Resuming Treatment: What Can European Countries Learn from One Another?

As we move towards the end (fingers crossed!) of a staggered and fractured response to a global pandemic, the final session of PET's annual conference asked what European countries can learn from one other in the resumption of fertility treatment.

The session, sponsored by the European Society of Human Reproduction and Embryology (ESHRE), was chaired by that organisation's former chair Dr Anna Veiga, who is also coordinator of ESHRE's COVID-19 Working Group. Covering Belgium, Italy and Ireland, three speakers from the working group built a picture of what is happening across Europe, and detailed the work that ESHRE has done to guide fertility services during the pandemic. Dr Veiga explained that their work has included guidance for clinics, practical support for professionals and patients by providing information, and improving knowledge by gathering data on the impact of COVID-19 on assisted reproductive technology (ART) and ART pregnancies in Europe, for example, or by offering a research grant.

The first talk was presented by Belgium-based Dr Nathalie Vermeulen, senior research specialist at ESHRE and lead developer of ESHRE's Guidelines, Consensus Documents and Recommendations. In her talk 'Assisted Conception in the European Union During the COVID-19 Pandemic', Dr Vermeulen presented data collected on COVID-19 and ART services. During the first wave, which was characterised by uncertainty across the board, ESHRE focused on monitoring the impact of the pandemic and gathering information from most countries in Europe. This showed that, although some clinics said the impact of the pandemic on their services was minimal, on average centres closed for about seven weeks. Closures began in Italy, but by April at least some centres were closed in all countries. All centres had restarted by the end of May. There was no link between the severity of COVID-19 in a country and the duration of centre closure, but in all countries, clinics only reopened once cases had declined. By the second wave, there was more knowledge available, meaning that many centres did not close, and most had some kind of system for triage and testing, as well as measures to ensure social distancing was in place at clinics to reduce the impact on the healthcare system. Centres, then, had been able to adapt their services, although there was undeniably still an impact on infertile couples.

In the second talk we received more specific information about triage, testing and decision-making in fertility clinics. The presenter, Dr Luca Gianaroli is scientific director of the Italian Society for the Study of Reproductive Medicine and of the International Institutes of Advanced Reproduction and Genetics and another former chair of ESHRE. Besides describing the triage recommended by ESHRE to determine whether it is safe to treat patients in fertility clinics in the pandemic – such as strategically using both antibody and PCR tests – Dr Gianaroli also shared some surprising insights about the impact of the pandemic on fertility outcomes. Compared to the early pandemic, for example, he said that the fertile age group is now affected by the virus. He also stressed the effects of the pandemic that are not directly related to the virus but are the consequences of the impact on health care provision in the pandemic. The stillbirth rate, for example, has increased in the UK, and Italy has seen a similar increase. This is the result, Dr Gianaroli said, of services being unavailable to pregnant women as a result of clinic closure or a reduction of services. These side effects also need to be taken into account in any assessment of how patients are treated during a pandemic.

The final talk of the session was given by Dr Edgar Mocanu, consultant in obstetrics and gynaecology at the Rotunda Hospital Dublin and honorary clinical senior lecturer at the Royal College of Surgeons in Ireland. In his talk 'ESHRE Guidance: The Adaptation of Fertility Clinics', Dr Mocanu described the system for funnelling risk developed by ESHRE to minimise harm to all those involved in the ART process. He emphasised the need to specify measures for each step of the treatment process – during the stimulation phase, for example, it is important to focus on reducing exposure, and clinics can decide early, using triage, whether they will bring a patient in for oocyte retrieval. The ESHRE model starts with educating staff and patients, followed by a code of conduct emphasising the avoidance of risk, then triage, testing, and potential exclusion (postponing therapy). Dr Mocanu also described the metric they adopted, a 14-day case notification rate, which offers measurable and easily available parameters to allow clinics to adapt and mitigate risk.

Dr Veiga ended by repeating that in the second wave of the virus, countries have been able to continue their activity by implementing ESHRE guidance. She said that a COVID-19 free fertility clinic is possible through triage and testing antibodies in combination with the PCR test. This is achievable when clinics implement the routine advice as well as a code of practice for patients and use staff to funnel risk from the start.

The questions provided some follow-up on the lessons learnt from the first two waves of the pandemic. Overall, the panellists seemed to feel that clinics have been able to adapt since the first wave, and that the guidelines developed by ESHRE will stand them in good stead for the rest of this, and any future pandemics. There was less certainty, however, on the questions relating to ART pregnancy and the pandemic. Dr Vermeulen said that ESHRE is gathering data on the impact of COVID-19 on ART pregnancies, but that the nine-month wait on this data means that at present, the results are inconclusive. Dr Mocanu said that it will be important to collect this data as patients will want to know the risk associated with any procedure and that this should be part of pre-treatment counselling. A problem with gathering this data is also, he said, that it is not possible to track patients all the way through assisted conception and pregnancy and delivery. The best data has been collected in Nordic countries where they have databases including all this information.

The troubling statistics on rising stillbirth were also addressed in the audience questions. 'How do we prevent this increase?', someone asked. Dr Gianaroli responded that there is not much that can be done at this stage, besides planning the provision of services for any future pandemics. The problem, he says, is that patients have minimised their visits to hospitals during the pandemic to avoid contracting the virus, while services have also already been reduced – these factors combined disrupt the programme of health services offered to patients, with deleterious consequences.

The session, then, offered a good overview of the quick learning curve undergone by ESHRE and European clinics over the course of the pandemic. The speakers and audience did not shy away from the difficult, unresolved, issues, but the overall tone was optimistic – after a devastating pandemic and the chaos of trying to adapt, there is 'light at the end of the darkness', Dr Mocanu said.

PET would like to thank the sponsor of this session, ESHRE, and the other sponsors of its conference - the Anne McLaren Memorial Trust Fund, the Edwards and Steptoe Research Trust Fund, Wellcome, the European Sperm Bank, Ferring Pharmaceuticals, the London Women's Clinic, Merck, Theramex, Vitrolife and the Institute of Medical Ethics.