Sexual dysfunction and infertility: a comparative study in a female population

(1)

(2)

INTITUTO DE CIÊNCIAS BIOMÉDICAS ABEL SALAZAR UNIVERSIDADE DO PORTO

MESTRADO INTEGRADO EM MEDICINA

Sexual Dysfunction and Infertility: a comparative study in a female

population

Maria Luísa Russo Lopes dos Santos

Endereço de correio eletrónico: lopesdossantos.luisa@gmail.com

Orientadora

Drª Cláudia Margarida Nascimento Marques Grau académico: Licenciatura

Professora Auxiliar Convidada do Instituto de Ciências Biomédicas Abel Salazar

Assistente Hospitalar Graduada no Centro Materno Infantil do Norte do Centro Hospitalar Universitário do Porto

Co-Orientador

Professor Doutor Luís Guedes-Martins Grau Académico: Doutoramento

Professor Auxiliar Convidado do Instituto de Ciências Biomédicas Abel Salazar

Assistente Hospitalar no Centro Materno Infantil do Norte do Centro Hospitalar Universitário do Porto

Afiliação

(3)

(4)

i

Agradecimentos

À Drª Cláudia Marques pela disponibilidade, incentivo e por todos os conhecimentos que me transmitiu ao longo da realização desta investigação.

Ao Professor Doutor Luís Guedes-Martins pela amabilidade e disponibilidade como co-orientador.

Ao Centro de Procriação Medicamente Assistida e à Drª Alexandrina Mendes pela dedicação na entrega dos inquéritos possibilitando a realização deste trabalho.

Ao Drº Rui Magalhães por toda a paciência na realização do tratamento estatístico dos dados. À minha familia pelo apoio durante esta longa etapa e aos meus amigos pelo companheirismo e fonte de motivação constante. Por todo o amor sem o qual este percurso não teria sido possível.

Por último, a Cabo-Verde e Benguela, onde encontrei casa longe de casa, por me ensinarem que o essencial é verdadeiramente invisível aos olhos.

“No final até podes ter uma lista de coisas que podiam ter corrido melhor, mas que nessa lista não venha que podias ter amado mais”

(5)

ii

Index

Abstract ... iii Resumo ...iv Abreviations ... v Introduction ... 1

Methods And Materials ... 2

Sample and procedure ... 2

Instruments ... 3

Socio-demographic Questionnaire ... 3

Female Sexual Function Index FSFI ... 3

Statistical Analysis ... 4

Results ... 4

Discussion and Conclusion ... 5

References ... 9

Tables ... 11

TABLE 1- DEMOGRAPHIC CHARACTERISTICS ... 11

TABLE 2- COMPARATION OF TOTAL FSFI AND DOMAIN SCORES IN CASE AND CONTROL GROUP ... 12

TABLE 3- UNIVARIATE ANALYSIS OF POSSIBLE RISK FACTORS FOR SEXUAL DYSFUNCTION ... 13

Attachment ... 14

Female Sexual Function Index ... 14

(6)

iii

Abstract

Introduction: The causes of female sexual dysfunction are not yet fully clarified and there are still some associated risk factors, that despite having been pointed out as such, are not widely accepted, infertility being one of them. For many couples, given the diagnosis of infertility, sexual relationship gains a new dimension and procreation becomes its main goal, enhancing psychological stress situations that may cause sexual dysfunction. On the other hand, the fact that the couple has a common goal, procreation, can increase their emotional bond, which can lead to a more pleasurable sexual intercourse. The aim of this study is to relate infertility with female sexual dysfunction.

Methods: This is a case-control study carried out in the Maternal-Infant Center of the North of the Porto University Hospital Center through the completion of the Female Sexual Function Index and a socio-demographic questionnaire. A convenience sample of women who resorted to the Medical Assisted Procreation consultation- cases, and the female population who uses the Family Planning consultation- controls was used. A descriptive analysis of the populations was performed, a t-test was used to compare scores and to evaluate the predictors of sexual dysfunction a univariate analysis was done. P was considered significant when < 0.05.

Results: A sample of 66 infertile women and 111 non-infertile women was obtained. The infertile women are older (34.2 ± 4.4 vs. 32.6 ± 5.2) and have a higher proportion of 0 children comparing with non-infertile women (83.0% vs. 47.6%, p < 0.001). Infertile women obtained higher results in the domains of satisfaction (5.7 ± 0.60 vs. 5.3 ± 0.96, p = 0.010), pain (5.4 ± 1.07 vs. 4.9 ± 1.38, p = 0044) and total (30.9 ± 3.71 vs. 29.1 ± 5.10, p = 0.019) in the Female Sexual Function Index questionnaire. We identified 5 women with sexual dysfunction in the group of infertile women and 24 women in the group of non-infertile women (9.4% vs 27.9% P = 0.009). Non-infertile women have a 3.72 times greater probability of having sexual dysfunction than the infertile women (P = 0.013). No statistically significant differences were found in the univariate analysis.

