Caroline (who spoke to Yahoo Life on the condition of anonymity) had it all mapped out. She’d serve as a bridesmaid in two weddings over the spring, give herself and her husband some time to achieve some personal wellness goals and get the ball rolling by making doctor’s appointments to discuss fertility planning and genetic testing. If all went as planned, she’d be pregnant by mid-2020, and deliver next spring, strategically avoiding having to endure the scorching summer heat in her last trimester.
“We hoped to attend some fun spring weddings and enjoy the flowing champagne and then promptly begin trying for a baby,” she tells Yahoo Life of her plans, which accounted for just about everything, but a global pandemic.
Now those weddings have either been scrapped or pushed to the summer, and Caroline’s baby plans are on indefinite hold. It’s not just the prospect of outgrowing her bridesmaid dresses that’s giving her pause; it’s anxiety about being pregnant and vulnerable during a health crisis, the likelihood of missing out on important milestones and uncertainty about being able to access safe childcare upon returning to work.
“It was after the first handful of weeks of shelter-in-place that the concerns of having a baby during COVID-19 hit us,” the 32-year-old lawyer says. “Stories about women giving birth alone at the hospital were being released, and I spoke with physician friends who confirmed this new reality. I could no longer imagine even stepping foot in a doctor’s office for a blood test or routine appointment. The fact that the expected steps of pregnancy — entering a doctor’s office — suddenly seemed like a risk truly stalled out our carefully made plans.
“Now friends report they will be made to wear a mask during labor and have leveled well-meaning warnings to refrain from pregnancy now if we can. I also feel proper sheltering in place requires significant distancing from even close family members and cannot imagine going through the expected joy of my first pregnancy in such an isolating manner and during such a taxing, worrisome time. Acknowledging pregnancy is not all rainbows and sparkles, I want to enjoy the process and experience every detail, including family pregnancy reveals and baby showers — preferably not via Zoom. I also cannot imagine sustaining my current firm practice and caring for an infant at home.”
“I think we are seeing a few more patients than normally for egg freezing,” he says, “and I’ve certainly had patients asking me about freezing their embryos for the future, [saying] ‘We don’t want to get pregnant for a couple of years.’”
If an accessible vaccine has yet to surface over the next year and COVID-19 remains a threat, Caroline will explore freezing her eggs at a fertility clinic to “buy a little more time before plunging into pregnancy during the full wave of COVID.” And she wouldn’t be alone. Dr. Eric Surrey, a reproductive endocrinologist at CCRM Fertility, which has locations across the U.S., tells Yahoo Life that his Colorado clinic has seen some increased interest in egg and embryo freezing procedures.
Indeed, many aspiring parents have already had their baby-making procedures delayed as a result of the coronavirus crisis, and not necessarily by choice. In mid-March, the American Society for Reproductive Medicine (ASRM) issued recommendations that clinics suspend elective surgeries and non-urgent diagnostic procedures (such as ultrasounds or blood work to determine any fertility issues) and the initiation of new treatment cycles, including intrauterine inseminations (IUIs) and in vitro fertilization (IVF); it was also advised that clinics consider canceling all embryo transfers (fresh and frozen). Women already considered “in-cycle,” or taking ovary-stimulating medication and in need of imminent retrieval and cryopreservation services, however, could continue to receive care, with added precautions and an effort to limit in-person interactions in place.
Under these guidelines, as well as state orders regarding nonemergency procedures, a woman planning to be inseminated the following month, for example, likely would have seen her procedure postponed, while a woman already in the process of taking medication and awaiting an egg retrieval would proceed under enhanced precautions, though any resulting eggs may have been frozen and stored rather than being fertilized and transferred days later.
As of late April, following new ASRM recommendations and state-by-state moves to reopen, CCRM and other fertility clinics have resumed treatments with a “lot more caution and safety,” says Surrey. He notes that the delays, coupled with the uncertainty and strain of the pandemic, made an emotionally grueling, physically demanding and time-sensitive process even more fraught, particularly for older patients.
“I don’t think there was a soul who was happy even when we stopped doing procedures,” Surrey says. “And I think you divide it into several scenarios. One is those where their hopes are dashed in the sense of they’re planning on doing a procedure and are told they can’t, but it’s not a huge risk for their fertility — the 29-year-old whose partner had a vasectomy, who has a little time to work with, but it’s very frustrating. The difference are women who are 42, who don’t have time to work with. And this is why we pressed very aggressively to get started with patients who really needed our help as soon as we possibly could.”
A joint statement issued in late May by ASRM, the International Federation of Fertility Societies (IFFS) and the European Society for Human Reproduction and Embryology (ESHRE) highlighted the importance of resuming fertility treatments, stating: “The essential nature of reproduction means that providing reproductive care and treating the millions of patients suffering from infertility must remain a priority, even in the midst of the COVID-19 pandemic.”
