35
9. Herpes zoster
28
10. German measles
10
Table 8. Ten Leading Communicable Diseases, Brgy Cembo, 2008
Pneumonia
ALRI
PTB
Mumps
Varicella
Conjunctivitis
Influenza
Scabies
Herpes Zoster
German Measles
518
151
66
62
59
53
48
45
15
8
Figure 9. Ten Leading Causes of Communicable Diseases, 2007
About 38. 35 % of the top communicable disease was cause by pneumonia. Thus followed by
upper respiratory tract infection (20.73 %), pulmonary tuberculosis (8.23%) and mumps (7.48 %)
10 Leading Communicable Diseases, Brgy
Cembo, 2008
15
8
45
Pneumonia
48
ALRI
53
PTB
Mumps
59
62
518
Varicella
Conjunctivitis
Influenza
66
Scabies
151
Herpes Zoster
German Measles
Figure 10. Ten Leading Communicable Diseases in Brgy Cembo, 2008
Pneumonia (50.54 %)is the most common communicable disease in Brgy Cembo in 2008.
Followed by acute lower respiratory infection (14.73%), PTB (6.44%) and mumps (6.05%).
Table 9 shows the 10 leading causes of death/mortality in barangay Cembo in the year 2007.
The top 3 diseases include: 1) heart disease (928 cases), 2)Cancer (15 cases) and Pneumonia (14 cases).
Table 9. Ten leading causes of death/mortality
Heart disease
Cancer
Pneumonia
Hypertension
CVA
Kidney failure
Diabetes mellitus
Asphyxia
Acute pancreatitis
Sepsis
28
15
14
6
5
3
3
3
2
2
Figure 11. Ten Leading Causes of Death in Barangay Cembo, 2007
Figure 11 shows the 10 leading causes of death in Barangay Cembo in the year 2007 with
the greatest number of cases who suffered from hear diseases.
Background of the Study
Males produce semen in the process of intercourse as their contribution in conception, which
contains the male sex cell. Semen is composed of four fractions that are contributed by the testes and
epididymis, the seminal vesicles, the prostate, and the bulbourethral glands. The integration of all four
fractions during ejaculation is essential for the production of a normal semen specimen. Spermatozoa,
the male sex cells, are produced in the seminiferous tubules, then mature and are stored in the
epididymis. This contributes to about 5% of the semen volume. Majority of the fluid comes from the
seminal vessels. Spermatozoa become motile only upon exposure to the fluid from the seminal vessels,
which has high fructose content. About 20-30% of the semen volume is acidic fluid from the prostate
gland. It has high concentrations of acid phosphatase, citric acid, zinc and proteolytic enzymes which are
responsible for both coagulation and liquefaction of the semen. The bulbourethral glands contribute
about 5%. It is thick, alkaline mucus that helps neutralize the acidity from the prostate and the vaginal
acidity as well.
Environmental studies on potential hazards to health have been elaborating in the past decade
or so. Studies have revealed the presence of pollutants and their hazardous effects to health. Many
degenerative diseases are largely due to exposures from environmental pollutants. Among the most
common of these pollutants is cigarette smoke, which is not only a largely growing health hazard, but
likewise a social phenomenon. Smoking is the act of consuming tobacco products such as cigars,
cigarettes and the like. A multitude of the population is engaged in this habit, and as a result,
experiences the long term effects of smoking. There are degenerative diseases that are precipitated or
aggravated by smoking such as lung cancer, hypertension, and diabetes. The act of smoking has also
been a reflection of behavior mostly amongst the young people of today. Though smoking is manifested
because of peer pressure, stress, and status quo, the lifestyle of the smoker and recipients of secondhand smoke has been affected. Clearly smoking is a threat to the integrity of health.
