European Journal of Obstetrics & Gynecology and Reproductive Biology 215 (2017) 153163

Contents lists available at ScienceDirect

European Journal of Obstetrics & Gynecology and

Reproductive Biology
journal homepage: www.elsevier.com/locate/ejogrb

Review article

Sexual dysfunction in infertile women: A systematic review and

meta-analysis
Carolina R. de Mendonaa,* , Jalsi T. Arrudaa , Matias Nollb , Paulo M. de O. Campolic ,
Waldemar N. do Amarald
a
Federal University of Gois, Goinia, Brazil
b
Federal Institute Goiano, Campus Ceres, Gois, Ceres, Brazil
c
Arajo Jorge Hospital, Cancer Combat Association in Gois, Goinia, Brazil
d
Department of Gynaecology and Obstetrics, School of Medicine, Federal University of Gois, Goinia, Brazil

A R T I C L E I N F O A B S T R A C T

Article history: Objective: This study aimed to assess the prevalence of sexual dysfunction and Female Sexual Function
Received 16 February 2017 Index (FSFI) score in women with infertility.
Received in revised form 31 May 2017 Study design: A systematic search of the literature was conducted using PubMed, EMBASE, IBECS, and
Accepted 6 June 2017
LILACS. The search was limited to articles published from January 2000 to September 2016, without
Available online xxx
language restriction. Data were analyzed using Stata 12.0. Random effects meta-analyses in weighted
mean difference (WMD) were performed for six comparative studies (infertility versus fertility).
Keywords:
Heterogeneity was estimated using I2. Moreover, to explore the heterogeneity sources among the studies,
Female sexual function index
Sexual disorder
meta-regression analyses were also performed. Quality of evidence was assessed using the Grading of
Infertility Recommendations Assessment, Development, and Evaluation guidelines, and risk of bias, with a graphic
Women funnel.
Results: Meta-analysis was performed in 11 of 13 comparative studies. The result indicated a signicant
association between an increase in sexual dysfunction and infertility in women (WMD = 0.16, 95%
condence interval = 0.254 to 0.084, p < 0.001), and high heterogeneity between studies was noted
(I2 = 98.6%, p < 0.000). Meta-regression analysis did not indicate heterogeneity (I2 = 0.00%). We also
performed a meta-analysis of individual FSFI domains in 10 studies. Infertile women had problems with
lubrication, orgasm, and satisfaction. Meta-regression analysis also showed that heterogeneity had no
inuence on the nal results of all the analyses.
Conclusions: Infertility was associated with an increase in female sexual dysfunction. The most affected
areas of sexual function were lubrication, orgasm, and satisfaction.
2017 Elsevier B.V. All rights reserved.

Contents

1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
2 Materials and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
2.1 Search strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
2.2 Eligibility criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
2.3 Study selection, data extraction, and quality of evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
2.4 Statistical analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
3 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
3.1 Included studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
3.2 Infertilitys effect on female sexual function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159

* Corresponding author at: Federal University of Gois, School of Medicine,

Department of Gynaecology and Obstetrics, Campus Colemar Natal e Silva, 235th
Street, University Sector, Goinia GO, 74605-050, Brazil.
E-mail addresses: carol_mendonca85@hotmail.com,
carolconcurso85@gmail.com (C.R. d. Mendona).

http://dx.doi.org/10.1016/j.ejogrb.2017.06.013
0301-2115/ 2017 Elsevier B.V. All rights reserved.
154 C.R. Mendona et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 215 (2017) 153163

3.3 Meta-analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159

3.4 Publication bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
4 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Author contribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Conict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162

1 Introduction Literature shows that women with infertility have more sexual
dysfunctions than the general population [913]. Sexual dysfunc-
Infertility is a worldwide problem that could cause signicant tions may be the result of infertility or the cause of infertility [8].
emotional and psychological harm to women even when it is due Couples who undergo human reproduction treatment may have
to a male factor [1]. Diagnosis of infertility among women results decreased sexual desire, lubrication, orgasm, satisfaction, and
in negative emotions and psychological distress, may have frequency of sexual intercourse, which could be attributed to stress
negative effects on the marital relationship and quality of life due to the treatment or medications [9,11]. However, results of
[27], and can generate emotions, such as anxiety, anger, despair, several studies conducted to evaluate sexual function of infertile
and sadness, in most people. Consequently, sexual activity may be couples are contradictory and heterogeneous [2,12,1419]. Wisch-
affected [8]. mann et al. [20] reported that reaching denite conclusions about
sexual dysfunctions in infertile women is primarily challenging

Fig. 1. Flow diagram of the selection of comparative studies and non-comparative studies.
Table 1
Characteristics of the comparative studies on sexual dysfunction in infertile and fertile women included in the systematic review.

