Treatment pauses due to the coronavirus pandemic and mental health in infertile patients: a systematic review and meta-analysis of observational studies | BMC Public Health

Treatment pauses due to the coronavirus pandemic and mental health in infertile patients: a systematic review and meta-analysis of observational studies | BMC Public Health

search results

A total of 681 studies were found by searching the database. After removing duplicates, 269 studies were screened for inclusion criteria and 242 studies were excluded. Twenty-seven retrieved full texts were assessed for eligibility. It should be noted that a full text was obtained after contacting the corresponding author.Among them, six studies (four qualitative studies and two brief communication) did not meet the inclusion criteria, so 21 studies involving 5901 participants were included in this systematic review [25, 52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71].In addition, 16 studies were included in the meta-analysis [52,53,54,55,56,57,58, 60, 61, 63,64,65,66, 68, 70, 71]. The study selection process is shown in Figure 1.

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figure 1

PRISMA study selection flowchart

Learning features

Diversity exists in research areas.Seven studies were from Europe (France [56]Italy [52, 68, 71]Portugal [25]Serbia [59]and Spain [65]); four from Asia (China [67, 70] and india [54, 55]); four studies were from the Middle East (Iran [60]Israel [63]and Türkiye [61, 64]), six studies were conducted in Canada and/or the United States [53, 57, 58, 62, 66, 69]. In addition to the study by Dong et al. (2021) and Rasekh Jahromi et al. (2022), which was a case-control study [60, 70], all studies had a cross-sectional design. All participants (n: 5901) were infertile patients seeking treatment during the covid-19 pandemic and their treatment plans were either stopped or postponed; the majority of them were women (90%, n: 5306); 8.5% ( n: 504) participants were male. In addition, 91 participants (1.5%) did not mention their gender (Table 1).

Table 1 Characteristics of published studies included in the systematic review

Due to social distancing practices, all but two studies [55, 70]all studies were conducted in the form of online surveys [25, 52,53,54, 56,57,58,59,60,61,62,63,64,65,66,67,68,69, 71].Additionally, eight studies used Google Sheets [52, 58, 60, 61, 63, 65, 68, 69]Two used REDCap [62, 66]two of whom used the SurveyMonkey.com platform [57, 71].Others did not specify online measures [25, 53,54,55,56, 59, 64, 67, 70].In terms of data collection tools, except for two studies that used self-organized questionnaires [55, 68]19 studies used validated instruments [25, 52,53,54, 56, 58,59,60,61,62,63,64,65,66,67, 69,70,71].Regarding the use of Covid-19 specific tools, only two studies used covid-19 related questionnaires, including the Covid-19 Fear Scale (FCV-19S) and the Covid-19 Anxiety Score [63, 64] (Table 1).

Seven studies were considered to be of high quality using the Newcastle-Ottawa scale [52, 57, 60, 65, 67, 69, 71]14 studies were of moderate quality [25, 53,54,55,56, 58, 59, 61,62,63,64, 66, 68, 70] and on quality assessment of cross-sectional studies, all articles (n=19) [25, 52,53,54,55,56,57,58,59, 61,62,63,64,65,66,67,68,69, 71] Get the highest score (three stars) in the results section. And 74% of articles (n= 14) [52,53,54, 56,57,58, 62, 63, 65,66,67,68,69, 71] Achieved the highest score in the comparability section with only 10.5% (n= 2) [52, 69] Get the highest score in the selection section. As for case-control studies (n= 2) [60, 70]only one study received the highest scores in the comparability and exposure sections (two and three stars respectively) [60]and both [60, 70] Got three out of four marks in the selection section. (See Additional file 3).

According to the findings of this review, anxiety rates among infertile women who had their treatment paused or postponed due to the Covid-19 pandemic ranged from 11% to 72%. Additionally, the prevalence of depression ranged from 14% to 77% and of stress from 38.9% to 64%, as will be discussed in more detail. Additionally, it is important to note that a meta-analysis of anxiety, depression, and stress in men could not be performed due to lack of data, as most of the studies under review did not include male patients in the analysis.

anxiety

The outcome was anxiety, measured across 15 studies [25, 52, 54,55,56,57,58, 62, 64,65,66,67,68, 70, 71]. Different tools include General Anxiety Disorder (GAD-7), State-Trait Anxiety Inventory (STAI, STAI-5 and STAI-6), Hospital Anxiety and Depression Scale (HADS), Mental Health Inventory (MHI- 5) and used the Depression, Anxiety and Stress Scale 21-item (DASS-21) to measure anxiety in infertile patients. Although Galhado et al. (2021) found no significant differences in anxiety scores between infertile patients who suspended treatment during the coronavirus pandemic and an infertile reference sample [25], LaBlanche et al. (2022) reported much higher than expected rates of anxiety in the infertile population [56].Two studies report increased rates of anxiety in confinement patients [65, 67].Fear of covid-19 infection and exposure to covid-19 related news have been reported to negatively impact patient anxiety [52, 54].being a woman [52, 71]had a previous IVF cycle [52, 67]and older [52, 54, 64] Increased anxiety scores were also found.

