TAMMY: Carrot serves employer customers, and their employees, in over 40 countries around the world where we are operational. We had our first webinar last week, during which we focused on how the novel coronavirus and the disease caused by it, COVID-19, has impacted access to fertility care in the United States. Today, what we’re going to do is focus on access to fertility care outside of the U.S., specifically in Europe and Canada.
While U.S. (positive case numbers) are escalating, countries in Europe are at a much more advanced stage of spread, and, last week, the Director General of WHO designated Europe as the new epicentre for COVID-19 and viral spread.
In this webinar, we will review a few most common questions — from planning to pregnancy — that Carrot is helping our members with, and then we’ll open up for questions from this audience. Q&A is live, so please use the Q&A feature in Zoom at any point to submit and ask your questions.
Before we get started, I also wanted to remind our audience of a few things
Before I do quick intros , on behalf of Carrot and all of our team here, we commend all of the healthcare workers who are supporting all patients during such a challenging time. We are really impressed with the thoughtfulness and care that fertility clinics have taken to support Carrot members during this very difficult and unusual time.
I am joined today by three speakers. The first is...
Heather McAlonan - who is a registered nurse and Head of Medical Operations at Carrot. Heather works closely with Carrot’s CMO and scientific advisor, as well as me at Carrot. Over a decade of experience as a fertility nurse and has had the opportunity to work for some of the top fertility centers in the nation.
Mikayla Johnson - Head of Global Operations at Carrot. Leads our Global Operations team and works closely with our global advisor to bring our members a positive experience across 40+ countries. She has been working with Carrot for nearly 3 years. Prior to Carrot, has experience with US health benefits, public policy in Canada, and consulting in China.
Aoife Lucey - Carrot’s European Representative based in Dublin. She has 20 years business consulting experience across 16 international markets, Aoife has worked with companies such as GSK Consumer Healthcare and Philips Healthcare. In her role as our European Representative for Carrot, Aoife communicates with fertility clinical directors, embryologists and fertility academics amongst others to ensure that Carrot keeps its finger on the pulse for its European Members.
With that we’re going to dive into some questions that we’ve gotten in advance.
TAMMY: To just get us started, what does the state of fertility care look like globally for patients right now, Mikayla?
MIKAYLA: To take a step back, fertility care and family forming interventions have always been very uniquely applied across the country level, sub-regions (such as state and province), and at specific city levels.
Over the past few months, Carrot has also been more specifically looking at COVID-19 to really zone in and monitor how this is impacting our members’ journeys, so that we can best help them. Carrot is aware that in some countries, physicians and nurses are being asked to assist with helping patients who have succumbed to COVID-19 - but this is not the case, in every country. All of this is of course part of the bigger picture where health systems are taking precautions to ensure people are safe as globally people work towards obtaining more information. Through the precautions Carrot has seen, either being taken country-wide or at a clinic level, it’s really important for fertility patients to know three things:
1. right now guidelines and mandates can vary at a regional-level, country-level, and also within a country.
2. public and private fertility clinics are closely watching their respective national, regional, and international guidelines on the topic. Of course when a country or a section of a country is placed on “shut-down” due to the spread of the coronavirus, then this will in many cases apply to both the public and private clinics, as well for the requirements they meet.
3. if you were seeking care in a different country or you were planning to move your oocytes/eggs, semen, or embryos to a different country for care, then there may be travel restrictions as we’ve all seen coming up; or you may be recommended or required to continue the transportation at a later date.
As a whole, the situation is constantly evolving and Carrot’s Global Operations team is continuing to keep a pulse on this. The Carrot Resource Center is a great place to start if people are looking for more information, and as they continue to evolve.
TAMMY: While we’re waiting for Aoife to get back, why don’t we take a look at Canada. Mikayla, what is the situation in Canada at the moment, and how should people who are looking at, or undergoing fertility care, navigate the landscape there?
MIKAYLA: Even though Canada is at the border to the US, there are differences between the two so I’m glad we have a chance to speak to it in this week’s webinar. Similar to other countries, there are suggested guidelines for patients and clinics. The Canadian Fertility and Andrology Society (CFAS), they are not a regulatory body but provide guidance to fertility clinics and patients— the most recent and up to date piece, that was as of March 18th, is that they recommended that patients to stay at home and attend fertility consultations through telemedicine, and that they do not move forward with new procedures.
For patients currently in the midst of care, the CFAS recommends clinics utilize telemedicine as much as possible, complete current IVF cycles by moving to freeze all rather than moving to an embryo transfer, and ultimately postpone any new IUI, IVF, or embryo transfer cycle starts, aside from urgent cryopreservation for oncology.
They have proposed that they will revisit this in 2 weeks, so around early April. Of course this could be updated prior to that time as the situation continues to evolve, and hopefully improve. However, at this time that is the current recommendation in Canada.
TAMMY: Got it, okay. I’m looking here at some questions, and I’m wondering if Heather can step in? It’s pretty similar to a question we got in the last webinar—With everything going on, should I attempt to get pregnant right now?
