key: cord-0706089-biinei6k authors: Sau-Gee Lam, Jennifer; Shere, Mahvash; Motamedi, Nickan; Vilos, George A.; Abu-Rafea, Basim; Vilos, Angelos G. title: Impact of the COVID-19 Pandemic on Access to Fertility Care: A Retrospective Study at a University-Affiliated Fertility Practice date: 2021-11-05 journal: J Obstet Gynaecol Can DOI: 10.1016/j.jogc.2021.10.017 sha: f80d7b9ee4b702f2c25cfc50b3fd5fecd51196eb doc_id: 706089 cord_uid: biinei6k OBJECTIVE: To elucidate the impact of the COVID-19 pandemic on access to fertility services. METHODS: A retrospective quality improvement study was conducted at a university-affiliated fertility practice in southwestern Ontario. Annual procedural volumes for intrauterine and donor inseminations (IUI/DI), in vitro fertilization and intracytoplasmic sperm injections (IVF/ICSI), and frozen embryo transfers (FET) during the COVID-19–affected year were compared with mean annual volumes from the 2 preceding years. In addition, volumes for the same procedures were compared between the first quarter of 2021 and mean first quarter volumes from 2018 to 2019. Piecewise linear regressions were conducted to evaluate whether any changes in monthly procedural volume were attributable to the COVID-19 pandemic. RESULTS: In 2020, our fertility practice attained the mean annual volumes of 89.7% for IUI/DI, 69.0% for IVF/ICSI, and 60.6% for FET. In contrast, in 2021, we performed mean first quarter volumes of 130.1% for IUI/DI, 164.3% for IVF/ICSI, and 126.8% for FET. The slopes of the pre- and post–COVID-19 segments of the piecewise linear regressions were significantly different for IUI/DI (P < 0.001) and IVF/ICSI (P = 0.001), but not for FET (P = 0.133). CONCLUSION: The COVID-19 pandemic resulted in decreased annual volumes of medically assisted reproductive procedures at a university-affiliated fertility practice in southwestern Ontario. Impact on monthly procedural volume was confirmed for IUI/DI and IVF/ICSI by linear regression. Local adaptations helped compensate and exceed expected volumes in 2021. As a result, the COVID-19 pandemic resulted in a short-lived limitation in access to fertility care. Inability to access healthcare has been a described effect of the Coronavirus-19 Disease (COVID-19) pandemic. 1, 2 The population of patients seeking fertility care are under particular biological duress, as they require healthcare services in order to conceive, unlike their fertile counterparts. Additionally, time is often a crucial factor underlying many infertility diagnoses. As such, delays in timing of care could affect a patient's ability to access government funding programs, and impact on the success of their treatments. On March 18 2020, following public health recommendations to cancel all non-essential procedures, 3 the Canadian Fertility & Andrology Society (CFAS) advised Canadian fertility centres to halt reproductive services. 4 As a result of the CFAS guidelines, centres for reproductive care were shuttered across the country. The effect of centre closures on the patient experience has been well documented. 5,6,7 However, the impact of these closures as well as adapted reopenings on procedural volume and efficiency have yet to be examined. The aim of our study was to elucidate the impact of the COVID-19 pandemic on access and availability of fertility services. Firstly, by quantifying the changes in procedural volumes during the pandemic at a university-affiliated fertility practice in Southwestern Ontario, Canada; secondly, by comparing the trends in procedural volumes before and after the onset of the pandemic. J o u r n a l P r e -p r o o f We conducted a retrospective quality improvement study using data from a university-affiliated fertility practice comprising two sites in London, Ontario, Canada. Monthly procedural volumes were tabulated for inseminations (IUI/DI), in vitro fertilization and intracytoplasmic sperm injections (IVF/ICSI) and frozen embryo transfers (FET) between January 1, 2018 and May 31, 2021. All procedures were captured in local databases at the hospital and office-based sites, and included in the study. For the descriptive analysis, we quantified the change in procedural volumes during the pandemic by comparing the annual volumes achieved for each of IUI/DI, IVF/ICSI, and FET in 2020 with the mean annual procedural volumes from 2018 and 2019. To compare the most recent procedural volumes with pre-pandemic values, we compared the first quarter volumes from 2021 to the mean first quarter volumes from 2018 and 2019. As the first quarter of 2020 coincided with the onset of the pandemic, we did not include this period in the pre-pandemic analysis. To compare the trends in procedural volumes before and after the onset of the pandemic, we performed piecewise linear regression models for each of IUI/DI, IVF/ICSI, and FET. We used J o u r n a l P r e -p r o o f monthly procedural volumes during pre-and post-COVID-19-affected periods. A comparison of the two segments of the regression model was tested against the null hypothesis that they could be defined by a single regression line. We defined the pre-COVID-19-affected period as January 1, 2018 to February 29, 2020, and the COVID-19-affected period as March 1, 2020 to May 31, 2021, the end of our collection period. March 2020 was selected as the start date for the COVID-19-affected period, as it was the first month that was affected by COVID-19 adaptations. Due to CFAS and Ontario Ministry of Health directives, 3,4 fertility services were halted at our centres between March 15, 2020 to June 7, 2020. A third-party statistician and The R Project for Statistical Computing, Version 4.0.2 were utilized for statistical analyses. 