title: Semen quality impairment is associated with sexual dysfunction according to its severity.
abstract: Is sexual dysfunction associated with severity of semen quality impairment in men with couple infertility?
  
  
  
  In males of infertile couples the prevalence of erectile dysfunction (ED) increases as a function of semen quality impairment severity.
  
  
  
  Infertile men are at a higher risk for sexual dysfunction, psychopathological and general health disorders. However, it has never been systematically investigated if these problems are associated with severity of semen quality impairment.
  
  
  
  Cross-sectional analysis of a first-time evaluation of 448 males of infertile couples attending an outpatient clinic from September 2010 to November 2015. In addition, 74 age-matched healthy, fertile men from an ultrasound study on male fertility were studied for comparison.
  
  
  
  All subjects underwent a complete physical, biochemical, scrotal and flaccid penile colour-Doppler ultrasound evaluation and semen analysis. Patients had already undergone at least one semen analysis; therefore, the majority were aware of their sperm quality before taking part in the study. Validated tools, such as the International Index of Sexual Function-15 (IIEF-15), Premature Ejaculation Diagnostic Tool (PEDT), Middlesex Hospital Questionnaire (MHQ), National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI), International Prostate Symptom Score and Chronic Disease Score (CDS), were used to evaluate, respectively, sexual dysfunction, premature ejaculation (PE), psychopathological traits, prostatitis-like symptoms, lower urinary tract symptoms and general health status.
  
  
  
  Among men with couple infertility, 96 showed azoospermia (Group #1), 245 at least one sperm abnormality (Group #2) and 107 normozoospermia (Group #3). Fertile men were considered as a control group (Group #4). After adjusting for age, we observed a higher prevalence of ED (IIEF-15-erectile function domain score <26) (18.3% versus 0%; P = 0.006) and PE (PEDT score >8) (12.9% versus 4.1%; P = 0.036) in males of infertile couples compared with fertile men. The ED prevalence increases as a function of semen quality impairment severity (P < 0.0001), even after adjusting for confounders (age, CDS, MHQ and NIH-CPSI total score), despite similar hormonal, glyco-metabolic and penile vascular status. Compared to fertile men, all three groups of males with couple infertility showed a poorer erectile function, associated with an overall psychopathological burden (MHQ total score), particularly with somatized anxiety (MHQ-S). Azoospermic men showed the worst erectile function and general health: in this group, erectile function was negatively associated not only with psychopathological disturbances (MHQ total and MHQ-S scores; P < 0.0001) but also with a less healthy phenotype (higher CDS; P = 0.015). In addition, azoospermic men reported higher PE prevalence and lower sexual desire and orgasmic function when compared to fertile men (all P < 0.05), all of which were related to psychopathological symptoms.
  
  
  
  The cross-sectional nature of the study represents its main limitation. A possible selection bias concerning the control group of healthy, fertile men recruited into an ultrasound study might have occurred. Finally, causality cannot be inferred in this type of study design and hence there should be some caution in interpreting the results.
  
  
  
  Investigation of male sexual function, general health and psychological status in infertile couples, especially if azoospermic, is advisable, in order to improve not only reproductive but also general and sexual health.
  
  
  
  Grants were received from the Ministry of University and Scientific Research (SIR project to F.L., protocol number: RBSI14LFMQ). There are no conflicts of interest.
  
  
  
  None.
authors.affiliation: Sexual Medicine and Andrology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy.
authors.forename: F
authors.initials: F
authors.lastname: Lotti
authors.affiliation: Sexual Medicine and Andrology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy.|Endocrinology Unit, Maggiore-Bellaria Hospital, Bologna, Italy.
authors.forename: G
authors.initials: G
authors.lastname: Corona
authors.affiliation: Sexual Medicine and Andrology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy.
authors.forename: G
authors.initials: G
authors.lastname: Castellini
authors.affiliation: Sexual Medicine and Andrology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy.
authors.forename: E
authors.initials: E
authors.lastname: Maseroli
authors.affiliation: Sexual Medicine and Andrology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy.
authors.forename: M G
authors.initials: MG
authors.lastname: Fino
authors.affiliation: Division of Obstetrics and Gynecology, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy.
authors.forename: M
authors.initials: M
authors.lastname: Cozzolino
authors.affiliation: Sexual Medicine and Andrology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy m.maggi@dfc.unifi.it.|I.N.B.B. - Istituto Nazionale Biostrutture e Biosistemi, 00136 Rome, Italy.
authors.forename: M
authors.initials: M
authors.lastname: Maggi
mesh_terms: D000328:Adult; D003430:Cross-Sectional Studies; D007172:Erectile Dysfunction / Q000150:complications* / Q000175:diagnosis / Q000503:physiopathology; D005260:Female; D006801:Humans; D007248:Infertility, Male / Q000150:complications* / Q000175:diagnosis / Q000503:physiopathology; D008297:Male; D055101:Semen Analysis; D012720:Severity of Illness Index; D013094:Spermatozoa / Q000002:abnormalities*
keywords: azoospermic men; erectile dysfunction; fertile men; general health status; infertile men; premature ejaculation; psychopathological disturbances; sexual dysfunction