ARTICLE
Sperm concentration and semen volume increase after
smoking cessation in infertile men
Deniz Kulaksiz1

, Tuncay Toprak 2✉, Eda Tokat 3

, Mehmet Yilmaz4

, Mehmet Akif Ramazanoglu 5

, Asgar Garayev6
,

Muhammed Sulukaya7

, Recep Burak Degirmentepe8

, Elnur Allahverdiyev9

, Murat Gul 10 and Ayhan Verit2

© The Author(s), under exclusive licence to Springer Nature Limited 2022

Smoking has negative reproductive consequences. This study investigated the effect of smoking cessation on the main semen
parameters. We included 90 participants who applied to our infertility clinic and smoked at least 20 cigarettes a day for at least 1
year. Of the 90 participants, 48 were in the study group and 42 were in the control group. Semen analysis was performed before
and at least 3 months after quitting smoking in the study group. Semen analysis was repeated at baseline and at least 3 months
later in the control group. Semen parameters such as volume, sperm concentration, total sperm count, morphology, and motility
were evaluated according to the World Health Organization criteria. Patient characteristics as well as the duration of the smoking
period, the number of cigarettes smoked per day and the time elapsed since smoking cessation were recorded. The mean age of
the participants was 34.69 ± 5.3 years, and the duration of infertility was 34.12 ± 12.1 months (n = 90). The number of cigarettes
smoked per day was 30.14 ± 6.69, and the smoking time was 8.31 ± 3.53 years. The average time to quit smoking was
104.2 ± 11.51 days (n = 48). A significant increase in semen volume, sperm concentration and total sperm count was observed
3 months after smoking cessation (2.48 ± 0.79 ml vs. 2.90 ± 0.77 ml, p = 0.002; 18.45 × 106

/ml ± 8.56 vs. 22.64 × 106
/ml ± 11.69,

p = 0.001; 45.04 ± 24.38 × 106 vs. 65.1 ± 34.9 × 106

, p < 0.001, respectively). This study showed that smoking cessation had a positive
effect on sperm concentration, semen volume, and total sperm count. Although smoking cessation contributed positively to sperm
motility and morphology, the difference was not statistically significant.
IJIR: Your Sexual Medicine Journal (2022) 34:614–619; https://doi.org/10.1038/s41443-022-00605-0

INTRODUCTION

The World Health Organization reports that approximately one-
third of individuals over the age of 15 worldwide smoke [1].

Smoking is a common health problem, and findings show that
smoking affects reproductive health in both women and men
more than consumption of alcohol or caffeine [2]. Cigarettes
contain approximately 600 ingredients, which create over 7000
chemicals when burned. Arsenic, benzene, carbon monoxide,
nicotine, and heavy metals are only a few of the toxic ingredients
found in cigarettes, although the fundamental ingredient of the
particle phase comprises nicotine aggregates [3]. Since cigarette
smoke includes over 30 chemicals that are reported to be

carcinogens, mutagens or allergens, it is reasonable to hypothe-
size that smoking exerts direct harmful effects on human germ

cells [4]. In fact, smoking can adversely influence the male
reproductive system [5], cause attenuated or impaired sperm
production in the testicles [6], and/or indirectly cause a hormonal
imbalance in the endocrine system [7]. The mechanisms by which
tobacco smoke affects spermatozoa are not fully understood. One
hypothesis is the production of “oxidative stress” that reduces

sperm quality [8]. Cigarette smoke contains various reactive
oxygen species, and smoking has been shown to increase
leukocyte concentrations in semen by 48% [9]. Smoking can also
damage the chromatin structure of sperm, causing endogenous
DNA strand breaks and thus impairing the fertilization capacity
[10]. DNA damage levels are higher in smokers [11].
Semen analysis is the most common and valid diagnostic test
for sperm quality and involves the evaluation of semen volume
and total count, sperm concentration, sperm morphology and
sperm motility [12]. Smoking may be associated with decreased
fertility in men due to decreased sperm motility and concentration
and morphologically decreased normal sperm percentage [13]. In
another study, smoking only had a negative effect on sperm
concentration [14]. A meta-analysis of studies with a large
population of 5865 men from 26 regions/countries reported that
smoking has an adverse effect on semen quality in both fertile and
sterile men and is associated with decreased sperm motility and
count, particularly in moderate to heavy smokers [15]. In another
study, smoking was associated with a significant decrease in
sperm count and deterioration in sperm morphology [7]. Although