It has been known that nicotine affects the body in a variety of ways. Nicotine has an addicting
effect, seen in people who abuse cigarette smoking. However, the effect of nicotine has not been
properly documented. Men who smoke should be aware of the possibility that nicotine can damage a
man’s fertility. We know that pregnant women who smoke can harm their fetuses but men are
oblivious to the potential damage of smoking to their offspring long before they meet their future
partners. If this study can target men’s innate drive to properly reproduce, we may have given them one
more reason to quit smoking. This study may then serve to be a contribution to the continuing
awareness of people regarding the hazards presented by cigarette smoke and a possible effect on the
male reproductive system.
Objectives
General: This study aims to investigate the effect of cigarette smoking on the semen analysis of males,
particularly on the parameters of semen volume, sperm motility, sperm morphology, and sperm count.
Specific: The specific objectives of the study are to:
1. Provide baseline information on the effect of cigarette smoking and sperm characteristics of
males residing at Cembo, Makati
2. Describe the participants of the study as to the socio-demographic characteristics; and
3. Determine the association between cigarette smoking of males to the following parameters:
a. semen volume
b. sperm motility
c. sperm morphology
d. sperm count
Significance of the Study
Smoking has been a growing problem especially as it directly influences health. It has been known
that cigarette smoking largely contributes to the development or elaboration of degenerative diseases
including cancers, hypertension, heart disease, and diabetes among a few. This study shall deal with the
effect of smoking on any of the three parameters of a routine sperm analysis: morphology, motility, and
count. The resultant effect can be a basis for inference of a larger scale effect as well as a contribution
for an existing baseline knowledge of a study such as this locally. This shall investigate and document
the effect of smoking on the sperm analysis particularly to this area of interest and population of
interest.
Scope and Delimitations
This study shall be applicable to males aged 21 and above, as is the legal age for males in our
country. A legal age for participants is also considered to avoid sensitive issues regarding the sexual
aspect of our study. This study shall be performed at the area assigned for this purpose, Barangay
Cembo, Makati City. All legal aged male residents of this barangay is eligible to be a participant. Cases of
TB, DM, mumps, genetic factors, trauma, and undescended testis are known to affect the sperm
analysis, hence respondents with these conditions may not be eligible to participate. However, only
three aspects of sperm analysis is included in this study, which are morphology, motility, and count.
These three main aspects would be the basis of concluding a normal or abnormal sperm analysis. The
individual influence on each parameter may be described subsequently in the study and may serve to
contribute to baseline knowledge for this and as well for future recommendations on latter studies.
REVIEW OF RELATED LITERATURE
Despite worldwide anti-smoking campaigns, cigarette smoking is still common. The highest
prevalence of smoking is observed in young adult males during their reproductive period at 46%
smokers between 20 and 39 years (Langgassner, 1999). In this regard, there has been number of studies
that have evaluated the effect of smoking and cigarette smoking. However, the results of recent studies
have either been contrary or similar to past studies. There has been no clear cut relationship between
the two.
According to Lewin et al, Cigarette smoking may be associated with sub-fertility in males and
may result in decreased sperm concentration, lower sperm motility, and a reduced percentage of
morphologically normal sperm respectively. In a recent meta-analysis (Vine, 1996 ), including 27 studies
on the association between cigarette smoking and semen quality, a mean reduction in sperm
concentration of 13%, a mean reduction of sperm motility of 10%, and a mean reduction of
morphologically normal sperm of 3% was reported in smokers.
A cross sectional study was conducted by Chia, et al (1998) to determine the semen parameters
(volume, concentration, motility, viability and normal morphology) of proven fertile males in Singapore
and compare it with World Health Organization recommended normal values and to examine some
factors that may affect spermatogenesis. A total of 243 men in the younger age group (19-47 years old),
whose wives were pregnant at the time of collection of semen, provided semen sample each after
sexual abstinence of 3 days. A questionnaire was used to elicit occupational exposure, alcoholic
consumption, smoking history, and past significant medical history. Most subjects had normal sperm
volume (56.4%), concentration (79.8%), motility (69.5%), and viability (53.5%) based on WHO criteria.
