Infertility is defined by the World Health Organization as a medical condition of the reproductive system characterized by the couples’ failure to establish a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse (Zegers-Hochschild et al., 2017). However, immediate attention must be given if any risk factor for infertility is present, such as advanced female age (Sharlip et al., 2002). For this reason, health professionals recommend evaluation and treatment after 6 months of unprotected regular intercourse without conception in women with ages equal or over 35 years old (Johnson et al., 2012; Practice Committee of the American Society for Reproductive Medicine, 2008).
The inability to have a child affects 9% of couples across the globe (Bovin, Bunting, Collins, & Nygren, 2007), but the reported number of infertile couples seems to be increasing. In 1990, an estimated 42.0 million couples worldwide experienced infertility, while in 2010 the values rose to 48.5 million (Mascarenhas, Flaxman, Boerma, Vanderpoel, & Stevens, 2012). The prevalence of infertility in reproductive-aged women varies widely. In developed countries, infertility rates were estimated at 9%, while in developing countries they varied between 5 and 15% (Bovin et al., 2007). In some regions of the world, including Central and South Asia, some countries of sub-Saharan Africa, Middle East and North Africa, Central and Eastern Europe, infertility rates may be 30% of the couples (Mascarenhas et al., 2012). In Portugal, an epidemiology study indicated that approximately 10% of couples face difficulties to conceive (Silva-Carvalho & Santos, 2009). Due to the different methodologies, including different definitions for infertility, the studies estimating the prevalence of infertility show inconsistent results. However, research has consistently shown that secondary infertility, that is, when there is previous history of successful pregnancy, is more common than primary infertility (Mascarenhas et al., 2012).
Infertility has a considerable impact on an individual’s quality of life, in conjunction with sex life, couples’ relationship, relationship with family and friends, financial stability and others. Many people characterized infertility as a life crisis and it is associated with anxiety, guilt, feelings of inadequacy, diminished self-esteem, and depression (Rooney & Domar, 2012).
Additionally, an infertility diagnosis can be a stressful event which, in response, may cause sexual problems (Saleh et al., 2003). The pressure of needing to have sex at specified times can undermine the spontaneity of sex, which becomes “mechanic” and diminishes intimacy, which in turn may have a disruptive influence on sexual functioning (Czyżkowska, Awruk, & Janowski, 2016; Wischmann, 2010). The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5, American Psychiatric Association, 2014) uses a broadly classificatory scheme of sexual dysfunction based on the normal human sexual response cycle. Because all aspects are connected, disorders can occur at one or more of the four phases of the cycle: desire, arousal, orgasm and resolution (Kaplan, 1979), and they can arise from physical conditions and psychological factors (Baldwin, 2001). The studies have been contradictory in what concerns sexual functioning in infertile individuals. Millheiser and colleagues (2010), for example, have shown a decline in sexual satisfaction in infertile women, when values pre-diagnosis were similar to those of the control group. This finding is in accordance with Czyżkowska and collaborators (2016), who compared sexual and dyadic functioning using as criteria a confirmed infertility diagnosis, done by a gynecologist. Results revealed an elevated risk of sexual dysfunctions, lower levels of sexual satisfaction (physical satisfaction, emotional satisfaction, and satisfaction with control) and less sexual reactivity in infertile women, as compared to fertile ones. Contrarily, a group of infertile women and men did not experience a decrease in their sexual satisfaction after the announcement of their infertility condition or when they start fertility care (Ohl et al., 2009). Actually, only a small number of studies have investigated the impact of an infertility diagnosis on sexual functioning (Braverrman, 2004). A brief synopsis of some previous investigations into infertility and sexual functioning is summarized in Appendix.
Literature suggests that the differences between infertile and non-infertile subjects in sexual functioning may be also attributed to the psychological maladjustment resulting from infertility, like depression and anxiety (Marci et al., 2012). Anxiety, as a feeling of apprehension and fear characterized by physical, psychological and cognitive symptoms, plays an important role in the developing and maintenance of sexual problems (Corretti & Baldi, 2007). The same was observed in infertile population (Pakpour et al., 2012; Saleh et al., 2003). In contrast, the constellation of symptoms associated with depression as loss of interest, reduction energy, lowered self-esteem and inability to experience pleasure may impair intimate relationships, producing sexual problems (Baldwin, 2001). In a multicenter study with 604 infertile Iranian women, depression was found to be a strong predictor of sexual problems (Pakpour, Yekaninejad, Zeidi, & Burri, 2012). Other authors have shown similar results (Kucur Suna et al., 2016; Shaharaki, Tanha, & Ghajarzadeh, 2018).
Most of the research focuses on the effects women experience with infertility and do not include men, but infertility does affect both partners. When people are under stress, there is a tendency to take it out on the ones they love, specifically their partner (Rooney & Domar, 2012). Studies rarely take on a couple perspective in order to explore sexuality issues in infertility. Moreover, the sexuality of infertile subjects might be influenced by their partner’s reaction to the diagnosis (Tao, Coates, & Maycock, 2011). It has been shown that female sexual function is correlated positively with male partner sexual function (Nelson, Shindel, Naughton, Ohebshalom, & Mulhall, 2008). Approximately 20% of male partners in infertile couples have mild to moderate erectile dysfunction as well as a decline in sexual satisfaction after an infertility diagnosis or in the setting of female sexual dysfunction (Shindel, Nelson, Naughton, Ohebshalom, & Mulhall, 2008). A study by Chevret, Jaudinot, Sullivan, Marrel, and Gendre (2004) also demonstrated the impact of male sexual function in female sexual satisfaction, indicating that female partners to men with erectile dysfunction reported significantly decreased sexual drive and sexual satisfaction when compared with those women whose partners did not have erectile dysfunction. Collier (2010) put forward the idea that the quality of the sexual function for one partner is always the main factor in determining the sexual function of the other, which either member of the couple may react with depression. Peterson, Sejbaek, Pirritano, and Schmidt (2013) have shown that severe depressive symptoms were significantly associated with increased infertility-related personal, marital and social distress in both members of the couple.
The present study intends to contribute to a better understanding of the complex influence of infertility diagnosis in the association between psychological symptoms and sexual functioning taking a dyadic approach. More specifically, this study’s aim is to explore whether female and male depression and anxiety symptoms are related to either partner’s sexual functioning by using a sample of couples trying to conceive with or without an infertility diagnosis and how relational outcomes vary when moderated by having knowledge of the diagnosis. Additionally, this study pretends to detect and assess to what extent couples’ sexuality is affected by infertility diagnosis.