Author Study GRADE* Conict Ethics Infertility Diagnostic/type of infertility Country Sample size, Age Mean Score FSFI P value Women sexual P
design of committee number FSFI dysfunction value
interest approval prevalence

Infertile Fertile Infertile Fertile Infertile Fertile Infertile Fertile

Mirblouk cross- *** No Yes Primary or secondary Iran 147 149 30.61  6.8 32.7  6.8 26.3  3.8 34.4  25.1 0.011 ND ND ND
et al. sectional
(2016)

C.R. Mendona et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 215 (2017) 153163
Ozkan et al. NA ** No Yes Idiopathic male infertility Turkey 56** 48 2445 2445 19.1  5.5 20.0  3.4 0.293 94.5% 100% ND
(2016)
Turan et al. case- *** No Yes One year and a history of infertility. Turkey 352 301 29.2  4.3 28.7  4.0 26.2  2.5 28.2  1.7 < 0.001 32.9% 17.2% 0.001
(2014) control
Davari cross- * No Yes Primary and secondary infertility. Iran 320 87 30.4 ND 25.7  4.5 32.0  1.1 0.001 ND ND ND
Tanha sectional
et al.
(2014)
Mendona case- *** No Yes One year and a history of infertility. Brazil 168 110 33.4  4.6 31.3  6.7 27.7  4.5 28.1  4.2 0.290 36.3% 28.2% 0.30
et al. control
(2014)
Iris et al. case- ** No Yes Primary infertility. Turkey 174 635 31.2  3.8 32.0  3.2 22.8  0.6 22.6  0.3 > 0.05 ND ND ND
(2013) control
Aggarwal case- * No Yes Premature ovarian failure (POF). Endometriosis India 267 233 2442 2442 22.4  3.9 22.3  3.3 ND 63.7% 46.3% 0.0001
et al. control Tubal/PID
(2013) Unexplained
Polycystic ovarian disease (PCOD).
Furukawa case- * No Yes Inability to become pregnant within 12 months or 6 USA 75 210 1845 1845 29.4 29.3 0.630 37.3% 31.9% 0.390
et al. control months. Severe male factor, tubal factor, or
(2012) recognized ovulatory dysfunction. Treatment.
de Almeida cross- * No Yes POF. Brazil 58 58 39.4  6.5 39.0  6.8 24.0  6.0 27.3  4.8 0.004 62.1% 37.8% 0.0093
et al. sectional
(2011)
Oskay et al. case- *** No Yes Failure to conceive after 12 months of unprotected Turkey 308 308 30.4  5.5 30.7  6.1 24.6  5.4 26.9  4.7 0.0001 61.7% 42.9% 0.00
(2010) control sexual intercourse
Millheiser case- *** No Yes History of 12 months of infertility USA 119 99 35.8 32.6 27.1 28.7 0.022 40.0% 25.0% 0026
et al. control
(2010)
Hentschel cross- ** ND Yes Women subjected to procedures of assisted Brazil 96 119 31.5  5.8 34.4  6.0 27.2  4.3 26.4  5.5 0.229 ND ND ND
et al. sectional reproduction.
(2008)
Drosdzol & NA * No Yes One year and a history of infertility. Poland 206 190 29.8  4.1 30.9  6.4 29.5  6.0 31.1  3.8 0.005 17.5% 12.1% 0.13
Skrzypulec (2008) Primary or secondary.

ND: no data available; * Quality of evidence was GRADE in four categories: very low quality, low quality, moderate quality, or high quality; **Diagnosed with idiopathic male infertility.

155
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Table 2
Characteristics of the non-comparative studies on sexual dysfunction in infertile women included in the systematic review.

