Transcription:
IVF and The Safety Precautions Taken During COVID-19

Melanie Cole (Host):  Welcome to Back to Health, your source for the latest in health, wellness and medical care, keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine. I’m Melanie Cole and today, we’re discussing IVF and the safety precautions taken during COVID-19. Joining me in this panel discussion are Dr. Dan Goldschlag and Dr. Joshua Stewart. They are both Assistant Professors of Reproductive Medicine at Weill Cornell Medicine and Assistant Attending Obstetrician and Gynecologists at New York Presbyterian Weill Cornell Medical Center.

Gentlemen, thank you so much for joining us today and Dr. Goldschlag, I’d like to start with you. How have you and your team been evolving care for your patients during this pandemic? Tell us a little bit what happens to women that are in mid-treatment or mid-cycle or if a woman contracts COVID while in treatment. Kind of give us the rundown on what’s been happening and what you’ve seen.

Dan Goldschlag, MD (Guest):  Sure. So, I think this all started evolving for us back towards the end of January, beginning of February when we were watching what was going on overseas in China. Most of us thought it was inevitable that at some point, the virus would spread but no one knew exactly when and to what extent. Somewhere in the middle of February, we started to elicit travel history so that was really the first maneuver that we were trying to do to understand risk and how COVID was going to effect the New York area and our practice. We would elicit questions where patients had been before, or had they been spending time with patients who had traveled in areas that already had prevalence of disease.

Towards the end of February, we also started instituting temperature checks looking for any patients that had evidence of any of the symptoms and were febrile to try to pick up patients that may have COVID in order to protect patients, staff and maintain good quality of care. It wasn’t until the second week in March that we stopped doing fertility care and that was mainly because our here at New York Presbyterian Hospital in the system, the healthcare system was getting overextended and there was a decision not to do any nonessential care at that point. Fertility care was deemed nonessential.

A few days later, both ASRM, New York State began to shut down on essential care so that followed soon after we had made an independent decision already at that point. So, during that time period, we did continue to do care for our cancer patients who were undergoing chemotherapy who needed to freeze eggs beforehand. We did complete cycles for patients that were in the middle of cycle. But we stopped initiating any new cycles. That was a closure of probably about six to seven weeks almost to about early May. Towards the mid part of April, New York State redefined fertility care as essential medical care so that opened up opportunities to restart things. And we were up and going probably about two weeks later doing just about everything that we had been doing all along but obviously with significant changes in how we were practicing.

In terms of changes, the whole issues with social distancing and universal precautions, avoiding the ability for respiratory illnesses had the patients wearing masks, providers wearing masks were all implemented to try to provide a safe way for couples to go through treatment. That process has continued up to date and as we’ve learned more about the disease, we’ve been able to ensure that we’re preventing it better. Currently, today when a patient walks in, travel history is still elicited, symptoms are still taken. In addition to that, we make sure that proper PPE is being used and we’ve redesigned our waiting room so that patients register and are quickly put into an individual exam room, so isolation is happening.

We’ve had to make some rough decisions also. Partners had always been welcome and were coming in with patients, now we are trying to limit the volume of flow to protect patients from each other. So, for a lot of the procedures, couples don’t join patients and any type of procedure that can be done on the phone is done through a video visit which has been pretty successful. Josh, anything you want to add in?

Joshua Stewart, MD (Guest):  No, I think that was great. One thing I will add is that we do know in our practice specifically, that patients that are undergoing IVF or invitro fertilization, are the patients that are most frequently in our offices. And so as Dr. Goldschlag alluded to, as we learn more about how the disease is transmitted, and we learned that many patients may be asymptomatic carriers that were not picked up on traditional screening methods; we also instituted universal screening by COVID swabbing, by nasopharyngeal swabs both at the beginning of starting an IVF cycle and prior to the egg retrieval for enhanced detection of patients that may be not picked up on traditional screening methods. And we’ve seen that that’s been very successful and also very reassuring to everyone that – our additional data that we are looking at right now and getting ready to publish actually has shown that just under one percent of patients or a very low percentage of patients may be asymptomatic carriers and it may not be appropriate for them to proceed with treatment until they’ve cleared the virus.

