International Journal of Impotence Research (2014) 26, 132134

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ORIGINAL ARTICLE
Sexual function in women with primary and secondary infertility
in comparison with controls
F Davari Tanha1, M Mohseni2 and M Ghajarzadeh3

Infertility is a distressing health condition that has diverse effects on couples lives. One of the most affected aspects of life in
infertile women is sexual function, which is a key factor in physical and marital health. The goal of this study was to evaluate sexual
function according to the type of infertility in comparison with controls. In this study, 191 women with primary infertility and 129
with secondary infertility along with 87 age-matched healthy controls were enrolled. They were asked to ll a valid and reliable FSFI
(Female Sexual Function Index). Age, partner age and duration of marriage were signicantly different between the primary and
secondary infertility groups. The score of each FSFI domain was signicantly higher in the control group, and the only signicant
difference between primary and secondary infertility groups was in the desire domain. Multiple linear regression analysis between
the total FSFI score as a dependent variable and age, partner age, Body Mass Index and marriage duration as independent variables
showed that age is a dependent predictor of FSFI in the primary group. We found signicant negative correlation between total
FSFI score and age, partner age and marriage duration (r1  0.21 and Po0.001, r2  0.14 and P 0.01, r3  0.19 and
Po0.001). 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.

International Journal of Impotence Research (2014) 26, 132134; doi:10.1038/ijir.2013.51; published online 16 January 2014
Keywords: primary infertility; secondary infertility; sexual dysfunction

INTRODUCTION were signicantly higher in women with secondary infertility than

Infertility, dened as the inability to conceive after 1 year of
unprotected sex,1 is a distressing health condition affecting about
20% of couples,2,3 with its prevalence having increased in recent
years.4
It could impair the quality of life in both men and women, as
mental, physical, social and personal aspects of their lives are
affected.4,5 It will often result in waste of time and money, marital
disruption and divorce in severe situations.
The literature shows that women with infertility are at risk of
experiencing anxiety, depression and stress, and suicide attempts
are nearly twofold higher in these cases.46
One of the affected aspects in infertile women that have not
been given sufcient importance is sexual function. Sexual
function is a key factor in physical and marital health, and sexual
dysfunction could deteriorate the quality of life.
Psychological status, adverse effects of medications, sex
hormone status, age of the patient and duration of marriage are
among possible causes of sexual dysfunction in infertile women.
Oskay et al. found sexual dysfunction in 61.7% of infertile
women and in 42.9% of fertile women. In their study, age, partner
age and duration of marriage were associated with FSFI (Female
Sexual Function Index) score.7 They did not differentiate betweeen
primary and secondary infertility in their study.
In another study conducted by Keskin et al., sexual dysfunction
was reported in 64% of women with primary infertility and in 76%
of women with secondary infertility.8 They found that the mean
age of women and their partners and the duration of marriage
in those with primary infertility.
We designed this study to evaluate womens sexual function
according to the type of infertility in comparison with controls.
MATERIALS AND METHODS
This cross-sectional study enrolled 191 women with primary infertility and
129 with secondary infertility referred to the infertility clinic of womens
Hospital (afliated to Tehran University of Medical Sciences) along with 87
age-matched healthy controls. Controls were non-pregnant, non-postpartum
and non-breastfeeding fertile (parityX1) hospital staff members (such as
nurses, physicians and midwives) with the desire to participate in the study.
The patients inclusion criteria were primary or secondary infertility and
participation in sexual intercourse at least once not earlier than 4 weeks prior
to the study; primary infertility is dened as inability of a women to become
pregnant or carry a pregnancy to a live child, and secondary infertility is the
same inability in women who were able to become pregnant or carry a
pregnancy to a live child previously. The exclusion criteria comprised any
psychological problems or being under treatment for infertility or depression.
All patients were asked to ll the informed consent forms. The study had
been approved by the local ethics committee.
Data on participants age, partners age, duration of marriage, Body Mass
Index (BMI), gravidity and parity in secondary infertile women were
collected by means of a structured questionnaire. Participants also were
asked to ll the valid and reliable FSFI questionnaire. FSFI is a 19-item self-
report instrument providing scores on six domains of sexual function as
well as a total score. These domains include the following: desire (two
items, questions 12), arousal (four items, questions 36), lubrication (four
items, questions 710), orgasm (three items, questions 1113), satisfaction