HEATHER: This is an excellent question, and it’s one I’ve been getting a lot. Right now everyone is waiting to see if there’s been any new information that’s surfaced since the last couple of weeks. Even still today, professional societies are recommending postponing pregnancy even if you have not been exposed or had the virus. The current guidance from our scientific advisors is consistent with this, and is based on the fact that there isn’t enough data or evidence that conclusively indicates how this virus may impact our reproductive health or those who are pregnant.
Since the outbreak of the COVID-19 virus in December 2019, scientists have not seen sufficient evidence that the virus can be transmitted to the baby in utero but, we are starting to see information coming out of studies from China that tested amniotic fluid, cord blood and the infant(s) after delivery from women who had contracted the virus, and what they are seeing, at this time, is very little evidence that there is any indication or vertical transmission during pregnancy.
This is promising information that suggests the risk of the virus being transmitted during pregnancy is low, but we are in the initial stages of getting more information, so again, professional societies are recommending postponing pregnancy even if you have not been exposed or had the virus.
I’d also like to clarify that at this time, pregnant women don’t appear to be at a higher risk for contracting the virus but due to the changes that occur during pregnancy, it could make pregnant women more susceptible. As such, pregnant people should be considered an “at risk” population.
And this is not to cause alarm for those currently pregnant, it is to make sure we are taking an abundance of precaution to identify those who may be more susceptible to getting sick, which means taking additional precautions.
TAMMY: Aoife are you back on the line?
AOIFE: I am indeed. Can you hear me clearly now? All of Dublin is working from home now, so our connection is iffy.
TAMMY: We sympathize and empathize! It’s no problem. We’re going through some questions we received in advance before we delve into some that are coming in through real time. With what we know so far about COVID-19 and pregnancy, is that any different if I am planning to pursue IUI or IVF? Is it even possible in Europe to initiate treatment?
AOIFE: The best guidance on this question comes from the professionals themselves. The European Society of Human Reproduction and Embryology (ESHRE) recommends 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, or in mid cycle, ESHRE suggests considering deferred pregnancy with oocyte or embryo freezing for later embryo transfer date.
Over the past week, in order to keep our finger on the pulse of what is happening across Europe for our Members, Carrot has spoken with a combination of clinic directors, embryologists, fertility nurses and clinic staff that are working in both the public and private sector, in each European country to help inform us of what is happening on the ground. What we are hearing them say are very much in alignment with ESHRE guidelines especially in countries that are very badly affected by COVID-19.
What Carrot has learnt is that most European Clinics are not starting any new IUI or IVF cycles, with some exceptions in being in Eastern Europe, with Russia and some areas in the Ukraine. So you will severely struggle in pursuit of IUI or IVF in Europe over the coming month or two. However, please do reach out to your own fertility clinic, or reach out to our Carrot Care team.
TAMMY: Aoife, are those barriers to access and difficulties, are they the same if you’re pursuing fertility preservation? Like egg, sperm, or embryo freezing? Is it equally as difficult?
AOIFE: Great question, and the answer is absolutely. If you have thought of egg or sperm freezing at this state, the recommendation from ESHRE would be to pause and wait until further notice. If your treatment was scheduled to start in the next couple of weeks and you have not heard directly from your clinic yet, please reach out to them. The chances are they will postpone.
TAMMY: Do you have any advice on how we as patients should be working more closely with our fertility clinic to know what to do? Should they be calling them proactively? What should they be doing in working with their clinic?
AOIFE: From the European point of view, we would say absolutely reach out directly to your clinic. What Carrot has found, this morning in particular, especially in parts of northern Europe, is that there are countries that simply are taking a long time to pick up the phone. But that is understandable at the moment. In this case, it might be more applicable to email the clinic.
TAMMY: Is that just because they’re overwhelmed?
AIOFE: That’s what they’re telling us. Sweden in particular, their directives are just coming through at the moment, so they’re just going over changing and rescheduling. With those clinics they’re giving you a time frame of 6-7 hours to call you back. So in those cases what you can do, if you’re not having any luck in calling, is to email the clinic- that would be the recommendation. The same would go for a couple of western European countries that are on lockdown. There are a number of clinics that are simply not picking up the phone, they’re just not there. So we would recommend emailing them if you can’t get them on the phone.
TAMMY: Got it. Are the dynamics the same over there in Canada, Mikayla?
MIKAYLA: Yes, I definitely want to echo what Aoife mentioned, and it is quite similar. Especially given last week and the changes that took place. They have been contacting patients directly to update them on their treatment plans. If you are in Canada and have not heard from your clinic then try reaching out to them to make sure you’re all set for any changes or next steps that you may need to take.
TAMMY: I’m just sorting through some of the questions that have come in. I’m going to read this one out loud and it seems like Heather can take the lead. The questions is: For those of us who haven’t started our fertility journeys yet and are thinking about the future, should I worry that if I am asymptomatic yet am harbouring the virus, that it will hurt the integrity of my sperm/semen or oocytes/eggs? What if I am symptomatic and likely have caught the virus?
