Qualitative research on infertile Chinese couples’ understanding of sexuality

Qualitative research on infertile Chinese couples’ understanding of sexuality Abstract Background Family physicians play an important role in the initial counselling and evaluation of infertility. Despite infertility regarded as a stressor and a life crisis for individuals or couples, little is known about the psychosexual aspects of infertility. On the basis that sexuality is a crucial part of quality of life, it is worthwhile to give more attention to sexuality of infertile couples during their time of experiencing infertility. Objective This study aimed to gain insight into the dynamic features of the sexuality of infertile couples and to provide meaningful evidence for improving their quality of life. Methods We employed a qualitative approach to conduct this study. Utilizing purposive sampling method, 56 participants (28 infertile Chinese couples) were recruited from the reproductive medicine centre of a general hospital, and in-depth interviews were conducted with each participant. Thematic content analysis was used to analyse the transcripts. Results Four themes emerged from the respondents’ narratives; these themes relate to the infertile couples’ understanding of sexuality: (i) gender identity, (ii) communication about sex, (iii) sexual life and (iv) sexual satisfaction. It was further found that Chinese culture’s values of fertility, perceptions about sexuality and sex, social norms regarding gender, and expectations about marital sexual life can have significant effects on infertile Chinese couples’ sexuality. Conclusion These findings should be highly considered by family physicians in their practice to provide infertile couples with information related to sexual well-being, coping styles, relationship, etc. Infertility, qualitative research, quality of life, sexuality Introduction Previous studies have proved that sexual dysfunction and reproductive tract diseases are factors that contribute to infertility (1–3). Additionally, there are specific findings on the sexual aspects of people who suffer from the clinical diagnosis and treatment of infertility, which are expressed through decreasing sexual frequency (4), lower sexual desire and satisfaction (5,6), and sexual dysfunction morbidity (7–9). There is an increased awareness that these sexual problems may have an impact on difficulties with conception by contributing to limited or absent sexual activity (10). However, most investigators rarely explore sexuality beyond the physical dimensions. Little is known about infertility from a psychosexual perspective (11). Less research addresses the sexuality of the infertile individual’s partner. Sexuality is not merely associated with reproductive function; it can serve as a means of giving and receiving pleasure, maintaining closeness within couples and making a major contribution to a person’s quality of life (12). Therefore, it would be useful to focus more attention on sexuality as it pertains to the well-being of couples unable to conceive a child. This study was undertaken within the framework of a larger research project (January 2010 to June 2011) on the relationships between biosocial demographics, infertility stress, sexuality and marital well-being to identify predicting factors that influence the marital well-being of infertile Chinese couples. For this qualitative study, we anticipated gaining insight into the dynamic features of the sexuality of infertile couples and how couples cope with sexual issues while experiencing infertility, and then to provide meaningful evidence for improving infertile couples’ quality of life. Methods Participants Participants were recruited from the Reproductive Medicine Centre in the First Affiliated Hospital of Harbin Medical University, Harbin City, Hei Longjiang Province, China. To be eligible for this study, participants had to be married and living together all the time. They had to be part of a heterosexual couple experiencing primary infertility in their current relationship, with at least 6 years of education to better understand each question from the interview outline. There were two exclusion criteria: (i) either one of the partners of an infertile couple having any illness not related to fertility and (ii) either one of the partners of an infertile couple having a diagnosis of an organic sexual disorder. Through purposeful sampling, 30 infertile couples attending the infertility clinic for treatment were invited to participate in this study. They were diagnosed with a variety of infertility-based etiology, including female factors (e.g., tubal factors, endometriosis, pelvic adhesions), male factors (e.g., low sperm count, psychogenic sexual dysfunction, gonadtropism), combined factors, and unexplained infertility due to factors not attributable to either partner. Twenty-four of the infertile couples were preparing for the first in vitro fertilization (IVF) treatment, with the other six infertile couples being in the second treatment cycle. All participants were also informed of the purpose of the study and the fact that participation was voluntary. They were also informed that they had the right to withdraw from the study at any time and their confidentiality was assured. Additionally, all the respondents’ names were replaced with pseudonyms in the transcripts. Interview approach An interview guide (Supplementary Table S1) for semi-structured interviews was used in this study, which included perspectives on sexuality, opinions regarding the relationship between sex and procreation, communication about sexual intimacy within couples, motivation and initiative for sex, social-demographic data and the type of infertility. The interview guide was piloted before the formal interviews, including interview style, length of interview, logical structure and questions’ probe of the research topic. A one-on-one, in-depth interview was conducted with each participant in a private site in the hospital’s reproductive medicine centre. To minimize threats to validity during interviewing, each interviewee was asked whether he or she preferred a same-sex or opposite-sex interviewer prior to the formal interview. Nine female interviewees indicated a preference for a female interviewer, and five male interviewees indicated a preference for a male interviewer. Other interviewees did not have any preference. The duration of interview varied between 60 and 90 minutes, depending on the information provided by the interviewees. Only one or two in-depth interviews were conducted in a day. Additionally, the researchers maintained an attitude of respect and neutrality when endeavouring to find issues that were of specific concern to the interviewees. Deviant case analysis was performed by searching cases that ran counter to the emerging themes (13). In order to ensure the credibility of the findings, member checking was conducted by asking the interviewees to review the researcher’s notes, interpretation, transcripts or findings during the interview. By applying these approaches, we decreased the possibility that the qualitative data would be caused by researcher bias. More attention was paid