Reproductive health paradigms in times of COVID‐19

Abstract

Ivonne Diaz Yamal, Chair, FIGO Committee for Reproductive Medicine, Endocrinology and Infertility. Ivonne Díaz Yamal is a Professor at University Militar Nueva Granada and Fundación Universitaria Sanitas, Bogota, Colombia. She is also the scientific director at Unidad de Fertilidad Procreación Medicamente Asistida, Bogota, Colombia. From 2016 to 2018, she served as president of FECOLSOG. She is also the chair for the Committee for Reproductive Medicine for FLASOG. Ivonne Díaz Yamal is the current chair of the FIGO Committee for Reproductive Medicine, Endocrinology and Infertility. For the past several months, we have witnessed one of the greatest global health challenges experienced by humankind. This unprecedented COVID-19 viral pandemic, characterized by its enigmatic nature and bewildering spread, respects no borders and has nearly paralyzed healthcare systems throughout the world. Indeed, in the absence of specific, proven medical interventions, healthcare systems have been overwhelmed, thus limiting their ability to treat patients with non-emergent medical conditions and those awaiting elective procedures. Although it is beyond the scope of this editorial to discuss what constitutes a necessary or elective procedure, this radical change in medical practice has had an enormous impact on discontinuation of fertility care services, especially the assisted reproductive technologies (ART). It is eminently clear that reducing or discontinuing elective procedures and essential ART treatments was crucial not only to enable hospitals and medical facilities to manage (or to treat) the explosive rise in SARS-CoV-2 patients, but also to reduce disease transmission vis-à-vis various mitigating strategies—especially individual isolation and social distancing, strategies utilized effectively in China and Italy. Thus, national authorities and local governmental regulations as well as guidelines published by several medical societies (the European Society of Human Reproduction and Embryology [ESHRE] and the American Society for Reproductive Medicine [ASRM]) have affirmed these recommendations.1-4 All have pointedly emphasized that social isolation and reduced social contact will slow the spread of the disease, reduce risk to medical staff, and conserve medical resources until better testing, tracking, treatments, and hopefully a vaccine become available. While it is recognized that the discontinuation of fertility services is necessary at present, it is essential that every effort be made to continue all reproductive health services to the extent possible. Women need ongoing access to safe and reliable contraception of their choice, management of sexually transmitted infections, and, when necessary, safe termination of pregnancy. It is also a concern that there have been reports of increased gender-based violence in some communities during lockdown. We need to be especially vigilant about this particular problem at this time. Important additional reproductive health considerations are the unknown effects of coronavirus infection on pregnant women and their fetuses, especially in the first trimester, in addition to the generally limited knowledge about the SARS-CoV-2 pathophysiology in pregnancy. The ability to cryopreserve embryos has enabled treatments in progress to be completed for many women and for emergency treatment for cancer patients to continue. For some older women and those with diminished ovarian reserve, treatment delay of a few months may theoretically cause harm in reducing their ultimate chances for a live birth. Additionally, the psychological toll of postponed treatment is a major health burden for those affected. However, the vast majority of infertile patients will not be significantly compromised by a few months’ delay in treatment. Nevertheless, infertility is a disease and fertility care should be considered as an essential medical service; thus, it is important to restart fertility and in vitro fertilization (IVF) treatments as soon as possible. Considerations for beginning IVF treatments should follow both governmental and local regulations as well as ASRM and ESHRE recommendations. First and foremost, restarting must depend on: the degree and prevalence of the disease burden in a given locality; the availability of personnel; personal protective equipment and other health resources; and the development of new patient treatment paradigms that ensure social distancing to maximize patient and personnel safety. Telehealth visits should be encouraged to reduce patient contact and appropriate changes should be made in laboratories to ensure social distancing and application of relevant viral precautions. All patients should be counseled about the possible risks of SARS-CoV-2 in pregnancy and be given the choice to either proceed or postpone treatment. To ensure safe practice and to minimize the risks related to SARS-COV-2 to our patients and staff, we must proceed cautiously as we resume treating patients. Future reproductive care will have to account for the ‘new normal,’ with acknowledgment that infertility care must evolve as we unravel this inscrutable disease.