Conclusions: Women with infertility have significantly higher total scores in the Female Sexual Function Index and in the satisfaction and pain domain scores having greater satisfaction in their sexual life when compared with non-infertile women

(7)

iv

Resumo

Introdução: As causas da disfunção sexual feminina não estão totalmente esclarecidas havendo ainda alguns fatores de risco, que apesar de terem sido identificados como tal, não são amplamente aceites, como é o caso da infertilidade. Dado o seu diagnóstico, para muitos casais, a relação sexual ganha uma nova dimensão e a procriação transforma-se no objetivo principal, provocando situações de stress psicológico que podem despoltar disfunção sexual. Por outro lado, o facto de o casal ter como objetivo comum a gravidez, pode fortalecer a sua ligação emocional, o que pode resultar numa relação sexual mais satisfatória. Com este estudo, tem-se como objetivo relacionar a infertilidade com a disfunção sexual feminina.

Métodos: Trata-se de um estudo de caso-controlo realizado no Centro Materno-Infantil do Norte através do preenchimento do Female Sexual Function Index e de um questionário sociodemográfico, numa amostra de conveniência de mulheres que recorreram à consulta do centro de Procriação Medicamente Assistida, casos, e a população feminina que recorreu à consulta de Planeamento Familiar, controlos. Realizou-se uma análise descritiva das populações, usou-se o t-test para comparação de scores e a análise univarida para avaliar os preditores de disfunção sexual. Considerou-se p significativo quando < 0,05.

Resultados: Obteve-se uma amostra de 66 mulheres inférteis e 111 mulheres não-inférteis. As mulheres inférteis são mais velhas (34.2 ± 4.4 vs. 32.6 ± 5.2) e têm uma maior proporção de 0 filhos, comparando com as mulheres não-inférteis (83.0% vs. 47.6%, p <0.001). As mulheres inférteis obtiveram resultados mais altos nos domínios de satisfação (5.7 ± 0.60 vs. 5.3 ± 0.96, p = 0.010), dor (5.4 ± 1.07 vs. 4.9 ± 1.38, p = 0.044) e no total (30.9 ± 3.71 vs. 29.1 ± 5.10, p = 0.019) no questionário FSFI. Identificaram-se 5 mulheres com disfunção sexual no grupo de mulheres inférteis e 24 mulheres no grupo de mulheres não-inférteis (9.4% vs. 27.9% P=0.009). As mulheres não inférteis têm uma probabilidade 3.72 vezes maior de ter disfunção sexual que o grupo de mulheres inférteis (p=0.013). Não foram encontradas diferenças estatisticamente significativas na análise univariada.

Conclusão: As mulheres com infertilidade têm resultados significativamente maiores tanto no total do Female Sexual Function Index como no domínio da dor e satisfação tendo mais satisfação na sua vida sexual quando comparadas com as mulheres não-inférteis.

Palavras-chave: Disfunção Sexual Feminina, Female Sexual Function Index, Infertilidade Feminina

.

(8)

v

Abbreviations

BMI - Body Mass Index

CHUP - Porto University Hospital Center CMIN - Maternal-Infant Center of the North

CMIN-CHUP - Maternal-Infant Center of the North of the Porto University Hospital Center DSM V - Diagnostic and Statistical Manual Of Mental Disorders Fifth Edition

FP - Family Planning

FSFI - Female Sexual Function Index

ICS- 10 - International Classification of Diseases-10 MAP - Medical Assisted Procreation

(9)

1

Introduction

Sexual dysfunction, according to the Diagnostic and Statistical Manual Of Mental Disorders Fifth Edition (DSM V), is defined as a heterogeneous group of disorders that are typically characterized by a clinically significant disturbance in a person's ability to respond sexually or to experience sexual pleasure. The sexual response involves a complex interaction among biological, sociocultural, and psychological factors [1]. The World Health Organization International Classification of Diseases-10 (ICS-10), defines sexual dysfunctions as a syndrome that comprise the various ways in which adult people may have difficulty experiencing personally satisfying, non-coercive sexual activities. The ICS-10 adds that the sexual response is a complex interaction of psychological and somatic processes, any of them being able to affect any stage of the sexual response [2].

Although there is very little information about the epidemiological data related to female sexual dysfunction, some studies refer a prevalence of about 75% in Portugal [3, 4]. Moreover between 40% a 45% of the adult female population has had at least one manifestation of sexual dysfunction worldwide [5]. In fact, female sexual dysfunction is a frequent health problem but its diagnosis can be subjective. In order to make the diagnosis more accurate, several questionnaires have been created [6, 7]. The questionnaire Female Sexual Function Index (FSFI) was developed by Rosen Et al.[6], having already been translated and validated for the Portuguese population [8]. This questionnaire has been successfully used in several studies that correlate sexual dysfunction with condition like menopause and diseases like uterine fibroids, pelvic organ prolapse, incontinence, breast cancer, type 1 diabetes and hypertension [9-14]. In this questionnaire, the female sexual function is evaluated in six domains: Desire, Arousal, Lubrication, Orgasm, Satisfaction and Pain. These domains derive from the correlation between the different phases of the female sexual function and the four major categories of female dysfunction: desire disorders, arousal disorder, orgasmic disorder and sexual pain disorders. Satisfaction and Lubrification, being considered one of the important dimensions of sexual function, were also included [6].

