Delay in IVF treatment up to 180 days does not affect pregnancy outcomes in women with diminished ovarian reserve

Mitigating multiples, less is more: examining trends in multifetal gestation rates with assisted reproductive technology

PURPOSE

Multifetal gestation (MFG) is much more common in pregnancies that utilize assisted reproductive technologies (ART). We assessed how these rates have changed over the previous decade and the impact on live birth rates (LBR).

METHODS

This retrospective cohort study uses the National Summary Reports of the Society for Assisted Reproductive Technology (SART) from 2014 to 2020. Data points included only autologous cycles. The data were divided into five age groups as reported in the database: < 35, 35-37, 38-40, 41-42, and > 42 years old. Descriptive statistics and a two-tailed T-test were used to determine the trends and statistical significance (p < 0.05).

RESULTS

Rates of twin births decreased substantially from 2014 to 2020 for autologous embryo transfers across all age groups and diagnoses. Surprisingly, the overall LBR for autologous IVF cycles decreased at similar rates from 2014 to 2020 in all age groups. The mean number of embryos transferred has dramatically reduced, especially across age groups < 42.

CONCLUSION

Rates of twin and higher-level gestations have decreased substantially over the past decade; the effect correlates with the increased utilization of eSET and PGT. The cause of infertility did not significantly impact the rate of MFG.

The impact and inflammatory characteristics of SARS-CoV-2 infection during ovarian stimulation on the outcomes of assisted reproductive treatment

Introduction

Despite the global prevalence of coronavirus disease 2019 (COVID-19), limited research has been conducted on the effects of SARS-CoV-2 infection on human reproduction. The aims of this study were to investigate the impact of SARS-CoV-2 infection during controlled ovarian stimulation (COS) on the outcomes of assisted reproductive treatment (ART) and the cytokine status of patients.

Methods

This retrospective cohort study included 202 couples who received ART treatment, 101 couples infected with SARS-CoV-2 during COS and 101 matched uninfected couples. The parameters of ovarian stimulation and pregnancy outcomes were compared between the two groups. The All-Human Inflammation Array Q3 kit was utilized to measure cytokine levels in both blood and follicular fluid.

Results

No difference was found in the number of good-quality embryos (3.3 ± 3.1 vs. 3.0 ± 2.2, P = 0.553) between the infected and uninfected groups. Among couples who received fresh embryo transfers, no difference was observed in clinical pregnancy rate (53.3% vs. 51.5%, P = 0.907). The rates of fertilization, implantation, miscarriage, ectopic pregnancy and live birth were also comparable between the two groups. After adjustments were made for confounders, regression models indicated that the quality of embryos (B = 0.16, P = 0.605) and clinical pregnancy rate (P = 0.206) remained unaffected by SARS-CoV-2 infection. The serum levels of MCP-1, TIMP-1, I-309, TNF-RI and TNF-RII were increased, while that of eotaxin-2 was decreased in COVID-19 patients. No significant difference was found in the levels of cytokines in follicular fluid between the two groups.

Conclusion

Asymptomatic or mild COVID-19 during COS had no adverse effects on ART outcomes. Although mild inflammation was present in the serum, it was not detected in the follicular fluid of these patients. The subsequent immune response needs further investigation.

Surgically retrieved spermatozoa for ICSI cycles in non-azoospermic males with high sperm DNA fragmentation in semen

Intracytoplasmic sperm injection (ICSI) using surgically retrieved spermatozoa outside the classic context of azoospermia has been increasingly used to overcome infertility. The primary indications include high levels of sperm DNA damage in ejaculated spermatozoa and severe oligozoospermia or cryptozoospermia, particularly in couples with ICSI failure for no apparent reason. Current evidence suggests that surgically retrieved spermatozoa for ICSI in the above context improves  outcomes, mainly concerning pregnancy and miscarriage rates. The reasons are not fully understood but may be related to the lower levels of DNA damage in spermatozoa retrieved from the testis compared with ejaculated counterparts. These findings are consistent with the notion that excessive sperm DNA damage  can be a limiting factor responsible for the failure to conceive. Using testicular in preference of low-quality ejaculated spermatozoa bypasses post-testicular sperm DNA damage caused primarily by oxidative stress, thus increasing the likelihood of oocyte fertilization by genomically intact spermatozoa. Despite the overall favorable results, data remain limited, and mainly concern males with confirmed sperm DNA damage in the ejaculate. Additionally, information regarding the health of ICSI offspring resulting from the use of surgically retrieved spermatoa of non-azoospermic males is still lacking. Efforts should be made to improve the male partner's reproductive health for safer ICSI utilization. A comprehensive andrological evaluation aiming to identify and treat the underlying male infertility factor contributing to sperm DNA damage is essential for achieving this goal.

Kisspeptin: a potential therapeutic target in patients with unexplained infertility?

BACKGROUND

Kisspeptin has recently emerged as a key regulator of the reproductive axis in women. Kisspeptin, acting centrally via the kisspeptin receptor, stimulates the secretion of the gonadotrophin-releasing hormone (GnRH).

AIMS

To investigate serum kisspeptin levels in infertility patients for its clinical utilisation in management and understanding of the pathophysiology of infertility in a wide array of patients.

METHODS

This prospective case-control study analysis involved 92 primary infertile women with PCOS, diminished ovarian reserve (DOR), unexplained infertility (UEI), and male factor infertility between 20 and 42 years of age. Serum samples were collected between the second and fifth day of the menstrual cycle. The kisspeptin level was determined using a human kisspeptin ELISA kit according to the manufacturer's procedure.

RESULTS

The median value of serum kisspeptin in the PCOS infertility group was significantly higher than that in the UEI group (p = 0.011). There was a statistically significant (p = 0.015, r =  -0.182) negative weak correlation found between serum kisspeptin levels and age. The optimal cutoff value obtained to differentiate the UEI from others (PCOS infertility + DOR + male factor infertility) according to the serum kisspeptin level was 214.3 ng/L with a sensitivity of 55% and specificity of 80.9%.

CONCLUSIONS

Understanding the role of kisspeptin may lead to its use as a biomarker in infertility diagnosis in UEI patients and might guide the use of kisspeptin analogues in selected patients for infertility management.

SARS-CoV-2, fertility and assisted reproduction

BACKGROUND

In 2020, SARS-CoV-2 and the COVID-19 pandemic had a huge impact on the access to and provision of ART treatments. Gradually, knowledge of the virus and its transmission has become available, allowing ART activities to resume. Still, questions on the impact of the virus on human gametes and fertility remain.

OBJECTIVE AND RATIONALE

This article summarizes published data, aiming to clarify the impact of SARS-CoV-2 and the COVID-19 disease on human fertility and assisted reproduction, as well as the impact of vaccination, and from this, provide answers to questions that are relevant for people contemplating pregnancy and for health care professionals.

