Dr Maria Arqué explains what fertility patients can do during the quarantine and COVID-19 lockdown to prepare for their future infertility treatment.
Dr Arqué begins by explaining that coronavirus is a big family of viruses that are extremely common and can cause colds and other upper respiratory infections. COVID-19 is the short name for coronavirus disease 2019, which is the official name that the World Health Organization gave to the new virus first found in Wuhan at the end of 2019. Then, as is known, the numbers are changing very rapidly. The John Hopkins website, which is one of the main reliable sources of information regarding this, showed on that day that there are more than 1.2 million people infected in the world. There are probably more people, as not enough tests are being done in many countries. That’s the reason the World Health Organization has already declared it a pandemic.
Dr Arqué shows a map above that was published in the New York Times in the last few days, which shows the cases worldwide. The countries that are mainly affected are, obviously, China, which had the infection earlier but has now gained more control, so they are no longer in one of the worst zones. The other countries affected, as seen on the map, include Italy, the US, Spain, Germany, Iran, France, South Korea, Switzerland, and the UK. However, this situation is dynamic and continues to change every day, as the policies in each country regarding measures to avoid infection are constantly evolving.
The common symptoms of COVID-19 can vary. Some people may be infected but show no symptoms at all, which is one of the main reasons why the virus can be very dangerous. Asymptomatic individuals can unknowingly spread the infection. For most people who do experience symptoms, the most common ones include a low-grade fever, body aches, coughing, nasal congestion, and a sore throat. However, some individuals may develop more severe symptoms, such as a high fever, severe cough, shortness of breath, and pneumonia.
One of the concerns regarding COVID-19 is the time between when a person is exposed to the virus and when they start showing symptoms. This period, known as the incubation period, has not yet been precisely determined. Based on current information, the incubation period can range from three days to thirteen days, with the average generally being around five days.
Dr Arqué explains that COVID-19 is most likely spread from person to person, primarily through droplets produced when people sneeze, cough, or talk. This is one of the main reasons why one of the key preventative measures is maintaining a “security distance” of at least 1.5 meters (or 6 feet), depending on the units used. Another way to contract the virus is by touching infected surfaces or objects. Some data suggests that COVID-19 can survive on various surfaces for several days. The good news is that if surfaces are cleaned correctly, the virus can be inactivated. One of the best ways to clean potentially infected surfaces is by using a diluted bleach solution or alcohol with at least 70% alcohol content.
Dr Arqué says that, so far, it is known that influenza, the common flu, has caused far more deaths during this flu season than COVID-19. However, when discussing the fatality rate—the number of deaths compared to the number of known positive cases—there are some caveats. The numbers available at any given time might not be entirely reliable because, as mentioned earlier, not enough tests are being conducted. This means there could be a large portion of the population who are infected but remain undiagnosed, potentially leading to an overestimation of the fatality rate. Nevertheless, based on the available data, COVID-19 appears to have a fatality rate between 2% and 4%, which is much lower than that of SARS, the previous coronavirus infection that mainly affected Asia in 2003, and MERS, which impacted the Middle East. In comparison, the fatality rate of influenza is around 0.1%. The main difference between COVID-19 and the flu is that not only is the percentage of people who die from COVID-19 higher but there is also no vaccine for COVID-19 (unlike the flu), which is a crucial factor in why COVID-19 cannot be directly compared to influenza.
Regarding the people who are at risk of getting coronavirus, Dr says that the good news is that children are at very low risk of developing severe disease or death from COVID-19. Unfortunately, older individuals, especially those with underlying medical conditions, are more likely to develop serious illnesses. These conditions include lung-related issues such as bronchitis and emphysema, heart failure, and diabetes. Additionally, people with other medical problems, such as blood disorders like sickle cell anaemia, those taking blood thinners, or those with chronic kidney disease, chronic liver disease, or conditions that weaken the immune system (such as cancer or HIV), are at higher risk. Recent or current pregnancy, particularly in the last two weeks, may also lower the immune response, although this is not yet fully understood. Other high-risk groups include those with diabetes, inherited metabolic disorders, heart disease, lung diseases, and neurological problems. These individuals need to be especially cautious and take extra care to avoid infection.
