Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation

Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.

1. Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation Sujoy Dasgupta 1 , Abhyuday Chanda 2 MS, DNB, MRCOG, MSc ; Consultant, Reproductive Medicine, Genome Fertility Centre, Kolkata, India M Sc, Bio-Statistician, Quartesian Clinical Research, Kolkata, India

2. Introduction Infertility is defined as “the failure to establish a clinical pregnancy after 12 months of regular, unprotected sexual intercourse” 1 The sexual history is often ignored. 1 Zegers-Hochschild F, Adamson GD, Dyer S, et al. The International Glossary on Infertility and Fertility Care, 2017.  Fertil Steril . 2017;108(3):393–406

3. Existing literature Some couples never had successful sexual intercourse but want to conceive 1 Only two studies on non-consummation and pregnancy 2,3 Sample sizes- 40 and 55, respectively 2,3 1 Jejeebhoy SJ. Infertility in India -- levels patterns and consequences: priorities for social science research. J Fam Wel . 1998;4(2):15-24 2 Nene UA, Coyaji K, Apte H. Infertility: a label of choice in the case of sexually dysfunctional couples. Patient Educ Couns . 2005 Dec;59(3):234-8. 3 Banerjee K, Singla B. Pregnancy Outcome of Home Intravaginal Insemination in Couples with Unconsummated Marriage. J Hum Reprod Sci. 2017 Oct-Dec;10(4):293-296.

4. Aims and Objectives Primary Objectives To detect the proportion of the couples presenting to the Fertility Clinic never had a single episode of successful sexual intercourse * before and the underlying factors associated . Secondary Objectives To detect the extent of improvement of sexual problems To detect acceptance of alternate fertility treatments- Intravaginal insemination [IVI] Intrauterine insemination [IUI] In-vitro fertilization [IVF] To detect the time to conceive (TTC)

5. Materials and Methods Study Design Case Control Study Study Setting Genome Fertility Centre, Kolkata Study Duration January 2016 to June 2019 (42 months) Approved by Institutional Human research Ethics Committee (IEC/2015/G-12/1)

6. Inclusion Criteria Never had any episode of successful sexual intercourse * in the current relationship Exclusion Criteria Reluctant to disclose the sexual history Previous investigations (if already done) showing Severe defects in sperms Bilateral tube block Premature ovarian failure Grade IV endometriosis Previously/ currently being treated for psychiatric disorders Couples who have medical contraindications to frequent intercourse (like HIV affected serodiscordant couple, severely compromised heart disease etc) * “Successful sexual intercourse” = Unprotected and complete penile-vaginal penetration, culminating in intravaginal ejaculation, essential to conceive “naturally”

7. Written Informed Consent from all the participants (both the partners) Asked specifically about different components of sexual functions Sexual dysfunction was defined according to Diagnostic and Statistical Manual of Mental Disorders, 5th Ed (DSM-5) 1 1 American Psychiatric Association. 2013. pp. 423-450

8. Sexual dysfunctions included in the study (DSM-5) Male Male hypoactive sexual desire disorder Erectile dysfunction Premature ejaculation Delayed ejaculation Female Female sexual interest/arousal disorder Genito -pelvic pain/ penetration disorder Female orgasmic disorder

9. Detailed medical history and physical examination (both the partners) Assessment and treatment of sexual dysfunction (including specialist referral ) Standard fertility consultation (investigations and treatment, when indicated)

10. Assessed after 6 months (Divided in 2 groups) Group A Subsequently had successful sexual intercourse * Group B Could not have successful sexual intercourse * They were followed up to see improvement in sexual intercourse Discussed alternative options- IVI ( Intravaginal insemination) at home IUI (Intrauterine Insemination) IVF (In vitro fertilization) * “Successful sexual intercourse” = Unprotected and complete penile-vaginal penetration, culminating in intravaginal ejaculation, essential to conceive “naturally”

11. Differences between these two groups were analyzed Using the SAS 9.4 software Categorical data- Chi square/ Fisher test Continuous data- Student's (unpaired) t-test/ Mann-Whitney U-test (after checking for normal distribution) They were followed longitudinally to compare the time to conception (TTC) using Kaplan Meier Analysis

12. If opted for intravaginal insemination (IVI) at home The male partner collected the semen by masturbation in a sterile container. A 5 cc syringe was used to aspirate the semen from the container. The female partner lied in the supine position with flexed legs The male partner inserted the syringe loaded with semen inside the vagina slowly. The woman was asked to rest for 20 min. Up to 3 cycles