to data saturation and thematic exhaustion, through constructive (during the process) and evaluative (post hoc) procedures. These ensured the trustworthiness of the research (14). Data analysis Given that participants’ notes taken during the interview were not extremely detailed, they were instructed to expand as soon as possible after each interview. The expansions included synthesizing the interviewees’ notes with their feeling, mood and interpretations. Through analysing the responses to individual questions from husbands and wives separately, representative quotations were selected and included to demonstrate the emerging themes. Transcripts were checked with the Chinese version of NVivo 9 software (Qualitative Solutions and Research International Pty Ltd, Melbourne, Australia), with items allocated a code and assigned to different categories. The researchers present them in English in this paper with as little editing as possible in order to mirror the words as originally spoken in Chinese. All efforts were made to retain the original intent of the participants’ responses as formulated in the Chinese language. Results Among 30 infertile couples recruited by purposive sampling, two couples preparing for IVF treatment withdrew from the study. One couple informed the researchers that they did not have time due to moving to a new house and the second couple did not give a reason. Table 1 describes each couple’s demographic information. Of the 56 participants (28 infertile couples), the mean age of males is 34.25 years (SD = 5.22) and that of females was 30.71 years (SD = 4.81). Of the participants, almost two-thirds of the males (n = 18, 64.3%) have a primary education level (from 6th grade to 9th grade); five (17.9%) males have a middle education level (from 10th grade to 12th grade) and five (17.9%) males have a high education level (college level). For the females, 17 (60.7%) females have a primary education level; 6 (21.4%) females have a middle education level, and 5 (17.9%) females have a high education level. Regarding the duration of marriage of these infertile couples, the average duration is 5.57 years (SD = 1.93), ranging from 1 to 9 years. Additionally, 12 (42.9%) couples reported having a low economic level, 8 couples (28.6%) had a medium economic level and 8 couples (28.6%) had a higher economic level. Among these participants, 9 couples (32.1%) had male factor infertility; 10 couples (35.7%) had female factor infertility and 4 couples (14.3%) had combined-factors infertility. Furthermore, five couples (17.9%) had unexplained factors infertility. The average duration of their experiencing infertility is 3.39 years (SD = 1.45), ranging from 1 to 7 years. Table 1. Biosocial demographics of the sample in qualitative interview (N = 28 infertile couples) Couple’s code name  Husband  Wife  Years of marriage  Family’s economic level  Type of infertility  Years of infertility  Age, years  Education  Age, years  Education  Couple 1  38  Primary  30  Primary  8  Low  Combined factors  5  Couple 2  43  Primary  38  Primary  6  Low  Female factor  4  Couple 3  44  Primary  38  Middle  9  Medium  Unexplained factors  6  Couple 4  45  High  37  High  3  High  Female factor  2  Couple 5  35  Primary  30  Primary  7  Low  Male factor  4  Couple 6  34  Primary  32  Middle  7  Medium  Female factor  3  Couple 7  34  Primary  30  Primary  8  Low  Male factor  7  Couple 8  33  Primary  30  Primary  8  Low  Combined factors  3  Couple 9  34  Primary  30  Primary  3  Low  Unexplained factors  3  Couple 10  29  Primary  27  Primary  7  Low  Female factor  3  Couple 11  40  Primary  37  Primary  6  Low  Female factor  4  Couple 12  38  High  30  Middle  6  Medium  Combined factors  4  Couple 13  39  High  37  High  6  High  Male factor  5  Couple 14  35  Middle  31  Middle  5  High  Combined factors  3  Couple 15  34  Middle  30  Middle  4  Medium  Male factor  2  Couple 16  33  Primary  28  Middle  5  High  Unexplained factors  3  Couple 17  32  Middle  27  Primary  6  Low  Male factor  4  Couple 18  34  High  31  High  4  High  Male factor  2  Couple 19  30  Primary  26  Primary  5  Low  Female factor  4  Couple 20  30  Primary  36  Primary  6  High  Female factor  3  Couple 21  27  Primary  25  Primary  5  Medium  Male factor  2  Couple 22  37  Middle  25  Primary  3  High  Male factor  1  Couple 23  35  Primary  37  Primary  6  Low  Female factor  3  Couple 24  34  High  36  High  7  High  Unexplained factors  5  Couple 25  35  Middle  32  High  8  Medium  Male factor  5  Couple 26  28  Primary  26  Primary  4  Medium  Unexplained factors  2  Couple 27  25  Primary  23  Primary  3  Medium  Female factor  2  Couple 28  24  Primary  21  Primary  1  Low  Female factor  1  Couple’s code name  Husband  Wife  Years of marriage  Family’s economic level  Type of infertility  Years of infertility  Age, years  Education  Age, years  Education  Couple 1  38  Primary  30  Primary  8  Low  Combined factors  5  Couple 2  43  Primary  38  Primary  6  Low  Female factor  4  Couple 3  44  Primary  38  Middle  9  Medium  Unexplained factors  6  Couple 4  45  High  37  High  3  High  Female factor  2  Couple 5  35  Primary  30  Primary  7  Low  Male factor  4  Couple 6  34  Primary  32  Middle  7  Medium  Female factor  3  Couple 7  34  Primary  30  Primary  8  Low  Male factor  7  Couple 8  33  Primary  30  Primary  8  Low  Combined factors  3  Couple 9  34  Primary  30  Primary  3  Low  Unexplained factors  3  Couple 10  29  Primary  27  Primary  7  Low  Female factor  3  Couple 11  40  Primary  37  Primary  6  Low  Female factor  4  Couple 12  38  High  30  Middle  6  Medium  Combined factors  4  Couple 13  39  High  37  High  6  High  Male factor  5  Couple 14  35  Middle  31  Middle  5  High  Combined factors  3  Couple 15  34  Middle  30  Middle  4  Medium  Male factor  2  Couple 16  33  Primary  28  Middle  5  High  Unexplained factors  3  Couple 17  32  Middle  27  Primary  6  Low  Male factor  4  Couple 18  34  High  31  High  4  High  Male factor  2  Couple 19  30  Primary  26  Primary  5  Low  Female factor  4  Couple 20  30  Primary  36  Primary  6  High  Female factor  3  Couple 21  27  Primary  25  Primary  5  Medium  Male factor  2  Couple 22  37  Middle  25  Primary  3  High  Male factor  1  Couple 23  35  Primary  37  Primary  6  Low  Female factor  3  Couple 24  34  High  36  High  7  High  Unexplained factors  5  Couple 25  35  Middle  32  High  8  Medium  Male factor  5  Couple 26  28  Primary  26  Primary  4  Medium  Unexplained factors  2  Couple 27  25  Primary  23  Primary  3  Medium  Female factor  2  Couple 28  24  Primary  21  Primary  1  Low  Female factor  1  Education level estimated by the following: primary means 6th grade–9th grade, middle means 10th grade–12th grade, high means college level. Economic level estimated by household monthly income (Chinese Yuan): low with less than 1999, medium with 2000–2999 and high with 3000. View Large Four themes related to the sexuality of infertile couples emerged from the respondents’ narratives: gender identity, communication about sex, sexual life and sexual satisfaction. The quotes cited below are selected because they demonstrate participants’ most