Background: Novel coronavirus disease 2019 (COVID-19) outbreak
negatively impacted on the mental wellbeing of infertile couples, because of the
World Health Organization’s recommendation to stop all fertility treatments. This
study aims to investigate the level of depression and hopelessness during the
COVID-19 outbreak, in women with primary and secondary infertility.
Methods: A 16-item online questionnaire was applied to a total of 220
women with primary and secondary infertility in June 2020. Participants’
knowledge and concerns about COVID-19 pandemic stop of treatments and follow-up
preferences were evaluated. In addition, the Beck Depression Inventory (BDI) and
the Beck Hopelessness Scale (BHS) were adapted to Turkish and applied to each
participant. Total scores of inventories between women were calculated. The
correlation between depression and hopelessness levels of the groups was
evaluated. Results: The BDI and BHS mean scores of 220 infertile women
who completed our questionnaire were 14.63
The World Health Organization (WHO) declared that novel coronavirus disease 2019 (COVID-19) became a global pandemic on 11 March 2020 . Since then, several guidelines, epidemiological bulletins and letters of recommendations have been published and updated in the medical field. In reproductive medicine, the European Society of Human Reproduction and Embryology (ESHRE) and the American Society for Reproductive Medicine (ASRM) suggested that patients with infertility should consider putting off their pregnancy plans [2,3]. All assisted reproductive technology (ART) treatments, including ovulation induction, intrauterine insemination (IUI), in vitro fertilization (IVF), oocyte and sperm cryopreservation, as well as fresh or frozen embryo transfer, were postponed by the fertility societies globally.
These decisions were made for possible complications of ART and pregnancy, mitigating the unknown risk of maternal fetal transmission in COVID-19-positive mothers and supporting the necessary reallocation of healthcare resources . All societies advocated that initiated cycles were to be completed and a freeze-all policy adopted, whereas transfers in preparation were discussed and, mostly, were postponed . Subsequently, ESHRE published a document on restarting infertility treatment during the COVID-19 pandemic, advising high-risk patients (diabetes mellitus, hypertension, those on immune suppressant therapy, past transplant patients and those with lung, liver or renal disease) to stop their ART treatment, finally recommending to all patients to postpone their treatment .
Conservative measures on IVF cycles stopping cycles during COVID-19 outbreak aggravate patients’ anxiety and the fear of remaining infertile for the possibility of losing the chance of fertilization. Generally, infertility is known to be a major cause of stress, as infertile couples were reported to have higher levels of anxiety and depression. Managing these patients by alleviating their symptoms is highly recommended during their fertility challenge .
Because of this pandemic problem that recently arose, surveys are needed to develop evidence-based strategies to reduce the negative psychological effects and psychiatric symptoms during the COVID-19 outbreak. In fact, studies have been administrated to general population, medical students, children, healthcare workers and COVID-19-positive patient groups [8-11].
Starting from these clinical findings, authors examined the mental health impacts of fertility treatment suspensions during COVID-19 pandemic by a cross-sectional investigation. This study aimed to measure the depression and hopelessness levels in women with primary and secondary infertility submitted to ART treatment during the COVID-19 outbreak, by an analysis of their thoughts, worries and expectations about discontinuing ART treatments. Authors divided infertility into primary and secondary for the psycho-attitudinal differences between couples who have never had pregnancies and those who have had pregnancies. The patients with primary infertility having never had pregnancies in the past, were logically more charged with expectations and hopes, unlike the latter.
As the Turkish Government suggested that citizens should minimize face-to-face interactions, potential participants were invited to take part electronically by the providers of the current research. This research was designed to measure depression and hopelessness levels in infertile women undergoing or planning to undergo infertility treatment during the COVID-19 outbreak. An online survey platform, Google Form, was used to deliver the survey during 1–30 June 2020 period. A total of 220 women with primary and secondary infertility and aged 18–48 years voluntarily completed the on-line questionnaire. They were selected randomly via computer system. Patients were approached from the hospital database of infertility clinics in Mid-black sea region of Turkey. Verbal informed consents were recorded at the beginning of the interviews of participants, via telephone. The power analysis was performed based on an expected prevalence of major depression as 17% in infertile women . The calculation showed that at least 217 participants would need to be enrolled with an alpha error level of 0.05 and a power of 80%. The study was performed in accordance with the Declaration of Helsinki. Ethical approval for the study was granted by Amasya University’s ethics committee (Decision no: 2020/6-36).
