The COVID-19 pandemic has brought huge challenges to our health service and to society as a whole. This has made me reflect on what it has meant to the fertility sector in the UK, the way we have responded and changes for the future.
I think it is fair to say that in January nobody really knew what was coming or how best to deal with the impending situation. I returned from the Updates in Fertility Treatment meeting in Seville, Spain towards the end of January, already conscious of the situation in Wuhan, China and the huge numbers of Chinese tourists in Europe. On 23 January I initiated a risk assessment in our IVF clinic for all our patients asking initially about travel to China, and then Iran and then Italy and then it was too late. I had also contacted our infectious diseases department who felt that our patient population was low risk and no special measures were thought to be needed - how quickly things changed!
In Leeds we have one of the largest IVF units in the country, embedded in one of the largest hospital trusts, with 2000 beds and 17,000 staff. Once the UK realised that it had to deal with the exploding pandemic, all hospitals had to create space to cope with uncertain demands whilst trying to maintain key services such as maternity, oncology and the acute daily needs of the population. In a short space of time we had emptied 800 beds, converted operating theatres into intensive care units and subdivided our hospitals into 'hot' and 'cold' areas. Non-acute services had to discontinue activity, amongst which was reproductive medicine.
The fertility sector is highly visible, much scrutinised and garners disproportionate media attention and commentary from multiple sources. We are also conflicted by the inadequacy of NHS funding for treatments and a highly competitive private sector. What is not appreciated by many, however, is that hospital-based IVF clinics do not operate in isolation. Most clinicians and some nurses also have other roles within their hospitals, attending gynaecology clinics, performing operating lists and being on call for acute gynaecology and sometimes also obstetric services.
In addition IVF clinics require the support of many other departments, including anaesthetics, pathology and radiology; and – for clinics like ours performing the whole range of complex assisted reproductive treatments – colleagues from a number of multi-disciplinary teams, all of whom were being urgently called upon to support the COVID-19 crisis. Furthermore patients undergoing IVF may need to access hospital facilities if they experience complications of treatment or problems in early pregnancy and many have co-morbidities which may increase their susceptibility to infection.
There was therefore no option other than to discontinue IVF treatments, and I remember only too well the week that the decision was taken. Already by then, both the European Society for Human Reproduction and Embryology (ESHRE) and the American Society of Reproductive Medicine (ASRM) had issued guidance to stop IVF and in the UK the Association of Reproductive and Clinical Scientists (ARCS) and British Fertility Society (BFS) were in intense discussion about advice for the profession, which they released on 16 March. Concurrently the Human Fertilisation and Embryology Authority (HFEA) were compiling guidance for IVF activity to cease, issuing General Direction 14 on 23 March, which also happened to be the day of the 'lockdown'.
In Leeds we were making our own plans alongside being called to urgent meetings about the Trust's overall strategy; and at the same time we were undergoing training in how to deal with sick patients with respiratory problems (being re-taught procedures that I last carried out some 30 years ago), infection control and being fitted for masks and shown how to don and doff the now infamous personal protective equipment (PPE). This was a scary time.
So we were preparing for Armageddon alongside communicating with our patients about the suspension of their much-longed-for IVF. We appreciate that this has been an immensely difficult time for our patients – not only having treatments discontinued but also not knowing when they could restart again – all against the backdrop of the country in crisis and lockdown, which as we all know has caused immeasurable distress for the entire population.
We must remember also that this has been an extremely difficult time for our staff, who are passionate about the care that they give to our patients and are emotionally entwined with their fertility journeys. Fertility problems are common and many of us who work in the sector also have our own deeply personal experiences which further impact on our desire to do the very best for our patients.
Throughout the country embryologists, nurses, admin staff and doctors have been relocated throughout their hospitals to help with staffing levels both within obstetrics and gynaecology and in other departments including intensive care units to look after desperately sick people with the infection. In addition, many staff have had to self-isolate because they have become unwell or have had to shield for their own medical or family reasons. Many also all have friends and family who have become sick and also tragically died from this relentless and unpredictable virus.
For many weeks I was concerned about the absence of advice on how to try to improve one's general health in order to reduce the chances of becoming seriously ill if infected. Several weeks ago we issued information which was sent to the 17,000 employees of Leeds Teaching Hospitals on nutritional health, including appropriate use of vitamin D and other supplements and have shared this more widely. We believe this may also be of significant benefit to those from black and minority ethnic groups who, for a number of reasons, are at greater risk of developing COVID-19. These same principles are also relevant in terms of optimising preconception health and thereby increasing the chance of a healthy pregnancy.
Alongside all of this we have remained busy. We have continued to do telephone and video clinics and used the time to update all our audits and standard operating procedures. Now, as we look forward to restarting, our clinics will look very different: footfall is being kept to a minimum, which means remote consultations will continue (which may suit those with busy lives or who travel a distance to clinic), distancing will be observed and PPE worn during scans and procedures. These measures will inevitably affect interactions with our patients and also between staff. We will continue to be empathetic to everyone's needs yet inevitably communications cannot be the same if you cannot see who you are talking to during a consultation about personal and emotional issues or if you are hidden behind masks and visors whilst performing intimate procedures or delivering bad news.
Regrettably during these unprecedented and unpredictable times there have been criticisms of the ARCS, BFS and HFEA both from within the profession and from a small number of commentators. Nonetheless I believe that the ARCS, BFS and HFEA were acting in good faith and with the best interests of our patients, the fertility sector, the NHS and the community as a whole. Behind these events, of course, were very real human stories of colleagues who were understandably worried with clinicians around the world dying after being exposed to the virus at work. It continues to be a challenging time with significant future uncertainties.
On the whole we have acted together and, I believe, demonstrated resilience under huge pressure and great co-operation and common purpose. We are fortunate to be working in such a well-regulated speciality which is providing us with a better structure to move forwards than in many other fields of medicine.
Declarations of interest: Professor Adam Balen is lead clinician of Leeds Fertility, which offers both NHS and privately funded assisted conception treatments. He is former chair of the BFS and sits on the Board of Trustees of the BFS and the Council of the Royal College of Obstetricians and Gynaecologists. He is also on the World Health Organisation Global Task Force on Infertility.