INFLUENCE OF MODIFIABLE RISK FACTORS ON FERTILITY 1

Influence of Modifiable Risk Factors on Fertility

Ashley Ventimiglia, Madeline Lucas, Alexei Rinko, Deanna Hall

NURS 3749: Nursing Research

Ms. Randi Heasley

April 6, 2022
INFLUENCE OF MODIFIABLE RISK FACTORS ON FERTILITY 2

Abstract

Female infertility is a rising concern affecting women across the world. The treatments that have

been approved to combat this growing issue are also known to be costly, time-consuming, and

emotionally taxing by many that undergo said therapy. By changing specific aspects of a

woman’s lifestyle, there is a high likelihood that her fecundability will be increased. These

modifiable factors have the potential to effectively increase a woman’s changes of achieving

conception without the use of medical procedures. While the research on many of these factors

may not be high in number, there is no doubt that the trustworthy studies that have been

conducted thus far prove beyond reasonable doubt that there is an inverse relation between the

rate of female fecundability and specific modifiable risk factors such as diet, exercise, alcohol

use and smoking that have been researched to date.

INFLUENCE OF MODIFIABLE RISK FACTORS ON FERTILITY 3

Introduction

Infertility is defined as “ not being able to get pregnant (conceive) after one year (or

longer) of unprotected sex.” (US Department of Health and Human Services 2020) Women who

struggle with infertility are seen more often than one may think. Although infertility treatment is

safe, it tends to be expensive, is often an invasive procedure and increases the risk of multiple

gestations. Thus, to reduce risk and cost, women should initially consider lifestyle change to

increase their fertility and chances of pregnancy. By educating women on modifiable lifestyle

factors, hopefully there will be a decrease in infertility rates among women. Some of these

aspects include modifiable factors such as diet, BMI in relation to exercise, alcohol intake, and

selective hormone therapy.

Diet

Studies show that women’s preconception, pregnancy diet, and nutritional status are

linked with maternal and neonatal outcomes, yet we ask ourselves, does our overall daily diet

and nutritional status affect the ability to become pregnant? According to the US Department of

Health and Human Services(2015-2020) the answer is yes. The article states

There is strong evidence that healthy preconception dietary patterns among both men

and women of reproductive age have a beneficial effect on fertility. A dietary pattern

consistent with the recommendations put forth by the U.S. Dietary Guidelines for

Americans, which recommends a high consumption of whole grains, monounsaturated or

polyunsaturated oils, vegetables, fruits, and fish, has been associated with improved

fertility in women and higher semen quality in men. p3

INFLUENCE OF MODIFIABLE RISK FACTORS ON FERTILITY 4

An overall healthier day to day diet is better for anyone trying to conceive. The article continues

to state “In the Nurses' Health Study (NHS) II, a large prospective cohort, women who had the

highest intake of a “fertility diet” comprised of plant protein from vegetable sources, full-fat

dairy foods, iron, and monounsaturated fats, during the preconception period, were found to have

a 66% (95% CI, 52, 77%) lower risk of infertility related to ovulatory disorders and a 27% (95%

CI, 5, 43%) lower risk of infertility due to other causes compared to women with the lowest

intake of this diet pattern.” Again, studies show that by eating healthier day to day this can

increase the women's likelihood of getting pregnant.

Specific food groups and diet styles can play a part in increasing fertility. Folate is very

important to include in a womens diet not only during pregnancy, but before trying to conceive.

Researcher Gaskins(2014) goes on to say “Data on the associations of specific nutrients and

foods with fertility may yield important insight into the possible mechanisms linking diet and

reproductive health. In addition to being linked to neural tube defects in infants, low levels of

folate are associated with a lower frequency of sporadic anovulation” (p3).meaning that

ovulation isn’t taking place. A great study showing the direct effects of folic acid in pregnancy is

seen in the experiment obtained by Westpal (2018) showing that “In a randomized controlled

trial of subfertile women who took a multivitamin containing 400 μg of folic acid for 3 months,

26% had a pregnancy compared to 10% of women in the placebo group”(p.2)Women who are

trying to conceive should increase their folic acid intake. Other foods containing high omega-6

and linoleic acid such as walnuts, sunflower seeds, eggs, avocado and peanut butter are

recommended for women trying to conceive. Studies show “Women who consumed higher

levels of omega-6, linoleic acid, and omega-3 had a higher incidence of pregnancy than those

with lower intake of these nutrients” (Moran, 2018, p.2). Given the positive effect of a healthy
INFLUENCE OF MODIFIABLE RISK FACTORS ON FERTILITY 5

diet on fertility outcomes, it is recommended that women struggling with infertility first take a

look at their daily diet before directly jumping into other medical procedures. Specifically, a diet

consistent with the U.S. Dietary Guidelines for Americans and include adequate levels of folic

acid intake and food groups high in omega-6 and linoleic acid for women should be

recommended.

