Dana Reddy, a Carlsbad resident and a patient at a La Jolla infertility clinic, has endometriosis – a disorder in which tissue that normally lines the uterus grows outside of it, making it more difficult to conceive children.
Seven months ago, she began a round of fertility treatments to prepare her for an embryo transfer – the final step in the in vitro fertilization process, when a fertility specialist places an embryo created in the laboratory into the uterus for implantation and pregnancy. She planned to have the procedure during the last week of March. But then her physician told her all elective treatments – including embryo transfers – were being put on hold due as a result of the coronavirus.
Reddy, 37, said she’d timed the treatments for late March in part because they were covered under her insurance from her employer at the time. In the two months between the initial closure and her clinic’s decision to resume treatments, she accepted a new position and lost her coverage. Her endometriosis worsened during that time, too.
Reddy said the clinic she goes to is now open and continuing embryo transfers for endometriosis patients. She said she plans to continue with the procedure despite the grueling delay and new economic challenges.
“IVF and fertility treatments take so long anyway,” she said. “So it’s a constant waiting game, and then to have to have an indefinite delay is really emotionally stressful.”
When the American Society for Reproductive Medicine on March 17 directed physicians and clinicians to suspend initiation of new treatment cycles, strongly consider cancellation of all embryo transfers and other elective procedures because of the unknown coronavirus implications, physicians and clinics scrambled to notify patients about the suspensions. By early April, most fertility treatments in the San Diego region and across the nation had come to a halt.
Fertility patients across the region expressed grief about the impacts the delay would have: depleted qualities and quantities of eggs in older patients, delays in family planning, financial impacts due to job losses, questionable insurance coverage and long-lasting health effects for those with health issues that impact fertility. Fertility patients and physicians told Voice of San Diego the closures caused devastation and anxiety across the board, particularly for those with ticking clocks and ovarian health conditions.
‘Saying IVF Is Not Essential Is Bullshit’
Jane, 43, told Voice of San Diego she planned to have an egg retrieval procedure at Reproductive Partners in La Jolla in March. She said because of the concern over the quality and quantity of her eggs, she and her husband tried to conceive a child naturally rather than wait for treatments to resume. She became pregnant but miscarried in late May. Voice of San Diego agreed to use a pseudonym for Jane at her request because she’s describing sensitive medical issues.
Jane said her feelings are raw because she just lost her child, and she’s concerned infertility issues are taboo and no one is talking about the effects on IVF patients whose time-sensitive treatments were put on pause.
“If the clinic was not shut down, I could’ve had an egg retrieval and not wasted time. At my age, every month and every day matters,” she said. “I’m not only losing the quality but the quantity of eggs. For someone with diminished ovarian reserve, they’re taking away essentially the only lifeline.”
She said she’s dealt with repeated miscarriages, each of which brings intense agony, and that “she’s the worst kind of patient someone can stop treatments for.” But she doesn’t blame the clinic or her doctor.
She criticized the American Society for Reproductive Medicine for enacting a sweeping policy.
“To say you’re putting a sweeping protocol across it and saying IVF is not essential is bullshit,” she said.
Sean Tipton, a chief advocacy, policy and development officer for American Society for Reproductive Medicine, told Voice of San Diego the decision to halt non-elective treatments was made in part to take the stress off of a taxed health care system amid the coronavirus pandemic and in part to keep an eye on impacts coronavirus would have on pregnancies.
“If there’s a shortage for emergency room workers, infertility service can be on hold for one or two weeks,” Tipton said.
On April 24, the group released a statement that said infertility “is a serious disease that requires treatment in a timely manner” and directed physicians to resume treatments based on safety and health protocols in their respective jurisdictions.
Some patients said critical time was lost while treatments were suspended, and that the delay had detrimental effects on their ability to conceive and their personal well-being.
Tipton said the organization is aware of exacerbating reproductive care issues and has listened to concerns from people who were worried about their cycles or insurance coverage being interrupted. He said he’s unaware of whether those concerns materialized but that the organization’s COVID-19 task force – a group of reproductive medicine and infectious disease experts tasked with examining data and drafting guidance during the pandemic for the professional reproductive care community, their patients and policymakers – took those issues into account.
“There’s no question over whether IVF treatments are essential,” Tipton said. “It’s about whether it’s essential this week.”
Michael Workman, a spokesman for the County Public Health Office, said when the county decided to postpone elective procedures to reduce the chances of the virus entering the hospital system, no specific decisions were made about in vitro fertilization. He said whether to continue procedures was made at the discretion of each facility.
Jane said that if another wave of coronavirus hits, she hopes fertility treatments stay available and that the industry incorporates the feedback it’s received.
Reddy called the guidelines that halted treatments “ridiculous” and said “COVID-19 is not just going to be gone, and things are going back to normal. They should’ve just kept things open and kept things safe.”
Oceanside resident Kim Whittemore, a board member at Boston-based nonprofit Fertility Within Reach, said she’s concerned the American Society for Reproductive Medicine made a unilateral decision to urge doctors and clinics to pause elective treatments, leaving some patients with time-sensitive issues in the lurch.
“Why can’t or why aren’t clinics allowed to make the decision? You and your clinician decide what’s best and why can’t procedures continue?” Whittemore said. “Now patients haven’t just lost time; they may have completely lost their opportunity.”
Some Treatments Are Resuming
Physicians at San Diego facilities who are now restarting some procedures said they battled between the first set of guidelines and concerns for their patients when deciding whether to shut down treatments. They say now there’s a slight backlog of infertility treatments, and they’re taking steps to provide patients with support.
Sandy Chuan, a physician at San Diego Fertility Center, said two days before the American Society of Reproductive Medicine urged the suspension of treatments, the physicians at her center were already considering the same move.