Overall prevalence of anxiety disorders among infertile women

Of the 15 studies mentioned above, 12 reported the number or percentage of women affected by anxiety during treatment breaks. The prevalence of anxiety varies across studies, with reported prevalence ranging from a low percentage 11 to a high percentage 72 . The estimated pooled prevalence was 48.4% (95% CI, 34.8-62.3) (Fig. 2).I2 The index is 98.01, indicating high heterogeneity. Meta-regression was performed and sample size was considered as a source of heterogeneity (p< 0.001).No publication bias was observed (Egger test p-value: 0.30).

figure 2
figure 2

Pooled prevalence of anxiety in female patients

Subgroup analysis of anxiety prevalence

The highest pooled prevalence estimate from both studies, calculated using STAI (40, 51), was 72.1% (95% CI, 68.7–75.4). The lowest estimate across three studies was calculated to be 51.3% (95% CI 48.2–54.4) using the GAD-7 (32, 39, 45). Heterogeneity between subgroups was not significant (phosphorus= 0.64) (Table 2).

Table 2 Subgroup analysis of anxiety prevalence using tools based on random effects analysis

frustrated

10 studies measured depression [25, 52, 53, 55, 57, 60, 61, 65, 66, 70]. Different tools, including the Patient Health Questionnaire (PHQ-8 and PHQ-9), Beck Depression Inventory (BDI), Hospital Anxiety and Depression Scale (HADS), Mental Health Inventory (MHI-5), and Depression, Anxiety and The Distress Scale-21 items (DASS-21) was used to measure depression in infertile patients. Although Galhado et al. (2021) found no significant differences in depression scores between infertility patients who suspended treatment during the coronavirus pandemic and an infertility reference sample [25], Dillard et al. (2022) reported that depressive symptoms were more severe during the pandemic [69] and Bivia-Roig et al. (2021) reported increased depression scores in incarcerated patients [65]. Furthermore, Rasekh Jahromi et al. (2022) reported that infertile women who delayed treatment were more depressed than those who did not receive treatment[60].Women are reportedly more likely to be depressed than men [52, 71]. Rasek Jahromi et al. (2022) and Sahin et al. (2021) both reported a positive correlation between depression and hopelessness [60, 61]; Contrary to Sahin et al. (2021) who found that women with secondary infertility had higher mean depression scores [61], Rasek Jahromi et al. (2022) reported that women with primary infertility were more depressed [60].

Pooled prevalence of depression among infertile women

Of the 10 studies, 9 reported the number or percentage of women who were depressed during treatment breaks. The prevalence of depression varies across studies, with reports ranging from a low of 14% to a high of 77%. The estimated pooled prevalence was 42% (95% CI, 26.7–59.4) (Fig. 3).I2 The index is 97.70, indicating high heterogeneity. Meta-regression was performed, considering sample size and mean age as sources of heterogeneity (p< 0.001).No publication bias was observed (Egger test p-value: 0.09).

image 3
image 3

Pooled prevalence of depression among female patients

Subgroup analysis of depression prevalence

To assess depression, three studies used the PHQ-9 (32,39,41), with a pooled prevalence of 37.4 (95% CI, 23.8-53.3). In addition, two studies used pooled prevalence rates of 62.9 (95% CI, 43.2–79) and 28.2 (95% CI, 14.8–47.2) for BDI (48, 49) and HADS (34,35), respectively. In addition, one study used the PHQ-8 (45) and a researcher-generated instrument (43) respectively. Subgroup analyzes revealed differences in prevalence estimates between tools used to assess depression (phosphorus= 0.001) (Table 3).

Table 3 Subgroup analysis of depression prevalence using tools based on random effects analysis

pressure

Eleven studies report stress in infertile patients whose treatment is suspended or delayed [25, 54, 56,57,58,59, 62, 63, 69,70,71]. Stress was assessed using the Perceived Stress Scale (PSS-10, PSS-4), Impact of Events Scale-Revised (IES-R), and Depression, Anxiety, and Stress Scale 21 items (DASS-21). Dillard et al. (2022) and Galhardo et al. (2021) reported that the mean scores on the Perceived Stress Scale 10 in their study were 19.9 and 20.9, respectively [25, 69].Three studies reported on the prevalence of stress [56, 57, 63].Higher stress levels observed in patients whose treatment was suspended or postponed due to the covid-19 pandemic [69, 70].Although two studies showed no significant relationship between patient demographic characteristics and stress [58, 69]others report age [56, 57, 63]duration of infertility [54, 57]Patient’s anxiety level [56, 58, 62],supporting system [54, 59]and coping strategies [57, 59] Associated with higher stress levels.

Summary prevalence of stress in infertile women

Of the 11 studies, 3 reported the number or percentage of women affected by stress during treatment breaks. The incidence of stress varies across studies, with reported rates ranging from a low of 50% to a high of 64%. The estimated pooled prevalence was 55% (95% CI, 45.4-65) (Fig. 4).I2 The index is 90.99, indicating high heterogeneity. No publication bias was observed (Egger test p value: 0.25). Due to the small number of studies, subgroup analysis and meta-regression were not performed (n:3) [72].

Figure 4
Figure 4

Pooled incidence of stress in female patients

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