The definition of sexual dysfunction from a psychological perspective is derived from the four-phase model of the human sexual response cycle proposed by Masters and Johnson and Kaplan (1980). The first phase, termed the arousal phase, encompasses the appetitive or motivational aspect of sexual response and includes a person’s sexual fantasies and urges. The second phase called the excitement phase, is the subjective sense of pleasure felt and is accompanied by erection and increased vaginal congestion and lubrication. The third phase is called orgasm or climax phase and encompasses peak sexual pleasure felt, associated with rhythmic contracture of the musculature around the genital area and ejaculatory inevitability culminating in ejaculation in men. The final phase is the phase of resolution, where there is a relief of sexual tension and general sense of well-being felt by both partners. Post the orgasm phase, women still remain receptive to stimulation. In men, after the phase of resolution, a period of refractoriness for both erection and ejaculation follows; nevertheless, the literature reports a few men report having multiple orgasms without refractory latency both with and without ejaculation (Dunn and Trost 1989).

A sexual dysfunction is defined as a problem affecting any one of the four phases of the sexual response cycle. Strictly stating, only the first three phases are of clinical significance. A sexual dysfunction may be situational (defined as occurring with a specific partner or situation or circumstance) or global. Sexual dysfunction can also be classified as either primary (present lifelong) or secondary (developing secondary to a particular pathology/medical condition). A sexual dysfunction can significantly affect a person’s mood, self-esteem, interpersonal relationship and quality of life. Recently, the DSM-IV criteria (Diagnostic and statistical manual of mental disorders) was revised. The DSM-V criteria were published in May 2013 and incorporate several changes. For a person to be diagnosed with sexual dysfunction, the dysfunction should have been present at least for a period of 6 months with a frequency between 75 and 100 % (DSM V 2013). Exceptions to the rule include disorders caused by medications and substance abuse. Importantly the dysfunction should have caused considerable distress to both partners. As per the revised guidelines, there are now three female sexual dysfunctions and four male sexual dysfunctions. Table 16.2 outlines both the male and female sexual dysfunctions as per the revised DSM-V criteria.

An important change of notable mention in the DSM-V guideline is the inclusion of both dyspareunia and vaginismus as a single entity titled genitopelvic pain/penetration disorder. This is because both the conditions show a high degree of overlap, and effective differentiation between these two conditions was not possible.

Sexual dysfunction in an infertility setting represents an unusual yet complex problem. Sexual dysfunctions that lead to infertility in men include erectile disorder and ejaculatory dysfunction. In women, genitopelvic pain/penetration disorder results in nonconsummation of the marriage and prospectively results in infertility. A sexual dysfunction in an infertility setting can have organic or psychogenic cause, although a mixed aetiology is not uncommon. It is important to understand that all organically induced dysfunction will have some degree of psychogenic overlap. A diagnosis of infertility itself may result in some degree of dysfunction. Over 40 % of female patients diagnosed with infertility report lower desire and/or arousal and also report a reduction in the frequency of intercourse (Millheiser et al. 2010). Among males, in a cross-sectional survey conducted among 357 men from 8 academic fertility units, where an independent diagnosis of male factor infertility was made, the diagnosis resulted in highly significant (p < 0.004) impact on sex life satisfaction and personal quality-of-life scores. The scores remained significant even after controlling for partner age, education status, race, religion, current employment status and duration of infertility (Smith et al. 2009). For most couples, a diagnosis of infertility exerts tremendous psychological, social, physical and financial burden. In a larger study involving over 843 couples, a greater degree of emotional distress and marital discordance was reported by the couples when a male factor infertility was exclusively diagnosed (Connolly et al. 1987). In another cross-sectional study, among 200 infertile couples, over 41.5 % of couples reported a reduction in sexual desire, while over 52.5 % of couples reported a reduction in sexual satisfaction after a diagnosis of infertility was made (Ramezanzadeh et al. 2006). More importantly the duration of infertility varied inversely to the degree of sexual satisfaction and this relationship reached statistical significance (p < 0.05).

In our clinic, the Department of Andrology and Reproductive Medicine, Chettinad Super Specialty Hospital, of the 544 male partners of couples who presented for an infertility evaluation between February 2014 and January 2015, 13 % of the men suffered from some form of sexual dysfunction (Table 16.3).

The management of infertility creates pressure and may cause or exacerbate an existing dysfunction. As a part of infertility management, the male partner may be forced to have sexual intercourse at a specific time of the month, around the time of ovulation. The stress to perform, on the day of ovulation, may thus result in a sexual dysfunction. The female partner may also lose interest in intercourse outside the fertile period. A situational dysfunction may result when the patient has difficulty in performing with a specific partner or in a particular situation or a definable circumstance. One example is the act of masturbation; normally a routine and/or pleasurable exercise may become stressful and/or embarrassing when the patient has to collect the entire sample in a wide-mouthed container, especially in a hospital setting.

From a clinical viewpoint, it should be remembered that one sexual dysfunction can frequently mask or exacerbate another dysfunction. One example of relevance would be the finding of a male patient stating that he loses his erection during attempted penetration and the female partner stating she has pain during penetration. One must not be hasty in making a diagnosis of erectile dysfunction in the male and/or vaginismus in the female. A thorough workup and charting of the sexual response cycle individually for each partner coupled with an in-depth history may simply point out that there was inadequate time allocated by the couple for foreplay which led to inadequate lubrication in the female consequently resulting in difficulties in penetration for the male and eventually erectile dysfunction over a period of time. A session of sex education describing the male and female sexual anatomy coupled with an explanation of the human sexual response cycle for these couples would ameliorate the problem.

Numerous medical conditions can affect sexual function either in a direct or an indirect manner (Ramezanzadeh et al. 2006; Gratzke et al. 2010; Phillips 1998). An in-depth history should comprehensively assess all medical/surgical conditions outlined in Table 16.4. An increased incidence of sexual dysfunction is reported in both men and women with poor physical and/or mental health (Weiner and Rosen 1997; Thranov and Klee 1994; Laumann et al. 1999). Cardiovascular status is an important parameter to be assessed during evaluation of sexual dysfunction in both men and women; patients should be stratified into low risk or high risk categories depending on the cardiac history before entailing on specific therapy for the sexual dysfunction (Miner et al. 2012; DeBusk et al. 2000). Specific medical causes of female sexual dysfunction are outlined in Table 16.5.