She said the decision was two-fold: consideration of the recommendation and concern over client and staff safety.
“Fertility has also been in a field considered ‘non-essential’ because it’s elective. It affects our patients’ quality of life, and for us it’s a challenge because we and many patients consider it essential,” Chuan said. “The impact was patients’ significant disappointment. It’s obviously an emotional process and fertility treatments are very detail-oriented. You have to make sure none are missed.”
Chuan said she spoke with colleagues throughout California while everyone was figuring out how coronavirus could affect pregnancies and whether medical facilities would need to be reserved for patients with coronavirus.
She said she was concerned especially for patients who are older and have been struggling for years to get pregnant, and others who didn’t necessarily have an age factor to worry about but still feel a sense of urgency to get their families started.
“The guidelines are meant nationally, but nationally it’s not the same in every situation. New York is different but San Diego is sparser and there’s more social distancing because of the way we live. There didn’t seem to be an overwhelming number of cases,” Chuan said.
Chuan said now physicians at San Diego Fertility Center are going through steps to restart patients in a proper way, including emotional support and providing logistics to keep patients and staff safe. She said prior to the closure, the facility was completing close to 100 to 120 embryo transfers per month with comfortable staffing in a lab. Since opening on June 1, they’ve had the manpower and space to accommodate about 80 to 100 embryo transfers.
“These are unprecedented times. We’re anxiously waiting to see how we do with these cases with reopening and obviously making it a priority to making it as safe as possible,” she said. “You feel like you’re in limbo or on hold. It’s another year to get to your family so it’s more time to wait.”
Alex Quaas, a physician at Reproductive Partners Fertility Center in La Jolla and a board member of the Pacific Coast Reproductive Society, said when he received guidelines to halt elective treatments he worried about his own practice and job stability and felt bad for his clients. He said he worried about his patients who have poor ovarian reserves and others who were preparing their ovaries for treatments they ultimately couldn’t get.
“I felt bad because some patients put in the time and effort to get started on treatments and then couldn’t do it,” Quaas said. “On the other hand, for a period of time I was worried the halt was going to be much longer. I’m happy now that even in May we were already able to do some treatments and help some patients get pregnant.”
He said in the end, the delay ended up being so short that he doesn’t think it had a massive impact for most patients, but the uncertainty of how long treatments would be paused concerned him.
“In that case if a person is 41 or 42, a few months can have a relatively strong impact on success rates, and there was one month of interrupted services in that time,” he said. “Patients who did have the most urgent need are the ones we’re prioritizing right now.”
He too said he’s now dealing with a backlog of people awaiting treatments. He said the clinic is prioritizing the most urgent treatments – including those for people over the age of 38 who have a low number of eggs or whose egg quality is decreasing – including Reddy, one of his patients.
The American Reproductive Society of Medicine’s latest update on June 8 says clinicians should take proper safety measures when reopening, like limiting patients per room and wearing face masks.
“Over the past several months, significant knowledge has been gained regarding the virus and its impact on patients and the medical system. However, the associated delay in care resulted in an increasing number of patients whose situation had become more urgent. … Since then, it has become clear that we will need to be practicing in a COVID-19 environment at least until an effective and safe vaccine or broadly effective treatment become widely available. Consequently, the Task Force continues to support the measured resumption of care,” the update reads.
Quaas said there’s never more than one person in the waiting room at Reproductive Partners and the clinic sometimes instructs people to wait in their cars. Everyone is required to wear face masks and patients are required to get tested for coronavirus.
He said he wants people to acknowledge that infertility is a disease.
“It’s not just when somebody thinks they need a face lift or want a breast augmentation. Some people sometimes consider our field as not necessary,” he said.
Some Patients Lost Jobs or Insurance Coverage
Though physicians and advocates insist infertility is a medical condition, few states require insurance providers to cover treatments.
In California, the Legislature in 2018 rejected a bill that would have required insurance companies to provide wide coverage for in-vitro fertility treatments. Gov. Gavin Newsom signed a bill last year requiring insurers to cover fertility preservation procedures such as sperm banking or egg freezing for patients undergoing treatments that make conception more difficult, like chemotherapy.
Few Californians have insurance that covers fertility treatment. Medications themselves can cost between $3,000 and $10,000 per cycle and between $10,000 and $15,000 for in vitro fertilization.
Christen, 36, who lives in Pacific Beach and is a patient at a San Diego fertility clinic, said she and her husband were told on March 12 over a Zoom meeting that her planned treatments were being put on hold. Voice of San Diego agreed to identify Christen by her first name only because she is sharing sensitive medical information.
She said she, like Reddy, was also hit financially when the retail store she works at placed her on furlough amid the pandemic – leaving her with less money for treatments, which she and her husband pay for out of pocket.
Reddy, meanwhile, said her new employer doesn’t cover her treatments.
“I could’ve chosen to stay at my old job for coverage but it’s not fair to not accept a job because I’m worried about the IVF insurance options. Now I don’t have any coverage,” she said. “I had insurance and because I basically switch jobs, my old plan covered IVF, and I thought it was going to be done.”
Reddy said she’s thankful her clinic is opening embryo transfers for clients with endometriosis. But it was frustrating, she said, to hear local leaders discussing reopening businesses like hair salons or beaches for surfing, while treatments to help her conceive a child still weren’t allowed.
Christen, for her part, said the situation remains stressful even now that some treatments can resume. She and her husband were disappointed when treatments stopped, but they’re also hesitant to begin an egg transfer now that coronavirus cases are ticking up in some states.
She worries that if she restarts treatments now, clinics may be advised to close down again.