To protect oneself and others from COVID-19, as well as other coronavirus diseases and influenza, Dr Maria mentions several actions that can help prevent the spread. It is important to avoid close contact with people who are sick and refrain from touching their eyes, nose, and mouth, especially after being outside and before washing hands. One should stay home when feeling unwell and isolate themselves to prevent spreading the virus. Covering coughs and sneezes with a tissue and disposing of it in the trash is also essential. Frequently touched objects and surfaces should be cleaned and disinfected using regular household cleaning sprays or wipes, or a solution of bleach and water, or alcohol-based solutions. Finally, washing hands often with soap and water is one of the most effective measures to protect against the virus.
Does COVID-19 affect fertility?
At the moment, there is no evidence that COVID-19 can affect fertility. While the lack of evidence does not necessarily mean that it cannot impact fertility, information from previous coronaviruses suggests that it should not directly affect fertility.
Nevertheless, a group of researchers from the European Society of Human Reproduction has started a research initiative to gather data from studies and publications around the world. Their goal is to provide more reliable information on this topic. However, for now, the knowledge about COVID-19 is still too limited to draw any conclusions about its potential impact on fertility.
Dr Arqué mentioned that a couple of articles were published in The Lancet last month, providing some information gathered from pregnant patients. The study focused on nine pregnant women in China who were all in the last trimester of pregnancy, and about to deliver their babies. After the babies were born, researchers examined the placenta, amniotic fluid, and umbilical cord to check for the presence of the virus. They found no evidence of vertical transmission, meaning that if the mother was affected, the virus was not transmitted to the baby. This finding is reassuring. However, the evidence is still limited, as the study only involved nine cases. More data is needed to provide more robust information on this matter.
On the other hand, there is no clear information on the possible effects of COVID-19 in the first and second trimesters of pregnancy. It is assumed that, if there is no vertical transmission, there may not be any negative effects on the baby. However, further data is needed to confirm this. Compared with previous coronaviruses, some studies have shown that SARS and MERS had detrimental effects on pregnancy, with reported complications like miscarriages, preterm deliveries, and other related issues. Based on the limited data available so far, it does not appear that COVID-19 will have as severe effects as the previous coronaviruses, but this is still to be confirmed as more research emerges. This is the current understanding of the situation.
Then, regarding patients who were in the middle of fertility treatment when the pandemic started or those who were seeking or waiting to begin treatment, Dr explains that the recommendations from both the American Society of Reproductive Medicine and the European Society of Human Reproduction are to suspend the initiation of any new treatments or cycles, including all types of treatments. They also strongly recommend the cancellation of all embryo transfers, both fresh and frozen. However, they advise continuing the care of patients who are currently in the cycle.
In most fertility clinics, the approach has been to complete the stimulation cycles for patients already undergoing treatment. Once stimulation is completed, the resulting embryos are frozen, as the recommendation is not to proceed with frozen embryo transfers at this time. Additionally, elective surgeries are recommended to be suspended, and there is a push to minimize in-person interactions. Telehealth is being encouraged to continue patient care during this period.
During quarantine, there are several practical steps individuals can take to prepare for an IVF cycle or fertility treatment, especially focusing on boosting the immune system and maintaining overall health. First and foremost, it is important not to smoke, as smoking can negatively impact fertility. A diet high in fruits, vegetables, and whole grains is also beneficial for general health. Taking a pre-pregnancy multivitamin that includes folic acid is particularly important for women planning to achieve pregnancy shortly. Regular exercise is another key recommendation, as it helps to manage stress and anxiety, which are common during such uncertain times, especially for those undergoing fertility treatments. Maintaining a healthy weight and ensuring a healthy BMI are also essential, as these factors increase the chances of a successful outcome in fertility treatment. Lastly, controlling stress levels is crucial, although the current situation with COVID-19 can make this challenging. On the positive side, there are numerous online tools and resources available to help individuals manage stress during this period.
