With input from Dr Monica Vasudev

1131: IMA-CMAAO Webinar on “Fertility and ART Practice during COVID-19”

31^st October, 2020, 4-5pm

Participants: Dr KK Aggarwal, President CMAAO, Dr RV Asokan, Hony Secretary General IMA, Dr Jayakrishnan Alapet, Dr S Sharma

Faculty: Dr Hrishikesh Pai, Director Bloom IVF

Key points from the discussion

• There is no evidence of viremia or presence of the virus in ovary, uterus, testes or semen. The COVID-19 virus is not present in follicular fluid or seminal plasma. It is also not associated with gametes or embryo.
• High risk patients (diabetes, HT, immunosuppressed, lung or liver disease) should not start ART till it is safe to do so.
• All patients should be given a choice to either proceed with their ART treatment or postpone. The patient preference should be documented.
• Those with low ovarian reserve, who desire fertility preservation, advanced age and those facing extirpative pelvic surgery, low semen count should be given priority.
• Patients must sign and adhere to the code of conduct.
• Patients and staff should be educated about COVID-19, importance of continued social distancing, situations where PPE may be required and the correct method to use PPE.
• Preventive measures: Staying at home, distancing, hand hygiene, face mask and respiratory hygiene.
• In OPDs/andrology/embryology, PPE includes surgical mask, glasses/face shield and nitrile gloves.
• During clinical examination/blood collection/USG/IUI/ET, use surgical mask, glasses/face shield/nitrile gloves, plastic apron/disposable gown.
• For long duration OPU deep GA/AGP: N95 mask, glasses/face shield, nitrile gloves/latex double gloves, coverall.
• ESHRE has given a list of questions to be asked of the patients; this questionnaire has also been used in ICMR guidelines.
• Adaptation of the IVF center is important. Replace ACs with air exchange machines, redesign waiting rooms and working spaces to ensure appropriate distancing and ventilation. Sanitize air with 38W 250nm UV lights for 15-30 minutes.
• Use telemedicine; send patients to local sonologists (nearest to them) and train them for monitoring.
• Avoid couple consultation and reduce person consultation time to less than 5 minutes.
• Follow-up patients three weeks after oocyte retrieval and/or embryo transfer to identify potential COVID-19 positive patients and implement necessary measures.
• Staff adaptation includes dividing staff into mini teams to reduce unnecessary exposure and to create back up teams, staff should avoid public transport, adjust work shifts, have emergency agreements between ART centers to guarantee continuity of treatment provision.
• Do triage 2 weeks before treatment; if triage positive, do RT PCR. If positive, then cancel cycle.
• Do RT PCR on husband/wife in intrauterine insemination (IUI)/IVF patients and do RT PCR on wife in frozen embryo transfer (FET) patients.
• Do triage all throughout the treatment period; if positive, do RT PCR.
• Freeze the eggs if husband is RT PCR positive and wife is negative.
• For ovarian stimulation monitoring, home self-monitoring of medicines has now become a norm. May give medicine refund if cycle is cancelled half way through.
• Create negative pressure in both OT and labs; lab pressure to be more than OT pressure.
• Aerosol generating procedures must be done only when strictly necessary and should be avoided when there is risk of COVID-19.
• Adhere to standard infection control procedures and good lab practice principles (standard use of IVF lab PPE and biological safety cabinets).
• Use AHUs, specialized HEPA filters, high intensity UV light to minimize viral load
• Embryo transfer must be performed in room with negative pressure; wear PPE; limit the number of staff in the room and also restrict access for the accompanying persons.
• ICMR has also proposed a Code of Conduct, which includes truthfully sharing of all information with the clinic when filling questionnaire for triage; comply with any requirements related to testing, tracking and tracing; practice social distancing – restrict social life and interaction to reduce risk of infection at the work place; practice frequent hand hygiene.
• Wear a mask, comply with any required quarantine requirements, self-shielding or maintaining a self-imposed self-quarantine whenever possible.
• Dr Pai’s modification of rules of the pandemic: Hand wash 10 times in a day, social distancing (6 foot), masks 2 layers with two different materials (cotton/silk), screening (triage, temperature, testing), stay at home if you have symptoms, avoid malls, restaurants, lifts, gyms etc., tackle COVID aerosols with AHU with air exchanges, plasma filters, filters with UV light or UV light 38 watts for 30 min.
• Other strategies include consolidation of practice, humane handling of workforce, don’t compromise on marketing and technological upgrade, long-term financial practice, conservation of resources and savings, relearn and retrain yourself.

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA