Official Publication for the Jordanian Royal Medical Services

The impact of Hookah on anti-Mullerian hormone level

Tariq IrteimahMD, Amaal AlDubais MD, Rami AlRubaihat MD, Nansy AlFayez MD.


Purpose: The aim of our study is to determine if smoking hookah has an effect on ovarian reserve by measuring the serum levels of Anti- Mullerian hormone. 

Material and methods:   A cross-sectional study was performed at the fertility clinic at Prince Ali Hospital, in the city of Karak, Jordan.   Two hundred healthy women within the 20 to 35 years age range, were chosen from those attending the fertility clinic. AMH serum levels were checked on one occasion on day 2–4 of the menstrual cycle. Data was collected from November 2020 to July 2021. The serum levels of AMH of 100 smoking hookah women were compared to the other non-smoking hookah women and results were analysed by Chi-square and independent samples T-result.

Result: A total of 200 hundred women were enrolled in the study. The mean age of the participants was 29 ±0.6  years. The mean AMH level was (2.29 ± 0.106 ng/mL) in hookah non- smokers compared to (1.5 ± 0.126 ng/mL) in hookah smokers. P values ≤ 0.05 were considered statistically significant. There is a considerable variation in Anti-Mullerian hormone levels between smokers and non-smokers.

Conclusion: Hookah smoking has a significant effect on serum Anti-Mullerian hormone levels.

Key words: Hookah, ovarian reserve, smoking, anti-Mullerian hormone.


   A hookah is an ancient waterpipe tobacco-smoking device. Its first use goes back to the Persian empire, and it was made by Abu’l-Fath Gilani, a Persian physician of Akbar (1,2). It was thought that inhaling tobacco smoke through a water pipe would filter the harmful ingredients. This theory, along with the scents and flavours added to tobacco, led to the misconception that hookah is a safer alternative compared to regular cigarette smoking (3). This misleading thought has increased hookah smoking, not just in the Middle East, but also worldwide (4). So, it is considered a critical issue.

The detrimental effects of hookah smoking have been consistently shown in many studies. The harmful effect of hookah on the cardiovascular system, as well as it being a major risk factor for certain cancers, is now well established. However, there are few good-quality studies, if any, which show the negative impact of hookah smoking on ovarian reserve, measured objectively by serum levels of anti-Müllerian hormone (5,6).

There is also a strong association between hookah smoking, and adverse fetal and maternal outcome in pregnant women, such as growth restriction, preterm labour, and pre-eclampsia (7,8). AMH, secreted by granulosa cells (9), begins to surge in the male fetus at 7 weeks of gestation. It inhibits development of the Müllerian ducts. In the female fetus, however, granulosa cells start secreting AMH at 36 weeks of gestation. In women, it has its peak at between 23 and 25 years old (10). AMH `1has the best predictive value for assessing ovarian reserve in ageing women. It is secreted by developing antral follicles, thus reflecting the number of primordial follicles. This mechanism of secretion makes AMH less fluctuating throughout the menstrual cycle (11,13). The role of AMH in predicting response in women undergoing fertility treatment is well established (12,14).

Cigarette smoking has a harmful effect on fertility and AMH levels (16), shown by several studies. However, there are scarce data in the literature about the effect of hookah. We found only one study related to the effect of hookah on AMH (15).

Through this study, we aim to identify the effect of hookah smoking on fertility, by objectively measuring the AMH levels in participants.



This cross-sectional study was performed at the fertility clinic at Prince Ali Hospital, in the city of Karak, Jordan. Ethical committee approval was obtained, as well as informed written consent from participants.

Two hundred healthy women, who met the inclusion criteria of the study, were randomly chosen from those attending the fertility clinic. AMH serum levels were checked on one occasion on day 2 or 3 or 4 of the menstrual cycle, as part of our regular investigations at our infertility clinic. 

Inclusion criteria were as follows:

Women with no previous medical history, aged between 20 and 35 years, presenting to the clinic with primary infertility, defined by the WHO as inability to achieve pregnancy after 12 months of regular unprotected sexual intercourse. Hookah smoking, at least once daily for at least one year.

Inclusion criteria were as follows:

Women with no previous medical history, aged between 20 and 35 years, presenting to the clinic with primary infertility, defined by the WHO as inability to achieve pregnancy after 12 months of regular unprotected sexual intercourse. Hookah smoking, at least once daily for at least one year.

And the exclusion criteria include:

•Any woman with chronic medical illness 

•Hormonal imbalances like premature ovarian failure 

•Irregular cycle and previous ovarian surgery.

•Smoking conventional cigarettes, in addition to hookah use.

AMH serum levels were determined and compared between 100 women who met the inclusion criteria and 100 non-hookah users. For all women included in the study, demographics have been recorded and confirmed from medical records. The study was described to the patients who were enrolled, and the questionnaire was explained. Confirmation about patients’ understanding of the study and questionnaire was obtained.

 Any patient has the right to withdraw at any time without affecting their treatment plan. Five cc of blood were collected and allowed to clot for 30 minutes. After that, centrifugation for 10 minutes at 4500 cycles per minute was performed before analysis using Cobas 6000 (F. Hoffmann-La Roche Ltd, Basel,

Switzerland). A total volume of 2–3 cc of serum was used for the analysis. Calibration and measurement of AMH. levels were done using an Elecsys AMH kit (F. Hoffmann-La Roche Ltd, Basel, Switzerland).

