COVID-19 and assisted reproduction
25 February 2022
SARS-COV-2 and assisted reproduction: an update in 2022
ESHRE reiterates its stance with regards to SARS-CoV-2 and assisted reproduction, supporting vaccination and access to fertility treatment.
Read here >
9 June 2021
Updated ESHRE statements on COVID-19 and ART
COVID-19 infection rates are declining and vaccination rates are rising, but COVID-19 still has a significant impact on ART services.
Awaiting sufficient vaccination levels to forego triage and testing or mitigation measures, ESHRE has updated its previous statements incorporating both the variety of available SARS-CoV-2 testing methods and vaccination status.
Please check out the updated statements:
- SARS-COV-2 and service adaptation: an update
- COVID-19 vaccination and assisted reproduction (update 3)
18 February 2021
COVID-19 vaccination and assisted reproduction
Update of the statement “COVID-19 vaccination and assisted reproduction” of 12 January 2021, with adaptation of the information on COVID-19 Vaccine AstraZeneca following EMA authorisation.
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10 February 2021
Joint IFFS/ ESHRE statement on COVID-19 vaccination for pregnant women and those considering pregnancy
The IFFS/ESHRE statement reviews current choices based on benefits and risks of vaccination for both women who plan to conceive but are not yet pregnant and those who are actually pregnant.
Read more>
12 January 2021
ESHRE has published a new statement on COVID-19 vaccination and assisted reproduction answering three important questions:
- Should men and women receive the COVID-19 vaccine before attempting conception?
- Should couples who received COVID-19 vaccination postpone conception, and if so, for how long?
- Should pregnant women be vaccinated?
Please check out the full statement here
10 December 2020
New ECDC update on COVID-19 advises fertility clinics to follow ESHRE risk mitigation guidance
The second update of the European Centre for Disease Prevention and Control (ECDC) technical report on COVID-19 and supply of substances of human origin in the EU/EEA recommends "to mitigate the risk of COVID-19 transmission, ART centres in EU/EEA Member States to follow the advice in the ESHRE Guidance on safe ART services during the third phase of the COVID19 pandemic.
14 October 2020
New local outbreaks and second waves of SARS-CoV-2 infection are now reported from several countries, particularly among people of reproductive age.
A new ESHRE guidance document, published today, aims to support clinics and practitioners in maintaining safe ART services during the third phase of the COVID-19 pandemic.
In addition to reaffirming ESHRE’s initial guidance published in April, the guidance document advises mitigation measures guided by local circumstances and epidemiological factors.
Read the full guidance here
29 May 2020
Representatives:
Anna Veiga – ESHRE / Spain
Luca Gianaroli – ESHRE /Italy
Steve Ory – IFFS /USA
Marcos Horton – IFFS / Argentina
Eve Feinberg – ASRM/USA
Alan Penzias – ASRM/USA
Declaration of principle
Reproduction is an essential human right that transcends race, gender, sexual orientation, or country of origin. Infertility is the impairment of reproductive capacity; it is a serious disease that affects 8-12% of couples of reproductive age and harms physical and mental well-being. Infertility is time-sensitive, and prognosis worsens with age. While there is no cure for most causes, the disease is most often treatable, and the majority of patients who seek treatment can ultimately become parents.
Defining the problem
The COVID-19 pandemic presents a unique global challenge on a scale not previously seen. The infectivity and mortality rates are higher than previous pandemics and the disease is present in almost every country. The propagation and containment have varied widely by location and, at present, the timeline to complete resolution is unknown. In the earliest stages of the pandemic, the American Society for Reproductive Medicine (ASRM) and the European Society of Human Reproduction and Embryology (ESHRE), independently recommended discontinuation of reproductive care except for the most urgent cases. More recently, with successful mitigation strategies in some areas and emergence of additional data, the societies have sanctioned gradual and judicious resumption of delivery of full reproductive care. In this document, ASRM, ESHRE and the International Federation of Fertility Societies (IFFS) have come together to jointly affirm the importance for continued reproductive care during the COVID-19 pandemic.
Reproductive medicine is essential
Reproductive care is essential for the well-being of society and for sustaining birth rates at a time that many nations are experiencing declines. During the pandemic, reproductive medicine professionals should continue to:
- Advocate for the well-being of patients.
