COVID-19 & fertility care: Asia


TAMMY:  Hello everyone and welcome! I think people are just starting to trickle in now. Thank you all for joining this webinar. My name is Tammy Sun, and I’m the CEO and Co-founder of Carrot Fertility. For our new listeners, this is the 4th webinar we’ve done here at Carrot to share important information about COVID-19 and its impact on fertility care. In previous webinars, we discussed the impact of COVID-19 on access to fertility care in the U.S., Canada, and Europe, as well as mental health and fertility care in the setting of the COVID-19 pandemic. Today, we’re focusing on access to fertility care in the Asia-Pacific (APAC) region, including some countries that are post-peak COVID-19, where some fertility clinics have begun to resume cycle treatments. 

While positive case numbers in the U.S. and many countries throughout Europe are escalating, many countries in Asia are seeing a decline in the rate of new cases, and some Asian countries are even loosening their self-isolation protocols as the disease becomes more well-controlled. 

In this webinar, we will review a few most common questions that Carrot is helping our members with, and then we’ll open up for questions from our audience. Q&A is live, please use the Q&A function in Zoom at any point to ask your questions.

I also wanted to remind our audience of a few things before we get started.

  1. Outside of this webinar, we’re regularly updating Carrot’s Coronavirus & Fertility Resource Center at carrotfertility.com with the latest guidance and common questions about COVID-19’s impact on fertility care and adoption worldwide. You can also access our Carrot Care Team for additional questions from that page whether you are a member or non-member.
  2. We also list global, local, and regional authorities so you can stay up-to-date on specific guidance for your area. If you’re joining us from outside of Asia and the Pacific, you can access these resources on our website.
  3. We’re not providing advice — always talk to your physician to determine the best plan for your situation

Now, I wanted to introduce our speakers for today.

Dr. Shehua Shen — Dr. Shen has over 26 years of experience in the field of in vitro fertilization (IVF). She was an Associate Professor in the Department of Obstetrics, Gynecology and Reproductive Sciences, and Director of the Embryology Laboratory at University of California, San Francisco (UCSF). She has worked with IVF Programs at the Women and Infants Hospital of Rhode Island/Brown University Medical School, the Brigham and Women’s Hospital/Harvard Medical School and the University of Washington. She was also a Vice President for Medical and Scientific Affairs in two start-up companies. Today, she is the CEO/President of Hernest Center for Reproductive Medicine.

Shehua is an active member of the American Society of Reproductive Medicine (ASRM), the European Society of Human Reproduction and Embryology (ESHRE), and the American Association of Bioanalysts (AAB). She has published more than 100 peer-reviewed manuscripts, book chapters, patents and conference abstracts in the area of research of improving embryo selection and IVF outcomes.

Kate Shi — Kate worked as a registered nurse in the United States for many years before she joined Hernest Center for Reproductive Medicine. She has been in assisted reproductive medicine for over 3 years and helped build the IVF program at Hernest. She leads and trains her nursing staff to deliver personalized care while providing scientific based patient education to aid their success in battling with infertility. 

Yumiko Kadota — Yumiko Kadota is Carrot’s Regional Director located in Japan. Yumiko has been instrumental in helping to build and localize Carrot’s processes, product, and support to Japan. Since joining in late 2018, she has been guiding Carrot members through their fertility and family-building journeys, and implemented local language support in Japanese. She has also fostered and built many key relationships with local medical experts and leading fertility centers in Japan. She is based in Tokyo, and prior to Carrot, she has had extensive experience working in the financial sector. 

Alex Zarka — Alex helps lead Carrot’s global operations in the Asia Pacific Region and Latin America. He works closely with Carrot’s Head of Global Operations, scientific advisor, and regional leads, to bring our members in APAC and Latin America a positive experience. He has been working with Carrot for over one year now. Prior to Carrot, Alex has experience working in various digital health, clinical medicine, and Medicare settings.

TAMMY: To just get us started, what is the high level snapshot of the state of fertility care look like in Asia, Australia, and New Zealand at the moment? Alex, can you take this one?

ALEX: Thanks for the great question, Tammy, and very honored to be a speaker on this webinar today. Since we have Dr. Shen, Kate, and Yumiko here, I will let them speak to China and Japan, but I can provide a general overview of the status in other Asia-Pacific locations.

