2. Materials and Methods
2.1. Participants and Procedure
A total of 129 Italian infertile people, 47.3% (N = 61) females and 52.7% (N = 68) males, aged between 26 and 57 years (M = 39.13; DS = 6.7; M
females = 37.4 (DS = 6.4); M
males = 40.6 (DS = 6.6)) participated in our study. Our sample was not composed of couples. More detailed sociodemographic information is reported in
Table 1.
The sample was recruited both in hospitals and in public and private centers for Medically Assisted Reproduction (MAR) in Northern Italy. We contacted physicians and psychologists working in these centers to explain the research and agree on timings and data collection methods. After that, physicians and psychologists contacted infertile couples and administered the questionnaires during the medical check-ups following the infertility diagnosis and through the treatment of infertility.
Data were collected in 2017, before COVID-19, so fertility treatments were not altered by the pandemic situation.
Data collection was carried out following the provisions of Italian law 196/2003 in collecting the participants’ consent, and all the questionnaires were anonymous. Before beginning the questionnaire, participants received both an oral and a written explanation of the study from a research assistant and a Doctor or Physician. The research was previously approved by the Ethics Committee of the Psychology Department of Milano-Bicocca University (protocol code 0029119/13, 16/10/2013) and was handled according to the Declaration of Helsinki.
2.2. Measures
Participants completed the following instruments:
An ad hoc questionnaire was created to collect participants’ socio-demographic information and aspects regarding infertility. In particular, it investigated:
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type and factor of infertility
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center consulted for the treatment
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type of treatment
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who decided to start the treatment
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people informed about the treatment decision
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thoughts about adoption
The Dyadic Adjustment Scale (DAS) [
63] is a 32-item self-report instrument that measures dyadic adjustment and measures each partner’s representation of the relationship by exploring four dimensions. DAS is composed of four subscales: Dyadic Consensus (13 items capturing agreements or disagreements between the two partners regarding different topics); Dyadic Cohesion (5 items, measuring how often partners share pleasant time and activities); Affectional Expression (4 items, showing how couples express and communicate feelings, love, and sexuality) and Dyadic Satisfaction (10 items, providing a measure of overall satisfaction and happiness for the relationship). Moreover, the instrument also gives a total score of dyadic adjustment with a range from 0 to 151 with higher scores indicating more positive dyadic adjustment. Typically, cut-off scores between 92 to 107 are used to discern between distressed and non-distressed couples.
We obtained a Cronbach’s alpha of 0.823 for the total score of DAS, 0.803 for Dyadic Consensus, 0.768 for Dyadic Cohesion, 0.552 for Affectional Expression, and 0.362 for Dyadic Satisfaction. While the Cronbach alphas of the total score, dyadic consensus, and dyadic cohesion were adequate, we discovered only moderate reliability of the two alphas of Affectional Expression and Dyadic Satisfaction that should be considered.
The Multidimensional Sexuality Questionnaire (MSQ) [
64] is a 60-item self-report scale that measures psychological dimensions linked to individual sexual life. Specifically, items are rated on a 5-point Likert scale and participants are asked to point out how much the item represents their sexual characteristics.
The instrument is constituted by 12 subscales including sexual motivation (e.g., “I am very motivated to be sexually active”), preoccupation (e.g., “I think about sex all the time”), assertiveness (e.g., “I am very assertive about the sexual aspects of my life”), depression (e.g., “I am disappointed about the quality of my sex life”), anxiety (e.g., “I feel anxious when I think about the sexual aspect of my life”), self-esteem (e.g., “I am a pretty good sexual partner”), monitoring (e.g., “I sometimes wonder what others think of the sexual aspects of my life”), internal control (e.g., “My sexuality is something that I am largely responsible for”), external control (e.g., “Most things that affect the sexual aspects of my life happen to me by accident”), consciousness (e.g., “I am very aware of my sexual feelings”), satisfaction (e.g., “I am very satisfied with the way my sexual needs are currently being met”), and fear (e.g., “I sometimes have a fear of sexual relationships”).
Out of the 12 dimensions obtainable by the MSQ, we focused our attention only on 3 subscales: sexual anxiety, sexual internal control, and sexual satisfaction.
We obtained Cronbach’s alphas on these dimensions of 0.700, 0.677, and 0.818, respectively.