The causes of female sexual dysfunction are not yet fully clarified. So far, several biological, psychological and social factors have been identified. However, there are still some risk factors, that despite having been pointed out as such, are not widely accepted, infertility being one of them [15]. Infertility is defined as the inability of a person to become pregnant after a year of unprotected and regular sexual intercourse [16]. Worldwide, it affects about 9% of couples [17] and in Portugal, 1 out of 10 couples are considered infertile [18]. Given the diagnosis of infertility, for many of these

(10)

2 couples, the sexual relationship gains a new dimension and procreation becomes its main goal [19], enhancing psychological stress situations [20] that may cause sexual dysfunction [21]. In fact, there seems to exist a change in the sexual habits of couples after the diagnosis of infertility, especially in the frequency and quality of sexual intercourse [22]. But, on the other hand, the fact that the couple has a common goal, becoming pregnancy, can increase their emotional bond, which can translate into a more pleasurable sexual intercourse [23].

There are already some studies that try to correlate infertility with sexual dysfunction. However, the results are scarce and somehow conflicting, since some of them show a higher prevalence of sexual dysfunction among women who are infertile [24-26] and some show no correlation between these two conditions [19, 27].

Moreover, studies done with validated questionnaires among the Portuguese population correlating sexual dysfunction with infertility were not found. As so, the aim of this study is to relate infertility with female sexual dysfunction. To do so, the correlation between the levels of sexual dysfunction among and an infertile women population and the levels of sexual dysfunction among a non-infertile women population will be evaluated.

Methods And Materials

Sample and procedure

The research protocol was analyzed and approved by the Ethics Committee for Health, the research Coordinator's Office, the Headmaster of Teaching, Training and Research Department of the Porto University Hospital Center (CHUP) and the Chairman of the Board of Administration- 2018.168(144DEFI/146-CES) .

This case-control study was conducted at the Maternal-Infant Center of the North of the Porto University Hospital Center (CMIN-CHUP) in the Obstetrics and Gynecology services.

A convenience sample of the women who resorted to the medical consultations of Medical Assisted Procreation (MAP) and Family Planning (FP) was used as the sample of this study. Their participation was completely voluntary, confidential and anonymous. The case group consisted of 66 women who resorted to MPA because of an infertility diagnosis (infertile group). On the other hand, the control group consists of 111 women who have resorted to the FP consultation (non-infertile group). The inclusion criteria for the non-infertile group was, maintaing a heterosexual relationship for at least one year and the exclusion criteria were pregnancy and previous diagnosis of cancer, infertility or sexual dysfunction.

(11)

3

For both groups, the exclusion criteria were: women younger than 18 years old and older than 40 years old or with the age missing from the socio-demographic questionnaire (which excluded 15 women from the non-infertile group), the poor completion of the questionnaire (which excluded 3 women from the infertile group and 1 from non-infertile group) and diseases, that caused chronic pain, reduction of mobility, psychiatric diseases and endocrine diseases (which excluded 10 women from the infertile group and 9 women from the non-infertile group). Thus, women with type 1 diabetes, endometriosis, Hashimoto's thyroiditis, psoriatic arthritis, hypothyroidism, dysmorphic syndrome, multiple sclerosis, depression, lupus erythematosus, rheumatoid arthritis, agoraphobia, bipolarity, and hernia were excluded, since these diseases seem to influence female sexual dysfunction, thus excluding possible bias [28-31].

Thus, the final sample consists of a total of 53 women in the infertile group and 86 in the non-infertile group.

All data were collected between October 2018 and March of 2019. At the end of the medical appointments, after a brief exposition of the study and its main goals, being highlighted the voluntary, confidential and anonymous character of their participation, an informative leaflet, a socio-demographic questionnaire and the FSFI were delivered to the women.

Instruments

Female Sexual Function Index FSFI

The FSFI (attachment A) is a questionnaire developed by Rosen et al. which has already been translated and validated for the Portuguese population by P. Pechorro et el. Through 19 questions, this questionnaire evaluates the female sexual function through the six domains. Each domain has a score that varies from 0, which indicates the absence of sexual activity in the last month, to 6, where the higher the value, the better the sexual function. The total score is obtained by the sum of the domains varying between 0 and 36. Female Sexual Dysfunction is considered when the score is equal or lower than 26,55.

Socio-demographic Questionnaire

The sociodemographic questionnaire (attachment B) was used to collect information about age, length of marital relationship, weight, height, number of children, education and whether the participants suffer from any disease, which should be specified in the case of a positive response. In the case population, information on the duration of infertility was also collected as well as the type of treatment performed so far (ovulation induction, artificial insemination, fertilization in vitro,

(12)

4 intracytoplasmatic microinjection or other). The aim was to standardize the populations and understand which of the sociodemographic variables evaluated had more influence on the sexual function of both the infertile and the non-infertile female population.

