Fertility Patients Under COVID-19: Attitudes, Perceptions and Psychological Reactions

Reut Ben-Kimhy; Michal Youngster; Tamar R. Medina-Artom; Sarit Avraham; Itai Gat; Lilach Marom Haham; Ariel Hourvitz; Alon Kedem


Hum Reprod. 2020;35(12):2774-2783. 

In This Article

Abstract and Introduction


Study Question: What are the perceptions of infertility patients and the factors correlating with their psychological distress, following suspension of fertility treatments during the Corona Virus Disease-19 (COVID-19) pandemic?

Summary Answer: Most patients preferred to resume treatment given the chance regardless of background characteristics; higher self-mastery and greater perceived social support were associated with lower distress, while feeling helpless was associated with higher distress.

What is Known Already: Infertility diagnosis and treatment frequently result in significant psychological distress. Recently published data have shown that clinic closure during the COVID-19 pandemic was associated with a sharp increase in the prevalence of anxiety and depression among infertile patients undergoing IVF and was perceived as an uncontrollable and stressful event. Personal resources play an important protective role in times of crisis, helping reduce levels of distress.

Study Design, Size, Duration: This cross-sectional questionnaire study included patients whose fertility treatment was suspended following the COVID-19 pandemic, in a tertiary hospital. The survey was delivered to 297 patients within 12 days at the beginning of April 2020.

Participants/Materials, Setting, Methods: The self-administered questionnaire included items addressing: (i) patients' demographic characteristics, (ii) anxiety related to COVID-19 infection risk and level of social support, (iii) patients' perceptions of the new guidelines and description of subsequently related emotions and (iv) two validated scales assessing levels of emotional distress and self-mastery. Multivariate analysis was conducted to assess factors alleviating or increasing emotional distress during the COVID-19 pandemic.

Main Results and the Role of Chance: There were 168 patients who completed the survey, giving a response rate of 57%. Study variables in the regression model explained 38.9% of the variance in psychological distress experienced by patients during treatment suspension. None of the background characteristics (e.g. age, marital status, parity, economic level or duration of treatments) had a significant contribution. Feeling helpless following the suspension of treatments was associated with higher distress (P < 0.01). Higher self-mastery and greater perceived social support were associated with lower distress (P < 0.01). Despite the ministry of health's decision, 72% of patients wished to resume treatment at the time of survey.

Limitations, Reasons for Caution: This was a cross-sectional study, thus information about patients' characteristics prior to the COVID-19 pandemic was not available. The length and implications of this pandemic are unknown. Therefore, the ability to draw conclusions about the psychological consequences of the crisis is limited at this point of time.

Wider Implications of the Findings: Personal resources play an important protective role in times of crisis, helping to reduce levels of distress. Study findings suggest that attention should be paid to strengthening and empowering patients' personal resources together with directly confronting and containing feelings of helplessness. In line with the European Society for Human Reproduction and Embryology (ESHRE) guidelines, especially at this time of high levels of distress, it is imperative to offer emotional support to reduce stress and concerns. Furthermore, as the pandemic is stabilizing, resumption of treatment should be considered as soon as appropriate according to local conditions.

Study Funding/Competing Interest(S): This study was funded by the IVF unit of the Shamir Medical Center. All authors declare no conflicts of interest.

Trial Registration Number: N/A


The Corona Virus Disease-19 (COVID-19) pandemic started in late December 2019 in Hubei Province, China (Huang et al., 2020) and has since spread rapidly around the globe with many countries in Europe and North America being severely affected (Practice, 2020; WHO, 2020). Its rapid dissemination and exponential infection rate led to a swift implementation of national emergency measures aiming at mitigating risk for the general population, including both patients and healthcare providers. These included self-hygiene, social distancing and widespread imposed quarantines. On 11 March, 20 days after the first Israeli COVID-19 patient was confirmed, the Israeli government began enforcing social distancing including restrictions on gatherings, school closures and public transportation limitations. A national state of emergency was declared, making the restrictions legally enforceable. Similar restrictions were enforced by many affected countries around the globe. In some countries, including Israel, in order to support current public measures and to conserve medical resources for critical care and respiratory support, all elective and non-urgent medical procedures, including reproductive medicine procedures, were discontinued.

