Sexual dysfunction in infertile women: A systematic review and meta-analysis

Sexual function in women with polycystic ovary syndrome: a systematic review and meta-analysis

BACKGROUND

Polycystic ovary syndrome (PCOS) is a common and distressing endocrine disorder associated with lower quality of life, subfertility, diabetes, cardiovascular disease, depression, anxiety, and eating disorders. PCOS characteristics, its comorbidities, and its treatment can potentially influence sexual function. However, studies on sexual function in women with PCOS are limited and contradictory.

OBJECTIVE AND RATIONALE

The aim was to perform a systematic review of the published literature on sexual function in women with PCOS and assess the quality of the research and certainty of outcomes, to inform the 2023 International Guidelines for the Assessment and Management of PCOS.

SEARCH METHODS

Eight electronic databases were searched until 1 June 2023. Studies reporting on sexual function using validated sexuality questionnaires or visual analogue scales (VAS) in PCOS populations were included. Random-effects models were used for meta-analysis comparing PCOS and non-PCOS groups with Hedges' g as the standardized mean difference. Study quality and certainty of outcomes were assessed by risk of bias assessments and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) method according to Cochrane. Funnel plots were visually inspected for publication bias.

OUTCOMES

There were 32 articles included, of which 28 used validated questionnaires and four used VAS. Pooled Female Sexual Function Index (FSFI) scores in random-effects models showed worse sexual function across most subdomains in women with PCOS, including arousal (Hedges's g [Hg] [95% CI] = -0.35 [-0.53, -0.17], I2 = 82%, P < 0.001), lubrication (Hg [95% CI] = -0.54 [-0.79, -0.30], I2 = 90%, P < 0.001), orgasm (Hg [95% CI] = -0.37 [-0.56, -0.19], I2 = 83%, P < 0.001), and pain (Hg [95% CI] = -0.36 [-0.59, -0.13] I2 = 90%, P < 0.001), as well as total sexual function (Hg [95% CI] = -0.75 [-1.37, -0.12], I2 = 98%, P  =  0.02) and sexual satisfaction (Hg [95% CI] = -0.31 [-0.45, -0.18], I2 = 68%, P < 0.001). Sensitivity and subgroup analyses based on fertility status and body mass index (BMI) did not alter the direction or significance of the results. Meta-analysis on the VAS studies demonstrated the negative impact of excess body hair on sexuality, lower sexual attractiveness, and lower sexual satisfaction in women with PCOS compared to controls, with no differences in the perceived importance of a satisfying sex life. No studies assessed sexual distress. GRADE assessments showed low certainty across all outcomes.

WIDER IMPLICATIONS

Psychosexual function appears to be impaired in those with PCOS, but there is a lack of evidence on the related distress scores, which are required to meet the criteria for psychosexual dysfunction. Health care professionals should discuss sexual function and distress and be aware of the multifactorial influences on sexual function in PCOS. Future research needs to assess both psychosexual function and distress to aid in understanding the degree of psychosexual dysfunction in PCOS. Finally, more diverse populations (e.g. non-heterosexual and more ethnically diverse groups) should be included in future studies and the efficacy of treatments for sexual dysfunction should also be assessed (e.g. lifestyle and pharmacological interventions).

Thyroid diseases and female sexual dysfunctions

INTRODUCTION

Female sexual dysfunctions (FSDs) have received little attention in the context of thyroid diseases, despite the high prevalence of both conditions.

OBJECTIVES

This review aims to update and summarize the state of knowledge on the association between thyroid diseases and FSDs and to investigate the complex mechanisms through which thyroid hormone imbalance can impact female sexual health in the context of the biopsychosocial model.

METHODS

A comprehensive literature search was performed through the PubMed, MEDLINE, and Scopus databases, using the following keywords: "female sexual function," "sexual dysfunction," "hypoactive sexual desire disorder," "thyroid disease," "thyroiditis," "hypothyroidism," and "hyperthyroidism."

RESULTS

To date, well-designed studies that describe the relationship between FSDs and thyroid disorders are lacking. However, despite the limitations on available studies, current data indicate that sexual alterations are frequently associated with thyroid diseases in women. A complex interplay of direct and indirect hormonal and nonhormonal mechanisms has been hypothesized, including hormonal changes, neurotransmitter imbalance, reduced nitric oxide release, mood disorders, and other systemic consequences of both hypothyroidism and hyperthyroidism. Thyroid hormone receptors have also been identified in the genitourinary system.

CONCLUSIONS

In a clinical setting, physicians should investigate the sexuality of patients consulting for thyroid disease. At the same time, an evaluation of thyroid function should be performed in patients presenting with FSD, especially after menopause, when the risk of thyroid diseases and FSDs increases strongly.

Attachment and Sexual Functioning in Couples Seeking Fertility Treatment: The Role of Infertility-Specific Coping Strategies

Couples facing infertility often experience sexual difficulties. Yet, little is known about the factors associated with these difficulties. We examined whether infertility-related coping strategies explain the associations between attachment insecurities (anxiety, avoidance) and sexual function and satisfaction in 97 couples seeking fertility treatment. Anxiety was associated with one's lower sexual satisfaction and function via self-neglect coping strategies. Anxiety was also associated with the partner's lower sexual satisfaction via self-blame coping. Avoidance was associated with lower partner support-seeking and sexual satisfaction. These findings support the roles of attachment and coping in the experience of sexual difficulties among couples seeking fertility treatment.