However, fertile men had a low mean percentage of normal sperm morphology (20%), although they
were normally distributed. Cigarette smoking was associated with significantly lower semen volumes
even after adjusting for alcohol consumption. The sperm parameters (volume, density, motility, viability
and normal morphology), were not significantly associated with ethnic differences. Social alcohol
consumption, cigarette smoking, and “recent fever” (history of fever 3 months prior to semen
collection) did not appear to affect sperm quality in this group of fertile men.
Hellstrom and Overstreet et al (2006) mentioned that initial standards were set out since 1950
to cater for the growing needs of research and clinical practice for standardized procedures for these
analyses. Their research aimed to determine semen and sperm reference ranges for an older
population, 45 years old and older. The participants in their study were either affected with mild or no
erectile dysfunction with four particular sperm parameters of semen volume, sperm concentration,
sperm motility, and sperm morphology. The total sperm count was mentioned to be a derived
parameter. It was determined that median semen volume, sperm motility, and sperm morphology
parameters declined significantly with age. There were associations between sperm parameters and
semen with smoking status, alcohol use, and serum hormone concentrations.
In relation to age, there was a decline in semen volume, sperm concentration, sperm
progressive motility and sperm morphology among individuals over 45 years of age. Semen volume and
sperm concentration increased according to how many days of sexual abstinence there were. However,
in patients with 5 or more days of abstinence, a reduction in progressive motility was found. No
modification of sperm normal morphology percentage with increased length of abstinence was found.
In a cross sectional study by Eskenazi, Wyrobek et al (2003) sought to characterize the
association between age and semen quality. There was noted age related decreases in semen quality,
most notably for semen volume and sperm motility. A sample of 97 men aged 22 – 80 without known
fertility problems were recruited. The men provided semen samples and information relating to lifestyle,
diet medical and occupational details. Parameters that were measured were semen volume, sperm
concentration, total sperm count, motility, progressive motility and total progressively motile sperm
count. The data suggest that men may become progressively les fertile as they age, however, unlike
women, there appears to be no evidence of an age threshold for men. Some broad modes of action
have explained the age dependent changes observed in semen quality. There may be cellular or
physiological changes in the genitourinary tract with ageing, some of these are the age related
narrowing and sclerosis of the testicular tubular lumen, and decreased numbers and function of Leydig
cell. Decreased semen volume with age may be caused by seminal vesicle insufficiency, since seminal
fluid contributes most of the ejaculate volume. Age also provides increased opportunities to suffer
reproductive damage from exogenous exposures or diseases. Older men are more likely have smoked
for a longer period than younger men, or to have illnesses including genitourinary infections.
Another srudy by Sloter and Schmid et al (2006) acknowledged the limited amount of
information regarding quantitative measures of factors that may affect semen quality. Their study
investigated the effects of age on sperm, quantitatively, using computer-assisted semen analysis. Their
population comprised of 97 healthy male volunteers, aged 22–80 years and were screened by current or
prior fertility or reproductive problems; smoked cigarettes in the last 6 months; vasectomy; reported
history of undescended testicle or prostate cancer; chemotherapy or radiation treatments for cancer; or
a previous semen analysis with zero sperm count. Mainly, a reduction on sperm motility was noted in
this study.
In studies made by Sofikitis et al (1995), and Zinaman et al (2000), reductions in sperm
concentration, motility and normal morphology percentage among infertile patients who smoke have
been observed. In a meta-analysis covering 27 studies on sperm quality among smokers, an average
reduction of 13% in sperm concentration, 10% in motility and 3% in normal morphology percentage
were observed (Vine, 1996).
The aim of this study by Colagar et al (2007) is to evaluate the relationship between cigarette
smoking and sperm quality in male partners of fertile and infertile couples undergoing infertility
evaluation. Study population included fertile non-smokers, fertile smokers, infertile nonsmokers and
fertile male smoker. Semen samples were collected by masturbation into a sterile container after sexual
abstinence for 2-3 days and were analyzed for appearance, volume, consistency and pH and evaluated
according to the World Health Organization criteria and Kruger’s criteria. Results show that sperm
parameters (sperm counts, motility and morphology) in smoker men were approximately lower than
nonsmoker men. Ejaculate volume was not different between fertile smoker-non smoker men.
