Exploring infertile women's experiences about sexual life: A qualitative study

Abstract

Background:

Infertility is a serious problem in a couple's life that affects their marriage relationships. So, dissatisfaction with sexual function resulting from interpersonal problems is common among these couples. This qualitative study aimed to explore the experiences of infertile women in their sexual life.

Materials and Methods:

This is a qualitative study with a phenomenological approach. The participants were 20 infertile women referring to the health care centers and infertility clinics of Isfahan and were selected through purposive sampling. Data were collected by tape recording of deep interviews and analyzed by Colaizzi's method.

Results:

Analysis of the participants’ experiences led to five main concepts: “Disturbed in femininity-body image,” “discouragement of sexual relations,” “sacrifice of sexual pleasure for the sake of getting pregnant,” “confusion in sexual relation during infertility treatment,” and “striving to protect their marriage.”

Conclusions:

Findings revealed that infertility affects women's different aspects of sexual life, especially disturbance in femininity-body image and sexual reluctance. With regard to women's willingness to protect their matrimonial life and prevent sexual trauma as a destroying factor for their family's mental health, it seems sexual counseling is necessary for infertile couples.

INTRODUCTION

Fertility has a considerable value among people from different cultures and the desire of having kids is one of the most basic human motives. In Iranian culture, pregnancy and motherhood are considered to be essential necessities of womanhood and are strongly emphasized. If trying to get pregnant fails, it can lead to an emotionally devastating experience. Therefore, infertility, as a crisis, can be one of the main stressors which drive the couples temporally or chronically to desperation.[1] Infertility, which refers to failure of conception after 1 year of coition using no contraception, is a problem experienced by 10-15% of the couples in the world.[2] The reported prevalence of infertility ranges from 12 to 21.9% in Iran.[3] Infertility results in some relational and emotional traumatic effects including anxiety, depression, losing self-esteem, and sexual problems.[4] Because people have unique personality traits, supportive systems, and lifestyles, the type of problem experienced by each and everyone may be different in many respects and they would express their experiences differently,[5] but the infertile ones seem to be more vulnerable and, therefore, express their problems more than others.[6]

Psychologists believe that if the cause of infertility belongs to women, they will face critical emotional conditions. Feeling worried and frightened of their spouses’ attitude towards the problem and the collapse of the family unit are the first concerns which make women seek for any possible interventional method to get rid of treatment failure. Besides the woman's love of being a mom, patriarchal paradigms for leaving offspring, lack of socio-economic supports for most of the women, low chance of remarriage for an infertile woman and condemnation of leading a solitary life are some of the factors which double their infertility concerns. Men after being diagnosed infertile experience a period of psychological destruction, an instability which results in anger, helplessness and sense of guiltiness. In this regard, infertility experts make every effort to achieve conception and also make the couples adapt to meet their existing circumstances to protect them against infertility psychological problems. But they do this through education of correct techniques to achieve conception and ignore conducting a more pleasurable sexual activity. Therefore, most infertile individuals experience loss of libido before having their infertility problem modified.[7] Ohi et al., in a study on the effect of infertility on sexuality, reported that although female participants were satisfied with their marital life, they experienced loss of libido and sexual responses during sexual activities. They believed that their sexual dysfunctions were a direct consequence of the treatments and techniques prescribed by the physicians to increase the chance of conception.[8] Another study by Vischmann et al. on the physiological characteristics of infertile women and men revealed that these couples experience a high level of psychological distress, especially depression and sexual dissatisfaction, and women suffer more from these dysfunctions compared to men.[9] Experiencing sexual problems in this period can threaten couples’ psychological health to a high extent.[5] As these individuals are exposed to various physical, social, and financial stressors, if they are deprived of their first and the most basic need (the desire for sexual activity), they will experience high emotional and physiological pressures.[10] Infertility problems have been found to be increasing in recent years, especially in Iran. Sexual issues are important in the preservation of individuals’ physical and mental health, and sexual desire is associated with human emotions and feelings. Appropriate detection of these feelings and emotions is not achieved through quantitative methods of measurement. So, this qualitative study was designed to discover the concepts and themes that emerged from description of sexual experiences by infertile couples by a phenomenological approach, perhaps as a step to improve their sexual health.