1
Associate professor of OBS&GYN,Department of endocrinology and reproductive medicine,Womens hospital, Tehran university of medical sciences, Women hospital, Karimkhan
avenue, Tehran, Iran; 2Womens hospital, Tehran university of medical sciences, women hospital, Karimkhan avenue, Tehran, Iran and 3Brain and Spinal Injury Research Center,
Tehran University of Medical Sciences, Imam hospital, Tehran, Iran. Correspondence: Dr F Davari Tanha, Associate professor of OBS&GYN, Department of endocrinology and
reproductive medicine, Womens hospital, Tehran university of medical sciences, Women hospital, Karimkhan avenue, Tehran 14489, Iran.
E-mail: fatedavari@yahoo.com
Received 23 April 2013; revised 23 November 2013; accepted 12 December 2013; published online 16 January 2014
 Sexual function in women with infertility
F Davari Tanha et al
133
(three items, questions 1416) and pain (three items, questions 1719).9 Although the total FSFI score was not signicantly different
The sum of the 19 items provides the total FSFI score. A total score of 26.55 between primary and secondary groups, mean score for the desire
was used initially as the cutoff for clinical sexual dysfunction.10 domain was signicantly lower in the secondary group, which is
All data were analyzed using SPSS software version 18.0 (SPSS Inc., indicative of higher dysfunction in the secondary group with
Chicago, IL, USA). respect to this item.
Students t-test and Fishers exact test were used to compare continuous
and categorical variables. The correlation coefcient (Spearman) was In a previous study conducted by Keskin et al., 122 women with
calculated to assess the association between variables. Multiple linear primary infertility and 51 with secondary infertility were evaluated.
regression analysis was conducted involving the FSFI score as the Women with secondary infertility had higher risk for sexual
dependent variable and age, partner age, BMI and duration of marriage dysfunction, and scores of arousal, orgasm, and satisfaction
as independent variables to assess their relevance for sexual function. domains were signicantly lower in this group.8 It should also
P-value o0.05 was considered signicant. be noted that, in contrast to our study, Keshins study did not
involve a healthy control group to compare domains of FSFI
between infertile and healthy women.
RESULTS In another study, Millheiser et al. assessed infertile and fertile
A total of 191 women with primary infertility, 129 with secondary women and reported sexual dysfunction in 40% of infertile
infertility and 87 healthy controls participated in this study. The women and 25% of healthy controls.11 In their evaluation, only the
mean age of women and their partners and duration of marriage scores for the desire, arousal and satisfaction domains of the FSFI
were signicantly different between two groups (Table 1). questionnaire were signicantly higher in healthy controls,
Only the desire domain of the FSFI questionnaire was whereas in our study scores of all domains were statistically
signicantly different between two groups (Table 2). higher in the control ones.
We found signicant negative correlation between total FSFI By means of the Sexual Function Questionnaire, Khademi et al.
score and age, partner age and marriage duration (r1  0.21 and reported arousal and orgasm dysfunction in up to 80% and 22% of
Po0.001, r2  0.14 and P 0.01, r3  0.19 and Po0.001) infertile women, respectively.12
(Table 3). Factors such as age, duration of marriage, partner age and
Multiple linear regression analysis between the total FSFI score psychological problems such as depression have been considered
as a dependent variable and age, partner age, BMI and marriage as leading causes of sexual dysfunction in infertile women. In the
duration as independent variables showed that age is a current study, mean age of women, partner age and duration of
dependent predictors of FSFI in the primary group. Results are marriage were signicantly different between two groups. Women
summarized in Tables 4 and 5. with secondary infertility had higher age and longer duration of
marriage and their husbands were older than partners of the
primary infertility group. Similar to the study by Oskay et al. 7 we
also found that total FSFI score correlated with age, partner age
DISCUSSION
and marriage duration.
The results of this study demonstrated that sexual function is
impaired in infertile women. Total FSFI score and the score of each
domain were signicantly higher in the control group than in
the infertile group, which is consistent with the ndings of
Oskay et al.7 In their study, the total FSFI score was 24.58 in the Table 3. Domains of FSFI questionnaire in patients and controls
infertile group and 26.55 in the control group. The mean total FSFI
score in this study was higher than the score in the study by Oskay Patients Controls P-value
et al. Desire 3.70.94 4.23.8 o0.001
These ndings are contrary to the ndings of Monga et al. They Arousal 3.91 5.40.3 o0.001
evaluated 18 infertile couples and 12 fertile couples, and reported Lubrication 4.51 5.40.3 o0.001
no signicant difference in the womens sexual function scores Orgasm 4.31.1 5.60.3 o0.001
between the two groups, whereas the quality of life in the infertile Satisfaction 4.61 5.60.2 o0.001
group was lower than that in the fertile group.5 Pain 4.51.2 5.60.3 o0.001
Total sexual function score 25.74.6 321.1 o0.001

