Abstract
Objective: The aim of the study was to determine whether Ramadan month-long daily fasting affects semen analysis parameters. Methods: This retrospective cohort study was conducted in tertiary academic medical center. Medical records of 97 Muslim patients who were admitted to the IVF unit from May 2011 to May 2021 were reviewed. Only men who provided at least one semen sample during Ramadan period (Ramadan month +70 days after) and one sample not during Ramadan were included. Semen characteristics of each patient were independently compared to themselves. Results: The post-gradient semen analysis indicated significantly lower progressive sperm motility (mean 30.01 ± 20.46 vs. 38.12 ± 25.13) (p < 0.001). The decrease in the progressive motility remained significant among patients with non-male factor indications (p < 0.001). In the non-male factor indication group, the difference in the progressive motility of the post-gradient semen analysis between the 2 samples was not statistically significant (p = 0.4). There were no significant differences between semen parameters before centrifuging. The incidence of asthenospermia (progressive sperm motility <32%) as an absolute parameter was higher after centrifuging the semen sample during the Ramadan period (p = 0.04). Conclusions: Semen samples collected during Ramadan period were associated with lower progressive motility and reduced semen volume compared to semen samples from the same men outside of the Ramadan period. A possible effect of these altered semen parameters on fertility should be investigated further.
Introduction
During the month of Ramadan, approximately 1.6 billion practicing Muslims worldwide abstain from eating, drinking, smoking, and sexual activities from sunrise to sunset [1]. This alteration in eating and sleeping patterns, along with other lifestyle changes during the period, leads to various physiological changes. Several studies have reported changes in metabolism, hormone secretion, body mass index, immune system, and preexisting medical conditions, such as diabetes [2‒5].
During Ramadan, the feast and fast periods are an average of 12 h each, depending on geographical location and time of year. A common dietary practice is to consume a large meal after sunset and a light meal before dawn, but individual practices vary significantly [6].
A few studies have reported on the impact of Ramadan fasting on male fertility. They focused on changes in sex hormone secretion and sexual behaviors and the results were often contradictory. One study reported significantly increased evening testosterone levels and decreased morning testosterone levels during the month in males, that persisted 2 weeks after Ramadan [7]. Another study showed decreased testosterone levels and increased follicle-stimulating hormone 20 days into the fasting period. However, Talib et al. [8] reported a decrease in sexual desire, frequency of sexual intercourse, and serum follicle-stimulating hormone level, with no significant changes in erectile function, serum testosterone, or luteinizing hormone [9]. Information regarding the effects of Ramadan fasting on male fertility is lacking. Studies that investigated changes in sex hormone secretion and sexual behavior did not directly investigate the impact of this type of fasting on male fertility. In addition, the results are often affected by multiple confounding variables due to variations in fasting practices.
Semen analysis is a standard laboratory test used to evaluate male fertility. To our knowledge, data on changes in semen analysis parameters before and after Ramadan are lacking. Therefore, the objective of this study was to investigate the impact of Ramadan fasting on semen analysis parameters.
Methods
This retrospective cohort study was conducted at a tertiary, university-affiliated medical center.
Ethics Approval
The retrospective study was approved by the Local Institutional Review Board, protocol number 244-21. The research adhered to the Helsinki Guidelines, and the Helsinki Committee of Meir Medical Center granted an exemption for obtaining informed consent due to the retrospective nature of the data collection. Moreover, the data were coded in a manner that safeguarded the confidentiality of identifying information.
We reviewed the medical records of all Muslim patients who underwent an IVF treatment from May 2011 to May 2021. The fasting period was defined as the beginning of the month of Ramadan until 70 days after it ended. Seventy days were included in this period, as it is the duration of spermatogenesis [10]. Participants were included only if they provided two semen samples: one during the month of Ramadan or within 70 days following it, and another from a control period, which is defined as any time outside of this 70-day window, either before or after Ramadan. Patients with chronic illnesses or chronic medications were excluded from the study. Smoking or specific dietary habits was not an exclusion criterion.
Patient Involvement
We conducted a preliminary survey among Muslim patients treated in our IVF unit to validate our assumption that most of them fast during Ramadan. Over 80% declared that they observe the fast every year. Therefore, we assumed that almost all the patients included in the study, fasted.
