Re-starting Treatments at Merrion Fertility Clinic

Re-starting Treatments

In line with the stabilisation of the virus across Europe and the lack of reports of harmful effects in the first trimester such as miscarriage or foetal abnormalities, the IVF community internationally is looking at slowly restarting services. On 23rd and 24th April respectively, ESHRE (European Society for Human Reproduction and Embryology) and ASRM (American Society for Reproductive Medicine) published guidance for clinics regarding slowly recommencing treatments.

Both acknowledged that Infertility is a disease that is time sensitive and, therefore, should be regarded as a necessary medical treatment. They advocated that, once the risk of COVID-19 infection was decreasing, Assisted Reproductive Technology (ART) treatments be restarted, in line with local regulations.

However, this is not ART treatment as we did in the past; rather, vigilance and measured steps must be taken to protect patients, staff and the wider community. These steps will require significant alterations to the way clinics operate and the recommencement of services will need to be done in a careful, measured manner.

At Merrion Fertility Clinic

We are watching all of these events extremely closely and it is our hope that we will be able to open our clinic to some patients in mid-May. This will depend on the situation in Ireland at that time but we are optimistic.

We are currently working on our procedures and practices to ensure that we can provide a safe service in a responsible but patient-friendly manner. Changes will include:

Triaging patients and staff

  • Monitoring staff and patients for any signs of infection
  • Screening questionnaires
  • Temperature checks
  • COVID-19 screening when available

Hygiene practices

  • Cleaning regimes
  • Hand sanitisers

Social distancing through

  • Reduced clinic visits
  • Staggered appointments
  • Restricting partners
  • Increased use of tele-health
  • Reduced numbers of staff in clinic

Use of PPE

  • Masks, gloves, aprons, gowns

These remain very uncertain times and, when we do open, the new required practices, combined with the need to accommodate patients who have had their treatment cancelled in March and April, will mean that some of our patients will continue to experience frustration and disappointment for a while but please rest assured, we are doing everything possible to minimise this.

Background – Why Treatments Were Stopped

As you all know, COVID-19 has taken the world by storm and left even very developed economies struggling. Back in early to mid-March, the virus was out of control in Italy and Spain and Ireland was facing a potential similar surge in cases and in deaths. There were very legitimate concerns about the ability of our health system to cope.

Very little was known about the virus in general and even less was known about its effect on pregnancy and particularly early pregnancy.   For this reason, international medical and scientific communities dealing with infertility such as ESHRE, ASRM and the British Fertility Society cautioned against fertility treatments at this time and recommended that clinics stop any treatments that could lead to pregnancy.   At the same time Ireland, like other countries, introduced very strict social distancing and lockdown measures.

In mid March 2020, therefore, all fertility clinics in Ireland decided to postpone fertility treatments.   This was never done lightly and we were always conscious of the huge distress it would cause our patients, particularly those who do not have time on their side. However, it was genuinely done in what at that time was very much the best interest of patients, our staff and our nation.

Thankfully, the future is looking much brighter than it did a month ago. The effect of the virus in Ireland has been tragic but it has not been as devastating as in other countries and the lockdown measures definitely seem to be working. We are all hoping that these restrictions will be eased somewhat in early May.

In addition, the evidence regarding pregnant women is reassuring.

Effect of the Virus on Pregnancy/Pregnant Women

As a group, pregnant women seem to be no more at risk of contracting the virus than non-pregnant women. The virus does not seem to be transmitted from mother to baby in the bloodstream, amniotic fluid or breast milk and there has been no evidence of any increase in fetal abnormalities. There may be a slight increase in premature deliveries but this is not certain.

However, the evidence to date is still predominantly for women diagnosed with the virus in late pregnancy. The most recent study of 116 cases from China only included 8 women in early or mid-pregnancy.

We also know that any severe infection or illness can have an adverse impact on pregnancy and COVID-19 is no exception. Pregnancy of itself produces changes in the woman’s cardiovascular, respiratory and blood clotting systems, which make ventilation and ICU care for any condition difficult. The majority of women who developed severe symptoms of COVID-19 worldwide were delivered early by Caesarean section, many of those prematurely.

