1. Introduction 
Recurrent pregnancy loss (RPL) is distinct from infertility and is defined as the spontaneous and consecutive loss of two or more clinical pregnancies before 24 weeks of gestation (ESHRE Guideline Group on RPL, 2018; Zegers-Hochschild et al., 2009). European Society of Human Reproduction and Embryology (ESHRE) defined primary RPL as RPL without a previous pregnancy (viable pregnancy) lasting more than 24 weeks of gestation, while secondary RPL is described as an episode of RPL after one or more previous pregnancies progressing more than 24 weeks of gestation. Accurate estimation of the prevalence of RPL seems complicated, but most of the studies have reported the prevalence rate to be 1-2% (ESHRE Guideline Group on RPL, 2018). 
Although the loss of pregnancy is considered a traumatic event (Adolfsson et al., 2012), the experience of abortion varies in different women. Factors, such as personality traits, cultural and religious background, and socioeconomic status have been reported to affect the psychological consequences of miscarriage (Major et al., 2009). Some of the psychological challenges in this regard involve emotional trauma, social problems, financial concerns, disruption of marital relations, and sexual dysfunction (Kicia et al., 2015; Serrano & Lima, 2006). Women suffering from RPL experience the lower health-related quality of life and higher levels of anxiety and depression than women without a history of miscarriage, which may cause sexual dysfunction in these women. 
Several studies have suggested conflicting results regarding sexual function and marital relations in women with a history of RPL (Serrano & Lima, 2006; Fok et al., 2006; Francisco et al., 2014; Oindi et al., 2019; Agrawal et al., 2012). For instance, the results of a study conducted in China indicated that women with recurrent miscarriages were significantly more likely to experience sexual dysfunction compared to women with a history of a single miscarriage (Fok et al., 2006). Furthermore, research performed on Portuguese pregnant women indicated that women with a history of recurrent spontaneous miscarriage have experienced impaired sexual function more significantly than those without this condition (Francisco et al., 2014). Conversely, a recent study demonstrated no association between fertility status and the prevalence of female sexual dysfunction (Oindi et al., 2019). A study conducted in India also showed that couples’ marital relations had no changes after a miscarriage, and spousal support was even higher after a miscarriage (Agrawal et al., 2012). Another study in Portugal indicated that marital relations were not adversely affected by recurrent miscarriages and even, discussing sexual issues with the spouse was facilitated after miscarriage, which could be considered as a beneficial effect of recurrent miscarriage on the couples’ marital and intimate relations (Serrano & Lima, 2006).
Because discussing sexual function may be considered taboo, it is not considered for patient evaluation (Erbil, 2011). In addition, women in low- and middle-income countries have limited access to post-abortion family planning, education, and counseling regarding sexual and reproductive health (Rogers and Dantas, 2017). Therefore, special attention must be paid to the post-abortion care, evaluation, and treatment of sexual issues. 
Limited data are available on RPL in Iran, and relevant studies have mainly focused on the etiologies or outcomes of this condition. However, fertility problems and female sexual dysfunction are common in various ethnic groups in Iran, and fertility problem is considered the leading cause of divorce and marital dissatisfaction (Abedinia et al., 2012; Ranjbar et al., 2015). In Iranian culture, childbearing is a positive value and the ultimate goal for couples so that the practice of childbearing defines the concept of family. Therefore, women who have problems conceiving face many limitations and psychological pressures (Behjati-Ardakani et al., 2017). Sexual dysfunction is highly prevalent in infertile Iranian women (64.3%) (Omani-Samani et al. 2019); therefore, women with a history of RPL are not excluded in relation to this disorder. RPL has been considered the “orphan” of infertility because this condition is often neglected in fertility research (Carp, 2014). No prior studies have investigated the prevalence of sexual dysfunction in women with a history of RPL in Iran. Considering the contradictory results about sexual function and marital relations in women with a history of RPL and the impact of cultural and religious background and socio-economic status on the psychological consequences of RPL, the present study was conducted to examine sexual function in women with a history of RPL. 
2. Materials and Methods 
This cross-sectional study is part of more extensive research that evaluated the association between depression and sexual function in women with a history of RPL (Azin et al., 2020). To assess their sexual function, 130 women with RPL history referred to the Recurrent Miscarriage Clinic of Avicenna Fertility Center in Tehran, Iran, from November 2018 to February 2019 were enrolled. This semi-public sector operates under the Iranian Academic Center for Education, Culture, and Research (ACECR) supervision, and provides specialized fertility care in Iran. The subjects were selected consecutively according to their convenient access to the clinic, and the sampling process ended when the entire sample was reached. 
