Impact of Faulty Lifestyle Behaviors on Male Fertility: A Narrative Review
Impact of Lifestyle factors on Male Fertility
DOI:
https://doi.org/10.1071/ejmbs.v1i2.11Anahtar Kelimeler:
Lifestyle- Infertility- Semen- Sperm- StressÖzet
There is global rise in male infertility cases in the past few decades. With declining semen quality due to a variety of reasons, more and more researches have been directed to find the cause of such rise in male infertility. Several modifiable factors including environmental pollution, occupational exposures and faulty lifestyle habits have been observed to be associated with poor semen quality and male infertility. The present review focuses on some of the lifestyle factors including rise in sedentary life, obesity, smoking, alcohol and drug abuse, excessive use of electronic gadgets, altered sleeping habits, stress and faulty dietary habits that have affected the male reproductive health adversely leading to decreased male fertility. Methodology: The literature from 2000 till 2021 was searched from World Health Organization site and various English peer-reviewed journals using the USA National Library of Medicine (PubMed) database, regional portal of Virtual Health Library, and Scientific Electronic Library Online. The search terms used were: “Lifestyle and male fertility”, “Obesity and male infertility”, “Stress and infertility”, “Electronic gadgets and male fertility”. Conclusion: Poor lifestyle habits have significant impact on the process of spermatogenesis leading to impaired semen quality including decreased sperm concentration, count, motility, viability and increased abnormal sperm morphology, sperm DNA fragmentation, thereby affecting overall male reproductive health and fertility. However, all these factors are treatable and reversible and by just bringing a positive change in daily lifestyle many of these risk factors can be circumvented.
Referanslar
Aboulmaouahib, S., Madkour, A., Kaarouch, I., Sefrioui, O., Saadani, B., Copin, H., Benkhalifa, M., Louanjli, N., Cadi, R. (2018). Impact of alcohol and cigarette smoking consumption in male fertility potential: Looks at lipid peroxidation, enzymatic antioxidant activities and sperm DNA damage. Andrologia, 50(3), e12926.
Adams, J. A., Galloway, T. S., Mondal, D., Esteves, S. C., Mathews, F. (2014). Effect of mobile telephones on sperm quality: a systematic review and meta-analysis. Environment International, 70, 106–112.
Afeiche, M., Williams, P. L., Mendiola, J., Gaskins, A. J., Jørgensen, N., Swan, S. H., Chavarro, J. E. (2013). Dairy food intake in relation to semen quality and reproductive hormone levels among physically active young men. Human reproduction (Oxford, England), 28(8), 2265–2275.
Afeiche, M. C., Bridges, N. D., Williams, P. L., Gaskins, A. J., Tanrikut, C., Petrozza, J. C., Hauser, R., Chavarro, J. E. (2014). Dairy intake and semen quality among men attending a fertility clinic. Fertility and sterility, 101(5), 1280–1287.
Agarwal, A., Deepinder, F., Sharma, R. K., Ranga, G., Li, J. (2008). Effect of cell phone usage on semen analysis in men attending infertility clinic: an observational study. Fertility and sterility, 89(1), 124–128.
Agarwal, A., Singh, A., Hamada, A., Kesari, K. (2011). Cell phones and male infertility: a review of recent innovations in technology and consequences. International braz j urol : official journal of the Brazilian Society of Urology, 37(4), 432–454.
Agarwal, A., Majzoub, A., Baskaran, S., Panner Selvam, M. K., Cho, C. L., Henkel, R., Finelli, R., Leisegang, K., Sengupta, P., Barbarosie, C., Parekh, N., Alves, M. G., Ko, E., Arafa, M., Tadros, N., Ramasamy, R., Kavoussi, P., Ambar, R., Kuchakulla, M., Robert, K. A., Lovine, C., Durairajanayagam, D., Jindal, S., Shah, R. (2020). Sperm DNA Fragmentation: A New Guideline for Clinicians. The world journal of men's health, 38(4), 412–471.
Al-Bayyari, N. (2017). The effect of cell phone usage on semen quality and fertility among Jordanian males. Middle East Fertility Society Journal, 22(3),178-182.
Alvarenga, T. A., Hirotsu, C., Mazaro-Costa, R., Tufik, S., Andersen, M. L. (2015). Impairment of male reproductive function after sleep deprivation. Fertility and sterility, 103(5), 1355–1362.