- Monitor local conditions, including prevalence of disease, status of government or state regulations, and availability of resources.
- Implement proactive risk assessment within their practices prior to restarting services.
- Prioritize care and judiciously allocate use of limited resources using medical criteria.
- Counsel patients about all options, including deferring evaluation and treatment.
- Adhere to active risk mitigation strategies to reduce the risk of viral transmission.
- Develop clear and codified plans to ensure the ability to provide care while maximizing the safety of their patients and staff.
- Remain informed and stay current regarding new medical findings.
- Develop or refine robust emergency plans.
- Be prepared to interrupt medical treatment if conditions warrant discontinuation.
Research needed
In addition to helping patients, reproductive medicine practices are uniquely positioned to gather data and help to further COVID-19 research.
- Reproductive medicine professionals and practices are essential front-line resources for screening, monitoring, and assessing the prevalence and impact of the disease on patients and their progeny through Point-of-Care data collection.
- ESHRE, ASRM and IFFS are committed to continuous monitoring of the effects of COVID-19 on gametes and reproductive tissues, collecting data on pregnant patients infected during the pandemic, and assessing the outcomes of mothers and neonates.
- Examples of these research and registry efforts follow:
a. In the U.S.A., the ASPIRE (Assessing the Safety of Pregnancy In the Coronavirus Pandemic) Study is a nationwide prospective cohort study of pregnant women and their offspring during the COVID-19 pandemic. All patients under the care of a reproductive medicine specialist who conceived spontaneously or with assisted reproductive technology (ART) between March 1st and December 31st are encouraged to participate.
b. ESHRE is gathering global case-by-case reporting on the outcome of medically assisted reproduction (MAR) conceived pregnancies in women with a confirmed infection.
c. The affiliate society of ASRM, the Society for Assisted Reproductive Technologies (SART) is including mandatory COVID-19-related questions in their Clinic Outcome Reporting System (CORS) registry of assisted reproductive technologies (ART), which accounts for over 95% of all ART cycles in the U.S.A.
d. ESHRE is gathering data and mapping MAR/ART activity during the pandemic, country by country whether and /or when they stopped offering treatment and when they have resumed care.
e. IFFS is conducting COVID-19-related periodic surveys to assess global trends in access to MAR/ART services.
Final thoughts
Reproductive care is essential and reproductive medicine professionals are in a unique position to promote health and wellbeing. In addition, ASRM, ESHRE and IFFS are collaborating to advocate for patients and to gather data and resources to enhance the understanding of COVID-19 as it pertains to reproduction, pregnancy, and the impact on the fetus and neonate. The lessons learned from these experiences will be useful as humanity deals with future pandemics.
Read in HROpen >
23 April 2020
As the COVID-19 pandemic is stabilising, the return to normal daily life will also see the need to restart the provison of ART treatments. Infertility is a disease and once the risk of SARS-CoV-2/COVID-19 infection is decreasing, all ART treatments can be restarted for any clinical indication, in line with local regulations.
However, vigilance and measured steps must be taken for safe practice and to minimise the risks related to SARS-CoV-2/COVID-19-positive patients or staff during treatment.
The ESHRE COVID-19 working group has prepared the “ESHRE Guidance on recommencing ART treatments”, a set of recommendations for centres planning to restart ART treatments.
Read the full Guidance here
2 April 2020 (last revision 17 April)
In view of the continuing prevalence of infection from the coronavirus SARS-CoV-2 (i.e. the virus causing COVID-19) and widespread initiatives to limit its spread, ESHRE reaffirms its recommendation to follow local and national government advice, particularly national daily updates.
The available evidence
To date, there is no clear evidence of any negative effect of SARS-CoV-2 infection on pregnancy, as indicated by the latest updates from the Centers for Disease Control and Prevention (CDC) in the USA and others in Europe.[1, 2] Even so, we should be mindful that viral infections can be more problematic for pregnant women and acknowledge that some of the medications used in virus-infected patients may not be recommended during pregnancy.
