Association between life style factors and sub-fertility among women, attend two specials hospital for women in Colombo: A case control study

Background: Sub-fertility has become a dominant health issue among married couples, expecting a baby with impacting social, psychological, and nancial consequences especially in developing countries. As well as life style factors, which cause to immense effect on reproductive health has been changing dramatically at present. This study accordingly determines the association between life style factors and sub-fertility of women. Method: 125 of case and 320 of control were enrolled. A pre tested structured questionnaire was used to collect the data through face to face interview. Chi-square, Man Whitney and independent sample T tests were performed (SPSS-22 version). Furthermore Odds Ratio (OR) was done for passive smoking and entertains with music. Result: The mean age at marriage was 25.1±3.1 and 26.5±3 for fertile sub-fertile women respectively. Vigorous and moderate physical activities were signicantly high among sub-fertile than fertile (P<0.05 C.I 95%), but total sitting time was not signicantly different between two groups (P=0.16 CI 95%). Time of sedentary hobbies were high among fertile than sub-fertile (P=0.00 CI 95%). OR for passive smoking was 1.32 CI 95% and it was 0.6 CI 95% for entertainment with music. Invoking blessing of god is the most common religious practices among both groups. Conclusion: This study demonstrated that the moderate physical activities and sedentary hobbies are not associated with fertility and second hand smoking has a negative effect while entertainment with music has a positive effect to the fertility.

are behavior and circumstances, that can be modi ed and contribute to improve the health and wellbeing of the people including fertility (7).
Although modi cation of life style factors, pave the way to increase the fertility, there are 86.8%sub-fertile women don't engage in a sport activity or exercise regularly in Sri Lanka.As well as one third of sub-fertile women are either overweight or obese (9).Premature deaths and morbidity due to chronic disease has increased dramatically due to unhealthy life style factors of the people in Sri Lanka (10).Hence there is a greater possibility that the same consequences have affected to the fertility of the people in Sri Lanka due to improper life style changes.
Under these circumstances it was imperative to study on association between modern life styles and subfertility of the women, who are expecting a baby.Physical activities (vigorous & moderate), leisure time activities (sedentary & physically active), exposure to the passive smoking and mental relaxing practices are the factors which have been studied.
Primary health care providers in Sri Lanka conduct more fertility awareness programmes for newly married couples in regular basis.Moreover they carry out individual counselling sessions for sub-fertile couples.Hence the nding of this study can be utilized to prioritize and specify the activities, pertaining to fertility, conducted by the divisional health authority in the country.Method 2.1 Study design: This was a case control study and cases were sub-fertile women, attended to the subfertility clinic and control were pregnant women attended to the antenatal clinics.Study was conducted in CSHW and DSHW in Colombo -08.Only primary sub-fertile women for cases and pregnant women with parity one as well as without had any fertility issues were selected for control in the study.Women, with any chronic disease were excluded from the study.The total amount of women, recruited for the study was 425 and 105 (25%) were sub-fertile and 320 (75%) were fertile.
2.2 Data collection: Written informed concern was obtained and interview administrated questionnaire was used to collect the data by trained data collectors.International Physical Activity Questionnaire (IPAQ) which was validated to Sri Lanka is utilized to prepare the questionnaire and it was focused to collect the data on socio demographic, reproductive health, physical activities, sedentary hobbies, leisure time activities, passive smoking and mental relaxing practice of the participants (11,12).Furthermore height and weight were measured to calculate the Body Mass Index (BMI) of the participants.Height was measured to the nearest 0.1cm using a stadiometer (seca 813, telescopic height measurement).Weight was measured to the nearest 0.1kg using a calibrated electronic scale (seca 813), and BMI was calculated as weight/height 2 .All measurements were taken by trained female data collectors.
Metabolic Equillent Task (MET) per week was calculated by multiplying duration (minutes per day) with frequency (days per week) and 6 and 4 for the vigorous and moderate activities respectively (13).Physical activities perform according to Occupation, exercise, sports, leisure time activities and day today activities were assessed.As well as time spend for sedentary hobbies were also calculated.Although brisk walking is under the category of moderate physical activity it was analyzed separately.Similarly television watching time was analyzed independently from sedentary hobbies because these two activities have great impact on fertility as well as overall health (14,15).Moreover frequency of exposure to the second hand smoking at the home and work place was assessed.As well as involving of following activities were assessed according to total frequency, taken as follows.When comparing the family planning methods sub-fertile women had higher usage of family planning than fertile (53. 4 & 35.6).Moreover oral contraception and condom were the commonly used methods by both groups (table-5).But the result of the T-test of years of sub-fertility and usage and not usage of family planning in sub-fertile group was 0.328 which is higher than standard alpha value (0.05).Two way Anova result showed that there was no signi cant interaction between ethnicity and fertility on the mean age at marriage (P=0.433) and it is illustrated by gure 1.Independent sample t test indicated that there was no signi cant difference between the years of expecting a baby and postponement of the pregnancy in sub-fertile group (C.I 95% p= .438).
BMI was signi cantly high (p=.036)among fertile women than sub-fertile.The average BMI was 23.4and 21.fertile and sub-fertile women respectively.The following box plots ( gure-2) are the standardized way of display the distribution of data of two groups and there were no outliers and IQR was higher among fertile group.
The result of the Man Whitney test for physical activities and sitting time are showed in table -07.The result of the two-way ANOVA indicated that there was no any statistically signi cant interaction between professions and fertility state on the sedentary time of fertile and sub-fertile women (P= 0.535).
Moreover gure 03 demonstrated that two lines are independently distributed.
OR of exposure to the second hand smoking and sub-fertility was 1.32 (95% CI) and OR between entertainment with music and sub-fertility was 0.6 (95% CI).The results of the chi-square test of going trip, petting animal and praying was higher than predetermined signi cant level (0.05,95% CI) table -8.Most of religious and cultural practices were peculiar to certain religion and therefore chisquare tests were performed to both groups according to religion to know the association between religions and particular practices.The result was summarized in series of table 9.

