Psychological and Sexual Effects of Infertility Diagnosis in Men in a Prospective Study

Psychological and Sexual Effects of Infertility Diagnosis in Men in a Prospective Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Psychological and Sexual Effects of Infertility Diagnosis in Men in a Prospective Study Serhat Yentur, Ibrahim Ogulcan Canitez, Enes Pay, Sergen Sahin, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6799257/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background Infertility is a growing global health concern that imposes not only biological but also profound psychological and emotional burdens on affected individuals. In men, the psychological impact of an infertility diagnosis—particularly its effect on anxiety, depression, and sexual function—remains insufficiently explored. Methods This prospective, single-center study evaluated 200 male patients aged 21 to 46 years who presented with suspected infertility. Psychological and sexual function assessments were conducted at baseline and three months post-diagnosis using the Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and the International Index of Erectile Function (IIEF-15). Demographic characteristics, hormonal profiles, semen analysis, and lifestyle factors (education, smoking, and alcohol consumption) were also recorded. Paired sample t-tests were used to assess within-subject changes over time, and one-way ANOVA was performed to explore associations with educational attainment and lifestyle habits. Results At three months following diagnosis, patients exhibited a significant increase in depression and anxiety scores (BDI: 6.10 ± 5.14 to 12.09 ± 6.76; BAI: 4.19 ± 3.87 to 8.90 ± 6.96; p < 0.001 for both). Concurrently, significant reductions were observed in sexual function scores, including erectile function (27.92 ± 3.42 to 25.80 ± 3.58; p < 0.001), orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction. Education level did not significantly affect depression or anxiety overall, but participants with only secondary education showed higher anxiety scores at follow-up (p = 0.007). Conclusions An infertility diagnosis is associated with a marked deterioration in psychological well-being and sexual performance in men. These findings underscore the necessity of incorporating routine psychological assessment and support into infertility management, especially for socioeconomically vulnerable populations. Infertility sexual dysfunction erectile dysfunction depression anxiety reproductive health Beck Depression Inventory Beck Anxiety Inventory International Index of Erectile Function Background The World Health Organization (WHO) defines infertility as the failure of a couple to conceive after one year of regular, unprotected sexual intercourse ( 1 ). Infertility rates have risen over time, with prevalence estimates between 3.5% and 16.7% in developed countries and between 7% and 12% in developing countries ( 2 ). Infertility presents significant emotional and psychological challenges in addition to its biological implications. This phenomenon signifies a specific life crisis marked by unpredictable outcomes and is associated to various medical, psychological, and social challenges influenced by cultural, religious, and socioeconomic components. Diagnosing and planning treatment for infertility often leads to increased stress, anxiety, and depression in individuals affected by the disease ( 3 – 5 ). The prevalence of psychiatric disorders in men and women experiencing infertility can reach 12.41% within two years of diagnosis, highlighting the significance of psychological support during the diagnostic and therapeutic process ( 3 ). Changes in hormonal levels and oxidative stress markers in blood and semen are associated with increased symptoms of depression and anxiety ( 6 ). Furthermore, research shows that elevated psychological distress may adversely affect the success rates of infertility treatments ( 7 , 8 ). Sexual dysfunction is a prevalent issue among individuals experiencing infertility. This may lead to increased anxiety, fear, reduced confidence in gender identity, and avoidance of sexual activity ( 9 ). These challenges may sustain a cycle of performance anxiety and exacerbate sexual difficulties. Sexual intimacy is significant not only for reproduction but also for fostering emotional connections, influencing self-perception, and enhancing relationship satisfaction ( 10 ). Research indicate that individuals experiencing infertility exhibit elevated levels of sexual dysfunction compared to those who are fertile ( 11 , 12 ). Infertility is a common issue that frequently goes unstated, particularly in the male population. Numerous individuals refrain from disclosing their experiences to family or friends, thereby heightening their psychological vulnerability. The inability to conceive naturally may result in feelings of shame, guilt, and low self-esteem, which are linked to depression, anxiety, emotional distress, and a reduced standard of life. A strong bidirectional relationship exists between psychiatric disorders and erectile dysfunction ( 13 , 14 ). Our clinic conducted a comprehensive study to explore the associations among psychological, sexual, and reproductive health in male patients presenting with infertility. Methods The research was conducted ethically in accordance with the principles of the World Medical Association Declaration of Helsinki. This prospective, single-center study was approved by the appropriate Institutional Review Board (Approval ID: 2024/05/19/485). Informed consent was obtained from all participants prior to data collection. 200 male patients, aged 21 to 46 years, presenting with suspected infertility from June 1, 2024, to October 20, 2024, were prospectively enrolled. The inclusion criteria included: absence of a prior infertility diagnosis, no previous consultations for sexual dysfunction at any healthcare facility, and voluntary consent to participate. Exclusion criteria comprised the presence of psychiatric disorders or ongoing psychiatric treatment, cognitive or communication impairments, a history of serious chronic illnesses (e.g., cancer, neurological disorders, cardiovascular disease, genetic conditions, diabetes), lack of infertility findings upon examination, non-attendance at follow-up visits, or incomplete study forms. Initially, 254 patients consented to participate and were requested to complete the Beck Depression Inventory (BDI), the Beck Anxiety Inventory (BAI), and the International Index of Erectile Function (IIEF-15) during their first clinic visit. Patients diagnosed with infertility were scheduled for a follow-up visit three months later, which involved a second semen analysis and reassessment. The 200 patients who satisfied the inclusion criteria were requested to complete the same set of forms once more, and all relevant information were documented. The collected data encompassed age, smoking and alcohol consumption, educational attainment, hormone profiles, and semen analysis outcomes. The BDI, developed by Beck et al., aims to evaluate the physical, emotional, cognitive, and motivational symptoms associated with depression ( 15 ). The Turkish version has been validated by Hisli et al ( 16 ). The BAI, designed for evaluating anxiety symptoms ( 17 ), was validated for Turkish use by Ulusoy et al ( 18 ). Each inventory comprises 21 self-reported items evaluated on a 0–3 scale, resulting in total scores between 0 and 63. The IIEF-15 evaluates multiple dimensions of male sexual function, encompassing erectile function, orgasmic function, sexual desire, satisfaction with intercourse, and overall satisfaction. Results were analyzed separately across