The inclusion criteria were: at least a primary school graduate, receiving infertility treatment (primary/secondary infertility), not diagnosed as having any psychiatric disorder, not using psychotropic medicine and agree to participate in the questionnaire and not abandon the survey during the questionnaire replies.
The structured questionnaire, inspired by previous research on the psychological effects of severe acute respiratory syndrome (SARS) outbreaks in Hong Kong , consisted of questions covering several areas: (1) socio-demographic and infertility features; (2) knowledge and concerns about COVID-19 (‘Worries about being infected by COVID-19’ -Yes/No, ‘Worries about infecting the baby by COVID-19’ -No transmission/Ongoing/Termination); (3) thoughts on cessation of ART treatments during the COVID-19 pandemic (‘Thoughts about stopping infertility treatments during COVID-19’ -Yes/No, ‘Thoughts about affecting the infertility treatment by COVID-19’ -Yes/No); (4) responses to the Beck Depression Inventory (BDI) and Beck Hopelessness Scale (BHS). An online orientation session was applied prior to the survey for women to improve their understanding of various elements of BDI and BHS. Participants agreed to “not abandon the survey during the questionnaire replies”.
The BDI was developed by Beck in 1961 to assess the risk of depression and
severity of depressive symptoms . The study subjects completed a
questionnaire consisting of 21 questions estimating the severity of various
depressive symptoms on a Likert scale of 0–3 (0, least severe; 3, most severe).
Scores of 0–9 indicate no depression, 10–18 mild depression, 19–29 moderate
The BHS was developed by Beck in 1974 to measure the future expectations of
adults, consisting of 20 statements with a score range of 0–20 . There are
three subscales: emotions and expectations; motivation loss; and hope. Questions
1, 6, 13, 15 and 19 relate to emotions and expectations, questions 2, 3, 9, 11,
12, 16, 17 and 20 relate to motivation loss and questions 4, 7, 8, 14 and 18
relate to hope. The individual is expected to mark ‘right’ for the statements
they consider applicable to themselves and ‘wrong’ for those they consider
inapplicable. The BHS is scored ‘1’ for a suitable answer and ‘0’ for an
unsuitable answer. Scores of 0–3 indicate no or minimal hopelessness whereas
scores of 4–8, 9–14 and
The study data were analysed statistically using IBM SPSS Statistics 21.0 (IBM
Corp., Armonk, NY, USA). Descriptive statistics (mean, median,
standard deviation, minimum, maximum, number, percentage) were used for data
analysis. The distribution of the data was evaluated with the Kolmogorov-Smirnov
test. For non-normally distributed parameters, the Mann-Whitney U test, the
Kruskal-Wallis test, and Fischer’s exact test were used for continuous variables
and the chi-square test was used for categorical variables. Correlations were
assessed using Pearson’s correlation coefficient, along with the related
P values. Values with test results of P
A total of 220 infertile patients completed online survey: 78 had primary
infertility and 142 had secondary infertility. They had a mean age of 30.66
Demographic and clinical characteristics of enrolled patients, during the
COVID-19 pandemic, were the following: the mean duration of marriage was 6.15
|Variable (n = 220)|
|Age (years)||30.66 |
|Duration of marriage (years)||6.15 |
|Duration of infertility (years)||4.16 |
|Primary and secondary education||67 (30.5)|
|High school||56 (25.5)|
|Educational workers||32 (14.5)|
|Healthcare workers||39 (17.7)|
|Other professions||34 (15.5)|
|On leave because of COVID-19||27 (12.3)|
|Variables presented as mean |
Mean BDI and BHS scores were 14.63
|Variable (n = 220)|
|Total BDI score||14.63 |
|Total BHS score||5.43 |
|Emotions and expectations score||4.13 |
|Motivation loss score||2.39 |
|Hope score||2.32 |
|Variables presented as mean |
A comparison of variables in women with primary and secondary infertility was presented in Table 3. Women with secondary infertility were significantly older than those with primary infertility (P = 0.000). The duration of infertility for both groups was similar (P = 0.531). Differences were not detected in ‘Thoughts about stopping infertility treatments during COVID-19’, ‘Worries about being infected by COVID-19’,‘Worries about infecting the baby by COVID-19’ or ‘Thoughts about affecting the infertility treatment by COVID-19’ for both groups (P = 0.755, P = 0.057, P = 0.263 and P = 0.051, respectively).
