Background Infertility is a major and problem influencing different aspects of couples life, especially those of women. Sexual dysfunction is the silent partner of infertility. This study aimed to identify the above-mentioned factors to make necessary decisions and perform efficient interventions to improve the sexual health of infertile women. This study investigated the factors influencing sexual dysfunction in infertile women in Mashhad, Iran. Materials and Methods This cross-sectional study was conducted on 85 infertile women visiting governmental Infertility Clinic and Research Center in Mashhad, Iran. The convenience sampling method was used in this study. The research tools included a demographic and infertility information form, a sexual self-efficacy questionnaire based on Schwarzer’s General Self-Efficacy Scale, Female Sexual Function Index (FSFI), and Evaluation and Nurturing Relationship Issues, Communication, and Happiness (ENRICH) Marital Satisfaction Scale. The descriptive statistical tests and logistic regression method were used to analyze data. Results The mean age of women was 31.18 ± 5.56 years old. The majority of participants (36.7%) had higher educa- tions, and 60% of them were housewives. Most of their husbands (49.4%) were self-employed. The mean period of infertility awareness was 6.02 ± 4.47 years, and the mean period of infertility treatment was 4.11 ± 4.46 years. The following variables influenced the sexual function of infertile women: sexual self-efficacy, sexual satisfaction, marital satisfaction, the educational level of both wife and husband, income, satisfaction with spouse appearance, and the high costs of infertility treatment. Conclusion The findings indicated that some factors such as sexual self-efficacy, marital satisfaction, sexual satisfac- tion, education, and cost of infertility treatment are associated with sexual function in infertile women.
Infertility is be defined as being unable to become pregnant
after having regular sexual contacts for one year
without using contraceptive methods (1, 2). Infertility is
a health issue in today’s world. According to the statistics
published by the World Health Organization on January
16, 2013, in developed countries one out of every four
couples is suffering from infertility (3). In general, male
factor, female factor, joint factor and unknown factor account
for 30-40%, 40-50%, 10-20% and 5-10% of infertility
cases, respectively (4). Infertility is observed in 10-
15% of American couples (5).
Several studies have been conducted on infertile couples
in Iran. In an epidemiological study in 2004, the
prevalence of infertility was reported 24.9% in Iranian
women of 19 to 49 years old (6). According to the statistics
presented by Iran’s Ministry of Health and Medical
Education in 2009, the prevalence of infertility was
estimated to be 20.2% in Iran (7). Sexual dysfunctions
comprise a heterogeneous group of disorders that are typically
characterized by a clinically significant disturbance
in a person’s ability to respond sexually or to experience
sexual pleasure (8). Sexual problems are highly prevalent
in women. In the United States, approximately 40% of
women have sexual concerns and 12% report distressing
sexual problems. Female sexual dysfunction takes different
forms, including lack of sexual desire, impaired arousal,
inability to achieve orgasm, pain with sexual activity,
or a combination of these issues (9).
The most important causes of sexual dysfunction in women
include lack of desire, excitement disorders, lack of orgasm,
dyspareunia and vaginism. The prevalence rates of
sexual dysfunction are 40 and 19.6% in the US and Sweden
respectively (2). Since an active and effective sexual contact
can increase the chance of fertility, it is believed that sexual
dysfunction has a more marked impact on infertile women
rather than fertile women (10). Sexual dysfunction is associated
with infertility. It is caused by the reduction or lack
of sexual activity. Sexual dysfunction is usually created or
intensified during the diagnosis and treatment of infertility.
In fact, sexual dysfunction is the silent partner of infertility.
It prevents effectiveness treatment of infertility (11).
Sexual behavior disorders can be a prior cause of infertility.
Generally, infertile couples seek treatment for infertility
instead of searching for deeper problem in their sexual relationships
(12). It was reported that many infertile women suffer
from one of the different types of sexual dysfunction (13).
Many factors can influence sexual dysfunction. The physical
factors include the ages of husband and wife, BMI, physical
activities, etc. The mental-emotional factors include feelings
for a sexual partner, sexual self-efficacy, self-confidence, the
mental image of body, the feeling of sexual attraction, etc.
Finally, the social factors include the educational levels of a
women and her husband, occupation, duration of marriage,
the quality of spousal relationships, socioeconomic status,
substances abuse, etc. (14). Many couples believe that conception
is the only result of a sexual relationships; otherwise,
this relationship is fruitless (15).