Arun, S., Burawat, J., Sukhorum, W., Sampannang, A., Maneenin, C., Iamsaard, S. (2016). Chronic restraint stress induces sperm acrosome reaction and changes in testicular tyrosine phosphorylated proteins in rats. International journal of reproductive biomedicine, 14(7), 443–452.
Arun, S., Burawat, J., Yannasithinon, S., Sukhorum, W., Limpongsa, A., Iamsaard, S. (2018). Phyllanthus emblica leaf extract ameliorates testicular damage in rats with chronic stress. Journal of Zhejiang University Science B, 19(12), 948–959.
Avendaño, C., Mata, A., Sanchez Sarmiento, C. A., Doncel, G. F. (2012). Use of laptop computers connected to internet through Wi-Fi decreases human sperm motility and increases sperm DNA fragmentation. Fertility and sterility, 97(1), 39–45.
Belloc, S., Benkhalifa, M., Cohen-Bacrie, M., Dalleac, A., Amar, E., Zini, A. (2014). Sperm deoxyribonucleic acid damage in normozoospermic men is related to age and sperm progressive motility. Fertility and sterility, 101(6), 1588–1593.
Bundhun, P. K., Janoo, G., Bhurtu, A., Teeluck, A. R., Soogund, M., Pursun, M., Huang, F. (2019). Tobacco smoking and semen quality in infertile males: a systematic review and meta-analysis. BMC public health, 19(1), 36.
Chavarro, J. E., Toth, T. L., Wright, D. L., Meeker, J. D., Hauser, R. (2010). Body mass index in relation to semen quality, sperm DNA integrity, and serum reproductive hormone levels among men attending an infertility clinic. Fertility and sterility, 93(7), 2222–2231.
Chen, Q., Yang, H., Zhou, N., Sun, L., Bao, H., Tan, L., Chen, H., Ling, X., Zhang, G., Huang, L., Li, L., Ma, M., Yang, H., Wang, X., Zou, P., Peng, K., Liu, T., Cui, Z., Ao, L., Roenneberg, T., Zhou, Z., Cao, J. (2016). Inverse U-shaped Association between Sleep Duration and Semen Quality: Longitudinal Observational Study (MARHCS) in Chongqing, China. Sleep, 39(1), 79–86.
Choi, J. H., Lee, S. H., Bae, J. H., Shim, J. S., Park, H. S., Kim, Y. S., Shin, C. (2016). Effect of Sleep Deprivation on the Male Reproductive System in Rats. Journal of Korean medical science, 31(10), 1624–1630.
Craig, J. R., Jenkins, T. G., Carrell, D. T., Hotaling, J. M. (2017). Obesity, male infertility, and the sperm epigenome. Fertility and sterility, 107(4), 848–859.
Cutillas-Tolín, A., Mínguez-Alarcón, L., Mendiola, J., López-Espín, J. J., Jørgensen, N., Navarrete-Muñoz, E. M., Torres-Cantero, A. M., Chavarro, J. E. (2015). Mediterranean and western dietary patterns are related to markers of testicular function among healthy men. Human reproduction (Oxford, England), 30(12), 2945–2955.
Dhami A. K. (2012). Study of electromagnetic radiation pollution in an Indian city. Environmental monitoring and assessment,184(11), 6507–6512.
du Plessis, S. S., Agarwal, A., Syriac, A. (2015). Marijuana, phytocannabinoids, the endocannabinoid system, and male fertility. Journal of assisted reproduction and genetics, 32(11), 1575–1588.
Dupont, C., Faure, C., Sermondade, N., Boubaya, M., Eustache, F., Clément, P., Briot, P., Berthaut, I., Levy, V., Cedrin-Durnerin, I., Benzacken, B., Chavatte-Palmer, P., Levy, R. (2013). Obesity leads to higher risk of sperm DNA damage in infertile patients. Asian journal of andrology, 15(5), 622–625.
Durairajanayagam D. (2018). Lifestyle causes of male infertility. Arab journal of urology, 16(1), 10–20.
El Salam M. (2018). Obesity, An Enemy of Male Fertility: A Mini Review. Oman medical journal, 33(1), 3–6.