Author Study GRADE* Conict Ethics Infertility Diagnostic/type of Country Patients Age Mean Score Women sexual
design of committee infertility number FSFI dysfunction
interest approval Infertile prevalence
women
Lo & Kok cross- ** No Yes One year and a history of China 159 32.8  3.81 24.99  4.22a 32.5%
(2016) sectional infertility. Primary or
secondary infertility.
Kucur Suna cross- *** No Yes One year and a history of Turkey 30 27.9  5.4 25.7  5.1 43.3%
et al. (2016) sectional infertility. Primary or
secondary infertility.
Eftekhar et al. cross- *** No Yes Polycystic Ovary Syndrome Iran 130 27.0  4.27 25.93  3.92 57.7%
(2014) sectional (PCOS)
Jamali et al. cross- *** No Yes One year and a history of Iran 122 30.9  6.8 21.6  1.7 87.1%
(2014) sectional infertility.
Tashbulatova cross- *** No Yes Women subjected to Turkey 200 30.9  6.1 31.6  4.5b 35.5%
et al. (2013) sectional procedures of assisted
reproduction.
Yeoh et al. cross- *** No Yes One year and a history of Malaysia 150 32.3  4.5 71.8  17.5c 11.3%
(2012) sectional infertility.
Pakpour et al. cross- *** No Yes One year and a history of Iran 604 30.1  7.8 21.6  3.8 35.6%
(2012) sectional infertility.
Keskin et al. NA ** No Yes Primary or secondary. Turkey 173 29.9  7.9 23.1  4.9 68.2%
(2011)
Carter et al. cross- *** No Yes Infertile women awaiting USA 50 40.2  4.3 24.1  2.4 46.8%
(2011) sectional oocyte donation
Nelson et al. cross- *** No Yes Heterosexual couples USA 121 32.0  5.0 28.0  6.8 26.0%
(2008) sectional presenting for initial
evaluation of infertility

*Quality of evidence was GRADE in four categories: very low quality, low quality, moderate quality, or high quality; a- The traditional Chinese version of the FSFI, cut-off was
23.45; b- Turkish translation FSFI, cut off 30 female sexual dysfunction; c- Malay translation FSFI, cut off 55 female sexual dysfunction.