Semen Analysis
Semen parameters were evaluated on the day of oocyte retrieval. Both native semen and semen after centrifuging were examined for volume, concentration, and motility (as is done with every semen examination in our facility). The same protocol was implemented for all samples during the study period, using the same products and equipment and the same embryology team. The samples were left to liquefy for 30 min. Sperm cells were isolated from the semen using a PureCeption bilayer kit (ORIGIO, Målov, Denmark) in accordance with the manufacturer’s instructions. Then, the sample was placed on a 40% and 80% silica bead gradient and centrifuged for 20 min at 500 RCF. The supernatant was removed and cells in the pellet were resuspended in 5 mL of Multipurpose Handling Medium-Complete (Irvine Scientific, CA, USA) and centrifuged again at 500 RCF for 5 min. The supernatant was discarded and the pellet containing the live sperm cells was resuspended in 100 µL human tubal fluid. For the stain-based morphological assays, 5 µL of the sample were placed on V-stain morpho-slide (Vitromed, Jena, Germany) and processed according to manufacturer’s guidelines. Semen quality was evaluated based on concentration, sperm count, motility, total motile count (TMC), and sperm morphology. Sample preparation and analysis were based on the 2010 World Health Organization (WHO) guidelines and criteria [11].
Medical records were reviewed for demographic information, indications for IVF treatment, and semen analysis before and after the preparation process. Semen analysis was evaluated for each patient for changes during Ramadan and during the control period – outside of the Ramadan period.
Statistical Analysis
Data were analyzed using SPSS v.27.0 for Windows (IBM Corp., Armonk, NY, USA). Descriptive parameters are expressed as mean ± standard deviation or median ± interquartile range, as required. Frequencies are presented as percentages. Wilcoxon sign test was used for paired variables with nonnormal distribution. The McNemar test was used for categorical parameters.
The sample size needed to attain a power of 80% and a level of significance of 5% (two-sided) was calculated. Ninety pairs of semen samples were required to achieve a 30% difference in semen parameters between the Ramadan and control periods. A p value <0.05 was considered statistically significant. All statistical tests were two-tailed.
Results
Among 345 eligible Muslim patients, 97 provided two relevant semen samples: one collected during the fasting period (fasting month +70 days after), and one collected outside this period. The mean patient age was 34.04 ± 5.4 years. Main indications for fertility treatment were male factor (56.8%), unexplained infertility (26.3%), mechanical factor (9.5%), and anovulation (7.4%).
The semen analyses during the Ramadan and control periods are presented in Table 1. The post-gradient semen analysis indicated significantly lower progressive semen motility (mean 30.01% ± 20.46 vs. 38.12% ± 25.13; p < 0.001) during the fasting period.
Comparison of semen parameters in 97 patients during Ramadan versus control periods
| Semen parameter | Ramadan period | Control period | p value | ||
|---|---|---|---|---|---|
| mean±SD | median (IQR) | mean±SD | median (IQR) | ||
| Before centrifuging | |||||
| Volume, mL | 3.28±2.27 | 2.50 (1.60–4.50) | 4.08±2.35 | 4.00 (2.00–5.50) | 0.001 |
| Concentration, ×106 | 23.02±28.85 | 10.00 (2.7–36.0) | 20.64±26.12 | 11.00 (2.00–28.00) | 0.44 |
| Progressive motility (%) | 34.18±23.91 | 33.00 (12.00–50.00) | 35.31±24.07 | 38.00 (16.00–50.00) | 0.437 |
| Total motile sperm count | 30.36±46.94 | 10.00 (1.20–37.50) | 32.45±49.40 | 11.2 (1.86–40.50) | 0.353 |
| After centrifuging | |||||
| Volume, mL | 1.89±0.27 | 0.10 (0.05–0.20) | 0.18±0.24 | 0.10 (0.05–0.15) | 0.788 |
| Concentration, ×106 | 61.29±210.81 | 22.00 (8.20–52.00) | 38.09±43.76 | 20.00 (7.00–54.00) | 1 |
| Progressive motility (%) | 30.01±20.46 | 30.50 (11.50–50.00) | 38.12±25.13 | 36.00 (17.00–58.50) | 0.001 |
