Yun Mi Kim; Ju-Hee Nho

doi:10.4040/jkan.24104

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Research Paper
The effects of a lifestyle intervention for men in infertile couples in South Korea: a non-randomized clinical trial: Yun Mi Kim¹, Ju-Hee Nho²; DOI: https://doi.org/10.4040/jkan.24104
Published online: April 16, 2025

¹Department of Nursing, Jesus University, Jeonju, Korea

²College of Nursing, Research Institute of Nursing Science, Jeonbuk National University, Jeonju, Korea

Corresponding author: Ju-Hee Nho College of Nursing, Research Institute of Nursing Science, Jeonbuk National University, 567 Baekje-daero, Deokjin-gu, Jeonju 54896, Korea E-mail: jhnho@jbnu.ac.kr

*This manuscript is a condensed version of the first author’s doctoral dissertation from Jeonbuk National University (2023). This work was presented at the 59th Korean Society of Women Health Nursing Conference in 2023, Daejeon, Republic of Korea.

• Received: August 20, 2024 • Revised: March 6, 2025 • Accepted: March 6, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution NoDerivs License (http://creativecommons.org/licenses/by-nd/4.0) If the original work is properly cited and retained without any modification or reproduction, it can be used and re-distributed in any format and medium.

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Abstract
Introduction
Methods
Results
Discussion
Conclusion
Article Information
References

Abstract

Purpose
This study aimed to evaluate the effects of an interaction model of client health behavior (IMCHB)-based lifestyle intervention on health-promoting behaviors, infertility stress, fertility-related quality of life, and semen quality in men in infertile couples.
Methods
This study used a quasi-experimental, non-equivalent control group, pretest-posttest design, with participants divided into an experimental group (n=17) and a control group (n=19). The 16-session, 8-week intervention included components such as reproductive health education, physical activity, nutritional management, and stress management. Data collection occurred between July 1, 2021 and September 27, 2022. The outcomes measured included health-promoting behaviors, infertility stress, fertility-related quality of life, and sperm quality (volume, total motility, immobility, concentration, and normal morphology).
Results
The experimental group showed significant improvements in health-promoting behaviors (z=–2.27, p=.023) and reductions in infertility stress (t=–2.40, p=.022) compared to the control group. Total sperm motility (F=4.39, p=.045) and normal morphology (z=2.86, p=.017) were also significantly higher in the experimental group than in the control group.
Conclusion
The IMCHB-based lifestyle intervention significantly increased health-promoting behaviors, reduced infertility stress, and improved key sperm parameters, indicating its effectiveness in supporting the reproductive health of men in infertile couples.
Key words: Fertility; Infertility; Life style; Men; Semen analysis

Introduction

Infertility, defined as the inability to conceive after a year of unprotected sexual activity, is a global health issue affecting millions of individuals of reproductive age [1]. According to the World Health Organization (WHO), approximately one-sixth of couples worldwide experience infertility problems [2]. Infertile couples face difficulties while trying to get pregnant; in particular, the men in infertile couples suffer from many burdens. Men in infertile couples experience significant psychological, social, and marital stress while trying to conceive [3]. Men in infertile couples have been shown to have lower self-esteem and higher psychological distress [4], and to experience more physical symptoms compared to those without infertility [4]. In addition, men in infertile couples had lower scores on some aspects of quality of life [5]. Fertility treatment has a negative impact on fertility-related quality of life for men [6]. Indeed, infertile men undergoing fertility treatment have lower quality of life than control groups, with significant differences in social and emotional role functioning [7]. Men in infertile couples are influenced by the woman’s ovulation cycle as a baseline for conjugal relations and pregnancy, and suffer from pressure on pregnancy outcomes [8]. This has been shown to decrease marital satisfaction and sexual functioning [4], and to lower quality of life in men in infertile couples [5]. Men in infertile couples felt the need for deeper communication with healthcare providers during fertility treatment [9,10]; moreover, they wanted more engagement and opportunities for men to acknowledge and express their feelings and experiences [10]. Healthcare providers should provide sufficient attention and support to men and women with infertility [2].

Identifying the causes of infertility is essential for improving overall and reproductive health among men in infertile couples. Men account for approximately 20%–30% of all infertility cases, with causes including structural issues of reproductive organs and lifestyle-related factors such as smoking, alcohol consumption, poor dietary habits, and stress [3,11]. A meta-analysis conducted across North America, Europe, Australia, and New Zealand revealed a 52.4% decrease in sperm concentration and a 59.3% decline in total sperm count from 1973 to 2011 [12]. Unhealthy lifestyle patterns negatively affect sperm quality and extend the time to conception, potentially contributing to declining fertility rates globally [11]. Previous studies indicate that lifestyle interventions effectively improve sperm quality, enhance pregnancy rates, and promote overall health in men from infertile couples [13,14]. Additionally, regular physical activity and maintaining a healthy lifestyle significantly improve sperm motility, morphology, sperm count, and overall semen quality [15,16]. Therefore, increased attention to men's reproductive health and implementation of comprehensive lifestyle interventions are essential for improving reproductive outcomes [4].

Despite the increasing recognition of male infertility, many interventions either focus exclusively on sperm quality [9] or offer fragmented approaches targeting individual factors, such as psychological issues [4], physical activity [10], or reproductive health knowledge [17]. However, comprehensive interventions addressing multiple dimensions simultaneously may be more effective for men in infertile couples [16]. Therefore, lifestyle interventions that integrate reproductive health education, physical activity, nutritional guidance, and stress management are necessary for this population [11,16].

Recently, lifestyle interventions delivered through digital healthcare platforms have been introduced and demonstrated to be effective. Digital healthcare has emerged as a popular medium capable of providing immediate and accurate feedback [18,19]. Such digital platforms commonly utilize mobile applications [18] and wearable smart bands [19] to monitor participants' lifestyles including physical activity, sleep patterns, and daily health status—in real time, enabling participants to self-assess their health conditions. Additionally, researchers can continuously track lifestyle changes and offer personalized feedback, thereby facilitating more effective health behavior modifications.