Received: 3 April 2022 Revised: 1 August 2022 Accepted: 2 August 2022
Published online: 13 August 2022
1
Department of Obstetrics and Gynecology, Trabzon Kanuni Training and Research Hospital, University of Health Sciences, Trabzon, MD, Turkey. 2

Department of Urology, Fatih

Sultan Mehmet Training and Research Hospital, University of Health Sciences, Istanbul, Turkey. 3

Department of Urology, Ankara Training and Research Hospital, University of

Health Sciences, Ankara, MD, Turkey. 4

Department of Urology, Faculty of Medicine, University of Freiburg—Medical Centre, Freiburg, MD, Germany. 5

Department of Urology,

Trabzon Kanuni Training and Research Hospital, Trabzon, MD, Turkey. 6

Department of Urology, Istanbul Florence Nightingale Hospital, Istanbul, MD, Turkey. 7
Department of

Urology, Malatya Training and Research Hospital, Malatya, MD, Turkey. 8

Department of Urology, Karasu State Hospital, Sakarya, MD, Turkey. 9

Department of Urology, Central

Clinic Hospital, Baku, MD, Azerbaijan. 10Department of Urology, Selcuk University Faculty of Medicine, Konya, Turkey. ✉email: [email protected]
www.nature.com/ijir IJIR: Your Sexual Medicine Journal

1234567890();,:

the negative effect of smoking on semen parameters is described
in the literature, contradictory evidence has been reported on
exactly which parameters are affected. Most of the studies
compare semen parameters of smokers with nonsmokers, and
there is only one case report in the literature investigating
whether the same individual has improved semen parameters
after a 3-month smoking cessation program [16]. We aimed to
determine the effects of smoking cessation on semen parameters.
To our knowledge, this is the first human study to show the effect
of smoking cessation on semen analysis parameters.
MATERIALS AND METHODS
We conducted a pilot study with 8 participants to evaluate a required
number of participants at a significance level of 0.05 using version 3.01 of
the G* Power software (Franz Foul, Kiel, Germany), and found that at least
40 participants were needed for each group. For the group represented by
the sample, the number of men with abnormal semen parameters who
smoked in Turkey was analyzed based on reported data. The prevalence of
smoking in men in Turkey is 42% [17], and the prevalence of abnormal

semen parameters in this population is 18.3% [18]. There are approxi-
mately 28 million adult men in Turkey [19]. While the mean total sperm

count before smoking cessation was 48.3 million, it was 61.2 million after
smoking cessation in the pilot study. The data of 8 participants were
included in the study group. We assumed that some participants would

not be able to quit smoking; thus, we enrolled 15% more participants in
the study group than in the control group. After institutional ethics
committee approval (FSMEAH-KAEK 2021/17) 130 men who applied to our
outpatient clinic because of infertility problems and who smoked at least
20 cigarettes a day for at least 1 year and were smoking at the time
recruitment were enrolled in the study.
Participants who smoked less than 20 cigarettes per day, drank alcohol
regularly or used recreational drugs in the previous 3 months, had a history
of vasectomy, varicocele, inguinal hernia operation, cryptorchidism,
hypospadias, testes injury, orchitis, or chronic urinary tract infection, had
radiation or chemotherapy treatment in the past, had chronic diseases
(e.g., diabetes, kidney diseases) and had abnormal reproductive organs or
azoospermia were excluded from the study. Chronic comorbid diseases
may impair semen parameters [20, 21]. Although infertile men with chronic
diseases are frequently seen, these patients were excluded to focus on the
effect of smoking.
In this prospective nonrandomized controlled trial, smoking cessation
was recommended to all patients; 70 patients who accepted smoking
cessation were assigned to the study group, and 60 patients who did not
accept smoking cessation were assigned to the control group. Eighteen
participants in the control group and 22 participants in the study group
were excluded from the study due to not being able to continue the
follow-ups for reasons such as the COVID-19 pandemic, being out of the
city, not being able to quit smoking, and not coming to the 3rd-month
visit. The participant evaluation flowchart is given in Fig. 1. We included the
remaining 90 men in the study after detailed examination of their medical
Fig. 1 Participant evaluation flowchart. Disclosure of participants included and excluded from the study. Reasons for drop-outs in groups.
Follow-up of the groups.