|Variables||Primary infertility||Secondary infertility||P value|
|(n = 78)||(n = 142)|
|Duration of infertility (years)||4.49
|Thoughts about stopping infertility treatments during COVID-19 pandemic|
|Yes||34 (43.6)||65 (45.8)||0.755|
|No||44 (56.4)||77 (54.2)|
|Worries about being infected by COVID-19|
|Yes||55 (70.5)||116 (81.7)||0.057|
|No||23 (29.5)||26 (18.3)|
|Worries about infecting the baby with COVID-19|
|No transmission||14 (17.9)||18 (12.7)||0.263|
|Ongoing||64 (82.1)||121 (85.2)|
|Thoughts about affecting the infertility treatment by COVID-19|
|Yes||15 (19.2)||45 (31.7)||0.051|
|No||33 (42.3)||40 (28.2)|
|Undecided||30 (38.5)||57 (40.1)|
|Variables presented as mean |
Forty women (51.28%) with primary infertility and 103 (72.53%) with secondary infertility had clinically depressive symptoms, whereas 23 (29.48%) with primary infertility and 95 (66.90%) with secondary infertility had clinical hopelessness symptoms. Total BDI and BHS scores were significantly higher in women with secondary infertility (P = 0.001 and P = 0.000, respectively). Furthermore, the BHS subscale scores were statistically lower in women with primary infertility (P = 0.000, P = 0.003 and P = 0.000, respectively) (Table 4).
|Primary infertility||Secondary infertility||P value|
|(n = 78)||(n = 142)|
|Total BDI score||11.81
|None||38 (48.7)||39 (27.5)||0.011|
|Mild depression||27 (34.6)||63 (44.4)|
|Moderate depression||11 (14.1)||29 (20.4)|
|Severe depression||2 (2.6)||11 (7.7)|
|Total BHS score||3.78
|None/minimal||46 (58.9)||47 (33)||0.001|
|Low hopelessness||25 (32.1)||64 (45.1)|
|Moderate hopelessness||5 (6.4)||14 (9.9)|
|High hopelessness||2 (2.6)||17 (12)|
|Emotions and expectations score||1.90
|Motivation loss score||1.85
|Variables presented as mean |
Total depression and hopelessness scores of both groups were in a strong positive correlation with primary and secondary infertility during the COVID-19 outbreak (r = 0.625 and r = 0.740, respectively; P = 0.000) (Table 5).
|Total depression score|
|Total hopelessness score||Primary infertility group||0.625||0.000|
|Secondary infertility group||0.740||0.000|
|Pearson’s correlation test; P |
The COVID-19 pandemic has shocked the social and scientific world, interrupting any human relationship or contact due to the risk of transmission of the virus to mankind. Due to the negative psychological impact of the COVID-19 pandemic on women in general and, above all, in women submitted to ART/IVF in the pandemic period, apart the ESHRE and the ASRM recommendations [2,3], also the Canadian Fertility and Andrology Society, announced on March 2020 their recommendations to immediately suspend all in-person fertility treatments throughout Canada and the U.S. indefinitely due to the COVID-19 pandemic . This caused a large worldwide psychological stress in patient to submit to ART/IVF.
Authors, therefore, evaluated the same kind of infertile patients, but in the Turkish population, showing that primary and secondary infertile women had mild depression and low hopelessness levels during the outbreak, and patients with secondary infertility had higher BDI and BHS scores, than women with primary infertility. Moreover, increased BHS scores were correlated with increased BDI scores for each infertility group and, clinically, half of patients with primary infertility and more than 72% with secondary infertility had clinically depressive symptoms, whereas less than 30% with primary infertility and more than 65% with secondary infertility had clinical hopelessness symptoms.
Moreover, authors showed that half of the women with primary infertility and the majority of those with secondary infertility experienced depression; criticizing these results, authors would have expected the opposite, given that the latter already have a previous pregnancy, while the others did not miss one and therefore the expectation should be higher. It may be that the blockade had upset couples already with a child, due to a sudden negative reshaping of their lives, unlike the first.
