The effects of exercise frequency on sexual function and psychological health in infertile women.

A total of 728 participants were included in this study and categorized into four groups based on physical exercise frequency: no regular exercise (group I), ≤2 times a month (group II), once a week (group III), and ≥2 times a week (group IV). Significant differences were observed in age and infertility duration across groups (both P  = .01). Specifically, group IV participants were older and had longer infertility durations than those in groups I–III. Education level and perceived stress also varied significantly ( P  < .01 and P  = .03, respectively), with a higher proportion of postgraduate education and very high stress reported in the group I. Other factors such as BMI, sexual activity frequency, income, and alcohol use showed no significant differences. Smoking status showed a marginal group difference ( P  = .05). Full details are provided in Table 1 . As shown in Supplementary Table 1 , the most common cause of infertility in our sample was tubal factors (32.69%), followed by male infertility (15.66%) and PCOS (15.38%). Baseline characteristics of the study participants. Data were described as mean ± SD or n (%). * P  < .05. ** P  < .01. Abbreviations : BMI, body mass index; SD, standard deviation. There is a significant difference between group I and group II. There is a significant difference between group I and group III. There is a significant difference between group I and group IV. There is a significant difference between group II and group IV. There is a significant difference between group III and group IV. While mean GAD-7 scores and the distribution of anxiety severity did not significantly differ across groups ( P  = .14 and P  = .15, respectively), depressive symptoms varied significantly ( P  = .02). Participants in the group I reported the highest PHQ-9 scores ( P  = .02), while minimal to mild symptoms were more common among regularly active participants. Full distributions are presented in Table 2 . Psychological health among the study participants. Abbreviations : GAD-7: General Anxiety Disorder-7; PHQ-9: Patient Health Questionnaire-9. * P  < .05. There is a significant difference between group I and group II. b There is a significant difference between group I and group III. There is a significant difference between group I and group IV. Total FSFI scores differed significantly across groups ( P  < .01), with group I reporting the lowest scores, while groups II–IV had similar but higher scores. Sexual dysfunction was most prevalent in group I (23.17%) and significantly lower in the other groups ( P  = .02), suggesting a potential protective effect of regular physical activity. Among FSFI subdomains, group I consistently showed lower scores in desire, arousal, satisfaction, and orgasm (all P  < .01), whereas no significant differences were observed in lubrication or coital pain. Marital satisfaction (QMI) also varied significantly ( P  < .01), with the lowest scores in group I and the highest in groups II and IV. These findings highlight positive associations between physical activity and sexual function—particularly in the areas of desire, arousal, satisfaction, and orgasm—as well as relationship quality ( Table 3 ). Female sexual health of the study participants. Abbreviations : FSFI, Female Sexual Function Index; QMI, Quality of Marriage Index. * P  < .05. ** P  < .01. There is a significant difference between group I and group II. There is a significant difference between group I and group III. There is a significant difference between group I and group IV. Multivariable logistic regression revealed that physical exercise frequency was not independently associated with sexual dysfunction after adjusting for potential confounders. Compared to group I, the adjusted ORs for sexual dysfunction were: 0.92 (95% CI: 0.46-1.83, P  = .81) for group II, 1.40 (95% CI: 0.69-2.82, P  = .35) for group III, 1.40 (95% CI: 0.62-3.15, P  = .42) for group IV. In contrast, several other variables emerged as significant independent predictors. Increasing age was modestly protective (OR = 0.93, 95% CI: 0.88-0.98, P  = .01), whereas longer infertility duration (OR = 1.46, 95% CI: 1.30-1.64, P  < .01) and lower sexual activity frequency (OR = 1.12, 95% CI: 1.01-1.23, P  = .03) were associated with higher odds of sexual dysfunction. Among psychological factors, the composite Psychological Distress Index, derived from principal component analysis of GAD-7 and PHQ-9 scores, was strongly associated with increased risk of sexual dysfunction (OR = 2.27, 95% CI: 1.83-2.82, P  < .01). Other variables—including BMI, income, education, stress level, smoking, and alcohol use—were not significant in the adjusted model ( Table 4 ). These results underscore the dominant role of psychological distress, infertility duration, and sexual activity frequency as independent risk factors for sexual dysfunction in infertile women, while suggesting that physical activity alone may not be a direct protective factor. Factors associated with sexual dysfunction: multivariable-adjusted odds ratios and 95% confidence intervals, using Psychological Distress Index. Abbreviations : 95% CI: 95% confidence interval; OR: odds ratio. * P  < .05. ** P  < .01.

