Fertility clinics across Canada have stopped initiating treatments as part of the broader pandemic-related suspension of elective medical procedures, leaving patients uncertain as to when, or if, they'll get their chance at becoming parents.

The closures are in response to a statement earlier this month by the Canadian Fertility and Andrology Society (CFAS) to its approximately 800 members recommending "suspending all diagnostic and elective procedures and surgeries" and "postponing any new cycle starts" other than for fertility preservation purposes related to cancer treatment.

On Tuesday, the CFAS released an update to its members reinforcing this stance, "Given that the number of total cases of COVID-19 (confirmed and probable) continues to rise."

The recommendations affect patients in the midst of, or about to start fertility treatments such as in-vitro fertilization (IVF), intrauterine insemination (IUI) and frozen embryo transfer (FET).

The president of the CFAS, Eileen McMahon, said the decision was made in consultation with their multidisciplinary board and guided by current federal and provincial public health recommendations.

"If it were up to us, we would continue services if it were safe to do so but it is not safe to do so. We are doing what is necessary to try to limit the spread and contain this pandemic."

McMahon said that while it has not been determined that it is unsafe to be pregnant at this time, "We can't actively help people get pregnant because that involves putting them at risk by coming to our clinic, (using) public transit, and (putting staff) at our clinic at risk of getting COVID…We shouldn't be bringing people out of their homes for procedures right now."

Delays in fertility treatments can be devastating, especially for women who are in their late thirties or early forties, or have low ovarian reserve, said Dr. Caitlin Dunne, a fertility specialist and co-director of the Pacific Centre for Reproductive Medicine in Vancouver.

"I can completely understand the frustration, anxiety, fear. As fertility doctors, we completely understand (patient) concerns and we want to be able to offer treatment again as soon as possible."

Christina Miller, 39, has had to postpone a frozen embryo transfer planned for April due to the novel coronavirus-related clinic closures in Calgary.

"Time is a real factor for me," said Miller.

She underwent frozen embryo transfers in 2018 and 2019, the first resulting in a miscarriage; the second didn't take because of a gall bladder attack that required surgery shortly after the procedure.

Miller said that over the past year she has been focusing on her health, losing 85 pounds in anticipation that this may be her final chance for a baby.

"I've already spent $25,000 and this third try might be my last chance."

She said that while more time won't affect the quality of her embryos, which were frozen when she was 37, for Miller, another year of waiting could affect her chances of a successful pregnancy.

Meanwhile in the U.S., some fertility doctors pushed back at recommendations to restrict fertility services issued March 17 by the American Society for Reproductive Medicine (ASRM). In an update this week, those recommendations were extended until April 13, but they added a statement asserting "infertility is a disease and infertility care is not elective."

In a March 23 letter obtained by The Canadian Press, members of a group called the Fertility Providers Alliance, which represents "400 fertility specialists" stated they wish "to engage (with the ASRM) to revisit and reshape ASRM's recommendations to the reproductive endocrinology community."

One of the signatories of the letter, Dr. Michael Alper, who is the medical director at Boston IVF, said that "to a lot of patients who are out there, a month or two delay is a really major problem," and that physicians represented by the FPA felt the initial recommendations set out by the ASRM were too restrictive.

"What we wanted to do is have a dialogue with the ASRM...Under what circumstances can we provide treatment to patients who want treatment in a safe manner?" he said. "So that was the nature of the dialogue with ASRM and I'm pleased that they listened and are seeing our point of view."

A separate petition started by Dr. Beverly G. Reed, a Dallas-area fertility specialist, states the ASRM's recommendations neglect women's rights to autonomy.

"It can feel frustrating when in some areas, essential personnel can include real estate agents, for example, but then patients can't get fertility care," Reed said in an interview.

While she plans to follow the ASRM guidelines, she argues that in some geographic locations it may be possible to continue treatment safely, "and that that decision should really be made by the physician and the patient after a thorough risk-benefit discussion."

"I had both same-sex couples and single mothers by choice who said, 'Look, all we want is an insemination,'" she said. "I would just need a pair of gloves and an insemination catheter. That's all I would need to treat them for that, and it would only require that one visit. And so it really just felt very triggering for them."

Dr. Eve C. Feinberg, president of the Society for Reproductive Endocrinology and Infertility and a member of the ASRM's COVID-19 task force said evidence shows a three-month delay in fertility treatment for women over 40 would not affect the likelihood of a successful pregnancy.

"The voice of reason behind the (ASRM) recommendation is really based upon the idea of flattening the curve (of) transmission. And when you're in the midst of a public-health crisis, such as a pandemic, you have to place the priority of care on society and societal good. And sometimes that means that individual autonomy comes second to societal benefit."

Feinberg goes on to say that the ASRM's task force — which includes fertility specialists as well as infectious disease experts — will continue to review their recommendations every two weeks and will take into consideration time delays that could affect treatment outcomes as well as advice from organizations such as the Centers for Disease Control.

In Toronto, Sarah Burke Dimitrova had planned to start an IVF cycle with her husband this week, but that's now been cancelled.

Through social media she has learned that some clinics in the U.S. have remained open, allowing patients to decide along with their providers whether to continue with treatment or not.

"I would like to see Canadian society and all providers and individual clinics do some work on determining how to prioritize patients…in terms of deciding what is essential,” the 32-year-old said, acknowledging that she may not fall into the category of an urgent case.

Burke Dimitrova notes that Ontario will fund one cycle of IVF for women up to age 42, which means delays could mean some women will no longer be able to access provincially funded fertility treatment.

"Are there considerations that can be taken into account so that services can continue at a lower volume than they were?"

So far, there has been no such movement in Canada, said Dr. Michael Ripley, a fertility specialist at Atlantic Assisted Reproductive Therapy in Halifax.

"No clinic can ensure safety by being open right now…there's a lot of evidence out there that patients can have the disease and be asymptomatically shedding the virus to people who then become infected."

Ripley said he worries that an impending economic recession could impact access to fertility services once restrictions are lifted in provinces like Nova Scotia, where treatment is not provincially funded.

"You may have patients that are no longer financially able to proceed with a fertility treatment after this depending on how it affects their income or their employment status."

But if Canadians do what they're directed to do right now, through physical distancing, diverting health-care resources to fighting the virus and flattening the curve over the coming weeks, "then health authorities may revisit the idea that non-essential procedures or elective procedures could resume," said Dunne from Vancouver.

For now, Dunne and Ripley and are providing virtual consults for their patients and keeping up to date as more data about COVID-19 becomes available.

Dunne said that despite her clinic closing, "Our patients' eggs, embryos (and) sperm are absolutely safe and we don't have any concerns that we won’t be able to care for them."

—Rebecca Renkas is a family physician based in Winnipeg. She is a fellow in global journalism at the Dalla Lana School of Public Health at the University of Toronto.

This report by The Canadian Press was first published April 1, 2020.

Note to readers: This is a corrected story. A previous version misspelled Eileen McMahon's last name.

The Canadian Press. All rights reserved.

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