13. Results Total number of couples coming to the fertility clinic 2057 Non-consummation (Not having a single episode of successful sexual intercourse) 128 (5.81%) Excluded 20 Finally INCLUDED in the study 108

14. Demographic Variables (N= 108) Mean ± standard deviation (SD) Range Male partner’ s age (years) 35.35 ± 3.15 26- 45 Female partner ’s age (years) 29.68 ± 3.65 22-38 Duration of Current Relationship (months) 24.05 ± 15.02 6-72 Already visited fertility clinic (before coming to us) 87 (80.56%)

15. Disclosure of Sexual Dysfunction at the first visit (N= 108)

16. Sexual dysfunction in individuals (N= 108)

17. Etiology of Sexual Dysfunction in Male Partners (defined according to DSM-5) *Many individuals had more than one sexual dysfunction 35 (32.41%)

18. Etiology of Sexual Dysfunction in Female Partners (defined according to DSM-5) *Many individuals had more than one sexual dysfunction

19. After 6 months (N= 108)

20. Differences in parameters between Group A and B Group A (Improved sexual function) N= 33 Group B (Sexual problem persisted) N= 75 P value Test used Man's Age in years (Mean ± SD) 35.27 ± 3.14 26 ± 3.38 0.409 Student’s t test Woman’s Age in years (Mean ± SD) 29.03 ± 3.49 29.25 ± 2.99 0.1251 Student’s t test Duration of sexual dysfunction in months (Mean ± SD) 16.36 ± 10.42 29.17 ± 14.98 <.0001 Student’s t test Visited fertility clinics before 24 63 0.1727 Chi Square test SD= Standard deviation

21. Mode of conception

22. Mode of conception

23. Group A (Improved sexual function) Group B (Sexual problem persisted) Duration in months Kaplan–Meier estimate of Time to conception (TTC) The starting point was the time when a couple started trying for pregnancy. The end-point was the timing of confirmation of pregnancy. The couples were censored at the date of the last visit. Numbers at risk in each group are given along the x-axis at multiple time-points. Log rank P value <0.0001

24. Summary of findings 6% couples presenting to the fertility clinic have non-consummation 34% did not easily disclose sexual dysfunction 31% couples subsequently had successful coitus 36% couples with persistent sexual problems accepted IVI and 22% conceived Couples having subsequent improvement in sexual function conceived earlier

25. Discussion Infertility in Asia- Viewed as “ woman’s problem ” 1,2 Sexual dysfunction in Asia- viewed as problem with “ masculinity ” 1,3 Male sexual dysfunction- couples preferred to label as “ infertility ” in order to avoid stigma 1 1 Nene UA, Coyaji K, Apte H. Infertility: a label of choice in the case of sexually dysfunctional couples. Patient Educ Couns . 2005 Dec;59(3):234-8. 2 Jejeebhoy SJ. Infertility in India -- levels patterns and consequences: priorities for social science research. J Fam Wel . 1998;4(2):15-24 3 Balen , F. & Bos , Henny . (2004). Infertility, culture, and psychology in worldwide perspective. Journal of Reproductive and Infant Psychology - J Reprod Infant Psychol. 22. 245-247.

26. Intravaginal insemination (IVI) Most of studies on IVI- HIV affected partner Ejaculatory dysfunction in men with spinal cord injury Same sex couples 1 Banerjee K, Singla B. Pregnancy Outcome of Home Intravaginal Insemination in Couples with Unconsummated Marriage. J Hum Reprod Sci. 2017 Oct-Dec;10(4):293-296. Sample size IVI accepted IVI pregnancy IVI cycles per couple Banerjee et al., 2017 1 55 55/55 29/55= 52.72% 6 Our study 108 27/75 6/27= 22.22% 3

27. Limitations of the study Psychological aspects not- assessed Results not compared with couples without sexual problems Follow up period to see time to conception (TTC)- inadequate

28. Conclusions Careful sexual history should be asked from all the couples presenting with “Infertility”. Advanced fertility treatment may be avoided. IVI is a useful method for conception for persistent sexual difficulty

29. Implications of the study The fertility-physicians should walk “extra mile” to explore sexual issues. Large-scale studies are needed→ fertility options in couples with different types of sexual difficulties

30. Conflict of interest None Funding- None

31. Acknowledgement Staffs of Genome Fertility Centre Couples participating in this study Team ASPIRE, 2024

32. Questions ???