MATERIALS AND METHODS

As the goal of this study was to describe infertile women's sexual experience in Isfahan, it was conducted with a descriptive phenomenological design in the year 2013. This method is a process of learning and finding the meaning of lived experiences of the participants. This process and conceptualization is formed through a dialog with the individuals experiencing the related conditions. In other words, the research goal in phenomenology is to explore the meaning and concept of the lived experiences that the study participants had in a special situation.[11]

In this study, the research environment consisted of the infertility clinic of Shahid Beheshti Hospital, Isfahan Infertility Center, and health care centers. The participants were selected through purposive sampling and comprised Iranian and Persian speaking women whose infertility had been confirmed by physician, had no children, had no sexual disability and mental and psychological disease, and were interested to attend the study. The goals of the study were explained to them, and they filled the consent form to attend the study and to have their interviews recorded. Sampling lasted for 6 months and continued until data saturation. Finally, 20 infertile women were selected for the study. To collect the data, the researcher selected the participants based on inclusion criteria through purposive sampling after obtaining the permission and a letter of introduction from the Nursing and Midwifery School of Isfahan University of Medical Sciences. Then, she introduced herself and explained the goals of the study and invited them to enter the study. To collect the data, semi-structured deep individual interviews were conducted. The major questions of the interview were on explanation of sexual responses (women's sexual desires and pleasures), description of their sexual behaviors, and the manner of formation of their marital relationships. Interviews were recorded in a quiet and private place. After each interview, the researcher listened to it several times and transcribed it. The number of interviews was at the most two for each participant and each session lasted for 30-50 min. Data analysis was conducted by the seven-step Colaizzi's method. In the first step of Colaizzi's method, the transcripts were precisely read and re-read several times in order to obtain a general sense about the whole content and share subjects’ feelings. In the second step, for each transcript, significant statements that pertained to the phenomenon under study were extracted from the transcripts (extracting the primary codes). In the third step, meanings were formulated from these significant statements, so that similar codes were sorted into categories, clusters of themes, and themes.[12] For instance, grouping of the codes of “hypoactive in sexual desire,” “pleasure-free sexual activity,” and “awful sexual activity” made “dissatisfaction with sexual desire” the sub-theme, and clustering of the codes “low desire for sexual activity,” “forced and disgustful sexual activity,” and “delayed sexual activity” made “aversion in sexual activity” the sub-theme. Combination of the two above-mentioned sub-themes yielded the theme of “discouragement of sexual relations.” In the fourth step, finally all inferred concepts formed five themes of “disturbed in femininity-body image,” “discouragement of sexual relations,” “sacrifice of sexual pleasure for the sake of getting pregnant,” “confusion in sexual relation during infertility treatment,” and “striving to support marriage.” In the fifth step, the researcher, in addition to presentation of explanations to the participants, and extraction of key sentences and categorizing them, integrated the findings of the study into an exhaustive description of the phenomenon under study. In the sixth and seventh steps of Colaizzi's method, the researcher described the fundamental structure of the phenomenon, and finally, validation of the findings was sought from the research participants to compare the researcher's descriptive results with their experiences.[12]

For checking the accuracy and consistency of data, four criteria suggested by Streubert and Carpenter (validity, Reliability, confirmability, and transferability) were adopted.[13] The researcher tried to reflect the lived experiences of the participants in her obtained findings. Validity of the data was evaluated by participants’ checking and peer review. Reliability was obtained through long mental contact with data by the researcher, extractio n of primary codes from the participants’ comments and examples of theme extractions. To enhance confirmability, interview transcriptions, codes, and the extracted concepts were referred to external auditors who reviewed the whole process of the study and performed an additional checking for the coding process and reached a consensus. For transferability, the extracted concepts were given to individuals who matched with the participants, but did not attend the study, to get their judgments about similarity of research results and their own experiences.

The study considered all ethical considerations and was accepted by the university ethics committee; it was conducted after obtaining participants’ informed written consent. They were also informed that they could quit from the study any time they wanted.