the identified subdomains in this study. Statistical Analysis Statistical analysis used the Statistical Package for the Social Sciences (SPSS) for Windows, version 29.0. Paired sample t-tests were performed to assess the impact of infertility diagnosis on levels of depression and anxiety. A one-way analysis of variance (ANOVA) was employed to evaluate the effect of education level on depression, anxiety, and sexual function. Post hoc tests were utilized to determine significant differences between groups as necessary. Results This prospective study evaluated the effects of an infertility diagnosis on depression, anxiety, and sexual function among 200 male patients. The average age of participants was 30.83 years (SD = 4.77), and the mean duration of infertility was 2.54 years. Semen analyses indicated a mean sperm volume of 3.13 mL (SD = 1.69), a sperm concentration of 51.44 million/mL (SD = 53.88), and total motility of 44.18% (SD = 20.58). A majority of participants were non-smokers (68.1%) and reported alcohol consumption (90.5%). A significant proportion of participants had completed university-level education (73.0%) and were diagnosed with primary infertility (93.0%) (Table 1 ). Table 1 Demographic and Clinical Characteristics of Patients Parameters Age (year) (x̄, sd) (30.83–4.77) Infertility period (year) (x̄, sd) (2.54–1.75) Semen volume (ml) (x̄, sd) (3.13–1.69) Spermatozoa Count (ml) (x̄, sd) (51.44–53.88) Total Motility (%)(x̄, sd) (44.18–20.58) Morphology (%) (x̄, sd) (1.34–1.62) Smoking (n, %) Smoker 68 (%32.9) None-smoker 139 (%68.1) Alcohol (n, %) Yes 181 (%90.5) No 19 (9.5) Education (n, %) Secondary School 29 (%14.5) University 146 (%73.0) Master Degree 25 (%12.5) Infertilite (n, %) Primer 186 (%93.0) Secondary 14 (%7.0) Following the diagnosis of infertility, significant alterations in psychological well-being were noted. Table 2 shows a significant change in the distribution of depression and anxiety levels from the initial assessment to the three-month follow-up. At baseline, 81% of participants showed minimal depressive symptoms; however, this figure declined significantly to 32.5% by the third month. Conversely, there was a significant increase in the rates of mild and moderate depression, coupled with a minor yet significant rise in severe depression cases. A similar trend was noted in anxiety scores: the percentage of individuals with minimal anxiety decreased from 93.5–69.0%, whereas mild and moderate anxiety levels experienced significant increases. Severe anxiety, previously absent at baseline, was reported by 2% of participants after three months. Table 2 Distribution of Patients Depression and Anxiety Conditions (n = 200) Initial Evaluation 3rd Month Beck Depression Inventory Minimal (n,%) 162 (%81) 65 (%32.5) Mild (n,%) 33 (%16.5) 97 (48.5) Moderate (n,%) 5 (2.5) 34 (17.0) Severe (n,%) - 4 (2.0) Beck Anxiety Scale Minimal (n,%) 187 (93.5) 138 (69.0) Mild (n,%) 11 (5.5) 44 (22.0) Moderate (n,%) 2 (1.0) 14 (7.0) Severe (n,%) - 4 (2.0) Significant declines in sexual function across all domains were observed, corresponding with these psychological deteriorations, as outlined in Table 3 . The mean score for erectile function decreased from 27.92 (SD = 3.42) to 25.80 (SD = 3.58) at follow-up, a change that was statistically significant (p < 0.001). Statistically significant reductions were observed in orgasmic function, sexual desire, satisfaction, and overall sexual satisfaction scores (all p < 0.001). Declines in sexual health were associated with significant increases in depressive and anxiety symptoms. The Beck Depression Inventory score increased from a baseline mean of 6.10 (SD = 5.14) to 12.09 (SD = 6.76), while the Beck Anxiety Inventory score nearly doubled, increasing from 4.19 (SD = 3.87) to 8.90 (SD = 6.96). Both changes were statistically significant (p < 0.001). Table 3 Changes in Sexual Function, Depression and Anxiety Levels Over Time Parameters mean ± SD P-value Erectile Function Initial Evaluation 27.92 ± 3.421 < .001** 3rd Month Evaluation 25.80 ± 3.576 Orgasmic Function Initial Evaluation 9.42 ± 1.196 < .001** 3rd Month Evaluation 8.49 ± 1.537 Sexual Desire Initial Evaluation 8.72 ± 1.269 < .001** 3rd Month Evaluation 8.02 ± 3.156 Sexual Satisfaction Initial Evaluation 12.94 ± 1.990 < .001** 3rd Month Evaluation 11.55 ± 2.205 Overall Satisfaction Initial Evaluation 9.43 ± 1.384 < .001** 3rd Month Evaluation 8.36 ± 1.240 Beck Depression Inventory Initial Evaluation 6.10 ± 5.142 < .001** 3rd Month Evaluation 12.09 ± 6.755 Beck Anxiety Inventory Initial Evaluation 4.19 ± 3.865 < .001** 3rd Month Evaluation 8.90 ± 6.962 Paired Sample T Test *p < 0.05 **p < 0.001 An examination of the correlation between educational attainment and psychological outcomes, as illustrated in Table 4 , indicated that education did not significantly influence baseline scores for depression or anxiety. At the three-month follow-up, participants with only a secondary school education exhibited significantly higher anxiety levels (mean = 10.92, SD = 2.02) than those with university or postgraduate education (p = 0.007). This indicates that reduced educational attainment may intensify anxiety related to infertility, despite no notable differences in depressive symptoms. Table 4 Distribution of Depression and Anxiety Scores According to Education Parameters Education N mean ± SD P-value Beck Depression Initial Evaluation Secondary School 29 6.93 ± 5.05 0.613 University 146 5.90 ± 4.17 Master Degree 25 6.24 ± 9.11 Beck Anxiety Initial Evaluation Secondary School 29 4.31 ± 2.62 0.196 University 146 4.38 ± 4.21 Master Degree 25 2.88 ± 2.57 Beck Depression 3rd Month Evaluation Secondary School 29 7.24 ± 1.34 0.167 University 146 6.10 ± 0.50 Master Degree 25 9.23 ± 1.84 Beck Anxiety 3rd Month Evaluation Secondary School 29 10.92 ± 2.02 0.007* University 146 6.18 ± 0.51 Master Degree 25 3.43 ± 0.68 One Way Anova Analysis *p < 0.05 **p < 0.001 These findings demonstrate that an infertility diagnosis negatively impacts male sexual health and significantly increases emotional distress over time, especially in individuals with lower educational attainment. Discussion This research examined the psychological and sexual effects of an infertility diagnosis in male patients. The results showed a significant increase in depression and anxiety levels by the third month post-diagnosis, coupled with a significant decrease in sexual function across all domains, including erectile function, orgasmic function, sexual desire, sexual satisfaction, and overall satisfaction. The variables such as education level, smoking, and alcohol consumption did not significantly affect these outcomes. Our findings are consistent with existing literature. Shindel et al. reported a higher prevalence of depression, erectile dysfunction, and sexual difficulties among infertile men compared to the general population ( 19 ). Similarly, a meta-analysis by Liu et al. involving 48 studies demonstrated a bidirectional relationship between depression and erectile dysfunction, supporting the notion that one condition may exacerbate the other ( 20 ). Infertility frequently results in psychological distress. Research indicates that 25–60% of individuals facing infertility exhibit psychiatric symptoms, with a notably higher prevalence of anxiety and depression in this demographic ( 21 ). In a cohort of 244 infertile Italian men, the prevalence of erectile dysfunction was 17.8%, which is nearly double that observed in fertile men ( 22 ). The results are significant in light of the increasing global anxiety levels, particularly following the COVID-19 pandemic ( 23 ). Differences in cultural, ethnic, geographic, and socioeconomic backgrounds may contribute to variability in findings across studies, factors that are not consistently accounted for in study designs. Bakhtiari et al. reported that 58% of infertile men experienced sexual dysfunction, with premature ejaculation and anorgasmia recognized as the most prevalent types ( 24 ). Volgsten et al. similarly reported that 31% of individuals undergoing fertility treatment experienced psychiatric disorders, especially major depression ( 25 ). This study supports previous results, showing a significant increase in depressive symptoms by the third month following diagnosis. Large-scale studies further highlight the emotional burden of infertility. In Denmark, a cohort of 42,000 women screened prior to fertility treatment revealed that 35% had indicators of depression ( 26 ). In a U.S.