A large number of studies have assessed the negative effect of alcohol consumption and/or smoking on sperm parameters, but the results remain controversial. Some studies have suggested a negative association between alcohol intake and semen quality but they could not confirm that a moderate consumption impairs semen parameters  . By comparing infertile non-smokers to infertile smokers a significant decrease in sperm count, progressive motility, normal forms and viability among them was observed  . Harmful effects of combined cigarette smoking and alcohol intake on fertility and reproduction are evident. Heavy smokers and heavy drinkers have worse seminal parameters in comparison to moderate smoking/drinking and nonsmoking/abstaining  . Several studies have reported an association of alcohol consumption and smoking with fertility disorders   , however, a worrying phenomenon of tobacco and alcohol consumptions keeps increasing, particularly among younger subjects  .
In a comparison of smokers with non smokers, active smoking, even if in small amount, is associated with a decreasing sperm concentration while no significant correlation is present with morphology or sperm motility  . The components in cigarette smoke can induce genetic and epigenetic alterations in infertile men   . Sexual dysfunction is common in male patients with alcohol dependence  . The association between alcohol consumption and mortality seems to vary depending on the amount of alcohol consumed. The consumption of light or moderate quantity of alcohol might reduce mortality from cardiovascular diseases. This favorable effect is not found for cigarette smoking  .
The association of varicocele with infertility has been widely examined although with not agreement in results. Varicocele is associated to an amendable male infertility. It is probably the cause of subfertility and can induce pathophysiological mechanisms and between these the oxidative stress has a central role. Many studies suggest that varicocelectomy influences positively semen quality and pregnancy results and about the progressive deterioration of semen parameters it seems there is a substantial difference between adults and adolescents    . In the present study we have studied couples with a history of infertility of more than two years and male partners with varicocele to deepen the role of varicocele in infertility. In this group of subjects we have assessed the relationship of infertility with smoking habit and/or alcohol intake.
2. Subjects and Methods
This study was carried out on 136 patients with varicocele admitted consecutively to the Outpatients Department of Infertility, a public center of infertility frequented by people of lower-middle social class, at the University of Rome La Sapienza (Italy) between 2005-2007. 59 patients were infertile men and the average age of the sample was of 32 years. All patients gave informed consent to participate in the study that was approved by the Department Council. Part of these patients has been included in previous studies    Diagnosis of varicocele was confirmed by use of the scrotal eco-colordoppler (TOSHIBA APLIO XV). Analysis of spermatic liquid was performed according to the World Health Organization (WHO) criteria (1999). Seminal liquid was obtained after sexual abstinence for three to five days. All subjects had no fever, no pharmacological treatment with non-steroidal anti-inflammatory drugs, antibiotics or cortisones in the two weeks preceding the examination. The whole spermatic liquid was collected in a sterile container and delivered to the laboratory within 60 min. Spermatic parameters were determined from the seminal liquid. Spermatic concentration is reported as millions of spermatozoa/ml. A typical spermatozoa and abnormal motility are reported in percent (%).
A couple was classified as infertile if it is unable to conceive after one year of regular intercourse with the intent to conceive.
The intent of this study is to evaluate in these patients the relationship between smoking and alcohol intake and the effect of age, smoking and alcohol on infertility.
Chi-square test of independence, Student t test, correlation analysis and discriminant analysis were carried out using the software Statistical Package for the Social Sciences-SPSS.
Table 1 shows separately in fertile and infertile men the proportion of patients with/without smoking and alcohol consumption, the proportion of infertile men and the average age of the patients.
Table 2 shows the relationship between smoking and alcohol consumption with infertility. Smoking and infertility haven’t association whereas alcohol consumption is significantly associated with infertility (p = 0.004). The proportion of drinkers is very high.
Table 3 shows the relationship between smoking and alcohol and absence of both smoking and alcohol with infertility. The relationship between smokers non drinkers and between drinkers non smokers with infertility is present (p = 0.02).
Table 4 shows the correlations between smoking and infertility and between alcohol consumption and infertility. Infertility is not correlated with smoking neither in the whole sample nor in drinkers whereas it is significantly correlated with alcohol consumption in both the whole sample and in smokers (p = 0.004).
Table 5 shows the effect of age on infertility, smoking habit and alcohol consumption. The proportion of infertile men (p < 0.001) as well as of alcohol consumption (0.016) increases with age whereas the smokers decrease and their relation is not significant.