SEARCH METHODS

PUBMED/MEDLINE and the WHO COVID-19 database were searched from inception to 5 October 2022 with search terms focusing on 'SARS-CoV-2' and gametes, embryos, reproductive function, fertility and ART. Non-English studies and papers published prior to 2020 were excluded, as well as reviews and non-peer reviewed publications. Full papers were assessed for relevance and quality, where feasible.

OUTCOMES

From the 148 papers included, the following observations were made. The SARS-CoV-2-binding proteins, angiotensin-converting enzyme 2 (ACE2) and type II transmembrane serine protease (TMPRSS2), are expressed in the testis, but co-expression remains to be proven. There is some evidence of SARS-CoV-2 RNA in the ejaculate of COVID-19 patients with severe disease, but not in those with mild/moderate disease. SARS-CoV-2 infection can impair spermatogenesis, but this seems to resolve after one spermatogenic cycle. Testosterone levels seem to be lower during and after COVID-19, but long-term data are lacking; disease severity may be associated with testosterone levels. COVID-19 cannot be considered a sexually transmitted disease. There is no co-expression of ACE2 and TMPRSS2 in the myometrium, uterus, ovaries or fallopian tubes. Oocytes seem to have the receptors and protease machinery to be susceptible to SARS-CoV-2 infection; however, viral RNA in oocytes has not been detected so far. Women contemplating pregnancy following COVID-19 may benefit from screening for thyroid dysfunction. There is a possible (transient) impact of COVID-19 on menstrual patterns. Embryos, and particularly late blastocysts, seem to have the machinery to be susceptible to SARS-CoV-2 infection. Most studies have not reported a significant impact of COVID-19 on ovarian reserve, ovarian function or follicular fluid parameters. Previous asymptomatic or mild SARS-CoV-2 infection in females does not seem to negatively affect laboratory and clinical outcomes of ART. There are no data on the minimum required interval, if any, between COVID-19 recovery and ART. There is no evidence of a negative effect of SARS-CoV-2 vaccination on semen parameters or spermatogenesis, ovarian function, ovarian reserve or folliculogenesis. A transient effect on the menstrual cycle has been documented. Despite concerns, cross reactivity between anti-SARS-CoV-2 spike protein antibodies and Syncytin-1, an essential protein in human implantation, is absent. There is no influence of mRNA SARS-CoV-2 vaccine on patients' performance during their immediate subsequent ART cycle. Pregnancy rates post-vaccination are similar to those in unvaccinated patients.

WIDER IMPLICATIONS

This review highlights existing knowledge on the impact of SARS-CoV-2 infection or COVID-19 on fertility and assisted reproduction, but also identifies gaps and offers suggestions for future research. The knowledge presented should help to provide evidence-based advice for practitioners and couples contemplating pregnancy alike, facilitating informed decision-making in an environment of significant emotional turmoil.

Oocyte Retrieval in Asymptomatic Patients Positive for SARS-CoV-2

Objective. To report two cases of oocyte retrieval performed in asymptomatic SARS-CoV-2-positive patients. Design. Case report. Setting. Outpatient private practice infertility center. Patients. A 28-year-old woman at risk for OHSS who took her trigger injection prior to testing positive for SARS-CoV-2 and a 19-year-old oncofertility patient who tested positive prior to retrieval due to a family exposure. Both patients were asymptomatic. Main Outcome Measures. Cycle outcomes, patient safety, and staff safety. Results. Both patients underwent successful oocyte retrieval procedures without developing symptoms or complications from COVID-19. No staff members that cared for these patients developed symptoms of COVID-19. Conclusion. Worsening fertility outcomes and potential for psychological and financial burdens to the patient must be balanced with risk of perioperative complications in patients testing positive for SARS-CoV-2. As we continue to provide fertility care in a world with COVID-19, appropriate risk mitigation strategies should be implemented to minimize exposure to SARS-CoV-2.

Network Pharmacology-Based Prediction and Verification of the Potential Mechanisms of He's Yangchao Formula against Diminished Ovarian Reserve

Background

He's Yangchao formula (HSYC) has been clinically proven to be effective in treating diminished ovarian reserve (DOR). However, the underlying molecular mechanisms of HSYC in DOR are unclear.

Objective

This study aims to predict the underlying mechanisms of He's Yangchao formula (HSYC) against DOR through network pharmacology strategies and verify in vivo.

Methods

Systematic network pharmacology was used to speculate the bioactive components, potential targets, and the underlying mechanism of HSYC in the treatment of DOR. Then, the CTX-induced DOR mouse model was established to verify the effect of HSYC against DOR and the possible molecular mechanisms as predicted in the network pharmacology approach.

Results

A total of 44 active components and 423 potential targets were obtained in HSYC. In addition, 91 targets of DOR were also screened. The identified hub genes were AKT1, ESR1, IL6, and P53. Further molecular docking showed that the four hub targets were well-bound with their corresponding compounds. In vivo experiments showed that HSYC could promote the recovery of the estrous cycle and increase the number of primordial, growing follicles and corpora lutea. Besides, The results of qRT-PCR showed HSYC could regulate the expression of AKT1, ESR1, P53, and IL6 in DOR mice.

Conclusion

It was demonstrated that HSYC could increase ovarian reserves, and AKT1, ESR1, IL6, and P53 may play an essential role in this effect, which provided a new reference for the current lack of active interventions of DOR.

Patients' views of delayed fertility care during the COVID-19 pandemic as a conception catastrophe: the experience of U.S. FertilityIQ users

BACKGROUND

Assessment of psychological reactions to delays in fertility treatment have often utilized single clinic samples during the time that fertility treatments were paused. We, therefore, assessed emotional reactions to treatment cancelations due to COVID-19 in infertility patients across the United States after treatments had begun to resume.

STUDY DESIGN

Cross-sectional survey emailed on 27 May 2020 and closed on 30 June 2020, to 53,600 FertilityIQ.com website users inquiring about their experience since the COVID-19 pandemic. A subset of FertilityIQ users (n = 13,490) opened the survey invitation and 1806 respondents participated in the survey (13.4% response rate).

RESULTS

The majority of respondents (female, 67.4%; male, 61.7%) were 31-40 years old; most were planning to start treatment immediately (women, 42.6%; men, 44.7%) or were undergoing treatment (women, 34.9%; men, 29.8%) at the time of treatment cancelation. Patients (women, 21.1%; men 19.1%) or clinics (women, 57.7%; men, 40.4%) canceled treatment. Most clinics had resumed treatment at the time of the study (women, 90.0%; men, 73.7%). Cancelation resulted in sadness (women, 83.9%; men 86.7%) and anger (women, 45.4%; men, 36.7%); greater than half of the participants whose treatment was canceled (women: 66.8%, n = 630; men: 73.7%, n = 14) agreed with cancelations. Greater than 70% of respondents were at least somewhat concerned about reproductive chances (women, 84.7%; men, 72.4%) and exclusion of partners (women, 73.3%; men, 72.4%). Distress/concern was associated with clinic cancelation, disagreement with delays, age, diagnosis, and concern about delays and pregnancy chances (p <.05).