With this in mind, over the coming weeks MFC will be:

  • ensuring that no high-risk patients begin treatment until it is deemed safe to by the relevant healthcare bodies
  • offering patients the option to postpone treatment should they wish to
  • providing advice and education on COVID-19 risk and prevention
  • having all patients sign a Code of Conduct which gives instruction on best practices during treatment
  • having patients fill out a COVID-19 triage questionnaire before and during treatment
  • following up with patients in the weeks after egg collection and embryo transfer to identify potential COVID-19 positive patients and implement necessary measures

Contacting Patients

We will be contacting people very soon to arrange appointments and start some treatments. In the meantime, our staff are available to answer queries and to provide support by phone or email (Ph. 01 663 5000 or info@merrionfertility.ie)

The situation is a lot brighter than it was six weeks ago and we look forward to seeing all of our patients again soon.

 

ESHRE Announcement on Recommencing ART Treatments

We are delighted to see that ESHRE has today released guidance on restarting ART treatments. This is great news for our patients but the safety requirements are stringent and require careful planning over the next few weeks. We are looking forward to seeing our patients again soon.

When you click on the link below to the ESHRE website, in the top left-hand corner, there is a downloadable document called ‘ESHRE Guidance on Recommencing ART Treatments’, which contains more detailed information and we highly recommend you review it.
www.eshre.eu/COVID19WG

ART In Europe

ART In Europe

We know that the cancellation and postponement of treatment due to Covid 19 has brought untold stress and disappointment for our patients and for those all across Europe – see map released by ESHRE on 20/04/20.

But there are signs that activity is resuming as Denmark, Germany and the Netherlands slowly recommence services. We in MFC hope to also commence treatments in May, if the current trends in suppression of the virus continue and if national restrictions begin to ease. This will have to begin slowly and under strict guidelines and we will update our website as things progress.

In the meantime, don’t lose hope, try to optimise your health and wellbeing and don’t hesitate to contact our team of caring professionals if you have any queries or concerns.

http://www.eshre.eu/COVID19WG

 

 

Coping During the COVID-19 Pandemic: Message for Our Patients

The Covid-19 pandemic has changed life as we know it. For those patients struggling with infertility, particularly those awaiting treatment, anxiety and distress are both common and understandable responses to an unprecedented situation. At Merrion Fertility Clinic, we are here to support and guide you through this uncertain time.

Merrion Fertility have a number of support systems in place, including:

  • Support group meeting next Wednesday, 15th April by phone/video link
  • Patient consultations via phone or video link
  • Clinic is currently fully staffed and available to answer any questions (though most of us are working remotely)
  • Kay Duff, our fertility counsellor, can be contacted through the clinic or confidentially on +353 (1) 8319625 or  at catherineduff76@gmail.com.

For additional practical information on coping with stress and anxiety, please see the following excellent article recently published by the Mental Health Professional Group.

https://www.asrm.org/news-and-publications/news-and-research/announcements/coping-during-the-covid-19-pandemic–messages-for-patients/

Now more than ever it is important to take good care of yourself, and to remember that we are all in this together.

Stay safe and well.

 

Is it safe to get pregnant during the Covid-19 Pandemic?

Covid-19

These are very uncertain times. The medical profession, scientists, politicians and the general public are grappling with how best to manage a new virus and a pandemic like none we have seen before.

Medical and scientific evidence about the virus is accumulating daily, but there is still a lot we don’t know.

The evidence to date on pregnant women who have contracted Covid-19 and delivered babies is very reassuring. International bodies including the Royal College of Obstetricians and Gynaecologists in London are at pains to reassure pregnant women that they do not need to panic but, like the rest of us, they need to take extra precautions, particularly around social distancing and hygiene.

To date we know of nine women in the Chinese city of Wuhan who were diagnosed with Covd-19 in late pregnancy (36-39 weeks). None of these women developed severe respiratory disease; their clinical course was similar to that of non-pregnant women with the disease. All their babies were delivered by Caesarean section; all the babies were well and no virus was found in the amniotic fluid, the infants or breast milk.

Since then, 13 other pregnancies have been reported in Chinese women outside Wuhan. One became critically ill but this incidence is no higher than in the non-pregnant population. Six of these women went into premature labour and there was one stillbirth but we cannot say if these complications were related to the virus. In other reports, two babies have been diagnosed with infection soon after birth, one in the US and one in London, but it seems likely the infection happened after the birth rather than during the pregnancy or birth. This is all very reassuring for pregnant women.

Trying to conceive

But what about those who are not pregnant but are thinking about it or are trying to conceive? Should they be getting pregnant at this moment in time? It is really difficult to give clear advice in this regard, because we just don’t have enough evidence or experience with this virus. The reassuring studies described above involve very small numbers of women and all were in the later stages of pregnancy. There have been no reports yet on the outcomes of women infected in early pregnancy. We don’t know how the virus behaves in early pregnancy.

