FEMALE SEXUAL DYSFUNCTION IN SUBFERTILITY PATIENTS VERSUS THOSE SEEKING FERTILITY CONTROL

Background: Female sexual dysfunction (FSD) and subfertility are common problems affecting approximately 43 and 20% of women respectively. Studies on association of female sexual dysfunction and infertility is not much .the presented study compare the prevalence of female sexual dysfunction in patients on assessment for sub-fertility and those either seeking or already on fertility control services at a private sonolive clinic in Benha. Methods:This was an analytical cross sectional study. Eligible women of reproductive age (20â€“43â€‰years), attending the private sonolive infertility clinic in Benha Egypt in the period from January 2019 to July 2020 with complaints of subfertility and those seeking fertility control services (as controls)were requested to fill a general demographic tool containing personal data and the Female Sexual Function Index (FSFI) questionnaire after informed consent. Sexual dysfunction was calculated as a percentage of patients not achieving an overall FSFI score of 26.55. Results:The prevalence of female sexual dysfunction was 45% in the subfertile group and 35% in fertility control group. The difference was statistically significant (p =â€‰0.006).the important affected items were desire and lubrication also infrequent coitus in the fertility window Conclusion:The present study demonstrated a significant association between the fertility status and the prevalence female sexual dysfunction. Subfertility type was associated with sexual dysfunction especially the desire and lubrication which affect the whole score of sexual dysfunction.


ISSN: 2320-5407
Int. J. Adv. Res. 9(01), 911-919 912 Sexualityin females is intermingled with preliminaries to be good; preliminaries include mental containment, emotional containment, and financial containment and lastly the physical containment in man sexuality is mostly physical.
Female Sexual Dysfunction (FSD) is defined as a disorder of sexual desire, arousal, orgasm, and sexual pain that results in significant personal distress. (4-6) Medical conditions, including cancer, kidney failure, multiple sclerosis, heart disease and bladder problems, can lead to sexual dysfunction.
Medications, including some antidepressants, blood pressure medications, antihistamines and chemotherapy drugs, can decrease your sexual desire.
Postmenopausal low hormonal status may lead to changes in lower genital tissues and sexual responsiveness. Low estrogen leads to decreased blood flow to the pelvic region, which can result in less genital sensation, more time to build arousal and reach orgasm.
The vaginal lining also becomes thinner and less elastic, particularly if you're not sexually active. These factors can lead to painful intercourse (dyspareunia). Sexual desire also decreases when hormonal levels decrease.
Untreated anxiety or depression can cause or contribute to sexual dysfunction, as can long-term stress and a history of sexual abuse. The worries of pregnancy and demands of being a new mother may have similar effects.
Long-standing conflicts with partner about sex or other aspects of relationship can diminish sexual responsiveness as well. Cultural and religious issues and problems with body image also can contribute.
Subfertility isa significant life stressor and might negatively impact on sexual function.
Thesubfertile couple is more prone to depression, anxiety and stress, the increased stress levels would adversely affect the marital satisfaction and adversely affect their sexual health. (7) Sexual dysfunction might result in decreased coital frequency compounding the issue of subfertility due to reduced exposure. On the other hand, the psychological pressure to get pregnant stemming from sex on demand could result in a reduction in enjoyment of sex aggravating sexual dysfunction.
Situational sexual dysfunction and loss of a couple's intimacy may occur as a consequence of timed intercourse where focus for coitus is no longer pleasure but conception Therefore, the relationship between subfertility and sexual function might be bidirectional and need to be addressed for adequate management of either problem. Early diagnosis and treatment of sexual dysfunction among this group of patients might improve outcomes of subfertility treatment. (8,9) Methodology:-Objective:-To compare the prevalence of sexual dysfunction, as measured by the FSFI-Q, between subfertile cases and those either seeking or on various contraceptive methods

Study design
This was case controlled study.

Study setting and participants
The study was conducted at the sonolive clinic a private clinic in Benha Egypt. Both new and old patients on various stages of fertility assessment or treatment and those presenting for or already on a contraceptive method were approached and assessed for eligibility.

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Sub-fertile patient was defined as one with inability to conceive after at least 12 months of regular unprotected coitus, participants given a written consent and asked to sign for approval of the questionnaires Inclusion criteria was Women 18-43 years of age attending the gynaecology outpatient sonoliveclinic in Benha city Egypt with subfertility and those either seeking or already on a contraceptive method who were sexually active in the preceding 4 weeks.

Exclusion criteria was
Local gynecological and obstetric conditions like pregnancy,puerperium;,gynecologic conditions like malignancies, fistula, urinary and fecal incontinence, chronic pelvic pain, genital prolapse and lower genital tract abnormality.
General systemic diseases that adversely affect sexual function like Diabetes, hypertension, endocrine disorders and psychiatric illnesses and those who previously had pelvic floor surgery were excluded due to the probable effect on sexual function.

Study procedures and tools
Patients attending the gynecology clinic with subfertility and those presenting for or already on contraception were approached by the principal investigator.
Eligible participants were then requested to fill the two data inquiries, the FSFI-Q and the demographic inquiry, after an explanation and giving informed consent.
Epidemiological inquiry about age, parity and weight frequency of coitus, Some of these included the partner's age, educational level, marital status, contraceptive use,substance abuse, history of sexual abuse and also domestic violence.
Sexual function was measured using the domains in the FSFI-Q with those with overall scores below 26.55 being considered to have impaired sexual functioning. None of the approached participants declined taking part in the study.