| TMC | 6.67±25.55 | 0.64 (0.15–3.23) | 5.34±14.91 | 0.73 (0.9–4.69) | 0.37 |
| Semen parameter | Ramadan period | Control period | p value | ||
|---|---|---|---|---|---|
| mean±SD | median (IQR) | mean±SD | median (IQR) | ||
| Before centrifuging | |||||
| Volume, mL | 3.28±2.27 | 2.50 (1.60–4.50) | 4.08±2.35 | 4.00 (2.00–5.50) | 0.001 |
| Concentration, ×106 | 23.02±28.85 | 10.00 (2.7–36.0) | 20.64±26.12 | 11.00 (2.00–28.00) | 0.44 |
| Progressive motility (%) | 34.18±23.91 | 33.00 (12.00–50.00) | 35.31±24.07 | 38.00 (16.00–50.00) | 0.437 |
| Total motile sperm count | 30.36±46.94 | 10.00 (1.20–37.50) | 32.45±49.40 | 11.2 (1.86–40.50) | 0.353 |
| After centrifuging | |||||
| Volume, mL | 1.89±0.27 | 0.10 (0.05–0.20) | 0.18±0.24 | 0.10 (0.05–0.15) | 0.788 |
| Concentration, ×106 | 61.29±210.81 | 22.00 (8.20–52.00) | 38.09±43.76 | 20.00 (7.00–54.00) | 1 |
| Progressive motility (%) | 30.01±20.46 | 30.50 (11.50–50.00) | 38.12±25.13 | 36.00 (17.00–58.50) | 0.001 |
| TMC | 6.67±25.55 | 0.64 (0.15–3.23) | 5.34±14.91 | 0.73 (0.9–4.69) | 0.37 |
SD, standard deviation; IQR, interquartile range.
When comparing male versus non-male factors as indications for IVF treatment (Table 2), the decrease in progressive motility remained significant in patients with non-male factor indications (p < 0.001). However, in the male factor indication group, the difference in progressive motility between the 2 samples was not significant (p = 0.4). There were no significant differences between semen parameters before centrifuging. There was no difference between the fasting and non-fasting samples in volume, concentration, and TMC after centrifuging the semen sample. A comparison of the incidence of semen abnormalities in the two time periods is presented in Table 3. The incidence of asthenospermia (progressive sperm motility <32%) as an absolute parameter was higher after centrifuging in semen samples taken during the Ramadan period (p = 0.04) [10].
Progressive motility (%) after centrifuge according to indication for treatment
| Variable | Ramadan period | Control period | p value |
|---|---|---|---|
| Male indication | 18.00 (3.25–43.00) | 20.00 (7.00–43.00) | 0.40 |
| Other indication | 39.00 (23.25–50.00) | 54.00 (33.00–69.00) | <0.001 |
| Variable | Ramadan period | Control period | p value |
|---|---|---|---|
| Male indication | 18.00 (3.25–43.00) | 20.00 (7.00–43.00) | 0.40 |
| Other indication | 39.00 (23.25–50.00) | 54.00 (33.00–69.00) | <0.001 |
Data are reported as median (intra-quartile range).
Comparison of semen abnormalities (%) in 97 patients during Ramadan versus control periods
| Semen abnormality | Ramadan period | Control period | p value |
|---|---|---|---|
| Before centrifuging | |||
| Oligospermia | 57.3 | 54.2 | 0.53 |
| Severe oligospermia | 33.7 | 30.5 | 0.47 |
| Asthenospermia | 44.2 | 45.2 | 0.85 |
| TMC ≤3 | 33.3 | 32.3 | 0.82 |
| After centrifuging | |||
| Oligospermia | 36.60 | 44.10 | 0.14 |
| Severe oligospermia | 20.40 | 18.30 | 0.56 |
| Asthenospermia | 51.60 | 39.60 | 0.04 |
| TMC ≤3 | 71.90 | 68.50 | 0.47 |
| Semen abnormality | Ramadan period | Control period | p value |
|---|---|---|---|
| Before centrifuging | |||
| Oligospermia | 57.3 | 54.2 | 0.53 |
| Severe oligospermia | 33.7 | 30.5 | 0.47 |
| Asthenospermia | 44.2 | 45.2 | 0.85 |
| TMC ≤3 | 33.3 | 32.3 | 0.82 |
| After centrifuging | |||
| Oligospermia | 36.60 | 44.10 | 0.14 |
| Severe oligospermia | 20.40 | 18.30 | 0.56 |
| Asthenospermia | 51.60 | 39.60 | 0.04 |
| TMC ≤3 | 71.90 | 68.50 | 0.47 |
Discussion
Main Findings
This study compared the results of semen analyses between a period of month-long daily fasting with a non-fasting period. The post-gradient semen analysis indicated that progressive semen motility was significantly lower during the fasting period. When comparing male versus non-male factors as indications for IVF treatment, the decrease in progressive motility remained significant in patients with non-male factor indications. The incidence of asthenospermia as an absolute parameter in semen samples taken during the fasting period was higher after centrifuging.