In the Pacific region, such as Australia and New Zealand - There have been escalating COVID-19 measures at the national, state, and provincial levels, and the Fertility Society of Australia has been releasing regular updates in response to these measures. Currently, the fertility society of Australia recommends that all patients who are considering to initiate treatment, for them to contact their clinic directly to determine a plan. What we are seeing is that there are national restrictions in place in regards to elective surgeries, but many clinics are continuing treatment for those patients that are already mid-cycle, but for patients who have yet to begin treatment, they are recommending to postpone for safety reasons. The country of New Zealand is currently on lockdown, so clinics in New Zealand are closed and have stopped treatment, except for most critical cases, such as those involving cancer.

In southern Asia, countries such as India are in full lockdown, however many fertility clinics are still offering resources and support for their patients. Our experts in India tell us that while IVF clinics and labs might be closed, they are still offering virtual consultations for their patients. 

In South East Asia, we are seeing a lot of differences at both the national and local level. For example in Thailand, some cities, such as Phuket are on full lockdown and so clinics are closed, however In Bangkok, fertility clinics remain open and are accepting new patients. In Singapore - Fertility care through private practices and private IVF labs are still open and accepting patients, but we are seeing that at public hospitals, most assisted reproduction services have been postponed, as they are located in bigger hospitals where they are caring for patients in other sections of the hospital who may have tested positive for COVID-19. 

East Asia, in regions such as Taiwan, Hong Kong and South Korea,from what we are seeing, fertility clinics have remained open, and are continuing to accept new patients. Similar to Singapore, In Hong Kong, we are seeing larger, public hospitals suspending fertility treatments, but otherwise clinics are operating at normal capacity. Many clinics have adopted special policies, such as temporarily not accepting walk-ins, limiting the number of accompanying visitors, and requiring temperature checks upon arrival. More recently in South Korea, we’ve also seen some clinics implement mobile pre-examination questions prior to in-person visits, to limit patient-to-patient contact.

While countries throughout the Asia-Pacific region, and subsequently fertility clinics, are in different phases in managing the outbreak, we are seeing fertility clinics that were previously closed are now reopening, and in some locations we have seen clinics that have remained open throughout this whole time. Of course the situation continues to constantly evolve, so we encourage our members and listeners to reach out to their clinics with any questions. The Carrot resource center is also a great source of information as well. 

TAMMY: Thanks for sharing that, Alex. Each country is so different. Yumiko, how is the situation in Japan? What’s happening with fertility care right now?

YUMIKO: Thank you for having me here today, Tammy. I would like to add some colour on Japan to the great summary by Alex. Similar to other countries, Japan has also heightened alert on COVID-19 with entry restrictions or quarantines since February, but lockdowns have not yet been  implemented here, so fertility clinics remain open as of today. However, Japan Society for Reproductive Medicine just released a guideline on April 1st recommending to put on hold fertility treatments given the uncertainty of COVID 19 effect on fertility healthcare. From yesterday we started to see clinics suspending new cycles of IVF and IUI, and recommending patients to cancel on-going treatments if possible. It is still a recommendation for now, but it can be expected most of the clinics will have limitations of treatments, or temporary closure in a very near future.

TAMMY: I thought we could do something that we’ve done in previous webinars, which is to aggregate and tackle some of the most common questions we have gotten prior to the webinar, then we can open it up to the Q&A. So we can start with the first question, which you can probably answer Dr. Shen, is there any research being done in China to assess how COVID-19 might impact pregnancy?  

Dr. SHEN: It is a really important question. The short answer is that we do not know yet whether getting pregnant right now is safe. The reason why is because the data we have so far are all from late stage pregnancies. Several small studies from China looked at newborns and infected mothers. No reliable evidence is as yet available to support the possibility of vertical transmission of COVID-19 infection from the mother to the baby. Analysis of amniotic fluid and cord blood, even breast milk, from nine infected women who delivered in China during the peak outbreak didn't detect the virus. Which is good news. Although a few babies tested positive for COVID-19, they all had exposure to infected people after birth. Regarding the mothers, the clinical characteristics reported in pregnant women with confirmed COVID-19 infection are similar to those reported for non-pregnant adults with confirmed infection. To summarize, no evidence supported vertical transmission yet. Further studies are needed to look at the evidence. 