Sample size
Hundred cases seeking fertility service enrolled in the study from the sonolive clinic a private gynecology clinic in Benha city Egypt and one hundred controls from those attending the clinic searching for fertility control

Data management and analysis
Data values were expressed as mean ± SD, count (%) and odds ratio. P < 0.05 was considered statistically significant. Data analysis was performed using smith statistical package.

Ethical considerations
Patient confidentiality and privacy was maintained during the entire study period with use of number identifiers alongside safe and restricted data storage.and a written consent given to be signed for approval.

The female sexual function index questionnaire (FSFI-Q)
The FSFI-Q is a multidimensional self-report tool for assessing key dimensions of female sexual functioning over the preceding 4 weeks. This standardized questionnaire described by Rosen and colleagues (10, 11)consists of 19items that assess six domains of female sexual functioning. The domains include: sexual desire (items 1 and 2), arousal (items 3-6), lubrication (items 7-10), orgasm (items 11-13), satisfaction (items 14-16) and sexual pain (items [17][18][19]. Each of the items has a Likert scale score ranging from 0 to 5 and each of the 6 domains' scores are calculated by adding the scores of the individual items that comprise the domain and multiplying by a respective domain factor which homogenizes each dimension's influence.
The full scale or total FSFI score ranges from 2 to 36 and is the sum of all the scores in the six domains]. scores more than 26.55 considered satisfactory and those below this figure considered having sexual dysfunction

Results:-
A total of 200 women were recruited by convenience sampling over the study duration (january2019 to July 2020). Of these, 100 had presented with subfertility and were at various stages of fertility assessment while the other 100 had presented for fertility control.
No significant difference regarding the epidemiological data in the cases and in the control group.
The subfertile and fertility control subjects did not differ significantly in terms of body mass index (BMI), previous miscarriage, education level. The most siginificant result in this table is that about 66 patients from the subfertile group had sex out of the fertility window time . Female sexual dysfunction prevalence as per female sexual function index (FSD) was 45% among the study subjects and 35 % in the control fertility control group using a cutoff score of 26.55 on the FSFI-Q, the prevalence of female sexual dysfunction scores. The most affected domains in both the subfertility and fertility control groups were desireandlubrication.
The proportion of those with sexual dysfunction in all the domains and total FSF score was higher in the subfertility group than the fertility control group though none was statistically significant .
The prevalence of FSD in the primary and secondary subfertile women was 45 (n = 45) and 35 (n = 35) respectively which was significantlysignificant (p = 0.004).

Discussion:-
Sexual dysfunction is a common problem which can negatively affect a woman's quality of life and interpersonal relationships.
This study demonstrated that 45% of the study participants had sexual dysfunction in the cases group with subfertility and seeking fertility and pregnancy while the prevalence in the control group on contraceptives or seeking contraception was 35%with statistical significant difference [p value 0.006 Among the sexual dysfunction the most dominant in the study was having sexual intercourse out of the fertility window.
Also the total score affected and the most important two factors were lubrication and desire ;These findings are comparable to other studies showing a sexual dysfunction prevalence of 26-28% among reproductive age women [12,13].
Our study population included only reproductive age women and had higher education attainment (90.3% had college level education).
Advancing age and multiparty especially above 3 children associated with greater sexual dysfunction (14,15).
On the other hand, higher education has been shown in other studies to be protective of sexual dysfunction (16). For instance, Safarinejad (2006) showed a prevalence rate of sexual dysfunction among Iranian women of 31.5%.
The study participants however included menopausal women (range 20-60 years) with only 38.8% having above high school education.

In Egypt, Ibrahim et al. (2013)
found a 52.8% prevalence of sexual dysfunction. However, majority (51.3%) were post-menopausal and 71% had undergone female genital mutilation (FGM) hence the higher prevalence as advanced age adversely affects sexual function and possibly female FGM especially if type II or III. (17) The primary aim of our study was to compare the prevalence of sexual dysfunction between patients on follow up for subfertility and those seeking fertility control services, sexual dysfunction is a modifiable factor for female infertility by adjusting intercourse frequency in the fertility window; and by knowing the sexual behavior in subfertile cases we can modify the act so this may help in increasing the fecundity rate.
We found a prevalence of sexual dysfunction of 45% in the subfertility and 35% in fertility control groups respectively.
Significant difference in the prevalence of sexual dysfunction between Thesubfertilegroup had lower mean total FSFI and domain scores though only the satisfaction score was statistically significant from the fertility control group.
The decreased satisfaction is possibly due to low self-esteem and poor body-image as a result of or as a cause of the subfertility and also the marital relationship especially with abusive husbands 918 The psycho-social pressures to conceive stemming from "sex-on-demand" might result in loss of couple intimacy and this was an important factor for those with low score ;cases felt like they are more like machines more like a mechanism (14).
Studies on the association between subfertility and female sexual dysfunction have reported conflicting results.  The case group on contraception. The study showed a significant impairment in sexual function in the case group though only 26.8% were on hormonal contraception pills (22) Sexual dysfunction in the present study showed a significant association with subfertility which can be modified by psychological adjustment by enhancing marital relationship also by frequent coitus in the fertility window

Conclusions And Recommendations:-
In conclusion, the present study demonstrated a significant association between the fertility status and the prevalence female sexual dysfunction. And there was a significant association between sexual dysfunction and subfertility it may be the cause and /or the result adjusting the modifiable factors in sexual intimacy may be then enhance fecundity rate in subfertile cases