Background: Female sexual dysfunction (FSD) is a common health problem that is inadequately investigated in Egypt. Sexual problems are reported by approximately 40 percent of females worldwide. There is a strong relationship between FSD, quality of life and infertility.

Objective: The aim of this study is to assess the prevalence of female sexual dysfunction and also to investigate possible risk factors that may cause sexual dysfunction in the Egyptian infertile women seeking fertility

Patients and Methods: This cross-sectional clinic-based survey was conducted at the infertility clinic, in Kasr Al-Ainy Hospital, Cairo, Egypt from October 2023 to February 2024. During this study, 186 women were enrolled and asked to answer the validated Arabic version of the Female Sexual Function Index and World Health Organization Quality of Life Questionnaire- Brief that were provided by female investigators.

Results: 186 females were included in our study. The prevalence of FSD was 56 females (30.1%) while 130 females (69.9%) had good sexual function with FSFI >28.1. Also, patients with sexual dysfunction had mean value of QoL that was (38.5±8.7) while females with good sexual function had mean value of QoL that (64.2±11.2) respectively.

We found that the most frequent risk factors of female sexual dysfunction were advanced maternal and paternal age, no maternal occupation, duration of marriage <5 years, nulliparous women ,maternal obesity, timed intercourse and number of IVF trials.

On the other hand, no relations were reported between female sexual dysfunction and family income, residence, menstrual Rhythm, associated chronic medical diseases, drug intake, contraception, vaginitis, mode of delivery, circumcision and previous episiotomy.

Conclusion: FSD is a major health problem that affect 30.1% of women attending infertility outpatient clinic in Kasr Alainy Hospital and greatly affected their quality of life.

Keywords: female sexual dysfunction, infertility, episiotomy, women

Sexual function is an essential component of life, and its dysfunction can affect the quality of life of an individual. Female sexual dysfunction (FSD) is a highly prevalent, underestimated health problem. According to the Diagnostic and Statistical Manual of Mental Diseases, sexual dysfunction is characterized by a disturbance in the sexual response cycle or by pain associated with sexual intercourse. It is defined as a disorder of sexual desire, arousal, or orgasm and/or sexual pain that leads to personal distress and affects quality of life and interpersonal relationships. Sexual dysfunction may be a problem since the start of sexual activity or may be acquired later in life after a period of normal sexual functioning.¹

Sexual dysfunction could be linked to many causes; educational level, age, employment, social level, mental health, religion, partner sexual function, medications, pelvic operations, infertility.²

Moreover, multiple deliveries, Lactation, menstruation, hormonal disturbance, and menopause could have marked impact on sexual function of ladies.³

There are three criteria for diagnosing a sexual disorder: symptoms need to have persisted for a minimum of 6 months, they need to have been experienced in all or almost all (75% to 100%) sexual encounters, and to have caused clinically significant distress.⁴

Due to embarrassment, religious sensitivities, and Eastern values, sexual issues are rarely raised by Egyptian women during medical care. As a result, FSD in Egypt is under-reported, under-treated and under-studied. How much risk of FSD is prevalent in Egypt and what exactly is its magnitude are common questions. Our aim is to evaluate the prevalence and predictors of FSD among a sample of women attending the primary care and gynecology clinics.

Aim of the work

The aim of this study is to evaluate the prevalence and risk factors of FSD among a sample of women suffering from primary or secondary infertility attending the infertility clinic.

In this study, 350 married females attending infertility clinic were assessed for eligibility. Ninety nine females did not meet inclusion criteria, 40 females refused to participate and 25 missing response. The remaining 186 females were included in the final analysis (Figure 1).

Figure 1 CONSORT Flowchart of participant eligibility.

Table 1 shows demographic characteristics for females in the study group. The most common age group was (18-25) represented by 43% (80 females). The most prevalent educational level was high school 26.8% (50 female). Most females were housewife 61.3% (114 female) and all participants were non smokers.

Table 2 shows demographic characteristics for husbands of participants in the study. The majority of participants husbands were 18-25years old 61.8% (115 male). The most prevalent educational level was high school 30.1% (55 male) and the majority of participants were skilled workers 67.7% (152 male). There were 101 males who were smokers.

Table 3 shows that the majority of participants had low family income 92.5% (172) .The majority of participants were urban 66.1% (123).

The majority of participants were obese 48.4% (90 female) and women with normal weight constitute the least percentage. Twenty percent of participants (36 females) were suffering from chronic medical diseases (diabetes, hypertension and bronchial asthma). Ten females used antidepressant drugs (Table 4).