Because of this uncertainty, three international fertility bodies – the European Society for Human Reproduction and Embryology, the American Society for Reproductive Medicine and the British Fertility Society have in the last few days given guidance to fertility specialists advising them not to provide any treatment which would lead to pregnancy.

Irish fertility clinics – and many others in the US and Europe – have stopped doing treatments that would result in a pregnancy at this time. This includes IVF cycles, intrauterine or artificial insemination (IUI) and the use of fertility drugs to induce ovulation.

For people midway through IVF treatment, it is advised to freeze embryos for future use rather than to transfer them now. It is important to stress that these are very much precautionary measures until we have more data regarding the effects of Covid-19 in early pregnancy. It is undoubtedly extremely stressful for patients, but most agree it is best to be cautious at this time.

Other factors that affect this decision are the need to observe social distancing to reduce spread of the disease and help to “flatten the curve”. We can do this only by minimising the number of people attending clinics. However, many clinics are still open and staffed by nurses, doctors and other support staff who can answer queries and help people through this difficult time.

Concieve naturally

The halting of fertility treatment by clinics raises the question as to whether people who do not have fertility problems should continue to conceive naturally or spontaneously. The short answer is that we just don’t know. There really is no guidance available yet about this.

We know that those with underlying health problems – people who are immune-suppressed or who have diabetes or chronic lung disease – are more at risk of serious illness if infected with the virus. It would seem prudent that this group consider avoiding pregnancy at this time.

Young women who are fit and healthy and have no fertility-related issues may wish to postpone pregnancy for a few months until we have more information. Older women and those with known fertility issues often do not have time on their side, so they may wish to continue trying to conceive – or they may wish to wait a little while too.

Duty of care

Because fertility treatment such as IVF is an elective medical treatment, those working in fertility clinics have a medical duty of care to their patients not to provide a treatment unless there is sufficient evidence that it is safe. However, individuals trying naturally will have to make their own decisions at this time of such uncertainty.

There are conflicting opinions among doctors and scientists as to whether we should reassure or worry the general public at this time. There is a fine balance to be struck.

The aim of this article is to share the current evidence – scanty as it is – in the public domain so that the general public are aware of the pros and cons of conceiving at the present time. The evidence and guidance will be updated over the coming weeks as more pregnancy outcomes are reported. In the meantime, some advice would be to not panic, stay on folic acid and any other recommended medications and use this time to optimise one’s physical and mental health.

Professor Mary Wingfield is clinical director at the Merrion Fertility Clinic and a consultant obstetrician gynaecologist at the National Maternity Hospital

 

Important Covid-19 update for MFC patients

 

 

 

 

 

MFC Policy re services

Monday 16th March 2020

It is with great regret that we are curtailing all our fertility treatments from today, 16th March 2020.

On 14th March, ESHRE, the European body which advises on fertility in Europe, issued advice that fertility patients should avoid conceiving at present due to possible risks of COVID-19 in pregnancy. (See full statement below).

This may be an overreaction but we have taken the difficult decision that it is best to be cautious at this point in time. We will be monitoring the situation carefully and will adjust our policy as required.

As of today we are cancelling:

  • All embryo transfers (fresh and frozen cycles unless exceptional circumstances)
  • All ovulation induction and IUI treatments

Our clinic is still staffed and we will be doing as much as possible to keep things going. Please contact us by phone or email if you have any particular concerns. Again, we apologise for any inconvenience and distress that this will undoubtedly cause.

European Society for Human reproduction and Embryology

Coronavirus Covid-19: ESHRE statement on pregnancy and conception,  14 March 2020.

There is no strong evidence of any negative effects of Covid-19 infection on pregnancies, especially those at early stages, as indicated by the latest updates from the Centers for Disease Control and Prevention (CDC) in the USA and others in Europe.(1,2)

There are a few reported cases of women positive for Covid-19 who delivered healthy infants free of the disease.(3) There have been reports of adverse neonatal outcomes (premature rupture of membranes, preterm delivery) in infants born to mothers positive for Covid-19 during their pregnancy, but the reports were based on limited data.(4) Similarly, one case report has been published of an infected infant, but again there was no strong evidence that this was the result of vertical transmission.(5)

These data, although encouraging, only report small numbers and must be interpreted with caution. They refer to pregnancies in their final stages, but we have no information on the possible effect of Covid-19 infection on pregnancies in their initial stages.(6)

However, in view of the above considerations and the maternal and neonatal outcomes reported in cases of other coronavirus infections (such as SARS), ESHRE continues to recommend a precautionary approach.(7) It is also important to note that some of medical treatment given to severely infected patients may indicate the use of drugs which are contraindicated in pregnant women.

