Watch the webinar with Dr Elias Tsakos, FRCOG, Medical Director of Embryoclinic–Assisted Reproduction Clinic in Thessaloniki, Greece, and find out about COVID-19 and its implications on fertility treatments.
The official name of the Coronavirus is SARS-CoV-2, and COVID-19 is the disease caused by the virus which is with us and going to be with us for some time, months, maybe a year or two. This situation which the whole world today is experiencing this unprecedented epidemic that became a pandemic very quickly, and we all have to accommodate and adapt to the new norm, into the new situation. Of course, the fertility world wasn’t left outside this implication.
Someone who has the virus it’s very likely to develop the disease, although not always, this is the case. It all started at the end of 2019 in China. It only took about two and a half months to become a pandemic as declared by the World Health Organization, and it’s now affecting most countries in the world, very near to 200 countries with millions of cases.
Of us, four months ago, we couldn’t have imagined the situation of the new law; however, many stressed that pandemics and epidemics are quite common in the modern world. There’s still an ongoing HIV and AIDS pandemic at the moment, and around 12 years ago, in 2008, there was another pandemic of H1N1 which was another similar virus to this present one.
Although it’s devastating and the overall effect of the SARS-Cov-2 virus has been huge, the modern world isn’t unaware of such situations.
This is a map taken from a snapshot from Johns Hopkins three days ago. There were 2.8 million cases at the time. This is like a real-time update to apply the cases in the world, so confirmed cases were 2.8 million and confirmed deaths almost 200,00.
Dr Tsakos confirmed that cases have gone after 3.1 million, so more than 300,000 in three days, and sadly, the death toll has gone up to 217,000, so another almost 20,000 deaths in the world within three days. I think this is just an indicator of how quickly this pandemic is spreading and how widely it’s affecting the entire world.
On the left of the picture, you can see the countries mostly affected by the virus and by the pandemic. As you can see, the US is topping this list with almost 1 million cases, followed by Spain, and then by Italy, France, Germany, and the United Kingdom. You can also see the similar unfortunate death toll of the virus, so it’s a real situation, it’s a real problem, and we would have to accept it in a way so we can adapt and accommodate our lifestyle and also our medical practice to this new norm for this situation.
The situation in Greece, although my team and I do have an activity in quite a few European countries including the UK, so hopefully and thankfully Greece will still be on the low side of this list. For the moment, there are just over two and a half thousand confirmed cases of COVID-19 in Greece. Today’s bigger in terms of the number of deaths, it’s 138, so we’ve gone up by 8 deaths in the last few days; however, Greece is one of the most fortunate countries and this has been simply, in our opinion, because early lockdown was imposed with businesses, schools, medical facilities, and IVF centres, completely closing about 45 days ago.
Now, Greece is one of the countries coming out of this lockdown due to the major and the main reduction in deaths. We have resumed some sort of service across the board of medical centres in Greece, that includes IVF services, and there’s going to be a complete release stated by the prime minister in a speech yesterday. Apparently, from the 4th of May, even non-urgent medical services should start. Of course, this hit the news. The Guardian wrote that Greece has been beating coronavirus despite dedicated debt, and the New York Times today had a very interesting article demonstrating the same.
Here, you can see how we’ve managed to keep the curve quite low for the NHS to cope with the illnesses and the mortality of the virus. You can also see here that from earlier April, almost about 25 days ago, we’ve been over the curve, over the top of the curve, and now we’re starting to decline.
There are new norms now, in everyday life, and new challenges affecting every aspect of modern living, including:
It’s quite a devastating issue and challenge that’s affecting the entire world. I think we’re all very well aware of that.
The question is, what’s happening with the medical profession, and how is the medical profession across the globe managing to cope with this situation?
One of the new situations is that over the last 45 days, we tried to keep a natural minimum of physical contact with our patients, so there was a very minimum amount of pre-scheduled appointments. In Dr Tsakos’ department, the team is involved not only with fertility and IVF but also with general gynaecology, obstetrics, and breast care where they are dealing with both benign and malignant diseases, and equally in the department we do care for benign, malignant, and gynaecological problems. We have to prioritize alongside the guidelines of the European Society of Human Reproduction, in line with some UK guidelines issued by the old college, and from the American societies as well.