The sample size was determined at a 95% confidence level and estimation accuracy of d=2. In addition, the standard deviation was estimated based on Mintz et al.’s study (Mintz et al., 2012). Therefore, the minimum required sample size was estimated to be 86 subjects based on the following formula. Although the minimum sample size to estimate the main variable was 86, at least ten samples were considered for each demographic variable in order to investigate the relationship between sociodemographic characteristics and FSFI. Accordingly, 130 subjects were included in this study. 
Inclusion criteria were non-pregnant married women aged 18 to 45 and literate, having a history of two or more consecutive failed pregnancies confirmed by ultrasound or histopathological examination before week 24 of pregnancy, at least six months have passed since the last miscarriage, no history of alcohol/drug abuse, and no mental disorders or diseases associated with increased risk of sexual dysfunction (e.g., diabetes, cardiovascular diseases, and cancers).
Because significant depression and anxiety have been demonstrated in the first month following RPL (Farren et al., 2018), participants with an interval of fewer than six months since their last miscarriage were excluded from the study. Women who had undergone infertility treatments including induction ovulation (IO), intrauterine insemination (IUI), in vitro fertilization (IVF), and intracytoplasmic sperm injection (ICSI) in the past three months were also excluded because infertility treatments could cause stress and interfere with the sexual relationship (Bakhtiari et al., 2016; Starc et al., 2019).
Study participants anonymously completed a demographic questionnaire and the female sexual function index (FSFI) in approximately 20 minutes in a private room at the clinic.
The demographic questionnaire included information concerning the women’s age, educational level, occupational status, duration of the miscarriage, contraceptive use, type of RPL, the interval from the last miscarriage, the procedure used to terminate the previous pregnancy, and the number of pregnancies (gravidity).
The FSFI-19 is widely utilized in clinical practice as a screening tool concerning female sexual dysfunction and in clinical trials as an outcome measure (Neijenhuijs et al., 2019; Goldfarb et al., 2013). Rosen first introduced this 19-item index to assess six domains of sexual function, including sexual desire (two items), sexual arousal (four items), vaginal lubrication (four items), orgasm (three items), sexual satisfaction (three items), and pain (three items). It is scored based on a Likert scale from 1 to 5. There is a zero option in responding to 15 of the items to indicate either “no sexual activity” or “did not attempt intercourse” within the past four weeks. The total FSFI score (2 to 36) is obtained by summing the scores of the six domains. Higher scores indicate better sexual functioning. For all six domains of the FSFI, Cronbach’s alpha value was ≥0.82 (Rosen, 2000). 
In the present study, the total score of ≤28 was interpreted as sexual dysfunction, while higher scores were described as satisfactory sexual function. The sensitivity analysis for the Persian version of FSFI determined the score of 28 as the cutoff point (sensitivity: 83%, specificity: 82%). The cutoff points determined for the domains of the Persian version of FSFI were as follows: sexual desire (3.3), sexual arousal (3.4), vaginal lubrication (3.7), orgasm (3.8), sexual satisfaction (3.4), and pain (3.8). The reliability of the Persian version of the tool was confirmed using Cronbach’s alpha coefficient, which was estimated at ≥0.70 for the entire questionnaire and its domains (Mohammadi et al., 2008). In the current study, Cronbach’s alpha coefficient for the total scale was 0.82 and for each subscale ranged from 0.71 to 0.86, representing a good internal consistency.
Statistical analysis was carried out using the SPSS software version 16 (SPSS Inc., Chicago, IL, USA). To assess the normal distribution of the study data, the Kolmogorov-Smirnov normality test was conducted, according to which the data met the required assumptions for conducting the nonparametric tests. The relationship between sexual function and the participants’ characteristics was assessed using the Kruskal-Wallis test or Mann-Whitney test. The significance level was set at P<0.05.
