Sexual and psychological health of couples with azoospermia in the context of the COVID-19 pandemic

Participant selection

A case–control cross-sectional questionnaire survey was administered at the Center of Reproductive Medicine of Shengjing Hospital of China Medical University between 1 July 2020 and 20 December 2020. The experimental group consisted of men with azoospermia and their wives, whereas the control group consisted of men with normozoospermia (according to WHO semen examination standards, (World Health Organization, 2010) and their wives. All participants were recruited from our Reproductive Medicine Center. The semen test results of the men in the control group was normal (men with normozoospermia), and no spouse was diagnosed with infertility. Men taking drugs (e.g., selective serotonin reuptake inhibitors, tricycle antidepressants, and phosphodiesterase type 5 inhibitors) that may affect their ejaculatory and erectile function and/or mental state were excluded (Gao et al., 2013). All participants were aware of their fertility status (including semen status) before completing the questionnaire. Before enrolment in the study, all participants were informed of the voluntary and anonymous nature of the study design and that their privacy would be protected. None of the participants had any biological children.

The questionnaires were completed in a private room at the Center of Reproductive Medicine of Shengjing Hospital of China Medical University to fully ensure participants’ privacy, and no spouses were present. Participants were not compensated in any form. Participants who provided inconsistent answers were excluded (e.g., in the questionnaire focused on sexual function, ‘did not attempt intercourse’ was selected in one question but not others).

Measures

We used a self-designed questionnaire and five standardised questionnaires, all of which were validated in the Chinese language.

Demographic variables

Data on the patients’ baseline information, including age, height, weight, occupation, educational level, work or life stress levels, and lifestyle habits (such as frequency of physical exercise, smoking status, and drinking status) were collected.

Men’s sexual function

Men’s sexual function was assessed using the International Index of Erectile Function-15 (IIEF-15) and Premature Ejaculation Diagnostic Tool (PEDT) and was based on their sexual status in the preceding 4 weeks. The IIEF-15 includes 15 items covering 5 domains of male sexual function (erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction). The total score ranges from 6 to 45, with Cronbach’s alpha values ≥ 0.91 (Rosen et al., 1997; Corona, Jannini & Maggi, 2006). The presence and severity of ED were based on the IIEF-15 score, with the severity of ED represented as follows: 26–30, none; 22–25, mild; 17–21, mild to moderate; 11–16, moderate; and <11, severe (Cappelleri et al., 1999).

The PEDT includes five items, which are scored on a 5-point scale from 0 to 4, with a total severity score ranging from 0 to 20. A PEDT score ≤ 8 indicated no premature ejaculation (PE), 9–10 indicated probable PE, and ≥11 indicated implied PE. The Cronbach’s alpha value was 0.78 (Symonds et al., 2007).

Women’s sexual function

Female sexual function was assessed using the Female Sexual Function Index (FSFI), which includes 19 items and 6 domains of sexual function (desire, arousal, lubrication, orgasm, satisfaction, and coital pain) based on the sexual status in the preceding 4 weeks. The scores for each domain range from 1.2 to 6 or from 0 to 6, and the total score ranges from 2 to 36, with Cronbach’s alpha value ≥ 0.82 (Rosen et al., 2000). A total FSFI score ≤ 23.45 (Chinese cut-off) indicated that the woman might have sexual dysfunction (Ma et al., 2014; Lo & Kok, 2018).

Sexual behaviours during lockdown

We measured five aspects of self-reported changes in sexual behaviours during the lockdown using five questions, which were adopted from previous studies’ questionnaires (Li et al., 2020a; Li et al., 2020b). Change in sexual desire was assessed by asking the following question: ‘Compared with that before the COVID-19 pandemic, how has your sexual desire changed’? Change in sexual frequency was assessed by asking the following question: ‘Compared with that before the COVID-19 pandemic, how has your sexual frequency changed’? Change in sexual satisfaction was evaluated by asking the following question: ‘Compared with that before the COVID-19 pandemic, how has your sexual satisfaction changed’? The answers to the above three questions were set as follows: increased, unchanged, and decreased. Change in frequency of masturbation was assessed by asking the following question: ‘How has your frequency of masturbation changed compared with that before the COVID-19 pandemic’? Change in frequency of pornography use was evaluated by asking the following question: ‘How has your frequency of pornography use changed compared with that before the COVID-19 pandemic’? The answers to the above two questions were set as follows: none, increased, unchanged, and decreased.