Assessment of sexual function before medically assisted procreation: A mixed-methods study among a sample of infertile women and men cared for in a fertility center

A mixed-methods study was conducted to investigate sexual function among infertile patients undergoing medically assisted procreation for the first time. The study employed an interview and content analysis approach, involving 45 infertile patients prior to their medically assisted procreation procedures. The findings revealed that infertile patients are a group at risk for sexual distress. Furthermore, patients with sexual dysfunctions exhibited lower levels of sexual activity, potentially diminishing their chances of achieving pregnancy. Participants faced challenges in openly discussing their sexual problems and demonstrated limited knowledge of sexual functioning. Among infertile women with sexual dysfunctions, the most frequently reported issues were sexual interest/arousal disorders, with a majority also experiencing pain during sexual activity and associated genital-pelvic pain disorders. In contrast, delayed ejaculation and erectile disorder seem to be more common in infertile men, while sexual desire and excitement disorders and premature ejaculation disorders appeared to be as common as in the general population. While the relationship between infertility and sexuality is complex, our study suggests that sexual dysfunctions or the absence of sexual activity may explain infertility. Therefore, it is imperative for clinicians to evaluate the sexual functioning of both men and women undergoing medically assisted procreation treatment, to increase their chances of procreation and offer them sexological support if needed. Future studies should expand their scope to include a larger sample size and delve into the potential etiological factors associated with sexual dysfunctions.

Psychometric properties of the Romanian version of the female sexual function index (FSFI-RO)

BACKGROUND

Female sexual dysfunction (FSD) is a highly prevalent health disorder and no self-report questionnaire on female sexual function is available in Romanian. Therefore we considered the Female Sexual Function Index (FSFI) to be the most appropriate due to its excellent psychometric properties. The FSFI is a measuring scale with 19 items that assess the six domains of female sexual function: desire, arousal, lubrication, orgasm, satisfaction and pain. The paper aims to analyze the psychometric reliability and validity of the FSFI-RO (Romanian Version of the Female Sexual Function Index).

METHODS

385 women (aged 18 to 51) enrolled in the present study. To assess the presence of FSD we used the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) criteria for sexual dysfunction. Then we categorized the participants into two groups: the FSD group (41%) and the healthy control group (59%). Women were then asked to fill out a form that included sociodemographic information and the FSFI-RO questionnaire. A sample of 50 women agreed to re-answer FSFI-RO in a 4-week interval in order to evaluate the test-retest validity of the questionnaire. The data were summarized using descriptive statistics: the test-retest reliability was measured by the intraclass correlation coefficient (ICC); Cronbach's alpha was employed to evaluate the internal consistency of the Romanian version of the FSFI, and validity was assessed by the content and construct validity.

RESULTS

The results showed high test-retest reliability, with ICC from 0.942 to 0.991 in the domains and 0.987 in the total score. Regarding the internal consistency of the FSFI-RO, Cronbach's α coefficients were found to be high (α = 0.944). Convergent construct validity proved to be moderate to high in desire, arousal, lubrication, orgasm and, satisfaction domains, and weak correlation in the pain domain. Regarding the discriminant construct validity, the scores for each domain and the total score showed statistically significant differences between the FSD group and the control group.

CONCLUSIONS

The FSFI-RO showed similar psychometric properties to those of the original version, therefore being a reliable and valid instrument that can be used in Romanian-speaking women.

History of infertility and sexual dysfunction in midlife women: Is there a link?

BACKGROUND

Infertility has been linked with an increased risk of sexual dysfunction in reproductive-aged women, with longer periods of infertility associated with a greater risk.

AIM

The study's aim was to examine whether a history of infertility treatment in women is linked to sexual dysfunction during midlife.

METHODS

The cross-sectional study was conducted among sexually active women, between the ages of 45 and 65 years, who sought consultation at the women's health clinics at a US tertiary care center. History of infertility treatment was assessed with a single question that asked participants if they were treated for infertility in the past. The association between a history of infertility treatment and sexual dysfunction-which was diagnosed by a combination of Female Sexual Function Index score ≤26.55 and Female Sexual Distress Scale-Revised score ≥11-was assessed in a multivariable logistic regression model that adjusted for multiple confounders.

OUTCOMES

The primary outcome was sexual dysfunction in midlife women.

RESULTS

The analysis included 5912 women, with a mean age of 54.1 years. Nearly 16% of women reported receiving treatment for infertility. More than half the women (55%) had sexual dysfunction: 56.3% of those with previous fertility treatments and 54.4% of those without any fertility treatment (P = .3). Receiving treatment for infertility in the younger years did not significantly increase the odds of sexual dysfunction in midlife in univariate (odds ratio, 1.08; 95% CI, 0.94-1.24; P = .3) and multivariable analyses (odds ratio, 1.11; 95% CI, 0.96-1.29; P = .17).

CLINICAL IMPLICATIONS

While infertility is known to be predictive of sexual dysfunction in women during their reproductive years, there was no association between a history of infertility treatment and sexual dysfunction in midlife women in the current study.

STRENGTHS AND LIMITATIONS

The study used validated questionnaires accounting for sexual complaints and distress and adjusted for multiple confounding factors. Limitations include the selection bias introduced by the study of women presenting for evaluation of sexual dysfunction, which may have been a result of factors stronger than the influence of infertility. Other limitations include the study's cross-sectional nature with suboptimal racial and ethnic representation.

CONCLUSION

Although infertility is commonly associated with female sexual dysfunction in women of reproductive age, the association was not present in midlife women in the current study.

The needs of subfertile couples continuing to attempt natural conception: in-depth interviews

STUDY QUESTION

What are the experiences and the support and sexual advice needs of subfertile couples continuing to attempt natural conception after the diagnostic fertility work-up?

SUMMARY ANSWER

Exploration of the experiences of couples showed that couples would have appreciated fertility clinic staff embedding expectant management into the fertility clinic trajectory, supportive staff with female and male patient interactions and advice on common experiences of peers and on managing their lifestyle, distress and subfertility-related sexual challenges.