Fig. 2. Results of the meta-analysis for total FSFI score comparative studies.
 C.R. Mendona et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 215 (2017) 153163
Fig. 3. Results of the meta-analysis for lubrication.
because of methodological deciencies of the studies, different
instruments used to measure female sexual function, and
discrepancies among the samples.
Female sexual dysfunction can be diagnosed based on self-
report or interview and using validated instruments [21]. The main
instruments used in sexual dysfunction evaluation in infertile
couples are the following: Brief Index of Sexual Functioning [22],
Sexual Function Questionnaire [23], Sexual History Questionnaire
[24], and Female Sexual Function Index (FSFI) [6,15,18,25]. Here, we
focus on FSFI, which is a 19-item self-report instrument created in
2000 that evaluates sexual function in women in six dimensions
(i.e., desire, excitement, lubrication, orgasm, satisfaction, and pain)
[26,27]. It was validated and translated into various languages, has
been widely used to measure sexual dysfunction in infertile
women, and has been accepted and used worldwide in both
clinical practice and research [6,15,18,19,25,28].
Therefore, our study aimed to evaluate the FSFI score and sexual
dysfunction prevalence in women with infertility. Given the
current literature gaps, a systematic review that could provide
an overview of studies addressing sexual dysfunctions in infertile
women and valuable information to practitioners dealing with
reproductive and sexual health and infertile couples is necessary.
2 Materials and methods
This systematic review was developed based on the recom-
mendations from the Preferred Reporting Items for Systematic
157
Reviews and Meta-Analyses (PRISMA) statements [29]. The
protocol is registered in the PROSPERO registry
(CRD42016041652, http://www. crd.york.ac.uk/PROSPERO).
2.1 Search strategy
A systematic search in ve available databases (PubMed,
EMBASE, IBECS, LILACS, and Cochrane Library) was conducted to
identify all relevant studies published between 2000 and 2016,
without language restriction. Relevant additional studies identi-
ed in the reference list of primary and event studies were also
analyzed (Fig. 1).
We used the following terms to search in PubMed: (((((sexual
function) AND infertility) AND women)) OR (((sexual dysfunction)
AND infertility) AND women)) OR ((female sexual function index)
AND infertility). The following lter was applied: publication date,
i.e., from January 1, 2000, to September 10, 2016. This same
combination of words was used to search in IBECS, LILACS, and
Cochrane Library.
The terms used to search in EMBASE were the following:
('female'/exp AND infertility'/exp OR female infertility'/exp OR
subfertility'/exp) AND ('sexual dysfunction'/exp OR female sexual
dysfunction'/exp OR psychosexual disorder'/exp OR frigidity'/exp
OR dyspareunia'/exp OR sexuality'/exp OR Female Sexual
Function Index) AND ('human'/exp) AND NOT ('editorial'/it OR
letter'/it).
158 C.R. Mendona et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 215 (2017) 153163
Fig. 4. Results of the meta-analysis for orgasm.
2.2 Eligibility criteria
The inclusion criteria were as follows: a) studies measuring
sexual dysfunction in women of heterosexual couples; b) studies
reporting total FSFI score and all domains individually; c) studies
describing sexual dysfunction prevalence and mean; d) observa-
tional studies (cross-sectional, case-control, or cohort) including
comparative studies (infertile versus fertile women) and non-
comparative studies (only infertile women); and e) studies on
women diagnosed as having infertility due to female or male
factors (primary or secondary infertility) who were undergoing
human reproduction treatment at the time of data collection or
those that dened infertility as the failure to achieve clinical
pregnancy after 12 months of regular, unprotected sexual
intercourse, which is based on the denition of the World Health
Organization. Moreover, sexual dysfunction was established when
the total FSFI score was <26.55 [27]. We excluded articles a) that
used other questionnaires or without clear identication of the
questionnaires used to measure female sexual function; b) that
were case reports; c) that assessed other illnesses; e) that failed to
mention infertility and sexual dysfunction in couples with
infertility, or infertility and sexuality in children and teenagers;
f) that had incomplete data even after we contacted the authors
through e-mail; and g) that had a sample size <20.
2.3 Study selection, data extraction, and quality of evidence
The articles included were reviewed by two investigators (CRM
and JTA). Relevant data were extracted and differences resolved by
consensus. Potentially eligible articles were obtained and read in
full. Disagreements on study inclusion were addressed by a third
reviewer (PMOC). The data collected were the following: authors
and year of publication, study design, country where the study was
conducted, group size, age, mean FSFI score and standard deviation
(SD), and female sexual dysfunction prevalence. Data from
comparative and non-comparative studies were collected sepa-
rately. Additional information was obtained by contacting authors
through e-mail. Study quality was assessed using the Grading of
Recommendations, Assessment, Development, and Evaluations
(GRADE) [30]. The quality of evidence of the studies was classied
into four categories: high, moderate, low, or very low quality [31].
We also analyzed the inuence of possible conicts of interest and
any information on ethical approval of the studies [32].
2.4 Statistical analysis
Statistical analyses were performed using STATA 12.0 software
(Stata Corporation, College Station, TX, USA). For the meta-analysis,
the population size and the mean and SD of the parameters that
reect the FSFI score for both infertile and fertile women were
considered. The percentage of variability attributable to heteroge-
neity was estimated with the I2 test, which was deemed signicant
when p < 0.05. I2 values of 25, 50, and 90% corresponded,
respectively, to low, moderate, and high levels of heterogeneity.
Data were pooled using a random effects model. Meta-regression
analysis was performed using the population size and mean FSFI
score of the infertile group to determine the association between
infertility and female sexual dysfunction. The meta-analysis and
 C.R. Mendona et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 215 (2017) 153163 159

Fig. 5. Results of the meta-analysis for satisfaction.

meta-regression analysis were performed at 95% condence 3.2 Infertilitys effect on female sexual function
interval (CI). Publication bias was assessed with a visual inspection
of a funnel plot. All statistical tests were with a signicance level of Based on the comparative studies, sexual dysfunction preva-
0.05. lence was higher in women with infertility. For most of the studies,
signicant differences in characteristics existed between infertile
and fertile women (Table 1). Among the 10 non-comparative
3 Results studies, 6 reported on sexual dysfunction in infertile women
(Table 2) [6,9,10,39,40,42]. Sexual dysfunction prevalence in
3.1 Included studies infertile women varied from 35.6 to 87.1%.

