International Journal of Impotence Research (2015) 27, 173–177 © 2015 Macmillan Publishers Limited All rights reserved 0955-9930/15 www.nature.com/ijir
ORIGINAL ARTICLE
Evaluation of sexual function and quality of life in Iranian women with tubal ligation: a historical cohort study Sh Jahanian Sadatmahalleh1, S Ziaei1, A Kazemnejad2 and E Mohamadi3 Tubal ligation (TL) is an option for contraception for women who have completed their family. The existence of sexual dysfunction and impaired quality of life (QOL) following this procedure has been the subject of debate for decades. The aim of this study was to evaluate the sexual function, QOL and other factors affecting Iranian women who underwent TL. A historical cohort study was carried out on 150 women who had undergone TL and on 150 women who had used a condom (as the control group). The sexual function of participants was evaluated and compared using Female Sexual Function Index (FSFI) questionnaire. They were also asked to fill out the Short Form Health Survey (SF-12) for evaluating their QOL. Furthermore, the effects of educational level and poststerilization regret in the women of TL group were evaluated. With regard to FSFI, all mean values were found to be lower in the TL women and the differences between the two groups were statistically significant in all domains. A significant difference was found in sexual dysfunction in orgasm (P = 0.02), satisfaction (P = 0.01), pain (P = 0.006) and total FSFI scores (P = 0.006) between the women regretting vs those not regretting their sterilization. In evaluating the relationship between FSFI and educational level, with the increase of educational level all domain scores increased significantly only in the TL group. There was a significant difference between the two groups in SF-12 scores (69.18 ± 14.05 vs 78.41 ± 12.50; P o 0.0001). Our findings reveal the adverse effects of TL on the sexual life and QOL of women. It is recommended that the awareness and knowledge of health-care professionals regarding the sexual function and QOL in women undergoing TL should be increased. International Journal of Impotence Research (2015) 27, 173–177; doi:10.1038/ijir.2015.11; published online 25 June 2015
INTRODUCTION Female sexual dysfunction (FSD) is a term used to describe various sexual problems such as low desire, reduced arousal, difficulty or inability to achieve orgasm and dyspareunia.1,2 Sexual health is an essential human right, as commanded by the World Health Organization (WHO).3 Sexuality is a prominent and complicated field in quality of life (QOL) research.4 Earlier reports have shown that sexual disorders may lead to health morbidity and diminished QOL.3 Sexual dysfunction negatively affects the QOL and may be responsible for psychopathological disturbances, yet it has remained as a taboo in many countries.4 Misinterpretation of religious codes, cultural taboos, inadequate sex education and feeling of embarrassment may complicate women's chances of consulting with health-care professionals.5,6 If female sexuality is disturbed, its subsequent outcomes may lead to familial disorders and even divorce, and reproduction may also be affected.7 Female sexual dysfunction has medical, anatomical, psychological and cultural components.1,2 Factors such as general health impairment, chronic diseases and adverse sociodemographic and behavioral conditions (including low level of education, low income and stress) seem to affect sexual function.8 FSD has a high prevalence as it affects 25–63% of women in different age populations.9–11 Limited data are available for diagnosis and management of female sexual disorder.12,13 Iranian women use natural and medical methods for contraception. In total, 17.8% of women in Iran use natural methods, of which 17.5% use coitus interruptus. The contraception methods used in Iranian women include taking tablets (29.9%), condom use (21.4%), tubal ligation (TL, 4.4%), intramuscular injections of
depots (2.3%), intrauterine contraceptive device (1.3%) and vasectomy (0.7%).14 TL is increasingly the favored method of contraception for women who have completed their families.15 Because so many healthy women choose this procedure, it is necessary to assess the sexual function, QOL and the potential physiologic and psychological effects of TL.16 Results of studies assessing the impact of TL on female sexual function are controversial.16–22 Some researchers have reported less satisfaction in women with TL,18 whereas others have found an increase in both sexual drive and sexual satisfaction following TL.16,19,20,22 There are only limited data on the possible effects of TL on women’s QOL and sexual function. As there are so many Iranian women who use TL as the main contraceptive method, assessment of sexual health and QOL in these women is very essential for health-care systems. Knowing the sexual problems and QOL in women with TL might provide an opportunity for planning and serving care and education. The aim of this study was to evaluate the sexual function, QOL and other factors affecting Iranian women who have undergone TL.
MATERIALS AND METHODS In this historical cohort study, first, a pilot study was conducted on 80 women. Then, using the appropriate formula with an α set at 0.05 and 1 − β at 0.95, it was found that a sample size of 149 women was needed for each group. Overall, 150 sexually active women (aged 18–40 years) who had undergone TL at least 1 year ago and 150 women who had used a condom
1 Department of Reproductive Health and Midwifery, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran; 2Department of Biostatistics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran and 3Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran. Correspondence: Professor S Ziaei, Department of Reproductive Health and Midwifery, Faculty of Medical Sciences, Tarbiat Modares University, Tehran 14155-111, Iran. Email: [email protected] Received 5 November 2014; revised 15 March 2015; accepted 22 May 2015; published online 25 June 2015
Evaluation of sexual function and QOL in Iranian women with TL ShJahanian Sadatmahalleh et al
174 Table 1.
Comparison of demographic and personal characteristics between TL and non-TL groups
Parameters
Non-TL N (%)
Mean ± s.d. Women’s age (years) Partner’s age (years) Age of menarche (years) Parity BMI (kg m − 2) Education level Primary school Completed high school University
35.95 ± 4.40 38.92 ± 4.41 12.75 ± 1.34 2.31 ± 0.56 27.57 ± 4.93
Method of delivery Normal vaginal delivery Cesarean section
P-value
TL Mean ± s.d.
N (%)
36.06 ± 3.20 38.15 ± 3.10 12.63 ± 1.18 2.42 ± 0.73 27.87 ± 4.76 27 (18) 56 (37.3) 67 (44.7) 51 (34) 99 (66)
0.81a 0.59a 0.41a 0.16a 0.71a 28 (18.7) 58 (38.7) 64 (42.7)
0.94b
38 (25.3) 112 (74.7)
0.12b
Abbreviations: BMI, body mass index; TL, tubal ligation. at-Test. bχ2-test.
(as contraceptive method) during the last 3 months and enrolled to a health-care center in Rudsar, Guilan Province (Iran) within 2013–2014 were included in this study. We compared the distribution of demographic and obstetrical characteristics, sexual function and QOL between the two groups. Women in the two groups were comparable in demographic and personal characteristics. The exclusion criteria used were as follows: gynecological disorders, suffering from chronic diseases, having no active sexual life, being in the postmenopausal period, using antidepressants, having a history of sexual abuse, being a cigarette smoker, having a history of operation except cesarean section and TL, breastfeeding, having no child and being pregnant at the time of the study. To assess sexual function, all participants were asked to fill out the Female Sexual Function Index (FSFI) questionnaire consisting of 19 questions.13 The FSFI is intended for women who have been sexually active in the previous 4 weeks. The domains of the questionnaire were: desire (two questions), arousal (four questions), lubrication (four questions), orgasm (three questions), satisfaction (three questions) and pain (three questions). The range of scores for all items was 0–5, except for items 1, 2, 15 and 16, which had the range between 1 and 5, with higher scores indicating better function in each domain. Factors were 0.6 for desire, 0.3 for arousal and lubrication, and 0.4 for orgasm, satisfaction and pain. Total score was obtained by adding the six domain scores. The domain score of 0 indicated that the women reported no sexual activity during the previous month; the full-scale score ranged from 2 to 36. In this study, we used the Persian version of the FSFI questionnaire translated by Mohammadi et al.23 Therefore, scores o 3.3 in desire, scores o 3.4 in arousal and orgasm, scores o 3.8 in satisfaction and pain, scores o3.7 in lubrication and the total scores o23 were considered to be FSD.23 The participants were asked to fill out the Short Form Health Survey (SF-12) questionnaire, a generic instrument to measure health-related QOL.23 SF-12 consists of 12 items in physical and mental domains. Based on the scores of these items, summary measures for the physical and mental components (PCS-12 and MCS-12) are constructed. The total score for SF-12 PCS/MCS ranging from 0 to 100, with a higher score indicating a higher health-related QOL (SF-12), has well been documented; the Persian version of SF-12 has also been evaluated for both reliability and validity.24 Furthermore, the effects of educational level and poststerilization regret in the women of TL group were evaluated. This study was approved by the Ethics Committee of Tarbiat Modares University. All women participated voluntarily and provided a signed informed consent.
