ESHRE reaffirms its guidance for a COVID-free clinic

Published 15 December 2020

ESHRE’s COVID-19 working group hosted a session at this year’s Progress Educational Trust annual meeting to reveal striking differences between clinic activity during the first infection wave and the second. A strict protocol of triage and testing can keep fertility centres COVID-free.

ESHRE hosted a session on the resumption of ART services after the first COVID-19 lockdown at this year’s annual meeting of the Progress Educational Trust, publisher of BioNews, and reported there had been very few clinic closures during this latest second wave of infection. The message from ESHRE, as evident in its most recent guideline (on ‘phase 3’ of the pandemic), was that a COVID-free clinic is now feasible within the framework of a strict programme of triage and testing.(1)

The PET meeting took as its broad theme ‘fertility, genomics and COVID-19’, and overall, with no evidence of direct viral transmission to the oocyte or to the fetus via the placenta, most speakers seemed less worried about the virus’s effect on fertility (male and female) and on the infant than six months ago – at least at the population level. Ashley Moffett, professor of reproductive immunology at the University of Cambridge, described intrauterine infection via placental or congenital routes as ‘unlikely’, and concluded that perinatal infection at and after delivery was the more likely explanation for any neonatal infection.

ESHRE’s own working group survey showed that most clinics in Europe had resumed their fertility services by the end of May – though some clinics in some Nordic countries and Germany had remained open throughout the first wave, and most clinics in Europe were still available for emergency treatments (such as fertility preservation) and pregnancy scans. Nathalie Vermeulen from ESHRE’s central office and a member of the COVID-19 working group said that in most cases the clinic closures had followed the recommendation or instruction (as in Spain and Portugal) of local authorities, and on average lasted seven weeks. However, as the latest wave escalated in October, the pattern of clinic activity proved much different from the first. This time, although one or two clinics did stop or curtail their services, there were clearly no blanket closures as before. Most centres, however, did adapt their protocols to the new wave of infections, with the majority adopting triage and testing for both patients and staff to reduce any risk of infection at the centre. Nathalie suggested that the difference in provision between the first and second waves was explained by a better knowledge of the virus and more time to adapt services.

The triage and test protocols were described in more detail by Luca Gianaroli, who explained how testing was recommended for all with a positive triage, and that treatment would be postponed for those whose IgM and/or PCR results were also positive. His colleague in the working group, Edgar Mocanu from Dublin, explained how the menu of mitigation measures recommended by ESHRE would depend on the 14-day case notification rate (via ECDC) local to each clinic and its likely impact, from ‘minor’ (20-59.9 cases per 100,000 reported) to ‘critical’ (more than 120 per 100,000). This, therefore, said Mocanu, is a two-step approach in which the first step is to monitor local epidemiological data and risk estimates, and the second to apply commensurate mitigation measures. Staff and patient triage in the form of questionnaire was essential whatever the estimates, as was implementation of a Code of Conduct. The Code of Conduct example offered by Gianaroli was under the arch warning of ‘take no risk’ and set out good practice measures of caution, vigilance and risk avoidance.

A map presented by Mocanu and derived from ECDC data on 26 October during the latest phase of infection saw most countries of Europe in the ‘major’ or ‘critical’ impact ranges, implying routine use of PPE, limited face-to-face interactions, and even consideration of a freeze-all transfer policy. The map of Europe was similar on 7 December, but not as intensely severe in impact. Indeed, as the working group’s chair Anna Veiga said in her summing up, it is the use of such measurable and easily available data as the ECDC’s case notification rates which allows the objective adaptation of services and implementation of risk mitigating measures.

However, with such demands on fertility clinics to avoid infections and – according to new data from the UK’s regulator – no slowdown in patient numbers, Gianaroli urged clinics not to forget their wider responsibilities in healthcare. As Focus on Reproduction reported a few weeks ago, many hospitals have seen the numbers of stillbirths rise during lockdown, both in developing and developed countries.(2) Now, Gianaroli added to the data with new figures from Italy showing significantly higher stillbirth rates in 2020 than in 2019 (3.23% vs 1.07%).

What about men? Men anyway, said geneticist Sharon Moalem, are at a chromosomal disadvantage (which may help explain the lower female COVID-19 mortality rates, he suggested) but so far, said andrologist Allan Pacey, there is no more than ‘plausible reason’ for concern at an effect of the coronavirus on sperm function. However, data from the few studies so far reported offer no grounds to support concerns that reproductive hormones or semen quality are affected by the virus. ’There is little evidence that SARS-CoV-2 is transmitted in semen,’ said Pacey, ‘but it cannot be ruled out.’

1. Safe ART services during the third phase of the COVID-19 pandemic.

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