Dr. Sandy Chuan, Partner at the San Diego Fertility Clinic (SDFC), was kind enough to share her thoughts with the SurrogateFirst team about the current situation, treatment best practices during the height of the outbreak, and what we know about Covid-19 and pregnancy.
Q: Dr. Chuan, how would you assess the current situation? When is it safe to return to treatments?
As of March 17, 2020, the American Society for Reproductive Medicine’s (ASRM) Task Force announced 5 key recommendations and best practices for the fertility practitioners to follow. The Association is the leading industry authority, representing the interests of all parties involved in infertility treatment. Therefore, being thoughtful of their recommendations, we started cancelling cycles shortly following this interview.
ASRM Coronavirus/COVID-19 Task Force’s stated recommendations:
- Suspend initiation of new treatment cycles, including ovulation induction, intrauterine inseminations (IUIs), in vitro fertilization (IVF) including retrievals and frozen embryo transfers, as well as non-urgent gamete cryopreservation.
- Strongly consider cancellation of all embryo transfers whether fresh or frozen.
- Continue to care for patients who are currently in-cycle or who require urgent stimulation and cryopreservation.
- Suspend elective surgeries and non-urgent diagnostic procedures.
- Minimize in-person interactions and increase utilization of telehealth.
Its difficult to predict when ASRM or any clinic will start to ease their recommendations. SurrogateFirst is evaluating the status on a weekly basis and making educated decisions based on existing information.
We believe that the goal of the recommendation by ASRM and the effort to minimize elective procedures across the entire medical field is to help flatten the new infection curve, so as not to overwhelm our health system. It is also an effort to preserve resources should infections peak around the country. Recently, there has been talk about opening up the country by regions based on their specific situations in regards to their amount of COVID-19 cases. Based on this logic from our Nation’s leaders, we believe that our location in San Diego, CA (where it seems that the efforts of the quarantine have been successful) we anticipate being able to consider a limited amount of treatment cycles to create embryos starting the end of April, in the best case scenario.
We are limiting our current number of cases so that we can implement all the public health measures necessary to keep patients and staff safe from the risk of infection. The situation is very fluid, but we are continuing with preparations while assessing the situation frequently. The criteria for these initial cycles is also due to patients being local (no travel risk) and being in excellent health. We are also evaluating the initiation of treatment cycles for egg donors who live in the area.
We have gotten very creative with utilizing telemedicine. We continue to hold patient consults via phone and video calls. This is very familiar to us, because we routinely do so for our out of area patients. But now we are taking the same approach for egg donor and surrogate screenings so that we can keep the process moving along. Our goal is to keep the process flowing in order to avoid a future bottle neck in the process when things return to normal at the center.
Q: Dr. Chuan, how do your patients get treatment during the coronavirus outbreak?
As our number one priority is to minimize patient and staff exposure to the coronavirus, every decision we have made is based on this priority of safety. When it comes to current treatment schedules and protocols, we are always mindful of the multiple factors to ensure we are balancing both convenience and necessity.
Initiating fertility treatment:
If you are early on in the process but you know you will need fertility treatments or are considering an evaluation, please schedule a consultation with your physician. Even though you may not be able to start active treatment right away, there is usually a process of initial evaluation and lead time to get into treatment, even when there is not a pandemic slowing us all down. There is a lot you can do in the meantime to position yourself to be able to start the right treatment for you when things fully resume.
For patients seeking to create embryos first, we can likely continue with this effort safely in the interim. So my advice is to meet with your physician and agencies to learn about the process and complete the items on the to do list which can be done now. You will be surprised at how much can be accomplished!
Q: Any advice for pregnant patients or those who’ve recently had embryo transfers?:
Local patients who live close to SDFC:
SDFC Clinic Visits – For patients in our area we are still offering blood work to confirm pregnancy and one OB monitoring ultrasound at around week 7. If everything looks good, you will graduate to your OB. Most OBs will do their first visit at between 9-10 weeks of pregnancy. We have scaled back to what we feel is the safest yet most effective for our patients’ journey in this challenging time. Typically, in IVF conceived pregnancies we are doing more frequent ultrasound monitoring than in general OB care, starting at about 6 weeks of pregnancy. The purpose of this is to help alleviate anxiety for the patients and watchful waiting for continued development of the much anticipated pregnancy. But in reality, there are not any interventions to change pregnancy outcomes or additional medical benefits that comes with these added visits. Therefore, during this unique time it does make sense to minimize the number of visits in the first trimester in an effort to minimize the risk of exposure to COVID-19.
Please expect to answer screening questions, for your temperature to be checked and to practice social distancing during your visit with us. Patients are also to come with a cough guard if possible, or we will provide a mask.
