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FERTILITY AND STERILITY௡ VOL. 79, NO. 4, APRIL 2003 Copyright ©2003 American Society for Reproductive Published by Elsevier Science Inc. Printed on acid-free paper in U.S.A.

Sexual dysfunction in men undergoing evaluation: a cohort observational study

Ramadan A. Saleh, M.D.,a Geetha M. Ranga, Ph.D.,b Rupesh Raina, M.D.,a David R. Nelson, M.S.,c and Ashok Agarwal, Ph.D., HCLDa

Center for Advanced Research in , Infertility, and Sexual Function, Urological Institute, Cleveland, Ohio, and Karthekeya Medical Research and Diagnostic Center, Bombay,

Objective: To study psychosexual problems in men undergoing infertility evaluation. Design: A cohort observational study. Setting: diagnostic center. Patient(s): Four hundred twelve men undergoing infertility evaluation between 1999 and 2001. Intervention(s): Baseline and follow-up data on sexual functions. analysis for samples collected by Received February 19, . A second analysis was requested in 2 weeks upon finding an abnormality of semen parameters. 2002; revised and accepted August 12, 2002. Penile vibratory stimulation to help men who failed to collect semen on their second or subsequent appointments. Presented at the 57th Annual Meeting of the Main Outcome Measure(s): Sexual functions ( and ) during the time of infertility evaluation. American Society for Result(s): Seven of 412 men were excluded from the analysis due to a past history of . Of , the remaining 405 men, 46 (11%) failed to collect semen by masturbation for a second after Orlando, Florida, October 20–25, 2001. repeated (2Ð4 times) at 2- to 3-day intervals. Nine of these men (20%) were able to collect semen using vibratory stimulation. All 46 men experienced problems with erection or orgasm and had severe anxiety Reprints requests: Ashok Agarwal, Ph.D., HCLD, during attempts to masturbate and during sexual contact with their partners. Director, Center for Conclusion(s): Our study indicates that some men may experience sexual dysfunction of a psychogenic nature Advanced Research in in response to the diagnosis of infertility. (Fertil Steril௡ 2003;79:909Ð12. ©2003 by American Society for , Reproductive Medicine.) Infertility and Sexual Function, Urological Key Words: Anxiety, male infertility, semen analysis, sexual dysfunction Institute, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Desk A19.1, In recent years, infertility has become the factor as a sole cause in about 35% (7). Some Cleveland, Ohio 44195 subject of significant media attention and pub- studies have suggested that infertile men expe- (FAX: 216-445-6049; E- mail: [email protected]). lic discussion, particularly in light of new ad- rience fewer disturbances than women on var- a Center for Advanced vances in the technology of assisted reproduc- ious indices of emotional functions (8, 9). Research in Human tion (1). Issues related to infertility have a Whether this observation is due to a general Reproduction, Infertility, and Sexual Function, significant impact, not only on the health and tendency for men to underreport their emo- Urological Institute,The well being of affected individuals or couples, tional responses is not clear (4). Nevertheless, Cleveland Clinic Foundation, Cleveland, but also on society as a whole (2). Infertility the few studies that examined the effects of a Ohio. has been correlated with psychological stress, gender-specific diagnosis indicated that a fer- b Karthekeya Medical at least for some individuals (3). Psychological tility problem, which lies solely on the male Research and Diagnostic effects of infertility were found similar to those partner, inflicts a particular psychological bur- Center, Bombay, India. c Department of of cancer and heart (4). However, den (10, 11). In addition, the incidence of de- Biostatistics and there is little agreement in the experimental and pression significantly increased among men Epidemiology, The anecdotal literature concerning the nature, tim- who were solely responsible for the infertility Cleveland Clinic Foundation, Cleveland, ing, and the extent of the emotional strain as a status compared with men who were either fertile Ohio. result of infertility (5). or shared the problem with their partners (11). 0015-0282/03/$30.00 Male factor infertility plays a role in approx- It has been proposed that a man who fails at doi:10.1016/S0015-0282(02) 04921-X imately 50% of infertility cases (6) with male is likely to evaluate himself as sexually