The majority of the participants were fairly satisfied with their spouses 45.6% (85 female). There were five females (%2.6) suffered from sexual abuse .Most participants (174 females:93.5%)were married from less than 5 years. marriage duration was less than 5 years 93.5% (174 female) (Table 5).

Most participants were nullipara 62.9 % (117 female). The most prevalent mode of delivery was cesarean section (27.5%; 51 female).Eighteen females delivered vaginally, all of them of had episiotomy during their vaginal delivery (Table 6).

Table 7 shows that the majority of participants had irregular menses 52.2% (97 female).Majority of females suffered from primary infertility (112females:60.8%) while 74 females(39.8%) suffered from secondary infertility after they delivered vaginally (18 females) or by CS (51 female ) or aborted (5 females. A small number of participants were circumcised (15.5%; 29 female). 60.2% of participants (122 female) had no genital tract infection in the form of vaginitis or cervicitis at time of interview. Only 2 of participants had 3rd or 4th degree perineal tears , also 14% of participants had chronic pelvic pain .Twenty-two of paticipants had gynecological conditions such as pelvic organ prolapse, urinary incontinence, abnormal uterine bleeding.

Table 8 shows that cause of infertility were variable with different percentages .Forty-three percent was female factors, (36.1%) was male factor, while about (12.3%) was unexplained infertility. The most common cause of females infertility was ovarian (47 females: 25.2%) followed by tubal factor (28 females: 15.1).

Table 9 shows that majority of females participating in study did folliculometry, hormonal profile and HSG, while only 17females (9.2%) performed DHL.

Twenty-seven of females participating in study did IVF procedures. Majority of study participants used medications for induction of ovulation (150 females: 80.6%) (Table 10).

Table 11 shows that mean±SD of Total FSFI score was (29.2±4.9) and mean±SD of Full QOL score was (42.27±3.9).

Table 12 shows that the prevalence of female good sexual function (with FSFI >28.1) was 69.9% (130 female) while 56 females (30.1%) had poor sexual dysfunction with FSFI <28.1.

Table 13 shows statistically significant association between female sexual dysfunction and age group 25-35 years, (with p-value 0.001).there was no statistically significance between sexual dysfunction and educational level however primary school and university levels were the most common educational levels affected. There was also a statistically significant association between sexual dysfunction and females with no occupation (p<0.001) among females in the study group.

Table 14 shows a statistically significant association between FSD and age (30-40yrs) (with p-value 0.001).there was no statistically significant association between sexual dysfunction and educational level (p-value 0.08) however high school level was the most common educational level affected. There was no statistically significant association between sexual dysfunction and occupation, however skilled manual workers were the most common group suffered from FSD.

Table 15 shows that there was no statistically significant association between sexual dysfunction and low family income (p-value 0.58); also, no statistically significant association between sexual dysfunction and urban residence (p value 0.19)

Table 16 shows a highly statistically significant association between sexual dysfunction and body mass index (p-value 0.001).FSD occurred more frequently with obesity. There is no statistically significant association between FSD and chronic medical diseases or drug intake.

Table 17 shows a highly statistically significant association between female sexual dysfunction and dissatisfaction with the spouse (p<0.001); also, we found a highly statistically significant association between sexual dysfunction and duration of marriage <5 years (p<0.001), most cases with FSD occurred with duration of marriage less than 5 years.

Table 18 shows that there were no statistically significant associations between female sexual dysfunction and contraception, menstrual Rhythm, vaginitis.

Table 19 shows a highly statistically significant association between female sexual dysfunction and nulliparity. There were no statistically significant association between female sexual dysfunction and circumcision, performing episiotomy, mode of delivery.

Table 20 shows a highly statistically significant association between female sexual dysfunction and number of IVF trials (p. value 0.001).there was also a statistically significant association between female sexual dysfunction and timed intercourse (p-value 0.001). There was no statistically significant association between female sexual dysfunction and intraurerine insemination

Table 21 shows a highly statistically significant between female sexual dysfunction and quality of life, with p-value (p<0.001).

Sexual problems are reported by approximately 40 percent of females worldwide, and approximately 12 percent (one in every eight females) have a sexual problem associated with personal or interpersonal distress.⁵

Female sexual dysfunction refers to a sexual problem associated with personal distress. It takes different forms, including lack of sexual desire, impaired arousal, inability to achieve orgasm, or pain with sexual activity.⁶

Sexual dysfunction may be a problem since the start of sexual activity or may be acquired later in life after a period of normal sexual functioning.⁷

Consequently, this study was conducted and aimed to assess the prevalence and risk factors of female sexual dysfunction among infertile females seeking fertility treatment.

This cross-sectional clinic-based survey trial was conducted at Obstetrics and Gynecology Department, Faculty of Medicine, Cairo University, infertility clinic from October 2023 until March 2024.