Comparing our data with current literature, Esposito et al.  evaluated the impact of the COVID-19 pandemic on infertile couples’ emotions, anxiety and future plans, in an observational study, performed by Italian ART centers and online forums on infertile couples’ candidate to ART and whose treatment was blocked due to the COVID-19 lockdown. The COVID-19 lockdown had a moderate/severe psychological impact on infertile patients, women were more emotionally distressed, anxious and depressed than men and the recommendation to stop ART program during COVID-19 generated higher distress levels in infertile couples. Lawson et al.  evaluated perceptions of delayed fertility care secondary to the COVID-19 pandemic by a cross-sectional anonymous survey of n = 787/2287 patients on recommendations to delay fertility treatments due to the COVID-19 pandemic. Most participants were distressed by the delay of treatments and supplemental education increased acceptance of recommendations but did not decrease distress. Boivin et al.  analyzed appraisals, coping strategies and emotional reactions of patients to COVID-19 fertility clinic closures, by a cross-sectional design, comprising a mixed-methods, English language, anonymous, online survey posted from April 9 to 21 to social media. The study was completed by 446 infertile women and 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. Participants reported more negative than positive emotions and, almost all participants reported stress, worry and frustration at the situation, while some expressed anger and resentment at the unfairness of the situation. Gordon et al.  examined the psychological impact of fertility treatment suspensions resulting from the COVID-19 pandemic and to clarify psychosocial predictors of better or worse mental health in 92 women from Canada and the United States, by a battery of questionnaires assessing depressive symptoms, perceived mental health impact, and change in quality of life related to treatment suspensions. Fifty-two of respondents endorsed clinical levels of depressive symptoms and fertility treatment suspensions have had a considerable negative impact on women’s mental health and quality of life.
Yılmaz and Kavak  determined a mean BDI score of 28
Keskin et al.  highlighted hopelessness as an important factor known to reduce the chance of success in infertility treatment, defining it as “having negative expectations about the future”. Social pressure, the challenge of infertility treatment and the duration of the diagnostic processes add up to the advanced levels of hopelessness of these women, whereas a high level of hope is a pivotal factor for coping with infertility problems . Study’ results highlighted 41% of women with primary infertility and more than 65% with secondary infertility with clinical hopelessness symptoms; as for depression, the lack of family upheavals in primary infertility could be an important factor, against the necessary family closure with offspring for the secondary infertility patients, due to the COVID-19 outbreak.
Infertile women’s BHS score was determined by Kargın et al. as 5.6
Infertile patients were also anxious and scared about the possibility of further compromising their chances of pregnancy, in relation to increasing age and the worse ovarian reserve during the ongoing COVID-19 pandemic emergency and the current recommendations to suspend ART treatment. So, psychological support was recommended for infertile patients searching for pregnancy, in order to avoid any uncertainty over their infertile condition. It might negatively affect their future reproductive choices, otherwise resulting in an increased prevalence of treatment drop out. Telemedicine and psychological support have established a useful tool for ART specialists . Several digital platforms have quickly spread, valuable in favouring communication and the relationship between fertility physicians and infertile patients.
The strengths of this study were the possibility to reach patients via internet. In this way, despite the least possible face-to-face contact situation, it provided more opportunity to reach more infertile women. The limitation of the research was that it does not have a longitudinal course. Answers to the BDI and BHS may change as ART treatment progresses and the condition of the COVID-19 outbreak worsens.
Depression and hopelessness of infertile women are at mild levels during the COVID-19 pandemic. Women with secondary infertility had higher BDI and BHS scores than women with primary infertility. The majority of infertile women wanted to proceed with ART treatment, despite their worry over COVID-19 infection in themselves and their babies. Suggestion: There is a need for clinical and psychological counselling services to be provided by a team of infertility specialists and psychologists online to ensure ART treatment of all infertile women during the COVID-19 pandemic.
BŞ and GS designed the research study. BŞ and PK performed the research. BŞ analyzed the data. BŞ, OFK, ŞH and AT wrote the manuscript. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript.
All subjects gave their informed consent for inclusion before they participated in the study. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of Amasya University (approval number: 2020/6-36).
We thanks to every participant to take their time to survey.
This research received no external funding.
The authors declare no conflict of interest.