important perceptions and experiences in the context of infertility. Gender identity From infertile couples’ discourses on their roles in family life or social space, as well as personal ability to perform a behaviour, gender identity is appropriately regarded as the principal theme. [Couple 22: husband]: I experienced severe trauma to my sense of self-worth. I can have sex with my wife, but I feel a sense of inferiority. Though I am a husband, I cannot be a father. [Couple 4: wife]: I deeply feel less of a normal woman. However, I do not want to adopt a child and only want to have my own child. I am distressed because I don’t have anything in common with other women. Other perceptions of gender identity due to infertility were expressed as follows. [Couple 14: wife]: The medical tests indicate my husband is also defective in fertility, but people around me always turn their eyes to me. Why are there more discourses on being female or womanhood, but not on being male or manhood? [Couple 25: husband]: Though all the tests indicate that I do not have any kind of sexual dysfunction, I still cannot give up the sense of emasculation. I almost lose a sense of self-confidence in my sexual ability. Communication about sex The study indicated that a number of infertile couples seldom discussed sexual matters with each other, and their communication about sex was limited specifically to their marital sexual life. [Couple 16: husband]: I never tell my wife about my desire for having sex with her, almost no verbal communication with each other. [Couple 16: wife]: I do not speak my willingness of having sex with my husband. We have a tacit agreement of having sex two or three times per week. Some couples reported there was little communication about sex because they lived with their family members (for example, their parents-in-law and siblings) and, therefore, lacked privacy. [Couple 26: husband]: I live with my parents; my sister is also in our family, and she is not married yet. We live in separate rooms, but in the same house without soundproofing. I never talk about sex openly with my wife. [Couple 26: wife]: I really feel it is not comfortable because my parents-in-law live in the next room. My husband and I cannot speak loudly and tend not to talk about sexual things. The themes also indicated that gender differences are associated with the expression of sexual demand. Husbands reported that they initiated sex, while their wives seldom expressed their demand for sex and did not talk directly to their husbands about their sexual desire. [Couple 27: husband]: I am really surprised my wife never talks about her thoughts in sexual demand, and I have no idea what she thinks. I am not satisfied with this status due to no relaxing and free mood in sex. [Couple 27: wife]: I never make my husband feel disappointed. I think a wife should give her husband a comfortable feeling. Although sometimes I am tired and do not want to do it, I still pretend I desire it. Interviewees who had a clear diagnosis of the cause of infertility shared a lack of sexual communication and decreased sexual desire. [Couple 25: husband]: I feel my sexual desire decreasing, and I am not active in sex. I seldom express my sexual needs to my wife and do not ask my wife’s sexual expectations and feelings. Sometimes when facing my wife’s initiation of sex, I pretend I’m too tired to do it. Other times, I just do it perfunctorily. [Couple 19: wife]: In these two years, I have tried to find all methods for conceiving, but nothing happened. Since being diagnosed as infertile, I feel a disruption with almost zero sex drive. Some couples communicated differently about sexual matters when they learned of their diagnosis of unexplained infertility. [Couple 3: husband]: My sperm is normal, and no physical disease is found to be related to the infertile condition. I do not feel any pressure about my sexual ability. I can initiate a discussion around my sexual needs with my wife, but she does not express her thoughts and feelings to me. During the interview with this participant’s wife, held separately according to the research procedure, she volunteered the following information: [Couple 3: wife]: I have no interest in sex; sometimes I feel disgusted by my husband’s sexual need. In the past, I really enjoyed having sex with my husband; now, I am not the person I was. Having sex has become a chore for me, with hardly any communication around it. Sexual life The theme on which the diagnosis of infertility had the greatest impact was the couple’s sexual life. The primary dependent variables having to do with infertile couples’ sexual life included their sexual behaviour, the frequency with which they had sex and their motivation for having sex. [Couple 22: husband]: I am not active in making love with my wife, and do not have a strong passion for it. Sometimes I intentionally decrease the frequency of sexual intercourse using physical fatigue as an excuse, because I feel over-sex is not good for the body. [Couple 20: wife]: My husband always expresses his demand for sex and initiates it directly, after which he goes to sleep. I feel my sexual arousal is very slow and hardly feel any sexual pleasure, so I look forward to its finishing as soon as possible. It was clear from some responses that participants’ sexual life focused mainly on sexual intercourse for conception. [Couple 1: wife]: For me, conceiving is the exclusive aim of having sex with my husband. I frequently decide when to have sex with my husband according to my cycle and doctor’s suggestions. My husband is not happy with this, but I do not want to change this. [Couple 22: husband]: Sometimes when I would like to have sex, we don’t do it because it is not the right time. Other times, even if I am too tired from work, we do it because my wife says it is the better day for conceiving. I dislike this planned activity for sexual intercourse; it is so boring. Twelve wives expected their husbands to give them physical cuddling, caressing or kissing other than sexual intercourse, and they had a greater expectation of intimacy in their marital sexual life. [Couple 16: wife]: I am really disgusted with my sexual life, because my husband only focuses on penetration during sex, no touching, no kissing, no speaking communication. Sometimes I feel I am in an empty status after sex. Sexual satisfaction Sexual satisfaction emerged as a strong theme, mentioned by eight out of ten participants. Some stated that a satisfying sexual experience alleviated the tension caused by infertility stress. In their responses, the interviewees also mentioned that sexual satisfaction had a positive effect on their marital relationship. [Couple 13: wife] My husband always talks to me kindly and humorously before he wants to have sex with me. He respects my thoughts about sexual activities, involving time, place, behavior pattern, and frequency of sex. I feel sexual satisfaction may increase the emotion of connection between us. [Couple 24: husband] I have an intimate experience with my wife when we have sex together, involving cuddling, kissing, and free sex talk. We share the emotional depth and closeness with each other. Though infertility