On 17 March 2020, the American Society for Reproductive Medicine (ASRM) published guidelines, followed a few days later by the European Society for Human Reproduction and Embryology (ESHRE), recommending the suspension of initiation of all new treatment cycles, excluding urgent pre-gonadotoxic treatment cryopreservation (ASRM, 2020; ESHRE, 2020). In case of ongoing treatments, cycles could be continued with a recommendation of embryo cryopreservation. All other elective surgeries and non-urgent reproductive diagnostic procedures were suspended. At the same time, medical providers were requested to inform patients about the fact that fetal and maternal risks of COVID-19 infection in pregnancy were still unknown (Rasmussen et al., 2020). On 22 March 2020, the Israeli Fertility Association and the Ministry of Health adopted the ASRM and ESHRE guidelines. Following this decision, new fertility treatments and diagnostic procedures in all public and private units were immediately suspended. Ongoing cycles were completed, and embryo transfers were performed, based on unit policy and patient preference.

The inability to conceive has a significant negative impact on women's psychological well-being (Maroufizadeh et al., 2015) and is experienced as devastating (Greil et al., 2010). Infertility diagnosis and fertility treatments are described as severe stressors which arouse significant psychological distress (Greil, 1997; Verhaak et al., 2007a, b) and a range of other emotional responses (Cassidy and Sintrovani, 2008), such as anger, depression, anxiety, feelings of worthlessness (Deka and Sarma, 2010), loss of control, social isolation, a sense of stigma (Greil et al., 2010) and a general disruption in the developmental trajectory of adulthood (Cousineau and Domar, 2007). All these troubling reactions may be exacerbated during a global crisis, such as the one experienced these days with the spread of the COVID-19.

Studies conducted on reactions to infertility and fertility treatments have identified several factors which may contribute to the emotional distress, including mostly primary infertility (Verhaak et al., 2007b.; Epstein and Rosenberg, 2005; Greil et al., 2011), older age (Greil et al., 2011; Qadir et al., 2015), lower educational level and socioeconomic status (Fekkes et al., 2003; Greil et al., 2011), duration of infertility (van Balen and Trimbos-Kemper, 1993) and the intense focus on having a child (Collins et al., 1992). Nonetheless, there are factors that may mitigate and even shield from emotional distress, including resilience (Ridenour et al., 2009), adaptive coping strategies, e.g. problem-focused coping (Musa et al., 2014), emotional processing and expression (Berghuis and Stanton, 2002), social support (Verhaak et al., 2005a; Peterson et al., 2006) and a sense that the individual is in control, i.e. self-mastery (Scheier et al., 1994; Aflakseir and Zarei, 2013).

Societies and individuals affected by large-scale disasters, like global pandemics, can develop stress-related disorders (Ćosić et al., 2020). Former studies on emotional responses to pandemics or quarantine have focused on emotions, such as anger, sadness, helplessness, relief, anxiety and confusion (Jin et al., 2007; Marjanovic et al., 2007; Reynolds et al., 2008; Kim and Niederdeppe, 2013; Jeong et al., 2016; Brooks et al., 2020; Ćosić et al., 2020). In the case of women in the midst of fertility treatments, their treatments were abruptly suspended, leaving them with a high level of uncertainty and loss of control concerning the future. In combination with social distancing and partial loss of social support, these emotions could possibly be intensified, contributing to higher levels of distress. Recently published data demonstrated that fertility clinic closure during the COVID-19 pandemic was associated with a sharp increase in the prevalence of anxiety and depression among patients undergoing fertility treatments (Ferrero et al., 2020) and was perceived as an uncontrollable and stressful event (Boivin et al., 2020).

The objective of the current study was to describe attitudes, perceptions and emotional distress of fertility patients, following suspension of infertility treatments during the COVID-19 pandemic. First, we aimed to understand whether patients, who are eager to conceive, believe the decision to suspend treatment to be justified and whether, given the choice, they would wish to resume treatments despite the COVID-19 infection risk. We hypothesized that patients of older age and nulliparity will be less inclined to concur with the guidelines and will be anxious to resume treatment, while anxiety related to COVID-19 infection will lead to opposite perceptions.

We then focused on factors that may contribute to the psychological distress experienced by infertility patients during the pandemic, some of which may allow targeted psychosocial intervention for patients who are at higher risk of distress. Specifically, based on the literature reviewed above, the study hypotheses were as follows. (i) sociodemographic variables and infertility history will be associated with psychological distress, so that nulliparity, older age, lower socioeconomic level and longer duration of fertility treatments, will be associated with higher levels of psychological distress. (ii) COVID-19-related variables including COVID-19 infection anxiety and negative emotional response to treatment suspension (e.g. anger, helplessness) will be associated with higher levels of distress. (iii) Women's personal resources such as self-mastery and perceived social support will be negatively associated with levels of psychological distress.