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May 18, 2020
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Boston IVF's Alan Penzias, MD Provides ASRM COVID-19 Task Force Update

Boston IVF reproductive endocrinologist and American Society of Reproductive Medicine COVID-19 Task Force member Alan Penzias, MD joins the ASRM Today podcast to provide an update on the panel's guidelines for fertility centers nationwide. 

We thank Dr. Penzias for his expertise in helping to create important COVID-19 guidelines for all IVF clinics nationwide – while also ensuring that Boston IVF's patients and staff receive the safest care during the pandemic and beyond.  





Welcome to ASRM today, a podcast that takes a deeper dive into the current topics of reproductive medicine.

Hello, everyone, I'm Dr. Jeffrey Hayes, your host for this episode of ASRM Today. On this episode, our guest is Dr. Alan Penzias, who's going to talk about the fourth update from the ASRM COVID-19 Task Force. Dr. Penzias, thank you for joining us.

Thank you for having me.

Dr. Penzias, tell our audience a little bit about yourself and your role on the COVID-19 taskforce.

I'm a physician member of the ASRM COVID-19 taskforce, the Director of the Fellowship Program and Reproductive Endocrinology and Infertility at Beth Israel Deaconess Medical Center in Boston – and an Associate Professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School. I'm also a practicing physician at Boston IVF and chair of the Practice Committee of the ASRM. I have expertise in evidence-based medicine and guideline development – and I hope my application of experience to this pandemic will help us work our way back to fulfilling our mission of treating patients.

Can you give a brief synopsis of what ASRM has published on COVID-19 to date?

In a recommendation issued on March 17, that initial recommendation called for a temporary pause in the initiation of new infertility treatments. The pandemic had just come to the United States and we saw the reports coming out of China and Italy with never-before-seen strains on their healthcare infrastructure.

We understood the gravity of the situation and were quickly learning about how the disease is transmitted. Recommending a temporary halt to fertility treatment was not done lightly. We, as fertility practitioners, have devoted our careers to helping those who are devastated by infertility and to others who require medically assisted reproduction.

On March 31, the first update to those initial recommendations were published and in it the taskforce reaffirmed the recommendation to suspend initiation of new treatment and anyone other than those with emergency situations such as, perhaps, cancer patients in need of oocyte cryopreservation. Wea provided clarifying statements which affirmed that infertility is a serious, time-dependent disease – and called attention to the devastating affect it had on the mental health of our patients. We also strongly encouraged the use of telehealth for communicating with our patients and suggested scheduling visits with mental health practitioners.

Two weeks thereafter, on April 13, in the four short weeks that followed the initial recommendations, we came out with update #2 – where we had learned a significant amount about the disease's transmission and began to see different regions of the country where the prevalence curve had begun to flatten. Knowing that we were going to have to learn to live in a world where COVID-19 exists, we signaled that we were preparing to provide a framework for the resumption of care.

Two weeks thereafter, on April 24, update #3 was a major shift. In update #3, we recognized the temporary halt to treatment along with other societal changes had helped change the trajectory of the disease. In update #3, we provided a detailed framework for clinics to use to assess their local conditions and disease prevalence, recommended a series of indicators that could be used to signal the resumption of care, and provided practices with important tools to perform a formal risk assessment and create a risk mitigation strategy that is flexible and responsive to the changing landscape of the COVID 19 pandemic.

All of this was designed to help clinics resume the important tasks of taking care of our patients while minimizing the risk to the patients and the clinic staff.

And I think that the last sentence is really critical, because we acknowledged that until we have a cure for COVID-19, where the virus is eradicated in all aspects of our lives, we will be pinched with that element of risk mitigation. We, as healthcare providers, have chosen to take on the obligation to provide care to patients who need it. In the case of infertility, this means doing so in an environment where risk is minimized but not eliminated.

Dr. Penzias, what is the main thrust of update #4?

The main thrust of update #4 focused on four different areas.

Testing was number one. We provide an update on testing, since this topic, in particular, seems to change every few days. It's become fairly clear that testing for the presence of viral RNA using PCR yields the greatest immediate diagnostic benefits. In a symptomatic individual, viral RNA is detectable as early as day one of symptoms and peaks within the first week of detection. Positivity usually starts to decline by week three. However, in severely ill hospitalized patients, PCR positivity maybe persist for three weeks and beyond after the illness onset. In asymptomatic individuals, which are those with only mild symptoms, the viral testing may be negative, a false negative, when in fact that individual may be infectious.

We also talk about the fact that not all test kits are equally effective and this has led to some confusion. But nonetheless, incorporating testing as a part of patient and staff management strategies, when accurate tests become widely available, is recommended.

We also describe a new category of test, and that is an antigen test. As of the issuance of update #4, there was one approved antigen test that quickly detects fragments of proteins found on or within the virus when testing samples collected from the nasal cavity using swabs. This could prove especially useful in reducing the time – from sample collection to results. From three to four days, down to two days, to even as soon as hours or even 15 minutes.

We also reiterated that serologic testing for antibodies was useful for population studies, but should not be used to diagnose the disease nor to give an “immunity passport”. Another major area that was assessed and spoken about in update #4 was with regard to pregnancy. We summarized what we currently know about the impact of COVID-19 on pregnant women and their newborns.

In general, the news is good. Full term, newborns born from mothers with active COVID-19 have done well overall as a group. Severe illness in general, including COVID 19, may precipitate premature labor or lead to early delivery, but in a series of nine women affected with COVID-19 who delivered via C-section, there was no viral RNA seen in the amniotic fluid, cord blood, or breast milk.

We also state what we don't know yet – that there is no data on the fetus, when a woman contracted COVID-19 in the first or second trimester. As fertility providers, we can play an important role in determining the impact of COVID-19 and SARS in pregnancy and the optimal management of pregnant patients. We call for reproductive care providers and their patients to participate in studies that will help understand these issues and provide a link to what's being called the ‘Aspire Study’ to help study this from conception forward.

A third area covered in update #4 speaks to third party reproduction. In the update, we addressed an important segment to fertility care, which is the use of donor sperm, donor eggs and gestational carriers. We address the issues attendant to mitigating risk to sperm and egg donors, as well as gestational carriers who are undergoing treatment, to help our patients. And we recommended enhanced FDA screening of the gamete donors and carriers to mitigate risks to our intended parents.

And finally we also spoke to personal protective equipment. It's the ubiquitous PPE. We revised the recommendations that were published in a table and update #3, based on additional guidance from OSHA and from infectious disease consultants – basically focusing on the risk of aerosolization and droplets spread as a vector and being able to remove the recommendation for the use of face shields in other fairly routine low-risk procedures.

What is the update responding to – and by that, I mean, is it increased understanding, changes in CDC and governmental guidance, etc.?

Update #4 is really responding to refinements more than new developments. It's really the refinements in us understanding critical components of risk mitigation.

One final question for you, Dr. Penzias – the ASRM COVID-19 taskforce has issued updates to the recommendations every two weeks –  until now. The next update is expected in four weeks. Why the change?

The rapid pace of new development seen at the start of the pandemic has begun to slow. We believe that the ASRM recommendations have provided clinics with a solid basis for creating an environment that minimizes risks to patients and to staff.

The framework also calls for clinics to develop their own internal teams to monitor developments and adapt protocols as new knowledge emergence. We believe that we've given many tools to the practices to help them face this pandemic and continue to provide the care that our patients need.

Dr. Penzias, thank you for being with us today.

My pleasure.

May 18, 2020 - 3:34 PM
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