 

As a precautionary measure – and in line with the position of other scientific societies in reproductive medicine – we advise that all fertility patients considering or planning treatment, even if they do not meet the diagnostic criteria for Covid-19 infection, should avoid becoming pregnant at this time. For those patients already having treatment, we suggest considering deferred pregnancy with oocyte or embryo freezing for later embryo transfer.

ESHRE further advises that patients who are pregnant or those (men and women) planning or undergoing fertility treatment should avoid travel to known areas of infection and contact with potentially infected individuals.

ESHRE will continue to monitor the scientific literature, especially in relation to ART and pregnancy. And reaffirms the view that all medical professionals have a duty to avoid additional stress to a healthcare system that in many locations is already overloaded.

CORONAVIRUS / COVID-19 UPDATE

Thank you for your patience in these very uncertain times.

We are observing the situation and keeping up to date with national and international recommendations. As you know, this is an evolving situation and advice is changing day by day. See www.hse.ie

Because we are a healthcare facility and our treatments are elective, we are adopting safe but strict procedures in an effort to protect all patients and staff and we will be giving our patients regular updates. We sincerely apologise for any inconvenience caused and please rest assured that we will do everything possible to minimise disruption and stress.

Our current recommendations and policies are as listed below. Please call or email us if you have any concerns.

Please do not enter the clinic if:

– You are known to have the Covid-19 virus, whether well or ill

– You have travelled to or from the affected regions listed below

– If you have been in contact with someone who has the virus

– You have flu like symptoms such as:

  • A cough
  • Shortness of breath
  • Breathing difficulties
  • Fever (high temperature)

If you are unsure, please call us on 01 663 5000 to discuss your situation

Avoid Unnecessary Patient Visits

We are organising telephone consultations to reduce the need to attend the clinic

We cannot allow partners or children to attend for the following:

  • Scans (except pregnancy scans)
  • Blood tests
  • Semen analysis

We have taken the difficult decision to postpone some services. This is in the interests of patient safety and we sincerely regret having to do this. Anyone who has had their treatment cancelled will be given priority when services get back up and running and there will be no financial implications.

How to Prevent

  • Wash your hands well to avoid contamination
  • Avoid touching eyes, nose or mouth with unwashed hands
  • Cover your mouth and nose with a tissue or sleeve when coughing or sneezing and discard used tissue
  • Clean and disinfect frequently touched objects and places
  • Distance yourself from others and avoid crowds/gatherings

What Should I Do?

  1. I have been to an affected region in the last 14 days and

HAVE symptoms

  • Stay away from other people
  • Phone your GP without delay
  • If you do not have a GP, phone 112 or 999

DO NOT HAVE symptoms

For advice see www.hse.ie

  1. I have been in close contact with a confirmed or probable case of COVID-19 in the last 14 days and

HAVE symptoms

  • Stay away from other people
  • Phone your GP without delay
  • If you do not have a GP, phone 112 or 999

DO NOT HAVE symptoms

For advice see www.hse.ie

Affected Regions

  • China
  • Hong Kong
  • Singapore
  • South Korea
  • Iran
  • Japan
  • the following regions in Italy – Lombardy, Veneto, Emilia-Romagna or Piedmont
  • Spain

 

 

 

Tackling Fertility in Endometriosis

Endometriosis Awareness Month

What is endometriosis?

Endometriosis is a chronic inflammatory condition that affects up to 1 in 10 women of reproductive age, and typically causes pelvic pain, painful periods and reduced fertility. In clinical terms, endometriosis means the growth of endometrial tissue (i.e. internal lining of the uterus or womb) outside the uterus. This can occur anywhere in the pelvis, most commonly behind the uterus, on the ovaries or in front of the uterus, and very rarely in regions distant from the pelvis, such as the lungs. Just like the endometrial lining of the uterus, these endometriosis lesions also release blood and inflammatory factors into the pelvis during menstruation. Over time, this can cause scarring, cysts and adhesions in some women, increasing pain around periods and even throughout the menstrual cycle. The presence of endometriosis can only be confirmed by laparoscopic (keyhole) surgery. Depending on the amount, location and type of endometriosis lesions observed by the clinician during laparoscopy, the disease is graded as minimal (Stage I), mild (stage II), moderate (stage III) and severe (Stage IV).

 

What causes endometriosis?

