Patient experiences of fertility clinic closure during the COVID-19 pandemic: appraisals, coping and emotions

Abstract

STUDY QUESTION What are appraisals, coping strategies and emotional reactions of patients to coronavirus disease 2019 (COVID-19) fertility clinic closures? SUMMARY ANSWER Clinic closure was appraised as stressful due to uncertainty and threat to the attainability of the parenthood goal but patients were able to cope using strategies that fit the uncertainty of the situation. WHAT IS KNOWN ALREADY Psychological research on COVID-19 suggests that people are more anxious than historical norms and moderately to extremely upset about fertility treatment cancellation owing to COVID-19. STUDY DESIGN, SIZE, DURATION The study was of cross-sectional design, comprising a mixed-methods, English language, anonymous, online survey posted from April 09 to April 21 to social media. Eligibility criteria were being affected by COVID-19 fertility clinic closure, 18 years of age or older and able to complete the survey in English. In total, 946 people clicked on the survey link, 76 did not consent, 420 started but did not complete survey, and 450 completed (48% completion, 446 women, four men). PARTICIPANTS/MATERIALS, SETTING, METHODS Overall 74.7% (n = 336) of respondents were residents in the UK with an average age of 33.6 years (SD = 4.4) and average years trying to conceive, 3.5 years (SD = 2.22). The survey comprised quantitative questions about the intensity of cognitive appraisals and emotions about clinic closure, and ability to cope with clinic closure. Open-text questions covered their understanding of COVID-19 and its effect on reproductive health and fertility plans, concerns and perceived benefits of clinic closure, and knowledge about closure. Sociodemographic information was collected. Descriptive and inferential statistics were used on quantitative data. Thematic qualitative analysis (inductive coding) was performed on the textual data from each question. Deductive coding grouped themes from each question into meta-themes related to cognitive stress and coping theory. MAIN RESULTS AND THE ROLE OF CHANCE Most patients (81.6%, n = 367) had tests or treatments postponed, with these being self (41.3%, n = 186) or publicly (46.4%, n = 209) funded. Patients appraised fertility clinic closure as having potential for a more negative than positive impact on their lives, and to be very or extremely uncontrollable and stressful (p ≤ .001). Most reported a slight to moderate ability to cope with closure. Data saturation was achieved with all open-text questions, with 33 broad themes identified and four meta-themes linked to components of the cognitive stress and coping theory. First, participants understood clinic closure was precautionary due to unknown effects of COVID-19 but some felt clinic closure was unfair relative to advice about getting pregnant given to the public. Second, closure was appraised as a threat to attainability of the parenthood goal largely due to uncertainty of the situation (e.g., re-opening, effect of delay) and intensification of pre-existing hardships of fertility problems (e.g., long time waiting for treatment, history of failed treatment). Third, closure taxed personal coping resources but most were able to cope using thought-management (e.g., distraction, focusing on positives), getting mentally and physically fit for next treatments, strengthening their social network, and keeping up-to-date. Finally, participants reported more negative than positive emotions (p ≤ .001) and almost all participants reported stress, worry and frustration at the situation, while some expressed anger and resentment at the unfairness of the situation. Overall, 11.9% were not at all able to cope, with reports of intense feelings of hopelessness and deteriorating wellbeing and mental health. LIMITATIONS, REASONS FOR CAUTION The survey captures patient reactions at a specific point in time, during lockdown and before clinics announced re-opening. Participants were self-selected (e.g., UK residents, women, 48% starting but not completing the survey), which may affect generalisability. WIDER IMPLICATIONS OF THE FINDINGS Fertility stakeholders (e.g., clinics, patient support groups, regulators, professional societies) need to work together to address the great uncertainty from COVID-19. This goal can be met proactively by setting up transparent processes for COVID-19 eventualities and signposting to information and coping resources. Future psychological research priorities should be on identifying patients at risk of distress with standardised measures and developing digital technologies appropriate for the realities of fertility care under COVID-19. STUDY FUNDING/COMPETING INTEREST(S) University funded research. Outside of the submitted work, Professor Boivin reports personal fees from Merck KGaA, Merck AB, Theramex, Ferring Pharmaceuticals A/S; grants from Merck Serono Ltd; and that she is co-developer of the Fertility Quality of Life (FertiQoL) and MediEmo apps. Outside of the submitted work, Dr. Mathur reports personal or consultancy fees from Manchester Fertility, Gedeon Richter, Ferring and Merck. Outside of the submitted work, Dr. Gameiro reports consultancy fees from Ferring Pharmaceuticals A/S, Access Fertility and SONA-Pharm LLC, and grants from Merck Serono Ltd. The other authors declare no conflicts of interest. TRIAL REGISTRATION NUMBER N/A

Suspension of fertility treatment during the COVID-19 pandemic: views, emotional reactions and psychological distress among women undergoing fertility treatment

“…Of note, only 1 in 10 of the respondents felt confused, suggesting that most of the respondents understood the guidelines and confusion didn't play a major part in their emotional reaction. A previous study by Boivin et al showed similar emotional reaction to clinics closure with more negative than positive emotions reported by the survey participants ( Boivin et al, 2020 ). Disagreement with the guidelines and higher COVID-19 related anxiety were significantly associated with higher distress.…”

“…These observations emphasize the importance of reaching out to the infertile population, offering psychological support such as professional online counseling and support groups. Employing extensive communication strategies, such as delivering updates via phone, email or social media regarding preparations for clinic reopening and personal discussions of treatment plans to be initiated at clinic reopening, can help reduce the patients' sense of uncertainty ( Boivin et al, 2020 ). Inquiring regarding one's coping resources (eg.…”

“…Inquiring regarding one's coping resources (eg. keeping busy, engaging in physical activity, social support) and encouraging the use of coping strategies such as distraction and positive reappraisal, previously shown to be useful in managing uncontrollable stressful experiences, could promote better tolerance of the unpredictable situation as well as improve the patients' well-being ( Ockhuijsen et al, 2014 ; Boivin et al, 2020 ). Early interventions, as described above, might help mitigate foreseeable negative impacts on patients' mental health in future outbreaks of COVID-19 or other calamities.…”

Psychological distress and postponed fertility care during the COVID-19 pandemic

“…Research finds that response rates in this range may not be associated with response bias and that large response rates in smaller samples may pose greater concerns for generalizability [ 19 ]. Further, given the similarities in overall acceptance of and psychological distress associated with the recommendations between our study and the previously published work using US patient populations [ 7 , 12 ] and internationally [ 20 , 21 ] it appears likely that our study results may be generalizable. Finally, although it is possible that participants who were the most distressed could have been more likely to respond to our survey than less distressed participants, our results show that a large percentage of fertility patients experienced distress as a result of the cancellation or delay of fertility care due to COVID-19.…”

A comprehensive review of the impact of COVID-19 on human reproductive biology, assisted reproduction care and pregnancy: a Canadian perspective

“…Almost all participants reported stress, worry and frustration. The majority reported a slight to moderate ability to cope with closure, but 11.9% were not able to cope at all, reporting intense feelings of hopelessness, deteriorating wellbeing, and impaired mental health [129].…”