Pregnancy, infertility, assisted reproductive technology (ART) and COVID

Laura Riccardi

The outbreak of COVID-19, an infectious disease that causes flu-like symptoms and has resulted in the deaths of over 125,000 people at the time of writing, has rapidly overwhelmed the healthcare system, shut down industries and international travel, and prompted sweeping changes to legislation and law enforcement. In addition to these sweeping changes, COVID-19 is having a significant impact on the lives and health of individuals. This includes the sexual and reproductive health of women across Australia, where we have been relatively inoculated against some of the worst outcomes, compared to countries like China, Italy and the United States.

While many individuals and organisations have alerted us to the risks of reducing access to contraception and abortion during the current public health crisis, less widely known is the impact of the virus on those who are trying to conceive. In Australia each year roughly 300,000 babies are born. This means there are a considerable number of women currently pregnant or with newborn babies that are experiencing significant physical, emotional and social changes in the context of a public health crisis. Additionally, COVID-19 has disrupted assisted reproductive technology procedures. With an estimated one in 25 Australian babies born via IVF, COVID-19 is a major threat to women’s reproductive autonomy and family planning. This article will explore the impacts of COVID-19 and subsequent restrictions on access to healthcare on pregnancy and infertility for women in Victoria.

Pregnancy and postpartum period during COVID-19

At present, there is limited evidence of vertical transmission of COVID-19 between a mother and foetus. Encouragingly, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists suggests that the majority of pregnant women who become infected will only experience mild to moderate symptoms.

Some health experts have speculated about COVID-19 and pregnancy; based on the impact of similar respiratory viruses, such as Middle East respiratory syndrome (MERS) and severe acute respiratory syndrome (SARS). In both instances, although the sample size of the studies was small, evidence suggests that MERS and SARS diagnoses in pregnant women were associated with severe maternal illness and mortality, spontaneous abortion, pre-term birth and stillbirth. Information regarding breastfeeding with COVID-19 is conflicting: the Victorian Maternal and Child Health Service, Royal Women’s Hospital and Unicef have stated that there is no evidence that COVID-19 is transmitted via breastmilk so symptomatic mothers who are well enough should continue to nurse their babies and toddlers; while an article published in The Lancet has advised against it.

Additionally, social distancing rules limit access to the usual support networks for women in pregnancy and the postpartum period following childbirth, periods that can be challenging for many women. As many as 1 in 5 mothers of children aged 2 years old or younger are diagnosed with depression, and more may experience symptoms but may not be diagnosed due to stigma or limited access to primary and specialist care, even in pre-COVID-19 times. Usual sources of support, such as maternal and child health services, breastfeeding support services, mother’s groups, and private care options, such as nannies and sleep schools, have likely been disrupted due to COVID-19. While the fear, uncertainty and isolation associated with COVID-19 and social distancing regulations are expected to have far-reaching impacts on mental health outcomes, there are some groups, like expectant and new mothers, that may be more at risk.

Assisted reproductive technology

Infertility is defined as the inability to conceive a pregnancy after twelve months of unprotected vaginal intercourse. It affects 1 in 6 couples in Australia, and is increasingly common due to a range of social, environmental and biological factors. Many women delay children either by choice or by default, due to lengthy formal education, increasing household debt, entering a marriage or partnership later or desire to establish a career or purchase a home. For some women, their fertility is affected to health factors such as smoking, alcohol or other drug use, weight and fitness, age and conditions such as polycystic ovary syndrome or endometriosis. Infertility is also equally related to male fertility factors, such as low sperm production, abnormal sperm production, or genetic factors.

For lesbian, bisexual or transgender women, there are different barriers. Many Australian women in same-sex relationships conceive using home-based self-insemination with a known donor, rather than going through clinical insemination or assisted reproduction.  However, home-based self-insemination can be unreliable and even clinical assisted reproductive methods can yield variable results.

Infertility in Australia has resulted in a growing number of couples seeking the assistance of assisted reproductive technology (ART). ART can include one or more of the following:

In vitro fertilisation (IVF), where an ovum is combined with sperm outside the body to create a fertilised egg or zygote, after which it is implanted in a uterus.

Intracytoplasmic sperm injection is similar to IVF, but involves the injection of a single sperm cell injected directly into an ovum.

Cyropreservation of gametes, where male and female sex cells (sperm and ova respectively), are preserved by freezing.

Use of fertility medication involves taking pharmaceutical drugs to enhance fertility, sometimes by stimulating the ovaries or inducing ovulation.

Ordinarily, many women experience barriers to accessing these services; for some, ART can be prohibitively expensive. However, COVID-19 has exacerbated difficulties in accessing assisted reproductive technology.

An estimated ten percent of Australians have lost their jobs due to COVID-19. Economists from Australia’s second largest bank, Westpac, have warned “these widespread disruptions to the economy are on a scale that we have not experienced in recent times – which has important implications for the labour market.” Job losses, reliance on welfare and limited savings may mean that many eligible candidates for ART can’t afford fertility procedures, or the cost of raising a child.

Social distancing regulations to prevent community transmission of COVID-19 mean that in Victoria, residents are prohibited from leaving the house for reasons other than to attend work or education; to shop for food and other necessary goods and services; to provide care for an unwell or disabled relative or friend; to exercise; or if otherwise required in accordance with Victoria’s state of emergency restrictions. This resulted in the temporary closure or suspension of many services. IVF Australia, for example, announced that patients who were midway through treatment or have extenuating medical circumstances may continue; but all facilities were mandated to suspend treatment for patients who have not yet commenced.

Additionally, governments and hospitals in Australia and internationally proposed that non-urgent elective surgeries and procedures be temporarily suspended, in order to stockpile resources such as personal protective equipment, ventilators, intensive care unit beds, anaesthetists and nurses, for the management and treatment of COVID-19.

Although there was a legitimate public health rationale for minimising non-urgent medical procedures, this decision nonetheless had a devastating impact on many women across Australia, particularly older women or those with a lower egg reserve. The ban was an impediment to women’s reproductive autonomy, which recent advances in research and technology have enabled.

More recently, the National Cabinet has reviewed restrictions on elective surgeries, in light of the diminishing number of COVID-19 cases reported in Australia, and announced that IVF services will resume from April 27 onwards. This is a welcome announcement for women seeking assistance to conceive, and those waiting to have surgery for endometriosis.

It is only through women having the right to choose the timing and number of children they wish to have, if they want them, that it is possible for women to exert their reproductive autonomy, and thus, address some of the inequalities between men and women.