الفهرس 
HIGHLIGHT ON WOMEN’S SEXUAL AROUSAL AND ORGASMOnly 14 pages are availabe for public view
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Abstract
S
exual dysfunctions are 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 (DSM-V diagnostic classification 2013).
It has several domains. The Diagnos¬tic and Statistical Manual of Mental Disorders (DSM-V) lists the types of sexual dysfunctions in females as fe¬male sexual interest/arousal disorder, female orgasmic disorder, and Genito-pelvic pain/penetration disorder (IsHak and Tobia, 2013).
When it comes to the definition of sexual health, we found that the WHO defines sexual health as “a state of physical, emotional, mental, and social well-being in relation to sexuality, not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences free of coercion, discrimination, and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected, and fulfilled” (World Health Organization, 2016).
Regarding the fertility, it is defined as the capacity to conceive and produce offspring. Infertility is the state of a diminished capacity to conceive and bear offspring. The current clinical definition of infertility is the inability to conceive after 12 months of frequent coitus. Infertility prevalence is approximately 13% among women and 10% among men (Datta et al., 2016).
On reviewing the relationship between infertility and sexual dysfunction, literature showed that women with infertility have more sexual dysfunctions than the general population. It was found also that sexual dysfunctions may be the result of infertility or the cause of infertility (Bakhtiari et al., 2016).
In the recent years, the relationship between infertility and psychiatric disorders has been explored, finding that the rates of psychiatric disorders are high in people affected by infertility (Maroufizadeh et al., 2018).
Also, the infertility diagnosis has a strong impact on mental health and sexual functions of the females. The commonest psychopathologies which were associated with the reproductive problem, were depression and anxiety (Cocchiaro et al., 2020).
The prevalence of psychiatric problems in infertile couples is estimated to be between 0.25 and 0.60 and the rate of depression and anxiety was significantly higher than the fertile group and the general population (De Berardis et al., 2014).
The studies investigating the impact of infertility on female sexual dysfunction are scarce, but they have consistently demonstrated that sexual complaints are very common among infertile women. Sometimes appropriate treatment of female sexual dysfunction can preclude the use of expensive and unnecessary treatment for infertility. This study compared sexual dysfunction and quality of life among the infertile women and fertile women. The study was conducted at the infertility outpatient clinic and the Gynecology outpatient clinic, Obstetrics and Gynecology hospital, Faculty of Medicine, Ain Shams University hospitals, Cairo, Egypt.
The aim of this study was primarily to assess the female sexual function among the infertile women, secondly was to compare between the infertile females and the fertile females regarding sexual dysfunction, thirdly was to determine other co-morbid psychiatric disorders in the infertile women with sexual dysfunction, then to detect socio-demographic and clinical risk factors of sexual dysfunction in the infertile women, and finally to investigate the impact of sexual dysfunction on the quality of life of the infertile women.
The sample of the study was consisted of two groups the first one was the infertile group who were recruited from the infertility outpatient clinic, 168 of married female patients selected from the infertility outpatient clinic, age: 18-45 years old, and the operational definition of infertile woman: Married female who failed to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse and lack of contraceptive use.
The second group was the fertile group which had 167 of married females who had the capability of producing offspring through normal sexual activity, and matched the cases group, selected from gynecology outpatient clinic, age: 18-45 years old, they were female who had at least one child and not in puerperium.
Exclusion criteria for both groups were history of surgical procedures of genital area, recent episiotomy, vaginal discharge, bleeding, or infection of genital area, history of absent or sexually unavailable partner in the last month, history of major surgeries as mastectomy and hysterectomy or chronic illness, history of medical conditions or medications (SSRI, MAOI, antihypertensive drugs, CNS stimulant, TCA and antipsychotics) or substance abuse (Alcohol, opiates, etc.) within the past 6 months, history of any psychiatric disorder (depression, anxiety disorder or psychosis … etc) and finally females who were not sexually active due to medical recommendations.
After an informed written consent was offered to the participants of the study that included the name of the study, its aim and detailed description of the scales which would be used in the study, all the females who participated fill the following questionnaire; designed questionnaire for demographic data, Arabic version of Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID-I): (El Missiry et al., 2004), The Arabic version of Female Sexual Function Index (FSFI) (Anis et al., 2011), the Arabic version of PCASEE Quality of Life Questionnaire: (Beck et al., 1993; Youssef et al., 2002), and finally Socioeconomic scale (El Shakhs, 1995).
