According to the increasing infertility rate in Iran, the main goal of the current study was to assess SF, QoL, depression, anxiety, self-esteem, and body image among infertile women. Also, due to the soaring use of TL by Iranian women in recent years, it is important to evaluate potential complications associated with this method. Recognition and diagnosis of sexual dysfunction as well as the impairment of QoL, indicate a need for sufficient education and comprehensive consultation by the healthcare system prior to the procedure.
Anxiety and Depression
Although TL is the most commonly used form of contraceptive method worldwide, the long term psychological effects are still obscure. Contrary to expectations, the result of this study showed that anxiety and depression symptoms in women who had undergone TL surgery would be higher than that in infertile women.
Many evidences indicated that depression and anxiety are more prevalent among women who had infertility compared to non-infertile women. Almost half of the infertile subjects had moderate to severe symptoms of depression and the level of anxiety was increased by infertility (25). Anxiety and depression caused by infertility may be due to various factors such as uncertainty about the cause of infertility, duration of treatment, and unspecified treatment, as well as financial and social pressures. Since cyclical hormonal changes are related to anxiety and depression, these observations may be due to undergoing TL (26). The results of a study by Lin et al. (27) indicated sterilization as a risk factor for depression and anxiety; the risk of depression and anxiety following TL was reported to be 2.34 and 2.88 times greater than before TL, respectively. A similar study has been conducted on one hundred sixty-two women who had experienced TL, reported increased Beck depression inventory scores after TL and were suffering from regret after sterilization (26). Complications by reason of TL cause regret (14), in addition to in traditional societies such as Iran, the picture of a woman is directly related to her fertility and motherhood ability and cause them to feel perfect and valuable. Although TL is a voluntary procedure, cultural factors that are rooted in one's unconscious cause conveys them feelings of inadequacy and unattractive that can manifest as sexual dysfunction and regret (9). It has been shown in several studies that anxiety and depression are more common in women regretting sterilization in comparison to the control group (14, 26).
Depression can be influenced by many factors including a feeling of guilt after an irreversible surgery, negative perceptions of others, a change in husband's intuition, cultural conditions, and religion status, or pre-existing emotional disorders. Women should be given time to consider their decision on fertility state and be provided with psychological support during this time.
Body image and Self-esteem
In the results of our study, infertile women had lower body image in comparison with TL and condom group. These results confirm the association between body image and infertility. In addition to physical appearance, a person's body image also reflects physical wellbeing and biological status (health/illness) (28). Previous studies have shown that self-concept, identity development, anxiety, and depression are factors closely related to a woman’s body image that might be affected by infertility (29). A strong relationship between infertility and depression has been reported in the literature (28), so depression in different stages of life may lead to a distorted body image (29). Based on our findings, self-esteem scores were lower in TL women compared to the other two groups. In many studies, however, the authors have indicated that there was no link between TL and self-esteem (11, 30).
This observation may support the hypothesis that although individuals continuously think about their appearances, after a physical disease state like infertility, they become more aware and alert of their bodies and are more mentally concerned (31).
In sum, very little research has been done on the relationship between undergoing TL and body image. Li et al. (11) and Raine et al. (30) showed that TL had no effect on body image. Further work is required to establish the validity of this result and different factors affecting the body image.
Sexual function status
In the present study, the prevalence of FSD in the TL women was around 50% in comparison to 27.4% in infertile group and 8.5% in condom groups. Therefore, results from many studies have confirmed that women with infertility had an increase in sexual dysfunction(32-34). Omani-Samani (35) carried out a meta-analysis study to estimate the prevalence of FSD among infertile Iranian women. Their result suggested that more than 64% of infertile Iranian women reported sexual dysfunction. It is well-known that the risk of FSD in infertile women is higher because the tendency of having sexual intercourse is strongly affected by pregnancy. Among infertile couples, sex is defined as a clinical tool, which should happen on certain days of the month, instead of an act of love (36). It has, on the other hand, been suggested that in some cases infertility might be a result of sexual dysfunction (37). The results of studies that have assessed the effects of TL on SF are controversial. Surprisingly, Smith et al. (12) and Li et al. (11) observed positive effects of sterilization on SF, which may be the result of reduced fear of getting pregnant. In contrast, Kunkeri et al. (38) and Jahanian Sadatmahalleh et al. (9) reported the higher FSD in women undergoing TL compared with their control group.
