|Ahead of print publication
Covid-19 pandemic: Impacts survey of fertility practitioners in Nigeria
Lateef Adekunle Akinola
Department Obstetrics and Gynaecology, Medison Specialist Women's Hospital, Lekki, Lagos, Nigeria
|Date of Submission||29-Jun-2020|
|Date of Acceptance||28-Aug-2020|
|Date of Web Publication||27-Oct-2020|
Lateef Adekunle Akinola,
Medison Specialist Women's Hospital, Lekki, Lagos
Source of Support: None, Conflict of Interest: None
Background: COVID-19 pandemic has created a huge disruption to the activities of physicians and other healthcare providers all over the world. Fertility centers, fertility practitioners and patients alike are not left out. Infertile couples and families also face significant disruptions to their treatment schedules, financial plans as well as uncertainty about when their fertility treatments will begin. This survey evaluates the impacts that COVID-19 pandemic will have on the budgetary and operational activities of Fertility Centre's and practitioners in Nigeria. Methodology: A question-based, cross-sectional survey of registered fertility practitioners of the Association for Fertility and Reproductive Health of Nigeria (AFRH) carried out on the 10TH to 15TH of April 2020. Results: Majority of the respondents felt that their fertility centers made a good adaptation to the new working environment. Majority agreed that services have been negatively impacted, while 64.42% of responding practitioners felt the pandemic had not resulted to staff retrenchments. Also, majority believe that business continuity and plan is not been disrupted by the pandemic. A third of the respondents use travel and exposure histories, physical examinations and taking temperature for diagnostic assessments. AFRH and Nigerian Center for Disease Control (NCDC) performance and response to Covid-19 pandemic were rated to be above average. Conclusion: Majority of the AFRH fertility practitioners surveyed felt that Covid-19 pandemic and its containment strategies negatively impacted work, services and budgetary needs of fertility practitioners in Nigeria, with no significant impact on staff employments. Response and guidance from the Association for fertility and reproductive Health and the NCDC towards curtailing the spread of Covid-19 infections to their members and the Nigerian communities, respectively, were rated above average.
Keywords: Fertility centers, fertility practitioners, impact, Nigeria, severe acute respiratory syndrome coronavirus-2, survey
| Introduction|| |
Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus-2 pandemic started late November 2019 in Wuhan, China. The Federal Government of Nigeria (FGN) and the Nigeria Center for Disease Control (NCDC) on the 28th of January announced a number of containment measures to stop the spread of the disease in Nigeria., These include surveillance of five international airports in Nigeria, (Lagos, Federal Capital Territory [Abuja], Kano, Enugu, and Port Harcourt) setting up coronavirus monitoring group with imminent readiness to activate all the necessary measures to curtail the infection. The first case in Nigeria was confirmed on the 25th of February 2020., On the 9th of March, Presidential Task Force was established to contain and monitor the spread of the virus in Nigeria.
The World Health Organization declared COVID-19 a pandemic on March 11, 2020. As of May 14, 2020, about 4,379,973 people had been infected worldwide and more than 298,185 had died. In Nigeria, the NCDC announced that as at the 14th of May 2020, there were about 4971 confirmed total cases, 164 deaths and 1070 discharges.,, However, from March 24, 2020, the FGN announced further measures to curb the spread of the infection, prevent human fatality and possible pressure on the health-care systems across Nigeria.,, From this date, the federal capital territory Abuja and Lagos State were put on the social lockdown enjoining all residents to stay at home and to avoid unnecessary outings and mass assembly. Further, containment measures to stem the spread of the infection by the Nigerian government, like other governments across the world, included closure of international airports and borders, expanded coronavirus diagnostic tests to find infected citizens, contact-tracing, quarantine of those infected, wearing of face mask, and advice on social distancing.