We have kept it open, and now we’re only doing emergency update work, emergency surgical work, and there’s no accompanying persons, no children allowed to visit. There were a lot of patient questionnaires to identify who was at risk, to screen them more or isolate them ethnically. We use the face masks quite early on, despite the difficulty in getting all the face masks. And of course, temperature measurement, handwashing, and social distancing.
By doing this, we maintained high levels of safety for patients and also for staff. There was a very strict time, even during the quarantine and lockdown, there were strict procedures to protect the staff, by doing all the personnel protection, the temperature checking, all the screening at regular intervals, and risk management, and quality control of our services to maintain open.
During the last time, two months or so, there’s been a lot of new data, a lot of new evidence, and a lot of new questions that haven’t been fully answered with regard to pregnancy, delivery, and breastfeeding. The initial reports are quite optimistic.
This has been posted on the College of Obstetricians and Gynaecologists website, so we’re very well aware of this situation. Although there are a lot of unknowns about the effect of coronavirus on pregnancy, the ACOG and most of the scientific societies across the globe do share the same attitude towards advising pregnant women to be careful, but they need to be reassured that the disease severity matches the non-pregnant health individuals.
Something quite reassuring; however, we must bear in mind that in pregnancy a lot of women may be asymptomatic, may have a very mild disease, may have very mild symptoms, and may be even negative to triage. By applying the questionnaire, taking the blood pressure, by asking them about possible contact travels and all that, they may still not identify the ones who are infected.
Given that fact and in the light of the paper published about a week ago which identified roughly 13% of asymptomatic people undergoing surgery with a high complication rate, in our hospitals in Greece we instituted routine PCR testing or not pregnant women at labour. This has become the norm.
Four or five days ago, since the lockdown, we haven’t identified any positive women coming into labour. We have one suspicious case who was referred to a COVID-19 reference centre, but then eventually she was proven to be negative as well. I have no experience in managing pregnancy affecting coronavirus; however, we’re very happy to continue helping even asymptomatic women with PCR, before the Labour Day, to protect:
This has been widely discussed in various institutions and I think quite a few facilities are considering applying that. This is not always easy, applicable, physically, or logistically easy to apply, but if it’s possible then we would hear some reassurance for patients and during labour.
There’s a lot of unknowns with the regards pregnancy and all women planning to undergo IVF or any fertility treatment, or having undergone that they have to be aware that there are a lot of unknowns with regards the effect of the virus on first trimester. We’re quite familiar with the adverse effects of the fever, of high temperature on the first and third trimester, as well as the adverse effects of the SARS-CoV-1 and MERS virus in the first trimester of pregnancy; however, more data is required and thankfully it’s going to be possible to have all that data collected in the next few weeks.
The action by ESHRE (European Society of Human Reproduction), the British and American Society for Reproductive Medicine were to close the clinics until we had evidence on how we ensure safety, how we would ensure that the quality was kept at high levels.
In Greece, I have a clinic helping, closed for about 45 days and, to my knowledge, this has been the case in most of the European Union countries, including the UK. We had to finish off the cycles already started, we were advised and we advised the patients in European certainties to freeze the embryos. We didn’t perform any embryo transfers and, in the last 45 days, most of us didn’t perform any transfer cases unless there was an emergency, like fertility preservation for cancer patients.
The good news is that there are no reports that SARS-CoV-2 in female or male reproductive organs, but the virus is transmitted into the follicular fluid or the oocyte, or into the male reproductive organs or sperm.
There’s been a very nice report published or pre-published. There are a lot of pre-publications these days; thus, we have the opportunity to see evidence, science, before they’re officially published or accepted for publication. There’s a wonderful paper, one of the highest scientific journals across the Atlantic and across the world, basically proving that there was no presence of the virus in sperm of affected males, so that was quite an optimistic initial finding.