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records and daily routines. We performed a detailed examination to detect
conditions that could cause infertility. The duration of smoking, average
number of cigarettes smoked per day, alcohol use, drug or substance
abuse (yes or no) and demographic data of the participants were recorded
in a questionnaire. To better determine the effect of smoking, the subjects
who smoked 20 or more cigarettes per day and were defined as heavy
smokers in previous studies [14, 15] were included in the study.
Spermatogenesis in humans takes approximately 74 days [22]. It is stated
that 3 months is usually a sufficient time to see changes in semen analysis
results [23–25]. Thus, the period for semen analysis comparison in the
present study was determined to be 3 months for semen analysis
comparison. The men in the study group were asked to provide samples
for semen analysis twice (a total of four times) before and after smoking
cessation. There was a difference of at least 1 week between repeated
semen analyses. The average of the two semen analysis results was
calculated. When 2 semen analyses differed significantly from each other,
the third one was performed and the average of the two that were close to
each other was accepted as correct. The same follow-up was performed at
3-month intervals in the control group. Semen analysis is an important
method for evaluating male fertility [26]. For this reason, semen analysis
was evaluated in the present study.
The ejaculate was collected by way of masturbation after a sexual

abstinence period of 3 to 5 days and kept in a leak proof sterile wide-
mouthed container. The sample was left to liquefy at 37 °C for 20 min and

was analyzed according to the World Health Organization’s guidelines [27].
Semen analysis included a macroscopic examination of appearance,
viscosity, volume, and pH. The semen volume was evaluated by weighing
the samples, and the result was recorded after 60 s. We microscopically
analyzed the collected samples for sperm motility (a + b), morphology, and
density. We evaluated sperm motility and concentration with a Makler’s
counting chamber. Only progressive mobility (WHO grades a + b) was
included so that the results were more accurate and consistent. WHO
criteria were used to define oligozoospermia [27].
Statistical analysis
SPSS Statistics 22.0 (IBM, USA) was used for statistical analysis. Normality of
distribution of the parameters was evaluated by the Kolmogorov–Smirnov
test. Continuous data are presented as the median (min-max) or mean ±
standard deviation (SD). Statistical comparisons within groups were made
using the Wilcoxon signed-rank test, since the variables were not normally
distributed. We made statistical comparisons between groups using the
independent samples t-test when the data were normally distributed and the
Mann–Whitney U test when they were not. Changes in semen parameters
between the cessation group and the control group were evaluated in terms
of age, BMI and duration of infertility with the multivariable logistic
regression analysis test. The Yates corrected chi-square test was used when
the significance test of the difference between the two percentages was
applied. p < 0.05 was considered statistically significant.
RESULTS
In terms of age, body mass index, educational level, duration of
infertility, smoking time, and average number of cigarettes
smoked per day, there were no statistically significant differences
between the groups. Patient demographic characteristics and
information about smoking status are presented in Table 1.

A significant increase in semen volume, sperm concentration and
total sperm count was observed 3 months after smoking cessation
(2.48 ± 0.79 ml vs. 2.90 ± 0.77 ml, p = 0.002; 18.45 × 106
/ml ± 8.56

vs. 22.64 × 106

/ml ± 11.69, p = 0.001; 45.04 ± 24.38 × 106 vs.

