William D. Petok, Ph.D.
The recent guidance issued by ASRM during the COVID-19 pandemic is a source for great debate. The guidance suggests, among other measures, that providers suspend the initiation of new treatment cycles including frozen embryo transfers, as well as non-urgent gamete cryopreservation. It also asks that providers strongly consider cancellation of all embryo transfers whether fresh or frozen, suspend elective surgeries and non-urgent diagnostic procedures and minimize in-person interactions by utilizing telehealth. The guidance presumes that patient and provider safety is the priority. Other healthcare societies have offered similar guidance to their providers and patients regarding non-urgent or non-essential procedures.
However, ASRM has come under attack from some quarters because only limited input was sought, many assisted reproductive health procedures do not take place in hospitals where the bulk of COIVD-19 patients will be treated, and clinics adhere to the highest standards of sanitary care already. One group went so far as to suggest that the guidelines were discriminatory because if individuals seeking to become pregnant without medical assistance weren’t being advised to stop their efforts, why then, should those who require assistance be forced to stop theirs.
The COVID-19 pandemic has been described as “unprecedented,” “a health emergency” and “a serious public health risk.” How organizations and individuals respond to these descriptors bears discussion. To state the obvious, unprecedented situations have no precedent and leaders are forced to make decisions without prior guidance. Emergencies require rapid decisions because they are serious, unexpected and often dangerous situations requiring immediate action. We could argue what “unexpected” means in this case but that’s a topic for other authors. And “serious…risk” suggests there is something to be very wary of. The guidance presumably is for health issues. One can’t help but think that another risk, down the road, will be legal in nature.
Emergencies require quick responses with the available information. The normal process of multiple reviews with copious amounts of feedback from various stakeholders just isn’t possible. And so, responsible organizations are forced to make quick but hopefully thoughtful decisions.
Clearly, COVID-19 presents an incredible set of stressors for both patients and providers. Fertility patients are already under great stress because they have been unsuccessful at achieving a goal they presumed would take place without assistance. Invasive testing, multiple clinic visits, waiting for results of those tests, medications that can cause emotional swings, unsuccessful procedures, family and societal expectations and the high cost, are but a few of those stressors. Now they are being asked to delay their quest for an indeterminate time. The lack of predictability, non-stop news reports about COVID-19 and personal concerns about employment and financial stability increase that stress.
Providers want to help their patients achieve their goals as quickly as possible and unpredictable delays are stressful. And the guidance places many clinics at financial risk because the employment of staff and facilities requires a significant cash flow. Unplanned reduction in staff is stressful because staff are real people with real families who likely depend on income from their jobs. Delivering bad news to people you work with daily is stressful.
The literature on stress and decision making is detailed and looks at both behavioral and neural level decisions. Suffice it to say, stress has an impact on decision making . This review indicates that even though we have the ability to make rational choices, we don’t always do it. And decision making can induce stress, especially when situations are unpredictable and uncontrollable. COVID-19 appears to provide just such a perfect storm. It is likely that both providers and patients are making decisions about care that are influenced by the stress of the situation. Because there isn’t enough information these decisions can be clouded by perceived self-interest, not taking the common good into account.
Ethics and altruism are important here too. Taleb and Norman  note that “Collective safety may require excessive individual risk avoidance, even if it conflicts with an individual’s own interests and benefits.” The decisions we make about providing or receiving care can have far reaching consequences. It is well accepted that gamete donors and gestational carriers should have some level of altruism to qualify as acceptable. We ask they not be “in it for the money.” Does the current situation demand that we require a level of altruism in ourselves and our patients under the circumstances predicated by COVID-19? Taleb and Norman state “,,,the prudent and ethical course of action for all individuals is to enact systemic precaution at the individual and local scale. The breakdown of scale-separation that a multiplicative contagion induces connects the individual to the collective, making everyone a potential bearer and source of risk.”
During the F&S Global Journal Club of April 7, 2020 the discussion turned to what constitutes an emergency and how that might impact our decisions going forward. The discussants debated when an emergency would be over, how flat the curve might have to be before we can return to prior modes of practice. Statistics were the focus. But the statistician’s emergency is not the same as the patient’s. Her/his inability to access planned procedures for diminished ovarian reserve (or whatever diagnosis they have) is a personal emergency and the only statistic that matters is an N of 1.
There are more questions than answers now. I believe the actions of ASRM and other organizations to limit care to urgent or critical situations is the best we can do for now. True, many fertility treatments take place in stand alone clinics. But they are staffed by people for whom testing is not available so it’s impossible to know if they carry the virus in transmittable form. And even the best precautions with patients are imperfect. Our patients desperately want the baby of their dreams. We don’t have enough data on fetal transmission of the virus to know the impact on a pregnancy from conception/transfer to delivery. And none of us wants to create a less than good baby. Nor do we want to risk a lawsuit down the road.
Yet, we feel for our patients and their dilemma. It is critical that we connect with them on both a professional and psychological level. We can give them scientific reasons for the decisions we’ve made about the care we can offer given the limited state of information we have about the virus, its impact on pregnancy, etc. At the same time, we can share in their distress that plans have been delayed for an indeterminate time. We are taught to avoid personal involvement with our patients. We have training suggesting that professionals keep boundaries between themselves and patients, not allowing our personal feelings into their care. But we must recognize their emotional state if we are to provide care to the person and not just their reproductive system. We can let them know that we are in limbo as well with limited information about risks to our own health and that of our co-workers and employees, not to mention our livelihoods. On some level our angst is shared.
All of this provides few answers to the dilemma we face alongside our patients. We currently don’t have enough resources to treat a massive influx of COVID-19 patients. Flattening the curve doesn’t get rid of the virus and only gives us time to acquire enough resources for the next wave. Until adequate testing, treatments and vaccines are available we can’t insure anyone’s immunity from harm. How do we provide the best care for the most people in the community in general and at the same time limit the damage to our patients and our practices? As more reliable information becomes available our decision making will presumably change. Hopefully, this will give more clarity to our patients, ourselves and reduce the stress that we all feel.
1. Starcke K, Brand M. Decision making under stress: A selective review. Neurosci Biobehav R 2012; 36:1228-1248.
2. Taleb NN, Norman J. Ethics of precaution: Individual and systemic risk. https://nassimtaleb.org/2020/03/ethics-precaution/ (accessed Apr 05, 2020).