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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 15  |  Issue : 1  |  Page : 9-20

Lifestyle factors between fertile and infertile women at Assiut Women’s Health Hospital


Department of Obstetrics and Gynecological Nursing, Faculty of Nursing, Assiut University, Assiut, Egypt

Date of Submission19-Sep-2017
Date of Acceptance10-Jan-2018
Date of Web Publication3-Sep-2018

Correspondence Address:
Entisar M Youness
Assistant Professor, Department of Obstetrics and Gynecological Nursing, Faculty of Nursing, Assiut University, Assiut
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ENJ.ENJ_34_17

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  Abstract 


Background Over the past few decades, many lifestyle factors have been increasingly evidenced to affect women’s fertility. Despite this evidence, many infertile women continue to ignore the importance of a healthy lifestyle on their reproductive health.
Aim The aim of the study was to compare the lifestyle factors between fertile and infertile women.
Patients and methods A descriptive comparative study design was used to conduct this study. A convenience sample of 200 women was recruited from Women’s Health Hospital, Assiut University. One hundred infertile women who were attending the infertility clinics were recruited as the study group and diagnosed as infertile, and another 100 fertile women who were attending the family planning clinic for seeking contraceptive services were taken as the control group. Tools of data collection included BMI, physical activity, nutrition status assessment, and smoking assessment.
Results A highly statistically significant difference was found between fertile and infertile women in terms of physical activity and BMI, whereas nutritional status, cigarette smoking, and caffeine consumption showed no statistical significant difference between the groups.
Conclusion Lifestyle factors significantly affected female fertility, as physical activity and BMI had a statistical significant difference between the groups.
Recommendations The unhealthy lifestyle status of the infertile women must be modified through effective measures. Modifiable lifestyle factors should be applied to all women who are seeking infertility treatment to help them make positive changes in their lives and improve their chances of conceiving, that is, getting a healthy pregnancy and a live baby. Moreover, developing guidelines for healthy lifestyles would be a prudent step toward helping healthcare providers especially nurses to implement this aspect of preconceptional care.

Keywords: female infertility, lifestyle factors, physical activity


How to cite this article:
Youness EM. Lifestyle factors between fertile and infertile women at Assiut Women’s Health Hospital. Egypt Nurs J 2018;15:9-20

How to cite this URL:
Youness EM. Lifestyle factors between fertile and infertile women at Assiut Women’s Health Hospital. Egypt Nurs J [serial online] 2018 [cited 2018 Sep 19];15:9-20. Available from: http://www.enj.eg.net/text.asp?2018/15/1/9/240353




  Introduction Top


Infertility is defined as failure of couples to reproduce or conceive after 12 months of regular marital life, without unprotected sexual intercourse (Anderson et al., 2010). The WHO defines infertility as a disease of the reproductive tract where the noncontracepting couples fail to achieve pregnancy over at least 12 months (Amin et al., 2015).

The prevalence of infertility is seen in approximately one of six couples, and it is estimated to affect ∼10–15% of couples after regular marital life. Infertility is the most common reproductive health problem that affects a large proportion of the young population worldwide (Khosrorad et al., 2015). Female infertility alone constitutes about one-third of the infertility problems, another one-third is owing to male causes, and the remaining causes are owing to both or the cause is unexplained (Lim et al., 2013).

The pathophysiology of infertility is mostly owing to genetic and endocrine disorders in women and men, chromosomal abnormalities, congenital, or infectious malformation of the reproductive system. Approximately 10–15% of the infertility causes are unexplained, with minimal abnormal findings on medical investigations. Most of the modifiable risk factors of infertility pertain to lifestyle habits and environmental factors. Environmental exposure and lifestyle habits represent sex-specific risks to infertility based on differences in reproductive physiology and genital system anatomy (Roland, 2015).

