Reproductive medical providers’ behaviors, considerations, and plans for fertility treatments during the COVID‐19 pandemic in Japan: A nationwide web‐based survey

Abstract Purpose This study was conducted to investigate how the COVID‐19 pandemic has impacted reproductive medical providers’ behaviors and considerations, including their concerns regarding the necessity of fertility treatments. Methods A web‐based questionnaire was distributed to Japan Society of Fertilization and Implantation (JSFI) members from May 18 through May 31, 2020 to survey their professional behaviors and concerns during the COVID‐19 pandemic. Results Most survey participants reported a decrease in the number of patients and a decrease in their workload. Most also believe that the use of fertility treatments will return to the pre‐pandemic levels after the COVID‐19 pandemic ends. Additionally, more than half of the participants reported that they consider fertility treatment neither necessary nor unnecessary during the COVID‐19 pandemic. Conclusions At the institute where reproductive medical providers worked in Japan, the number of outpatients and the working time tended to decrease during the COVID‐19 pandemic. However, amid fears of infection during the COVID‐19 pandemic, the reproductive medical providers working at fertility institutes in Japan have remained engaged in their work with a sense of mission and hope.

associations, including the CDC, the WHO, the American Society for Reproductive Medicine (ASRM), the European Society for Human Reproduction and Embryology (ESRHE), RCOG, ACOG, and the Japan Society for Reproductive Medicine (JSRM). In particular, most fertility treatments with the exception of fertility preservation for cancer patients were suspended.
The outbreak of COVID-19 in the first few months of 2020 suddenly and unexpectedly confronted fertility patients with a new set of losses and uncertainties. Owing to the implementation of stringent social distancing measures and the suspension of "nonessential" medical treatments and procedures, fertility treatments were halted in the US, the UK, and other European countries. 2 Fertility treatments may have decreased because of the COVID-19 pandemic even though vast numbers of assisted reproductive technology (ART) cycles have been reported in Japan in recent years. 3 Although there are no available data indicating whether the number of fertility treatments has been affected by the COVID-19 pandemic, previous studies have reported that reproductive medical providers faced many problems during the 2003 SARS outbreak. [4][5][6][7] Indeed, studies have revealed that reproductive medical providers feared contagion and were concerned about the possibility of infecting their families, friends, and colleagues. 4 They also reported feeling stigmatized 4,5 and were reluctant to work; some providers even contemplated resignation. 5 Reports of the SARS outbreak also describe reproductive medical providers experiencing high levels of stress and anxiety. 6 Similarly, health care professionals treating and caring for patients with infertility may be experiencing similar behaviors and mental health issues due to the COVID-19 pandemic.
The primary purpose of this study was to conduct a nationwide survey to investigate reproductive medical providers' workrelated actions and considerations during the COVID-19 pandemic.
Additionally, we aimed to clarify their perceptions about whether fertility treatment was necessary during the COVID-19 pandemic based on discussions about the social value of offering fertility treatments and on whether it is justifiable to suspend them in the event of a health crisis of this proportion.

| MATERIAL S AND ME THODS
We conducted a web-based survey about behaviors and responses to the tumultuous COVID-19 pandemic situation among the members of the Japan Society of Fertilization and Implantation (JSFI). A self-report questionnaire was initially designed to survey behaviors and responses during the COVID-19 pandemic ( Table 1). The questionnaire consisted of 17 multiple-choice questions; for each item, one or more answers could be chosen. If a participant's answer did not match any of the provided choices for an item, the participant was permitted to provide their own response. Six of the 17 items collected demographic information (ie, age, gender, and job title) and information about the fertility institute (ie, prefecture and the number of oocyte retrievals). The other 11 items involved participants' behaviors and concerns related to ART activity in their institute during TA B L E 1 The Questionnaire of behaviors, considerations, and plans in reproductive medical providers the COVID-19 pandemic. Information about this survey was available on the JSFI website, and surveys were simultaneously emailed to 1641 JSFI members who were registered on the mailing list of the JSFI on May 18, 2020. 7 The survey website contained a statement explaining to the participants that responding to the survey implied that the participants had provided informed consent. Participants were able to answer the survey from May 18, 2020, to May 31, 2020.

| RE SULTS
A total of 638 valid completed surveys (response rate of 44.2%) were obtained from 1641 members ( medical doctors and 40.8% were embryologists, even though embryology is the main aspect of the survey. Participants who work at high volume fertility centers-centers reporting more than 1000 cycles of oocyte retrievals-made up 17.2% of all respondents. More than 80% of participants were from urban areas ( Figure 1). The majority of participants (89.2%) indicated they were not willing to abstain from working in the field because of the pandemic, although most of them feared nosocomial COVID-19 infection ( Figure 2).
Most participants (86.2%) reported practicing disinfection behaviors (88.9%) and using protective equipment (86.2%) most of the time when working directly with patients ( Figure 3).
Regarding levels of ART activity during the COVID-19 pandemic, 34.2% of participants indicated there had been no change compared to before the pandemic, but 41.7% indicated reductions in ART activity at their clinic ( Figure 4). Approximately one-third (  to 30% after the pandemic (Figure 12).  There is limited evidence regarding SARS or MERS and pregnancy because SARS and MERS had limited spread; the rate of fatality for all reporting cases of SARS in pregnancy was higher as well as MERS in pregnancy. [13][14][15][16][17] In addition, the miscarriage rate was 57.1% in women infected with SARS in very early pregnancy. 17   be useful for further investigations because of the ease with which researchers can reach out to additional targets.

| D ISCUSS I ON
In this survey, documented data such as those presented in this article will provide a basis for further study regarding behaviors and responses of reproductive medical providers to the COVID-19 crisis.
Such conclusions will be valuable for health authorities and health care professionals in case of a future global pandemic. This paper reflects the current state of reproductive health care at a time when we have been forced into a new way of life by an emerging global infectious disease that we have never experienced before. The findings may form the basis for improving the current situation and can be used in the future when similar crises arise.

ACK N OWLED G EM ENTS
The authors thank the members of JSFI for participating in this survey, and Ms Mariko Shimokawa, who is the secretary of JSFI, for her assistance.