Despite being recognized since the 1800s, its high prevalence in the global female population and the significant economic and medical impacts it imposes, the exact cause of endometriosis remains poorly understood. The leading theory is that of ‘retrograde menstruation’, i.e. that during menstruation, blood can reflux back through the Fallopian tubes and into the pelvis, carrying small fragments of endometrial lining. It is thought that these fragments can either implant and themselves cause endometriosis, or stimulate the lining of the pelvis to develop into endometriosis. In support of a role for retrograde menstrual bleeding, it is very unusual for endometriosis to occur in women who are not menstruating, and it is more common in women who have long, heavy and frequent periods. However, retrograde menstruation is estimated to occur in up to 90% of women, while only 10% of women will develop endometriosis, so this is clearly not the whole story. We know that there is a genetic predisposition for endometriosis, particularly the severe forms of the disease. Women who have a first-degree relative (i.e. mother or sister) with endometriosis are six times more likely to develop it themselves, but as yet there is no genetic test to determine endometriosis risk. No major differences have been found in the actual menstrual blood of women with or without endometriosis, but a number of studies have shown distinct changes in the endometrial lining of the uterus itself. Differences have also been found in the pelvic fluid of women with endometriosis, but whether these changes are a cause or result of the disease remains unknown.

 

How does endometriosis affect fertility?

Endometriosis is a leading cause of reduced fertility in women, occurring in  30-50% of women attending fertility clinics for assisted reproduction. However, up to two-thirds of women with endometriosis will have no difficulty conceiving, and it is not yet clear what distinguishes those women who will struggle from those who will not. In severe endometriosis, distortion of the ovaries and Fallopian tubes can impede fertilization and pregnancy establishment, while ovarian cysts (called endometriomas or chocolate cysts) can interfere with ovulation and the ability of the ovary to produce good quality eggs. In milder grades of endometriosis, where the pelvis is not significantly distorted, the reasons for subfertility are less obvious. Many studies have indicated that the immune system of women with endometriosis-associated infertility may be different to that of healthy fertile women. For instance, studies have revealed increased inflammatory factors in the fluid of the peritoneal cavity and in the endometrium of women with endometriosis, which are likely to impact ovulation, egg development and embryo implantation. Research from Merrion Fertility Clinic, in collaboration with Trinity College Dublin, found differences in uterine immune cells in women with endometriosis-associated infertility who had a successful cycle of IVF compared to women who were unsuccessful. While there is compelling research evidence of immune dysfunction, it is important to note that, as yet, there are no  immune tests or treatments that are of value. Neither is there any international consensus on the cause or mechanism of subfertility in endometriosis.

 

What are the options to treat infertility in endometriosis?

For women with endometriosis who are trying to conceive, it is generally recommended that they seek help after 6 months of trying. If a woman is unsuccessful after a year of trying, it is very likely that she will need assistance to conceive. The two main options are surgery or assisted reproduction, most commonly IVF. For women with mild forms of endometriosis, there is evidence that surgical removal or destruction of the lesions can improve fertility, possibly by reducing pelvic inflammation. Surgery has also been shown to improve fertility in severe endometriosis. If the pelvis is restored to a near normal state, around 30-50% of women will conceive in the 12 months following surgery. For this reason, for young women with no other significant infertility factors (e.g. partner’s sperm quality), laparoscopic surgery is typically the first option. In women over 35, the benefits of surgery as opposed to proceeding directly to assisted reproduction need to be carefully weighed. IUI is a viable option only for women with mild disease (Stages I and II), but not for those with significant scarring or inflammation. IVF is a very effective treatment for the majority of women with endometriosis. For young women with severe endometriosis, who are not yet in a position to conceive and may require major surgery and/or removal of an ovary, egg freezing (oocyte vitrification) should be considered as an option to preserve their future fertility.

 

 

For further reading, please see:

The Fertility Handbook (Gill Press), Professor Mary Wingfield

https://merrionfertility.ie/patient-information/causes-of-female-infertility/endometriosis/

http://endometriosis.org/

 

Is Fertility Law in Ireland set to change?

Fertility Law

Legislation regarding assisted reproduction in Ireland has yet to be implemented, and while we await formation of our new government, it is not clear when this will proceed. Parts of the Children and Family Relationships Act 2015 (CFRA) that deal specifically with donor-assisted human reproduction (excluding surrogacy) are due to take effect on 4 May 2020. This will leave a number of important issues unresolved, including parentage of children born to LGBT families using donor assisted technologies, the legal position of their parents, and the status of donor gametes currently in storage.

Solicitor Fiona Duffy, partner at Patrick F O’Reilly & Co., discusses the current legislative and regulatory concerns surrounding ART in Ireland in the article below:

https://www.bionews.org.uk/page_147640