Covid19 and fertilty final Dr.Sherbiny 19-4-2020

Covid-19 And Fertility
An Evidence Based View
Dr. Mohamed El Sherbiny MD
Senior consultantObsteterics & Gynecology
19 April 2020

Covid-19: Background
● Covid-19 is an upper & lower respiratory
illness caused by a novel strain of coronavirus
● In December 2019 the first cases were
reported in the city of Wuhan, China.
● On March 11, the WHO announced the
current COVID-19 outbreak as a pandemic.
●It rapidly spread and affected almost every
continent in this world.
European Society of Human Reproduction and Embryology (ESHRE) March 17, 2020

Coronavirus World Map 18 April 2020
Confirmed Cases : 2,160,207; Deaths146,088
Covid-19 WHO Map , 18 April 2020

Covid-19: Background
Transmission: It is mainly respiratory
droplets from coughing & sneezing and
infected surface and followed by eyes.
Clinical Presentation (in Wuhan china)
•Fever : 88% •Fatigue : 38%
•Dry cough in 67% •Myalgias : 15%
•Dyspnea in 19 % • Pneumonia: 3.4%
International Pulmonologist’s Consensus COVID-19 April,2020

ESHRE Guidance
●All fertility patients considering or planning
treatment, even if they do not meet the
diagnostic criteria for COVID-19, should avoid
becoming pregnant at this time.
●For those patients already having treatment,
it is suggested to consider deferring
pregnancy with oocyte or embryo freezing for
later embryo transfer.
European Society of Human Reproduction and Embryology (ESHRE) March 17, 2020

1) Suspend initiation of new treatment
cycles, including ovulation induction, IUIs,
IVF including retrievals and frozen embryo
transfers, as well as non-urgent gamete
cryopreservation
Covid-19 and Fertility
ASRM Guidance
American Society for Reproductive Medicine (ASRM) April 13 to April 27, 2020

2) Strongly consider cancellation of all
embryo transfers whether fresh or frozen.
3) Continue to care for patients who are
currently ‘‘in-cycle’’ or who require urgent
stimulation and cryopreservation.
ASRM Guidance

4) Suspend elective surgeries and non-
urgent diagnostic procedures;
5)Minimize in-person interactions and
increase utilization of telehealth.
ASRM Guidance

●All these societies suspend fertility
treatments except urgent fertility
preservation in oncology patients
• British Fertility Society (BFS)
• Human Fertilization & Embryology
Authority (HFEA)
• Fertility Society of Australia (FSA)
• Dutch Society of Obstetrics
&Gynecology
Cochrane Gynaecology and Fertility updated April 16, 2020

Non-elective Fertility Preservation:
Example: Sperm and oocyte or embryo
storage for cancer patients, provided they
show no symptoms of infection
British Fertility Society March 18, 2020 Updated April 14, 2020
Cochrane Gynaecology and Fertility April 11, 2020
British Fertility
Society Guidance

Centers are expected to keep
communication open with patients for
advice and reassurance
British Fertility Society March 18, 2020 Updated April 14, 2020
British Fertility
Society Guidance

Covid-19
Joint Statements on
Elective Surgery

Covid-19 Joint Statements
The American College of Obstetricians and
Gynecologists (ACOG) joins
1) The American Society for Reproductive Medicine
2) The American Association of Gynecologic
Laparoscopists
3) The American Urogynecologic Society,
4) The Society of Family Planning,
5) The Society of Gynecologic Surgeons,
6) The Society For Maternal-fetal Medicine,
7) The Society of Gynecologic Oncology and
8) The American College of Surgeons.
Covid-19 Joint Statements: ACOG,ASRM,AAGL,AUS, FSP,SGS,SMFM,SGO, ACS,3-4/2020

Covid-19
Joint Statements on Elective Surgery
In areas where COVID-19 is particularly prevalent
or where there is particular stress on the health
care system, it may be advantageous to identify
and modify surgical scheduling, including for
procedures that are medically indicated, when a
patient’s health and safety would not be harmed
by such delay.

