Use by gynecologists of a modified sensate focus technique to treat vaginismus causing infertility Of 5,341 infertile couples seen over an 8-year period, 76 (1.4%) had primary vaginismus, of whom 63 were treated with the use of a simplified sensate focus technique. There was complete symptomatic resolution of vaginismus in 60 women, and pregnancy was achieved in 33. (Fertil Steril Ò 2010;94:2393–5. Ó2010 by American Society for Reproductive Medicine.) Key Words: Vaginismus, sensate focus technique, infertility, behavioral therapy, invitro fertilisation Problems in sexual intercourse have an important cause and effect relationship with infertility in a large proportion of infertile couples (1, 2). In our earlier study, a large number (52.5%) of infertile women reported suffering from psychosexual problems (3). Vaginismus is one such psychosomatic disorder of the female partner which precludes the intravaginal deposition of sperm. Such cases may frequently present with nonconsummation of marriage, dyspareunia, and infertility, and with secondary erectile dysfunc- tion in the male partner (4–7). The incidence of vaginismus varies from 2% in the general population to 47% in sex therapy clinics (8–11). Several different treatments have been tried to treat vaginismus (12–18). Many unnecessary procedures such as hymenectomy and surgical widening of vagina have also been performed (19). In spite of an important relationship between vaginismus and infertility, there are hardly any reports on the outcome of infertil- ity after the management of vaginismus (20, 21). ‘‘Sensate focus,’’ a technique originally described by Masters and Johnson, involved counseling and active participation of both partners in vaginal dilatation (12). This was later modified by Kaplan to treat different sexual problems and enhance sexual pleasure (13). The technique consists of a series of structured instruc- tions for touching activities to help couples overcome anxiety and increase comfort with physical intimacy. The focus is on touch rather than on performance (14). We designed this study to assess the clinical role of vaginismus as a cause of infertility and a management approach in the hands of the gynecologists. The study was performed at an assisted repro- duction center in northern India. Approval of the institutional review board of the center was obtained before the study was undertaken. We used a simplified treatment program based on a program described by Lamont (22) which stressed individual therapy and digital self-dilatation by the female partner. This method has the advantage of a better therapeutic alliance with the woman to let her assume self-responsibility and take gradual control of her condition. Our program was undertaken in the infertility clinic without the need for referral to a psychologist or a sex therapist. Our study included all women of reproductive age who wished to become pregnant and had presented with one or more of the follow- ing symptoms: [1] nonconsummation of marriage; [2] dyspareunia without any obvious organic cause; [3] presence of infertility, sig- nificant vaginismus on genital examination, and admission by the woman of incomplete penetration and/or extravaginal deposition of semen; and/or [4] secondary onset erectile dysfunction in the male partner in the presence of vaginismus in the female partner. The severity of vaginismus was graded from 1 to 5 according to Lamont’s criteria on the basis of genital examination (22). The treatment protocol consisted of four main components distributed over weekly sessions, each of 15 minutes’ duration (Table 1): [1] counseling and education regarding the anatomic and psychological basis of vaginismus to both partners; [2] Kegel exercises, gradual desensitization, and learning of pelvic muscle relaxation; [3] counseling of male partner to remove any fears or performance anxiety along with treatment of erectile dysfunction; [4] sensate focus exercises to increase communication and strengthen relationship, with stepwise learning of intercourse (12, 13, 22, 23). A flexible approach was used, depending upon the severity of vaginismus, the level of participation of the male partner, and the degree of rapport developed with the couple. In general, the first few visits were devoted to reassurance, confidence-building, explanation, and desensitization. These com- ponents were gradually replaced by sensate focus exercises in the form of task assignments as a part of the stepwise learning of intercourse (see Table 1). Hymenectomy was performed in those women who failed to achieve sexual intercourse after resolution of vaginismus because of the presence of a rigid hymen. Of the total 5341 infertile couples seen at the center during the 8-year study period, 76 women (1.4%) had infertility diagnosed as primary vaginismus; 13 women who did not consent to the Umesh N. Jindal, M.D. Sheetal Jindal, M.D. Jindal IVF and Sant Memorial Hospital, Chandigarh, India Received December 17, 2009; revised March 26, 2010; accepted March 29, 2010; published online May 7, 2010. U.N.J. has nothing to disclose. S.J. has nothing to disclose. Reprint requests: Umesh N. Jindal, M.D., Director and Consultant, Jindal IVF and Sant Memorial Hospital, 3050, Sector 20-D, Chandigarh, India (FAX: þ 91-172-2745959; E-mail: [email protected]). 0015-0282/$36.00 Fertility and Sterility â Vol. 94, No. 6, November 2010 2393 doi:10.1016/j.fertnstert.2010.03.071 Copyright ª2010 American Society for Reproductive Medicine, Published by Elsevier Inc.
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