ESHRE’s Updates - Assisted Reproduction and COVID-19
Covid 19 is continuing to spread and ESHRE reaffirms its recommendation to follow local and national government advice, particularly national daily updates.
On March 14, 2020, as a precautionary measure ESHRE advised that “all fertility patients considering or planning treatment, even if they do not meet the diagnostic criteria for COVID-19 infection, should avoid becoming pregnant at this time”. Read the full statement republished on March 19: Coronavirus Covid-19: ESHRE statement on pregnancy and conception
Current Evidence
The available data on the exact effects of COVID-19 on fertility and pregnancy is scarce. Current statements released by the Centers for Disease Control and Prevention (CDC) in the USA and others in Europe in relation to SARS-CoV-2 infection, has suggested that there is no clear evidence of any negative effect on pregnancy.
Despite this reassurance, we collectively as a population need to be conscious that viral infections can be more severe for pregnant women and understand that some of the medications used in virus-infected patients may not be recommended during pregnancy.
Reported Pregnancy Outcomes
A recent study on 38 pregnant women with Covid 19 revealed that unlike coronavirus infections of pregnant women caused by SARS and MERS, in the 38 pregnant women observed, COVID-19
did not lead to maternal deaths.
was not transmitted to the fetus in the womb (there were no confirmed cases of intrauterine transmission of SARS-CoV-2 from mothers with COVID-19 to their fetuses. All neonatal specimens tested, including in some cases placentas, were negative by rt-PCR for SARS-CoV-2.
At this point in the global pandemic of COVID-19 infection there is no evidence that SARS-CoV-2 undergoes intrauterine or transplacental transmission from infected pregnant women to their fetuses.
There has however been a small case series that reported adverse outcomes such as premature rupture of membranes and preterm delivery. There has also been a report of 5 cases of neonatal SARS-CoV-2 infection and IgM (and IgG) antibodies against the virus found in the new born babies blood 2 hours after birth (3 cases). Antibodies are produced when exposure has been made and so although infection at delivery cannot be ruled out, IgM antibodies usually do not appear until 3 to 7 days after infection. It is unclear whether these data are indicative of vertical transmission of SARS-CoV-2.
In general, the data on pregnancy outcomes, although reassuring, only report small numbers and must be interpreted with caution. Furthermore, as reports mainly refer to infection in the third trimester, there is no information on the possible effect of SARS-CoV-2 infection on pregnancies in their initial stages.
ESHRE’s Guidance
'As per ESHRE-
In view of the above considerations and outcomes reported in cases of other coronavirus infections (such as SARS and MERS), 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 contributing additional stress to a healthcare system that in many locations is already overloaded.
ESHRE advises that assisted reproduction treatments should not be started at present for the following reasons:
- To avoid complications from assisted reproduction treatment and pregnancy
- To avoid potential SARS-CoV-2 related complications during pregnancy
- To mitigate the unknown risk of vertical transmission in SARS-CoV-2 positive patients
- To support the necessary reallocation of healthcare resources
- To observe the current recommendations of social distancing.
In cases of urgent fertility preservation in oncology patients, the cryopreservation of gametes, embryos or tissue should still be considered.
For those patients having started assisted reproduction treatment at the present time, elective oocyte or embryo freezing for later embryo transfer (freeze-all) is recommended.
Any risk of viral contamination to gametes and embryos in the IVF laboratory, either from infected patients or professionals, is likely to be minimal (if at all) because the repeated washing steps required for the culture and freezing protocols will result in a high dilution of any possible contaminants.Even with no specific data available, it is assumed that sperm, oocytes and embryos do not have receptors for SARS-CoV-2 and are unlikely to be infected. Furthermore, the zona pellucida represents a high level of protection for oocytes and embryos. Regardless of the biological details, it is prudent to defer all elective fertility-promoting medical procedures, primarily to maintain social distancing and protect any and all medical resources.
Since many uncertainties remain about the effects of SARS-CoV-2 infection on ART and pregnancy, and despite different approaches among treatment centres and countries, ESHRE currently considers any risk too high when similar treatments can be performed at a later date.
Healthcare professionals and clinics should remain available to provide supportive care , psychological support and clinical advice to their patients, preferably via online consultation. As always, good clinical and laboratory practice is strongly recommended by ESHRE to guarantee safety for processed tissues and cells, professionals and patients.
ESHRE will continue to monitor the scientific literature and this statement will be regularly updated.
Resources
Cochrane Gynaecology and Fertility Group - An up-to-date overview of data extracted from all published reports on pregnancy and neonatal outcomes in women with confirmed COVID-19
European Society of Human Reproduction and Embryology (ESHRE)
Coronavirus Covid-19: ESHRE statement on pregnancy and conception
American Society for Reproductive Medicine (ASRM)
Patient Management and Clinical Recommendations During The Coronavirus (COVID-19) Pandemic.
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