The World Health Organization (WHO) defines infertility as “the inability of a sexually active couple to achieve pregnancy despite unprotected intercourse for a period of greater than 12 months.” It is estimated that almost 72.4 million couples worldwide have had problems with fertility.
Previous research examining the sexual consequences of male infertility has shown less sexual satisfaction and more sexual dysfunction, with erectile dysfunction (ED) and premature ejaculation (PE) as common complaints. One study noted that infertile men reported a “worse quality of life.”
Infertility also has emotional and psychological repercussions. Studies have shown higher rates of anxiety and depression of the male partners in infertile couples.
Several studies have examined the relationship between sexual and psychological problems in infertile men. While associations between ED and psychological distress have been shown, a better understanding of these associations could help clinicians who treat sexual dysfunction and infertility.
The goals of this study were to determine the incidence of sexual and psychological problems for infertile men in China and to learn more about their possible associations in this population.
This non-interventional, observational, cross-sectional field survey took place in an affiliated hospital of Anhui Medical University in Anhui, China, where men sought treatment for infertility. A control group consisted of 942 men between the ages of 23 and 45 who had at least one child.
To participate in the study, all infertile and fertile men had to be aged 18 or older, be in a heterosexual, stable relationship lasting at least one year, and be able to read and speak Chinese. Men with mental and/or other major medical diseases were excluded, as were men taking medication(s) that could affect their ejaculatory and erectile function or psychological status.
Study Design and Procedure
The study was conducted in four stages:
- First stage. A face-to-face interview was conducted with all participants. Demographic information, including age, body mass index (BMI), smoking, educational status, occupational status and monthly income, was collected at this time. Reproductive and sexual histories were also taken.
- Second stage. Anxiety and depression were assessed for each participant. Researchers used the Chinese versions of the self-rating anxiety scale (SAS) and self-rating depression scale (SDS). Cut-off points for diagnosis of anxiety and depression were used following Chinese norms. Ranges to designate mild, moderate, and severe forms of anxiety and depression were also determined.
- Third stage. Intravaginal ejaculatory latency time (IELT) was assessed. Men and their partners were instructed to use a stopwatch to measure the time interval between initial vaginal penetration and ejaculation. The couples were required to have intercourse at least twice a week for four weeks and to keep a record of all sexual events during that time frame.
- Fourth stage. Based on the sexual status of the previous four weeks, all men completed the Chinese versions of the PE diagnostic tool (PEDT) and the international index of erectile function (IIEF-5). Degrees of premature ejaculation and erectile dysfunction were classified by severity.
One thousand four hundred and sixty-eight infertile men and 942 fertile men completed all of the assessments. In both groups, the majority of men were in their twenties and thirties. Approximately two-thirds of them smoked. The mean BMI for the infertile men was 24.43 ± 5.07 kg/m². For fertile men, this value was 25.05 ± 4.19 kg/m².
Highlights of the results include the following:
- Infertile men had significantly higher rates of sexual dysfunction (PE and ED) and psychological burden (anxiety and depression) than fertile men.
- In the infertile group, 7.08% of the men were diagnosed with PE and 11.92% were diagnosed with probable PE according to the PEDT. For the fertile group, these rates were 3.82% and 7.11% respectively.
- Based on IIEF scores, 18.05% of the infertile men had ED. Most of these cases were considered mild. Among the fertile men, 8.28% were diagnosed with ED. Again, most cases were mild.
- Based on SAS and SDS scores, 38.01% infertile men were diagnosed with anxiety and 15.74% were diagnosed with depression. Fertile men had lower rates of each condition: 26.65% were diagnosed with anxiety, 10.08% with depression.
- After adjusting for age, PEDT score was positively associated with the SAS and SDS scores.
- The IELT was negatively associated with the SAS and SDS scores.
- Negative relationships were observed between the IIEF-5 score and the SAS and SDS scores.
- Anxiety and depression were significantly associated with PE and a higher risk for ED.
This was the first study in China to determine the incidence of sexual dysfunction and psychological burden and their possible associations in infertile men. Results showed that the incidence of both sexual and psychological issues were higher in a group of infertile men when compared to a group of fertile men. A significant association was found between sexual and psychological problems in infertile men.
After reviewing past research, the authors determined that their results confirmed previous data. However, they pointed out that different researchers use different diagnostic criteria and that cultural and religious differences should be considered. Further research is needed to confirm and extend the authors’ findings.
The association between sexual and psychological problems in infertile men has not been widely studied, especially in China, the authors wrote.
They explained that their results confirmed the negative relationship between psychological burden and sexual function. “In particular,” they added that, “the negative association between IELT and anxiety or depression was firstly reported in infertile men in China.”
Nevertheless, the possible mechanisms between sexual and psychological problems have not been well studied, the authors said. Based on past research, they speculated that infertile men may feel guilty, anxious, and depressed because they want to have a child but cannot. These negative feelings could affect sexual function. However, since their study had a cross-sectional design, they could not clarify a causal relationship between sexual dysfunction and psychological burden. Further research could explore this angle.
The researchers noted that approximately 62% of the infertile men in their study could not recognize the relationship between sexual dysfunction and psychological distress. Shame and embarrassment prevented them from addressing their sexual issues during fertility treatment. To the authors’ knowledge, many Chinese physicians were also unaware of the relationship between sexual dysfunction and psychological distress. Further examination of this topic could be helpful in treating men with infertility.
While the researchers’ findings agree with previous studies from other countries, they were based on just one clinic in China. It is not known whether these results would be similar at other centres or among men who did not seek treatment.
In addition, men may have given “socially acceptable” answers to the face-to-face interview questions.
Also, this study did not look at discrepancies between male and female partners.
Larger, in-depth studies are therefore needed to confirm and extrapolate these results, the authors concluded.