CORONAVIRUS

COVID-19 and the suspension of fertility treatment

Published 09 April 2020

A timely report from the Italian gynecologist Antonio La Marca and colleagues in the USA and UK, published on 20 March when Italy found itself at the epicentre of this devastating pandemic, has pieced together the escalation of infection in Italy and the organisational and clinical measures needed 'to flatten the curve of new cases'.(1) They catalogue a seemingly endless list of measures which fertility centres might take as precautions against infection, ranging from cancelled 'in-person' meetings to advice 'not to pursue fertility tourism'. And they go on to note that the guidance so far published on pregnancy 'has been based on very limited data and experience with prior coronaviruses'.

Indeed, the early formal guidance relevant to fertility clinics considered only pregnancy. Position papers and patient Q&As, came from, amongst others, the CDC and the American and Royal Colleges and they concentrated their focus on pregnancy and its attendant risks for the mother and baby.(2,3,4) Most reports, however, were prefixed with the simple acknowledgement of limited information, that 'we do not know at this time'. The RCOG guidance, following the advice of the UK's Chief Medical Officer, did specifically identify pregnant women as a 'vulnerable' group, largely on the basis of their higher susceptibility to viral infection - though no evidence was cited for this. However, this information, as in reports from all other groups, also suggested that pregnant women with COVID-19 infection were unlikely to be more severely affected than others and that as yet there was no evidence - notably in reports from China - of vertical transmission. This reassurance seemed later supported by a review of 38 pregnancies in China, which found no intrauterine transmission of COVID-19 to the fetus.(5) Caution, however, remained the watchword.

So it was also caution which defined the first two formal statements on assisted reproduction, the first from ASRM on 12 March and the second from ESHRE on 14 March. ASRM advised fertility patients with coronavirus symptoms to avoid pregnancy 'until they are disease-free', adding that 'this recommendation does not necessarily apply when there solely is a suspicion of COVID-19.' The implication was that treatment might continue under controlled conditions. ESHRE's statement a few days later, while still 'precautionary', went a few strides further and advised that 'all fertility patients considering or planning treatment, even if they do not meet the diagnostic criteria for COVID-19 infection, should avoid becoming pregnant at this time'.(6) In the immediate aftermath of publication there were some who thought the ESHRE position too proscriptive, and that preventive measures in place in clinics might be sufficient for a cautious continuation of services. Indeed, the first guidance from the Fertility Society of Australia seemed to favour a more 'proportionate response' in which some fertility treatments might continue, while a few individual pleas from patients described the disappointment which any suspension of treatment would bring.(7)

However, as the scale of the pandemic grew exponentially, it rapidly became clear that any notion of continued routine treatment had become near impossible. As the Fertility Society of Australia noted in its later update of 24 March, 'elective surgical procedures need to be scaled back or suspended in order to preserve resources' and reduce the risks of infection.(8) The final line of ESHRE's statement had reaffirmed this same view 'that all medical professionals have a duty to avoid additional stress to a healthcare system that in many locations is already overloaded'.

And so on 17 March the ASRM updated its guidance, now calling for (not suggesting) a suspension of new treatment cycles, cancellation of all embryo transfers (fresh or frozen), and a halt to elective procedures.(9) The ASRM noted, as had ESHRE a few days before, that its new recommendations were 'aimed at guarding the health and safety of patients and providers; while also recognising a social responsibility to comply with national public health recommendations'. Thus, in just a few days, the initiative for suspending fertility treatments had shifted from pregnancy and its putative risks to a responsibility to safeguard public health and support healthcare systems and providers in the front line.

This too was the trend evident in ESHRE's latest statement, published on 2 April and developed by a newly formed COVID-19 working group. While ESHRE now reaffirmed its 'reassuring' message in terms of pregnancy in COVID-19-infected women, it continued to advise that fertility treatments should not be started at the present time.(10) This advice was explained by five reasons, three involving possible complications from pregnancy and two of practical expediency: 'to support the necessary reallocation of health resources; and to observe the current recommendations of social distancing'. And this second ESHRE statement emphatically repeated its reminder of a professional 'duty' to avoid adding stress to overloaded healthcare systems. The ESHRE statement also considered the IVF lab as a potential source of infection, noting that good clinical and laboratory practice and current freezing and culture protocols were likely to minimise the possibility of viral contamination.

ESHRE did recognise that some treatments were not 'elective' and that urgent procedures for fertility preservation, for example, 'should still be considered'. This was an opinion forcibly expressed in the ASRM's first update to its 17 March advice, which was published on 31 March.(11) Thus, while the ASRM continued to advise not starting any new treatments and cancelling all embryo transfers, it here only noted the suspension of ' elective surgeries and non-urgent diagnostic procedures'. The ASRM, however, insisted that 'infertility is a disease, and infertility care is not elective', adding: 'The treatment of infertility, as well as the treatment of many other critical diseases, including cancer treatment, other gynecologic surgery, and organ transplantation, are being postponed in the face of the COVID-19 pandemic.' The ASRM nevertheless advised that those clinics 'engaged in urgent reproductive care' should adhere to prevention and protection regulations.