-based study from Northern California, 56% of women and 32% of men undergoing fertility evaluation reported significant depressive symptoms, with anxiety present in 76% of women and 61% of men ( 27 ). Infertile men often experience psychological distress exacerbated by negative self-perception and anxiety regarding sexual performance, which may hinder arousal and lead to performance anxiety ( 28 ). This may establish a feedback loop that includes avoidance, exacerbated sexual dysfunction, and increased emotional strain. Young men may exhibit increased vulnerability as a result of elevated psychosocial pressures and familial expectations. The identified dynamics may lead to feelings of guilt, helplessness, and fear, thereby reinforcing the connection between psychological state and sexual function. The study fails to demonstrate causality; however, the observed association appears and requires more longitudinal research. While some studies suggest that education may offer protection against mental health disorders ( 29 , 30 ), our results failed to find a significant association between education level and either depression or anxiety. This discrepancy may be explained by contextual or cultural factors, emphasizing the complex and multifactorial nature of psychological vulnerability. Infertility extends its impact beyond individual outcomes, influencing areas such as marital relationships and adherence to treatment protocols. Several clinicians, including urologists, often do not regularly evaluate psychological distress in this population, even though it significantly affects adherence to treatment. Domar et al. showed that elevated levels of depression significantly decrease the probability of commencing or continuing fertility treatment ( 31 ). This highlights the significance of including psychosocial support, such as cognitive-behavioral therapy, sexual counseling, and psychosexual education, into standard infertility care. Conclusion After the diagnosis of infertility, patients reported a notable decrease in erectile function, orgasmic function, sexual desire, sexual satisfaction, and overall satisfaction, with a significant increase in anxiety and depression levels. The findings emphasize the importance of a multidisciplinary approach in infertility care, emphasizing the routine assessment and management of psychological distress. Abbreviations ANOVA Analysis of Variance BAI Beck Anxiety Inventory BDI Beck Depression Inventory IIEF 15–International Index of Erectile Function–15 items SD Standard Deviation SPSS Statistical Package for the Social Sciences WHO World Health Organization Declarations Ethics approval and consent to participate This study was conducted in accordance with the ethical standards of the World Medical Association Declaration of Helsinki. This prospective, single-center study was approved by the Ethics Committee of the University of Health Sciences, Bagcilar Research and Training Hospital, Istanbul, Turkiye (Approval ID: 2024/05/19/485). Informed consent was obtained from all participants prior to inclusion in the study. Clinical Trial Number None. Consent for publication None. Availability of data and materials The data are not publicly available due to legal and ethical restrictions, including the absence of patient consent for data sharing. Access to the data may be considered upon reasonable request and with appropriate institutional approvals. Competing interests The authors declare that they have no competing interests. Funding None. Authors' contributions Research conception and design: Serhat Yentur, Enes Pay, Ismail Engin Kandirali. Data acquisition: Serhat Yentur, Enes Pay,Aykut Colakerol. Statistical analysis: Ismail Engin Kandirali, Sergen Sahin. Data analysis and interpretation: Serhat Yentur, Enes Pay, Aykut Colakerol, Sergen Sahin. Drafting of the manuscript: Serhat Yentur,Aykut Colakerol, Sergen Sahin, Ibrahim Ogulcan Canitez. Critical revision of the manuscript: Ismail Engin Kandirali, Sergen Sahin, Ibrahim Ogulcan Canitez. Supervision: Ismail Engin Kandirali, Ibrahim Ogulcan Canitez Approval of the final manuscript: All authors. Acknowledgements None. ORCID / E-MAIL: Serhat Yentur: 0000-0003-4196-2145 / [email protected] Enes Pay: 0009-0000-9489-7469 / [email protected] Ismail Engin Kandirali: 0000-0003-0580-2144 / [email protected] Aykut Colakerol: 0000-0002-5076-5306 / [email protected] Sergen Sahin: 0000-0003-2951-5991 / [email protected] Ibrahim Ogulcan Canitez: 0000-0002-2906-5452 / [email protected] References Organisation WH. WHO laboratory manual for the examination of human semen and sperm-cervical mucus interaction: Cambridge university press; 1999. AS Lara L, B Salomao P, PMS Romao A, M Reis R, A Navarro P, JS Rosa-e-Silva AC, A Ferriani R. Effect of infertility on the sexual function of couples: state of the art. Recent Patents on Endocrine, Metabolic & Immune Drug Discovery. 2015;9(1):46-53. Wang J-Y, Chen J-D, Huang C-C, Liu C-S, Chung T-F, Hsieh M-H, Wang C-W. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6799257","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":486568660,"identity":"e8fcf301-4b78-4c1f-93e2-2bf1a2cf573a","order_by":0,"name":"Serhat Yentur","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDElEQVRIiWNgGAWjYDCCA0DM2ADn2iSAqYQCwlokoDrTEhjYQFoMiNdyGKKFAY8WvtvHHz6u3GFXZ3C89/hj3j3n8/jluxM/PDBgkOcXO4BVi+S5HGPDs2eSJQzOnEts5nl2u1iyjXezBNBhhjNnJ2DVYnCGh02ysY1ZwuBGjmEzz4HbiRuO8W4AaUkwuI1LC/vzn41t9RIG99+AtJwDadn8A78WBjPGxrbDQFt4QFoOgLRsw2uL5BkeY6DDjkvOPJNjOHPOgeTEmW252ywSDCRw+oXvDPvDj41t1fx8x88YfHhzwC6xn/ns5ps/Kmzk+aWxa4EDhQOofAn8ykFAvoGwmlEwCkbBKBihAABw+maFPt6zGAAAAABJRU5ErkJggg==","orcid":"","institution":"Bagcilar Research and Training Hospital, Urology Clinic, Istanbul","correspondingAuthor":true,"prefix":"","firstName":"Serhat","middleName":"","lastName":"Yentur","suffix":""},{"id":486568661,"identity":"889ebaa7-897e-44b0-8266-59696fc90479","order_by":1,"name":"Ibrahim Ogulcan Canitez","email":"","orcid":"","institution":"Bagcilar Research and Training Hospital, Urology Clinic, Istanbul","correspondingAuthor":false,"prefix":"","firstName":"Ibrahim","middleName":"Ogulcan","lastName":"Canitez","suffix":""},{"id":486568662,"identity":"bbca0698-bdb4-4f69-a470-15048e61ad01","order_by":2,"name":"Enes Pay","email":"","orcid":"","institution":"Bagcilar Research and Training Hospital, Urology Clinic, Istanbul","correspondingAuthor":false,"prefix":"","firstName":"Enes","middleName":"","lastName":"Pay","suffix":""},{"id":486568663,"identity":"908449ff-de88-4426-8c70-814284dc75d0","order_by":3,"name":"Sergen Sahin","email":"","orcid":"","institution":"Bagcilar Research and Training Hospital, Urology Clinic, Istanbul","correspondingAuthor":false,"prefix":"","firstName":"Sergen","middleName":"","lastName":"Sahin","suffix":""},{"id":486568664,"identity":"53d6d884-a29f-4921-acba-fada54b21f03","order_by":4,"name":"Aykut Colakerol","email":"","orcid":"","institution":"Bagcilar