During this time, patients can take several additional steps to support their health. If they drink alcohol, it is recommended to consume it in moderation—no more than one or two units of alcohol for men and no more than one unit for women. It is also important to ensure they get enough sleep and take steps to avoid infection. This includes washing hands as frequently as possible and refraining from touching the face, especially after coming into contact with objects that have not been sanitized. Following the recommendations provided by health authorities and governments, which are widely shared in the media, is crucial in minimizing the risk of infection.
Since undergoing fertility treatment is a process that takes time, one of the things patients can do during this period is have online consultations with their healthcare providers. These consultations can help start the process, allow for an initial diagnosis or assessment of the situation, and determine potential treatment options. They can also provide guidance on the necessary tests to undergo, helping patients take steps toward starting fertility treatment as soon as the lockdown or quarantine ends, and fertility clinics resume normal activities.
As fertility physicians and healthcare providers, Dr Arqué says that their main goal is to be mindful of the overall health situation and to avoid putting patients at risk. The main reason for the current recommendations is to help prevent the spread of COVID-19. While we are very aware that this is a challenging situation, especially for those eagerly hoping to have a child, the intention is to provide ongoing care and support. During this time, we will continue to be available online to assist patients and offer guidance through the process. Dr Arqué recommends using consultations with fertility specialists or clinics to begin making plans and setting timelines, given the current limitations.
Having a clear plan can help manage the situation, reduce stress, and provide a sense of progress during this uncertain time.
Moreover, she says that, during this time, it is crucial to seek accurate and current information to reduce anxiety. The information gathered should come from reliable sources, such as the CDC (Centers for Disease Control) in the U.S., which is known for providing trustworthy and up-to-date information on infectious diseases. Other credible sources include the World Health Organization, the American Society for Reproductive Medicine, and the European Society for Human Reproduction. Additionally, limiting the use of social media and other news sources can help manage stress. To further reduce anxiety and improve sleep, using relaxation or mindfulness apps is recommended. Focusing on the present moment can be helpful, and some examples of apps include Ferticalm for women and Fertistrong for men. These recommendations, published on the American Society for Reproductive Medicine’s website, are expected to be very useful during this time.
She recommends that people try to take a break from COVID-19-related topics for at least an hour each day. Focusing on other things during this time can be very helpful. It’s also important to pay attention to the messages we give to ourselves, as positive self-talk can be powerful. For example, saying, “This isn’t the situation I expected, but it doesn’t mean it won’t work,” can be encouraging. Additionally, staying in touch with a supportive network is essential. With the rise of online social meeting apps, staying connected with friends and family has become easier and even more popular during this period. One of the positive aspects of quarantine today is the ability to use these tools to maintain connections with others. Moreover, RESOLVE, one of the main infertility associations in the U.S., is offering support groups via virtual technology, which could be another valuable resource to consider.
I don’t think now is a good moment to undergo IVF stimulation because, as I mentioned, the recommendations from the main societies are to halt fertility treatments for the time being. If you have not yet started IVF stimulation, I don’t think it’s the right time to begin. On the other hand, if you need to take medication like corticosteroids, which suppress the immune system to some extent, you would be at a higher risk of getting an infection. Therefore, I believe it would be much better to wait until the situation is under control before starting IVF stimulation.
Well, I think that in preparation for the next cycle, you can follow all the advice I explained, which is very general. I am sorry that none of the embryos survived up to day 5. At this point, it needs to be assessed if there is an egg quality issue. From there, we can try to see if there’s any way to stimulate you without having an ovarian response issue and hopefully achieve an embryo transfer with an embryo that reaches the day 5 stage.
Firstly, IVF is being suspended for now. I recommend trying naturally if you have a very long history of miscarriages. This is something to consider, as it may not be that it’s difficult for you to get pregnant, but more of an issue with recurrent miscarriages. The emotional side of having to go through another miscarriage is very important to consider. Depending on how you’re feeling about that, if you feel that the anxiety of not trying or not being able to do fertility treatment in the meantime is worse than trying again, even though it may end up in another miscarriage, that’s something to weigh in your decision.