But the question now arises as to what represents urgent and non-urgent reproductive care.(12) ESHRE gave medically indicated fertility preservation as an example of non-elective need, but might this, proposed ASRM, also include diminished ovarian reserve, or 'other conditions where extended delays may impact patient outcomes'. Thus, behind a commitment 'to a return to routine patient care as soon as possible' and within the context of the pandemic's continuation, the ASRM noted that 'reproductive care professionals, in consultation with their patients, will have to consider reassessing the criteria of what represents urgent and non-urgent care'. There was also here a recognition of the frustration and disappointment felt by many patients, some already waiting patiently for treatment. A Harvard bioethicist, commenting on their predicament for a Fertility and Sterility 'dialog', nevertheless said that the cancellations were 'necessary and ethically required'.(13)

As COVID-19 infection does indeed continue in most corners of the world, all eyes are now turned on the Chinese province of Hubei, where the coronavirus first emerged. Cases there have apparently diminished to almost nil, and the first moves to relax strict social distancing and isolation regulations have been announced.(14) China first reported its cases to the WHO on New Year's eve, and now, three months in, there are signs of some recovery in factory output and purchasing. Will a return to social normality be possible, or will a second wave of infection emerge? No-one, it seems, is holding their breath. And in fertility clinics the question of any return to normality seems dependent - at least in some countries - on a distinction between urgent and non-urgent treatments. In the UK, for example, the HFEA ruled that centres can still see patients who are currently in treatment for any essential appointments (such as monitoring ultrasound scans, OHSS checks or early pregnancy monitoring), but after 15 April the only patients to be treated are those requiring non-elective fertility preservation.(15) 'For the avoidance of doubt,' insisted the HFEA, 'fertility preservation refers to patients who are about to commence radiotherapy or chemotherapy in the face of cancer or are about to use chemotherapy for a serious systemic disease. The premature infertility test does not apply to women whose fertility is declining due to age or the onset of the menopause.' With the first signs of recovery possibly evident in Spain and Italy, where steep infection rates appear to have eased a little, there are many already looking ahead to an exit strategy and the slow return to normality. And for fertility clinics too their immediate questions are when and how a normal service might be resumed.



1. La Marca A, Niederberger C, Pellicer A, Nelson SM. COVID-19: lessons from the Italian reproductive medical experience. Fertil Steril 2020;
https://doi.org/10.1016/j.fertnstert.2020.03.021
2. https://www.cdc.gov/coronavirus/2019-ncov/prepare/pregnancy-breastfeeding.html
3. https://www.acog.org/patient-resources/faqs/pregnancy/coronavirus-pregnancy-and-breastfeeding
4. https://www.rcog.org.uk/globalassets/documents/guidelines/2020-03-26-covid19-pregnancy-guidance.pdf
5. Schwartz DA. An analysis of 38 pregnant women with COVID-19, their newborn infants, and maternal-fetal transmission of SARS-CoV-2: Maternal coronavirus infections and pregnancy outcomes. Arch Pathol Lab Med 2020; doi: 10.5858/arpa.2020-0901-SA
6. https://www.eshre.eu/Press-Room/ESHRE-News#COVID19P
7. See for example https://www.huffingtonpost.co.uk/entry/ivf-cancelled-coronavirus_uk_5e71ee5ac5b63c3b64876837?utm_hp_ref=uk-ivf
8. https://www.fertilitysociety.com.au
9. https://www.asrm.org/Patient-Mgmt-COVID-19
10. https://www.eshre.eu/Press-Room/ESHRE-News#COVID19_April2
11. https://www.asrm.org/globalassets/asrm/asrm-content/news-and-publications/covid-19/covidtaskforceupdate1.pdf
12. https://www.theatlantic.com/science/archive/2020/03/patients-whose-surgeries-are-canceled-because-coronavirus/608176/
13. https://www.fertstertdialog.com/rooms/871-covid-19/posts/62574-why-our-ethics-demand-canceling-in-vitro-fertilization-for-now
14. https://www.nature.com/articles/d41586-020-00938-0?utm_source=Nature+Briefing&utm_campaign=09c7da52c4-briefing-dy-20200331&utm_medium=email&utm_term=0_c9dfd39373-09c7da52c4-42808419
15. https://www.hfea.gov.uk/treatments/covid-19-and-fertility-treatment/coronavirus-covid-19-guidance-for-professionals/

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