Sexual problems associated with infertility, pregnancy, and ageing

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Abstract
Sexuality and infertility Infertility may interact with a couple's or individual's sexuality and sexual expression in two main ways. Sexual problems may be caused or exacerbated by the diagnosis, investigation, and management of infertility (or subfertility) or they may be a contributory factor in childlessness. Any examination of a couple's difficulty in conceiving must include overt and clear questioning about their sexual activity. Responses to infertility In response to being unable to conceive, many people feel emotions such as anger, panic, despair, and grief, and these may affect sexual activity. The stress of infertility and its treatment may also cause sexual difficulties for both men and women. Intercourse may be avoided, with patterns of behaviour established so that one or other partner is not reminded of the fertility problem. Post-coital tests or repeated need to provide semen samples may result in a man feeling under pressure to perform, which can adversely affect his erectile or ejaculatory ability. For some men, one or two failures during intercourse begin a vicious circle of fear of failure, with anxiety leading to further failures. Partners may also develop arousal difficulties because of anxiety or distress. Some people feel that their partner wants them only when there is a chance of conception, and sexual activity can then become a battleground for issues of power and control. Such stresses conspire to alienate couples from the recreational aspects of sexual expression and focus them, often obsessively, on the procreative aspect of sexual intercourse. Prayers being read before a lingham, the phallic symbol of Shiva, Hindu god of fertility. Fertility has always been vitally important in human society, and emotional reactions to infertility may affect sexual activity Sexual problems that result in infertility Childlessness may be the result of an existing sexual dysfunction. One study of infertile couples found that 5% had a history of sexual problems. View this table: In this window In a new window Useful questions to elicit information (taken from Read, 1995) To avoid waste of time and resources, patients must be given the opportunity to discuss their previous pattern of sexual functioning to see if it has changed because of their fertility problems. It seems inexcusable that people can have months or years of invasive and expensive treatment when simple questions about their sexual lives may elicit information that could spare them the ordeal. Infertility examinations should include an evaluation of couples' sexual behaviour, with special reference to frequency and timing of coitus. Two further categories of sexual dysfunction need to be borne in mind. The first is retrograde ejaculation, in which the ejaculate is expelled back into the bladder rather than externally. This can be checked by examining a post-ejaculatory urine sample for sperm. Men with this condition experience “dry” orgasm—they feel the sensation of muscular action and orgasm but do not produce an ejaculate. This is a fairly common presentation in fertility units and can be managed medically by centrifuging the urine to collect the sperm. View this table: In this window In a new window Sexual problems during or after pregnancy The second point that should be considered is whether the sperm are being introduced into the vagina. This can mean talking in clear terms to the couple about the nature of their sexual activity. Some couples engage in anal intercourse, umbilical sex, or manual stimulation alone and naively consider that this should result in pregnancy. This article is adapted from the second edition of the ABC of Sexual Health, which will be published later this year Footnotes The photograph of a Shiva lingam is reproduced with permission of the Hutchinson Library. The cartoon “I've changed my mind” is reproduced with permission of Jacky Fleming from Be a Bloody Train Driver. The painting by Bonnat is reproduced with permission of Lauros-Giraudon and the Bridgeman Art Library. Competing interests None declared. The ABC of Sexual Health is edited by John Tomlinson, specialist in sexual health, Winchester, john@jptomlinson.com

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