The Ontario fertility medical directors recognize the impact of Covid-19 infection in pregnancy. We share in the acute concerns of our frontline colleagues and health care policy planners across the province.
Fertility service providers have successfully dealt with the pandemic over the past year, screening staff and patients before entering, seeing patients in PPE, maintaining social distancing, and minimizing patient/health care provider encounters to only those that are essential to provide care; and this has resulted in no known outbreaks of spread among staff and patients within our clinics. In addition, virtually all of our staff have been either fully vaccinated or have received the first dose. We have demonstrated that following PPE guidelines our practices can run safely with minimal risk to patients and staff.
There is an extremely low risk of significant complications from fertility treatment requiring care in a hospital, and thus our treatments pose no significant burden on the human and health resources needed to deliver essential and urgent health services across Ontario.
All regulatory bodies, including the SOGC, continue to endorse pregnancy, without restriction. But unlike the broader population, fertility patients require timely access to fertility procedures to achieve their family planning goals. It is also important to note that pregnancies resulting from infertility treatment make up less than 2% of all pregnancies in Ontario.
It is widely recognized that access to fertility care is a reproductive right and an essential service. In this context, we have carefully considered the question of continuing to provide fertility treatment services in the context of Dr William’s CMOH Directive #2 update, distributed last week.
“Decisions to postpone non-emergent and non-urgent surgeries and procedures should be proportionate to the real or anticipated capacity needed to maintain the health and human resources to deliver essential and urgent health services across the system.”
It is our collective assessment that the real or anticipated impact that fertility services have on the healthcare system overall is insignificant. It is exceedingly rare for an infertility patient to experience a treatment related complication that would necessitate hospitalization or management by the health care system. Simply put, our patients are not a burden to the health care system, our facilities do not draw resources away from the health care system, and our human resources, and competency, are likely not useable in acute care settings.
Minimizing Harm to Patients. Decisions should strive to limit harm to patients. Surgeries and procedures that have higher implications for morbidity/mortality if delayed for longer periods of time should be prioritized over those with fewer implications for morbidity/mortality if delayed for a longer period of time. This requires considering the differential benefits and burdens to patients and patient populations as well as available alternatives to manage symptoms and relieve pain and suffering.
The emotional issues surrounding reproduction are extremely complex and further complicated by the physiologic limitations of female age and declining fertility. The emotional burden of delaying fertility treatments in fertility patients is substantial and long lasting. The frustration of time lost and opportunities lost is beyond measure. Based on real data from studies carried out when services were abruptly stopped in early 2020, another cessation of the provision of fertility services will cause significant emotional and psychological harm to the fertility community, without any measurable impact on relieving burdens to our health care system.
Equity requires that all persons with the same clinical needs shouldbe treated in the same way unless relevant differences exist (e.g., different levels of clinical urgency), and that special attention is paid to actions that might further disadvantage the already disadvantaged or vulnerable.
Patients suffering from infertility have long been marginalized by the health care system and society at large. Through the work of countless fertility organizations we have made tremendous improvements in access to care and social acceptance of infertility. However negative perceptions still persist. Cessation of care to this vulnerable population would further disadvantage our patients with no clear anticipated benefit to our health care system.
Certain patients and patient populations may be particularly burdened as a result of deferring non-emergent and non-urgent surgeries and procedures. Patients should have the ability to have their health monitored, receive appropriate alternative care, and receive surgical or procedural care if their medical condition changes and their need becomes urgent or emergent.
To use the language of the directive our “patients would be particularly burdened by deferring” fertility services. Our patients are clear that continuing to have access to care is a priority for them. Each case is unique, and every patient deserves to make informed choices. Urgency, however, is a defining condition of the infertile patient, as the diagnosis is based on the passage of time.
All four elements of the suggested rubric support ongoing access to fertility-related procedures.
In summary, access to fertility care remains an essential service. Through the past year there have been no outbreaks of Covid in any fertility setting. We will continue to offer best practices for the safety of all our patients and staff.
The overwhelming sentiment from our fertility patients is that they wish to continue treatment for family planning and building. Ceasing treatment will certainly cause significant distress and can have long-lasting implications. As stated above, treating our patients is not a burden to the health care system and our facilities do not draw resources away from the health care system.
We feel that the most significant opportunity we can provide for our patients is access to vaccination prior to, and during pregnancy…at the earliest stage of pregnancy possible. We are well resourced to provide testing access, as well as promote vaccination services for all of our active patients.
We recognize too that unvaccinated patients with pre-existing conditions now face specific risks within a strained healthcare system. For some, fertility preservation (rather than pregnancy) may be the right choice. In addition, clinics may decide at this time, and/or in the future, to limit access to certain procedures, or to certain patient groups, based on clinical assessment and medical judgement.
In this way, working together, the fertility clinics of Ontario will continue in our support of essential reproductive care for all Ontarians.