Eskiocak, S., Gozen, A. S., Taskiran, A., Kilic, A. S., Eskiocak, M., Gulen, S. (2006). Effect of psychological stress on the L-arginine-nitric oxide pathway and semen quality. Brazilian journal of medical and biological research = Revista brasileira de pesquisas medicas e biologicas, 39(5), 581–588.
Eslamian, G., Amirjannati, N., Rashidkhani, B., Sadeghi, M. R., Baghestani, A. R., Hekmatdoost, A. (2016). Adherence to the Western Pattern Is Potentially an Unfavorable Indicator of Asthenozoospermia Risk: A Case-Control Study. Journal of the American College of Nutrition, 35(1), 50–58.
Esmaeili, V., Shahverdi, A. H., Moghadasian, M. H., Alizadeh, A. R. (2015). Dietary fatty acids affect semen quality: a review. Andrology, 3(3), 450–461.
Fitzgerald, L. Z., Robbins, W. A., Kesner, J. S., Xun, L. (2012). Reproductive hormones and interleukin-6 in serious leisure male athletes. European journal of applied physiology, 112(11), 3765–3773.
Foucaut, A. M., Faure, C., Julia, C., Czernichow, S., Levy, R., Dupont, C., ALIFERT collaborative group. (2019). Sedentary behavior, physical inactivity and body composition in relation to idiopathic infertility among men and women. PloS one, 14(4), e0210770.
Gabrielsen, J. S., Tanrikut, C. (2016). Chronic exposures and male fertility: the impacts of environment, diet, and drug use on spermatogenesis. Andrology, 4(4), 648–661.
García-Díaz, E. C., Gómez-Quiroz, L. E., Arenas-Ríos, E., Aragón-Martínez, A., Ibarra-Arias, J. A., del Socorro I Retana-Márquez, M. (2015). Oxidative status in testis and epididymal sperm parameters after acute and chronic stress by cold-water immersion in the adult rat. Systems biology in reproductive medicine, 61(3), 150–160.
Gaskins, A. J., Colaci, D. S., Mendiola, J., Swan, S. H., Chavarro, J. E. (2012). Dietary patterns and semen quality in young men. Human reproduction (Oxford, England), 27(10), 2899–2907.
Gaskins, A. J., Mendiola, J., Afeiche, M., Jørgensen, N., Swan, S. H., Chavarro, J. E. (2015). Physical activity and television watching in relation to semen quality in young men. British journal of sports medicine, 49(4), 265–270.
Gaur, D. S., Talekar, M. S., Pathak, V. P. (2010). Alcohol intake and cigarette smoking: impact of two major lifestyle factors on male fertility. Indian journal of pathology & microbiology, 53(1), 35–40.
Gill, K., Jakubik, J., Kups, M., Rosiak-Gill, A., Kurzawa, R., Kurpisz, M., Fraczek, M., Piasecka, M. (2019). The impact of sedentary work on sperm nuclear DNA integrity. Folia histochemica et cytobiologica, 57(1), 15–22.
Gorpinchenko, I., Nikitin, O., Banyra, O., Shulyak, A. (2014). The influence of direct mobile phone radiation on sperm quality. Central European journal of urology, 67(1), 65–71.
Gude D., (2012). Alcohol and fertility. Journal of human reproductive sciences, 5(2), 226–228.
Guthauser, B., Boitrelle, F., Plat, A., Thiercelin, N., Vialard, F. (2014). Chronic excessive alcohol consumption and male fertility: a case report on reversible azoospermia and a literature review. Alcohol and alcoholism (Oxford, Oxfordshire), 49(1), 42–44.
Harlev, A., Agarwal, A., Gunes, S.O., Shetty, A., du Plessis, S.S. (2015). Smoking and Male Infertility: An Evidence-Based Review. World J Mens Health, 33(3),143-60.
Hassa, H., Yildirim, A., Can, C., Turgut, M., Tanir, H. M., Senses, T., Sahin-Mutlu, F. (2006). Effect of smoking on semen parameters of men attending an infertility clinic. Clinical and experimental obstetrics & gynecology, 33(1), 19–22.
Iamsaard, S., Tongpan, S., Yannasithinon, S., Arun, S., Wu, A.T.H., Sukhorum, W. (2020). Effect of chronic stress on expression and secretion of seminal vesicle proteins in adult rats. Andrologia, 53(1), e13800.