Close interaction between participants and professionals is essential to improving an individual’s lifestyle patterns. In particular, in the process of monitoring and providing feedback on lifestyle using digital platforms, information provision and support from professionals to help improve the participant’s behavior and decision-making control are key elements. Cox’s interaction model of client health behavior (IMCHB) emphasizes that professionals can facilitate health behavior change through their encounters with clients to motivate them [20]. The IMCHB model lends itself to comprehensive intervention development because it consists of three main components: client singularity, professional-client interaction, and health outcomes. The model clarifies the variable factors that nurses should assess before implementing an intervention and how interactions with the population can lead to positive health outcomes. Provision of health information, emotional support, decision-making control, and professional intervention are important factors in reducing stress and improving quality of life for infertile couples [7,21]. The interaction between nurse and client plays a key role in health behavior change and maintenance [22].

This study aims to determine the effectiveness of an integrated lifestyle intervention consisting of reproductive health education, physical activity, nutritional management, and stress management for men in infertile couples. The IMCHB was used to provide health information, emotional support, decision control, and professional and technical support to health behavior determinants by a nurse interacting with the participants. Additionally, based on IMCHB and the application of digital healthcare methods, this study examined the effects of an intervention that incorporated more active and accurate feedback and interaction.

1. Purpose

This study aims to evaluate the effects of an IMCHB-based lifestyle intervention on health-promoting behaviors (HPB), infertility stress, fertility-related quality of life, and sperm quality of men in infertile couples.

2. Hypotheses

The hypotheses of the study are as follows:

H1. The experimental group receiving an IMCHB-based lifestyle intervention would reveal greater improvement in HPB than the control group.
H2. The experimental group receiving an IMCHB-based lifestyle intervention would exhibit lower infertility stress than the control group.
H3. The experimental group receiving an IMCHB-based lifestyle intervention would demonstrate greater improvements in fertility-related quality of life than the control group.
H4. The experimental group receiving an IMCHB-based lifestyle intervention would demonstrate better sperm quality (volume, total motility, immobility, concentration, and normal morphology) than the control group.

Methods

1. Study design

This study adopted a quasi-experimental design with a nonequivalence control group pre-test–post-test to examine the effects of an IMCHB-based lifestyle intervention on men in infertile couples.

2. Participants

The target population of the study was infertile couples with men aged 19 years or older, residing in Jeonju, who were diagnosed with infertility and were undergoing treatment, and who understood the purpose of this study and agreed to participate. Convenience sampling was used to recruit participants. The sample size was calculated using G*Power ver. 3.1.9.2 software (Heinrich-Heine-Universität Düsseldorf) [23], based on an independent t-test as the statistical test, with a significance level of .05, a power of .80, and an effect size of .80 [15,17]. The minimum required sample size was 17 participants per group. A total of 50 participants were selected, with 25 participants in each group, to account for a predicted dropout rate of 20%–30%. The inclusion criteria were: (1) those aged 19 or older, (2) men in infertile couples diagnosed with infertility by an obstetrician and gynecologist, (3) men in infertile couples using assisted reproductive technology, and (4) individuals who understood the research purpose and voluntarily agreed to participate. The exclusion criteria were: (1) those with chromosomal abnormalities, (2) men receiving medical treatment for secondary infertility, (3) men using drugs (e.g., marijuana, amphetamines, opioids), (4) men who had taken anabolic steroids within the past 6 months, (5) men who had taken medications affecting urinary function (e.g., alpha-blockers, 5-alpha-reductase inhibitors) within the past 4 weeks, and (6) men who had participated in cognitive behavioral interventions within the past 6 months [1,24]. Among the 25 participants each in the experimental and control groups, eight individuals in the experimental group withdrew from the study (refusal to participate, n=5; hospital transfer, n=2; psychological change, n=1), and six participants withdrew from the control group (refusal to participate, n=3; varicose vein surgery, n=1; disconnect, n=1; psychological change, n=1). The final sample comprised 17 individuals in the experimental group and 19 in the control group. The flow diagram of study enrollment and procedures is presented in Figure 1.

3. Measurements

1) Health-promoting behaviors

The Health-Promoting Lifestyle Profile II (HPLP II) consists of 52 items, each scored on a 4-point Likert scale ranging from 1 to 4 (score range, 52–208), with higher scores indicating higher levels of HPB. The scale comprises six subscales: health responsibility (nine items; score range, 9–36), physical activity (eight items; score range, 8–32), nutrition (nine items; score range, 9–36), spiritual growth (nine items; score range, 9–36), interpersonal relations (nine items; score range, 9–36), and stress management (eight items; score range, 8–32) [25]. The Cronbach’s α of the instrument was reported as .94 in the original development [25], .92 for the Korean version [26], and .97 in this study.

2) Infertility stress

Infertility stress was assessed using the Fertility Problem Inventory (FPI) [27], which was translated into Korean [28]. The FPI consists of 46 items, each scored on a 6-point Likert scale ranging from 1 to 6 (score range, 46–276). The scale evaluates infertility-related stress across five dimensions: relationship concerns (10 items), social concerns (10 items), sexual concerns (eight items), need for parenthood (10 items), and rejection of a child-free lifestyle (eight items). Some negatively worded items are reverse-scored, with higher total scores indicating greater infertility-related stress. The original tool demonstrated good reliability (Cronbach’s α=.92), while the Cronbach’s α in this study was .84.

3) Fertility-related quality of life

The tool used to measure fertility quality of life (FertiQoL) was developed by Boivin et al. [29] in collaboration with the European Society of Human Reproduction & Embryology and the American Society of Reproductive Medicine. This tool was designed to assess infertile couples’ quality of life [30]. This study used the Korean version of the FertiQoL [31]. The FertiQoL consists of 36 items, each scored on a 5-point Likert scale from 0 to 4. It comprises two single items—overall physical health and overall life satisfaction—which are used for background information but are not included in the total or subscale scores. The remaining 34 items are divided into four core domains: emotional (six items), mind–body (six items), relational (six items), and social (six items), and two treatment-related domains: treatment environment (six items) and treatment tolerability (four items). The FertiQoL score evaluated by calculating the score for each domain and from 0 to 100 [29], with higher scores indicating better fertility-related quality of life. At the time of development and in the current study, the Cronbach’s α was .92, and .87, respectively.

