Three counseling approaches improved sexual function scores in pregnant women — but 21 of 24 studies came from Iran
Journal: International Journal of Gynaecology and Obstetrics | Published: 2025-08-27 | Type: Systematic Review, Meta-Analysis | PMID: 40862488 Authors: de Aquino Antonio Carlos Queiroz et al. (Federal University of Rio Grande do Norte, Brazil; University of Rochester Medical Center, USA) Funding/COI: Funding not listed. Authors declare no conflicts of interest.
de Aquino et al., 2025 pooled 24 RCTs (1,557 participants) testing non-pharmacologic interventions for sexual dysfunction during pregnancy. Cognitive behavioral therapy (CBT), the PLISSIT counseling model, and structured sex education all produced statistically significant improvements on the Female Sexual Function Index (FSFI), a validated 36-point scale. The problem: 21 of 24 studies were conducted in Iran, follow-up maxed out at 8 weeks, and heterogeneity was high enough in two of three pooled interventions to make the summary estimates questionable.
The methodological framework is solid on paper: PROSPERO-registered protocol (CRD42022382974), PRISMA-compliant reporting, eight databases searched, dual independent reviewers, Cochrane RoB 2.0 for bias assessment, GRADE for evidence certainty. Restricting inclusion to RCTs is the right call given how easily uncontrolled studies would inflate effect sizes here. The comparison arm — routine prenatal consultation with no structured intervention — is a low bar, and the observed FSFI gains reflect that gap.
Heterogeneity is the headline problem. The PLISSIT and sex education pools both show I²≥80%, which means the individual studies are producing results inconsistent enough that pooled estimates should be interpreted cautiously. CBT fares better on domain-level heterogeneity, but there is a direct numerical discrepancy between the abstract (which reports I²=3% for CBT total FSFI score) and the synthesis section of the same paper (which reports I²=73% for the same estimate). That internal inconsistency was not acknowledged or explained anywhere in the paper — it is an error in a published meta-analysis, and it matters.
This is a competent meta-analysis doing exactly what a meta-analysis should: aggregating the available RCT evidence and running the numbers. The finding that structured counseling outperforms a routine prenatal visit for sexual function scores is not surprising, and the effect sizes (~6 FSFI points across three interventions) are clinically plausible. The value is in the synthesis. The limitations are real but largely structural — you cannot blind participants to receiving therapy, and you cannot retroactively diversify a literature that is geographically concentrated. The undisclosed I² discrepancy in the CBT analysis is the most troubling issue and should have been caught in peer review. Worth reading for the GRADE domain-level tables, but treat the headline pooled estimates — especially for sex education, where GRADE rated evidence as low to very low — with appropriate skepticism.