Since fertility is regarded as a value in Iranian culture and
notions, infertility questions the individual and social competencies
of women, i.e. the feelings of maternity and spousal
values); therefore, a women’s entire marital and sexual
relationships with her husband will be affected. Given the
importance of identifying the factors influencing sexual dysfunction
in infertile women, the current study employed a
modern approach using statistical models to investigate the
subject. This study aimed to identify the above-mentioned
factors to make necessary decisions and perform efficient interventions
to improve the sexual health of infertile women.
This study investigated the factors influencing sexual dysfunction
in infertile women in Mashhad, Iran.
Materials and Methods
In this cross-sectional study, type I error (Za=1.96) and
the statistical power (Zß=1.28) were taken into account to
select 85 infertile women as the population sample. The
following formula was used for sampling:
The convenience sampling method was employed to select
the participants from the women visiting Montasarieh
Infertility Clinic and Research Center in Mashhad, Iran. The
Ethics Committee of Shahid Beheshti University of Medical
Sciences approved this study (approval No. 2881/116). All
participants received information about the purpose of this
study and gave their verbal informed consent to participate.
The participants were aged between 20 and 45 years old.
Participants, did not suffer from any physical, mental, or
medical problems. They were not addicted to any substances
or alcohol. The information collection tools included an
informational form with demographic and infertility information
and Female Sexual Function Index (FSFI) and
at demographic variables included age, mental and physical
status, surgery history, medication and drugs, having a
child or foster child. Infertility variables were duration of
infertility and treatment, cause of infertility, kind of treatment,
hope for cure, cost of treatment, and information
about sexual relationship sexual. FSFI is one of the gold
standard for female sexual dysfunction (FSD) assessment
and in this study, the nominal and content validities of FSFI
were re-evaluated by obstetricians and gynecologists, psychologists,
midwives, and health education experts.
The reliability of this index was determined 0.9 through
a retest. The researcher obtained the information from
participants individually. The standard FSFI includes 19
items regarding sexual desire, sexual excitement, dyspareunia,
and the inability to reach orgasm. Each item has
five choices. According to the scoring system, a score below
28 indicates a poor sexual function, whereas a score
between 28 and 36 shows a desirable sexual function
(9). Sexual self-efficacy questionnaire developed based
on Schwarzer’s General Self-Efficacy Scale includes 10
items. Each item has three choices. Following completion
of the questionnaire, a score of -0-10- was considered
low, -10-20- moderate and -20-30- high efficacy (16).
ENRICH Marital Satisfaction Scale includes 47 items regarding
idealistic distortion, marital satisfaction, personality
issues, communication, conflict resolution, etc & with 5-Likert
scale. According to the scoring system, a score below 30
indicates very poor satisfaction, -30-40- poor satisfaction,
-40-60- moderate satisfaction, -60-70- high satisfaction and
above 70 very high satisfaction (17). Then the descriptive-
analytical tests were used to analyze the results. Finally,
the logistic regression method was employed to investigate
the relation between influencing and predicting factors and
sexual function in infertile women, because sexual function
possesses qualitative variables with two state (undesirable=0
when sexual function less than 28 according FSFI and desirable=
1 when sexual function is between 36-28).
Infertile women were investigated with respect to demographic
characteristics (Table 1). The mean age of
infertile women was 31.18 ± 5.56 years old, and 32% of
them were aged between 26 and 30 years old. The cause
of infertility was the female factor in 28 participants
(32.9%), the male factor in 24 participants (28.3%), joint
factor in 15 participants (17.6%), and unknown factor in
15 participants (17.6%). Moreover, three of them (3.5%)
visited the clinic for the first time. The average duration
of diagnosed infertility was 6.02 ± 4.47 years, and
the average duration of infertility treatment was 4.11 ±
4.41. Furthermore, 54.1% of infertile women reported
high levels of marital satisfaction, and 60% of them (51
participants) reported medium self-efficacy in their sexual
relationships. 71.8% of infertile women show poor
sexual performances (Table 2).
Distribution of some demographic variables among infertile women
Less than 1,700,000,0 Rials
Equal to 1,700,000,0 Rials
More than 1,700,000,0 Rials
"Number and percent" of sexual function among infertile women
n (%) or mean + SD
Sexual function desirable,
Sexual function undesirable
Total score of sexual function
25.93 + 4.32
Table 3 indicated some infertility information. Based on the logistic regression model, the following variables influenced social function: sexual self-efficacy, sexual satisfaction, marital satisfaction, couple satisfaction with spouse appearance, and the high costs of infertility treatment (Table 4).
Distribution of some infertility information
Using of ART
Ovulation and intercourse
Hope for a cure
The cost problem
ART; Assisted reproductive technology, IUI; Intrauterine inseminations, and IVF; In vitro fertilization.