Exercise

In addition to diet’s effect on fertility, the involvement of physical exercise is shown to

have an impact on decreasing fertility. Although exercise has proven to have widely positive

impacts on health in general, studies show that exercise has negative effects on fertility when

performed in a specific manner. In the last several decades, women have become increasingly

more involved in athletic endeavors and subsequently, the need for research on women's health

related to physical exercise has increased. The findings related to this topic are largely

indeterminate due to difficulty isolating the variable of physical activity from other extraneous

factors such as eating habits and underlying health conditions. Although this is true, studies are

still being performed to attempt to acquire as much knowledge as possible on the topic.

Specifically, a study called The North -Trøndelag Health Study examined 3,887

Norwegian women under the age of 45, and focused on the relationship between physical

exercise and fertility rates reported by the subjects. The results confirm that vigorous physical

exercise can have a harmful effect on fertility rates. “There have only been a few studies

regarding the effect of PA (physical activity) on fertility status and parity in the general female

population. Our results are somewhat comparable to results of a retrospective case–control study

which found a 6.2-fold increased risk of infertility in women who exercised vigorously (defined

as aerobic activities with estimated energy requirements of 6 kcal/min) for at least 60 min per
INFLUENCE OF MODIFIABLE RISK FACTORS ON FERTILITY 6

day. In particular, women who were active on most days of the week were 3.2 times more likely

to be infertile than inactive women. Exercising to exhaustion was associated with 2.3 times the

odds of infertility compared with lower levels of intensity.”(Gudmundsdottir et al., 2009)

The intensity of the exercise is determinant of whether physical activity can be helpful or

harmful to a woman hoping to conceive. When an excessive amount of strenuous exercise is

performed, it may cause what is called amenorrhea. Amenorrhea is defined as the absence of

menstruation. Again, it is difficult to limit the cause of this disorder exclusively to exercise

because an insufficient diet and underlying conditions are also major factors. This is supported in

a report by James H Liu, M.D., Bansari Patel, M.D., and Gretchen Collins that was published in

2016. In this article, it states that this amenorrhea can also be caused by a disturbance in cortisol

levels in the body, and that this added “stress response is the cause for alterations in the body's

natural stress response.” The body also responds to extremely low levels of energy caused by

either excessive exercise, anorexia, or both and compensates by conserving energy.This energy

conservation is achieved with the combination of the cessation of ovulation and the reduction of

metabolism.

To further support this point, another study focused on the impact of lifestyle factors on

fertility states,

“ Excessive exercise can negatively alter energy balance in the body and affect the

reproductive system . When energy demand exceeds dietary energy intake, a negative

energy balance may occur and may result in hypothalamic dysfunction and alterations in

gonadotropin-releasing hormone (GnRH) pulsality, leading to menstrual abnormalities,

particularly among female athletes. Increased frequency, intensity, and duration of

exercise were found to be significantly correlated with decreased fertility in women. A

INFLUENCE OF MODIFIABLE RISK FACTORS ON FERTILITY 7

study examining 2,232 women undergoing in vitro fertilization (IVF) found that women

who engaged in cardiovascular exercise for 4 hours or more per week for as little as one

year prior to the treatment had a 40% decrease in live birth rate, as well as higher risks of

cycle cancellation and implantation failure. (Rakesh Sharma, et. al., 2016)

Ultimately this cessation of ovulation and alteration in the menstrual cycle are the main factors

causing infertility in highly active women. With the knowledge that specific exercise patterns

negatively impact fertility rates, women should monitor the frequency and intensity of their

physical activity in times in which they are trying to conceive to ensure that they are not harming

their chances to become pregnant in any way.

Alcohol

The consumption of alcohol during pregnancy is a hardly debated subject; drinking

alcoholic beverages while pregnant is a dangerous decision that could easily lead to Fetal

Alcohol Syndrome, low birth weight, or miscarriage. With definitive evidence proving the

negative consequences of alcohol consumption during pregnancy, why is there so little

discussion regarding alcohol and its effect on fecundability?