4) Sperm quality

Sperm quality was measured using Computer-Assisted Semen Analysis (CASA), a method widely used since the 1970s to enhance the accuracy and reliability of sperm function assessment. The main physiological indicators measured include volume, total motility, immobility, concentration, and normal morphology. The CASA precisely distinguishes sperm from other substances, providing an objective evaluation of critical sperm parameters. This method significantly improved the precision of sperm quality evaluation [32]. The sperm quality followed the WHO guidelines [32,33], with the following reference values:

• Sperm volume: ≥1.5 mL, measured using a sterilized syringe.
• Total motility: ≥40%, including both progressive and non-progressive motility.
• Immobility: Percentage of non-moving sperm.
• Concentration: ≥15 million sperm/mL.
• Normal morphology: ≥4%, indicating sperm with normal size, shape, and structure. Abnormalities in sperm morphology, such as those in the head, mid piece, or tail, can reduce reproductive capacity.

4. Research procedure

1) Participant assignment

The study was conducted from July 1, 2021, to September 27, 2022, with data collection occurring throughout this period. Participants were recruited through posters placed in the clinics and waiting rooms of the obstetrics, gynecology, and urology departments at Presbyterian Medical Center in Jeonju, Jeonbuk in South Korea. The study included participants who met the selection criteria and voluntarily agreed to participate. Before conducting the study, the researchers explained the procedures and objectives to all participants and their spouses. Written informed consent was obtained after providing the explanation, and all participants voluntarily agreed to participate. The experimental and control group assignments were sequentially based on odd and even numbers. The control group was assigned first, followed by the experimental group.

2) Pre-test

The pre-test included questionnaires, body weight measurements, and semen analysis. General characteristics, HPBs, infertility stress, and FertiQoL were assessed using structured questionnaires, which required approximately 20 minutes to complete. Participants' body weights were measured after urination while wearing only light clothing, using a designated scale provided by the hospital.

Participants directly collected semen samples in a clean, designated semen collection room at the hospital. They were instructed to abstain from ejaculation for 72 hours before collection, to wash their hands thoroughly prior to sample collection, and to collect semen directly into the provided container without using condoms or other containers. Collected semen samples were transported to the analysis laboratory within 1 hour. Semen analysis was conducted by a semen analyst from the Department of Diagnostic Laboratory Medicine and a researcher, with results subsequently verified by medical staff from the Departments of Obstetrics and Gynecology and Urology. The semen samples were liquefied at 37.0℃ for 30 minutes before being analyzed according to WHO guidelines [32,33].

3) IMCHB-based lifestyle intervention

The 16 sessions of the 8-week lifestyle intervention were developed based on previous studies [22,34], including core components related to reproductive health education, physical activity, nutritional management, and stress management. The intervention was a 1:1 individualized program structured into education, feedback via phone consultations, and self-monitoring. The researcher (first author) delivered educational materials related to core components to the participants using digital short message services every Tuesday. The educational materials provided each week included reproductive health education, physical activity, nutritional management, and stress management. On Fridays, participants received weekly feedback sessions to reinforce their knowledge and address their concerns. The researcher (first author) provided consulting content via telephone based on each participant’s status and questions. This session included affective support such as praise, encouragement, and support) for about 30 minutes each participant. Additionally, a uniform resource locator was provided to complete a lifestyle checklist to self-monitor lifestyle improvements every evening. The duration of lifestyle intervention varied from 3 [35] to 24 weeks [36] for adult men. Considering the characteristics of men in infertile couples and their active social lives, and based on previous research results showing that physiological indicators require at least 8 weeks to change [37], the 8-week intervention was conducted.

Reproductive health education included reproductive health for men and women, lifestyle factors affecting fertility, and lifestyle modification strategies for optimizing reproductive outcomes [38,39]. Physical activity management consisted of regular physical activity, aerobic and resistance exercise. The participants were educated on the intensity and method of walking, methods of strength training and aerobic exercise, precautions during physical activity, and how to use a smart band [40] and physical activity diary. The intensity of walking was determined by considering the perceived exertion and target heart rate (50%–60%) recommended by the American College of Sports Medicine and providing safe exercise guidance [41]. Walking was performed at a brisk pace of 5,000 steps per hour in the first week and gradually increased to 10,000 steps, for 60 minutes 5 times a week for 8 weeks. Strength training was performed for 30 to 40 minutes twice a week and recorded on a smart band [40] using a mobile phone. In this study, mobile devices were used for physical activity assessment [40], and participants were asked to access a mobile checklist through a personalized online record to provide a self-assessment of their daily lives. In nutritional management, participants assessed their eating habits using a 24-hour recall method and weighed themselves daily [22,34]. Additionally, men’s healthy diet and nutrition education, nutrition label confirmation, and nutritional education related to reproductive health were included in education materials. Stress management consisted of relaxation and mindfulness techniques (meditation, bedtime relaxation) [10,35], talking with one’s spouse (before going to bed, taking a walk) [4,28], sufficient sleep of about 7 hours [11], and light walking with one’s spouse. The researcher educated the mindfulness techniques to participants. The participants used a smart band to measure muscle tension every evening and were trained to relax their muscles and thoughts through abdominal breathing and positive thinking.

Smart band technology and digital feedback were integrated to enhance adherence to lifestyle modifications. The participants were instructed to wear the smart band throughout the day, including during daily activities and sleep [40]. They were required to sync their smart band data with a mobile application at least once per day [40], allowing researchers to monitor their activity levels, step counts, movement patterns in real time, and daily self-monitoring checklist evaluating their lifestyle [38]. The collected data were analyzed by researchers, who reviewed weekly trends and compiled individualized feedback reports. This report was discussed during weekly consulting sessions, where participants received tailored recommendations on optimizing their physical activity, dietary habits, and stress management strategies. This structured digital approach ensured real-time tracking, continuous reinforcement, and individualized support, promoting sustainable health behavior changes throughout the intervention period [9] (Table 1).

4) Routine care

Routine management, including standard medical check-ups and nursing care, was provided to the control group. Participants in the control group visited the hospital only for scheduled sperm analyses over the 8-week study period and received general health-related information from obstetricians, gynecologists, or nurses. Upon completion of the intervention, researchers provided participants in the control group with an educational booklet containing materials on reproductive health, physical activity, nutritional management, and stress management previously provided to the experimental group.