There’s a big debate as to whether pregnancies should be deferred. I think most fertility specialists do agree that fertility patients are urgent, we don’t think that there are nonurgent patients because there’s an urgency in most cases where we perform fertility care, either because of advanced female age or because of planning, logistics, psychological consequences, and so forth. There’s no reason for natural pregnancy to be deferred to the moment, and there’s no such guideline in the world, so it doesn’t sound very logical to us once we do have the evidence of how to reopen the clinics and our institute safely, following specific.
The European Society of Human Reproduction issued, a few days ago, some guidelines as to how to reopen, how to triage the patients, and how to ensure safety and quality in reproductive care in the era of COVID-19.
At the moment, fertility treatment in the UK is paused, and it’s also paused in the majority of European countries; however, some countries are now reopening. I understand that Denmark and Germany have started doing that, offering services. We had an announcement by the Prime Minister that from Monday the 4th of May, all nonurgent patients’ departments will re-open or all nonurgent cases and surgical procedures will start to be performed as we’re coming out of the lockdown. We’re also part of the European society, so we’re expecting our own authorities to state in the next few days with regards to the absolute details of reopening.
The overall feeling in Greece is that this would be in line with the European Society of Human Reproduction. Pausing fertility treatment and pausing the operation of the fertility clinic has caused an immense psychological burden on our patients, and then most of us, including our team would be around the clinic, being available using the internet, telephones, social media, or platforms to communicate with our patients.
I would like to apologize to our patients for not being able to treat them. I would like to share with them my understanding and my feelings of grief, sadness, and uncertainty in light of the new situation. We weren’t able to provide treatment, but I think that was the right thing to do because we all complied with the international guidelines and that was for the safety of the patients. I believe it’s our duty now to ensure that when we restart, this is done in an organized manner, safely, following and respecting all the modern data and all the scientific evidence on the same pathology.
There’s been a lot of discussion, a working group, active discussions across the board of the members of ESHRE. There are six main guidelines put in place, which you can see in the following picture.
ESHRE is recommending the antibody testing; however, I understand there’s a lot of debate on the antibody testing and, in particular, with regards to its accuracy. In Greece, I think most of the IVF clinics that have been in touch with, will be probably start instituting the PCR, the genetic testing, which seems be more accurate and quicker sometimes to identify the asymptomatic patient. May I stress here that if somebody has symptoms, then by all means they’re in this category. They need to be tested.
The big problem is in patients who are completely asymptomatic. Patients may be carrying the virus without being aware of that. Thus, we’re discussing now with an infection control team and with our infection consultant colleagues in Greece, abroad, and everywhere, seriously considering to test everyone who’s going through IVF, not with the antibody test which is not that accurate, but testing with the TCR testing; either just before starting the procedure, or at some stage before the egg collection to ensure that patients aren’t carriers of the virus.
What we do with patients we also do it for our staff, just to ensure that the staff are healthy and can continue working in a quality manner.
There’s a recent guidance by the Human Fertilisation and Embryology Authority in the UK which is basically stating that there are some conditions under which it was going to be at the start of the treatment, that was only issued five days ago, so basically there are some specific conditions under which they did the treatment and care will start and be instituted on the UK, hopefully in the next few weeks.
The American Society also issued a statement well to have a glimpse of the pre-statement on the 27th April. There are similar guidelines that have been put in place.
During the lockdown, during the pause, we stopped almost all of our services, including some cancer cases that we classified as non-urgent. I would classify it as nonurgent in terms of weeks, and now of course we’re re-scheduling those cases for next week, and if quality fertility investigations were paused, then fertility surgery with regards to endometriosis or varying cysts, and so forth. All of this is starting in Greece on the 4th of May.
Dr Tsakos finished by giving 10 tips. These are inspired by Hippocrates, the father of modern medicine. Eight of them were inspired by Hippocrates, one by Leonardo da Vinci, and one by Greek folk.
