key: cord-333627-tcgamaev
authors: Kam, Ariana; Gottfried, Jennifer; Mieleszko, Julia E.; Kim, You J.; Nejat, Edward J.; Luk, Janelle
title: PERCEIVED STRESS, INSOMNIA SEVERITY, AND THE IMPACT OF EVENTS AMONG IN VITRO FERTILIZATION (IVF) PATIENTS DURING THE CORONAVIRUS DISEASE 2019 (COVID-19) PANDEMIC
date: 2020-09-30
journal: Fertility and Sterility
DOI: 10.1016/j.fertnstert.2020.08.500
sha: 
doc_id: 333627
cord_uid: tcgamaev

nan

MATERIALS AND METHODS: Respondents were classified according to medical specialty and average number of hours worked per week. Descriptive statistics, including frequency distribution, were used for categorical variables, while mean, median, standard deviation, interquartile range, minimum, and maximum values were used for continuous variables. Chi square or Fisher's Exact test was performed to determine differences in the distribution of reproductive health practices among specialty and work hour groups.

RESULTS: A total of 229 respondents were included in the study (26% Obstetrics and Gynecology (OBGYN), 22% Internal Medicine, 10% Pediatrics, 10% Emergency Medicine, 8% General Surgery, 24% Other). The distribution by age and marital status was similar across the specialty groups. Most respondents had an OBGYN visit within the past year (44.3%), while 22.6% had an OBGYN visit more than 3 years prior. Most respondents (88%) experienced a barrier in visiting an OBGYN provider during residency, and lack of time was the most common reason reported. Ninety-two percent of respondents were using contraception (39% long acting reversible contraception and 32% ring or oral contraceptive pills). Most respondents (87%) were not pregnant at the time of the survey or trying to conceive during residency, and this was not significantly different across the specialty groups (p¼0.2663). Forty-five percent of respondents felt that if they got pregnant during residency, it would negatively affect the way their peers viewed them as physicians. Over half (54%) of the respondents felt that their medical profession negatively impacted their plans for fertility, and this was not significantly different across specialty groups (p¼0.3716).

CONCLUSIONS: Our data demonstrate that most female residents experienced a barrier in seeing an OBGYN provider and nearly half of the respondents felt that pregnancy during their training would negatively affect their image as a physician. Additionally, our data shows that over half of the respondents felt that their medical profession negatively impacted their plans for fertility. Based on our analysis, we recommend placing additional emphasis on reproductive health needs when addressing the wellness of medical residents. Identifying opportunities for improvement in this area could help diminish the escalating problem of physician stress and ultimately improve residents' reproductive health needs. Pandemic'' a statement for clinical management of infertility care based on the anticipated burden of COVID-19 at that time. Receptivity of these initial recommendations has varied across the media, patients, and women's health providers. Our objective is to evaluate the perception of the initial ASRM COVID-19 associated recommendations held by women's health providers.

DESIGN: Cross-sectional study. MATERIALS AND METHODS: After IRB exemption was obtained, an electronic survey was sent to all women's health providers, including physicians, mid-level providers and nurses, in all subspecialties of obstetrics and gynecology at a single large academic center. All data is being collected anonymously and stored in a REDCap database. Preliminary analysis was done with REDCap to be followed by further statistical analysis once data collection is complete.

RESULTS:Of the 278 eligible providers, the survey response rate is 40% (n¼112), representing 8 OB/GYN sub-specialties and all categories of providers. The majority of respondents are female (81%) and %40 years of age (67%). Most providers view infertility treatment as elective, specifically defined as not a medical necessity (44%). Of the 29% of providers who reported provision of infertility care, 69% reported practice changes between March 16-31and another 19% initiated practice changes after March 31 st . Six percent of the surveyed providers continued all fertility treatment in the same manner as before the pandemic; 15% cancelled all fertility treatment immediately, 33% completed treatment for patients currently in cycle but cancelled new cycle starts and 30% continued some treatment on caseby case basis. Safety concerns for the practice (94%), shared decision making with patients (84%), and ASRM guidance (69%) were amongst the most important factors to impact continuation of fertility treatment.