5) Post-test

After completion of the 8-week intervention, a post-test was conducted using identical procedures and instruments as in the pre-test, including questionnaires, body weight measurements, and semen analyses. To minimize measurement errors, data were collected by the same researchers and examiners who conducted the pre-test, using consistent methodologies.

5. Data analysis

The collected data were analyzed using the IBM SPSS for Windows ver. 25.0 (IBM Corp.), with the level of statistical significance set at p<.05. Frequency analysis and descriptive statistics were applied to evaluate general characteristics. The experimental and control groups’ general characteristics and research variables were tested for normality and baseline homogeneity using the chi-square test, independent t-test, Mann-Whitney U test, and Fisher’s exact test. To evaluate the effects of the IMCHB program, an independent t-test was performed for variables that satisfied the assumptions of normality and homogeneity (infertility stress, fertility-related quality of life). The Mann-Whitney U test was applied to dependent variables that violated the assumption of normality (HPB, volume, concentration, and normal morphology). Ranked analysis of covariance (ANCOVA) was employed for dependent variables (total motility, immobility) that did not meet either the normality or homogeneity assumptions.

6. Ethical considerations

This study was approved by the Institutional Review Board (IRB) of Presbyterian Medical Center (IRB No. 2021-05-009) and registered with the Clinical Research Information Service (Registration No. KCT0007863). After participants voluntarily agreed to participate, the researcher provided comprehensive information regarding the study's objectives, expected effects, procedures, and participants' rights, subsequently obtaining written informed consent. Participants were informed that they could refuse to participate or withdraw at any point during the study without any disadvantage. Both questionnaires and semen analyses were conducted in private offices or laboratories to protect participants' confidentiality. It was explicitly communicated to participants that all collected data would remain confidential and would be securely destroyed upon completion of the research. After study completion, participants in the control group were offered the same intervention provided to the experimental group, if desired.

Results

1. Test of homogeneity on participant characteristics

The mean age of the participants and spouses was 37.24±4.76 years and 34.94±4.48 years, respectively. The duration of marriage was 49.18±35.91 months, and most of the participants had education above university level. There was no significant difference between the two groups in general characteristics such as age, spouse’s age, duration of marriage, and education. The sperm quality (total motility and immobility) was significantly different between the two groups, and other main variables such as HPB, infertility stress, and FertiQoL showed no significant difference between the two groups (Table 2).

2. Effectiveness of the IMCHB-based lifestyle intervention

1) Hypothesis 1

Hypothesis 1: The experimental group receiving an IMCHB-based lifestyle intervention would reveal greater improvement in HPB than the control group.

The median score of the experimental group’s HPB increased by 8.0 to 132.0 points, while the median score of the control group decreased by 1.0 to 119.0 points. This was significantly higher in the experimental group than in the control group; thus, hypothesis 1 was supported (z=–2.27, p=.023) (Table 3).

2) Hypothesis 2

Hypothesis 2: The experimental group receiving an IMCHB-based lifestyle intervention would exhibit lower infertility stress than the control group.

The infertility stress score of the experimental group decreased from 166.00±19.98 to 114.53±22.59, and the control group decreased from 149.58±27.55 to 126.79±26.00. The results revealed that the experimental group showed a statistically significant decrease compared to control group (t=–2.40, p=.022); thus, hypothesis 2 was supported (Table 3).

3) Hypothesis 3

Hypothesis 3: The experimental group receiving an IMCHB-based lifestyle intervention would demonstrate greater improvements in fertility-related quality of life than the control group.

The score of the experimental group increased from 72.37±11.47 to 74.12±6.88, and the control group increased from 70.26±10.89 to 69.70±11.74 points after intervention. There was no significant difference in the score level between the two groups (t=0.63, p=.531); thus, hypothesis 3 was not supported (Table 3).

4) Hypothesis 4

Hypothesis 4: The experimental group receiving an IMCHB-based lifestyle intervention would demonstrate better sperm quality (volume, total motility, immobility, concentration, and normal morphology) than the control group.

In the experimental group, the volume was unchanged at 4.00 mL after the intervention, while the control group decreased from 3.50 to 3.00 mL. The difference was not statistically significant (z=–0.49, p=.626). The total motility was analyzed using rank ANCOVA, and the median was significantly different between the two groups (F=4.39, p=.045). The immobility rate decreased in both groups: from 35.02% to 13.92% in the experimental group, and from 16.16% to 9.57% in the control group. However, this difference was not statistically significant (F=2.04, p=.164). Sperm concentration (10⁶/mL) in the experimental group increased from 25.53 to 34.41, and the control group increased from 36.40 to 51.11. The difference was not statistically significant (z=–1.57, p=.117). Regarding normal morphology (%), the median score in the experimental group increased from 9.98 to 23.55, and in the control group decreased 17.48 in the control group. This difference was statistically significant (z=2.86, p=.017). Thus, some aspects of Hypothesis 4 were supported (Table 3).

Discussion

This study was conducted to evaluate the effects of an IMCHB-based lifestyle intervention among men in infertile couples. The findings indicated that the intervention was effective in enhancing HPB, reducing infertility stress, and improving sperm quality.

In this study, the IMCHB-based lifestyle intervention significantly improved the HPB of men in infertile couples. Participants wore a smart band every day to record their activities and were monitored through telephone consulting and mobile checklists. Integrating digital monitoring through smart bands and mobile checklists allowed for continuous tracking of behaviors, which has been shown to positively impact physical and psychological well-being in similar interventions [9,38]. The use of wearable devices in medical settings can contribute to improving men’s health in a relatively safe and cost-effective manner [40]. Previous studies have demonstrated that wearable devices can significantly improve men’s health in the long term, including alcohol, tobacco use, obesity, heart disease, and male sexual health [19]. This study confirmed that lifestyle intervention utilizing digital health technology is effective for men’s health. This multifaceted approach contributed to improving both physical and psychological factors, which led to improvements in the participants’ overall lifestyle habits. The results of this study are consistent with prior research establishing that regular physical activity and nutritional management positively affected HPB [25,26]. In addition, professionals and continuous feedback may have played an important role in helping participants maintain and improve their health behaviors [42,43]. Telephone counseling interactions with medical staff positively affected participants’ decision-making [43], increased participant satisfaction, and improved focus on health issues [9,35,43]. In this study, counseling and feedback were also considered important factors in maintaining and improving participants’ HPB [35,43].