Psychological health

Anxiety symptoms were evaluated using the 7-item Generalized Anxiety Disorder scale (GAD-7). The items are scored on a 4-point scale, from 0 to 3, and the total score ranges from 0 to 21. The cut-off score of ≥ 10 was used to assess the presence of anxiety (Löwe et al., 2008).

Depression symptoms were evaluated using the 9-item Patient Health Questionnaire (PHQ-9), with Cronbach’s α value ranging from 0.73 to 0.95. The items are scored on a 4-point scale from 0 to 3, with a total severity score ranging from 0 to 27. The cut-off score of ≥ 10 was used to assess the presence of depression (Kroenke, Spitzer & Williams, 2001).

Additionally, a question on COVID-19-related anxiety (‘Does the novel coronavirus pneumonia pandemic make you anxious’) was also asked, in which respondents rated their anxiety as severe, slight, or none.

Statistical analyses

Data analyses were performed using the statistical software Statistical Package for the Social Sciences (version 22.0; International Business Machines Corp., Armonk, NY, USA). Results are presented in a tabular format. Categorical variables are summarised as counts and percentages, in addition to continuous measures with counts, means, and standard deviations (SDs). The chi-square test was used to compare categorical data, and the independent t-test and one-way analysis of variance (ANOVA) were used to compare numerical data. Effect sizes were used to evaluate the strength of each statistical analysis and were measured with Cohen’s d for independent t-tests, and Cramer’s V for chi-square (χ²) tests.

We used the APIM (Cook William & Snyder Douglas, 2005) to assess the association between sexual function and psychological health for both sexes. We used the R package ‘lavaan’ for calculating the mediation effects. The actor effect was defined as the effect of an individual’s sexual function on his/her own depression and anxiety symptoms, and the partner effect was defined as the effect of an individual’s sexual function on his/her partner’s depression and anxiety symptoms (Fernandes et al., 2021). The overall fitting model and goodness-of-fit were evaluated with the following indices: degrees of freedom values (χ²/df) < 3, root mean square error of approximation (RMSEA) < 0.10, standardised root mean square residual (SRMR) < 0.10, normed fit index (NFI) > 0.90, and comparative fit index (CFI) > 0.90 (Ryu, 2014).

A two-tailed p value <0.05 indicated statistical significance for all tests.

Ethical approval

The study protocol was approved by the Institutional Review Board for Research on Human Subjects at the Center of Reproductive Medicine (approval number 2020PS009F).

Participant responses and demographic characteristics

A total of 128 couples (men diagnosed with azoospermia and their wives) belonging to the experimental group participated in the study; 28 couples were excluded because they provided inconsistent answers and/or failed to answer all questions (18 failed to answer all questions and 10 provided inconsistent answers). A total of 135 couples (men diagnosed with normozoospermia and their wives) belonging to the control group participated in the study; 35 couples were excluded (23 failed to answer all questions and 12 provided inconsistent answers). Ultimately, the responses of 200 couples (100 couples with azoospermia, 100 couples with normozoospermia) were included in the analysis (response rate, 76%).

Table 1 shows participants’ demographic characteristics. The average ages were 34.52 (SD 4.71) years for patients with azoospermia and 34.95 (SD 4.00) years for patients with normozoospermia (t = −0.70, p = 0.49). The average ages of the wives in the corresponding groups were 32.76 (SD 4.32) and 33.51 (SD 4.42) years, respectively (t = −1.21, p = 0.23). There were no significant differences in the body mass index, income, educational levels, lifestyle factors (smoking status, drinking status, frequency of physical exercise) or stress levels between the two male groups (p >0.05). Educational levels (χ² = 15.78, p = 0.00) and drinking status (χ² = 8.11, p = 0.04) were significantly different between the two female groups (Table 1).

Comparison of sexual function and behaviours between the couples with azoospermia and normozoospermia

The results of the independent t-test showed that the total IIEF-15 score (53.07 ± 11.11 vs. 57.52 ± 8.57, t = −3.17, p = 0.00) and ratings from four domains of male sexual function (erectile function [23.25 ±5.13 vs. 24.82 ± 4.18, t = −2.37, p = 0.02], orgasmic function [7.34 ± 1.82 vs. 8.04 ± 1.48, t = −2.98, p = 0.00], intercourse satisfaction [9.45 ± 2.71 vs. 10.55 ± 2.18, t = −3.16, p = 0.00], and overall satisfaction [6.96 ± 2.24 vs. 7.67 ±1.86, t = −2.44, p = 0.02]) were lower for men with azoospermia than for men with normozoospermia. In contrast, the PEDT scores (6.58 ± 3.13 vs. 5.17 ± 2.22, t = 3.67, p = 0.00) and PE incidence (χ² = 14.73, p = 0.00) were higher for men with azoospermia than for men with normozoospermia. The chi-square test showed that the sexual satisfaction (χ² = 7.32, p = 0.03) was lower in men with azoospermia than in men with normozoospermia. Results of the independent t-test showed that the frequency of sexual activity was lower in men with azoospermia than in men with normozoospermia (4.14 ± 2.72 vs. 5.04 ± 2.25, t = −2.55, p = 0.01). The sexual desire scores (6.07 ± 1.37 vs. 6.24 ± 1.29, t = −0.90, p = 0.37) and incidence of ED (χ² = 6.40, p = 0.09) were not significantly different between the two groups (Table 2).