The average age of the patients was 32 years and Table 6 shows the correlation between infertility and smoking and alcohol consumption in relation to 32 years. Infertility is highly related to alcohol consumption only in patients with an age lower than or equal to 32 years (p = 0.008).
Table 1. The proportion of patients in relation to smoking, alcohol, infertility and age.
Table 2. The relationship of smoking and alcohol with infertility.
Table 3. The relationship of the presence/absence of smoking and alcohol with infertility.
Table 4. The correlation between alcohol consumption and infertility and between smoking and infertility.
Table 5. The effect of age on infertility, smoking and alcohol consumption.
>28 ≤32 yr: over 28 years and under or equal to 32 years.
Table 6. The correlation between smoking and infertility and between alcohol consumption and infertility in relation to age.
Table 7 shows the results of a discriminant analysis that assesses the effects of alcohol, smoking and age on infertility separately in men with an age ≤ 32 years and > 32 years. In men with an age ≤ 32 years, infertility depends on all the three variables. Alcohol consumption gives a very important contribution to discrimination followed by smoking whereas the contribution from the age is small.
Considering some parameters examined, Table 8 shows the difference between fertility and infertility in relation to the groups of alcohol consumption and smoking. The difference is significant for spermatozoa concentration and atypical spermatozoa in non smokers-non drinkers, it is significant for rectilinear mobility in smokers-non drinkers, and it is significant for rectilinear mobility in drinkers-non smokers. A borderline significance is present for atypical spermatozoa in drinkers non smoking and for spermatozoa concentration,
Table 7. Discriminant analysis. The effect of alcohol consumption, smoking and age on infertility in relation to the average age.
Table 8. Some parameters examined: difference between fertile and infertile men in relation to smoking and alcohol consumption.
rectilinear mobility and atypical spermatozoa the difference is significant in drinkers-smokers but the number of the patients is very small.
Examining the difference between fertility and infertility separately in patients with an age ≤ 32 years and in those with an age > 32 years, in patients non smokers-non drinkers we have found a significant difference for spermatozoa concentration (p = 0.03, n = 33) and for atypical spermatozoa (p = 0.001, n = 31), in smokers-drinkers a borderline difference (p = 0.047, n = 12) for atypical spermatozoa and a significant difference (p = 0.002, n = 10) for atypical and diskynetic spermatozoa in drinkers-non smokers.
In the present study we have examined the male partner of couples with marital infertility lasting more than two years. The male partner had varicocele and the mean subject age was 32 years.
As a large number of controversial studies have been made, we focused on the negative effect on sperm parameters of, alcohol consumption and smoking. Our research shows that alcohol is an important risk factor for infertility in men with varicocele. Examining separately the relationship of infertility with smoking and alcohol consumption, only the relationship with alcohol consumption was significant (Table 2). When the relation of infertility with smoking without alcohol consumption and with of alcohol consumption without smoking was assessed, the proportion of alcohol consumers non smokers was higher than the others (Table 3). The correlation analysis between smoking, alcohol consumption and infertility also showed that alcohol consumption is an important risk factor for infertility (Table 4).
The proportion of infertility and alcohol consumption increased significantly with age (Table 5) but alcohol consumption was associated with infertility only in young subjects (Table 6). The absence of this relationship in men older than 32 y is probably due to clinical, environmental or functional factors that remain to be elucidated.
Many clinical studies have demonstrated that alcohol alters and decreases testosterone metabolism. High alcohol consumption and alcohol dependence can cause lower testosterone level and alter sexual function. Testosterone is involved directly in almost all components of the male reproductive process and a decrease in testosterone correlates with a range of clinical problems including reduced fertility, reduced semen volume, impotence and inability to get an erection   . Rivier and Vale have also found that alcohol intake stimulates adrenal hormone release which also interferes with reproductive functions in humans and animals  .
On these men, subsequently, we have examined the association of some genetic polymorphisms with infertility to see their influence on spermatic parameters in particular on spermatozoa motility and male infertility   and highlighted that the use of antioxidants supplementation on sperm parameters could improve fertility  . The sample is small because our study includes only subjects with varicocele. Our results must to be taken into account when they are compared to other studies where the subject group examined includes men with and without varicocele. Despite the limitations our results lay the foundation for broader analyses using larger cohorts and examining populations including individuals with diverse ethnicities and socio-economic background.