brings some negative influence to my feelings, it does not bring turmoil to my life. Another strong theme that emerged was the negative impact of having to plan sexual activity for the purpose of procreation. Participants clearly did not respond positively to sex becoming routinized for fertility purposes rather than for pleasure and satisfaction. [Couple 3: wife] My marital sexual life has changed from “willing to do it” to “having to do it.” I am fed up with it, mainly because I experience a lack of orgasm and mutual intimacy. Sometimes I really do not want to have sex with my husband and eventually refuse his demand. This, however, causes considerable tension between us. [Couple 21: husband] My wife dislikes changing sexual positions and behavior patterns in our sexual activities, but I want to try these for more romance and fun. My wife always thinks that having a child is our priority. I fear that our incongruence on this matter will destroy our marriage life. Discussion In this study, infertile men reported that infertility threatened their gender identity. Even though the participants did not have any sexual dysfunction for reproduction, they still expressed concern about their ability to be biological fathers. This is consistent with the finding that infertile men hold extreme perceptions of themselves as emasculated when they confront infertility (5). For infertile couples where the man was not the infertile partner, though the husband’s sense of gender identity was not dependent on his sexual performance, men still had a negative perception of their gender identity; this could be explained by the fact that the link between fertility and potency is strongly highlighted in Chinese culture. Likewise, infertile women in our study reported a negative sense of gender identity such as feeling unfeminine due to a failure to conceive; this might be due to motherhood being considered as a major role of women and a respected part of a female’s identity (15). Regarding communication about sex in infertile couples, the study found it was fairly limited. This could be explained by the fact that sex is still somewhat of a taboo topic even though there are rapid changes in sexual mores in current Chinese society (16). Additionally, infertile couples viewed fertility as their paramount concern in their sexual relationship, with little interest in sexual desire or feelings. Additionally, some infertile couples lived in a limited space shared with their family members. Clearly, in this sort of family environment, they do not have a reasonable opportunity for private communication and are concerned about privacy. There was a discrepancy in sexual communication between husbands and wives. Most husbands were more likely to initiate sexual expression in demanding sex, which is associated with cultural factors that tend to enhance the role of the husband as the dominator, while women are expected to play a more passive role (17). The results of this study suggest that a majority of the couples were dissatisfied with their sexual lives, which appears to be associated with their perceived experience of infertility, and is similar to other studies (18–20). Additionally, the sense of gender identity and sexual communication in marital life conflated with a decrease in sexual desire and pleasure. Moreover, some infertile couples complained that planning sexual intercourse around ovulation disrupted their sense of pleasure. For them, the lack of spontaneous sex and sex for fun with intimacy, combined with the expectation of having a child, created emotional pressure. The majority of participants believed that enjoyable and mutual sexual satisfaction is beneficial to the marital relationship. This finding is line with other studies, which indicate that dissatisfaction with sexual relationships can instigate and/or worsen marital relationships (21–23). However, over half of the participants in this study did not take measures to improve their sexual lives because they are limited in their understanding of the difference between sex and sexuality, also with a lack of communication on sexual intimacy. From the results of this study, we found infertile couples’ sexuality involved a broad range of cognitions, emotions and behaviours, also influenced by cultural value, social norm, and their experiencing infertility. Clearly, infertile couples’ understanding of sexuality is more than the physical act of intercourse; it includes self-identity, communication, sharing pleasure, and deepening intimacy. For primary care physicians, these variables would be meaningful in the early stages of assessing the individual and family aspects of the infertility diagnosis and to analyse as a concomitant task associated with treatment and quality of life. Additionally, since family physicians are not necessarily trained to be sensitive to the sexual difficulties experienced by infertile couples, these findings may provide suggestions for referring infertile individuals or couples to a specialist for sexual and relationship interventions. Of note in this study, the researched infertile couples were experiencing primary infertility; there were no couples with secondary infertility. Given the different experiences between couples with primary and secondary infertility, further research, including diverse sampled participants, would help extend understanding of infertile couples’ sexuality through comparison. Therefore, future larger-scale studies would be beneficial to raise awareness of care providers and the general population. Moreover, case studies might be necessary for further discussing sexuality among couples with different duration of infertility and length of the marriage. Conclusion This study suggests that men and women who are coping with infertility experience sexuality differently in terms of having different needs in, expectations for, and feelings about their marital sexual life. The findings should be fully valued by family physicians for providing infertile couples with information related to sexual well-being, coping styles, relationships, etc. Supplementary Material Supplementary data are available at Family Practice online. Declaration Funding: departmental resources. Ethical approval: the Human Research Ethics Committee of Curtin University (Australia) and the Ethical Committee of the First Affiliated Hospital, Harbin Medical University (China). Conflict of interest: none. Acknowledgements We greatly appreciate the staffs of IVF centre at the First Affiliated Hospital of Harbin Medical University for their help in recruiting the study subjects and their assistance in qualitative data collection. We also thank all the participants in this study. References 1. Rantala ML, Koskimies AI. Sexual behavior of infertile couples. Int J Fertil  1988; 33: 26– 30. Google Scholar PubMed  2. 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Sexual and relationship satisfaction among persons with young-onset Parkinson’s disease. J Sex Med  2010; 7: 1438– 44. Google Scholar CrossRef Search ADS PubMed  23. Yasan A, Gürgen F. Marital satisfaction, sexual problems, and the possible difficulties on sex therapy in traditional Islamic culture. J Sex Marital Ther  2009; 35: 68– 75. Google Scholar CrossRef Search ADS PubMed  © The Author(s) 2017. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Family Practice Oxford University Press

