Last week, the New York Department of Health quietly issued an advisory clarifying that “sexual and reproductive health services” are “essential” and thus exempt from “shelter in place” requirements. The document went on to list services such as abortion, obstetrical care, STI treatment, and, perhaps more surprising, fertility services, including “infertility treatment.”
Just last month, fertility clinics across the country drastically limited services following guidance from the American Society for Reproductive Medicine (ASRM), which advised clinicians to avoid initiating “new, non-urgent fertility treatments,” with urgent cases being limited to only extreme circumstances. In response, thousands of doctors, patients, and supporters rallied around a petition urging more nuanced and permissive guidelines. Now, some New York fertility clinics have suggested that the health department advisory paves the way for expanded services, although contradictory guidelines from the ASRM complicate the matter.
A few days after the advisory, the Twitter account for Kindbody, a fertility practice with offices in New York, posted, “The decision of how and when to provide fertility services is now one to be made between a patient and doctor.” CNY Fertility took to Facebook with a similar message: “We support this and will map out a proper plan over the next week for CNY Fertility to provide a safe environment for our staff and clients.” This week, RMA of New York sent out an email alerting patients that “the decision of how and when to provide these services is now one to be made between a patient and their doctor.”
This development has been strangely absent from headlines, given it follows a weeks-ago flurry of media attention around the initial shutdown of services. But it’s made the rounds in online fertility communities, where patients have celebrated with party popper emojis and multiple exclamation points. “I needed to see this tonight! I have been in such a funk after having to cancel our retrieval in March,” a patient wrote on CNY Fertility’s Facebook page. “This is the best news I’ve heard all week! Here comes the happy tears!” said another. The responses were not all positive, though: “Yes we’re all here in hopes of having our miracle babies, but at what cost? The virus is nowhere near over,” wrote one woman.
A petition launched last month for ASRM to reconsider its restrictive guidelines had garnered over 18,000 signatures, many from patients who had to put their fertility treatment on hold, and some of whom fear this pause could mean they never get another chance at having a baby. Beverly Reed, the fertility doctor in Texas who started the petition, said of the New York advisory, “I applaud this decision.” Meanwhile, however, ASRM on Monday revisited the guidelines it issued in mid-March and reasserted them, noting the “prevailing conditions on the ground, the fact that the number of cases and related deaths continues to increase, the recommendations of the CDC and other authoritative bodies, and the lack of available, approved, sensitive and specific testing.”
This presents two conflicting sets of instructions. The ASRM guidelines specifically advise against initiating new cycles of fertility treatment, while the New York advisory asserts that “the ultimate decision on when such services must occur is between a patient and clinical producer.” Interestingly, the New York advisory links to ASRM’s guidelines and a health department representative told Jezebel that it encourages “providers to consider relevant clinical guidance when making these decisions, such as those provided by American Society for Reproductive Medicine.” Ultimately, clinicians must riddle this out for themselves.
Lynn Westphal, chief medical officer at Kindbody, says the clinic has shifted to virtual services wherever possible and had previously limited services to urgent cases, “including taking care of patients needing fertility preservation because of a cancer diagnosis,” which falls in line with ASRM’s guidelines. Now, in response to the New York state advisory, the clinic is “carefully expanding our definition of urgent cases, and will be starting new fertility treatments on a case by case basis,” she said. Westphal emphasized that this will be done with caution. “There is a lot we still don’t know about the virus, and all patients will be counseled carefully about the risks and benefits of proceeding with treatment,” she said.
Extend Fertility, a clinic based in New York, has not changed its approach in response to the New York advisory, but Joshua Klein, chief clinical officer, says that the advisory “will help lay the groundwork for the transition back to providing fertility services in the near future.” Currently, the clinic has deferred the initiation of new treatment cycles and continued to treat patients who recently completed treatment cycles, while limiting in-office visits and initiating rigorous safety protocols. Klein noted that “many of our patients are struggling right now with the grief and anxiety that an indefinite pause on fertility treatment represents,” but says he is optimistic that “we will be able to resume fertility treatments soon enough that the impact of patients’ family-building will be negligible.”
Reed says that with the conflicting guidelines “it can be difficult to know which to follow,” but that following the stricter of the two might be “prudent.” That said, Reed speculated that “there may be clinics who feel comfortable with proceeding with treatment now that they have the support of their state,” and noted that ASRM has not threatened any consequences for not following its covid-19 guidance. Similarly, an ASRM spokesperson emphasized to Jezebel that it is an educational rather than regulatory body. Westphal argues that ASRM’s covid-19 taskforce “is a group of experts that provide valuable guidelines, but at the end of the day, the decision lies with the physician and the patient.”
Alongside the reasserted guidelines, ASRM acknowledged that covid-19 presents fertility clinics with a dilemma with no clear solution. The task force noted that “it is likely the... pandemic will be with us for some time, at least until an effective vaccine is available” and deemed it necessary to “begin to consider strategies and best practices for resuming time-sensitive fertility treatments.” At the same time, the panel of experts said that “the timing of the restart of infertility care, other than that currently deemed urgent or emergency, has yet, and may be impossible, to be precisely determined.”
In other words, whether it’s New York clinics currently considering a cautious expansion of services or potential future fertility industry return-to-work guidelines, even the “best” approach may be mired in uncertainty.