CONCLUSIONS

Respondents were distressed/concerned about the effect of the pandemic on their fertility. Distress was highest in women with a poorer fertility prognosis, no control over treatment cancelation, and high concern about the effect of treatment delay on pregnancy chances. Emotional support, education regarding treatment delay and fertility, and efforts where possible, to include patients in decisions to delay treatment are warranted in future treatment delays.

Fertility treatment delays during COVID-19: Profiles, feelings and concerns of impacted patients

The coronavirus disease 2019 (COVID-19) pandemic resulted in unprecedented measures across all health services around the globe, including the large-scale cessation of assisted reproductive technology treatment in Europe as clinics closed, causing disruption and delay to the fertility treatment of thousands of patients in the UK alone. This research explores how patients were impacted by the delay and disruption, and their feelings, concerns and reactions. A mixed-methods, anonymous, online questionnaire, live between 19 May and 30 June 2020, was used to target all fertility patients aged >18 years whose treatment had been impacted by COVID-19. In total, 709 people began the questionnaire and 501 completed it in the time available (70.7% completion rate). Patients reported feeling 'powerless/helpless' (78.3%), 'frustrated' (59.3%) and 'anxious' (54.7%) in response to the closure of fertility clinics. The majority were 'very concerned' about time passing and not knowing when they could start treatment again (79.0%), and the length of waiting lists when clinics reopened (70.9%). While 76.8% of respondents had some concerns around contracting COVID-19, 42.9% were 'not at all concerned' about undergoing in-vitro fertilization treatment during a pandemic. Variables such as funding source, duration of infertility, previous experience of fertility treatment, treatment stage and the presence of children were correlated with significant intragroup differences in the types of concerns reported. The large majority (72.7%) of respondents stated their eagerness to start treatment as soon as possible, and 9.4% said that they had already resumed treatment; only 6.0% of respondents wanted to wait due to concerns related to COVID-19.

The new normal: a UK fertility clinic experience of universal RT-PCR SARS-CoV-2 testing

Following the temporary closure of fertility clinics in 2020 in many countries across the world, the SARS-CoV-2 pandemic has meant that the sector has had to rapidly adapt to novel ways of operating. The aim of this study was to investigate the efficacy and feasibility of universal real-time polymerase chain reaction testing at an IVF clinic within a UK tertiary referral centre. Between March and December 2020, we performed 2,401 SARS-CoV-2 RT-PCR tests on 1,215 individual patients, of which eight were positive (0.3%). Appropriate positive case identification allowed for delay in treatment initiation or cancellation as applicable. This has allowed our unit to continue to operate safely and efficiently.

"Short agonist stop" protocol, an ovarian stimulation for poor responders in in vitro fertilization (IVF): A pilot study

INTRODUCTION

Poor responder patients remain a challenge in assisted reproductive technologies. The "short agonist stop" (SAS) stimulation protocol uses a double stimulation (flare up effect with the gonadotropin-releasing hormone (GnRH) agonist (GnRH-a) then gonadotropins) associated with a less strenuous blockage (discontinuation of GnRH-a) to favor follicular recruitment in order to obtain a better ovarian response. This study aims to compare the number of oocytes obtained after a SAS stimulation protocol with those obtained after the previous stimulation protocol, in the same women, with poor ovarian response (POR) diagnosed according to the POSEIDON criteria.

DESIGN

This therapeutic observational retrospective cohort from 2018 to 2022, with a case-control evaluation compared with the same patients' previous performance, included women with POR undergoing IVF with SAS stimulation protocol. The primary outcome was the number of total oocytes recovered and secondary outcomes were the numbers of mature oocytes, total embryos observed at day 2 and usable cleaved embryos and blastocysts (day 5/6).

RESULTS

63 patients with SAS and previous cycles were included. In the SAS group, the mean number of oocytes was significantly higher: 7.3 vs 5.7, p=0.018 in comparison with the previous attempt. So was the number of mature oocytes (5.8 vs 4.1, p=0.032) and the total mean number of embryos obtained at day 2 (4.1 versus 2.7, p=0.016). The SAS stimulation generated 84 usable embryos: 57 cleaved embryos and 27 blastocysts. The mean number of usable embryos was similar in both groups (1.64 vs 1.31, respectively, p=0.178). In total, out of 63 patients, after the SAS protocol, and subsequent embryo transfers (fresh and frozen, n=54), 9 patients had ongoing pregnancies and no miscarriage occurred. The cumulative ongoing pregnancy rate (cOPR) after the SAS protocol was 14.3% (9/63) per oocyte pick-up and 16.7% (9/54) per transfer.

CONCLUSION

SAS stimulation is a short and original protocol strengthening the therapeutic arsenal of poor responders, that may offer promising results for those patients with low prognosis and previous failed IVF. Results must be confirmed with a randomized controlled trial.

Expectant Management Before In vitro Fertilization in Women Aged 39 or Above and Unexplained Infertility Does Not Decrease Live Birth Rates Compared to Immediate Treatment

Unexplained infertile couples can have further expectant management before starting assisted reproductive treatments. However, ovarian reserve and in vitro fertilization (IVF) outcomes rapidly decline after 39 years or more. It is thus important to clarify whether a waiting policy is also appropriate for women of advanced age. Couples who had access to a waiting list for approximately 1 year before receiving reimbursed public IVF were compared with those paying for access to immediate treatment. To allow for comparisons between these two strategies, we followed up couples who opted to pay for 1 year after the last embryo transfer from their first cycle. We calculated the proportion of live births in both groups and compared these using logistic regression models and a two-sample Z test for equality of proportions. Six hundred thirty-five couples were evaluated. Out of 359 couples in the immediate group, 70 (19.5%) had a live birth of which 11 after natural conception and 59 after IVF. Out of 276 couples in the waiting group, 57 (20.7%) had a live birth of which 37 after natural conception and 20 after IVF. There was no statistically significant difference between the two strategies in terms of the crude cumulative live birth rate (cLBR). The adjusted odds ratio of 0.69 (95%CI:0.39–1.22) did not change this conclusion as our sensitivity analyses. The cLBR for the ‘waiting before IVF’ and the ‘immediate’ strategies were similar. Further studies are needed to better characterize couples affected by unexplained infertility in order to individualize treatment strategies.