Strengths and Limitations
This study was the first to examine the effect of Ramadan fasting on the parameters of semen analysis. It directly assessed the impact of this specific type of intermittent fasting on semen parameters. However, several limitations warrant consideration.
While participants provided two semen samples, one during and one outside of the Ramadan period, the exact time intervals between these samples were not standardized or recorded, which introduces a potential source of variability. Nevertheless, by comparing samples from the same individual, we aimed to mitigate potential time-related differences.
Furthermore, our assumption that all Muslim participants observed fasting during Ramadan was based on a local survey, which found that 80% of Muslim patients adhered to the fast. It is essential to note that individual fasting practices can vary, and future studies might benefit from direct inquiries about these habits to refine data accuracy. Additionally, while we considered the potential confounding effect of reduced frequency of intercourse during fasting, on sperm motility. Semen analysis was conducted during the period including the month of Ramadan and 70 days after its onset, which should make the effect of frequency of intercourse insignificant. Importantly, this study did not account for potential infectious diseases or vitamin intake that could influence sperm parameters. Future research could investigate these factors more thoroughly to offer a more comprehensive understanding.
In addition to the aforementioned limitations, it’s imperative to emphasize the scope for future research. To truly isolate the specific impact of fasting on sperm parameters, upcoming studies should dissect the individual effects of dietary habits, sleep patterns, smoking, and other potential confounders during Ramadan. This comprehensive approach will not only refine our current understanding but also provide a holistic view of the multifaceted influences on male fertility during this period.
Interpretation
Asthenospermia, defined as sperm motility less than 40% on semen analysis or 32% progressive motility [11], is a common cause of male infertility, with a prevalence of 18.71% among infertile men [12]. Several studies have demonstrated that sperm motility parameters are associated with clinical pregnancy outcomes. For example, the initial native motility of sperm was found to be associated with clinical outcomes [13]. The study reported that for every 10% increase in native motility, fertilization rate increased by 0.7%, implantation rate by 1.6%, and odds of clinical pregnancy by 1.07. The reported differences in clinical outcomes were negligible. A recent study showed that no live births occurred when the TMC was under two million sperm [14]. Another study found that native total motile sperm count correlated with the spontaneous ongoing pregnancy rate and suggested using this parameter as the method of choice to indicate the severity of male infertility [15].
Potential causes of asthenospermia include structural and energy-driving defects of the sperm, genetic contributions, and molecular pathways that induce apoptosis or increased oxidative stress [16]. Intermittent fasting during Ramadan was found to be associated with impaired sperm motility in our study. Altered energy metabolism and an inflammatory/oxidative stress environment during Ramadan fasting are two potential causes of the adverse effects on sperm motility. Dietary changes during Ramadan alter sugar and fat metabolism that can acutely induce changes in sperm motility. One study reported that human sperm motility is acutely influenced by nutrient flux through nutrient-sensitive tRNA-derived small RNA [17]. Specifically, the group found that the level of nuclear internal T-loop tRNA-derived small RNA (primarily of mitochondrial origin) is sugar-sensitive and positively associated with changes in sperm motility. Similarly, lipid metabolism was also found to affect sperm motility. Ding et al. [18] reported that a high-fat diet alters the gut microbes of mice and negatively affects sperm motility. They found an increase in Bacteroides and Prevotella, which have a strong negative correlation with sperm motility and a positive correlation with serum toxin levels. Furthermore, oxidized LDL was found to inhibit testosterone biosynthesis through impairment in mitochondrial function in Leydig cells. Future studies should further categorize the dietary patterns of subjects during the feast period and investigate the effects of nutrient flux on sperm motility mentioned above.
