Effect of Abstinence Time on Semen Parameters among Male Patients Referring to Urology Clinic

Introduction: Premature ejaculation (PE) is one of the most common disorders in sexual intercourses among men and may occur for any man in any period of his life. PE results in some mental disorders such as anxiety, depression and marital disaffection and can have psychological impacts. The present study is aimed to investigate the effect of the abstinence time on the semen analysis parameters among men. Methods: The present cross-sectional study was conducted on a statistical population including 100 male patients referring to the urology clinic in Ali-Ibn-Abitaleb Hospital. Once included in the study, these individuals are divided into three groups with short-term abstinence (less than 2 days),


INTRODUCTION
Reproduction of humans, like other mammals, involves the formation of male and female gametes followed by fusion of their nuclei and formation of the zygote.In humans, the gametes are produced by sex glands known as gonads.The male gamete is called sperm (or spermatozoon) and the female gamete is called ovum.Having a child is one of the major concerns of any couple and failure to do so it can result in worries in both the couple and their family members [1][2][3].So far, no standard time of abstinence has been defined for ejaculation since it may differ from one couple to another depending on their satisfaction and desire on t sexual intercourse.However, it has been proposed that either one or both partners are not fully satisfied in 50% or more of the sexual intercourses.In this situation, the male partner may be suspected of having PE but requiring further investigations.The main symptom of premature ejaculation is uncontrollable ejaculation that occurs either before sexual relationship or a little after that with a little arousal and in an unwanted manner [1].This problem can cause sexual dissatisfaction for either party of the relationship and also increase the anxiety resulted from such disorder [1,2].PE is one of the most common sexual disorders among men and may occur for any man in any period of his life [1,3].Approximately, one-third of the men are suffering from PE [1][2][3].PE is a complicated situation that may cause by mental disorders such as anxiety, depression, sexual disaffection and, have psychological impacts.Therefore, early diagnosis and treatment of the disorder are of great importance [4].Infertility or inability to have the natural process of reproduction is one of the bitter and tormenting experiences in life., The importance of which can be increased by the mental and social circumstances so that it may be changed into a crisis for the individual [5].However, studies suggest that infertility is an unfavourable experience especially for women; because the maternal role has been accepted as a fundamental role for women.Most of the infertile women state that they cannot imagine a life without a child; while men express different emotions.On the other hand, most of the treatment methods are used for women.However, the men's role in infertility was denied for a long time and only women were considered as the cause of infertility [6].The experience of infertility is associated with physical, economic, psychological, and social stress.The infertility patterns in developing countries are completely different from those in developed countries, and the occurrence of preventable infertilities is very prevalent in developing countries.In 50% of couples malefactor, is solely or in association with the female factor, is responsible for infertility.There are several diagnosable reasons for the male factor-caused infertility including varicocele, cryptorchidism, infections, obstructive lesions, cystic fibrosis, trauma, tumours, and oxidative stress, all of which cause spermatogenesis failure through cytokine and, thereby, result in infertility [7].Semen analysis is the first step in the diagnosis of male infertility [8], which leads to the classification of the patients into different groups including normospermia, oligospermia, asthenospermia, teratozoospermia, leukocytospermia, azoospermia, or a combination of them.The patients with varicocele have significant oligospermia, and varicocele surgery can improve the semen volume as well as sperm density, motility, and vitality [8,9].Didymitis causes decreased testicular volume and oligospermia [10].Being exposed to heat, noise, and physical exercise causes testicular damage and finally terato and oligoasthenospermia [11].Patients with an STI background have an obvious leukocytospermia, and sufficient primary treatment of STI can prevent delayed complications [12].Azoospermia can be caused by ejaculatory duct obstruction (EDO), hypospermatogenesis, lack of spermatogenesis, maturation arrest, Sertoli cellonly syndrome, or Leydig cell hyperplasia.As indicated by the studies, the quality of the seminal fluid and infertility have been reduced over the past decade [12,13].Deterioration of semen samples depends on environmental and occupational pollution, changes in living conditions, exposure to poisons, and nutritional habits [13][14][15].Lifestyle, excessive use of alcohol, and smoking may lead to the decrease of seminal plasma antioxidants level which puts the sperm at extra risk of oxidative damage [16].In recent years, oxidative stress and the role of oxygen radicals in pathophysiology of human sperm function and male infertility has become known.From the production of spermatozoa in testis until it gets into the female reproductive system, it is continuously and constantly in contact with environmental oxidase; also, oxidative stress has been known as one of the most important causes of male infertility [17].The factors contributing to male fertility include sperm count, sperm motility, and sperm morphology.Performing the assisted reproductive techniques require a desired sperm volume and quality.The first step in the examination and evaluation of male fertility is to estimate the sperm parameters via seminal fluid analysis [17].The WHO guidelines recommend 2 to 7-days abstinence before collecting the semen specimens; nevertheless, no clearly explained base has been provided for this recommendation and there is only poor supportive evidence for the recommended 2 to 7-day abstinence.It has been observed, particularly among the infertile men, that the increased abstinence time leads to the increase in some of the seminal fluid parameters such as semen volume, total sperm count, and sperm concentration [18].In a retrospective study, the information of 15623 patients who had been visited in a fertility clinic between 2013 and 2002 was investigated.The results indicated that, in normozoospermic men, the prolonged abstinence time was associated with the increase in ejaculation volume, sperm concentration, total sperm volume, and total motile sperm count.On the other hand, in the oligozoospermic men, the increased abstinence time has no significant relationship with the improvement of the seminal fluid parameters [19].In a research conducted in the USA, researchers found t that the short abstinence time had no harmful effect on the seminal fluid parameters based on the thresholds determined by the WTO in 2010 [20].In a study conducted in 2013, semen samples were was collected from the men whose wives were under assisted reproductive treatment between 1996 and 2007.Four semen parameters were compared including volume density, motility, and the sperm appearance based on the Tigerbergs (Kruger) criteria.Two other defined parameters were also measured which included: total motile count (TMC) and total normal morphology count (TNMC).4133 paired sperm samples collected over the past 24 hours were included in the study and analyzed by the above-mentioned approach, According to the results, in the samples of the second day, sperm volume and density were significantly decreased compared with the samples of the first day.No significant change was observed between the samples of the first and the second days in terms of the sperm motility percentage and sperm morphology.Compared with the samples of the first day, TMC and TNMC were also significantly decreased in the samples of the second day (21).
On this basis, the present study was aimed to investigate the effects of the abstinence time on the seminal fluid parameters among the male patients referring to the urology and infertility clinics in Ali-Ibn-Abitaleb Hospital in Zahedan city in 2018-2019.