Qualitative research on infertile Chinese couples’ understanding of sexuality

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Abstract

Abstract Background Family physicians play an important role in the initial counselling and evaluation of infertility. Despite infertility regarded as a stressor and a life crisis for individuals or couples, little is known about the psychosexual aspects of infertility. On the basis that sexuality is a crucial part of quality of life, it is worthwhile to give more attention to sexuality of infertile couples during their time of experiencing infertility. Objective This study aimed to gain insight into the dynamic features of the sexuality of infertile couples and to provide meaningful evidence for improving their quality of life. Methods We employed a qualitative approach to conduct this study. Utilizing purposive sampling method, 56 participants (28 infertile Chinese couples) were recruited from the reproductive medicine centre of a general hospital, and in-depth interviews were conducted with each participant. Thematic content analysis was used to analyse the transcripts. Results Four themes emerged from the respondents’ narratives; these themes relate to the infertile couples’ understanding of sexuality: (i) gender identity, (ii) communication about sex, (iii) sexual life and (iv) sexual satisfaction. It was further found that Chinese culture’s values of fertility, perceptions about sexuality and sex, social norms regarding gender, and expectations about marital sexual life can have significant effects on infertile Chinese couples’ sexuality. Conclusion These findings should be highly considered by family physicians in their practice to provide infertile couples with information related to sexual well-being, coping styles, relationship, etc. Infertility, qualitative research, quality of life, sexuality Introduction Previous studies have proved that sexual dysfunction and reproductive tract diseases are factors that contribute to infertility (1–3). Additionally, there are specific findings on the sexual aspects of people who suffer from the clinical diagnosis and treatment of infertility, which are expressed through decreasing sexual frequency (4), lower sexual desire and satisfaction (5,6), and sexual dysfunction morbidity (7–9). There is an increased awareness that these sexual problems may have an impact on difficulties with conception by contributing to limited or absent sexual activity (10). However, most investigators rarely explore sexuality beyond the physical dimensions. Little is known about infertility from a psychosexual perspective (11). Less research addresses the sexuality of the infertile individual’s partner. Sexuality is not merely associated with reproductive function; it can serve as a means of giving and receiving pleasure, maintaining closeness within couples and making a major contribution to a person’s quality of life (12). Therefore, it would be useful to focus more attention on sexuality as it pertains to the well-being of couples unable to conceive a child. This study was undertaken within the framework of a larger research project (January 2010 to June 2011) on the relationships between biosocial demographics, infertility stress, sexuality and marital well-being to identify predicting factors that influence the marital well-being of infertile Chinese couples. For this qualitative study, we anticipated gaining insight into the dynamic features of the sexuality of infertile couples and how couples cope with sexual issues while experiencing infertility, and then to provide meaningful evidence for improving infertile couples’ quality of life. Methods Participants Participants were recruited from the Reproductive Medicine Centre in the First Affiliated Hospital of Harbin Medical University, Harbin City, Hei Longjiang Province, China. To be eligible for this study, participants had to be married and living together all the time. They had to be part of a heterosexual couple experiencing primary infertility in their current relationship, with at least 6 years of education to better understand each question from the interview outline. There were two exclusion criteria: (i) either one of the partners of an infertile couple having any illness not related to fertility and (ii) either one of the partners of an infertile couple having a diagnosis of an organic sexual disorder. Through purposeful sampling, 30 infertile couples attending the infertility clinic for treatment were invited to participate in this study. They were diagnosed with a variety of infertility-based etiology, including female factors (e.g., tubal factors, endometriosis, pelvic adhesions), male factors (e.g., low sperm count, psychogenic sexual dysfunction, gonadtropism), combined factors, and unexplained infertility due to factors not attributable to either partner. Twenty-four of the infertile couples were preparing for the first in vitro fertilization (IVF) treatment, with the other six infertile couples being in the second treatment cycle. All participants were also informed of the purpose of the study and the fact that participation was voluntary. They were also informed that they had the right to withdraw from the study at any time and their confidentiality was assured. Additionally, all the respondents’ names were replaced with pseudonyms in the transcripts. Interview approach An interview guide (Supplementary Table S1) for semi-structured interviews was used in this study, which included perspectives on sexuality, opinions regarding the relationship between sex and procreation, communication about sexual intimacy within couples, motivation and initiative for sex, social-demographic data and the type of infertility. The interview guide was piloted before the formal interviews, including interview style, length of interview, logical structure and questions’ probe of the research topic. A one-on-one, in-depth interview was conducted with each participant in a private site in the hospital’s reproductive medicine centre. To minimize threats to validity during interviewing, each interviewee was asked whether he or she preferred a same-sex or opposite-sex interviewer prior to the formal interview. Nine female interviewees indicated a preference for a female interviewer, and five male interviewees indicated a preference for a male interviewer. Other interviewees did not have any preference. The duration of interview varied between 60 and 90 minutes, depending on the information provided by the interviewees. Only one or two in-depth interviews were conducted in a day. Additionally, the researchers maintained an attitude of respect and neutrality when endeavouring to find issues that were of specific concern to the interviewees. Deviant case analysis was performed by searching cases that ran counter to the emerging themes (13). In order to ensure the credibility of the findings, member checking was conducted by asking the interviewees to review the researcher’s notes, interpretation, transcripts