There are a lot of discussions as to what is the best approach. We’re all quite familiar with the UK model, the US model, the Swedish model, the Greek model, and so forth. My advice to all of you would be to please comply with your national model, the leaders in every country know much better than we do, they have more data, more experience, and a better plan. Let’s stick to their plan and let’s hope that it’s the right one for us.
According to Hippocrates, even if it sounds extreme, this may be necessary because “extreme remedies are very appropriate for extreme situations and diseases.”
In Greece, we have the saying that cleanliness is what makes you half Royal.
This refers to water, not any fluids, like alcohol, because water is the driving force of all nature, according to Leonardo da Vinci.
There might be an amazing opportunity to improve your lifestyle, reduce your stress, improve your nutrition, and understand what nutrition is because most people, even myself up to a few years ago, thought that nutrition and diet are more than the same thing, which is not. Also, cut down on smoking and alcohol, and let food be the medicine and medicine be the food, according to Hippocrates.
It’s a wonderful opportunity to exercise. This is still allowed once a day in the UK, as far as I’m aware, and once a day in Greece.
Walking is man’s best medicine.
That was identified by Hippocrates, two and a half thousand years ago.
A wise man should consider that health is the greatest of human blessings.- Hippocrates
This is the time when we just fanatically look on the internet, tablet, phone, and so forth, but let’s keep that to a minimum because it can be helpful.
As Hippocrates said:
Everything in excess is opposed by nature.
This may be the time to start a new project and allow the natural healing force within each one of us, which is the greatest force in getting well. Let’s not forget that, the natural healing force within each one of us.
It’s the time to keep in touch with your medical team so you have a kickstart and you have a head start for when the reopening happens. Most of the medical teams, all of them, you know are there. They have plenty of time because they don’t have real patients, so they do have enough time to dedicate to the virtual patients, the e-patients, for consultations, discussions, webinars, meetings, and so forth.
This is the time to get educated, to ask questions, and to find answers. This is the time to reflect and appreciate the difference, according to Hippocrates, between science and opinion; because science is knowledge and opinion is usually ignorance.
Whatever seems to be impossible now will probably possible in a few weeks, in a few months. Don’t lose faith because healing is a matter of time, but it’s also a matter of opportunity.
Up until now, we’ve always thought as medics, in the medical profession, that we must preserve, protect, and create life; however, we just discovered that you shouldn’t just be saving lives, we should be saving hope because that’s what the world is needing more than anything at the moment.
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Absolutely, this is the best time to start preparing for the reopening, as we’re all aware it may take quite a few weeks for all the tests to be completed before IVF. If an issue is identified then, the treatment may be required f. e. some vitamin deficiency or some thyroid or hormonal problem, that needs to be corrected and so forth. So start talking to your clinic team now, just start making a plan, asking questions, getting answers, making a plan, understanding a situation and also getting all the energy you need, not just physically but also emotionally and spiritually. This is the best time to use the lockdown as an opportunity for empowerment and preparing yourself for the next step.
I don’t know what is the answer. I hope there’s going to be a vaccination soon, this is not a 100% certain. The word has not discovered vaccines for every single disease, f.e. there is no vaccine for HIV, hepatitis C, and there’s no vaccine for SARS etc. , so it’s not certain that the vaccine will be available anytime soon. In the last couple of months, all of us, in the medical profession we’ve been under a heavy scientific bombardment as to what is the effect of this new situation into our specialities and our everyday practices. We don’t know the answers, I don’t know how it will affect the treatments. I would hope that vaccine is similar to the seasonal flu vaccine, hopefully, it will be available before the end of the year, but even if it’s available at the beginning of next year, that’s still good news, and that will transform the pandemic into an epidemic.
I am afraid it is another I don’t know. I don’t think this is an issue, definitely in our clinic, we haven’t come across here so we will have to discuss it. In general, the feeling is that we’re partners in this amazing loss, so the general feeling of the clinics is that we would try to be as understanding as possible. However, one has to realize that apart from the immense psychological stress of most patients, families, siblings and carers, there’s been an amazing emotional and psychological and also financial stress on clinics as well. This situation is not nice to anyone, and I don’t think anyone has escaped any of those consequences. I understand that all clinics have a lot of understanding, and we’re very happy to discuss in individual situations, so there are no concrete decisions in place.