Over the past few decades, several lifestyle factors have been apparently found to increase fertility, and they significantly affect the chance of pregnancy and delivery. No one can ignore that lifestyle behaviors have been shown to affect reproductive health in both the infertile and the general population. There is a great relationship between infertility and lifestyle factors. These lifestyle factors are summarized in many literature reviews as physical activity, BMI, diet and nutrition, smoking, and taking over-the-counter supplements (Homan and Norman, 2009).

Physical activity has proved to be effective in reproductive health by changing the state of energy balance. Previous studies found that the frequency of physical activity was significantly associated with spontaneous childlessness (Gudmundsdottir et al., 2009). Women who are exercising vigorously have on increased incidence of infertility. Moreover, strenuous exercises in women of normal weight are not compensated for by increased energy balance. In this state of negative balance, the necessities of reproductive machinery may not be met owing to decreased energy requirements (Nybacka et al., 2011).

Maintenance of ideal weight and BMI is evidenced to be importance for all health and well-being. It has been assumed that the negative effect of weight on fertility is associated with being overweight or underweight. Thus, women who are underweight (BMI<19) may not be getting enough nutrients, leading to infrequently or absolutely prevention of ovulation or may lower response to medications that are used to induce or regulate ovulation. However, in overweight women (BMI>25), insulin levels increase to the extent of causing the ovaries to reproduce more male hormones and stop releasing eggs which results in ovulatory dysfunction. Fortunately, with optimal changes and adjustment of body weight, both overweight and underweight women may resume ovulatory function on their own without the need for assisted fertility treatment (Shady Grove Fertility, 2016).

Excess body weight is also associated with polycystic ovarian syndrome, which is linked to hyperandrogenism, anovulation, and infertility. In addition, excess body weight exacerbates problems related to polycystic ovarian syndromes, such as hyperandrogenism, menstrual disturbances, insulin resistance, and infertility (Barazan et al., 2014). Being undernourished can disrupt the menstrual cycle whereas being overweight or underweight leads to improper body function.

Physical activity along with weight loss has a protective effect on fertility. Among infertile obese women, those who experienced weight loss (about 10 kg/m2) through diet and exercise intervention resumed spontaneous pregnancy, had lower miscarriage rates, and increased live births. Regardless of BMI, physical activity in moderate amount is weakly correlated with better fecundity in women (Roland, 2015).

Smoking can have an effect on fertility; passive smoking refers to the involuntary inhalation of tobacco smoke present in the air breathed. For women who are not actually smokers, conflicting results were presented from studies that cigarette smoking decreases their fertility. However, there is much debate on the effect of smoking on various aspects of male or female fertility, and it is regarded to be an important risk factor for infertility (Taymor, 2010).

Environmental hazards and occupational exposure have putative threads to the general and reproductive health. Providing health and safety workplace standards and education is the role of healthcare provider; thus, when women attempt at conceiving, they should identify with their healthcare providers if there are any environmental exposures through workplace, leisure activities, diet, and community that affect their reproductive health (Pacey, 2010).

Men and women planning to achieve contraception and pregnancy should optimize fertility by maintaining healthy body weight, being physically active, and consuming a healthy diet, and also, they must quit smoking (Barazan et al., 2014).

Little is known about the effect of physical activity, BMI, nutritional status, and smoking on female fertility in the general population (Gudmundsdottir et al., 2009). So, the researcher was interested in assessing the effect of these lifestyle factors on female infertility and comparing the lifestyle factors between fertile and infertile women.


  Aim of the study Top


The aim was to compare the lifestyle factors between fertile and infertile women.

Research question

Do lifestyle factors affect female fertility?


  Patients and methods Top


Study design

A descriptive comparative study design was used to conduct this study.

Setting

The study was conducted at the infertility and family planning clinics at Women’s Health Hospital, Assiut University. These clinics provide tertiary care, and the infertility clinic is one of the most important clinic as it provides infertility treatment for people all over the Egyptian countryside.