Host:  Well thank you for that answer. So, Dr. Stewart, I’d like to expand for a moment on that. When you are advising someone to see a fertility specialist, especially now, when does that happen? What does that discussion look like and how do you discuss with a woman the risks, if any, of complications for fertility treatments during this pandemic? Or if they do test positive for COVID-19, do you then recommend they discontinue treatment or don’t start at all? Tell us how that all works together.

Dr. Stewart:  Yeah, absolutely. It’s a great question and obviously something that’s on everybody’s mind. I think that we all agree that – our advice for when somebody should see a fertility specialist as far as timing is concerned doesn’t really change now versus pre COVID pandemic. We would still use the same sets of guidelines to recommend evaluation and potentially initiating treatment with a fertility specialist. And there’s a wide range of how that is applicable to the individual. For instance, for some patients, waiting after six to 12 months of trying on their own or timing intercourse at home with home ovulation prediction kits and those sorts of things may be appropriate whereas for other patients with certain conditions like PCOS or polycystic ovarian syndrome or amenorrhea or absence of periods; it may be appropriate for them to be seen by a fertility specialist much sooner.

A lot of the patients that we end up seeing we work with in conjunction with their general obstetrician and gynecologist. And for instance, we have great relationships with lot of general OB-GYNs both at Cornell and throughout the city that we work with very closely that may refer patients to be seen by one of our fertility specialists here at Weill Cornell. We really like to focus as we always have on a very individualized approach with patients. And Dr. Goldschlag mentioned with looking at patients’ travel history and whether or not they’ve tested positive for COVID since the pandemic started or have had antibody testing and whether or not they are still symptomatic can really help us dictate when it’s appropriate to move forward with fertility treatment and pregnancy.

Dr. Goldschlag:  One thing I would add to that is seeing a fertility specialist when a couple isn’t getting pregnant is important. But sometimes initiating treatment is not absolutely necessary. So, often patients who come in will find out there are simple things that can be done, fertility treatment may not be appropriate at this point. And some couples once they go through evaluation and assessment who have good ovarian function and it’s not urgent to become pregnant will actually decide to put things on hold while they are watching the situation. We’re comfortable in terms of moving forward and providing care but we’re also watching and listening to patients and want to provide the care when they are ready for it.

Dr. Stewart:  A couple of the physicians from our group recently published a study that sort of alludes to what Dr. Goldschlag was saying. This was actually research that was initiated before the pandemic, but I think has been very reassuring to a lot of individuals and couples that are nervous about reinitiating or initiating formal treatment cycles that for many individuals, delaying even up to six months may not really have a significant impact on their treatment. And so for patients that for instance are maybe isolating outside of New York City, and aren’t able to be back in person for in patient visits. They may be able to be reassured that delaying for a few months may not have a significant impact on their treatment.

Host:  Well that’s really important information for couples that are considering fertility treatments at this time to know. Thank you for that and Dr. Goldschlag, what procedures are you performing now? What have you brought back and what services are available and considered really important during this pandemic?

Dr. Goldschlag:  So, in New York State, and regulations are different from state to state; fertility care is deemed essential. So, that has allowed us to offer the full gamut of services that we normally provide. So, couple looking for IVF, or couples looking for artificial insemination or medicated cycles for ovulation induction; those are all things that we’re actively doing. In addition to that, we are doing egg freezing in terms of from a fertility preservation point of view for patients who aren’t ready to be pregnant yet but feel it’s in their best interest to freeze eggs now when they are younger. So, pretty much anything that we have been doing pre-pandemic, we’re doing now. Caveat to that is that we’re watching. Watching the situation. We get daily reports from the governors office and if things do change, then there’s always that potential that we cutback.

Host:  So, Dr. Stewart, let’s talk about the pros and cons of resuming treatment right now and are there national recommendations going on with this? What do we know and what are you thinking that you want listeners to know about these pros and cons when they are considering all of this? It’s a lot to think about.

Dr. Stewart:  Yeah, absolutely. This is something that is at the front of all of our minds and one of the things that we sort of touched upon before is that we are really trying to restructure the logistics of our practice and how we deliver care to really make it accessible with social distancing recommendations and with the current pandemic. So, one of the things that we’re doing is trying to utilize Telehealth as much as we possibly can. And one thing that I think is helpful for patients to know is that even the initial consultation can now be done over Telehealth or video visit. And so, initiating treatment in the fertility setting, a lot of it starts with that first appointment and meeting either in-person of over the video visit with a fertility physician and taking a detailed medical and surgical history as well as either pregnancy or obstetrical history and fertility history. And that first visit really helps delineate what the next steps need to be. Eventually, we do need an in-person exam for bloodwork and ultrasound and then talking through the various options that may be appropriate for an individual or couple.