MATERIALS AND METHODS
Once the project was approved by the Research Center of the College of Medicine, a total of 100 male patients were included in the study and their information was recorded in the predesigned checklist.These individuals were then divided into three groups, including short-term abstinence time (less than 2 days), mid-term abstinence time (2-9 days), and long-term abstinence time (more than 9 days).The subjects were asked to deliver their seminal fluid at the specified time to the laboratory in less than an hour.The inclusion criteria in this work included being at the age of fertility (20-45 years) and the lack of psychotropic drug use.The patients with a history of cryptorchidism and fever in the past 3 months, history of mumps, and history of sexually transmitted diseases (STD) were excluded from the research.Analysis of the collected data was performed using the Pearson correlation test, Spearman correlation test, and regression in SPSS software (P value <0.05).

RESULTS
In this section, the research findings are presented in two parts, namely descriptive and inferential, which include the demographic characteristics of the sample group, the mean and standard deviation of the research variables, and statistical inference from the investigation of the research hypotheses.
Table (1) shows the frequency distribution and percentage of the respondents in terms of their age.Occupation and educational level.As can be seen, most of the participants aged 28-38 years old, were clerks or self-employed and had bachelor's degrees or lower (Table -1).The relationship between the abstinence time and sperm concentration in the seminal fluid was investigated using the Spearman and Pearson correlation coefficients (Table -3).
The results of the Spearman and Pearson tests indicated that the abstinence time was significantly related to the sperm concentration in the seminal fluid.
The Spearman and Pearson correlation coefficients were used to investigate the relationship between the abstinence time and sperm volume in the seminal fluid .
The results of the Spearman and Pearson tests indicated a significant relationship between the abstinence time and the sperm volume in the seminal fluid (r=0.260,P<0.01).
To investigate the relationship between the abstinence time and sperm pH in the seminal fluid, the Pearson and Spearman correlation coefficients were used (Table -5).
According to the results of the Spearman and Pearson correlation tests, the abstinence time was significantly related to the sperm pH in the seminal fluid (r=0.219,P<0.01).

DISCUSSION
The present work was conducted to investigate the effects of the abstinence time on the semen parameters among the male patients referring to the urology clinic.The study was applied descriptive-correlational research in which the study population included all the male patients referring to the urology clinic of Ali-Ibn-Abi Taleb Hospital in Zahedan in 2018.The study population included 100 cases of these patients who were selected via the convenient sampling method.
In this study, the frequency of distribution and percentage of the participants in terms of their job, educational level, and age were as follows.In terms of job, 34 (34%) subjects were clerks, 47 (47%) were self-employed, and 19 (19%) were university students.In terms of educational level, 41 (41%) subjects had high school diplomas, 43 (43%) had bachelor's degrees, and 16 (16%) had master's degrees.And in terms of     [20] showed that increasing the abstinence time would increase total sperm count, sperm concentration, seminal fluid volume, and pH [20].In another study conducted by Lehavi et al. [21] found that delaying the ejaculation even for 24 hours would change the semen parameters such as concentration, total sperm count, volume, and pH in the seminal fluid, [21].Moreover, in a study conducted by Agarwal et al. [19] aiming to determine the best EA for maximizing the semen quality in order to improve both diagnostic and therapeutic approaches, it was shown that an abstinence time of 9 days and higher led to the increase in the semen concentration and pH among the normozoospermic subjects [19].
Other findings in this study indicated that the abstinence time was significantly related to sperm motility and morphology.The relationship was inverse so that increase in the abstinence time, led to lower the motility and morphology of the sperm.In another study by Keihani et al. [18] found that the long-term abstinence period negatively affects the semen parameters in cryopreserved samples for Assisted Reproductive Technology (ART).Considering the motility and morphology in oligospermic patients there had been inverse and adverse effects on the slow progressive motility and morphology of the sperms [18].Gosalvez et al. ( 2011) conducted a prospective study to investigate the effects of re-ejaculation on Sperm DNA Fragmentation (SDF) and findings showed that the cryopreservation of the sperm in the laboratory reduced the motility of sperm meanwhile, increasing the number of sperm with abnormal morphology [22].In another study by Sharma et al. [23] found out that increasing the abstinence time from two (2) to nine (9) days or even more would result in the slow progressive motility of the sperm [23].

CONCLUSION
In the present work, it was attempted to determine the relationship between the abstinence time and the quality of the sperm parameters.Results of the present study showed that the abstinence time is significantly associated with the total sperm count, sperm concentration seminal fluid volume, and pH.

CONSENT
As per international standard, patient's written consent has been collected and preserved by the author(s).

ETHICAL APPROVAL
As per international standard, ethical approval has been collected and preserved by the author.

COMPETING INTERESTS
Authors have declared that no competing interests exist.

Table 3 . Effect of the abstinence time on the sperm concentration in seminal fluid
**significant at 0.05 level