THE RELATIONSHIP BETWEEN PERCEIVED STRESS DURING THE COVID-19 PANDEMIC AND MENSTRUAL CYCLES AND SYMPTOMS

OBJECTIVE: The COVID-19 pandemic exacerbated existing and initiated new psychosocial, interpersonal, and environmental stressors. For menstruating people, these stressors may contribute to cycle irregularity and make family building an even more challenging journey. This study investigates the relationship between perceived stress and menstrual cycle and symptom changes during the COVID-19 pandemic. MATERIALS AND METHODS: A survey was administered to users of Ovia Health's Fertility mobile application in the United States from March 2020 to April 2021. Items captured changes in menstruation pattern and symptomology and included the Perceived Stress Scale 4-item version (PSS-4).1 A paired t-test was used to assess differences between groups. A p-value of < 0.05 was considered statistically significant. RESULTS: Out of a total of 12,302 respondents, 36% reported experiencing some menstrual cycle and/or symptom changes. Most commonly reported changes included cycle starting early or late (87%), stronger symptoms during menstruation (e.g. low back pain, cramping, discharge changes) (29%), and heavier bleeding during periods (27%). Respondents reporting menstrual cycle or symptom changes tended to score slightly higher on average on the PSS-4 compared to those who did not report any changes (8.5 v. 8.3, respectively, p < 0.05). PSS-4 scores in this sample were notably higher in all respondents, regardless of cycle/symptom irregularity, compared to pre-pandemic benchmarking in similar populations.2-3 CONCLUSIONS: These results demonstrate that this sample's reported stress levels during the pandemic were noticeably higher than pre-pandemic benchmarks, and that these stress levels may contribute to changes in reproductive physiological processes such as menstruation. These changes may be especially frustrating and impactful for individuals trying to conceive and those struggling with infertility. IMPACT STATEMENT: Reproductive medicine specialists should be aware of the relationship between stress fostered by the COVID-19 pandemic and menstrual pattern disruption, especially for patients trying to conceive with irregular menstrual patterns or those struggling with infertility. Providers should work together with their patients to formulate strategies to mitigate the impact of stress on menstrual cycle changes in order to optimize conception and fertility treatment outcomes.

READY (OR NOT): CHANGES IN CONCEPTION ATTEMPTS DURING THE COVID-19 PANDEMIC

OBJECTIVE: Over the course of the first 12 months of the COVID-19 pandemic in the United States and around the globe, reproductive and obstetric research began to reveal the potentially detrimental impacts of COVID-19 on pregnant people and fetuses, and more importantly how society and healthcare facilities can protect these vulnerable individuals. However, for millions of people planning to start or grow their families during 2020, these effects and steps to minimize risk to both parent and child were still largely unknown. This investigation captures changes in attitudes and behavior surrounding conception efforts during the height of the COVID-19 pandemic. MATERIALS AND METHODS: A survey was administered to users of Ovia Health's Fertility mobile application in the United States from March 2020 to April 2021 to assess conception effort behavior and geographic location. A Chi-squared test was performed to determine if geographical region impacted conception efforts. A p-value of < 0.05 was considered statistically significant. RESULTS: A total of 20,046 respondents qualified for inclusion in analyses. Of the 16,527 respondents actively trying to get pregnant or attempted pregnancy in the last six months, one in ten reported altering their conception plans during the last year. Most respondents decided to temporarily pause TTC efforts specifically due to the pandemic (70%), and 6% delayed conception attempts indefinitely until the conclusion of the pandemic. Main contributors to these decisions included the potential impact of COVID-19 on pregnant people or fetuses (39%), lack of support people during pregnancy and labor (25%), and concern about finances or job security (23%). Rates of temporary TTC pause were comparable across the United States, ranging from a high of 31% in the Northeast and a low of 21% in the Southeast (p > 0.05). Rates of prolonged TTC abandonment were lower and also comparable across regions, ranging from 9% in the Pacific to 4% in the Southeast (p > 0.05). People of any age were equally likely to temporarily pause or abandon conception efforts indefinitely (p > 0.05). CONCLUSIONS: Instability, isolation, and insufficient information fostered by the COVID-19 pandemic contributed to individuals' decisions to either temporarily pause or abandon their conception attempts indefinitely. Changes in TTC behavior were comparable across all U.S. geographic regions and ages, demonstrating the pandemic's indiscriminate impact on family building behavior in this sample. As individuals revisit or resume their family building journeys, especially those whose fertility opportunities may be narrowing, reproductive medicine specialists should support patients who altered or continue to alter their conception plans during the pandemic. IMPACT STATEMENT: Reproductive medicine specialists and ancillary clinical team members should be aware of the impact COVID-19 had on family building behavior and prepare to support patients as they revisit their family building plans, particularly those who may struggle with infertility and whose fertility opportunities are becoming increasingly limited.

HOW MUCH LONGER? RATES OF ART DELAY OR CANCELLATION DURING THE COVID-19 CRISIS

OBJECTIVE: The strain on the healthcare system and attempts to limit virus transmission during the COVID-19 pandemic reduced patients' access to healthcare services, particularly those seeking specialized or elective health services such as infertility treatment. Mandatory fertility clinic closures prolonged conception efforts and further complicated the already arduous family building journey. This study investigates the incidence of assisted reproductive technology (ART) delay or abandonment during the COVID-19 pandemic and assesses whether these rates varied by U.S. geographic region. MATERIALS AND METHODS: A survey was administered to users of Ovia Health's Fertility mobile application in the United States from March 2020 to April 2021. A Chi-squared test was performed to assess differences in ART delay or cancellation and geographical region. A p-value of < 0.05 was considered statistically significant. RESULTS: A total of 20,047 respondents qualified for inclusion in this analysis. Of the 16,527 respondents currently or formerly trying to conceive within the last six months, 16% reported utilizing intrauterine insemination (IUI), in vitro fertilization (IVF), or another form of ART. Though the majority of treatments proceeded as planned, almost one in five (17%) were delayed or cancelled between March 2020 and April 2021. Main contributors to the decision to delay or cancel ART efforts were temporary fertility clinic closures (28%), concern about the impact of COVID-19 on pregnant people or fetuses (28%), attempting to avoid healthcare facilities (22%), lack of availability of support people during pregnancy and labor (17%), and concerns about finances or job security (16%). ART delay or cancellation did not differ by geographic region (p > 0.05). CONCLUSIONS: Our results demonstrate how the closure of fertility clinics during the COVID-19 pandemic and concern about COVID-19's detrimental impact during pregnancy pushed people seeking these services to delay indefinitely or altogether abandon their family building efforts. These trends were similar across the United States, regardless of geographical region. As ART treatments and care plans resume, reproductive medicine specialists should reinforce safety mitigation strategies to reduce the risk of COVID-19 transmission, foster COVID-19 vaccination discussions, and empower and restore patients' confidence with the latest COVID-19 research findings. IMPACT STATEMENT: Clinical service models resuming ART services should center around addressing patients' main concerns for delaying or abandoning ART efforts, especially focused on empowering patients whose family building journeys were interrupted by fertility center closures during the COVID-19 pandemic.