Joint IFS-ISAR-ACE Recommendations on Resuming/Opening up Assisted Reproductive Technology Services

Cairo Consensus on Accreditation as the Basis for Future-Proofing the ART Laboratory

An international consensus meeting was convened to discuss globally applicable strategies for 'future-proofing' ART laboratories. The central theme was how the application of the foundational principles of laboratory accreditation enables any centre to create an ethos and framework that will support future-proofing in all regards. Discussions focussed on ART laboratory services from egg retrieval and semen specimen receipt to embryo transfer, as well as pertinent cryobanking activities. Issues related to whether ART treatment should be considered an essential service, overall clinic operations, general patient care, and the provision of clinical treatment, were not included as they fall under the purview of physicians and public health authorities. This report details the 16 core consensus points reached, which are supported by extensive practical recommendations that cover the gamut of ART laboratory operations.

Impact of COVID-19 Pandemic on Clinical and Embryological Outcomes of Assisted Reproductive Techniques

Background:

The emergence of the COVID pandemic unfolded a series of precautions and dilemmas and the complete suspension of health services. With the gradual emergence of data showing near minimal effects of the virus on pregnancy, Assisted Reproductive Techniques (ART) services were gradually resumed following guidelines and advisories.

Aim:

The purpose of this study was to detect the COVID positivity rate in women undergoing ART treatment during the COVID pandemic and compare clinical and embryological outcomes to the ART cycles performed in the pre-COVID era.

Study Setting and Design:

This was a retrospective cohort study of all women undergoing controlled ovarian stimulation, followed by a fresh or frozen embryo transfer (ET) between 1st October 2019 and 31st March 2020 (control group) and between 1st April 2020 and 31st September 2020 (study group) at Nova IVF Fertility Clinic, Ahmedabad.

Material and Methods:

The study group underwent ART during the first wave of COVID-19 pandemic in India and when gradual unlocking of facilities including ART was advised as per the national ART advisory by the ICMR in December 2020. The outcomes were compared with the control group (cycles in pre-covid time).

Statistical Analysis:

Statistical analysis was performed in SPSS (v25.0) and included Mann-Whitney U, Fisher's exact and Pearson Chi-square as appropriate. Values of P < 0.05 were considered statistically significant.

Results:

A total of 367 in vitro fertilisation (IVF) stimulations were initiated. A total of 342 retrievals and 606 ETs (171 fresh and 435 frozen) were completed during the study period with a COVID positivity rate of 6.8% (25/367) amongst fresh and 3.9% (18/453) amongst frozen ETs, respectively; the PR and IR in the study group was similar to the control group (47.6 vs. 55.1 P = 0.4 and 68.7 vs. 66.4; P = 0.52, respectively). The maternal complication rates were similar in both groups with a COVID positivity rate of 10.2% (23/225) and 1 maternal death in the study group. The live birth rates were similar.

Conclusions:

We did not find a noteworthy difference in the clinical and embryological outcomes in the IVF cycles conducted in the COVID era as compared to the pre-COVID time. Thus, with adequate precautions and safety measures, ART services conducted during the COVID pandemic have comparable birth outcomes and can be safely advocated.

The Impact of Postponed Fertility Treatment on the Sexual Health of Infertile Patients Owing to the COVID-19 Pandemic

Background: With the onset of the coronavirus disease 2019 (COVID-19) pandemic at the beginning of 2020, all non-essential medical treatments were suspended, including fertility treatments. As a unique group in society, patients with infertility may be more sensitive and vulnerable in the face of pressure and crisis. However, to the best of our knowledge, there have been no reports on the influence of postponed fertility treatment on the sexual health of infertile patients owing to COVID-19. Therefore, this study aimed to investigate whether postponed fertility treatment resulting from COVID-19 affects the sexual health of patients with infertility.

Methods: A total of 1,442 participants were included for analysis in this large-scale study. Those with postponed fertility treatment were categorised as group A (n = 474), whereas those whose fertility treatment was not delayed were in group B (n = 968). The sexual health and psychological well-being were compared between the two groups.

Results: The total Female Sexual Function Index score and five domains of female sexual function (arousal ability, vaginal lubrication, orgasm, satisfaction, and coital pain) were significantly lower in group A than those in group B (p < 0.05). The International Index of Erectile Dysfunction score and Premature Ejaculation Diagnostic Tool score were significantly higher in group A than those in group B (p < 0.05).

Conclusions: Delaying fertility treatment obviously affects patients' sexual and mental health. Through a structural equation model, we observed that postponed fertility treatment mediates sexual health by regulating psychological distress and couple relationship quality.

