This prospective before-and-after study was conducted at the Reproductive Medical Center of Shengjing Hospital. The study periods were April and May 2022 (during the lockdown), December and January 2023 (when controls were fully liberalized), and May and August 2023 (in the post-pandemic era). Infertility is defined as the incapacity to conceive after one year of unprotected intercourse [14].

In establishing inclusion criteria, individuals were required to have a confirmed diagnosis of infertility, fall within the age range of 20 to 45 years, be married, and cohabit with their spouses. To mitigate the potential impact of age and endocrine factors on sexual function and health, the study exclusively enrolled participants under the age of 45 who were married and living with their spouses. Conversely, exclusion criteria comprised individuals who withdrew from the study midway or failed to complete the entire questionnaire during each stage, those consuming medications known to affect sexual function and/or mental state (selective serotonin reuptake inhibitors, tricyclic antidepressants, and phosphodiesterase type 5 inhibitors) [15], individuals with clinically diagnosed sexual dysfunction predating their infertility diagnosis, and those with pre-existing psychiatric conditions known to induce sexual dysfunction. All participants were sourced from the pool of patients undergoing assisted reproductive technology treatments at the reproductive medical center, with each participant providing informed consent for their involvement in the study. This study has been approved by the ethics committee (approval number: 2020PS009F) and conforms to the principles of the Declaration of Helsinki.

This study explored the sexual and mental health of women with infertility during the three stages of the COVID-19 pandemic using questionnaires comprising data of general information about the patients, levels of anxiety and depression, changes in sexual behavior, and levels of sexual function (Fig. 1). Demographic information about the participants included age, height, weight, economic status, duration of infertility, education level, frequency of physical exercise, smoking, and drinking status.

We gauged participants’ levels of anxiety and depression utilizing well-established standardized mental health questionnaires. For the assessment of anxiety symptoms, the 7-item Generalized Anxiety Disorder scale (GAD-7) was employed. Each item was scored on a 4-point scale, ranging from 0 to 3. The cumulative score spanned from 0 to 21, with scores of 5, 10, and 15 signifying mild, moderate, and severe anxiety symptomatology, respectively [16].

To evaluate depression symptoms, we employed the 9-item Patient Health Questionnaire (PHQ-9). Items on the PHQ-9 were scored on a 4-point scale, ranging from 0 to 3. The overall score ranged from 0 to 27, with scores of 5, 10, 15, and 20 denoting mild, moderate, moderate-severe, and severe depression symptom levels, respectively [17]. This systematic approach ensured a comprehensive and nuanced evaluation of participants’ mental health, providing a detailed understanding of both anxiety and depression across various severity levels. The use of established scales and scoring criteria further enhanced the reliability and comparability of the assessments.

To evaluate changes in sexual behavior, we explored participants’ sexual desire, frequency of intercourse, sexual satisfaction, frequency of masturbation, and pornography use across three distinct stages, employing structured questionnaires. Female sexual function was assessed through the Female Sexual Function Index (FSFI), a comprehensive instrument featuring 19 items and six domains (desire, arousal, lubrication, orgasm, satisfaction, and coital pain). This assessment was based on the participants’ sexual experiences in the preceding four weeks [18].

A total FSFI score of ≤ 23.45, aligned with the Chinese cut-off, served as an indicator of potential sexual dysfunction [19, 20]. The Cronbach’s alpha values, surpassing or equal to 0.82, reflected the reliability of the FSFI in measuring female sexual function [18]. This methodology facilitated a thorough examination of various aspects of sexual behavior and function, providing valuable insights into potential changes and challenges experienced by the participants throughout the specified stages.

The data was analyzed using the SPSS statistical software (version 22.0; SPSS Inc., Chicago, IL, USA). Categorical variables were succinctly presented as counts and percentages, while continuous variables were summarized using means and standard deviations (SDs). The Chi-square test was applied to compare categorical data, and the ANOVA was employed for numerical data. To gauge the effect size and ascertain the robustness of each statistical analysis, Cramer’s V was calculated for the chi-squared test, and η² for the ANOVA. Post-hoc analysis was implemented to assess differences between multiple groups, and a two-tailed p-value < 0.05 was considered indicative of statistical significance.