Research and Training Hospital, Urology Clinic, Istanbul","correspondingAuthor":false,"prefix":"","firstName":"Aykut","middleName":"","lastName":"Colakerol","suffix":""},{"id":486568665,"identity":"d785289c-4af0-4b6d-ba62-ddf8cb5100aa","order_by":5,"name":"Ismail Engin Kandirali","email":"","orcid":"","institution":"Bagcilar Research and Training Hospital, Urology Clinic, Istanbul","correspondingAuthor":false,"prefix":"","firstName":"Ismail","middleName":"Engin","lastName":"Kandirali","suffix":""}],"badges":[],"createdAt":"2025-06-02 06:23:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6799257/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6799257/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87174311,"identity":"4a20908d-2ea8-477f-bdeb-4c4704833570","added_by":"auto","created_at":"2025-07-21 08:17:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":585684,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6799257/v1/99313c06-64df-4974-8809-9b0672fc1cd2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Psychological and Sexual Effects of Infertility Diagnosis in Men in a Prospective Study","fulltext":[{"header":"Background","content":"\u003cp\u003eThe World Health Organization (WHO) defines infertility as the failure of a couple to conceive after one year of regular, unprotected sexual intercourse (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Infertility rates have risen over time, with prevalence estimates between 3.5% and 16.7% in developed countries and between 7% and 12% in developing countries (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eInfertility presents significant emotional and psychological challenges in addition to its biological implications. This phenomenon signifies a specific life crisis marked by unpredictable outcomes and is associated to various medical, psychological, and social challenges influenced by cultural, religious, and socioeconomic components. Diagnosing and planning treatment for infertility often leads to increased stress, anxiety, and depression in individuals affected by the disease (\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe prevalence of psychiatric disorders in men and women experiencing infertility can reach 12.41% within two years of diagnosis, highlighting the significance of psychological support during the diagnostic and therapeutic process (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Changes in hormonal levels and oxidative stress markers in blood and semen are associated with increased symptoms of depression and anxiety (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Furthermore, research shows that elevated psychological distress may adversely affect the success rates of infertility treatments (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSexual dysfunction is a prevalent issue among individuals experiencing infertility. This may lead to increased anxiety, fear, reduced confidence in gender identity, and avoidance of sexual activity (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). These challenges may sustain a cycle of performance anxiety and exacerbate sexual difficulties. Sexual intimacy is significant not only for reproduction but also for fostering emotional connections, influencing self-perception, and enhancing relationship satisfaction (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Research indicate that individuals experiencing infertility exhibit elevated levels of sexual dysfunction compared to those who are fertile (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eInfertility is a common issue that frequently goes unstated, particularly in the male population. Numerous individuals refrain from disclosing their experiences to family or friends, thereby heightening their psychological vulnerability. The inability to conceive naturally may result in feelings of shame, guilt, and low self-esteem, which are linked to depression, anxiety, emotional distress, and a reduced standard of life.\u003c/p\u003e\u003cp\u003eA strong bidirectional relationship exists between psychiatric disorders and erectile dysfunction (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Our clinic conducted a comprehensive study to explore the associations among psychological, sexual, and reproductive health in male patients presenting with infertility.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e The research was conducted ethically in accordance with the principles of the World Medical Association Declaration of Helsinki. This prospective, single-center study was approved by the appropriate Institutional Review Board (Approval ID: 2024/05/19/485). Informed consent was obtained from all participants prior to data collection.\u003c/p\u003e\u003cp\u003e200 male patients, aged 21 to 46 years, presenting with suspected infertility from June 1, 2024, to October 20, 2024, were prospectively enrolled. The inclusion criteria included: absence of a prior infertility diagnosis, no previous consultations for sexual dysfunction at any healthcare facility, and voluntary consent to participate. Exclusion criteria comprised the presence of psychiatric disorders or ongoing psychiatric treatment, cognitive or communication impairments, a history of serious chronic illnesses (e.g., cancer, neurological disorders, cardiovascular disease, genetic conditions, diabetes), lack of infertility findings upon examination, non-attendance at follow-up visits, or incomplete study forms.\u003c/p\u003e\u003cp\u003eInitially, 254 patients consented to participate and were requested to complete the Beck Depression Inventory (BDI), the Beck Anxiety Inventory (BAI), and the International Index of Erectile Function (IIEF-15) during their first clinic visit. Patients diagnosed with infertility were scheduled for a follow-up visit three months later, which involved a second semen analysis and reassessment. The 200 patients who satisfied the inclusion criteria were requested to complete the same set of forms once more, and all relevant information were documented. The collected data encompassed age, smoking and alcohol consumption, educational attainment, hormone profiles, and semen analysis outcomes.\u003c/p\u003e\u003cp\u003eThe BDI, developed by Beck et al., aims to evaluate the physical, emotional, cognitive, and motivational symptoms associated with depression (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The Turkish version has been validated by Hisli et al (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). The BAI, designed for evaluating anxiety symptoms (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), was validated for Turkish use by Ulusoy et al (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Each inventory comprises 21 self-reported items evaluated on a 0\u0026ndash;3 scale, resulting in total scores between 0 and 63.\u003c/p\u003e\u003cp\u003eThe IIEF-15 evaluates multiple dimensions of male sexual function, encompassing erectile function, orgasmic function, sexual desire, satisfaction with intercourse, and overall satisfaction. Results were analyzed separately across the identified subdomains in this study.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eStatistical analysis used the Statistical Package for the Social Sciences (SPSS) for Windows, version 29.0. Paired sample t-tests were performed to assess the impact of infertility diagnosis on levels of depression and anxiety. A one-way analysis of variance (ANOVA) was employed to evaluate the effect of education level on depression, anxiety, and sexual function. Post hoc tests were utilized to determine significant differences between groups as necessary.