COVID-19 and Your Fertility

Here at The Fertility Project, we truly believe that starting the conversation about women’s health is the only way to normalize it. We care about all women, world wide. We care about the women who are trying to conceive. We care about women who are trying to prevent pregnancies. We care about the teenager embarking on puberty, knowing that the education system does a horrific job at educating about their health. We care about the women going to menopause with little to no information about it. We care about you. All of you, and right now we need to be talking about what’s right here at our doorstep: COVID-19. COVID-19 is a global crisis with millions of people changing their every day lives, social distancing, and for many women, losing their jobs.

COVID-19, its symptoms, and its rapid spread through the United Stated and the world is all the media is talking about. But what about COVID-19’s effect on pregnant women and women who are undergoing fertility treatments?

We asked our friend, Christiana, a senior clinical Embryologist to give us some insight about how this virus is impacting our fertility, pregnancies, and fertility treatments. Luckily for us, Chrisiana is incredible and dove right into this project. Here’s what she had to say about COVID-19 and your fertility:

COVID-19 & FERTILITY

It is a devastating time for fertility patients worldwide. The stress and anxiety routinely experienced during the fertility journey can be overwhelming without the added burden of a pandemic.

New recommendations from health regulators globally are now advising those actively trying to conceive to delay, or even cancel, treatment due to the spread of Covid-19 and the many unknowns surrounding this novel coronavirus and its impact on fertility. Despite the emotional distress accompanied by these announcements, it is important to understand that this is the only responsible course of action for the fertility sector during this unprecedented time. It is understandably devastating for the fertility community, as most patients have gone through tremendous loss and grief leading to fertility treatment, only to be dealt with the blow of sudden cancellations and yet further unknowns. However, these are unusual times and we are collectively being asked to adapt to this new reality in order to play our part in restricting the spread of this common threat.

The virus

In order to understand why it was important to halt the commencement of new fertility treatment cycles during this time, it is important to understand how this virus is transmitted and the possible repercussions in pregnancy and beyond. The novel coronavirus (SARS- COV-2) is a new strain of coronavirus causing Covid-19. The situation is evolving rapidly but at the time of writing this article, there is no strong evidence of any negative effects of Covid-19 infection on eggs, sperm, embryos or pregnancies (especially those at early stages), as indicated by the latest updates from the Centers for Disease Control and Prevention (CDC) in the USA and the Royal College of Obstetricians and Gynecologists (RCOG) in the UK.

Transmission

Most cases of Covid-19 worldwide have shown evidence of human transmission. The virus can be found in respiratory secretions, feces and fomites.

There are currently two ways in which Covid-19 can spread:

1.  Directly from close contact with an infected person (within 2 meters), as respiratory secretions can enter the eyes, mouth, nose or airways. The risk increases the longer someone has close contact with an infected person who has symptoms.
2.  Indirectly, by touching a surface or object (or hand of an infected person) that has been contaminated with respiratory secretions and then touching one’s own mouth, nose or eyes.

Pregnant women, at present, do not appear to be more likely to contract the virus than the general population. But, during pregnancy the body’s immune system is weakened (in both naturally conceived and ART conceived pregnancies) and as such response to viral infections in general, can occasionally result in more severe symptoms- this would be the case for a COVID-19 infection. It is worth nothing that some of the medical treatment given to severely infected patients may require the use of drugs which are contraindicated in pregnant women (this includes new anti-viral drugs). Another significant concern is the risk of transmission from mother to baby antenatally (during the pregnancy). This is known as vertical transmission and emerging evidence suggests that although likely, the proportion of pregnancies affected and the consequences to the newborn have yet to be determined. There are a few reported cases of women positive for Covid-19, who have delivered healthy infants free of the disease.(3) On the other hand, there have also been reports of adverse outcomes (premature rupture of membranes & preterm delivery) in infants born to mothers positive for Covid-19 during their pregnancy.(4,5)

Until very recently, there was just one case report published of an infected newborn, but with no strong evidence that this was the result of vertical transmission.(6) However, a new report published on 26th March 2020, describes a newborn birthed to a Covid- 19 positive mother, which was found to have SARS-COV- 2 IgM in serum at birth. This represents a clear indication of a neonatal immune response to an in-utero infection, as IgM does not cross the placenta. Most data refer to pregnancies in their final stages, but there is very little information on the possible effects of Covid-19 infection on pregnancies in their initial stages, hence the concern for those planning pregnancies around this time. (7)

Effect on the mother and developing fetus

It is promising that currently there are no data to suggest there is an increased risk of miscarriage or early pregnancy loss in relation to Covid-19. There is also no evidence to suggest that the virus is teratogenic, i.e. would induce congenital abnormalities. Despite some evidence for preterm birth in women with Covid-19, it is still unclear whether these cases were spontaneous or a result of the viral infection. To date, there is only one reported case of a woman with severe Covid-19 who after an emergency cesarean at 34 weeks, delivered a stillborn baby and was admitted to the intensive care unit with multiple organ dysfunction and acute respiratory distress syndrome. So far there have been no deaths reported in pregnant women.

