Keywords

1 Introduction

This chapter will address various conception-related aspects of sexuality. It will offer relevant information for the midwife, though, in many countries, midwives only become involved after conception has taken place. On the one hand, such information is essential because understanding sexual troubles that develop in the ‘trying to conceive’-phase can have (and probably will have) consequences for sexuality during pregnancy and post-partum. But also because in some countries, the midwife is involved in the broader area of reproductive health. That includes pre-conception care, an area supported by the WHO [1]. This chapter will integrate sexuality in pre-conception care, although almost nowhere mentioned in the literature.

That approach is a logical consequence of ‘chain care’, where the awareness of the ultimate intended outcome upgrades multi-disciplinarity among all professionals.

We use the term ‘chain care’ here. Medical care today exists in an era of superspecialisation. In our field, a couple can come in contact with fertility expertise, obstetric expertise, childbirth expertise, neonatal expertise, sexology expertise and family & relationship expertise. Each profession will focus on its own specific area and influence the couple with relevant recommendations. In that fragmented way, however, both the professional and the couple easily forget the ultimate intended outcome: happy family life and happy couplehood.

In ‘chain care’, the various professions not only cooperate (multi-disciplinarity) but are also aware of the ultimate intended outcome and integrate that awareness into their approach.

‘Good sex’ is a relevant factor in conception. This chapter will deal with such ‘good conception sex’ and explain how factors like intercourse frequency, quality of male arousal, quality of female arousal and proper timing can contribute to the chance to conceive.

That may seem rather unromantic. It is also true that many pregnancies just happen without planning. However, especially in the Western World, many pregnancies are deliberately planned. Such a ‘planned approach’ is part of the lifestyle of many modern couples, who want to design their own life and future. For them, when conception does not happen soon enough, it is not uncommon to get confused. As a result, couples fairly quickly look for medical assistance to keep the parenthood part of their life plan on track. Unfortunately, many professionals then turn to diagnostics and treatment, forgetting (and denying) that sex is the common way to get pregnant.

When conception does not happen in due time, many couples end up in a vicious circle where ‘no-conception-yet’ creates poor sex and where ‘poor sex’ diminishes the chance to conceive and eventually can threaten the quality of the intimate relationship [2].

This chapter intends to provide some clarity in such processes and will successively address:

  • How sexual pleasure can get lost in healthy, ‘trying to conceive’ couples

  • Sexual aspects of pre-conception care

  • The sexual physiology of conception.

The chapter will not deal with disturbed fertility resulting from sexual dysfunction or the sexual aspects of infertility. We will approach those areas in Chap. 11.

2 ‘Conception Inefficiency’ - Losing Sexual Pleasure Along the Way

If fertility is not disturbed, many couples will get pregnant without needing great (conception) sex. That does not really matter as long as conceiving is not, or not yet, important. However, for many contemporary couples, the reality is somewhat different. In the affluent Western World, many couples wait for an extended period before they feel ready to step into parenthood. Then, after discontinuing contraception, they tend to believe that conception will take place within 2 or 3 months.

Some couples will be lucky, and many then experience a boost in self-esteem because of getting pregnant. Others will be less lucky with the risk of disappointment lying in wait. Not succeeding in this area (which usually means not-yet succeeding) can really diminish the couple’s self-esteem. That alone can already considerably decrease sexual desire. Wanting so badly to conceive can quickly influence also the couple’s spontaneity and sexual timing schedule, resulting in stress, less intimacy and intercourse without genuine arousal. A vicious circle can develop between ‘poor sex’ and lower conception chance. That does not mean subfertility, rather ‘conception inefficiency’.

In older fertile women, additional stress can develop when the fear of ‘being too late’ starts interfering.

Such a period of poor sex (because of ‘no-pregnancy-yet’) can spill over into the pregnancy and then into the post-partum phase, finally having negative influences on the relationship quality and happy parenthood.

3 Sexual Aspects of Pre-conception Care

According to the WHO, the ultimate aim of pre-conception care is to improve maternal and child health in the short-term and long-term [1]. From a sexual health point of view, we prefer to broaden that WHO intention and explicitly include the couple’s health, which for an important part means the couple’s sexual health.

Based on that perspective, we will focus on four phases that should belong to pre-conception care:

  1. 1.

    The phase before conception (‘sex for adapting to paternal antigens’)

  2. 2.