Statistical analysis All statistical analyses were performed by the SPSS software (version 20.0) (SPSS, Chicago, IL, USA). Student’s t-test and χ2-test were used to reveal the statistical differences between the groups. Stepwise multiple linear regression analysis was performed to compare the association between dependent and independent variables. P o0.05 was considered to be statistically significant. International Journal of Impotence Research (2015), 173 – 177
RESULTS The mean duration of TL was 4.6 ± 1.2 years. Table 1 describes the characteristics of women in the TL and non-TL groups. There was no statistically significant difference in the women’s age, partner’s age, menarche age, body mass index, parity, educational level and the method of delivery between the two groups. Reasons shaping sterilization decision making The reason for requesting sterilization in the majority of women was having enough children or having no desire for more children (37.4%). Other reasons were higher effectiveness of sterilization (32.6%), unsatisfaction with other contraceptive methods for their many side effects (25.1%) and low family income (4.8%). Sexual function status Evaluation of the two groups with regard to FSFI showed that all mean values were lower in the women of TL group. The differences of scores in the two groups were statistically significant in the domains of desire (3.07 ± 0.76 vs 3.35 ± 0.84, P = 0.03), arousal (3.43 ± 0.94 vs 3.76 ± 0.95, P = 0.03), lubrication (4.04 ± 1.14 vs 4.70 ± 0.93, P o 0.0001), orgasm (4.10 ± 1.20 vs 4.60 ± 1.00, Po 0.0001), satisfaction (4.29 ± 1.33 vs 4.73 ± 1.06, P = 0.01), pain (4.29 ± 1.33 vs 4.91 ± 1.06, P o0.0001) and total FSFI scores (23.37 ± 4.99 vs 26.07 ± 4.34, P o 0.0001) (Table 2). The women in TL group had more sexual dysfunction in the domains of desire (64.7% vs 45.3%; P = 0.001), lubrication (42.7% vs 14.7%; P o 0.0001), orgasm (24% vs 11.3%; P = 0.006), satisfaction (32% vs 15.3%; P = 0.001), pain (32% vs 13.3%; P o0.0001) and total FSFI scores (44% vs 20%; P o 0.0001) compared with the nonTL group, except for arousal (45.3% vs 36%; P = 0.12) (data not shown). QOL status The comparison of SF-12 scores between the TL and non-TL women is shown in Table 2. The mean total scores of SF-12 were significantly lower in the TL group compared with the non-TL group (69.18 ± 14.05 vs 78.41 ± 12.50; P o 0.0001) (Table 2). The PCS-12 and MCS-12 mean scores were significantly lower in the TL women as compared with the non-TL group (PCS-12: 68.14 ± 16.01 vs 79.02 ± 14.19; MCS-12: 70.22 ± 15.08 vs 77.80 ± 13.27, respectively) (P o0.0001). Also, of the 150 women with TL, 30 (20%) regretted their decision of sterilization; the mean scores of sexual function were found to be lower in the women regretting sterilization compared © 2015 Macmillan Publishers Limited
Evaluation of sexual function and QOL in Iranian women with TL ShJahanian Sadatmahalleh et al
175 Table 2. Scores and total scores for the domain subgroups of sexual function and QOL between TL and non-TL groups Parameters FSFI Desire Arousal Lubrication Orgasm Satisfaction Pain Total score SF-12 Sum score physical components (PCS-12) Sum score mental components (MCS-12) Total score
Non-TL
TL
P-valuea
3.35 ± 0.84 3.76 ± 0.95 4.70 ± 0.93 4.60 ± 1.00 4.73 ± 1.06 4.91 ± 1.06 26.07 ± 4.34
3.07 ± 0.76 3.43 ± 0.94 4.04 ± 1.14 4.10 ± 1.20 4.29 ± 1.33 4.29 ± 1.33 23.37 ± 4.99
0.03 0.03 o0.0001 o0.0001 0.01 o0.0001 o0.0001
79.02 ± 14.19 68.14 ± 16.01 o0.0001 77.80 ± 13.27 70.22 ± 15.08 o0.0001 78.41 ± 12.50 69.18 ± 14.05 o0.0001
Table 4.
Comparison of FSFI in different education levels in the TL
group Parameters
Primary school FSFI Desire Arousal Lubrication Orgasm Satisfaction Pain Total score
P-valuea
Education level
2.74 ± 0.77 2.51 ± 1.03 2.89 ± 1.27 2.88 ± 1.41 3.35 ± 1.26 3.52 ± 1.76 17.92 ± 5.46
Completed high school
University
2.98 ± 0.71 3.30 ± 0.74 3.49 ± 0.61 3.78 ± 0.89 4.28 ± 0.85 4.33 ± 1.01 4.24 ± 0.79 4.51 ± 1.07 4.51 ± 0.88 4.78 ± 1.06 4.36 ± 0.99 4.57 ± 1.28 23.89 ± 2.89 25.28 ± 4.62
0.003 o0.0001 o0.0001 o0.0001 o0.0001 0.002 o0.0001
Abbreviations: ANOVA, analysis of variance; FSFI, Female Sexual Function Index; TL, tubal ligation. Values are mean ± s.d. aOne-way ANOVA.
Abbreviations: FSFI, Female Sexual Function Index; QOL, quality of life; SF-12, Short Form-12; TL, tubal ligation. Values are mean ± s.d. at-Test.
Table 5.
Variables influencing the sexual function of women in the TL
group
Table 3.
Comparison of poststerilization regret and FSFI in the TL
group Parameters
FSFI Desire Arousal Lubrication Orgasm Satisfaction Pain Total score
Post-sterilization regret Yes (n = 30)
No (n = 120)
2.90 ± 0.77 3.14 ± 1.09 3.76 ± 1.37 3.66 ± 1.39 3.95 ± 1.18 3.71 ± 1.67 21.13 ± 6.28
3.12 ± 0.75 3.50 ± 0.89 4.11 ± 1.07 4.21 ± 1.13 4.53 ± 1.13 4.44 ± 1.19 22.93 ± 4.47
P-valuea
0.15 0.05 0.12 0.02 0.01 0.006 0.006
Abbreviations: FSFI, Female Sexual Function Index; TL, tubal ligation. Values are mean ± s.d. at-Test.
with the women not regretting sterilization, and the differences between the two groups were statistically significant during orgasm (3.66 ± 1.39 vs 4.21 ± 1.13; P = 0.02), satisfaction (3.95 ± 1.18 vs 4.53 ± 1.13; P = 0.01), pain (3.71 ± 1.67 vs 4.44 ± 1.19; P = 0.006) and total FSFI scores (21.13 ± 6.28 vs 22.93 ± 4.47; P = 0.006) (Table 3). In the evaluation of the relationship between FSFI and educational level, with the increase of the educational level, the scores of all domains increased significantly only in the TL group (Table 4). Stepwise multiple linear regression analysis was performed to compare the association between dependent (sexual function) and independent (age, partner age, parity, level of education, method of delivery and poststerilization regret) variables. Level of education (P o 0.0001) and poststerilization regret (P = 0.001) were the main variables that significantly influenced the sexual function in the women of TL group (Table 5). DISCUSSION Sterilization is for women who have completed their families or who are sure that they never want to have children.25 In the present research, the participants were asked to discuss the reasons for choosing sterilization as a contraceptive method. © 2015 Macmillan Publishers Limited
Women’s age Partner’s age Age at sterilization Parity Education level Method of delivery Post-sterilization regret
Coefficient
s.e.
P-valuea
0.12 − 0.22 − 0.30 − 0.16 3.32 0.23 −2.91
0.58 0.53 0.20 0.64 0.50 0.84 0.88
0.32 0.28 0.33 0.92 o0.0001 0.89 0.001
Abbreviation: TL, tubal ligation. aP-value multiple regression.