Universal SARS-CoV-2 polymerase chain reaction screening and assisted reproductive technology in a coronavirus disease 2019 pandemic epicenter: screening and cycle outcomes from a New York City fertility center

OBJECTIVE

To evaluate the prevalence of coronavirus disease 2019 (COVID-19) and efficacy of a universal screening program in patients undergoing controlled ovarian stimulation (COS).

DESIGN

Single-center retrospective cohort study.

SETTING

Academic fertility center in an epicenter of the COVID-19 pandemic.

PATIENT(S)

All patients undergoing COS from June 17, 2019, to February 28, 2021.

INTERVENTION(S)

Universal COVID-19 screening starting June 17, 2020, with SARS-CoV-2 polymerase chain reaction testing within 5 days of oocyte retrieval, patient-reported symptom screening, and temperature monitoring.

MAIN OUTCOMES MEASURE(S)

The primary outcome was the number of positive COVID-19 cases in patients undergoing COS cycles. The secondary outcomes were cycle outcomes compared with before COVID-19 COS cycles, adverse outcomes in COVID-canceled cycles, and center-specific COVID-19 detection rates compared with New York City cases.

RESULT(S)

From June 17, 2020, to February 28, 2021, 1,696 COS cycles were initiated with only seven positive COVID-19 cases for an overall positivity rate of 0.4%. When compared with before COVID cycles from June 17, 2019, to February 28, 2020, the volume of COS cycles were higher, while the overall cycle cancelation rate was lower during COVID-19. Cycle outcomes including oocyte yield and blast utilization rates were unchanged from pre-COVID cycles. Cases of COVID-19, while very low, occurred more frequently during surges in New York City rates.

CONCLUSION(S)

Assisted reproductive technology can be performed during the COVID-19 pandemic utilizing frequent universal screening and safe practices with low SARS-CoV-2 positivity, low cycle cancelation rates, and positive patient outcomes.

How to provide fertility treatment during COVID-19 pandemic

PURPOSE OF REVIEW

The emergence of the novel coronavirus infection that arose in Wuhan, China in December 2019 has resulted in an epidemic that has quickly expanded to become one of the most significant public health threats in recent times. The objective of this review is to summarize how this pandemic has affected the activity of a Reproductive Medicine Center, which established a series of measures in parallel with governments decisions and scientific societies.

RECENT FINDINGS

The control measures adopted for restarting the healthcare activity should be equitable and inclusive. Moreover, this pandemic has implied changes in treatments and strategies to be alert regarding the daily changing information. Finally, for ensuring a safe practice both for patients and staff, it is important to detect asymptomatic patients, so Reproductive Medicine centers must take special care with screening and testing procedures.

SUMMARY

The pandemic has pushed up toward a new reality in terms of Assisted Reproductive treatments, where social distance and responsibility are protagonists. We face a new challenge of balancing between responding to the committed efforts of infertile couples to achieve pregnancy and safeguarding the health of the future parents and their children during this time of pandemic.

Incidence of first trimester pregnancy loss in the infertile population during the first wave of the coronavirus disease 2019 pandemic in New York City

Objective

To describe the incidence of first trimester clinical pregnancy loss in the infertile population during the first wave of the COVID-19 pandemic in New York City.

Design

Web-based cross-sectional survey.

Setting

New York City-based academic reproductive medicine practice.

Patient(s)

A total of 305 infertile patients with a confirmed intrauterine pregnancy in their first trimester between December 1, 2019, and April 1, 2020, were matched by age and treatment type to pregnant patients from the year prior.

Intervention(s)

None.

Main Outcome Measure(s)

First trimester clinical pregnancy loss rate.

Result(s)

In total, the first trimester pregnancy loss rate was lower in the COVID-19 era cohort compared with that in the pre-COVID-19 era cohort (11.9% vs. 20.1%). There was no difference between cohorts in the pregnancy loss rate of women conceiving via fresh embryo transfer (19.6% vs. 24.4%) or via frozen embryo transfer with preimplantation genetic testing (5.4% vs. 9.5%,). In women conceiving via frozen embryo transfer without preimplantation genetic testing, the pregnancy loss rate was statistically lower in the COVID-19 group (12.5% vs. 24.5%). There was no difference in the pregnancy loss rate by treatment type when stratifying by COVID-19 testing or symptom status. Of the 40 (13.1%) patients with a pregnancy loss, there was no difference in self-reported COVID-19 symptoms or symptom type compared with results in those who did not experience a pregnancy loss.

Conclusion

Despite patients expressing significant worry about COVID-19 and pregnancy, our data provides reassuring information that the first trimester pregnancy loss rate is not elevated for women conceiving via assisted reproductive technology during the global COVID-19 pandemic.

We are here for you: infertility clinic communication during the first wave of the COVID-19 pandemic

Purpose

To study how SART-member fertility clinics communicated via clinic websites during the first wave of the COVID-19 pandemic following publication of ASRM COVID-19 Task Force recommendations.

Methods

SART-member fertility clinic websites were systematically surveyed for the presence of an REI-specific COVID-19 message (REI-CM) and analyzed for their adherence to ASRM guidance.

Results

Of the 381 active clinic websites, 249 (65.3%) had REI-specific COVID messaging. The presence of REI-CM was more common in private than in academic practices (73% vs 38%, p < 0.001) and with increasing practice volume: 38% of clinics with < 200 annual cycles vs 91% of clinics with > 1000 cycles (p < 0.001). Adherence to ASRM guidance was more common in academic than in private practices (54% vs 31%, p = 0.02). Additionally, 9% of REI-CM (n = 23) announced continued treatment regardless of a patient’s clinical urgency. This messaging was more common in groups doing > 1000 cycles a year (18%, p = 0.009). Clinics treating all-comers were less likely to cite ASRM than other clinics (41% vs 62%, p = 0.045). However, 75% (n = 14) cited COVID-19 guidance from WHO, CDC, and state and local governments.

Conclusions

Clinic response to ASRM recommendations during the first wave of COVID-19 pandemic was heterogeneous. Although academic practices were more likely to follow ASRM guidance, there was a lower extent of patient-facing messaging among academic practices than private clinics. In event of further escalations of this and future pandemics, clinics can learn from experiences to provide clear messaging to patients.