65.1 ± 34.9 × 106

, p < 0.001, respectively). There was no statistically
significant difference in terms of baseline semen characteristics
between the groups. Semen volume, sperm concentration and
total sperm count were significantly higher in the study group
than in the control group in the 3rd month (p = 0.001, p = 0.001,

and p < 0.001, respectively). Although sperm motility and mor-
phology increased after smoking cessation, the difference was not

statistically significant (p = 0.190, and p = 0.120, respectively).
Changes in semen parameters in the groups are presented in
Table 2. Changes in semen parameters were compared with
multivariable logistic regression analysis in terms of age, BMI, and
duration of infertility (Table 3). One patient in the control group
and 8 patients in the study group became normospermic in the
3rd month. While the proportion of oligozoospermic patients
decreased significantly from 70.8% to 54.2% in the cessation
group (p = 0.043), it decreased from 69% to 66.6% in the control
group (p = 0.441).
DISCUSSION
Smoking has been reported to cause many adverse health
outcomes [28]. Evidence is controversial on whether smoking
affects semen parameters [29]. In the present study, a significant
increase was shown in semen volume 3 months after smoking
cessation. This might be an indicator of the effects of smoking on
accessory glands and improvement due to smoking cessation. The
other hypothesis was that nicotine in cigarettes might affect the
functioning of the auxiliary sex glands that control the volume of
semen through their secretion. There are studies showing that the
decrease in semen volume in smokers is inversely correlated to
the number of cigarettes consumed daily [30].
Our study highlights the fact that smoking has negative
consequences on semen quality. In our study, smoking cessation
improved sperm concentration and total sperm count. In the
literature, nicotine has been shown to reduce the total sperm
count in smokers [5]. In other studies, semen abnormalities have
been observed in smokers, depending on dose [30, 31]. Nicotine
negatively influences sperm count and morphology, whereas
seminal cotinine negatively affects sperm motility [29].
Although not statistically significant in our study, we found that
smoking cessation improved sperm motility. There are studies
showing a decrease in sperm motility in smokers [30, 32] because
of the toxic effects of nicotine [33] or an increased rate of carbon
monoxide in the blood, which leads to a decrease in oxygenated
hemoglobin and thus affects sperm mitochondrial oxygen
utilization.
In the present study, we found that smoking cessation did not
significantly change sperm morphology. One explanation for this

Table 1. Demographic characteristics and information about smoking status of patients.

Cessation Group (n = 48) Control Group (n = 42) p value*
Age (year) 34.3 ± 5.4 (28–40) 35.2 ± 5.3 (29–41) 0.342
Body mass index (kg/m2

) 23.2 ± 3.9 (19.1–27.3) 23.7 ± 3.7 (19.8–27.7) 0.282
Educational level (year) 11.7 ± 4.1 (7–16) 11.2 ± 4.6 (6–16) 0.201
Duration of infertility (month) 34.8 ± 11.5 (23–47) 33.3 ± 12.6 (20–46) 0.323
Smoking time (year) 8.2 ± 3.6 (4–12) 8.4 ± 3.4 (4–12) 0.103
Average number of cigarettes smoked per day 30.7 ± 6.8 (20–40) 29.4 ± 6.6 (20–40) 0.126
Smoking cessation time (day) 104.2 ± 11.51 (90–120) n.a n.a
Data are given as “mean ± SD”. Range values are given in parentheses.
*Independent T-Test.

