Expert / 1 June, 2020 / Dr Larisa Corda
Struggling with subfertility no matter when, always brings pain and suffering, whether it be in a couple or as a single person wishing to get pregnant on their own. But never has this pain been more pronounced that in this pandemic, which has widened the chasm between those who seem to get pregnant at the drop of a hat and whose babies at this time will become the new coronials, and those who look on and wait in agony, as fertility care is forced to a standstill and shows no sign of resuming any time soon, until we understand more about the nature of coronavirus and what effects it has on pregnancy.
The worst injustice about the whole situation is that people who need fertility treatment have often suffered for many years and had to endure a long and harrowing process to get to the point of treatment. For many, this has involved considerable emotional and financial sacrifice. Many have faced years of stigma and discrimination, including that on the NHS, where a very strict set of criteria has to be fulfilled to qualify for funding, where rules are free to be interpreted differently and local clinical commissioning groups have reign over their own criteria independent of national guidance. Added to which there’s the stigma imposed by society who more often than not don’t recognise subfertility as a disease, but as a self-imposed condition secondary to career prioritisation or refusing to settle down too soon.
In the pandemic, where fertility treatment is not possible, patients are left facing a whole new level of discrimination, this time imposed by a new virus, that shows no signs of leaving our population any time soon, and is actively preventing patients from being able to access the very care that offers them their only chance of having a family. It’s one of the cruellest double whammies almost impossible to endure, in particular given the uncertainties of when treatment can resume and when we can gain the confidence to predict the virus’s pattern of behaviour in pregnancy.
So here is the problem in summary. To date, we only have a small number of cases where it’s been possible to understand a bit about the coronavirus and pregnancy. The observations so far have left more questions than provided answers and have focused only on the third trimester, due to the fact the virus hasn’t been in our society for long enough yet. The effect on the first and second trimester will only be seen over time, and this will require several more weeks or months, so until then, we are looking at historial data from previous related viruses, such as SARS, to try and anticipate the effect that this virus may possibly have. So far, we have seen that there may be a small chance of preterm birth with the virus, and possible vertical transmission between the mother and baby. The consequences of which are not fully understood.
Is there a potential for intrauterine growth restriction, congenital anomalies or even miscarriage?
We just don’t have these answers yet and the painful truth of the matter is that until we wait this out and collect further evidence, we just can’t be certain of what this virus is capable of, and new and expectant mothers, especially those who have waited a long time to become pregnant, are certainly not someone who should be experimented on with this.
So, in order to be safe, the HFEA and ARCG have taken the only approach possible, which has been to suspend all non-urgent fertility treatment, including IUI, IVF and ovulation induction as well as gamete donation, and only allow that which is urgent and essential to go ahead.
By this, we mean only those undergoing cancer treatment who need to have gamete preservation to provide the only chance they have of being able to have their own biological child in the future. But even here, especially in those who may be immunocompromised and therefore more at risk of contracting the virus and developing complications, decisions have to be made on an individual basis and to consider the number of face to face appointments that may need to be minimised which, in a field like fertility, is very difficult to do, especially as treatment can involve daily scans and blood tests.
What there hasn’t been clear cut guidance on so far is whether couples should attempt to get pregnant naturally or not. Given how uncertain we remain over the effects of the virus, the best answer to this would probably be to abstain from pregnancy altogether, but this in itself may be a very difficult thing to do. There is also an additional consideration here, and that is the effect of pregnancy on the NHS. Maternity care has always been and remains a ringfenced area of the hospital where care will continue, albeit with certain adjustments, such as a reduction in face to face appointments and telephone consultations along with video instead, to try and reduce the risk of infection where possible. But even these services have a limit on resources and given that the majority of hospital care has had to be diverted towards treating patients with COVID, if we actively add further pregnancies, in particular those that may be more complicated, we may effectively drive the NHS to breaking point or to a level where maternity care may have to be compromised, because there are not enough resources to care for patients in the way that is necessary.
This is a time when every pregnant woman is inevitably anxious about contracting COVID and if she does, what the effect may be to her and her unborn baby. Pregnant women remain in the most vulnerable list, not because they are likelier to get COVID but because if they do, their bodies may not process the virus in the same as those who are not pregnant, which in itself could lead to complications that we don’t yet understand or know about.
None of us have any choice but to wait this out and attempt to resume normal services as soon as possible. There are also those who are on elective clinic or waiting lists requiring gynaecological surgery or treatment for conditions such as endometriosis or polyp or fibroid removal, which in some cases is needed prior to the start of any fertility treatment. This, again, cannot go ahead right now because of the critical situation the NHS faces in dealing with COVID.
However, what is important is for anyone anxiously waiting to start fertility treatment, to look at this time in waiting as time to invest in their own wellbeing and health. This is not to diminish the desire in wanting to go ahead as soon as possible, which is significant for anyone suffering with subfertility in this pandemic, but to see this as a time when you and your partner can change certain habits for the better, in order to try and optimise your health and fertility, as well as the health of your baby, through various lifestyle interventions, such as diet, exercise, sleep, stress management and toxin free living. I discuss all of this and provide tips on how to do this in The Conception Plan (link). This will mean that when the time comes when we can safely resume the provision of fertility services, you will be in the best possible position to get pregnant and when you are, give yourself the best chance of having a healthy pregnancy.
These changes can often take at least 3 months to be effective, if not longer, so please consider the time spent in lockdown as time actually spent prioritising your own health. Once we understand the effects of the virus on pregnancy, or gain better control of it and once we are able to co-ordinate services with the NHS and be sure that we will not be creating any additional strain on an already stretched system, we’ll be able to go ahead and help provide the desperately needed treatment to all those who need it and who have found themselves the unsuspecting victims of this entire pandemic.
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