JBRA Assist. Reprod. 2020;24(3):233-234
EDITORIAL
doi: 10.5935/1518-0557.20200048
1Department of Obstetrics and Gynaecology of the Universidade Federal de Minas Gerais, Brazil
2ORIGEN, Center for Reproductive Medicine, Brazil
3Instituto Valenciano de Infertilidad, Universidad de Valencia, Valencia, Spain.
On March 11th, 2020, the World Health Organization (WHO) declared the coronavirus
disease 2019 (COVID-19) a pandemic. Since then, all federal and local authorities as
well as regulatory agencies have asserted and developed robust policies in order to
reduce the spread of the disease, worsening of clinical presentation and deaths related
to the infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2),
the virus responsible for COVID-19. Their statements also address concerns on the risks
to pregnant women and maternal transmission to babies.
As much as reproductive medicine is concerned, physicians and patients are still
searching the best ways to face the challenges that are still ahead. Therefore, it is
very likely that all reproductive medicine scientific societies worldwide have published
its guidelines to head local authorities and reproductive medicine professionals on what
would be the best conduct. Although there is still a lack of scientific evidence on
whether there is a negative impact of the COVID-19 on reproductive outcomes as well as
vertical transmission, the most frequent suggestions have been to avoid pregnancies and
discontinue fertility treatments, with exception for fertility preservation in oncologic
patients and urgent cases (ASRMa; ESHREa; REDLARA & SBRA, 2020). These
recommendations aimed to reduce non-essential contacts and prevent possible maternal and
fetal complications and also to support the necessary reallocation of healthcare
resources.
More recently, new orientations have been published to guide Assisted Reproductive
Technology (ART) treatments restart for any clinical indication, where COVID-19
infection is decreasing, in line with local regulations (ASRM, 2020b; ESHRE, 2020b).
However, so far, we do not know how long this pandemic will last, and when life will
return to normal. Due to this uncertainty, we also cannot affirm when clinics will be
able to offer routine basis treatment for all infertile couples looking for treatment.
Postponing ART cycles, might represent disastrous consequences for older patients, those
with reduced ovarian reserve and also for those with financial problems. In this group
of patients, the restriction for ART treatments might affect the chance to conceive
after the end of this period.
According to the WHO, infertility is a disease of the reproductive system which
generates disability and affects more than 50 million couples around the world (Mascarenhas et al., 2012). A
considerable amount of this population has benefited from ART as it has been estimated
that over 8 million babies have been born since the birth of the first IVF baby. Not to
mention that more than a half million babies that are born from over 2 million in vitro
fertilization cycles per year (Fauser, 2019).
Infertility treatment changes and cancellations are creating a clear crisis for those
who badly want to have a child. Thus, it should be relevant if scientific organizations,
governments and regulatory health agencies could consider the inclusion of fertility
preservation treatment in the forthcoming guidelines in order to minimize the negative
impact of delaying ART treatment on pregnancy rates.
Fertility preservation might be performed through gamete and embryo cryostorage. Sperm
cryopreservation is and old and well stablished technique that have been showing regular
results for more than fifty years. Embryo freezing is also a well stablished technique,
being performed for over 30 years. Moreover, recently, it has been reported that the
transfer of frozen/thawed embryos provide similar or even better results than those
observed after fresh cycle embryo transfer (Roque et al., 2019).
Oocyte cryopreservation is no longer an experimental technique and is considered one of
the most important advances in assisted reproduction. It is indicated for oncologic
patients and for those who decide to postpone motherhood. The results are comparable to
those observed with embryo freezing proving to be effective for protecting fertility
(Cobo et al., 2018). However,
even for fertility preservation, age and ovarian reserve are fundamental for success
since the more oocytes one gets, the higher the pregnancy rates. These facts reiterate
the need not to impose a delay in infertility treatment and therefore fertility
preservation should be offered for all patients who cannot or are not allowed to become
pregnant at this moment.
Moreover, it is indeed fundamental to consider that ART treatment and fertility
preservation do not implicate any harm to the patients, as, so far, there have been no
confirmation of transmission of COVID-19 via gametes and embryos, and there is no
scientific evidence of uterine vertical transmission (Cochrane Gynaecology and
Fertility, 2020). Also, as we do not know how long this pandemic will last and when life
will return to normal, irrespective of all efforts that have been made worldwide,
instead of not doing nothing and, as doing nothing, we can worsen patient’s reproductive
prognosis, we could preserve fertility and, at least, postpone our doubts and
uncertainties.
Accordingly, it is our opinion that COVID-19 could be a new indication for fertility
preservation for a determined deadline, until complete return of assisted reproduction
treatments in regular basis.
Cobo A, García-Velasco J, Domingo J, Pellicer A, Remohí J. Elective
and Onco-fertility preservation: factors related to IVF outcomes. Hum Reprod.
2018; 33:2222-31. PMID: 30383235 DOI: 10.1093/humrep/dey321
Medline Crossref
Fauser BC. Towards the global coverage of a unified registry of IVF
outcomes. Reprod Biomed Online. 2019; 38:133-7. PMID: 30593441 DOI:
10.1016/j.rbmo.2018.12.001
Medline Crossref
Mascarenhas MN, Flaxman SR, Boerma T, Vanderpoel S, Stevens GA.
National, regional, and global trends in infertility prevalence since 1990: a
systematic analysis of 277 health surveys. PLoS Med. 2012; 9:e1001356. PMID:
23271957 DOI: 10.1371/journal.pmed.1001356
Medline Crossref
Roque M, Haahr T, Geber S, Esteves SC, Humaidan P. Fresh versus
elective frozen embryo transfer in IVF/ICSI cycles: a systematic review and
meta-analysis of reproductive outcomes. Hum Reprod Update. 2019; 25:2-14. PMID:
30388233 DOI: 10.1093/humupd/dmy033.
Medline Crossref