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The SARS-CoV-2 virus, causing the current COVID-19 pandemic, is now almost 8 months among us. It has changed everything almost everywhere in the world. With millions of people infected and, in the U.S. alone, almost 250,000 deaths linked to the pandemic, this is only the beginning of the story. Unexpected and, often, unintended medical consequences from how the pandemic was handled by local, state, and federal governments may have created even more victims than the virus. The only difference is, nobody talks about those unexpected and unintended consequences.
This will, hopefully, change now that the elections are over, and the pandemic goes back to be a public health problem, rather than a political football. Within such a context, we here want to address what the current COVID-19 status means for those who currently wish to conceive.
A Brief Status Update
The pandemic is currently in its 3rd wave. Not widely recognized, the 1st wave between March and May primarily affected only the East Coast, including the New York tristate area. The rest of the U.S. also had cases and, therefore, also experienced this 1st wave, but cases occurred in much smaller numbers and experienced much lower mortality than on the East Coast. By now we know that the reason was that East and West entries of the SARS-CoV-2 virus into the territory of the U.S. occurred with 2 different strains of the virus, which varied in only one position on the spike protein of the virus that made the East Coast virus 10 times more infectious. Consequently, the East Coast during the 1st wave was where cases and deaths mounted.
Like most waves of this virus in the U.S. and elsewhere in the world, the 1st wave lasted approximately 10 weeks. Ever since, the East Coast has been experiencing very low disease prevalence and mortality has fallen to very low levels, while elsewhere in the country 2nd and 3rd waves started happening. Interestingly, the 2nd wave involved southern and western states which during the 1st wave were infected by the milder viral strain.
Why the East Coast remained mostly disease-free but southwestern states experienced a very substantial 2nd wave could for the longest time only be speculated. Those suspicions were, however, confirmed when in recent weeks several reports clearly demonstrated that the more aggressive viral strain that initially infected the East Coast was becoming dominant all over the world. The virus infecting south-western states had entered the U.S. coming directly from China, while the East Coast strain entered, coming from Europe, where it had mutated from the milder to the more infectious strain.
In the U.S., a paper that just appeared, for example, documented in detail how in Houston, TX, the more aggressive East Coast strain in the 2nd wave took over the terrain of the state from the milder strain that had been there before and caused a huge wave of disease that has since abated.
That NY and most of the rest of the East Coast were hardly affected in the 2nd wave suggested an additionally important message: The more infectious virus, quite obviously, also induced better immunity than the milder virus. Since the East Coast had been infected in the 1st wave by the more aggressive virus, it also developed better immunity. South-western states, which during the 1st wave only experienced the milder strain, did not achieve enough immunity to prevent the stronger strain from invading their territory and, still, cause significant disease.
An article in the November 7 and 8 edition of The Wall Street Journal demonstrated that the here laid out behavior of the SARS-CoV-2 virus is applicable not only in the U.S. The article reported that Bergamo, a beautiful city in Lombardy in the northern parts of Italy, in the current wave that is sweeping the country demonstrates almost no disease. Like NYC in the U.S., Bergamo during the 1st wave was among the worst-affected cities in all of Italy, if not the world, with very large case numbers and high mortality rates.
As this article is written, we are, likely, at the peak of the 3rd U.S. wave which, yet again, affects selectively only the remaining parts of the U.S., the Midwestern states which, until a few weeks ago, had contact only with the milder viral strain. These states, likely, represented the only U.S. mainland territory so far not exposed to the more infectious strain. That states of the southwest, which had been badly affected in the 2nd wave, now, are almost disease-free, again confirms the observations made before in NYC and along the whole East Coast: The more infectious strain of the virus, while very obviously a much more dangerous virus, also more effectively induced a level of immunity in the region that does not represent what is widely called herd immunity (a level of immunity that prevents all further infections by a virus) but allows, with continuing proper mitigation steps, a level of immunity, by CHR investigators called “functional immunity,” that is sufficient to suppress the virus to endemic levels and, therefore, makes it socially, economically and politically more tolerable.
Assuming “functional immunity” to be a correct hypothesis, one could expect that the current 3rd wave, after running the usual course of approximately 10 weeks, before the year’s end should have induced this level of immunity also in Midwestern states. All of the U.S mainland will, therefore, within a few short weeks reach a level of “functional immunity” which is socially and medically more tolerable than unmitigated infection rates and lockdowns of the economy.
How Pregnancy Affects COVID-19
Though there is, still, a considerable lack of knowledge and even the most basic understanding of the SARS-CoV-2 virus, it is, on the other hand, truly remarkable what has been discovered within a relatively short time period. Recent studies, therefore, also inform better – though not yet totally adequately - about how pregnancy affects the disease. As we are learning more, it is increasingly becoming apparent how similar effects of pregnancy are on the pregnant mother infected with COVID-19 to those from the flu.
A recent study from the _Centers for Disease Control and Prevention (CDC) _demonstrated this when reporting that pregnancy may make COVID-19 clinically more severe, as more pregnant women are, proportionally, admitted to ICUs than non-pregnant women. The good news, however, is that there was absolutely no difference in mortality from COVID-19 when pregnant and non-pregnant women were compared. This is exactly how we for decades have known the influenza virus is affected by pregnancy, where one also sees more and more severe cases but not increased mortality.
What this means for the woman contemplating pregnancy is self-evident: Try as much as possible to avoid the virus through careful distancing, hygiene and mask wearing. If there is suspicion of exposure to the virus, get tested. But it also means that, should you catch the virus, it is unlikely you will need hospital care, and if you do, you and your baby with great likelihood will survive it well.
One very important point must be made, however, especially for women who are in the midst of fertility treatments: Should you, one of your family members, or close contacts be diagnosed with the virus, your fertility treatment must be interrupted and this, likely, is the rule at all IVF centers, including CHR. Interruption is, of course, not only in the best interest of the affected patients (because who possibly wants to end up in an ICU during pregnancy) but also in the best interests of all other patients at the fertility center and, of course, the staff as well.
How COVID-19 Affects Pregnancy
Here again, our knowledge has greatly increased in recent weeks and months. The good news is that, in principle, the virus does not cross the placenta into the baby. Though a very small number of likely cases where such a crossing happened have been reported, they can be counted on the fingers of one hand. Most of these cases, likely, represented women who have significant medical issues that damaged their placentas and, thereby, allowed the virus to transition into the fetus. Just this week, a case was reported where viral DNA was found in the blood of baby born prematurely by Cesarean section. The newborn, however, cultured negatively and never developed any symptoms.
This, however, does not mean that an acute case of COVID-19 in pregnancy cannot experience significant complications. Once again, they are, however, practically identical to the complications seen with influenza during pregnancy. Most are, likely, not caused by the virus but by conditions caused by the response of the body to the viral infection. For example, high fever or certain cytokines, released by immune cells fighting the virus, can lead to premature labor. Once a woman is diagnosed as infected with SARS-CoV-19 in pregnancy, she, therefore, likely, will be hospitalized, so that the medical team can immediately intervene should that become necessary.
The news about COVID-19, thus, has remained more positive than initially anticipated and can be compared to the long-known pregnancy course of being infected by the influenza virus. Because practically almost all reports in the literature have demonstrated no adverse effects on offspring, this, for a change, can be viewed a relatively good COVID-19 news.
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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