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result is that these parameters probably require more tobacco
abstinence to decline to normal values. Another explanation is
that the patient’s long history of smoking caused irreversible
damage to some germ cells, and smoking cessation has no effect
on sperm morphology. A third possible explanation may be the
small number of participants included in the study. Although
some studies have not found any relationship between smoking
and sperm morphology, other studies have shown impairment in
sperm morphology in smokers [34], even inversely proportional to
the number of cigarettes smoked [30].
Our findings are partly in agreement with the meta-analysis of
Sharma et al. [15], which found that cigarette smoking has an
absolute adverse effect on semen parameters, particularly sperm
count and motility. However, this meta-analysis included both
fertile and infertile men, and several laboratory methods were
used for semen analysis. Ranganathan et al. [35] found a negative
effect of smoking on all semen parameters of infertile men,
especially on sperm motility, and significant changes in sperm
DNA fragmentation. Our results contrasted with those of Trummer
et al. [36] who found no significant differences in conventional
semen parameters or an increase in leukocytes, which are a main

source of reactive oxygen species (ROS) in the ejaculate, in
smokers.
To our knowledge, our study is the first to evaluate the effect of
smoking cessation on semen quality. Except for a case report [16]
that showed better semen parameters after 3 months of smoking
cessation, the studies in the literature compared smokers with
nonsmokers to describe the effect of smoking on semen quality.
Similar data were shown in a recent study showing a benefit of
assisted reproductive technology (ART) after the male partner quit
smoking. In this study, examining the effect of smoking cessation
on ART every passing year since a smoking man quit smoking, the
risk of failure during an ART cycle decreased by 4% each year,
regardless of the duration and intensity of smoking [37]. Although
they showed an improvement in ART after the male partner
stopped smoking, they calculated the number of cigarettes used,
the time of smoking cessation for former smokers and the
planned conservative smoking cessation period of at least
2 months for current smokers. In this respect, this study differs
from our study in terms of the duration of smoking cessation,
smoking dose, and the purpose. Therefore, the benefit of ART in
this study after the male partner quit smoking was open to bias.

Table 3. Multivariable logistic regression analysis at baseline/3rd month (n = 90).

Semen volume Sperm concentration Total sperm count Sperm motility Sperm morphology
OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
p value p value p value p value p value
Age 1.20 (1.16–1.24) 1.19 (1.15–1.23) 1.42 (1.37–1.47) 1.11 (1.07–1.15) 1.17 (1.12–1.22)
0.001 0.001 <0.001 0.186 0.113
Body Mass Index 1.14 (1.10–1.18) 1.13 (1.09–1.17) 1.36 (1.31–1.41) 1.06 (1.01–1.11) 1.13 (1.08–1.18)
0.002 0.001 <0.001 0.202 0.132
Duration of infertility 1.17 (1.12–1.22) 1.16 (1.12–1.20) 1.39 (1.33–1.45) 1.08 (1.01–1.15) 1.15 (1.11–1.19)
0.002 0.001 <0.001 0.188 0.115
Smoking cessation 1.16 (1.11–1.20) 1.18 (1.14–1.22) 1.41 (1.35–1.48) 1.06 (1.01–1.11) 1.13 (1.07–1.19)
0.001 0.001 <0.001 0.196 0.138

OR odds ratio (Increase in semen parameters with smoking cessation).
CI confidence interval.
Table 2. Baseline and 3rd month semen parameters of the cessation group and the control group.

Cessation group
(n = 48)

Control group
(n = 42)

p value**
Semen volume (ml) Baseline 2.48 ± 0.79 (1.5–3.5) 2.46 ± 0.75 (1.5–3.5) 0.257
3rd month 2.90 ± 0.77 (2.0–4.0) 2.45 ± 0.81 (1.5–3.5) 0.001
p value* 0.002 0.170

Sperm concentration (x106 /ml) Baseline 18.45 ± 8.56 (9–28) 17.56 ± 9.61 (7–28) 0.116
3rd month 22.64 ± 11.69 (10–35) 18.51 ± 9.42 (9–28) 0.001
p value* 0.001 0.192

Total sperm count (x106

) Baseline 45.04 ± 24.38 (20–70) 44.67 ± 22.7 (20–69) 0.241
3rd month 65.1 ± 34.9 (29–102) 46.2 ± 21.7 (23–69) <0.001
p value* <0.001 0.090