Ilacqua, A., Izzo, G., Emerenziani, G. P., Baldari, C., Aversa, A. (2018). Lifestyle and fertility: the influence of stress and quality of life on male fertility. Reproductive biology and endocrinology, 16(1), 115.
Jensen, T. K., Andersson, A. M., Skakkebæk, N. E., Joensen, U. N., Blomberg Jensen, M., Lassen, T. H., Nordkap, L., Olesen, I. A., Hansen, Å. M., Rod, N. H., Jørgensen, N. (2013). Association of sleep disturbances with reduced semen quality: a cross-sectional study among 953 healthy young Danish men. American journal of epidemiology, 177(10), 1027–1037.
Jhuang, Y. H., Chung, C. H., Wang, I. D., Peng, C. K., Meng, E., Chien, W. C., Chang, P. Y. (2021). Association of Obstructive Sleep Apnea with the Risk of Male Infertility in Taiwan. JAMA network open, 4(1), e2031846.
Jóźków, P., Rossato, M. (2017). The Impact of Intense Exercise on Semen Quality. American journal of men's health, 11(3), 654–662.
Kesari, K. K., Kumar, S., Behari, J. (2010). Mobile phone usage and male infertility in Wistar rats. Indian journal of experimental biology, 48(10), 987–992.
Kesari, K. K., Behari, J. (2012). Evidence for mobile phone radiation exposure effects on reproductive pattern of male rats: role of ROS. Electromagnetic biology and medicine, 31(3), 213–222.
Kesari, K. K., Agarwal, A., Henkel, R. (2018). Radiations and male fertility. Reproductive biology and endocrinology, 16(1), 118.
Keszthelyi, M., Gyarmathy, V. A., Kaposi, A., Kopa, Z. (2020). The potential role of central obesity in male infertility: body mass index versus waist to hip ratio as they relate to selected semen parameters. BMC public health, 20(1), 307.
Lalinde-Acevedo, P. C., Mayorga-Torres, B., Agarwal, A., du Plessis, S. S., Ahmad, G., Cadavid, Á. P., Cardona Maya, W. D. (2017). Physically Active Men Show Better Semen Parameters than Their Sedentary Counterparts. International journal of fertility & sterility, 11(3), 156–165.
Lateef, O. M., Akintubosun, M. O. (2020). Sleep and Reproductive Health. Journal of circadian rhythms, 18, 1.
Leisegang, K., Sengupta, P., Agarwal, A., Henkal, R. (2020). Obesity and male infertility: Mechanisms and management. Andrologia, 2020, e13617.
Lingappa, H. A., Govindashetty, A. M., Puttaveerachary, A. K., Manchaiah, S., Krishnamurthy, A., Bashir, S., Doddaiah, N. (2015). Evaluation of Effect of Cigarette Smoking on Vital Seminal Parameters Which Influence Fertility. Journal of clinical and diagnostic research, 9(7), EC13–EC15.
Liu, C. Y., Chou, Y. C., Chao, J. C., Hsu, C. Y., Cha, T. L., Tsao, C. W. (2015). The Association between Dietary Patterns and Semen Quality in a General Asian Population of 7282 Males. PloS one, 10(7), e0134224.
Liu, M. M., Liu, L., Chen, L., Yin, X. J., Liu, H., Zhang, Y. H., Li, P. L., Wang, S., Li, X. X., Yu, C. H. (2017). Sleep Deprivation and Late Bedtime Impair Sperm Health Through Increasing Antisperm Antibody Production: A Prospective Study of 981 Healthy Men. Medical science monitor: international medical journal of experimental and clinical research, 23, 1842–1848.
Mathur, S., Jawad, K., Dayal, S. (2019). Effect of smoking and alcohol consumption on reproductive hormones and semen parameters in male partners of infertile couples. International Journal of Contemporary Medical Research, 6(9), I5-I9.
Meena, R., Kumari, K., Kumar, J., Rajamani, P., Verma, H. N., Kesari, K. K. (2014). Therapeutic approaches of melatonin in microwave radiations-induced oxidative stress-mediated toxicity on male fertility pattern of Wistar rats. Electromagnetic biology and medicine, 33(2), 81–91.
