On March 20th, we continued our weekly free Ask Maven Anything webinar series with experts to answer some of the most common questions we’re receiving from members about how the novel coronavirus (COVID-19) outbreak is impacting women and families.
Dr. Brian Levine, Reproductive Endocrinologist and founding partner of CCRM, and Dr. Jane van Dis, Maven Medical Director and OB-GYN, joined Kate Ryder on everything you need to know about the latest fertility guidance from ASRM, what to know if your due date is soon, and more. The Q&A is below, or watch the full 30-minute webinar.
Some of the questions discussed include:
- How much difference does a month or two make now that there is this pause for retrievals and transfers in IVF or egg freezing?
- How are hospitals currently preparing for safe deliveries?
- What should I do if I’m currently in-cycle in fertility?
- If someone gets pregnant right now naturally, what do they need to know?
- Is it safe to take anxiety medication if I’m currently pregnant?
“As of today, we are telling everyone that we’re going to wait until March 30th when the American Society for Reproductive Medicine comes out with another statement where they help guide us guide our patients,” shared Dr. Brian Levine. “It’s frustrating, but it’s for the safety of both the patients and the providers in the clinic.”
“What pregnant women need to know is that hospitals are not going to be giving away their L&D [labor and delivery] rooms,” explained Dr. Jane van Dis. “Pregnancy is not an elective case, and those units will still be operating.”
Q: ASRM came out with guidelines this week for fertility patients. Can you please explain those and what they mean?
Dr. Brian Levine: ASRM, the American Society for Reproductive Medicine, is one of the bodies that advises fertility doctors as well as the OB-GYNs who practice reproductive endocrinology and infertility, on best practices. Effectively, the ASRM came forward with a position statement on March 17th explaining that, right now, we don’t know the effects of COVID-19 on people who are trying to get pregnant, stay pregnant, or are in other phases or trimesters of their pregnancy.
In this guidance, ASRM presented four strong statements:
- Don’t start any treatment right now, unless it’s an emergency.
- Delay the transfer of embryos and delay freezing eggs.
- Talk to your providers about using teleconference or telemedicine to limit your exposure to other people.
- Make a plan with your doctor if you’re in the midst of a cycle right now, or in process with a gestational surrogacy or carrier.
These are very broad statements, but the key takeaway message is: let’s take a pause, and ASRM will be revisiting this on March 30th.
Q: If a woman becomes pregnant naturally in the next eight weeks, what should she do?
Dr. Brian Levine: If someone gets pregnant in the next eight weeks, they don’t need to panic. They just need to be a good citizen and follow all of the latest recommendations from the CDC. They should talk to their OB-GYN through a virtual appointment, and ask them for their advice.
If you do get a positive pregnancy test, it is important to know that it’s a pregnancy that is intrauterine and not an ectopic pregnancy. Right now, there’s no guidance given about changing any management or therapies, and you should just treat yourself like you would if you were pregnant any other time, except stay at home, practice social distancing, and call your doctor rather than scheduling an in-person appointment.
Q: Here’s a question from a woman in her late 30s with low AMH levels, who was scheduled to start an egg freezing cycle, which has now been postponed: how much difference does a month or two make if we’re taking a pause on a lot of these retrievals and treatments?
Dr. Brian Levine: This is probably the #1 question that we’re getting; we’re hearing, “I get it, I need to pause, but for how long because my body is still aging at the same rate it was before all of this”. The truth is, we don’t know. No one’s fertility is predictable. What we’re telling people right now is: it’s not going to be impossible to freeze your eggs in the future, but it won’t be in the imminent future. As of today, we’re telling our patients that we’re going to wait until March 30th when the ASRM comes out with their next statement where they guide us to help guide our patients. It’s frustrating, but it’s for the safety of both the patients and the providers.
Q: Given the pause, should patients be expecting wait times once cycles resume again?
Dr. Brian Levine: We’re preparing for a surge of patients that will likely come through the door. Simply put, individuals are not predictable with their cycles. The mental stress of going through this COVID-19 pandemic can lead to people having a change in their regular menstrual cycles. Most likely, when we do get the green light that it’s okay to proceed with evaluating and treating patients, we’ll have people who are in multiple phases of their menstrual cycles.
If clinics do go to full shutdown, there is a natural phase that has to occur to allow the clinic to ramp back up when the time is right. That means getting incubators and other tools back online and up to the quality assurance and quality control level that they need to be at in order to handle eggs and embryos.