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThis prospective study evaluated the effects of an infertility diagnosis on depression, anxiety, and sexual function among 200 male patients. The average age of participants was 30.83 years (SD\u0026thinsp;=\u0026thinsp;4.77), and the mean duration of infertility was 2.54 years. Semen analyses indicated a mean sperm volume of 3.13 mL (SD\u0026thinsp;=\u0026thinsp;1.69), a sperm concentration of 51.44\u0026nbsp;million/mL (SD\u0026thinsp;=\u0026thinsp;53.88), and total motility of 44.18% (SD\u0026thinsp;=\u0026thinsp;20.58). A majority of participants were non-smokers (68.1%) and reported alcohol consumption (90.5%). A significant proportion of participants had completed university-level education (73.0%) and were diagnosed with primary infertility (93.0%) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic and Clinical Characteristics of Patients\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParameters\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (year) (x̄, sd)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e(30.83\u0026ndash;4.77)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInfertility period (year) (x̄, sd)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e(2.54\u0026ndash;1.75)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSemen volume (ml) (x̄, sd)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e(3.13\u0026ndash;1.69)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSpermatozoa Count (ml) (x̄, sd)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e(51.44\u0026ndash;53.88)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal Motility (%)(x̄, sd)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e(44.18\u0026ndash;20.58)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMorphology (%) (x̄, sd)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e(1.34\u0026ndash;1.62)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmoking (n, %)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmoker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e68 (%32.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNone-smoker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e139 (%68.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAlcohol (n, %)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e181 (%90.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e19 (9.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducation (n, %)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSecondary School\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e29 (%14.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUniversity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e146 (%73.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMaster Degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e25 (%12.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInfertilite (n, %)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e186 (%93.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSecondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14 (%7.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFollowing the diagnosis of infertility, significant alterations in psychological well-being were noted. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows a significant change in the distribution of depression and anxiety levels from the initial assessment to the three-month follow-up. At baseline, 81% of participants showed minimal depressive symptoms; however, this figure declined significantly to 32.5% by the third month. Conversely, there was a significant increase in the rates of mild and moderate depression, coupled with a minor yet significant rise in severe depression cases. A similar trend was noted in anxiety scores: the percentage of individuals with minimal anxiety decreased from 93.5\u0026ndash;69.0%, whereas mild and moderate anxiety levels experienced significant increases. Severe anxiety, previously absent at baseline, was reported by 2% of participants after three months.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDistribution of Patients Depression and Anxiety Conditions\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" morerows=\"1\" nameend=\"c3\" namest=\"c1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;200)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eInitial Evaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3rd Month\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eBeck Depression Inventory\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMinimal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(n,%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e162 (%81)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e65 (%32.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMild\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(n,%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e33 (%16.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e97 (48.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(n,%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5 (2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e34 (17.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSevere\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(n,%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4 (2.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eBeck Anxiety Scale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMinimal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(n,%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e187 (93.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e138 (69.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMild\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(n,%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11 (5.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e44 (22.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(n,%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e14 (7.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSevere\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(n,%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4 (2.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSignificant declines in sexual function across all domains were observed, corresponding with these psychological deteriorations, as outlined in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The mean score for erectile function decreased from 27.92 (SD\u0026thinsp;=\u0026thinsp;3.42) to 25.80 (SD\u0026thinsp;=\u0026thinsp;3.58) at follow-up, a change that was statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Statistically significant reductions were observed in orgasmic function, sexual desire, satisfaction, and overall sexual satisfaction scores (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Declines in sexual health were associated with significant increases in depressive and anxiety symptoms. The Beck Depression Inventory score increased from a baseline mean of 6.10 (SD\u0026thinsp;=\u0026thinsp;5.14) to 12.09 (SD\u0026thinsp;=\u0026thinsp;6.76), while the Beck Anxiety Inventory score nearly doubled, increasing from 4.19 (SD\u0026thinsp;=\u0026thinsp;3.87) to 8.90 (SD\u0026thinsp;=\u0026thinsp;6.96). Both changes were statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eChanges in Sexual Function, Depression and Anxiety Levels Over Time\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eParameters\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003emean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eErectile Function\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInitial Evaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e27.92\u0026thinsp;\u0026plusmn;\u0026thinsp;3.421\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3rd Month Evaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e25.80\u0026thinsp;\u0026plusmn;\u0026thinsp;3.576\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eOrgasmic Function\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInitial Evaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e9.42\u0026thinsp;\u0026plusmn;\u0026thinsp;1.196\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3rd Month Evaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e8.49\u0026thinsp;\u0026plusmn;\u0026thinsp;1.537\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSexual Desire\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInitial Evaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e8.72\u0026thinsp;\u0026plusmn;\u0026thinsp;1.269\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3rd Month Evaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e8.02\u0026thinsp;\u0026plusmn;\u0026thinsp;3.156\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSexual Satisfaction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInitial Evaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e12.94\u0026thinsp;\u0026plusmn;\u0026thinsp;1.990\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3rd Month Evaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e11.55\u0026thinsp;\u0026plusmn;\u0026thinsp;2.205\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eOverall Satisfaction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInitial Evaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e9.43\u0026thinsp;\u0026plusmn;\u0026thinsp;1.384\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3rd Month Evaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e8.36\u0026thinsp;\u0026plusmn;\u0026thinsp;1.240\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eBeck Depression Inventory\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInitial Evaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e6.10\u0026thinsp;\u0026plusmn;\u0026thinsp;5.142\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3rd Month Evaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e12.09\u0026thinsp;\u0026plusmn;\u0026thinsp;6.755\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eBeck Anxiety Inventory\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInitial Evaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e4.19\u0026thinsp;\u0026plusmn;\u0026thinsp;3.865\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3rd Month Evaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e8.90\u0026thinsp;\u0026plusmn;\u0026thinsp;6.962\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003ePaired Sample T Test *p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 **p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAn examination of the correlation between educational attainment and psychological outcomes, as illustrated in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, indicated that education did not significantly influence baseline scores for depression or anxiety. At the three-month follow-up, participants with only a secondary school education exhibited significantly higher anxiety levels (mean\u0026thinsp;=\u0026thinsp;10.92, SD\u0026thinsp;=\u0026thinsp;2.02) than those with university or postgraduate education (p\u0026thinsp;=\u0026thinsp;0.007). This indicates that reduced educational attainment may intensify anxiety related to infertility, despite no notable differences in depressive symptoms.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDistribution of Depression and Anxiety Scores According to Education\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParameters\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEducation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003emean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eBeck Depression Initial Evaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSecondary School\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e6.93\u0026thinsp;\u0026plusmn;\u0026thinsp;5.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.613\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUniversity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e146\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e5.90\u0026thinsp;\u0026plusmn;\u0026thinsp;4.17\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMaster Degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e6.24\u0026thinsp;\u0026plusmn;\u0026thinsp;9.11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eBeck Anxiety Initial Evaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSecondary School\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e4.31\u0026thinsp;\u0026plusmn;\u0026thinsp;2.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.196\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUniversity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e146\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e4.38\u0026thinsp;\u0026plusmn;\u0026thinsp;4.21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMaster Degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e2.88\u0026thinsp;\u0026plusmn;\u0026thinsp;2.57\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eBeck Depression 3rd Month Evaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSecondary School\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e7.24\u0026thinsp;\u0026plusmn;\u0026thinsp;1.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.167\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUniversity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e146\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e6.10\u0026thinsp;\u0026plusmn;\u0026thinsp;0.50\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMaster Degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e9.23\u0026thinsp;\u0026plusmn;\u0026thinsp;1.84\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eBeck Anxiety 3rd Month Evaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSecondary School\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e10.92\u0026thinsp;\u0026plusmn;\u0026thinsp;2.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003e0.007*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUniversity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e146\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e6.18\u0026thinsp;\u0026plusmn;\u0026thinsp;0.51\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMaster Degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e3.43\u0026thinsp;\u0026plusmn;\u0026thinsp;0.68\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eOne Way Anova Analysis *p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 **p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThese findings demonstrate that an infertility diagnosis negatively impacts male sexual health and significantly increases emotional distress over time, especially in individuals with lower educational attainment.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis research examined the psychological and sexual effects of an infertility diagnosis in male patients. The results showed a significant increase in depression and anxiety levels by the third month post-diagnosis, coupled with a significant decrease in sexual function across all domains, including erectile function, orgasmic function, sexual desire, sexual satisfaction, and overall satisfaction. The variables such as education level, smoking, and alcohol consumption did not significantly affect these outcomes.