The pathophysiology of coronavirus disease 2019 (COVID-19) is associated with a variety of functional changes in multiple physiological parameters.

The direct effects of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on male and female urogenital organs have yet to be determined. Nevertheless, various explanations based on biological similarities between SARS-CoV and SARS-CoV-2 have been offered.

Study: How has COVID-19 affected sex and fertility?  Credit: Chinnapong/

To learn: How has COVID-19 affected sex and fertility? Credit: Chinnapong/

In a recent Trends in urology & men’s health The study discusses the possible effects of SARS-CoV-2 on sexual activity and fertility.

Genital ACE2 receptors

SARS-CoV-2 primarily infects cells that have angiotensin converting enzyme 2 (ACE2) receptors on their surface. In addition to ACE2, the transmembrane serine protease 2 (TMPRSS-2) is often required.

Except for the epididymis, ACE2 receptor expression is observed throughout the male genital tract, particularly in Sertoli cells and sperm stem cells. Previous studies have shown that biopsies taken from the testicles of infertile men express elevated levels of ACE2 receptors in both germ and somatic cells.

ACE2 receptors are also expressed in the ovaries, endometrium, myometrium and decidua, and in the vagina, according to two recent reviews. The trophoblast in the first trimester, as well as the placenta, chorion, amnion, and umbilical cord of late pregnancy have higher ACE2 expression.

A recent study showed that ACE2 receptor expression is relatively minimal in tissue samples from female genital tract and mammary cells, with TMPRSS-2 expression also being minimal or absent. Therefore, it is unlikely that SAR-CoV-2 infection could occur in the female genital tract.

SARS-CoV-2 infection of the genital tract

Several viruses have been detected in semen samples; However, since other possible transmission routes cannot be completely ruled out, it is difficult to prove sexual intercourse as a method of virus transmission. Additionally, previous studies have shown that the presence of SARS-CoV-2 in the vagina is extremely rare, with only four positive results out of 98 women tested.

The impact of COVID-19 on sexual activity

The impact of the COVID-19 pandemic on sexual activity, particularly during lockdown periods, is complicated by several circumstances and may vary from country to country. For example, a study conducted in Turkey found an increasing frequency but lower quality of sexual activity during the current pandemic.

Although various reports in the UK claim that the frequency and quality of intercourse has increased during the COVID-19 lockdowns, the majority of the available evidence supports the opposite. In fact, the sex lives of couples worldwide have reportedly deteriorated as a result of the pandemic. This applies to both quantitative elements such as potency, duration and frequency of intercourse and foreplay, and more subjective aspects such as lubrication, pleasure and libido.

Although several publications have warned of the possible transmission of COVID-19 through sexual intercourse, no evidence has so far confirmed this mode of transmission. Nonetheless, several characteristics of sexual activity increase the likelihood of virus transmission; However, because sperm can take up to 72 days to mature, it’s possible for sperm to remain infectious after being removed from other sites. This is particularly possible when antiviral antibodies cannot cross the blood-testicular barrier.

COVID-19 and fertility

The direct effects of SARS-CoV-2 on sperm remain uncertain. All World Health Organization (WHO) standard parameters for semen analysis were significantly affected in a study involving 84 men with COVID-19 who required hospitalization.

Here, semen samples were analyzed every ten days for up to 60 days, with the semen volume of infected men being about half that of healthy men. In addition, the rate of progressive motility was also reduced by about 50%, which was accompanied by poor morphology. Although the sperm count in each sample and its motility statistically improved over time, these improvements were not clinically significant at 60 days, although they did show a significant p-value.

SARS-CoV-2 has been shown to damage sperm, especially in severe illness; However, the mechanism responsible for this damage is still unknown. A prospective study of infected men found a transient decrease in conception rates.

COVID-19, like any other serious illness, causes menstrual changes, specifically a longer period and decreased volume.

So far, no changes in sex hormones have been detected in people infected with SARS-CoV-2.

In particular, the COVID-19 pandemic is associated with the lowest reproductive rate since 1938. However, COVID-19 itself does not appear to affect the number of births, which is the most important determinant of fertility.

Magazine reference:

  • Christopher Holzhaus. (2022). How has COVID-19 affected sex and fertility? Trends in urology & men’s health 13(3); 17-21. doi:10.1002/tre.855.

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