As for how long clinics will be suspended, I wish I knew. I’m the first one who is looking forward to resuming care and helping patients get pregnant again. Based on the situation in Spain, I think the lockdown will last at least until the 11th of April, and it might be extended a bit longer. If we look at how things have evolved in China and other countries, I hope that by May, we can begin resuming normal work activities, and by June, I hope things will return to normal.
Regarding the availability of donors, I think that if clinics already work with frozen eggs, this shouldn’t be a major concern. As for whether donors will be tested for coronavirus, there are no policies yet on whether this will happen. Currently, we don’t have enough information to determine if coronavirus can affect fertility, but I don’t believe it should. One of the advantages of coronavirus, compared to the issues we had with Zika, is that the virus clears from the body within 14 days. So, if we had to test donors for coronavirus, the maximum waiting time would be two weeks. In contrast, the Zika virus had teratogenic effects and lasted much longer in the body. If testing is recommended, it wouldn’t significantly delay the availability of donors. The most we might need is a two-week clearance period to ensure the virus is no longer present. If we decide to test, we would do a PCR test to check if the virus is active and could be spread.
We should always be concerned about how sperm may be affected by a fever. There is a lot of data and several published studies that suggest when a male has a fever and provides a sperm sample, the sample may be altered, and the sperm quality may not be as good as usual. My recommendation would be that if you have a fever or have had one in the past few days, it’s best to avoid providing a sperm sample until you have fully recovered. Ideally, you should wait until you are symptom-free for at least a few days, and if possible, up to a week.
I mean, nowadays, everyone is potentially someone who could have the coronavirus. I think that as long as you keep the 2-meter distance we mentioned, wash your hands, ensure that others wash their hands as well, and try to avoid touching each other, it should be safe enough. Of course, it depends on each country, but maintaining social distancing and following all those safety measures would be the ideal approach.
That’s what I was trying to convey in the presentation. I think now would be a good moment to start planning for IVF, taking into consideration that life will hopefully get back to normal in the next couple of months. I would recommend starting to plan for that, but with some flexibility, as things may not go exactly as we hope—life has shown us that very clearly. However, I believe this is a good time to focus on planning and getting the necessary tests done. I am fully aware that in some countries and cases, it might be difficult to get tested or have access to healthcare right now, especially for non-urgent matters. But overall, I think we should try to start planning and advance as much as possible with the fertility journey during this time.
It is still unknown how the coronavirus is going to behave with warmer temperatures. For the other coronaviruses that we know, it appears that the expansion and survival of the virus tend to be less in warmer conditions. So, we would expect that there will be fewer cases. Additionally, coronavirus is not usually an infection that we get during the summer, especially with the global health policies put in place to contain the spread of the virus. I hope that by summer, things will improve significantly, and that most clinics will reopen and operate normally again.
What I think, and I hope, is that by May we will be working again, and fully operational by June. However, I believe that during April, things are still going to be complicated. As I mentioned, our lockdown is going to last until the 11th of April, and there is a chance it might be extended a bit further. But the fact that the clinic is not open physically doesn’t mean that we cannot provide healthcare. We can still have online consultations, and our entire team is working full-time from home to provide you with all the care you might need during this time.
Not necessarily, no. I don’t think that this should weaken your immune system. This is a very general question, and it depends on each patient and whether you already have an immune problem. But generally, it should not weaken your immune system.
I’m sorry that you’ve been waiting for 2 years and that you find yourself in this situation, which is not making things easy. My very strong recommendation would be to create the embryos so that, if the donor is in the middle of the stimulation and the clinic has decided to finish her cycle, the embryos are created and frozen. Then, you can have the embryo transfer at another moment when you’re not in such a stressful situation. If they freeze the embryos at the blastocyst stage and use vitrification, you should have very good chances of pregnancy even with frozen embryos. In good clinics, the survival rate of frozen embryos is usually around 98%, so you shouldn’t be worried about that. I also think that all the anxiety and stress this situation might be causing you right now could negatively affect the likelihood of achieving pregnancy. I know it’s tough to have to wait after waiting for so long, but my very strong recommendation would be to freeze the embryos right now.