Sample

A total of 200 women were recruited by convenience sampling. On the basis of the statistical calculation, sample size was determined as 100 fertile woman and 100 infertile women to be enrolled in this study. Sample size was calculated by using Epi-info Statistical Package, version 3.3, with power 80% value of 2.5 is chosen as the acceptable limit of precision, at 95% level of confidence, and also with expected prevalence of infertility of 20%. Accordingly, sample size was estimated to be 90+10% women to guard against nondespondence rate. The calculated total size chosen for the study was 100 infertile women as a case study and another 100 fertile women from the family planning clinic as controls.

Patients

The study patients contained two groups.
  • Study group: 100 infertile women attending the infertility clinic who had been previously diagnosed as being infertile and were seeking infertility treatment.
  • Control group: 100 fertile women from the family planning clinic who were seeking contraceptive services and were being followed up after booking their first visit to the clinic were invited to participate as the control group, because all of them are within the reproductive age.
  • Exclusion criteria: For the study group, women with male factor infertility and those who aged more than 35 years were excluded to focus on the target variables which may play an important role in infertility as elderly women.


For the control group, fertile women who use hormonal contraceptive for more than 5 years to avoid factors as weight gain as an adverse effect of the hormonal methods.

Tools of data collection

Data of this study was collected through two main tools:
  1. Tool one: This is a structured interviewing questionnaire and that was designed by the researcher based upon relevant international studies in the field of infertility treatment. It contained sociodemographic data such as name, age, education, residence, employment, and occupational exposure to particular substances. It also contained data relevant to infertility history which involved type of infertility, duration of infertility/years, their diagnosed cause of infertility, received infertility treatment, and underwent previous gynecological operations.
  2. Tool two: This was used for lifestyle factors assessment and was designed by the researcher based on relevant international studies in the field of infertility treatment, which included assessment of obesity by calculation of BMI (kg/m2), physical activity, nutrition assessment, and finally smoking and caffeine use. It included:
    1. BMI assessment scale: This was used to assess obesity. It was done by calculating BMI as an indicator of the degree of obesity by kg/m2 for both groups. In this study, the researcher determined obesity by a measure, that is, BMI, based on calculating the height and weight of the women and determined the following:
      1. normal by a BMI index (kg/m2) of less than 25.
      2. overweight by a BMI of 25 (kg/m2) or greater, and
      3. underweight (having BMI<0 kg/m2).
    2. Physical activity tool: The International Physical Activity Questionnaire (IPAQ), was adopted from Craiget al., 2004, which was used to measure the level of physical activity. Validity and reliability of this tool had been previously confirmed by numerous studies assessing physical activity. IPAQ is an instrument designed primarily for population surveillance of adults (15–69 years). So, it is used as an evaluation tool in interventional studies. There are two types of this tool, short form and detailed form. The researcher used the short form of this questionnaire as it was used before. The short form of IPAQ asks about three specific types of activity. These three types are walking, moderate-intensity activity, and vigorous-intensity activity. The frequency of activities is measured in days per week and the duration in time per day. The total activities were collected separately for each specific type of activity. Questions of this tool were related to the time women spent being physically active in the past 7 days. Women were asked to think about the activities they did at work, at house, to get from place to place, and in the spare time for recreational activities, exercises, or sports.
      • For each type of activity, walking equals 3.3 metabolic equivalence of tasks (METs), moderate-intensity activities such as working at the house, equal 4.0 METs, vigorous-intensity activities such as working outside at the farms equal 8.0 MET. Meaning that if a woman walks about times per week for 30 min at once, the MET was calculated as 3.3×30×5=495 MET-min/week. If the woman did moderate-intensity activity such as working at the house or at the work for five times per week for 30 min, the MET was calculated as 40×30×5=600 MET-min/week. For vigorous-intensity activities such as working at the farm or practicing vigorous exercises for 5 times per week for 30 min, MET was calculated as 8.0×30×5=1200 MET-min/week. For each women of both groups, the IPQA tool was calculated and the sum of all energy requirements were considered to show low, moderate, and high level of physical activity ([Figure 1]).
        Figure 1 Physical activity interpretations.