Statistical Analysis

The SPSS statistical software package summer 19.0 was used for the statistical analysis. The descriptive analysis of the two populations was performed through mean and standard deviation tables for the continuous variables and frequency and percentage tables for the categorical variables. To compare the domain scores and the total FSFI score of both groups, the t-test, was used. A univariate logistic regression analysis was performed to evaluate the predictors of sexual dysfunction in each of the groups. Differences between indices were considered statistically significant when p<0.05.

Results

The demographic characteristics of both study groups are shown in Table 1.

Although there is no statistical difference, the infertile group is older than the non-infertile group (34.2 ± 4.4 vs. 32.6 ± 5.2). In the group of infertile women there is a higher proportion of women with 0 children, whereas in the group of non-infertile women there is a higher proportion of women with 2 or more children (83.0% vs. 47.6%, p <0.001). For the variables length of marital relationship, BMI and education, no significant differences were found.

Regarding the results of the FSFI and its domains (Table 2), differences were found in the satisfaction domain, having a higher score the infertile group (5.7 ± 0.60 vs. 5.3 ± 0.96, p = 0.010) and in the pain domain, once again with the higher score in the infertile group (5.4 ± 1.07 vs. 4.9 ± 1.38, p = 0.044). This is reflected in the mean total score, where the infertile group has a higher score than the non-infertile group (30.9 ± 3.71 vs. 29.1 ± 5.10, p = 0.019).

These results allowed the identification of 5 women with sexual dysfunction in the infertile group (9.4%) and 24 women with dysfunction in the non-infertile group (27.9%) (p = 0.009).

It was also possible to conclude that the non-infertile group had a 3.72 times greater odds of having sexual dysfunction than the infertile group (p = 0.013).

(13)

5

Discussion and Conclusion

The main aim of this study was to relate infertility with female sexual dysfunction by assessing the levels of sexual dysfunction using the FSFI questionnaire of women who resorted to the MAP and FP consultations. The fact that the causes of sexual dysfunction are not fully clarified, coupled with the conflicting results of studies attempting to relate infertility with sexual dysfunction, makes this study pertinent.

These two groups of women had very different expectations when they resorted to their respective consultations. The control sample consisted of women who resorted to the FP consultations, since this is a predominantly healthy population, with ages similar to the study population and whose objective was the opposite of the women of study population: not to become pregnant. It was still possible to obtain two standardized samples regarding to age, length of marital relationship, BMI and education. Regarding the size of the sample, it is important to highlight that is a small sample for the desired dimension of the study.

In the present study, in the non-infertile population, sexual dysfunction was found in 27.9% of the women. Several studies conducted in Portugal point to a prevalence of female sexual dysfunction of around 75% [3, 4], but it is important to highlight that these studies were conducted with unvalidated questionnaires. Nevertheless, worldwide, studies conducted with the FSFI questionnaire show results ranging from 28% to 63% [32, 33]. The lower value observed in the present study may be due to the exclusion of women over 40 years of age, since there seems to be an increase in sexual dysfunction with increasing ages [28]. In the infertile population, 9.4% of women presented sexual dysfunction, demonstrating that women with infertility have greater satisfaction in their sexual life when compared with non-infertile women. They also demonstrated significantly higher total scores in FSFI in addition to satisfaction and pain domain scores, showing further proofs of a better sexual function as well, than women without infertility.

These results are somehow unexpected when compared to previous studies. Millheiser et al. compared 119 infertile women with 99 controls, using the FSFI questionnaire, and concluded that 40% of infertile women and 25% in the control group had sexual dysfunction [34]. On the other hand, in the study conducted by Monga et al., where the FSFI questionnaire was also used, no significant differences were found between the 30 infertile and control couples [19]. The same results were found in studies conducted by Furukawa et al. [23] and Hentschel et al. [35] , where the total FSFI scores did not indicate any differences between the infertile women group and the control groups used.

(14)

6 There are several possible explanations to support the findings of the present study. Some characteristics are inherent to the population of non-infertile women that may explain the fact that they have a greater sexual dysfunction when compared with the population of infertile women. Firstly, the non-infertile women of this study mainly present 2 children or more. Children seem to negatively influence the sexual life of both the couple and the woman, since it entails change where there is an increase of conflicts between the couple, that can be reflected in some degree of sexual dysfunction [36]. This dysfunction seems to be greater the lower the age of the children. In fact, some studies show that women with children up to 3 years old have more difficulty in keeping a healthy sex life [37], with problems affecting the domains of pain, orgasm, arousal and lubrication [38]. Thus, to better clarify this point, it is important to include the age of the children in the socio-demographic questionnaire in further studies, in order to perceive whether women with children up to 3 years old have more sexual dysfunction.