Statistical analysis in infertile smoker-non smoker showed that sperm quality in infertile smoker is lower
than infertile non-smoker.
This study by C.H. Ramlau-Hansen et al (2006) focused on the association between current
smoking and semen characteristics and hormonal levels in a large group of healthy men. The aim of this
study is accordingly to investigate the dose–response relationship between current cigarette smoking
and conventional semen characteristics and hormonal levels in a large group of healthy men. There
were seven separate occupational or environmental semen quality studies from 1987 to 2004 that were
considered in this study. A total of 2562 men participated, each providing semen and blood sample and
answering a questionnaire about lifestyle and factors related to health. Appropriate semen and smoking
data were available for 2542 men. From the data obtained, there was an inverse dose–response relation
between smoking and semen volume, total sperm count and percentage motile sperm. Heavy smokers
had a 19% lower sperm concentration than non-smokers. In conclusion, current smoking in adult life
moderately impairs the semen quality. It is well known that semen quality is associated to fecundity.
Therefore, it would be sensible to advise men to abstain from smoking to avoid decreased fecundity.
A study conducted by Sobreiro et al (2005), revealed that there were no differences in semen
parameters related to smoking. In the prospective study, 500 fertile candidates for voluntary
sterilization by vasectomy between September 999 and August 2002 at the Urology Division, Hospital
dos Clinicos, Universidade de Sao Paulo, Brazil were included. Subjects were grouped into non-smokers
and smokers (1-10 cigarettes/day, 11-20 cigarettes/day; and >20 cigarettes/day). Results showed that
there were no statistically significant differences in semen parameters observed between smokers and
non-smokers, or between the groups of smokers. However, one possible explanation for these results is
that only fertile subjects were studies, and cases of infertility associated with smoking were excluded
from the sample population.
A case-control study was done by Okonofua, F., et al (2005) to evaluate the association between
selected potential socio-demographic and behavioral risk factors and infertility in Nigerian men. The
cases were 150 men found to have abnormal semen parameters when their wives presented for
investigation and treatment of infertility in the clinic. The controls were 150 men with normal semen
parameters and their spouses were pregnant at the time of the study. Both groups were matched for
age, place of residence and key socio-demographic variables. Infertile men were significantly more likely
than fertile men to report having experienced penile discharge, painful micturition and genital ulcers,
less likely to seek treatment for these symptoms and more likely to seek treatment with informal sector
providers. Multivariate analysis showed that male infertility was significantly associated with bacteria in
semen cultures, self-reporting of previous use of traditional medications and moderate to heavy alcohol
intake. There were no significant differences between them in the proportions reporting that they had
ever smoked; however, infertile men were more likely to report longer duration of smoking. The types
of smoking (cigarettes or marijuana) and the frequency of smoking did not differ between the two
groups. Although this study showed that a higher proportion of infertile men reported having ever
smoked and that infertile men had longer duration of smoking, the results of the association between
smoking and male infertility were not significant in the multivariate analysis. It was contrary to
published findings in other populations which consistently showed a strong association between
cigarette smoking and male infertility.
From experimental studies done by Mehrannia, T. (2007), they evaluated the effects of cigarette
on the sperm quality of men attending the infertility center. Two hundred fourteen infertile men who
had been smoking cigarette and 130 infertile non-smokers were employed in the study. It included men
aged 25-45 years who were able to provide an ejaculate. None of the subjects had any urogenital or
serious systemic disease. They never used any contraceptive. Smokers were categorized as mild (≤10
cigarettes per day), moderate (>10 and ≤20 cigarettes per day), and heavy smokers (>20 cigarettes per
day). The smokers according to the duration of smoking were divided into short term (1-10 years) and
long term (11-20 years). Samples were collected by masturbation after a sexual abstinence of 3-6 days.