This cross-sectional study was conducted at the Reproductive Medicine Center of Shengjing Hospital affiliated to China Medical University. Participant recruitment occurred from March 2021 to March 2024, and data collection was completed between June 2021 and June 2024. The primary objective was to evaluate the association between physical exercise frequency and both sexual and psychological health among infertile women. Eligible participants were women aged 20-44 years with a clinical diagnosis of infertility, defined as the failure to conceive after at least 12 months of regular, unprotected sexual intercourse. 25 To ensure valid sexual function assessment, all participants were required to be sexually active and regularly engage in penile-vaginal intercourse, consistent with the scoring criteria of the Female Sexual Function Index (FSFI). Women were excluded if they had any of the following conditions: severe endometriosis, diabetes mellitus, hypertension, congenital or acquired abnormalities of the lower genital tract, active genitourinary infections, pelvic organ prolapse, or psychiatric disorders known to affect sexual function. Additional exclusion criteria included current use of medications that could influence sexual function (eg, antidepressants, antipsychotics, antihypertensives, hormonal agents, or centrally acting sedatives); presence of severe male factor infertility or male sexual dysfunction in the partner; and self-reported perimenopausal symptoms. Participants with an FSFI total score < 8, indicating insufficient sexual activity for valid evaluation, were excluded after initial questionnaire screening and prior to data analysis. Inconsistencies in questionnaire responses were also grounds for exclusion. Participants were categorized into four groups based on self-reported physical activity frequency. Group I: no regular physical activity; group II: ≤2 times a month; group III: once a week; group IV: ≥2 times a week. It should be noted that physical activity in this study was categorized solely based on self-reported weekly frequency, without accounting for the intensity, type, or duration of exercise. Therefore, activities with different energy expenditures (eg, a light gym session vs. long-distance running) may have been grouped together. This simplified classification was chosen due to limitations in data collection but may not fully reflect participants’ actual activity levels. Sexual function was assessed using the 19-item FSFI, which evaluates six domains: desire, arousal, lubrication, orgasm, satisfaction, and pain. Total scores range from 2 to 36, with a score of ≤23.45 indicating sexual dysfunction. 26 , 27 Domain-specific cutoffs were applied as follows: desire ≤2.7, arousal ≤3.15, lubrication ≤4.05, orgasm ≤3.8, and pain ≤3.8. 26 , 27 Anxiety was measured using the Generalized Anxiety Disorder-7 (GAD-7), a validated 7-item self-report questionnaire with scores ranging from 0 to 21. Cutoff values of 5, 10, and 15 were used to define mild, moderate, and severe anxiety, respectively. 28 Depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9), a 9-item scale based on DSM-IV criteria. Total scores range from 0 to 27, and the following severity classifications were applied: minimal (0-4), mild (5-9), moderate (10-14), moderately severe (15-19), and severe (20-27). A score ≥ 10 was considered indicative of clinically significant depression. 29 , 30 Marital satisfaction was evaluated using the Quality of Marriage Index (QMI), a validated 6-item instrument measuring perceived satisfaction in marital or committed relationships. Each item is rated on a 7-point Likert scale, yielding total scores between 6 and 45, with higher scores indicating greater satisfaction. 31 The QMI has demonstrated high internal consistency (Cronbach’s α  > .90) and is widely used in studies on relationship quality and sexual health. 32 , 33 Sample size was calculated using Cohen’s d , assuming a medium effect size (0.5), power of 80%, and a significance level of .05. Based on these assumptions and the available population, a total of 728 participants were recruited across the four exercise frequency groups, ensuring sufficient statistical power for between-group comparisons. All statistical analyses were performed using IBM SPSS Statistics version 26.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to summarize demographic and clinical characteristics. Categorical variables were analyzed using chi-square tests, while continuous variables were compared using one-way analysis of variance. Multivariable logistic regression was conducted to identify independent predictors of sexual dysfunction based on FSFI total and domain-specific scores. Results were reported as odds ratios (ORs) with 95% confidence intervals (CIs). A two-tailed P value <.05 was considered statistically significant. Missing data were managed using multiple imputation. No sensitivity analysis was performed, as the study was cross-sectional without longitudinal follow-up. To address potential multicollinearity among independent variables, we performed a variance inflation factor (VIF) analysis prior to multivariable modeling. While most variables, including income, smoking, drinking, stress perception, and marital quality (QMI), had acceptable VIF values (<2), both PHQ-9 (depression) and GAD-7 (anxiety) exhibited VIF values above 9, indicating strong collinearity. To mitigate this, we applied principal component analysis (PCA) to standardized PHQ-9 and GAD-7 scores. The first principal component, which accounted for 96.97% of the total variance and loaded equally on both scales (loading = 0.707), was retained as a composite Psychological Distress Index. This index was used in the final regression model in place of the original anxiety and depression variables. The study protocol was approved by the Institutional Review Board of Shengjing Hospital affiliated to China Medical University (Approval No. 2021PS018F) and conducted in accordance with the Declaration of Helsinki. All participants provided written informed consent prior to enrollment.

