In early 2020, the COVID-19 pandemic gripped the United States, bringing with it countless uncertainties about the virus itself, its mode of transmission, and the best methods for testing and optimal treatment. The growing number of individuals infected nationally threatened the ability of virtually all health care systems to care for sick individuals effectively, and resources previously allocated to elective and nonurgent medical care were shunted to relieve an onslaught of patients requiring care for SARS-CoV-2. This ultimately resulted in a national pause in the provision of nonurgent fertility treatment. Later on, as initial restrictions were lifted, fertility practices in the United States were required to evolve and adapt in order to continue providing services amidst an ongoing pandemic.

Caring for patients undergoing controlled ovarian stimulation (COS) and oocyte retrieval requires careful consideration, given the large number of in-person visits required for ultrasound assessment and laboratory evaluation over weeks of treatment. This treatment results in a high number of interactions between patients and staff members. As the pandemic progressed, the American Society for Reproductive Medicine (ASRM) COVID-19 Task Force developed recommendations to optimize the provision of fertility services, with the goal of helping clinics develop protocols for safe practices, including use of social distancing and appropriate personal protective equipment, testing patients during treatment, screening patients for symptoms, and considering canceling procedures in the setting of a positive COVID-19 test (1COVID-19 screening during fertility treatment: how do guidelines compare against each other?.).Recommendations from different societies, including ASRM and the European Society of Human Reproduction and Embryology, helped steer clinics. However, the general lack of data informing these recommendations contributed to their heterogeneity and prevented the creation of guidelines, which would have required that more data regarding optimal management exist (1COVID-19 screening during fertility treatment: how do guidelines compare against each other?.). Early on, the role of testing for COVID-19 became an important subject in maintaining safety while providing assisted reproductive technology (ART) treatment, although the role that testing played in preserving the safety of providers and patients remained unclear.In their retrospective cohort study, Shaw et al. (2

Shaw J, Tozour J, Blakemore JK, Grifo J. Universal SARS-CoV-2 PCR screening and assisted reproductive technology in a COVID-19 pandemic epicenter: screening and cycle outcomes from a New York City fertility center. Fertil Steril. In press.

) aimed to describe the rate of COVID-19 positivity by polymerase chain reaction (PCR) testing of patients undergoing COS in an academic fertility center in New York City from June 2020 to February 2021. A New York City mandate required PCR testing within 5 days of oocyte retrieval during this study period. In addition to universal testing, this clinic also screened for patient-reported symptoms, participated in temperature monitoring, and worked to maintain social distancing in clinical spaces.

Of the 1,696 COS cycles, only seven patients had a positive COVID-19 test, for an overall positivity rate of 0.4%. One of these seven patients experienced severe symptoms of COVID-19, and no patients were diagnosed with ovarian hyperstimulation syndrome. Additionally, this study found that the volume of COS cycles was higher than in the year before the COVID-19 pandemic, and the rate of cancelation was lower. Oocyte yield and blast usage at transfer were unchanged.

This study demonstrated that patients undergoing COS who required frequent health care visits, including ultrasound monitoring and laboratory draws, largely remained negative when tested for SARS-CoV-2, which provides further support for the safety of providing this health care service when appropriate precautions are taken. The large number of subjects captured in this study period where preprocedural testing was mandated and therefore universal is a clear strength.

Additionally, the investigators highlight that the COVID-19 positivity rate by PCR testing in their clinic was “significantly below community levels and levels within our hospital system” (2

Shaw J, Tozour J, Blakemore JK, Grifo J. Universal SARS-CoV-2 PCR screening and assisted reproductive technology in a COVID-19 pandemic epicenter: screening and cycle outcomes from a New York City fertility center. Fertil Steril. In press.

). This low positivity rate calls to attention a striking difference in the COVID-19 positivity rate between patients undergoing COS and those in the general population in New York City at the time. This study was composed of primarily White women, with ≤5% representation from patients who identified as Hispanic or Black. The COVID-19 pandemic has accentuated disparities in health and health care access, particularly among African American and Latino populations, likely stemming from the complex interplay of unequal access to care, systemic racism, and structural and social determinants of health, among other factors (3Webb Hooper M. Nápoles A.M. Pérez-Stable E.J. COVID-19 and racial/ethnic disparities.). The disparities noted in the pandemic itself and also in the prevalence of SARS-CoV-2 in the primarily White population in this study mirror the known disparities in infertility diagnosis, care, and access in the United States.

More globally, the study results emphasize in this highly compliant population of patients the ability of ART treatment to continue during a pandemic with minimal risk of cycle cancelation due to positivity, despite high prevalence in a surrounding area. One must question, however, whether these data are generalizable to all fertility clinics. Is New York City unique in some way that is not appreciated by the investigators of this study? Were similar findings noted in other major metropolitan cities, such as Chicago, Houston, and Los Angeles? As the COVID-19 pandemic continues, data like these can help inform guidelines to maintain safety in the provision of fertility services, especially with the threat of COVID-19 variants in the future. The caveat, of course, is that these statements only hold true when data are aggregated from more than one center, when accurate testing for the circulating virus exists and is easily accessible, and when the burden on the health care system is not forced into an imbalance by provision of non-lifesaving medical care. In short, the study does not provide a carte blanche for provision of ART in any future pandemic, but rather suggests that with methodical, systematic consideration of the healthcare system as a whole and access to accurate, timely testing and appropriate personal protective equipment, ART services can continue without significant harm to providers and patients.

References

COVID-19 screening during fertility treatment: how do guidelines compare against each other?.

J Assist Reprod Genet. 37: 1831-1835

Shaw J, Tozour J, Blakemore JK, Grifo J. Universal SARS-CoV-2 PCR screening and assisted reproductive technology in a COVID-19 pandemic epicenter: screening and cycle outcomes from a New York City fertility center. Fertil Steril. In press.

Webb Hooper M. Nápoles A.M. Pérez-Stable E.J.

COVID-19 and racial/ethnic disparities.

J Am Med Assoc. 323: 2466-2467Article InfoPublication History

Published online: July 09, 2021

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Identification

DOI: https://doi.org/10.1016/j.fertnstert.2021.06.021

Copyright

©2021 American Society for Reproductive Medicine, Published by Elsevier Inc.

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