HEATHER: This is a great question and a challenging one as scientists are still learning more information about this coronavirus virus everyday and scientists are unclear about the implications that COVID-19 has on our oocytes and sperm or our overall reproductive health.
Again whether you are currently asymptomatic, confirmed to have the virus, or have been in contact with someone known to have the virus, we truly do not have enough information to understand the implications this has on our future fertility.
And to circle back to the part of the question about if it will hurt the integrity of my sperm or eggs.Thus far, there is only anecdotal data on potential changes in sperm in those who have tested positive for COVID-19, but we’re likely to see more information in the coming months that may help shed some light on this question. Again, there is no evidence thus far that the virus or the disease it causes, has shown an impact on oocytes or ovarian reserve. However, it is highly likely that scientists will be shedding more light on these questions concerning future fertility for both men and women with more data in the coming months.
TAMMY: This one is from Europe, so Aoife can answer— Hi Carrot I’m in Ireland and had planned for care in Spain. What if my plan was already arranged to travel abroad for treatment? What can I do, now?
AOIFE: Phew, unfortunately not great news here at the moment. I know with Italy, France, Belgium, and yes, unfortunately Spain now officially on lockdown to combat the spread of COVID-19, I am afraid that all flights between Ireland and Spain are essentially cancelled. And that’s quite a popular question from our fertility members. The root between Ireland and Spain is a well traveled one from the fertility point of view. So unfortunately there are grounded flights there.
To give other listeners on the webinar an idea of the level of impact on travel in Europe; Ryanair, our number 1 airline carrier, now expects to reduce its seat capacity by up to 80%, and ‘a full grounding of the fleet cannot be ruled out’. Lufthansa, thich is the german national carrier, has grounded 700 of its 763 airplanes. So we’re really talking about a huge disruption here.
The one thing that cannot be forgotten here is I know the things people have to go through in order to prepare. Patients invest so much in the lead up to any fertility treatment. When mentally, emotionally and physically you ready yourself to start treatment, and then it gets postponed like this, it can be very difficult news to hear, and it’s important to acknowledge that. I know that faced with this situation, I might consider just going ahead and rushing to start my fertility preservation cycle now, as I have that Carrot benefit there. But we really want to re-echo ESHE’s recommendation, and the recommendation of some of the clinic directors we spoke to this morning, which is not to move forward at this time.
But I would like to end, and say that the clear exception Europe-wide is in the case of urgent care - often related to cancer - and the urgent need to preserve fertility before treatment. That’s absolutely the exception.
TAMMY: We’re coming to the close of the webinar but I wanted to add one more question, which seems like it may be more common. Heather can take the lead on this one— I just found out this week that my IUI was successful and I am now pregnant. Is there anything that I can do to reduce my risks of contracting the virus that causes COVID19? Is there information on whether if I do get infected that it will hurt my pregnancy?
HEATHER: The best way to reduce your risk of contracting the virus is understanding how the virus can spread. Most cases of transmission are from person to person through droplets in the air from someone who coughs or sneezes, or possibly came in contact with surfaces that have the virus. So continuing to follow our governmental, local, or regional recommendations to continue to maintain proper social distancing, good hand hygiene, and making sure you reduce foot traffic to and from various places. Make sure you reduce any non-essential travel and are taking every precaution to prevent yourself from being exposed to the virus. As you are very early on in your pregnancy this means talking with your provider to understand what are the essential appointments that will require in person visits. Also, if you are very early in your pregnancy your birth plan may look very different now than it will look in several months. This is all dependant on the progression of COVID-19
To address the second part of the question… I was able to locate the articles I referenced earlier, and there is some data that was recently reported in the journal, Frontiers of Pediatrics, the authors of the study were professors from a technical university in Wuhan, China, they noted two cases of possible transmissions of the virus from mother to baby, but it is important to note that it is unclear whether the transmission was prior to or after the birth of baby.
Another previously published study in the medical journal The Lancet. In this case, professors from a different region in Hubei, China, had tested the amniotic fluid from nine mothers that had the virus and those samples tested negative for the virus. This information is very positive, and led the authors to conclude that (and now this is a direct quote from the article): “There is no evidence for intrauterine infection caused by vertical transmission in women who develop COVID-19 pneumonia in late pregnancy.”
Again, this is just not yet considered strong enough evidence because the sample size (in other words, the number of women and babies studied) is not large enough to provide us with a definitive answer. We also don’t have any data on outcomes for those who contracted COVID-19 early in pregnancy yet. This is why it is so important to be overly cautious at this time and follow your national CDC or equivalent governmental agency, and any regional guidance to avoid as best as possible your risk of exposure to the virus, by using good hand hygiene, social distancing, and avoiding unnecessary travel if at all possible.
Tammy: I want to be respectful of everyone’s time, and thank Mikayla, Heather, and Aoife for joining us today. We are going to post a copy of the webinar on our COVID-19 Fertility Resource and Center page, you can find that at carrotfertility.com. We will also keep that page updated with all the latest news, information, resources as much as possible. Our next webinar will also be a global webinar and cover the situation of fertility care in countries across Asia for our members there.
I want to thank everyone for joining us today. Stay healthy and well.