Patients should know that there might be a backlog, or there might not. There could be more patients than available opportunities to treat them in the initial few weeks to months--depending on how long this delay is.
Q: Should men be freezing their sperm right now?
Dr. Brian Levine: The COVID-19 outbreak is not a reason to go to your doctor and freeze your sperm ahead of time. We know is that any febrile illness (the clinical term for a fever, or elevated body temperature) can cause issues with male fertility and sperm production. It takes approximately 72 days for a man to be able to produce a single spermatozoa, but it’s a continuum and men keep making sperm every single day. If someone has a high fever, it’s expected that their sperm count will drop after that, and it will take approximately three months for them to fully recover. But COVID-19 is not similar to Zika virus, where the virus could be living in your semen, testicles, or the tissue surrounding the sperm. The key takeaway is an illness with a high fever like COVID-19 can cause a drop in your total sperm count, but your numbers do rebound and freezing your sperm proactively is not necessary.
Q: What is the latest information for pregnant women and COVID-19?
Dr. Jane van Dis: It’s really important to emphasize for everyone that four out of five people who contract the virus get it from someone who wasn’t showing any symptoms, which is why social distancing is so important. At this time, we know that symptoms are appearing in 2-9 days, and that the median time is five days after encountering the virus. This is all information that was presented by the Society for Maternal Fetal Medicine on March 19. We’re still looking at approximately 80% who contract the virus getting mildly ill, and 14% requiring hospitalization.
- For pregnant women: ACOG (American College of Obstetricians and Gynecologists) has issued helpful guidelines, and they put out a practice algorithm last Friday (March 13) sharing with us that still, a fever greater than 100.4, and one or more of the following--cough, difficulty breathing, shortness of breath, or gastrointestinal symptoms--are signs that you need to call your doctor and get advice.
- For parents: In pediatric literature, there is good and interesting news coming from a study looking at 2100 pediatric infections in China that reveals 90% of those children had asymptomatic or mild-to-moderate infections, and only 6% had severe infections. And that’s compared to 15-20% of adults. So we’re still seeing children are capable of getting infections, but 90% of the children in this study had mild infections. And then a study coming out of Italy looking, again, at children showed that only 1.2% of cases in this cohort occurred in children 18 and under.
Every week, we’re getting new information about the effects on pregnant women and children, and we will convey those to you.
Q: For people delivering in the next eight weeks, how should they think about changes to their birth plan?
Dr. Jane van Dis: This question is on a lot of pregnant women’s minds. Delivery will still be based on gestational age, how far along you are, whether there are any maternal indications such as severe preeclampsia, or whether there are any fetal indications such as intrauterine growth restriction, the baby not growing very well, or the like. The standard protocols by which we recommend delivery are still in practice and being followed.
Q: Should people fear that hospitals will not have room for pregnant women?
Dr. Jane van Dis: What pregnant women need to know is that hospitals are not going to be giving away their Labor & Delivery rooms. Pregnancy is not an elective case, and those units will still be operating for deliveries only.
Q: Should pregnant women consider a home birth?
Dr. Jane van Dis: COVID-19 should not be the reason that you choose a home birth. Women choose many different types of births, and we respect that maternal choice. I do emphasize that if you are considering a home birth, you should speak with a provider in order to fully evaluate what the risks might be for you, and what the risks might be for your newborn. A study that came out recently revealed that newborns who were born at home had a rate of death four times higher than those born in a hospital. You should also think about the fact that half of all home births require transfer to a hospital. And this is the most striking thing for women to consider right now, because in the coming weeks and days, we expect that our healthcare system is going to be very stressed and what would be devastating is if you called for an ambulance during a home birth and there wasn’t one available, due to the massive influx in need. While I understand the thought of staying away from the hospital may feel like the best approach, if you’re going to make that decision, just do so with all of the information that you can so you make a choice that is comfortable and right for you.
Q: For women and their families preparing to go into the hospital for delivery, how can they stay safe at the hospital from COVID-19 and how are hospitals preparing for safe deliveries?
Dr. Jane van Dis: Most hospitals are limiting visitors, some to only one or two people. There can’t be any alternating between people, like we would commonly see in a Labor & Delivery room. A lot of hospitals are currently putting in a separate entrance.
The most important recommendation is to call before you go to your hospital, especially if you are having any signs or symptoms of COVID-19. So if you have a fever and a cough, call ahead so that you don’t go straight to Labor & Delivery unannounced, as you might have otherwise, so that everyone can effectively keep other patients and healthcare workers safe when they present to the hospital.
