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    Continually updated but major update 5/25/19

    COVID-19 and treatment of infertility

    The COVID-19 pandemic in the U.S. and the rest of the world has caused fertility centers and their national societies to question the risks to patients, staff, and the developing fetus by this new virus. The virus is commonly spread by individuals who do not have symptoms and it remains alive on surfaces (on plastic, paper, glass, and wood for up to 3-4 days), making avoidance very difficult. Patients with symptoms (such as fever or dry cough, unexplained marked fatigue or transient loss of sense of smell) should not go in for care, which risks other patients and health care workers. Instead you should contact your health provider by phone. Your provider may recommend self-isolation at home with or without testing.

    Now that the rates of infection and serious complications requiring ICU care are stabilizing, the focus will change to widespread testing, which can allow for following up and testing contacts, thereby supporting more vigorous efforts to prevent spread. That may allow consideration of providing care for infertile couples in regions with lower rates of infection as long as rigid standards for both patients and staff are followed. It is likely to still require use of masks and physical distancing to keep to an absolute minimum the chance of spread from patient to patient and to staff and among staff and patients. Family members may not be allowed to accompany the patient into the center, and the patient may be asked to wait in their car to avoid contacting others in the waiting room.

    In the U.S., the American Society for Reproductive Medicine (ASRM) and the Society for Assisted Reproductive Technology (SART) have recommended for fertility centers to treat only women for whom any delay would markedly affect their chance of being successful. For example, women with cancer generally only have a few weeks before starting chemotherapy to have their eggs or embryos frozen for use following their cancer treatment and a disease-free interval. When infection rates have stabilized, treatment of a broader selection of infertile couples is expected, particularly in regions with fewer cases of COVID-19.

    Your fertility specialists realize the anxiety and concern that patients naturally have in adjusting to any delay of treatment. If that is what they recommend, you can be sure that their decision is based on your best interests and those of their team members. If a delay is necessary, there are things that a couple can do during the time they are waiting that can improve their chance of being successful when treatment is resumed. The quality of the eggs and the sperm and therefore of the embryos are the main factors influencing success. The oocytes and sperm for the treatment cycle have been developing for 3 to 6 months and up to 90 days, respectively. Therefore improving the environment (the woman and her partner) surrounding and nurishing those gametes is critical. In fact, it would be entirely reasonable for all infertile couples to routinely maximize the health of their gametes for 3 to even 6 months before starting treatment. That may enhance their success enough to at least counterbalance and even exceed and loss in success due to the delay. Those efforts also may reduce miscarriage, which is particularly stressful and heart-breaking for the couple. During any imposed delay, that will also give you something very worthwhile on which to focus, and the great news is that those same improved lifestyle measures will also enhance your general health and longevity! We do not advise proceeding if you are experiencing substantial stress from the COVID-19 pandemic. That could decrease your chance for success. Stress has a marked effect on the health of the gametes (moreso for the eggs), probably by constricting the flow of blood and therefore nurishment available to the ovaries and testicles. Whether or not you proceed with treatment, recent information suggests that regular exercise may protect against serious lung, heart, or kidney impairment with COVID-19. That appears to be through reduced oxidative stress, in part by increased levels of an important extracellular antioxidant, superoxide dismutase (https://neurosciencenews.com/coronavirus-exercise-16169) (Yan Z and Spaulding HR)

    The following pages of this website will discuss in detail the lifestyle changes you should make to enhance your chances of success, but they are also summerized below.

    1. Decrease stress and your response to stress. Do not plan to have a treatment cycle during a stressful time.

    2. Exercise at a moderate level, such as a 30 minute brisk walk most days of the week. This is of more critical importance for women who are obese.

    3. Improve your diet. A mediterranean diet with more fish, greens, fruits, and vegetables and avoiding red meat and excess fat and sugar has been related to improved fertility for both partners

    4. Stop smoking, alcohol, and avoid overcooking and charring of foods, trans fats and BPA; the male partner should not use hot tubs.

    5. These lifestyle changes will help with weight control. They are likely to help more than trying to lose a lot of weight in a hurry, which could even have negative effects.

    6. Consider taking supplements, which is particularly important if your diet is not optimal. Omega-3's and antioxidants are particularly important.

    Whether or not you decide to proceed with treatment, you should follow guidelines from experts to limit your chance of being infected by COVID-19 as well as protecting the health of others:

    1. Maximize your health, including regular exercise, good nutrition, and plenty of sleep.

    2. Maintain a distance of at least 6 feet from others and be aware that ordinary masks and face coverings are not sufficient to relax that rule; health care workers may be wearing more protective masks when they need to be closer to patients.

