COVID-19 and infertility: thoughts, feelings and coping with clinic closure

The COVID-19 pandemic caused fertility clinic closures worldwide. Closures were often abrupt, meaning patients were unable to access treatment and, depending on timing, cycles in progress were abandoned or converted to freeze all, which involves freezing all embryos in an IVF cycle without a fresh embryo transfer. Although clinics are now re-opening, much uncertainty remains about how treatment will be delivered, resumed and prioritised; and whether there will be a re-closure of clinics due to a second wave or localised lockdowns.

Presented at this year's European Society of Human Reproduction (ESHRE) meeting, the research authors of 'Patient experiences of fertility clinic closure during the COVID-19 pandemic: appraisals, coping and emotions' describe the psychosocial impact of fertility clinic closures. Of the 450 patients surveyed during the midst of clinic closures, 82 percent had their fertility tests or treatment postponed, viewed clinic closures to be devastating but a 'necessary evil' due to the unknown effects of COVID-19 on fertility, pregnancy and babies' health.

Although patients understood the necessity to close clinics, the inconsistent guidelines and the lack of communication to patients from their clinics failed to reassure patients about the resumption of their fertility treatment. Clinic closures were also perceived as unfair in comparison to advice given to the general public about becoming pregnant. Furthermore, clinic closures had a negative, uncontrollable and stressful effect on patients' lives.

Clinic closures left patients feeling uncertain about the attainment of their parenthood goals. Patients experienced a sense of 'running out of time' and a loss of, or threat to, their family dream because they would 'have gone another year without a child', an experience that was described by patients to have shattered their worlds. Patients did, however, demonstrate an ability to cope with the negative event of clinic closures and the sense of uncertainty it evoked. Patients reported employing a number of coping mechanisms such as thought management (eg, distraction coping, yoga, meditation), physical activity, and information seeking (eg, checking clinic websites).

While most patients reported that they coped with clinic closure, 11.8 percent of patients felt they did not have the resources to cope. These patients reported finding nothing helpful despite trying, expressing deeper helplessness, sadness and depressive feelings and reverting back to 'thinking about never being a mum'. Stress was also found to manifest in physical and behavioural reactions; with patients stating they felt nauseous the majority of the time, were unable to eat properly or sleep very well. Four patients even reported suicidal ideation because of the huge impact clinic closures had on their mental health.

The results of this research highlight the need for a more rapid joined-up response to clinic closures and the provision of accurate, consistent information presented in a way that matches patient preferences (eg, format). This could help reduce patient uncertainty, manage treatment expectations and boost coping resources. Going forward, to minimise disappointment, patients will need to be forewarned about how their treatment experience will change, the criteria that may lead to more change or the delay or even termination of treatment (eg, presence of COVID-19 symptoms). The formulation and provision of this information should be continuously updated by governing bodies and provided to patients via clinics prior to the initiation of treatment or treatment resumption.

Results additionally point to the need for clinics to take a more proactive approach to the provision of psychosocial support, supported by wider governing bodies and guided by psychologists, this would help the delivery of personalised support at different levels of intensity depending on specific needs. For example, patients previously identified as being high risk of distress or patients with a history of traumatic events (eg, miscarriage) may need additional support to prevent such memories from being re-triggered during a crisis, such as the cessation of treatment due to COVID-19. The provision of psychosocial support is particularly important given that fertility treatment is associated with an increased psychological burden, that is without the added pressure of a pandemic and the closure of fertility clinics taxing patients already stretched coping mechanisms.

The COVID-19 fertility clinic closure was an exceptional event but may well recur, or at minimum substantially change the delivery of fertility care worldwide. Managing fertility care under COVID-19 will, therefore, require fertility stakeholders (eg, clinics, patient's groups, government and regulators, health services), to work together to address the needs of patients and formulate processes for COVID-19 eventualities. This would help ensure that both clinics and patients are prepared for the possible re-closure of clinics due to a second wave, localised lockdown or other similar uncertain events. These processes should involve communication strategies optimised for uncertain and unpredictable situations, expectation management and psychological support.