The prominent reason given by women for choosing sterilization was that they were finished with child bearing (37.4%) and wanted a convenient contraceptive method (32.6%). As sterilization offers permanency, and requires a one-time effort, some women considered it a convenient and effective method of birth control. The majority of participants stated that they were unsatisfied with other contraceptive methods for their many side effects (25.1%) as another reason for requesting sterilization. However, there was a small group whose reason was low family income (4.8%). The women with TL had likely more sexual dysfunction compared with the non-TL women after controlling the important socioeconomic confounders. On the other hand, a low-economic status is a variable that can affect QOL; however, as the two groups were matched in socioeconomic status, there was nothing else to affect the QOL and sexual function in women with TL. As a result, the women’s sexual dysfunction and QOL were affected by sterilization. Sexual function status It was revealed that TL may be a risk factor for women’s sexual dysfunction. Sexual dysfunction can have damaging effects on women’s sense of wholeness, confidence, social relations and marital status.26 In the present study, the prevalence of FSD in the TL women was 44% in comparison with 20% in the non-TL group. This result is similar to that of Ghadirian et al.27 Basgul et al.28 also reported that 23.1% of the participating women noted changes in their sexual relationships, with 13% describing these changes as negative following TL. Bolourian and Ganjloo29 showed that surgery on female sexual organs such as TL in Iran might lead to a significant reduction of their sexual desire and satisfaction, and increase the probability of dyspareunia. Kazemeyan et al.30 International Journal of Impotence Research (2015), 173 – 177
Evaluation of sexual function and QOL in Iranian women with TL ShJahanian Sadatmahalleh et al
176 reported that sexual symptom scores in women who had undergone TL were significantly lower compared with those of the control group. Also, their study was consistent with studies in other countries whose culture was similar to that of Iran.31 These results also confirm the findings by other researchers that there is a significant increase in the incidence of sexual dysfunction in women undergoing TL when compared with other groups.16,27,32–34 It has also been reported that women with TL were more likely than non-TL women to seek medical advice from a physician regarding sexual problems.35 Our findings in the present study are inconsistent with the results of many similar studies conducted in other countries.15,17,21,22,36–38 Costello et al.16 performed a study with 4576 women enrolled in a prospective, multicenter cohort study, and evaluated whether interval TL might lead to any change in their interest and sexual pleasure. Most women with TL reported its positive effects on their sexual function.16 The results of a study on sexual relationships in women after TL showed an increase in coital frequency, and revealed no significant impact on females’ sexual satisfaction.17 Reports also differ regarding changes in sexual satisfaction after TL. In a study conducted in the United Kingdom,15 138 multiparous women with TL and 135 women using non-permanent birth control were interviewed. The women with TL stated significant improvement in their sexual relationships as compared with other women. Li et al.22 found an increase in both sexual drive and sexual satisfaction following TL. Another study reported that sexual function benefits from surgical interventions such as TL.39 There is no evidence that sexual problems are more prevalent among the women who had a TL than non-TL women.36,40 It has been reported that sexual satisfaction and coital frequency were not affected in women with TL.20,21,37,38,41 Toorzani et al.14 mentioned that the use of TL in women did not increase sexual satisfaction. The results of another study conducted in Iran showed that there was no significant difference between using any of contraceptive methods (such as TL) and sexual dysfunction in women.5 Making a decision about sterilization is difficult for both women and men, as it means ending fertility. As negative biological and psychological issues may occur after all surgeries and cause loss of sexual function, the same negative effects after TL have been expected,31 although arguments on the post-TL syndrome have been continuing for half a century, and whether this syndrome has negative effects on the sexual function and general health status has not been described.31 Some variables such as cultural patterns, as well as biological, physiological and psychological aspects, interact with the level of sexual satisfaction.42 The difference between our findings and this study may, however, be attributed to a difference in cultural factors among the women studied. This is an important result, since based on the authors’ experience, it is an entirely common concern raised by patients about the influence of TL on women’s sexual life.22 Some authors have found that, owing to permitting sexual activity without the fear of unwanted pregnancy, TL has positive effects on women’s sexual function.22,43,44 QOL status The present study showed that low levels of QOL were more common in the women with TL in comparison with the non-TL women. This finding is similar to the result of Gulum et al.31 In contrast, the results of another study reported that surgical interventions such as TL positively impacts QOL.39 However, Li et al.22 did not find such associations. One possible interpretation of our finding could be because of the effective role of FSD on women’s QOL. According to a study by Oksuz et al.,26 FSD is a highly prevalent health problem in women with TL, and can have a profound impact on their QOL. However, this effectiveness was International Journal of Impotence Research (2015), 173 – 177
not evaluated specifically in our study. It is very difficult to make a detailed assessment of sexual function and the effects of any abnormality in women’s QOL.32 A significant difference was found in sexual dysfunction in orgasm, satisfaction, pain and total FSFI scores between the women regretting vs those not regretting their sterilization. Costello et al.16 reported a relationship between sexual dysfunction and poststerilization regret in women with TL. Kjer37 reported that the majority of women who announced feelings of changed femininity or lack of excitement in sexual life were those who regretted their decision after TL. Shah et al.43 suggested that TL had a positive impact on sexual relationship unless the women were uncertain over the procedure. On evaluating the relationship between FSFI and educational level, it was observed that with the increase of educational level, all domain scores increased significantly only in the TL group. Our findings further showed that educational level and poststerilization regret were the variables that significantly influenced sexual function in the TL group. Some studies reported that increased educational level positively influenced the sexual function of women in the TL group.31,32,45 Women with higher levels of education may have a better understanding of psychosomatic reactions, which may lead to a better score in sexual function. These women may have higher confidence, and may be more informed of their needs and roles in sexual relationship.32 Indeed, one of the main reasons for women’s sexual dysfunction is insufficient experience and knowledge in the field of sexual relationships.22 Different results of the studies mentioned above imply that the relationship between TL and sexual function is a complex process, which is influenced by multiple factors, including different cultural conditions, ethnicity and misinterpretation of religious codes.46 After TL, different factors can result in increased sexual dysfunction such as change in self-concept and understanding of her existence as a woman, which in some cultures and societies, carries a high meaning load. Perhaps, it can be stated that different and incoherent reports on women’s sexual functioning condition after TL can be because of different meaning loads of this operation in various cultures. In societies such as Iran, the picture a woman holds of herself is to a high degree dependent on her fertility and motherhood ability. It conveys to women feelings of satisfaction, perfection and value. Despite the women’s voluntary participation in the sterilization programs, the cultural factors, which are rooted and penetrated in their deep unconscious layers, seem to produce in some of them an unattractive and imperfect picture, which after a while can be reflected in the appearance of sexual dysfunction and regret from this operation. Furthermore, an individual’s feeling of the irreversibility of the operation may result in tempting thoughts, which in turn are influential in sexual function. Also, the lack of knowledge of women in reaching satisfaction and orgasm in their sexual relationships are other main reasons of women’s sexual dysfunction and low QOL.46 CONCLUSION In this study, it was observed that sexual function and QOL in the women undergoing TL were lower compared with that in the nonTL group. Also, in the women with TL, higher levels of education and higher scores of sexual function were obtained. Finally, our results indicated that TL probably is not a safe method of contraception. This emphasizes the importance of a comprehensive consultation before TL, especially in women with a low level of education. CONFLICT OF INTEREST The authors declare no conflict of interest.
© 2015 Macmillan Publishers Limited
Evaluation of sexual function and QOL in Iranian women with TL ShJahanian Sadatmahalleh et al
ACKNOWLEDGMENTS We are grateful to the entire colleagues of Guilan University of Medical Sciences (Rasht, Iran) for their contributions in accomplishing this project. The study was supported by Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran.
