What is COVID-19 and how does it differ from previous types of Coronavirus Strains?
Coronaviruses are a large family of viruses which may cause illness in animals or humans. In humans, several coronaviruses are known to cause respiratory infections ranging from the common cold to more severe diseases such as Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS). The most recently discovered coronavirus causes coronavirus disease COVID-19.
This novel coronavirus (SARS-COV-2) is a new strain of coronavirus, not previously identified in humans, causing COVID-19 first identified in Wuhan City, China towards the end of 2019,
According to the WHO, the most common symptoms of COVID-19 are fever, dry cough, and tiredness. Some patients may have aches and pains, nasal congestion, sore throat or diarrhoea.
These symptoms are usually mild and begin gradually. Some people become infected but only have very mild symptoms. Most people (about 80%) recover from the disease without needing hospital treatment.
Around 1 out of every 5 people who gets COVID-19 becomes seriously ill and develops difficulty breathing. Older people, and those with underlying medical problems like high blood pressure, heart and lung problems, diabetes, or cancer, are at higher risk of developing serious illness.
However anyone can catch COVID-19 and become seriously ill. Even people with very mild or no symptoms of COVID-19 can transmit the virus. People of all ages who experience fever, cough and difficulty breathing should seek medical attention.
How is Covid-19 transmitted?
Most cases of COVID-19 are due to human-to-human transmission. This virus can be readily isolated from respiratory secretions, faeces and fomites (simple inanimate objects or materials which when contaminated with or exposed to infection can transfer disease such as clothes, utensils, and furniture). There are two routes by which COVID-19 can spread. The first is directly through close contact with an infected person (within 2 metres) where respiratory secretions can enter the eyes, mouth, nose or airways. This risk increases the longer someone has close contact with an infected person who has symptoms. The second route is indirectly via the touching of a surface, object or the hand of an infected person contaminated with respiratory secretions and subsequently touching one’s own mouth, nose or eyes.
How can I reduce my risk of infection?
The most important thing to do is to follow government guidance.
For women and the rest of their households, this includes:
- We would recommend patients and potential donors to self-isolate as much as possible, from the start of ovarian stimulation treatment until egg collection.
- We will expect patients and potential donors to self-isolate from second Covid test (as below) to egg collection.
- Regular hand washing
- Use a tissue when you or anyone in your family coughs or sneezes, discard this and wash your hands
- Avoid contact with someone who is displaying symptoms of coronavirus. These symptoms include high temperature and/or new and continuous cough
- Avoid non-essential use of public transport
- Work from home, where possible.
- Avoid large and small gatherings in public spaces, noting that pubs, restaurants, leisure centres and similar venues are currently shut as infections spread easily in closed spaces where people gather together.
- Avoid gatherings with friends and family. Keep in touch using remote technology such as phone, internet, and social media
- Use telephone or online services to contact your GP or other essential services
For all hospital visits:
- You will be required to wear surgical masks that we will provide on entry to the hospital
- See Diagrams in Appendix for further information and how to safely use
How has the clinic deemed it acceptable to restart fertility treatments?
As a fertility clinic, have a clear clinical and ethical responsibility to our patients and a wider social responsibility to promote public health by ensuring the isolation measures recommended by Public Heath England health were strictly adhered to, not only to prevent harm from infection for our patients, but also to support the government and NHS efforts to combat this epidemic. Although undoubtedly disappointing for our patients not to be able to start new treatment cycles, and difficult for us to stop our IVF programme, we knew this was the correct decision in March as the pandemic escalated, and was supported by national guidance from the British Fertility Society and HFEA.
Throughout the treatment pause, whilst supporting the NHS with emergency early pregnancy work, we have been planning how to recommence treatments safely.
As the COVID-19 pandemic begins to stabilise, we will be following published guidelines to enable us to restart treatment cycles safely. The HFEA have set out the following criteria that need to be met:
- that Government restrictions on social contact and travel are lifted or eased
- that restarting fertility treatment would not have a negative impact on the NHS
- that there was no evidence that Covid-19 impacted on the health of pregnant women or their babies
- that fertility clinics are able to provide a safe service.
Once these were met, the HFEA allowed us to restart and we outline some of the measures we have in place below.
What are the differences in the treatment process in light of Covid?
These include are not are not limited to:
- The use of PPE as per strict guidance by staff and patients
- Measures in-clinic to minimize unnecessary interactions and maximize social distancing
- Egg collection under Sedation to minimize risk to patients and staff
- Covid-Triage policy introduced
- Covid-Test policy introduced
- Strict visitor policy as below (female partner only apart from pre-assessment and consent)
- All visits MUST BE by appointment only and there will be no drop in service
Will I be tested before I start treatment?