Professional Body Decisions relating to Fertility Treatment

In view of the above considerations, both the American Society for Reproductive Medicine (ASRM) and the European Society for Human Reproduction and Embryology (ESHRE), continue to recommend a precautionary approach to fertility treatment.(8) The general consensus is that all fertility patients considering or planning treatment should avoid becoming pregnant at this time. This means the suspension of initiation of all new treatment cycles including ovulation induction, Intra Uterine Insemination (IUI), In vitro Fertilization (IVF), Intra Cytoplasmic Sperm Injection (ICSI) and embryo transfers, as well as non-urgent sperm, egg and/or embryo freezing. For those patients already in treatment the recommendation is to delay pregnancy by freezing eggs or embryos for a later embryo transfer.

Why:

• Every patient or staff member involved is a potential asymptomatic carrier.
• The small risk of infection, bleeding, ovarian hyperstimulation and ovarian torsion could collide dramatically with the healthcare systems other stressors during this time.
• Anesthetists and/or anesthesiologists are currently in short supply globally and busy managing ventilators during this pandemic.
• Appropriate protective equipment is in short supply.
• Fertility healthcare workers may need to be deployed to other healthcare and laboratory tasks.
• Clinical and lab spaces may need to be re-purposed for other uses.
• The strained medical system will make it a difficult time to be pregnant, e.g. it could be hard to secure a D&C after a miscarriage as some hospitals may limit the support they offer even during labor and delivery.
• Pregnant women have compromised immune systems and are more prone to severe symptoms – their management will be difficult (will not be able to take new drugs).

All medical professionals have a duty to avoid additional stress to healthcare systems that in many locations are already overloaded. The situation is constantly evolving and as time goes by and more pregnancies are monitored in real-time, more substantial data will be generated which will ultimately lead to more solid data and streamlined guidelines. Although it is difficult to predict how long this pandemic will last, the social, economic and healthcare disruptions created over the past few weeks are likely to be with us for some time. The unknowns far outweigh the knowns of pregnancy and Covid-19. Hence the best approach is to proceed with extreme caution.

What this means for you

The consequences of this pandemic are and will continue to be immensely disruptive to so many lives across the globe. The impact of Covid-19 on patients’ family building plans will be echoed for years to come. For most patients waiting for a few months to begin treatment will not have a great impact. However, cancer patients and women who are in the later stages of their fertility, i.e. women in their 40s, will be significantly affected. In order to ensure these patients do not lose the chance of ever becoming a parent, some countries including the US, are allowing certain groups of patients to proceed with treatment.

For patients planning on starting a new cycle: your cycle will be postponed with very few exceptions.

For patients who are currently in cycle: it is recommended that clinics continue to provide treatment and complete the cycle. In Europe egg or embryo freezing is strongly recommended in these cases.

For patients who have an appointment scheduled: clinics are being encouraged to implement telehealth options (telephone or video chat) thus minimizing in person interactions. Your appointment could thus still go ahead – contact your fertility clinic for more details.

For patients who are currently pregnant: since pregnant women may be more susceptible to severe complications from respiratory infections you will now be considered part of the at-risk population and should practice strict social distancing and isolation during these uncertain times.

What can you do in the meantime?

• Make sure you stay connected with your clinic so that you can be easily contacted once treatments can resume.
• Prevention is key: hand hygiene and social distancing are the way forward.
• Now would be a good time to focus on your health in general: improve your nutrition and implement an exercise regime. Look after your body in preparation for when you can have treatment.
• Enquire about any support services your clinic may have in place during this time.
• Stay connected with family and friends. Build your own personal support system. Reach out for support if and when you need it.
• Be mindful, rest and recharge.
• De-catastrophize and limit your exposure to virus- related news if this causes you anxiety.

Fertility clinics worldwide are being asked to act in an ethical and socially responsible manner. Your safety and that of all healthcare workers within any field of medicine at the present time is of paramount importance. Stay home and safe everyone.

The Fertility Project is lucky, to say the least, to be able to bring such valuable information to you and to have Christiana help us educate women world wide.

Please check out her website!

Keep calm and wash your hands- we’ve got this,

The Fertility Project