Discussion
This study demonstrated that majority of women in fertile group were in the age category of 25-29 years and the previous study, conducted in Sri Lanka have shown the same result (9).The mean age of marriage of female in Sri Lanka is 23.4 years (17).But in this study it was a 25 and 26.5 years for fertile and sub-fertile women respectively.Differentiation according to ethnicity could not be observed between Tamil and Sinhala but percentage of Muslim women in sub-fertile group was comparatively low.
Moreover it has been showed by one study that Muslims have high fertility than other ethnic group in Sri Lanka(18).Majority of women of fertile and sub-fertile groups are A/L quali ed and percentage is equal for both groups (45%).There was no anyone with post graduate quali cation in sub-fertile group and percentage of women with education quali cation, upper than A/L was higher among fertile group.But some previous studies showed that level of education of women affect in three fertility outcomes, childlessness, timing of children, and number of children (19).In spite of that another study have stated that there is no association between level of education and knowledge on fertility (20).
Sub-fertile women had high usage of family planning, and oral contraceptives and condoms are the most common methods.But we did not observe the association between years of sub-fertility and family planning usage (Independent sample T test).The most probable reason of that was sub-fertility has a complex aetiology and time for sub-fertility is depend on lot of confounding factors.Although national Contraceptive Prevalence Rate (CPR) in Sri Lanka is 65%, it did not affect to the sub-fertility (21).Furthermore few studies have demonstrated that both condom usage and oral contraceptives can preserve fertility of women (22,23).The mean value of BMI of sub-fertile women was in the healthy range but it was 23.4 for fertile women as well as the percentage of obese women was high among fertile than sub-fertile (30% and 10.5%).But conversely previous studies have stated that overweight and obesity of women had poor reproductive outcomes (24,25).In this study, participants were measured only for general obesity not for the abdominal obesity, as well as certain study have mentioned that abdominal obesity have more adverse effect on fertility(26).Moreover one previous study have been stated the need for more intervention to reduce the BMI to increase the fertility of young women (27).
This study compared the moderate and vigorous physical activities of fertile and sub-fertile women and it demonstrated that sub-fertile women had higher MET of vigorous and moderate physical activities than fertile women.The most common vigorous physical activities were cycling, aerobics, construction works and involved day today activities in high intensities.This was supported by previous study and it had been concluded that increased frequency, duration, and intensity of physical activity were associated with increased sub-fertility(28).In spite of that most of women involved the moderate physical activities like, light weight lifting, aerobics, washing cloths and other day today activities.Further, we found that there was a 59% fertile woman live with extended family.Hence the domestic and day today activities are shared with family members and therefore opportunity to involve the physical activity is low in extended family.But One previous study stated that women who involved moderate physical activity has took relatively short duration to get pregnant than who did not involve (29).As well as another study concludes that moderate physical activities improve the fertility regardless the BMI (30).Walking is an important moderate physical activity because anybody can easily involve and considerable amount of calories can be burned.Therefore walking was analysed separately, and it had been found that MET of walking of sub-fertile women was higher than fertile women.The mean tank of total sitting time was not signi cantly different between two groups.But total sitting time was associated with the occupation of both groups.The occupations, way of transport, and hobbies of fertile women were more sedentary than sub-fertile.Moreover reading newspaper, and novels, entertains with music, watching television, and involving other screen based hobbies were the dominant sedentary activities of both groups.But fertile women spent more times for those activities than sub-fertile and house wives of both groups had more sedentary time than other professions.This nding is similar to some previous studies which was stated that sedentary hobbies are not associated with the fertility of the women (31,32).
To nd the association between Second Hand Smoking (SHS) and sub-fertility, O.R was calculated (O.R=1.3).O.R 1.3 means that woman who expose to SHS has 1.3 times higher chance to be sub-fertile than woman who does not expose to SHS.The ndings have been demonstrated by previous studies.
One study concluded that if women are exposed to SHS from more than two years they have the problem with conserving and early menopause (33).The deleterious effects of smoking for the fertility of women are obvious and it has been proved with several epidemiological studies (34,35) Another study states that risk of SHS s similar to the active smoking and women and children are more vulnerable for SHS(36).But conversely another study showed that SHS is not appreciably associated with fertility of women (37).
Women in both groups in our study did not expose to tobacco smoke for a long period, as well as their frequency of exposure and duration was very low.Instead of that most of women exposed to SHS at their home environment and therefore they have opportunity to avoid the harmful exposure.Sleep is a critical component to health and well-being.Therefore number of sleeping hours was taken in to consideration in our study.But we identi ed there was a majority of sub-fertile women had not good restful sleep at night and one study has found that quality of sleep and duration of sleep is associated with the level of stress(38).As well as another two studies have stated that mental stress increase the risk of subfertility (39,40).This was reinforced by two previous studies and it has been stated that poor sleep cause to irregularities of menstrual cycle which cause to sub-fertility (41,42).
Hobbies were analysed to nd the association for fertility of two groups because most of hobbies cause to reduce the stress and improve the fertility by regulating the healthy hormones.Some studies have showed that listening to music can reduce emotional distress and improve the fertility(43) (42).In this study odds ratio was calculated (O.R=0.6) to nd the association between music and sub-fertility and the result indicated that entertainment with music is a protective factor to increase the fertility.Furthermore we found that going picnic and involving social works were high among fertile women than sub-fertile.
These events help to detachment of day today busy work and it is great opportunity to get together with friends and family members.One study showed that tourism has the positive effect on life satisfaction and reduce the level of stress (44).Petting animal was not the hobby of majority of women in both groups and comparatively the percentage of fertile women was high.But some literature pointed out that petting animal, provide an unconditional source of affection, enhance self-esteem, and emotional stability, reduce the feeling of loneliness and isolation and help to people to socialize (45).
Religious practices help to cope-up the stressful life situations and therefore stress releasing religious practices were analysed with fertile and sub-fertile groups.But lot of practices are inherent to the particular religion and people are adhering to follow according their own religious beliefs.But one previous study showed that any religious practice can help to reduce the distress of sub-fertile women (46).Our study demonstrated that the percentage of Sub-fertile women, who involved the meditation, were higher than percentage of fertile women.Involving meditation help to be mindfulness and it pave the way to reduce the stress (47).Another study indicated that meditation help to reduce the stress due to fertility problems of women (40).
According to our study ndings, religious practices, such as boodi puja, pirith chanting, and belief and superstition were very common to Buddhist women and those were analyzed only for Buddhists.It was found that sub-fertile women follow the belief and superstition rather than fertile women.A broad range of human behaviour is in uenced by religion and religious practices which are imperative to affect the fertility of human being.Hence the women who expects to achieve the nobles position in the world (motherhood) is behaved by their emotional involvement rather than rational way.Consequently subfertile women involve lot of belief and superstition activities.Meditation is the most common practice among both group of Buddhist women and similarly praying is the dominant religious practice among catholic women of both fertile and sub-fertile women.Almost all the Hindu and Islam women involved the invoking blessing of god and praying respectively.In spite of the religion, Invoking blessing of god was the most common practice of all the women in two groups in our study.In general sub-fertile women refer to the religious practices than fertile.Moreover some previous studies have stated that yoga can improve the reproductive health including fertility(48,49).But least percentages of women in both groups involve in yoga.
Even though lifestyle factors have great impact on fertility, certain important factors like dietary habits were excluded in our study due to resource constrains.Therefore studies on fertility should be more concentrated on behavioural factors including diets, exposure to the electromagnetic eld, radiation and toxic chemicals in foods in future studies in Sri Lanka.Furthermore we assessed the physical activity through a questionnaire.But the accuracy of data is depending on the recall ability of the participants and this was another limitation of the study.Objective measurements by accelerometers or direct observations are suggested to overcome such drawbacks.

