Guidance on Fertility care and surgery during COVID-19 | 19 March 2020

Introduction

There are concerns about the current COVID-19 situation and whether fertility treatment should be stopped. We are also aware that there are different opinions amongst professional bodies on the continuation or not of fertility treatment and elective surgery. Those professional bodies that recommend stopping fertility treatment, do that simply as a precautionary measure and not because of the inherent risk of fertility treatment on the propagation of COVID-19. ESHRE and ASRM have recommended considering stopping fertility treatment. The Australian Fertility Society has recommended on 19 March that there is no evidence to recommend contraception or cessation of attempts to conceive, either unassisted or assisted. It is, however, prudent to consider the postponement of fertility treatment.

Based on recent publications by the Lancet medical journal, Translational Pediatrics and statements from the CDC:

  • At the moment, pregnant women do not appear to be more severely unwell if they develop COVID-19 infection than the general population. It is expected that the large majority of pregnant women will experience only mild or moderate cold/flu-like symptoms.
  • For women who are trying to conceive, or who are in early pregnancy, there is no evidence to suggest an increased risk of miscarriage with COVID-19.
  • Furthermore, there is also no evidence that the virus can pass to the developing fetus (vertical transmission).
  • Newborn babies and infants do not appear to be at increased risk of complications from the infection.
  • Undergoing fertility treatment does not increase the risk of contracting COVID -19 (beyond the risk that any individual takes by venturing into public space).
  • Young healthy women (typical of women undergoing fertility treatment) are at lower risk of developing the severe disease if affected by COVID -19.
  • Women who have to sever COVID-19 infection during pregnancy could be at increased risk of miscarriage or early labour.

Recommendations

  • All standard precautions and preventative measures as stated in the National Department of health should be strictly adhered to.
  • Patients who are currently in the treatment cycle and are asymptomatic and have not had contact with someone diagnosed with COVID-19 should continue with the treatment as planned if they so wish.
  • Patients who want to start a treatment cycle should be asymptomatic and should not have a positive contact history with someone diagnosed with COVID-19. They should be informed that we do not have much information on the future impact of fertility treatment on COVID-19 propagation.
  • Patients who are currently on the treatment cycle and then develop symptoms or come into contact with someone diagnosed with COVID-19, should NOT come to the clinic. They must inform the clinic immediately. The local medical authority dealing with COVD-19 should also be informed.
  • All nonessential travels should be avoided during the fertility treatment cycle and beyond.
  • Freeze all cycles and cancelling initiation of new cycles is an option that clinics may opt for.

Social Distancing

  • Informed consent should be taken electronically using telephone/Skype and the consent must be signed remotely.
  • Staggering arrival times for appointments (no more than 1 patient at a time in the waiting rooms/ allow at least 2-meter space between patients).
  • Patients should come alone to routine monitoring visits thus limiting accompanying persons and partners. No children should be allowed to accompany the patients.
  • Limit consultation time to less than 10 minutes per patient wherever possible.
  • Limit the number of consultations per cycle.
  • Patients should be encouraged to leave the fertility clinic ASAP.
  • Intensify the cleaning and disinfection of common spaces in fertility clinics according to relevant recommendations.

Patients Requiring Surgery

  • Surgical procedures should be considered not based solely on COVID associated risks, but rather on the assimilation of all available medical and logistic information.
  • All elective, non-essential surgery should be postponed, however, fertility-enhancing, and fertility preservation surgery should not be delayed in qualifying patients.
  • Patients diagnosed with COVID-19 and those who had contact with persons diagnosed with COVID-19, should not undergo any fertility surgery or procedure.
  • Informed consent should be taken remotely, and the consent forms must be signed and then sent to the practice.
  • The Pre-Operative screening questionnaire should be sent to all patients requiring elective surgery as a means of triaging patients. The SASA pre-operative screening tool can be used in this regard.
  • Where possible, procedures should be performed in an office setting rather than a theatre.

Fertility Clinic Staff

  • Must take all necessary precautions including decontamination of work services, ultrasound machines and probes.
  • All staff members and patients must have their skin temperature measured using an infrared thermometer or a similar device. Those whose skin temperature is 37,5- 38 degrees or more, should not be allowed into the clinic but rather referred for COVID-19 testing and self-isolation.
  • Alcohol-based decontamination should be provided to all patients as they enter the clinic and when they leave the clinic.
  • Staff members or patients with a high likelihood of having COVID-19 because of symptoms (fever and/or cough, shortness of breath) or exposure (exposure within 2 meters of a confirmed COVID-19 patient and within 14 days of onset of symptoms, or a person with a positive COVID-19 test result) should self-isolate and not access clinical spaces until they have been confirmed to be COVID-19 negative.
  • The COVID-19 situation is evolving rapidly and the SASREG board will review these guidelines on a weekly base. We will follow all the advice or orders from our national and local governments.

Dr Jack Biko, Dr Nomathamsaqa Matebese, Dr Sagie Naidoo, Dr Victor Hulme, Dr Gerhard Hanekom, Dr Yusuf Dasoo, Dr Chris Venter, Mrs Gloria Raidani, Mr Gerhard Boshoff, Dr Zozo Nene, Dr Igno Siebert, Dr Abri de Bruin, Mrs Mandy Rodrigues, Prof Silke Dyer and Dr Sulaiman Heylen.


References

  • American College of Surgeons: COVID – 19: Guidance for Triage of Non-Emergent surgical Procedures, Online March 17, 2020.
  • HFEA Coronavirus (COVID-19) guidance – current status as of 18 March 2020.
  • ASRM: Patient Management and Clinical Recommendations During the Coronavirus (COVID-19) Pandemic – As of March 17, 2020.
  • ESHRE: Coronavirus Covid-19: ESHRE statement on pregnancy and conception, 14 March 2020.
  • Centers for Disease control: Coronavirus Disease 2019
  • Royal College of Obstetricians and Gynaecologists. Coronavirus (COVID-19) Infection in Pregnancy: Information for healthcare professionals. 2020 18 March.
  • Chen H, Guo J, Wang C, Luo F, Yu X, Zhang W, et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. Lancet. 2020;395(10226):809-15. Zhu H et al. Transl Pediatr 2020.
  • Liu Y, Chen H, Tang K, Guo Y. Clinical manifestations and outcome of SARS-CoV-2 infection during pregnancy. J Infection 2020.
  • Liu D, Li L, Wu X, Zheng D, Wang J, Yang L, Zheng C. Pregnancy and Perinatal Outcomes of Women With Coronavirus Disease (COVID-19) Pneumonia: A Preliminary Analysis. AJR American journal of roentgenology 2020.
  • Wang X, Zhou Z, Zhang J, et al. A case of 2019 Novel Coronavirus in a pregnant woman with preterm delivery. Clinical Infectious Diseases 2020.
  • Adams JG, Walls RM. Supporting the Health Care Workforce During the COVID-19 Global Epidemic. JAMA. Published online March 12, 2020. doi:10.1001/jama.2020.3972
  • Favre G, Pomar L, Qi X, Nielsen-Saines K, Musso D, Baud D. Guidelines for pregnant women with suspected SARS-CoV-2 infection. Lancet Infect Dis. 2020.
  • The Fertility Society of Australia: Statement of the Covid-19 FSA Response Committee (19 March 2020).
  • World Health Organization. Coronavirus disease 2019 (COVID-19) Situation Report – 58. 2020 18 March.