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Anxieties and apprehensions among women waiting for fertility treatments during the COVID‐19 pandemic

While health systems around the world are busy trying to manage the COVID-19 pandemic, many elective services - including fertility services - have been suspended over the last 8-9 months [1]. However, "time" is a crucial factor for infertile couples, and infertility has been shown to have a significant negative impact on the psychological health of women, and has been found to produce a variety of emotional responses [2].

While health systems around the world are busy trying to manage the COVID-19 pandemic, many elective services-including fertility services-have been suspended over the last 8-9 months. 1 However, "time" is a crucial factor for infertile couples, and infertility has been shown to have a significant negative impact on the psychological health of women, and has been found to produce a variety of emotional responses. 2 As a tertiary care referral centre (All India Institute of Medical Sciences (AIIMS), New Delhi, India), our unit was catering between 100 to 200 new registrations per month of infertile couples consulting for various infertility treatments before the pandemic ( Figure 1).
However, these services were shut down following the sudden declaration of national lockdown in India on March 24, 2020, as manpower and infrastructure were shifted towards management of the pandemic. 3 Studies from Western countries have shown that infertility remains a high-ranking stressor even during the COVID-19 pandemic. 4,5 In a study from Israel by Kimhy et al., it was found that 72% of couples wished to resume treatment despite the pandemic. 6 The need to resume fertility treatments needs to be addressed while curtailing COVID-19, which is unlikely to end in next 4-6 months, and delaying treatment is likely to significantly impact infertile patients who are seeking it. There is a need to adopt guidelines and standard operating procedures (SOPs) depending on the facilities available and triaging patients in need of fertility services, depending on age and cause of infertility.
Teleconsultation services were started in our hospital in May 2020 to provide online consultations for patients and to identify those in need of in-person appointments from June 2020. But still it has not been possible for complete resumption of fertility treatment due to deviation of health system towards pandemic management  Despite the anxiety about the higher risk of COVID-19 infection if they were to conceive during pandemic (100; 59%), and money constraints (97; 57%) due to lockdown, almost 90% of those in the study (154/170) were worried about the delays to fertility treatment and wanted immediate resumption of their treatment.
The stress of losing one egg per month and failing to conceive with each cycle was a major area of concern for 83.5% (142/170) of participants, and especially in those over 30 years of age (P = 0.39).
More than half of patients (88; 52%) reported increasing their coital frequency because of a desire to conceive and almost 64% (n = 109) stated that they were not avoiding conception during the pandemic. The proportion of women who reported that they were not avoiding conception despite the pandemic was significantly higher (80%; 12/15) among women over 35 years compared to those under 25 years (5/16) (P = 0.023).
Among women waiting for IVF, 86% (56/65) were more worried about declining chances of IVF with advancing age. The most common reason reported for resuming IVF during the pandemic was concern of advancing age (61.5%), followed by emotional disturbance. All the participants opted for resumption of IVF treatment and the majority (84.6%) reported they would opt for embryo transfer in the same cycle despite the pandemic.
Similar to studies from other countries, the present study also showed that infertility and forced delays in treatment were more stressful for women than contracting the COVID-19 infection. [4][5][6] This reflects many of the societal pressures and social stigmas associated with infertility, and thus the pressing need to resume treatment for those seeking it, despite the pandemic.
Due to the national lockdown, India has witnessed massive transmigration, which has led to widespread job losses and subsequent money constraints. Despite these challenges, the majority of our participants wished to resume infertility treatments. Apart from significant differences in opinion about avoiding conception among different age groups, other responses were comparable among age groups and SES classes, although this may be limited due to the small sample size of our study.
This study has helped us to develop a proposed plan for management of infertile patients waiting for resumption of treatment over the last 6 months. Table 1 describes the proposed plan to triage these patients at our centre according to age and cause of infertility.
To conclude, despite the unprecedented pandemic, infertility and delays to treatment remain a major stressor for infertile women seeking treatment, and thus highlights the need to triage these couples while ensuring the safety of patients and health care workers.
More data is needed to address the specific needs of these women and to make guidelines according to local facilities and national guidelines in order to clear the backlog.

CO N FLI C T S O F I NTE R E S T
The authors have no conflicts of interest.