Another possible cause of impaired sperm motility during extended periods of daily fasting is the altered level of oxidative stress. Oxidative stress was found to induce axonemal damage and midpiece morphological defects in sperm, which lead to impaired motility [19]. While fasting and reduced caloric intake were hypothesized to alleviate oxidative stress in healthy individuals, a study found a significantly increased level of oxidative stress at the end of the third week of Ramadan, with a significant increase in body weight and total body fat percent [20].
Changes in sleep patterns during Ramadan can also affect sperm quality. A randomized clinical trial reported that short duration of sleep (less than 6 h) is associated with lower sperm counts and decreased sperm motility [21]. The study also reported a higher proportion of semen samples positive for antisperm antibodies among subjects who had less than 6 h of sleep. Similarly, a cross-sectional study reported an inverse, U-shaped association between sleep disturbances and sperm quality, including sperm concentration, total sperm count, percent motile, and percent morphologically normal spermatozoa, as well as testis size [22]. Future investigations should elucidate the mechanisms of these changes and assess prospectively whether restoration of normal sleeping patterns improves semen quality.
Similarly, changes in smoking habits can affect sperm quality. While smoking is prohibited during the fast, it is permitted during the feast period and might be accompanied by overcompensated smoking. Smoking habits during non-fasting times affect semen analysis parameters. Studies have shown smoking is associated with reduced sperm count and motility [23, 24]. Therefore, smoking habits, in addition to dietary habits and sleeping patterns should be considered in the assessment of sperm quality during Ramadan and the following 70-day period.
In the current study, we found that Ramadan fasting had a stronger effect on sperm parameters among patients without male factor indications. This highlights the importance of determining the effects of fasting on sperm quality and clinical pregnancy outcomes when counseling this group of patients who attempt to conceive naturally.
Intermittent fasting has become an increasingly popular diet for weight loss [22]. There are different regimens of intermittent fasting, including complete alternate-day fasting, modified fasting, and time-restricted feeding. Ramadan fasting is a type of intermittent fasting. Therefore, studies that examine the effects of intermittent fasting on fertility contribute to our understanding of the potential effects of this fast on fertility, as well.
Previous animal and human studies have suggested that intermittent fasting may be beneficial for the overall health and wellbeing of individuals [25]. The benefits include longer lifespan, decreased mortality rate from cancers and cardiovascular diseases, and improved insulin sensitivity [26, 27]. Other studies indicated potential adverse effects of intermittent fasting on fertility. Most of these diets are restricted to 20–40% reductions in daily energy intake per day. In women, undernourishment and low BMI lead to reproductive dysfunction and infertility [28, 29].
Another finding of the current study was reduced semen volume among patients during the fasting period. Due to the reduced frequency of intercourse during Ramadan, we expected to see increased semen volume. However, restricted fluid intake may have contributed to the reduced semen volume [30].
Ramadan fasting is customary among a large proportion of the world’s population, which makes it one of the most commonly observed fasts. Therefore, further studies and increased understanding of its effect on fertility might also shed light on the possible effects of intermittent fasting on weight loss.
Conclusions
For couples trying to conceive during Ramadan, it is important to understand how fasting during this period may affect their chance of achieving pregnancy, which might affect the decision regarding the timing of semen collection. As future studies elucidate the potential effects of dietary practices and body weight composition on the function of sperm, clinicians will be able to better counsel the patients to optimize their chances of natural conception while engaging in extended periods of daily fasting.
Acknowledgment
Faye Schreiber, MS, edited the manuscript. She is an employee of Meir Medical Center.
Statement of Ethics
The retrospective study was approved by the local Institutional Review Board, protocol number 244-21. The study was conducted according to the Helsinki Guidelines. Informed consent was not required.
Conflict of Interest Statement
The authors declare that they have no conflict of interests.
Funding Sources
No funding was received for this study.
Author Contributions
O.E., N.D., B.S., N.M., M.L., H.S., N.S., A.W., and E.H.H.: substantial contributions to the study conception and design, analysis, and interpretation of data; drafting the manuscript and revising it for important intellectual content; and final approval of the version to be published.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Further inquiries can be directed to the corresponding author.
References