The Experiences in Close Relationship-Revised (ECR-R) [
65,
66] is a 36-item self-report instrument that measures feelings and behaviors linked to attachment in romantic relationships. Participants are asked to fulfill the items using a 7-point Likert scale (from 1 “strongly disagree” to 7 “strongly agree”), with higher scores revealing higher endorsement of the construct. Through the instrument, romantic attachment can be classified in two dimensions: Avoidance of intimacy (level of preoccupation related to sharing emotional closeness, i.e., “I prefer to not show my partner how I feel deep down”), and Anxiety about abandonment (measures the preoccupation with the relationship or the need for intimacy, i.e., “I worry about being alone”). In our sample, we obtained a Cronbach’s alpha of 0.475 for the Avoidance dimension and 0.450 for the Anxiety, finding only moderate reliability that should be considered.
2.3. Analysis Plan
Firstly, we conducted descriptive statistics and Pearson bivariate correlations, and Fisher’s Z tests among all the research variables considering both infertile men and women. We then performed an independent t-test to compare the two groups.
Secondly, we ran linear regressions to explore the relationship between infertility aspects, dyadic adjustment, attachment, and sexuality. We differentiated all the analyses according to gender, dividing infertile women from infertile men. We used the statistical software IBM SPSS version 28 (IBM Corp, Armonk, NY, USA) for all the analyses.
4. Discussion
Infertility is a life crisis that involves several challenges [
8,
15,
61]; a specific dimension of life that seems to be strongly impacted by infertility is sexuality as discovering they are infertile changes how a person experiences sexuality both individually and within the couple [
8,
28,
62]. Nevertheless, the results of the various studies in the literature regarding sexuality in infertile couples and the difference between women and men are contradictory.
Wischmann and colleagues [
67] found that 500 couples starting infertility therapy reported no difference in satisfaction with their sex lives over and against the norm, even if the men reported slightly higher sexual discomfort than women [
67]. Conversely, in a study conducted on 144 couples in the process of beginning in vitro fertilization (IVF) treatment, Slade and colleagues reported that the women explicit significantly higher dissatisfaction with their sex lives than their male partners, although within the clinical norm [
68]. Moreover, in his survey, Möller [
69] reports that 50% of his sample (considerably more women than men) claimed that they modified their sex lives as a result of the unfulfilled desire for a child. In particular, two-thirds indicate that their sex lives have declined, and one-third experience at least an initial intensification [
69]. Finally, other studies report that couples wishing for a child claim to experience sexual pleasure and frequent sexual intercourse to a larger extent than the corresponding norms [
70].
Although the two groups did not differ regarding their sexual dimensions (anxiety, internal control, satisfaction) and personal aspects, such as attachment and dyadic adjustment, multiple regressions show significant differences with respect to gender. Indeed, women’s factors associated with infertility such as the type of infertility, the type of treatment, and thoughts about adoption did not affect their sexual life in any of the aspects considered in our study, while a significant effect of type of infertility and infertility is present for sexual anxiety in infertile men. These results confirm the results found by Nachtigall and colleagues [
71] who showed that men with male factor infertility experienced more negative emotional responses, including a sense of loss, stigma, and reduced self-esteem than men whose partners were infertile or who were in couples suffering from unexplained infertility. Furthermore, the men in the infertile couples had higher levels of depressive symptoms and anxiety than did fertile men [
72]. These findings could be explained by several reasons. If infertility lasts for a long time, sexual relationships could become more closely associated with experiences of failure. This unpleasant feeling of worthlessness and lack may also impact patients’ perception of their bodies and their reproductive function, though this was observed to be more likely among women than men [
73]. Additionally, during infertility treatment, some couples perceive the medical team as symbolically present during sexual intercourse, and the pressure of time and the purpose of “baby-making” make sexual intercourse very difficult, usually because of erectile dysfunction. This initial erectile dysfunction, aside from increasing the sexual anxiety in infertile men, may turn into a persistent sexual disorder because of a “vicious circle” effect which manifests in the following steps: “performance anxiety—inhibition—erectile dysfunction—the feeling of shame and failure—performance anxiety”.