Detection of SARS-CoV2 virus using the real-time reverse transcriptase polymerase chain reaction in semen and seminal plasma from men with active COVID-19 infection - A pilot study

Introduction

SARS-CoV-2 has been detected in various body fluids. Its presence in semen has been tested with contradictory results. This study aimed to detect the presence of SARS-CoV-2 virus using the real-time reverse transcriptase-polymerase chain reaction (rRT-PCR) in semen and seminal plasma from men with active COVID-19 infection.

Methods

In a cross-sectional study at a COVID facility, men aged 20-45 years with active COVID-19 infection provided semen samples within 7 days of symptom onset or 5 days of nasopharyngeal rRT-PCR test positivity in asymptomatic men. Testing of SARS-CoV-2 was performed using rRT-PCR and semen analysis was done for sperm counts and motility as per the WHO (2010) standards.

Results

A total of 37 men with a mean age of 32.2 ± 5.6 years were tested. SARS CoV-2 virus could not be isolated in any of the samples. Further, microscopic analysis done on 17 samples showed normal semen parameters during the active phase of disease.

Conclusion

Men with mild COVID-19 disease or asymptomatic individuals do not shed virus in their semen, ruling out sexual contact as a mode of transmission in this subset of population.

COVID-19 Pandemic Impacts Decision-Making and Psychosocial Behavior in Women Seeking Fertility Treatment in APAC—an ASPIRE Patient Experience Report

Background: ASPIRE (Asia-Pacific Initiative on Reproduction) aims to develop a “patient-centered” guide to provide fertility treatment based on patient preferences, needs, and concerns during and beyond the SARS-Cov-2 pandemic.

Methods: Women, aged 20–45 years old, trying to conceive for more than 6 months and contemplating for pregnancy including IVF treatment. A country wise analysis of patient behavior, attitudes and concerns, reasons for disruption of treatment and availability of assistance from fertility clinics during SARS-Cov-2 pandemic was performed. Six problem statements addressing patient concerns were identified and corresponding solutions to improve patient experience were formulated. A two-tier recommendation was developed. Tier 1 comprises recommendations in which the rate of “absolutely agree” responses were [Formula: see text]60%, whereas tier 2 refers to recommendations in which the rate of “absolutely agree” plus “agree” together was >60%.

Results: Women in countries that have better infection control and are living a new normal were less worried about the pandemic influencing their lifestyle and finances. The proportion of women choosing not to continue IVF/IUI treatment during COVID-19 was similar across countries. Sixty-five percent of women in Group A intend to continue treatment during COVID-19 pandemic. Nine out of 10 patients are expected to resume or start treatment once fertility clinics are accessible. A patient-centered guide focusing on management of patient safety concerns, reduction in difficulty of access to hospitals, prioritization of patients, provision of emotional support, and improvement in patient education and acceptance of remote health services was developed.

Conclusion: This ASPIRE patient experience report highlights a patient-centered guide on provision of safe fertility treatment across the Asia-Pacific region, which can be adapted to suit country-specific requirements depending on the stage of the pandemic, local restrictions, and availability of resources.

The prevalence of SARS-CoV-2 antibodies in triage-negative patients and staff of a fertility setting from lockdown release throughout 2020

STUDY QUESTION

What is the prevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibodies in triage-negative patients undergoing ART and fertility care providers after lockdown release and throughout 2020?

SUMMARY ANSWER

Out of the triage-negative patients whose blood samples were assessed for SARS-CoV-2 antibodies over 6 months, 5.2% yielded positive results with a significantly higher rate in health care workers (HCWs) and a significant month-by-month increase in those with evidence of antibodies.

WHAT IS KNOWN ALREADY

Patients of reproductive age are more prone to asymptomatic or minimal forms of coronavirus disease 2019 (COVID-19) as compared to older age groups, and the identification of those with active infection and those already exposed (and probably immunized) is important for safety and cost-effective use of testing resources in the fertility setting. Data on the prevalence of SARS-CoV-2 in ART patients are limited and encompass short time frames; current rates are unknown. There is also no consensus on the optimal way of screening triage-negative ART patients in moderate/high-risk areas.

STUDY DESIGN SIZE DURATION

A prospective longitudinal unicentric study on triage negative ART patients (n = 516) and clinical staff (n = 30) was carried out. We analyzed 705 serological tests for SARS-CoV-2 sampled between 17 May 2020 (the first working day after lockdown release) up to 1 December 2020, to assess the positivity rates for SARS-CoV-2 antibodies.

PARTICIPANTS/MATERIALS SETTING METHODS

We collected data on the serological status for IgM and IgG antibodies against SARS-CoV-2 in 516 triage-negative men (n = 123) and women (n = 393) undergoing ART at a private fertility center and 30 HCWs that were at work during the study period. Antibodies were detected with a capture chemiluminescence assay (CLIA) targeting the highly Immunogenic S1 and S2 domains on the virus spike protein. We also analyzed the molecular test results of the cases exhibiting a positive serology.

