Elizabeth Grill1, Rose Khavari2, Jonathan Zurawin3, Juan Ramon Flores Gonzalez4 and Alexander W. Pastuszak5
(1)
The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, New York, NY, USA
(2)
Houston Methodist Hospital Department of Urology, Houston Methodist Center for Restorative Pelvic Medicine, Houston, TX, USA
(3)
Baylor College of Medicine, Houston, TX, USA
(4)
Department of Surgery, University of Texas Medical School at Houston, Houston, TX, USA
(5)
Division of Male Reproductive Medicine and Surgery, Center for Reproductive Medicine, Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA
Alexander W. Pastuszak
Email: pastusza@bcm.edu
Keywords
InfertilitySexual dysfunctionCouplePsychosocial interventions
32.1 Introduction
Sexual dysfunction can significantly affect both partners in a relationship as well as the couple as a whole. Thus, a couple’s sexuality should be considered as a dyadic unit encompassing a reciprocal exchange of positive and negative feedback. One partner’s libido and climax positively influences the other’s sexual desire, helping to affirm sexual identity. Conversely, if one partner perceives a lack of sexual response from the other, his or her self-image may be undermined. For instance, women whose partners have erectile dysfunction (ED) report a decline in their own sexual desire, arousal, orgasm, and satisfaction [1, 2]. Accordingly, optimal dyadic sexual function is an important element for a couple’s bonding.
Contemporary population-based studies assessing the prevalence and incidence of sexual dysfunction are not available and a paucity of data exists. Previous analysis of the National Health and Social Life Survey data from 1992 observed sexual dysfunction in the United States in 43 % of women and 31 % of men [3]. However, only approximately 12 % of 31,581 women endorsed the combined presence of sexual problems and distress associated with those problems, a more valid indicator of the impact of sexual dysfunction in women [4]. While there are numerous causes of sexual dysfunction, in this chapter we focus on the impact of infertility on sexual dysfunction in the man, woman, and couple, with special consideration of the couple as a unit. Given the growing body of knowledge relating organic and psychological causes of sexual dysfunction, as well as the growing rate of fertility evaluation, providing a perspective on the interplay between infertility and sexual dysfunction and appropriate management is necessary. Here, we dissect the relationships between infertility and sexual dysfunction in men and women individually, as well as in the couple.
32.2 Infertility and Sexual Dysfunction in the Man, Woman, and Couple
Infertility is defined as “the inability to conceive after 1 year of unprotected sex” [5] and may affect up to 15 % of couples [5, 6]. Importantly, male and female factors each can contribute independently to fertility difficulties in up to 50 % of cases [7–9]. Sexual function and childbearing are considered important aspects of most partnerships and deeply impact quality of life. For many couples, the inability to conceive or give birth to a healthy child often forces partners to reevaluate their sense of femininity and masculinity, gender identity, and ultimately the meaning of their relationship. Furthermore, couples with fertility difficulties confront many challenges including societal and parental pressures for propagation, physical and psychological burdens, and potential financial burdens if considering assisted reproductive technologies. Such stressors can lead to poor marital adjustment and decreased quality of life, as well as to sexual dysfunction. Common feelings in the setting of infertility, such as loss, anger, guilt, despair, depression, shame, and anxiety, often overshadow the usual feelings of warmth, affection, and emotional connection that are the natural prerequisites of sexual intimacy [10, 11]. Sex lives are quickly taken from the intimacy of the bedroom to the control of the healthcare establishment [12]. Sex is altered and becomes methodical, predictable, and unexciting for many couples struggling with infertility, and couples begin to associate sex with failure to conceive and may avoid it.
Infertility, with its direct link to procreative sexual behavior , is thus experienced as a stressful life crisis that has been compared to that of cancer, AIDS, and other devastating illnesses as well as the loss of a loved one [13–15]. Infertile couples have reported sexual problems ranging from lack of desire, pleasure, or spontaneity to sexual dysfunction. Keye [16] determined that the three areas of sexual difficulty in infertile couples were (1) the actual physical condition causing infertility or resulting from treatment, (2) sexual intercourse becoming only a means of reproduction rather than intimacy or pleasure, and (3) the global psychological impact of the infertility experience.