While research has been conducted throughout countless studies regarding the effects of

drug, tobacco, and alcohol use during pregnancy, there is very little information currently

surrounding the potential consequences that may arise through the use of these things when

trying to achieve conception (Anwar et al. 2021, p. 121). Though research events of this nature

may be few and far between, the peer-reviewed studies that are able to be learned from at this

time contain strong evidence to suggest that the negative relationship between these two topics is

undeniable.
INFLUENCE OF MODIFIABLE RISK FACTORS ON FERTILITY 8

According to three members of the Alcohol Research Program at Stritch School of

Medicine, Loyola University, “A study of healthy nonalcoholic women found that a substantial

portion who drank small amounts of alcohol (i.e., social drinkers) stopped cycling normally and

became at least temporarily infertile” (Emanuele et al. 2002, p. 32). There is significant evidence

to prove that the consumption of alcohol is able to alter the female reproductive system, therefore

causing enough disruption to cause infertility for an unspecified amount of time. Alcohol’s

Effects on Female Reproductive Function also states, “It is important to stress that alcohol

ingestion at the wrong time, even in amounts insufficient to cause permanent tissue damage, can

disrupt the delicate balance critical to maintaining human female reproductive hormonal cycles

and result in infertility” (Emanuele et al. 2002, p.32).

The female reproductive system is affected easily by the influences of consumable toxins

that are ingested into the body. “Alcoholic women are known to have a variety or menstrual and

reproductive disorders, from irregular menstrual cycles to complete cessation of menses, absence

of ovulation (i.e., anovulation), and infertility” (Emanuele et al. 2002, p. 31). The delicate

balance of the female reproductive system is negatively altered by even just a few drinks

consumed per week, “We found an association between women’s alcohol intake and decreased

fecundability even among women who had five or fewer drinks a week…” (Jensen et al. 1998, p.

15). During a study conducted to determine how alcohol consumption affects fertility in relation

to menstrual cycles, it was concluded that, “...even modest drinking levels may decrease

fecundability if consumed during critical physiologic intervals of the menstrual cycle” (Anwar et

al. 2021, p. 124).

There is sufficient evidence to conclude that there is an inverse relationship between the

consumption of alcohol and female fecundability. “...it seems reasonable to encourage women to
INFLUENCE OF MODIFIABLE RISK FACTORS ON FERTILITY 9

reduce their intake of alcohol or not to drink at all when they are trying to become pregnant”

(Jensen et al. 1998, p. 14). Because alcohol so clearly negatively impacts the female reproductive

system, it can be concluded that there is no better way to avoid infertility of this specific nature

than to refrain from consuming alcohol of any type and of any amount.

Smoking

It's no secret that smoking is detrimental to one’s general health, but how does it

influence fertility in women? A Polish study reviewed female reproductive hormones in non-

smokers, second-hand smokers, and smokers. The hormones recorded include follicle-

stimulating hormone (FSH), luteinizing hormone (L), estradiol (E2), and progesterone (P). The

levels of FSH in women who smoke is significantly elevated compared to women who do not

smoke. This finding is significant because if FSH is elevated, the quality of ovulation is

decreased and can disrupt the pituitary-ovarian function. They also found that P secretion is

elevated far beyond normal levels during the end of the menstrual cycle (day 21). This is thought

to be the reason that women who smoke may have shortened menstrual cycles. Furthermore, they

go on to say, “In smoking patients, the serum level of LH are significantly higher in the first days

of the menstrual cycle, manifesting the potential for disturbing ovulation, and resulting in

insufficiency of the luteal phase” (Florek et al, 2021). The luteal phase and luteinizing hormone

are responsible for releasing an egg from the ovary (ovulation) and breaking down the exterior

wall in order to be fertilized. When this phase is considered insufficient, fertility and ovulation is

disturbed. All of these explained findings directly contribute to hormones that affect ovulation

and female reproductivity negatively.

Another concern in today’s age is an increase in E-cigarette use. With the vast number of

studies on regular cigarette smoking affecting multiple body systems, the market flooded with
INFLUENCE OF MODIFIABLE RISK FACTORS ON FERTILITY 10

new, “safer”, nicotine delivery. However, the longer these kinds of products are on the shelves, it

seems researchers find more side effects to come with them. An article from Fertility and

Sterility Dialog explains, “At present evidence does not offer any assurance that e-cigarettes are

less harmful than tobacco cigarettes during pregnancy. E-cigarette refill flavor fluids have been

found to be cytotoxic to human embryonic stem cells”, and goes on to list toxins, such as

formaldehyde and lead, that can enter the body through e-cigarettes (Agarwal et al, 2021).