Statistical analysis:

Pearson’s chi-square test was used to evaluate if there were differences between different parameters and hookah smoking.Data were analysed using SPSS-22 electronic data analysis software (IBM, Armonk, NY, USA).Statistical significance was determined at the 95% confidence interval level.Mean AMH was compared between two groups using a two-tailed t-test of independent samples.



Two hundred women participated in this study; 100 were hookah smokers and the other 100 were hookah not users.The mean age for the participating women was 29+ 0. 6 years. The youngest age for smokers was 23 years, while the oldest was 35 years. The youngest non-smoker woman was 20 years, and the oldest was 35 years old. Table III

AMH levels were normally distributed for both groups evident by the normality statistical tests Kolmogorov-smirnov p= 0.2, which consider a non-significance (0.2> 0.05).

  The mean AMH level was (2.29 ± 0.106 ng/mL) in hookah non- smokers compared to (1.5 ± 0.126 ng/mL) in hookah smokers Table I. Upon comparing the mean in AMH between smokers and non-smokers, independent t test revealed a statistically significant difference.t (198) =4.803, p<0.001). The mean difference between both groups in AMH was 0.79 with 95% confidence interval of 0.47 to 1.11, indicating the hookah smokers has a lower level of AMH as compared to hookah non-smokers.

The normal AMH levels were between 1.2 and 3.2 ng/ml. Referring to Table II  of the total sample, 59 women had AMH levels less than 1.2 ng/mL, 44 were from the hookah smoking group and the remaining 15 were from the non-smoking group. Also 111 women had AMH levels between 1.2 and 3.2 ng/mL, 65 of them were from the hookah non- smoking group and the remaining 46 were from the smoking group. This was considered as a subgroup of the normal AMH range.

Of the total sample of participants, 30 women had AMH levels more than 3.2 ng/mL, 20 of them were from the hookah non- smoking group and the remaining 10 were from the smoking group. Table II                     

A chi square of independence revealed a statistical significant association between hookah smoking and level of AMH, a low level of AMH was associated with hookah smokers compared to hookah non-smoking X²  (2) =126.480. p< 0.001.


Table I:  independent t test result for mean differences

AMH mean values



Std. deviation



P value

















Table II: Numbers of women smoking and non-smoking with serum level of AM


< 1.2 ng/mL

1.2–3.2 ng/mL

> 3.2 ng/mL



P value


15 (15%)

65 (65%)

20 (20%)





44 (44%)

46 (46%)

10 (10%)




Observed cases







Table III: Mean age for smoker and non-smoker women


Mean age and SD

Non smoker






Tobacco is a major, direct cause of more than 8 million deaths each year, according to the WHO (18). There is an alarming increase in hookah use amongst women, and studies show that the number of women using hookah exceeds that of men (19,20).

This increase has been attributed, at least partly, to the misconception that hookah is a ‘safer alternative to conventional cigarette smoking’ and many women acknowledged their psychological dependence on hookahs as being addictive to smoking hookah. Studies have constantly shown the harmful effect of hookah on the general health of women, and wellbeing (21). And increased risk of premature menopause, reduced bone density, infertility, ectopic pregnancy, increased infant disease and mortality, intrauterine growth restriction and increased chromosomal disorders (29)(30).

Smoking cigarettes adversely affects the ovarian reserve of women, leading to poor response during ovarian stimulation (22), and it elevates atresia of the follicles (23) so it will lead to early menopause in women who smoke (24). Furthermore, cigarette is associated with a decline in AMH levels in reproductive age groups (17)

Hookah smoke contains 82 toxic chemicals and carcinogens (24,25) such as nicotine, carbon monoxide, tar and heavy metals, and 1 hour of hookah smoking releases 100 to 200 puffs in comparison to 10 puffs from cigarette smoking (26,27) so they have greater effect on the reproductive system.(31) Comparing our results between hookah smokers and hookah non- smokers  the average AMH in hookah non- smokers was 2.29 ng/mL but for smokers it was 1.5 ng/mL, showing the decline in AMH in smokers, as the normal result of AMH was 1.2ng/ml to 3.2ng/ml.

Only 15% of non-smokers had a low AMH level beyond 1.5 ng/ml. In contrast, to 44% of smokers low AMH less than 1.2 ng/mL, showing the effect of hookah toxins on AMH. We therefore found a significant reduction of AMH in hookah smokers, which will affect their fertility and may reduce their fecundity. Moreover, there is an increased prevalence of infertility around the world and primary infertility have been reported in 3.6% of tobacco smokers. (Delpishe et al 2014). Also, tobacco use likely increases infertility by 1.6-fold (32).

 We found that hookah smoking has a direct damaging effect on ovarian reserve, expressed here by the serum levels of AMH.Although no studies till now addressed the mechanism of how these changes occurred. However, we only found one study evaluating the effect of hookah on AMH levels, in which the effect was not statistically significant (28). And that study had a small sample, and patients were randomly selected from all clinics, and not specifically the infertility setting.

On the other hand, there is a strong association between hookah smokers and low semen count and volume and motility, so it has a negative impact on sperm parameters (33) which contribute to the increase in infertility issues these days among couples smoking hookah by their negative impact on the AMH in women and sperm parameters in men.



  The study did not record the duration nor the number of hookah smoking sessions. It would be advisable to understand if the duration of hookah smoking has a greater effect, for example, on AMH levels.

Further studies with a larger number of participants are recommended. And a long-term follow-up of participants who quit smoking would show if the detrimental effect is reversible.



In a nutshell, our findings shows that hookah has a negative impact on serum levels of Anti-Mullerian hormone



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