To the ASRM COVID-19 Taskforce,

     It is with much respect that we address the members of the American Society for Reproductive Medicine (ASRM) COVID-2019 Taskforce. This letter is to address the recent release of the document entitled “Patient Management and Clinical Recommendations During the Coronavirus (COVID-19) Pandemic”. We recognize and appreciate the time and effort that the taskforce took to examine the unprecedented worldwide threat that COVID-19 brings to us all and how it may relate to the fertility community.

     Prior to the release of the above referenced ASRM guidelines, the European Society of Human Reproduction and Embryology (ESHRE) released their own set of guidelines limiting fertility treatment. In the Reproductive Endocrinology & Infertility (REI) community, we were expecting ASRM to follow ESHRE’s lead with reasonable limits on fertility treatment. However, we were stunned that the ASRM guidelines called for an essential shut down of all fertility treatment and evaluation. We have no doubt that the intent of the taskforce was noble and one of beneficence. However, our concern is that the principles of justice, respect for patient autonomy, and nonmaleficence were severely neglected.

     Before we discuss the violations of those principles, we need to address some terms that are commonly used while describing fertility treatment. First, we take aim with those who refer to fertility treatment as elective. If a person with Type 1 diabetes needs insulin because his or her pancreas is not functioning properly, people would term that as necessary treatment. Yet, a woman that that needs medication because her ovaries are not functioning properly is told that this is “elective” treatment. Why? Because an ovary is a female organ? Because people don’t value reproductive rights? Fertility treatment should no longer be termed “elective”. Fertility treatment is both necessary and time sensitive.

     The principle of justice dictates that we should treat others equitably and distribute burdens fairly. Despite the COVID-19 outbreak, no guidelines or organizations have asked fertile patients to avoid pregnancy or use contraception. Our infertility patients are now asking us: “Why are WE the only ones being asked to make a sacrifice to avoid pregnancy?”. And this is does not just affect infertility patients. What about same sex couples and single mothers by choice? Are they being treated equitably? Our patients’ desires to conceive should be respected and they should have the same opportunities to conceive that any other person would have in the United States (or even the world). They feel discriminated against and it is our duty to remedy this for them. Infertility is already an isolating diagnosis and the new ASRM recommendations have caused them to feel even more isolated. As fertility physicians, we should be our patients’ biggest advocates. They deserve the right to treatment and evaluation.

     The principle of autonomy dictates that we have an obligation to respect the decisions made by other people concerning their own lives. Throughout history, women have been vulnerable to oppression. In modern times, one would hope that this is no longer an issue that women face. But, here we are again- women are being told they do not currently have the right to make the decision for themselves on whether it is safe to attempt fertility treatment or pregnancy. How can an organization meant to support women not realize that women are completely capable of deciding for themselves their own next steps? We agree that any women moving forward with treatment at this time should be counseled regarding the risks and benefits of doing so. They should be counseled that COVID-19 is not known to cause birth defects, but that our data is limited and thus, we cannot give complete reassurance. In addition, if they were to get a severe COVID-19 infection during pregnancy, they may require treatment with medications that have not yet been tested to be safe in pregnancy.

     The principle of nonmaleficence dictates that we should do no harm to patients. For women with infertility, we know that their chances for success are inversely correlated with age. It is such a time sensitive and urgent issue that even ASRM’s Committee Opinion 589 says “In women older than 40 years, immediate evaluation and treatment are warranted.” By delaying treatment and evaluation in women over the age of 40 or in women with diminished ovarian reserve, we are causing harm to them. In fact, some women may lose their chance to ever have a child with their own eggs. This is unacceptable to abandon a group of women at the time in their life when they need us the most. For a woman in her 40s trying to have a family, every single month counts. There are certainly risks of proceeding with treatment such as concern for cycle cancellation due to COVID-19 illness or need for quarantine. But, there are also risks to not proceeding with treatment. We should not be the cause for the harm that comes with waiting. Our patients feel like they have already done their duty. These are women who spent their lives being responsible and following the rules. Many put themselves through medical school, law school, college, etc. And now is their narrow window to try for a baby. We cannot let them down. How can we have told women for years that time is of the essence and then turn our backs on them now?

     Now that we have reviewed the concerns for basic principle violation, we need to address some other nuances. First, the United States is a large country and the different parts of the country are seeing COVID-19 at different rates and over different timelines. We acknowledge that COVID-19 is likely to eventually reach all parts of the country. However, clinic shutdowns may need to be strategically timed according to the local number of cases as well as according to the local hospital facility capabilities and supplies. 

     Can we fulfill our duty to our patients as well as our duty to society to decrease the spread of COVID-19? Can both be achieved? Absolutely. Here are our recommendations:

1.     We agree with maximizing the use of telemedicine for all visits that do not require an examination or procedure.

2.     For appointments that require examination or a procedure, patients should be screened by phone before their appointment. Patients with any symptoms of COVID-19 or any known exposure will need to delay treatment and evaluation.

3.     Upon arrival to the practice, patients should wait in their car and call the clinic to let the clinic know they have arrived. When the clinic is ready for them to come in, the patient can be called and brought back directly into an exam room for the examination or procedure that is needed. Their temperature should be taken. No companions are allowed to accompany the patient unless needed as a translator. No hugs or handshakes and the staff member and patient should maintain as much distance apart as possible while performing the procedure.

4.     After the exam or procedure, the room should be cleaned including wiping down all surfaces and door handles with disinfectant.

5.     Patients should be allowed to resume diagnostic testing. For semen analysis, they should collect at home and drop off rather than collect at the clinic.

6.     Patients should be allowed to resume fertility treatment of all types. If ACOG ultimately recommends that all women avoid pregnancy, then suspension of treatment at that point would be reasonable. But, in that case, women should still be allowed to do IVF with freeze all.

7.     Patients and staff should practice social distancing.

8.     Employees should be briefed with an action plan on what to do if exposed to a patient with COVID-19 and/or what to do if they develop symptoms of COVID-19.

9.     We agree that delaying surgeries at this time is reasonable to preserve supplies. However, should supplies become more readily available, it will be reasonable to resume operating.

     To conclude, we believe that the ASRM COVID-19 recommendations violate the principles of justice, autonomy, and nonmaleficense. In addition, the guidelines did not account for geographic/situational flexibility or the fact that REIs practice in a wide variety of settings ranging from university hospital based settings to small, stand alone outpatient practices. While they are only guidelines (not rules), most REI physicians feel obligated to follow them. In fact, the Society of Assisted Reproductive Technology (SART- an organization that most reputable clinics report their IVF statistics to) states in its bylaws that its members need to follow ASRM guidance. From here on out, we want to unite as a REI community and implement safe ways to decrease COVID-19 spread. We want to protect our patients, our staff, and ourselves.  We want to do what we can to flatten the curve. But, we ask that the ASRM COVID-19 Taskforce consider immediate modification of the guidelines to allow for more flexibility for our patients through this trying time. We feel that we can take measures to reduce COVID-19 risk without asking our patients to suffer without treatment.

Respectfully,

Beverly G. Reed, MD

Instagram handle: @drhappyeggs

Media inquiries can be sent to: petition.media.inquiries@gmail.com

**Edited to add that Progenesis is now offering COVID-19 testing to fertility patients and fertility clinic staff. This allows us to address the concern for asymptomatic viral shedding and is another tool to help us be able to offer fertility care while also minimizing COVID-19 spread.

***Edited to later add that all patients and staff should wear masks to reduce the risk of spread amongst asymptomatic people.