Author: Tao, Peng
Date published: October 14, 2011
Globally 8-12% of couples experience difficulty conceiving a child.1 Although assisted reproduction technology (ART) provides the possibility of achieving pregnancy, almost 40% of people undergoing ART still cannot conceive.2,3 Infertility has been described as a stressor and a life crisis for individuals or couples, which results in a lower quality of life and marital conflicts.4-7 Furthermore, there is an increasing use of medical services for the infertile. 8 Although many studies have been published about infertility diagnosis and treatments, and consensus in the literature demonstrating sexual problems as crucial contributing factors,9-12 we feel that little is known regarding the psychosexual aspects of infertility. In particular little is known about the sexuality of infertile individuals or couples in the presence of a clinical diagnosis and treatment. Facing a childless status and experiencing medical treatment, the infertile couple are likely to suffer from various psychosexual problems. In addition, the diagnosis of infertility and contributing factors such as unsuccessful treatment, continuing lack of conception and childbearing, and the absence of the role as a parent may have a negative impact on marital relations,1,4,13 thus should be given careful consideration as part of an holistic approach to case management. Research is therefore necessary to understand and address these psychosocial sexual issues.
Healthy sexuality is central to psychological well-being and quality of life,14 both the World Health Organization (WHO)15 and the World Association for Sexual Health (WAS)16 state that sexuality is an integral part of being human, it is influenced by many factors, it is diverse and cannot be separated from the essential elements of human life. Historically, we found there is a lack of consensus concerning the definition of sexuality. Woods17 describes a holistic perspective on sexuality, which suggests sexuality is concerned with biologic, psychologic, sociologic, spiritual, and cultural aspects of life. Furthermore, sexuality has three major dimensions including sexual self concept, sexual relationships and sexual function. McCabe et al18 suggest sexuality is an important aspect in people's lives, it involves a broad range of cognitions, emotions and behaviours. Master et al19 suggest that sexuality is a multidimensional phenomenon with biological, psychological, behavioural, clinical, moral, and cultural aspects. Similarly, Bernhard20 also suggests sexuality as a multidimensional phenomena, composed of biological, socioeconomic, psychological and spiritual components. In addition, McCarthy et al21 suggest sexuality is more than the physical act of intercourse, as it influences self-identity, communication, sharing pleasure, deepening intimacy and may lessen stress in one's life. However, from the above mentioned definition of sexuality, we can have a clear understanding that sexuality is not just the state of being physically able to perform a sex act or to conceive a child, but as an integral component of human life with multidimensional content. In conclusion, Woods's perspective on sexuality provides a useful conceptual framework for holistic, sexuality research, also combining with clear definition on every dimension as follows:17 1) sexual self concept refers to the image one has of oneself as a man or a woman and the evaluation of one's adequacy in masculine or feminine roles, including body image, sexual self schema and sexual esteem; 2) sexual relationships as the interpersonal relationships in which one's sexuality is shared with another; 3) sexual function is about the ability of an individual to give and receive sexual pleasure, including various physical and psychological progresses in the sexual response cycle. These have been acknowledged by various studies. 22-26
From the purpose of the study, in this paper Woods's conceptual framework of sexuality was used to make analysis pertaining to sexuality in infertile individuals or couples. We focused on changes in sexuality following infertility diagnosis and treatment and provide recommendations for future research. The following questions were addressed.
(1) How is sexual self concept impacted in infertile individuals and their partners?
(2) Does infertility have a negative impact on the sexual relationship between infertile individuals and their partners?
(3) Is sexual function affected by infertility?
Based on the purpose of this study, research articles for this literature review were searched via a range of databases, which were MedLine (Ovid), PsycInfo (Ovid) and Scopus. In addition, references lists from retrieved articles were also hand searched for relevance. Duplicated articles, or those that did not meet inclusion criteria were excluded from the review.
The bibliography was compiled using Infertility "OR" Childless in the title, abstract, or keywords. Since some studies linked with sexuality are explored in the context of clinical treatment, so in our review study, in-vitro fertilisation (IVF) "OR" intra-cytoplasmic sperm injection (ICSI) "OR" ART were also included as terms in the search strategy. All of these terms were in various combinations with infertile individuals or couples' sexuality. These included sexual self concept, body image, sexual esteem, communication, intimacy, relationship, sexual function/dysfunction, sexual disorder, sexual health, sex life, sexual behaviour or sexual problems. Furthermore, the databases were searched with combinations of infertile males, infertile females, infertile subject, infertile couples, spouses, or partner.