The initial search, reading titles and abstracts, resulted in 1677

3.3 Meta-analysis
articles. Among the 41 articles selected for full reading, 8 studies
using a different questionnaire and 10 with incomplete data were
Meta-analysis was performed in 11 of the 13 comparative
excluded. Twenty-three articles were included in the nal analysis,
studies [1216,19,35,37,38,43,44]; two studies had no mean and SD
of which 13 were comparative studies and 10 were non-
data and were thus excluded [18,34]. The infertile group consisted
comparative studies (Fig. 1). The 23 studies included 4085 infertile
of 2152 women; the fertile group, 2238 women. The result
women and 2547 women in the control group. Five studies were
indicated a signicant association between an increase in sexual
performed in developed countries (USA [6,18,33,34] and Poland
dysfunction and infertility in women (WMD = 0.16, 95% CI =
[35]); 18 studies, in developing countries (China [36], Brazil
0.254 to 0.084, p < 0.001), and high heterogeneity between
[12,13,37], India [16], Iran [9,14,3840], Malaysia [41], and Turkey
studies was noted (I2 = 98.6%, p < 0.000). Thus, we selected the
[10,11,15,19,4244]).
random effects model (WMD = 1.924, 95% CI = 3.332 to 0.516,
The studies included women of different ages and ethnicities
p = 0.007, tau2 = 5.1592; Fig. 2). Subsequently, meta-regression
and from different geographical areas, with infertility diagnosis
analyses were performed to nd the source of heterogeneity
related to female and male factors. Some studies measured
(tau2 = 2946, I2 = 0.00%, adjusted R2 = 40.67%). No heterogeneity
primary infertility against secondary infertility [9,10,40].
was observed.
Moreover, some studies reported on the frequency of sexual
We also performed a meta-analysis of individual FSFI domains
dysfunction, and others reported on the mean FSFI score [11,36,41].
in 10 studies [1215,19,35,37,38,43,44]. One study had no data on
None of the identied studies evaluated male sexual dysfunction.
individual FSFI domains [16], even after we contacted the authors,
160 C.R. Mendona et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 215 (2017) 153163
Fig. 6. Results of the meta-analysis for desire.
and thus was excluded. Based on the random effects model,
infertile women had problems with lubrication (WMD = 0.267,
95% CI = 0.471 to 0.064, p = 0.010) (I2 = 96.6%, P for heterogene-
ity = 0.000) (Fig. 3), orgasm (WMD = 0.272, 95% CI = 0.540 to
0.003, p = 0.047) (I2 = 97.8%, P for heterogeneity = 0.000) (Fig. 4),
and satisfaction (WMD = 0.216, 95% CI = 0.418 to 0.015,
p = 0.036) (I2 = 96.9%, P for heterogeneity = 0.000) (Fig. 5), and
high evidence of heterogeneity was observed. Meanwhile, meta-
regression analysis revealed the following: lubrication (tau2 =
2.843, I2 = 0.00%, adjusted R2 = 43.40%), orgasm (tau2 = 3.273,
I2 = 0.00%, adjusted R2 = 34.83%), and satisfaction (tau2 = 4.241,
I2 = 0.00%, adjusted R2 = 15.56%). The analysis showed that hetero-
geneity had no inuence on the results of all the analyses.
The meta-analysis showed that infertility was not associated
with sexual desire dysfunction (WMD = 0.099, 95% CI = 0.406 to
0.207, p = 0.526) (I2 = 97.9, P for heterogeneity = 0.000) (Fig. 6),
excitation (WMD = 0.241, 95% CI = 0.568 to 0.086, p = 0.149)
(I2 = 98.5%, P for heterogeneity = 0.000) (Fig. 7), and pain (WMD =
0.281, 95% CI = 0.608 to 0.046, p = 0.092) (I2 = 98.7%, P for
heterogeneity = 0.000) (Fig. 8). High evidence of heterogeneity was
observed. Meta-regression analysis showed that heterogeneity
was corrected in all analyses: desire (tau2 = 74.1, I2 = 0.00%, adjusted
R2 = 98.52%), excitation (tau2 = 3.638, I2 = 0.00%, adjusted
R2 = 27.57%), and pain (tau2 = 4.197, I2 = 0.00%, adjusted R2 = 16.43%).
3.4 Publication bias
The funnel plot revealed a symmetric pattern, suggesting no
publication bias in our meta-analysis (Fig. 9). Analysis of the
methodological quality of the studies performed using GRADE
indicated low to moderate quality, which is expected in
observational studies. All studies reported ethical approval, and
no conict of interest among the authors existed.
4 Discussion
This systematic review is the rst to evaluate sexual dysfunc-
tion prevalence and sexual dysfunction score in women with
infertility. Although the issue of infertility and its effect on female
sexual function is not new, most of the studies were contradictory,
which motivated us to conduct a systematic review. The results
from the meta-analysis conrmed that women with infertility had
an increase in sexual dysfunction. The most affected sexual
function domains were lubrication, orgasm, and satisfaction.
Our ndings are signicant and could help professionals
dealing with sexual and reproductive health; the diagnosis of
infertility, treatment period, and drugs used in the treatment
possibly contributed to the increase in sexual dysfunction [9,11,16].
The treatment phases could also result in marital problems as
sexual relation is now focused on conception, which in turn could
interfere with sexual satisfaction [16]. Other studies that were
excluded reported on the inuence of sexual desire, problems with
arousal, dyspareunia, inability to reach orgasm, and negative body
image in infertile women related to sexual dysfunction
[2,6,7,45,46].
The FSFI questionnaire was created in 2000; however, studies
on sexual dysfunction in infertile couples were published after
2008. Since then, several researchers have used the FSFI. We found
a predominance of studies published in developing countries,
including Iran and Turkey, whose culture treats topics on sexuality
and sexual function as unacceptable and taboo [47,48]. A recent
study has shown that the patriarchal characteristics of the Turkish
C.R. Mendona et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 215 (2017) 153163 161