3. Results 
A total of 130 married women with a history of two or more failed pregnancies, as confirmed by ultrasonography or histopathologic examination, were enrolled in the study. The Mean±SD age of the participants was 31.53±5.11 years, and the majority had academic education (54.6%).  Most of the participants were housewives (73.1%), and their Mean±SD duration of marriage was 8.9±4.13 years. According to the obtained results, 70.8% of the participants experienced primary RPL. The Mean±SD interval since the last miscarriage was 15.48±12.22 months before the study. 
The Mean±SD gestational age in the previous abortion was reported as 8.18±3.42 weeks, and 85.3% of these cases occurred before week 12 of pregnancy. The demographic characteristics and reproductive history of the participants are presented in Table 1. The results of the Kruskal-Wallis test indicated no correlations between sexual function and the participants’ characteristics (Table 1). 



According to the FSFI, 50.0% of the women with a history of RPL had lower scores than the cutoff point, while 50.0% obtained higher scores. The Mean±SD score of the FSFI was 26.59±5.73 (≤28). The status of sexual function and its domains, including sexual desire, sexual arousal, orgasm, sexual satisfaction, and pain are presented in Table 2. According to the findings, sexual desire was the most prevalent sexual disorder (72.3%), while vaginal lubrication had the lowest prevalence (5.4%). 



4. Discussion 
The present study provided new information on the prevalence of sexual dysfunction in women with a history of RPL in a fertility center in Tehran. According to the current study’s findings, the mean score of sexual dysfunction was 26.59±5.73, which was below the determined cutoff point. Moreover, half of the participants demonstrated impaired sexual function, which is a considerable proportion. Similar to women with other fertility problems, women with a history of RPL may also experience sexual dysfunction. Couples may experience stress due to trying to conceive quickly and having a set schedule for sexual activities. Fertility problems may also damage the couple’s relationships and increase marital difficulties (Carp, 2014). According to a study in Portugal, the total mean score of sexual function in pregnant women with a history of RPL was 16.4±1.9 (Francisco et al., 2014), which is lower than the present study. However, it may be due to a decline in sexual function during pregnancy (Serati et al., 2010). In another study that evaluated the sexual function of women visiting gynecology clinics, the prevalence of sexual dysfunction in women with a history of at least two miscarriages was reported as 45.5%. The researchers stated that this indicates a higher prevalence of the condition compared to women without a miscarriage or those who have had a single miscarriage (Hamidi Madani et al., 2018). 
In recent studies conducted in Iran, infertile women have also experienced highly impaired sexual function (Omani-Samani et al., 2019; Direkvand-Moghadam et al., 2015; Shahraki et al., 2018). However, according to a review study regarding the prevalence of sexual dysfunction in the general population in Iran, 52% of women had sexual dysfunction (Ghiasi and Keramat, 2018). In general, due to the high prevalence of female sexual dysfunction in the general population in Iran, the sexual function of women with RPL may not be significantly different from the general population. Therefore, it is necessary to pay attention to the socio-cultural aspects of sexuality in Iran, because Iranian women’s description of sexual norms is different from women in Western countries in some ways, and emotional intimacy is the main aspect of Iranian women’s sexuality and a prerequisite for a fruitful sexual life. Because the healthcare system in Iran is not well-suited to solving sexual problems, and individuals often use informal sexual education (Farnam et al., 2014), our findings highlighted the need to provide effective sexual and reproductive healthcare services to all Iranian women. Women with a history of RPL should also be mainly targeted for sexual counseling in infertility centers.
