Impact of infertility duration on female sexual health

Inclusion criteria: This study’s participants included women who were diagnosed with infertility and younger than 45 years to prevent potential biases, such as age and endocrine environmental factors, given that the incidence of sexual dysfunction increases significantly in perimenopausal women due to a decline in their hormone levels [1, 18‐23]. This criterion was consistent with the age in previous studies on the sexual functions of women with infertility [4, 9].

Exclusion criteria: Females diagnosed with 1) polycystic ovary syndrome (PCOS), 2) endometriosis, 3) premature ovarian failure, 4) diabetes, 5) high blood pressure, 6) lower genital tract abnormalities, 7) genitourinary infections, 8) genital prolapse, or 9) whose partners had severe male infertility, 10) whose partners had been diagnosed by specialists with sexual dysfunction, 11) presence of psychiatric conditions (that could cause sexual dysfunction), or 12) used drugs that affected sexual functions (e.g., selective serotonin reuptake inhibitors, as well as serotonin and norepinephrine reuptake inhibitors) [8]. We excluded several types of infertilities, such as endometriosis [24], PCOS [25, 26], premature ovarian failure [27, 28], and severe male infertility [29‐31], that were reported to have affected sexual functions. Taking into account of previous studies, women with a total FSFI score < 8 were excluded because this score implies that they do not have sufficient sexual activity [4, 32, 33]. Participants who did not complete the questionnaire and whose answers were inconsistent (e.g. in questions that focused on sexual functions, “did not attempt intercourse” was selected in one question but not in others) were also excluded.

The self-administered questionnaire comprised three parts. The first part was designed to collect information about the sociodemographic characteristics of patients with infertility: age, body mass index (BMI), primary/secondary infertility, smoking status (0=yes, 1=no), economic level, infertility duration, education level(0= ≤ high school, 1=college, 2=undergraduate, 3= ≥postgraduate), drinking alcohol status(1=usually, 2=sometimes, 3=rarely, 4=never), stress in work and life(0=very high, 1=high, 2=general, 3=low, 4=none), and frequency of physical exercise(0=none, 1= <1 time a week, 2=1 time a week, 3= ≥2 times a week).

The second part was a survey of participants' sexual health and sexuality for measuring the FSFI [34] and the four aspects of sexuality, that were adopted from a previous study’s questionnaire [24], including the questions on the importance of sex in general, dyspareunia, the possibility of orgasms in different sexual activities, and the duration of intercourse and foreplay. The importance of sex in general was assessed by asking the following multiple-choice questions: “Is sex important to you?” Response options were set as: very important, important, general, unimportant, and very unimportant. Dyspareunia was assessed by asking “Have you experienced difficulties during sexual intercourse?” Response options were set as: never, very rarely, rarely, sometimes, usually, and almost always. With regard to the possibility of reaching orgasm in different sexual activities, the following three questions were asked: 1. What is the possibility of your reaching orgasm through masturbating? 2. What is the possibility of your reaching orgasm during non-coital intercourse, such as foreplay or oral sex? 3. What is the possibility of your having an orgasm during sexual intercourse? The response options were set as: almost always, always, sometimes, rarely, never, and never tried. The duration of intercourse and foreplay were also evaluated by two questions, whose response options were <1, 1–2, 3–4, 5–7, 8–10, 11–15, 16–30, > 30 minutes and < 1, 2–10, 11–20, 21–30, 31–60, > 60 minutes, respectively. The FSFI includes 19 items and 6 domains of sexual functions (desire, arousal, lubrication, orgasm, satisfaction, and coital pain) based on the sexual status in the preceding 4 weeks [34]. The scores for each domain range from 1.2 to 6 or from 0 to 6, and the total score ranges from 2 to 36, with a Cronbach’s alpha value ≥ 0.82 [20]. The Chinese cut-off of the total FSFI score was ≤ 23.45, which indicated that the women could have sexual dysfunction [35, 36]. The cut-off scores for each domain were established as follows: ≤ 2.7 low desire, ≤ 3.15 arousal disorder, ≤ 4.05 lubrication disorder, ≤ 3.8 orgasm disorder, and ≤ 3.8 sexual pain [36].

The third part was a survey of psychological depression evaluated by Patient Health Questionnaire (PHQ-9) [37]. The items were scored on a 4-point scale from 0 to 3, with a total severity score ranging from 0 to 27. A cut-off score of ≥ 10 was used to assess the presence of depression with a Cronbach’s α value ranging from 0.73 to 0.95 [37].