One thing that will be different in the hospitals, in Labor & Delivery in particular, is that we’re going to see more virtual care. On Maven, we have virtual doulas, lactation consultants, certified nurse midwives; so even if your doula who you worked with throughout your pregnancy is restricted because your hospital is only allowing one person with you and you’re going to bring your partner, you can still connect virtually with birth personnel. I want to remind women that even though some of the systems are changing, you shouldn’t feel alone.
Q: For women in their first or second trimesters, we’re starting to hear from our members about appointments getting pushed or early appointments getting canceled. This is causing some anxiety, particularly for women in high-risk pregnancies or who have had miscarriages prior to their current pregnancies. How should pregnant women in their first or second trimesters be thinking about these changes?
Dr. Jane van Dis: I connect with a lot of OB-GYNs across the country every day, and what I’m seeing is that a lot of OBs are imagining how they can move some of their visits to a telehealth solution. So your OB-GYN might recommend that some of your visits be via telehealth, and that shouldn’t alarm you or scare you—that’s just to limit your exposure to others and allow you to go through some of the normal prenatal care from your home. We as a workforce, as OB-GYNs, are working with the American College of OB-GYNs (ACOG) and the Society for Maternal Fetal Medicine (SMFM) trying to understand what has to happen in-person, and what can be accomplished via telehealth, and we think that there may be some new guidelines coming.
We do know there are a couple of milestones in a pregnancy that require you to either get a lab or an ultrasound:
- A first trimester ultrasound to date the pregnancy and determine a due date, and make sure it’s in the uterus, as well as obtain some first trimester baseline labs
- There’s another lab draw at 18 weeks
- An anatomy scan is very important at 20–22 weeks
- There are labs again at 28 weeks, including rhogam if you are Rh-negative
- Lastly, there’s an important lab at 35 weeks to determine your GBS (Group B Strep) status
Again, I will emphasize that there are a lot of things that can be accomplished via telemedicine—at Maven, we obviously have maternal fetal medicine doctors on our platform, we have genetic counselors, we have mental health practitioners, doulas, CNMs, lactation consultants, dietitians, diabetic coaches—so I would expect that, if your in-person OB-GYN is recommending telehealth, that you avail yourself to that because it does allow you to keep that social distance.
Q: If a mother and her infant test positive for COVID-19, will they be separated in the hospital, and for how long?
Dr. Jane van Dis: That is a good question, and the current recommendation is that they should be separated. Now, what that separation looks like depends on a specific hospital’s protocol; sometimes, I’m reading that the baby and mom are in separate rooms, but in other instances I’ve seen a six-foot distance with some type of barrier, maybe a cloth curtain, in between mom and baby. So we are working through these protocols, and recommendations obviously need to be specific to the hospital you are delivering at, but given that we are seeing that newborns and infants are affected by this virus, and that they can require critical care, taking the appropriate precautions for COVID-positive pregnant women after birth in terms of separation are very much warranted.
Q: When do you think elective procedures will resume?
Dr. Brian Levine: Unfortunately, we don’t have any insight into the actual timeline of when we will be allowed to start elective procedures, and this is happening on a state-by-state basis. We do know that the American Society for Anesthesiologists came forward with a petition statement recommending that procedures be done outside of the hospital setting, so I think what we’re going to see over the next couple of weeks is that it will be permissible to do elective procedures, provided that they’re not using hospital-based resources. I think that’s going to be partially due to the fact that a lot of people cannot wait for these procedures, which would be likely orthopedic or other procedures, but also because there’s going to be a backlog, and many people won’t get treated at all.
In the fertility world, I think it might be eased up even sooner, given the fact that people are going to continue to age and there is going to be a backlog of cases, but we just don’t know right now, and it’s really on a state-by-state basis.
Q: Here’s a question from a member: “I’m self-pay and live in New York City, but I’m currently in Los Angeles. If I can’t make it back to my city for the procedure if my city isn’t starting egg freezing cycles, can I just do a cycle here? What are the considerations involved?”
Dr. Brian Levine: I always urge patients who get “stuck” somewhere else that it is up to the clinic that they’re looking to go to, and their comfort level with proceeding with a cycle. There are some really basic things that need to be known before stimulating any patient: what is their risk of ovarian hyperstimulation or getting sick as a result of the stimulation itself, and also what are the other health complications or considerations had before stimulating them.