        Click here to view
    3. Nutritional status assessment tool: This was used to assess nutritional status as a lifestyle factor. Assessment was done by using a questionnaire which was prepared to assess fertile and infertile women’s nutrition status based on researches and according to the study by Bragaet al.(2012); they used the mini-nutritional assessment tool that was approved by the Nestlé Nutrition Institute.
      • Nutritional assessment status was done by asking the questions related upon the previous 3 months of the study. It included two parts, screening and assessment. Screening part included the condition of food intake over the past 3 months owing to loss of appetite, digestive problems, chewing or swallowing difficulties, weight loss, mobility, experiencing psychological stress or acute disease, neurological problems, and BMI. The total score of the screening part was maximum of 14 points.
      • The assessment part included the following: taking prescription drugs per day, the number of meals women intake daily, selected consumption markers for protein intake, consuming fruits or vegetables per day, mode of feeding, and self-view of nutritional status. Mid-arm and calf circumference were also measured. Moreover, the questionnaire contains a question for the women regarding how they considered their health in comparison with other people of the same age.
      • The total score of the assessment part was maximum of 16 points. The assessment scores of Mini-nutritional assessment tool were summed, and the nutritional indicator scores were as follows:
        1. 24–30 Points were regarded as proper nutritional status.
        2. 17–23 Points were regarded as fairly good nutritional status or at risk of malnutrition.
        3. Less than 17 points were regarded as poor nutritional status or having malnutrition.
    4. Smoking habits were assessed by asking women whether it was direct or passive, and caffeine consumption was assessed by directly asking them whether they drank coffee or not.
      • At the end, the scores of the four dimensions of the lifestyle were calculated as percent and summed up. Total scores less than 33.3% were represented as unhealthy lifestyle, 33.3–66.6% were represented as relatively healthy lifestyle, and more than 66.6% of the total score represented as health lifestyle.
      • Content validity and reliability of the lifestyle questionnaire was obtained through distribution of it to a panel of five staff members: four staff members of the faculty including obstetrics and gynecological nursing and medical staff, and one staff from the public health medicine, a nutrition specialist. All the staff members were requested to carefully read all items of the questionnaire and provide their comments. Then correction of some words was done to ensure feasibility and applicability of the questionnaire.


      Pilot study

      Pilot study was done on 10% of the studied women (20 women), 10 from each group, to test the clarity of the questions and to detect any further problems or difficulties that would help in making the necessary modifications requiring reconstructing the questionnaire. Women of the pilot study were excluded from the main study.

      Ethical consideration

      The aim of the study was explained to all women. Women had the right to agree or refuse to participate in the study. Oral consent was obtained from all women who participated in the study, and they were informed that the collected data were used for the study only and confidentiality was kept.

      An official permission clarifying the purpose of the study was obtained to gain approval from the ethical committee of the Faculty of Nursing, Assiut University, as well as an approval from the clinics administrative personnel at Assiut Women’s Health Hospital to conduct this study.

      Procedure

      This study was conducted over a period of 12-month duration from the first of January 2016 till the end of December 2016; each interview with the women took about 30–45 min.

      The researcher invited the infertile and fertile women who attending the family planning and the infertility clinics to participate in the study. All the participants were informed about the aim of the study and were ensured that their collected data were used only by the researcher and confidentiality was maintained. They were invited to give their oral consent, which indicated their approval to participate in the study. Each woman in this study of the two groups was interviewed individually to fill the structured questionnaire of the study. The researcher started with greeting each woman and introducing herself to the women, and then she provided an explanation about the nature of the study and its importance to them.

      The researcher met each woman individually and collected data related to sociodemographic questionnaire containing items on age, education level, occupation, and occupational exposure to environmental hazards. The medical and infertility history of women was taken such as the duration and cause of infertility.