REFERENCES 1 Salonia A, Munarriz RM, Naspro R, Nappi RE, Briganti A, Chionna R et al. Women's sexual dysfunction: a pathophysiological review. BJU Int 2004; 93: 1156–1164. 2 Shifren JL, Monz BU, Russo PA, Segreti A, Johannes CB. Sexual problems and distress in United States women: prevalence and correlates. Obstet Gynecol 2008; 112: 970–978. 3 Biddle AK, West SL, D'Aloisio AA, Wheeler SB, Borisov NN, Thorp J. Hypoactive sexual desire disorder in postmenopausal women: quality of life and health burden. Value Health 2009; 12: 763–772. 4 Papaharitou S, Nakopoulou E, Kirana P, Iraklidou M, Athanasiadis L, Hatzichristou D. Women's sexual concerns: data analysis from a help-line. J Sex Med 2005; 2: 652–657. 5 Safarinejad MR. Female sexual dysfunction in a population-based study in Iran: prevalence and associated risk factors. Int J Impot Res 2006; 18: 382–395. 6 Fourcroy JL. Customs, culture, and tradition—what role do they play in a woman's sexuality? J Sex Med 2006; 3: 954–959. 7 Kadri N, McHichi Alami KH, McHakra Tahiri S. Sexual dysfunction in women: population based epidemiological study. Arch Womens Ment Health 2002; 5: 59–63. 8 Avis NE, Zhao X, Johannes CB, Ory M, Brockwell S, Greendale GA. Correlates of sexual function among multi-ethnic middle-aged women: results from the Study of Women's Health Across the Nation (SWAN). Menopause 2005; 12: 385–398. 9 Rosen RC, Taylor JF, Leiblum SR, Bachmann GA. Prevalence of sexual dysfunction in women: results of a survey study of 329 women in an outpatient gynecological clinic. J Sex Marital Ther 1993; 19: 171–188. 10 Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA 1999; 281: 537–544. 11 Goldmeier D, Judd A, Schroeder K. Prevalence of sexual dysfunction in new heterosexual attenders at a central London genitourinary medicine clinic in 1998. Sex Transm Infect 2000; 76: 208–209. 12 Cayan S, Akbay E, Bozlu M, Canpolat B, Acar D, Ulusoy E. The prevalence of female sexual dysfunction and potential risk factors that may impair sexual function in Turkish women. Urol Int 2004; 72: 52–57. 13 Rosen R, Brown C, Heiman J, Leiblum S, Meston C, Shabsigh R et al. The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther 2000; 26: 191–208. 14 Toorzani ZM, Zahraei RH, Ehsanpour S, Nasiri M, Shahidi S, Soleimani B. A study on the relationship of sexual satisfaction and common contraceptive methods employed by the couples. Iran J Nurs Midwifery Res 2010; 15: 115–119. 15 Cooper JE, Bledin KD, Brice B, Mackenzie S. Effects of female sterilization: one year follow-up in a prospective controlled study of psychological and psychiatric outcome. J Psychosom Res 1985; 29: 13–22. 16 Costello C, Hillis SD, Marchbanks PA, Jamieson DJ, Peterson HB. The effect of interval tubal sterilization on sexual interest and pleasure. Obstet Gynecol 2002; 100: 511–517. 17 Shain RN, Miller WB, Holden AE, Rosenthal M. Impact of tubal sterilization and vasectomy on female marital sexuality: results of a controlled longitudinal study. Am J Obstet Gynecol 1991; 164: 763–771. 18 Alder E, Cook A, Gray J, Tyrer G, Warner P, Bancroft J et al. The effects of sterilisation: a comparison of sterilised women with the wives of vasectomised men. Contraception 1981; 23: 45–54. 19 Cooper P, Gath D, Fieldsend R, Rose N. Psychological and physical outcome after elective tubal sterilization. J Psychosom Res 1981; 25: 357–360. 20 Cooper P, Gath D, Rose N, Fieldsend R. Psychological sequelae to elective sterilisation: a prospective study. BMJ (Clin Res Ed) 1982; 284: 461–464.
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177 21 Smith EM, Friedrich E, Pribor EF. Psychosocial consequences of sterilization: a review of the literature and preliminary findings. Compr Psychiatry 1994; 35: 157–163. 22 Li RH, Lo SS, Teh DK, Tong NC, Tsui MH, Cheung KB et al. Impact of common contraceptive methods on quality of life and sexual function in Hong Kong Chinese women. Contraception 2004; 70: 474–482. 23 Mohammadi KH, Heydari M, Faghihzadeh S. The Female Sexual Function Index (FSFI): validation of the Iranian version. Payesh 2008; 7: 269–278. 24 Montazeri A, Vahdaninia M, Mousavi SJ, Omidvari S. The Iranian version of 12-item Short Form Health Survey (SF-12): factor structure, internal consistency and construct validity. BMC Public Health 2009; 9: 341. 25 Shih G, Dube K, Dehlendorf C. 'We never thought of a vasectomy': a qualitative study of men and women's counseling around sterilization. Contraception 2013; 88: 376–381. 26 Oksuz E, Malhan S. Prevalence and risk factors for female sexual dysfunction in Turkish women. J Urol 2006; 175: 654–658. 27 Fataneh G, Marjan MH, Nasrin R, Taraneh T. Sexual function in Iranian women using different methods of contraception. J Clin Nurs 2013; 22: 3016–3023. 28 Basgul A, Uzuner A, Kavak ZN, Bozkurt N, Onaran H, Erturk MS. Impact of tubal sterilization on women's health. Clin Exp Obstet Gynecol 2007; 34: 39–41. 29 Bolourian Z, Ganjloo J. Evaluation of sexual dysfunction and some related factor in women. J Reprod Infertil 2007; 31: 163–170. 30 Kazemeyan A, Mohammadpour F, Safdari F. Comparison of psychological and sexual consequences of tubal ligation and other contraceptive methods in women referring to Shahrekord health centers in 2005–2007, Iran. J Shahrekord Univ Med Sci 2009; 10: 83–88. 31 Gulum M, Yeni E, Sahin MA, Savas M, Ciftci H. Sexual functions and quality of life in women with tubal sterilization. Int J Impot Res 2010; 22: 267–271. 32 Hentschel H, Alberton DL, Sawdy RJ, Capp E, Goldim JR, Passos EP. Sexual function in women from infertile couples and in women seeking surgical sterilization. J Sex Marital Ther 2008; 34: 107–114. 33 Lee TY, Sun GH, Chao SC. The effect of an infertility diagnosis on the distress, marital and sexual satisfaction between husbands and wives in Taiwan. Hum Reprod 2001; 16: 1762–1767. 34 Monga M, Alexandrescu B, Katz SE, Stein M, Ganiats T. Impact of infertility on quality of life, marital adjustment, and sexual function. Urology 2004; 63: 126–130. 35 Warehime MN, Bass L, Pedulla D. Effects of tubal ligation among American women. J Reprod Med 2007; 52: 263–272. 36 Smith A, Lyons A, Ferris J, Richters J, Pitts M, Shelley J. Are sexual problems more common in women who have had a tubal ligation? A population-based study of Australian women. BJOG 2010; 117: 463–468. 37 Kjer JJ. Sexual adjustment to tubal sterilization. Eur J Obstet Gynecol Reprod Biol 1990; 35: 211–214. 38 Bean FD, Clark MP, South S, Swicegood G, Williams D. Changes in sexual desire after voluntary sterilization. Soc Biol 1980; 27: 186–193. 39 Pauls RN. Impact of gynecological surgery on female sexual function. Int J Impot Res 2010; 22: 105–114. 40 Hsiao YC, Sung SH. Married women's satisfaction with their choice of contraception. J Nurs Res 2003; 11: 119–128. 41 Tang CS, Chung TK. Psychosexual adjustment following sterilization: a prospective study on Chinese women. J Psychosom Res 1997; 42: 187–196. 42 Gonzalez M, Viafara G, Caba F, Molina T, Ortiz C. Libido and orgasm in middleaged woman. Maturitas 2006; 53: 1–10. 43 Shah MB, Hoffstetter S. Contraception and sexuality. Miner Ginecol 2010; 62: 331–347. 44 Schaffir J. Hormonal contraception and sexual desire: a critical review. J Sex Marital Ther 2006; 32: 305–314. 45 Rudatsikira E, Muula AS, Siziya S. Current use of smokeless tobacco among adolescents in the Republic of Congo. BMC Public Health 2010; 10: 16. 46 Imeni B, Karampourian A. Investigating the effect of sexual satisfaction on family stability. In: Proceedings of the Second National Congress on Family and Sexual Problems. Shahed University, Family Health Clinic, Tehran, Iran, 2005.