In this very charged time, some places are having a “lockdown”, so it’s not possible right now in Los Angeles or San Francisco to proceed with treatment. In the next couple days to weeks to months, it’s quite possible that you’ll be able to do their cycle, but it will be up to that actual clinic if they’re still running and if they do want to accept patients that were initially not their own. So it’s a clinic-to-clinic basis.
Q: What are the risks/benefits of using anti-anxiety medications while pregnant? From a member: “I’ve treated my anxiety with Zoloft in the past, but I’m currently unmedicated. My anxiety has been under control my entire pregnancy (I’m 25 weeks) until this past week when it started interfering with my sleep.”
Dr. Jane van Dis: You’re not alone. A lot of us are feeling heightened anxiety. I think that any medical decisions about what medications to take must be made in consult with your doctor because your doctor knows your medical history and all the other medications you might be taking as well.
Having said that, anxiety is a normal and appropriate response to a crisis like this, and I would say for those who are experiencing anxiety, having the access to mental health professionals is also something that should be availed. I can’t really offer advice about a specific medical recommendation, but I can tell you that working with your doctor along with mental health professionals can really help in the next few weeks and months.
Q: What are the specific ramifications to the fetus if the mother gets coronavirus? Is it more dangerous for a pregnant woman to get coronavirus earlier or later in their pregnancy?
Dr. Jane van Dis: What we know is that there currently is no evidence of vertical transmission—that is to say, if a mother is pregnant with COVID-19, she does not give COVID-19 to the baby while in utero. That is our knowledge to date. In terms of when the infection might be the most risk to a developing embryo or fetus, we know that a fever in the first trimester can increase the risk for miscarriage, becasuse we saw that in some of the SARS data that has come out, which is another coronavirus. So we need more information, more data, to be able to give a very concise opinion about which trimester might be the most dangerous, but what I would say is that if you have a fever, you need to reach out to your doctor and find a way to address that.
We get fevers for all sorts of things in pregnancy—we sometimes see fevers due to a kidney infection in the first trimester—anytime there’s a fever in pregnancy, it’s something that we as OB-GYNs and medical professionals all want to treat. So I recommend taking precaution whenever you have a fever in pregnancy, and we’ll know more about which trimester later on.
Q: “I’m pregnant and I like to run outside. I’ve heard contradicting statements about whether the virus is airborne. If I’m practicing social distancing, should I feel safe running in my neighborhood as an at-risk category person?”
Dr. Jane van Dis: I think running outside is probably good for mental and physical health, and the discussion about airborne vs. droplet is one that has gotten a lot of conversation. According to the CDC, we still understand this to be a droplet precaution, so I think that getting outside and getting fresh air, so long as you’re keeping your social distance (at least six feet), will be good for mental and physical health.
Q: Can a baby contract COVID-19 when born naturally vs. a C-section, and is there a greater risk for C-section?
Dr. Jane van Dis: We have not seen that there’s a greater risk for C-section. Some of the case studies that we saw coming out of China had increased rates of C-section for women who had COVID-19. You can imagine if you’re having respiratory issues, or if your lungs aren’t at full capacity, pushing for three hours would be too taxing on the maternal physiology—so Cesarean sections might have been performed for maternal indications, maybe for fetal indications. But to my knowledge, there’s no difference between vaginal birth vs. C-section, in terms of passing COVID-19 to the fetus. What we are thinking is that passage of COVID-19 to the fetus occurs via respiratory droplet after birth.
Q: “If we’re following lockdown and we’re trying to be safe at home, do we also need to physically distance ourselves from family members in our homes if we’re pregnant? If we’re going to the grocery store to get food and supplies, should I be distancing?”
Dr. Jane van Dis: That is a hard question because we all have different living arrangements and we don’t all have the ability to social distance in a way that really matters. Therefore, I would say that in the same household, we need to make sure everyone is practicing good hand washing. Unless someone in your home is showing signs of illness, pregnant women shouldn’t social distance within their own home.
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In a time of heightened anxiety, misinformation, and a lack of access to medical providers, we at Maven are committed to ensuring women and families have access to the most up-to-date information and fact-based resources, as well as on-demand care and support when they need it without having to leave home.
- Stay well and stay informed by visiting our coronavirus resource center - we’re updating this regularly, and will share information here on next week’s Ask Maven Anything webinar (updated March 20)
- Read more FAQs on pregnancy and coronavirus answered by Dr. Jane van Dis (updated March 20)
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