By Dr. Tom Hannam MD FRCSC REI

At HFC we are remaining closed to procedures for now.

Everyone is learning how to best handle the challenge of the moment.

In Canada, centres closed to in-person services more or less all-at-once in the middle of March. Guidance came from the CFAS (our voluntary Canadian fertility society) and remains in place today.

From March 31 the society reconfirmed their position:

  • Conduct virtual consultations by telemedicine or phone
  • Complete current IVF cycles utilizing freeze-all only
  • Suspend all diagnostic and elective procedures and surgeries
  • Postpone any new cycle starts (IUI, IVF, FET), aside from urgent cryopreservation for oncology, until further notice

Given that the situation is evolving and changing, this guidance document will be revisited at least every two weeks, or as more information becomes available. 

When will it be safe to reopen?

So how will the CFAS and the rest of us know when it is appropriate to re-open our services? (It is much easier to close services than to reopen into a risk environment.)

There are two aspects to the question: when it will be appropriate to open fertility services to support pregnancy, and when it will be socially responsible to offer services that consume PPE and/or hospital resources (such as egg or embryo freezing).

Ultimately these decisions will need to be made at local levels. But it is helpful to follow some U.S. and international discussions. Oftentimes these conversations (and arguments) are very public. 

Opening Services to Pregnancy

Around the world, obstetrical societies continue to endorse pregnancy.

Perhaps more accurately, there is no relative prohibition against people trying to build their family, no exhortations to use birth control differently, or discuss terminating wanted pregnancies, for example. The conversations are nothing like what we had around Zika.

If pregnancy is, therefore, “ok” despite the manifest challenges that can present when pregnant women suffer from COVID-19, then why not help people get pregnant?

I know of Ob/Gyns in Toronto prescribing letrozole now for women who ovulate irregularly, so they can ovulate regularly, have intercourse at home like everyone else, and get pregnant, like everyone else. Why should most patients be denied this option? 

By extension, Boston IVF is doing just that today, with IUIs and Frozen Embryo Transfer services available now. I wrote to Michael Alper, suggesting he was “brave” for singular choices, and his response was clear.

“Not brave, just doing the right thing for our patients,” he wrote.

Dr. Alper is a physician working from a place of integrity. Like others, their team believes they can complete services safely while not putting pressure on local hospital services. These are not easy or straightforward decisions.

Opening Services to Procedures

Procedures like egg and embryo freezing do consume PPE, a scarce resource, and complications can send patients to hospitals. Procedures also reduce social distancing, putting patients and staff (and society) at greater risk than if everyone had just stayed home.

On the other hand, staying home doesn’t help people in need, and as a “solution” will be increasingly inappropriate to the fertility community. Readers of this blog will agree that fertility is an essential service.

In New York, Governor Cuomo made it clear that the State agrees, and goes on to enumerate a list of services that any of us would hope and expect to be considered essential:

  • Birth control, including Long Active Reversible Contraceptives, such as IUDs;
  • Fertility services, including infertility treatment and procedures;
  • Gynaecological surgeries to address acute complications related to conditions, such as fibroids or endometriosis;
  • Abortion services;
  • Obstetrical care, such as vaginal and cesarean deliveries;
  • Evaluation, diagnosis, and treatment of sexually transmitted diseases;
  • Evaluation for gynaecologic and breast cancer, when medically indicated based on patient history and/or physical exam.

Following this publication, our CCRM colleagues in NYC plan to open up services directly

But I don’t want to make it seem like the controversy is ending. It isn’t. Until there is vaccine, or accessible and accurate point of care testing for Canadians, until we can feel secure that valuable PPE is available to front lines and to fertility staff, until these conditions and more can be met, it isn’t certain that all procedures should be available across the country.

Yesterday the ASRM reiterated that they are sticking by their guidelines, as ‘thirty-five reproductive epidemiologists’ support the suggestion to limit procedures everywhere.

Ongoing Conversation

Tonight, members of the ASRM Task Force and other leaders in the field supported a live Zoom meeting for about 1,500 fertility clinicians and other stakeholders from across North America and around the world.

A snap survey had the majority of clinicians agreeing with closure procedures for now. (By contrast, similar surveys with patients have, by far, supported that the decision should be between the patient and their doctor).

Fundamentally, the ASRM leadership feels a multi-week delay is appropriate. It is also clear that not everyone agrees with nearly everything they said.

Fertility is time-sensitive and the decisions being made will affect families and lives. In the U.S., according to one survey, 20% of clinics are still open to procedures.

In Canada, to my knowledge, no clinics are providing in-person services this week. CFAS leadership continues to meet.

When HFC and CCRM Toronto Will Re-open to Procedures

Professional guidelines are not regulatory. The ultimate decision to care rests between a patient and their clinical provider.

So I’ll own this moment personally: I recognize fertility services are essential, but we are not opening to procedures today.

I am adding to our risk mitigation strategies and will resume services when our care can be appropriate for patients, staff, and the broader community. There isn’t a perfect time and there won’t be a perfect solution, but I am hopeful we can open soon in partnership with our community.


 

About the Author

Dr. Tom Hannam
The founder of the Hannam Fertility Centre, Dr. Hannam has sat on the board of the Canadian Fertility and Andrology Society, and is a member of the American Society for Reproductive Medicine, the Society of Obstetrics and Gynaecology of Canada, and the European Society for Human Reproduction and Endocrinology.

 

 

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