Effectiveness of sexual health counseling based on mindfulness approach on sexual satisfaction in women suffering from infertility: An RCT

Abstract Background The infertility phenomenon affects physiological and psychosocial aspects. Sexual counseling can improve sexual and marital satisfaction. Objective This study aimed to determine the effectiveness of sexual health counseling based on the mindfulness approach on sexual satisfaction of women suffering from infertility. Materials and Methods This randomized clinical trial study was conducted on 44 women suffering from infertility referred to the Yazd Reproductive Science Institute, Yazd, Iran. Women were randomly divided into 2 groups. The intervention group (n = 22) received 8 sessions of sexual counseling, while control group (n = 22) received routine care. The data collection tool was the sexual satisfaction questionnaire. Results The mean age of women was 30.05 ± 4.9 yr, infertility duration was 6.83 ± 4.27 yr, and the mean duration of marriage was 8.3 ± 4.01 yr. The mean score of sexual satisfaction of women suffering from infertility in the intervention group was 62.9 ± 7.32, 71.6 ± 5.95, and 70.9 ± 6.26, before the intervention (baseline), after intervention (8 th wk), and follow-up (12 th wk) respectively. The mean score of sexual satisfaction of women suffering from infertility in the control group was 63.3 ± 6.82, 64.2 ± 7.93, and 62.25 ± 7.99, at baseline, 8 th wk later, and after follow-up (12 th wk), respectively. Sexual satisfaction scores increased before and one month after the intervention in the counseling group, and this difference was statistically significant (p < 0.001). Conclusion Mindfulness-based sexual health counseling programs may improve sexual satisfaction in women suffering from infertility in the intervention group.


Introduction
Despite the variations in attitudes toward sexuality in recent centuries, the importance of fertility is still maintained in the human mind, with one being a factor in strengthening marital life (1). The occurrence of infertility for females has increased due to several reasons such as late marriage and late childbirth (2). In contrast to fertility, there is another important aspect called infertility, defined as the inability to have a child after 1 yr of continuous sexual activity without using contraceptive methods (3). Epidemiological studies show that infertility affects about 10-15% of couples in the United States and 20% of the Western population (4,5). In Iran, this amount reaches to more than 3 million infertile couples (6).
Infertility is a multifactorial problem, and many couples do not have enough knowledge and skills to manage this problem properly. In recent years, considerable attention has been paid to the role of psychological aspects of infertility, and medical knowledge, suggests the link between infertility and psychological factor (7). The correlation analysis discovered significant positive correlations between sexual dissatisfaction and infertility-related and sexual concerns in couples (8).
In Iranian infertile couples, the most common psychological and emotional problems are dissatisfaction, frustration, anxiety, and fear (9). Stress, depression, low self-esteem, marital dissatisfaction, sexual dissatisfaction, impaired marital quality, decreased intimacy, fear of ending a marital relationship, helplessness, and clinical depression manifestations have been reported as psychological consequences of infertility (10,11). Many studies have investigated the effects of infertility on sexual satisfaction and self-esteem (12), sexual function (13), and the social effects of infertility among couples (14). Sexual satisfaction is every person's judgment about the sexual behavior they enjoy, and it is largely affected by the consequences of infertility, such as having sex with failure to conceive. Decreased sexual satisfaction for any reason has many negative consequences. During infertility treatment, 50-60% of couples reported a marked decrease in sexual satisfaction (15). Sexual counseling can affect the quality of sexual relations, lead to increased satisfaction in sexual relations between couples, and may increase their enjoyment (16).
All processes play a role in the relationship between specific aspects of infertility-related sexual satisfaction. The authors' suggest psychosocial support for couples experiencing infertility (17).
Psychological treatments, along with infertility treatment programs, increase mental health, make infertile people more resistant to stress, increase the effectiveness of infertility treatments, and pursue infertile people for follow-up treatment.
Mindfulness-based cognitive therapy is a recent development in cognitive therapy that is a shortterm, structured intervention based on Kabat-Zinn's (1990) mind-based stress reduction model and incorporating cognitive therapy principles (15).
Due to the increasing prevalence of infertility among women, and its psychological impacts, such as decreased sexual satisfaction, the use of psychological treatment approaches is particularly important for sexual satisfaction.
Regarding the limited counseling interventions in sexual health with a mindfulness approach in infertile women, this study aimed to determine the effect of mindfulness sexual health counseling on the sexual satisfaction of these women in Yazd.

Study design and setting
This randomized clinical trial study with the control group (baseline, after the intervention, and follow-up) was done on women suffering from infertility referred to Yazd Reproductive Sciences Institute, Yazd, Iran from October 2019 to Febuary 2020.
The sample size was calculated to be 44 (22 in each group), considering the significance level of 5%, the power of 80%, and the type II error of 0.20.
In this formula, 1-α and 1-β are the reliability and test power levels, respectively, and were considered equal to 0.95 and 0.80. As a result, Z_ (1-α / 2) and Z_ (1-β) of the normal distribution

Intervention
The

Ethical considerations
This study was based on the Master's Degree Written consent was obtained from all of them.

Statistical analysis
After filling the questionnaires, the Shapiro-

Results
This study aimed to determine the effectiveness According to the independent t test, the results showed that the mean score of age, duration of infertility, the number of pregnancies, there are no statistical differences between the 2 groups.
The majority of women in the intervention and the control group were housewives (p = 0.48). The Chi-square test, and Fisher's exact test showed no significant difference between the 2 groups (Table   II).
To determine and compare the mean score  (Table III).
The results showed that in the intervention group, the mean score of sexual satisfaction improved after the intervention (8 th wk) (p < 0.001) and in the follow-up period (p < 0.001) (12 th wk).
But there was no significant difference between the mean score of sexual satisfaction after intervention (8 th wk) and the follow-up period in the intervention group (p = 0.21) (Table IV).
Also, in the control group, the mean of sexual

Discussion
This study aimed to determine the effect of sexual health counseling based on mindfulness approaches on sexual satisfaction in women suffering from infertility. The results showed that mindfulness had a significant impact on improving the sexual satisfaction of these women after the intervention and follow-up period.
A qualitative study showed that infertile couples face 4 basic challenges. They include shock, reaction, processing, and reorientation.
The subthemes were disbelief and denial, internal processing, avoidance, marriage at risk, external processing, stigma, forgetting, saving marriage, and sexual consent (21).
Many studies recommended sexual health counseling for women suffering from infertility.
One study showed that mindfulness-based cognitive therapy reduced anxiety, stress, and depression (9). In addition, a different study Their research has shown that mindfulness training has an impact on depression and anxiety in women suffering from infertility (29,30).
This method reduces anxiety and meta-worry in women who have recurrent miscarriages (31) and treats depressive symptoms in diabetic patients (32

Conclusion
According to the results of this study, it seems that mindfulness group training in the form of counseling affects the cognitive One of the strengths of the study is the participants' willingness to continue sexual counseling sessions. One of the weak points of this study was not possible to hold online sexual counseling sessions.

Research limitations
One of the major limitations of this study was the lack of switch over all issues affecting sexual satisfaction, which was partially controlled by random allocation.
Impossibility of long follow-up period.
The unwillingness of some attendees to attend the meetings was due to the lengthy time of classes and the inclusion of those who initially agreed to hold 8 sessions weekly.
Confidence in reporting self-reported mental illness was a limitation of our study.