As some fertility clinics in Europe make a cautious return to work, new ESHRE guidance from its COVID-19 working group advises 'a measured return' to treatment, aiming for an infection-free working environment.
Both public and private fertility clinics in Denmark have been allowed to restart their routine treatments - including egg donation - from Monday 20 April. Some private clinics had been totally closed, while public centres had only continued their fertility preservation and other urgent appointments. The move, authorised by Denmark's National Board of Health the previous week, is dependent on clinics devising and observing a written safety protocol for patient and staff protection.
'We won't be back to normal for the next few weeks,' ESHRE Executive Committee member Anja Pinborg told Focus on Reproduction. 'We will be starting at around half capacity, mainly with patients in the system. But no PGT-M. We'd need more staff in the lab and couldn't keep the required two metres apart.' The reduction in treatments, said Pinborg, who is medical head of the fertility clinic of Copenhagen University Hospital, aims to restrict patient numbers in the waiting areas and reflect the secondment of staff (doctors and paramedics) to the hospital's ICU. The previous week Denmark had also become Europe's first country to open its primary schools after lockdown, following a substantial decline in the number of COVID-19 infections.
Neighbouring Sweden has taken what many have seen as a more relaxed view of the pandemic, with many shops - and some IVF clinics - staying open. There has been no national guidance for clinics in Sweden, although some professional recommendations were developed. Kersti Lundin from Sahlgrenska University Hospital in Gothenburg reported to Focus on Reproduction that three of Sweden's seven public centres did shut down very quickly, but that, she explained, was mainly to allocate resources elsewhere. 'The other public units either continued more or less as usual or, like ours in Gothenburg, chose a middle way,' said Lundin. 'We decided to continue with restrictions, with no new patients for work-up and oocyte pick-ups only with patients already in treatment.' Freeze-all is now the only approach, with no partners allowed in the clinic, and all doors locked.
The German Society of Reproductive Medicine (DGRM) has also now relaxed its precautionary guidance for clinics, which until its latest statement (on 15 April) had largely followed the ESHRE position. Indeed, the DGRM continues to heed the precautions of ESHRE and ASRM, particularly on the question of infection in early pregnancy and in minimising personal contact. However, some elective treatments have restarted, with the DGRM leaving resumption to the discretion of centres and patients - for example, in cases of reduced ovarian reserve or advanced maternal age. Nevertheless, written consent must now include a recognition that little is known of the effects of COVID-19 infection on pregnancy, and any decisions taken must be within the context of the broader coronavirus recommendations.
These measured steps in northern Europe come at a time when both ESHRE and the ASRM are beginning to look ahead to the resumption of fertility services. ESHRE's latest revised guidance, published on 23 April by its COVID-19 working group, states at the outset that 'once the risk of SARS-CoV-2/COVID-19 infection is decreasing, all ART therapies can be re-started for any clinical indication', providing that re-start is in line with local regulations.(1) Excluded from any consideration for treatment are 'high-risk' patients (diabetics, hypertensives, immunocompromised), and all patients should be offered the choice to proceed with or defer their treatment.
A large part of these latest ESHRE recommendations relate to staff and patient safety, with examples of detailed triage questionnaires and scenarios for both. For patients, the guidance makes clear that triage should be performed two weeks before starting treatment, with antibody testing recommended for any suspected cases of infection. For staff, the guidance recommends that clinics, depending on size, divide staff into 'mini-teams' with 'minimum interactions' and working in a rotating schedule. 'Vigilance and measured steps for safe practice' remain ESHRE's watchwords. And the working goup adds that clinics are recommended to apply this guidance, and where needed to adapt to local or national legislation and advice.
This detailed ESHRE update comes two weeks after the ASRM updated its initial COVID-19 statement for a second time.(2) While still describing the situation as 'critical' and recognising that 'it is not yet prudent to resume non-emergency infertility procedures', this second update did glance ahead to the resumption of services and 'time-sensitive fertility treatments in the face of COVID-19'. Now, a third update from the ASRM, made public on 24 April, while insisting that 'fertility care is an essential health service', still recognises the responsibility of clinics to minimise infection and preserve healthcare resources.(3) So the update advises no resumption of services without an assessment of their impact on 'their community’s risk and resources, even when clinical activities are permitted by law'. And, like ESHRE, ASRM goes on to set out the detailed steps of risk assessment (formalised and documented) as one of four pillars on which any return to treatment should be based - alongside risk mitigation, consideration of resources, and the availability of thorough counselling. However, this third update from ASRM, written as before at a time when the pandemic shows little sign of decline in the USA, has now removed any suggestion of suspended treatments or cancellation of all embryo transfers.
Such stringent recommendations were not without criticism; indeed, in the USA one lobby group, the 'Fertility Providers Alliance', whose existence seems only evident by press release, appeared to be set up only to counter any recommendation to suspend programmes. And of course there have been many patient accounts of their dismay and frustration at the cancellation of their own treatments.(4) But caution still dominates every guideline, even if some clinics are beginning to re-open in northern Europe and most eyes everywhere are now turning to look ahead.(5)
1. See https://www.eshre.eu/Home/COVID19WG
5. Meseguer M, Niederberger C, Pellicer A. Deep inside the pandemic, from inactivity to action; let's be ready. Fertil Steril 2020;