    The phase of conception (‘what to do and not to do when wanting to conceive’)

  3. 3.

    The period of pregnancy (‘how to invest in future sexual wellbeing’)

  4. 4.

    The post-partum period (‘how to restart one’s sexual life’).

We will give this information to the woman/couple in a narrative way (including some do’s and don’ts) and add some explanation for the HCP.

We will give the explanatory narratives for the woman/couple in italics.

3.1 The Phase Before Conception

A fascinating new line of obstetric knowledge deals with immunology. Some pregnancy disturbances appear to happen less when the mother has had ample exposure to paternal semen (the ejaculate of the father of this pregnancy). Regularly having condomless sex for 6 months is associated with less pre-eclampsia and less abnormal uterine activity (resulting in small-for-gestational-age babies) [3]. There are also indications that paternal semen exposure can prevent part of recurrent abortions. For a more extensive explanation, see Chap. 4.

For practice, you have to know if the couple regularly had sex in a way that the woman was exposed (vaginally, orally or anally) to the paternal semen. In other words: you have to ask the clients.

If the answer is negative, you can use the following narrative:

  • When a woman is pregnant, half of the baby is foreign material (antigens from the father). That foreign material can cause trouble for the pregnancy. It increases the risk for high blood pressure problems and abnormal womb activity, resulting in too small babies. Besides, it seems that it can be an underlying reason for miscarriages.

  • We are learning that the woman can get adapted to the antigens of this specific father. Research shows that regular exposure to his semen diminishes those risks. So, we recommend considering postponing conception for half a year and regularly having sex with exposure to semen and without condoms. That could also have an extra benefit, since semen is partly absorbed, with anti-depressant influence [4].

That should be followed by some practical explanation, depending on why there was no yet exposure to paternal semen. Sometimes that information will ask for a balancing act with exposure in the non-fertile days of the cycle.

3.2 The Phase of Conception

  • ‘You’ll be in the process of trying to get pregnant.

  • Some couples will be lucky because they just conceive effortlessly. Congratulations to them!

  • In other couples, however, it’ll take more time. The focus then quickly moves away from sexual pleasure towards ‘We have to get pregnant’, sometimes resulting in vicious circles of disappointment, stress and sexual timing that is not only not productive but also not based on sexual pleasure and desire.

  • Let’s be clear. That doesn’t work!

  • On the one hand, pleasure and intimacy are relevant elements towards conception. Higher levels of sexual arousal in women and men increase the conception chance.

  • The same goes for more frequent sexual intercourse and a relaxed approach.

  • There is also another reason to pay attention to good sex and sexual pleasure. The way you will have and enjoy sex during this period of conception will influence the quality of your sexual life during the pregnancy, which subsequently will affect how your sexual relationship will take shape after birth’.

For the couple, sex after pregnancy might seem far away. It can be very beneficial to make couples aware that keeping a good sexual life during this conception phase will spill over into a good sexual life during pregnancy and post-partum. That will finally benefit all parties, with better bonds between the partners and between parents and baby.

Recommendations for Couples

Do:

  • Invest in sexual pleasure and sexual desire.

  • Try as much as possible to be at the same time parents-to-be and lovers. Giving priority to sexuality and intimacy (above career, social media, friends and relatives) is a long-term investment in a sound future as partners and lovers.

  • When using ovulation as an indicator moment, be aware that the chance to conceive is highest with intercourse on day 2 before ovulation.

  • Continue ejaculating regularly. Too long intervals between ejaculations will diminish the quality of the sperm. Once ejaculation every 1–3 days appears the good frequency for conceiving. So, masturbation can sometimes be helpful to keep the sperm quality optimal.

Don’t:

  • Don’t continue sexual intercourse when it hurts. The pain usually means that you are not (or not yet) sufficiently aroused.

  • Don’t stop intercourse because the day of ovulation is over. Semen appears to facilitate proper ingrowth (nestling) in the womb.

3.3 The Period of Pregnancy

  • ‘When you are pregnant, there is a real possibility that changes will occur in your intimate and sexual life. Sexual desire can increase or decrease. In some couples, the changes will go in the same direction for both partners, but frequently it turns out to be different.

  • Moreover, these things change throughout pregnancy because of physical adaptations in the woman and emotional anticipation of your future role as parents.

  • So we emphasise that the quality of your sexual life during the pregnancy will affect your sexual life after childbirth.