Sure, I mean in our clinic, my team and I, we’ve always been traditionally offering free online consultations to our patients. Free initial Skypes are still available. We also offer proper full online consultations for patients who wish to get on with their treatment without initial appointments. I think most clinics are doing the same, there’s a lot of work that could be done online, and I encourage patients to take advantage of that.
It depends on the type of treatment and depends on individual requests. Since the borders will not open before the 15th of June, we have prioritised all the patients who had to cancel because of COVID-19, they will be on top of our priority list, so we’re hoping to work with the local patients, the Greek patients. From the middle of June onwards, we will allow going all international patients, starting from the ones who cancelled the treatment for the planned treatment and then going further to the ones who are 48,49 and so forth. A good piece of news is that, although the age limit in Greece like in most European countries, is 50 for the female partner. We had a letter issued by our regulatory body in Greece that this limit could be extended to 50 plus a few months if treatment has been cancelled because of COVID-19. I think this is only the beginning because there’s a lot of talks in Greece in the last couple of years, to extend the upper limit for the patients to the age of 53. And, to answer your question, if you would require egg donation, and if you would have standard characteristic requests, then the normal egg donation waiting list is no longer than 6 weeks.
It depends on individual countries legislation. The institution in the UK is the HFEA. In Greece, we have a similar institution which is in line with the European Society of Human Reproduction. A related body of each country has the absolute responsibility to decide on timings and decide on conditions under which we reopen, and the General Medical Council of each country has a huge say in this.
I would hope that no donor and no patient would be misdiagnosed as negative, and I would be quite confident in that. I mean, at the moment in Greece the overall case rate is 1 in 300, so there are about 3,000 declared cases, even if the actual cases are about 30,000 that’s about 1 in 300 which is very low, however, if we will be also performing the PCR, which can be very accurate, even in a simplification, I think the absolute chance is extremely slim if not non-existent.
I wouldn’t worry too much about it, because Greece and the UK have very strong ties. The governments are communicating and collaborating and so forth, and Greece has been the first country that declared that there is not going to be a difference in the status of either Greek citizens in the UK or UK citizens in Greece and so forth. With regards to IVF and egg donation treatment, there will be no effect whatsoever. The only slight issue may be in the case in which embryos or genetic material needs to be transferred between the countries, as you probably know transportation of genetic material, so if you have sperm or embryos in the UK and you wish to transfer them before Brexit, the official Brexit, then within Europe, you don’t need any special license, so you do that as if you’re transferring between a London clinic and the Manchester clinic. After Brexit, we would need to have a special license by the authorities, but that again shouldn’t be an issue.
As I said before, there is a likelihood that some sort of testing might be required before you travel and there’s a lot of talks between the governments, at the moment, before they allow international travel, so that would be either PCR antibody testing. Once someone has landed and they are attending for treatment, ideally I would want you to do PCR before you start treatment and one before the egg collection or the embryo transfer. Because of the cost implications, we are now in discussions with our scientific authorities, and with the scientific board of our hospitals, in order to identify which is the best time to do it. I think, at the moment it seems that the best time to do the PCR testing, is just before the egg collection, results come out in about 12 to 24 hours. Maybe, the day of the trigger might be the ideal time. PCR testing is maybe valuable for asymptomatic patients. If somebody has symptoms, they would definitely have the full check, the antibody screening and the PCR testing, and if there is any suspicion, the treatment will not go ahead.
If you’re transferring the embryos within the UK, then there’s no deadline, you can do it at any time. My suggestion is that you should trust the clinics involved, so if you’re transferring embryos within UK clinics, just ask the clinic’s, the receiving clinic or the clinic of origin within the European Union, I would do it as soon as possible because it’s going to be much less complex before the official Brexit. Courier companies, they do work as far as I’m aware, again ask for the advice from your clinics, I mean, we all have some associated genetic transportation companies, and you can find them on the Internet as well.