While we were processing the sample, we had 7 patients who refused to complete the female sexual function index questionnaire as it was embarrassing for them, however other females were reluctant in the beginning of the interview to complete the female sexual dysfunction index scale, because of its sensitive content about their sexual life.
The results showed that on comparison between infertile females and fertile females regarding sexual dysfunction, in the infertile group, 25.59% had no sexual dysfunction while 74.4% had sexual dysfunction. Meanwhile in the fertile group 35.32% had no sexual dysfunction and 64.67% had sexual dysfunction.
Several other studies showed similar finding for example, the study by Mirblouk and his colleagues, their results showed that FSD was 74.5% among group of Iranian infertile females (Mirblouk et al., 2016).
Our results also were consistent with an Egyptian study which was held at Cairo University Hospital and conducted by Gabr and his colleagues, the results showed that proportion of females with sexual dysfunction was higher in the infertile versus control group (47% versus 30%, 95%CI for the difference: 8%, 26%, p-value: <0.001) (Gabr et al., 2017).
However, current study results were inconsistent with Iris and his colleges, as their results reported no significant correlation between infertility and sexual dysfunction but reported lower sexual domains score with increased duration of infertility (Iris et al., 2013).
Comparison between sexual dysfunction index variables between infertile females and fertile females only sexual arousal, pain and lubrication showed significant results. Which were not with another Egyptian study by Mustafa and his colleagues who found that desire and orgasm were the most affected domains (Mustafa et al., 2019).
At the end, on correlation between the infertility duration and the sexual dysfunction, negative spearman correlation was found, between the females sexual function all parameters, total score of FSFI index, and the infertility duration, denoting a decrease of infertility duration with improved female sexual function indices and vice versa.
Regarding the co-morbid psychiatric disorders in infertile females group, results revealed significant statistically relation between sexual dysfunction and psychiatric comorbidities.
Moreover, on comparison between comorbid psychiatric disorder in the infertile group 43 of the infertile females who had no sexual dysfunction there was 1 patient with mood disorder, while in the 125 females of the infertile females who had sexual dysfunction, 19 females were found to have anxiety disorder and 25 patients had mood disorder with significant results.
Our results were similar with another study’s results, in which the sexual functions and the depression prevalence of the infertile women were assessed, the results showed that the depression prevalence was significantly higher in the women with sexual dysfunction (Kucur et al., 2016). It was also congruent with another Korean study which results showed that anxiety and depression reported in 23% and 17% of infertile women under treatment (Chi et al., 2016).
However, results were not similar to an Indian study which was conducted in 2018 by Singh and his colleagues, and they reported other psychiatric comorbidities e.g., paranoid ideation, psychoticism, and phobic anxiety which more prevalent among the infertile females, it could be explained that while in social gatherings, without adequate evidence, these women would believe that they were being watched or were being talked about in relation to their childless status (Singh, 2018). This difference could be explained by different culture and different scales that were used in both studies.
Furthermore, it was shown that the infertile females who had sexual dysfunction exhibited poor quality of life in all domains of the PCASEE questionnaire i.e., physical domain, QOL cognitive domain, QOL affective domain, QOL social domain, QOL economic domain, and QOL ego domain. These results were similar to Adulogu and his colleagues study, their results revealed that the infertile women were more anxious, more depressed, more emotionally unstable than the fertile women, which could be accounted to higher susceptibility of the infertile women to develop high levels of emotional distress and other psychological conditions such as depression and anxiety more so than the fertile women (Adulogu et al., 2018).
Further investigation for to detect socio-demographic and clinical of sexual dysfunction in the infertile women, results revealed that living in rural area, being housewives, females with lowed education level, and finally average socio-economic status were found to be socio-demographic risk factors for sexual dysfunction. The results were similar to Turikish study regarding the housewives, (Ozturk et al., 2019). And inconsistent with an Egyptian study which showed that the infertile group had higher proportions of the working females with 65% (Gabr et al., 2017). But concordant with Mustafa and his colleagues regarding the educational level (Mustafa et al., 2019).
To conclude, female sexual dysfunction has a definite impact on infertility, further assessments should be considered in the infertility clinic, proper documentation as well. Management should include psychotherapy, lubricants, targeted sexual therapy and pharmacological treatment, these interventions should be offered to the females suffering from sexual dysfunction who rarely go under further assessments due to cultural barriers.