To the best of our knowledge, this is the first study to compare the prevalence of sexual dysfunction among women suffering from most-common causes of infertility, including PCOS, endometriosis and male factor. Our study demonstrated that:
1) The lowest overall FSFI score was for women with PCOS and the most common problems in these women were sexual desire, arousal, and lubrication. Previous studies showed controversial results on sexual function in women with PCOS. Fliegner et al. [18] studied sexual function and socio-sexual difficulties in women with PCOS and found that these women were no different from those of the control group in terms of the number of sexual disorders, but their overall FSFI score was much lower than the control group. It seems that women with PCOS feel embarrassed and limit themselves because of hirsutism and obesity. In fact, these women feel unattractive due to hirsutism and their acne, and they limit themselves even more in the society. These women are not self-sufficient and usually do not feel good about their bodies, so this inner feeling can affect the physiological function of the body and directly affect the process of sexual desire and arousal [19, 20]. We also realized for these women, the most common problems were with desire, arousal and lubrication, which can be related to the internal sense of self, infertility and even medications like contraceptives, anti-androgens and GnRH antagonists used during infertility treatment [21–25]. Our findings are inconsistent with the study conducted by Battaglia et al.[26] who found that in PCOS women, probably, moderate hirsutism and hyperandrogenism do not induce the sense of loss of feminine identity and have no impact on sexual self-worth and sexual satisfaction. This difference is probably due to differences in the measurement tools. The tools used by Battaglia et al. in their study, were the male sexual fantasy questionnaire (MSFQ) and Beck’s Depression Inventory Questionnaire (BD).
2) In women with endometriosis, the overall score of orgasm, satisfaction, and pain was lower than the other groups. Consistent with our work, Tripoli et al. [27] studied quality of life and sexual satisfaction in women suffering from chronic pelvic pain (CPP) with or without endometriosis. They found that CPP caused by endometriosis or other gynecological conditions, leads to a significant reduction of quality of life and sexual satisfaction. In their study, 40% of those suffering from endometriosis or CPP caused by other gynecological diseases, were sexually unsatisfied. They reported a decreased frequency of sexual intercourse and vaginismus, and aversion, and reduced expression of sensuality. Giulia et al. [28] evaluated sexual satisfaction, desire, and orgasm, and pelvic problem interfering with sex in women with deep infiltrating endometriosis. The results of their study showed that women with endometriosis have sexual dysfunction that is associated with reduced quality of life. They also found that the presence of dyspareunia in these women led to a decrease in sexual desire and thus sexual dysfunction. One of the most common complaints of women with endometriosis is pain. Depending on the severity of the pain, women's daily activities, sexual activity, and even entertainment were reduced. Also, these limitations caused mood swings, irritability and sexual dysfunction in a person with a sexual partner [28]. In fact, in these women, the issue of dyspareunia and pain during sex and orgasm led to a decrease in sexual desire and the number of times it occurs; thus, affecting the level of sexual satisfaction. Verit et al. [29] found similar results and reported that 69.9% of women with chronic pelvic pain had sexual dysfunction. During sexual intercourse, these women thought that they would feel pain, which caused them anxiety.
3) As a final result, we found that the prevalence of sexual dysfunction in the primary infertility group was not significantly different from the secondary infertility group in all subscale except arousal, lubrication and satisfaction (p < 0.05). In our study, sexual arousal and satisfaction were significantly lower and lubrication was higher in women with primary infertility compared to women with secondary infertility. It appears that problems with arousal and satisfaction are the main causes of sexual problems in women with primary infertility. This may be due to the fact that the level of stress is higher in women with primary infertility [30], and women with secondary infertility might be probably more comfortable with having children and more likely to have sex. It may be hypothesized from this finding that the stress produced by infertility impacts the psychological or relationship aspect of sexuality (arousal) more than the physical aspects (lubrication), but this cannot be conclusively stated based on these data [10]. Although in our study, there was no significant difference between the mean total score of anxiety (7.05 ± 4.64 vs. 6.77 ± 3.95; P = 0.761), depression (5.41 ± 4.49 vs. 4.32 ± 3.4; P = 0.211) and total HADS (12.39 ± 8.43 vs. 11.09 ± 6.81; P = 0.430) between the two groups of primary and secondary infertility, respectively, the mean score was slightly higher in women with primary infertility than those with secondary infertility; this small difference might be clinically important and might have a potential effect on some aspects of sexual function.
The results of various studies in this regard are inconsistent. Keskin et al. [10] evaluated prevalence of sexual dysfunction between primary and secondary infertile women. They found a higher prevalence of sexual dysfunction in secondary infertile women in comparison with primary infertile women. In this study, secondary infertile women had decreased sexual desire, orgasm, and satisfaction compared to the primary group. But in the study conducted by Shahraki et al. [31] in Iranian women with infertility, different results were shown. They found that sexual dysfunction was more common in women with primary infertility. Also, their results showed that total FSFI score and all of its domains were significantly higher in controls vs. infertile ones and only desire subscale was significantly higher in the primary group. In our study, except for satisfaction, in other subscale of sexual function, no significant difference was found between the two groups.
In spite of the importance of the present results, this study has some limitations. The main limitations of our study are external validity or the generalizability of the study due to the limited number of subjects involved, the multifactorial nature of female sexual dysfunction and data collected from Iranian women.