Organic sexual dysfunctions are regarded as a minor cause of infertility, impacting approximately 5 % of all infertility cases [17]. Overall, sexual dysfunction alone is common, with 40–45 % of adult women and 20–30 % of adult men with at least one manifestation of sexual dysfunction [18]. Male sexual disorders such as chronic ED and anejaculation make natural conception impossible, whereas in women, severe presentation of genito-pelvic pain/penetration disorders such as vaginismus and apareunia prevent natural pregnancy [19]. However, sexual problems are common in infertile couples, with women more affected than men [20]. As the focus of sexual activity continues to emphasize procreation, infertile men and women may feel depressed, lose interest in “sex-on-demand,” or find it difficult to feel sexual when they are chronically frustrated and unhappy due to childlessness. Loss of libido may be the result of chronic health problems or the invasiveness of medical treatment for infertility. It may be due to the medications and hormones that can interfere with sexual response and/or interest or to the stresses and demands that infertility places on the marriage, social relationships, work life, or financial resources [21].
Studies have linked the physical, psychological, and financial challenges of assisted reproduction to increased marital conflict, decreased sexual self-esteem, feelings of inadequacy, and frequency of sexual intercourse [13, 22]. Overall, infertility is associated with decreased sexual activity and appears to become worse as the number of childless years increases [19]. The interplay between the infertility and sexual dysfunction can affect one’s reproductive potential and impact interpersonal relationships and self-image.
32.3 Infertility and Sexual Dysfunction in Men: A Medical Perspective
The male sexual dysfunctions most likely to affect male fertility are those that cause ED and affect sexual desire, arousal (reviewed in Chap. 16 “Hypoactive Sexual Desire in Men”), and ejaculation (reviewed in Chap. 14, “Evaluation and Treatment of Disorders of Ejaculation” and Chap. 15 “Evaluation and Treatment of Orgasmic Disorders”), limiting the ability to effectively inseminate the female partner [23]. In 1999, Laumann et al. reported on sexual dysfunction in a modern young US population, observing ED in 7–9 % of men 18–39 years old [24]. In this population, ED was associated with emotional stress, low physical satisfaction, and low general happiness.
The causes of ED are often multifactorial, comprising a mix of organic and psychogenic factors, although a psychogenic factor is a contributor in almost all cases, particularly in younger men (reviewed in Chap. 6 “Urologic and Clinical Evaluation of the Male with Erectile Dysfunction”) [25]. Importantly, depression and other psychological factors are also linked to ED. The Massachusetts Male Aging Study (MMAS) observed an increased risk of ED (OR 1.82) in men with depressive symptoms [26], and other studies have supported this relationship [27]. When considering psychogenic ED, the link with sexual confidence and performance anxiety should not be overlooked, and numerous studies have reinforced a clear association between ED and sexual confidence [28, 29].
Medications can result in male sexual dysfunction and can negatively impact fertility. Some common medications affecting the male sexual response include thiazide diuretics and beta-blockers (i.e., propranolol) that can decrease blood flow to the penis and cause decreased libido and ED [30]. Decreased sexual desire, ejaculatory difficulties, and ED can also occur with the use of spironolactone, antipsychotics, SSRIs, SNRIs, and tricyclic antidepressants [30].