Secondly, the non-infertile women are subject to hormonal contraception. Regarding to this, the existing studies are not very consensual. Smith et al. states that the use of hormonal contraception of any kind causes a decrease in sexual activity and interferes in the areas of arousal, orgasm and lubrification [39]. However, Graham et al. states that, although there is a decrease in satisfaction 3 months after the onset of hormonal contraception, there are no long-term changes [40] . Thus, since the relationship between the use of hormonal contraceptives and female sexual dysfunction is inconsistent [41], it may be a confusing factor of the present study. However, it is important to highlight that, if a selection of women who used only non-hormonal contraceptive methods (copper intrauterine device or tubes laqueation) had been made, the control population would have significantly aged when compared to the study population, therefore causing a bias in the study. Another factor that may justify the greater sexual dysfunction observed in the women who resorted to the family planning consultation is that they avoid having sexual intercourse on the fertile days of the menstrual cycle, even when using one or more contraceptive methods. The fertile days are the days associated with greater sexual pleasure [35] and the fact that women are deprived of having sexual intercourse on that day can explain the found differences. On the other hand, infertile women, in order to increase their chances of becoming pregnant, try to have more sexual intercourse on fertile days, which may also justify their lower sexual dysfunction by obtaining more pleasure these days.

It is also important to emphasize that in the diagnosis of infertility, there are couples that form a stronger emotional connection because they share the desire to have a child. This emotional bond

(15)

7

can be reflected in more satisfying intercourse [23], thus justifying the higher scores of the non-infertile population.

The socio-demographic questionnaire we developed, despite having fulfilled one of the main objectives, to standardize the populations, was shown to be too ambitious regarding the number of variables in relation to size of the population achieved. This reflected in the statistical analysis since it was not possible to perform the multivariate analysis. No statistical differences were found in the univariate analysis performed. Nevertheless, in the future it would be important to increase the sample size in order to perceive factors that may influence sexual dysfunction.

It is important to mention that sexual dysfunction is an extremely difficult pathology to measure, since most clinical methods used for its diagnosis can be considered subjective [1, 2]. The FSFI allows a more objective evaluation method that provides a better orientation of health professionals in the diagnosis of sexual dysfunction. Nevertheless, some limitations in the questionnaire were identified during the study. In the validated Portuguese translation of the questionnaire, there are similarities between questions that might make them difficult to interpret and distinguish and may lead to incorrect fulfill of questionnaire. Thus, the presence of a researcher during the fulfillment of the questionnaires can help women to clarify any doubts, and it is something to be considered in the future. It is also noteworthy that FSFI does not have a validated cut-off for its domains in the Portuguese population. Therefore, the conclusions from the results becomes more limited, not being possible to distinguish between the type of sexual dysfunction identified in this study.

Variables like the quality of life and depression can influence the female sexual function in a major way [23, 42]. As so, in the future, the use of other questionnaires that evaluate these parameters can help to interpret the results obtained in a more critical way.

For a better understanding of the influence of infertility in sexuality, further studies shall include the analysis of male sexual dysfunction and evaluate other risk factors such as depression and medication used in infertility treatment.

It is important to emphasize that, although this study relates infertility with female sexual dysfunction, this is not a longitudinal study and a convenience sample was used. As so, caution is needed when extrapolating the results for the Portuguese population.

Female sexuality is a prevalent health problem that still lacks some understanding. Thus, it is important to carry out more scientific studies to obtain more clinical recognition, so that the disease

(16)

8 itself can be more understood and more women can be diagnosed and treated in order to feel sexually satisfied.

(17)

9

References

1. Association, A.P., Diagnostic and statistical manual of mental disorders (5th ed.). 2013, Washington, DC: Author.

2. WHO, The ICD-10 Classification of Mental and Behavioral Disorders. Clinical descriptions and diagnostic guidelines. 2016: World Health Organization.

3. Ribeiro, B., A.T. Magalhães, and I. Mota, Disfunção sexual feminina em idade reprodutiva: prevalência e fatores associados. Revista Portuguesa de Medicina Geral e Familiar, 2013. 29: p. 16-24.

4. Cerejo, A.C., Disfunção sexual feminina: Prevalência e factores relacionados. 2006, 2006. 22(6): p. -680.

5. Lewis, R.W., et al., Epidemiology/risk factors of sexual dysfunction. J Sex Med, 2004. 1(1): p. 35-9.

6. Rosen, R., et al., The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther, 2000. 26(2): p. 191-208.

7. Quirk, F., et al., Development of a Sexual Function Questionnaire for Clinical Trials of Female Sexual Dysfunction. Vol. 11. 2002. 277-89.

8. Santos Pechorro, P., et al., Validação da versão portuguesa do Índice de Funcionamento Sexual Feminino – 6. Revista Internacional de Andrología, 2017. 15(1): p. 8-14.

9. Revicki, D.A., et al., Content Validity of the Female Sexual Function Index (FSFI) in Pre‐ and Postmenopausal Women with Hypoactive Sexual Desire Disorder. The Journal of Sexual Medicine, 2011. 8(8): p. 2237-2245.

