Infertility is a worldwide health concern, affecting approximately 168 million people of reproductive age, globally [1]. Infertility is defined as the inability to consume a child after 12 or more months of unprotected intercourse [1]. Involuntary childlessness can be considered a life crisis with a great impact on physical, social, emotional, and psychological aspects of life [1–4]. Social stigma, domestic violence, divorce, decrease in self-esteem, stress, anxiety, and depression are amongst the adverse psychosocial effect of infertility [1, 4–6]. Even though fertility treatments have evolved during the past decades, these procedures often cause patients physical and or mental distress [2, 5, 7]. The emotional tension experienced by infertile women may lead to changes in endocrine system regulation and probably result in adverse pregnancy outcomes [5, 6, 8].
A pandemic occurs when a disease spread worldwide, passing international borders and infecting a large number of people [9]. Pandemics and the measures that are taken to control or suppress them such as patient isolation, social distancing, and quarantine can increase mental distress and perceived risk of disease, which leads to psychological consequences including stress, anxiety, depression, delirium, and even post-traumatic stress disorder [10].
In December 2019, cases of infection with the new coronavirus were reported in Wuhan, China [11]. Soon after, the virus was spread across the world, and in May 2020 it was declared a pandemic by World Health Organization [12, 13]. The majority of people infected with this virus through droplet transmission have mild to moderate symptoms, but in some cases, the severity of symptoms may lead to death [13]. Until now 767,984,989 people were infected by the virus and more than 6.9 million people lost their lives [14]. In addition to physical effects, coronavirus can affect the psychological well-being of individuals [11, 15]. People reported fear of infection and/or death, depression, anger, violence, anxiety, and insecurity as the result of the coronavirus pandemic [11, 16, 17].
In order to disconnect the transmission chain and decrease the pressure on the health system, governments adopted strategies including social distancing, quarantine practices, and postponing non-urgent medical treatments [18–20]. Even though access to fertility treatments is considered a reproductive right [1], due to the coronavirus pandemic and its unknown effect on fertility and pregnancy most fertility treatments were postponed [18, 19]. The European Society of Human Reproduction and Embryology (ESRHE) and the American Society for Reproductive Medicine (ASRM), also recommended the suspension of new ART cycles [21, 22]. For infertile couples, especially those with poor prognoses, "time" is a crucial element, and the treatment suspension can harm their mental health [19, 23–25].
The results of systematic reviews indicate that treatment suspension or postponement has a negative effect on patients' mental health. In a systematic review on the mental health and treatment impacts of covid-19 on neurocognitive disorders, an increase in mental health disorders in patients whose treatments were suspended due to the coronavirus pandemic was reported [26]. Similarly, another systematic review reported a negative relationship between mental health and treatment suspension in cancer patients [27].
As it was mentioned, both infertility and the coronavirus pandemic have negative mental outcomes, so that is added the impact of treatment suspension, the severity of adverse mental health effects on infertile patients would be increased. Although different studies have been conducted regarding the relationship between treatment suspension due to the coronavirus pandemic and the mental health of infertile patients; to the best of our knowledge, no systematic review has been conducted in this relation. It is noteworthy that two systematic reviews have been published with respect to fertility treatment during the Covid-19 pandemic. One systematic review examined the challenges of oncofertility and fertility preservation treatment and the importance of telemedicine during the Covid-19 pandemic [28]. Another systematic review was conducted on the psychological impact of the Covid-19 pandemic on fertility care, and its finding suggested that the covid-19 pandemic caused negative psychological impacts on fertility care [29]; but because of the heterogeneity of articles, the researchers were not able to perform a meta-analysis. In their review, patients were also heterogeneous, with some studies conducted on patients receiving treatment, and some with patients whose treatment was halted or postponed. As it was mentioned, systematic reviews on patients other than those who undergo fertility care, suggest that treatment suspension or postponement has a negative effect on patients' mental health. Consequently, the mental health status of a patient, who is undergoing fertility treatment might be different from those who experienced treatment postponement. Therefore, this systematic review and meta-analysis were conducted to assess the relationship between the infertility treatment suspensions, due to the Covid-19 pandemic, and the mental health of infertile patients.