Mortazavi, S. A., Taeb, S., Mortazavi, S. M., Zarei, S., Haghani, M., Habibzadeh, P., Shojaei-Fard, M. B. (2016). The Fundamental Reasons Why Laptop Computers should not be Used on Your Lap. Journal of biomedical physics & engineering, 6(4), 279–284.
Mostafa, T. (2010). Cigarette smoking and male infertility. Journal of Advanced Research, 1(3), 179-186.
Nargund V. H. (2015). Effects of psychological stress on male fertility. Nature reviews. Urology, 12(7), 373–382.
Nassan, F. L., Chavarro, J. E., Tanrikut, C. (2018). Diet and men's fertility: does diet affect sperm quality? Fertility and sterility, 110(4), 570–577.
Pacey, A. A., Povey, A. C., Clyma, J. A., McNamee, R., Moore, H. D., Baillie, H., Cherry, N. M., Participating Centres of Chaps-UK. (2014). Modifiable and non-modifiable risk factors for poor sperm morphology. Human reproduction (Oxford, England), 29(8), 1629–1636.
Palnitkar, G., Phillips, C. L., Hoyos, C. M., Marren, A. J., Bowman, M. C., Yee, B. J. (2018). Linking sleep disturbance to idiopathic male infertility. Sleep medicine reviews, 42, 149–159.
Priskorn, L., Jensen, T. K., Bang, A. K., Nordkap, L., Joensen, U. N., Lassen, T. H., Olesen, I. A., Swan, S. H., Skakkebaek, N. E., Jørgensen, N. (2016). Is Sedentary Lifestyle Associated with Testicular Function? A Cross-Sectional Study of 1,210 Men. American journal of epidemiology, 184(4), 284–294.
Ribeiro, C. T., De Souza, D. B., Costa, W. S., Sampaio, F., Pereira-Sampaio, M. A. (2018). Immediate and late effects of chronic stress in the testes of prepubertal and adult rats. Asian journal of andrology, 20(4), 385–390.
Ricci, E., Al-Beitawi, S., Cipriani, S., Alteri, A., Chiaffarino, F., Candiani, M., Gerli, S., Viganó, P., Parazzini, F. (2018). Dietary habits and semen parameters: a systematic narrative review. Andrology, 6(1), 104–116.
Rizk, N.I., Rizk, M.S., Mohamed, A.S., & Naguib, Y.M., (2020). Attenuation of sleep deprivation dependent deterioration in male fertility parameters by vitamin C. Reprod Biol Endocrinol, 18, 2.
Salas-Huetos, A., Bulló, M., Salas-Salvadó, J. (2017). Dietary patterns, foods and nutrients in male fertility parameters and fecundability: a systematic review of observational studies. Human reproduction update, 23(4), 371–389.
Salas-Huetos, A., James, E. R., Aston, K. I., Jenkins, T. G., Carrell, D. T. (2019). Diet and sperm quality: Nutrients, foods and dietary patterns. Reproductive biology, 19(3), 219–224.
Samplaski, M. K., Bachir, B. G., Lo, K. C., Grober, E. D., Lau, S., Jarvi, K. A. (2015). Cocaine Use in the Infertile Male Population: A Marker for Conditions Resulting in Subfertility. Current urology, 8(1), 38–42.
Sansone, A., Di Dato, C., de Angelis, C., Menafra, D., Pozza, C., Pivonello, R., Isidori, A., Gianfrilli, D. (2018). Smoke, alcohol and drug addiction and male fertility. Reproductive biology and endocrinology, 16(1), 3.
Sedentary Behaviour Research Network. (2012). Letter to the Editor: Standardized use of the terms “sedentary” and “sedentary behaviors”. Appl Physiol Nutr Metab, 37, 543–345.
Sermondade, N., Faure, C., Fezeu, L., Shayeb, A. G., Bonde, J. P., Jensen, T. K., Van Wely, M., Cao, J., Martini, A. C., Eskandar, M., Chavarro, J. E., Koloszar, S., Twigt, J. M., Ramlau-Hansen, C. H., Borges, E., Jr, Lotti, F., Steegers-Theunissen, R. P., Zorn, B., Polotsky, A. J., La Vignera, S., Eskenazi, B., Tremellen, K., Magnusdottir, E.V., Fejes, I., Hercberg, S., Lévy, R., Czernichow, S. (2013). BMI in relation to sperm count: an updated systematic review and collaborative meta-analysis. Human reproduction update, 19(3), 221–231.