No, you will not be tested if you are well and pass our triage test developed from professional body guidance (BFS / ESHRE) but will be tested later as below.
- Triage Questionnaire Test at booking of any appointment prior to visit
- Triage Questionnaire Test at nurse pre-assessment Appointment (in person by the nurses)
- Triage Questionnaire Test at start of treatment
- Triage clearance prior to every visit
- All women will be tested on 2 occasions prior to egg collection, the second of which will be as close to collection as test turnaround will allow.
- If you test positive your VEC will be cancelled
- All women following testing will be required to self-isolate at home until the collection following this test
- Male partners using fresh sperm will be retested on the day of egg collection
- If the male partner tests positive of if you become unwell following collection your embryos will be cultured and frozen for later use
- This pathway of testing pre theatre testing and self isolation will also apply to those men undertaking surgical sperm retrieval
- For Sperm Freeze Patients: Covid screen 72hrs before freeze appointment and self-isolation until appointment
Is it safe for me to become pregnant?
Becoming pregnant during the coronavirus pandemic is a matter of personal choice. Whenever we talk about pregnancy and medical risk we have to look at the impact of the disease on pregnancy and the impact of the pregnancy on the disease which we outline below.
However, even when Assisted Reproductive Treatments (ART) were stopped to ensure socially responsible distancing could be maximised, minimise the spread of the disease and to support NHS, women were not being told to avoid natural conception and no professional body in the UK or elsewhere in the world advocated this. This is reassuring, as is the stance of the governing bodies such as the RCOG and the reassurance of being allowed to recommence ART by the fertility regulating bodies (BFS, ESHRE, ASRM and by the fertility regulator (HFEA).
What are the risks to me of Covid-19 in pregnancy?
According to WHO and RCOG, pregnant women no evidence that pregnant women who get this infection are more at risk of serious complications than any other healthy individuals, although the available data on the exact effects of COVID-19 on fertility and pregnancy is scarce.
- The RCOG also confirms that pregnant women generally do not appear to be more likely to be seriously unwell than other healthy adults if they develop coronavirus.
- It is expected the large majority of pregnant women will experience only mild or moderate cold/flu like symptoms. Cough, fever, shortness of breath, headache and loss of sense of smell are other relevant symptoms.
- More severe symptoms such as pneumonia and severe hypoxia (low oxygen saturation), seem to be more common in older people, those with weakened immune systems or long-term conditions such as diabetes, hypertension, chronic lung disease and cancer.
- Pregnancy is generally a hypercoagulable state (increased tendency to clotting) and emerging evidence suggests that those admitted to hospital with Covid-19 are also at a higher risk. If you then consider the further risk of reduced mobility resulting from self-isolation at home, it follows that infection with or hospital admission with Covid-19 is likely to be associated with an increase risk of maternal venous-thromboembolism (blood clots) and this needs to be monitored and treated carefully.
- If you think you may have symptoms of COVID-19 you should use the NHS 111 online service for information, or NHS 24 if in Scotland. If you develop more severe symptoms or your recovery is delayed, this may be a sign that you are developing a more significant chest infection that requires specialised care.
What are the risks to my baby of Covid-19 if I develop it in pregnancy?
The RCOG confirms that “this is a very new virus we are just beginning to learn about it. There is no evidence to suggest an increased risk of miscarriage and it is considered unlikely that if you have the virus it would cause problems with your baby’s development, and none have been observed currently”
- Emerging evidence suggests that transmission from a woman to her baby during pregnancy or birth (vertical transmission) is probable. There has been a report of two cases in which this seems likely, but reassuringly the babies were both discharged from hospital and are well.
- In all previously reported cases worldwide, infection was found at least 30 hours after birth. It is important to emphasise that in all reported cases of newborn babies developing coronavirus very soon after birth, the baby was well.
- Across the world emerging reports suggest some babies have been born prematurely to women who were very unwell with coronavirus. It is unclear whether coronavirus caused these premature births, or whether it was recommended that the baby was born early for the benefit of the women’s health and to enable her to recover.
- The UK is conducting near-real-time surveillance (observation) of women who are hospitalised and test positive for COVID-19 during pregnancy, through well-established systems already used by all maternity units – this is the UK Obstetric Surveillance System (UKOSS). Imperial College London are also running a surveillance programme (PAN-COVID) to monitor pregnancy and neonatal outcomes for women with COVID-19. We will update our information if and as soon as there is any change in the evidence.