● Recommendation that hospitals suspend
elective surgeries during the COVID-19 crisis
pandemic.
● Obstetric and gynecologic procedures for
which a delay will negatively affect patient
health and safety should not be delayed .
Covid-19
Joint Statements on Elective Surgery

ART should not be started at present. Why?
● To avoid complications of ART& pregnancy.
● To avoid potential Covid-19 related
complications during pregnancy.
● To decrease the unknown risk of vertical
transmission in Covid-19 positive patients.
Covid-19 And ART: ESHRE Guidance
European Society of Human Reproduction and Embryology (ESHRE) April 2, 2020

ART should not be started at present. Why?
Continue:
● To support the necessary reallocation of
healthcare resources
● To observe the current recommendations
of social distancing.

● In cases of urgent fertility preservation in
oncology patients, the cryopreservation of
gametes, embryos or tissue should still be
considered.
● For those patients having started ART at
the present time, elective oocyte or embryo
freezing for later embryo transfer (freeze-all)
is recommended.

It is likely to be minimal (if at all). Why?
● Sperm, oocytes and embryos do not have
receptors for Covid-19 and are unlikely to
be infected.
● The zona pellucida represents a high level
of protection for oocytes and embryos.
Is There Any Risk of Viral Contamination
to Gametes& Embryos in The IVF Lab.?

It is likely to be minimal (if at all). Why?
Cont.
● The repeated washing steps required for
the culture and freezing protocols will
result in a high dilution of any possible
contamination.
Is There Any Risk of Viral Contamination
to Gametes& Embryos in The IVF Lab.?

Supportive Care
Heathcare professionals and clinics should
remain available to provide supportive
care preferably via online consultation :
 Psychological support and
 Clinical advice

Will Covid-19 Affect
Male Fertility?

Will Covid-19 Affect Male Fertility?
Why This Question ?
1- Broad range of virus families may induce
orchitis and even result in male infertility:
● HIV ● Mumps virus,
● Influenza virus ● Zika virus
● CoxsacKie virus ● SARS (similar to Covid-19)
Wang, etal., Preprints 2020, 2020020299 (doi: 10.20944/preprints202002.0299.v1).
Liu, et al. Andrologia, 2018, 50(11): e13140. doi: 10.1111/and.13140

There are 2 relevant Chinese studies
1- ACE2 expression in kidney and testis
may cause kidney and testis damage
after 2019-ncov infection (Caibin fan, kai li,
yanhong ding, wei lu2, jianqing wang : China 12-2-20)
2- Effect of SARS-CoV-2 infection upon
male gonadal function: A single center-
based study.
(Ling Ma, Wen Xie, Danyang , Lei Shi1, Yanhong Mao, Yao Xiong,
Yuanzhen Zhang, Ming Zhang China 21-3-20)
Will Covid-19 Affect Male Fertility?

1- ACE2 expression in kidney and testis may cause kidney
and testis damage after 2019-ncov infection
(Caibin fan, kai li, yanhong ding, wei lu2, jianqing wang :
The basic of the study: Angiotensin-converting
enzyme 2 (ACE2), The receptor for entry into the
host cells by Covid-19 is highly abundant in in type
II alveolar epithelial cells (AT2) in human lungs
First study
China 12-2-20

• The authors used the online datasets to
analyze ACE2expression in different organs.
• The research was based on the datasets of
146 male patients in three different settings.
• The results indicate that ACE2 highly
expresses in renal tubular cells, Leydig cells
and cells in seminiferous ducts in testis.
Fan, et al., MedRxiv,2020, doi: ttps://doi.org/10.1101/2020.02.12.20022418
ACE2 Expression in Kidney and Testis May
Cause Kidney and Testis Damage

This first Chinese study concluded that:
Due to the potential pathogenicity of the
virus to testicular tissues, following-up and
evaluation of the reproductive functions
may be necessary in recovered male Covid-
19 patients, especially the young male
patients.