Although COVID-19 containment measures are effective, however, they appear costly, with disruption of social activities, livelihood, and consequent rise in communal insecurity. It is not known what impact COVID-19 and the containment measures will have on nonemergent health-care services such as fertility treatment. This survey evaluates what the impacts could be on the budgetary and operational activities of fertility centers' practitioners in Nigeria.
| Materials and Methods|| |
This was a questionnaire-based, cross-sectional survey of registered fertility practitioners of the Association for Fertility and Reproductive Health of Nigeria (AFRH) carried out from 10th to 15th of April 2020, using the Survey Monkey platform. The AFRH members are made up of physicians, nurses, embryologists, and other reproductive health practitioners. The survey was designed using Survey Monkey platform and the survey link generated was sent to the AFRH WhatsApp group (https://www.surveymonkey.com/r/Fertility-Practitioners-In-Nigeria-COVID-19-Impacts). One hundred and ten of 140 members on WhatsApp platform completed the survey and have been analyzed. Top executives include Medical Directors (MDs), Chief Executive Officers (CEOs), or Facility Owners (FOs). Others members of the fertility centers participating in running the affairs of the organizations included Directors, Managers, and Employees.
| Results|| |
A cross-sectional, questionnaire-based survey was conducted among AFRH members registered on the associations fertility and in vitro fertilization (IVF) update WhatsApp page. The respondents include MD/CEO/FO, directors, managers, and employees. A total of 140 fertility practitioners were asked to complete the survey. The response rate was 73.57% and 78.57% (103-110/140).
Q1: Which best describes your role?
Out of a total of 110 respondents that completed the survey, 57.27% (63/110) were employees; 22.73% (25/110) MD, CEO, and FO, while 11.82% (13/110) were managers and 8.18% (9/110) directors [Figure 1].
Q2: What is the staff strength of your fertility center?
About 76.36% (84/110) of responding fertility practitioners work in centers with 1–50 employees, whereas 19.09% (21/110) and 4.55% (5/110) work in centers with 51–100 and >100 staff strength, respectively [Figure 2].
Q3: What type of fertility/Assisted Reproductive Technology treatments is available at your fertility center presently?
About 46.73%(50/107), 45.79% (49/107) and 7.48% (8/107) of respondents' Assisted Reproductive Technology (ART) centers do all fertility and ART treatments, excluding preimplantation genetic tests (PGT); all fertility/ART treatments including PGT and all fertility and ART treatments except IVF/ICSI (Intracytoplasmic Sperm Injection) and PGT, respectively [Figure 3].
|Figure 3: What type of fertility/Assisted Reproductive Technology treatments is available at your fertility center presently?|
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Q4: As fertility professional, how important is it for you to get tested for coronavirus disease 2019?
Out of 110 surveyed respondents, 68.81% (75/109) felt it was very important, 23.85% (25/109) felt it was important, and 7.34% (8/109) felt it was not important [Figure 4]. Among those responding practitioners that felt it is not important to get tested were about 13% (14/110) of the MD/CEO/FO, 8% (9/110) of the managers, and 7% (8/110) of the employees [Figure 4].
|Figure 4: As fertility professional, how important is it for you to get tested for coronavirus disease 2019?|
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Q5: Are you currently using any preventive methods to reduce patient's risks of coronavirus disease 2019?
One hundred and four out of a total of 109 (95.41%) respondents mentioned that their centers currently use some preventive screening methods to reduce patient's risk of contracting COVID-19 viral infection at their centers but 5.45% (6/110) do not use any screening methods [Figure 5].
|Figure 5: Are you currently using any preventive methods to reduce patients risks of SAR- coronavirus-19 virus infection?|
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Q6: What type of coronavirus disease 2019 screening tests available at your in vitro fertilization clinic for patients and staffs?
None of the practitioners surveyed have access to reversed transcriptase-polymerase chain reaction (RT-PCR) screening method. However, 38.18% (42/110) screened with temperature monitoring and physical assessment, 36.36% (40/110) used detailed history of at risk and/or infected patients, while 23.64% (26/110) have no screening methods available. One center each 0.9% (1/110) have the enzyme-linked immunosorbent assay (ELISA) antibody test and immunoglobulin (Ig) G/IgM rapid test available [Figure 6].
|Figure 6: What type of coronavirus disease 2019 test available at your in vitro fertilization clinic for patients and staffs?|
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Q7: How likely will you screen your patients for coronavirus disease 2019 infection before their in vitro fertilization treatments?
