On March 11, 2020, the World Health Organization officially declared the SARS-CoV-2 infection a pandemic. This historic declaration led the Italian government to implement a set of restrictive measures that significantly impacted the freedom of movement for individuals.

These measures had dramatic economic repercussions, particularly affecting freelance workers and those with fixed-term contracts. Only workers with indefinite contracts benefited from extraordinary measures implemented by the government to preserve employment during the pandemic emergency.

A similar situation was observed in the health and social assistance sector, despite the increasing and urgent care needs related to the pandemic. The manufacturing sector, which constitutes approximately 20% of the total workforce, maintained stable employment levels, primarily due to extensive use of furlough schemes and extraordinary measures to preserve employment during the pandemic emergency.

The health crisis resulting from the pandemic inevitably altered the work environment and the delivery of services. The search for a balance between preventing the spread of the pandemic in workplaces and the need to provide services encouraged the legislature to enact measures to facilitate and streamline the implementation of the so-called “smart working.” Consequently, the number of workers adopting this method increased from just over 1 million to over 4 million in a few months.

However, despite these measures, the economic crisis caused by the pandemic inevitably led to a worsening of absolute poverty conditions. In 2020, over 2 million families (7.7% of the total, up from 6.4% in 2019) and over 5.6 million individuals (9.4%, up from 7.7%) were in this condition. After the improvement recorded in 2019, the effect of the pandemic increased the absolute poverty index, making it the highest since 2005 [1] .

Regarding relative poverty, there were just over 2.6 million families below the threshold (10.1%, down from 11.4% in 2019). As a natural and dramatic consequence of the average impoverishment of the population, there was a decrease in birth rates throughout the national territory [2] .

In 2020, the new births among the resident population were 404,892, about 15,000 less than in 2019 (−3.6%). However, it is essential to specify that this negative trend predates the SARS-CoV-2 pandemic; indeed, since 2008, births have decreased by 171,767 units (−29.8%).

The decline is primarily attributable to births from couples with both Italian parents (316,547 in 2020, over 163,000 fewer than in 2008). More specifically, this phenomenon has multifactorial origins, leading to significant changes in the female population of childbearing age, conventionally set between 15 and 49 years [3] .

Firstly, the so-called baby boomers (women born between the second half of the 1960s and the first half of the 1970s) are progressively leaving or concluding the reproductive phase. Secondly, younger generations are becoming less numerous, facing the effects of the baby bust, a period of sharp decline in fertility from 1976 to 1995, reaching a historic low of 1.19 children per woman in 1995. Thus, it is undeniable that Italian women of childbearing age are becoming less numerous.

Since the 2000s, immigration has partially mitigated the effects of the baby bust by introducing a young population. However, the positive contribution of young immigrant women is gradually losing effectiveness as they also experience the consequences of social phenomena leading to the impoverishment of Italian women of childbearing age as they age.

Specifically, the births within marriage are decreasing, totaling 259,823 in 2020, nearly 20,000 less than in 2019, and a 44.0% decrease compared to 2008. Subsequent studies, unfortunately, showed that this negative trend continued in 2021. According to provisional data for the January-September period, births were about 12,500 less than the same period in 2020, almost double the decrease recorded in the same period the previous year. This significant decrease was related to the negative effects triggered by the SARS-CoV-2 pandemic, which in January 2021 alone recorded the largest drop ever (almost 5,000 fewer births, −13.6%).

Analyzing more precisely the consequences of the SARS-CoV-2 pandemic on birth rates, it was observed that, although births decreased by 2.5% in the first ten months of 2020, in line with the trend from 2009 to 2019 (−2.8% on average annually), this decline markedly accelerated in November (−8.3% compared to the same month the previous year) and, especially, in December (−10.7%), corresponding to conceptions during the early months of the epidemic wave.

The situation is even more dramatic in the north-western regions of Italy, most affected by the pandemic during the first wave, where birth rates in December dropped by 15.4%. Undoubtedly, uncertainty in the health and economic sectors and lockdown-related restrictions have increasingly led Italian and immigrant families to postpone their conceptions. Supporting this hypothesis, January 2021 saw the maximum reduction in births nationwide (−13.6%), with the peak in the southern regions (−15.3%). This decline continued, albeit to a lesser extent, in February 2021 (−4.9%). Unfortunately, less optimistic projections show that this negative trend, stimulated by the pandemic, could persist beyond its conclusion. The only encouraging data, confirmed by a study from our department, was the spontaneous conception rate in couples on the waiting list for assisted reproductive techniques, reaching 15%, a figure comparable to unexplained infertility; this data was correlated with the increase in sexual intercourse due to domestic confinement ( Figure 1 ) [4] .