Inclusion and exclusion criteria
The literature search was based on a theoretical design rather than on a systematic review format. To be included in the review, the retrieved articles were confined to the following criteria:
Criteria 1: Peer-reviewed articles published in the English language between 1990 and 2011;
Criteria 2: The primary or secondary objective of the study was regarding sexuality in the context of infertility;
Criteria 3: The study participants comprised of infertile subjects, or infertile couples comprising infertile subjects and their partners;
Criteria 4: The study needed to report originally collected data via the validated questionnaire. Reviews, editorials and debates, letters, case reports, non-peer-reviewed articles, meeting abstracts and brief communications were excluded.
In addition, studies that discussed infertility as a consequence of other conditions such as hysterectomy, tubal ligation or cancer were to be excluded because the changes of sexuality are intrinsically linked to the baseline status, and also different health conditions might affect the subjects' sexuality.
Through the literature retrieving strategy, finally 24 studies were sourced via online search. The results of this comprehensive search are outlined in Figure 1. In addition, through a hand search, one further research paper was found which met the selection criteria. Therefore, in total 25 studies were sourced which examined some aspects of sexuality in infertile individuals and couples.
All papers selected were reviewed to ensure congruency with the aim of the study. The relationship between infertility and sexuality were discussed using the following themes.
(1) How is sexual self concept impacted in infertile individuals and their partners?
Despite an extensive literature search, we found no sourced study that examined sexual self schema and body image of infertile individuals.
In some studies, infertile self-esteem was given more attention, the results demonstrated that infertile males had lower self-esteem,27-29 which was associated with changes in stress levels over the course of treatment. 30 Women on IVF were found to have lower self-esteem than controls prior to the treatment cycle,31,32 also associated with unsuccessful IVF treatment in infertile females,33,34 but effective adjustment to infertility could contribute to positive self-esteem.35 Of all the retrieved studies, two studies of infertile couples specifically focused on the term of sexual self-esteem, which suggested that infertility-related stress tended to decrease the sexual self-esteem of women more than their male partner. 36,37
It is a fact that there is a scarcity of research about sexual esteem in infertile individuals and their partners, and self-esteem is addressed in more studies. This might be due to self-esteem being recognised as an important part of both a person's sexual confidence and adequacy.38 However, sexual esteem mainly refers to the tendency to evaluate one's sexuality positively and is related to others39 its discussion specifically in the context of infertility in the future will be helpful for better understanding the sexuality of infertile clients and their partners.
(2) Does infertility have a negative impact on the sexual relationship of infertile couples?
Infertile males had a lower sexual and personal quality of life compared with the male partners of couples without perceived male factor infertility.40 It was also found that the male partner in infertile couples experienced less sexual satisfaction when compared with the female partner. It was hypothesised that this was due to the psychological pressure associated with efforts to conceive, or to the forced timing of intercourse around the female's ovulatory cycle.4 Furthermore, diagnosed male factor and infertility duration of 3-6 years contributed to higher relationship instability and lower sexual satisfaction in both females and males from infertile couples.41
The sexual satisfaction of infertile females was found to be various at different stages of treatment, with the most profound change occurring during treatment. This impacted most on the couple's sexual relations. Furthermore, other studies demonstrated that females with unsuccessful IVF treatment had a lower satisfaction with married life compared to those who subsequently conceived or adopted.33,42,43 In addition, Lee et al44 suggested that the wives expressed less sexual satisfaction than their partners both in only male factor infertility and combining male-female factor infertility; also the results showed no difference in sexual satisfaction between wives and husbands in infertile couples with unexplained factor infertility; but the wives from infertile couples with female factor infertility had less sexual satisfaction than their husbands. However, other studies had contrary results which suggested infertility and its treatment did not have a negative influence on sexual relationship and satisfaction because the shared stress of infertility could make both couples more involved jointly with the same problem. 45-48
(3) Is sexual function affected by infertility?
Regarding sexual function in infertile subjects, most of the retrieved studies discussed premature ejaculation and erectile dysfunction, and in females sexual desire, sexual arousal, orgasm and sexual pain.