IMCHB-based lifestyle intervention significantly reduced infertility stress in men in infertile couples. According to the IMCHB model, interaction goes beyond simple information provision; it continuously contributes to stress management and health behavior change through psychological support and encouragement [20]. In particular, this study provided interaction through telephone counseling and daily check-up feedback, which is consistent with previous studies that these methods greatly contributed to stress relief [42,43]. When examining the effects of specific interactions, communication with spouses, conversations before bedtime, light walking activities, and meditation contributed to psychological stability [15,17,35]. In this study, walking was encouraged at least once a week, which is similar to previous studies that found that physical activity with spouses helps promote communication between couples and enhance psychological stability [15,17]. Indeed, such interactions positively affected both participants and their spouses and may have contributed to alleviating the stress caused by infertility [17,28]. This outcome is interpreted as being directly associated to improved lifestyle and stress management skills. Accordingly, counseling and feedback played an important role not only in reducing participants’ stress, but also in improving their lifestyle habits [34]. Consulting may have effectively managed stress by inducing healthy behaviors such as smoking cessation and drinking abstinence [15,17].

In this study, the experimental group demonstrated significant increases in sperm motility and normal morphology. These findings have important clinical implications for infertility treatment, as improved sperm motility and normal morphology are closely associated with increased pregnancy success rates [12,24]. These results align with previous research indicating that physical activity positively affects semen quality and reproductive hormones in men [11,15,36]. Participants utilized smart bands to monitor daily step counts and physical activity levels, and maintained healthy lifestyle habits through consistent telephone counseling and feedback [40]. Prior research has also indicated that men with low physical activity levels are approximately 2.20 times more likely to experience infertility compared to those engaging in higher levels of physical activity [14].

Interventions promoting physical activity may have played a significant role in improving sperm motility and normal morphology ratio [11,15,36]. Furthermore, the results of this study are consistent with previous studies [5,14], which indicated that healthy lifestyle habits positively affect men's fertility [11,15,44]. Similarly, previous researches have reported that lifestyle improvements enhance sperm motility and normal morphology [11,12,15]. These changes may be attributed to lifestyle improvements, suggesting a positive impact not only on health behaviors but also on fertility outcomes [11,17]. Thus, the integrated lifestyle improvement approach applied in this study significantly contributed to enhancing health and fertility in men from infertile couples.

In addition, interventions involving continuous monitoring and improvements in physical activity, nutritional management, and stress management may have effectively reduced the stress and social pressures experienced by participants during infertility treatment [16,28,35]. The finding that improved lifestyle habits moderated stress aligns with previous studies demonstrating that stress reduction positively affects sperm quality [11,35,45]. Consequently, the IMCHB-based lifestyle intervention significantly alleviated stress among men in infertile couples by providing psychological support through counseling, feedback, enhanced communication with spouses, and improved lifestyle habits.

However, the current study did not demonstrate significant changes in other sperm parameters, including sperm volume, immobility, and sperm concentration. Previous studies have reported that sperm volume is influenced more by individual physiological characteristics and collection conditions (e.g., abstinence period) than by lifestyle interventions [12,36]. Short-term lifestyle interventions may have limited effects on sperm motility and concentration, often requiring long-term lifestyle modifications (e.g., 12–14 weeks) [15,36]. Additionally, stress and oxidative damage are known to impair sperm motility, emphasizing the need for psychological support and prolonged intervention [45,46]. The lack of awareness and motivation among men regarding the need for semen analysis at the time of the study was also a limitation. Previous studies have mentioned that the low awareness of the need for lifestyle improvement and the lack of motivation to participate in the study among infertile men made it difficult to conduct large-scale studies [16,30,44]. To solve this problem, a public awareness campaign emphasizing the importance of semen analysis and multidisciplinary intervention is required.

In this study, the IMCHB-based lifestyle intervention did not result in statistically significant changes in fertility-related quality of life. The 8-week intervention period applied in this study might not have been sufficient to induce significant changes in fertility-related quality of life. Although lifestyle modifications generally have long-term impacts on quality of life, this study measured the effects only once, after the 8-week intervention; therefore, no significant difference was identified. Long-term lifestyle interventions that account for socio-economic factors may yield more substantial improvements in quality of life [16,17,30]. Another critical factor that may have limited improvements in fertility-related quality of life was the social restrictions resulting from the COVID-19 (coronavirus disease 2019) pandemic during the study period. The pandemic likely influenced external factors related to quality of life improvements by restricting participants' social activities and access to medical services [7]. This highlights the significance of external environmental factors in enhancing quality of life [28,30]. Therefore, future research should employ longer intervention periods and comprehensively consider various environmental factors to facilitate more in-depth evaluations of interventions aimed at improving fertility-related quality of life.

In addition, there was no significant difference in body mass index between the two groups of participants after the intervention. In previous studies, the intervention period was 3 or 6 months [16,36], but in this study, it was 8 weeks and there appeared to be no difference in body mass index. The weight change requires continuous change over time in lifestyle interventions, thus, further research with a larger sample size with long-term intervention will be necessary.

This study demonstrated that the IMCHB-based lifestyle intervention positively influenced HPB, infertility stress, and reproductive health among men in infertile couples. The intervention comprehensively addressed multiple factors, including physical activity, nutrition, stress management, and reproductive health, resulting in substantial improvements. Future studies should implement long-term interventions and employ multidisciplinary approaches that incorporate consideration of relevant environmental factors. A significant increase in sperm motility and normal morphology represents a critical clinical outcome that is closely associated with improved pregnancy success rates [12,24]. The findings of this study provide essential clinical evidence demonstrating that the IMCHB-based lifestyle intervention positively influences HPB, infertility stress, and reproductive health in men from infertile couples.

However, this study has several limitations. First, the small sample size and single-site setting at a medical center in South Korea limit the generalizability of the findings. The dropout rate was 28% in this study. Although efforts were made to reduce the dropout rate, such as spouse consent, compensation, and maintaining continuous communication, it was not possible to completely prevent some participants from dropping out; some participants complained about the burden of semen analysis. In an intervention study targeting infertile couples, various strategies including spouse consent were reported to be effective in reducing the dropout rate, but complete prevention was difficult [16,17]. In the future, we suggest large-scale randomized control study and research to find ways to reduce the dropout rate. Second, participants who did not complete the intervention were excluded from the final analysis, meaning attrition analysis was not conducted. This could introduce potential bias, and future studies should consider performing attrition analyses to assess its impact. Third, this study only measured variables before and after the 8-week intervention and did not conduct a long-term follow-up. Long-term follow-up is needed to determine the effects on variables that have a lasting effect, such as quality of life, sperm quality and body weight. Despite these limitations, the significance of the lifestyle intervention lies in the fact that it was confirmed to be effective on HPB, infertility stress, and especially semen quality of men in infertile couples.