909 inadequate and may experience temporary impotence (12) mal forms Ն30% (17). Our study included men who and decreased (13). Constant worry about the problem had an abnormality in one or more of abnormal standard may arouse inhibitory and interfere with smooth semen parameters in their first semen analysis. muscle relaxation in the , thus causing partial or com- plete failure of erection (14). Whether sexual performance in Study Groups Individuals with a total baseline IIEF-5 score of less than men undergoing initial infertility evaluation is negatively 20 (n ϭ 7) were excluded from the study because their affected by abnormal results of their laboratory workup is sexual functions were already impaired. The remaining 98% not known. This information is important because it will help (405/412) of patients had normal sexual functions (a total determine whether appropriate counseling should be pro- IIEF-5 score Ն20) and were able to collect the first semen vided to these men. Therefore, the objective of this study was sample by masturbation without difficulty. Patients were to examine sexual functions of men undergoing infertility informed that they had abnormal semen analysis results, and evaluation at a male infertility diagnostic center. scheduled for a second semen analysis in 2 weeks. Of the 405 patients, 46 (11%) failed to collect semen by masturba- MATERIALS AND METHODS tion for the second analysis (group 1), whereas the remaining 359 (89%) patients had no difficulty in collecting semen Data Collection (group 2). The institutional review board approved this study. We collected baseline and follow-up data of 412 men referred to Patients in group 1 (n ϭ 46) were scheduled for subse- the clinic for a history of primary infertility of quent attempts of , by masturbation, at 2- to more than 12 months between 1999 and 2001. These patients 3-day intervals (2 to 4 attempts/patient). Patients were also were diagnosed with male factor infertility based on the given the option of collecting the samples at home, by finding of abnormal semen analysis. Data included medical masturbation, or during with their partners and sexual history and results of standard semen analysis. () and to deliver the sample to the labora- tory within 1 hour of collection. Patients who failed to Sexual Function Data collect semen after two to four attempts by masturbation and Assessment of baseline sexual functions (erection and coitus interruptus (group 1) were aided by vibratory stimu- orgasm) of all participants was performed using an abridged, lation. This was performed using a mechanical five-item version of the International Index of Erectile Func- applied to the undersurface of the and set to tion (IIEF-5) (15, 16). The IIEF-5 questionnaire form is a vibrate at a designated frequency and wave amplitude to give simple and reliable diagnostic tool for direct assessment of a strong, prolonged stimulus. Only 9 patients of the 46 were male sexual functions, namely erection and orgasm (15). The responsive to the vibratory stimulation and could collect a response to each of the five questions was ranked from 1 sample (group 1a), whereas the remaining patients could not (almost never/never) to 5 (almost always/always). The total do so (group 1b). IIEF-5 score was calculated as the sum of responses to the five items; thus, the score ranges from 5 to 25. Follow-up Statistical Analysis assessment of sexual functions was performed in men who Univariate comparison of continuous variables between failed to collect semen on their second or subsequent ap- the groups was performed with Kruskal-Wallis tests. Wil- pointments. The items of the IIEF-5 questionnaire form were coxon rank-sum tests were used for pairwise comparisons modified to provide information on sexual activity (erection between the groups. Fisher’s exact test was used for cate- and orgasm) during masturbation as well as sexual inter- gorical variables. Multivariate analyses were performed with course. We compared baseline vs. follow-up IIEF-Scores in logistic regression. No confounding variables were detected. the later group. All hypothesis testing was two-tailed with statistical signif- icance assessed at PϽ.05 level. Semen Analysis All analyses were conducted with SAS statistical software All subjects were asked to collect semen by masturbation package (version 8.1 SAS Institute Inc., Cary, NC). Sum- for initial fertility evaluation after failure to initiate natural mary statistics are presented as mean (ϮSD) for IIEF-5 after 1 year of natural intercourse. Semen speci- scores, and median (25th, 75th percentiles) for other vari- mens were collected in a private room near the laboratory ables. after a period of 48 to 72 hours of sexual . Stan- dard semen analysis was performed according to the World Health Organization guidelines (17) to determine sperm con- RESULTS centration and motility. Smears were prepared for assess- Patients in group 1 had an IIEF-5 score of 11.2 Ϯ 2.6 ment of sperm morphology using the World Health Organi- during the follow-up period which was significantly lower zation classification (17). Normal values for standard sperm than the baseline score (22.6 Ϯ 2.3) (PϽ.01). Patient’s age, parameters were considered as sperm concentration Ն20 ϫ length of infertility and results of semen analysis from initial 106/mL of semen, percent motility Ն50%, and percent nor- collection in groups 1 and 2 are shown in Table 1. The length

