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Female Sexual Function, Dysfunction, and Pregnancy: Implications for Practice, Sex for Pregnancy: Tips, Positions, Frequency, Timing, and More

Sexual Function in Pregnancy

Many pregnant women believe that sexual function diminishes over the course of pregnancy, typically because of practical concerns. The first trimester of pregnancy is often a time when libido decreases because of fatigue, emotional lability, nausea, sore breasts, and heightened anxieties or fears about miscarriage.[16] During the second trimester, women are said to feel more erotic and energetic, with an increase in libido as physical discomforts subside, vaginal lubrication increases, and previous apprehensions diminish.[16] Women may want to engage in sexual activity frequently and because of increased genital blood flow may end up reaching orgasm for the first time, multiple times, and/or easier than before they were pregnant.[16] By the third trimester, physical aches and obstacles can again become overwhelming, making traditional sexual acts more difficult and less frequent.[8,16]

Sexual needs of the pregnant woman and her partner can be met in a variety of ways. Several positions, such as side by side, woman on top, and hands and knees can be more comfortable during pregnancy.[16] In addition to vaginal intercourse, sexual activity in pregnancy can include masturbation, massage, oral sex, foreplay, mutual caressing, kissing, fantasy, the use of sex toys, and cuddling.[8,16]

In a cross-sectional study of 141 pregnant women by Bartellas et al.,[8] 71% of the respondents who completed the questionnaires reported a decrease in sexual frequency during pregnancy compared to prepregnancy activities. The third trimester of pregnancy appears to mark a particular period in which sexual behaviors become the most infrequent. During the first trimester, 96% of pregnant women engaged in vaginal intercourse, whereas only 67% did so by the third trimester.[8] Aslan et al.[35] surveyed 40 healthy pregnant women using the Female Sexual Function Index (FSFI) questionnaire. Participants completed the questionnaire one time per trimester during their pregnancies. The frequency of intercourse attempts over a 4-week period went from a mean of 6.9 times in the first trimester to a mean of 2.5 times in the third trimester.[35] Conversely, DeJudicibus et al.[12] used a questionnaire designed to have women recall how frequently they typically had intercourse before pregnancy and then during pregnancy and found an average of once per week before pregnancy and once per month during pregnancy, with a significant decline in the third trimester. Gökyildiz et al.[36] used a 63-question face-to-face interview to determine the effects of pregnancy on the sexual life of 150 women at ≥34 weeks' gestation, all of whom were experiencing a normal pregnancy. Before becoming pregnant, 84.7% of women had intercourse one to four times per week, which decreased to 70% in the first, 61.3% in the second, and 32% in the third trimesters, respectively.[37]

Fatigue is a major predictor of sexual frequency during pregnancy.[12,37] Other commonly cited reasons for lessening sexual activity include decreased sexual desire, libido, interest and satisfaction, and an increase in pain.[12,35–38] In the study by Gökyildiz et al.,[36] 79.3% of women participants were satisfied with their sexual lives before pregnancy, which decreased to 56%, 42.7%, and 20% in the first, second, and third trimesters, respectively. According to Erol et al.,[38] a lack of libido or desire in 92.6% of the participants was the second most common sexual dysfunction cited during pregnancy.

Fear of Harming the Fetus

Fears of harming the fetus or inducing preterm labor are other contributors to the decline in sexual activity. Between 45% and 49% of women and 55% to 62% of their partners reported an overall fear of causing some sort of obstetric complication from engaging in sexual intercourse while pregnant.[8,37] In a cross-sectional study of 190 women with a mean age of 26.7 years, a structured questionnaire that inquired about perceptions and beliefs of sexual intercourse before and during pregnancy found that 43.7% felt that sexual intercourse during pregnancy could cause problems like preterm labor, damage to the baby, and bleeding.[39] In the Bartellas et al.[8] survey of a mixture of 141 primigravid and multigravid women, the number of women who were afraid of causing preterm labor grew with each trimester, from 9% of women in the first trimester, to 21% in the second trimester, and to 49% by the third trimester. Sexual activity was shown to decrease in proportion to the increase in women fearful of causing preterm labor.

However, the literature does not support an association between sexual intercourse and increased risk of preterm labor and delivery. Yost et al.[40] evaluated the effect of coitus on preterm birth in a population of women (n = 165) who had a previous preterm delivery, and found that 28% of the women who reported infrequent or no sexual intercourse early in pregnancy had a preterm birth versus 38% of women who engaged in some sexual activity (P = .35). This difference was not statistically significant. The author concluded that there is not enough evidence to suggest abstaining from sexual intercourse in order to avoid preterm birth.[40]

Fok et al.[13] surveyed 298 pregnant Chinese women through self-administered questionnaires investigating sexual experience during pregnancy. The majority of women and their partners (82.9% and 84.9%, respectively) expressed concerns about the effects of sexual intercourse on the pregnancy and baby. The most common concerns were bleeding (n = 222; 74.8%), labor (n = 180; 60.7%), infection (n = 180; 60.7%), rupture of membranes (n = 161; 54%), and damage to the fetus (n = 214; 71.8%). Despite these fears, only bleeding and pain after sexual intercourse during pregnancy were observed and occurred in less than 12% of the women surveyed.[13] In an otherwise normal pregnancy, there is no conclusive data that indicate that sexual activity should be considered a threat to the fetus or a risk factor for inducing miscarriage or early labor and delivery.[16]

Female Sexual Function Index

The studies that have investigated sexual function during pregnancy have some limitations. The study populations are small, homogeneous, lack randomization, and are often retrospective. Although the results of these studies are largely similar, differing measures and methods make it difficult to aggregate this data. One proposal to help quantify this research is the use of the FSFI questionnaire. The FSFI has been validated and shown to be a reliable measure of female sexual function via 19 questions that assess desire, arousal, lubrication, orgasm, satisfaction, and pain domains.[41] It was designed to be a tool to measure female sexual function for women of all ages, both pre- and postmenopause.[41] This tool was used in the studies by Aslan et al.[35] and Erol et al.,[38] which allows for quantified results about female sexual function and dysfunction during pregnancy. However, the FSFI was not originally drafted to measure female sexual function specifically in pregnancy. Future research needs to be performed to develop a measurement tool to investigate female sexual function during pregnancy that includes physical, emotional, and sociocultural variables.