Conclusion

The current study was scientifically revealed to be effective in improving HPB, sperm quality as well as decreasing stress through lifestyle intervention without invasive procedures or medication. Accordingly, it will contribute to improving the physical, psychological, and reproductive health of infertile couples by providing nurse-led lifestyle interventions at obstetrics and gynecology or community health centers.

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Conflicts of Interest

No potential conflict of interest relevant to this article was reported.

Acknowledgements

None.

Funding

This work was supported by a National Research Foundation of Korea (NRF) grant funded by the Korean government (No., NRF-2020R1F1A1050767).

Data Sharing Statement

Please contact the corresponding author for data availability.

Author Contributions

Conceptualization or/and Methodology: YMK, JHN. Data curation or/and Analysis: YMK, JHN. Funding acquisition: JHN. Investigation: JHN. Project administration or/and Supervision: JHN. Resources or/and Software: YMK, JHN. Validation: YMK, JHN. Visualization: YMK, JHN. Writing: original draft or/and Review & Editing: YMK, JHN. Final approval of the manuscript: YMK, JHN.

Fig. 1.

Study flow chart.

Table 1.

IMCHB-based lifestyle intervention for men in infertile couples

Session: 1, 3, 5, 7, 9, 11, 13, 15 (every Tuesday for 8 weeks)		Session: 2, 4, 6, 8, 10, 12, 14, 16 (every Friday for 8 weeks)		Session: daily		Elements of client professional interaction
Education	Method	Feedback	Method	Monitoring	Method	Elements of client professional interaction
Reproductive health education	Digital short message service	Consultation	Telephone	Self-checking	Wearable device	Client professional interaction
- Reproductive health for men and women		- Individualized feedback		- Assessing the lifestyle patterns via lifestyle checklist	Uniform resource locator	- Text messages
- Lifestyle factors affecting fertility		- Recommendations on optimizing their physical activity, dietary habits, and stress management strategies.				- Monitoring
- Lifestyle modification strategies for optimizing reproductive outcomes						- Telephone consultations and monitoring
Physical activity management						- Assessment of exercise, diet, and stress status
- Intensity and method of walking						Health information
- Methods of strength training and aerobic exercise						- Education and information
- Precautions during physical activity						- Knowledge reinforcement
- How to use a smart band and a physical activity diary						Professional/technical competencies
Nutritional management						- Telephone and individual counseling
- Men’s healthy diet and nutrition education						- Decisional control: phone calls and mobile messages
- Nutrition label confirmation						Affective support
- Nutritional education related to reproductive health						- Praise
- 24-hour dietary recall						- Encouragement
Stress management						- Support
- Relaxation and mindfulness techniques (meditation, bedtime relaxation)
- Talking with one’s spouse (before going to bed, taking a walk)
- Sufficient sleep (about 7 hours)
- Light walking with one’s spouse

IMCHB, interaction model of client health behavior.

Table 2.

Homogeneity of general characteristics and variables between groups (N=36)

Characteristic	Exp. (n=17)	Cont. (n=19)	χ² or t or z	p
Characteristic	n (%)/M±SD/med (IQR)		χ² or t or z	p
Age (yr)			0.15	.881
≤30	1 (5.9)	0 (0.0)
31–34	5 (29.4)	8 (42.1)
35–40	5 (29.4)	5 (26.3)
≥41	6 (35.3)	6 (31.6)
Mean±SD	37.24±4.76	38.00±5.16
Age of spouse (yr)			0.99	.804
≤30	3 (17.7)	2 (10.5)
31–34	5 (29.4)	8 (42.1)
35–40	4 (23.5)	4 (21.1)
≥41	5 (29.4)	5 (26.3)
Mean±SD	34.94±4.48	35.42±4.49
Marriage duration (mo)			5.55	.136
≤24	3 (17.7)	5 (26.3)
25–36	5 (29.4)	5 (26.3)
37–48	4 (23.5)	0 (0.0)
≥49	5 (29.4)	9 (47.4)
Mean±SD	49.18±35.91	53.89±36.18
Religion			1.99	.192
Yes	12 (70.6)	9 (47.4)
No	5 (29.4)	10 (52.6)
Education			0.96	.434
≤High school	5 (29.4)	3 (15.8)
≥University	12 (70.6)	16 (84.2)
Chronic disease			0.01	>.999
Yes	1 (5.9)	1 (5.3)
No	16 (94.1)	18 (94.7)
Monthly individual income (10,000 KRW)			1.14	.887
<200	1 (5.9)	1 (5.3)
200–299	5 (29.4)	6 (31.6)
300–399	3 (17.7)	2 (10.5)
400–499	4 (23.5)	3 (15.8)
≥500	4 (23.5)	7 (36.8)
Alcohol consumption			0.63	.502
Yes	12 (70.6)	11 (57.9)
No	5 (29.4)	8 (42.1)
Smoking			0.39	.695
Yes	3 (17.7)	5 (26.3)
No	14 (82.3)	14 (73.7)
Physical activity			0.01	>.999
Yes	6 (35.3)	7 (36.8)
No	11 (64.7)	12 (63.2)
Sleeping hours (hr)			2.73	.158
<3	1 (5.9)	0 (0.0)
3–5	7 (41.2)	2 (10.5)
6–7	7 (41.2)	14 (73.7)
≥8	2 (11.7)	3 (15.8)
Body mass index (kg/m²)	26.07±3.39	25.40±3.11	0.62	.540
Normal (18.5–24.9)	8 (47.1)	6 (35.3)
Overweight (18.5–24.9)	5 (29.4)	6 (35.3)	1.12	.570
Obesity (≥30.0)	4 (23.5)	5 (29.4)
Semen analysis experience			0.39	.736
Yes	8 (47.1)	7 (36.8)
No	9 (52.9)	12 (63.2)
Health-promoting behaviors	117.00 (IQR, 109.00)	113.00 (IQR, 104.00)	–0.65^a)	.516
Infertility stress	166.00±19.98	149.58±27.55	2.03	.051
Fertility-related quality of life	72.37±11.47	70.27±10.89	0.56	.577
Volume (mL) (n=30)	4.00 (IQR, 3.00)	3.50 (IQR, 2.75)	–0.49^a)	.626
Total motility (%) (n=30)	64.98 (IQR, 41.39)	83.84 (IQR, 76.33)	–2.03^a)	.042
Immobility (%) (n=30)	35.02 (IQR, 13.60)	16.16 (IQR< 8.86)	2.97^a)	.007
Concentration (million/mL) (n=30)	25.53 (IQR, 13.26)	36.40 (IQR, 21.25)	–1.57^a)	.117
Normal morphology (%) (n=30)	9.98 (IQR, 8.12)	19.76 (IQR, 11.74)	–1.47^a)	.143

