PCOS as a common hormonal disorder can affects various aspects of women’s life. The results of previous studies revealed that women diagnosed with PCOS suffer from sexual dysfunction (12). As mentioned earlier hormonal imbalances, HA and its related clinical features such as obesity, acne, hirsutism, and alopecia lead to physical and psychological changes that reduce women’s sexual satisfaction (22). Infertility and its treatment as common complications that PCOS women are faced with can affect the women’s sexual function (23, 24). In addition, some studies have suggested that infertility is a risk factor for sexual dysfunction in women diagnosed with infertility; however, the results of previous researches were controversial (24, 25).
The present study was designed to compare sexual function in fertile and infertile women diagnosed with PCOS according to the Rotterdam criteria. The most interesting finding of this study was that there was no significant difference between fertile and infertile PCOS women in FSFI characteristic except from pain. The findings of the present study are similar to the results of study conducted by Mwembi et al. (26) who reported that there was no statistically significant difference in different dimensions of sexual function in fertile and infertile women. Furthermore, Monga et al.(27) reported that infertility did not significantly affect women's sexual function. Also in order to investigating the effects of infertility on couples' relationships, some studies have revealed that infertility did not have any significant effect on sexual function and marital relationship (28-30). In addition, infertility-related psychological complications have been reported uncommon (31).
This outcome is contrary to that of luk et al. (32) who found that infertility can affect psychological well-being, marital relationships, sexual relationships, and QoL of couples’ lives. Furthermore, Moghaddam et al. (33) not only reported significant reduction in infertile women’s sexual function compared with fertile women, but also found an inverse relationship between desire and infertility. Coskuner et al. (34) argued that although sexual function was significantly different between fertile and infertile women, sexual QoL was same between these groups.
There are various explanations for the inconsistency of the association between infertility and sexual function. For instance, although previous researches have shown strong association between the level of androgens and sexual function, no significant difference was observed between fertile and infertile women in terms of testosterone level in our study, (35). It seems that the results of comparing sexual function between these groups may be affected by this association.
SHBG was significantly higher in infertile women and Zheng et al. (36) reported a significant negative association between sexual desire and SHBG. The findings of our study are supported by Nazarpour et al. (37) and Moghassemi et al. (38) study, they also reported that there was no significant association between serum SHBG levels and female sexual function. Different results of the studies mentioned above imply that the relationship between infertility and sexual function is a complex process, which might be influenced by multiple factors, including age, economic status, duration of marriage, type of marriage, duration of infertility’s treatment and marriage satisfaction (39).
As a matter of fact, the longer duration of infertility they face, the more sexual dysfunction they suffer (40). Moreover, Hassanin et al. (41) stated that infertility is one of the most important cause of sexual dysfunction in four to six years after infertility diagnosis. In other words, increasing the duration of infertility and unsuccessful treatment reduces the hope of having children and can have adverse effects on sexual function. In our study the mean duration of infertility in infertile group was 4.1± 3.60 and the effects of infertility on women’s sexual function may be displayed over a longer period of time.
oskayet al.(42) in their study with the aim of evaluation sexual function in Turkish infertile women argued that simply having the purpose of achieving pregnancy through sexual intercourse and the frequency of sexual intercourse per week can affect sexual function in infertile women. They reported that by the increasing frequency of intercourse per week sexual function in all domain increase. Also another important factors that can affect sexual function in infertile women is the cause of infertility. Infertile women that have been diagnosed with mixed factor compared to women with unknown cause are more likely to have sexual dysfunction. From this it is conclude that in women diagnosed with infertility the effect of infertility on sexual function can vary depending on the cause and severity of infertility and the importance of having children in couples.
Furthermore, Pakpour et al. (43) reported that older age, self-reported depression, secondary infertility, lower educational level and higher partner education as the further risk factors for female sexual dysfunction in infertile couples.
In our study, the level of education in the fertile group was higher than infertile group. Based on the results of some previous studies, it was expected that an increase in education level would be associated with an increase in sexual satisfaction (44). Also in the study of samimi et al (45). The quality of women's sexual life with increasing educations level has shown a statistically significant increase. However, the finding that higher levels of education raise women's sexual satisfaction and improve sexual performance has been rejected by some recent studies (46, 47).
Another important factor that may affect the quality of life and consequently the quality of sexual life is an individual's occupation. Based on the result of study by Nikbina et al.(44), the type of occupation had a statistically significant relationship with the scores of different areas of female sexual function. Contrary to these results, in the study of Alizadeh et al. (48)., there was no statistically significant difference between the sexual performance of employed and housewives women. Although employment might lead to being independence and expression of women in society, it has not been affected in being satisfied from married life.
Women’s sexual function is related to their mental health status (49). Depression significantly affects the quality of women's sexual life (50). Kim et al. (51) showed strong relationship between depression and taking infertility treatment in infertile women. Possible explanation for this association can include experiencing abortion after pregnancy with infertility treatments, anxiety of high risk pregnancy, burden of pregnancy and importance of having child.
Different cultural conditions may explain this inconsistency between the results. Hence, in eastern societies, fertility and motherhood ability are considered as the important social and family values, infertility impose psychological burden to individuals (52, 53). What can be deduced from the results of various studies is that although infertility can influence sexual function through various ways, the other manifestations and complications of PCOS and other concurrent factor are more influential factors in patients’ sexual dysfunction.
The results of our study showed that the pain score was significantly higher in the fertile group. Factors that can affects sexual pain in women includes younger age, lower BMI, less emotional intimacy with a sexual partner, vaginal infections, especially fungal infections, and severe depression (54). In our study, there were no significant different between two group in terms of age and BMI, but accurate information on other factors that may affect sexual pain was not available. Consequently, for the best comparison of sexual function between fertile and infertile women with PCOS, evaluation of many factors is required. The main weakness of this study was the paucity of adequate information about women’s mental health status such as depression, anxiety, cause and severity of infertility, sexual problem in partner and burden of infertility which could affect their sexual function. Further studies, which take these variables into account, will need to be undertaken.