After reviewing a summary of initial ASRM recommendations provided within the survey, 67% of all participants viewed the recommendations as fair, and 71% as reasonable. Most (43%) agreed that ASRM recommendations should be enforced for all patients despite patient opinion. Sixty-six percent agreed that some degree of infertility treatment should be allowed currently, however the least supported treatment type was in vitro fertilization (32%). Regardless of infertility diagnosis, 70% did not feel that women should refrain from planned conception during the pandemic.

CONCLUSIONS: Considering the immediate and long term impact of the COVID-19 pandemic on fertility care delivery, a better understanding of perceptions regarding infertility management during this time is important. In doing so, we must consider the full spectrum of women's health providers. Our study shows overall support for the initial ASRM recommendations from women's health providers within our institution. We intend to use the methods used for this study to conduct a larger assessment of women's health providers nationwide. OBJECTIVE: The objective of this study was to evaluate the Perceived Stress Scale, Insomnia Severity Index, and Impact of Events Scale-Revised scores of patients at a fertility clinic in Manhattan during the coronavirus disease 2019 (COVID-19) pandemic.

DESIGN: Surveys were administered to 220 patients at a fertility clinic in Manhattan during the COVID-19 pandemic. The surveys included a 7-item questionnaire on patient demographics, the Perceived Stress Scale (10-item questionnaire), the Insomnia Severity Index (7-item questionnaire), and the Impact of Events Scale-Revised (IES-R, 21-item questionnaire).

MATERIALS AND METHODS: Online surveys were administered to 220 patients at Generation Next Fertility (GNF), located in Manhattan. Percentages of patients who met different thresholds along the Perceived Stress Scale, Insomnia Severity Index, and the IES-R questionnaires were calculated. We excluded one question from the standard 22-item IES-R questionnaire: ''During the past seven days with respect to (insert event) have you felt yourself acting or feeling like you were back at that time?'' All patients who did not respond to the Perceived Stress Scale, Insomnia Severity Index, and/or IES-R questionnaires were excluded from the respective analyses. Multiple linear regression was run to determine if surpassing a high school education and being unemployed were correlated with higher Perceived Stress Scale scores. A p-value of less than 0.05 was considered as statistically significant.

RESULTS: According to the results of the Perceived Stress Scale, 66.9% of patients at the Manhattan-based fertility clinic self-reported experiencing moderate stress during the COVID-19 pandemic. 21.9% and 11.2% of patients perceived low and high stress, respectively. There was no statistically significant relationship between the demographic variables of not surpassing a high school education and being unemployed and the perceived stress levels of IVF patients during the COVID-19 pandemic. Additionally, the results of the Insomnia Severity Index survey demonstrated that 43.7% of patients selfreported no clinically significant insomnia, 39.5% self-reported subthreshold insomnia, 15.6% self-reported clinical insomnia of moderate severity, and 1.2% self-reported severe clinical insomnia. Furthermore, the results of the IES-R survey showed that 52.1% of patients self-reported scores high enough to indicate that post-traumatic stress disorder (PSTD) is of clinical concern, 27.1% of patients self-reported scores at the cut-off level or higher for a probable diagnosis of PTSD, and 18.8% of patients self-reported scores that are high enough to suppress immune system functioning (for even 10 years after the COVID-19 pandemic).

CONCLUSIONS: According to surveys administered at an IVF clinic in Manhattan, the majority of the patients self-reported moderate stress, no clinically significant levels of insomnia, and PTSD levels of clinical concern during the COVID-19 pandemic. Not surpassing a high school education and being unemployed did not influence patients' perceived stress levels during the COVID-19 pandemic.

References: Christianson, Steven, and Joan Marren. "The impact of event scale-revised (IES-R)." Medsurg Nurs 21.5 (2012): 321-322.

Cohen, Sheldon, T. Kamarck, and R. Mermelstein. "Perceived stress scale." Measuring stress: A guide for health and social scientists 10 (1994).

