COVID-19

This section of the Dialog is dedicated to “Consider This” articles that discuss the effects of COVID-19 on reproductive health practices.

What addition steps are you taking to prepare for COVID19 in your fertility clinics?

Started over 2 years ago

The Interactive Associates for Fertility and Sterility have been compiling a list of actions that fertility clinics have been taking to mitigate COVID19.  We've pulled these suggestions from a variety of social media discussions that have been ongoing over the last few weeks with colleagues from around the globe.  The intent is to give a place here for dialog to occur about how we are tackling this pandemic.  Hopefully we can share information with each other and take a proactive approach to prepare for this.  

What other additional steps has your clinic done to minimize the risk and impact of COVID19 for your staff and patients?


Micah J Hill, DO Interactive Associate in Chief   Kurt Barnhart, MD, MSCE Video and New Media Editor  

Given ASRM's recommendation to suspend the initiation of new cycles, these are some suggestions for clinical care that people are implementing for patients already in cycles:

  • Develop a protocol for mid-cycle and post-trigger cancellations should a patient become exposed to or infected with COVID-19.
  • Set clear expectations with patients currently in treatment about potential for cycle interruption or cancellations.
  • Develop a counseling form for patients to sign that details the risks on continuing treatment and the possibility of cycle cancellation before treatment is completed.
  • Consider minimizing monitoring ultrasound visits to only those that are truly necessary for clinical decision-making.
  • Consider a more conservative stimulation approach, potential early trigger, and use of GnRH agonist trigger as to minimize risk of OHSS, particularly for patients with comorbidities.
  • Consider dosing patients with expectation that some may miss scheduled monitoring appointments due to difficulty getting to clinic, need to stay home due to dependents, fear, or quarantine.
  • Consider use of home urine pregnancy tests and ovulation predictor kits for assessment of post-trigger HCG and LH levels in lieu of in-person blood work.
  • Consider allowing partners to produce semen specimens at home instead of within your center or lab.
  • Consider the use of misoprostol & mifepristone or office based uterine evacuation procedures for management of missed abortions in lieu of inpatient surgical
  • procedures with the expectation that operative room time will be limited for non-urgent or emergent cases.
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  • Consider the use of misoprostol & mifepristone or office based uterine evacuation procedures for management of missed abortions in lieu of inpatient surgical procedures with the expectation that operative room time will be limited for non-urgent or emergent cases.

These are some suggestions clinics have taken to attempt to minimize patient and staff exposure to COVID in the workplace:

  • Most current evidence demonstrates COVID19 is viable at 3 hours aeroslized and at least as long as 72 hours on surfaces like plastic and stainless steal.  Consider cleaning protocols for surfaces in common rooms like waiting rooms, exam rooms, and procedure rooms. See NEJM article for details on COVID19 viabilty in common conditions at https://www.nejm.org/doi/full/10.1056/NEJMc2004973
  • Limit the number of health care providers to the smallest number of essential personnel.
  • Identify and encourage staff who are able to work remotely to do so and focus on tasks such as answering patient calls, scheduling, reviewing results, and triaging phone calls or adminstrative tasks like data entry.
  • Consider staggering staffing so that teams do not overlap.  This way if one provider gets infected, the entire team may not be exposed.  For example, some IM teams have gone to 3 days on and 10 days day self quarantined approach.  Others have gone to one week on, one week off approaches.  The key is those not on are at home and social distancing.  Those teams on are the same people, so that one asymptomatic infected staff cannot infect multiple teams.
  • Suspend non-essential research and education activities, such as having students, visiting trainees, or researchers directly interacting with patients.  Use video and tele conferencing when possible.
  • Discourage non-essential travel both domestically and internationally, such as that to conferences or educational meetings and even vacation to at risk destinations.
  • Change the layout of common spaces, like waiting rooms, to ensure there is 6 feet of seperation between patients and staff.
  • Remove materials from common spaces that may harbor virus particles, such as magazines and books of baby photos.
  • Remove non-cleanable materials like magazines from semen collection rooms.  Institute cleaning procedures to disenfect remote controls and other surfaces inbtweeen collections. 
  • Reduce and stagger patient procedures to limit potential patient cross infection.
  • Optimize the use of telemedicine and phone visits for appointments when appropriate. These include follow-up appointments and post-op visits that do not require an exam, labs, or ultrasound, as well as other types of appointments where an in person examination or ultrasound can be deferred to a later time.
  • Consider limiting patient companions (excluding partners) for in person appointments
  • Encourage patients to coordinate home delivery of medications rather than pharmacy pick-up, as long as these are operating normally. This includes ensuring adequate supply of medications to complete a cycle safely.
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From my own personal experience, these are our intial steps we instituted on Monday:

We have cancelled FETs after Wednesday. We recommended consider delayed transfer at a future time and had them sign a consent that they were counseled to possible maternal risks and unknown fetal risks if they wanted to proceed with transfer this week.  We called all patients undergoing stimulation and offered them to be rescheduled at no cost.  75% of patients agreed to cancel and reschedule while the other 25% wanted to proceed.  It should be noted that our patients do not pay for medication , which may effect such decisions.  All fresh cycles have been told that we will not do a fresh transfer and if they proceed, all blastocysts will be frozen.  We cancelled all diagnostic procedures (SIS, HSG, surgeries) and outpatient treatments (OI, IUI) after today.  We also changed work flow, the waiting room space, pre and post anesthesia space, and TVOR and ET room cleaning procedures. 

This is just what we did in response to this weeks status.  Im very curious to hear and learn ideas from others.

As one example, I saw in a Tweet thread from Pietro Bartoletto last week the idea to minimze OHSS risk even more in this pandemic.  For whatever reason, the idea that COVID19 combined with a process that could lead to pulmonary edema or emboli is a double whammy, had escaped my thoughts.  So we moved this week to Lupron trigger all antagon protocols, regardless of OHSS risk.

So please share your wisdom and experince in this place, so we can all learn from each other!

As mentioned in the Task Force document, the psychological health and well-being of patients should be stressed during this difficult time. There has been (rightfully so) a lot of heartache talking to patients recently about unexpectedly cancelling their cycle. Without knowing when this pandemic will resolve and when we can reschedule patients, the fear of "running out of time and never achieving pregnancy" was commonly mentioned by patients. Checking in on our patients and offering mental health referrals will be a valuable tool to offer. This Task Force document is a fantastic resource and very helpful during this unusual time.

Delaying pregnancies as recently recommended by ASRM is the right thing to do. By delaying IUIs and embryo transfers, we are avoiding potential pregnancy complications such as a miscarriage or an ectopic pregnancy which could pull away critical healthcare resources in this time of need.

All excellent comments, thank you for sharing your experiences!

Another proposal that we adopted in our team was the creation of a "COVID19 task force". The main rationale around this was to manage the huge influx of new ideas and last-minute issues that this expedited contingency planning caused to the clinic as a whole. What we noticed is that our personnel is full of excellent suggestions on how to mitigate the consequences of our current scenario on patient and personnel safety and that frequently these ideas or issue reports were lost as they went up the chain of power. Hence, having a dedicated taskforce to manage these inputs has helped significantly.

Another issue, coming from a country which from tomorrow onwards will be on "lockdown", is to dedicate as maximum efforts possible to internal communication and personnel morale. We have had some of our personnel "disappear" due to exhaustion and panic, something I feel has ever since reduced since the team started receiving more support.