According to the proven effects of infertility on the quality of SF (32), this finding was unexpected. But a possible explanation for this might be “post tubal sterilization syndrome” that causes a decrease of libido, menstruation disorders, pelvis pain, dyspareunia, and depression (39).
SF is complex and involves interactions of many factors, including emotional connection, body image, and other elements such as cultural differences, ethnicity, misinterpretation of religious codes, personal belief regarding her role as a woman, and social pressures(40, 41). Overall, it seems that having a discussion about sexual matters is centuries-long taboo, especially speaking about them with others, including the spouse and their doctor (38).
Regarding the importance of SF in life, marital relationship and the significant association between post-sterilization regret and FSD in women with TL (44), Jahanian Sadatmahalleh et. al. reported the prevalence of FSD in the TL group was 63.4% in comparison with 40.8% in the control group (14). Being completely informed about TL procedure and its complications, and having access to other contraceptive options prior to the operation may be helpful in avoiding future dissatisfaction.
Quality of life status
We found that QoL in women with TL (both physical and mental demands) was significantly lower than other groups.
Several reports have shown that infertility is associated with decreased physical and mental health(45, 46). The result of a qualitative study which conducted on 16 people who received successful infertility treatment supported evidence from previous observations. The effects of the stage of infertility process, gender, and the quality of the relationship on marital relationship and QoL have been indicated; infertility causes many problems such as dissatisfaction, stress, sadness, insomnia, increased/decreased appetite, increased smoking, social pressure, exposure to questions of curiosity about having children, avoiding from being where children are, losing the privacy of sex life, having sex in some planned days just for reproduction, interruption in work life and the high cost of treatment. Therefore, it is probable that the scores of QoL have decreased in infertile women (47).
Numerous studies which have evaluated the impact of TL on women's QoL, have observed conflicting results. For instance Pauls R. (13) conducted a study to summarize recent literature on SF following benign gynecological surgeries, including tubal ligation. They concluded that the QoL and SF in the majority of the cases benefit from surgical interventions. However, Li et. al. (11) did not find such associations. Thus far, several studies have demonstrated that TL has a negative impact on QoL(9, 10). In a similar study that was conducted by Monga et. al. (48) 18 infertile couples and 12 couples seeking elective sterilization were interviewed. The total marital adjustment and quality of well-being’s score of the women who seek infertility treatment were lower than in women with elective sterilization.
One possible interpretation for our result could be the occurrence of menstrual abnormalities after TL (49). The spectrum of menstrual disorders can be wide and includes more frequent menstrual periods, irregular menstrual cycles, menorrhagia, metrorhagia, spotting, dysmenorrhea, and oligo menorrhea (50). Given the importance of the menstrual pattern in Iranian women’s lives, any menstrual disorder can have a devastating effect on personal life and religious duties. Therefore, TL is a decision that can later cause women to feel guilty.
Discrepancies in QoL and SF conditions after TL surgery can be the result of different definition of TL in various cultures. In societies with traditional cultures, such as Iran, self-satisfaction, value, and the image that a woman holds of herself is closely reliant on their motherhood ability. Although TL seems to be a voluntary choice at first, it might induce a feeling of guilt in some women. Therefore, sexual dysfunction, a decrease in QoL, and regret for having done this operation might happen after a while (9). In sum, due to the growing demand for TL surgery as a means of contraception, the number of women who regret choosing this method as a permanent approach have been increased (51). Regression is associated with sadness, pain, harm, affliction, anxiety, and displeasure, all of which affect the QoL (52).
Despite the fact that, multiple psychological and physical factors such as FSD affect a woman’s QoL (53), many physicians refuse to look for details about SF and women often do not perceive it as a disorder and never discuss this with their doctors, so many women have suffered in silence for years (38). Women should view SF as a biological and enjoyable need and be free to talk about their sexual problems, and this cannot be achieved except through education and counseling (38).
Despite the well-known adverse effects of infertility on women's health, the results of this study imply the relationship between TL and the poor quality of various aspects of a woman’s life. Based on our knowledge, this study has compared infertile and TL women for the first time and has provided a great value for fertility and childbearing in societies like Iran. This study distinguishes the importance of making the right decisions about anything that may affect fertility more than previous studies. Nonetheless, this study was limited by the absence of sufficient information about the history of QoL, FSD, and the mental health of individuals before TL surgery. A larger sample size would be helpful to determine more significant results.