  • Once the baby is born, many couples struggle to get their sex life back on track.

  • In the first year after the baby is born, sexuality is an important reason for the tension in the relationship.

  • We also know that couples who successfully keep an active and satisfying sex life during pregnancy will have less (sexual) tension afterwards.

  • In other words: investing in a healthy and satisfying relationship and sexual life throughout pregnancy is a long-term investment in good couplehood and good parenthood.

Recommendations for Couples

Do:

  • Pay extra attention to sexual pleasure and sexual desire.

  • If you are not (yet) used to it, try already at the beginning of the pregnancy to learn to enjoy sex without penetration. Next to being fun, it will provide an extra leeway towards the end of pregnancy, when penetration may no longer be possible or pleasurable.

Don’t:

  • Don’t continue sexual intercourse when it hurts. That usually happens because of a lack of arousal.

  • In the second half of the pregnancy, refrain from having intercourse in the male-superior position. Not only because the big belly makes that position unpleasant for many women, but also because it can be a risk factor for more prematurity and premature rupture of the membranes.

The HCP has several roles concerning sexuality and intimacy during pregnancy.

On the one hand, create a sexuality-friendly open atmosphere and clarify that whenever the woman or her partner has worries or questions, they should bring them up.

On the other hand, proactively educate couples on possible sexual alterations due to a shifting relationship and changes in the woman’s body and function. This way, we invest in the sexual future after birth and the transition to parenthood.

3.4 The Post-partum Phase

When dealing with couples in the period around conception, it might seem strange to talk about the post-partum phase already. However, good chain care requires anticipation of the subsequent phases. After all, most couples finally strive for a healthy family with a healthy child living under the wings of a healthy couple. Given that many couples face relationship tension in the post-partum year, with sexuality problems upfront, we believe that discussing common peri-partum and post-partum realities should be an integral part of pre-conception care [2].

In the first post-partum months, the mindset of the majority of young mothers is primarily focussed on the baby and not on the partner. Regularly, her hormones and her vagina are not yet ready for intercourse, especially not when she is also breastfeeding or when she has experienced any form of birth trauma.

On the other hand, many young fathers want to return to their previous sexual pattern, with testosterone levels far higher than the mother has, which usually means more sexual desire. At the same time, men can get seriously confused by their new roles as fathers and the sudden change from a dyad to a threesome. Sexuality is a common male ‘method’ for stress relief. That combination of factors can cause confusing or severe complications in the couple’s sexual life. Such disappointment and alienation after childbirth can easily have negative repercussions for the sexual future of the couple [2].

  • It might seem strange to address sexuality for the period around and after birth. However, during that phase, your sexual life can get entirely disrupted.

  • There is nothing wrong with the sexual routine you have developed together. That sexual routine, however, is most probably not very useful in the later stages of pregnancy and the first months after birth. Certainly not when you intend to breastfeed the baby.

  • Since those sexual disturbances can have long-lasting effects on the relationship and negatively influence parenthood, it seems wise to anticipate and be prepared.

  • So the challenge here is: How to keep sexuality rewarding and connecting during this period?

  • We’ll address the two most important topics: ‘Sexually keeping up with each other’ and ‘The automatism to end a sexual encounter with penetration and orgasm’.

  • Regarding sexually keeping up: in all couples, the partners differ in their level of sexual desire. That doesn’t need to be a problem. However, dealing with those differences can be difficult and might become a problem. Couples who learn how to deal with those differences tend to have a happier and more satisfying sex life. As the pregnancy proceeds and after birth, that becomes very relevant.

  • Regarding penetration (with or without orgasm) as end-of-sex: Many couples develop a routine to end a sexual encounter by penetration and intra-vaginal (male) orgasm. There is nothing wrong with that, however, such automatism precludes relaxed intimacy when the vagina is sore. In the last pregnancy months and after birth, it is common that the woman is not ready for penetration.

  • Then, when ‘real sex’ means penetration, a sexual encounter inevitably will end in pain for her, resulting in distress and disappointment for both.

  • Many couples avoid that trap by ‘intimate masturbation’: cuddle until the woman’s need for intimacy is satisfied and the partner can proceed to extra-vaginal stimulation and orgasm while lying in her arms.

  • When negotiated and agreed upon by the couple, such sexual routine adaptations resulted in many couples in sexual encounters with less tension, less pain, fewer feelings of guilt and more intimacy.

