The experience of infertility can change the very meaning of sex, with many finding that it is no longer a source of pleasure, joy and intimacy.
Instead, sex can become monotonous and associated with feelings of failure, shame and disappointment. Depending on a person’s upbringing, their cultural and religious backgrounds, the experience of infertility can also test an individual’s ideas of femininity or masculinity, which can impact overall sexual functioning and result in relationship dissatisfaction and conflict.
Infertility is defined as the inability to achieve and/or sustain a viable pregnancy after 12 months of regular, unprotected intercourse.
It is estimated that approximately 15-20% of both men and women of reproductive age experience fertility problems, with one in six Australian couples reportedly experiencing infertility. With opposite-sex attracted couples, in 40% of cases the problem lies with the man and in other cases 40% with the woman, with 10% being due to both partners, while with the remaining 10% the cause is unknown.
To assist in the ability to conceive there is a range of treatment options available for both opposite sex and same sex couples which include:
Tracking the woman’s ovulation cycle, in order to confirm ovulation and timing intercourse for when the woman may be most fertile.
Induced ovulation through medication.
Artificial insemination or intrauterine insemination which is a simple and less invasive form of treatment than IVF. The male partner’s and/or donor’s sperm are introduced through insemination to the cervix and into the uterus.
In Vitro Fertilisation (IVF) is a procedure that is often used to overcome a range of fertility issues, and involves an egg and sperm joining together outside of the body. The fertilised egg then grows in a protected environment for some days prior to being transferred into the woman’s uterus.
Intracytoplasmic Sperm Injection (ICSI), which is commonly used alongside IVF. This occurs when a laboratory technician is able to inject a single sperm directly into an egg, and is commonly used when there is low sperm count or motility. If fertilisation occurs the embryo(s) will be transferred into the uterus.
Fertility surgery to investigate the causes of infertility or overcome any obstacle that may be hindering conception, such as fibroids or endometriosis.
Infertility in Women
Fertility problems occur in one in three women over the age of 35. These may be the result of endocrine imbalances or anatomical impairment, with the most common cause of infertility in women being ovulation problems. Common issues include:
Ovulation problems: Women are born with their entire egg supply, and over time these eggs can become less viable which can result in difficulties with conceiving naturally. Irregular or absent/ missing periods can add to the struggle, and may also indicate that a woman’s ovulation cycle is irregular or absent as well.
Blocked fallopian tubes: Blocked or scarred fallopian tubes can impede the progress of the egg, preventing it from meeting the sperm.
Endometriosis: This can impact a woman in a number of ways, from painful, heavy periods, to uncomfortable sexual experiences, to infertility. Endometriosis is a condition where the cells from the lining of the uterus (the endometrium) spread to other parts of the pelvic region, and may damage the fallopian tubes and ovaries.
Cervical problems: For the sperm to reach the uterus and fallopian tubes it must travel through the cervix, the entrance of the uterus. To make this process easier cervical mucus is normally thick and watery at the time of ovulation, with any changes in cervical mucus such as thickness or quality impeding the sperm from getting to their final destination.
Uterine problems: Problems within the uterus such as fibroids (non-malignant tumours inside the womb) and polyps (overgrowths of the endometrium) can impact the chances of conceiving and may require surgery.
Infertility in Men
For men, the main causes of infertility centre around problems with sperm, with one in 25 men having a low sperm count, and one in 35 found to be sterile. Other reasons why a man may be infertile include:
Obstruction: Sperm is produced in the man’s testicles and takes up to ten days to pass through a series of small tubes called the epididymis, where they mature before exiting into a larger tube known as the vas deferens. The vas deferens discharges the sperm into the ejaculatory duct where they are mixed with seminal fluid. During ejaculation, muscular contractions force the semen through the urethra and out the penis. Any blockages or absences of tubes may cause infertility and may be the result of a previous injury or vasectomy.
Functional problems: Injury, infection and/or chemotherapy can have an impact on a man’s testicles and lead to infertility.
Hormonal problems: A relatively uncommon cause of infertility in men, is the failure to make enough of the hormone gonadotrophin.
Other problems with sperm: Sperm may be abnormal in shape or low motility, which can impact conception as these can impede the sperm swimming to and penetrating the egg.
There are some other factors that can cause fertility issues for both men and women, such as a history of sexual transmitted disease, genital / pelvic infection, previous abdominal surgeries, and lifestyle factors such as obesity, smoking, alcohol and drug use.
Sexuality and Infertility
Research has shown that couples during and post treatment for infertility, may experience temporary or permanent sexual impairment.
Both men and women report having some level of concern about their sexual functioning during the often-invasive, long-drawn out medical assessment and treatment.
In some cases, sexual dysfunction may be the cause of infertility (eg vaginismus, erectile problems), also hindering successful treatment such as when vaginismus obstructs intrauterine insemination, egg retrieval or embryo transfer and/or when erectile problems hamper a man’s ability to produce a sample of semen.
When it comes to gender differences regarding sexual functioning and fertility problems, research has demonstrated that men are more likely to experience negative impacts on their sexual function and sexual difficulties compared to women. However, some research does propose that women are equally, if not more affected by sexual problems during fertility testing and associated treatment, possibly as a result of the demands these place on the woman’s body.
For women, sexual problems may arise from reduced desire, an inability to orgasm and painful intercourse. The stress, potential depression and poor self-image that often coincides with infertility and associated medical treatments can impact a woman’s level of motivation, interest and receptivity to sexual intimacy, and lead to a decrease in overall sexual satisfaction. Sex becomes less rewarding, as the nonsexual rewards of emotional intimacy and closeness are replaced with the want and need to have sex for the purpose of successfully conceiving.
This shift in purpose from pleasure to procreation, and the monthly association of sex with reproductive outcomes, add to the decrease in desire for sexual intimacy, adding to the incidence of sexual difficulties and dissatisfaction which are often reported by women who experience fertility problems.
Men on the other hand, report experiencing a similar toll on overall sexual functioning, with the course of fertility testing and treatment impacting on a man’s sexual self-esteem, desire and functioning. This can lead to erectile dysfunction, ejaculatory problems, loss of libido and a decreased interest and frequency in intercourse.
Sex Therapy and Infertility
Commonly, sex therapists are not included in the team of experts involved in infertility treatment, however according to Daniluk, Koert, and Breckon, they should be. Sex therapists are often trained and educated on the workings of our reproductive systems, and feel comfortable with discussions on sexuality, including how infertility and related treatments are affecting sexual function.
Early intervention efforts have been reported to be helpful in reducing the toll infertility can take on sexual functioning, with sex therapists often providing psycho-social education-based counselling that aims to decrease the distress caused by infertility, as well as helpful information on fertility, associated treatments and their impacts. Sexual therapists also work in helping couples to maintain a fulfilling sex life during and post fertility treatment.
Approaches to treatment by sex therapists are generally individualised in order to address the specific sexual problems and contributing factors affecting the couple. Behavioural strategies a sexual therapist may use include:
Stress and anxiety reduction techniques such as progressive relaxation, mindfulness meditation and assertiveness training;
Directed masturbation as part of homework strategies for both women and men who may have trouble in achieving orgasm;
Further explicit homework techniques such as massage and communication exercises;
Sensate focus techniques and associated exercises;
Orgasmic reconditioning through directed fantasy in relation to masturbation and a shift in arousal to specific stimuli;
Imagery techniques that include an assessment and rehearsal of sexual responses;
Additionally, people may require the additional use of particular medications, the use of devices (eg vibrators, penis pumps) and medical or surgical intervention.