    3.If you must sneeze or cough due to seasonal alergies, cover your face in the inside of your elbow.

    4. If stay at home orders are active for your area, limit any outside activity to esential activities such as regular exercise, visits to health providers, and visits to buy food (try to do that at times of the day when fewer people will be in the grocery store and buy other needed items online).

    5. Wash your hands frequently with (preferably hot) water and soap suds for at least 20 seconds. Using hand cream after washing is helpful because dry cracks in the skin can harbor the virus.

    6. Do not touch your face until after thoroughly washing your hands. The virus speads by entering the eyes, nose, or mouth.

    7. Wearing face coverings can help to reduce the chance of air-born particles/droplets containing COVID-19 reaching your face. Their effectiveness is not great, so be sure to still keep at least 6 feet from others. Avoid bicycling behind another bicycle rider as the forward motion exposes you to infection even with more than 6 feet of separation. A similar problem occurs when any person is upwind from you. Exercising outdoors is generally safer, but with the above exceptions.

    Delay of fertility

    Couples are delaying their efforts to have a family because of careers and because contraception allows them to wait until their circumstances are more ideal. Unfortunately, fertility decreases with ages of the male (De la Rochebrochard, 2006, Fratterelli, 2008, Girsh, 2008) as well as the female. The antioxidant status of tissues of the body is lower as age increases. scaleThe older age at marriage often means contact with more sexual partners and sexually transmitted diseases like chlamydia which can damage the fallopian tubes. Endometriosis increases as more menstrual periods occur. Finally, more time allows more body weight to accumulate. Even an extra 100 calories per day causes a weight gain of 10 pounds per year and 100 pounds in 10 years. Obesity decreases fertility, increases miscarriage, and causes pregnancies to be more complicated (see weight and fertility).

    Personal habits

    smoking and alcoholPersonal habits such as smoking and alcohol can have effects on fertility. Surprisingly, even second hand smoke damages the sperm and eggs, apparently as much as smoking.

    Exercise and fertility

    Modern society has devised so many tools to avoid physical activity that we all have to make a conscious effort to set aside time for exercise. exerciseRecent studies show that fertility increases with moderate exercise in both the male and female partner. It makes sense, because exercise improves blood flow and the body's natural antioxidant status. On the other hand, high levels of exercise appear to reduce fertility. Two studies have suggested more than 3-5 hours of vigorous exercise per week for the female partner may reduce fertility (Morris, 2006, Wise, 2012), hence the above guidelines. Moderate or even high exercise for the male will enhance erectile function and will help prevent any decline of that function with aging. However, in a very thorough and well controlled study, normal young men assigned to regular high intensity exercise had significant reductions of most semen parameters and gonadotropin and testosterone levels (Safarinejad, 2009, Hayden RP, 2018). As it is likely that men with decreased semen quality would have similar or greater adverse effects, we do not recomment regular, high intensity exercise for the male partner. Biking for > or = 5 hours per week (Wise, 2011) has been reported to have negative effects on sperm. Overheating of the testicles may explain the effect of biking.

    Nutrition and fertility - click on "lifestyle and fertility"

    Sexual dysfunction and fertility

    Sexual difficulties are much more common with infertility (see sexual dysfunction and infertility). In one study almost a quarter of couples had sexual dysfunction. This is partly due to the same factors that can harm the eggs and sperm- excess body weight, a less than healthful diet, insufficient exercise, insufficient antioxidant intake, smoking, second hand smoke, and excessive alcohol all impair erectile function (see sexual dysfunction and infertility page on this site and "Survival of the Firmest" available for purchase on Amazon/kindle or "itunes"). Certainly the stress of infertility and fertility treatments and having to time relations to the time of ovulation are also factors, but sex doesn't have to be regimented. fertile timeHaving relations every 1-2 days around ovulation is ideal. Just don't let 3 days pass during that crucial time, and if your ovulation test turns positive, be sure to have relations that night or the next morning. Even before IUI, having regular ejaculation increases the success rate and that probably holds for IVF as well. The sperm's DNA remains more intact when sperm spend less time in the collecting system where oxidative stress can damage them. And, as a bonus, having more frequent erections also improves erectile function and will help to prevent erectile dysfunction in the future.

    Stress and fertility

    Stress is certainly a factor. stressThe level of stress for a woman with infertility has been compared to having a diagnosis of cancer or HIV. Also, some individuals are naturally more reactive to stress. In one study, women scheduled for IVF were tested with stressful visual and auditory stimuli (Facchinetti, 1997). Those who failed to conceive had significantly greater rises of their blood pressure and pulse rate. That study suggested the adverse effect of stress is due to constriction of blood flow to the pelvic organs.

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