This study reveals that although regular physical activity is associated with better sexual function and psychological well-being in infertile women, exercise frequency is not an independent predictor of sexual dysfunction when psychological and demographic confounders are considered. Instead, key determinants of sexual dysfunction include elevated levels of anxiety and depression, longer infertility duration, and reduced sexual activity frequency. These findings underscore the critical role of psychological distress and relationship dynamics in shaping sexual health outcomes. Comprehensive, integrated care strategies that incorporate mental health support and address relational factors are essential. Future longitudinal and interventional research is warranted to clarify causal pathways and evaluate the efficacy of lifestyle and psychosocial interventions in improving sexual health among women with infertility.

This study investigated the associations between physical exercise frequency, sexual function, and psychological health among infertile women. In univariate analyses, higher physical activity frequency (≥1 time a week) was associated with better sexual function scores and lower levels of depression and anxiety. However, multivariable regression analysis showed that physical activity frequency was not an independent predictor of sexual dysfunction. Instead, psychological factors (particularly anxiety and depression), longer infertility duration, and lower frequency of sexual activity emerged as the main contributors. Although physical activity was not an independent predictor in the adjusted model, its positive effects on sexual function were evident in unadjusted analyses, particularly in the domains of desire, arousal, satisfaction, and orgasm. These findings align with previous research suggesting that physical activity may benefit sexual health by improving cardiovascular function, enhancing hormonal balance, and alleviating psychological distress. 34–36 A recent meta-analysis by Salari et al., which reported a significantly higher pooled prevalence of sexual dysfunction among women with low physical activity (64.6%) compared to those with higher activity levels (47%). 36 These findings suggest a general protective trend associated with physical activity, though individual outcomes may vary by population. Several mechanisms may explain how physical activity enhances sexual health in infertile women. Exercise improves cardiovascular and endothelial function, promoting better genital blood flow. 37 , 38 It also modulates hormone levels, reduces systemic inflammation, and enhances self-image and mood—factors that influence sexual confidence and responsiveness. 39 , 40 In our study, women who exercised more frequently also reported higher marital satisfaction, which may indirectly support sexual function through improved relationship dynamics and emotional well-being. Our results also demonstrated that women who exercised more frequently reported higher marital satisfaction, as indicated by significantly elevated QMI scores. This may be explained by improved mood, self-perception, and body image associated with regular exercise. 41 , 42 While these benefits may not exert a direct physiological effect on sexual function, they may act indirectly by enhancing relationship quality and emotional well-being. Consistent with prior literature, regular physical activity has also been shown to reduce anxiety and depressive symptoms, which are themselves major predictors of sexual dysfunction. 35 , 43 For example, research by Prémusz et al. found a strong inverse relationship between physical activity and psychological problems such as anxiety and depression. 43 In Vitro Fertilization and Embryo Transfer patients, Wang et al. reported that increases in everyday physical activity (including occupational and household tasks) were associated with better mental health outcomes. 44 Taken together, these findings support the inclusion of physical activity as part of a broader psychosocial care strategy in infertility management. It is also important to acknowledge the potential bidirectional nature of the relationship between physical activity, psychological health, and sexual function. Poor psychological status, such as depression or anxiety, may reduce both the motivation and capacity to engage in physical activity, thereby exacerbating sexual dysfunction. 45 Conversely, sexual dysfunction itself—particularly in the context of infertility—can increase emotional distress, leading to a reinforcing cycle of psychological burden and impaired physical and sexual health. 