The novel Corona virus pandemic across the globe has created an unprecedented situation with major challenges that continues as we understand the pattern of this disease. But as the COVID-19 pandemic is stabilising and with the return to normal daily life it is time to consider resuming infertility services in keeping with the guidelines set by ministry of health and family welfare.
Keeping the present situation in view, the IFS- ISAR and ACE has come out with Joint statement released on 26th May’ 2020 with recommendations on resuming/ opening up ART services. This document is drafted to provide centers across the country a guidance as to how should they restart the services.
These are based on the understanding of the COVID-19 disease as of today and shall change with evolving scientific, political and economic situations
The fundamental principle guiding all units is to implement measures that will protect the
patients as well as the staff and minimize the chance of spread of COVID-19.
This involves triage of patients and staff before starting and continuing the treatment cycle. All units should follow their SOP and code of conduct, for both the patients and staff.
The salient features which needs to be considered before starting the treatment cycle are :
1.Services should be started in a phased manner beginning with diagnostic services, COH and TI/IUI, and then subsequently IVF over a period of 2-3 weeks.
2. Sufficient clinical staff, in-house embryologists and nurses should be available that can work in shifts with a ready back-up team in case any staff member is suspected or tested COVID-19 positive and need quarantining.
3. For diagnostic services the following points need to be reconsidered
a)Before Semen analysis ensure that the husband is negative for COVID-19 with RT-PCR (preferable)
b) HSG – To be done with all standard infection control precautions and adequate PPE.
c) Office hysteroscopy (OH) – Office diagnostic hysteroscopy may be done with local para or
intracervical block , for operative hysteroscopy regional anesthesia to be preferred safeguarding the
risks to anesthetist from GA.
d) Laparoscopy (operative) – Elective laparoscopic procedure should be done based on the urgency of
fertility treatment.
5. Proper consent and counselling is an important part of the treatment . The couple should be informed about the following :
a. Potential risks involved in proceeding with fertility testing and treatment during the
COVID-19 pandemic.
b. That information on effects of COVID-19 infection on fertility treatment and early pregnancy are limited. However, there is no evidence that infection increases risk of fetal malformations or miscarriage at present
c. The decision of couple to proceed or postpone the treatment cycle should entirely be theirs.
6. During selection of patients following points need to be considered :
- Treatment should be started for low risk cases who require minimum visits to the clinic. Treatment for high risk patients (those with hypertension, diabetes, on immunosuppressants or transplant patients, with renal, liver, lung disease or medical conditions) should be deferred.
b. Third party reproduction which includes donor and surrogate cycles may be avoided.
c. ART cycles for fertility preservation in cancer survivors to be started at the earliest.
d. Patient prioritization should be done based on:
i. The impact of delay on patient prognosis due to medical factors, such as age, ovarian
reserve or endometriosis.
ii. The impact of treatment delay on the mental and emotional well-being of patients.
7. Triaging and screening includes:
a. Detailed history of travel, symptoms and contact history.
b. Temperature recording and SpO2 (preferable) for screening.
c. Testing: Diagnostic evaluation will be done using RT-PCR, or depending on the regional/local protocol
as well as availability of the test.
d.Testing shall be done at following points –
i) At the commencement of treatment that is day 2 of IVF/ICSI cycle.
ii) Repeat test to be done at-least 48 hours before hCG trigger.
iii) Husband’s to undergo COVID-19 at least 48 hours prior to hCG trigger (ideal to have it on day 2,
when cycle is to be started).
e. In case either partner turns positive on tests the cycle is either not commenced or cancelled depending on situation and contact tracing should be done.
8. Following changes has to be made in the infrastructure
i. Triaging of patients and staff should be done outside the reception area.
ii. Physical distancing (at least 2 mtrs/ 6 ft) should be maintained between individuals
including staff and patients.
iii. Sanitization should be performed routinely as per the local protocols and all individuals
including patients and staff should wear masks at all times and follow hand hygiene.
9. Precautions to be taken during IUI/ IVF cycles
a) cycle is started only for triage negative and confirmed COVID- 19 negative cases
b) Couples to be advised social isolation for 2 weeks prior to reduce risks of infections.
c) Stimulation protocols are planned in a way that involves minimal visits for scans like
fixed antagonist protocol for IVF cycles and lower gonadotropins dosages to reduce risk
of OHSS. In doubtful agonist trigger and freeze all policy to be followed.
d) Lower doses of gonadotropins for IUI cycles with minimal monitoring
e) Prior to OPU patient’s COVID status should be ensured and OPU should be cancelled if the patient tests positive. At the time of OPU IV sedation/propofol or regional should be the preferred mode of anaesthesia for safety to anesthetist.
f) Embryo transfer is performed only in cases of low risk/asymptomatic patients and partners. A freeze-all policy is applied for patients who became symptomatic after the oocyte retrieval
g) Patients to check for pregnancy (beta hCG) at home and intimate over telephone and is called for viability scan 4-5 weeks after ET.
h) In patients who have recovered from symptomatic/ asymptomatic COVID-19 infection IVF cycle is undertaken only after a thorough review.
10. Embryology Lab :
a)Universal Good laboratory practices should be followed in the embryology lab by each staff with proper use of Personal protective equipment (eye protectors, face masks, gloves, shoe covers and disposable laboratory coats).
b) Semen freezing is advised only in indicated cases and not as a regular back up for all OPU.
c) All body fluids including follicular fluid and semen should be handled as potential source of SARS CoV-2 and appropriate precautions should be taken.
f. laboratory surfaces and collection rooms should be diligently cleaned with nonembryo-toxic disinfectants.
e)High security straws and/or vapor phase storage tanks should be used for cryopreservation of samples from COVID-19 positive patients.
f)Gametes/embryos generated after the ART labs restart are desirable to store in Separate
cryotanks and appropriate precautions should be taken during freezing.