COVID-19 OUTBREAK AND THE REPERCUSSIONS FOR OUR PATIENTS AT WATERSTONE CLINIC
A year has gone by since the appearance of COVID-19. The prevalence of the virus in the Irish population is higher now than at any previous time, and extreme vigilance is necessary over the next couple of months.
Early in 2020, when the WHO was still advising against mask-wearing, Waterstone Clinic strongly advocated the use of masks to prevent viral transmission. We continue to advise our patients and staff to wear masks whenever they are closer than 2 meters to anyone who is not a household member. Coughing, laughing, shouting and singing in the proximity of others remain risky activities and small poorly ventilated spaces, particularly cars, are dangerous places.
Anyone entering our facility must assume that they might be infected but not yet symptomatic and do all they can to minimise the risk of transmitting the virus to other patients or to our staff. This means that we need to be strict in our procedures at the Clinic and minimise the number of people who enter the building every day. We therefore require our patients to attend their appointments alone. We will invite partners to attend certain appointments, and we will specify which these are.
BECOMING PREGNANT DURING THE PANDEMIC
With regard to the wisdom of women becoming pregnant against the backdrop of increasing virus prevalence, an update is in order.
Further data about the risks of COVID-19 in pregnancy have emerged over the past nine months, and the following is the current consensus: compared to the general pregnant population, women with COVID-19 infection in pregnancy appear approximately twice as likely to be admitted to intensive care units and to require ventilation. However, the likelihood of death for pregnant women with COVID-19 appears only slightly greater (possibly 50% more likely) if more likely at all. The absolute risk for pregnant women with COVID-19 in the Western world appears to be about 1 in 1,000, which is a small risk, but a new risk for pregnant women that did not exist two years ago.
With regard to risk for the fetus in pregnancies affected by COVID-19: there does not appear to be an increased risk of early miscarriage or birth abnormalities, nor is there any convincing evidence of vertical transmission (i.e. from mother to fetus). There is certainly an increased risk of premature delivery (3 times higher than in the general pregnant population) sometimes because of premature rupture of the membranes but more commonly because of concerns about maternal wellbeing. Extremely premature delivery can result in death or disability for the baby.
FERTILITY OPTIONS DURING THE PANDEMIC
We are all aware that fertility prospects for women diminish as they get older, particularly from the late thirties onwards. Fertility patients in their early thirties with good egg numbers could choose to defer treatment in the hope of a safer world in a year’s time. However, there is more urgency for older patients, particularly those with low egg numbers, to move forward with treatment.
Patients also have the option of going ahead with treatment and deferring pregnancy. Patients undergoing IVF or ICSI treatment can choose to freeze (cryopreserve) all viable embryos but not become pregnant immediately: a “freeze all” strategy. Embryo cryopreservation at Waterstone Clinic is highly successful and has become an integral component of our IVF/ICSI treatment programme. Last year, 40% of the babies born after IVF/ICSI treatment were from frozen embryos. Frozen embryos appear as successful in producing a pregnancy as fresh embryos, and they can be stored safely for many years. The “freeze all” approach is not appropriate for all patients, however. We would advise patients with a poorer prognosis, who are older, or have low egg numbers, to go forward with an attempt at pregnancy.
A potential alternative strategy for all women hoping to become pregnant soon is to get vaccinated against COVID-19 first, if vaccination can be accessed. The vaccines appear to be both effective and safe, and vaccination will hopefully bring the pandemic to an end.
PRECAUTIONS IN PREGNANCY
Whether vaccinated or not, pregnant women are advised to continue being very careful about avoiding exposure to infection. Waterstone Clinic’s advice for pregnant women remains in line with that issued by the Royal College of Obstetricians and Gynaecologists for NHS workers on 26 March 2020:
- Pregnant women of any gestation should be offered the choice of whether or not to work in a role involving direct contact with the public.
- Women less than 28 weeks pregnant should practice social distancing but can continue to work in a position involving direct contact with the public, provided the necessary precautions are taken (including mask-wearing).
- Women who are more than 28 weeks pregnant or have underlying health conditions should avoid direct contact with the public, and it is recommended that they stay at home.
Speak to your HR or the occupational health department of your employer to discuss ways of reducing your risk. If you cannot adhere to these guidelines when undergoing fertility treatment, and during your pregnancy, you should not proceed with an attempt at pregnancy and should consider a “freeze all” IVF or ICSI cycle until you are vaccinated or have a change in your work-related risk.
GUIDELINES ON VACCINATION AND PREGNANCY
Official advice about vaccination for women who are pregnant, or hoping to conceive, has been confusing and has changed over time. Theoretically, mRNA vaccines such as the Pfizer BioNTech and Moderna Products, because they do not contain live virus, should not involve any risk for a pregnant woman or her fetus. Nor should there be any necessity for women who have been vaccinated or who are waiting for their second dose of the vaccine to defer fertility treatment.
In the USA, all of the professional medical bodies concerned with fertility and pregnancy care have agreed that mRNA vaccines should not be withheld from women who are trying to conceive, who are pregnant, or who are breastfeeding. The American Society for Reproductive Medicine (ASRM) has actually recommended that patients undergoing fertility treatment should be encouraged to receive vaccination.
The advice from similar authorities in the UK and Ireland has been far less clear cut and has changed over time. The Royal College of Obstetricians and Gynaecologists (RCOG) in the UK initially recommended that pregnant women should not be vaccinated and that vaccinated patients should not get pregnant for three months afterwards. However, the RCOG changed its guidelines two weeks later, and now advise that women who have been vaccinated do not need to avoid pregnancy for any time afterwards. The RCOG’s updated advice for pregnant women is that vaccination should be considered depending on individual circumstances, such as exposure to the public at work, or medical conditions that increase risk.
Irish authorities have not issued any guidance regarding vaccination for women who intend to conceive soon. However, the HSE has recommended that a pregnancy test is not necessary for any woman receiving the vaccine. The HSE advice for pregnant women is non-directive and similar to that of the RCOG: routine vaccination for all pregnant women is not currently being recommended, but vaccination should be considered for pregnant women at higher risk, leaving decision-making to the individual GPs or obstetricians concerned. The HSE currently recommends that if pregnant women are vaccinated, this should only take place between 14 and 33 weeks’ gestation.
Obviously, COVID-19 is still a new disease, and the vaccines developed to combat it are even newer. A number of vaccines are already available, some of which are quite different from each other. While the Pfizer BioNTech and Moderna vaccines are both mRNA vaccines and are very similar to each other. The Oxford AstraZeneca vaccine and Johnson&Johnson (Janssen) vaccine are both non-replicating viral vector vaccines employing a modified adenovirus. The Novavax vaccine is a protein subunit vaccine that also contains an “adjuvant” to help improve the immune response.
Advice from professional bodies for women who are pregnant or are hoping to conceive is bound to change as time passes and guidelines may differ depending on which vaccine is involved. Please continue to do all you can to minimise the risk of contracting and transmitting the virus.