\u003c/p\u003e\u003cp\u003eOur findings are consistent with existing literature. Shindel et al. reported a higher prevalence of depression, erectile dysfunction, and sexual difficulties among infertile men compared to the general population (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Similarly, a meta-analysis by Liu et al. involving 48 studies demonstrated a bidirectional relationship between depression and erectile dysfunction, supporting the notion that one condition may exacerbate the other (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eInfertility frequently results in psychological distress. Research indicates that 25\u0026ndash;60% of individuals facing infertility exhibit psychiatric symptoms, with a notably higher prevalence of anxiety and depression in this demographic (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). In a cohort of 244 infertile Italian men, the prevalence of erectile dysfunction was 17.8%, which is nearly double that observed in fertile men (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The results are significant in light of the increasing global anxiety levels, particularly following the COVID-19 pandemic (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDifferences in cultural, ethnic, geographic, and socioeconomic backgrounds may contribute to variability in findings across studies, factors that are not consistently accounted for in study designs. Bakhtiari et al. reported that 58% of infertile men experienced sexual dysfunction, with premature ejaculation and anorgasmia recognized as the most prevalent types (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Volgsten et al. similarly reported that 31% of individuals undergoing fertility treatment experienced psychiatric disorders, especially major depression (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). This study supports previous results, showing a significant increase in depressive symptoms by the third month following diagnosis.\u003c/p\u003e\u003cp\u003eLarge-scale studies further highlight the emotional burden of infertility. In Denmark, a cohort of 42,000 women screened prior to fertility treatment revealed that 35% had indicators of depression (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). In a U.S.-based study from Northern California, 56% of women and 32% of men undergoing fertility evaluation reported significant depressive symptoms, with anxiety present in 76% of women and 61% of men (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eInfertile men often experience psychological distress exacerbated by negative self-perception and anxiety regarding sexual performance, which may hinder arousal and lead to performance anxiety (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). This may establish a feedback loop that includes avoidance, exacerbated sexual dysfunction, and increased emotional strain. Young men may exhibit increased vulnerability as a result of elevated psychosocial pressures and familial expectations. The identified dynamics may lead to feelings of guilt, helplessness, and fear, thereby reinforcing the connection between psychological state and sexual function. The study fails to demonstrate causality; however, the observed association appears and requires more longitudinal research.\u003c/p\u003e\u003cp\u003eWhile some studies suggest that education may offer protection against mental health disorders (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), our results failed to find a significant association between education level and either depression or anxiety. This discrepancy may be explained by contextual or cultural factors, emphasizing the complex and multifactorial nature of psychological vulnerability.\u003c/p\u003e\u003cp\u003eInfertility extends its impact beyond individual outcomes, influencing areas such as marital relationships and adherence to treatment protocols. Several clinicians, including urologists, often do not regularly evaluate psychological distress in this population, even though it significantly affects adherence to treatment. Domar et al. showed that elevated levels of depression significantly decrease the probability of commencing or continuing fertility treatment (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). This highlights the significance of including psychosocial support, such as cognitive-behavioral therapy, sexual counseling, and psychosexual education, into standard infertility care.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAfter the diagnosis of infertility, patients reported a notable decrease in erectile function, orgasmic function, sexual desire, sexual satisfaction, and overall satisfaction, with a significant increase in anxiety and depression levels. The findings emphasize the importance of a multidisciplinary approach in infertility care, emphasizing the routine assessment and management of psychological distress.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eANOVA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAnalysis of Variance\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBAI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBeck Anxiety Inventory\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBDI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eBeck Depression Inventory\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIIEF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e15\u0026ndash;International Index of Erectile Function\u0026ndash;15 items\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eStandard Deviation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSPSS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eStatistical Package for the Social Sciences\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWorld Health Organization\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical standards of the World Medical Association Declaration of Helsinki.\u0026nbsp;This prospective, single-center study was approved by the Ethics Committee of the University of Health Sciences, Bagcilar Research and Training Hospital, Istanbul, Turkiye (Approval ID: 2024/05/19/485).\u0026nbsp;Informed consent was obtained from all participants prior to inclusion in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data are not publicly available due to legal and ethical restrictions, including the absence of patient consent for data sharing. Access to the data may be considered upon reasonable request and with appropriate institutional approvals.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResearch conception and design:\u0026nbsp;Serhat Yentur, Enes Pay,\u0026nbsp;Ismail Engin Kandirali.\u003c/p\u003e\n\u003cp\u003eData acquisition:\u0026nbsp;Serhat Yentur, Enes Pay,Aykut Colakerol.\u003c/p\u003e\n\u003cp\u003eStatistical analysis: Ismail Engin Kandirali, Sergen Sahin.\u003c/p\u003e\n\u003cp\u003eData analysis and interpretation:\u0026nbsp;Serhat Yentur,\u0026nbsp;Enes Pay,\u0026nbsp;Aykut Colakerol, Sergen Sahin.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDrafting of the manuscript:\u0026nbsp;Serhat Yentur,Aykut Colakerol, Sergen Sahin,\u0026nbsp;Ibrahim Ogulcan Canitez.\u003c/p\u003e\n\u003cp\u003eCritical revision of the manuscript:\u0026nbsp;Ismail Engin Kandirali, Sergen Sahin,\u0026nbsp;Ibrahim Ogulcan Canitez.\u003c/p\u003e\n\u003cp\u003eSupervision:\u0026nbsp;Ismail Engin Kandirali, Ibrahim Ogulcan Canitez\u003c/p\u003e\n\u003cp\u003eApproval of the final manuscript: All authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eORCID / E-MAIL:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSerhat Yentur: 0000-0003-4196-2145 /\u0026nbsp;[email protected]\u003c/p\u003e\n\u003cp\u003eEnes Pay: 0009-0000-9489-7469 / [email protected]\u003c/p\u003e\n\u003cp\u003eIsmail Engin Kandirali: 0000-0003-0580-2144 /\u0026nbsp;[email protected]\u003c/p\u003e\n\u003cp\u003eAykut Colakerol:\u0026nbsp;0000-0002-5076-5306 / [email protected]\u003c/p\u003e\n\u003cp\u003eSergen Sahin:\u0026nbsp;0000-0003-2951-5991 / [email protected]\u003c/p\u003e\n\u003cp\u003eIbrahim Ogulcan Canitez: 0000-0002-2906-5452 / [email protected]\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eOrganisation WH. WHO laboratory manual for the examination of human semen and sperm-cervical mucus interaction: Cambridge university press; 1999.