 Ricci, E., Al Beitawi, S., Cipriani, S., Candiani, M., Chiaffarino, F., Viganò, P., Noli, S. and Parazzini, F. (2017) Semen Quality and Alcohol Intake: A Systematic Review and Meta-Analysis. Reproductive BioMedicine Online, 34, 38-47.
 Mostafa, R.M., Nasrallah, Y.S., Hassan, M.M., Farrag, A.F., Majzoub, A. and Agarwal, A. (2018) The Effect of Cigarette Smoking on Human Seminal Parameters, Sperm Chromatin Structure and Condensation. Andrologia, 50, e12910.
 Boeri, L., Capogrosso, P., Ventimiglia, E., Pederzoli, F., Cazzaniga, W., Chierigo, F., Dehò, F., Montanari, E., Montorsi, F. and Salonia, A. (2019) Heavy Cigarette Smoking and Alcohol Consumption Are Associated with Impaired Sperm Parameters in Primary Infertile Men. Asian Journal of Andrology, 21, 478-485.
 Sansone, A., Di Dato, C., de Angelis, C., Menafra, D., Pozza, C., Pivonello, R., Isidori, A. and Gianfrilli, D. (2018) Smoke, Alcohol and Drug Addiction and Male Fertility. Reproductive Biology and Endocrinology, 15, 3.
 Aryanpur, M., Tarahomi, M., Sharif, I.H., Heydari, G., Hessami, Z., Akhoundi, M. and Masjedi, M.R. (2011) Comparison of Spermatozoa Quality in Male Smokers and Nonsmokers of Iranian Infertile Couples. International Journal of Fertility & Sterility, 5, 152-157.
 Prabhakaran, D.K., Nisha, A. and Varghese, P.J. (2018) Prevalence and Correlates of Sexual Dysfunction in Male Patients with Alcohol Dependence Syndrome: A Cross-Sectional Study. Indian Journal of Psychiatry, 60, 71-77.
 Xu, W.H., Zhang, X.L., Gao, Y.T., Xiang, Y.B., Gao, L.F., Zheng, W. and Shu, X.O. (2007) Joint Effect of Cigarette Smoking and Alcohol Consumption on Mortality. Preventive Medicine, 45, 313-319.
 Jensen, C.F.S., Ostergren, P., Dupree, J.M., Ohl, D.A., Sonksen, J. and Fode, M. (2017) Varicocele and Male Infertility. Nature Reviews Urology, 14, 523-533.
 Gentile, V., Nicotra, M., Scaravelli, G., Antonini, G., Ambrosi, S., Saccucci, P., Adanti, S., Bottini, E. and Gloria-Bottini, F. (2014) ACP1 Genetic Polymorphism and Spermatic Parameters in Men with Varicocele. Andrologia, 46, 147-150.
 Gentile, V., Nicotra, M., Minucci, S., Ambrosi, S., Saccucci, P., Gloria-Bottini, F. and Bottini, E. (2015) The Relationship between p53 Codon 72 Genetic polymorphism and Sperm Parameters. A Study of Men with Varicocele. Reproductive Medicine and Biology, 14, 11-15.
 Gentile, V., Nicotra, M., Bottini, E., Gloria-Bottini, F., Modafferi, F. and Gentile, G. (2016) Genetic Variability within ADA Gene Region and Infertility in Subjects with Varicocele. Journal of Andrology & Gynaecology, 4, 4.
 Sarkola, T. and Eriksson, C.J. (2003) Testosterone Increases in Men after a Low Dose of Alcohol. Alcoholism: Clinical and Experimental Research, 27, 682-685.
 Rivier, C. and Vale, W. (1988) Interaction between Ethanol and Stress on ACTH and β-Endorphin Secretion. Alcoholism: Clinical and Experimental Research, 12, 206-210.
 Busetto, G.M., Agarwal, A., Virmani, A., Antonini, G., Ragonesi, G., Del Giudice, F., Micic, S., Gentile, V. and De Berardinis, E. (2018) Effect of Metabolic and Antioxidant Supplementation on Sperm Parameters in Oligo-Astheno-Teratozoospermia, with and without Varicocele: A Double-Blind Placebo-Controlled Study. Andrologia, 50, e12927.