  • We honestly believe that no couple should get pregnant before they feel sufficiently at ease with sex and orgasm without the need to vaginal penetration.

4 Recommendations for the Professional

Let us assume that the reader believes in the benefits of such sexual anticipation as a form of sexual health prevention. It will not be easy for many HCPs to integrate this into pre-conception care. Here are some arguments in support:

  • Couples who have learned to cope with differences in sexual desire and who can cope with sex without penetration will benefit throughout the rest of their relationship.

  • Honest, open information about sexuality generally improves the relationship of trust between the woman, the couple and the HCP.

Do:

  • Prepare a leaflet with the required sexual information in your patients’ language(s).Footnote 1

  • If this sexual anticipation talk is new, try to practise with your partner or colleague a few times. Talking out loud about sex is different from just saying it in your mind.

  • The next step could be to practise with a friendly couple a few times. Discussing sex with a male partner present is different anyway.

  • Adapt (within your comfort zone) your narrative to the language of the couple.

  • Ask the couple how they, with the provided information, could develop changes in anticipation of the future. That sometimes causes a confidence boost when a couple succeeds in ‘helping themselves’ with their own ideas.

Don’t:

  • Be careful not to let your own sexual frame of reference prevail.

  • Don’t let the leaflet replace your own verbal connection when using flyers. It is better to hand out a leaflet at the end of your conversation, and next time ask if that raised any questions.

  • Sometimes it is tempting to recommend couples: ‘Do this or do that!’ directly. That is not wise in terms of the professional relationship with the couple. When a couple obediently follows your ‘direct sexual advice’, you run the risk of virtually becoming a part of their ‘sex scene’, which can be very tricky. It is better to recommend indirectly via experiences of other couples: ‘I know that some couples in the same situation did such and so. For many, that helped rather well. So, maybe that is something for you to consider!’.

5 The Sexual Physiology of Conception [5]

In healthy couples who do not use contraception, the average time required for conception is 5.3 months, and 25% of couples have conceived after 1 month of unprotected intercourse [6]. Since, for some other healthy couples, it can take more than 1½ years, it feels a bit like a lottery.

As long as a couple is fertile, they can get pregnant, even when their sex is clumsy. However, it will be evident that the chance of conception is far higher with good procreative sex.

In this part, we will first address the various aspects of ‘optimal sexual logistics’ (timing, choreography, etc.), and we then will close with some recommendations on how to improve sexual desire when that threatens to get lost.

5.1 Frequency of Intercourse

Frequently engaging in coitus enhances the chance of conception considerably. With intercourse 4×/week, the chance of conception is 4–5× greater than with intercourse occurring ≤1/week. With a regular menstrual cycle, intercourse 2–3×/week appears okay.

5.2 Timing of Intercourse

For conception, one needs spermatozoa and a fresh ovum. Healthy spermatozoa can survive up to 6 days in the woman’s body. The ovum survives 12–24 h after ovulation (although some unintended conceptions seem to happen 48 h after ovulation). For conception, intercourse should take place in the ‘fertile window’. That is the period from 6 days before till 12 h after ovulation. The optimal time within the fertile window is when the cervical mucus is abundant, whitish and slippery as egg white. Another reliable (but much more expensive) method is an ovulation test. The best time for intercourse is 2 days before ovulation [7].

Between ejaculation and fertilisation, spermatozoa undergo capacitation, which takes 1–4 h before they are ready for their job. Capacitation is a chemical process in the cervical mucus and cervical crypts, enabling the sperm cell to impregnate the ovum. From the ejaculated pool, continuously new capacitated spermatozoa start their journey. Remember that an ejaculate contains some 50 million spermatozoa.

The conception chance is highest when sufficient viable spermatozoa are already available at the ovulation site. That supports the advice to regularly have intercourse during the fertile window (and the 2 days before ovulation). So, couples who wait for intercourse till the ovulation test indicates actual ovulation will miss the optimal opportunities for conception.

After having conceived, the embryo has to implant successfully in the nidation window (day 6–12 after ovulation). Proper nidation (usually at day 9) appears to be positively influenced by regular intercourse. Probably acting via humoral immunity by which the emerging embryo is accepted by a woman’s body, despite being a ‘foreign invader’ [8].