WHAT IS KNOWN ALREADY

Dutch and British professional guidelines advise newly diagnosed subfertile couples with a ‘good prognosis’ to continue to attempt natural conception and do not require fertility clinic staff to interact with patients. Fertility clinic staff and subfertile couples struggle to follow these guidelines as they feel an urgent need for action. Subfertile couples might benefit from sexual advice, as subfertility is negatively associated with sexual functioning, which is important for natural conception.

STUDY DESIGN, SIZE, DURATION

Twelve one-time in-depth interviews (2015–2017) were conducted with 10 heterosexual couples and 2 women whose partners did not participate, then the interviews were subjected to inductive content analysis, reaching inductive thematic saturation.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The 22 interviewees had experienced 3–18 months of expectant management after their diagnostic fertility work-up in a Belgian or a Dutch tertiary fertility clinic. The face-to-face in-depth interviews explored positive and negative experiences and unmet needs. The transcribed interviews were subjected to inductive content analysis, by two researchers discussing initial disagreements.

MAIN RESULTS AND THE ROLE OF CHANCE

Couples would appreciate fertility clinic staff embedding expectant management in the fertility clinic trajectory, by starting off with reassuring couples that their very thorough diagnostic fertility work-up demonstrated their good chance of natural conception, and by involving couples in deciding on the duration of expectant management and by planning the follow-up appointment after expectant management up front. Couples had encountered sexual challenges during expectant management and had an interest in sexual advice, focused on increasing pleasure and partner bonding and preventing the rise of dysfunctions. The couples agreed that a (secured) website with evidence-based, non-patronizing text and mixed media would be an appropriate format for a novel support programme. Couples were keen for interactions with fertility clinic staff which addressed both partners of subfertile couples. Couples also valued advice on managing their lifestyle and distress and would have liked information on the experiences of their peers.

LIMITATIONS, REASONS FOR CAUTION

Recall bias is plausible given the retrospective nature of this study. This explorative interview study was not designed for examining country or gender differences in experiences and needs but it did generate new findings on inter-country differences.

WIDER IMPLICATIONS OF THE FINDINGS

Rather than simply advising expectant management, fertility clinics are encouraged to offer couples who continue to attempt natural conception after their diagnostic fertility work-up, supportive patient–staff interactions with advice on common experiences of peers and on managing their lifestyle, distress and sexual challenges related to subfertility.

STUDY FUNDING/COMPETING INTEREST(S)

Funded by Flanders Research Foundation and the University of Amsterdam. There are no competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Does prevalence of sexual dysfunction differ among the most common causes of infertility? A cross-sectional study

BACKGROUND

Sexuality as a fundamental component of women's health, can be affected by infertility. The current study aimed at comparing the prevalence of sexual dysfunction among women with the most common causes of infertility.

METHODS

The current cross-sectional study was conducted on 240 infertile females with infertility due to polycystic ovary syndrome (PCOS, n = 80), endometriosis (n = 80) and male factor (n = 80) at Royan Institute for Reproductive Biomedicine (Tehran, Iran) and 160 fertile women at health care centers, between May 2016 and June 2017. Sexual function was assessed by Female Sexual Function Index (FSFI). Data were analyzed using SPSS (version 25.00) and differences were regarded statistically significant at p < 0. 05.

RESULTS

The prevalence of female sexual dysfunction was 98.8% in women with PCOS, 100.0% in those with endometriosis, and 80.0% in those with male factor infertility. Overall, 36.2% of the enrolled fertile women were suffering from sexual dysfunction.

CONCLUSIONS

There was an association between the prevalence of female sexual dysfunction or individual domain scores of the FSFI, and infertility etiologies. Therefore, infertility care providers are required to take this into consideration and develop preventive strategies in this regard. Infertility as a major health care problem affects an estimated 8-12% of couples of reproductive age globally and sexuality as an important part of women's health, can be affected by infertility. In this study, the prevalence of sexual dysfunction among women with the most common causes of infertility has been evaluated. The present study was conducted on 240 infertile females with infertility due to polycystic ovary syndrome (PCOS, n = 80), endometriosis (n = 80) and male factor (n = 80) at Royan Institute (Tehran, Iran) and 160 fertile women at health care centers, between May 2016 and June 2017. Sexual function was assessed by Female Sexual Function Index (FSFI); a brief self-report measure of sexual functioning. Results highlight that the prevalence of sexual dysfunction in women with endometriosis and PCOS was higher than in other groups. As, the prevalence of female sexual dysfunction was 98.8% in women with PCOS, 100.0% in those with endometriosis, and 80.0% in those with male factor infertility. In total, 36.2% of the enrolled fertile women were suffering from sexual dysfunction. The results point to an association between the prevalence of female sexual dysfunction and causes of infertility. Therefore, infertility care providers are required to take this into consideration and develop preventive strategies in this regard.

"When Love Does not bear a Fruit": Patterns and Prevalence of Sexual Difficulties in Infertile Men and Women as Predictors of Emotional Distress

Background

Self-identity, sexuality, and subfertility have multidirectional effects on each other. Subfertility is known to alter sexual esteem, threaten identity, body image, sexual attractivness, coital pleasure, and sexual satisfaction.

Objective

This study aimed to evaluate sexual difficulties as predictors of infertility-specific stress in patients undergoing fertility treatments and to assess the profile of sexual dysfunctions in participants.

Study Setting and Design

This cross-sectional study was conducted in a tertiary hospital setup of a medical college.

Methods

Three hundred married men and women diagnosed with infertility participated. The psychological evaluation test, international classification of diseases (10^th, CDDG), female sexual functioning index, and international index of erectile functioning were used as measures.