International Journal of Impotence Research (2015), 173 – 177
ORIGINAL ARTICLE
Evaluation of sexual function and quality of life in Iranian women with tubal ligation: a historical cohort study Sh Jahanian Sadatmahalleh1, S Ziaei1, A Kazemnejad2 and E Mohamadi3 Tubal ligation (TL) is an option for contraception for women who have completed their family. The existence of sexual dysfunction and impaired quality of life (QOL) following this procedure has been the subject of debate for decades. The aim of this study was to evaluate the sexual function, QOL and other factors affecting Iranian women who underwent TL. A historical cohort study was carried out on 150 women who had undergone TL and on 150 women who had used a condom (as the control group). The sexual function of participants was evaluated and compared using Female Sexual Function Index (FSFI) questionnaire. They were also asked to fill out the Short Form Health Survey (SF-12) for evaluating their QOL. Furthermore, the effects of educational level and poststerilization regret in the women of TL group were evaluated. With regard to FSFI, all mean values were found to be lower in the TL women and the differences between the two groups were statistically significant in all domains. A significant difference was found in sexual dysfunction in orgasm (P = 0.02), satisfaction (P = 0.01), pain (P = 0.006) and total FSFI scores (P = 0.006) between the women regretting vs those not regretting their sterilization. In evaluating the relationship between FSFI and educational level, with the increase of educational level all domain scores increased significantly only in the TL group. There was a significant difference between the two groups in SF-12 scores (69.18 ± 14.05 vs 78.41 ± 12.50; P o 0.0001). Our findings reveal the adverse effects of TL on the sexual life and QOL of women. It is recommended that the awareness and knowledge of health-care professionals regarding the sexual function and QOL in women undergoing TL should be increased. International Journal of Impotence Research (2015) 27, 173–177; doi:10.1038/ijir.2015.11; published online 25 June 2015
INTRODUCTION Female sexual dysfunction (FSD) is a term used to describe various sexual problems such as low desire, reduced arousal, difficulty or inability to achieve orgasm and dyspareunia.1,2 Sexual health is an essential human right, as commanded by the World Health Organization (WHO).3 Sexuality is a prominent and complicated field in quality of life (QOL) research.4 Earlier reports have shown that sexual disorders may lead to health morbidity and diminished QOL.3 Sexual dysfunction negatively affects the QOL and may be responsible for psychopathological disturbances, yet it has remained as a taboo in many countries.4 Misinterpretation of religious codes, cultural taboos, inadequate sex education and feeling of embarrassment may complicate women's chances of consulting with health-care professionals.5,6 If female sexuality is disturbed, its subsequent outcomes may lead to familial disorders and even divorce, and reproduction may also be affected.7 Female sexual dysfunction has medical, anatomical, psychological and cultural components.1,2 Factors such as general health impairment, chronic diseases and adverse sociodemographic and behavioral conditions (including low level of education, low income and stress) seem to affect sexual function.8 FSD has a high prevalence as it affects 25–63% of women in different age populations.9–11 Limited data are available for diagnosis and management of female sexual disorder.12,13 Iranian women use natural and medical methods for contraception. In total, 17.8% of women in Iran use natural methods, of which 17.5% use coitus interruptus. The contraception methods used in Iranian women include taking tablets (29.9%), condom use (21.4%), tubal ligation (TL, 4.4%), intramuscular injections of
depots (2.3%), intrauterine contraceptive device (1.3%) and vasectomy (0.7%).14 TL is increasingly the favored method of contraception for women who have completed their families.15 Because so many healthy women choose this procedure, it is necessary to assess the sexual function, QOL and the potential physiologic and psychological effects of TL.16 Results of studies assessing the impact of TL on female sexual function are controversial.16–22 Some researchers have reported less satisfaction in women with TL,18 whereas others have found an increase in both sexual drive and sexual satisfaction following TL.16,19,20,22 There are only limited data on the possible effects of TL on women’s QOL and sexual function. As there are so many Iranian women who use TL as the main contraceptive method, assessment of sexual health and QOL in these women is very essential for health-care systems. Knowing the sexual problems and QOL in women with TL might provide an opportunity for planning and serving care and education. The aim of this study was to evaluate the sexual function, QOL and other factors affecting Iranian women who have undergone TL.
MATERIALS AND METHODS In this historical cohort study, first, a pilot study was conducted on 80 women. Then, using the appropriate formula with an α set at 0.05 and 1 − β at 0.95, it was found that a sample size of 149 women was needed for each group. Overall, 150 sexually active women (aged 18–40 years) who had undergone TL at least 1 year ago and 150 women who had used a condom
1 Department of Reproductive Health and Midwifery, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran; 2Department of Biostatistics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran and 3Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran. Correspondence: Professor S Ziaei, Department of Reproductive Health and Midwifery, Faculty of Medical Sciences, Tarbiat Modares University, Tehran 14155-111, Iran. Email: [email protected] Received 5 November 2014; revised 15 March 2015; accepted 22 May 2015; published online 25 June 2015
Evaluation of sexual function and QOL in Iranian women with TL ShJahanian Sadatmahalleh et al
174 Table 1.
Comparison of demographic and personal characteristics between TL and non-TL groups
Parameters
Non-TL N (%)
Mean ± s.d. Women’s age (years) Partner’s age (years) Age of menarche (years) Parity BMI (kg m − 2) Education level Primary school Completed high school University
35.95 ± 4.40 38.92 ± 4.41 12.75 ± 1.34 2.31 ± 0.56 27.57 ± 4.93
Method of delivery Normal vaginal delivery Cesarean section
P-value
TL Mean ± s.d.
N (%)
36.06 ± 3.20 38.15 ± 3.10 12.63 ± 1.18 2.42 ± 0.73 27.87 ± 4.76 27 (18) 56 (37.3) 67 (44.7) 51 (34) 99 (66)
0.81a 0.59a 0.41a 0.16a 0.71a 28 (18.7) 58 (38.7) 64 (42.7)
0.94b
38 (25.3) 112 (74.7)
0.12b
Abbreviations: BMI, body mass index; TL, tubal ligation. at-Test. bχ2-test.
(as contraceptive method) during the last 3 months and enrolled to a health-care center in Rudsar, Guilan Province (Iran) within 2013–2014 were included in this study. We compared the distribution of demographic and obstetrical characteristics, sexual function and QOL between the two groups. Women in the two groups were comparable in demographic and personal characteristics. The exclusion criteria used were as follows: gynecological disorders, suffering from chronic diseases, having no active sexual life, being in the postmenopausal period, using antidepressants, having a history of sexual abuse, being a cigarette smoker, having a history of operation except cesarean section and TL, breastfeeding, having no child and being pregnant at the time of the study. To assess sexual function, all participants were asked to fill out the Female Sexual Function Index (FSFI) questionnaire consisting of 19 questions.13 The FSFI is intended for women who have been sexually active in the previous 4 weeks. The domains of the questionnaire were: desire (two questions), arousal (four questions), lubrication (four questions), orgasm (three questions), satisfaction (three questions) and pain (three questions). The range of scores for all items was 0–5, except for items 1, 2, 15 and 16, which had the range between 1 and 5, with higher scores indicating better function in each domain. Factors were 0.6 for desire, 0.3 for arousal and lubrication, and 0.4 for orgasm, satisfaction and pain. Total score was obtained by adding the six domain scores. The domain score of 0 indicated that the women reported no sexual activity during the previous month; the full-scale score ranged from 2 to 36. In this study, we used the Persian version of the FSFI questionnaire translated by Mohammadi et al.23 Therefore, scores o 3.3 in desire, scores o 3.4 in arousal and orgasm, scores o 3.8 in satisfaction and pain, scores o3.7 in lubrication and the total scores o23 were considered to be FSD.23 The participants were asked to fill out the Short Form Health Survey (SF-12) questionnaire, a generic instrument to measure health-related QOL.23 SF-12 consists of 12 items in physical and mental domains. Based on the scores of these items, summary measures for the physical and mental components (PCS-12 and MCS-12) are constructed. The total score for SF-12 PCS/MCS ranging from 0 to 100, with a higher score indicating a higher health-related QOL (SF-12), has well been documented; the Persian version of SF-12 has also been evaluated for both reliability and validity.24 Furthermore, the effects of educational level and poststerilization regret in the women of TL group were evaluated. This study was approved by the Ethics Committee of Tarbiat Modares University. All women participated voluntarily and provided a signed informed consent.