About 39.62% (42/106) will not screen patients at all, while majority 60.38% (64/106) of respondents will screen patients before starting the treatment [Figure 7]. About 50% (12.5/25), 50% (4.5/9), 31% (4/13), and 36% (23/63) of MD/CEO/FO, directors, managers, and employees, respectively, felt it is unnecessary to screen patients before IVF treatments.
|Figure 7: How likely will you screen your patients for coronavirus disease 2019 before their in vitro fertilization treatments?|
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Q8: How has your fertility centers operations been impacted by coronavirus disease 2019 and the Nigeria Center for Disease Control/Nigerian Governmental Policies to date?
Majority of the respondents, 85.98% (92/107) felt that their centers operations and practices have been negatively impacted by the FGN and NCDC advise on social distancing, lockdowns, and center closures [Figure 8].
|Figure 8: How has your fertility centers operations been impacted by coronavirus disease 2019 and the Nigeria center for disease control/governmental policies to date?|
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Q9: As a whole how well do you think your fertility center has adapted to the new working environment?
Majority of the responding fertility practitioners also expressed that their fertility centers have adapted to the new working environment well and that their centers' plans on business continuity, are going according to plan and not significantly negatively impacted by the fallout from the pandemic. Furthermore, about two-thirds of the respondents, 64.42% (67/104) felt that the fall in income and services due to COVID-19 pandemic has not caused job losses in their centers [Figure 9].
|Figure 9: As a whole, how well do you think your fertility center has adapted to the new working environment?|
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Q10: How will you rate the following responses to coronavirus disease 2019 so far by the following organizations? Nigerian governments, Nigeria Center for Disease Control, Health Management Organizations (HMOs), patients and Association for Fertility and Reproductive Health?
The respondents rated NCDC and AFRH performance above average. The Nigerian governments' actions and policy and communication of COVID-19 containments guides were rated average. The respondents, however, rated the HMOs and patients poorly, well below average [Figure 10].
|Figure 10: How will you rate the following responses to coronavirus disease 2019 so far by the following organizations?|
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| Discussion|| |
This was a cross-sectional, questionnaire-based survey conducted among AFRH members registered on the associations Fertility and IVF update WhatsApp page. This study will be the first of its kind, directly surveying fertility practitioners on the impact of COVID-19 on their activities. About 140 members are registered on the page, and the response rate was over 73%. About 57.27% (63/110) were employees; 22.73% (25) MD, CEO and FO, while 11.83% (13) were managers and 8.18% (9) directors [Figure 1]. Majority 76.36% (84) of responding fertility practitioners work in centers with 1–50 employees [Figure 2] showing that majority of the centers are small clinics with the staff population <50.
Range of fertility and Assisted Reproductive Technology treatment methods available at responding practitioners' centers
It is noteworthy, that about 46.73% (50/107), 45.79% (49/107) and 7.48% (8/107) of respondents' ART centers do all fertility and ART treatments, excluding PGT; all fertility/ART treatments, including PGT and all fertility and ART treatments except IVF/ICSI and PGT, respectively [Figure 3]. Of note, 45.79% (49/107) carryout full spectrum of ART treatments including PGT analyses. At present, about 3 ART centers in Nigeria (2 in Lagos and 1 in Abuja) presently have the technology to carry out full PGT screening in Nigeria without sending biopsied specimen abroad for analyses. Clearly, this is important, can speed up PGT screening results turnover permitting embryo transfers within 24 h of biopsies taken, makes unnecessary cryopreservation of biopsied embryos avoidable, also making the screening more affordable and less expensive for patients.