Statistical Analysis

Data were analyzed using SPSS (version 15, Chicago, USA). Chi-square test was used for univariate analysis between stress and presence of sexual dysfunctions in men and women. Medians, quartile, and cutoff scores were used to profile the sexual issues in participants.

Results

Prevalence of sexual dysfunctions since marriage was higher in women (75%) than men (60%). Ninety-two percent of women and 86% of men experienced emergence of sexual difficulties after the couple started treatments.

Conclusions

Sexual dysfunctions appear to be a consistent psychosocial concern for those awaiting conception. These appear to worsen during the treatments. Our findings suggest the need to sensitively approach and explore sexual anamnesis with the couple before recourse to medically assisted reproductive treatments. Psychological interventions for sexual issues in distressed patients before, during, and after treatments such as controlled ovarian hyperstimulation, intrauterine insemination, in vitro fertilization, and intracytoplasmic sperm injection are most needed.

Comparison of various aspects of women's lives between infertile and women with and without tubal ligation: a comparative cross-sectional study

Background

The aim of this study is to compare anxiety, depression, body image, self-esteem, sexual function, and quality of life (QoL) between infertile women and control fertile women undergoing tubal ligation (TL) and using condom.

Methods

This cross-sectional study was conducted on 600 women in three groups of infertile and control fertile women with or without TL (200 women in each group), who met the inclusion criteria. They were selected from Royan Institute and a number of health care centers in Tehran (Iran) from May 2017 to February 2019. The subjects were asked to fill out the Short Form Health Survey (SF-12), Female Sexual Function Index (FSFI), Hospital Anxiety and Depression Scale (HADS), Body Image Concern Inventory (BICI), and Rosenberg’ Self-Esteem Scale (RSES). One-way ANOVA was used to identify the possible statistical differences between the three groups of participants.

Results

The mean scores of all FSFI domains were lower in the control TL women, and the differences between the three groups in all dimensions were statistically significant. In addition, the TL group had more female sexual dysfunction (FSD) comparing to the infertile and condom group (22.43 ± 5.30, 24.79 ± 4.74, and 28.03 ± 3.29, respectively P <  0.001). There was a significant difference between the three groups in SF-12 scores (76.59 ± 13.14, 68.49 ± 14.47, and 78.87 ± 12.62, respectively P < 0.001). Also there was a significant difference between the three groups in anxiety, depression, and total scores of HADS (P  < 0.001). Furthermore, infertile women had lower body image (P  < 0.05) and the TL group had lower self-esteem comparing to the two other groups (P  < 0.05).

Conclusions

The findings revealed the adverse effects of using TL on the anxiety, depression, sexual life, body image, and QoL of women. It is recommended that health-care professionals should increase their awareness and knowledge regarding the side-effects of using TL on women’s lives and share this information with the patients.

Fecundability in reproductive aged women at risk of sexual dysfunction and associated risk factors: a prospective preconception cohort study

BACKGROUND

Female sexual dysfunction (FSD) is a prevalent problem, affecting up to 41% of reproductive aged women worldwide. However, the association between female sexual function (FSF) and fecundability in women attempting to conceive remains unclear. We aimed 1) to examine the association between FSF in reproductive-aged preconception Asian women and fecundability, as measured by time-to-pregnancy in menstrual cycles, and 2) to examine lifestyle and behavioral factors associated with FSF.

METHODS

From the Singapore PREconception Study of long-Term maternal and child Outcomes (S-PRESTO) prospective cohort, we evaluated FSF using the 6-item Female Sexual Function Index (FSFI-6) and ascertained time-to-pregnancy within a year of baseline assessment. We estimated fecundability ratio (FR) and 95% confidence interval (CI) using the discrete-time proportional hazards model, accounting for left-truncation and right censoring. We used multivariable logistic and linear regression models to identify potential factors related to FSF.

RESULTS

Among 513 participants, 58.9% had low FSF as defined by a total FSFI-6 score at or below the median value of 22. Compared to women with high FSF, those with low FSF had a 27% reduction in fecundability (FR 0.73; 95% CI 0.54, 0.99), with adjustment for age, ethnicity, education, parity and body mass index. Overall, the FRs generally reduced with decreasing FSFI-6 scores. Physical activity, obesity, absence of probable depression and anxiety were independently associated with reduced odds of low FSF and increased FSFI-6 scores, after adjusting for sociodemographic characteristics.

CONCLUSIONS

Low FSF is associated with a longer time-to-pregnancy. Early evaluation and optimization of FSF through increased physical activity and optimal mental health may help to improve female fecundity. The finding of obese women having improved FSF remains uncertain which warrants further investigations on plausibly mechanisms. In general, the current finding highlights the importance of addressing FSF in preconception care service for general women, which is currently lacking as part of the fertility promotion effort in the country.

The stepwise development of an interactive web-based sex education programme for subfertile couples: the Pleasure & Pregnancy programme

STUDY QUESTION

Can we develop a web-based sex education programme (programme running in a web browser) that addresses the needs of subfertile couples who are advised expectant management for at least 6 months?

SUMMARY ANSWER

The 'Pleasure & Pregnancy' programme addresses couples' needs, is likely to improve couples' sexual functioning, and is subsequently hypothesised to improve the chance of natural pregnancy.

WHAT IS KNOWN ALREADY

According to professional guidelines (e.g. the Netherlands and UK) couples with unexplained subfertility and a good chance of natural pregnancy, should be advised at least 6 months of expectant management. Adherence to expectant management is challenging as couples and gynaecologist prefer a more active approach. Targeting sexuality may be useful as subfertility is a risk factor for decreased sexual functioning.

