241Archivio Italiano di Urologia e Andrologia 2019; 91, 4

ORIGINAL PAPER

Evaluation of sexual dysfunction prevalence in infertile
men with non-obstructive azoospermia  

Taha Numan Yıkılmaz, Erdem Öztürk, Nurullah Hamidi, !smail Selvi, Halil Başar, Levent Peşkircioğlu

Department of Urology, Dr. Abdurrahman Yurtaslan Oncology Training and Research Hospital, Ankara.

Objectives: To determine the prevalence of
sexual dysfunction in male partners of

infertile couples and evaluate the effect of childlessness on
erectile dysfunction (ED) and sexual relationship stress.
Materials and methods: We collected datas of couples who
attended our clinics for infertility between 2009 and 2016.
Erectile dysfunction was investigated with the Questionnaires
of International Index of Erectile Function-15 (IIEF-15)
whereas premature ejaculation (PE) status with the Premature
Ejaculation Diagnostic Tool (PEDT). The stress status of the
childlessness in terms of sexual intercourse was scored by the
Visual analogue scale (VAS) questionnaire. These scores were
measured before and after a successful assisted reproductive
treatment with the birth of the child. 
Results: The median age of the 193 male patients was 31 years
(range 23-48). Erectile dysfunction was found in 68 (35.2%)
and PE in 42 (21.7%) subjects. One hundred and forty-one
couples were treated with assisted reproductive treatments.
Forty eight couples had successful pregnancy. The IIEF-15 test
was repeated after the birth of the child to the male partners
of  these couples. We observed that the IIEF-15 scores
increased from 16 to 21 (p = 0.014). However there were no
significant improvement on their ejaculation status (p > 0.05).
The mean VAS scores of male partners was 5.2 (3-10) in the
treatment period while it decreased to 4.1 (0-8) after the birth
of the chils (p = 0.02). Statistically analysis showed a correla-
tion between VAS and infertility as did IIEF-15. 
Conclusions: We observed that having children has a reducing
effect on sexual relationship stress. Infertility is absolutely
blamed on the women and men. This condition may have neg-
ative effects on male sexual performance and it is closely relat-
ed with some emerging female sexual disorders. It should be
taken into consideration that infertile couples may have sexual
dysfunction.

KEY WORDS: Andrology; Infertility; Childlessness; Anxiety;
Erectile dysfunction.
Submitted 12 May 2019; Accepted 2 August 2019 

Summary

No conflict of interest declared.

DOI: 10.4081/aiua.2019.4.241

INTRODUCTION
Infertility is the inability to have child after 1 year of
unprotected intercouse. Fifteen percent of couples expe-
rience difficulty conceiving a child. In between one-third
and one-half of these, an abnormality can be found in
the male partner (1). Infertility has been described as a
stressor and a life crisis for individuals or couples, which
results in a lower life quality and enhanced marital con-
flicts (2-5). These stresses play havoc with the couple’s
sex life. The physical health and emotional well-being of

many individuals and couples of reproductive age are
significantly affected by infertility. Sexual function is one
of the important components of health and overall qual-
ity of life (6). Thus, couples with infertility may have
abnormalities of sexual function, reduced sexual activity
and this leads to an increase in the numbers of past years
without a baby owner (7).
The relationship between sexual problems and infertili-
ty is unclear. Infertility causes many psychosexual prob-
lems such as loss of libido (with a consequent decrease
in sexual activity), impotence, inhibition of orgasm and
premature ejaculation (little or no control over ejacula-
tory response withnejaculation that may occur before
vaginal entry achieved) or retarded ejaculation (difficul-
ty ejaculating intravaginally, or at all) in male (8). 
In contrast, sexual dysfunction may have an etiological
role on infertility. Several studies from the United States
(US) have suggested that infertility does not impact on
sexual or erectile function after controlling for differ-
ences in intercourse frequency and/or socio-economic
factors (9-11). One the other hand, many studies from
US have suggested that infertility is often associated with
sexual problems in men (12). The aim of this study is
determining the prevalence of sexual dysfunction in
male partners of infertile couples and evaluating the
effect of childlessness on erectile dysfunction (ED) and
sexual relationship stress in male partners.

MATERIALS AND METHODS
We collected data of couples who attended our clinics for
infertility from 2009 to 2016. Age of couples, education-
al status of couples, duration of marriage, timing of
obtaining first sexuality education, the number of suc-
cessful or unsuccessful conception history of prior pater-
nity, number of intercourse and sexual function were
enrolled. Sexual function involved erectile dysfunction
and premature ejaculation for men. Erectile dysfunction
was investigated with the Questionnaires of International
Index of Erectile Function-15 (IIEF-15) (11), in its Turkish
translation.
Male participants were invited to complete several self-
reported questionnaires including modified the IIEF-15
and the modified International Index of Erectile Function
(IIEF-5) which consists 5 questions: 2 regarding erectile
function, 1 concerning orgasmic function, 1 question on
sexual desire, and 1 on satisfaction with intercourse.