The report was widely shared on
Chinese social media then spread to
worldwide social media.

The research has yet to have been peer
reviewed. However, the results on this research
could have large implications and effect on the
thousands of male patients infected with the
coronavirus.
Comment 1
16 February 2020
Comments on The 1st Chinese Study

Comment 2 (20 February 2020):
News Week, Health Speaking to Newsweek,
Professor Allan Pacey, emphasized That:
● At present it is somewhat premature to
conclude from this study [that] Covid-19 will
definitely affect male fertility, but it is useful that
the authors have raised this concern so that
researchers can in due course take a look at the
fertility of those who were infected by Covid-19

● The team at Tongji Medical College in Wuhan,
where the virus originated published the report on
the hospital website.
● However it was deleted just hours after being
uploaded after it was widely shared on Chinese
and worldwide social media.
12 March 2020

17 March 2020

Comment 3:
Unproven report linking coronavirus to male
infertility removed
● The team did not perform a study to assess
male fertility in patients who had been
infected with the coronavirus.
● There is no evidence to suggest that the
virus is found in the testes.

Ma, et al, medRxiv preprint.https://doi.org/10.1101/2020.03.21.20037267 doi
21 March 2020
The 2nd Chinese Study

Effect of SARS-CoV-2 infection upon male
gonadal function: A single center-based study
Ling Ma#1, Wen Xie#2,5, Danyang Li1, Lei Shi1, Yanhong Mao1, Yao
Xiong1, Yuanzhen Zhang*1,3,4, Ming Zhang*1,3.
Reproductive Medicine Centre,Zhongnan Hospital,Wuhan University
Wuhan 430071, Hubei Province, P. R. China.
Patients: Total of 181 reproductive-aged men
● A 81 men with Covid-19 infection versus
● A 100 age-matched healthy men

Results:
It is found that in males with COVID-19 there
a significant :
 LH & Testosterone (T) & T/LH ratio: 
Denoting possible damage of Leydig cells.
 CRP:  Abnormal cytokines such as
interferon : Possible spermatogenesis

Recommendations of The Study
Since >50% of people with Covid-19 were
reproductive-aged , more attention should
be paid to the possible effect of Covid-19,
and gonadal function evaluation including
semen analysis is necessary in the follow-
up of those who recovered from Covid-19

Limitations in This Study (by the authors)
1-Neither semen parameters nor existence
of Covid-19 in semen was detected,
which are more evidence for testes injury.
2- The small size of samples, only 2 mild
cases, 7 severe cases and 2 critical cases
are included, which may affect the power
of statistical analysis

Covid-19 And Male Infertility : Summary
● So far, no study has confirmed that the
coronavirus can damage male testicles and
adversely hurt male fertility.
●As far as testis is rich in ACE2, the team
suggested men who get the virus might
consider getting tests on their semen quality
after 3 months .

Fevers are known to overheat the testicles
which can temporarily reduce male fertility
Considering that one of the primary
symptoms of Covid-19 is a high fever, it’s
reasonable to assume that men with Covid-
19 will also experiencereduced fertility.
The impact should be temporary, and
similar to that of baths or hot tubs
AVAWORLED ,Covid-19and Male Fertility: What is the Impact? Published Apr 9, 2020
Covid-19 And Male Infertility
Essential takeaways

 Will Covid-19 Affect Male Fertility?
In the short term it is probably,
temporarily.
The long-term outcome is a little less
clear
AVAWORLED ,Covid-19and Male Fertility: What is the Impact? Published Apr 9, 2020
Covid-19 And Male Infertility
Essential takeaways

What Is The Impact of
The Social Media on
Covid-19 And Male fertility?
 Sperm freezing : Men do that as they
are fearing covid-19 causes infertility.
 Psychology: Fear, anxiety or panic from
the possibility of testicular damage.
 Sperm-business is flourish .