46 , 47 These interactions underscore the importance of addressing mental health concerns as both potential causes and consequences of sexual dysfunction and physical inactivity. An integrative framework that considers these bidirectional effects is therefore essential in both research and clinical care. However, the lack of independent association between physical activity frequency and sexual function in our adjusted analysis contrasts with some earlier studies. This discrepancy may reflect differences in sample composition, measurement tools, or statistical adjustment for confounding variables such as psychological distress and relationship quality. It is possible that exercise exerts its beneficial effects on sexual function primarily through mediating improvements in mood and interpersonal dynamics, rather than through direct physiological mechanisms. Anxiety and depression were the strongest independent predictors of sexual dysfunction in our cohort. This is in line with the biopsychosocial model of sexual health, in which psychological distress interferes with all phases of the sexual response cycle. Rowland emphasized that anxiety can disrupt desire, lubrication, and orgasm by reducing focus on sexual stimuli and increasing cognitive distraction. 48 Similarly, depressive symptoms are known to suppress sexual desire, arousal, and satisfaction. Ozturk et al. found that sexual dysfunction was significantly more prevalent among infertile women with depression. 49 Our findings further support this, with depression associated with a more than 4-fold increase in the odds of sexual dysfunction. Given the strong intercorrelation observed between anxiety and depression measures in our data, we did not include GAD-7 and PHQ-9 simultaneously in the final regression model. Instead, we applied PCA to create a unified Psychological Distress Index, based on standardized GAD-7 and PHQ-9 scores. The first principal component accounted for 96.97% of the total variance and loaded equally on both variables (loading = 0.707), indicating that it effectively represented a general dimension of psychological distress. This approach minimized multicollinearity while preserving the contribution of psychological factors in the model. Nevertheless, we acknowledge that this method may obscure the potentially distinct effects of anxiety and depression on sexual function. Future studies using larger, longitudinal samples and path modeling techniques may help to disentangle their respective influences. Our study also identified longer infertility duration as a significant risk factor for sexual dysfunction. This supports prior research by Dong et al., who reported that sexual dysfunction increased with infertility duration. 8 Demirci and Sen observed that women with prolonged infertility experienced reduced libido, lower intercourse frequency, and greater coital difficulties, including dyspareunia and vaginismus. 50 Similarly, Iris et al. reported that sexual dysfunction—including arousal, orgasm, and lubrication disorders—was significantly more common in women with infertility lasting over five years. 51 This cumulative evidence emphasizes the chronic psychological and relational burden of prolonged infertility and its impact on sexual health. Sexual activity frequency also emerged as a strong independent factor. Infrequent intercourse may reduce intimacy and emotional closeness, thereby increasing the likelihood of sexual dysfunction. Our findings are consistent with Zare et al., who highlighted that infrequent sexual activity is associated with reduced libido and orgasm difficulties. 52 Pastoor et al. further confirmed that regular sexual activity supports sexual function, whereas low frequency increases dysfunction risk. 53 Moreover, Chen et al. showed that regular sexual activity was inversely associated with depressive symptoms, suggesting a potential feedback loop between sexual and psychological health. 54 The novelty of our study lies in its specific focus on exercise frequency—a variable often overlooked in previous research on infertility and sexual health. By integrating assessments of sexual function, psychological well-being, and lifestyle behaviors in a relatively large sample of infertile women, this study provides evidence that supports a biopsychosocial framework for addressing sexual dysfunction in this population. In our sample, tubal factors, male infertility, and PCOS were the most prevalent causes. Although subgroup analyses by etiology were not statistically powered, future research should explore how specific infertility causes—particularly treatable versus untreatable types—may differentially impact sexual and psychological outcomes and response to lifestyle interventions such as physical activity. While physical activity may not independently predict sexual function, it likely contributes indirectly by improving mental health and relationship satisfaction. These findings underscore the importance of incorporating psychological screening and support into routine infertility care. Clinicians should recognize anxiety, depression, and sexual relationship factors as central issues. Moderate physical activity may still be recommended as part of a holistic strategy to support psychological and relational resilience, even if not sufficient as a standalone intervention. Strengths of this