During this study, 186 women were enrolled, after consenting each of them and data was collected using a structured interview questionnaire where each participant was interviewed and given the same questions in the same way and the same order. Participants were asked to answer the validated Arabic version of the Female Sexual Function Index and World Health Organization Quality of Life Questionnaire- Brief that was provided by female investigators.

To the best of our knowledge, there are few studies in literature assessing our study outcomes and most of studies that disagreed with our results were due to several causes as different study methodology, outcomes, sample size and different medical conditions of studied cases at time of enrollment, different socioeconomic, religious and cultural background.

Regarding our 1ry outcome, we revealed that the prevalence of female sexual dysfunction was 30.1% (56 females) while 69.9% females (130) had good sexual function as regard FSFI >28.1. Patients with sexual dysfunction had mean value of QoL that was (38.5±8.7) while females with good sexual function had mean value of QoL that (64.2±11.2) respectively.

Alselaiti et al.⁸ estimated the prevalence of FSD in Bahrain, which is male-centered and impacted with cultural and Islamic religious standards, and the associated variables with FSD, including the barriers to seeking medical help from health-care professionals. They reported that of 360 enrolled women, 43% reported having sexual problems during intercourse (p < 0.05, 95% CI 38.1–48.6%). Most of the sexual problems were related to having painful intercourse (42%) or low sexual desire (37%). Furthermore, the mean age of females with FSD was (30-45years) significantly higher than females with no FSD (19-28years), with (p-value< 0.05). Most importantly, the multinomial logistic regression analysis showed that husband polygamy was linked to FSD with an OR of 2.469 (95% CI 1.218– 5.001). On the other hand, females with low to no parity were associated with lower rates of FSD with an OR of 0.482 (95% CI 0.252–0.922). Furthermore, more than 96% of females were not asked by their doctor about their sexual problems, and 87% of the participants did not dare to discuss the problem with their doctor.⁸

Regarding our 2ry outcome (risk factors) for FSD, our study reported that female sexual dysfunction was statistically significantly higher among women aged between 26-35 years, with and no occupation, duration of marriage < 5 years. Also, sexual dysfunction was statistically significantly higher among participants’ husbands aged 24-30 years.

In a large US study by Shifren et al.,⁹ education was identified as a protective factor against sexually distressing problems.⁹

In studies from Iran and Jordan, Abdo et al.,¹⁰; Safarinejad et al.,¹¹; and Vahdaninia et al.,¹² found that young women who are educated and have gainful employment are less likely to show symptoms of sexual dysfunction.^10–12

However, several studies from China have shown that young women who have higher education were more likely to report sexual dysfunction.^5,13,14

Through higher education, a study made by Choi et al.¹⁵ reported that these women gain increased awareness of their sexual needs and rights, and such women tend to feel more disappointed with their marital and sexual relationships, which may lead to poor sexual functioning.¹⁵

Similarly, while increased frequency of sexual intercourse was found to have a protective effect in most cultures, some studies such as Lau et al.¹³ and Ojomu et al.¹⁶ in traditional cultures showed that frequent sex might be demanded by the partner and is therefore a risk factor for sexual dysfunction in these women.^13,16

Some predictors showed variation within the domains. For example, female sexual dysfunction has generally been shown to be age-related in study. Older age tends to be a risk factor for all domains except for pain disorder(s), where it is shown to have a protective effect. A previous study showed a U-shaped prevalence of sexual dysfunction, with younger and older women being most affected.¹⁷

In our study, we noted highly statistically significant association between sexual dysfunction and nulliparity, dissatisfaction with spouse and maternal obesity.

Finally, no statistically significant associations were reported between sexual dysfunction and family income, residence, menstrual Rhythm, associated chronic medical diseases, drug intake, contraception, vaginitis, mode of delivery, circumcision and previous episiotomy

McCool-Myers et al.¹⁸ reported that consistently significant risk factors of female sexual dysfunction were poor physical health, poor mental health, stress, abortion, genitourinary problems, female genital mutilation, relationship dissatisfaction, sexual abuse, and being religious.¹⁸

Risk factors such as high acceptance of pornography, masturbation, liberal sex values and knowledge of the clitoris were unique to Asian population studies.

Lau et al.¹³ explain that in these societies such women are considered non-traditional. Women who do not conform to traditional female roles in these societies may experience greater difficulties with their male partners.¹³

Current practices in these cultures such as arranged marriages, marriages at a young age, polygamy and female genital mutilation are associated with significantly higher levels of sexual dysfunction in women.^19,20

Finally, women in conservative cultures may also be too hesitant to express their needs or feel that it is socially unacceptable to discuss sexual problems with their partner as reported Lo and Kok¹⁵ and Choi et al.^15,21

In our study, we noted that most of the study population were suffering from primary infertility about (60.2%) compared to patients with secondary infertility who were about (39.8%).