I think that sort of leads into your question about what are the benefits or resuming care now and I think one of those things is for many couples, the initial evaluation or workup may take several weeks and so I think that in fertility medicine, starting earlier is always advisable. And so there are many things that can be done right now during the pandemic that are safe and accessible to patients. And that’s one of the things that we’ve been working on for the past several months. We’re even seeing lots of patients that are isolating or quarantined outside of New York City and we’re able to do the initial consultation over Telehealth visits and can actually in many situations set up some of the testing to be done remotely. We’ve been able to arrange for at home phlebotomists to come and arrange for blood testing or for the patients to get blood testing or things like semen analysis at labs locally and then forward the results to us.

Obviously, this needed to be taken on a case by case basis and it’s ultimately a plan that’s developed with the physician and the patients and something that makes everybody feel comfortable. There’s a lot of patients that are feeling very anxious about reinitiating care and treatment but a lot of patients are also very anxious about delaying their fertility care or delaying pregnancy and so, one of the benefits would be that we have resumed full fertility treatment care and we’re doing so in a way that is safe for patients.

Dr. Goldschlag:  Often, by going through these steps and engaging the system and learning about it we find that patients are much more comfortable to come into the office. So, once they learn about what’s going to go on, and how things have changed in the office and what we are doing to protect patients; a lot of the fears go away, and most patients are very comfortable with moving on with the process.

Host:  Well it certainly is encouraging. So, Dr. Goldschlag, I think a big question on everyone’s mind is can COVID-19 be transmitted with fertility treatments? Do we need to quarantine those frozen sperm if someone does oncofertility treatments as you mentioned before any of these kinds of things embryos, from COVID-19 patients, can it be transmitted in utero? What do we know about this?

Dr. Goldschlag:  Part of the big concerns often patients have is just walking into a medical facility, walking through the hallways of a hospital that’s treating potentially COVID positive patients. What risk that represents to them. And I think we’ve come a far ways from mid-March where we’ve learned that this is a respiratory disease and that if we really do stick with the social isolation, appropriate distancing and wearing masks; that those risks become very, very low. Now in terms of their fertility treatment itself, when a patient comes into the office; the rooms are sanitized between patients and patients are really isolated so they are just dealing with their provider and their nurse. So, the risks become quite low if at all from a COVID point of view.

Semen itself, has been shown to have the virus present potentially in men even after they’ve already recovered from their disease. The natural root of contracting COVID is the respiratory illness. It’s not through blood and it wouldn’t be through vaginal. So, the risk from sperm in general, would probably be very, very low and hard to quantitate. Right now, there are no protocols for quarantining sperm or quarantining oocytes. Sperm and eggs are washed before they are used and probably very safe and very, very low risk. And the same thing would be for embryos.

Host:  Dr. Stewart, why don’t you expand on that for us by telling the listeners what they are giving up from a fertility perspective, if they delay for a few months and speak about evidence of vertical transmission, mother to fetus because I think that that’s a question on everybody’s minds.

Dr. Stewart:  I think that as we kind of spoke about a little bit earlier, there’s very good evidence and patients should feel reassured that in the vast majority of situations; delaying fertility treatment for a few months will not have a significant impact on their overall outcome. So, certainly for patients that have special circumstances surrounding the pandemic or are anxious about reinitiating care; they should be reassured that staying engaged with their provider over the phone or through Telehealth visits is an excellent way to stay involved with their care but if they are delaying actual formal treatment for a few months that it should not have an overall significant impact on their end outcome.

Certainly, right now as far as for patients that are not affected with COVID-19, there’s no recommendations from the American Society of Reproductive Medicine that patients that are not affected by COVID should be delaying pregnancy or even a question that’s come up actually because it had been discussed during the Zika pandemic that there’s no recommendation certainly that pregnancy should be terminated or avoided during the pandemic at this time. Which is obviously very reassuring to patients.