study include its relatively large sample size, the use of validated instruments (FSFI, GAD-7, PHQ-9, QMI), and the application of multivariate modeling to adjust for potential confounders. However, several limitations should be acknowledged. The cross-sectional design precludes any inference of causality. In addition, reliance on self-reported measures introduces the possibility of recall and social desirability biases. Our sample was restricted to sexually active infertile women, which may limit the generalizability of the findings to all women experiencing infertility. Furthermore, important factors such as partner sexual function, cultural influences, and specific stages of infertility treatment were not fully captured in this analysis. Finally, subgroup analyses by exercise intensity or infertility etiology may have lacked sufficient power to detect meaningful differences. Another notable limitation concerns the measurement of physical activity. In this study, exercise was classified solely by reported frequency, without consideration of intensity, type, or duration. As a result, individuals engaging in less frequent but high-intensity or prolonged exercise may have been misclassified as less active compared to those participating more often in low-intensity activities, potentially attenuating true associations. Future studies should employ standardized physical activity assessment tools, such as the International Physical Activity Questionnaire or metabolic equivalent-based estimations, to achieve a more precise and comprehensive characterization of activity patterns. Although we documented the underlying causes of infertility, our analysis did not stratify outcomes by specific etiologies due to limited subgroup sizes. Future research could usefully examine how particular, especially treatable, infertility causes differentially impact sexual function and psychological well-being.

Infertility is a significant global health concern, affecting a substantial proportion of couples, with female infertility being a major contributor to reproductive health challenges and reduced quality of life in women. 1 , 2 The etiology of female infertility is multifactorial, commonly involving ovulatory dysfunction, fallopian tube obstruction, polycystic ovary syndrome (PCOS), and endometriosis. 3–5 In addition to physical burdens, infertility can profoundly impact psychological health. 6 , 7 Due to societal and cultural expectations surrounding fertility, infertile women often face considerable emotional stress, with elevated rates of anxiety, depression, and psychological distress. 2 , 7–9 These psychological burdens can negatively affect self-esteem and emotional well-being and may also contribute to or exacerbate sexual dysfunction, impeding the ability to maintain satisfying sexual relationships. 10 , 11 Sexual dysfunction is relatively common among infertile women, affecting domains such as desire, arousal, and satisfaction and is closely associated with psychological comorbidities including anxiety and depression. 8 , 12–15 Research has shown that the longer the duration of infertility, the greater its negative impact on sexual health. 8 Wheeler and Guntupalli demonstrated that female sexual dysfunction significantly compromises quality of life, relationship satisfaction, and general well-being. 12 Velten et al. observed that women with sexual dysfunction exhibit lower visual attention to sexual stimuli, suggesting an impaired sexual arousal response. 13 Collectively, these findings underscore the intricate relationship between reproductive concerns, psychological health, and sexual function. Physical exercise is widely recognized for its broad benefits on women’s physical and mental health. 16 , 17 Regular physical activity improves cardiovascular function and muscular strength and has been shown to significantly alleviate symptoms of anxiety and depression. 18–20 In women experiencing infertility, exercise may reduce stress via neuroendocrine modulation, improve mood and self-perception, and positively influence sexual health through mechanisms such as hormonal regulation, enhanced blood circulation, and improved body image. 21–23 Prior evidence suggests that moderate-intensity physical activity may be a viable non-pharmacological approach to enhance both psychological well-being and sexual function in this population. 24 Despite increasing awareness of the general health benefits of exercise, there is limited research specifically addressing the role of exercise frequency in the sexual and psychological health of infertile women. Therefore, the present study aims to explore the associations between physical exercise frequency, sexual function, and psychological well-being in sexually active women with infertility. Does the frequency of physical activity exert a significant impact on sexual function and psychological health in infertile women when accounting for potential confounding factors such as anxiety and depression?