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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

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2. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: Yes

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Reviewer #1: No

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Reviewer #1: Yes

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Reviewer #1: Title: Impact of Voluntary Termination of Pregnancy on Female Sexual Function: A French Monocentric Longitudinal Study

Article type: Research Article

Summary

This prospective, monocentric longitudinal study evaluates the prevalence and trajectory of female sexual dysfunction over six months following voluntary termination of pregnancy (VTOP), using the validated Female Sexual Function Index (FSFI) diagnostic threshold. The authors report a reduction in sexual dysfunction prevalence and improvement in FSFI scores over time among women completing follow-up, with relationship status and psychological symptoms associated with persistent dysfunction.

The topic is clinically relevant and underexplored, and the use of a validated FSFI cutoff strengthens interpretability. However, very high attrition, limited power at later time points, and potential selection bias substantially constrain causal inference and generalizability. The manuscript is generally well written and transparent about limitations, but several methodological and interpretive issues should be addressed before the work can be considered robust enough for publication.

Major Comments

1. Attrition Bias and Internal Validity (Major Concern)

Loss to follow-up is extreme: only 47 of 186 participants (25.3%) completed the 6-month assessment, and only 24 (12.9%) completed all time points. This raises serious concerns about selection bias and threatens the validity of longitudinal conclusions.

• Although the authors correctly state that missingness is likely MNAR and avoid imputation, the primary conclusion (“sexual dysfunction appeared to improve”) relies entirely on completers, who differ systematically from non-completers (e.g., higher prevalence of sexual violence and anxiety).

• Mixed-effects models do not resolve bias when attrition is informative.

Recommendations:

• Explicitly reframe conclusions as conditional on follow-up completion, including in the abstract.

• Provide a baseline comparison table between completers and non-completers at 6 months, not only descriptive statements.

• Consider sensitivity analyses such as:

o Pattern-mixture or worst-case scenario bounds.

o A conservative assumption that non-completers did not improve.

2. Absence of a True Pre-Pregnancy Baseline

Baseline FSFI measurement occurred after pregnancy discovery but prior to VTOP, not before the unintended pregnancy itself. This complicates causal interpretation.

• Improvements may reflect resolution of pregnancy-related stress, not effects attributable to VTOP or post-VTOP recovery.

• The discussion acknowledges this limitation but still implies recovery “after VTOP.”

Recommendations:

• More clearly distinguish between:

o Effects of unintended pregnancy

o Effects of VTOP

o Natural temporal regression

• Revise causal language throughout (e.g., “following VTOP” → “over time after pregnancy resolution”).

3. Sample Size Justification and Statistical Power

Sample size was determined empirically rather than through formal power calculations.

• While acceptable for exploratory research, this limits confidence in null findings for secondary outcomes.

• Several adjusted analyses may be underpowered, especially at later time points.

Recommendations:

• Explicitly state which analyses are exploratory.

• Avoid overinterpretation of non-significant associations (e.g., violence history, VTOP method).

4. Measurement of Psychological Covariates

Psychological symptoms (sadness, anxiety, guilt, fatigue) are assessed using non-validated, study-specific items rather than standardized scales (e.g., PHQ-9, GAD-7).

• This limits reproducibility and interpretability.

• The term “depressive symptoms” may overstate what was actually measured.

Recommendations:

• Clarify terminology (e.g., “self-reported psychological symptoms”).

• Acknowledge the lack of validated mental-health instruments as a limitation.

• Avoid clinical labeling where diagnostic thresholds were not applied.

5. Generalizability

The study is monocentric, with a high proportion of surgical VTOP (66%), exclusion of women with psychiatric comorbidities, and reliance on internet-based follow-up.

• Results may not generalize to:

o Medical abortion settings

o Women with pre-existing mental health conditions

o Populations with limited digital access

Recommendation: Expand the generalizability discussion and avoid extrapolation beyond similar care settings.

6. Qsuestionnaire validation:

The Methods section should more clearly justify the use of the FSFI diagnostic cutpoint (≤26.55), including its psychometric validation, applicability to the French population, and rationale for its use as a binary outcome defining sexual dysfunction.

7. Discussion Enrichment:

In addition to other points that discussed above and should be considered in the discussion, the Discussion would benefit from enrichment addressing how reliance on this diagnostic cutpoint and on a self-reported questionnaire influences interpretation of prevalence estimates, longitudinal change, and clinical relevance, particularly in the absence of a true pre-pregnancy baseline. Specifically, the authors may wish to discuss (optional):

(i) the distinction between changes in FSFI-defined dysfunction prevalence versus changes in continuous FSFI scores;

(ii) the extent to which observed improvements may reflect resolution of pregnancy-related psychological stress rather than post-VTOP recovery per se; and

(iii) how self-reported sexual function measures may be influenced by concurrent emotional state, relationship context, and recall bias over time.

Minor Comments

1. FSFI Interpretation: Clarify whether domain-level changes exceeded minimal clinically important differences, not just statistical significance.

2. Figures: Figure 2 could benefit from displaying raw numerators (n/N) alongside percentages.

3. Language: Some statements in the Discussion imply causality; revise to observational phrasing.

Strengths

• Prospective longitudinal design.

• Use of a validated FSFI diagnostic threshold, addressing a key gap in prior literature.

• Transparent reporting of limitations and ethical safeguards.

• Clinically relevant focus on sexual health, an often-neglected outcome in VTOP care.

Overall Recommendation

Major Revision

The study addresses an important and underreported aspect of reproductive health and meets PLOS ONE’s scope. However, substantial revisions are needed to tighten causal language, address attrition bias more rigorously, and temper conclusions. With these changes, the manuscript could make a valuable descriptive contribution to the literature.

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Reviewer #1: Yes: Saharnaz NedjatSaharnaz NedjatSaharnaz NedjatSaharnaz Nedjat

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Impact of Voluntary Termination of Pregnancy on Female Sexual Function: A French Monocentric Longitudinal Study

PONE-D-26-01018R1

Dear Dr.Rouchou,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Mahsa Ghajarzadeh

Academic Editor

PLOS One

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