Though the research is still ongoing, most current evidence is showing that e-cigarettes are

affecting female fertility in the same way traditional cigarettes do.

Combating traditional and e-cigarette smoking has been a growing movement in the past

couple decades. Since 1998, “Truth: anti-tobacco campaign” has advertised many different

complications that come with smoking and tobacco use such as respiratory, vision, dental, and

metabolic issues, but not much emphasis has been put on reproductive health related to smoking.

It is public and common knowledge that smoking can cause respiratory issues like lung cancer

and asthma, but most young adult and reproductive age women have never been educated about

the long-term effects it has on fertility.

Conclusion

While there are many unmodifiable factors that may lead to infertility in women, there

are also countless factors that are able to be adjusted by an individual in order to increase

fecundability. Modifiable factors such as diet, exercise, alcohol consumption, and smoking have

strong inverse relationships with the fertility of women. With the elimination of negative

influences that can be controlled, women everywhere have the opportunity to have more control

over their own fertility.

INFLUENCE OF MODIFIABLE RISK FACTORS ON FERTILITY 11

References

Agarwal, S., Trolice, M., & Lindheim, S. R. (2021, August 6). E-cigarette use in

reproductive-aged women and pregnancy: A rising health concern. Fertility and Sterility

Dialog. Retrieved April 1, 2022, from https://www.fertstertdialog.com/posts/58628-

29711

Anwar, M. Y., Marcus, M., Taylor, K. (2021, June 8). The association between alcohol intake

and fecundability during menstrual cycle phases. Oxford Academic. Retrieved March 23,

2022, from https://academic.oup.com/humrep/article/36/9/2538/6294415?

login=false#304927788

Emanuele, M. A., Wezeman, F., Emanuele, N. V. (2002). Alcohol’s effects on female

reproductive function. Alcohol Research & Health. Retrieved March 23, 2022, from

https://content.ebscohost.com/ContentServer.asp?

T=P&P=AN&K=106786561&S=R&D=rzh&EbscoContent=dGJyMMvl7ESeqLY4y9fw

OLCmsEqep7dSs6i4SbGWxWXS&ContentCustomer=dGJyMPGss0uvqrZOuePfgeyx44

Dt6fIA

Florek, E., Piekoszewski, W., Czarnywojtek, A., Sędziak, A., Jawień, W., Dera-Szymanowska,

A., Szukalska, M., Szymanowski, K., Chuchracki, M., & Ruchała, M. (2021, November

4). Differences in sex hormone levels in the menstrual cycle due to tobacco smoking -

myth or reality? Endokrynologia Polska. Retrieved April 1, 2022, from

https://journals.viamedica.pl/endokrynologia_polska/article/view/EP.a2021.0097/65764
INFLUENCE OF MODIFIABLE RISK FACTORS ON FERTILITY 12

Gudmundsdottir, S. L., Flanders, W. D., & Augestad, L. B. (2009, October 3). Physical activity

and fertility in women: the North-Trøndelag Health Study . Oxford Academic. Retrieved

April 1, 2022, from https://academic.oup.com/humrep/article/24/12/3196/647657?

login=true

Jensen, T., Hjollund, N., Henriksen, T., Scheike, T., Kolstad, H.,Giwercman, A., Ernst, E.,

Bonde, J.P., Skakkebaek, N., Olsen, J. (1998, August 22). Does moderate alcohol

consumption affect fertility? Follow up study among couples planning first pregnancy.

The BMJ. Retrieved March 23, 2022, from https://doi.org/10.1136/bmj.317.7157.505

Liu, J. H., Patel, B., & Collins, G. (2015, April 24). Central Causes of Amenorrhea. Europe PMC.