8 Analysis of medically assisted reproduction volumes for the year 2020 revealed that our clinics did not attain the mean annual rates from the two preceding years. Our centres were able to attain 89.7% of the mean annual IUI/DI volume from 2018 to 2019, 69.0% of mean annual IVF/ICSI volume, and 60.6% of mean annual FET volume. While most studies on reproductive care during the COVID-19 pandemic focused on patient well-being, 5,6,7 our study is the first to quantify the effect of the pandemic on availability of fertility services. The key findings of our study demonstrate that there was a modest reduction in delivered fertility services or procedures (IUI/DI -10.3%, IVF/ICSI -31.0%, and FET -39.4%) J o u r n a l P r e -p r o o f attributable to the COVID-19 pandemic. Although this was an anticipated finding with known centre closures, the magnitude of the impact was not previously described. In contrast to mean first quarter figures prior to the pandemic, the centre performed 30.1% more inseminations (IUI/DI), 64.3% more IVF/ICSI and 26.8% more FET in the first quarter of 2021. The rise above pre-pandemic volumes may be attributable to a resolution of patient backlog, or more efficient procedure delivery following COVID-19 adaptations. In clinical context, our hospital site saw a trend towards an increased live birth rate from a pre-COVID-19 rate (January 2018 -November 2020, accounting for 9 months gestation) of 476.7 births/month to a 488.4 births/month COVID-19 period rate (December 2020 -September 2021), though this was not statistically significant (p=0.38). We illustrated a significant alteration in trend in procedural volume after the onset of the pandemic with IUI/DI (pre-pandemic m = 0.4, post-pandemic m = 6.0; p<0.001) and IVF/ICSI (pre-pandemic m = -0.5, post-pandemic m = 3.0; p=0.001), though the same trend was not seen with FET (pre-pandemic m = -0.04; post-pandemic m = 0.9; p=0.133). The difference in FET procedural volumes being more modest would explain why the comparison did not meet statistical significance, but the same global trend was seen as with IUI/DI and IVF/ICSI ( Figure 1 ). A possible reason for this smaller increase in FET volume may be related to patients being more willing to delay a frozen embryo transfer, rather than delay the more age and time-sensitive IVF/ICSI cycles. Alternatively, COVID-19 related delays in fresh IVF/ICSI cycles may have resulted in a secondary paucity of frozen embryos to transfer. Our findings should be considered in the context of the closures and setbacks experienced by our fertility practice. Our practice cancelled FET and donor insemination cycles, and converted IUI to timed intercourse. Following CFAS guidance, this also meant conversion of ongoing IVF/ICSI cycles to a freeze-all approach and adoption of virtual care. 4 Initially, reopening of our clinics was hampered by capped numbers from Ontario Health regulations 9 , shortages of personal protective equipment (PPE) and medications for conscious sedation. Locally, we suffered decreased staffing due to hospital redeployment strategies and inefficient screening procedures ( Figure 2 ). Our practice underwent numerous adaptations throughout the pandemic, which may contextualize the increase in quarterly procedural volume seen in 2021. These adaptations are summarized in Figure 3 , and may have led to an increase in the efficiency of procedure delivery. Simplified insemination procedures utilizing urinary LH kits for ovulation prediction decreased patient visits for ultrasound and bloodwork. Virtual care also decreased requirements for clinic space and staffing, allowing multiple physicians to run clinics concurrently. Universal patient masking, efficient screening, and updated computers and software for virtual encounters helped to process patients faster. Omission of holiday closures to compensate for expected losses started the new year at an advantage. From a patient perspective, the literature suggests there was a high degree of patient anxiety regarding cycle cancellation, 5,6,7 and this may explain increased volumes on reopening. As a single practice study, our results may not be generalizable to the Canadian or global fertility populations. There were also site-specific confounders to our data and its analysis. Our hospital-J o u r n a l P r e -p r o o f based site was impacted by a centre closure due to building maintenance between December 20th 2019 -February 24, 2020. This affected all of the medically assisted reproduction procedures, but primarily IVF/ICSI and FET as they are only conducted at this site. As a result, this would suggest that the drop in annual volume for IVF/ICSI and FET is slightly overestimated, and the true decrease attributable to the pandemic is likely closer to the value for IUI/DI. While our study has been limited to our single university-affiliated fertility practice, in a future study we hope to explore the experiences of other Canadian reproductive centres during the COVID-19 pandemic, to characterize how medically-assisted reproduction was affected across the nation. The COVID-19 pandemic has had a significant effect on access to healthcare including reproductive services. Our study is the first to provide a quantification of this impact, demonstrating approximately a 10-40% reduction in medically assisted reproduction in the year 2020 depending on the procedure. Month-to-month data showed a rapid recovery in delivered procedures after clinic closures were lifted, particularly for IUI/DI and IVF/ICSI, with a nonsignificant trend for FET. All medically assisted reproductive procedures saw a recovery and exceeded projected volumes for the first quarter of 2021. As a result, the impact of COVID-19 on fertility services was a defined decrease in availability of procedures, but one that was limited. Future research should evaluate how fertility practices were affected on a national scale to illustrate a more generalized picture. Access to healthcare during COVID-19 Reduced Access to Care: The Research and Development Survey (RANDS) during COVID-19 Memorandum to Ontario health and hospitals. Ramping down elective surgeries and other non-emergent activities Patient experiences of fertility clinic closure during the COVID-19 pandemic: appraisals, coping and emotions The psychological impact of fertility treatment suspensions during the COVID-19 pandemic The R project for statistical computing Updated -A measured approach to planning for surgeries and procedures during the COVID-19 pandemic