Fig. 7. Results of the meta-analysis for excitation.

Fig. 8. Results of the meta-analysis for pain.

162 C.R. Mendona et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 215 (2017) 153163
Fig. 9. Funnel plot of the comparative studies.
society continue to be inuential even in individuals with high
educational level. Women are raised from childhood with
prohibited concepts linked to female sexuality. Furthermore,
the Turkish society holds beliefs on discrimination against and
negative perceptions about women [48].
This study has some limitations. First, several studies were
excluded because of the lack of information on total FSFI score,
even after we contacted the authors [46,4951]. Second, some
studies showed errors in the methodological description
[15,19,34]. The case-control studies had no odds ratio results in
relation to infertility and sexual dysfunction. The last limitation is
the high heterogeneity of the studies.
Despite the high heterogeneity in the meta-analysis results, the
nal results were corrected using meta-regression. The heteroge-
neity of the studies could be attributed to cultural differences, age
of the participants, diagnosis of infertility, type of assisted
reproduction treatment, female and male infertility factors, and
differences in the allocation of the studied groups. Another aspect
is that differences in the control group may not be representative of
the general population; data of the samples analyzed were
collected in a hospital and/or community setting.
An important strength of this review is the inclusion of articles
that used the FSFI as an outcome variable. Due to ethical
considerations, research evaluating sexual function is performed
by analytical observational studies; thus, we tried to obtain a wide
variety of case-control, cohort, and cross-sectional studies that
were carefully analyzed. The lack of data and the diversity of
studies require a careful and differentiated examination. Data were
evaluated carefully to minimize the risk of bias. The evaluation of
quality and risk of bias was performed using two validated
methodologies, i.e., the funnel graph and the GRADE [30]. We also
excluded studies with a potential risk of bias.
Future studies considering male infertility factor and male
sexual dysfunction are recommended. We suggest that further
studies be conducted with criteria related to sample selection,
sample size, rigorous statistical analysis, and study design.
Moreover, future studies should take into account the age of
women, number of unsuccessful attempts of assisted reproduction
treatment, primary or secondary infertility, and infertility groups
(male/female/mixed/unexplained) when interpreting the results.
Professionals involved in reproductive health and human
sexuality should be able to assist couples as regards sexual
dysfunctions and seek to alleviate the problems that can arise with
diagnosis and treatment. The guidance and monitoring must start
from the diagnosis of infertility to the end of the treatment period,
including assisted reproduction. Psychotherapeutic monitoring
also helps minimize sexual dysfunction and enhances quality of
life. Thus, counseling couples about sexual dysfunctions and
proposing treatment strategies could help improve their sexual
and affective relationship as well as increase the success rate of
assisted reproductive treatment.
In conclusion, infertility was associated with an increase in
female sexual dysfunction. The most affected areas of sexual
function were lubrication, orgasm, and satisfaction.
Author contribution
Carolina Rodrigues de Mendona: protocol development, data
collection or management, data analysis, manuscript writing
Jalsi Tacon Arruda: protocol development, data collection or
management, data analysis, manuscript writing
Paulo Moacir de Oliveira Campoli: data analysis, manuscript
writing
Matias Noll: manuscript writing, critical review
Waldemar Naves do Amaral: manuscript writing, critical review
Funding
This study had no funding or research contract.
Conict of interest
The authors declare no conict of interest.
Acknowledgments
The authors thank Eduardo Bonilha Rolin Jnior from the
Ministry of Health, Coordination of Documentation and Informa-
tion Library, Switching Bibliographical Sector, and the authors of
the studies who answered by e-mail courteously.
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