Statistical analysis All statistical analyses were performed by the SPSS software (version 20.0) (SPSS, Chicago, IL, USA). Student’s t-test and χ2-test were used to reveal the statistical differences between the groups. Stepwise multiple linear regression analysis was performed to compare the association between dependent and independent variables. P o0.05 was considered to be statistically significant. International Journal of Impotence Research (2015), 173 – 177
RESULTS The mean duration of TL was 4.6 ± 1.2 years. Table 1 describes the characteristics of women in the TL and non-TL groups. There was no statistically significant difference in the women’s age, partner’s age, menarche age, body mass index, parity, educational level and the method of delivery between the two groups. Reasons shaping sterilization decision making The reason for requesting sterilization in the majority of women was having enough children or having no desire for more children (37.4%). Other reasons were higher effectiveness of sterilization (32.6%), unsatisfaction with other contraceptive methods for their many side effects (25.1%) and low family income (4.8%). Sexual function status Evaluation of the two groups with regard to FSFI showed that all mean values were lower in the women of TL group. The differences of scores in the two groups were statistically significant in the domains of desire (3.07 ± 0.76 vs 3.35 ± 0.84, P = 0.03), arousal (3.43 ± 0.94 vs 3.76 ± 0.95, P = 0.03), lubrication (4.04 ± 1.14 vs 4.70 ± 0.93, P o 0.0001), orgasm (4.10 ± 1.20 vs 4.60 ± 1.00, Po 0.0001), satisfaction (4.29 ± 1.33 vs 4.73 ± 1.06, P = 0.01), pain (4.29 ± 1.33 vs 4.91 ± 1.06, P o0.0001) and total FSFI scores (23.37 ± 4.99 vs 26.07 ± 4.34, P o 0.0001) (Table 2). The women in TL group had more sexual dysfunction in the domains of desire (64.7% vs 45.3%; P = 0.001), lubrication (42.7% vs 14.7%; P o 0.0001), orgasm (24% vs 11.3%; P = 0.006), satisfaction (32% vs 15.3%; P = 0.001), pain (32% vs 13.3%; P o0.0001) and total FSFI scores (44% vs 20%; P o 0.0001) compared with the nonTL group, except for arousal (45.3% vs 36%; P = 0.12) (data not shown). QOL status The comparison of SF-12 scores between the TL and non-TL women is shown in Table 2. The mean total scores of SF-12 were significantly lower in the TL group compared with the non-TL group (69.18 ± 14.05 vs 78.41 ± 12.50; P o 0.0001) (Table 2). The PCS-12 and MCS-12 mean scores were significantly lower in the TL women as compared with the non-TL group (PCS-12: 68.14 ± 16.01 vs 79.02 ± 14.19; MCS-12: 70.22 ± 15.08 vs 77.80 ± 13.27, respectively) (P o0.0001). Also, of the 150 women with TL, 30 (20%) regretted their decision of sterilization; the mean scores of sexual function were found to be lower in the women regretting sterilization compared © 2015 Macmillan Publishers Limited
Evaluation of sexual function and QOL in Iranian women with TL ShJahanian Sadatmahalleh et al
175 Table 2. Scores and total scores for the domain subgroups of sexual function and QOL between TL and non-TL groups Parameters FSFI Desire Arousal Lubrication Orgasm Satisfaction Pain Total score SF-12 Sum score physical components (PCS-12) Sum score mental components (MCS-12) Total score
Non-TL
TL
P-valuea
3.35 ± 0.84 3.76 ± 0.95 4.70 ± 0.93 4.60 ± 1.00 4.73 ± 1.06 4.91 ± 1.06 26.07 ± 4.34
3.07 ± 0.76 3.43 ± 0.94 4.04 ± 1.14 4.10 ± 1.20 4.29 ± 1.33 4.29 ± 1.33 23.37 ± 4.99
0.03 0.03 o0.0001 o0.0001 0.01 o0.0001 o0.0001
79.02 ± 14.19 68.14 ± 16.01 o0.0001 77.80 ± 13.27 70.22 ± 15.08 o0.0001 78.41 ± 12.50 69.18 ± 14.05 o0.0001
Table 4.
Comparison of FSFI in different education levels in the TL
group Parameters
Primary school FSFI Desire Arousal Lubrication Orgasm Satisfaction Pain Total score
P-valuea
Education level
2.74 ± 0.77 2.51 ± 1.03 2.89 ± 1.27 2.88 ± 1.41 3.35 ± 1.26 3.52 ± 1.76 17.92 ± 5.46
Completed high school
University
2.98 ± 0.71 3.30 ± 0.74 3.49 ± 0.61 3.78 ± 0.89 4.28 ± 0.85 4.33 ± 1.01 4.24 ± 0.79 4.51 ± 1.07 4.51 ± 0.88 4.78 ± 1.06 4.36 ± 0.99 4.57 ± 1.28 23.89 ± 2.89 25.28 ± 4.62
0.003 o0.0001 o0.0001 o0.0001 o0.0001 0.002 o0.0001
Abbreviations: ANOVA, analysis of variance; FSFI, Female Sexual Function Index; TL, tubal ligation. Values are mean ± s.d. aOne-way ANOVA.
Abbreviations: FSFI, Female Sexual Function Index; QOL, quality of life; SF-12, Short Form-12; TL, tubal ligation. Values are mean ± s.d. at-Test.
Table 5.
Variables influencing the sexual function of women in the TL
group
Table 3.
Comparison of poststerilization regret and FSFI in the TL
group Parameters
FSFI Desire Arousal Lubrication Orgasm Satisfaction Pain Total score
Post-sterilization regret Yes (n = 30)
No (n = 120)
2.90 ± 0.77 3.14 ± 1.09 3.76 ± 1.37 3.66 ± 1.39 3.95 ± 1.18 3.71 ± 1.67 21.13 ± 6.28
3.12 ± 0.75 3.50 ± 0.89 4.11 ± 1.07 4.21 ± 1.13 4.53 ± 1.13 4.44 ± 1.19 22.93 ± 4.47
P-valuea
0.15 0.05 0.12 0.02 0.01 0.006 0.006
Abbreviations: FSFI, Female Sexual Function Index; TL, tubal ligation. Values are mean ± s.d. at-Test.
with the women not regretting sterilization, and the differences between the two groups were statistically significant during orgasm (3.66 ± 1.39 vs 4.21 ± 1.13; P = 0.02), satisfaction (3.95 ± 1.18 vs 4.53 ± 1.13; P = 0.01), pain (3.71 ± 1.67 vs 4.44 ± 1.19; P = 0.006) and total FSFI scores (21.13 ± 6.28 vs 22.93 ± 4.47; P = 0.006) (Table 3). In the evaluation of the relationship between FSFI and educational level, with the increase of the educational level, the scores of all domains increased significantly only in the TL group (Table 4). Stepwise multiple linear regression analysis was performed to compare the association between dependent (sexual function) and independent (age, partner age, parity, level of education, method of delivery and poststerilization regret) variables. Level of education (P o 0.0001) and poststerilization regret (P = 0.001) were the main variables that significantly influenced the sexual function in the women of TL group (Table 5). DISCUSSION Sterilization is for women who have completed their families or who are sure that they never want to have children.25 In the present research, the participants were asked to discuss the reasons for choosing sterilization as a contraceptive method. © 2015 Macmillan Publishers Limited
Women’s age Partner’s age Age at sterilization Parity Education level Method of delivery Post-sterilization regret
Coefficient
s.e.
P-valuea
0.12 − 0.22 − 0.30 − 0.16 3.32 0.23 −2.91
0.58 0.53 0.20 0.64 0.50 0.84 0.88
0.32 0.28 0.33 0.92 o0.0001 0.89 0.001
Abbreviation: TL, tubal ligation. aP-value multiple regression.