We would like to make it clear that these reports are limited to late stage of pregnancy. There is no data available about the impact of COVID virus infection during early stage of pregnancy. 

TAMMY: Interesting, and Dr. Shen, how might this impact gametes (oocytes/eggs and semen/sperm)?

Dr. SHEN: This is a novel virus and we do not have any data on the impact of virus infection on eggs or sperm yet. The COVID-19 virus appears to be isolated to the respiratory and gastrointestinal systems. At this moment, it does not appear that the virus resides in the female reproductive tract. However, there is some evidence indicating that the virus may infect the male reproductive systems. This is based on research work that found large presence of the ACE2 (Angiotensin Converting Enzyme 2) receptors in male reproductive systems. ACE2 is one of the major receptors that the SARS-CoV-2 virus causing COVID-19 attaches to for entry into the human cell. But we do not know whether the large number of receptors equals to the testicular damage caused by virus. Studies have been designed to address this issue. The good news is that, this receptor is rarely, if ever, seen in the female reproductive system. 

TAMMY: In the United States a lot of fertility clinics have shut down. Kate, what measures did fertility clinics in Asia take during peak outbreak? 

KATE: In China almost all fertility clinics had temporarily closed during peak outbreak, but many started online consultations. Hernest for example, we moved all our consultation appointments online when we were closed, our doctors worked from home and consulted patients via video chat. We did everything that can be done remotely to prepare our patients for treatment later. Some clinics used courier service to deliver patient medications. Many clinics did not resume cycle treatment for a while after reopening, only saw patients in need and by appointment made in advance.  All those measures were meant for crowd control and to minimalize the risk of exposure. I think the difference between smaller clinics and larger hospitals would be how long they were closed for, and the extent of care they were able to transfer online. Usually the smaller clinics stayed closed for a bit longer than the larger ones, they also had fewer resources to transform the services alternatively, mainly because of smaller volume of patients and staff. But the larger hospitals resumed service pretty quickly, a week or two after they temporarily closed.

TAMMY: One of the questions we got was for China,  and Kate you mentioned some of the fertility clinics in China were temporarily closed. Are any of those fertility clinics now resuming cycles? Is this happening in different areas of China or all over? What is the pattern that you’re seeing over there?

KATE: I would say over 90% of the fertility clinics nationwide have resumed medical activities, most of them have resumed cycles as well. Definitely not everything back to normal all at once yet, there are still restrictions in place such as no walk-ins allowed, no out-of-town patients are treated, and a cap on how many patients can be seen per day, etc.. This is happening all over China but there are regional differences. For instance, clinics located in eastern China and in core cities had a much earlier reopening date, and resumed more clinical activities than the ones in western China and non-core cities.

TAMMY: Okay, so let’s toggle over to the open Q&A. These are some of the questions that we’ve gotten from the audience. So this one can be for you Dr. Shen, what measures are being taken to address risks if people return for fertility care? 

Dr. SHEN: At our clinic in China, we have a triage desk at the entry door. We ask patients their history of travel and potential contacting with infected people. We measure their temperature and ask whether they have any respiratory symptoms. We make sure they wear mask properly. You know many people do not know how to wear it properly. Finally, we use sanitizer to wash their hands to make sure they’re disinfected before letting them get into the clinic area. At the same time, all staff must wear proper PPE. Social distancing is reinforced as much as what space allows. Staff wear gloves properly and wash their hands diligently. The clinic area, particularly the door handles and elevator buttons, are rigorously disinfected periodically throughout the day. In summary, we will isolate potential infected patients immediately, basically at the first sight. The key principle is protecting healthy patients and staff, while we try to provide the infertility care that patients need. 

TAMMY: What about in Japan, Yumiko? Are there measures that you see are being taken to mitigate and reduce risk for when people return to fertility centers?

YUMIKO: In general here in Japan, public hygiene standard is quite high and clinics have been introducing extra precautionary measures, such as Dr. Shen mentioned, in preventing hospital acquired infection. Taking a body temperature check, and travel history check, as well as sanitizing the hands when entering the building. We can expect fertility clinics will ask at least the current or higher level of self control to the patients before returning for treatments. 