5.3 Frequency of Ejaculation

It is not wise to ejaculate very frequently (several times per day) when trying to conceive because that will diminish the sperm quality. On the other hand, ‘saving’ (prolonged period of abstinence till ovulation) also decreases sperm quality. Abstinence of 5 days gives the optimal quality and amount of sperm, relevant for male partners with limited opportunities for sexual contact. For couples living together, the optimal frequency is probably once every 1–2 days, because of the above mentioned benefits of repeated intra-vaginal ejaculation.

5.4 Female Sexual Arousal

Whereas the vaginal surface is typically just moist, sexual arousal creates lubrication, a fluid with several functions. Lubrication has fertility functions next to pleasure and preventing mechanical irritation (which causes pain). With a high O2 content and the proper pH, the lubrication fluid facilitates metabolism, mobility and lifespan of the spermatozoa [5].

The vagina of the sexually not-aroused woman has an acid pH (between 3.8 and 5.0) in which yeasts and other pathogens cannot grow. Spermatozoa, however, are immobilised at a pH <6.3. That is why lubrication fluid has a neutral pH of around 7.0.

Besides, good lubrication will make the penis slide better, prevent dyspareunia and increase sexual pleasure. That is another relevant argument for good arousal since it will increase the chance of repeated sex and thus the chances of conception. Artificial lubricants were supposed to harm spermatozoa. However, recent research corrected this idea [9]. Lubricant use gave a slight increase in the conception rate.

At high arousal, the cervix and uterus move away from the posterior vaginal wall (the ‘tenting effect’), preventing the bulk of sperm from entering the cervix before capacitation has started to take place [2].

5.5 Male Sexual Arousal

With a high level of male sexual arousal, the sperm quality gets better [10]. There is also a timing element. With a more extended pre-ejaculatory arousal period, the sperm concentration will improve [11].

Good arousal will also increase the chance of repeated sex with a higher chance of conception.

5.6 Female Orgasm

Orgasm’s impact on conception chances is still not fully clear [12]. Immediately after ejaculation, the sperm coagulates and then (after approximately 10 min) decoagulates. Since the spermatozoa first need some hours before being capacitated and viable to start the journey to the ovum, an orgasm most probably will not favour conception with the ejaculate of this sexual encounter.

That could be different from the ejaculated sperm of last evening. Around the ovulation period, subendometrial smooth muscles send peristaltic waves from the cervix to the Fallopian tube at the side of the ovulation. Oxytocin, peaking during orgasm, facilitates those myometrial waves. From that perspective, orgasm could bring the sperm of last evening to the site of ovulation. But maybe more important here again, a satisfactory orgasm can be a good reason to repeat the sexual encounter and by the higher frequency enhances the conception chance.

Recommendations (for narratives or folders) for the couple to improve their sexual life when sexual pleasure is dwindling

When you dearly want to get pregnant, but don’t have success, you can easily lose your sexual desire. The pressure to sexually perform well will not increase sexual pleasure. And neither ‘having sex at fixed times’ nor ‘enjoying sex on command’ is easy. After all, one cannot be forced to have fun. From such situations, we have learned some strategies to improve your sex life. Many of those recommendations aim to create conditions for intimacy since intimacy is an important condition for sexual desire and enjoyable sex.

  • Make sure you will not be disturbed. Keep social media out of the bedroom (just turn off that smartphone, TV and doorbell).

  • Create time for intimacy. Doing things together with nobody else around can reestablish your bond. Doing household chores or craftwork together can work as foreplay. Some couples benefit from physical activities like working out, dancing, sporting or enjoying wellness treatment together.

  • Create intimacy. A cold, non-cosy bedroom with an iron board in the corner is not very erotic.

  • Take joint responsibility to strengthen your sexual relationship. Instead of repeatedly reminding the other what is not working, you better indicate what could bring you in a more sexual mood. Many couples enjoy thinking back to the exciting moments when they fell in love or had good sex.

  • Accept being different. Usually, women are more sensitive to undivided attention, romance and intimacy, and men are more sensitive to variety, visual cues (from lingerie to nudity) and explicitly shown excitement.

  • There tends to be a lot of arousal at the edge of your comfort zone. Depending on the limits of your comfort zone, you could try to spice things up. Examples are incense, massage oil, sauna, romantic movies, X-rated movies, toys, etc.

  • Some alcohol can create extra relaxation, looseness and sexual ease for some couples. That is not dangerous for the baby before nidation (usually at day 9 after ovulation) as the fetus is still wholly separated from and not influenced by the mother’s circulation.