Sharma, R., Biedenharn, K. R., Fedor, J. M., Agarwal, A. (2013). Lifestyle factors and reproductive health: taking control of your fertility. Reproductive biology and endocrinology, 11, 66.
Sharma, R., Harlev, A., Agarwal, A., Esteves, S. C. (2016). Cigarette Smoking and Semen Quality: A New Meta-Analysis Examining the Effect of the 2010 World Health Organization Laboratory Methods for the Examination of Human Semen. European urology, 70(4), 635–645.
Sheynkin, Y., Jung, M., Yoo, P., Schulsinger, D., Komaroff, E. (2005). Increase in scrotal temperature in laptop computer users. Human reproduction (Oxford, England), 20(2), 452–455.
Shrivastava, V., Marmor, H., Chernyak, S., Goldstein, M., Feliciano, M., Vigodner, M. (2014). Cigarette smoke affects posttranslational modifications and inhibits capacitation-induced changes in human sperm proteins. Reproductive toxicology (Elmsford, N.Y.), 43, 125–129.
Skoracka, K., Eder, P., Łykowska-Szuber, L., Dobrowolska, A., Krela-Kaźmierczak, I. (2020). Diet and Nutritional Factors in Male (In)fertility-Underestimated Factors. Journal of clinical medicine, 9(5), 1400.
Sun, B., Messerlian, C., Sun, Z. H., Duan, P., Chen, H. G., Chen, Y. J., Wang, P., Wang, L., Meng, T. Q., Wang, Q., Arvizu, M., Chavarro, J. E., Wang, Y. X., Xiong, C. L., Pan, A. (2019). Physical activity and sedentary time in relation to semen quality in healthy men screened as potential sperm donors. Human reproduction (Oxford, England), 34(12), 2330–2339.
Taha, E. A., Ezz-Aldin, A. M., Sayed, S. K., Ghandour, N. M., Mostafa, T. (2014). Smoking influence on sperm vitality, DNA fragmentation, reactive oxygen species and zinc in oligoasthenoteratozoospermic men with varicocele. Andrologia, 46(6), 687–691.
Vaamonde, D., Da Silva-Grigoletto, M. E., García-Manso, J. M., Vaamonde-Lemos, R., Swanson, R. J., Oehninger, S. C. (2009). Response of semen parameters to three training modalities. Fertility and sterility, 92(6), 1941–1946.
Vaamonde, D., Da Silva-Grigoletto, M. E., García-Manso, J. M., Barrera, N., Vaamonde-Lemos, R. (2012). Physically active men show better semen parameters and hormone values than sedentary men. European journal of applied physiology, 112(9), 3267–3273.
Vaamonde, D., Garcia-Manso, J. M., Hackney, A. C. (2017). Impact of physical activity and exercise on male reproductive potential: a new assessment questionnaire. Revista andaluza de medicina del deporte, 10(2), 79–93.
Viganò, P., Chiaffarino, F., Bonzi, V., Salonia, A., Ricci, E., Papaleo, E., Mauri, P. A., Parazzini, F. (2017). Sleep disturbances and semen quality in an Italian cross-sectional study. Basic and clinical andrology, 27, 16.
Walczak-Jedrzejowska, R., Wolski, J. K., Slowikowska-Hilczer, J. (2013). The role of oxidative stress and antioxidants in male fertility. Central European journal of urology, 66(1), 60–67.
World Health Organization, (2014). Fact Sheet No. 193. Electromagnetic Fields and Public Health: Mobile Phones. Geneva, p. 1. Available from: http://www.who.int/peh- emf/publications/factsheets/en [Last accessed on 2016 August 4].
World Health Organization, (2016). Obesity and overweight. Fact Sheet. Available at: http://www.who.int/mediacentre/factsheets/fs311/en/. Last accessed March 12, 2017.
World Health Organization, (2020). Infertility. Fact sheets. Available at: https://www.who.int/news-room/fact-sheets/detail/infertility
Zou, P., Sun, L., Chen, Q., Zhang, G., Yang, W., Zeng, Y., Zhou, N., Li, Y., Liu, J., Ao, L., Cao, J., Yang, H. (2019). Social support modifies an association between work stress and semen quality: Results from 384 Chinese male workers. Journal of psychosomatic research, 117, 65–70.