MAIN RESULTS AND THE ROLE OF CHANCE

The data showed that 5.2% of the triage-negative ART patients had a positive serological result for SARS-CoV-2, with an overall conversion rate of 2.1% for IgG and 4.6% for IgM. There was no significant difference in seroprevalence between sexes. The small cohort (n = 30) of HCWs had a markedly increased seroprevalence (12.9% for Ig M and 22.6% for IgG). The highest seropositivity in our cohort was recorded in November (16.2%). The IgM positivity rates revealed significant monthly increments, paralleling official prevalence rates based on nasopharyngeal swabs. No positive molecular tests were identified in cases exhibiting a solitary positive IgG result. We show that despite a 6-fold increase in the number of ART patients with a positive serology between May and December 2020, most of our patients remain unexposed to the virus. The study was undertaken in a high-risk area for COVID-19, with a 20-times increase in the active cases across the study period.

LIMITATIONS REASONS FOR CAUTION

The geographical restriction, alongside the lack of running a second, differently-targeted immunoassay (orthogonal testing), could limit the generalizability and translation of our results to other fertility settings or other immunoassays.

WIDER IMPLICATIONS OF THE FINDINGS

The low positivity rates for IgG against the SARS-CoV-2 spike protein seen at the end of 2020 imply that most of the fertility patients are still at risk for SARS-CoV-2 infection. Until mass vaccination and other measures effectively diminish the pandemic, risk mitigation strategies must be maintained in the fertility units in the foreseeable future. Patients with a solitary IgG+ status are most likely 'non-infectious' and can elude further testing without giving up the strict use of universal protective measures. With increasing seroprevalences owing to infection or vaccination, and with the consecutive increase in test performance, it is possible that serological screening of ART patients might be more cost-effective than PCR testing, especially for the many patients with repeat treatments/procedures in a time-frame of months.

STUDY FUNDING/COMPETING INTERESTS

This research received no external funding. All authors declare having no conflict of interest with regard to this trial.

State of ART in the COVID-19 era and consequences on human reproductive system

The outbreak of the COVID-19 virus has created havoc on the socio-economic aspect of the world. With billions of lives affected by this wrecking pandemic, global fertility services were also not left untouched by its impact. The possibility of sexual transmission of SARS-CoV-2 virus, its impact on male and female fertility, pregnancy, its potential teratogenic effect, and handling of gametes in the clinical laboratories were major concerns among reproductive medicine specialists which led down all the reproductive health services including IUI, IVF/ICSI in most of the countries. Even the people did not intend to conceive during the pandemic crisis and were hesitant to avail such services. Discrete evidence regarding the pathophysiology of COVID-19 infection and its impact on the human reproductive system is not very clear. In this review article, we intend to incorporate all the evidence related to the COVID-19 infection and its impact on human reproduction available to date. It's our responsibility to provide rightful information and to keep our patients familiar with the existing lack of clear evidence. In this COVID-19 era, it's important that the fertility management be prioritized in sub-fertile couples with diminished fertility reserve, and high-risk conditions like malignancies, that may affect their long-term fertility prospects.

Emotional Impact of Delay in Fertility Treatment due to COVID-19 Pandemic

Background:

COVID-19 pandemic is an unprecedented public health emergency. When the pandemic started in our country fertility treatment was suspended for sometimes following national and international guidelines. This has led to delay in fertility treatment for some couples which was emotionally upsetting.

Methodology and Design:

This study was done on the patients enrolled at our various fertility units across India. The survey questionnaire was sent to patients during the month of first May to June 15, 2020, when COVID-19 pandemic was active across the country, and fertility units were just resuming the services back. The questionnaire was distributed to 100 patients who were currently under treatment and their response was recorded. Ethical committee approval was not taken as surveys are exempted from IRB.

Results:

This survey was undertaken to understand the emotional impact of delay/cancelation in the fertility treatment during the COVID-19 pandemic. The survey revealed that majority (95%) of couples felt cancelation of cycles as upsetting and 16% reporting it to be extremely upsetting. The impact was seen in the form of mood disturbances, anxiety, sleep disturbances, and depressive ideas. Almost half of the couples (49.4%) were desirous to start the fertility treatment immediately. Their knowledge regarding COVID-19 and pregnancy and future child was limited.

Conclusion:

COVID-19 has had impact on every sphere of life. Delay in treatment and cancelation of cycles were emotionally upsetting to majority of couples and they were keen to restart the treatment sooner than later.

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.