Study question What are the perceptions of infertility patients and the factors correlating with their psychological distress, following suspension of fertility treatments during the 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 has 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: 1. patients' demographic characteristics, 2. anxiety related to COVID-19 infection risk and level of social support, 3. patients' perceptions of the new guidelines and description of subsequently related emotions, and 4. 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 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 stabilising, 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.

Research question: What are the patients' views and emotional reactions towards fertility treatment suspension during the COVID-19 pandemic as well as the factors affecting their psychological distress? Design: A cross-sectional study conducted in an academic fertility center. Online questionnaires were distributed between April 18 th to April 23 rd 2020 to patients whose treatment cycle had been postponed or discontinued. The outcome measures included (a) Agreement with the reproductive society guidelines to postpone treatments (b) Willingness to resume treatments, given the choice (c) Patients' emotional reactions (d) Psychological distress level, measured by the Mental Health Inventory validated scale. A multivariate linear regression was conducted to identify factors associated with psychological distress.Results: Due to the small number of male respondents, only female patients were included in the analysis (N=181). 43% expressed disagreement with the guidelines and 82% were willing to resume treatments, given the choice. Sadness and anxiety were the most common emotional reactions expressed towards the guidelines. In the multivariate analysis, COVID-19 related anxiety and disagreement with treatment suspension were found to be significantly associated with patients' psychological distress. Patients' background characteristics did not contribute significantly to their distress.Conclusions: Fertility treatment suspension during the initial phase of the COVID-19 pandemic was associated with patients' negative emotional reactions. Anxiety related to COVID-19 and disagreement with treatment suspension were found to be significantly associated with psychological distress among female fertility patients, regardless of their background characteristics. Our findings suggest the need to monitor patients' mental health and provide psychological support should a shutdown of fertility care re-occur.

ObjectiveTo evaluate cognitive flexibility and labor and delivery outcomes.MethodsA prospective study was conducted of nulliparas with singleton term pregnancy, admitted for labor to a tertiary referral center from 1 January to 31 July, 2017. After epidural anesthesia, parturients completed the validated Psychological Flexibility Questionnaire (20 questions that evaluate a person's level of cognitive flexibility) before delivery. They were asked to grade (from 1 to 10) their hope for vaginal delivery (Hope score). Within 2 hours after delivery, they graded (1–10) the similarity between their delivery and their expectations (Expectation score). Outcomes of the flexible versus less flexible group were compared.ResultsAmong the flexible (n=120) versus less flexible (n=40) group, vaginal delivery was more common (74.2% vs 20.8%) than vacuum extraction (20.8% vs 35%) or cesarean delivery (5% vs 12.5%) (P=0.031). High Expectation score and delivery without grade III–IV perineal tear (P=0.032) were correlated. Groups were similar regarding Expectation (P=0.163) and Hope scores (P=0.591). The mode of delivery of parturients was not correlated with their mothers’ (P=0.836) or sisters’ (P=0.758).ConclusionHigh cognitive flexibility increases the likelihood of vaginal delivery. These findings support the mind–body correlation. Maternal cognitive perceptions can influence labor and delivery and should be considered when counseling patients during labor.