Published 07 May 2019
Sexual disorders may be a cause and consequence of infertility, but evidence of their impact remains sketchy, and strategies to deal with them hindered by inconsistency and misinformation.
The message from this SIGs Ethics & Law, Psychology & Counselling, and Nurses & Midwives Campus in April was that clinicians increase their efforts to ask infertile patients about their sex lives and to educate them about sexuality. Many in fertility care are unsure how to initiate these conversations or avoid them, which highlights the need for updated guidelines on how best to help couples get pregnant, along with higher quality data on the benefit of intervention programmes.
Sexual disorders such as psychogenic conditions, erectile dysfunction (ED), or low libido can be both the cause and consequence of a couple's unfulfilled wish to have a baby. Evidence presented by Tewes Wischmann from Heidelberg University Medical School in Germany shows an overall prevalence of sexual dysfunction (SD) of 43% in women and 31% in men in the general population, yet rates 'vary immensely' depending on the instruments used to assess.
Behaviours actually causing infertility are relatively unusual and include a lack of sexual intercourse, reportedly evident in 7% of women and 1% of men.(1) In contrast, SD as a consequence of an infertility diagnosis is common and triggered by the 'emotional rollercoaster' of trying to conceive. Wischmann's research has found that on average half of such respondents (overwhelmingly women) reported a change in their sex lives, and two-thirds a deterioration following the diagnosis.(2)
Findings from research
Data also vary on the impact of ART on sexuality. Studies report the prevalence of SD during ART to be between 11 and 87% in women, and 7 and 75% in men. The ESHRE guideline on psychosocial care in infertility states that patients during their fertility work-up do not present a higher prevalence of SD than the general population. Yet the link between ART and SD is evidenced by research showing that men fail to produce a sperm sample in every 16th ART cycle, and premature ejaculation is up to three times more common in infertile men than in the general population. However, the sex life of couples faced with involuntary childlessness seems to be unaffected in the long-term by their fertility problem.
The implications for future research, says Wischmann, include the need to take into account the instruments used and the populations studied, as well as sexual diversity (only heterosexual couples have been studied to date). Culture, religion and societal norms must also be considered, such as anxieties around masturbation and semen collection for Jewish or Muslim men.
Similarly, new guidelines on when couples should be having sex in order to conceive are also necessary to improve fertility practice, according to Mariana Martins from the University of Porto in Portugal. The UK's National Institute for Health and Care Excellence (NICE) supports a 'sex every other day' approach, on the grounds that it is less stressful for couples than determining the woman's ovulation window. However, Martins proposed that insufficient evidence exists to conclude that this is the right strategy for those without a diagnosis who have been having unprotected sex for 12 months. A 2015 Cochrane review concluded that the overall quality of evidence on timed versus spontaneous intercourse ranged from 'low to very low' for all outcomes. 'Most patients aren't even with each other every other day,' she added.
Advising patients is a dilemma for clinics, many of whom end up recommending and adopting different approaches in different countries - such as ovulation prediction, basal body temperature charts, or self-insemination in cases where penetrative sex is not possible.
Research is under way into how information around fertility and conception can empower patients. Exploratory data have been collected by Martins to determine how couples perceive the use of different strategies, such as cervical mucus monitoring, leg elevation, and timed sex (every other day). Based on responses from 399 women and men, the findings show that women who've had previous ART or IUI are more likely to have sex every other day. Most have heard of the fertile week but again it's women who've had ART who are most likely to use this strategy, whereas men may have used it but then stopped.
In general, the results suggest that patients are misinformed and are being educated too late about sexuality. For example, more than half who'd previously had fertility treatment were keeping their legs elevated after sex, despite there being no evidence that this increases the chance of pregnancy. Clinics assume patients have some knowledge of fecundity and fertility, but Martins emphasised that they don't - and nurses often don't ask them such basics as if they're even having sex.
The recurrent theme during this meeting was thus the 'chicken and egg' relationship between infertility and sexual dysfunction. Which comes first is not fully understood, nor which to treat first. What's obvious though is that without intercourse couples have no chance of getting pregnant, yet many need education about when and how. And clinicians have a duty to their patients to start a dialogue about the physical and psychological obstacles to intercourse they may be facing.
1. Schilling K, Toth B, Rösner S, et al. Prevalence of behaviour-related fertility disorders in a clinical sample: results of a pilot study. Arch Gynecol Obstet 2012; 286: 1307-14.
2. Wischmann T, Schilling K, Toth B, et al. Sexuality, Self-Esteem and Partnership Quality in Infertile Women and Men. Geburtshilfe Frauenheilkd 2014; 74: 759-763.