Fortunately, the increase in births observed in March, probably attributable to the population’s belief in overcoming the health emergency, led to a slight reversal of the trend with an increase in births compared to the same month of the previous year (+4.5%); these were births conceived during the transition phase between the two epidemic waves of 2020 [5] .

The trend of births remained weakly positive in April (+1%), only to collapse, especially in June (−5.9%) and July (−5.8%), corresponding to conceptions during the second epidemic wave.

The data available to us indicate that, in 2020, women aged 15 to 49 in Italy had an average of 1.24 children (1.27 in 2019), accentuating the decline since 2010, when the relative maximum of 1.44 was recorded. These fertility levels appear to be the lowest since the early 2000s.

When aiming to stratify fertility levels among women residing in Italy based on their regions, contrary to common beliefs, the North confirms the lead in the highest fertility levels for the total residents, especially in the Autonomous Provinces of Bolzano and Trento, Veneto, and Lombardy. This trend is reversed in the Central and Southern regions of Italy, where fertility levels have slightly declined compared to the same months of the previous year. However, the negative record is held by Sardinia, which continues to present the lowest fertility level among residents in the national territory—a value that is further decreasing compared to 2019.

Regional differences in total fertility are a direct consequence of socio-economic disparities within the national territory. A more flourishing economy and the consequent higher work and well-being expectations in the North, compared to the Central and Southern regions, have encouraged the migration of young families to these areas. However, despite more relaxed life expectations, during the pandemic, the average number of children per woman residing in Italy decreased equally in both the North (from 1.16 to 1.14) and the South (from 1.23 to 1.21), maintaining almost stable values in the Central region (1.11).

Another undeniable finding from recent studies is that, comparing fertility rates by age in 1995, 2010 (Italian women and total residents), and 2020 (Italian women and total residents), there is a shift in fertility towards increasingly mature ages. Compared to 1995, fertility rates have only increased in age groups above 30, showing a completely reversed trend in younger age groups. Consequently, the current average age for the first conception in Italy is 31.4 years ( Figure 2 , Figure 3 ).

Delving into a more detailed analysis of the fertility decline stratified by age groups of women residing in Italy, the clear correlation with the SARS-CoV-2 pandemic and its socio-economic consequences becomes apparent. Nationally, during January-October 2020, the decline in births primarily affected very young women (−5.6% for women up to 24 years old), as previously mentioned. This phenomenon is likely due to the economic uncertainty caused by the pandemic, which disproportionately impacted younger age groups, making them less capable of establishing and supporting a new family. On the contrary, women aged over 30, likely with more stable economic foundations, perceived a less unfavorable period for procreation and partly compensated for this negative trend in birth rates.

Another alarming finding is evident when considering the fertility rate in women over 45 years old. The data showed a marked contraction starting from November 2020. The likely explanation for this phenomenon lies in the reduced use of Assisted Reproductive Technology (ART), which peaked during the lockdown months. This conception technique is more prevalent among women aged 40 and above, particularly through assisted fertilization with egg donation.

From the presented data, it is now clear and indisputable that the dramatic impact of the pandemic on the fertility of the Italian population has only exacerbated an already critical pre-existing condition.

Let’s delve into the trends of both homologous and heterologous Assisted Reproductive Techniques (ART) and birth rates in the Lazio region, where our study was conducted. Figure 4 illustrates the increase in ART procedures over the years, displaying a consistently rising trend that, from 2005 to 2019, has not shown any deviations ( Figure 4 ) [6] .

This data aligns with the information presented thus far. According to ministry data from 2018, Lazio held the third position (after Lombardy and Tuscany) for the number of initiated cycles and the second position (after Campania) for the number of centers ( Table 1 ). Of the initiated cycles, 1,109 were in public centers and 3533 in private ones. Lazio ranks second in the number of cycles using gamete donation. This data has notably increased after the introduction of heterologous fertilization at the San Filippo Neri PMA Center in Lazio.