Generally the results of findings from the retrieved studies indicated that infertility could influence sexual activity in infertile couples, and that fertility problem stress tended to decrease frequency of intercourse.29,36,49 Frequency of coitus could be regarded as an acceptable indicator of sexual satisfaction in male partners of infertile couples.50 As for the sexual function of infertile subjects, studies demonstrated premature ejaculation and erectile dysfunction were prevalent among male partners of infertile couples.51-53 In addition, a cohort observational study reported 11% of males experienced problems with erection or orgasm after the diagnosis of abnormal semen parameters, which might be psychologically related in the evaluation of infertility. 54
Among infertile females, some studies demonstrated sexual dysfunctions, especially sexual arousal, as being very common.10,53,55-60 Another study indicated there was no statistically significant difference in sexual function between infertile females and females seeking elective sterilisation, but a trend was noted toward greater sexual problems in these two female groups. 4
In this review, all studies were descriptive quantitative studies which basically mapped sexuality in the context of infertility. Results suggested that infertility and associated treatment may lead to changes in sexual self-esteem, sexual relations and sexual function, which further affected the infertile couple's quality of life, and well-being.
For the infertile subjects, infertility affects self concept and role perceptions, and is a threat to personal identity. For infertile women, the negative impact on self-esteem has a greater effect on sexual confidence than it does in infertile men. Unfortunately, the retrieved studies do not record further analysis on these changes. It would be helpful if there had been an investigation of the extent and the perceived reasons for such changes. Almost no studies examine the impact of gender-specific diagnosis on changing sexual self concept in men and women, respectively. Such information would be useful along with a comparative analysis. Sexual self concept is a core component of sexuality,61 it is necessary to give more attention to the experience of infertility and its influence on one's cognitive view of self and one's sexuality. Future studies should further address how infertility and its treatment have the potential to affect the sexual self concept. This should include issues such as female's body image and infertile subject's sexual esteem, in conjunction with how infertility affects partners.
Regarding sexual relations for infertile couples, some studies demonstrated there were no significant correlations between infertility and sexual relations but other studies suggested infertility impaired sexual relations. We postulate that this result might be explained by different aspects such as gender differences in the reaction to infertility, the different stages of infertility treatment and/or different social demographics. In order to have a comprehensive understanding of sexual relations in the context of infertility, it is necessary to further consider the association between sexual self concept and sexual relations, and the quality of communication in infertile couples. However, most retrieved studies focused on the assumption that infertility might negatively affect sexual relations. Future studies should investigate factors that might positively affect sexual relations in infertile couples.
Among the infertile subjects, we found the sexual dysfunction could be a consequence of the diagnosis, investigation and treatment of infertility. The main reason for the infertile male's sexual dysfunction was related to a perception of losing his masculinity.62 Problems associated with sexual pleasure appeared to be due to the mechanical and forced sexual activities for conception purposes, which included scheduled post-coital tests, and the optimal states for sexual intercourse during the female ovulatory period. 63 Sexual dysfunction was also prevalent in female partners of infertile couples, and positively correlated with the male partner's sexual function. 64
Although the retrieved studies provided some indication of the effect of infertility on sexuality, most focused on the physical aspects of sexuality such as sexual behaviour, problems or disorders.4,55,60,62,65-74 These studies did not make further analysis on the influence of age, length of conjugal relationship, the period since diagnosis and treatment, treatment stages, general health status, and socio-demographic conditions. In addition, the studies of sexuality were confined to physical aspects, and failed to address the impact on the partner or the influence this might have. Further, the studies rarely took a gender perspective to explore sexuality issues. In addition, we found very little research that focused on factors that might positively affect sexual self-esteem, sexual relationship and sexual function. It is our view that it is necessary to address sexual self concept and sexual relations and sexual function with a holistic approach.
The literature substantiates that sexuality can be greatly affected by infertility and its treatment, with infertile subjects experiencing difficulties in different aspects of sexuality. It is necessary for further research to examine the reciprocal relations between sexual self concept, sexual relationship and sexual function in the context of infertility. Moreover, the sexuality of infertile subjects might be influenced by their partner's reaction to the diagnosis.
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Not commissioned. Externally peer reviewed.
CONFLICTS OF INTEREST
The authors declare no competing interests.
This review is part of the corresponding author's PhD study named as Infertility and Marital Well-being among Infertile, Chinese Couples from Hei Longjiang Province in China, which is funded by Curtin Strategic International Research Scholarship (CSIRS).
ETHICS COMMITTEE APPROVAL
The corresponding author's PhD study is approved by Human Research Ethics Committee of Curtin University (Perth, Australia) and the Ethical Committee of the First Clinical College of Harbin Medical University (China).
Peng Tao1,2, Rosemary Coates2, Bruce Maycock3
1. Research and Education Center in Sexual Health, Harbin Medical University, China
2. Department of Sexology, Curtin University, Australia
3. Curtin Health Innovation Research Institute, Curtin University, Australia
Research and Education Center in Sexual Health, School of Public Health, Harbin Medical University, No.157, Bao Jian Road, Nan Gang District, Harbin City,150081, People's Republic of China