Recent updates on pregnancy outcomes in infected mothers report healthy infants born free of the disease.[3] However, there are small case series reporting adverse outcomes, such as premature rupture of membranes and preterm delivery.[4] Neonatal SARS-CoV-2 infection (five cases) [5-7] and the presence of IgM (and IgG) antibodies against the virus in newborns (three cases) [8, 9] have also been reported. It is unclear whether these data are indicative of vertical transmission of SARS-CoV-2.
An up-to-date overview of data extracted from all published reports on pregnancy and neonatal outcomes in women with confirmed COVID-19 is available from the Cochrane Gynaecology and Fertility Group (https://cgf.cochrane.org/news/covid-19-coronavirus-disease-fertility-and-pregnancy). 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.[10]
ESHRE’s guidance
In view of the above considerations and outcomes reported in cases of other coronavirus infections (such as SARS and MERS) [11, 12], 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 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. [13, 14]
ESHRE will continue to monitor the scientific literature and this statement will be regularly updated.
The ESHRE COVID-19 working group is presently preparing recommendations for clinics planning to restart ART services. These will consider patient selection, general and specific organisation of services and good laboratory and clinical practice, with an emphasis on both patient and professional safety and responsibilities.
References
1. https://www.cdc.gov/coronavirus/2019-ncov/prepare/pregnancy-breastfeeding.html?CDC_AA_refVal=https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/pregnancy-faq.html
2. https://www.rcog.org.uk/globalassets/documents/guidelines/2020-03-28-covid19-pregnancy-guidance.pdf
3. Schwartz DA, An Analysis of 38 Pregnant Women with COVID-19, Their Newborn Infants, and Maternal-Fetal Transmission of SARS-CoV-2: Maternal Coronavirus Infections and Pregnancy Outcomes. Arch Pathol Lab Med, 2020. https://doi.org/10.5858/arpa.2020-0901-SA
4. Liu Y, Chen H, Tang K, et al., Clinical manifestations and outcome of SARS-CoV-2 infection during pregnancy. J Infect, 2020. https://doi.org/10.1016/j.jinf.2020.02.028
5. Yu N, Li W, Kang Q, et al., Clinical features and obstetric and neonatal outcomes of pregnant patients with COVID-19 in Wuhan, China: a retrospective, single-centre, descriptive study. Lancet Infect Dis, 2020. https://doi.org/10.1016/S1473-3099(20)30176-6
6. Wang X, Zhou Z, Zhang J, et al., A case of 2019 Novel Coronavirus in a pregnant woman with preterm delivery. Clin Infect Dis, 2020. https://doi.org/10.1093/cid/ciaa200
7. Zeng L, Xia S, Yuan W, et al., Neonatal Early-Onset Infection With SARS-CoV-2 in 33 Neonates Born to Mothers With COVID-19 in Wuhan, China. JAMA Pediatr, 2020. https://doi.org/10.1001/jamapediatrics.2020.0878
8. Dong L, Tian J, He S, et al., Possible Vertical Transmission of SARS-CoV-2 From an Infected Mother to Her Newborn. Jama, 2020. https://doi.org/10.1001/jama.2020.4621
9. Zeng H, Xu C, Fan J, et al., Antibodies in Infants Born to Mothers With COVID-19 Pneumonia. JAMA, 2020. https://doi.org/10.1001/jama.2020.4861
10. Liang H and Acharya G, Novel corona virus disease (COVID-19) in pregnancy: What clinical recommendations to follow? Acta Obstet Gynecol Scand, 2020. https://doi.org/10.1111/aogs.13836
11. Schwartz DA and Graham AL, Potential Maternal and Infant Outcomes from (Wuhan) Coronavirus 2019-nCoV Infecting Pregnant Women: Lessons from SARS, MERS, and Other Human Coronavirus Infections. Viruses, 2020. 12 (2). https://doi.org/10.3390/v12020194
12. Rasmussen SA, Smulian JC, Lednicky JA, et al., Coronavirus Disease 2019 (COVID-19) and Pregnancy: What obstetricians need to know. Am J Obstet Gynecol, 2020. https://doi.org/10.1016/j.ajog.2020.02.017
13. ESHRE Guideline Group on Good Practice in IVF Labs, De los Santos MJ, Apter S, et al., Revised guidelines for good practice in IVF laboratories (2015)†. Hum Reprod, 2016. 31: 685-686. https://doi.org/10.1093/humrep/dew016
14. European Directorate for the Quality of Medicines (EDQM), Guide to the quality and safety of tissues and cells for human application 2019: https://register.edqm.eu/freepub.
