Infertility is deeply personal and affects 15% of the population. Many who struggle to conceive may never access care because of cost, inertia, or embarrassment associated with having difficulty conceiving. Those with infertility endure many anxieties, uncertainties, feelings of helplessness, and fears about the future -- and now, there's theCOVID-19 pandemicon top of it all.

Amid rapidly evolving public health guidelines, COVID-19 places healthcare providers in a similar climate of anxiety, uncertainty, feelings of helplessness, and fears about the future. Some of us physicians are developing a finer appreciation of the fear of the unknown that regularly complicates decision-making for our fertility patients. For those of us who see things as "black-and-white," and who may be overly dependent on guidelines and algorithms, it is likely a particularly difficult time. We all need to start appreciating nuances and gray areas in medicine. In learning to live with uncertainty, we should learn that with every plan, we must be flexible, ready to absorb new information, and ready to change direction with very little notice.

Over the past month, we have had many questions from our patients about COVID-19, pregnancy, and fertility. Here is a summary of common questions, current data, and recommendations from our national societies:

What are the risks of birth defects with COVID-19?

There are inadequate data to suggest any increased risk of birth defects with COVID-19 infection in the mother. This is reassuring, especially compared to the clearly increased risk of birth defects with varicella, rubella, and Zika virus infections in the mother. Further studies are needed.

Is there evidence of vertical transmission (mother-to-fetus transmission) of COVID-19?

There are inadequate data to suggest that COVID-19 can be passed from mother to fetus. Further studies are needed.

What do we know about the impact of COVID-19 virus infection in utero?

There are few reports of COVID-19-positive women who have given birth. One report from China suggests a possible increased risk of preterm delivery or intrauterine growth restriction; however, these limited data only address COVID-19 infection in late pregnancy. More data will emerge as women who were infected during the early stages of pregnancy progress to delivery over the coming months.

It is unclear whether the reported implications and outcomes associated with COVID-19 are the same as those with other types of coronavirus infections (such as SARS-CoV and MERS-CoV) during pregnancy. Further studies are urgently needed.

What are the national recommendations?

On March 17, the American Society of Reproductive Medicine (ASRM)published guidance for fertility specialists, which included five key recommendations: (1) suspend initiation of new treatment cycles; (2) strongly consider cancellation of all embryo transfers; (3) continue to care for patients who require urgent stimulation and cryopreservation (such as in cases of fertility preservation prior to impending cancer treatment); (4) suspend elective surgeries and non-urgent diagnostic procedures; and (5) minimize in-person interactions and increase utilization of telehealth.

In a March 31 update, ASRM reaffirmed this guidance and noted that they plan to reassess and issue updated recommendations every 2 weeks.

ASRM further noted that infertility should *not* be considered elective. Indeed, the World Health Organization and the American Medical Association have recognized infertility as a disease and a global public health issue.

What services are available and considered "urgent" during this pandemic?

This is a loaded question that likely needs to be individualized in different geographic regions. Regarding "urgent" surgeries, the American College of Surgeons states, "The medical need for a given procedure should be established by a surgeon with direct expertise in the relevant surgical specialty to determine what medical risks will be incurred by case delay."

Can patients begin treatment cycles right now?

For those couples desiring to start fertility treatments, unfortunately, there is currently a national stoppage in America (and also in Europe). While infertility is not elective, fertility treatments (except for very specific indications) are considered non-urgent treatment. While this will be re-evaluated every 2 weeks, we are currently in a "wait and see" situation. While everyone wants to reinstate care as soon as possible, we also need to be conscious of the rapidly evolving nature of COVID-19, and the need for our healthcare system to preserve, conserve, and even hopefully build up some reserves of valuable personal protective equipment during this worldwide COVID-19 public health emergency.

Can COVID-19 be transmitted with fertility treatments?

Specifically, can a woman without COVID-19 acquire it using sperm from a man with COVID-19? There are no data on this question, and further studies are needed.

Regarding fertility treatments, do we need to "quarantine" frozen sperm, oocytes, or embryos from COVID-19 patients?