The study’s participants comprised patients recruited from the Reproductive Medical Centre, who voluntarily participated and to whom anonymous and confidential questionnaires were distributed. They filled them out in a private setting (alone), without any time limit, and the completed questionnaires were placed in a box and collected altogether. The approval for this study was given by the Hospital’s Institutional Review Board for research on human subjects, and the participants were not reimbursed for their involvement.

Data analysis was performed using the statistical software SPSS (version 22.0; SPSS Inc., Chicago, IL, USA). Categorical variables were summarised with counts(n) and percentages (%); continuous measures, with counts, means, standard deviations (SDs).

The chi-square test was used to compare the categorical variables and one-way analysis of variance (ANOVA) were used to compare numerical data. Multivariable logistic regression was employed to explore the factors that affect sexual function and each of the five outcomes of desire disorder, arousal disorder, lubrication disorder, orgasm disorder, and coital pain disorder. P value, OR, and 95% CI were evaluated, and a two-tailed p value < 0.05 indicated statistical significance.

A total of 791 patients participated in this study, and 76 patients were excluded from the study (52 patients failed to complete all the questions, 23 provided inconsistent answers, and 1 had a total FSFI score below 8). Thus, responses of 715 participants were included in the analysis and the response rate was 90.39%. Table 1 summarizes the participants’ demographic characteristics. Of the participants, the average age was 32.68 years (SD, 4.37; range 21-44) and the average infertility duration was 4.08 years (SD, 3.05; range 1-20). There are significant differences in age, BMI, education levels, and physical exercise frequency among the four groups of participants (p < 0.05). There were no significant differences in primary or secondary infertility stress, income levels, or smoking and drinking status among the four groups of participants (p > 0.05) (Table 1).

As the number of years of infertility increased, the PHQ-9 score and the incidence of psychological depression increased significantly (p < 0.05). The total FSFI score and those of its six domains were not significantly different among the four groups. Likewise, the incidence of sexual dysfunction, low desire, arousal disorder, lubrication disorder, orgasm disorder, and sexual pain was not significantly different among the four groups (p > 0.05) (Table 2).

No significant differences were identified in the frequency of orgasms during different sexual activities and sexual intercourse or foreplay duration in patients with different infertility durations among the four groups (p > 0.05) (Table 3).

A multivariable logistic regression model was used to analyze relevant factors— age; BMI; income, education, and stress levels; frequency of sex and physical exercise; smoking and drinking status; and psychological distress—that affect the sexual function.

The results reveal that as the infertility duration increases, the incidence of sexual dysfunction also increases. When infertility duration was greater than 8 years, the values were as follows: low desire (AOR = 1.252, 95% CI: 0.590-2.656, P = 0.558), arousal disorder (AOR = 2.955, 95% CI: 1.194-7.314, P = 0.019), orgasmic disorder (AOR = 2.089, 95% CI: 0.876-4.984, P = 0.097), coital pain (AOR = 3.811, 95% CI: 1.045-13.897, P = 0.043), and lubrication disorder (AOR = 5.077, 95% CI: 1.340-19.244, P = 0.017), and the incidence of sexual dysfunction (AOR = 5.158, 95% CI: 1.935-13.746, P = 0.001). Among them, the incidence of arousal disorder, coital pain, lubrication disorder, and sexual dysfunction significantly increased (p < 0.05). The state of depression was a risk factor for arousal disorder, orgasmic disorder, coital pain, lubrication disorder, and the incidence of sexual dysfunction, but not for sexual desire. Factors significantly and independently associated with low desire were lower frequency of sex and lower education levels. A lower likelihood of arousal disorder was significantly associated with infertility duration of greater than 8 years, increased age, smoking status, and high levels of psychological distress. Orgasmic disorder was significantly associated with BMI and psychological distress. A higher coital pain was significantly associated with infertility duration of greater than 8 years, higher frequency of alcohol consumption, and psychological distress. The risk factors for lubrication disorder were infertility duration of greater than 8 years, lower frequency of sexual life, high stress levels, and psychological distress. A higher likelihood of sexual dysfunction was observed in patients with increasing infertility duration, increasing age, lower frequency of sexual life, and high levels of psychological distress (Table 4).