19 March 2020
In view of the increasing incidence of infection from the coronavirus Covid-19 and widespread initiatives to limit its spread, ESHRE reaffirms its recommendation that Society members follow local and national government advice, particularly national daily advice updates, with compliance encouraged where feasible.
Pregnancy and conception
There is no strong evidence of any negative effects of Covid-19 infection on pregnancies, especially those at early stages, as indicated by the latest updates from the Centers for Disease Control and Prevention (CDC) in the USA and others in Europe.(1,2)
There are a few reported cases of women positive for Covid-19 who delivered healthy infants free of the disease.(3) There have been reports of adverse neonatal outcomes (premature rupture of membranes, preterm delivery) in infants born to mothers positive for Covid-19 during their pregnancy, but the reports were based on limited data.(4,5) Similarly, one case report has been published of an infected infant, but again there was no strong evidence that this was the result of vertical transmission.(6)
These data, although encouraging, only report small numbers and must be interpreted with caution. They refer to pregnancies in their final stages, but we have no information on the possible effect of Covid-19 infection on pregnancies in their initial stages.(7)
However, in view of the above considerations and the maternal and neonatal outcomes reported in cases of other coronavirus infections (such as SARS), ESHRE continues to recommend a precautionary approach.(8) It is also important to note that some of medical treatment given to severely infected patients may indicate the use of drugs which are contraindicated in pregnant women.
As a precautionary measure - and in line with the position of other scientific societies in reproductive medicine - we advise 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. For those patients already having treatment, we suggest considering deferred pregnancy with oocyte or embryo freezing for later embryo transfer.
ESHRE further advises that patients who are pregnant or those (men and women) planning or undergoing fertility treatment should avoid travel to known areas of infection and contact with potentially infected individuals.
ESHRE will continue to monitor the scientific literature, especially in relation to ART and pregnancy. And reaffirms the view that all medical professionals have a duty to avoid additional stress to a healthcare system that in many locations is already overloaded.
1. https://www.cdc.gov/coronavirus/2019-ncov/prepare/pregnancy-breastfeeding.html?CDC_AA_refVal=https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/pregnancy-faq.html
2. https://www.rcog.org.uk/globalassets/documents/guidelines/coronavirus-covid-19-infection-in-pregnancy-v2-20-03-13.pdf
3. Schwartz DA. An Analysis of 38 Pregnant Women with COVID-19, Their Newborn Infants, and Maternal-Fetal Transmission of SARS-CoV-2: Maternal Coronavirus Infections and Pregnancy Outcomes. Archives of pathology & laboratory medicine 2020. https://doi.org/10.5858/arpa.2020-0901-SA
4. Liu Y, Chen H, Tang K, Guo Y. Clinical manifestations and outcome of SARS-CoV-2 infection during pregnancy. J Infection 2020; doi.org/10.1016/j.jinf.2020.02.028
5. 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: 1-6. https://www.ajronline.org/doi/10.2214/AJR.20.23072
6. 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; doi.org/10.1093/cid/ciaa200
7. Liang H, Acharya G. Novel corona virus disease (COVID-19) in pregnancy: What clinical recommendations to follow? AOGS 2020; doi.org/10.1111/aogs.13836
8. Schwartz DA, Graham AL. Potential and maternal infant outcomes from coronavirus 2019-nCoV (SARS-CV2) infecting pregnant women: Lessons from SARS, MERS, and other coronavirus infection. Viruses 2020; doi.org/10.3390/v12020194
Further references
* https://www.who.int/emergencies/diseases/novel-coronavirus-2019
* https://www.iffs-reproduction.org/page/COVID-19
* https://www.acog.org/Clinical-Guidance-and-Publications/Practice-Advisories/Practice-Advisory-Novel-Coronavirus2019
* https://www.asrm.org/news-and-publications/news-and-research/press-releases-and-bulletins/covid-19-suggestions-on-managing-patients-who-are-undergoing-infertility-therapy-or-desiring-pregnancy/