Values are presented as number (%), mean±SD, or median (IQR).

Cont., control group; Exp., experimental group; IQR, interquartile range; KRW, Korean won; SD, standard deviation.

^a)By Mann-Whitney U test.

Table 3.

Effects of the IMCHB-based lifestyle intervention for men in infertile couples (N=36)

Variable	Pre-test	Post-test	Difference	z or t or F	p
Variable	Med (IQR)/M±SD			z or t or F	p
Health promoting behaviors				–2.27^a)	.023
Exp. (n=17)	117.00 (109.00)	132.00 (125.00)	8.00 (1.00)
Cont. (n=19)	113.00 (104.00)	119.00 (104.00)	–1.00 (–5.00)
Infertility stress				–2.40^b)	.022
Exp. (n=17)	166.00±19.98	114.53±22.59	–51.47±34.35
Cont. (n=19)	149.58±27.55	126.79±26.00	–22.79±37.18
Fertility-related quality of life				0.63^b)	.531
Exp. (n=17)	72.37±11.47	74.12±6.88	1.76±10.08
Cont. (n=19)	70.26±10.89	69.70±11.74	–0.57±11.74
Volume (mL) (n=30)				–0.49^a)	.626
Exp. (n=17)	4.00 (3.00)	4.00 (4.00)	0.00 (0.00)
Cont. (n=13)	3.50 (2.75)	3.00 (2.00)	0.00 (0.00)
Total motility (%) (n=30)				4.39^c)	.045
Exp. (n=17)	64.98 (41.39)	86.09 (72.83)	16.33 (1.67)
Cont. (n=13)	83.84 (76.33)	90.43 (70.24)	0.00 (–8.74)
Immobility (%) (n=30)				2.04^c)	.164
Exp. (n=17)	35.02 (13.60)	13.92 (10.98)	–16.33 (–31.45)
Cont. (n=13)	16.16 (8.86)	9.57 (6.40)	–0.61 (–8.54)
Concentration (million/mL) (n=30)				–1.57^a)	.117
Exp. (n=17)	25.53 (13.26)	34.41 (17.67)	3.92 (–4.44)
Cont. (n=13)	36.40 (21.25)	51.11 (21.79)	2.03 (–6.80)
Normal morphology (%) (n=30)				2.86^a)	.017
Exp. (n=17)	9.98 (8.12)	23.55 (9.91)	2.52 (0.02)
Cont. (n=13)	19.76 (11.74)	17.48 (9.95)	–0.23 (–10.24)

Values are presented as median (interquartile range) or mean±standard deviation.

Cont., control group; Exp., experimental group; IMCHB, interaction model of client health behavior.

^a)By Mann-Whitney U test. ^b)By independent t-test. ^c)By ranked analysis of covariance (covariate: pre-test score of total motility and immobility).

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The effects of a lifestyle intervention for men in infertile couples in South Korea: a non-randomized clinical trial

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The effects of a lifestyle intervention for men in infertile couples in South Korea: a non-randomized clinical trial

Fig. 1. Study flow chart.

Fig. 1.

The effects of a lifestyle intervention for men in infertile couples in South Korea: a non-randomized clinical trial

Session: 1, 3, 5, 7, 9, 11, 13, 15 (every Tuesday for 8 weeks)		Session: 2, 4, 6, 8, 10, 12, 14, 16 (every Friday for 8 weeks)		Session: daily		Elements of client professional interaction
Education	Method	Feedback	Method	Monitoring	Method	Elements of client professional interaction
Reproductive health education	Digital short message service	Consultation	Telephone	Self-checking	Wearable device	Client professional interaction
- Reproductive health for men and women		- Individualized feedback		- Assessing the lifestyle patterns via lifestyle checklist	Uniform resource locator	- Text messages
- Lifestyle factors affecting fertility		- Recommendations on optimizing their physical activity, dietary habits, and stress management strategies.				- Monitoring
- Lifestyle modification strategies for optimizing reproductive outcomes						- Telephone consultations and monitoring
Physical activity management						- Assessment of exercise, diet, and stress status
- Intensity and method of walking						Health information
- Methods of strength training and aerobic exercise						- Education and information
- Precautions during physical activity						- Knowledge reinforcement
- How to use a smart band and a physical activity diary						Professional/technical competencies
Nutritional management						- Telephone and individual counseling
- Men’s healthy diet and nutrition education						- Decisional control: phone calls and mobile messages
- Nutrition label confirmation						Affective support
- Nutritional education related to reproductive health						- Praise
- 24-hour dietary recall						- Encouragement
Stress management						- Support
- Relaxation and mindfulness techniques (meditation, bedtime relaxation)
- Talking with one’s spouse (before going to bed, taking a walk)
- Sufficient sleep (about 7 hours)
- Light walking with one’s spouse