COVID-19 and human reproduction: A pandemic that packs a serious punch

The COVID-19 pandemic has led to a worldwide health emergency that has impacted 188 countries at last count. The rapid community transmission and relatively high mortality rates with COVID-19 in modern times are relatively unique features of this flu pandemic and have resulted in an unparalleled global health crisis. SARS-CoV-2, being a respiratory virus, mainly affects the lungs, but is capable of infecting other vital organs, such as brain, heart and kidney. Emerging evidence suggests that the virus also targets male and female reproductive organs that express its main receptor ACE2, although it is as yet unclear if this has any implications for human fertility. Furthermore, professional bodies have recommended discontinuing fertility services during the pandemic such that reproductive services have also been affected. Although increased safety measures have helped to mitigate the propagation of COVID-19 in a number of countries, it seems that there is no predictable timeline to containment of the virus, a goal likely to remain elusive until an effective vaccine becomes available  and widely distributed across the globe. In parallel, research on reproduction has been postponed for obvious reasons, while diagnostic tests that detect the virus or antibodies against it are of vital importance to support public health policies, such as social distancing and our obligation to wear masks in public spaces. This review aims to provide an overview of critical research and ethics issues that have been continuously emerging in the field of reproductive medicine as the COVID-19 pandemic tragically unfolds.Abbreviations: ACE2: angiotensin- converting enzyme 2; ART: Assisted reproductive technology; ASRM: American Society for Reproductive Medicine; CCR9: C-C Motif Chemokine Receptor 9; CDC: Centers for Disease Control and Prevention; COVID-19: Coronavirus disease 2019; Ct: Cycle threshold; CXCR6: C-X-C Motif Chemokine Receptor 6; ELISA: enzyme-linked immunosorbent assay; ESHRE: European Society of Human Reproduction and Embryology; ET: Embryo transfer; FSH: Follicle Stimulating Hormone; FFPE: formalin fixed paraffin embedded; FYCO1: FYVE And Coiled-Coil Domain Autophagy Adaptor 1; IFFS: International Federation of Fertility Societies; IUI: Intrauterine insemination; IVF: In vitro fertilization; LH: Luteinizing Hormone; LZTFL1: Leucine Zipper Transcription Factor Like 1; MAR: medically assisted reproduction services; MERS: Middle East Respiratory syndrome; NGS: Next Generation Sequencing; ORF: Open Reading Frame; PPE: personal protective equipment; RE: RNA Element; REDa: RNA Element Discovery algorithm; RT-PCR: Reverse=trascriptase transcriptase-polymerase chain reaction; SARS: Severe acute respiratory syndrome; SARS-CoV-2: Severe Acute Respiratory Syndrome Coronavirus 2; SLC6A20: Solute Carrier Family 6 Member 20; SMS: Single Molecule Sequencing; T: Testosterone; TMPRSS2: transmembrane serine protease 2; WHO: World Health Organization; XCR1: X-C Motif Chemokine Receptor.

Early experience with universal SARS-CoV-2 testing in a New York-based reproductive endocrinology ‎practice

The SARS-CoV-2 pandemic peak around March 2020 led to temporary closures of most fertility clinics. Many clinics reopened but required universal SARS-CoV-2 screening. However, the rate of positive results and the necessity for such testing is unknown. We report here on early results from asingle-center academic NewYork fertility practice utilizing universal SARS-CoV-2 screening. This mixed prospective retrospective cohort included 164 patients who underwent at least one SARS-CoV-2 screening test for fertility treatment between May and July2020. Patients completed 1 to 3 nasopharyngeal SARS-CoV-2 tests per cycle and remained symptom-free to continue fertility treatments. SARS-CoV-2 test results, past results, history of Covid-19 infection, and patient/cycle characteristics were recorded and tabulated through October2020. Outcomes included positive SARS-CoV-2 RNA tests, rate of prior Covid-19 infections, and clinical courses of patients testing positive. Patients underwent 263 cycles entailing 460 total SARS-CoV-2 screening tests. Fifteen patients reported astrong prior clinical history of Covid-19. Six patients experienced apositive SARS-CoV-2 test (2.3% of all cycles). Among 77 cycles (n = 58 patients) entailing one SARS-CoV-2 test, 2 cases (2.6%) were noted. Among 173 cycles (n = 121 patients) entailing two SARS-CoV-2 tests, 4 cycles (2.3%) were noted. Zero (0%) of 13 cycles (n = 13 patients) entailing 3 SARS-CoV-2 tests were positive. All patients were cleared to resume treatment within one month. Overall, anew asymptomatic infection was identified in 2 cycles (0.8%), while 4 of the 6 positive SARS-CoV-2 tests were among patients with aprior history of Covid-19. 3 of 4 also had adocumented prior positive RNA test. Our data suggest that universal SARS-CoV-2 screening among fertility patients is feasible, with an approximately 2% positive rate per cycle among the patients of this study. Most positive patients had aprior remote infection, but their infectiousness while being screened remains unclear.Abbreviations: REI: reproductive endocrinology and infertility; IUI: intrauterine insemination; IVF: in vitro fertilization; sono: sonography; cryo: cryopreservation; FET: frozen embryo transfer.

Prioritizing IVF treatment in the post-COVID 19 era: a predictive modelling study based on UK national data

STUDY QUESTION

Can we use prediction modelling to estimate the impact of coronavirus disease 2019 (COVID 19) related delay in starting IVF or ICSI in different groups of women?

SUMMARY ANSWER

Yes, using a combination of three different models we can predict the impact of delaying access to treatment by 6 and 12 months on the probability of conception leading to live birth in women of different age groups with different categories of infertility.

WHAT IS KNOWN ALREADY

Increased age and duration of infertility can prejudice the chances of success following IVF, but couples with unexplained infertility have a chance of conceiving naturally without treatment whilst waiting for IVF. The worldwide suspension of IVF could lead to worse outcomes in couples awaiting treatment, but it is unclear to what extent this could affect individual couples based on age and cause of infertility.

STUDY DESIGN, SIZE, DURATION

A population based cohort study based on national data from all licensed clinics in the UK obtained from the Human Fertilisation and Embryology Authority Register. Linked data from 9589 women who underwent their first IVF or ICSI treatment in 2017 and consented to the use of their data for research were used to predict livebirth numbers.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Three prediction models were used to estimate the chances of livebirth associated with immediate treatment versus a delay of 6 and 12 months in couples about to embark on IVF or ICSI.

MAIN RESULTS AND THE ROLE OF CHANCE

We estimated that a 6-month delay would reduce livebirths by 0.4%, 2.4%, 5.7%, 9.5% and 11.8% in women aged <30, 30-35, 36-37, 38-39 and 40-42 years, respectively, while corresponding values associated with a delay of 12 months were 0.9%, 4.9%, 11.9%, 18.8% and 22.4%, respectively. In women with known causes of infertility, worst case (best case) predicted chances of livebirth after a delay of 6 months in women aged <30, 30-35, 36-37, 38-39 and 40-42 years varied between 31.6% (35.0%), 29.0% (31.6%), 23.1% (25.2%), 17.2% (19.4%) and 10.3% (12.3%) for tubal infertility and 34.3% (39.2%), 31.6% (35.3%) 25.2%(28.5%) 18.3% (21.3%), and 11.3% (14.1%) for male factor infertility. The corresponding values in those treated immediately were 31.7%, 29.8%, 24.5%, 19.0% and 11.7% for tubal factor and 34.4%, 32.4%, 26.7%, 20.2% and 12.8% in male factor infertility. In women with unexplained infertility the predicted chances of livebirth after a delay of 6 months followed by one complete IVF cycle were 41.0%, 36.6%, 29.4%, 22.4% and 15.1% in women aged <30, 30-35, 36-37, 38-39 and 40-42 years, respectively, compared to 34.9%, 32.5%, 26.9%, 20.7% and 13.2% in similar groups of women treated without any delay. The additional waiting period, which provided more time for spontaneous conception, was predicted to increase the relative number of babies born by 17.5%, 12.6%, 9.1%, 8.4% and 13.8%, in women aged <30, 30-35, 36-37, 38-39 and 40-42 years, respectively. A 12-month delay showed a similar pattern in all subgroups.