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242

IIEF-15, a 15-item questionnaire for the evaluation of 5
domains of male sexual function (desire, erectile func-
tion, intercourse satisfaction, orgasmic function and
overall satisfaction) (13, 14). The questionnaire investi-
gated both spontaneous sex for pleasure and sex intend-
ed to lead to pregnancy. An IIEF-15 Erectile Function
domain score less than 26 was used as a cut-off for the
presence of erectile dysfunction (15). According to IIEF-
15, score was categorized as: (score 6-10) severe ED;
(score 11-16) moderate ED; (score 17-21) mild to mod-
erate ED; (score 22-25) mild ED; (score 26-30) no ED. 
Premature ejaculation (PE) was determined by a ques-
tionnaire consisting of 5 separate questions called
Premature ejaculation diagnostic tool (PEDT) (16). A PEDT
score less than 8 indicates no PE, on the contrary PE was
diagnosed. The subjects underwent standard semen
analysis, according to World Health Organization crite-
ria. Semen samples obtained by masturbation after 3-5
days of sexual abstinence. Azoospermic men were evalu-
ated according to the clinical parameters (testicular vol-
ume and structure, serum FSH levels and testicular biop-
sy) and only non-obstructive azoospermia patients were
included in the study. The stress status of the childless-
ness in terms of sexual intercourse was scored by the
Visual analogue scale (VAS) questionnaire. The scores
before and after the birth of the child were compared.
Patients with known systematic and psychiatric diseases,
taking a medicine that may cause sexual dysfunction or
the ones complaining of secondary infertility were
excluded from the study. All the data provided were
enrolled as part of a routinely clinical procedure and,
ethical approval for the study was received from the
Ethics Commitee. Written informed consent was
obtained from patients who participated in this study.

Statistical analysis
All statistical analyses were performed with Statistical
Package for the Social Science (SPSS Inc, Chicago, Illinois,
USA) version 16.0. Normality of tests was analyzed with
the Kolmogorov-Smirnov and Shapiro-Wilk tests. 
The independent samples t test was used for pairwise
comparisons of parameters that were distributed nor-
mally, and the Mann Whitney U-test was used for
parameters that were not distributed normally. 
Differences were considered significant when p < 0.05.

RESULTS
The median age of the 193 male patients and their part-
ners were 31 (range 23-48) and 27.2 (range 18-43)
years, respectively. When the socio-cultural levels of
male partners were examined, 59% of them were gradu-
ated from high school or university. Couples have been
married for an average of 45 months (range 12-193) and
the median period of infertility in these couples was 27
months (range 12-180). The average number of weekly
frequency of coitus was around 2.5 (range 0.5-7). In this
study, all of the cases consisted of primarily infertile cou-
ples, whereas a previously successful birth was not
observed in any case. The mean number of treatments of
couples prior to involvement in study was 0.6 (range 0-
7) including oral medications, injectable fertility drugs,

intrauterine insemination (IUI).The majority of men was
in their first marriage (93%), while a minority was in
their second (6%) or third marriage (1%) (Table 1).
The results of the IIEF-15 questionnaire showed that 68
(35.2%) men reported an overall ED. Of these, 31
(15.5%) patients reported a mild ED (score 22-25), 25
(12.9%) patients a mild to moderate (score 17-21), 9
(4.6%) patients a moderate ED (score 11-16) and 3 (1.5
%) patients have reported a severe form (score 6-10).
Premature ejaculation was seen in 42 (21.7%) patients
according to PEDT score. In patients with a PEDT score
> 8 acquired and lifelong PE was reported by 56.2% and
43.8% of the patients, respectively. Erectile dysfunction
was not seen in 50% of cases with PE, whereas PE was
not observed in cases with severe ED.
Patients were divided into two groups according to pres-
ence of ED, (group 1: IIEF-15 ED score < 26 [n:68];
group 2: no ED [n:125]). The mean age of the patients
was 33.1 ± 6.55 and 31.3 ± 4.93, respectively (p = 0.14).
When comparing two groups there was no relationship
between ED presence and education level but the educa-
tion levels of men with severe and moderate ED were sig-
nificantly lower than men with mild ED (p < 0.05). Age
of partners was 29.4 ± 6.02 and 27.5 ± 5.15, respective-
ly, and weekly frequency of coitus was 2.1 ± 0.84 and
2.5 ± 0.97 respectively; differences were statistically sig-
nificant (p = 0.053 and 0.002, respectively).
The mean number of treatment protocols applied to
these couples was 2.1 (0-4). One hundred and forty-one
of the couples were treated with different treatment
modalities such as oral drugs, injectable fertility drugs,
intrauterine insemination (IUI). Successful pregnancies
were obtained in 61 cases with assisted reproduction
treatments after a mean of 10 months (3-18 months).
Thirteen pregnancies were terminated due to different
reasons. After the treatment period, the IIEF-15 test was
repeated to 48 male partners of couples having children.
We observed that IIEF-15 scores increased from 16 to 21
and that improvement in IIEF-15 scores was statistically

