There was a timely review and discussion of best practice, guidelines and practical realities surrounding COVID, with an emphasis on testing, at the recent event 'IVF: A Test Case – Whether, When and How Clinics Should Test Patients and Staff for COVID-19'. The event was produced by the Progress Educational Trust (PET).
PET's director, Sarah Norcross, chaired the event with presentations from Professor Jason Kasraie, chair of the Association of Clinical and Reproductive Scientists (ARCS), and Dr Ippokratis Sarris, director of King's Fertility.
Professor Kasraie opened the session by introducing the five key principles given in the second edition of the UK guidelines issued jointly by ARCS and the British Fertility Society on 12 June (see BioNews 1046). These included the resumption of services in a manner that would minimise the chance of spreading COVID to patients and fertility clinic staff, ultimately building resilience into working practices to avoid future clinic closures. At the time the advice was published, there were no widely available, reliable serological tests in the UK, so reliance was placed on symptomatic screening and antigen testing where possible. However, centres were also advised to follow local and national guidelines and consider implementing a testing policy as soon as practicable. The guidelines are due to be updated this month to reflect changes in availability and testing options.
Professor Kasraie explained that within the service he directs, testing is available and encouraged for IVF patients, but acknowledged that the type and timing of COVID tests for patients varies between clinics: some do not test routinely, only if symptoms are evident from a patient triage questionnaire. He highlighted that such inconsistencies were also apparent for staff testing and staff responsibilities.
Differences are also visible between international professional bodies, for example, ESHRE does not emphasise staff triage for COVID, whereas this an expectation in the UK.
The UK approach to reopening clinics has been criticised as overly cautious, but Professor Kasraie defended the position, explaining that since publication of the guidelines, there are more questions than answers. Issues of asymptomatic community transmission blur the boundaries of identification and reducing risk. Interpreting guidelines in the context of the time they were written is essential. He concluded by advising clinics to build resilience for adapting test strategies alongside changing guidelines and test development.
Dr Sarris opened with the question 'To test or not to test?'. He explained that currently testing is not a legal requirement, but UK regulators say that testing should occur. Guidance from UK professional bodies defines both a minimum standard and best practice.
Dr Sarris described the timeline of his own clinic's closure and application to recommence treatment between March and May 2020, with at least 35 new documents having to be written to cover COVID risk assessment and working practice.
He also brought up the most contentious issue of the discussion: who should pick up the cost of testing? Newspaper headlines of couples facing a £400 charge for COVID testing (see BioNews 1052) brought attention to variable testing strategies, but Dr Sarris explained that international guidelines vary, and urged clinics to be mindful of potential negative feedback if adopting a best practice strategy to testing.
Dr Sarris emphasised that a single test is just a 'snapshot' and probably not sufficient to say where a patient is in a COVID infection cycle. The overall risk in pregnancy is thought to be low; data for COVID transmission via gametes and seminal fluid is not clear.
He finished by setting the scene for audience questions, by asking attendees: 'What would you do if your partner, sister or friend was having IVF treatment? Would you want them to be tested?'
The first question posed to the speakers was a plea for a heads-up on what new testing guidelines might advise. Both speakers agreed that new guidelines would be a compromise, with options to meet the changing landscape.
A common theme was the burden of the cost of patient testing. An analogy was drawn between payment for the compulsory viral screening of patients that is required before all UK IVF treatment. If a similar model were applied, this would provide the option to pass on testing fees depending on the setting, clinic practice and availability. It was noted, however, that this model would also reinforce the unfortunate postcode lottery that already exists in relation to IVF funding itself.
One attendee asked: 'If you could test at only one point in the IVF cycle, when would be most beneficial?' The speakers gave different answers – one advised just before egg retrieval, while the other advised before the start of stimulation medication. Still, both presenters agreed that patients and partners – not to mention anyone providing gametes for treatment – should be tested. However, infection control policies in laboratories mean that people providing samples only for diagnostic investigations, such as semen analysis, should not require testing.
The final question posed to the speakers was: 'If there is a second wave of infection, should clinics be closed on a regional basis?' Professor Kasraie responded that the tragedy of clinics shutting again should ideally be avoided by building resilience, using the knowledge we now have about COVID-19. Dr Sarris acknowledged the impact of uncertainty on patients, and concurred that resilience – refining practice around changing guidance – is the key to maintaining the provision of service.
Register now for PET's next free-to-attend online event 'An All-Consuming Problem? How to Protect Patients in the Fertility Market', taking place on Thursday 14 January 2021.