- For further information on later pregnancy care, delivery, breastfeeding and postnatal care and the Covid crisis please read the RCOG information in full.
If the risks are so limited, why are pregnant women in the “vulnerable”?
Pregnant woman were placed in a vulnerable group by the Chief Medical Officer on 16th March. This means they had been advised to reduce social contact through social distancing measures from early on in the crisis.
Based on the evidence we have so far, pregnant women are still no more likely to contract coronavirus than the general population. What we do know is that pregnancy in a small proportion of women can alter how your body handles severe viral infections. This is something that midwives and obstetricians have known for many years and are used to dealing with. As yet, there is no evidence that pregnant women who get coronavirus are more at risk of serious complications than any other healthy individuals.
What has driven the decisions made by officials to place pregnant women in the vulnerable category is caution. We know that some viral infections are worse in pregnant women. At the moment, there’s no evidence that this is the case for coronavirus infection, but the amount of evidence available is still quite limited.
How are can I be reassured of any risk of infection from hospital staff?
Throughout the crisis, whilst the Lister Fertility Clinic has remained open and maintained clinical activity in support of the NHS, as part of HCA Healthcare has followed strict and wide-ranging protocols involving more stringent testing, PPE use, contact tracing and requirements before return to work is acceptable than local NHS trusts and PHE recommendations.
These include and are not limited to:
- Temperature checking performed on arrival at work daily
- Strict PPE guidance for use in clinical, non-clinical and theatre settings
- Isolation policy in place with symptoms
- Isolation policy in place with family member with symptoms
- Testing policy in place with symptoms at home or in workplace
- Contact Tracing and testing policy in place
- Occupational Health Advice and management in place
- Necessity for 2 negative tests pre-return to work in place
What else is the clinic and hospital doing to decrease my risk?
As well as the measure above, the hospital is further ensuring patient and staff safety with:
- Maximisation of Telemedicine to minimize unnecessary contact
- Treatment cycles processes arranged to reduce unnecessary visits and staff-patient contact
- Redesign of waiting areas to guarantee appropriate distancing
- As default post in-cycle scan conversations with nurse or doctors will be done by phone
- Continued use of appropriate PPE by all staff with guidance for use in different settings
- Strict limitation of visitation guidelines in hospital that must be adhered to
- Patients only to attend for treatment visits
- Partners only to attend for:
- Pre-assessment appointments
- Day of egg collection
- Children are not allowed in the building at present
- We will also be recommending any contract tracing apps / software when they are introduced
- Our policy will be reviewed every 2 weeks or earlier with any new guidance
Can I discontinue my treatment if anything happens to make me worry that I have become at risk?
Yes, you are able to abandon treatment at any time during your treatment cycle prior to egg collection. If there are concerns following egg collection, the eggs or embryos can be frozen for transfer at a later date. Cycle charges for cycle abandonment would be incurred, the extent of which would depend on stage of cycle as per our pricelist. Any drugs purchased would not be able to be returned or refunded.
Is there a risk that my cycle could be cancelled if I proceed with treatment now?
Although, you can proceed with the treatment if you are well and are asymptomatic this is a possibility.
- There is a risk you or your partner may acquire the infection after you have commenced the treatment.
- Depending on where you are in the cycle we would advise you appropriately. This may involve abandonment of the cycle if you are symptomatic at the early stage of the cycle or freeze embryos if after collection.
- We will not proceed with egg collection if you test positive beforehand
- We will not proceed with transfer if you become unwell after collection or if the male partner tests positive on day of collection
- A plan for a further cycle to discuss embryo transfer will be made once you are well enough to proceed again.
- Cycle charges for cycle abandonment would be incurred, the extent of which would depend on stage of cycle as per our pricelist. Any drugs purchased would not be able to be returned or refunded.
What happens if I or someone else feels or becomes unwell with Covid symptoms while in the clinic?
The hospital has a specific process of isolation of any staff member or patient who becomes unwell or shows symptoms while in the hospital with a designated “quarantine area” before they are escorted out of the hospital and would follow current guidelines for self-isolation.
Patients and / or partners who are either symptomatic or confirmed as COVID-19 positive will need to postpone treatment as above.
What happens if I get a complication from treatment: Is it safe to be admitted to hospital at the moment?
Whilst we take every precaution to minimize the risk of any complications following treatments (such as post egg collection or with ovarian hyperstimulation) and they are rare, hospital admission for review and treatment can occasionally be necessary. Although admission to the Lister is always available with all the precautions in place that we have outlined many will understandably prefer to be treated at their local NHS hospital.
