In this large-scale case-control study, we report the impact of infertility duration on the FSD of infertile patients after analyzing the risk factors that affect their sexual health. The multivariate regression equation model reveals that the infertility duration is more than 8 years, which is a risk factor for the occurrence of sexual dysfunction.
According to our review of the literature, there has been only one clinical study9 investigating the impact of infertility duration on FSD. The study found that sexual dysfunction, including low desire, arousal disorder, orgasm disorder, coital pain, and lubrication disorder were significantly highest in more than 5 years compared with less than 2 years and 2–5 years of infertility duration groups. 9 However, this study did not include interferences of potential confounding factors that would affect sexual function, such as age, BMI, income level, education level, smoking, and drinking. Moreover, it did not indicate that the exclusion criteria and the sample size was relatively small. Thus, we believe the conclusions drawn from this study have substantial limitations.
The cause of FSD is complex and multifactorial. A new study reviews the common etiologies and risk factors for FSD: age and menopausal status, psychiatric conditions (anxiety, depression), medical conditions (diabetes, hypertension, neurologic disease, premature ovarian failure, gynecologic diseases), stress (emotional or environmental), medications (psychotropic medications, antihypertensives, histamine blockers, hormonal medications), relationship and lifestyle may all play a role.2 To increase the reliability of the results of this study, some above-mentioned causes and risk factors were excluded.
In our study, the incidence of sexual dysfunction in the four groups was 17.2%, 16.0%, 20.6%, and 16.2%, respectively, and the incidence of sexual dysfunction in infertile patients was lower than in previous studies. 4,15 This is mainly because the cut-off value we selected for the Chinese version (23.45) 21,22is lower than the cut-off value used in other studies (26.55).4,15 In contrast, we excluded several types of infertility that can affect sexual function, such as endometriosis,24 PCOS,25,26 premature ovarian failure, 27,28 severely male infertile,29,30,31 and taking drugs that affect sexual function8. The incidence of sexual dysfunction in perimenopausal women is significantly increased due to the decline in hormone levels,1,32−37 to prevent potential biases such as age and endocrine environmental factors, this study only included infertile patients younger than 45 years of age. It is consistent with the age included in previous studies on the sexual function of infertile women.4,9
Facchin et al.4 compared the infertility duration of infertile patients with and without sexual dysfunction, which were 5.4 ± 3.4 VS. 5.9 ± 3.9,multivariate regression analysis shows that infertility duration is not a risk factor for sexual dysfunction. Another study analyzed the sexual dysfunction of Turkish women (including 352 infertile women and 301 normal fertility women) found that infertility duration > 3 years was a risk factor for sexual dysfunction.6 In our study, we identified that infertility duration > 8 years was a risk factor of arousal, pain, lubrication disorder, and sexual dysfunction, but not for desire and orgasmic dysfunction.
In this study, we observed that the depression (PHQ-9) score increases significantly with the increase in infertility duration. When we conducted multivariate regression analysis with depressive status as a potential confounding factor, we observed that depression was a risk factor for sexual dysfunction except for sexual desire. Therefore, it can be speculated that the increase in the infertility duration increases the incidence of sexual dysfunction by affecting psychological and emotional. Many studies have reported the impact of psychological depression on sexual function in infertile patients.4,12,38 With the increase of infertility duration, infertility-related stress also gradually increases, which affects the mental health of infertile patients .39 Research comparisons have found that infertility for more than 3 years significantly increases anxiety and depression mood and decreases the quality of life of infertile patients.39 Decreased sexual dysfunction will seriously affect the quality of life and damage mental health. Conversely, a depressed mental state may also increase the incidence of sexual dysfunction.6
Infertile patients undergoing assisted reproduction often report sexual disorder, especially in terms of decreased interest and desire for sex, poorer arousal and lubrication, and orgasm difficulties.12,40−41 Studies have found that sexual desire disorder occurs differently in women of different ages, the prevalence of this diagnosis is reported at 8.9% in 18–44-year-olds, 12.3% in 45–64-year-olds, and 7.4% in the age group > 65 years.42 In this study, the loss of sexual desire increased with the increase in years of infertility (average 17.2% increased to 23.0%), but there was no significant difference. This is higher than the previously reported incidence of decreased sexual desire in women younger than 44 years old.42 This may be due to the following reasons: among infertile women, they realize that normal intercourse does not lead to pregnancy, so they may lose their desire for sex; in contrast, sexual intercourse for the sake of childbirth, rather than simply for pleasure, may also inhibit the occurrence of sexual desire.
This study found that an infertility duration of more than 8 years is a risk factor for sexual arousal disorder. This disorder is also related to age, depression, and smoking. Previous research found that unhappy life events, psychosocial distress, drug use, gynecological disorders, and disruptions to hormone production can precipitate sexual arousal disorder.32 Other studies also believe that smoking increases the incidence of sexual dysfunction.43–45
Infertility-related depression mainly affects sexual function and quality of sexual life, not the frequency of sexual life.4 In our study, we also did not find any difference in the frequency of sexual activities among the groups. This is consistent with our research. On the other hand, few studies have reported the possibility of infertile patients achieving orgasms during different sexual activities, and the possibility of achieving orgasms during sexual activities is closely related to the participants’ sexual satisfaction.24 This study did not identify differences in sexual satisfaction among patients with different infertility duration, nor did they find possible differences in their orgasms during different sexual activities. Therefore we believe that the infertility duration did not have a significant effect on orgasm function. However, we noted that the possibility of infertile patients always and often achieving orgasms during different sexual activities is less than 30%, which is much lower than the reported percentage for normal fertility women in sexual activities.24 This may be because sexual intercourse is purposeful (fertility) rather than out of instinct and pleasure.
Previous studies reported that sexual satisfaction is closely related to the possibility of achieving orgasm46 which is associated with penile–vaginal intercourse but inversely associated with other sexual activities.47 The study found that this was mainly caused by psychological factors (immature psychological defence mechanisms).48 In this study, we also found that depression is a risk factor for orgasm disorder, and the infertility duration did not play a role.
However, sexual intercourse duration mainly affects the possibility of orgasm dysfunction. Researchers believe that women’s likelihood or consistency of partnered orgasm is associated with penile-vaginal intercourse duration but not with foreplay duration.49 An extremely short foreplay duration may indicate that the partner has insufficient emotional intimacy during sex, while an extremely long foreplay duration may indicate intercourse difficulties, which could also affect sexual satisfaction. In our group, we did not identify any difference between them. It can be seen that the infertility duration has a minimal effect on orgasm function or sexual satisfaction.
This study also has some limitations. Our study is a retrospective study and a large sample of multi-center experiments is still required to further confirm the conclusions of this study.