Pietro Bortoletto, M.D., Micah Hill, D.O., on behalf of the Interactive Associates of Fertility & Sterility
On April 7th, Fertility & Sterility hosted an online forum to discuss the impact of COVID-19 on the field of reproductive medicine. Over 1,000 viewers tuned in to hear the panel discussion moderated by Dr. Kurt Barnhart, F&S Video & New Media editor, Interactive Associate-In-Chief, Dr. Micah Hill, and Interactive Associate Dr. Pietro Bortoletto. The panel included the current presidents of the American Society of Reproductive Medicine Dr. Catherine Racowsky (ASRM), Society for Assisted Reproductive Technology Dr. Paul Lin (SART), and Society for Reproductive Endocrinology & Infertility Dr. Eve Feinberg (SREI). Joining them were Dr. Antonio La Marca and Dr. Diana Alecsandru, reproductive endocrinologists from Modena, Italy and Madrid, Spain sharing the international experience and their countries' response to COVID-19. Dr. Bill Petok and Dr. Enrique Schisterman also joined to discuss the psychological and epidemiologic aspects of COVID-19. Together, the group shared their insights on the creation of the ASRM COVID-19 Task Force as well as how the field, their practice, and their patients' lives have changed. Throughout the discussion, audience members were polled on a wide range of topics. Here are key take-aways, both as an audience member and poll moderator.
Since their publishing, 92% of attendees reported that they have read the ASRM COVID-19 Patient Management recommendations published March 17 and updated March 30th 2020 and April 13th 2020. Within this document, several recommendations were made regarding the continuation and initiation of reproductive care. Of the attendees, 80% reported that their practice had suspended new treatment cycles with 16% stating that they suspended cycles on a case-by-case basis. Less than 4% of attendees had not suspended new treatment cycles as of April 7th, 2020. Of those practices with patients mid-treatment cycle at the time of the ASRM guidance being published, 22% suspended patient treatment mid-cycle while 55% allowed patients to complete their current cycle. Twenty-three percent made decisions regarding suspending treatment on a case-by-case basis. Suspending an ovarian stimulation cycle without an oocyte retrieval is not without consequence to patients and thought must be taken on how to mitigate potential risks. SARS-CoV-2 infection is a predominantly upper respiratory syndrome and special care must be taken to minimize ovarian hyperstimulation syndrome (OHSS) and its propensity for pulmonary complications. For patients mid-cycle whose treatment was being suspended, 28% reported using GnRH agonist triggers for OHSS risk reduction, 2% were using a dopamine receptor agonist post-trigger and 2% used GnRH antagonist post-trigger. Nearly 46% were using a combination of the aforementioned three strategies for OHSS risk reduction. Luckily, less than 4% of attendees were still proceeding with new treatment cycles - minimizing assisted reproductive technology (ART) related risks to patients.
The ASRM guidance advised practices to strongly consider cancellation of all embryo transfers whether fresh or frozen. Of those practices performing frozen embryo transfer (FET) cycles, 82% had suspended cycles with 13% making case-by-case determinations, and 5% still conducting FET cycles. Attempting to conceive during the COVID-19 pandemic, with or without ART, raises several questions - first of which is, is it safe? While the answer to this question is rapidly evolving, providers are faced with these questions on a daily basis. Given the information currently available to providers, 49% of attendees felt uncomfortable counseling patients regarding risks of ART complications and pregnancy related to a COVID-19 infection. We all eagerly await more information regarding the effects of SARS-CoV-2 in early pregnancy and beyond.
One of the hallmarks of the response to COVID-19 pandemic has been social distancing and the cessation of non-essential services. With all 50 states currently under a disaster declaration and over 90% of Americans under stay at home orders, how we prioritize basic health care contacts has changed dramatically. Eighty-seven percent of attendees reported that their practice had suspended non-urgent surgery and non-urgent diagnostic procedures. Only 10% still allowed for non-urgent services, but on a case-by-case basis.
While procedures may have canceled or rescheduled, clinical care has continued, albeit with some modifications. Seventy-eight percent of attendees reported that >75% of their in-person patient visits had been converted to tele-medicine encounters. Ten percent reported 50-75% had been converted to telemedicine, and 6% between 25-50% converted. Not only have the patient encounters shifted to different spaces and time, so too have the clinical teams. Forty-five percent reported that their staff have been asked to assist in non-ART related clinical duties during the COVID-19 pandemic. For example, some REI fellows have transitioned from clinical to research roles, while some have been asked to redeploy to other areas of the hospital, such as the intensive care unit or medicine wards. For clinical staff, and patients, these shifts in how (and if) we are delivering care are not without consequence. Fertility patients, and providers, are unsurprisingly anxious and panicked about COVID-19, fearful about what the future holds. In fact, 52% of respondents report that their patients or staff asked about psychological support related to COVID-19 and their mental health. As we all seek answers and a quick resolution to this pandemic, the Mental Health Professional Group of the ASRM have provided resources for patients and providers that you may find helpful.
Ultimately, the ASRM recommendations are meant to guide and inform how a practice responds to the COVID-19 pandemic. When considering the strength of the ASRM COVID-19 Patient Management recommendations, 20% of respondents felt the recommendations were “too strong”, 6% felt they were “too lax”, and 74% felt that they were “just right”. Like you, we are eager to see how the recommendations evolve and how we can all return to what we love - helping our patients build families.