Retrieved April 1, 2022, from https://europepmc.org/article/NBK/nbk278939

Sharma, R., Biedenharn, K. R., Fedor, J. M., & Agarwal, A. (2013, July 16). Lifestyle

factors and Reproductive Health: Taking control of your fertility - reproductive biology

and endocrinology. BioMed Central. Retrieved April 1, 2022, from

https://rbej.biomedcentral.com/articles/10.1186/1477-7827-11-66

Centers for Disease Control and Prevention. (2022, March 1). Infertility. Centers for Disease

Control and Prevention. Retrieved March 5, 2022, from

https://www.cdc.gov/reproductivehealth/infertility/index.htm

Double-blind, placebo-controlled study of Fertilityblend: a nutritional supplement for improving

fertility in women. Westphal LM, Polan ML, Trant AS Clin Exp Obstet Gynecol. 2006;

33(4):205-8.h https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6079277/
INFLUENCE OF MODIFIABLE RISK FACTORS ON FERTILITY 13

Gaskins AJ, Rich-Edwards JW, Hauser R, Williams PL, Gillman MW, Ginsburg ES, Missmer

SA, Chavarro JE Obstet Gynecol. 2014 Jul; 124(1):23-31.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6079277/

US Department of Health and Human Services; US Department of Agriculture . 2015-2020

Dietary Guidelines for Americans. 8th ed. Washington, DC: US Dept of Health and

Human Services; (2015).https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6079277/

 INFLUENCE OF MODIFIABLE RISK FACTORS ON FERTILITY 14

Author(s) & Year Purpose Sample Measurement Treatments Results Discussion

S.L. Studies 3887 Measured by No treatments The results show This study

Gudmundsdottir, physical Norwegian questioners and are listed. This that fertility is suggests that

W.D. Flanders, L.B. activity’s women. surveys. study focuses dramatically fertility is

Augestad affect on on informing affected. The impacted by the

2009 fertility in a the reader authors go on tp effects of heavy

Norwegian about fertility give results from exercise greatly

population rates in women their study that and mildly affects

who exercise uses stats on women who

and hoe much percentages that moderately

fertility is fertility is exercise. The stats

affected based negatively show specific

on how much affected percentages of

exercise is fertility rates on

performed. the women

affected

James H Liu, M.D., To define the No sample. No survey. The The treatments There were no Amenorrhea is

Bansari Patel, M.D., causes of The purpose purpose of this are not so much results recorded defined as when a

and Gretchen Amennorhea of this article article is to mentioned for in this paper. Just woman does not

Collins is to define define the 3 amenorrhea in the factual menstruate. This

2016 Amenorrhea main cause of this paper as information that happens because

Amenorrhea much as the amenorrhea is of the factors to in

and was not three main caused by the box to the left.

intended to be a causes of the anorexia nervosa. The article is

study disorder Extreme exercise intended to inform

and starvation the reader about

this condition
 INFLUENCE OF MODIFIABLE RISK FACTORS ON FERTILITY 15

Author(s) Purpose Sample Measurement Treatments Results Discussion

& Year

Anwar et al. To determine the N= 470 The interviewed Treating infertility Moderate and heavy This study showed a

(2021) effect of alcohol 57 participants did participants were required related to alcohol beer drinkers are significant correlation

consumption on not provide the daily to keep a daily diary consumption includes indicated to have a between heavy drinking

women and its information required regarding their menstrual the elimination of significantly lower and a lower probability

association with of each participant or cycle characteristics, alcohol from an conception rate than of conception. An

fecundability had short menstrual intercourse frequency and individual’s diet if that of individuals that inverse association

based on specific cycles (<22 days). length of time, methods of said individual is consume 0-2 beers between the amount of

phases of the contraception used, caffeine attempting to achieve each week. alcohol intake and the
Heavy Drinkers:
menstrual cycle of intake, smoking habits, conception. probability of conception
N= 81 Moderate and heavy
each participant. stress level, physical is able to be clearly
(Mean Intake >6 wine and liquor
exercise, and number of interpreted by the results
drinks/week). drinkers showed an
alcoholic beverages of this study.
implication toward the
Medium Level consumed. Participants also
same results, but were
Drinkers: provided urine samples on
disregarded due to the
N= 104 days 1 and 2 of each
small sample sizes of
(Mean Intake 3-6 menstrual cycle.
each group causing the
drinks/week).
results to be interpreted

Light Level as imprecise.

Drinkers:

N= 182

(Mean Intake 1-2

drinks/week).