or findings during the interview. By applying these approaches, we decreased the possibility that the qualitative data would be caused by researcher bias. More attention was paid to data saturation and thematic exhaustion, through constructive (during the process) and evaluative (post hoc) procedures. These ensured the trustworthiness of the research (14). Data analysis Given that participants’ notes taken during the interview were not extremely detailed, they were instructed to expand as soon as possible after each interview. The expansions included synthesizing the interviewees’ notes with their feeling, mood and interpretations. Through analysing the responses to individual questions from husbands and wives separately, representative quotations were selected and included to demonstrate the emerging themes. Transcripts were checked with the Chinese version of NVivo 9 software (Qualitative Solutions and Research International Pty Ltd, Melbourne, Australia), with items allocated a code and assigned to different categories. The researchers present them in English in this paper with as little editing as possible in order to mirror the words as originally spoken in Chinese. All efforts were made to retain the original intent of the participants’ responses as formulated in the Chinese language. Results Among 30 infertile couples recruited by purposive sampling, two couples preparing for IVF treatment withdrew from the study. One couple informed the researchers that they did not have time due to moving to a new house and the second couple did not give a reason. Table 1 describes each couple’s demographic information. Of the 56 participants (28 infertile couples), the mean age of males is 34.25 years (SD = 5.22) and that of females was 30.71 years (SD = 4.81). Of the participants, almost two-thirds of the males (n = 18, 64.3%) have a primary education level (from 6th grade to 9th grade); five (17.9%) males have a middle education level (from 10th grade to 12th grade) and five (17.9%) males have a high education level (college level). For the females, 17 (60.7%) females have a primary education level; 6 (21.4%) females have a middle education level, and 5 (17.9%) females have a high education level. Regarding the duration of marriage of these infertile couples, the average duration is 5.57 years (SD = 1.93), ranging from 1 to 9 years. Additionally, 12 (42.9%) couples reported having a low economic level, 8 couples (28.6%) had a medium economic level and 8 couples (28.6%) had a higher economic level. Among these participants, 9 couples (32.1%) had male factor infertility; 10 couples (35.7%) had female factor infertility and 4 couples (14.3%) had combined-factors infertility. Furthermore, five couples (17.9%) had unexplained factors infertility. The average duration of their experiencing infertility is 3.39 years (SD = 1.45), ranging from 1 to 7 years. Table 1. Biosocial demographics of the sample in qualitative interview (N = 28 infertile couples) Couple’s code name  Husband  Wife  Years of marriage  Family’s economic level  Type of infertility  Years of infertility  Age, years  Education  Age, years  Education  Couple 1  38  Primary  30  Primary  8  Low  Combined factors  5  Couple 2  43  Primary  38  Primary  6  Low  Female factor  4  Couple 3  44  Primary  38  Middle  9  Medium  Unexplained factors  6  Couple 4  45  High  37  High  3  High  Female factor  2  Couple 5  35  Primary  30  Primary  7  Low  Male factor  4  Couple 6  34  Primary  32  Middle  7  Medium  Female factor  3  Couple 7  34  Primary  30  Primary  8  Low  Male factor  7  Couple 8  33  Primary  30  Primary  8  Low  Combined factors  3  Couple 9  34  Primary  30  Primary  3  Low  Unexplained factors  3  Couple 10  29  Primary  27  Primary  7  Low  Female factor  3  Couple 11  40  Primary  37  Primary  6  Low  Female factor  4  Couple 12  38  High  30  Middle  6  Medium  Combined factors  4  Couple 13  39  High  37  High  6  High  Male factor  5  Couple 14  35  Middle  31  Middle  5  High  Combined factors  3  Couple 15  34  Middle  30  Middle  4  Medium  Male factor  2  Couple 16  33  Primary  28  Middle  5  High  Unexplained factors  3  Couple 17  32  Middle  27  Primary  6  Low  Male factor  4  Couple 18  34  High  31  High  4  High  Male factor  2  Couple 19  30  Primary  26  Primary  5  Low  Female factor  4  Couple 20  30  Primary  36  Primary  6  High  Female factor  3  Couple 21  27  Primary  25  Primary  5  Medium  Male factor  2  Couple 22  37  Middle  25  Primary  3  High  Male factor  1  Couple 23  35  Primary  37  Primary  6  Low  Female factor  3  Couple 24  34  High  36  High  7  High  Unexplained factors  5  Couple 25  35  Middle  32  High  8  Medium  Male factor  5  Couple 26  28  Primary  26  Primary  4  Medium  Unexplained factors  2  Couple 27  25  Primary  23  Primary  3  Medium  Female factor  2  Couple 28  24  Primary  21  Primary  1  Low  Female factor  1  Couple’s code name  Husband  Wife  Years of marriage  Family’s economic level  Type of infertility  Years of infertility  Age, years  Education  Age, years  Education  Couple 1  38  Primary  30  Primary  8  Low  Combined factors  5  Couple 2  43  Primary  38  Primary  6  Low  Female factor  4  Couple 3  44  Primary  38  Middle  9  Medium  Unexplained factors  6  Couple 4  45  High  37  High  3  High  Female factor  2  Couple 5  35  Primary  30  Primary  7  Low  Male factor  4  Couple 6  34  Primary  32  Middle  7  Medium  Female factor  3  Couple 7  34  Primary  30  Primary  8  Low  Male factor  7  Couple 8  33  Primary  30  Primary  8  Low  Combined factors  3  Couple 9  34  Primary  30  Primary  3  Low  Unexplained factors  3  Couple 10  29  Primary  27  Primary  7  Low  Female factor  3  Couple 11  40  Primary  37  Primary  6  Low  Female factor  4  Couple 12  38  High  30  Middle  6  Medium  Combined factors  4  Couple 13  39  High  37  High  6  High  Male factor  5  Couple 14  35  Middle  31  Middle  5  High  Combined factors  3  Couple 15  34  Middle  30  Middle  4  Medium  Male factor  2  Couple 16  33  Primary  28  Middle  5  High  Unexplained factors  3  Couple 17  32  Middle  27  Primary  6  Low  Male factor  4  Couple 18  34  High  31  High  4  High  Male factor  2  Couple 19  30  Primary  26  Primary  5  Low  Female factor  4  Couple 20  30  Primary  36  Primary  6  High  Female factor  3  Couple 21  27  Primary  25  Primary  5  Medium  Male factor  2  Couple 22  37  Middle  25  Primary  3  High  Male factor  1  Couple 23  35  Primary  37  Primary  6  Low  Female factor  3  Couple 24  34  High  36  High  7  High  Unexplained factors  5  Couple 25  35  Middle  32  High  8  Medium  Male factor  5  Couple 26  28  Primary  26  Primary  4  Medium  Unexplained factors  2  Couple 27  25  Primary  23  Primary  3  Medium  Female factor  2  Couple 28  24  Primary  21  Primary  1  Low  Female factor  1  Education level estimated by the following: primary means 6th grade–9th grade, middle means 10th grade–12th grade, high means college level. Economic level estimated by household monthly income (Chinese Yuan): low with less than 1999, medium with 2000–2999 and high with 3000. View Large Four themes related to the sexuality of infertile couples emerged from the