Conclusion
In conclusion the exposure to the passive smoking was a risk factor for the fertility and conversely entertain with music was the protective factor for the fertility.To avoid the vigorous physical activities is suggested to reduce the risk of sub-fertility of women who expecting a baby and there was no evidence to support the association between moderated physical activity and sedentary hobbies with fertility.Newly married and sub-fertile couples should be awared on the importance of the life style factors on fertility.In spite of that they should be empowered with necessary skills and therefore training programmes on moderate physical activities and yoga exercise should be conducted by the primary healthcare providers in the country.Finally existence of god and blessing of god is strongly believed by the people, disregarding their religion.Body Mass Index (BMI) of the participants Sedentary hobbies of the women according to profession

Figure 1
Abbreviations BMI: Body Mass Index

Table 1 :
(45) of frequencies of mental relaxing practices of the participants -fertile women at the interview was 26.6±3 and 31.7±4respectively.But average age at marriage for fertile women was 25.1±3 and it was 26.5±3 for sub-fertile women.Moreover there were 31.4% of sub-fertile women were in the oldest age category(35-39 years).Regarding the level of education, most of fertile and sub fertile women were A/L quali ed and represent in similar percentage in both groups(45).There were only 2.5% of women in fertile group who had the post graduate quali cation and no any women in sub-fertile group such quali cation.

Table 2 :
Characteristics of the sample by age, ethnicity, religion, level of education & occupation

Table 3 :
BMI of the participants

Table 4 :
Summary of the monthly income

Table 5 :
Family Planning method of the participants Sub-fertile women were lack of full restful sleep (8 hours per night) and only 7.6% women had a restful sleep.But 56.6% of fertile women had restful sleep more than ve days per week (table-6).

Table 6 :
No of hours of sleeping at night of participantsIndependent sample T test showed that age at marriage was not signi cantly different between fertile and sub-fertile groups (C.I 95%, P=.915).But it was signi cantly different according to ethnicity of fertile groups (F=6.6 and P= .001).Turkey post test showed that between Sinhala and Muslim (P=.001) and Tamil and Muslim (P=.024) had signi cant difference of age at marriage.In sub-fertile groups, there was no signi cant difference in age at marriage according to ethnicity.

Table 7 :
vigorous & moderate physical activities, walking time and sitting time of the participants

Table 8 :
Leisure time activities & religious practices of the participants