\u003c/li\u003e\n\u003cli\u003eAS Lara L, B Salomao P, PMS Romao A, M Reis R, A Navarro P, JS Rosa-e-Silva AC, A Ferriani R. Effect of infertility on the sexual function of couples: state of the art. Recent Patents on Endocrine, Metabolic \u0026amp; Immune Drug Discovery. 2015;9(1):46-53.\u003c/li\u003e\n\u003cli\u003eWang J-Y, Chen J-D, Huang C-C, Liu C-S, Chung T-F, Hsieh M-H, Wang C-W. Investigation of time-dependent risk of mental disorders after infertility diagnosis, through survival analysis and data mining: a nationwide cohort study. The European Journal of Contraception \u0026amp; Reproductive Health Care. 2018;23(3):218-26.\u003c/li\u003e\n\u003cli\u003eGulum M, Yeni E, Ciftci H, Akin Y, Huri E, Celik H, Erel O. Effects of psychological status on the oxidation parameters of semen and blood in azoospermic men. Urology journal. 2019;16(3):295-9.\u003c/li\u003e\n\u003cli\u003eArafa M, Henkel R, Agarwal A, Majzoub A, Elbardisi H. Correlation of oxidation\u0026ndash;reduction potential with hormones, semen parameters and testicular volume. Andrologia. 2019;51(5):e13258.\u003c/li\u003e\n\u003cli\u003eWdowiak A, Bien A, Iwanowicz-Palus G, Makara-Studzińska M, Bojar I. Impact of emotional disorders on semen quality in men treated for infertility. 2017.\u003c/li\u003e\n\u003cli\u003eTerzioglu F, Turk R, Yucel C, Dilbaz S, Cinar O, Karahalil B. The effect of anxiety and depression scores of couples who underwent assisted reproductive techniques on the pregnancy outcomes. African health sciences. 2016;16(2):441-50.\u003c/li\u003e\n\u003cli\u003eHaimovici F, Anderson JL, Bates GW, Racowsky C, Ginsburg ES, Simovici D, Fichorova RN. Stress, anxiety, and depression of both partners in infertile couples are associated with cytokine levels and adverse IVF outcome. American journal of reproductive immunology. 2018;79(4):e12832.\u003c/li\u003e\n\u003cli\u003eYafi FA, Jenkins L, Albersen M, Corona G, Isidori AM, Goldfarb S, et al. Erectile dysfunction. Nature reviews Disease primers. 2016;2(1):1-20.\u003c/li\u003e\n\u003cli\u003eSeymenler S, Siyez DM. İnfertilite psikolojik danışmanlığı. Psikiyatride G\u0026uuml;ncel Yaklaşımlar. 2018;10(2):186-97.\u003c/li\u003e\n\u003cli\u003eBayar U, Basaran M, Atasoy N, Kokturk F, Arikan II, Barut A, et al. Sexual dysfunction in infertile couples: evaluation and treatment of infertility. J Pak Med Assoc. 2014;64(2):138-45.\u003c/li\u003e\n\u003cli\u003eOskay UY, Beji NK, Serdaroglu H. The issue of infertility and sexual function in Turkish women. Sexuality and Disability. 2010;28:71-9.\u003c/li\u003e\n\u003cli\u003eRajkumar RP, Kumaran AK. Depression and anxiety in men with sexual dysfunction: a retrospective study. 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Human reproduction. 2017;32(3):582-7.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"discpsy","sideBox":"Learn more about [Discover Psychology](https://www.springer.com/44202)","snPcode":"","submissionUrl":"","title":"Discover Psychology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Infertility, sexual dysfunction, erectile dysfunction, depression, anxiety, reproductive health, Beck Depression Inventory, Beck Anxiety Inventory, International Index of Erectile Function","lastPublishedDoi":"10.21203/rs.3.rs-6799257/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6799257/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInfertility is a growing global health concern that imposes not only biological but also profound psychological and emotional burdens on affected individuals. In men, the psychological impact of an infertility diagnosis—particularly its effect on anxiety, depression, and sexual function—remains insufficiently explored.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis prospective, single-center study evaluated 200 male patients aged 21 to 46 years who presented with suspected infertility. Psychological and sexual function assessments were conducted at baseline and three months post-diagnosis using the Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and the International Index of Erectile Function (IIEF-15). Demographic characteristics, hormonal profiles, semen analysis, and lifestyle factors (education, smoking, and alcohol consumption) were also recorded. Paired sample t-tests were used to assess within-subject changes over time, and one-way ANOVA was performed to explore associations with educational attainment and lifestyle habits.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAt three months following diagnosis, patients exhibited a significant increase in depression and anxiety scores (BDI: 6.10 ± 5.14 to 12.09 ± 6.76; BAI: 4.19 ± 3.87 to 8.90 ± 6.96; p \u0026lt; 0.001 for both). Concurrently, significant reductions were observed in sexual function scores, including erectile function (27.92 ± 3.42 to 25.80 ± 3.58; p \u0026lt; 0.001), orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction. Education level did not significantly affect depression or anxiety overall, but participants with only secondary education showed higher anxiety scores at follow-up (p = 0.007).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn infertility diagnosis is associated with a marked deterioration in psychological well-being and sexual performance in men. These findings underscore the necessity of incorporating routine psychological assessment and support into infertility management, especially for socioeconomically vulnerable populations.\u003c/p\u003e","manuscriptTitle":"Psychological and Sexual Effects of Infertility Diagnosis in Men in a Prospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-21 08:17:19","doi":"10.21203/rs.3.rs-6799257/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-14T20:59:46+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-31T15:42:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"229972179368349510421391183062201173362","date":"2025-07-27T10:36:42+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-26T08:48:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"332214953185558131812835101509474177329","date":"2025-07-24T15:52:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"176895763101989789439875546656427184621","date":"2025-07-24T11:20:21+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-16T23:54:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-12T00:33:56+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-06T21:59:32+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-11T16:49:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Psychology","date":"2025-06-11T16:46:34+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"discpsy","sideBox":"Learn more about [Discover Psychology](https://www.springer.com/44202)","snPcode":"","submissionUrl":"","title":"Discover Psychology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"eba842cb-22ba-4220-b5a2-01ae5aff418e","owner":[],"postedDate":"July 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-24T09:10:54+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-21 08:17:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6799257","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6799257","identity":"rs-6799257","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}