respondents’ narratives: gender identity, communication about sex, sexual life and sexual satisfaction. The quotes cited below are selected because they demonstrate participants’ most important perceptions and experiences in the context of infertility. Gender identity From infertile couples’ discourses on their roles in family life or social space, as well as personal ability to perform a behaviour, gender identity is appropriately regarded as the principal theme. [Couple 22: husband]: I experienced severe trauma to my sense of self-worth. I can have sex with my wife, but I feel a sense of inferiority. Though I am a husband, I cannot be a father. [Couple 4: wife]: I deeply feel less of a normal woman. However, I do not want to adopt a child and only want to have my own child. I am distressed because I don’t have anything in common with other women. Other perceptions of gender identity due to infertility were expressed as follows. [Couple 14: wife]: The medical tests indicate my husband is also defective in fertility, but people around me always turn their eyes to me. Why are there more discourses on being female or womanhood, but not on being male or manhood? [Couple 25: husband]: Though all the tests indicate that I do not have any kind of sexual dysfunction, I still cannot give up the sense of emasculation. I almost lose a sense of self-confidence in my sexual ability. Communication about sex The study indicated that a number of infertile couples seldom discussed sexual matters with each other, and their communication about sex was limited specifically to their marital sexual life. [Couple 16: husband]: I never tell my wife about my desire for having sex with her, almost no verbal communication with each other. [Couple 16: wife]: I do not speak my willingness of having sex with my husband. We have a tacit agreement of having sex two or three times per week. Some couples reported there was little communication about sex because they lived with their family members (for example, their parents-in-law and siblings) and, therefore, lacked privacy. [Couple 26: husband]: I live with my parents; my sister is also in our family, and she is not married yet. We live in separate rooms, but in the same house without soundproofing. I never talk about sex openly with my wife. [Couple 26: wife]: I really feel it is not comfortable because my parents-in-law live in the next room. My husband and I cannot speak loudly and tend not to talk about sexual things. The themes also indicated that gender differences are associated with the expression of sexual demand. Husbands reported that they initiated sex, while their wives seldom expressed their demand for sex and did not talk directly to their husbands about their sexual desire. [Couple 27: husband]: I am really surprised my wife never talks about her thoughts in sexual demand, and I have no idea what she thinks. I am not satisfied with this status due to no relaxing and free mood in sex. [Couple 27: wife]: I never make my husband feel disappointed. I think a wife should give her husband a comfortable feeling. Although sometimes I am tired and do not want to do it, I still pretend I desire it. Interviewees who had a clear diagnosis of the cause of infertility shared a lack of sexual communication and decreased sexual desire. [Couple 25: husband]: I feel my sexual desire decreasing, and I am not active in sex. I seldom express my sexual needs to my wife and do not ask my wife’s sexual expectations and feelings. Sometimes when facing my wife’s initiation of sex, I pretend I’m too tired to do it. Other times, I just do it perfunctorily. [Couple 19: wife]: In these two years, I have tried to find all methods for conceiving, but nothing happened. Since being diagnosed as infertile, I feel a disruption with almost zero sex drive. Some couples communicated differently about sexual matters when they learned of their diagnosis of unexplained infertility. [Couple 3: husband]: My sperm is normal, and no physical disease is found to be related to the infertile condition. I do not feel any pressure about my sexual ability. I can initiate a discussion around my sexual needs with my wife, but she does not express her thoughts and feelings to me. During the interview with this participant’s wife, held separately according to the research procedure, she volunteered the following information: [Couple 3: wife]: I have no interest in sex; sometimes I feel disgusted by my husband’s sexual need. In the past, I really enjoyed having sex with my husband; now, I am not the person I was. Having sex has become a chore for me, with hardly any communication around it. Sexual life The theme on which the diagnosis of infertility had the greatest impact was the couple’s sexual life. The primary dependent variables having to do with infertile couples’ sexual life included their sexual behaviour, the frequency with which they had sex and their motivation for having sex. [Couple 22: husband]: I am not active in making love with my wife, and do not have a strong passion for it. Sometimes I intentionally decrease the frequency of sexual intercourse using physical fatigue as an excuse, because I feel over-sex is not good for the body. [Couple 20: wife]: My husband always expresses his demand for sex and initiates it directly, after which he goes to sleep. I feel my sexual arousal is very slow and hardly feel any sexual pleasure, so I look forward to its finishing as soon as possible. It was clear from some responses that participants’ sexual life focused mainly on sexual intercourse for conception. [Couple 1: wife]: For me, conceiving is the exclusive aim of having sex with my husband. I frequently decide when to have sex with my husband according to my cycle and doctor’s suggestions. My husband is not happy with this, but I do not want to change this. [Couple 22: husband]: Sometimes when I would like to have sex, we don’t do it because it is not the right time. Other times, even if I am too tired from work, we do it because my wife says it is the better day for conceiving. I dislike this planned activity for sexual intercourse; it is so boring. Twelve wives expected their husbands to give them physical cuddling, caressing or kissing other than sexual intercourse, and they had a greater expectation of intimacy in their marital sexual life. [Couple 16: wife]: I am really disgusted with my sexual life, because my husband only focuses on penetration during sex, no touching, no kissing, no speaking communication. Sometimes I feel I am in an empty status after sex. Sexual satisfaction Sexual satisfaction emerged as a strong theme, mentioned by eight out of ten participants. Some stated that a satisfying sexual experience alleviated the tension caused by infertility stress. In their responses, the interviewees also mentioned that sexual satisfaction had a positive effect on their marital relationship. [Couple 13: wife] My husband always talks to me kindly and humorously before he wants to have sex with me. He respects my thoughts about sexual activities, involving time, place, behavior pattern, and frequency of sex. I feel sexual satisfaction may increase the emotion of connection between us. [Couple 24: husband] I have an