Covid-19 And Sperm Freezing
● The potential impact of coronavirus on fertility
(either short or long -term).
● If the Covid-19 pandemic is pushing off the family
plans, sperm freezing may be a good option .
● Age (especially 35 years) may affects male fertility
Coronavirus and sperm freezing: protecting
your fertility during the COVID-19 pandemic
Why ? &When?
14 April 2020

Social distancing recommendations are still
in place, so visiting a doctor’s office or
hospital to discuss sperm freezing is not
recommended, or possible, at the moment.
Mail-in sperm testing and freezing options,
like the Legacy® or CryoChoice's® kits, are
good option to preserve your fertility from
the safety and comfort of your own home
Coronavirus and sperm freezing: protecting
your fertility during the COVID-19 pandemic
14 April 2020

The market of companies sending men
preservable sample collection kits and return
postage, run lab tests on returned cups, and
promise to cryogenically store viable seed have
always been steady business.
However, shockingly, amid COVID-19, the
business is booming (flourish) more than ever.
April 2020

Surge in men panic buying at-home
collection kits – (CryoChoice's ® ) to freeze
their sperm among fears Covid-19 will leave
them unable to have kids - despite NO
evidence the virus harms fertility
Nervous men freezing
sperm over coronavirus fears
13 April 2020

Men aren’t alone in their panic.
Many women are rushing to get their eggs
frozen among fears of the coronavirus.
A top fertility clinic in Manhattan says it’s
been streamed with women begging to
freeze their eggs during the pandemic.
Nervous Women freezing
Their eggs over Covid-19 fears
13 April 2020

American men are panic-freezing their sperm with
at-home kits due to questionable fears.
14 April, 2020

Covid-19 And Sperm Freezing
Sperm-business is flourish
● Apparently, one at-home sperm collection
firm CryoChoice has seen sales jump by as
much as 20 % in recent weeks (declining is
expected due to postponding of fertility).
● Another at-home sperm collection start-up
Legacy’s staff claim they’ve seen up to 10 times
their usual order volume in recent days
14 April 2020

Sales of CryoChoice's at-home
sperm collection kits have
spiked 20% (instead of to
decline)
At-home sperm collection
business is booming thanks to
fears that coronavirus will
impact male fertility

Several sperm-freezing clinics
have reported spikes in the
number of men ordering their at-
home collection kits

Can Covid-19
Be Sexually
Transmitted?

Can Covid-19 Be Sexually Transmitted?
● To date, it has not been reported to be
sexually transmitted, but since sexual intercourse
involves close contact, kissing and touching,
these are the ways of transmitting this virus.
● If someone has symptoms or suspects they are
infected, they need to go into quarantine and
avoid close contacts.
● Sex with strangers should be avoided.
United Nations International Children's Emergency Fund UNICEF , April -2020

Covid-19 : Safe Sex ?
 CDC: Social distancing” may cut down on sex.
 The safest sex is masturbation.
 The lowest sexual risk is mutually monogamous
couples ( in Egypt the wife & husband ).
 Washing hands often with soap and water for at
least 20 seconds before and after sex.
 Take care during sex.
● No Kissing ● No anal sex or touch
● Oral sex with condom ???
American Sexual Health Association & The New York City (NYC) Health Department 4-2020

General Principles:
●Other coronaviruses do not efficiently
transmit through sex
● Covid-19 has not yet been found in semen
or vaginal fluid.
● Covid-19 has been found in feces of
people who are infected with the virus.
The New York City (NYC) Health Department 4-2020

Skip sex if you/your partner is not feeling well:
1- If you or a partner may have Covid-19, avoid
sex and especially kissing.
2- If you start to feel unwell, you may be about to
develop symptoms of Covid-19, which include
fever, cough, sore throat or shortness of breath.

Skip sex if you/your partner is not feeling well:
3-If you or your partner has a medical condition
that can lead to more severe Covid-19 including:
 Lung disease
 Heart disease
 Diabetes
 Cancer
 Immunocompromised

Covid19 and fertilty final Dr.Sherbiny 19-4-2020

Covid19 and fertilty final Dr.Sherbiny 19-4-2020

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