Table 1. Demographic characteristics of two groups

Table 4. Multiple linear regression analysis in primary infertile women
Primary Secondary P-value
B 95% CI P-value
Age 28.56.1 32.45.2 o0.001
Partner age 32.65.7 36.97.3 o0.001 Age  0.28 (  0.37,  0.66) 0.005
Duration of marriage 64.1 10.44.7 o0.001 Partner age 0.08 (  0.09, 0.24) 0.39
BMI (kg /m  2) 25.64 25.93.2 0.39 BMI 0.11 (  0.02, 0.31) 0.09
Marriage duration  0.14 (  0.34, 0.007) 0.06

Table 2. Domains of FSFI questionnaire in two groups

Primary Secondary P-value Table 5. Multiple linear regression analysis in secondary infertile
women
Desire 3.80.95 3.60.92 0.03
Arousal 40.97 3.81 0.08 B 95% CI P-value
Lubrication 4.51.1 4.50.96 0.9
Orgasm 4.41.1 4.31.1 0.7 Age  0.019 (  0.22, 0.19) 0.88
Satisfaction 4.61.1 4.50.97 0.1 Partner age 0.003 (  0.15, 0.15) 0.98
Pain 4.41.1 4.51.1 0.3 BMI  0.02 (  0.26, 0.21) 0.81
Total sexual function score 25.94.8 25.54.3 0.3 Marriage duration  0.17 (  0.37, 0.05) 0.15

& 2014 Macmillan Publishers Limited International Journal of Impotence Research (2014), 132 134
 Sexual function in women with infertility
F Davari Tanha et al
134
Regarding BMI score, our ndings are compatible with the
ndings of Keshin et al.8 Both studies showed that BMI was not
statistically different between two infertile groups.
Regression analysis in our study showed that age was an
independent predictor of sexual function in women with primary
infertility, but not in those with secondary causes. In the study by
Keshin et al., age and income were independent predictors of FSFI
score, although they did not distinguish primary from secondary
infertility.8
Infertility is a medical situation that has diverse effects on
couples lives. Anxiety, depression, reduced self-esteem, marital
distress and marital disruption are common in couples with
infertility.
Psychological pressure on both men and women to have
children will decrease intercourse intimacy and satisfaction.
Previous studies demonstrated that infertility diagnosis reduces
the couples sexual activity.1315
Depression is the most common emotional problem in infertile
women. It has been reported that primary infertile women suffer
from depression more often than those with secondary infertility.8
As depression alone could lead to sexual dysfunction, we excluded
depressed cases from our study to control its effect on the
participants sexual function.
As we excluded depressed women to avoid the effect of
depression on sexual function, the lower FSFI score in secondary
infertile cases compared with primary ones could be due to the
higher age of infertile women and their partners and the longer
duration of marriage, similar to that seen in the study by Keskin
et al.8
Previous loss of pregnancy and concern about limited fertility
time may cause psychological distress, which could impact the
sexual function in secondary infertile patients.
The advantage of our study is that we compared three
groupsprimary infertile women, secondary infertile women
and healthy subjectsas a result of which the effects of infertility
on sexual life could be shown more precisely in comparison with
previous studies.
This study has some limitations. First, we did not collect
comprehensive information of the control group. Second, we had
little information about womens partners.
We suggest multi-center investigations with larger sample sizes
and comprehensive evaluation of male partners and the control
group in future studies.
International Journal of Impotence Research (2014), 132 134
CONCLUSION
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.
CONFLICT OF INTEREST
The authors declare no conict of interest.
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