RESULTS

The participants were 20 infertile women aged 20-48 years, with an educational level of above high school diploma (n = 7), diploma (n = 8), an associate degree (n = 2), and a bachelor's degree (n = 3). The length of marital life was 2-4 years in eight participants, 6-10 years in five, and >10 years in eight participants. The length of infertility diagnosis ranged 1-20 years. After data analysis, five themes and 11 sub-themes were extracted which have been presented in Table 1.

Table 1.

Themes and sub-themes which were extracted from infertile women's lived experiences

Disturbed in femininity-body image

The first inferred concept was disturbed in femininity-body image which was formed from two concepts of “disturbed body image toward fertility” and “disturbed body image toward ability in sexual relations.”

Disturbed body-image toward fertility

Most of the participants stated that one of their goals in marriage was pregnancy and having children. Therefore, disability in this regard can lead to their concern about their fertility and a disturbed body image toward their reproductive system function.

One of participants stated that she felt her reproductive system was inefficient.

She stated: “Infertility has negatively affected my mind so that I think my femininity is totally futile. I would lose temper and hit my genital area for its inefficiency asking why I cannot be pregnant like others. I sometimes think to throw it away as it is useless.”

Disturbed body image toward ability in sexual relations

Some of the participants stated that when they found out about their defective reproductive system, they felt they could not have the pleasure of sexual relation and lost their trust to provide sexual satisfaction to their spouses. A 25-year-old woman stated: “When I got to know about my infertility, I felt I was defeated in my sexual affairs and had no interest on these relations. I really felt disabled. I think when I cannot get pregnant, sexual relations are meaningless and I cannot have a good and ideal relation like before.”

Discouragement of sexual relations

The second concept was “discouragement of sexual relations.” Most of the participants believed that pregnancy and raising children were the goals and outcomes of sexual function and encountered discouragement of sexual relations due to their defect in fertility and frequent repetitive sexual relations with aversion and no pleasure.

Aversion to sexual relation

Most of the participants believed they performed their sexual relation with the goal of pregnancy after the diagnosis of their infertility, and as they did not achieve this goal, they had no desire for sexual relation anymore and found it a useless action, so they avoided that. A 28-year-old infertile woman stated: “As all my efforts for pregnancy were useless, I hate sexual relation and even getting close to my spouse. I dislike getting close to him, let alone having a sexual relation.”

Unwillingness of sexual relations

Participants clarified that their disability in pregnancy caused them to be thinking about just pregnancy during their intercourse, and as they were hopeless about getting pregnant, their sexual relation was not pleasant and they had no good feeling about it. A 42-year-old infertile woman stated: “When I knew about our infertility, I had no interest to have sexual relation and my desire and motivation to have sexual relation has notably decreased. We have very few intercourses, once in ten days or even once in a month. I feel no pleasure during our intercourse. Even sometimes, it is hard for me and gives me a bad feeling.”

Sacrifice of sexual pleasure for the sake of getting pregnant

It was another theme obtained from analyse of participants’ lived experiences concerning sexual relation. They sated that after their diagnosis of infertility, they had sexual activity just to have a child and ignored pleasure in their sexual relations. This theme emerged from two sub-themes of “restriction of sexual relation to pregnancy” and “lack of sexual pleasure due to feeling of its uselessness.”

Sexual relations conditioned by pregnancy

Most of the participants stated that after getting hopeless about their getting pregnant, they had no more desire for a sexual relation and performed sexual intercourse with the hope of getting pregnant on specific days when the chance of pregnancy was higher. An infertile woman stated: “I have stress during my sexual relation whether I get pregnant this time or not! So I accept sexual relation on the days with the higher possibility of pregnancy just with hope of a child. Sexual relation will get meaningful to me, when it gives me a baby.”

Lack of sexual pleasure due to feeling of its uselessness

The participants believed pregnancy is the outcome of sexual relation; therefore, their most important goal was achieving pregnancy, and as they did not achieve this goal, they found their sexual relation to be repetitive and useless and, consequently, were deprived of sexual pleasure. A 25-year-old infertile woman stated: “Some years after our infertility, I feel sexual relation is a useless and pointless action and gives no result. Why it should be repeated when I cannot get pregnant. It has no use anymore. These thoughts caused me to feel no pleasure in my sexual relation.”