The study also show the causes of infertility were variable with different percentages .forty three percent (43.5%) was female factors, (36.1%) was male factor, while about (12.3%) was unexplained infertility.

There was highly statistically significant association between sexual dysfunction and number of IVF trials and timed intercourse. Twenty-seven females in our study did IVF Trials, 19 females (70.3%) of them complained from different female sexual dysfunction.

Dong et al (2021), the incidence of FSD and psychological distress might rise, particularly when the period of infertility is more than eight years.

Winkelman, W. D et al.,²²:found that causes of infertility were as follow :female factor only (58.8%), whereas 30.4% of infertility was a combination of male and female factors, 7.3% was male factor only, and 3.5% was unexplained infertility. In bivariate and multivariate analyses, women who perceived they had female factor only infertility reported greater sexual impact compared with woman with male factor infertility (P = .01). Respondents who were younger than 40 years experienced a significantly higher sexual impact than respondents older than 40 years (P < .01). When stratified by primary and secondary infertility, respondents with primary infertility overall reported higher sexual impact scores.²²

Millheiser et al.²³ study found that Twenty-five percent of our control group had Female Sexual Function Index scores that put them at risk for sexual dysfunction (<26.55), whereas 40% of patients with infertility met this criterion. Compared with the control group, the patients with infertility had significantly lower scores in the desire and arousal domains and lower frequency of intercourse and masturbation. The patients with infertility retrospectively reported a sex-life satisfaction score that was similar to that of the controls before their diagnosis, whereas their current sex-life satisfaction scores were significantly lower than those of the controls.²³

Mariam Saadeldine et al.,²⁴ the relationship between obesity and female sexual function is not consistent across studies. While women with obesity are more likely to have worse sexual function and avoid sexual activity, many studies have failed to identify these associations. Lifestyle changes resulting in weight loss lead to better sexual function, and bariatric surgery has been shown to improve sexual function in the first couple of years following the procedure; yet, the long-term effects of weight loss and bariatric surgery are still uncertain. The evidence on the relationship between obesity and female sexual function is mixed. Nevertheless, weight loss has been shown to improve sexual function in women with obesity.²⁴

The strength points of this study are that

1. It was cross-sectional clinic- based survey design and having no patients who were lost during the study period
2. It was the first study in Cairo University Hospitals to assess the prevalence and risk factors of female sexual dysfunction in females seeking fertility
3. All assessment and evaluation of study outcomes were done by the same team.

Limitations of the study

• Communication with some women was challenging due to embarrassment, religious sensitivities, and Eastern values. Some of them considered open discussion is a taboo.
• Facing uncooperative women who didn’t have enough time to wait for their turn.
• This study was a hospital-based study, hence there was a limited number of cases with relatively smaller sample size relative to study outcomes, not being a multicentric study and this represents significant risk of publication bias and did not represent a particular community.
• The study was performed at a tertiary hospital, hence there were multiple factors couldn’t be represented as most of tertiary hospital are free of fees, targeted by patients of general population, lower levels of education, family income and different parameters which depend on the type of patient.

Female sexual dysfunction is a major health problem and about 30.1% of women attended infertility outpatient clinic in Kasr Alainy Hospital suffered from sexual dysfunction that greatly affected their quality of life.

The most frequent risk factors of female sexual dysfunction were advanced maternal and paternal age, l, no maternal occupation, duration of marriage <5 years, nulliparous women ,maternal obesity, timed intercourse and number of IVF trials.

On the other hand, no relations were reported between female sexual dysfunction and family income, residence, menstrual Rhythm, associated chronic medical diseases, drug intake, contraception, vaginitis, mode of delivery, circumcision and previous episiotomy

Recommendations

1. Female sexual dysfunction is advised to be evaluated using easy and simple questionnaires for women attending outpatient clinics for early diagnosis and better management of this healthcare problem and improving their quality of life.
2. Future prevention strategies should aim to address modifiable factors (e.g. physical activity, women education, employment, family income, family planning and access to sex education; international efforts in empowering women should continue.)
3. The present study can burden the knowledge and shed some light on future prospective studies with larger sample sizes to confirm our results and reassess other risk factors.
4. This study was a hospital-based study, hence there was a limited number of cases with relatively smaller sample size relative to study outcomes, so we recommend the study to be a multicentric study to be more representive.

None.

None.

The authors report no conflicts of interest.

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