I don’t have the exact answer to that. It takes a while, but if you’ve already started the granulocyte and tacrolimus and are weaning off prednisolone, you’re still a little immune-suppressed. Hopefully, I’d say that within a month, you should be back to normal. What I would recommend is that you take all the precautions that were given as general advice and apply them even more strictly to try to avoid the risk of COVID-19, but you should be fine.
I wish I had a magic recipe, pill, or something that I could tell you that if you take it, your eggs will be of fantastic quality. Unfortunately, there is nothing proven, and there’s very little scientific evidence to say that any medication will improve egg quality. However, following all the general health advice I gave before, such as not smoking and having a healthy diet, will help. There are some supplements, like melatonin or certain antioxidants and vitamins, that have limited data, and sometimes even controversial evidence, on whether they might help with egg quality. I don’t think taking melatonin or a multivitamin for pre-pregnancy will do any harm, but it’s important to be conscious that we don’t have enough evidence to say for sure that it will improve egg quality.
I’m so sorry for your situation. We usually use the long protocol after a cycle in which we had a very unsynchronized response, which is what I understand from the information you’ve given me. However, I’m missing some parts of the information here. I think that after three unsuccessful IVF attempts, egg donation is something to at least consider. That said, I would probably need a bit more detail about your medical history to provide a proper assessment. If you’re interested, we can arrange an online consultation with my team, which is free of charge for the initial consultation. If you provide me with a little more information, I can give you more detailed advice.
I think there is no problem. From what I understand, you’re in the second mock cycle, and I don’t think there is any issue with continuing the mock cycle and having a hysteroscopy before the embryo transfer in April. The challenge, however, is that you’ll likely need to travel to Spain to do the hysteroscopy. What I would suggest is that you contact your clinic and discuss your concerns regarding the likelihood of being able to travel to Spain and proceed with the next steps of the treatment.
They may suggest doing another round of the mock cycle and extending everything for another month, to see if it becomes easier for you to travel. It’s difficult to give you precise advice, but from a health perspective, I don’t think there is anything you need to be concerned about. I completely understand, though, that you don’t want to remain in the mock cycle indefinitely. So, yes, I recommend speaking with them to see what advice they give you, in terms of whether you’ll likely be able to fly. Alternatively, you could explore the possibility of doing the hysteroscopy in your own country, if that makes it easier.
A mock cycle is a cycle in which we give you the same medication that we would use for real endometrial preparation when you’re about to have either a frozen embryo transfer or the transfer of embryos from an egg donor. The goal is to assess how the endometrium responds to the medication. Typically, we use a mock cycle for patients who are already in menopause and haven’t had hormones in their bodies for a long time, or for those with a history of having a thin lining. It’s also used simply to see, before undergoing the real cycle, how the endometrium responds.
Yes, elective surgery refers to any surgery that can be delayed without jeopardizing the health of the patient. The only surgeries that should be done right now are those that are urgent, such as if you break your leg or have appendicitis, or similar conditions. Other surgeries, which are considered scheduled or program surgeries, should be delayed.
Yes, because what we’re going to do with a mock cycle is give you the estrogen and progesterone that you need to have a good lining. That’s the main reason why we can help patients who are in menopause or have premature ovarian failure, or similar conditions, to get pregnant. We can replace the hormones that your body is not producing naturally, so yes, that would be a possibility.
This is a very general question, but the lockdown is affecting everything. For all the embryos that have already been biopsied, which I assume is probably most of the embryos, as most clinics are following those recommendations, it’s a matter of the labs doing the genetic assessment of the embryos. As far as I’m concerned, at least the one we’re working with has the genetic information they need. However, I don’t know if it’s affecting other labs differently, and we might experience some delays with results because of the general situation. Everything is moving more slowly.
Generally speaking, I think that a pre-pregnancy general multivitamin, which for sure contains folic acid, is what you should be taking. So, it depends. There are a lot of brands and different brands depending on the country where you are, but the most important one that you should be taking is folic acid, also check your vitamin D levels and if your vitamin D is low I would also recommend taking a supplement of vitamin D, which there’s a lot of people who lacks vitamin D and those are the most important ones.
