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.
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.