Specimens were evaluated according to the WHO guidelines. The ejaculate volume, pH, count, viability
and time to liquefaction were measured. From the data, it was found that the semen volume, acidity,
sperm concentration, viability and forward progression were much lower in the smokers than in the
nonsmokers. The semen parameters were much lower in the nonsmokers of infertile men than in fertile
men. There was no significant difference in results of semen quality seen between mild, moderate and
short term smokers and nonsmokers. Those parameters in the heavy and long term smokers were
significantly lower than their corresponding values in nonsmokers.
Another study by Chen, Z., et al (2004) evaluated the relationship of human semen parameters,
particularly sperm concentration, motility and morphology, to season, age and smoking status. Studies
on the seasonal variations in semen parameters revealed that there was a significant seasonal variation
in sperm count. The sperm counts were highest in late winter & early spring, and was lowest in late
summer. Age, on the other hand, was said to have an inverse relationship with the total sperm count.
With regards to the association of smoking, data found were said to be less clear. From the data
obtained, it was found that the mean sperm concentration in spring was significantly higher than in the
winter, summer and fall. Median sperm concentration by month was higher in March, April, May, and
June than all other months. Mean sperm motility was also higher in the spring than in the summer, fall
and winter. Seasonal variations in sperm morphology parameters were noted. The mean percent
normal morphology in spring was greater than in summer, fall or winter, although it was not statistically
significant. There was no statistically significant relationship between age with semen volume, sperm
concentration, percent motility and percent normal morphology. In the study, only 22 men were current
smokers and 57 ex-smokers. It was found that there was no statistically significant relationship between
semen quality and smoking status, though current smokers tended to have lower mean sperm
concentration (83 million/ml) than never smokers (104 million/ml). There were seasonal variations in
sperm concentration and suggestive evidence of seasonal variation in sperm motility and percent sperm
with normal morphology. Although smoking status was not a significant predictor of semen parameters,
this may have been due to the small number of current smokers in the study.
A prospective study done by Harald Trummer et al (2002), semen parameters and hormone
concentrations of infertile smokers were compared with infertile non- and ex-smokers. Work-up for
infertility included a medical history, physical examination, as well as the assessment of hormone and
semen parameters. Medical history and particularly any history of previous genital disease was assessed
using a questionnaire including the number of cigarettes per day and the duration of smoking as well as
the smoking status of the female partner. Men who had stopped smoking
6 months prior to the
examination for infertility were classified as ex-smokers and men who had never smoked as nonsmokers. Every man who had smoked cigarettes for >6 months and was still smoking was classified as a
smoker. Smokers were categorized as mild ( 10 cigarettes per day), moderate (>10 and 20 cigarettes
per day) and heavy smokers (>20 cigarettes per day). After the primary evaluation for infertility, all men
without a history of, or current, genital disease as well as men who had neither azoospermia nor severe
oligozoospermia were invited for a second semen analysis 3 months later. The reason to exclude these
men was that men with non-idiopathic infertility received causative treatment as soon as possible, and
men with a high grade oligozoospermia or azoospermia were offered assisted reproductive techniques, if
appropriate. In conclusion, in their large study with a total of 1104 infertile men including 571 nonsmokers, 109 ex-smokers and 478 smokers, no significant differences in conventional ejaculate
parameters (sperm concentration, morphology and motility) between non-smokers, ex-smokers and
smokers were observed, although azoospermia was more prevalent among ex-smokers than the other
two groups.
METHODOLOGY
Subjects
Males aged 21 and older who are residents of Barangay Cembo are to be included in this study.
Smokers and non-smokers may be able to participate in the study. Questionnaires are to be handed out
to participants, containing information pertinent to health information of the subjects.
Collection of Samples
The researchers will be recruiting study subjects from Barangay Cembo, Makati City. The
proponents will survey the said area for possible candidates for the study. Subjects will be provided with
sufficient information about the research and will be asked to accomplish a questionnaire once they
consent to participate in the study.
Specimens are to be obtained following a period of sexual abstinence of at least 3 days and not
longer than 5 days. Specimens are to be collected in plastic containers to be kept at room temperature.