Characteristic	Exp. (n=17)	Cont. (n=19)	χ² or t or z	p
Characteristic	n (%)/M±SD/med (IQR)		χ² or t or z	p
Age (yr)			0.15	.881
≤30	1 (5.9)	0 (0.0)
31–34	5 (29.4)	8 (42.1)
35–40	5 (29.4)	5 (26.3)
≥41	6 (35.3)	6 (31.6)
Mean±SD	37.24±4.76	38.00±5.16
Age of spouse (yr)			0.99	.804
≤30	3 (17.7)	2 (10.5)
31–34	5 (29.4)	8 (42.1)
35–40	4 (23.5)	4 (21.1)
≥41	5 (29.4)	5 (26.3)
Mean±SD	34.94±4.48	35.42±4.49
Marriage duration (mo)			5.55	.136
≤24	3 (17.7)	5 (26.3)
25–36	5 (29.4)	5 (26.3)
37–48	4 (23.5)	0 (0.0)
≥49	5 (29.4)	9 (47.4)
Mean±SD	49.18±35.91	53.89±36.18
Religion			1.99	.192
Yes	12 (70.6)	9 (47.4)
No	5 (29.4)	10 (52.6)
Education			0.96	.434
≤High school	5 (29.4)	3 (15.8)
≥University	12 (70.6)	16 (84.2)
Chronic disease			0.01	>.999
Yes	1 (5.9)	1 (5.3)
No	16 (94.1)	18 (94.7)
Monthly individual income (10,000 KRW)			1.14	.887
<200	1 (5.9)	1 (5.3)
200–299	5 (29.4)	6 (31.6)
300–399	3 (17.7)	2 (10.5)
400–499	4 (23.5)	3 (15.8)
≥500	4 (23.5)	7 (36.8)
Alcohol consumption			0.63	.502
Yes	12 (70.6)	11 (57.9)
No	5 (29.4)	8 (42.1)
Smoking			0.39	.695
Yes	3 (17.7)	5 (26.3)
No	14 (82.3)	14 (73.7)
Physical activity			0.01	>.999
Yes	6 (35.3)	7 (36.8)
No	11 (64.7)	12 (63.2)
Sleeping hours (hr)			2.73	.158
<3	1 (5.9)	0 (0.0)
3–5	7 (41.2)	2 (10.5)
6–7	7 (41.2)	14 (73.7)
≥8	2 (11.7)	3 (15.8)
Body mass index (kg/m²)	26.07±3.39	25.40±3.11	0.62	.540
Normal (18.5–24.9)	8 (47.1)	6 (35.3)
Overweight (18.5–24.9)	5 (29.4)	6 (35.3)	1.12	.570
Obesity (≥30.0)	4 (23.5)	5 (29.4)
Semen analysis experience			0.39	.736
Yes	8 (47.1)	7 (36.8)
No	9 (52.9)	12 (63.2)
Health-promoting behaviors	117.00 (IQR, 109.00)	113.00 (IQR, 104.00)	–0.65^a)	.516
Infertility stress	166.00±19.98	149.58±27.55	2.03	.051
Fertility-related quality of life	72.37±11.47	70.27±10.89	0.56	.577
Volume (mL) (n=30)	4.00 (IQR, 3.00)	3.50 (IQR, 2.75)	–0.49^a)	.626
Total motility (%) (n=30)	64.98 (IQR, 41.39)	83.84 (IQR, 76.33)	–2.03^a)	.042
Immobility (%) (n=30)	35.02 (IQR, 13.60)	16.16 (IQR< 8.86)	2.97^a)	.007
Concentration (million/mL) (n=30)	25.53 (IQR, 13.26)	36.40 (IQR, 21.25)	–1.57^a)	.117
Normal morphology (%) (n=30)	9.98 (IQR, 8.12)	19.76 (IQR, 11.74)	–1.47^a)	.143

Variable	Pre-test	Post-test	Difference	z or t or F	p
Variable	Med (IQR)/M±SD			z or t or F	p
Health promoting behaviors				–2.27^a)	.023
Exp. (n=17)	117.00 (109.00)	132.00 (125.00)	8.00 (1.00)
Cont. (n=19)	113.00 (104.00)	119.00 (104.00)	–1.00 (–5.00)
Infertility stress				–2.40^b)	.022
Exp. (n=17)	166.00±19.98	114.53±22.59	–51.47±34.35
Cont. (n=19)	149.58±27.55	126.79±26.00	–22.79±37.18
Fertility-related quality of life				0.63^b)	.531
Exp. (n=17)	72.37±11.47	74.12±6.88	1.76±10.08
Cont. (n=19)	70.26±10.89	69.70±11.74	–0.57±11.74
Volume (mL) (n=30)				–0.49^a)	.626
Exp. (n=17)	4.00 (3.00)	4.00 (4.00)	0.00 (0.00)
Cont. (n=13)	3.50 (2.75)	3.00 (2.00)	0.00 (0.00)
Total motility (%) (n=30)				4.39^c)	.045
Exp. (n=17)	64.98 (41.39)	86.09 (72.83)	16.33 (1.67)
Cont. (n=13)	83.84 (76.33)	90.43 (70.24)	0.00 (–8.74)
Immobility (%) (n=30)				2.04^c)	.164
Exp. (n=17)	35.02 (13.60)	13.92 (10.98)	–16.33 (–31.45)
Cont. (n=13)	16.16 (8.86)	9.57 (6.40)	–0.61 (–8.54)
Concentration (million/mL) (n=30)				–1.57^a)	.117
Exp. (n=17)	25.53 (13.26)	34.41 (17.67)	3.92 (–4.44)
Cont. (n=13)	36.40 (21.25)	51.11 (21.79)	2.03 (–6.80)
Normal morphology (%) (n=30)				2.86^a)	.017
Exp. (n=17)	9.98 (8.12)	23.55 (9.91)	2.52 (0.02)
Cont. (n=13)	19.76 (11.74)	17.48 (9.95)	–0.23 (–10.24)

Table 1. IMCHB-based lifestyle intervention for men in infertile couples

IMCHB, interaction model of client health behavior.

Table 2. Homogeneity of general characteristics and variables between groups (N=36)

Values are presented as number (%), mean±SD, or median (IQR).

Cont., control group; Exp., experimental group; IQR, interquartile range; KRW, Korean won; SD, standard deviation.

By Mann-Whitney U test.

Table 3. Effects of the IMCHB-based lifestyle intervention for men in infertile couples (N=36)

Values are presented as median (interquartile range) or mean±standard deviation.

Cont., control group; Exp., experimental group; IMCHB, interaction model of client health behavior.

^a)By Mann-Whitney U test. ^b)By independent t-test. ^c)By ranked analysis of covariance (covariate: pre-test score of total motility and immobility).