10. Laughlin-Tommaso, S.K., B.J. Borah, and E.A. Stewart, Effect of menses on standardized assessment of sexual dysfunction among women with uterine fibroids: a cohort study. Fertil Steril, 2015. 104(2): p. 435-9.

11. Rogers, R.G., et al., A new measure of sexual function in women with pelvic floor disorders (PFD): the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR). Int Urogynecol J, 2013. 24(7): p. 1091-103.

12. Boquiren, V.M., et al., Sexual functioning in breast cancer survivors experiencing body image disturbance. Psychooncology, 2016. 25(1): p. 66-76.

13. Maiorino, M.I., et al., Sexual function in young women with type 1 diabetes: the METRO study. J Endocrinol Invest, 2017. 40(2): p. 169-177.

14. Foy, C.G., et al., Blood Pressure, Sexual Activity, and Dysfunction in Women With Hypertension: Baseline Findings From the Systolic Blood Pressure Intervention Trial (SPRINT). J Sex Med, 2016. 13(9): p. 1333-1346.

15. McCabe, M.P., et al., Risk Factors for Sexual Dysfunction Among Women and Men: A Consensus Statement From the Fourth International Consultation on Sexual Medicine 2015. J Sex Med, 2016. 13(2): p. 153-67.

16. Beckmann, C.R.B., Obstetrics and gynecology. 2010, Baltimore, MD: Wolters Kluwer Health/Lippincott Williams & Wilkins.

17. Boivin, J., et al., International estimates of infertility prevalence and treatment-seeking: potential need and demand for infertility medical care. Hum Reprod, 2007. 22(6): p. 1506-12.

18. Carvalho, J.L.S. and A. Santos, Estudo Afrodite. Caraterização da infertilidade em Portugal. I-estudo na comunidade. Faculdade de Medicina da Universidade do Porto, Sociedade Portuguesa de Medicina da Reprodução. 2009. 1-75.

19. Monga, M., et al., Impact of infertility on quality of life, marital adjustment, and sexual function. Urology, 2004. 63(1): p. 126-30.

20. Rooney, K.L. and A.D. Domar, The relationship between stress and infertility. Dialogues in clinical neuroscience, 2018. 20(1): p. 41-47.

(18)

10 21. McCool-Myers, M., et al., Predictors of female sexual dysfunction: a systematic review and

qualitative analysis through gender inequality paradigms. BMC Womens Health, 2018. 18(1): p. 108.

22. Piva, I., et al., A literature review on the relationship between infertility and sexual dysfunction: does fun end with baby making? Eur J Contracept Reprod Health Care, 2014. 19(4): p. 231-7.

23. Furukawa, A.P., et al., Dyspareunia and sexual dysfunction in women seeking fertility treatment. Fertil Steril, 2012. 98(6): p. 1544-8.e2.

24. Nelson, C.J., et al., Prevalence and predictors of sexual problems, relationship stress, and depression in female partners of infertile couples. J Sex Med, 2008. 5(8): p. 1907-14. 25. Bayar, U., et al., Sexual dysfunction in infertile couples: evaluation and treatment of

infertility. J Pak Med Assoc, 2014. 64(2): p. 138-45.

26. Davari Tanha, F., M. Mohseni, and M. Ghajarzadeh, Sexual function in women with primary and secondary infertility in comparison with controls. Int J Impot Res, 2014. 26(4): p. 132-4.

27. Leiblum, S.R., A. Aviv, and R. Hamer, Life after infertility treatment: a long-term investigation of marital and sexual function. Hum Reprod, 1998. 13(12): p. 3569-74. 28. Faubion, S.S. and J.E. Rullo, Sexual Dysfunction in Women: A Practical Approach. Am Fam

Physician, 2015. 92(4): p. 281-8.

29. Krysiak, R., et al., Sexual function and depressive symptoms in young women with thyroid autoimmunity and subclinical hypothyroidism. Clin Endocrinol (Oxf), 2016. 84(6): p. 925-31.

30. Yin, R., et al., The impact of systemic lupus erythematosus on women's sexual functioning: A systematic review and meta-analysis. Medicine (Baltimore), 2017. 96(27): p. e7162. 31. Sorensen, T., A. Giraldi, and M. Vinberg, Sexual distress and quality of life among women

with bipolar disorder. Int J Bipolar Disord, 2017. 5(1): p. 29.

32. Lammerink, E.A.G., et al., A Survey of Female Sexual Functioning in the General Dutch Population. J Sex Med, 2017. 14(7): p. 937-949.

33. Lou, W.J., et al., Prevalence and Factors Associated with Female Sexual Dysfunction in Beijing, China. Chin Med J (Engl), 2017. 130(12): p. 1389-1394.

34. Millheiser, L.S., et al., Is infertility a risk factor for female sexual dysfunction? A case-control study. Fertil Steril, 2010. 94(6): p. 2022-5.

35. Hentschel, H., et al., Sexual function in women from infertile couples and in women seeking surgical sterilization. J Sex Marital Ther, 2008. 34(2): p. 107-14.