When considering male factor infertility, 6 % of men who are evaluated for infertility have coexisting significant pathologies, including genetic abnormalities, malignancy, and endocrinopathy, and as a result a diagnosis of infertility is directly linked to general male health [31]. Cancer and its treatment using radiation, surgery, and/or chemotherapy is well known to negatively impact male fertility, either via direct effects on the gonads (chemotherapy, radiation) or on structures required for male sexual function (surgery) [32, 33]. Most commonly in younger men, metastatic testicular cancer requiring retroperitoneal lymph node dissection (RPLND) may disrupt the lumbar sympathetic and hypogastric plexuses causing anejaculation or retrograde ejaculation, as well as ED [34–36]. Retroperitoneal procedures may also cause obstruction of the vas deferens or ejaculatory ducts [37]. Radical prostatectomy and cystoprostatectomy carry with them a risk of ED from neurovascular injury and infertility due to transection of the vas deferens, removal of the seminal vesicles, and injury to lumbar and hypogastric plexuses [37]. Iatrogenic disturbance of the bladder neck with resultant urinary incontinence during transurethral resection of the prostate, and less so following bladder neck incision, can result in retrograde ejaculation in up to 75 % of men who undergo those procedures for benign causes as well [38, 39].
Whether the cause is vascular, neurogenic, hormonal, drug induced, anatomic, or psychogenic, the end result is the same, with decreased sexual desire, an inability to achieve and maintain an adequate erection, or the inability to deliver sperm to the optimal location for fertilization. This sexual dysfunction not only limits the man’s fertility but can also have a profound negative impact on self-esteem, quality of life, psychosocial health, and relationships.
32.4 Infertility and Sexual Dysfunction in Men: Psychosocial Implications
Having a diagnosis of infertility or subfertility is a psychological and relationship stressor and is associated with sexual dysfunction [15, 40]. Some studies suggest that infertile men experience less distress than women using various indices of emotional state [41, 42]. However, over time, male partners of infertile couples report significantly less desire, more stressful marital relationships, and worse sexual function and satisfaction compared to fertile control couples [43, 44]. Having a diagnosis of male factor infertility lasting 3–6 years contributes to decreased relationship stability, sexual activity, and lower sexual satisfaction in both male and female partners from infertile couples, with the decrease in sexual activity increasing as the amount of fruitless years accrue [19, 45]. Men also report less ability to control ejaculation and less satisfaction with their sexual performance in general [5, 46, 47], and men who are the sole contributors to infertility in the relationship have a higher incidence of depression compared with men who were either fertile or shared the problem with their partners [48].
The emotional ramifications of a diagnosis of infertility, no matter the etiology, can further impact procreative potential through alteration of physical function, and a vicious cycle can develop where one condition can potentiate the other. Men in infertile relationships have a higher than expected incidence of ED and depressive symptoms, lower self-esteem, higher anxiety, more somatic symptoms, and more dysfunctional sexual relationships [49]. During infertility, many men develop performance anxiety, sexual avoidance, or even aversion to sex, especially if sex is for “procreation purposes only” and their partner is sexually unresponsive. Regimenting intercourse can decrease libido in 10 % of patients, and ED may occur in up to 20 % of men engaging in timed intercourse [50]. Frequently, infertile men complain of feeling “used” like “stud service” (that all his partner wants from him is his sperm) or of the “queen bee syndrome” (his sole importance is to fertilize his partner) [51, 52]. In a study of infertile men in Germany, a short-lasting partnership and high sexual dissatisfaction prior to the diagnosis of infertility caused more distress in infertile men, whereas being in a longer-lasting and sexually satisfying partnership seemed to have a buffering effect with regard to sexual distress and infertility [53].
32.5 Infertility and Sexual Dysfunction in Women: A Medical Perspective
Although the term “infertility” is generally used to indicate a couple with challenges in conceiving pregnancy naturally, as compared to the general population (20 % per cycle), the more appropriate term should be “subfertility,” suggesting a decreased capacity for conceiving naturally. The National Survey of Family Growth reports 10.9 % (6.7 million) of women 15–44 years of age with impaired fecundity between 2006 and 2010 in the United States. Of these women, 11.9 % (7.4 million) have ever received any fertility services [54]. The incidence of etiologies causing infertility varies between different populations. However, among 14,141 couples in 21 publications, abnormal semen factors contributed to 25 % of infertility cases and female factors 54 %, with ovulatory disorders implicated in 27 % of cases, tubal disorders in 22 %, and endometriosis in 5 % [55].