LIMITATIONS, REASONS FOR CAUTION

Major sources of uncertainty include the use of prediction models generated in different populations and the need for a number of assumptions. Although the models are validated and the bases for the assumptions are robust, it is impossible to eliminate the possibility of imprecision in our predictions. Therefore, our predicted live birth rates need to be validated in prospective studies to confirm their accuracy.

WIDER IMPLICATIONS OF THE FINDINGS

A delay in starting IVF reduces success rates in all couples. For the first time, we have shown that while this results in fewer babies in older women and those with a known cause of infertility, it has a less detrimental effect on couples with unexplained infertility, some of whom conceive naturally whilst waiting for treatment. Post COVID 19, clinics planning a phased return to normal clinical services should prioritise older women and those with a known cause of infertility.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was received for this study. B.W.M. is supported by an NHMRC Practitioner Fellowship (GNT1082548) and reports consultancy work for ObsEva, Merck, Merck KGaA, Guerbet and iGenomics. SB is Editor-in-Chief of Human Reproduction Open. None of the other authors declare any conflicts of interest.

Human eggs, zygotes, and embryos express the receptor angiotensin 1-converting enzyme 2 and transmembrane serine protease 2 protein necessary for severe acute respiratory syndrome coronavirus 2 infection

OBJECTIVE

To study messenger ribonucleic acid (mRNA) and protein expressions of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) entry receptors (angiotensin 1-converting enzyme 2 [ACE2] and CD147) and proteases (transmembrane serine protease 2 [TMPRSS2] and cathepsin L [CTSL]) in human oocytes, embryos, and cumulus (CCs) and granulosa cells (GCs).

DESIGN

Research study.

SETTING

Clinical in vitro fertilization (IVF) treatment center.

PATIENTS

Patients undergoing IVF were treated at the Colorado Center for Reproductive Medicine.

INTERVENTIONS

Oocytes (germinal vesicle and metaphase II [MII]) and embryos (1-cell [1C] and blastocyst [BL]) were donated for research at the disposition by the patients undergoing IVF. Follicular cells (CC and GC) were collected from women undergoing egg retrieval after ovarian stimulation without an ovulatory trigger for in vitro maturation/IVF treatment cycles.

MAIN OUTCOME MEASURES

Presence or absence of ACE2, CD147, TMPRSS2, and CTSL mRNAs detected using quantitative reverse transcription polymerase chain reaction and proteins detected using capillary Western blotting in human oocytes, embryos, and ovarian follicular cells.

RESULTS

The quantitative reverse transcription polymerase chain reaction analysis revealed high abundance of ACE2 gene transcripts in germinal vesicle and MII oocytes than in CC, GC, and BL. ACE2 protein was present only in the MII oocytes, and 1C and BL embryos, but other ACE2 protein variants were observed in all the samples. TMPRSS2 protein was present in all the samples, whereas mRNA was observed only in the BL stage. All the samples were positive for CD147 and CTSL mRNA expressions. However, CCs and GCs were the only samples that showed coexpression of both CD147 and CTSL proteins in low abundance.

CONCLUSIONS

CCs and GCs are the least susceptible to SARS-CoV-2 infection because of lack of the required combination of receptors and proteases (ACE2/TMPRSS2 or CD147/CTSL) in high abundance. The coexpression of ACE2 and TMPRSS2 proteins in the MII oocytes, zygotes, and BLs demonstrated that these gametes and embryos have the cellular machinery required and, thus, are potentially susceptible to SARS-CoV-2 infection if exposed to the virus. However, we do not know whether the infection occurs in vivo or in vitro in an assisted reproductive technology setting yet.

COVID-19: Uncertainties from Conception to Birth

Scientific information on the impact of the new coronavirus (SARS-CoV-2) on the health of pregnant women, fetuses and newborns is considered of limited confidence, lacking good-quality evidence, and drawing biased conclusions. As a matter of fact, the initial impressions that the evolution of COVID-19 was no different between pregnant and non-pregnant women, and that SARS-CoV-2 was not vertically transmitted, are confronted by the documentation of worsening of the disease during pregnancy, poor obstetric outcomes, and the possibility of vertical transmission. The present article aims to compile the data available on the association of COVID-19 and reproductive events, from conception to birth.

Psychological distress and postponed fertility care during the COVID-19 pandemic

Purpose

To evaluate perceptions of delayed fertility care secondary to the COVID-19 pandemic.

Methods

This was a cross-sectional anonymous survey of N = 787/2,287 patients (response rate = 42.6%) from a single academic fertility center. Participants were randomized 1:1 to receive supplemental educational explaining the rationale behind recommendations to delay fertility treatments due to the COVID-19 pandemic. Assessment of well-being was conducted via the Personal Health Questionnaire Depression Scale, the Generalized Anxiety Disorder-7, the Ways of Coping-Revised, the Appraisal of Life Events Scale, and influence of supplemental education on agreement with ASRM COVID-19 Taskforce recommendations and associated distress.

Results

Participants in the education v. no education groups were 35.51 (SD = 4.06) and 37.24 (SD = 5.34) years old, married (90.8% v. 89.8%), had a graduate degree (53.9% v. 55.4%), > 1 year of infertility (73.4% v. 74.4%), and were nulliparous (69.0% v. 72.6%), with moderate to high distress (64.9% v. 64.2%) (ns). Distress was related to age, duration of infertility, and engagement in social support seeking and avoidant coping strategies (P < 0.001). Agreement with recommendations was related to receipt of supplemental education, history of pregnancy loss, and use of cognitive coping (P = 0.001).

Conclusion

Most participants were distressed by the delay of treatments. Supplemental education increased acceptance of recommendations but did not decrease distress. Future treatment delays should include education related to and assessment of understanding of recommendations, and inclusion of mental health professionals in patient care.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10815-020-02023-x.