The last piece I think was about the impact of COVID-19 virus in pregnancy and about vertical transmission or transmission of the virus from mother to fetus. The baseline response on this is that we have very little information right now and we’re continuing to gather research both here at Cornell, nationwide and worldwide about the impact of COVID-19 on pregnancy and on fetuses and babies that are delivered. A couple of things to note is that the information and research that has been published, very limited, the sample size is very small and the majority of that has been done in the second and third trimester of pregnancy.

So, of paramount concern to both the medical community and patients is what happens in pregnancy affected by COVID-19 early in the first trimester of pregnancy? And we’re actually conducting and enrolling patients here at Cornell looking at that specifically and so obviously, we will have more information as things move forward. To touch upon that, there has not yet been any definitive evidence of vertical transmission from mother to fetus yet. There have been reported cases of infected newborns which fortunately have all had very good recoveries, but the route of infection is clear whether or not that happens through an infected mother around the time of delivery through respiratory droplets or whether it was actually due to transmission in utero from mother to fetus.

Dr. Goldschlag:  Some studies out there that have looked pretty well at amniotic fluid, cord blood and they’ve never found any evidence of COVID. Like you were saying, there’s a real chance that this COVID viruses that have been seen in these neonates have been contracted in the traditional route through respiratory exposure.

Host:  It’s so interesting and what we’re seeing today with people worrying about all of this, I thank you both for really clearing some of this up and giving us a lot of encouragement. I’d like to give you each a chance for a final thought. So, Dr. Goldschlag, please tell us what you would like patients to know about the safety and the care that you are offering them and what you want them to know as they consider fertility treatments at this time.

Dr. Goldschlag:  So, I think if infertility was on a patient’s mind before the pandemic; it should still be something that’s addressed during the pandemic and post-pandemic. It will addressed potentially in different ways for different patients. So, for example, a patient may not be ready to get pregnant given what’s going on, but she may be ready to make eggs or embryos and freeze them now and feel more comfortable about putting things on hold. So that can be a solution for some patients.

But in general, for most patients, it’s going to be a safe and effective solution in terms of moving forward and we encourage patients to call, engage the system. Telehealth has been a great way to learn more about it and decide whether or not now is the appropriate time.

Host:  And Dr. Stewart, last word to you. How are you helping your patients remain calm and manage the emotional challenges of this pandemic along with the challenges of going through IVF at such an uncertain time? Because it certainly can be a stressful situation to go through fertility treatments but right now, is unprecedented. So, what are you telling your patients about managing that stress and helping them with those emotional challenges?

Dr. Stewart:  I think that first just acknowledging as you said that this is a very stressful time and often fertility in itself, and fertility issues can be a significant life stressor at baseline. And so, when it’s exacerbated by everything that’s going on in the world right now, we often know that those fears and anxieties are compounded and so, we’re really engaging patients in that conversation from the very first visit through every follow up visit and every ultrasound and bloodwork result and I think that patients are finding it very comforting to just acknowledge those fears and anxieties. I think as far as engaging with the healthcare system again in the COVID-19 pandemic, I think once patients are in the office and they see how we’ve restructured the waiting room, the screening procedures, the increased level of testing, the other safety precautions that we’re taking with personal protective equipment and social distancing; I think that they are feeling much more reassured than just anticipating the anxiety of what it might be like.

And lastly, you alluded to the mental health component and that’s something that we’ve been very intentional about addressing and one of the things that we’re very lucky at Weill Cornell Reproductive Medicine is that we work with a team of reproductive psychologists with all of our patients and they are an integral part of our healthcare team and they’ve actually started offering virtual support sessions for patients to address and discuss some of the special unique issues about undergoing fertility treatments. They have offered individual follow ups after those virtual support classes that have been very helpful to a lot of our patients.

Host:  Thank you so much, gentlemen, for coming on and really reassuring listeners about the safety precautions, what you’re doing to keep couples that are going through fertility treatments safe in the community and really how the process works now. Thank you again, for joining us.

And that concludes today’s episode of Back to Health. We’d like to thank our listeners and invite our audience to download, subscribe, rate and review Back to Health on Apple Podcasts, Spotify, Google Play Music. For more health tips please visit www.weillcornell.org and search podcasts. And parents, don’t forget to check out our Kids Health Cast. I’m Melanie Cole.