Ovulatory disorders represent a major cause for subfertility and infertility, and polycystic ovary syndrome (PCOS) is the primary disorder in this category that leads to anovulation or oligoovulation. While PCOS can significantly affect a woman’s health-related quality of life including fertility, body image, self-esteem, and menstrual cycles, it can also negatively affect the sexual desire and arousal that directly contributes to the couple’s sexual health [56]. Medical management and hormonal developments in the recent decades have improved management of PCOS [57].
Tubal abnormalities and obstruction can contribute to 22 % of infertility causes in couples and can be evaluated using hysterosalpingogram and managed accordingly. Uterine causes of female subfertility include intrauterine adhesions and leiomyomas. Intrauterine adhesions can be lysed using hysteroscopic intervention, which can increase the rate and success of pregnancies in this patient population [58]. In general leiomyomas do not interfere with pregnancy unless they are large and result in uterine distortion or are located in the cervical area, distorting the endocervix and interfering with sperm transport.
Endometriosis, the presence and growth of uterine glands and stroma in aberrant locations, can contribute significantly to infertility, pain, and detriments to sexual health. Endometriosis symptoms vary widely from mild to severe. The significant pelvic adhesions and inflammation caused by endometriosis are the main factors leading to challenges in conceiving normally, which can further burden the relationship and sexual health in a couple. In addition, the pain that is present in many patients with endometriosis contributes to sexual pain disorders and can play a significant role in the couple’s sexual dynamic [59]. Montanari and colleagues evaluated 182 women with deep infiltrating endometriosis and showed significantly lower satisfaction scores in Sexual Health Questionnaire (SHOW-Q) that correlated with decrements in quality of life [60]. Other conditions included in the genito-pelvic pain and penetration disorder (formerly known as dyspareunia and vaginismus) that may limit vaginal penetration during intercourse are atrophic vaginitis, vulvodynia, and painful bladder syndrome (interstitial cystitis).
Other gynecological disorders that may be indirectly related to female fertility that may negatively affect sexual function in a female, and thus in the couple, include pelvic organ prolapse, urinary and fecal incontinence, and anal, bladder, colorectal, and gynecological malignancies.
Despite the high prevalence of sexual dysfunction in couples dealing with fertility difficulties, sexual dysfunctions more commonly result from fertility difficulties rather than cause infertility. Sexual dysfunction and infertility have emotional and psychological ramifications within a couple’s relationship, and data suggest that patients with secondary infertility may have higher prevalence of sexual dysfunction [60, 61].
32.6 Infertility and Sexual Dysfunction in Women: Psychosocial Implications
Evaluation and treatment of infertility in the female and couple, beginning with semen analysis and the female evaluation, can result in emotional stress and affect the couple’s sexual relationship. This is exacerbated with timing of intercourse and postcoital testing performed at some centers, interfering with the spontaneity of a couple’s intimacy. However, these stresses appear to manifest more prominently in the female partner, as shown by Oddens et al. while surveying 281 women prior to starting treatment for infertility. The authors showed lower scores for coital frequency, sexual interest, and pleasure in non-mothers when compared to an age and relationship duration matched group of mothers [62]. In contrast, in a study by Müller et al., 68 men surveyed at an andrology clinic before and after fertility treatment revealed no change in their sexual satisfaction [63]. Emotional stress within couples resulting from fertility treatments, particularly in the female partner, was evaluated by Hammarberg et al., who observed that 2–3 years after infertility treatment, 59 % of 116 women reported treatment as having a negative impact on their sexual relationship [64]. In addition, when used in women for ovulatory stimulation, hormonal therapy alone can cause weight gain, breast tenderness, and mood imbalances that can negatively affect a couple’s sexual health.