While studies about the impact of infertility on sexuality are numerous, research about the impact of dyadic adjustment and attachment on sexuality in infertility couples is scarce [
24,
47,
55]. As we aimed to understand the connection between attachment and dyadic adjustment of the couple and their influences on sexuality, we believe that this constitutes the novelty of the current study.
In both women and men of our sample, the results showed that higher levels of dyadic adjustment anticipated higher levels of sexual satisfaction. Even if we didn’t find studies that focused on the specific influence of dyadic adjustment on sexuality in infertile couples, Güleç and colleagues [
55] showed that, within an infertile group, the men scored higher DAS satisfaction than women; however, there wasn’t a difference between infertile men and women in terms of the other DAS dimension scores [
55]. Tashbulatova [
57,
74] reported that, in general, couple’s adjustment positively influenced sexual functioning in couples, but it may be even more true for infertile couples, who showed higher levels of marital harmony than fertile ones: in order to safeguard marriage, these partners have to cope for long periods with the crisis and treatment of infertility, thinking together about decisions to be made and sharing support and affection. A high marital harmony and a good dyadic adjustment between the partners who go through the condition of infertility could strengthen their union also in the sexual sphere leading to an increase in sexual satisfaction [
61].
Regarding the relation between ECR attachment and the dimensions of sexuality, we found slightly different results between the two groups.
First, the presence of anxious attachment decreases sexual internal control in women. If partners have been trying to have a baby for a long time, individuals with high levels of anxiety can be burdened by feelings of defeat, performance concerns [
48], and apprehension of losing their partner. Because of their difficulty in emotional regulation [
48,
75], for anxious women, it might be very hard to connect with their body sensations during sexual intercourse. Additionally, as we know that the moments and number of intercourses are often planned by the treatment, women with an anxious attachment may lose the feeling of sexual internal control as their sexuality could be perceived as something that no longer depends on their choice.
Conversely, it is largely known that individuals with high levels of avoidance generally strive to maintain emotional distance [
48]; this strategy could explain the lower level of sexual anxiety in women and the higher levels of sexual internal control in men. Avoidance is surely linked with the need to be in control of situations [
48] and this may well be generalized to sexuality.
One interesting result of our study is that we did not discover a significant relationship between attachment, dyadic adjustment, and sexual anxiety for infertile men. Moreover, our results showed a non-significant relationship also between attachment anxiety and sexual anxiety for both infertile women and infertile men. These results are in line with the literature reporting that avoidant attachment could be more relevant in influencing infertile people’s sexual life rather than anxiety [
48]. One possible explanation could be linked to the psychological constitutional elements of the anxious attachment itself. Attachment-related anxiety has been defined as a fear of abandonment by the partner, which leads the anxious person to request (and desire) physical proximity and reassurance from the other partner. When facing a fertility issue, the physical proximity could be preserved (or also increased with the aim to have a baby) and, for this reason, people with anxious attachment could not experience an increase of sexual anxiety as, conversely, people with avoidant attachment could.
Moreover, adult romantic relationships are characterized by three motivational systems (attachment, sexuality, and caregiving) that could be strongly influenced by individual characteristics, meaning that some specific connection between them could not be fully detected.
Nevertheless, more in-depth studies about these aspects in infertile men and women are needed, as it would be recommended to evaluate the connection between sexuality and attachment by combining standardized instruments with attachment in-depth interviews.
Certainly, there are some limitations to this study. First, it has a cross-sectional design, which doesn’t allow us to conclude a causal relationship. Second, we did not consider all the dimensions implicated in sexuality, but we decided to focus only on those dimensions (sexual anxiety, satisfaction, internal control) that offer a global idea of individual sexuality; thus, we may miss further relevant dimensions within infertile couples undergoing treatment.
Third, we did not consider other essential aspects in analyzing the impact of infertility on sexuality: in fact, we did not focus on social support or the support within the couple dealing with childlessness.
Another limit that should be taken into consideration is the sample size: indeed, the relatively small number of participants suggests the need to conduct more studies on the comparison between infertile men and women and to plan some follow-up studies for this sample. However, as far as we know, the current study aimed at examining aspects not yet explored, so its results should be considered a valuable starting point for future research on this topic.
Finally, longitudinal studies applying statistical methods for paired data are needed to fully understand the impact of infertility on sexual life focusing on its development and changes over time.