Table 2 shows Demographic data of experimental and control groups.

Table 2

Considering the Chi-squared test results, the hypothesis of homogeneity between the groups is significant.

Table 3. Mean and standard deviation of sexual function and its items at pre-test and post-test states in experimental and control groups

Considering the data presented in Table 3, the experimental group achieved higher scores after the intervention. In order to assess the significance of the changes and determine the effect size of sexual training on sexual function improvement in the experimental group, first the pre-test scores were modified. Then, using the ANCOVA, the effect size of sexual skills training on sexual function improvement in infertile women was determined. Before using ANCOVA, its assumptions were reviewed. In order to determine normal distribution of data, the Shapiro-Wilk test was used. To address the assumptions, Leven’s test was used. The Box test was not significant for any of the variables (BOX= 39.741, F= 1.191, P= 0.250). Other assumptions of ANCOVA were reviewed and all of them showed that assumptions have been addressed.

Table 4. Analysis of covariance to compare sexual function scores between experimental and control groups

Table 4 shows that, after modifying pre-test scores, there was significant difference in post-test scores of desire (F (12, 1)= 54.416, P < 0.001), psychologic arousal (F (12, 1)= 30.538, P< 0.001), lubrication (F(12, 1)= 50.648, P< 0.001), orgasm (F(12, 1)= 54.617, P< 0.001), satisfaction (F(12, 1)= 47.035, P< 0.001), and sexual function (F(12, 1)= 38.819, P<0.001) between experimental and control groups. In other words, it can be stated that with 9% confidence that sexual skills training improved sexual function of infertile women. Considering the Eta squared value, the effect size of this training was 76%. As seen in Table 4, sexual skills training was also effective on pain (F(12, 1)= 5.274, P< 0.05). Considering Eta squared value of lower than 0.35, it shows that this training was not so effective on pain.

DISCUSSION

This study was done with the objective of determining the effect of training sexual skills with a cognitive-behavioral therapy on sexual dysfunction of infertile women. For the experimental group, 10 weekly sessions of training sexual skills were performed, while no intervention was done in the control group. Both groups completed the FSFI at baseline and again after 10 weeks. Considering the ANCOVA results, it can be concluded that sexual function scores were significant after 10 weeks between experimental and control groups. Post-test scores were higher in the experimental group which reflects the efficacy of the sexual skills training. Therefore, all the study hypotheses, except hypothesis 6 which relates to pain, are approved.

There are limited studies about the effect of training sexual skills on sexual dysfunction in Iran. The findings of the study are in agreement with some former studies (34-42). All the mentioned studies indicated the effectiveness of sexual skills training with cognitive-behavioral therapy on sexual function. The intervention used here had a significant effect on all items of sexual function, except for pain. Although the change in pain score was not statistically significant, when mean score at pre-test (6.60) is compared to post-test score (12.40), we observe improvement. However, this change was not statistically significant. It should be noted that the training used here lasted for 10 weeks and this time course is too short to resolve pain. According to a previous study (43), the required time to address vaginismus was 34 sessions in 12 months. During this long time, patients gradually achieved higher level of vaginal muscles control and non-painful intercourse. The lack of significance regarding effect on pain may be justified by the study period.

The current findings are compatible with a previous study (44) that studied a 6-month therapeutic plan to improve sexual function and satisfaction and marital life skills. In addition to relation between infertility and sexual function that always should be addressed in treatment of infertility, sexual desire is also an important factor (45). It can be stated that sexual relations by affecting couples’ thoughts and feelings directly or indirectly can affect their life. The couples that have agreement with regard to sexual relations are happier and can ignore many life problems (46). One of the main fundamental methods to achieve this healthy sexual behavior is providing appropriate education. Research in this field shows that sexual skills training is effective on health behaviors and can improve understanding of persons about sexual issues (47).

Perhaps the reason for significant effect of sexual skills training on sexual dysfunction in infertile women is that the need of such patients for such training to resolve problems in sexual function which existed long ago or developed after infertility was diagnosed, prepared them properly to implement this training. The training provided a basis that patients themselves see their relations beyond infertility and try to improve their sexual relations.

Another issue that is a strength in this study that spouses of the women were contacted and were advised regarding sexual dysfunction. They were notified that they should also collaborate in this study and as this study was done in a university center, they allowed their spouses to participate at the study. The sessions were held very regularly and this helped the effectiveness of the intervention.

There are some possibilities in terms of effectiveness of sexual skills training with cognitive-behavioral therapy approach on sexual dysfunction. First, exercises used were not merely physical ones. These sexual exercises can result in complex psychologic reactions. For example, with sensory-focus exercises not only pleasurable reactions are strengthened, but also prevent unwanted sexual tensions. By reducing unpredictable sexual tensions in couples, emotional relations are enhanced by such exercises and cause couples to be more kind towards each other. Secondly, the treatments used here allowed the subjects to state their excitement freely. This free relation usually resolves anxiety and facilitates subjects’ feelings. Third, suppressing guilty feelings or unconscious fear of enjoyment and replacing prohibiting cognitions with correct cognitions can justify the effectiveness of the therapeutic intervention studied here. When pregnancy does not occur, infertile couples may think that they do not have effective sexual relation and gradually may forget that sexual relation is mainly to address a fundamental need and its ignorance can cause damage to their life (48).

In the current study, the sessions were held only for women in the absence of their spouses. It is suggested that in the future studies, such training be held in the presence of the spouses (couple therapy) and compare this with group therapy.

CONCLUSION

The results of this study indicated that sexual skills training with cognitive-behavioral approach was effective on sexual dysfunction among infertile women. We suggest that obstetricians and gynecologists, midwives, nurses, and psychologists use this method in addition to other approved methods. Treatment of sexual dysfunction in infertile women is very important by twofold. Firstly, treatment of infertility is important. Secondly, by treating sexual dysfunction, marital relations are improved. This is an effective method to avoid marital and familial conflicts and resultant consequences. As married individuals have various sexual behaviors and patterns, by training couples, it is possible to enhance their sexual knowledge and make cognitive changes.

Acknowledgements
We thank all patients and staff who helped us in conducting this study