Table 1. 
Sociodemographic and clinical characteristics of the subjects.

All patients (n: 193)
Age (years) 31 ± 4.2
Partner’s age (years) 27.2 ± 3.1
Education (%)

Primary/secondary 41
High/University 59

Duration of marriage (months) 45 (12-193)
Number of marriage (%)

First 93
Second 6
Third 1

Duration of infertility (months) 27 (12-180)
Frequency of coitus (per week) 2.5 (0.5-7)
Erectile dysfunction n (%) 68 (35.2)
IIEF-15 score n (%)

No ED (26-30) 125 (64.8)
Mild ED (22-25) 31 (15.5)
Mild to Moderate (17-21) 25 (12.9)
Moderate (11-16) 9 (4.6)
Severe (6-10) 3 (1.5)

Premature ejaculation n (%) 42 (21.7)

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significant (p = 0.014). At the same time PE was ques-
tioned by PEDT in this group of patients, but no statisti-
cal difference was observed.
We evaluated the effect of having children on stress lev-
els by VAS score. The Visual analogue scale (VAS) ques-
tionnaire was filled during the period of  the use of assist-
ed reproduction methods and in the next period after
having children in order to evaluate the stress related to
infertility. Their stress levels regarding sexual function in
these two periods were scored as follows; 0: no stress,
10: very stressful. The mean VAS scores of male partners
was 5.2 (3-10) in treatment period while the same group
mean score decreased to 4.1 (0-8) when they had chil-
dren (p = 0.02). Statistical analysis showed a correlation
between VAS and infertility like IIEF-15 (Table 2).

DISCUSSION
Sexual dysfunctions are common problems in society.
Premature ejaculation (29.3%) is the main sexual dis-
pleasure in men in the general population; ED (14.5%)
follows as the second sexual health problem (17). 
The prevalence of infertile couples ranges from 4% to 17%
and sexual dysfunction may play an etiological role in
these couples (18, 19). In one study, investigating pres-
ence of ED and PE in infertile men, Lotti et al. proved that
both ED and PE were higher in them compared to fertile
men (20). Another study in infertile men on in vitro fertil-
isation treatment, found no significant difference in infer-
tile men in terms of ED, but these patients had more
depressive mood (21). In a community research by Jain et
al. premature ejaculation (66%) was the most common
problem and it was followed by erectile dysfunction
(15%), decreased libido (11%) and orgasmic failure (8%)
among the infertile men (22). In a similar study by Lotti et
al. erection and ejaculation status of infertile men were
evaluated with IIEF and PEDT (12). They also researched
psychological status with Middlesex Hospital Questionnaire
(MHQ) and prostatitis symptoms with National Institutes of
Health-chronic prostatitis symptom index (NIH-CPSI). Lotti
et al. found lower rates of PE and ED (15.6% and 17.8%)
than in our study (21.7% and 34.7%, respectively). Also
depression was significantly associated with ED and they
found a positive relationship between PE and prostatitis
symptoms and phobic anxiety. According to these rates, it
was obvious that men who had known that they were
infertile, came across with more sexual problems such as
PE and ED than fertile ones. These male partners, espe-
cially living in conservative societies, have a feeling of
guiltiness and weakness so sexual fuction can not be fully
performed by them (23).
There are many factors that can lead to the relation