Fertility patients under COVID-19: attitudes, perceptions and psychological reactions

STUDY QUESTION

What are the perceptions of infertility patients and the factors correlating with their psychological distress, following suspension of fertility treatments during the Corona Virus Disease-19 (COVID-19) pandemic?

SUMMARY ANSWER

Most patients preferred to resume treatment given the chance regardless of background characteristics; higher self-mastery and greater perceived social support were associated with lower distress, while feeling helpless was associated with higher distress.

WHAT IS KNOWN ALREADY

Infertility diagnosis and treatment frequently result in significant psychological distress. Recently published data have shown that clinic closure during the COVID-19 pandemic was associated with a sharp increase in the prevalence of anxiety and depression among infertile patients undergoing IVF and was perceived as an uncontrollable and stressful event. Personal resources play an important protective role in times of crisis, helping reduce levels of distress.

STUDY DESIGN, SIZE, DURATION

This cross-sectional questionnaire study included patients whose fertility treatment was suspended following the COVID-19 pandemic, in a tertiary hospital. The survey was delivered to 297 patients within 12 days at the beginning of April 2020.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The self-administered questionnaire included items addressing: (i) patients' demographic characteristics, (ii) anxiety related to COVID-19 infection risk and level of social support, (iii) patients' perceptions of the new guidelines and description of subsequently related emotions and (iv) two validated scales assessing levels of emotional distress and self-mastery. Multivariate analysis was conducted to assess factors alleviating or increasing emotional distress during the COVID-19 pandemic.

MAIN RESULTS AND THE ROLE OF CHANCE

There were 168 patients who completed the survey, giving a response rate of 57%. Study variables in the regression model explained 38.9% of the variance in psychological distress experienced by patients during treatment suspension. None of the background characteristics (e.g. age, marital status, parity, economic level or duration of treatments) had a significant contribution. Feeling helpless following the suspension of treatments was associated with higher distress (P < 0.01). Higher self-mastery and greater perceived social support were associated with lower distress (P < 0.01). Despite the ministry of health's decision, 72% of patients wished to resume treatment at the time of survey.

LIMITATIONS, REASONS FOR CAUTION

This was a cross-sectional study, thus information about patients' characteristics prior to the COVID-19 pandemic was not available. The length and implications of this pandemic are unknown. Therefore, the ability to draw conclusions about the psychological consequences of the crisis is limited at this point of time.

WIDER IMPLICATIONS OF THE FINDINGS

Personal resources play an important protective role in times of crisis, helping to reduce levels of distress. Study findings suggest that attention should be paid to strengthening and empowering patients' personal resources together with directly confronting and containing feelings of helplessness. In line with the European Society for Human Reproduction and Embryology (ESHRE) guidelines, especially at this time of high levels of distress, it is imperative to offer emotional support to reduce stress and concerns. Furthermore, as the pandemic is stabilizing, resumption of treatment should be considered as soon as appropriate according to local conditions.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by the IVF unit of the Shamir Medical Center. All authors declare no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Melatonin: Multi-Target Mechanism Against Diminished Ovarian Reserve Based on Network Pharmacology

BACKGROUND

Diminished ovarian reserve (DOR) significantly increases the risk of female infertility and contributes to reproductive technology failure. Recently, the role of melatonin in improving ovarian reserve (OR) has attracted widespread attention. However, details on the pharmacological targets and mechanisms of melatonin-improved OR remain unclear.

OBJECTIVE

A systems pharmacology strategy was proposed to elucidate the potential therapeutic mechanism of melatonin on DOR at the molecular, pathway, and network levels.

METHODS

The systems pharmacological approach consisted of target identification, data integration, network construction, bioinformatics analysis, and molecular docking.

RESULTS

From the molecular perspective, 26 potential therapeutic targets were identified. They participate in biological processes related to DOR development, such as reproductive structure development, epithelial cell proliferation, extrinsic apoptotic signaling pathway, PI3K signaling, among others. Eight hub targets (MAPK1, AKT1, EGFR, HRAS, SRC, ESR1, AR, and ALB) were identified. From the pathway level, 17 significant pathways, including the PI3K-Akt signaling pathway and the estrogen signaling pathway, were identified. In addition, the 17 signaling pathways interacted with the 26 potential therapeutic targets to form 4 functional modules. From the network point of view, by regulating five target subnetworks (aging, cell growth and death, development and regeneration, endocrine and immune systems), melatonin could exhibit anti-aging, anti-apoptosis, endocrine, and immune system regulation effects. The molecular docking results showed that melatonin bound well to all hub targets.

CONCLUSION

This study systematically and intuitively illustrated the possible pharmacological mechanisms of OR improvement by melatonin through anti-aging, anti-apoptosis, endocrine, and immune system regulation effects.

Challenges in Urology during the COVID-19 Pandemic

The COVID-19 pandemic has caused a global health threat. This disease has brought about huge changes in the priorities of medical and surgical procedures. This short review article summarizes several test methods for COVID-19 that are currently being used or under development. This paper also introduces the corresponding changes in the diagnosis and treatment of urological diseases during the COVID-19 pandemic. We further discuss the potential impacts of the pandemic on urology, including the outpatient setting, clinical work, teaching, and research.

Assisted reproductive technology, justice and autonomy in an era of COVID-19

Fertility services were significantly curtailed or suspended as an initial response to the coronavirus (COVID-19) pandemic earlier this year, following guidance from European Society for Human Reproduction and Embryology (ESHRE) and the American Society for Reproductive Medicine (ASRM) as well as a General Direction (GD0014) issued by the Human Fertilisation and Embryo Authority (HFEA). It is difficult to argue with triage of medical care and resources in the face of anticipated overwhelming demand, but this situation resulted in considerable distress, as shown by a change.org petition opposing ASRM recommendations, which has gathered over 21,000 signatures to date. Although halting assisted reproductive technology (ART) as the pandemic unfolded was ethical because public health goals superseded individual patient autonomy, the fertility sector now faces a greater challenge balancing ethical considerations in an era characterized by the ongoing threat of COVID-19. This article discusses justice and autonomy in the context of ART, potential conflicts and resolutions.

Patient experiences of fertility clinic closure during the COVID-19 pandemic: appraisals, coping and emotions

STUDY QUESTION

What are appraisals, coping strategies and emotional reactions of patients to coronavirus disease 2019 (COVID-19) fertility clinic closures?

SUMMARY ANSWER

Clinic closure was appraised as stressful due to uncertainty and threat to the attainability of the parenthood goal but patients were able to cope using strategies that fit the uncertainty of the situation.

WHAT IS KNOWN ALREADY

Psychological research on COVID-19 suggests that people are more anxious than historical norms and moderately to extremely upset about fertility treatment cancellation owing to COVID-19.

