Assisted reproduction and covid-19: what are the guidelines?

In this period, most of the world’s fertility centers that deal with assisted reproduction have temporarily suspended the treatments they had planned.

This has been a major blow for all the couples who have been on the list for some time, and for those couples who do not have much time to become parents (for example for women who have a reduced ovarian reserve )

The question that arises most frequently is the following.

Will postponing my care affect my ability to have a child?

This question was answered by the ASRM (American Society for Reproductive Medicine) acknowledging how difficult it is for a couple to consider postponing treatment. In fact, couples who arrive at PMA come from a long journey of trials and losses. A painful and exhausting journey, and which sees PMA as a last resort or in any case the only way out to try to make the dream of parenthood come true.

Now, to hinder this path, there is an invisible enemy, COVID19, a virus that has caused a pandemic ( declared as such by the WHO on March 11, 2020 ) a completely new event for our society. Therefore the prevailing watchword in this phase is PRUDENCE .

According to the ASRM  there is no evidence that delaying treatment by a month or two will ultimately affect the ability to have a baby, although there are concerns related to older age and/or reduced ovarian reserve. The ASRM recommendations, which you can find here , are continually reviewed and updated.

Fertility centers must comply with national and regional guidelines that define when it is safe to resume caring for infertile patients. As soon as they are deemed medically safe and the likelihood of transmitting COVID-19 is significantly reduced, most restrictions will be lifted.

Why were PMA-related activities suspended?

The recommendation to suspend treatments has various reasons, which are reported   on the ESHRE (European Society of Human Reproduction and Embryology) website and which we have reported here in translated form.

ESHRE, we recall, is the point of reference for all European centers dealing with assisted reproduction.

We also took into consideration the recommendations of the SIRU (Italian Society for Human Reproduction) , and of the ASRM (American Society for Reproductive Medicine) published during this COVID-19 pandemic

Warning : all these recommendations can be suddenly modified following new scientific information or new government directives.

ESHRE also reiterates the need to follow local and national government advice (in our case reported by the Ministry of Health ).

What do we know

To date, there is no clear evidence of adverse effects of SARS-CoV-2 infection (more commonly known as COVID-19)  on pregnancy , as indicated by the latest updates from the Centers for Disease Control and Prevention (CDC) in the United States and in Europe. [1, 2]

However, it should be borne in mind that viral infections can be more problematic for pregnant women and it should not be forgotten that some of the drugs used in patients infected with COVID-19 may not be recommended during pregnancy.

The most recent updates on pregnancy outcomes in infected mothers report babies born negative for the virus. [3]

However, some cases have been reported describing adverse outcomes, such as premature rupture of membranes and preterm delivery. [4]

Neonatal SARS-CoV-2 infection (five cases) [5-7] and the presence of IgM (and IgG) antibodies against the virus in newborns (three cases) [8, 9] have also been reported.

However, it is not clear whether these data are indicative of vertical (mother-to-child) transmission of the virus .

In general, data on pregnancy outcomes, while reassuring and comforting , are derived from small-number studies and should be interpreted with caution .

Furthermore, since the data mainly refer to infection in the third trimester, and it could not be otherwise given that the virus appeared a few months ago, there is no information on the possible effect of COVID-19 infection in the early stages of pregnancy [ 10]

ESHRE recommendations

In light of the above considerations ESHRE continues to recommend a precautionary approach to assisted reproduction, which is consistent with the position of other scientific societies in reproductive medicine. During the pandemic, all medical professionals have a duty to avoid adding further stress to a healthcare system that is already overburdened in many locations.

ESHRE recommends not starting assisted reproductive treatments at this time for the following reasons:

• To avoid complications due to assisted reproduction treatment and pregnancy
• To avoid potential complications related to COVID-9 infection during pregnancy
• To mitigate the unknown risk of vertical transmission in positive patients
• Support the necessary reallocation of health resources
• Observe current social distancing recommendations.

In case of urgent fertility preservation in cancer patients , cryopreservation of gametes, embryos or tissues should still be considered .

For those patients who have started assisted reproduction treatment at this time, elective freezing of oocytes or embryos is recommended for later embryo transfer.

Any risk of viral contamination of gametes and embryos in the IVF laboratory, whether by infected patients or professionals, will likely be minimal (if at all) because the repeated washing steps required for culture and freezing protocols will result in a high dilution of any contaminants.

Regardless of the biological details, according to ESHRE  it is prudent to postpone all fertility promotion medical procedures , primarily to maintain social distancing and protect all medical assets.

As many uncertainties remain about the effects of COVID-19 infection on IVF treatments and pregnancy, ESHRE currently considers the risk too high when similar treatments can be performed at a later date.

Finally, ESHRE recommends that healthcare professionals and clinics remain available to provide care, psychological support and clinical advice to their patients, preferably through online consultations.

ESHRE will continue to monitor the scientific literature and these statements will be regularly updated at this link .

Phase 2 of the PMA

The ESHRE COVID-19 working group is currently preparing recommendations for clinics planning to restart IVF services. These recommendations will consider patient selection, general and specific organization of services, and good laboratory and clinical practice, with particular attention to both patient and practitioner safety and responsibilities.