Importance of coronavirus disease 2019 screening by fertility centers and its benefits
To prevent the spread of infection among staff and patients, it is very important that fertility practitioners do screen themselves and patients' regularly. Those found to test positive for the COVID-19 need to be appropriately quarantined and treated. Of 109 surveyed respondents, 68.18% (n=75/109), 23.85% (n=26/109) and 7.34% (n=8/109) felt it was very important, important, and not important for them as fertility professionals to get tested for COVID-19, respectively, [Figure 4]. Among those responding practitioners that felt it is not important to get tested were about 13% of the MD/CEO/FO, 8% of the managers and 7% of the employees [Figure 4]. The reasons for this are not obvious from this survey. About 95% of respondents use preventive method(s) to screen patients [Figure 5] and [Figure 6].
Furthermore, screening patients to detect those at high risk of infection before starting their treatments is important to ensure the health and well-being of patients and health-care workers, and prevent risks of COVID-19 cross-infections. About 60.38% (64/106) of all respondents indicated that they will screen patients before IVF treatment and 39.62% (42/106)would not [Figure 7]. Interestingly, a further analysis of the data showed that half of all the MD/CEO/FO and Directors; and about a third of the Managers and Employees felt that it was not necessary to screen patients before IVF treatments. As screening test for COVID-19 is not universally available in Nigeria and most parts of the world, it is reasonable to assume that all patients have the potential risk of transmitting coronavirus. This, therefore, makes it more necessary to test patients, not the least to prevent cross-infections, for triaging purposes/treatments of infected people and for making ART treatment plans for individual patients before the beginning of their fertility treatments.
Furthermore, it is pertinent when reopening fertility services, that fertility practitioners have a robust way of triaging patients to low-, moderate-, and high-risk patients to prevent the cross infections of staffs/noninfected patients and for other reasons stated above. One hundred and four 95.41 (104/109) respondents mentioned that their centers currently use some preventive screening methods to reduce patient's risk of contracting COVID-19 viral infection at their centers but 4.59% (5/109) do not use any screening methods.
The survey further asked all respondents the types of COVID-19 screening tests available at their centers, among the more expensive RT-PCR genetic test, ELISA, and IgM/IgG antibody tests to the less expensive history of exposures/travels, physical examinations, and temperature measurement. The sensitivity/specificity of these tests varies from 61% to 72%/100% for RT-PCR  to nonspecific tests like physical examination and measurement of temperature. From this survey, it was found that all the centers do not have any of the RT-PCR screening methods. A third of the responding fertility practitioners use combined travel and exposure history, physical examination, and temperature measurements for screening and triaging patients [Figure 6]. This is basic, costing little or nothing, easy to do and can at least enable triage to low-, moderate-, or high-risk categories. Low-risk patients may wish to commence their treatments as soon as expedient, while those found to be of moderate or high-risks can be referred for evaluation and possible treatments as necessary.
Disruptions to regular working patterns/hours and its possible effects on fertility practitioners and ART centers
The AFRH like the American Society for Reproductive Medicine and European Society of Human Reproduction and Embryology, at the height of COVID-19 pandemic, advised suspension of all new fertility treatments and freezing all embryos generated from any ongoing treatments.,,, These recommendations were made in response to the guidance from the government and NCDC , and to demonstrate that fertility clinics were also contributing their quota to curtail the spread of coronavirus infection in the community. Most fertility and ART centers in Nigeria were, therefore, compelled to limit or close most of the services they offer. It is, therefore, not unreasonable that the majority of the respondents felt that COVID-19 pandemic have significant negative disruptions on the services they offer, more so, working hours were reduced or made more flexible, and majority of staff started working and networking remotely from home. These disruptions to regular working patterns might not uncommonly be associated with decrease in staff remunerations and can bring about reductions in overall financial and budgetary plans of ART centers.
From the survey, about 20% (22/110) had challenges adjusting to home/remote networking arrangements and another 17% (19/110) with challenges accessing internet and their business communication systems. These difficulties might not be unexpected; remote networking, and information technology access quickly became the new normal (in response to curtail spread of COVID-19 infection) and are not the usual working pattern most are accustomed to.