Most fertility laboratories keep cryopreserved sperm, oocytes, or embryos from HIV-positive individuals in separate freezing tanks to "quarantine" them from frozen genetic material from the general population. Should these labs similarly "quarantine" frozen genetic material from COVID-19 patients separately? Further studies are needed.

Are there any risks of complications for fertility treatments in COVID-19 patients?

One potential risk with in vitro fertilization (IVF) is a phenomenon called "severe ovarian hyperstimulation syndrome," which may result in respiratory and cardiovascular difficulties. Given that COVID-19 infection can similarly result in respiratory and cardiovascular difficulties, it is unknown how women with COVID-19 will handle severe ovarian hyperstimulation syndrome. There are currently no reports of such complications.

Is it safe to try to conceive naturally?

For those couples who wish to try to conceive on their own, we individualize counseling based on patient health status. According to the CDC: diabetes, cardiovascular disease, morbid obesity, and immunocompromise are risk factors for critical illness from COVID-19 infection.

Similar to the 1918 flu pandemic, there are also some concerns that there may be a second wave of COVID-19 cases this fall or winter. Furthermore, we know that a small percentage of pregnant women may have a pregnancy complication (such as preterm labor, premature rupture of membranes, or eclamptic seizures) that may require a hospital stay; however, hospitalization during the COVID-19 pandemic may confer an increased risk of COVID-19 infection. Labor and delivery during this time of COVID-19 may be complicated by recommendations for early epidural placement, a higher chance of cesarean section, and emerging policies to separate mom and baby to minimize the risk of transmission of COVID-19 to the newborn.

For healthy patients who are willing to accept these risks if they conceive now and deliver during a possible resurgence of COVID-19 cases this fall or winter, it would be reasonable to try to conceive naturally.

Should the non-COVID-19 patient delay pregnancy during the current pandemic?

For those debating whether to continue contraception (versus whether to immediately start trying for a natural cycle pregnancy) during these uncertain times, it would be reasonable for certain patients to continue contraception.

While there are no recommendations about contraception for the American public, the European Society of Human Reproduction and Embryology advises that "all fertility patients considering or planning treatment, even if they do not meet the diagnostic criteria of COVID-19 infection, should avoid becoming pregnant at this time." This difference may be due to healthcare systems in certain European countries becoming overwhelmed by COVID-19 cases, leaving those healthcare workers with a lack of resources, personal protective equipment, and availability to treat routine patients outside of their pandemic response.

Finally, there remains much uncertainty about COVID-19, in general.

Infection rates: we will not have reliable data on true infection rates until widespread and accurate testing is more readily available.

Prevalence rates: we will not have reliable data on the number of patients who have recovered from COVID-19 until we have an accurate and reliable test for COVID-19 antibodies.

Fatality rates: without knowing how many cases we truly have, any estimate of true case fatality rates is doomed, except for closed systems like theDiamond Princesscruise ship.

We also have important unknowns, regarding the course of the pandemic, local hospital resources, and the effects on small businesses and the economy.

We empathize with our fertility patients who want to be pregnant already; unfortunately, so much remains unknown about COVID-19. The decision to try for conception, or to continue with contraception, is highly personal and needs to be individualized based on personal health, local conditions, and the current state of the pandemic in your local area.

Here are three questions that fertility patients should consider asking themselves:

Is my personal health and lifestyle in a place where I believe I can have a safe pregnancy?

Am I comfortable becoming pregnant and seeking care (including emergency care if complications arise) in an environment that may be wholly focused on combating COVID-19?

Am I confident that I will have the support I need during and after the pregnancy in a society that may still be practicing high levels of social distancing?

Our state and national leaders are right: this is a war, and we need to band together, so that we don't get overwhelmed. Our hope is that our collective global response to this pandemic will increase our sense of community and togetherness. We need to fight fear, panic, social isolation, and coronavirus cabin fever, while also remembering to take care of ourselves and each other. This too shall pass.

Nikki Kagan is a medical student, and Albert Hsu, MD, is a reproductive endocrinologist at the University of Missouri. All opinions expressed here are their own.

See the original post:
Fertility treatments in the age of COVID-19 - The Miami Times