Non-Drinkers:

N= 46

(Mean Intake 0

drinks/week).
 INFLUENCE OF MODIFIABLE RISK FACTORS ON FERTILITY 16

Author(s) & Year Purpose Sample Measurement Treatments Results Discussion

Agarwal, S., Trolice, Reports No sample Looks at the This reading Switching The rise in

M., & Lindheim, S. general facts used, general nicotine levels suggests that from popularity of

R. and study overview of and the general smokers using traditional E-cigarettes

findings of E- data from E-cigarettes smoking to is posing a

August 2021
cigarette use multiple can E-cigarettes risk on

and its effects studies progressively while previous

on fertility decrease their pregnant has non-smokers.

smoking not been Though the

habits, proven to be initial

however this effective or intension of

puts non- healthier E-cigarettes

smokers at than was to help

risk to start smoking traditional

using E- traditional smokers

cigarettes. cigarettes. quit/reduce

tobacco

smoking.

US Department to inform “There is strong certain food diet treatment to see an this article
evidence that
of Health and readers of the groups that are suggestions increase of helps educate
healthy
suggested supposed to women and prove to
Human preconception
dietary help women getting readers that a
Services; US dietary patterns

guidelines among both men struggling with pregnant healthy diet

Department of
and women of infertility while plays an
Agriculture reproductive age
maintaining important
2015-2020 have a beneficial
this healthy role in a
effect on fertility.
lifestyle. women's
A dietary pattern

consistent with ability to

the conceive
recommendations
 INFLUENCE OF MODIFIABLE RISK FACTORS ON FERTILITY 17

put forth by the

U.S. Dietary

Guidelines for

Americans,

which

recommends a

high consumption

of whole grains,

monounsaturated

or

polyunsaturated

oils, vegetables,

fruits, and fish,

has been

associated with

improved fertility

in women and

higher semen

quality in men.

Inform 7,511 measures tx includes mothers less This current

Gaskins
mothers nulliparous adequate intake proper intake likely to study did
AJ,2014
struggling women of nutrients and of suggested struggle support our

with infertility folic acid and nutrients and with research

and other how it related folic acid infertility question

readers to mothers mothers also "How do

struggling with less likely to modifiable

infertility have Nero risk factors

tube defects effect

in the fetus women

struggling

with

infertility"

modifiable
INFLUENCE OF MODIFIABLE RISK FACTORS ON FERTILITY 18

risk factors

being;

Nutrition and

folic acid

importance

in the diet

supports our

research

Author(s) Purpose Sample Measurement Treatments Results Discussion

& Year

Jensen et al. To observe N= 423 The couples were instructed to discontinue all Achieving There is a There is an

(1998) the Couples contraception, provide monthly questionnaires conception is strong unmistakable

consumption 22 original regarding noted to be far negative inverse

of alcohol and couples were demographic/medical/reproductive/occupational/lifesty more likely to relationship relationship

the impact dropped due le (including alcohol consumption) information, and occur with the between the between the

that it has on to lack of provide a semen sample. The couples were studied for elimination of consumption consumption of

female information 6 cycles or until pregnancy was achieved. alcohol entirely of alcohol in alcohol in any

fecundability. provided or from the diet of moderate to amount and the

azoospermia. the individual heavy fecundability of

wanting to amounts that a female when

Group 1:
become pregnant, is also visible attempting to
(0
not by only in the subjects achieve
drinks/week)
limiting the that conception.
388 Cycles
intake of alcohol. consumed just

Group 2: a few drinks

(1-5 per week.

drinks/week)
INFLUENCE OF MODIFIABLE RISK FACTORS ON FERTILITY 19

771 Cycles

Group 3:

(6-10

drinks/week)

283 Cycles

Group 4:

(11-15

drinks/week)

102 Cycles

Group 5:

(16+

drinks/week)

52 Cycles

Florek, E., Determine the 153 women of Measured No treatments The sex hormone Smoking women

Piekoszewski, W., effects of reproductive with survey used in the levels during the who are trying to

Czarnywojtek, A., smoking, age, sectioned to study, but this three cycle phases get pregnant or

Sędziak, A., second-hand into three determine research in smokers is struggling with

Jawień, W., Dera- smoke, and groups smoking determines the significantly infertility can

Szymanowska, non-smoking (smokers, status, tests benefit of abnormal which significantly

A., Szukalska, on second-hand done to cessation of directly effects improve the

M., reproductivity smokers, non- determine smoking with ovulation and chances of a

Szymanowski, K., and fertility smokers) levels of sex regard to fertility. healthy pregnancy

Chuchracki, M., hormones reproductivity and return to

& Ruchała, M. during normal

menstrual menstruation
November 2021
cycle