When was the last time you had sex for fun? If you are a couple receiving treatment for infertility you may be thinking you can’t remember that far back, to when sex was about making love to your partner instead of making a baby. In a recent article in the NY Post, a reporter undergoing treatment for infertility described the effect infertility treatment has in these words,” So far there has been more waiting than mating.”

For many infertile men and women sexual problems develop because of the emotional stress and physical demands of treatment. One study found that even couples who have never had sexual problems will be less satisfied sexually at some point during treatment while others found that problems increased the longer the couple was in treatment. Less often, sexual dysfunction is the cause of infertility because it interrupts the sex act and prevents conception. For example, vaginismus is a condition in women where vaginal muscle spasms prevent penetration.

In males, sexual problems may be caused by disorders of desire, arousal, or ejaculation/orgasm. These include erectile dysfunction (ED), premature ejaculation, and retrograde ejaculation, a condition that causes semen to go into the bladder rather than out of the penis during orgasm. In females, sexual problems may result in disorders of arousal or orgasm, vaginismus and dyspareunia, a condition that makes intercourse painful. Dyspareunia can be caused by sexually transmitted diseases (STDs), pelvic inflammatory disease (PID) or endometriosis, a condition where tissue similar to the lining of the uterus is also found in other parts of the body, mainly the abdominal cavity. Of these sexual problems, premature ejaculation is the most commonly occurring in men and arousal disorders the most commonly occurring in women. Sexual dysfunction can also result from the use of certain non-fertility related medications such as those used to treat high blood pressure, psychosis and depression.

Social and cultural pressure on the infertile couple to have a baby just intensifies their emotional distress since sexuality is tied into self-esteem and how we see ourselves as men and women. Sexual dysfunction that goes on for a long time usually results from feeling unattractive, defective, guilty, shameful, depressed and angry. By comparison, loss of sex drive may stem from the stress of infertility on the marriage or the demands of treatment. Silent resignation may result when one or both partners stop caring about sexual satisfaction and see lovemaking only as a duty.

For women, the relationship between sexuality and reproduction may be even more difficult to separate so that problems in one area naturally cause problems in the other. Research has shown that women assume responsibility for infertility even if the cause is due to a male factor, they seek treatment more often and most of the tests and treatments are done to them. Combined with certain medications that can affect desire, it is easy to see how feelings of loss, inadequacy and low self-worth can hurt sexuality.

On the other hand, it is assumed that men can perform sexually whenever they want, a myth that can prevent them from discussing the problem or asking for help when they need it. One of these assumptions is that it is “no big deal” for a man to produce a sample on demand, multiple times, in a less than ideal atmosphere - a busy, noisy, doctor’s office. Research shows that men diagnosed with male factor infertility respond emotionally with feelings of failure, inadequacy, loss of potency and poor self-esteem, similar to those women experience. The result may be sexual intercourse becomes routine and lacks excitement which may then lead to performance anxiety or dreading sex altogether. Men in one study described the following two scenarios: “stud service or feelings of being wanted for sperm only” and “queen bee syndrome, or feeling their only importance is to fertilize their partner.”

One study of more than 500 infertile couples listed the following as causes of their sexual dysfunction:

• Dyspareunia (painful intercourse)
• Progesterone-inhibited sexual desire
• Sex on demand
• Unrealistic sexual demands
• Rigid or a routinized approach to sex
• Poor body image
• Depression
• Guilt
• Ambivalence

The same researcher asked 87 infertile couples what clinicians could do to reduce the impact of infertility on sexuality. Some of their responses included:

• Discuss potential problems ahead of time
• Encourage discussion between the couple
• Avoid placing blame
• Avoid being too specific about the timing and technique for intercourse

On a more positive note, research shows that most infertile couples find their relationships get stronger when dealing with the challenges of infertility and sexual problems related to infertility are usually short-lived. Since couples rarely seek treatment for sexual dysfunction here are some suggestions from an infertility counselor that may help avoid problems:

1. For men- bring ear plugs to drown out the office noise and your own magazines or videos if you must produce a sample in the doctor’s office
2. Take turns planning special “sex” dates at non-fertile times
3. Practice “non-intercourse” sexual pleasuring
4. Plan treatment holidays focusing on renewing intimacy and warmth
5. Plan a hotel date or special time away from home for “distraction-free” sex
6. Devote time to activities and interests you enjoy as a couple
7. Be creative and inventive
8. Try erotic books, games or videos
9. Renew your commitment to each other

If you continue to experience sexual problems don’t be afraid to discuss this with your physician or ask for the name of a counselor or sex therapist.

For more information on this topic visit these websites:
Resolve:
http://www.resolve.org/site/PageServer?pagename=lrn_jfm_mfi
http://www.resolve.org/site/DocServer/WhatsLove.pdf?docID=581
http://www.resolve.org/site/PageServer?pagename=cop_tainf_iaos
American Fertility Association:
http://theafa.org/secure/nobarriers/pubs/AFA_Infocus_FertilityandSexuality.pdf
American Society of Reproductive Medicine:
http://www.asrm.org/Patients/FactSheets/Sexual_Dysfunction-Fact.pdf

References:
Aribag S, Aribag A. Psychosexual factors in infertility. J Med Assoc Thai 1985; 68: 87-90.

Berg B, Wilson J. Psychological functioning across stages of treatment in infertility. J Behav Med 1991; 14: 11-26.

Brill M. Antidepressants and sexual dysfunction. Fertil Steril 2004; 81: 35-40.

Drake T, Grunert G. A cyclic pattern of sexual dysfunction in the infertility investigation. Fertil Steril 1979; 32: 542-5.

Hammer Burns L. Sexual counseling and infertility. In Hammer Burns L, Covington S, eds. Infertility Counseling: A Comprehensive Handbook for Clinicians. New York: The Parthenon Publishing Group Inc; 149-76.

Karahasanoglu A, Barglow P, Growe G. Psychological aspects of infertility. J Reprod Med 1972; 9: 241-7.

Keye W. The impact of infertility on psychosexual function. Fertil Steril 1980; 34: 308-9.

Keye W. Psychosexual responses to infertility. Cini Obstet Gynecol 1984; 27: 760-66.

Keye W, Deneris A. Female sexual activity, satisfaction and function in infertile women. Infertility 1982; 5: 275-85.

Leader A. Infertility: clinical and psychological aspects. Psychiatr Ann 1984; 14: 461-7.

MacLean F. Drug induced sexual dysfunction and infertility. The Pharmaceutical Journal 1999; 262: 780-4.

Mazor M. Emotional reactions to infertility. In: Mazor M, Simon H, eds. Infertility: Medical, Emotional, and Social Considerations. New York: Human Sciences Press, 1984; 23-35.

Nachtigall R, Becker G, Wozny M. The effects of gender-specific diagnosis on men’s and women’s response to infertility. Fertil Steril 1992; 57: 113-21.

Read J. Sexual problems associated with infertility, pregnancy and ageing. BMJ 2004; 329: 559-61.

Reading A. Sexual aspects of infertility and its treatment. In Greenfeld D, ed, Psychological Issues in Infertility 1993; 4: 559-67.