TAMMY: Here is another question that is sort of related to the tepidness and hesitation that people might have or feel when they come back. The question is, can they feel confident continuing or resuming their fertility care? Dr. Shen, can you talk a little about this?

Dr. SHEN: Yes, they can. We are committed to taking care of patients, particularly in this unprecedented time. We strictly follow guidelines, there are very detailed guidelines for us, to minimize any chance of cross infection. For example, asking patients to make appointments instead of walking-in. What we’re doing is talking about changing the patient’s habit. One of the things that we have been doing, as Kate talked about, is to offer free virtual consultations to our patients and address their questions, which will continue for a while. Many programs in China have offered such service. To re-emphasize, protecting patients and staff from the virus infection is the top priority. At the same time, we want to do everything not to compromise patient’s fertility care and treatment. To some patients, fertility treatment is time-sensitive, not entirely elective or can be postponed for long periods of time. Physicians and patients should discuss thoroughly and make good decisions. 

TAMMY:  We still have a few more questions which we can handle, we’ll do one about travelling. Kate, how are fertility clinics handling out-of-town patients in need of IVF treatment now that China is recovering from this COVID19 outbreak?

KATE: In the first wave of reopening after peak outbreak, clinics did not resume seeing out-of-town patients right away, for many, it is still temporarily on hold, services were offered to local patients only, Hernest is one of those clinics. However, some larger clinics have started open to patients from close by areas. Take the largest IVF clinic in southern China as an example, they do over 40 thousand cycles a year and treat patients from all 31 provinces in China. They reopened their clinic in late February and started with treating locals first, then the population within the province in which the clinic is located, and worked their way to patients from nearby provinces and of further distance. By mid-March, they have fully resumed seeing patients from all over the country and overseas like they normally do before the outbreak.

TAMMY: For those who have to cancel or postpone their IVF cycle, or fertility treatments, when will they be able to resume treatment? Alex, from an operations perspective, since you spend so much time on this everyday maybe you can take this on— for those who have had to cancel, when will they be able to restart?

ALEX: That’s a very good question, but a difficult one to answer. For those who are located in areas where clinics are postponing treatments, it’s unclear when those clinics will be able to resume. Doctors and fertility centers have been closely following the advice and directives of their local government, as well as their national and regional fertility societies. Ultimately your healthcare providers are taking every precaution to ensure that you are safe. They will certainly resume treatment, but it’s difficult to predict when exactly that will be. 

TAMMY: This next question comes up at every webinar, so we should continue to address it, in different geographic settings. Dr Shen, one person would like to know with everything going on, should they be trying to get pregnant now? 

Dr. SHEN: Whether to get pregnant now is concerning whether the infection of COVID-19 is associated with a high incidence of adverse maternal and neonatal complications, such as spontaneous miscarriage, preterm delivery, intrauterine growth restriction, etc. As I mentioned previously, we only have little data to indicate that no evidence supported vertical transmission. We do not know what effects the coronavirus might have on a fetus, particularly in the early stages of development, or how severely it could sicken pregnant women. One thing that you should definitely do is to prevent an infection if you attempt to get pregnant now. 

TAMMY: I just noticed that we still have a couple questions that we haven’t had the chance to answer, but we will through our COVID-19 Fertility Resource Center. We’re just on time right now, and out of respect for everyone’s time I would like to wrap up and thank our speakers for joining us today. Thank you so much for your time, and for the folks who were listening, we hope this webinar was useful and informative. Certainly this is a very difficult time for everyone, and many of you still have questions, so please feel free to use our resource center. And know the Carrot team is continually driving efforts to support those of you who are seeking fertility and family-building journeys during this time. We are constantly monitoring the global, regional, and local landscape to make sure we keep you up to date on what is most impactful for your decision making. 

So just a quick reminder for those of you who are listening, our Coronavirus & Fertility Resource Center page can be found at carrotfertility.com, and both members and non-members are also encouraged to reach out to the Carrot Care Team directly for any questions. Thank you to everyone for joining us here today. Stay well, stay healthy, and stay safe.  

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