Spring flowers add much-needed brightness to life during the COVID-19 crisis. Image by Sergee Bee via Unsplash.
[This article deals with rapidly evolving circumstances. It was written by Norbert Gleicher, MD, on March 25, 2020 and published on March 26, 2020. For a list of all COVID-19 Bulletins, please scroll to the bottom.]
The controversy surrounding the recent _ASRM _Position Statement
Whether to remain open as an infertility center has become a very controversial issue within the national IVF community. The American Society for Reproductive Medicine (ASRM) published a Position Statement, which we in its summary reprinted in the COVID-19 Bulletin on March 17, 2020. In this statement, ASRM, in our opinion, issued logical and appropriate guidelines which were then significantly misinterpreted and, in rather unprecedented ways, came under attack. In the same March 17 Bulletin, we explained CHR’s position regarding the ASRM statement, hopefully understanding its subtleties. Those who were infuriated over the ASRM statement for all the wrong reasons, likely overlooked those nuances.
On first impression, the _ASRM _statement may, indeed, appear dictatorial and overreaching, if one only reads the following four summary points made in the statement.
- Suspension of initiation of new treatment cycles, including ovulation induction, intrauterine inseminations (IUIs), in vitro fertilization (IVF) including retrievals and frozen embryo transfers, and non-urgent gamete cryopreservation.
- Strongly consider cancellation of all embryo transfers, whether fresh or frozen.
- Suspend elective surgeries and non-urgent diagnostic procedures.
- Minimize in-person interactions and increase utilization of telehealth.
But the statement also contained a fifth point that stated:
- Continue to care for patients who are currently ‘in-cycle” or who require urgent stimulation and cryopreservation.
With this fifth statement, _ASRM _fully acknowledges that there are “urgent” cases that should not and cannot be deferred. There, indeed, is no reason why an elective egg freezing cycle in a healthy 28-year-old cannot be deferred. But should it be deferred in a healthy 38-year-old with already low ovarian reserve? Similarly, whether a 32-year-old with tubal disease and normal ovarian reserve has her IVF cycle today or in three months, likely, does not matter much; yet, in a 45-year-old, three months can be a lifetime.
The ASRM statement also came under fire for allegedly abandoning the concept of infertility being a disease. CHR does not see this to be the case: Infertility remains, as much (or as little) a disease before and after the ASRM statement.
ASRM statement is reasonable in taking urgency into consideration
If one looks objectively at the _ASRM _statement, it can be summarized in one logical sentence: What is urgent is urgent and what can wait can wait. The reality of infertility care is that most IVF centers do not treat many urgent cases of their own choosing. How many IVF centers in the U.S., for example, treat older women with use of their own eggs? National IVF outcome registries clearly demonstrate that most centers pretty automatically advance their patients into egg donation cycles after ages 42-43. Are donor egg cycles “urgent?” Obviously, they are not! The same can be said about other “urgent” circumstances for patients, where timely treatments are essential. How many IVF centers make themselves available for emergency egg freezing cycles in young women diagnosed with cancer? Or how many IVF centers maintain a license to freeze ovarian tissue in such emergency situations?
The truth of the matter is that the services that most fertility/IVF centers provide can, indeed, not be viewed as “urgent.” Median age of IVF patients in the U.S. has remained steady over the last few years at around 36 years. Patients in their 30s, in an overwhelming majority, will not be adversely affected by short delays in their IVF cycles. Considering the current worldwide COVID-19 crisis, ASRM’s argument that in such “non-urgent cases”cycles should be delayed, in CHR’s opinion, makes sense, if one considers the cost-benefits for individuals, health care workers as well as society as a whole.
Where ASRM fell short
Where the ASRM opinion, however, fell somewhat short was more the tone than the substance of the announcement: _ASRM _should have commented on a patient’s absolute right to self-determination, as well as on physicians’ right to refuse treatments if their belief systems so mandate. Moreover, _ASRM _should have been clearer in the definition of what represent “urgent” clinical activity in infertility.
CHR is a good example why this is of importance: The median age of patients at CHR is not 36 years but, over the last three years, has been 43 years. This means that at least half of CHR’s patients are actually over age 43. As already noted, two to three months at such advanced ages can represent a lifetime. In contrast to most IVF centers, those centers that, like CHR, in a majority serve women at these advance ages, have different ethical obligations toward maintaining services for their patients. They, indeed, must stay open for as long as possible and, if that is no longer possible, they must attempt to try to find for these “urgent” cases other providers who can still offer services.
Fertility centers' responsibilities during the COVID-19 pandemic
CHR, therefore, views the current dispute within the profession regarding the ASMR’s Position Statement as greatly overblown. Assuming good will on both sides of the disagreement, everybody can, likely, agree to the following:
- “Non-urgent” infertility treatment can and should be deferred during the COVID-19 epidemic.
- Fertility centers that face the need to conduct “urgent” treatments, may continue to do so, as long as they offer a protective environment at the center for patients and staff in accordance with national infectious disease guidelines for COVID-19.
- The definition of treatment as “urgent” requires the likelihood that a delay of 3-months or more may reduce the chance of a successful treatment and/or cause other damage to patients.
- Fertility centers have an affirmative obligation to respect their patient’s right to self-determination but also have obligations to be protective of their employees and responsive to best interests of society as a whole.
CHR will further comment on this subject in the April issue of the CHR VOICE.
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Norbert Gleicher, MD, FACOG, FACS
Norbert Gleicher, MD, leads CHR’s clinical and research efforts as Medical Director and Chief Scientist. A world-renowned specialist in reproductive endocrinology, Dr. Gleicher has published hundreds of peer-reviewed papers and lectured globally while keeping an active clinical career focused on ovarian aging, immunological issues and other difficult cases of infertility.
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