      Each domain of the lifestyle tool was assessed separately, and the score of it was calculated.

      For the obesity assessment, the researcher used the clinics scale; it is an electronic scale that represents the weight and the length. Then the researcher calculated the BMI according to the equation of height (m2) to the weight (kg).

      For determining the level of physical activity, the researcher asked the related questions of the tool for each task separately such as walking, practicing the daily work at the house or at the work, and practicing vigorous activities at the work, or at the farm for those who were from rural areas, or practicing vigorous exercises. Each activity was calculated for frequency in minutes per week and the researcher summed all of them, and the score was made to consider the level of activity as low, moderate, or high level of physical activity.

      Nutrition assessment for each participant woman was done by the use of the nutritional assessment tool; each woman was asked about questions related to the nutrition within the previous three months of conducting the study. According to the answers to the tool parts, the researcher categorized the nutrition status as proper, fairly good, or at risk of malnutrition and poor nutrition status.

      Questions to assess cigarette smoking if it was passive or active were asked, and also assessment of caffeine consumption was done.

      Participation of the studied women in both groups appeared to be positive. For continuous benefits for the study, each woman of both groups was given a well-prepared scientific booklet about modifications of lifestyle behaviors for improving their reproductive health according to the studies by Rossi et al. (2016) and Kendra (2015), which was given at the end of the data collection to prevent contamination of the collected data.

      The booklet contents were obtained from national and international reviews, articles, and researches and were translated by the researcher into simple clear understandable Arabic language and were rich with pictures about the healthy food and the suitable exercises. The booklet included items about the lifestyle modifications such as maintaining a healthy weight by being neither overweight nor underweight through eating a healthy diet, which includes plenty of fruits, vegetables, whole grains, and unsaturated fats and proteins, and avoiding smoking as it adversely affects fertility. Furthermore, the booklet contained the role of exercises, physical activity, and healthy sleeping pattern and their effects on improving the fertility. It also contained instructions about how to cope with stressors, avoidance of using illegal drugs, and exposure to toxic substances. There are advices about the use of folic acid and vitamins as prescribed by the physician as well.

      Statistical analysis

      Categorical variables were described by numbers and percent, whereas continuous variables described by mean and SD. χ2-Test was used to compare between categorical variables. A two-tailed P value less than 0.05 was considered statistical significant. Statistical analysis was done by using the SPSS, version 20.0 software.


        Results Top


      [Table 1] shows that the mean age of the infertile group was 25.43±4.05 years and the fertile group was 26.04±5.26 years, with no statistical significant difference, P=0.359. It also presented that there is no statistically significant difference among fertile and infertile women in terms of their educational level, occupation, residence as well as exposure to environmental pollution.
      Table 1 Distribution of the studied women according to their sociodemographic characteristics

      Click here to view


      [Table 2] presents that about one-third (30%) of the infertile women were making an attempt for pregnancy from 5 to 10 years. Ovulatory disorders were responsible for 89% of causes of infertility. Medical disorders were found in 23% of the infertile women and those who were attempting previous assisted reproductive techniques treatment trials.
      Table 2 Distribution of the infertile group according to their infertility history

      Click here to view


      According to the scores of lifestyle questionnaire, [Table 3] shows a statistical significant difference between both groups regarding physical activity. Regarding physical activity, this table shows a higher percentage of high physical activity among the fertile group (78%) than the infertile group (52%). Moreover, obesity was higher among the infertile group (23%) than the fertile group (12%) through calculation of body mass index, (P=0.000 and 0.055, respectively). No significant difference was found among both groups according to their nutritional status and smoking and caffeine habits.
      Table 3 Distribution of the studied women according to their lifestyle dimensions

      Click here to view


      Regarding the lifestyle status, [Figure 2] represents a highly statistical significant difference between groups. Fertile women showed a significantly higher percentage of healthy lifestyle (84%) than infertile women (69%). Relatively healthy lifestyle status was seen in 22 versus 13% and unhealthy lifestyle status was present in 9 versus 3% of the infertile and fertile groups, respectively (P=0.033).
      Figure 2 Distribution of the studied women according to their lifestyle status.