Confusion in sexual relation during infertility treatment

Variety and complications of infertility treatment methods and their overlap with intercourses created sexual confusion in the participants as they were concerned when they had to talk about their sexual affairs to the treatment team. Concerns of planned intercourses and infertility treatment failure led to their confusion and lowered their sexual desire.

Concerns of a planned sexual relation during treatment

Participants claimed they had to have intercourses based on the physician's description to increase their chance of pregnancy. This issue caused them not to experience sexual pleasure due to their anxiety about pregnancies. A 28-year-old infertile woman stated: “When I had to take the physician's prescribed medication, we had to have sex in due time every night. I extremely got stressed to plan so as to coincide the medications with my husband's coming back home. Because of his job he may not to be home some nights or he may come back home late and would be so tired and not in a mood for anything. I had a weird stress as I had to follow physician's order precisely and felt no pleasure in intercourse as I was just fallowing the order.”

Suppression of sexual desire after infertility treatment failure

Most of the participants stated that they developed hopelessness after the infertility treatment failed, so sexual relation was tiresome for them and they had no desire to do it. A 23-year-old woman stated: “During infertility treatment, when my menstruation was delayed for two or three days, I would think I was pregnant, but after my cycle started, the world was dark for me and I was confined to the home and crying. I had no desire to have a sexual relation anymore. I even did not like my spouse to come close to me.”

Sexual behavior has changed

Some other participants stated that they had no desire for sexual relation after infertility treatment failure, but preferred to be kissed, patted, and to have verbal communications. A 27-year-old woman stated: “Every time my period starts, I dislike to have a sexual relation and I hate it for a while. I liked my spouse to talk to me, kiss me or support me.”

Striving to protect their marriage

Participants stated that infertility caused them emotional, psychological, familial, and social problems. They were worried about issues such as ruining their marital life, divorce, and their spouses’ remarriage, and tried to maintain their normal life through obedience in their sexual relation and seeking for a protector to improve their sexual function.

Obedience in marital relations

Although infertility led to lower sexual desire among infertile women, they responded to their spouses’ request for sexual relation despite their low sexual desire to prevent their normal life from disintegrating and to satisfy their spouses. A 28-year-old infertile woman stated: “I had less desire for it (sexual relation), especially from when I got to know about my infertility. It takes on my nerves, but I do it to satisfy my husband.”

Seeking for a protector in sexual function

Participants stated that they felt the diagnosis of their infertility and unsuccessful treatments made them lose their ability and the desire for a pleasant sexual relation; therefore, they sought support and guidance of their relatives and friends as well as their spouses and physicians. They believed a successful relationship is essential for a normal life. A 30-year-old infertile woman with history of 6 years infertility stated: “When I knew about my infertility, I got sexually cold, I disliked intercourse for a while, but my spouse insisted on visiting a physician. It was hard for me but I knew it was essential for our common life. I visited a doctor. Her counseling and prescription of medications positively changed my sexual relation with my spouse and I wish I could have a baby.”

DISCUSSION

In the analysis and investigation of participants’ sexual experiences in the present study, one of the main themes was “disturbed in femininity-body image.” This disturbance is raised though the body image fertility as well as sexual relationship ability. In other words, women considered the ability of having children as a feature of femininity and as a product of sexual relations. Therefore, after getting to know about their infertility, they are mentally concerned not only about their femininity but also about their sexual relationship with their spouses. Participants believed that their identity of femininity merely depended on their ability of fertility. So, infertility made them disturbed.

Tao et al. reported that anxiety and concerns about giving birth to children, as well as the grief due to infertility are counted as the major crises in life. They believed that if a woman is unable to give birth to a child, her body image is impaired.[14] On the other hand, body image influences behaviors such as marital relationship and sexual relations. Infertility is accompanied by a negative body image and poor marital relationship.[15] Beshart et al.[16] showed that infertility can disturb the sexual function through formation of a negative body image in infertile women.