36. Colson, M.H., [Female sexuality and parenthood]. Gynecol Obstet Fertil, 2014. 42(10): p. 714-20.

37. Woolhouse, H., E. McDonald, and S. Brown, Women's experiences of sex and intimacy after childbirth: making the adjustment to motherhood. J Psychosom Obstet Gynaecol, 2012. 33(4): p. 185-90.

38. Stulhofer, A., K. Kuljanic, and D.S. Buzina, Sexual health difficulties in a population-based sample of Croatian women aged 18-35 and the effects of the dual (career and

motherhood) role. J Sex Med, 2011. 8(5): p. 1314-21.

39. Smith, N.K., K.N. Jozkowski, and S.A. Sanders, Hormonal contraception and female pain, orgasm and sexual pleasure. J Sex Med, 2014. 11(2): p. 462-70.

40. Graham, C.A., et al., Does oral contraceptive-induced reduction in free testosterone adversely affect the sexuality or mood of women? Psychoneuroendocrinology, 2007. 32(3): p. 246-55.

41. Casey, P.M., K.L. MacLaughlin, and S.S. Faubion, Impact of Contraception on Female Sexual Function. J Womens Health (Larchmt), 2017. 26(3): p. 207-213.

42. Drosdzol, A. and V. Skrzypulec, Quality of life and sexual functioning of Polish infertile couples. Eur J Contracept Reprod Health Care, 2008. 13(3): p. 271-81.

(19)

11

Tables

TABLE 1- DEMOGRAPHIC CHARACTERISTICS

Infertil group Non-infertil group p value

Age (years) 34.2 ± 4.4 32.6 ± 5.2 0.064 Length of marital relationship (years) 9.3 ± 4.5 10.5 ± 11.6 0.484 BMI (Kg/m2₎ _{24.4 ± 4.4} _{24.6 ± 5.1} _0.808 Duration of infertility (years) 3.7 ± 2.0 ---- ---- Number of children < 0.001 0 44/53 (83.0) 19/84 (22.6) 1 9/53 (17.0) 25/84 (29.8) 2+ 0/53 (0) 40/84 (47.6) Education 0.654

Until the 3rd cycle 8/53 (15.1) 18/84 (21.4)

Until the 12th year 19/53 (35.8) 28/84 (33.3)

Higher education 26/53 (49.1) 38/84 (45.2)

Values for continuous variables are mean ± standard deviation. Values for categorical variables are number/total number of cases (%).

Bold indicates statistical significance.

(20)

12 TABLE 2- COMPARATION OF TOTAL FSFI AND DOMAIN SCORES IN CASE AND CONTROL GROUP

Infertil group (n=53) Non-infertil group (n=86) p value

Desire 4.2 ± 0.89 3.9 ± 1.04 0.077 Arousal 5.1 ± 0.80 4.8 ± 1.01 0.096 Lubrication 5.4 ± 0.88 5.3 ± 1.02 0.460 Orgasm 5.2 ± 0.93 4.9 ± 1.13 0.110 Satisfaction 5.7 ± 0.60 5.3 ± 0.96 0.010 Pain 5,4 ± 1,07 4.9 ± 1.38 0.044 TOTAL SCORE 30.9 ± 3.71 29.1 ± 5.10 0.019

Values for continuous variables are mean ± standard deviation. p<0,05 was considered statitically significant

(21)

13

TABLE 3- UNIVARIATE ANALYSIS OF POSSIBLE RISK FACTORS FOR SEXUAL DYSFUNCTION INFERTILE GROUP

Odds ration (OR)

95% Confidence interval

p value

Lower Upper

Age (years) 0.90 0.75 1.08 0.247

Length of marital relationship (years) 0.98 0.80 1.21 0.867

BMI (Kg/m2₎ _0.71 _0.50 _1.01 _0.056

Duration of infertility (years) 1.23 0.63 2.40 0.548 NON-INFERTILE GROUP

Odds ration (OR)

95% Confidence interval

p value

Lower Upper

Age (years) 1.02 0.93 1.12 0.701

Length of marital relationship (years) 0.99 0,95 1.04 0.706

BMI (Kg/m2₎ _0.98 _0,89 _1.07 _0.623

(22)

14

Attachment

A- Female Sexual Function Index

FSFI

(Rosen et al, 2000; tradução e adaptação de P. Nobre, 2001)

INSTRUÇÕES:

Estas questões perguntam sobre os seus sentimentos e respostas sexuais durante as últimas 4 semanas. Por favor responda às seguintes questões. As suas respostas serão mantidas completamente confidenciais. Ao responder a estas questões as seguintes definições aplicam-se:

Atividade sexual pode incluir carícias, preliminares, masturbação e relação sexual.

Relação sexual é definida como a penetração (entrada) do pénis na vagina.

Estimulação sexual inclui situações como preliminares com um parceiro, autoestimulação

(masturbação), ou fantasia sexual.

Desejo ou interesse sexual é um sentimento que inclui querer ter uma experiência sexual, sentir-se

recetiva à iniciativa sexual de um parceiro, e pensar ou fantasiar acerca de ter sexo.