In the present study, sexual desire was the most common complaint regarding the sexual function of the participants, while vaginal lubrication was the least frequent. In contrast, in the study conducted in Portugal, a comparison of women with a history of recurrent miscarriage with those without miscarriage was indicative of sexual dysfunction in all the domains of sexual function, except for sexual desire (He et al., 2019). However, a systematic review indicated that poor physical health, low life satisfaction, and a sense of guilt about previous miscarriages are the risk factors for sexual desire disorders in women (McCool-Myers et al., 2018). Low libido is strongly linked to depression (Basson & Gilks, 2018), common in women with RPL (Kolte et al., 2015). Furthermore, it has been reported that loss of sexual desire is higher among women who had repeated induced abortions. In a study on sexual dysfunction after a first-trimester induced abortion in a Chinese population, the women with an abortion history reported a greater willingness to engage in sexual behavior without love than those without an abortion history (Fok et al., 2006). It has been proposed that sexual pleasure is often not prioritized by subfertile couples due to concerns regarding the loss of a pregnancy or the pressure for childbearing, which could in turn adversely affect sexual desire. The pressure to perform sexual activity within a specified period (intercourse in the ovulation period) for conception may also lead to the lack of sexual desire or sexual pleasure in women. Therefore, sexuality and reproductive capacity are closely correlated in subfertile couples (Lewis and Black, 2006), and fertility problems may lead to changes in their sexual self-esteem, sexual relations, and sexual function (Tao et al., 2011). Although healthcare providers may inquire about couples’ sexual activity and practices, there is often limited discussion regarding sexuality unless the patient raises the issues. Sexuality should not be examined only for pregnancy and childbirth purposes (Banaei et al., 2020), and subfertile couples’ satisfaction and sexual pleasure should also be addressed in fertility clinics. Considering that the lack of sexual desire has been reported to be the most common concern in the general population (Ghiasi & Keramat, 2018), pregnant women (Jamali & Mosalanejad, 2013), and infertile women (Omani-Samani et al., 2019), establishing a systematic framework for the provision of sexual health services to all women seems to be essential. 
Our results showed that sexual function and its domains had no significant correlations with demographic characteristics. Similarly, in a study in Denmark, gestational age and the procedure used to terminate the last pregnancy had no significant associations with female sexual function (Boesen et al., 2004). Moreover, a study conducted in Italy indicated that women undergoing medical termination of pregnancy had higher FSFI scores than the women undergoing surgical termination of pregnancy, which suggests the effect of the procedure used to terminate the last pregnancy on sexual function. However, this finding is inconsistent with the results of the present study. On the other hand, the mentioned study demonstrated that women’s age is not correlated with their sexual function, which is in line with the findings of the current research. The effect of age on female sexual function is unclear (McCool-Myers et al., 2018), and further studies are required to examine the predictors of sexual function, specifically in women suffering from RPL.
In the present study, diminished vaginal lubrication had the lowest prevalence. Vaginal lubrication and sexual satisfaction are the least recognized areas of sexual dysfunction in the general population in Iran (Hamidi Madani et al., 2018), and in a review study conducted by Ghiasi and Keramat, orgasmic disorders were reported to have the lowest prevalence in the women of the reproductive age (Ghiasi & Keramat, 2018). 
One of the limitations of the current study was including patients from one referral recurrent miscarriage clinic, which might raise questions about the generalizability of the findings. In addition, women with a history of RPL usually refer to fertility centers less often, and this contributed to the reduction of the sample size. Therefore, the findings of the present study should be interpreted and used with more caution. In addition, the lack of a comparison group can be mentioned as another limitation. 
5. Conclusion
The findings of this study showed that half of the women with RPL had impaired sexual function. Also, these women predominantly experienced decreased sexual desire, while they did not have much problem in terms of vaginal lubrication. No relationship was found between RPL and the sociodemographic characteristics of these women. Further investigations are recommended to be conducted in order to compare the sexual function of women with RPL history with the general population or infertile women. Since sexual dysfunction is common in Iran, the results cannot necessarily be attributed to RPL. Given that psychological functioning, sexual satisfaction, and erectile function may impair in men with RPL partners (Zhang et al., 2016), similar studies need to be conducted in Iran to assess the sexual function of the men whose partners experience RPL. The women with RPL predominantly experienced decreased sexual desire, while their vaginal lubrication was not problematic. Sexual health clinics should be established in infertility centers to provide sexual healthcare services to strengthen infertile couples’ marital relations. This study may contribute to drawing the attention of policymakers toward sexual issues in women with RPL history. Appropriate interventions to reduce sexual dysfunction in women with RPL are highly recommended. 
Ethical Considerations
Compliance with ethical guidelines
The ethics committee of the Iran University of Medical Sciences (IR.IUMS.REC 1396.31743) approved the research proposal. The objectives of the research were explained to the participants and informed written consent was obtained from all the women who participated in the study. 
Funding
This study was funded by a grant from the Iran University of Medical Sciences (IUMS) (No.: 96-03-123-31743). The funding body has no role in the design of the study and the collection, analysis, and interpretation of data.
Authors' contributions
All authors equally contributed to preparing this article.
Conflict of interest
The authors declared no conflict of interest.

The authors wish to thank Mrs. Haleh Maleki for her support. Without her help, this work would never have been possible. We also appreciate the women who participated in the study. 


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