Regression logistic of related factors of sexual function
After high school
After high school
Less than 1,700,000,0 Rials
Equal to 1,700,000,0 Rials
More than 1,700.000.0 Rials
OR; Odds ratio and CI; Confidence interval
This research indicated that 71.8% of infertile women
were suffering from sexual dysfunction. Regardless of the
duration and causes, infertility causes mental health and
sexual problems and infertile women suffer from these
conditions more than fertile women (16). Previous studies
indicate that sexual self-efficacy is related to sexual
function, as individuals with a poor sexual self-efficacy
and individuals with average sexual self-efficacy face
problems in sexual function fourteen times and five times
more than individuals with high sexual self-efficacy, respectively.
In 2013, Champion and et al. (17) conducted a study entitled
sexual self-efficacy and marital satisfaction on 194
university students. They showed that sexual satisfaction
referred to an individual’s pleasure from the type of sexual
relationships. Also, the concept of marital-sexual satisfaction
depends on an individual’s perception of self-efficacy
whether as sexual activity satisfaction or emotional satisfaction.
According to another study, self-efficacy and self-
confidence should increase in sexual issues to have better
and healthier sexual functions (18). Previous investigations
indicated that marital satisfaction was significantly related
to sexual function. In other words, sexual satisfaction can
result in fewer complaints made by women with sexual
disorders (19). In fact, a sexual partner’s behavior, sexual
adequacy, and martial life status influence sexual function.
Women having happy and exciting relationships with
their husbands experience sexual disorders less often.
They feel more self-confident and think that their husbands
like their bodies; therefore, they feel that they are
more sexually attractive to their husbands. On the other
hand, women having negative attitudes towards their bodies
are nervous in private and romantic relationships with
their husbands. Such women are not sure about having
sexual activities (20-22). The results of this study indicate
that satisfaction with spouse appearance improves sexual
function by five times in both men and women. Likewise,
Kalra et al. (23) stated that the shape of body is one of the
factors influencing the emergence of sexual dysfunction.
Moreover, this study indicated a relation between educational
attainment and sexual function. As individuals with
high school diplomas or lower educations face sexual
dysfunction problems three times more than the individuals
with higher educations.
Fajewonyomi et al. (24) indicated that women with higher
educations would face sexual dysfunction less often. In fact,
higher educational attainments increase the chance that individuals
can speak about their sexual problems or their spouses.
Training and high educational attainments are necessary
to have desirable and normal sexual activities (25).
Income is another effective factor (22). To confirm this
statement, the results of this study showed that low-income
individuals face sexual problems four times more than
high-income individuals. Moreover, Audu (26) indicated
that income would influence sexual function. Also, Cayan
et al. (27) suggested low income as a risk factor for the
emergence of sexual dysfunctions. Difficulty in providing
the costs of infertility treatment increases the chance
of sexual dysfunction by nine times. Similarly, Mollaiy
nezhad et al. (28) stated that sexual dysfunction was significantly
related to the duration of infertility treatment,
treatment costs, the number of unsuccessful pregnancies,
and the hope for successful treatment. Likewise, Noorani
et al. (29) and Karamidehkordi and Latifnejad Roudsari
(30) showed that infertile women whose husbands helped
them during treatment and covered the costs, experienced
better marital and sexual satisfaction. One of our research
limitations was inclusion of women with primary infertility.
In addition, the infertile women were selected from
only one infertility clinic in Mashhad, we used self-report
scales and clinician rated psychological parameters.
The finding indicated that some factors such as sexual
self-efficacy, marital satisfaction, sexual satisfaction, education,
cost of infertility treatment are associated with
sexual function in infertile women.
Alirezaei, S., Ozgoli, G., & Alavi Majd, H. (2018). Evaluation of Factors Associated with Sexual Function in Infertile Women. International Journal of Fertility and Sterility, 12(2), 125-129. doi: 10.22074/ijfs.2018.5193
Somayeh Alirezaei; Gity Ozgoli; Hamidreza Alavi Majd. "Evaluation of Factors Associated with Sexual Function in Infertile Women". International Journal of Fertility and Sterility, 12, 2, 2018, 125-129. doi: 10.22074/ijfs.2018.5193
Alirezaei, S., Ozgoli, G., Alavi Majd, H. (2018). 'Evaluation of Factors Associated with Sexual Function in Infertile Women', International Journal of Fertility and Sterility, 12(2), pp. 125-129. doi: 10.22074/ijfs.2018.5193
Alirezaei, S., Ozgoli, G., Alavi Majd, H. Evaluation of Factors Associated with Sexual Function in Infertile Women. International Journal of Fertility and Sterility, 2018; 12(2): 125-129. doi: 10.22074/ijfs.2018.5193