A call from reproductive epidemiologists regarding ASRM COVID-19 Task Force Guidelines
35 reproductive epidemiologists describe support for the ASRM COVID-19 guidance.
Cande V. Ananth, PhD, MPH, Rutgers Robert Wood Johnson Medical School, NJ
Donna Baird, PhD
Michael S. Bloom, PhD, University, at Albany, State University of New York
Lisa Bodnar, PhD, MPH, RD, University of Pittsburgh Graduate School of Public Health
Nansi S. Boghossian, PhD, MPH, University of South Carolina
Jorge Chavarro, MD, ScD, ScM, Harvard T.H. Chan School of Public Health
Galit Levi Dunietz, MPH, PhD, University of Michigan, Medical School
Cara L Eckhardt, PhD, MPH, OHSU-PSU School of Public Health, Portland OR
Shelley Ehrlich MD, ScD, MPH, Cincinnati Children’s Hospital Medical Center
Leslie V. Farland, ScD, Mel and Enid Zuckerman College of Public Health, University of Arizona
Kelly Ferguson, PhD
Audrey J. Gaskins, ScD, Emory University Rollins School of Public Health
Bernard L Harlow, PhD, Boston University School of Public Health
Holly R. Harris, ScD, MPH, Fred Hutchinson Cancer Research Center
Sonia Hernandez-Diaz, MD, DrPH, Harvard T. H. Chan School of Public Health
Russell S. Kirby, PhD, MS, University of South Florida College of Public Health
Courtney D. Lynch, PhD, MPH, The Ohio State University Colleges of Medicine and Public Health
Tuija Mannisto, MD, PhD, Chief medical officer, Northern Finland Laboratory Center NordLab
Pauline Mendola, PhD, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH
Carmen Messerlian, PhD, MS, Harvard T.H. Chan School of Public Health
Stacey Missmer, ScD
Sunni Mumford, PhD, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH
Feiby L. Nassan, ScD, MBBCh, MSc, Harvard T. H. Chan School of Public Health
Andy Olshan, PhD
Anna Z. Pollack, PhD, MPH, George Mason University
Enrique F. Schisterman, PhD, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH
Karen Schliep, PhD, MSPH, University of Utah Health
Melissa M. Smarr, Emory University Rollins School of Public Health.
Lindsey Sjaarda, PhD, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH
Brandie D. Taylor, PhD, MPH, Temple University College of Public Health
Kathryn Terry, ScD, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
Marie E. Thoma, PhD, MHS, University of Maryland School of Public Health
Jean Wactawski-Wende, PhD, University at Buffalo
Lauren A. Wise, ScD, Boston University School of Public Health
Xu Xiong, MD, DrPH, Tulane University School of Public Health and Tropical Medicine
The work of P. Mendola, S. Mumford, E. Schisterman, and L. Sjaarda was supported by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH
We find ourselves in an unprecedented crisis as the United States faces its greatest health threat in modern history. A few weeks after the March 17 ASRM COVID-19 Taskforce guidance to suspend all new infertility treatment, the country's situation has worsened considerably—over 16,000 Americans are dead, with tens of thousands more expected to perish, personal protective equipment (PPE) is in catastrophically short supply, and the peak of the epidemic is still ahead of us. It is unconscionable that guidance set forth by the ASRM COVID-19 Taskforce which reflects CDC guidance to healthcare professionals has been met with resistance, including an incomplete adoption of its recommendations from networks representing some of the largest patient pools in the country. For some REI centers to have initially adopted an adaptive ‘wait and see’ approach the first few weeks, and shockingly still now to disregard any part of the Taskforce guidance, contributes to the non-essential consumption of gloves, masks, face shields, and gowns used in patient care and in the andrology and embryology laboratories, adding to the escalating devastation and dire situation many of our colleagues are facing. Indeed, the most forceful example of this resistance was a petition opposing the Taskforce guidance when it was published in mid-March, deliberating the essential foundations of medicine and patient care, including justice, patient autonomy, nonmaleficence, in addition to concepts around the violation of women's rights as arguments against the guidelines. A scholarly debate of these issues and the meaning of the Hippocratic oath in a global health emergency while crucial to the foundation of medicine in usual circumstances, is a waste of precious time in our current state of a global pandemic rapidly crippling life-saving care around the world. These issues primarily speak to the rights to receive care, and its antithesis—the rationing of care. In this pandemic, learning from countries ahead of us, the time to ration care was weeks ago. Some may have initially supported the petition against ASRM’s Taskforce guidance because of a particular situation for their own patient (for example, a patient who was about to begin chemotherapy). However, it must be acknowledged that the Taskforce put together this guidance with the appropriate priority of swiftness over addressing every possible scenario because speed and decisive action were the best tools we had to mitigate the damage of this pandemic, and remains our only hope to limit its devastation. We know from basic epidemiologic principles that earlier action is exponentially more effective than reactionary measures later. Accordingly, we contend that no REI provider should continue care that is not in complete compliance with the ASRM Taskforce guidance to stop all new treatment and continue limited care only for completing in-cycle patients or providing urgent stimulation and cryopreservation for rare cases. In short, ASRM’s quick and aggressive guidance should be applauded for its wisdom to mitigate loss of life across the country.