They will be collected by masturbation or if it is not possible, thru the use of only non-lubricant
containing polymeric silicone condoms. The specimens will then be delivered to the laboratory within 1
hour of specimen collection. The time of specimen collection as well as the time of specimen receipt
shall be noted.
Data Analysis
Prevalence ratio (PR) is used in cross-sectional studies as a measure of relationship between a
disease entity and an exposure factor. In this case, this will be used to measure a relationship between
cigarette smoking and an abnormal result for semen volume, sperm morphology, sperm motility, and
sperm count. At a study performed by Thomson and Kriebel (1998), they deemed that the prevalence
ratio is a conservative, consistent, and interpretable way to measure effects or associations in a cross
sectional study, more appropriate than an Odds ratio. Subsequently, the prevalence difference
measures the likeliness of encountering the exposed [to a risk factor] subject at the time of consultation,
and is also measured and interpreted in the study.
Operational Definition of Variables
1. Smoking - is the act of consuming tobacco products such as cigars, cigarettes and the like
2. Smoker – any person who has a history of smoking or is currently smoking.
3. Non-smoker – any person who has never smoked
4. Semen analysis – evaluation of certain characteristics of a male's semen and the sperm
contained in the semen
5. Semen volume – normal volume is 2-5ml
6. Sperm morphology – shape of spermatozoa, which may be classified as normal-oval shaped,
tapered, amorphous, duplicated and immature. Normal spermatozoid must have an oval form
with smooth contour, acrosomal cap encompassing 40-70% of head, no abnormalities of
midpiece, or tail and no cytoplasmic vacuoles of more than half of the sperm head. Head size is
5-6m M x 2.5-3.5m M. Any borderline sperm are counted as abnormal (amorphous,
tapered,duplicated, immature, coiled tail, blunted tail, midpiece abnormalities).
7. Sperm motility – normal motility is when at least 50% of observed sperm move forward
normally.
8. Sperm count –or sperm concentration, measurement of the concentration of sperm in a man's
ejaculate. Normal count range considered in this study is 20-160 million/ml. Anything less is
considered oligospermia; absence of sperm is azoospermia.
9. Abstinence – defined as having no sexual contact within the past 72 hours prior to specimen
collection
RESULTS AND DISCUSSION
Semen is composed of four fractions that are contributed by the testes and epididymis, the
seminal vesicles, the prostate, and the bulbourethral glands. The integration of all four fractions during
ejaculation is essential for the production of a normal semen specimen.
Analysis of semen includes several parameters such as: appearance, volume, viscosity, pH,
sperm concentration and count, motility and morphology. It has a gray-white color, appears translucent
with a characteristic musty odor. It usually liquefies within 30 to 60 minutes. Failure of liquefaction
occurs due to a deficiency in prostatic enzymes.
Normal semen volume ranges between 2 and 5 ml. Increased volume may be seen following
extended abstinence and a decreased volume is due to infertility with the improper functioning of one
of the semen-producing organs. Incomplete specimen collection is also one consideration. Viscosity, on
the other hand, refers to the consistency of the fluid may be related to specimen liquefaction. Ratings
of 0 (watery) to 4 (gel-like) can be assigned. The pH of semen is alkaline with a range of 7.2 to 8.0. An
increased pH is indicative of infection within the reproductive tract, while a decreased pH is associated
with increased prostatic fluid.
The normal value for sperm concentration is 20 to 160 million sperm per milliliter, while the
normal for total sperm count is greater than 40 million per ejaculate. It is computed as the product of
the sperm concentration and the specimen volume.
Sperm moves in a forward, progressive movement. Motility is evaluated as to the speed and
direction of the motility and is graded on a scale of 0 to 4. A grade of 4 indicates a rapid, straight-line
movement and 0 indicating no movement. A minimum of 50% motility with a rating of 2.0 after 1 hour
is considered normal.
With regards to sperm morphology, it is evaluated with to both the head and tail appearance.