910 Saleh et al. Psychological aspects of infertility Vol. 79, No. 4, April 2003 the length of infertility (Pϭ.4 and .2, respectively). All 46 TABLE 1 patients who failed to collect semen specimen by masturba- tion or during sexual contact with their partners reported Comparison of patient’s age, length of infertility, and results of semen analysis from initial collection between severe anxiety. groups 1 and 2. Group 1 Group 2 DISCUSSION Variable (n ϭ 46) (n ϭ 359) P value Infertility is an emotional crisis and a physical challenge Age (y) 32 (27, 35) 30 (27, 34) .17 because it interferes with one of the most fundamental hu- Length of infertility (y) 2.2 (1.5, 3.8) 1.3 (1, 2.4) .02 man activities (18). From a list of 87 items of stressful life Sperm concentration (ϫ106/mL) 9 (1, 82) 33 (6, 88) .06 Motility (%) 41 (0, 53) 48 (25, 58) .05 events, infertility has been ranked as one of the most nega- Normal sperm forms (%) 13 (4, 32) 22 (8, 40) .08 tive stressful situations—akin to the death of a son or a Group 1 ϭ men who failed to collect a sample for second semen analysis. spouse (19). In this study, 11% (46/405) of men undergoing Group 2 ϭ men who were able to collect a sample for second semen infertility evaluation experienced problems with erection or analysis. Values are median and interquartile range (25th and 75th percen- orgasm after detection of an abnormality in the results of Ͻ tiles). Wilcoxon rank-sum test was used for the analysis and P .05 was their first semen analysis. Because these men had normal significant. sexual functions before the infertility evaluation, we specu- Saleh. Psychological aspects of infertility. Fertil Steril 2003. late that in these cases was psychogenic in nature and was triggered by the abnormal results of semen analysis. The psychogenic nature of erectile dysfunction in of infertility in group 1 was significantly greater than group these patients was also evident from its association with a 2(PϽ.02). in group 1 was significantly lower longer duration of infertility and with increased levels of than in group 2 (PϽ.04). Sperm concentration and percent anxiety. normal sperm forms in group 1 were lower than in group 2, but the differences did not reach a statistical significance Our study indicates that sperm parameters are signifi- (Pϭ.06 and .08, respectively). No significant differences cantly lower among men who experience sexual dysfunction. were observed between the two groups in the patient’s age This may reflect an adverse emotional reaction to severe (Pϭ.17). abnormalities of sperm production. Our finding is in agree- Patient’s age, length of infertility and results of semen ment with an earlier report that men experience greater analysis from initial collection in groups 1a and 1b are distress when an identifiable cause for the failure to conceive demonstrated in Table 2. Sperm concentration and motility lies in a problem with sperm production (11). Some inves- in group 1a were significantly lower than in group 1b (PϽ.04 tigators have claimed that the link between fertility and and PϽ.01, respectively). Percent normal sperm forms in potency is particularly strong and that the capacity to pro- group 1a was lower than in group 1b, but did not reach create is essential to the male identity (10, 20). Before a statistical significance (Pϭ.05). No significant differences conclusion can be reached from the findings of our study, it were observed between the two groups in the patient’s age or is important to bear in mind certain study limitations. First, although this study interprets the findings within a theoreti- cally causal framework, the speculation of a causal relation- ship between infertility and sexual dysfunction should be TABLE 2 treated with some caution due to the retrospective nature of the study. In this regard, a prospective, longitudinal design Comparison of patient’s age, length of infertility, and would better address the issue of a possible causal relation- results of semen analysis from initial collection between ship between these two variables. groups 1a and 1b. Second, it is not possible to say whether the sample is Group 1a Group 1b representative of infertile men in general. Men attending an ϭ ϭ Variable (n 9) (n 37) P value infertility clinic may differ from those who refuse to seek Age (y) 29 (27, 34) 32 (29, 35) .39 medical help for infertility. Finally, it was not possible to Length of infertility (y) 2.5 (1.7, 3.8) 1.9 (1.5, 2.9) .19 obtain complete information about the psychological profiles Sperm concentration (ϫ106/mL) 74 (53, 83) 4 (0.5, 49) .04 of the study participants or their partners. As a result, we Motility (%) 58 (48, 61) 35 (0, 49) .01 were unable to identify other potential psychological distur- Normal sperm forms (%) 22 (9, 34) 11 (2, 29) .05 bances in the infertile men who experienced erectile dys- Group 1a ϭ men who responded to vibratory stimulation. Group 1b ϭ men who did not respond to vibratory stimulation. Values are median and function or even in the remaining population who had a interquartile range (25th and 75th percentiles). Wilcoxon rank-sum test was normal sexual function. Despite these reservations, the in- used for the analysis and PϽ.05 was significant. teresting findings in our study bring to light certain facts Saleh. Psychological aspects of infertility. Fertil Steril 2003. regarding the lack of psychological readiness of men under-

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912 Saleh et al. Psychological aspects of infertility Vol. 79, No. 4, April 2003