Mary Ellen Pavone, M.D., M.S.C.I., on behalf of Northwestern Fertility and Reproductive Medicine
As of Tuesday March 17, 2020, FRM has stop initiating new cycles including IUI, IVF, OI, FET and planned egg freezing, in accordance with ASRM recommendations. We are also not offering semen analyses, HSG, SIS, or non-urgent/emergent surgeries including hysteroscopy or laparoscopy. Our patients that were/are currently in stimulation phase are being allowed to complete their cycles (if they desire) and are being strongly encouraged to “freeze all” for future FETs. In line with ASRM’s statement, we are still allowing patients who will need gonadotoxic therapies the opportunity to start stimulation because for this group, ovarian stimulation is time sensitive since they would not have a similar opportunity in the future. Our morning monitoring is being scheduled to allow for distancing and minimal congregation of patients in our waiting area. Any OB scans deemed necessary are being done in the afternoon, again to encourage distancing. We are asking our nurses, scheduling and other support staff to work from home as much as possible. In addition, we are offering telemedicine consults to new and established patients, and our psychologists are available to speak to patients who need extra support. All of this is being done to encourage distancing and to minimize strain on the medical system.
What makes this virus different than other viruses or the flu? COVID-19 (coronavirus disease 2019) is the disease caused by the SARS-CoV-2 virus. Based on current epidemiological survey, the latency period is generally from three to seven days, with a maximum of 14 days. It is believed that there are high titers of virus in the oropharynx early in the course of disease, at which time the infected individual may exhibit little or no symptoms, but that individual is highly contagious during this latency period. One study indicated that, on average, each infected person spreads the infection to at least an additional two to four people, and it is believed that until this number falls below 1.0, it is likely that the outbreak will continue to spread. The currently reported case fatality rate is approximately 1.4% to 2%, and more commonly occurs in older patients and those with co-morbidities. Importantly, patients with mild disease do not require hospital interventions, but isolation is necessary to contain virus transmission. In just one day, there were more than 17,000 new cases.
In terms of pregnancy, while a small study from China suggested that the effect of COVID-19 on the fetus later in pregnancy is not severe, a newer meta-analysis examining cornonavirus spectrum infections during pregnancy has suggested that preterm birth is the most common adverse pregnancy outcome. Miscarriage, preeclampsia, c-section and perinatal death were also more common than the general population. Some believe that the virus has mutated since its original presentation in China, so data on pregnancy outcomes may not be applicable to this newer form we are seeing in the US. In addition, pregnant women may present with atypical symptoms, which may delay initial diagnosis. Certain experimental therapies used to treat those with severe disease would also not be able to be used during pregnancy because of concern of exposing the fetus.
We must do our part as physicians to prevent the spread of this disease, as well as to conserve resources needed by healthcare workers treating those who are affected. The most straightforward way to do this is to stop performing non-urgent or emergent cases, and, with the exception of those patients about to undergo gonadotoxic therapy, our patients fall into that category. Although we all believe that fertility treatments are needed and necessary, and not “elective” we must do our part to help “flatten the curve”. As Dr. Schattman stated, there is no evidence indicating that delaying fertility treatment for one month has any impact on overall prognosis. In fact, our field has always prided itself on being self-regulated and we have fought so hard to keep government out of reproductive medicine. By creating guidelines that are in line with national recommendations coming from the CDC and Surgeon General, it was ASRM’s hope that government would not have to intervene. However, with the lack of consensus among practices in following these guidelines, sadly, in several states, government is stepping in and revoking medical licenses of those who are continuing to provide non-urgent care.
Why is delaying non-essential medical treatments necessary at this time? We must do everything we can to reduce the number of people exposed. Because we do not know who is infected, especially at the beginning stages of the disease, we must limit overall exposure to people in general. No matter what precautions ART practices are taking, without isolation, it is not enough. Asymptomatic shedding, by definition, means that individuals will be spreading the disease without having symptoms and no screening tool will be able to identify those individuals. By keeping ART practices open and running, we risk that our asymptomatic patients will infect others, including physicians and staff, as well as elderly or immunocompromised who tend to have a worse disease course. Although typical infertility patients tend to be younger and healthier, that does not mean all will have a benign disease course if they are infected with COVID-19; in fact, 29% of current cases are those 20-44 years old, with 12% ending up in the ICU. In addition, every ART case requires the use of PPE which is in short supply and needed by healthcare workers fighting this disease in the front line. Anesthesiologists and CRNAs working on ART cases are needed to manage ventilators. In many hospitals, including ours, ORs that were built and used for scheduled non-urgent/emergent cases are being converted to ICUs to care for the sickest of patients. We must do our job to conserve valuable and limited resources which will give the sickest infected patients a fighting chance, and, just as importantly, to protect our healthcare workers, families and friends from contracting this disease.
For those who believe that COVID-19 is not a factor in their geographic area and therefore they do not need to enact safety measures, you are likely mistaken. Just because your state or municipality does not currently have any positive tests does not mean that no one is infected. There are simply not enough tests or testing sites in the U.S. to capture all infected individuals and the testing preconditions are restrictive. In order to qualify for testing, hospitals require symptoms plus travel to an infected area or contact with a COVID+ person. Therefore, asymptomatic or minimally symptomatic patients would not be tested. Additionally, in many areas, results take several days to return. In Italy, for example, because aggressive containment measures were delayed, the virus spread so virulently that in one day, it claimed more than 700 lives. There are not enough ventilators for patients in need in Italy and therefore physicians are having to decide who lives and who dies. We must do our part to help mitigate this disease so that U.S. physicians do not face these same ethical dilemmas.
This is a worldwide pandemic, the likes of which none of us has ever experienced. Unprecedented events call for unprecedented measures. As physicians, we must do everything in our power to mitigate this disease, and that means doing our part to encourage people to stay home as well as to conserve valuable medical resources and personnel. The current ASRM recommendations will be re-evaluated at the end of March, and at FRM, we plan to continually reassess our practice as new recommendations are released.
We must all work together to encourage patients to stay home so we can #flattenthecurve.