Excitação sexual é um sentimento que inclui aspetos físicos e mentais. Pode incluir sentimentos de

calor ou comichão nos genitais, lubrificação (“ficar molhada”), ou contrações musculares.

ASSINALE APENAS UMA RESPOSTA POR QUESTÃO

1. Nas últimas 4 semanas, com que frequência sentiu desejo ou interesse sexual? Quase sempre ou sempre

A maior parte das vezes (mais de metade das vezes) Algumas vezes (cerca de metade das vezes)

Poucas vezes (menos de metade das vezes) Quase nunca ou nunca

2. Nas últimas 4 semanas, como classificaria o seu nível (grau) de desejo ou interesse sexual?

Muito elevado Elevado Moderado Baixo

(23)

15

3. Nas últimas 4 semanas, com que frequência se sentiu sexualmente excitada durante a atividade sexual ou a relação sexual?

Não tive atividade sexual Quase sempre ou sempre

4. Nas últimas 4 semanas, como classificaria o seu nível de excitação sexual durante a atividade sexual ou a relação sexual?

Não tive atividade sexual Muito elevado

Elevado Moderado Baixo

Muito baixo ou nenhum

5. Nas últimas 4 semanas, qual a sua confiança em conseguir ficar sexualmente excitada durante a atividade sexual ou a relação sexual?

Não tive atividade sexual Confiança muito elevada Confiança elevada Confiança moderada Confiança baixa

Confiança muito baixa ou nenhuma

6. Nas últimas 4 semanas, com que frequência se sentiu satisfeita com a sua excitação sexual durante a atividade sexual ou a relação sexual?

7. Nas últimas 4 semanas, com que frequência ficou lubrificada (“molhada”) durante a atividade sexual ou a relação sexual?

(24)

16 8. Nas últimas 4 semanas, qual a dificuldade que teve em ficar lubrificada (“molhada”)

durante a atividade sexual ou a relação sexual? Não tive atividade sexual

Extremamente difícil ou impossível Muito difícil

Difícil

Ligeiramente difícil Nenhuma dificuldade

9. Nas últimas 4 semanas, com que frequência manteve a sua lubrificação (“estar molhada”) até ao fim da atividade sexual ou a relação sexual?

10. Nas últimas 4 semanas, qual a dificuldade que teve em manter a sua lubrificação (“estar molhada”) até ao fim da atividade sexual ou a relação sexual?

Não tive atividade sexual

Difícil

11. Nas últimas 4 semanas, quando teve estimulação sexual ou a relação sexual, com que frequência atingiu o orgasmo (clímax)?

12. Nas últimas 4 semanas, quando teve estimulação sexual ou a relação sexual, qual a dificuldade que teve em atingir o orgasmo (clímax)?

Não tive atividade sexual

Difícil

(25)

17

13. Nas últimas 4 semanas, qual foi o seu nível de satisfação com a sua capacidade de atingir o orgasmo (clímax) durante a atividade sexual ou a relação sexual?

Não tive atividade sexual Muito satisfeita

Moderadamente satisfeita

Igualmente satisfeita e insatisfeita Moderadamente insatisfeita Muito insatisfeita

14. Nas últimas 4 semanas, qual foi o seu nível de satisfação com o grau de proximidade emocional entre si e o seu parceiro durante a atividade sexual?

Não tive atividade sexual Muito satisfeita

15. Nas últimas 4 semanas, qual o seu nível de satisfação com o relacionamento sexual que mantém com o seu parceiro?

Muito satisfeita

16. Nas últimas 4 semanas, qual o seu nível de satisfação com a sua vida sexual em geral? Muito satisfeita

17. Nas últimas 4 semanas, com que frequência sentiu desconforto ou dor durante a penetração vaginal?

Não tentei ter relações sexuais Quase sempre ou sempre

18. Nas últimas 4 semanas, com que frequência sentiu desconforto ou dor após a penetração vaginal?

Não tentei ter relações sexuais Quase sempre ou sempre

(26)

18 19. Nas últimas 4 semanas, como classificaria o seu nível (grau) de desconforto ou dor

durante ou após a penetração vaginal? Não tentei ter relações sexuais

Muito elevado Elevado Moderado Baixo

(27)

19

B- Socio-demographic Questionnaire

QUESTIONÁRIO SÓCIO-DEMOGRÁFICO Idade_____

Duração da relação conjugal (em anos)______ Peso_______

Altura_______

Número de filhos_____

Habilitações Académicas (assinalar a opção correspondente) Até ao 3º Ciclo

Até ao 12º ano Formação Superior Padece de alguma doença?

Sim Não

Se sim, quais? ____________________________________________________

Duração da infertilidade (se aplicável) ___________

Tipo de tratamentos efetuados até ao momento (se aplicável): Indução da ovulação

Inseminação Artificial (IA) Fertilização In Vitro (FIV)

Microinjecção intracitoplasmática (ICSI) Outro