Sexual dysfunction is high in all infertile women, and women with secondary infertility suffer more from impaired sexual function compared with those with primary infertility [61]. Hurwitz et al. [65] detected increased sexual dysfunction in 50 % of females and reported loss of sexual desire as the leading cause of dysfunction. Oskay et al. [66] found sexual dysfunction in 61.7 % of infertile women and in 42.9 % of fertile women, and Millheiser et al. [67] detected sexual dysfunction in 25 % of fertile and 40 % of infertile women. Both research groups found lower scores of desire and arousal parameters in the infertile group as compared to the fertile group. Women reported severe marital strain, as well as sexual inhibitions, anorgasmia, and reduced interest in sex [68]. Andrews and associates found that infertility-specific stress had a stronger negative impact on women’s sense of sexual identity and self-efficacy than it did on men [69].
32.7 Treatment of Sexual Dysfunction in the Couple
Even couples that never encounter major or disrupting sexual problems often experience episodic or situational diminished sexual desire and satisfaction in response to the emotional distress or physical strains of infertility or a specific treatment. Episodic loss of sexual desire in one or both partners can usually be addressed with minimal education and reassurance. However, consistent and extensive diminished sexual desire in infertile men and women is more problematic and usually multifactorial.
Infertile couples are reluctant to discuss sexual dysfunction if they fear that it will interrupt medical treatment. Even so, no clinician working with infertile couples should assume that a couple is having regular sexual intercourse sufficient for reproduction or ignore the possibility of unusual sexual practices that interfere with conception and/or medical treatment plans [21]. Clinicians treating sexual problems can intervene on several different therapeutic levels and are encouraged to provide patient education to patients and their partners in treatment decisions whenever possible [70].
Overall, the management of sexual dysfunction is best provided by a combination approach, which successfully integrates both physical and psychosocial factors [71]. Combination therapy integrating sex therapy and oftentimes sexual pharmaceuticals is frequently the best treatment approach for sexual dysfunction. Contextual factors, including difficulties with a current interpersonal relationship, should also be clarified and previous sexual scripts should be assessed [72]. In some couples, partners blame themselves or each other for infertility or medical diagnosis, resulting in anger that interferes with sexual desire and functioning. Several questions should be asked, including whether sexual relations were ever good with the current partner, what changed, and what the patient’s view of causation is. Other questions to consider when assessing infertility patients are whether anything changed in their emotional or sexual relationship since they have been trying to conceive and how often they engage in sexually intimate acts and/or have penetrative sex [21]. Numerous partner-related psychosexual issues may also adversely affect outcome. If the sexual problems reflect more fundamental relationship problems, it may be that marital issues must take precedence over further infertility treatment.
32.8 Referral, Consultation, and Collaboration
It is clear that the stress, psychological demands, and physically intrusive procedures associated with infertility treatment can affect sexual self-image, desire, and performance. Whether sexual dysfunction is a preexisting condition or an unwelcome side effect of infertility treatment, it can be a devastating and discouraging blow, compounding the disappointment of childlessness and the distress of medical treatment. All too often, the sexual problems of infertile couples are ignored or minimized in a belief that they will dissipate on their own or will have few long-term consequences. Unfortunately, although some sexual problems may disappear when the pressures of infertility treatment end, sexual difficulties typically linger or become more problematic after treatment ends or parenthood is achieved [10, 73]. Depending on the comfort level, preference, resources, and availability, the physician may choose to treat the couple or refer them to a sex therapist and/or infertility counselor [21, 74].
32.9 Conclusions
Infertility in the man, woman, and couple can result in significant distress and sexual dysfunction. In both men and women, infertility can result in sexual dysfunction, and vice versa, as a function of frequently coexisting organic and psychological factors. Importantly, the interplay between the organic and psychosocial factors leading to infertility-related sexual dysfunction cannot be overlooked, and appropriate treatment should be targeted to both individual and the couple to address the organic and psychosocial issues.
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