The second extracted theme was “discouragement of sexual relations.” Analysis of participants’ experiences showed that pregnancy was the expected outcome of sexual function, as women had no sexual problem until they got to know about their infertility. But after diagnosis of their infertility, they felt useless in their sexual relations through time and got sexually cold. The participants also mentioned that they suffered from a decrease in sexual frequency and failure to achieve orgasm, and faced stress in sexual relation. Numerous studies have somehow confirmed the findings of the present study concerning discouragement of sexual relations, and showed that infertility is a great risk factor for sexual dysfunction among infertile women. Lee et al.[17] reported a decrease in sexual desire and discouragement of sexual relation as the most common sexual problems in infertile women. Perlis et al.[18] also reported that infertile couples have a low desire for sexual relation during their infertility period due to hopelessness of pregnancy, and stop all their sexual activities.

Another theme obtained from participants’ experiences was “sacrifice of sexual pleasure for the sake of getting pregnant.” Participants conducted their sexual activity just for having a baby after the diagnosis of infertility and tried to achieve pregnancy in each sexual relation. Therefore, they spent all their efforts on pregnancy during sexual relations and ignored provision of sexual pleasure. So, women achieved no orgasm and sexual pleasure was sacrificed for pregnancy. As orgasm is a mental phenomenon which is easily influenced by psychological and mental factors,[19] psychological and emotional outcomes of infertility can be a factor for disturbance in achieving orgasm and sexual pleasure in women. Hosseini et al. showed that infertile women face problems in achieving orgasm due to their concerns about the failure of pregnancy in their current sexual relation.[20] Dyer et al. reported that infertile women think of just having a baby during their sexual relation, and the concerns of another failure in pregnancy increases their stress, melts away their sexual pleasure, and diminishes the sexual self-esteem.[21]

The fourth extracted theme was “confusion in sexual relation during infertility treatment.” The women were very anxious and worried as they had to talk about their sexual affairs and sexual relation patterns, which is a personal and private issue, with the infertility treatment team and receive a time table for their sexual relations. On the other hand, as during infertility treatment, the intercourses had to be conducted based on a time table and the related physician's order to achieve pregnancy, the participants experienced stressful moments and concerns during their sexual relation. Sherrod et al.[22] showed that scheduled intercourses for the treatment process, missing casual intercourses, and anxiety and stress concerning the time of ovulation not only decreased wanted intercourses but also increased infertile couples’ stress. Many participants in the study of Khoda Karami et al.[15] believed that suggestion of a specific time table for sexual relation during infertility treatment period can interfere with couples’ other daily life plans. They also believed as the number of sexual relations is recommended by the physicians with the goal of just achieving pregnancy, it may be boring for many of the couples.

The last theme obtained in the present study was “striving to protect their marriage.” Experience of the participants showed that they were worried about ruining their normal life due to social, cultural, and familial pressure that resulted from infertility, as well as tolerating different and tiring infertility treatments and obedience in sexual relation. So, they sought a protector to improve their sexual relations to preserve their normal life. Wischmann et al.[9] showed that infertile women follow infertility counseling sessions more, compared to men, due to their concern to preserve the unit of family and to improve their sexual life. Beshart et al.[16] showed that infertility can be a threat for marriage and continuation of a normal life due to relinquishing motherhood and spousal feelings. On the other hand, psychological outcomes of infertility, such as depression, anxiety, feeling of guilt, and blame, can lead to disorders in self-esteem and a negative body image, and consequently, influence infertile women's behavior and sexual satisfaction. Therefore, the marital life of infertile couples is exposed to destruction and should be protected through supportive systems.

CONCLUSION

The obtained results showed that infertility affects various dimensions of women's sexual life and causes problems for them like “disturbed in femininity-body image,” “discouragement of sexual relations,” “sacrifice of sexual pleasure for the sake of getting pregnant,” “confusion in sexual relation during infertility treatment,” and “striving to protect their marriage.” Based on these results, it is concluded that infertile women experience many sexual problems due to their infertility, which can act as the predisposing factors for mood disorders and destruction of families. Therefore, in order to prevent the social damage resulting from these problems, designing and conducting supportive programs and sexual counseling is suggested for these individuals.