The prominent reason given by women for choosing sterilization was that they were finished with child bearing (37.4%) and wanted a convenient contraceptive method (32.6%). As sterilization offers permanency, and requires a one-time effort, some women considered it a convenient and effective method of birth control. The majority of participants stated that they were unsatisfied with other contraceptive methods for their many side effects (25.1%) as another reason for requesting sterilization. However, there was a small group whose reason was low family income (4.8%). The women with TL had likely more sexual dysfunction compared with the non-TL women after controlling the important socioeconomic confounders. On the other hand, a low-economic status is a variable that can affect QOL; however, as the two groups were matched in socioeconomic status, there was nothing else to affect the QOL and sexual function in women with TL. As a result, the women’s sexual dysfunction and QOL were affected by sterilization. Sexual function status It was revealed that TL may be a risk factor for women’s sexual dysfunction. Sexual dysfunction can have damaging effects on women’s sense of wholeness, confidence, social relations and marital status.26 In the present study, the prevalence of FSD in the TL women was 44% in comparison with 20% in the non-TL group. This result is similar to that of Ghadirian et al.27 Basgul et al.28 also reported that 23.1% of the participating women noted changes in their sexual relationships, with 13% describing these changes as negative following TL. Bolourian and Ganjloo29 showed that surgery on female sexual organs such as TL in Iran might lead to a significant reduction of their sexual desire and satisfaction, and increase the probability of dyspareunia. Kazemeyan et al.30 International Journal of Impotence Research (2015), 173 – 177
Evaluation of sexual function and QOL in Iranian women with TL ShJahanian Sadatmahalleh et al
176 reported that sexual symptom scores in women who had undergone TL were significantly lower compared with those of the control group. Also, their study was consistent with studies in other countries whose culture was similar to that of Iran.31 These results also confirm the findings by other researchers that there is a significant increase in the incidence of sexual dysfunction in women undergoing TL when compared with other groups.16,27,32–34 It has also been reported that women with TL were more likely than non-TL women to seek medical advice from a physician regarding sexual problems.35 Our findings in the present study are inconsistent with the results of many similar studies conducted in other countries.15,17,21,22,36–38 Costello et al.16 performed a study with 4576 women enrolled in a prospective, multicenter cohort study, and evaluated whether interval TL might lead to any change in their interest and sexual pleasure. Most women with TL reported its positive effects on their sexual function.16 The results of a study on sexual relationships in women after TL showed an increase in coital frequency, and revealed no significant impact on females’ sexual satisfaction.17 Reports also differ regarding changes in sexual satisfaction after TL. In a study conducted in the United Kingdom,15 138 multiparous women with TL and 135 women using non-permanent birth control were interviewed. The women with TL stated significant improvement in their sexual relationships as compared with other women. Li et al.22 found an increase in both sexual drive and sexual satisfaction following TL. Another study reported that sexual function benefits from surgical interventions such as TL.39 There is no evidence that sexual problems are more prevalent among the women who had a TL than non-TL women.36,40 It has been reported that sexual satisfaction and coital frequency were not affected in women with TL.20,21,37,38,41 Toorzani et al.14 mentioned that the use of TL in women did not increase sexual satisfaction. The results of another study conducted in Iran showed that there was no significant difference between using any of contraceptive methods (such as TL) and sexual dysfunction in women.5 Making a decision about sterilization is difficult for both women and men, as it means ending fertility. As negative biological and psychological issues may occur after all surgeries and cause loss of sexual function, the same negative effects after TL have been expected,31 although arguments on the post-TL syndrome have been continuing for half a century, and whether this syndrome has negative effects on the sexual function and general health status has not been described.31 Some variables such as cultural patterns, as well as biological, physiological and psychological aspects, interact with the level of sexual satisfaction.42 The difference between our findings and this study may, however, be attributed to a difference in cultural factors among the women studied. This is an important result, since based on the authors’ experience, it is an entirely common concern raised by patients about the influence of TL on women’s sexual life.22 Some authors have found that, owing to permitting sexual activity without the fear of unwanted pregnancy, TL has positive effects on women’s sexual function.22,43,44 QOL status The present study showed that low levels of QOL were more common in the women with TL in comparison with the non-TL women. This finding is similar to the result of Gulum et al.31 In contrast, the results of another study reported that surgical interventions such as TL positively impacts QOL.39 However, Li et al.22 did not find such associations. One possible interpretation of our finding could be because of the effective role of FSD on women’s QOL. According to a study by Oksuz et al.,26 FSD is a highly prevalent health problem in women with TL, and can have a profound impact on their QOL. However, this effectiveness was International Journal of Impotence Research (2015), 173 – 177
not evaluated specifically in our study. It is very difficult to make a detailed assessment of sexual function and the effects of any abnormality in women’s QOL.32 A significant difference was found in sexual dysfunction in orgasm, satisfaction, pain and total FSFI scores between the women regretting vs those not regretting their sterilization. Costello et al.16 reported a relationship between sexual dysfunction and poststerilization regret in women with TL. Kjer37 reported that the majority of women who announced feelings of changed femininity or lack of excitement in sexual life were those who regretted their decision after TL. Shah et al.43 suggested that TL had a positive impact on sexual relationship unless the women were uncertain over the procedure. On evaluating the relationship between FSFI and educational level, it was observed that with the increase of educational level, all domain scores increased significantly only in the TL group. Our findings further showed that educational level and poststerilization regret were the variables that significantly influenced sexual function in the TL group. Some studies reported that increased educational level positively influenced the sexual function of women in the TL group.31,32,45 Women with higher levels of education may have a better understanding of psychosomatic reactions, which may lead to a better score in sexual function. These women may have higher confidence, and may be more informed of their needs and roles in sexual relationship.32 Indeed, one of the main reasons for women’s sexual dysfunction is insufficient experience and knowledge in the field of sexual relationships.22 Different results of the studies mentioned above imply that the relationship between TL and sexual function is a complex process, which is influenced by multiple factors, including different cultural conditions, ethnicity and misinterpretation of religious codes.46 After TL, different factors can result in increased sexual dysfunction such as change in self-concept and understanding of her existence as a woman, which in some cultures and societies, carries a high meaning load. Perhaps, it can be stated that different and incoherent reports on women’s sexual functioning condition after TL can be because of different meaning loads of this operation in various cultures. In societies such as Iran, the picture a woman holds of herself is to a high degree dependent on her fertility and motherhood ability. It conveys to women feelings of satisfaction, perfection and value. Despite the women’s voluntary participation in the sterilization programs, the cultural factors, which are rooted and penetrated in their deep unconscious layers, seem to produce in some of them an unattractive and imperfect picture, which after a while can be reflected in the appearance of sexual dysfunction and regret from this operation. Furthermore, an individual’s feeling of the irreversibility of the operation may result in tempting thoughts, which in turn are influential in sexual function. Also, the lack of knowledge of women in reaching satisfaction and orgasm in their sexual relationships are other main reasons of women’s sexual dysfunction and low QOL.46 CONCLUSION In this study, it was observed that sexual function and QOL in the women undergoing TL were lower compared with that in the nonTL group. Also, in the women with TL, higher levels of education and higher scores of sexual function were obtained. Finally, our results indicated that TL probably is not a safe method of contraception. This emphasizes the importance of a comprehensive consultation before TL, especially in women with a low level of education. CONFLICT OF INTEREST The authors declare no conflict of interest.
© 2015 Macmillan Publishers Limited
Evaluation of sexual function and QOL in Iranian women with TL ShJahanian Sadatmahalleh et al
ACKNOWLEDGMENTS We are grateful to the entire colleagues of Guilan University of Medical Sciences (Rasht, Iran) for their contributions in accomplishing this project. The study was supported by Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran.