Morin OBJECTIVE: SARS-CoV-2 entry in host cells requires the presence of angiotensin-converting enzyme 2 (ACE2) as the extracellular receptor, and the serine protease TMPRSS2 to cleave the viral spike protein for incorporation into the host cell. Basigin (BSG/CD147) may also act as an ACE2 independent receptor mechanism. The cysteine protease cathepsin-L (CTSL) may also cleave the viral spike proteins and facilitate cell entry. The objective of this study was to characterize the mRNA and protein expression of these cellular entry receptors and proteases in female reproductive cells to determine their susceptibility to SARS-CoV-2 infection.

DESIGN: Prospective Research Study. MATERIALS AND METHODS: Materials and Methods: Oocytes (GV, MII), follicular cells (cumulus, CC; granulosa, GC) and embryos (1 cell, 1C; blastocyst, BL) were collected from a minimum of three different patients per sample type, with consent. Samples were analyzed for mRNA expression of ACE2, CD147, TMPRSS2, and CTSL genes relative to GAPDH using RT-qPCR. Primers were validated using human mixed tissue cDNA. Protein quantification was performed by immunoblotting using the Jess system (ProteinSimple) optimized to detect over 10 proteins/5-10 oocytes or embryos. Antibodies for ACE2, CD147, TMPRSS2, and CTSL proteins were validated and then used to determine protein abundance relative to total protein. Data were obtained from three independent biological replicates and analyzed using one-way ANOVA.

RESULTS: Results from q-PCR analysis revealed high (p<0.05) abundance of ACE2 transcripts in GV and MII oocytes compared to CC, GC, and BL. ACE2 protein was present in all the samples, but was relatively higher (p<0.17) in M2 oocytes, 1C, BL, and CC compared to GV oocytes and GC. TMPRSS2 protein was abundant in MII oocytes, 1C, and BL, and was present but at low levels in GVoocytes and follicular cells. Protein abundance of CD147 was five-fold higher (p<0.05) in GVand 1.5 fold higher in GC compared to all other samples analyzed. No CTSL protein was observed with the expected molecular weight (38 kD), although a 55 kD band (a possible isoform) was detected in GV oocytes and CC.

CONCLUSIONS: Cumulus and granulosa cells are least susceptible to SARS-CoV-2 infection due to the lack of required receptors and proteases. Co-expression of the protein for ACE2 and TMPRSS2 in MII oocytes, zygotes, and blastocysts suggests that these reproductive cells are susceptible to SARS-CoV-2 infection. In conclusion, using a combined approach of mRNA and protein analysis from the same samples suggests that mature human oocytes and preimplantation embryos have the cellular machinery required for SARS-Cov2 entry, although we do not know if this occurs in vivo. The potential for viral infection in oocytes and embryos has important ramifications for ART. Care must be taken to avoid introduction of the virus to the embryo while in the ART laboratory, as well as potentially introducing the virus from an infected embryo to laboratory workspaces. 

There was a trend toward increased REI-CM use in states with a SIP order for R30 days (70% of 212, p¼0.064). ASRM guidance was cited in 61% (n¼152) of REI-CM; however, only 33% (n¼82) outlined treatment practices that reflected ASRM guidance published at the time of the data extraction. Adherence to ASRM guidelines was more common in academic than private practices (54% vs 31%, p¼0.02) but was not correlated with size of practice or geographic region. Conversely, 18% (n¼44) of practices announced treating patients on a ''case-by-case basis'' with definitions ranging from specific (''women with AMH <0.7'') to vague (''as determined by our providers alongside our patients''). Additionally, 9% of REI-CM (n¼23) announced continued treatment regardless of a patient's clinical urgency. This messaging was more common in groups doing >1000 cycles a year (18%, p¼0.009), with a trend toward practices in the northeast (16%, p¼0.113) and in states with SIP orders lasting <30 days (14%, p¼0.09). Clinics treating all-comers were less likely to cite ASRM than other clinics (41% vs 62%, p¼0.045). However, 75% (n¼14) cited COVID-19 guidance from WHO, CDC and state and local governments. CONCLUSIONS: While public messaging may not reflect the actual practices of a clinic, this study reveals heterogeneity in how clinics incorporated ASRM recommendations and responded to the early stages of the COVID-19 pandemic. Academic practices were more likely to indicate their adherence to ASRM recommendations. High volume groups were more likely to communicate with their patients about what treatments they offered and to treat patients outside ASRM guidance