STUDY DESIGN, SIZE, DURATION

The study was of cross-sectional design, comprising a mixed-methods, English language, anonymous, online survey posted from April 09 to April 21 to social media. Eligibility criteria were being affected by COVID-19 fertility clinic closure, 18 years of age or older and able to complete the survey in English. In total, 946 people clicked on the survey link, 76 did not consent, 420 started but did not complete survey, and 450 completed (48% completion, 446 women, four men).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Overall 74.7% (n = 336) of respondents were residents in the UK with an average age of 33.6 years (SD = 4.4) and average years trying to conceive, 3.5 years (SD = 2.22). The survey comprised quantitative questions about the intensity of cognitive appraisals and emotions about clinic closure, and ability to cope with clinic closure. Open-text questions covered their understanding of COVID-19 and its effect on reproductive health and fertility plans, concerns and perceived benefits of clinic closure, and knowledge about closure. Sociodemographic information was collected. Descriptive and inferential statistics were used on quantitative data. Thematic qualitative analysis (inductive coding) was performed on the textual data from each question. Deductive coding grouped themes from each question into meta-themes related to cognitive stress and coping theory.

MAIN RESULTS AND THE ROLE OF CHANCE

Most patients (81.6%, n = 367) had tests or treatments postponed, with these being self (41.3%, n = 186) or publicly (46.4%, n = 209) funded. Patients appraised fertility clinic closure as having potential for a more negative than positive impact on their lives, and to be very or extremely uncontrollable and stressful (p ≤ .001). Most reported a slight to moderate ability to cope with closure. Data saturation was achieved with all open-text questions, with 33 broad themes identified and four meta-themes linked to components of the cognitive stress and coping theory. First, participants understood clinic closure was precautionary due to unknown effects of COVID-19 but some felt clinic closure was unfair relative to advice about getting pregnant given to the public. Second, closure was appraised as a threat to attainability of the parenthood goal largely due to uncertainty of the situation (e.g., re-opening, effect of delay) and intensification of pre-existing hardships of fertility problems (e.g., long time waiting for treatment, history of failed treatment). Third, closure taxed personal coping resources but most were able to cope using thought-management (e.g., distraction, focusing on positives), getting mentally and physically fit for next treatments, strengthening their social network, and keeping up-to-date. Finally, participants reported more negative than positive emotions (p ≤  .001) and almost all participants reported stress, worry and frustration at the situation, while some expressed anger and resentment at the unfairness of the situation. Overall, 11.9% were not at all able to cope, with reports of intense feelings of hopelessness and deteriorating wellbeing and mental health.

LIMITATIONS, REASONS FOR CAUTION

The survey captures patient reactions at a specific point in time, during lockdown and before clinics announced re-opening. Participants were self-selected (e.g., UK residents, women, 48% starting but not completing the survey), which may affect generalisability.

WIDER IMPLICATIONS OF THE FINDINGS

Fertility stakeholders (e.g., clinics, patient support groups, regulators, professional societies) need to work together to address the great uncertainty from COVID-19. This goal can be met proactively by setting up transparent processes for COVID-19 eventualities and signposting to information and coping resources. Future psychological research priorities should be on identifying patients at risk of distress with standardised measures and developing digital technologies appropriate for the realities of fertility care under COVID-19.

STUDY FUNDING/COMPETING INTEREST(S)

University funded research. Outside of the submitted work, Professor Boivin reports personal fees from Merck KGaA, Merck AB, Theramex, Ferring Pharmaceuticals A/S; grants from Merck Serono Ltd; and that she is co-developer of the Fertility Quality of Life (FertiQoL) and MediEmo apps. Outside of the submitted work, Dr. Mathur reports personal or consultancy fees from Manchester Fertility, Gedeon Richter, Ferring and Merck. Outside of the submitted work, Dr. Gameiro reports consultancy fees from Ferring Pharmaceuticals A/S, Access Fertility and SONA-Pharm LLC, and grants from Merck Serono Ltd. The other authors declare no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A

Navigating assisted reproduction treatment in the time of COVID-19: concerns and considerations

The COVID-19 pandemic has fueled numerous debates in the field of assisted reproductive technology (ART) as the effect of SARS-CoV-2 on pregnancy and infancy is still considered uncharted territory. Various theses and recommendations on what optimal practice is have emerged, as evidenced by surveys, webinars, and recent publications. ART specialists are faced with dilemmas in light of the lack of concrete scientific evidence required to pave the way towards future safe practice. Meanwhile, infertile couples were similarly left in limbo unable to exercise their reproductive autonomy unlike fertile couples-where achieving a pregnancy via natural conception is a matter of decision. ART treatment being classified as non-essential has only recently re-started, facing new challenges while enabling pregnancy at a time of uncertainty. This article highlights matters of bioethical nature to be considered in the ART world at the time of COVID-19 while presenting an all-inclusive critique of the current status. When pursuing pregnancy through IVF treatment during the pandemic, distancing and caution have the lead role in an effort to defend the health of the intended parents and future children. To promote patient autonomy along with our ethical, moral, and legal duty towards our patients, emphasis should be given on ascertaining shared decision-making, and ensuring that an appropriate all-inclusive informed consent is signed prior to initiating any IVF treatment.

Resuming Assisted Reproduction Services during COVID-19 Pandemic: An Initial Indian Experience

BACKGROUND

The pandemic of COVID-19 has affected many countries and medical services including assisted reproductive treatment (ART) have been hampered.

AIM

The study was conducted to assess the preparedness of ART clinics and staff to resume services; patients' reasons to initiate treatment; and key performance indicators (KPIs) of ART laboratories during the pandemic.

SETTING AND DESIGN

This was a semidescriptive, prospective study in two private in vitro fertilization (IVF) clinics in Maharashtra, India, when COVID-19 testing for asymptomatic people was unavailable.

MATERIALS AND METHODS

Time required for replenishing consumables and clinic preparedness to function under "new norms" of pandemic was documented. Infection mitigation measures and triaging strategy were evaluated. KPIs following resumption were analyzed. The Student's t-test was performed for comparing parameters.

RESULTS

Thirty percent of the patients consulted through telemedicine accepted or were eligible to initiate treatment on clinic resumption. Lack of safe transport and financial constraints prevented majority from undergoing IVF, and 9% delayed treatment due to fear of pandemic. With adequate training, staff compliance to meet new demands was achieved within a week, but procuring consumables and injections was time-consuming. Fifty-two cycles of IVF were performed including fresh and frozen embryo transfers with satisfactory KPIs even during pandemic. Conscious sedation and analgesia during oocyte retrieval were associated with reduced procedure time and no intervention for airway maintenance compared to general anesthesia. Self-reported pain scores by patients ranged from nil to mild on a graphic rating scale.

CONCLUSIONS

This study provides practical insight for the resumption of IVF services during the COVID-19 pandemic.