The current outbreak of covid-19 has affected every aspect of our lives, particularly health and social care services. When the lockdown was announced, the Human Fertilisation and Embryology Authority (HFEA) responsible for the licensing of IVF clinics issued directions that all IVF clinics should be closed for new treatments from 23 March, which was a serious blow for women and couples. The Department of Health and Social Care has now announced that fertility clinics can apply to the HFEA to start services during the week commencing the 11 May under strict guidelines. [1]

This is welcome news for couples seeking treatment for infertility, most of whom will have been in contact with their clinics during the lockdown to seek support and reassurance. 

An important point of reassurance for women trying to conceive naturally and those seeking fertility treatment is that at present there is no known increased risk to her or her fetus from covid-19 if pregnancy occurs. The recent RCOG update on covid-19 states: “Based on the evidence we have so far, pregnant women are still no more likely to contract coronavirus than the general population.” [2] For this reason, NHS England have not advised women to avoid pregnancy by taking contraception during the pandemic. 

The covid-19 crisis has been a “wake up” call to the IVF sector to prioritise the safety of women undergoing IVF treatment and ensure that emergency hospital admissions are kept to a minimum in order to alleviate the burden on the NHS. IVF entails stimulating the ovaries with daily injections of Follicle Stimulating Hormone to mature multiple oocytes in each ovary, which are collected under conscious sedation as an outpatient procedure in a dedicated theatre. The leading cause of unplanned hospital admission is severe ovarian hyperstimulation syndrome (OHSS), which can infrequently require ICU care, but this risk is considerably reduced if modern low ovarian stimulation protocols are used.

We believe the advice should be to minimise the risk of severe OHSS when lockdown is ended by recommending low dose protocols and closely monitoring treatment cycles to keep oestradiol levels and the number of mature follicles low. This, we believe, could minimise the risk of hospital admissions from OHSS. We would not support routinely maximising the number of oocytes at egg collection by prolonging the duration of stimulation for a planned agonist trigger and “freeze all embryos” in high responders as the agonist trigger can reduce, but does not eliminate moderate or severe OHSS. Encouragingly, the latest studies show that the success rates with lower stimulation are comparable to conventional or high stimulation protocols, so the change should be acceptable in the post lockdown era. [4]

Hospital admission is also slightly increased from complications of bleeding and infection following egg collection procedure. In a recent large review by Levi-Setti et al (5) of 12 615 patients, admission to hospital occurred in 0.56% of patients. [5] The major risk factors being high number of oocytes retrieved, long duration of procedure, and inexperience of the surgeon. Of the hospital admissions, hemoperitoneum was responsible for more than half of the admissions, which is not surprising as a high number of oocytes retrieved from overstimulated ovaries is associated with bleeding due to increased ovarian vascularity and vascular endothelial growth factor (VEGF) levels. This is another reason for employing lower stimulation in IVF cycles after lockdown for fewer oocytes collected may also mean fewer bleeding complications, such as haematoma and pelvic infection. 

Strict guidelines to follow physical distancing and safety measures must be put in place to protect patients, staff, and the public. Video or telephone consultations should be used to reduce travel and clinic appointments. There should be strict adherence to physical distancing rules by minimising the number of patients attending and avoiding too many people in the waiting room at any one time. There will be strict screening of patients over the phone and avoidance of appointments for patients who have any symptoms of covid-19 or anyone in the family with symptoms. Staff should wear face masks and appropriate personal protective equipment during patient visits and procedures. It is important to reduce monitoring scans and appointments. The HFEA is currently working with the sector to establish safe working practices. 

Infertility is classified as a disease and IVF is an essential medical treatment for many women and couples. It is good to see that our government has recognised the distress faced by many fertility patients and has acted swiftly to re-start fertility services. Saving lives and creating lives are not mutually exclusive and they can both be achieved safely and responsibly now that the IVF lockdown has been lifted

Geeta Nargund is the lead consultant for reproductive medicine at St George’s Hospital and medical director of Create Fertility. 

Stuart Campbell is the emeritus professor at St George’s Hospital Medical School and director of ultrasound at Create Fertility. 

Conflict of interests: Create Fertility is a private clinic, which provides self funded treatment as well as working with NHS CCGs. 

References:

1. https://www.gov.uk/government/news/health-secretary-welcomes-reopening-of-fertility-services

2. Coronavirus (COVID-19) RCOG update 17 April 2020

3. Clinical Characteristics of pregnant women with COVID-19 in Wuhan, China; Chen L, Li Q, Zheng D et al; New England Journal of Medicine, 17 April 2020

4. Mild stimulation for in vitro fertilisation: Nargund G, Datta A and Fauser BCJM; Fertility and Sterility 2017

5. Appraisal of clinical complications after 23,827 oocyte retrievals in a large assisted reproduction program: Levi-Setti PE, Cirillo F, Scolaro V et al, Fertility and Sterility; 2018