Abnormalities with head morphology are associated with poor ovum penetration; whereas tail
abnormalities affect motility. The normal sperm has an oval shaped head approximately 5μm long and 3
μm wide, with a long, flagellar tail approximately 45 μm long. The sperm morphology is evaluated from
a thinly smeared stained slide stained with Giemsa, Wright’s or Papanicolau stain. Abnormalities in the
head structure include: double heads, giant and amorphous heads, pinheads, tapered heads and
constricted heads. Sperm tail abnormalities are frequently double, coiled, or bent. The normal
morphology is >30% normal forms (strict criteria) and >50% normal forms (routine criteria). White
blood cells may also be noted and a count of <1.0 million/ml is considered normal.
Charateristic
Age - yr
Married - no./total no.
Comorbidities - no/total no.
Personal & Social History
Alcoholic beverage drinker
Illicit drug use
Smoker Group
(N = 24)
Non-smoker Group
(N = 6)
22-57
19/24 (79.2%)
11/24 (45.8%/)
28-48
4/6 (66.7%)
1/6 (16.7%)
19/24 (79.2%)
3/24 (12.5%)
2/6 (33.3%)
1/6 (16.7%)
The study sample consisted of 30 participants, of whom 80% (24/30) were smokers and 20%
(6/30) were non-smokers. Smoking history ranged from 0.9 – 37-pack years. Study population included
men ages 22 – 57 years old of whom 76.7% (23/30) were married, 19/24 in the smoker group and 4/6 in
the non-smoker group. The following comorbidities encountered were asthma, allergy, hypertension,
heart diseases, pulmonary tuberculosis, and nephrolithiasis. The study population had comobidities in
45.8% (11/24) of subjects in the smoker group and 16.7% (1/6) in the non-smoker group. The personal
and social history included alcohol intake and drug use, 79.2% and 12.5% in the smoker group and
33.3% and 16.7% in the non-smoker group respectively.
Semen Volume of Cigarette Smokers in Barangay Cembo, Makati
20
15
10
5
0
normal
abnormal
Figure 1. Semen Volume of Cigarette Smokers in Barangay Cembo, Makati City .
Semen volume was compared with the normal value of 2-5mL. Using the Prevalence Ratio, data
has revealed that smoking is a risk factor for abnormal semen volume (PR = 1.25 ). Subsequently,
prevalence difference (PD) measures the likeliness of encountering smokers with abnormal semen
volume at the time of examination. Data reveals there is a 17% chance to encounter smokers with
abnormal semen volume.
Sperm Motility of CigaretteSmokers in Barangay Cembo, Makati
25
20
15
10
5
0
normal
abnormal
Figure 2. Sperm Motility of Cigarette Smokers in Barangay Cembo, Makati City
On the other hand, sperm motility was observed from the semen samples of the patients, and
the data shows that smoking is not a risk factor for abnormal sperm motility (PR = 0.875).
Sperm Morphology of Cigarette Smokers in Barangay Cembo, Makati
25
20
15
10
5
0
normal
abnormal
Figure 3. Sperm Morphology of Cigarette Smokers in Barangay Cembo, Makati City
Morphology is then observed and the majority of the subjects belong to the normal category.
Using the Prevalence Ratio, data has revealed that smoking is a risk factor for abnormal semen volume
(PR = 1.1). Also, there is 8% chance to encounter smokers with abnormal sperm morphology.
Sperm Count of Cigarette Smokers in Barangay Cembo, Makati
25
20
15
10
5
0
normal
abnormal
Figure 4. Sperm Count of Cigarette Smokers in Barangay Cembo, Makati City
The sperm cells were then counted using a standard measure. Likewise, Using the Prevalence
Ratio, data has revealed that smoking is a risk factor for abnormal sperm count (PR = 1.1). Also, there is
8% chance to encounter smokers with abnormal sperm count.