The HFEA will only allow us to recommence treatments when it is confident that this does not have a negative impact in the NHS and by this point the NHS will be available to admit for these emergency purposes and will have all the appropriate safety measures in place to minimize any Covid-related risk but they may differ to ours.
If I become unwell or test positive for COVID-19, when is it safe to then consider treatment and become pregnant?
There is no set time but we would recommend a full recovery period be allowed as although pregnant women have no increased risk of acquiring the infection, the immune system can be suppressed in early pregnancy. Recovery from Covid is very individual and everyone recovers at different speed both physically and emotionally. Once you feel you have recovered from the symptoms of the illness, you can contact us and prepare for your next treatment. You will require a negative Covid test result to proceed with treatment (we will screen you in advance of starting a new cycle) and if you required respiratory support a medical review before commencing,
Are there any groups of people in whom you would recommend to not start treatment yet?
Yes, the ESHRE guidance recommends that high-risk patients (e.g. diabetes, hypertension, using immunosuppressant therapy, past transplant patients, lung, liver or renal disease) should not start ART treatment in the initial phase of restarting treatment. Our medical team will assess the risk status on a case by case basis. This should be reassessed 3 months following commencing treatments. We will also to avoid using any empirical immunosuppressant treatments such as steroids and IVIG in view of the increased risk of infection along with lack of evidence base.
I have been diagnosed with cancer and chemotherapy is recommended. Can I still attempt to freeze my eggs or embryos?
Although this group are in theory high-risk, the time critical nature of their treatment dictates that we can proceed with the treatment if their oncology and fertility consultants deem it reasonable to go ahead.
Are my frozen embryos, eggs, or sperm safe?
Yes. There is no immediate threat to the safety of cryopreserved eggs, sperm or embryos. Throughout the crisis and lockdown, clinics had policies and procedures to maintain the liquid nitrogen tanks containing frozen embryos, eggs, and sperm.
My mandatory tests are just out of date: Will I need to repeat them?
No. The screening requirements for patients undertaking IVF are set out in the 1990 HFEA Act and it is a legal requirement to have them within 3 months of first treatment and then every 2 years.
However, the HFEA, have confirmed that if the gap is extended due to circumstances arising as a consequence of COVID-19, we can still consider treatment without repeating after risk-assessment of your safety and lab safety.
This is obviously a “non-compliance” of the HFEA Code of Practice but we are comfortable with this decision in the current unprecedented circumstances.
What is the current travel advice surrounding Covid-19 and how does pregnancy affect this?
If you are in the UK, you should follow the advice given by the Foreign and Commonwealth Office on social distancing and non-essential travel which is being regularly updated in line with the evolving situation. This certainly will be updated as the disease evolves. All individuals, including pregnant women, should ensure they have adequate insurance arrangements prior to travel. You should also check that your travel insurance will provide cover for birth and care of your newborn baby if you give birth while abroad.
Will the clinic provide extra support and counselling through this difficult time?
Yes. In this unprecedented time of pressure and uncertainty, we are aware how difficult it must be for those who were expecting to commence treatment or investigation. The stress and anxiety experienced routinely during fertility treatment can be overwhelming and even without the added burden of the Covid-19 crisis and delay, the emotional and psychological distress is often heightened by the feeling of having such little control over the outcomes.
- Covid Support Line: This is why we established our Covid support line available to all, whether our patients or not, offering the opportunity to speak with one of our expert fertility Consultants via a free support line between 9am – 5pm (Monday to Friday) to discuss COVID-19 and fertility related queries, current treatment plans and how this delay will affect them and options for when treatment can begin. This will continue to be available in the early stages after restarting treatment (available 9-5 on 07850 502 709).
- Free Counselling Service: We recognise how difficult it is to cope with the emotional and psychological distress experienced due to the COVID-19 crisis which is why we continue to offer our normal free counselling serviceefor support via phone / FaceTime or Skype to our patients. Being able to talk about this and considering coping strategies can help patients to manage better as they navigate their way through their individual fertility journey. To book a free counselling appointment please call us on 0207 881 2000 or email Secretarygroup@lfclinic.com
- The Fertility Community is a close-knit and supportive one and we would recommend utilising this community with excellent content and information via groups such as IVF babble and Fertility network UK are few of the sites you can look at. Some of these sites have an online support community, local support groups, webinars, and other content to help you connect, get support, and stay informed.
- Government Social Distancing Advice
2. Government Travel Advice
- RCOG Information on Pregnancy
- WHO information
- ESHRE guidance on restarting treatments
- BFS guidance on restarting treatments
- HFEA information on Covid