Impact on fertility practice and services
The recommendations to suspend most or all fertility services by AFRH, appeared reasonable, in light of the many yet unknowns about the pathogenesis of COVID-19 and the dearth of data on its potential risk to sperm, oocytes, embryos, pregnancy, and the foetus.
When specifically, asked how has the COVID-19 pandemic and the directives by government, NCDC, AFRH affected their fertility practices, majority of the respondents >80% felt that their practices have been significantly negatively impacted. Specifically, 73% of respondents expressed a significant negative impact on the number of incoming enquiries from new patients and 78% (86/110) mentioned that their ART centers were closed. Furthermore, 83%–85% (91/110–94/110) of respondents expressed that there was a significant negative impact on the overall and financial health of their fertility centers and on previously planned fertility treatments for patients [Figure 8]. Despite all these, however, most respondents (64.42%) felt that the fall in services and income due to COVID-19 pandemic has not caused job losses in their centers. In the same vein, majority of the responding fertility practitioners (>80%) also expressed that their fertility centers have adapted to the new working environment well and 57% (63/110) said that their centers' plans on business continuity are going according to plan and not significantly negatively impacted by the fallout from the pandemic [Figure 9].
Perception on the effectiveness of responses by the Nigerian Government, NCDC, HMO, AFRH, and patients' responses to stem the spread of COVID-19 in the community
As of May 11, 2020, there were 4787 cases of COVID-19 and over 158 deaths in Nigeria. To stop the spread of the infection and curb its associated morbidity and mortality, Nigeria governments and public health authorities, enforced strict rules on social distancing, strict quarantine policy for those at risk of spreading the infection and community lockdowns., These measures also brought about the closure of schools and businesses and sending most of the workforce home. These actions led to the disruption of business activities in many economic sectors. As mentioned above, most fertility centers heeded these advices to close completely or partially. This undoubtedly came with a significant drop in services and patients' patronage. AFRH fertility practitioners were asked to assess the effectiveness of the policy responses of Nigeria government and public health authorities to COVID-19 pandemic containment. Majority of the respondents [Figure 10] felt that NCDC 45.79% (49/107) and AFRH 42.10% (45/107) advisory to the public and AFRH members to contain COVID-19 pandemic were rated above average, while efforts made by the Nigerian government were rated average. The responses of health maintenance organizations (HMOs) and patients were, however, rated poorly and below average. The Nigerian Governments' performance was rated average. The criteria used by the responding fertility practitioners for these assessments are unknown and not addressed by the present survey.
| Conclusion|| |
A cross-sectional, questionnaire-based survey was conducted among registered AFRH members. The response rate was >73%. Over 80% of surveyed fertility practitioners felt that their practices have been negatively impacted by the COVID-19 pandemic and the Nigerian Governments/NCDC directives on social distancing, quarantine and lockdowns, to contain the spread of the disease. Not unexpectedly, the fear or likelihood of job losses and salary cuts might also contribute to these feelings of loss by majority of the staff. Majority, however, felt that their fertility centers adapted well to the new working environment and that their centers plan for growth and continuity are still on course and going according to plan. The NCDC and AFRH advisory to the public and AFRH members, respectively, to contain COVID-19 pandemic were rated above average, while that of the efforts made by the Nigerian government were rated about average. A third of the responding fertility practitioners use combined travel/exposure history, physical examination, and temperature measurements for screening and triaging patients. Till date, there is still no cure or vaccines available. More research work and knowledge about COVID-19, risks of contacting, morbidity/mortality rates, and need for preventive methods are necessary. Furthermore, from this survey, about 41% of surveyed practitioners' centers have available technologies to carry out the full spectrum of fertility services including PGT. It is advisable and important to carry out a census of all available ART technologies and specialists in Nigeria, to know what is available and can be done here in Nigeria and to stem the tide of medical tourism for ART treatments.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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