      Click here to view


      [Table 4] reveals the relationship between the fertile and infertile women in relation to their healthy, relatively healthy, and unhealthy lifestyle status. Regarding the age groups, healthy lifestyle status shows a highly statistical significant difference (P=0.03) between the fertile and the infertile age groups. It also shows that a highly statistical significant difference was present between healthy, relatively healthy fertile and unfertile women in relation to their occupational status, as the fertile employed women had a higher healthy lifestyle status (32.1%) than the infertile employed women (P=0.000 and 0.025, respectively).
      Table 4 Distribution of the studied women according to their sociodemographic characteristics in relation to their lifestyle status

      Click here to view


      [Table 5] reveals the relationship between the fertile and infertile women’s sociodemographic characteristics in relation to their healthy, relatively healthy, and unhealthy lifestyle status. It shows that a statistical significant difference was present between both groups regarding their age, educational level, occupation, and residence and their healthy lifestyle status (P=0.03, 0.04, 0.000 and 0.04, respectively). Concerning physical activity, this table highlights that higher percentage of high level of physical activity was presented among the healthy lifestyle fertile group (86.9%) than those of the infertile group (72.3%).
      Table 5 Distribution of the studied women according to their life style status in relation to the lifestyle dimensions

      Click here to view


      Concerning the distribution of the studied women according to the causes of infertility in relation to their lifestyle status [Table 6] shows that the most common cause of infertility was the ovulatory disorders even among the healthy lifestyle status (75%), the relatively healthy (10%) and the unhealthy lifestyle status (4%), with a highly statistical significant difference among the groups.
      Table 6 Distribution of the studied women according to the causes of infertility in relation to their lifestyle status

      Click here to view



        Discussion Top


      Although there is abundant evidence of the effect of the lifestyle factors on female infertility, fertile and infertile women’s lifestyle has not been widely studied. Therefore, the present study was conducted to compare the lifestyle factors between fertile and infertile women.

      On the basis of the findings of the present study, most of the studied fertile and infertile women had healthy lifestyle status. However, the study results showed a highly statistical significant difference between the two groups in terms of physical activity and BMI, whereas there were no statistical significant differences between the fertile and infertile women in relation to the nutritional status, smoking, and caffeine consumption. These results contradict the results of Homan et al., 2012 who studied the fertility assessment and advised targeting lifestyle choices and behavior, a result of a pilot study. They examined various dimensions of lifestyle including nutrition, physical activity, cigarette smoking, alcohol and drug abuse, and caffeine consumption. They found that all couples had unhealthy lifestyle.

      Such inconsistency between the results of the two studies can be owing to the evaluation of different dimensions of lifestyle or the concept as a whole, the administration of different questionnaires, different sample size, and unalike cultural contexts.

      Research studies in the field of lifestyle factors and fertility have yielded contradicting results. The present study found that physical activity showed a highly statistical significant difference between the two studied groups, meaning that moderate and low level of physical activity were significantly more among the infertile group.

      The present study findings are supported by the results of Esmaeilzadah et al. (2012) and Wise et al. (2011) who assessed the effect of physical activity and BMI among women who experienced infertility, and they found that regular physical activity affects improving female and male fertility, as regular and suitable physical activity has been proven to control blood glucose and insulin level, adjust luteinizing and follicle-stimulating hormones and increase the level of testosterone in males. However, these results are different from the results of Revonta et al. (2010), who studied the health and lifestyle among fertile and infertile men and women. They found that no statistical significant difference in physical activity was observed between their studied fertile and infertile women or fertile and infertile men. The observed differences and dissimilarity between the results of various researches might be caused by the use of different evaluation tool or questionnaire. Moreover, women’s perception of intense and moderate level of physical activity might have affected the obtained results. Therefore, further studies are required to be implemented upon a large sample size to assess the correlation between BMI and intensity and duration of physical activity in fertile and infertile women and men.