between infertility and sexual dysfunction such as age,
race, religion, social status, employment status, level of
education and previous paternity experience. In our
study, we found that education levels of men with severe
and moderate ED were significantly lower than in men
with mild ED, similarly to the literature (23). Kızılay et al.
found a close correlation between sperm parameters and
sexual dysfunction in infertile couples. According to this
study, poor sperm quality for count, morphology and
motility were associated with severe ED in men and a par-
allel increase of female sexual dysfunction was observed
(24). They also reported that worse sperm parameters
accompanied declines in testosterone and IIEF scores.
This comparison is not possible in terms of the azoosper-
mia of all the cases in our study. However, known
azoospermic group had the worst erectile function, higher
PE prevalence, lower sexual desire, orgasmic function and
general health condition among all infertile males (25).
In 2014, Bayar et al. examined sexual dysfunction before
and after treatment in patients who received IVF treat-
ment (26). IIEF form for male partners and FSFI form for
female partners were used for determining sexual dys-
function. At the third month of IVF treatment, severity of
sexual dysfunction increased to 72% of female partners
and 48% of male partners. But in the subgroup analysis,
there were not found significant differencies in erection
status and PE. In our study we investigated the changes
in ED and PE in case of couple’s having a baby and we
observed that IIEF-15 scores increased from 16 to 21 in
male partners after having a baby after treatment. This
improvement in IIEF-15 scores was statistically signifi-
cant (p = 0.014). At the same time PE was questioned by
PEDT in this group of patients, but no statistical differ-
ence was observed.
It had been observed that psychosexual problems rise at
the maximum level when duration of childlessness last-
ed less than two years or more than eight years (14). Song
et al. searched stress related to infertility and timed inter-
course during fertile periods of male partners in infertile
couples with VAS questionnaires (8). The mean VAS
score of sexual relationship stress was significantly high-
er during fertile than non-fertile periods (3.4 vs 2.1). As
the fecundity of healthy couples is about 20% per cycle,
the wife and the environment create stress on men' sex-
ual function during fertile periods (8). We investigated
the effect of sexual relationship stress in infertile couples
who had children after assisted reproduction proce-
dures. To our knowledge, this is the first study to quan-
titatively investigate stress levels of male partners of
infertile couples between the periods before after the
birth of the child. In our study, after having child the
VAS scores of male partners showed a statistically sig-
nificant decrease to 4.1 from 5.2 during sexual inter-
course. Furthermore this significant improvement was
also observed on sexual functions. We observed a statis-
tically significant increase in the mean IIEF-15 levels
from 16 to 21 in case of having a baby although the same
improvement was not seen in PE.
Our study has some limitations. Firstly, sexual functions
of female partners were not investigated. A decrease in
female sexual desire may cause a negative effect on sexual
function of their male partners. Secondly, we did not eval-

243Archivio Italiano di Urologia e Andrologia 2019; 91, 4

Sexual dysfunction and non-obstructive azoospermia

Table 2. 
Comparison of stress levels of 48 male partners with
childhood by using VAS questionnaire and ED and PE scores
between childlessness and after having child.

Childlessness Having child p
IIEF (0-30) 16 21 0.014
PE (0-20) 6.3 ± 2.1 5.9 ± 1.7
VAS (0-10) 5.2 (3-10) 4.1 (0-8) 0.02

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244

uate the psychological or somatic status of patients with
psychiatric tests such as Middlesex Hospital Questionnaire
(MHQ) or Short Form Health Survey 36 (SF-36) which can
effect patients’ sexual functions. Lastly, our study did not
include fertile couples as a control group. Also the retro-
spective design of our study is an important bias. 
Therefore, randomised prospective studies with large
groups of infertile and fertile groups are needed to under-
stand the main pathogenesis of male sexual dysfunction.

CONCLUSIONS
We aimed to investigate the prevalence of sexual dysfunc-
tion which included ED and PE in infertile men. Erectile
dysfunction was more common in our patient group than
the literature. We consider this as a repercussion of com-
municative obstacles encountered in conservative soci-
eties. Moreover another finding, contrasting the literature,
was related to the assessment of ED, PE and quantitative
stress degree related to infertility (VAS scores) after having
a baby through assisted reproduction treatments. We
observed that having children is a reducing effect on sex-
ual relationship stress. Sexuality can be deprived of its
amusement and erotic value in case of a known infertility
status. This condition may have negative affects on male
sexual performance and it is closely related with occuring
female sexual disorders. It should not be forgotten that
infertile couples may have sexual dysfunction.

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Correspondence
Taha Numan Yıkılmaz, MD (Corresponding Author) - numanyikilmaz@gmail.com 
Erdem Öztürk, MD - drerdemozturk@gmail.com 
Halil Başar, MD - drhalilbasar@gmail.com
!smail Selvi, MD - drismailselvi@gmail.com  
Department of Urology, Ankara Dr. Abdurrahman Yurtaslan Oncology Training 
and Research Hospital, Ankara 06200, Turkey 

Nurullah Hamidi, MD - drnurullahhamidi@gmail.com 
Atatürk Training and Research Hospital, Ankara 06200, Department of Urology

Levent Peşkircioğlu, MD - drlevent@gmail.com
Baskent University Ankara Education and Research Hospital, Department of
Urology, Ankara, Turkey

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