For the wives, the results of the independent t-test showed that the total FSFI scores (25.12 ± 5.56 vs. 26.75 ± 4.82, t = −2.22, p = 0.03) and ratings from three of the six domains of female sexual function (orgasm [4.22 ± 1.26 vs. 4.60 ± 1.03, t = −2.33, p = 0.02], satisfaction [4.10 ±1.39 vs. 4.72 ± 1.09, t = −3.51, p = 0.00], and coital pain [4.72 ± 1.06 vs. 5.04 ± 0.92, t = −2.27, p = 0.02]) were lower in the group with azoospermia than in the group with normozoospermia. The chi-square test revealed that sexual satisfaction was lower in the group with azoospermia than in the group with normozoospermia (χ² = 14.18, p = 0.00). The results of the independent t-test indicated that the scores for sexual desire, sexual arousal ability, and vaginal lubricity were not significantly different between the two groups (p > 0.05) (Table 3).

Changes in sexual behaviours of the couples with azoospermia and normozoospermia during the lockdown

Regarding changes in sexual behaviours among men, the chi-square test revealed no significant differences in the perceived changes in sexual satisfaction (χ² = 0.71, p = 0.70), sexual desire (χ² = 0.00, p = 1.00), frequency of sexual activity (χ² = 0.23, p = 0.89), frequency of masturbation (χ² = 4.62, p = 0.20), or pornography use (χ² = 2.71, p = 0.44) between the two groups (Table 4).

Among women, the chi-square test showed that the perceived changes in sexual satisfaction (χ² = 7.22, p = 0.03), frequency of masturbation (χ² = 21.96, p = 0.00), and pornography use (χ² = 10.90, p = 0.01) were significantly different between the group with azoospermia and normozoospermia. However, there were no significant differences in the perceived changes in sexual desire (χ² = 2.79, p = 0.25) or frequency of sexual activity (χ² = 1.73, p = 0.42) (Table 4).

Psychological health of the couples with azoospermia and normozoospermia in the context of the COVID-19 pandemic

The GAD-7 scores (men: 7.18 ± 5.56 vs. 5.68 ± 4.58, t = −2.08, p = 0.04; women: 6.65 ± 5.06 vs. 5.10 ± 3.29, t = 2.57, p = 0.01) and PHQ-9 scores (men: 10.21 ± 6.37 vs. 7.49 ± 6.10, t = 3.08, p = 0.00; women: 8.81 ± 6.50 vs. 6.98 ± 4.43, t = 2.33, p = 0.02) were significantly higher for couples with azoospermia than for couples with normozoospermia. The incidence rates of anxiety, depression, and COVID-19-related anxiety were higher among couples with azoospermia than among couples with normozoospermia (p < 0.05) (Table 5).

Association between sexual function and psychological health in couples with azoospermia

Results of the APIM showed that for couples with azoospermia, sexual function negatively correlated with their own anxiety (men: β = −0.22, standard error (SE) = 0.04, Z = −5.08, p = 0.00; women: β = −0.38, SE = 0.09, Z = −4.46, p = 0.00) and depression symptoms (men: β = −0.21, SE = 0.05, Z = −4.46, p = 0.00; women: β = −0.57, SE = 0.12, Z = −4.89, p = 0.00) but not with their partner’s anxiety (men: β = −0.00, SE = 0.04, Z = −0.07, p = 0.94; women: β = −0.07, SE = 0.09, Z = −0.77, p = 0.44) and depression symptoms (men: β = 0.01, SE = 0.05, Z = 0.25, p = 0.80; women: β = −0.12, SE = 0.11, Z = −1.08, p = 0.28). The model revealed a good overall fit (χ2/df =0.00, CFI = 1.00, RMSEA = 0.00, SRMR = 0.00, NFI = 1.00). None of the studied partner effects were significant, but the actor effects were significant (Fig. 1).