An interesting aspect is the survey conducted by the National Institute of Health aimed at public and private centers in Italy to assess the reduction in activity during the pandemic.

In general, about 9500 fewer ART cycles were observed in the first quarter of 2020 compared to the same period in 2019, representing a 34.8% reduction in activity. Specifically, for In Vitro Fertilization (IVF), there is a 46.4% reduction in cycles, a 34.1% reduction for fresh ART cycles, a 33.7% reduction for Frozen Embryo Transfer (FER), and a 39.2% reduction for cycles involving gamete donation ( Figure 5 ; Figure 6 ).

In February 2016, the Lazio Region adopted the costs of the public service established by the Conference of State-Regions-Autonomous Provinces (DCA 19/2016) for homologous fertilization ( Tables 2-4 ).

For heterologous fertilization, the costs proposed by San Filippo Neri—ASL Roma 1 were applied, activating the service on July 27, 2018.

Regarding private costs, these vary widely from center to center and depending on the geographical location:

[Note: Figures are in Euros.]

This was an observational, cross-sectional study conducted at the Assisted Reproductive Techniques Center of San Filippo Neri Hospital in Rome, the only hospital in Central and Southern Italy offering gamete donation services in the public system. Couples gave informed consent for clinical data use. Ethical approval was obtained from the Ethical Committee of Asl Roma 1. Results were obtained through an online questionnaire consisting of 20 multiple-choice questions, with participants providing anonymous responses. The questionnaire was administered to 500 patients, and 295 responses were received. Each participant answered the following questions by selecting only one of the possible alternatives:

Data expressed as percentage.

Our results highlight how the onset of the pandemic and the consequent economic and social restrictions have affected access to assisted reproductive techniques (ART) and the desire to seek pregnancy. It is evident that in a population where 60% of individuals base their choice of ART on income, the economic constraints resulting from the past two years of the pandemic may have had devastating effects on fertility and the number of births, especially in the advanced maternal age group.

In addition to the economic challenges faced by the participants in our study and the Italian population in general, the impact of the pandemic on the functioning of ART centers must be considered. As previously mentioned in the survey published by the Ministry of Health, the activities conducted within ART centers, both in private and public facilities, experienced a significant slowdown or complete stoppage to make room for COVID wards or other services deemed of primary importance during the initial phases of the pandemic. The survey revealed that approximately 78% of centers suspended all activities without initiating new cycles. Only 3 centers out of 176 reported that they did not completely suspend activities and continued to start new ART treatments.

These findings are consistent with recent international evidence. For instance, a large prospective cohort in China reported a marked decrease in ART utilization after the outbreak of COVID-19, with utilization rates dropping from 6.71% in 2019 to 6.55% in 2020, reflecting the impact of service suspensions and reduced access during the pandemic’s early phases [7] . Similarly, an analysis of IVF activity in Jakarta showed an initial decline in cycles during 2020, followed by a progressive recovery between mid-2020 and 2021, when clinics reorganized with safety measures such as negative-pressure operating rooms and systematic testing [8] . Together, these studies support the view that ART activity was strongly conditioned by the health emergency, but once structural and organizational adaptations were introduced, services partially rebounded.

The study and analysis of these data provide a current overview of the conditions of infertile couples in our country, allowing for the implementation of interventions to restore interest and the economic conditions necessary for the initiation of assisted reproductive pathways. Further investigations will be necessary to assess the long-term consequences on the number of pregnancies and newborns once normal conditions are restored at the end of the health emergency.

Finally, the study’s findings should be interpreted in light of several limitations. The use of a voluntary online questionnaire resulted in a non-random sample and a moderate response rate (59%), making the study susceptible to self-selection bias. Participants who chose to complete the survey may have been more motivated or affected by the issues being studied than those who did not. Consequently, the sample may not be fully representative of the general population, which threatens the external validity of the results. The findings are therefore most generalizable to the specific group of individuals who were willing to participate and should not be considered representative of the broader population.

A.P.: conception and design; F.S., E.N., and S.N.: data collection and interpretation; F.S.: wrote the manuscript; A.P.: provided suggestions and revised the manuscript for final submission. All authors have read and agreed to the published version of the manuscript.