Sperm motility (A + B) (%) Baseline 20.54 ± 15.72 (4–38) 21.47 ± 14.76 (4–38) 0.316
3rd month 21.41 ± 14.97 (6–38) 20.6 ± 15.92 (4–38) 0.185
p value* 0.190 0.180

Sperm morphology (%) Baseline 2.22 ± 1.69 (0–10) 2.39 ± 1.58 (0–9) 0.211
3rd month 2.43 ± 1.47 (0–11) 2.26 ± 1.71 (0–10) 0.131
p value* 0.120 0.140

Data are given as “mean ± SD”. Range values are given in parentheses.
*Wilcoxon signed-rank test, **Independent T-Test.

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Another study that supports our study indirectly found no
significant difference in semen quality in any category in men who
previously smoked, compared with men who had never smoked. It
was indirectly shown that smoking cessation could have a positive
effect on semen quality [38]. Experimental animal (rat) studies
have shown that nicotine has dose-dependent detrimental effects
on sperm and this effect could be improved by nicotine cessation
[39].
Study limitations
Our study had some methodological limitations. First, the results
reflected the changing semen quality of men with infertility
problems who presented to an andrology outpatient clinic;
therefore, the study results should not be generalized to the
fertile population. Therefore, this situation can cause a selection
bias. The second limitation of our study was that self-reported
smoking was the only source of information about smoking habits
in our study, as in most published studies. There was no
information about subjective measures of cigarette exposure,
such as types of cigarettes, actual content in different products,
smoking methods, and breathing depth, or about objective
measures of cigarette smoke exposure such as cotinine levels. In
addition, subjects might have underreported their lifestyle habits,
particularly regarding the amount of smoking, which may cause a
bias in the results. A study showing that the nicotine metabolite
cotinine could provide a better measure of smoke exposure than
the number of cigarettes smoked per day found a correlation
between seminal plasma cotinine levels and decreased sperm
motility [40]. Therefore, biochemical evaluation of smoking
exposure is more desirable for the determination of smoking
effects. However, there are studies showing high accuracy
between the self-reported number of cigarettes and the values
measured with biochemical elements in the blood [41]. Some
studies have found a person’s self-report of smoking reliable
despite some misclassifications of smokers because of its
subjectivity [42]. Because our study did not examine cotinine or
other markers, we included only heavy smokers (over 20 cigarettes
per day) to observe the effect of smoking. Third, the groups were
formed as nonrandomized. Patients who quit smoking were more
likely to have a healthier lifestyle with a potential impact on
semen analysis. As another limitation, the time could be extended
up to 6 months to monitor changes in semen parameters.
However, maintaining motivation in the cessation group could be
difficult. In addition, no significant difference was observed
between 3 months and 6 months in studies comparing the
improvement in semen analysis [23–25]. Finally, hormonal
evaluation was not performed on the participants in our study.
Hormone profile evaluation is recommended when the sperm
concentration is <15 million/ml [43]. Since we did not include
azoospermic participants in our study, we did not evaluate the
hormone profile.

CONCLUSIONS
Our study showed that smoking cessation may improve semen
quality and reduce the number of patients with abnormal
parameters by improving semen volume, sperm concentration
and total sperm count. Therefore, infertile patients should be
strongly advised to quit smoking before any treatment.

DATA AVAILABILITY
The data that support the findings of this study are available from the corresponding
author (TT) upon reasonable request.

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AUTHOR CONTRIBUTIONS
Conceptualization, statistical analysis, writing—original draft, writing—review and
editing: DK, TT, ET, MY, MAR. Conceptualization, investigation, data curation,
resources: TT, MY, MAR, AG, MS Conceptualization, formal analysis, review: AG, MS.
Paper editing, review: DK, EA, RBD, MG, AV Supervision: MG, AV. All authors read and
approved the final paper.

COMPETING INTERESTS
The authors declare no competing interests.
ETHICS APPROVAL
Fatih Sultan Mehmet Training and Research Hospital Clinical Research Ethics
Committee 2021/17 approval was obtained.
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