STUDY DESIGN, SIZE, DURATION

A novel programme was developed according to the three steps of the Medical Research Councils' (MRC) framework. First, relevant literature was explored. Second, an interdisciplinary expert panel developed a theory (based on a systematic literature review and patient interviews) on how the chance of natural conception can be improved. Third, the expected process and outcomes were modelled.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Two licenced clinical sexologists, two gynaecologists, a clinical embryologist and two midwife-researchers, all from Belgium and the Netherlands, proposed components for the sex education programme. PubMed was searched systematically for randomised controlled trials (RCTs) evaluating the proposed components in different patient populations. The needs of 12 heterosexual Dutch or Belgian couples who were advised expectant management were explored with in-depth interviews. The content and delivery characteristics of the novel programme were described in detail with the aid of 'Intervention Taxonomy'. To model the outcomes, a protocol for an RCT was designed, registered and submitted for publication.

MAIN RESULTS AND THE ROLE OF CHANCE

To help maintain or improve sexual functioning, mainly pleasure, and hence increase pregnancy rates, the web-based Pleasure & Pregnancy programme contains a combination of psychosexual education and couple communication, mindfulness and sensate focus exercises. Information on the biology of conception and interaction with fertility clinic staff and peers were added based on couples' needs to increase potential acceptability.

LIMITATIONS AND REASON FOR CAUTION

This paper outlines the development phase of a sex education programme according to the MRC-framework. Whether the Pleasure & Pregnancy programme actually is acceptable, improves sexual functioning, increases pregnancy rates and is cost-effective remains to be determined.

WIDER IMPLICATIONS OF THE FINDINGS

No previous interactive web-based sex education programme has aimed to increase the natural pregnancy rate of subfertile couples by targeting their sexual pleasure. The Pleasure & Pregnancy programme addresses couples' needs and its effect on sexual functioning and pregnancy rate is plausible but remains to be demonstrated by an RCT which is currently ongoing.

STUDY FUNDING/COMPETING INTEREST(S)

Funding was provided by The Netherlands Organisation for Health Research and Development (ZonMw), Flanders Research Foundation and the University of Amsterdam. C.B.L. is editor-in-chief of Human Reproductionbut was blinded to all parts of the peer review process. The remaining authors have no conflict of interest to report.

TRIAL REGISTRATION NUMBER

Not applicable.

The Effect of Sexual Counseling Using BETTER Model on Sexual Function of Women with Infertility: A Randomized Controlled Trial

Objective: Infertility can have adverse effects on sexuality of women. This study aims to examine the effect of sexual counseling based on the BETTER Model on the sexual function of Iranian women with infertility. Method: Eighty women with infertility were randomly assigned to either intervention or control groups. Female Sexual Function Index and Enrich Marital Satisfaction Scale were completed by participants at baseline and two months after. Results: All domains of FSFI (except for pain) were significantly increased (p < 0.001) after the intervention. Conclusions: Results showed that two sessions of sexual counseling can be used to improve the sexual health of infertile women.

Violence and sexual dysfunction among infertile Egyptian women

OBJECTIVE

To evaluate domestic violence and sexual dysfunction in infertile women.

MATERIALS AND METHODS

We recruited women complaining of infertility (primary or secondary infertility). A control group of fertile women attending the outpatient clinic for any concern was recruited. Domestic violence was evaluated using the Arabic validated NorVold Domestic Abuse Questionnaire (NORAQ). Female sexual function was evaluated using the Arabic validated female sexual function index.

RESULTS

There was no significant difference between both groups in rates of exposure to violence (p-value 0.830). Primary infertility was a significant contributing factor in infertile women's exposure to violence (p-value 0.001). All the studied population had female sexual dysfunction, with more dysfunction was reported by the infertile women (total score 18.87 ± 5.92, 19.51 ± 5.42, p-value 0.072). They differed significantly in arousal (2.83 ± 1.33, 3.13 ± 1.29, p-value 0.001) and satisfaction (3.98 ± 1.27, 4.28 ± 1.28, p-value 0.003) which were impaired in infertile women.

CONCLUSIONS

The recruited infertile women were exposed to violence. Emotional abuse was the most common reported type of violence. Sexual dysfunction was reported in the entire studied population with no significant difference relating to fertility.

Differences in and Correlates of Sexual Function in Infertile Women with and without Polycystic Ovary Syndrome

Background

The aim of this study was to examine sexual function and its correlates among infertile women with polycystic ovary syndrome (PCOS) in comparison with their non-PCOS counterparts.

Materials and Methods

In this case-control study, 209 infertile women (116 PCOS and 93 non-PCOS) from Tehran, Iran, were evaluated in February and March 2018. Female sexual function index (FSFI), hormonal status, and docu- mented reports of hyperandrogenic manifestations of the patients were investigated.

Results

The mean age of the patients was 32.00 ± 5.00 years old. Eighty-four (40.2%) patients including 42.2% of the PCOS patients and 37.6% of the non-PCOS cases (P>0.05), were suspected of female sexual dysfunction (FSD). The most impaired functions in both groups were desire and arousal. Sexual function was not significantly different between the groups. However, PCOS women had more orgasm problems and acne worsened their sexual function. To- tal FSFI was positively associated with prolactin level but negatively associated with central obesity in the non-PCOS group; it was negatively correlated with marital duration in the PCOS group. Luteinizing hormone (LH) and pain, pro- lactin level and lubrication, and central obesity and arousal were correlated in the non-PCOS women. Prolactin level and orgasm, marital duration and arousal, and marital duration and the total FSFI were correlated in the PCOS women.