The hazards of cigarette smoking and its effects on male fertility have been the concern of
growing interest on a global scale. At present there are a number of studies that have been done which
show varying associations between smoking and sperm parameters. According to Vine at al (2005), a
mean reduction in sperm concentration of 13%, a mean reduction of sperm motility of 10%, and a mean
reduction of morphologically normal sperm of 3% was reported in smokers. On the other hand, in a
study conducted by Sepaniak et al (2006), there was no significant correlation between the conventional
sperm parameters of smokers and non-smokers in terms of sperm density, motility, viability and
morphology. In light of this, the proponents felt the need to conduct this study to shed light on the said
matter, and at the same time, to serve as pilot study in the local setting.
From the statistical analysis, data showed that smoking was a risk factor for abnormal semen
volume, abnormal sperm count, and abnormal sperm morphology as suggested by the resultant values
of the prevalence ratio.
The decreased sperm motility may be attributed to age. There has been an association seen
between aging and a functional decline in Leydig cells. Smaller semen volume and lower sperm motility
have been found to accompany advancing age in fertile individuals (Gray, 1999). The length of
abstinence affect as well the semen parameters. With abstinence, there is an increase in sperm
concentration accompanied however, by decrease in progressive motility and normal morphology
(Pellestor, 1994). It may also have been due to the delay in specimen processing, which ideally should
be analyzed within an hour from time of collection to appreciate better the motility.
Sperm count, on the other may be decreased due to smoking since, cotinine and nicotine
(components of smoke) serum levels are increased. These factors adversely affect the spermatogenesis
and the sperm fertilizing potential (Mehrann 2007).
Finally, it is important to bear in mind that, in the majority of cases, smoking is just one aspect of
a lifestyle that may include the consumption of alcohol, illegal medications or drugs, stress, dietary
modifications and other factors that may have synergic or independent effects on sperm quality.
Another important matter is the sample size. The study had a total of 30 subjects, which
consisted of 24 smokers and six non-smokers. This size was found to be not significant as calculated
using the Chi square.
SUMMARY
Cigarette smoking has always been a concern because of its numerous adverse effects on
health. The government advocates various anti-smoking campaigns but its success is still questionable.
Although this study may not be enough to dissuade or prevent people from smoking, this will give
people one more reason to think about when they smoke.
Various studies have already found some relationship between cigarette smoking and sperm
volume, sperm motility, morphology and sperm count but there has not been significant local research
regarding this. The study therefore aimed to investigate the effect of smoking on semen and its
parameters such as volume, motility, morphology, and sperm count of Male residents living in Cembo,
Makati City. Moreover, this study may also be helpful in providing us with some baseline knowledge
about this matter.
Smokers and non-smokers who were at least 21 years old were included in this study.
Specimens were collected after a period of at least 3 days of abstinence, with the appropriate
instructions. Considering the small population of the study. Prevalence Proportion was used to analyze
the given data.
From the statistical analysis, data showed that smoking was a risk factor for abnormal semen
volume, abnormal sperm count, and abnormal sperm morphology as suggested by the resultant
values of the prevalence ratio.
Among the smoking group, sperm motility, morphology and count were the statistically
significant parameters. For the non-smoking group, all results were found to be normal.
The study serves to provide baseline information on the association of cigarette smoking on the
sperm parameters of our sample population, consisting of males aged 21 and above, residing in Cembo,
Makati. In conclusion, the present study found that cigarette smoking had a significant influence on
semen analysis parameters of semen volume, sperm motility, sperm morphology and sperm count.
Smokers at a risk to develop in particular abnormal semen volume, sperm morphology, and sperm
count.
RECOMMENDATIONS
Due to small population size of this study, the researchers recommend a more significant (n=60)
population size with equal number of smokers and non-smokers. Further studies should also standardize
the manner of semen collection and ensure strict compliance of the subjects to the recommended
abstinence period prior to collection. In addition, further studies may describe co-morbid conditions
present in the subjects that may have an effect on the results of the sperm analysis. Moreover, future
studies should be conducted to further evaluate the correlation of the number of smoking pack years
the abnormalities in sperm parameters.
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