      Regarding the nutritional status, the present study showed that there is no statistical significant difference between the fertile and the infertile groups, as most of the fertile and infertile women have normal nutritional status. These results were similar to the results of Revonta et al. (2010), who stated that fertile and infertile women and men had more favorable nutritional status.

      The similarity of the nutritional status between groups of the present study might be contributing to the similarity of the studied women in the residence or the employment status, as these women came from the same socioeconomical areas.

      The role of health professionals including nurses is a key role in achieving optimal preconceptional normal averages of body weight and the need for optimizing diet and physical activity behaviors for prevention and management of overweight and obesity (Moran et al., 2016).

      Findings of the present study about BMI as an indicator of obesity showed that fertile group presented higher percentages of normal weight than the infertile women. Moreover, obesity was significantly higher among the infertile group than the fertile group. These results were similar to the findings of Anderson et al. (2010), who reviewed the literature regarding modifiable lifestyle factors in people seeking infertility treatment. They stated that the chance of pregnancy was halved for overweight women as compared with women of normal BMI. Furthermore, they found that the results of the studies that were reviewed generally suggested that there was a relationship between female fertility and elevated BMI.

      Cigarette smoking and caffeine consumption of women at the present study were more common in infertile women than the fertile women, with no statistically significant difference between fertile and infertile women while emphasizing on the zero results of cigarette smoking among the groups. These results are at the same line with the results of as they suggested a lack of a significant difference in smoking and caffeine consumption between fertile and infertile women and men. On the contrary, the current study findings about cigarette smoking did not match the results of previous studies in that point. Ariyanpur et al. (2011), when provided a comparison of spermatozoa quality in male smokers and nonsmokers of Iranian infertile couples failed to establish a significant difference in smoking between fertile couples and the rest of population. However, Braga et al. (2012), who studied food intake and social habits in patients and its relationship to intracytoplasmic sperm injection outcome, found that most of the infertile men smoked cigarette regularly. However, Wright et al. (2006), when assessing the effect of female tobacco smoking on IVF outcome stated that only few percentages of their participating infertile women were smokers at the time of the study conduction.

      The apparent difference between the present study results and the findings of the other researches might be owing to the consideration of the specific culture and religious context in our Egyptian country. Meanwhile, the study participants were females which might have refused to provide a current data about their smoking habits for fear of stigmatization that may be responsible for no frequency of the smoking except the passive smoking.


        Conclusion Top


      The infertile women significantly had low physical activity percentages and more BMI (obesity) than the fertile group. However, no significant difference was observed between groups regarding the nutritional status, smoking, and caffeine consumption, as the prevalence of women who were malnourished or at risk of malnutrition, those with passive smoking, and consumed more caffeine was not significantly higher among the infertile group than the fertile group. So, lifestyle factors such physical activity and BMI significantly affected female fertility.

      Recommendations

      The unhealthy lifestyle status of the infertile women must be modified through effective measures. Modifiable lifestyle factors should be considered in all women who are seeking infertility treatment to help them make positive changes in their lives and improve their chances of conceiving, that is, getting a healthy pregnancy and a live baby. Moreover, developing guidelines for healthy lifestyles would be a prudent step toward helping healthcare providers especially nurses to implement this aspect of preconceptional care.

      Acknowledgements

      The researcher wishes to acknowledge the head of Women’s Health Hospital and the head nurses of infertility and family planning clinics as well as all women who took part in this study for their support and contribution toward the success of the study.[24]

      Financial support and sponsorship

      Nil.

      Conflicts of interest

      There are no conflicts of interest.



       
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          Figures

        [Figure 1], [Figure 2]
       
       
          Tables

        [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



       

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Abstract
Introduction
Aim of the study
Patients and methods
Results
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References
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