Conclusion

Sexual function was similarly low in infertile PCOS and non-PCOS women. However, orgasm problems and the negative effect of acne varied between the two groups. Further investigations may target how hormonal profile may affect sexual function. Practitioners should scrutinize the specific impaired sexual domains and their correlated conditions in PCOS women, notably orgasm, acne, and prolactin level. Interventions should be well tailored based on particular needs of infertile PCOS women.

Sexual functioning as predictor of depressive symptoms and life satisfaction in females with Polycystic Ovary Syndrome (PCOS)

Background & Objective:

PCOS is the one of the frequently diagnosed endocrine syndrome in Pakistani women. However, little attention has been devoted to empirical investigation of the role of sexual dysfunction in developing depressive symptoms and reducing life satisfaction. Our objective was to determine the contribution of Sexual dysfunction in developing depressive symptoms and life dissatisfaction in females diagnosed with PCOS.

Methods:

This correlation study was carried out from 1^st September 2019 to 15^th February 2020 at COMSATS University Islamabad, Lahore Campus. A sample of 60 women with PCOS between reproductive age 18 – 38 years (Mage = 27.86, SD = 4.58) was selected through purposive sampling technique from the government hospitals of Lahore, Pakistan. The participants responded to a Demographic Information Form, Female Sexual Functioning Index, Siddiqui Shah Depression and Life Satisfaction Scale.

Results:

Correlation analysis revealed significant positive link of sexual dysfunction with depressive symptoms and negative link with life satisfaction level. Further, regression analysis revealed sexual functioning as significant predictor of depressive symptoms only.

Conclusion:

Sexual dysfunction play a major role in general mental health of females, therefore, screening and identification as well as preventive measure need to be introduced at early level of development. In addition, current study findings suggest that once females are diagnosed with PCOS, they should be provided sufficient counselling services in order to deal with depressive symptoms and feeling of low life satisfaction. Further, targeted interventions and counselling services may also facilitate in optimising patient care.

Psychosocial and professional burden of Medically Assisted Reproduction (MAR): Results from a French survey

OBJECTIVE

To evaluate the impact of infertility and Medically Assisted Reproduction (MAR) throughout all aspects of life among infertile women and men.

MATERIALS AND METHODS

An online survey included 1 045 French patients (355 men, 690 women) who were living or had lived the experience of infertility and MAR. The questionnaire included 56 questions on several domains: global feelings, treatment burden, rapport with medical staff, psychosocial impact, sexual life and professional consequences.

RESULTS

Respondents had experienced an average of 3.6 (95% CI: 3.3-3.9) MAR cycles: 5% (n = 46) were pregnant, 4% (n = 47) were waiting to start MAR, 50% (n = 522) succeeded in having a live birth following MAR, 19% (n = 199) were currently undergoing ART, and 21% (n = 221) dropped out of the MAR process without a live birth. Satisfaction rates regarding the received medical care were above 80%, but 42% of patients pointed out the lack of information about non-medical support. An important impact on sexual life was reported, with 21% of patients admitted having not had intercourse for several weeks or even several months. Concerning the impact on professional life, 63% of active workers currently in an MAR program (n = 185) considered that MAR had strong repercussions on the organization of their working life with 49% of them reporting a negative impact on the quality of their work, and 46% of them reporting the necessity to lie about missing work during their treatment.

CONCLUSION

Despite a high overall level of satisfaction regarding medical care, the burden of infertility and MAR on quality of life is strong, especially on sexuality and professional organization. Clinical staff should be encouraged to develop non-medical support for all patients at any stage of infertility treatment. Enterprises should be warned about the professional impact of infertility and MAR to help their employees reconcile personal and professional life.

Association Between Overt Hyperthyroidism and Risk of Sexual Dysfunction in Both Sexes: A Systematic Review and Meta-Analysis

BACKGROUND

Numerous studies have shown the detrimental effects of overt hyperthyroidism on sexual functioning but a quantitative result has not yet been synthesized.

AIM

To conduct a systematic review and meta-analysis that quantifies the association between overt hyperthyroidism and the risk of sexual dysfunction (SD).

METHODS

A meta-analysis of studies in the literature published prior to February 1, 2020, from 4 electronic databases (MEDLINE, Embase, Cochrane Library databases, and PsychINFO) was conducted. All analyses were performed using the random-effects model comparing individuals with and without overt hyperthyroidism.

OUTCOMES

The strength of the association between overt hyperthyroidism and risk of SD was quantified by calculating the relative risk (RR) and the standard mean difierences with 95% CI. The quality of evidence for the reported outcome was based on the Grading of Recommendations Assessment, Development, and Evaluation approach.

RESULTS

Of 571 publications, a total of 7 studies involving 323,257 individuals were included. Synthetic results from 7 eligible studies indicated that overt hyperthyroidism led to significant SD in both sexes (pooled RR = 2.59, 95% CI: 1.3-5.17, P = .007; heterogeneity: I² = 98.8%, P < .001). When we analyzed the data of men and women independently, the pooled results consistently showed that men and women with overt hyperthyroidism were at over 2-fold higher risk of SD than the general populations (RR for males = 2.59, 95% CI: 1.03-6.52, P = .044; RR for females = 2.51, 95% CI: 1.47-4.28, P = .001). Combined standard mean diffierences from those studies providing the Female Sexual Function Index (FSFI) suggested that women with overt hyperthyroidism were associated with a significantly lower FSFI value in FSFI total scores, subscale sexual arousal, lubrication, orgasm, and satisfaction domain (all P < .05). The overall quality of evidence in our study was considered to be moderate.

CLINICAL IMPLICATIONS

Clinicians should know the detrimental effects of overt hyperthyroidism on sexual functioning in clinical practice. Measurement of thyroid hormones should be included in the assessment of patients presenting with SD when they show symptoms of clinical hyperthyroidism.