The virus is ubiquitous. Increased efforts for hygiene, facility cleaning, and lowering person-to-person contact were what we initially hoped would help reduce transmission in February and up to early March. However, human behavior and the insidious nature of this virus have made containment and prevention efforts difficult. Many appear to be infected with mild or few symptoms and the virus clearly cannot be reliably detected by screening patients at arrival for appointments. To perform any procedures other than the most urgent of in-person care is unconscionable at present; this would mislead patients into a false sense of security, that all is under control, or that things aren’t bad enough to affect them. These are inaccurate messages that have the potential to ultimately put patients at risk and undercut the trust patients put in their physicians. Therefore, every REI group, practice, and physician must universally do their part to make a positive impact. To combat this pandemic, the only responsible actions are to immediately support every means necessary to physically separate people and to support the protection of healthcare workers and infrastructure. Examples from across the globe have now shown us that better hygiene and social distancing are not enough to stem the tide. However, these insufficient measures are the only options for some segments of society, as people must access groceries, those with life-threatening illness must be treated, the dead must be buried, and care must be provided for the children of those performing these functions irrespective of the pandemic’s severity. Unlike these critical functions, temporarily suspending infertility care is entirely possible and is the responsible choice. To continue all but the most critical of REI care (e.g. cryopreservation for a cancer patient) is a direct dismissal of the safety of frontline healthcare colleagues and those in critical jobs who cannot stay home. Healthcare professionals and other essential workers depend on help from the public to minimize contacts with each other, preventing every possible new COVID-19 case, and require every piece of PPE that exists or can be produced. There is no separate pool of PPE resources for hospitals versus stand-alone clinics, let alone for nursing homes, first responders, funeral homes, grocery store workers, or childcare providers. With a limited supply, there quite simply isn’t enough to go around to provide adequate coverage for all who require access to life protecting gear. In the field of REI care, a near shutdown is feasible and must be universally adopted. No allowance can be made for the potential shuffling of patients from clinics who completely adhere to the guidance over to clinics that do not, which would undermine the entire public health effort of the reproductive medicine field and create inequity and confusion for patients.
We all agree that infertility treatment is imperative in usual times and have built careers upon this truth. Still, we must acknowledge that many will unfairly suffer from this pandemic—the retail shop owner and the restaurant server who cannot cover their rent or mortgage, the disadvantaged and working poor whose access to household essentials and food is more limited than ever, the tens of thousands of people who will lose family members without closure—and, unfortunately—the infertile couple whose wish for treatment towards a healthy pregnancy and child will be delayed. To fight against this reality is to suggest that individual patient liberties and beneficence are more important than stopping a novel infection that hospitalizes up to 20% of its victims in a healthcare system with inadequate capacity and a critical shortage of PPE.
The reproductive medicine community has a role to play in this crisis by stopping all non-emergent patient care with the goal of helping to mobilize resources, increase capacity, and provide PPE from clinics and laboratories to those on the frontlines of this crisis. The distribution of available PPE to areas most in need alone is an enormous challenge. Though we cannot predict the timeline yet, the good news is this extreme surge scenario is likely to be temporary. We urge you to please do what we know is the best course of action to support those working on the frontlines and protect the lives of those most vulnerable to this virus by heeding the guidance put forward by the ASRM Taskforce while there may still be time to make a difference. We repeat that ASRM’s quick and aggressive guidance should be applauded for its wisdom to mitigate loss of life across the country. May the REI community be remembered during this pandemic as a leader in helping to slow the toll of human life lost around us and act in good faith to do our part to make a difference in solidarity with our colleagues and other workers on the frontlines.