intimate experience with my wife when we have sex together, involving cuddling, kissing, and free sex talk. We share the emotional depth and closeness with each other. Though infertility brings some negative influence to my feelings, it does not bring turmoil to my life. Another strong theme that emerged was the negative impact of having to plan sexual activity for the purpose of procreation. Participants clearly did not respond positively to sex becoming routinized for fertility purposes rather than for pleasure and satisfaction. [Couple 3: wife] My marital sexual life has changed from “willing to do it” to “having to do it.” I am fed up with it, mainly because I experience a lack of orgasm and mutual intimacy. Sometimes I really do not want to have sex with my husband and eventually refuse his demand. This, however, causes considerable tension between us. [Couple 21: husband] My wife dislikes changing sexual positions and behavior patterns in our sexual activities, but I want to try these for more romance and fun. My wife always thinks that having a child is our priority. I fear that our incongruence on this matter will destroy our marriage life. Discussion In this study, infertile men reported that infertility threatened their gender identity. Even though the participants did not have any sexual dysfunction for reproduction, they still expressed concern about their ability to be biological fathers. This is consistent with the finding that infertile men hold extreme perceptions of themselves as emasculated when they confront infertility (5). For infertile couples where the man was not the infertile partner, though the husband’s sense of gender identity was not dependent on his sexual performance, men still had a negative perception of their gender identity; this could be explained by the fact that the link between fertility and potency is strongly highlighted in Chinese culture. Likewise, infertile women in our study reported a negative sense of gender identity such as feeling unfeminine due to a failure to conceive; this might be due to motherhood being considered as a major role of women and a respected part of a female’s identity (15). Regarding communication about sex in infertile couples, the study found it was fairly limited. This could be explained by the fact that sex is still somewhat of a taboo topic even though there are rapid changes in sexual mores in current Chinese society (16). Additionally, infertile couples viewed fertility as their paramount concern in their sexual relationship, with little interest in sexual desire or feelings. Additionally, some infertile couples lived in a limited space shared with their family members. Clearly, in this sort of family environment, they do not have a reasonable opportunity for private communication and are concerned about privacy. There was a discrepancy in sexual communication between husbands and wives. Most husbands were more likely to initiate sexual expression in demanding sex, which is associated with cultural factors that tend to enhance the role of the husband as the dominator, while women are expected to play a more passive role (17). The results of this study suggest that a majority of the couples were dissatisfied with their sexual lives, which appears to be associated with their perceived experience of infertility, and is similar to other studies (18–20). Additionally, the sense of gender identity and sexual communication in marital life conflated with a decrease in sexual desire and pleasure. Moreover, some infertile couples complained that planning sexual intercourse around ovulation disrupted their sense of pleasure. For them, the lack of spontaneous sex and sex for fun with intimacy, combined with the expectation of having a child, created emotional pressure. The majority of participants believed that enjoyable and mutual sexual satisfaction is beneficial to the marital relationship. This finding is line with other studies, which indicate that dissatisfaction with sexual relationships can instigate and/or worsen marital relationships (21–23). However, over half of the participants in this study did not take measures to improve their sexual lives because they are limited in their understanding of the difference between sex and sexuality, also with a lack of communication on sexual intimacy. From the results of this study, we found infertile couples’ sexuality involved a broad range of cognitions, emotions and behaviours, also influenced by cultural value, social norm, and their experiencing infertility. Clearly, infertile couples’ understanding of sexuality is more than the physical act of intercourse; it includes self-identity, communication, sharing pleasure, and deepening intimacy. For primary care physicians, these variables would be meaningful in the early stages of assessing the individual and family aspects of the infertility diagnosis and to analyse as a concomitant task associated with treatment and quality of life. Additionally, since family physicians are not necessarily trained to be sensitive to the sexual difficulties experienced by infertile couples, these findings may provide suggestions for referring infertile individuals or couples to a specialist for sexual and relationship interventions. Of note in this study, the researched infertile couples were experiencing primary infertility; there were no couples with secondary infertility. Given the different experiences between couples with primary and secondary infertility, further research, including diverse sampled participants, would help extend understanding of infertile couples’ sexuality through comparison. Therefore, future larger-scale studies would be beneficial to raise awareness of care providers and the general population. Moreover, case studies might be necessary for further discussing sexuality among couples with different duration of infertility and length of the marriage. Conclusion This study suggests that men and women who are coping with infertility experience sexuality differently in terms of having different needs in, expectations for, and feelings about their marital sexual life. The findings should be fully valued by family physicians for providing infertile couples with information related to sexual well-being, coping styles, relationships, etc. Supplementary Material Supplementary data are available at Family Practice online. Declaration Funding: departmental resources. Ethical approval: the Human Research Ethics Committee of Curtin University (Australia) and the Ethical Committee of the First Affiliated Hospital, Harbin Medical University (China). Conflict of interest: none. Acknowledgements We greatly appreciate the staffs of IVF centre at the First Affiliated Hospital of Harbin Medical University for their help in recruiting the study subjects and their assistance in qualitative data collection. We also thank all the participants in this study. References 1. Rantala ML, Koskimies AI. Sexual behavior of infertile couples. Int J Fertil  1988; 33: 26– 30. Google Scholar PubMed  2. 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Family PracticeOxford University Press

Published: Feb 1, 2018

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