STRENGTHS & LIMITATIONS

This is the first meta-analysis quantifying the relationship between overt hyperthyroidism and the risks of SD. However, the combined results were derived from limited retrospective studies along with substantial heterogeneities.

CONCLUSION

Our study has confirmed the potentially devastating sexual health consequences caused by overt hyperthyroidism. However, additional rigorous studies with sizable samples are still needed to better elucidate this evidence. Pan Y, Xie Q, Zhang Z, et al. Association Between Overt Hyperthyroidism and Risk of Sexual Dysfunction in Both Sexes: A Systematic Review and Meta-Analysis. J Sex Med 2020;17:2198-2207.

Deep Dyspareunia, Superficial Dyspareunia, and Infertility Concerns Among Women With Endometriosis: A Cross-Sectional Study

Introduction

Deep dyspareunia is a cardinal symptom of endometriosis, and as many as 40% of people with this condition experience comorbid superficial dyspareunia.

Aim

To evaluate the relationship between sexual pain and infertility concerns among women with endometriosis.

Methods

This is a cross-sectional study conducted at a university-based tertiary center for endometriosis. 300 reproductive-aged participants in the prospective Endometriosis Pelvic Pain Interdisciplinary Cohort (ClinicalTrials.gov Identifier: NCT02911090) with histologically confirmed endometriosis were included (2013–2017).

Main Outcome Measure

The total score on the infertility concerns module of the Endometriosis Health Profile-30 categorized into 5 groups (0, 1–4, 5–8, 9–12, 13–16).

Results

The odds of infertility concerns did not increase with severity of deep dyspareunia (odds ratio = 1.02, 95% CI: 0.95–1.09, P = .58). However, the odds of infertility concerns increased with severity of superficial dyspareunia (odds ratio = 1.09, 95% CI: 1.02–1.16, P = .011); this relationship persisted after adjusting for endometriosis-specific factors, infertility risk factors, reproductive history, and demographic characteristics (adjusted odds ratio [AOR] = 1.14, 95% CI: 1.06–1.24, P < .001). Other factors in the model independently associated with increased infertility concerns were previous difficulty conceiving (AOR = 2.09, 95% CI 1.04–4.19, P = .038), currently trying to conceive (AOR = 5.23, 95% CI 2.77–9.98, P < .001), nulliparity (AOR = 3.21, 95% CI 1.63–6.41, P < .001), and younger age (AOR = 0.94, 95% CI: 0.89–0.98, P = .005).

Conclusion

Severity of superficial dyspareunia, but not deep dyspareunia, was associated with increased odds of infertility concerns among women with endometriosis. Strengths of the study included the use of a validated measure of infertility concerns and disaggregation of sexual pain into deep and superficial dyspareunia. Limitations included the setting of a tertiary center for pelvic pain, which affects generalizability to fertility clinic and primary care settings. Women experiencing introital dyspareunia, who can have difficulties with achieving penetrative intercourse, may be concerned about their future fertility and should be counselled appropriately.

Wahl KJ, Orr NL, Lisonek M, et al. Deep Dyspareunia, Superficial Dyspareunia, and Infertility Concerns Among Women With Endometriosis: A Cross-Sectional Study. Sex Med 2020;8:274–281.

Validation of the Vietnamese Translation Version of the Female Sexual Function Index in Infertile Patients

INTRODUCTION

The Female Sexual Function Index (FSFI) is regarded as a self-administered screening questionnaire for assessing the presence of any type of sexual dysfunction.

AIM

The aim of this study was to investigate the psychometric properties of the Vietnamese translation version of the Female Sexual Function Index (VN-FSFI) in a sample of infertile Vietnamese women.

METHODS

An existing Vietnamese translated-FSFI version was used as a first-step approach to back-translate into English. Based on the comparison of the original English version and the back-translation script, a modified version of the FSFI was revised. This version was evaluated for "content validity" by a panel of 3 experts and for "face validity" by a pilot study that was based on its results to refine to reach the last Vietnamese FSFI version (VN-FSFI version). A cross-sectional survey to investigate psychometric reliability and validity of the last VN-FSFI version was conducted with 271 infertile Vietnamese women from January 2017 through February 2018, at a hospital located in a central region of Vietnam. Construct validity was evaluated by principal component analysis using varimax rotation and factor analysis. Reliability studies on internal consistency (Cronbach's alpha coefficient, domain inter-correlations, and domain-total correlations) and on test-retest (Intraclass correlation coefficient).

MAIN OUTCOME MEASURE

Construct validity and the reliability of the VN-FSFI version.

RESULTS

Based on principal component analysis, a 5-factor model was established, consisting of arousal/orgasm, satisfaction, pain, lubrication, and desire that explained 72.32% of the total variance. The factorial structure supported to 6 retrieved domains that corresponded to the original version. The Cronbach's alpha coefficients were 0.92 for the total scale and 0.72-0.89 for the domains. Domain inter-correlations ranged from 0.36-0.73 and domain-total correlation coefficients ranged from 0.67-0.84. Test-retest correlation coefficients over 2-4 weeks were 0.97 (P < .001) for the total scale and 0.84-0.96 for the domains.

CONCLUSION

With good psychometric properties, which are almost similar to the original English version, this Vietnamese translation version of the Female Sexual Function Index (VN-FSFI version) was proved to be a valid and reliable instrument to measure multidimensional aspects of sexual function in infertile Vietnamese women. Ho TTT, Le MT, Truong QV, et al. Validation of the Vietnamese Translation Version of the Female Sexual Function Index in Infertile Patients. Sex Med 2019;8:57-64.

Examination of sexual functions and depressive symptoms among infertile and fertile women

Objective:

To examine the sexual functions and depressive symptoms of infertile and fertile women.