Q: How does pregnancy testing work for out of town patients?:
For patients that recently had transfers before the nationwide shutdown, we are able to provide lab slips for testing at your local lab depending on the situation in your local area. For patients living in San Diego, we are still offering blood tests to confirm pregnancy. However, we can substitute blood tests with serial home pregnancy tests in areas where it would be difficult to get blood work done or when the patient does not feel safe to go out for testing. Our recommendation is for patients to test once first about 12 days after the transfer, if its negative we ask that patients repeat the pregnancy test once more a week later. If you test negative twice during a one week interval then and we would likely advise you to stop medications.
Q: How does where you live affect monitoring your pregnancy?:
For pregnant patients who are trying to access care the situation is highly variable across the country. Depending on your area, you may be able to still access early pregnancy monitoring at a local fertility clinic or through your OB.
Currently, please note to our best knowledge some OBGYN offices are canceling all non-essential visits, including delaying or minimizing visits for pregnancy. Therefore, it is likely that you may be only seen for one visit during early pregnancy around 8 -10 weeks per guidelines for general OB care, if you are not able to find a fertility clinic near you which is willing to offer early pregnancy monitoring ultrasounds prior to 8-10 weeks of gestation.
Typically, in IVF conceived pregnancies we are doing more frequent ultrasound monitoring than in general OB care, starting at about 6 weeks of pregnancy. The purpose of this is to help alleviate anxiety for the patients and watchful waiting for continued development of the much anticipated pregnancy. But in reality, there are not any interventions to change pregnancy outcomes. Therefore, during this unique time it does make sense to minimize the number of visits in the first trimester in an effort to minimize the risk of exposure to COVID-19.
Q: How can COVID-19 impact a pregnancy?
At SDFC we are following ASRM recommendations and taking extra caution in all our treatments. This is a new disease, so there is currently limited research on COVID-19, but there has been some helpful data coming out of China.
A JAMA publication based on data from Wuhan, suggests that pregnant women are not any more at risk than other age matched women in the general population; and that pregnant women with COVID-19 did not suffer more severe or worse outcomes than non-pregnant women. In other words it did not compromise them more than others in the same age group.
This was very different from what was observed during the SARS outbreak, in which only 5% of infections were pregnant women but the pregnant patients correlated to 14% of all deaths. We also see this with the common flu, which seems to negatively affect pregnant women more due to their immunocompromised state. This initial data is reassuring, but we are still recommending that pregnant women take extra care in avoidance. The CDC has put pregnant women in a more at risk group regardless of this early data.
I believe this concern for the immunocompromised state in pregnancy is partly why ASRM has recommended suspension of embryo transfers. In addition, high fevers due to any cause in early pregnancy can increase the risk of miscarriage. This is another good reason to consider holding off until the peak of the pandemic has passed.
Another concern for any infection is the risk of transmission to the baby during gestation- this is called vertical transmission. For example, women with active HIV and Hepatitis B &C have a significant chance of passing the infection to their babies during pregnancies. Physicians take many measures to suppress the viral replication during these pregnancies to try to minimize risk of infection to the babies.
However, generally speaking, we dont have the same concern when it comes to respiratory illness due to viral infection. For example, the common cold, flu and SARs have not been shown to have vertical transmission. This is in line with what studies have shown about COVID-19, which is a very similar virus in structure.
In a Chinese study published in the Lancet, researchers at Wuhan University studied 9 infected pregnant patients who presented with pneumonia in the 3rd trimester. All the women survived, did not require ventilator or ICU care and there was no evidence of vertical transmission of the virus to the babies.They looked for the virus in cord blood, amniotic fluid and breast milk. They also tested the babies by doing multiple swabs of the nasopharynx . None of the tests were positive for COVID-19, which is very reassuring based on these early studies. Two of the babies did fall ill with mild illness, one at 17 days and the other at 3 days after birth. It is thought that the infections were likely related to contact infection rather than in utero transmission.
This offers us some reassurance that all the women who are currently pregnant will likely not have a severely adverse event due to COVID. I hope that this helps to alleviate some anxiety, but again I still recommend for all pregnant women to exercise extra caution and strictly follow public health recommendations just to be safe.
Q: So what happens next, Dr. Chuan?
I know that these are unprecedented times with profound impact on all areas of our lives. For our patients who are impacted by this limitation to access fertility care, the delay is frustrating and the fear of exposure for those already pregnant is anxiety provoking, to say the least.
But I do have faith that the strong public health efforts in the US and around the world are paying off and that soon we will be able to resume our normal lives.
Have faith and stay well; you will all be back on the right path to parenthood again very soon!
Sandy S. Chuan, MD F.A.C.O.G.
Dr. Sandy Chuan is a double board-certified fertility specialist, with extensive experience in complex IVF cases and third-party reproduction. She is known for delivering individualized care; combining the best of science with compassion to optimize the chance for success for every patient. During her career as a fertility specialist, Dr. Chuan has received numerous awards including Americas Top Doctor from 2017-2019 and in 2018 Dr. Chuan was named “Top Doctor” by the San Diego County Medical Society (SDCMS) in San Diego Magazine.
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