ASRM has continued to issue updates featuring guidance on “practicing in a COVID-19 environment at least until an effective and safe vaccine or broadly effective treatment becomes widely available.” This involves monitoring local regulations and coronavirus reporting, as well as mitigating risks for patients. Surrey laments the dearth of data on how COVID-19 impacts pregnancy and says the situation is “rapidly evolving”; as more data comes in, procedures may change. In the meantime, clinics like CCRM are heeding ASRM advice and implementing precautions that put safety first and limit in-person contact, while at the same time being sensitive to patients’ emotional well-being.
“We’re not so much introducing sterility, which may be the case with, like, a retail store,” Surrey says, noting that fertility clinics are by nature already clean, sterile environments. Standard practices like disinfecting and handwashing are now conducted in a “much more rigorous fashion” these days, with staff members required to wear PPE and patients encouraged to wear face masks.
Surrey’s clinic and others have also introduced in-house COVID-19 testing, used for staff members on a rolling basis as well as any patient undergoing reproductive surgery. Patients who come into clinics are subject to health screenings beforehand, including temperature checks. A patient showing symptoms of illness or testing positive for COVID-19 while midcycle will be forced to suspend or cancel treatment. Clinic spaces have also been adjusted to help maintain social distancing, with contactless transactions in place for payment and signing in.
Like most medical professionals, fertility clinics are also pivoting to telehealth appointments where possible, such as for an initial consultation. To improve efficiency and cut down on in-person interactions, CCRM has also introduced its One-Day Work-Up Program at 11 North American centers. Under the program, multiple fertility testing procedures — which can typically take weeks or even months — are condensed into a single one-day visit. This not only minimizes contact but also helps expedite the treatment process and helps women recoup some of the time they may have lost due to pandemic-related delays.
In an effort to reduce foot traffic, clinics are also restricting access to individuals other than patients in most cases. While Surrey acknowledges that “everybody needs a support person,” CCRM clinics are asking patients to come unaccompanied for routine checkups. For significant appointments like a first pregnancy ultrasound or surgical procedures such as an egg retrieval or embryo transfer, a partner is allowed to join to offer emotional support. A partner or support person may, however, be subject to social distancing restrictions or have to wait in the lobby or outside for a less-invasive IUI.
This poses a challenge for those working with gestational surrogates. Due to these limits, intended parents may be unable to be present for scans or even embryo transfers, though Surrey says his team does “everything we possibly can to enhance and make the experience as good as possible” for those who can’t come into the office, including calling them directly or even FaceTiming during a procedure. ASRM also recommends that both clinic staff and women hoping to become pregnant limit travel to reduce their exposure to COVID-19, and specifically advises intended parents against initiating treatment cycles with gestational carriers who live in another country. Travel restrictions, which are slowly easing, also create an obstacle; due to differing state laws regarding surrogacy, it’s not uncommon for intended parents to live in a different state from the woman carrying their child.
One proactive, more practical measure taken at Surrey’s clinic relates to staffing. Employees are now divided into teams working separate schedules — a clinic bubble, essentially. This helps contain potential spread while ensuring that the entire staff isn’t compromised, forcing a mass quarantine and clinic closure.
“If there were a problem, say somebody got sick in Team A and you had to quarantine everybody in that team, there’s another team that can come in,” he explains.
While Surrey cautions that it’s difficult to predict how long certain risk-minimizing procedures will be enforced — “I get asked to read my tea leaves pretty much 10 times a day,” he says of trying to forecast the future — he does consider telehealth, a streamlined appointment and testing process and enhanced safety measures as long-term developments. More importantly, he says the coronavirus pandemic has taught medical professionals how to plan for the worst-case scenario while building resilience as well as a more nimble mindset. If an anticipated second wave of the coronavirus does come, clinics should be prepared.
“This at least puts us in a place where if there’s a spike and we have relaxed things, we can immediately go back into a more restrictive environment,” he explains.
But with mass unemployment and an economic downturn, will people even have the option of paying for fertility treatments costing tens of thousands of dollars? Surrey refers to the 2008 recession, noting that while some business did “drop off” as people struggled to regain their financial footing, the industry eventually picked back up.
“Time will tell,” he says of how demand for high-cost fertility treatments is impacted by this pandemic, but it may all still boil down to those so-called biological clocks.
“There’s that pressure for older patients, [who think] ‘I don’t have time to work with’ — this is a critical issue,” he says. “There may be a little more push-off for the younger patients who feel, ‘You know what, I’ve got a little time to work with.’”
In other words, those feeling an urgency to conceive will likely try to push forward, regardless of financial uncertainty. And for those who have reservations about becoming pregnant during a pandemic, like Caroline, some compromise may be found in cryopreservation.
“The beauty of being able to freeze embryos is you can take this one step at a time,” Surrey says. “At least we know that we have embryos that are waiting for them. If it wasn’t safe for them to get pregnant right away, at least the aging part becomes less of an issue.”