Methods:

This study was conducted between October 2015 and April 2016 using a descriptive, cross-sectional and comparative design. The sample of this study consisted of 96 infertile and 96 fertile women. The data were collected using an information form, the Beck Depression Inventory and the Index of Female Sexual Function. The data were analyzed The Mann-Whitney U test, chi-square test, and Spearman’s correlation analysis.

Results:

The rate of sexual dysfunction (87.5% vs. 69.8%) and the Index of Female Sexual Function total score (31.8 ± 7.8 vs 35.7 ± 6.3) were significantly higher in infertile women than fertile women (p=0.003, p<0.001, respectively). The sexual satisfaction and discomfort during sexual intercourse subscales of the Index of Female Sexual Function were significantly lower among infertile women than fertile women (p<0.001 for all); however, no significant difference was observed in the sexual intercourse/libido score of the Index of Female Sexual Function between infertile and fertile women (p=0.590). The correlation coefficients between the Beck Depression Inventory total score and the total and subscale scores of the IFSF did not significantly differ between infertile and fertile women (p>0.05 for all).

Conclusion:

The sexual dysfunction rate among infertile women was higher than that among fertile women. Sexual functions decreased when depressive symptoms increased for both infertile and fertile women.

Polycystic Ovary Syndrome (PCOS) and Sexual Dysfunctions

Objectives: Polycystic ovary syndrome (PCOS) is a very common endocrine disorder affecting 5% to 10% of women in reproductive age all over the world. Many comorbidities have been associated with PCOS including infertility, obesity, depression, anxiety, hirsutism, alopecia, and sexu al dysfunctions. In this paper, we have reviewed the available Indian and international literature regarding psychiatric and sexual comorbidities of PCOS.

Methods: PubMed, Cochrane, Google Scholar, and other databases were used to conduct the search. Research published in English was included. We searched the databases using the terms ‘polycystic ovary syndrome’, ‘PCOS’, ‘infertility and PCOS’, ‘sexual dysfunctions and PCOS’, etc.

Results: For this review, we could find about 90 papers pertaining to the subject. Most of them focused on the effect of infertility and symptoms of PCOS such as hirsutism on body image and sexual dysfunctions. Meta-analyses showed that women with PCOS had poor rates of sexual desire, orgasm, and lubrication. Body image often had a negative impact on sexual thoughts and fantasies.

Conclusion: Focus on sexual dysfunctions in PCOS has been emphasized only recently after high rates of its prevalence have been found. Hence, management of PCOS involves a multidisciplinary approach where proper assessment and management of sexual dysfunctions should be given its due importance.

Effects of dehydroepiandrosterone (DHEA) supplementation on sexual function in premenopausal infertile women

PURPOSE

To investigate the effects of dehydroepiandrosterone (DHEA) supplementation on female sexual function in premenopausal infertile women of advanced ages.

METHODS

This observational study was conducted in an academically affiliated private fertility center. Patients included 87 premenopausal infertile women, 50 of whom completed the study including the Female Sexual Function Index (FSFI) questionnaires and comprehensive endocrine evaluation before and 4-8 weeks after initiating 25 mg of oral micronized DHEA TID.

RESULTS

Age of patients was 41.1 ± 4.2 years, BMI 24.4 ± 6.1 kg/m², 86% were married, and 42% were parous. Following supplementation with DHEA, all serum androgen levels increased (each P < 0.0001), while FSH levels decreased by 2.6 ± 4.4 from a baseline of 10.3 ± 5.4 mIU/mL (P = 0.009). The FSFI score for the whole study group increased by 7% (from 27.2 ± 6.9 to 29.2 ± 5.6; P = 0.0166). Domain scores for desire increased by 17% (P = 0.0004) and by 12% for arousal (P = 0.0122); lubrication demonstrated an 8% trend towards improvement (P = 0.0551), while no changes in domain scores for orgasm, satisfaction, or pain were observed. Women in the lowest starting FSFI score quartile (<25.7), experienced a 6.1 ± 8.0 (34%) increase in total FSFI score following DHEA supplementation. Among these women, improvements in domain categories were noted for desire (40%), arousal (46%), lubrication (33%), orgasm (54%), satisfaction (24%), and pain (25%).

CONCLUSIONS

This uncontrolled observational study implies that supplementation with DHEA improves sexual function in older premenopausal women with low baseline FSFI scores.

Is polycystic ovary syndrome associated with risk of female sexual dysfunction? A systematic review and meta-analysis

The aim of this study was to evaluate whether polycystic ovary syndrome (PCOS) is a risk factor for female sexual dysfunction (FSD) by conducting a systematic review and meta-analysis. The databases PubMed, EMBASE and the Cochrane Library were searched for relevant studies. The association between PCOS and risk of FSD was assessed by relative risk or standard mean differences with 95% confidence interval. The protocol for this meta-analysis is available from PROSPERO (CRD42018102247). Overall, 2626 participants (mean age 25-36 years) were included from 10 studies (five cross-sectional and five case-control studies), 1163 of whom were women with PCOS. The pooled results from eight included studies providing the number of cases revealed no significant association between PCOS and increased risk of FSD (RR = 1.09, 95% CI 0.9 to 1.32; heterogeneity: I² = 11.0%). The combined overall standard mean difference from five studies reporting Female Sexual Function Index (FSFI) scores showed that patients with PCOS had similar values in total FSFI scores compared with healthy controls (standard mean difference = -0.03, 95% CI -0.12 to 0.05; heterogeneity: I² = 0.0%). Sensitivity analyses yielded similar results. This meta-analysis suggests no direct association between PCOS and risk of FSD. Well-controlled trials with large sample sizes, however, are needed to validate this evidence.