REFERENCES 1 Salonia A, Munarriz RM, Naspro R, Nappi RE, Briganti A, Chionna R et al. Women's sexual dysfunction: a pathophysiological review. BJU Int 2004; 93: 1156–1164. 2 Shifren JL, Monz BU, Russo PA, Segreti A, Johannes CB. Sexual problems and distress in United States women: prevalence and correlates. Obstet Gynecol 2008; 112: 970–978. 3 Biddle AK, West SL, D'Aloisio AA, Wheeler SB, Borisov NN, Thorp J. Hypoactive sexual desire disorder in postmenopausal women: quality of life and health burden. Value Health 2009; 12: 763–772. 4 Papaharitou S, Nakopoulou E, Kirana P, Iraklidou M, Athanasiadis L, Hatzichristou D. Women's sexual concerns: data analysis from a help-line. J Sex Med 2005; 2: 652–657. 5 Safarinejad MR. Female sexual dysfunction in a population-based study in Iran: prevalence and associated risk factors. Int J Impot Res 2006; 18: 382–395. 6 Fourcroy JL. Customs, culture, and tradition—what role do they play in a woman's sexuality? J Sex Med 2006; 3: 954–959. 7 Kadri N, McHichi Alami KH, McHakra Tahiri S. Sexual dysfunction in women: population based epidemiological study. Arch Womens Ment Health 2002; 5: 59–63. 8 Avis NE, Zhao X, Johannes CB, Ory M, Brockwell S, Greendale GA. Correlates of sexual function among multi-ethnic middle-aged women: results from the Study of Women's Health Across the Nation (SWAN). Menopause 2005; 12: 385–398. 9 Rosen RC, Taylor JF, Leiblum SR, Bachmann GA. Prevalence of sexual dysfunction in women: results of a survey study of 329 women in an outpatient gynecological clinic. J Sex Marital Ther 1993; 19: 171–188. 10 Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA 1999; 281: 537–544. 11 Goldmeier D, Judd A, Schroeder K. Prevalence of sexual dysfunction in new heterosexual attenders at a central London genitourinary medicine clinic in 1998. Sex Transm Infect 2000; 76: 208–209. 12 Cayan S, Akbay E, Bozlu M, Canpolat B, Acar D, Ulusoy E. The prevalence of female sexual dysfunction and potential risk factors that may impair sexual function in Turkish women. Urol Int 2004; 72: 52–57. 13 Rosen R, Brown C, Heiman J, Leiblum S, Meston C, Shabsigh R et al. The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther 2000; 26: 191–208. 14 Toorzani ZM, Zahraei RH, Ehsanpour S, Nasiri M, Shahidi S, Soleimani B. A study on the relationship of sexual satisfaction and common contraceptive methods employed by the couples. Iran J Nurs Midwifery Res 2010; 15: 115–119. 15 Cooper JE, Bledin KD, Brice B, Mackenzie S. Effects of female sterilization: one year follow-up in a prospective controlled study of psychological and psychiatric outcome. J Psychosom Res 1985; 29: 13–22. 16 Costello C, Hillis SD, Marchbanks PA, Jamieson DJ, Peterson HB. The effect of interval tubal sterilization on sexual interest and pleasure. Obstet Gynecol 2002; 100: 511–517. 17 Shain RN, Miller WB, Holden AE, Rosenthal M. Impact of tubal sterilization and vasectomy on female marital sexuality: results of a controlled longitudinal study. Am J Obstet Gynecol 1991; 164: 763–771. 18 Alder E, Cook A, Gray J, Tyrer G, Warner P, Bancroft J et al. The effects of sterilisation: a comparison of sterilised women with the wives of vasectomised men. Contraception 1981; 23: 45–54. 19 Cooper P, Gath D, Fieldsend R, Rose N. Psychological and physical outcome after elective tubal sterilization. J Psychosom Res 1981; 25: 357–360. 20 Cooper P, Gath D, Rose N, Fieldsend R. Psychological sequelae to elective sterilisation: a prospective study. BMJ (Clin Res Ed) 1982; 284: 461–464.
© 2015 Macmillan Publishers Limited
177 21 Smith EM, Friedrich E, Pribor EF. Psychosocial consequences of sterilization: a review of the literature and preliminary findings. Compr Psychiatry 1994; 35: 157–163. 22 Li RH, Lo SS, Teh DK, Tong NC, Tsui MH, Cheung KB et al. Impact of common contraceptive methods on quality of life and sexual function in Hong Kong Chinese women. Contraception 2004; 70: 474–482. 23 Mohammadi KH, Heydari M, Faghihzadeh S. The Female Sexual Function Index (FSFI): validation of the Iranian version. Payesh 2008; 7: 269–278. 24 Montazeri A, Vahdaninia M, Mousavi SJ, Omidvari S. The Iranian version of 12-item Short Form Health Survey (SF-12): factor structure, internal consistency and construct validity. BMC Public Health 2009; 9: 341. 25 Shih G, Dube K, Dehlendorf C. 'We never thought of a vasectomy': a qualitative study of men and women's counseling around sterilization. Contraception 2013; 88: 376–381. 26 Oksuz E, Malhan S. Prevalence and risk factors for female sexual dysfunction in Turkish women. J Urol 2006; 175: 654–658. 27 Fataneh G, Marjan MH, Nasrin R, Taraneh T. Sexual function in Iranian women using different methods of contraception. J Clin Nurs 2013; 22: 3016–3023. 28 Basgul A, Uzuner A, Kavak ZN, Bozkurt N, Onaran H, Erturk MS. Impact of tubal sterilization on women's health. Clin Exp Obstet Gynecol 2007; 34: 39–41. 29 Bolourian Z, Ganjloo J. Evaluation of sexual dysfunction and some related factor in women. J Reprod Infertil 2007; 31: 163–170. 30 Kazemeyan A, Mohammadpour F, Safdari F. Comparison of psychological and sexual consequences of tubal ligation and other contraceptive methods in women referring to Shahrekord health centers in 2005–2007, Iran. J Shahrekord Univ Med Sci 2009; 10: 83–88. 31 Gulum M, Yeni E, Sahin MA, Savas M, Ciftci H. Sexual functions and quality of life in women with tubal sterilization. Int J Impot Res 2010; 22: 267–271. 32 Hentschel H, Alberton DL, Sawdy RJ, Capp E, Goldim JR, Passos EP. Sexual function in women from infertile couples and in women seeking surgical sterilization. J Sex Marital Ther 2008; 34: 107–114. 33 Lee TY, Sun GH, Chao SC. The effect of an infertility diagnosis on the distress, marital and sexual satisfaction between husbands and wives in Taiwan. Hum Reprod 2001; 16: 1762–1767. 34 Monga M, Alexandrescu B, Katz SE, Stein M, Ganiats T. Impact of infertility on quality of life, marital adjustment, and sexual function. Urology 2004; 63: 126–130. 35 Warehime MN, Bass L, Pedulla D. Effects of tubal ligation among American women. J Reprod Med 2007; 52: 263–272. 36 Smith A, Lyons A, Ferris J, Richters J, Pitts M, Shelley J. Are sexual problems more common in women who have had a tubal ligation? A population-based study of Australian women. BJOG 2010; 117: 463–468. 37 Kjer JJ. Sexual adjustment to tubal sterilization. Eur J Obstet Gynecol Reprod Biol 1990; 35: 211–214. 38 Bean FD, Clark MP, South S, Swicegood G, Williams D. Changes in sexual desire after voluntary sterilization. Soc Biol 1980; 27: 186–193. 39 Pauls RN. Impact of gynecological surgery on female sexual function. Int J Impot Res 2010; 22: 105–114. 40 Hsiao YC, Sung SH. Married women's satisfaction with their choice of contraception. J Nurs Res 2003; 11: 119–128. 41 Tang CS, Chung TK. Psychosexual adjustment following sterilization: a prospective study on Chinese women. J Psychosom Res 1997; 42: 187–196. 42 Gonzalez M, Viafara G, Caba F, Molina T, Ortiz C. Libido and orgasm in middleaged woman. Maturitas 2006; 53: 1–10. 43 Shah MB, Hoffstetter S. Contraception and sexuality. Miner Ginecol 2010; 62: 331–347. 44 Schaffir J. Hormonal contraception and sexual desire: a critical review. J Sex Marital Ther 2006; 32: 305–314. 45 Rudatsikira E, Muula AS, Siziya S. Current use of smokeless tobacco among adolescents in the Republic of Congo. BMC Public Health 2010; 10: 16. 46 Imeni B, Karampourian A. Investigating the effect of sexual satisfaction on family stability. In: Proceedings of the Second National Congress on Family and Sexual Problems. Shahed University, Family Health Clinic, Tehran, Iran, 2005.
International Journal of Impotence Research (2015), 173 – 177
