Expert / 19 May, 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. Never has this pain been more pronounced than 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. Fertility care has come to a resounding standstill during the lockdown, while at no other time in recent history has the notion of family meant so much, especially when you don’t have one.
The worst injustice about the whole situation is that people who need fertility treatment have often suffered for many years and have 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. The NHS is an organisation 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. A virus that 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, it’s only been possible to gain evidence and date prospectively about this virus, that so far has not been around for long enough for us to understand the true and entire effects on pregnancy.
Some recent evidence from the UK surveillance system in place that monitors all expectant mothers who get coronavirus, has offered reassurance that women who get coronavirus are not any more likely than the general population, to develop complications or more severe disease and that the greatest risk appears to be in the third trimester.
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 historical data from previous related viruses, such as SARS, to try and anticipate the effect that this virus may possibly have. The chance of being admitted to hospital with COVID if you are pregnant is very low at 0.5%, and the chance of needing intensive care if you are admitted is 1 in 10.
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. 1 in 5 babies born to mothers admitted due to COVID were born premature, and 1 in 20 tested positive for COVID themselves, but only half of these tests were immediately after birth.
The overwhelming number of babies born to mothers with coronavirus are well and do not suffer any consequences from this. 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, it isn’t possible to be categorical about it though initial data would indicate that these risks are not probable.
To be sure, all expectant mothers who get the virus will be under surveillance. What is of proven concern is that mothers who belong to the BAME community are 4 times likelier to be admitted to hospital with COVID and have a more serious disease, with 56% of those mothers admitted belonging to ethnic minority groups. Is this due to systemic racial inequalities that affect our healthcare system or a genetic and biological phenomenon that means BAME women are more vulnerable to the effect of the virus, or possibly both?
We must remain committed to understanding this disproportionate and alarming effect if we are to ensure that we keep all mothers and babies safe. We know, for example, that hypertensive disease is 60% more likely to affect black mothers and that this is one of the main risk factors for more severe CVID disease, as well as diabetes, older age and obesity. Calling on the need for careful counselling of anyone who has these risk factors, and optimisation of their medical condition before pregnancy.
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Before we had this recent evidence come to light, in order to be safe, the HFEA and ARCG took the only approach possible, which was to suspend all non-urgent fertility treatment, including IUI, IVF and ovulation induction as well as gamete donation, and only allow that which was considered urgent and essential to go ahead. By this, we mean only those undergoing cancer treatment who needed 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. There’s also the persistent speculation about whether the virus can affect sperm (this has not been proven to be the case) and most recently, whether it can be transmitted in semen and what the effects of this may be on the partner but also on the sperm themselves if any. We also have to take into account 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 a very difficult point if we are to go into a second wave of the pandemic. This is why the provision of fertility, maternity and general healthcare services all have to be balanced together and upgraded in tandem with the latest figures on the spread of the virus and its reproductive rate. Without the general public following rules on social distancing and other measures, we risk a second wave occurring that could compromise all treatment that takes place, including fertility and maternity.
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 could lead to uncertain effects that are still being fully investigated. However, what has become a possibly even bigger threat for maternity services is women being too anxious to come to hospital or place an unnecessary burden on the NHS, and instead of choosing to stay at home even if they are worried about non-COVID symptoms, such as reduced foetal movements.
What every maternity unit has been keen to stress is that they remain open to see women with concerns such as this and it’s vital that women who are worried get in touch with their service or midwife to discuss and if asked to come into hospital, to be reassured that they will be safe with the use of all necessary safeguarding measures.
But there is welcome and good news as the government is now allowing fertility clinics to apply for reopening, providing they are able to demonstrate how they will safeguard all women and men who attend for treatment, including screening for COVID and the use of PPE, as well minimising the risk of transmission between patients and staff.
It signals a huge acknowledgement in recognition of the fact that fertility services are a healthcare priority and that everything should be done to help people start their own families.
What we need to see next follow suit is the resumption of elective gynaecological services, for endometriosis, abnormal periods and so on, that have to be dealt with if fertility services are to resume as normal, or else there will be those whose treatment may be compromised or will have to be put on hold. 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 from 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. This will mean that when the time comes for you to start treatment, 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, that will not only serve you well in pregnancy but thereafter.
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